Trauma Case Conference: Traumatic Arrest

Welcome to another edition of the Trauma Case Conference where we discuss some of the pertinent management issues related to the care of complex trauma patients.

This edition is presented by Dr. Gupta!

Case Summary:

A young female is transferred from outside hospital s/p presumed blunt trauma: pedestrian vs auto. The patient was in cardiac arrest in the field and proceeded to get CPR w/ROSC prior to arrival to the outside hospital. While there, the patient again arrested and had ROSC prior to transfer on dopamine infusion. On arrival, the patient is found to be pulseless with no signs of life. The patient underwent bilateral finger thoracostomies w/out return of air/blood and CPR with epinephrine prior to ROSC. She was found to have diffuse cerebral edema and grade IV bilateral internal carotid injuries – injuries suggesting brain death.

Learning Points

• Signs of Life (American College of Surgeons Committee on Trauma): pupillary response, spontaneous ventilation, presence of carotid pulse, measurable or palpable blood pressure, extremity movement, cardiac electrical activity
• EAST strong recommendation: DO perform ED thoracotomy in the setting of pulseless patient with penetrating trauma and signs of life
• EAST strong recommendation: Do NOT perform ED thoracotomy in the setting of pulseless patient with blunt trauma and NO signs of life
• EAST conditional recommendation: Consider ED Thoracotomy in all other pulseless trauma patients
• WEST utilizes time of CPR as surrogate marker after which to perform ED thoracotomy in absence of signs of life: 10 minutes of CPR after blunt trauma; 15 minutes after penetrating trauma
• Brain Death Assessment: Identification of the proximate cause and irreversibility of coma; Exclude any condition that might confound the subsequent examination of cortical or brain stem function (i.e. toxic metabolic disorder, sedative drugs, paralytics, shock/hypothermia, etc.); Complete neuro exam with absence of brainstem reflexes (i.e. cough, gag, corneal, vestibulocochlear, oculocephalic), Apnea test (i.e inc in baseline pCO2 20mmHg or pCO2 >60 after disconnecting ventilator with no spontaneous respirations or hypotension or desaturation or arrhythmias)

Further Reading

• Burnett P, Cameron P. Traumatic arrest, Trauma in Adults. Tintinallis Emergency Medicine A Comprehensive Study Guide 7^th McGraw-Hill Education, 2010.
• Goila A, Pawar M. The diagnosis of brain death. Indian J Crit Care Med. 2009 Jan-Mar, 13(1): 7-11.
• Inaba K, Spangler M. Trauma Surgeons Gone Wild: How to Crack the Chest. EMRAP: 2017 January.
• Ramenofsky M, Bell R, et al. Resuscitative Thoracotomy, Thoracic Trauma. ATLS Student Course Manual. American College of Surgeons 2012:101-2.
• Seamon M, Haut E, Van Arendonk, et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery off Trauma. Journal of Trauma and Acute Care Surgery 2015 July, 79(1): 159-173.