Chest compressions in TCA theoretically no good if there are multiple rib fractures and / or "empty heart" that .... against REBOA or Thoracotomy 

Jason good question and one that pops up very frequently in CG day's

My current practice is to not do CPR and concentrate on the reversible causes;

First priority is getting large bore IV access (Sub-clavian) giving blood and FFP in a 1:1 via a rapid infuser and Secure the airway.

Next I would want ECG then ultrasound of the heart.

Bi-lateral thorocostomy's (unless no pneumo confirmed seen on US)

Pelvic sling, tourniquets etc.. 

There is a study awaited out of Texas on this very same issue which may help clarify.

Rhys

The Emcrit Blog had a good commentary about this by John Hinds.  his protocol was similar to GO R Thomas.

Agree with most of previous comments in principle. Worth seeing what rhythm pt. has to see if shockable. Realistically speaking, all those lines and blood products do not happen instantly (e.g. thawing and getting FFP, subclavian lines), so in the meantime, might have to do CPR! 

The pt is not breathing and does not have a pulse.  CPR is necessary with airway management.  I would not put an IV in before tending to those issues.  Although we all know that a team would be working on the pt so a strict order is a false argument to set up.   Also a chest tube for PTX or hemothorax are very high on my to do list.  U/S can help here to work up the etiology for the cardiovascular collapse. 

The patient in cardiac arrest need CPR first, probably the first rhythm that ECG show is PEA.

probably chest compression increase the damage but without CPR sure the patient die

Thank you all. The international perspective is interesting.

There is a growing school of thought in the UK that we should de-emphasise chest compressions and focus on the reversible causes of traumatic cardiac arrest (hypoxia, hypovolaemia, tension pneumoTx, cardiac tamponade) as the priority. In particular, those patients with haemorrhage as the primary pathophysiology underlying their cardiac arrest may be potentially amenable to damage control (haemostatic) resuscitation.

The theory and some discussion can be found at the following reference but further work is underway to provide some evidence for practice:

www.ncbi.nlm.nih.gov/pubmed/25572990

Unless the reversible causes are treated any CPR is likely be futile.   A great discussion regarding this and why CPR should not take priority over reversing causes is at:http://blog.ercast.org/trauma-arrest/

No compressions while potentially reversible causes are being treated (ETI, thorocostomies, IV/IO access, fluid/blood products, splinting pelvis/femurs, etc.). However, once airway, access and thorocostomies achieved, no harm in getting back on the chest. everything is prioritized and reassessed. 

DrNichols:.."no harm in getting back on the chest. everything is prioritized and reassessed. ".....but, to be or no to be: open  massage cardiac or MCE?

Hello, No Dr here! HEMS Paramedic, RN and wannabe researcher. In my current practice (HEMS) we only do open cardiac massage if we have done a thoracotomy for penetrating torso trauma (where we are hoping to find a tense, clotted pericardial tamponade). 

In France there are recent expert recommandations (2015). 

"Experts do not recommend performing a thoracotomy for resuscitation prehospital for the closed chest trauma.

In hospita,l experts suggest not to perform resuscitation thoracotomy in case of cardiac arrest after blunt chest trauma , if the resuscitation period

Cardiopulmonary than 10 minutes without recovery of circulatory activity , and / or whenan initial asystole in the absence of tamponade ( G2 ) ". 

So: RCP, thoracotomy, ultrasound for tamponade... if no response after 10 minutes: stop. 

in my opinion pre hospital team must start CPR at the moment of cardiac arrest installed, and continued by medical team from ED. It is possible that cardiac arrest is a consequence of underevaluation or  management of a peri arrest condition such as hipovolemia or tension pneumothorax, or tamponade, but the ressuscitation must start and progress associate to identification and management of reversible causes.

However, the open chest resuscitation needs can be take under consideration, in this circumstances, only if the pacient has at least vital signs at entrance into the ED moment.

The patient underwent arrest on the way. Both CPR and IV/IO should be started by the paramedics. In the ED one should secure the airway, check the rhythm and then look for reversible causes. Portable ultrasound and CPR machines are handy tools in ED. But, in my opinion, CPR should not stop at any time either on the way or in the ED. There can always be more than one H or T present in the same patient, so you can never be sure that tackling single H or T without continuing CPR is a good option.

I do not suggest (as some do) that we should not do External Cardiac Massage at all. Rather, if there is a procedure to do that ECM could get in the way of (I.e. bilateral thorocostomies, ETI, etc) that ECM should be withheld until completed. Then, when ECM is no longer getting in the way, resume chest compressions. 

Rationale to support this. When the patient arrives in your care, is there a palpable pulse with  good quality compressions? If there is not, what benefit will compressions provide? 

I agree with Vivek, can be more than one H to T. However in traumatic cardiac arrest my money is on tension pneumo, tamponade, hypovolemia, hypoxia. If no pulse with compressions, compression will not help until these are corrected.  

The patient's brain may not survive the time it takes to put in a chest tube. With every minute without the chest compression the chances of survival decrease by 10%. Talking about four main issues raised by Marty, we can easily to take care of hypovolemia and hypoxia without interrupting CPR. For tension pneumo or even for hemothorax, needle drainage may be a better option, and can be done without interrupting CPR. Pericardial tamponade is a tricky situation, where we may have to stop to introduce a pigtail. In expert hands, under USG guidance it should not take more than half a minute. I agree that thoracic trauma presents special situations, but what I would suggest is mock drill on manikins where we can practice pericardial drainage and pneumothorax drainage with minimum interruptions in chest compressions.

I hear what you are saying Vivek, and that was how we practiced in my environment (Australian Emergency Departments & HEMS) until about 5 years ago. We now try and do thorocostomies bilaterally at the same time (If ECM is being preformed the performer will be in the way of someone). In regards to tamponade, pericardial tamponade in trauma is different to medical, blood in the pericardial sack will normally be clotted, in order to relieve the tense pericardium I would argue an open procedure would be required as the clots will not be aspirated through a needle or thin catheter.

I agree that fluid/blood products can be administered during ECM, and that hypoxia (assuming it is not from tension pneumo) can be managed with airway attention during ECM. I would argue that a needle decompression is only a temporising measure for tension, and a chest tube/finger thorocostomy will be required. 

However, at the end of all this I bring you back to my point; If no palpable pulse with ECM, how is continuing it going to perfuse the patients brain? 

In my practice these days we have had a cultural change. Everyones focus is on treating potentially reversible causes of traumatic arrest ASAP (within a few minutes). Then once all procedures are bone and we are just 'filling the patient up' with fluid/blood products, by all means we get back on the chest. Everything is prioritised, even ECM. 

Would start IPPV and chest compressions whilst on ambulance trolley, followed by immediate bilateral thoracostomies and FAST of pericardium to exclude tamponade and to determine filling and function.

Quick poll answer? YES. As for ECM while inserting bilateral chest tubes, there is a trick for that.  Although unorthodox, the compressor can get up on the gurney with the patient.  By positioning the compressor's knees up against the patient's shoulders, effective compressions can be done.  Instead of a perpendicular approach, the compressor is in-line with the patient.  Right and left chest tubes can then be inserted simultaneously and without the need for the interruption of CPR..    

Jason,

you obviously touched a hot topic. Maybe these articles (one on penetrating cardiac trauma) add to the picture of your question.

Kind regards,

Dietrich Doll

I would start chest compressions without thinking twice. No use getting a corpse to CT or X-rays

Jason, another aspect crossed my mind. Even though only 3 % of blunt heart asystole survivors continue life without neurologic sequelae, guidelines are made  for high volume resuscitation rooms and for restricted health cost funding scenarios. Even if a percentage is as low as 1%, it may not say anything for your single patient. He survives or dies. Nevertheless, in a crowded mass casualty setting with 5 penetrating and one blunt cardiac arrest, you know to whom you would allocate the least ressources.

Kind regards,

Dietrich Doll

From a first aid stand point, which might be a bit below what you are asking given they are in the resus room.

First Aiders now learn in-line with Australian Resus Council Guidelines here that if the person is unconscious and no longer breathing normally commence CPR.

A lot of valid but maybe somewhat theoretical answers.

Back to the scenario. Major trauma, initially conscious with a pulse, now unresponsive and without a pulse. Arriving in an Emergency Department.

So we are discussing a specialist level approach not first aid and let us assume you want an answer applicable to you in Plymouth.

If we assume this person suffered an arrhythmia, is hypoglycaemic, hyper/hypokalaemic or any such cause of arrest that will provide you with a filled heart and adequate blood volume without obstruction start CPR immediately and try and do a good job at it.

If we believe this person has a tension pneumothorax, tamponade or has bleed such a large volume that his heart and vasculature is essentially empty, CPR will do nothing or very little until that is fixed. If you have the spare pair of hands, have that person perform CPR but fix the underlying issue.

Now how far that goes, i.e. thoracotomy is debatable and will depend on the physician present in your resus room. Immediate release of any tension pneumothorax will be paramount and fixing a tamponade may be achievable quickly (good example London HEMS data?). Replacing major blood volumes in a timely fashion that will preserve the brain is a major challange and all too often the reason why we will fail to successfully resuscitate but it is worth trying.

If you find an essentially "empty heart" CPR will be utterly futile, but go for your patients life I say, whilst filling him or her up.

Now do not hope for any person to present more than observational research data. I am afraid you may have to settle for expert opinions.

To conclude I suggest, start CPR as long as it does not interfere with or delay any attempt to treat reversible causes for the arrest. Your 30 year old motorcyclist experienced a complication of major trauma. Given the trauma expert environment he is in, let us treat him as such and go beyond bystander CPR guidelines.

IN THE GUIDELINES YOU SHOULD START CHEST COMPRESSION AS SOON AS POSSIBLE, ALSO YOUR COMPRESSION SHOULD BE UNINTERRUPTED .

Intubation and chest drain if pneumthorax or hemothorax is discovered. Remember 5 H and 5 T.

I think many people are responding from the viewpoint of a "medical" cardiac arrest and not taking into account the scenario presented.  The question is whether or not chest compressions are useful in a casualty who we could realistically expect to have nothing but a traumatic cause for his arrest (i.e. hypovolaemia, tension pneumothorax or cardiac tamponade).

In the presence of rib fractures (likely in this case) there is a risk of compressions making the situation worse and the benefit from performing them would be minimal.  Although it is very hard not to initiate chest compressions in an asystolic casualty, I think personnel would be better employed in preparing for airway management, finger thoracotomies, getting the ED thoracotomy kit out and running blood products through a rapid infusor.  I would not commence chest compressions in this case.

If the casualty was 75 years old and the scenario was the same (motorcycle MVC, deteriorated en route, arrested on arrival to ED) then the answer wouldn't be as cut and dry...!

I would not do external massage, but open chest / clamp descending thoracic aorta/ open pericardium while ET intubation is being done. Others would argue REBOA is warranted because of dismal prognosis.

Very interesting discussion.

We have been doing REBOA on wide bases and in some cases, parallel to thoracotomy. We could in some cases consentrate the thoracotomy for beeding control and not go to aortic clamping so its not always ET vs REBOA, but can be done parallel. There is some limited data suggesting that afterload increase due to REBOA might help the resucitation with less invasive and maybe faster Endo approach (unpublished data).

We will discuss related issues to this in the comming EVTM sympsoium in Sweden ( you can see the details on www.jevtm.com/sympsoium).

Important to combine views to get better results in these patients described above, especialy knowing the low survival..

Check out the latest New Zealand and Australian guidlines

Guideline 11.10.1 - Management of Cardiac Arrest due to Trauma

http://resus.org.au/guidelines/

These focus on consider and correct of pertinent aspects and ate designed fir first aiders to surgeons.  If no ROSC After 10 minutes further resuscitation is not recommended and shold stop

Further to the discussion, we have done some work to try to answer this research question, which has recently been published in Resuscitation and the full text is available at https://www.resuscitationjournal.com/article/S0300-9572(19)30165-0/fulltext#

Watts S, Smith JE, Gwyther R, Kirkman E. "Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest". Resuscitation 2019;140:37-42.