Presented at Joint Trauma Conference on December 17, 2013. Mayo Clinic, Rochester MN.
Authors: Rachelle Beste, Dustin Leigh, Ashley Martin, Diana Shewmaker, Cameron Wangsgard
Reviewed by: Daniel Cabrera
Update July 2015
Blunt Agonal Arrest
Blunt agonal arrest referes to the severely injured patient in extremis (Class IV Shock) not responding to fluid resuscitation. They may or may not have a palpable pulse.Markers include:
• Heart rate < 60 bpm
• Systolic blood pressure < 80
• Any ventricular tachycardia, ventricular fibrillation, or PEA
• Loss of signs of life
Trauma resuscitation of the patient in blunt agonal arrest includes a rapid assessment and treatment of reversible, life-saving traumatic etiologies of the arrest. This includes hemorrhage/hypovolemia, airway compromise, tension pneumothorax, and pericardial tamponade. ACLS and BLS in an the resuscitation of the blunt agonal arrest patient is classically thought to be of limited benefit due to the nature of the underlying injuries that lead to arrest in the trauma patient. The result is that a initial airway assessment, needle decompression/chest tubes, and rapid fluid resuscitation with blood products should take priority over chest compressions in the blunt trauma agonal arrest patient.Our normal trauma algorithm is followed with a few key steps taking place:
- Obtain a definitive airway (orotracheal vs. surgical)
- Bilateral needle thoracostomy followed by bilateral tube thoracostomy when able
- Initiate massive blood transfusion/resuscitation
- Attach cardiac leads and obtain an US of the heart to assess for pericardial effusion and cardiac kinetic activity (typically a subxiphoid or peristernal long view)
- Trauma Center Practice Management Guideline: Traumatic Blunt Agonal / Arrest Algorithm. Mayo Clinic, Rochester. Last Reviewed: 10/2012.
Thoracostomy Tube Placement
Bleeding or coagulopathy, correct if possible.
- Chest tube tray (see attached powerpoint)
- Sterile gloves
- Two packets 0-silk
- Sterile gauze
- Drainage system (Atrium Oasis)
- Chest tube selection
- Traumatic pneumothorax or hemothorax: 36-40 French to allow evacuation of clot
- Large pneumothorax, unstable: 24-28 French
- Large pneumothorax, stable: 16- 22 French
- If time allows: pre-procedure CXR, informed consent, and consideration of procedural sedation
- Optimize patient positioning with abduction of ipsilateral arm to patient’s head
- Barrier precautions and sterile field
- Locate triangle of safety (anterior border of latissimus dorsi, lateral border of pec major, line above nipple or inframammary crease)
- Apply chlorhexidine
- Insertion will be at 4th-5th intercostal space in the anterior axillary line
- Incision site should be one intercostal space BELOW actual chest-tube insertion site
- Skin wheal with 1% lidocaine and 25-gauge needle
- Aspirate and anesthetize subcutaneous tissues, intercostal muscle, periosteal surface with 20 cc lidocaine and 21-gauge needle
- March up periosteal surface, continuing to aspirate and anesthetize to chest-tube insertion site
- Confirm entry into pleural space with aspiration of air or flash of pleural fluid. Inject any remaining lidocaine.
Incision and Disection:
- Use scalpel to make 1.5-2 cm incision parallel to rib. Avoid making too small of an incision.
- Use a kelly clamp to dissect subcutaneous tunnel cephalad to insertion site above rib. Remember neurovascular bundle is inferior to rib.
- Once at parietal pleura, gently push closed Kelly clamp through. Open clamp to spread the intercostal muscle and parietal pleura while maintaining tract. Space will need to accommodate clamped chest tube and index finger.
- Use index finger to ensure proper position. Confirm there are no adhesions between lung and pleural surface in order to proceed.
- Clamp proximal and distal end of chest tube.
- Insert end with side ports along finger tract until into pleural cavity.
- Unclamp and advance manually. Aim apically for pneumothorax and basally for evacuation of any fluid.
- Note insertion of last port hole and total depth of insertion, usually 2-5 cm beyond last port, depending on body habitus.
- Use 0-silk sutures to secure chest tube. Place two simple interrupted sutures on each side of the chest tube. Each suture should be tightly tied and wrapped around chest tube several times prior to again tying.
- Ensure securement by tugging chest tube with minimal displacement.
- Tape tube to side of patient with mesentery fold and wrap petroleum-based gauze around tube.
- Cover with sterile gauze, multiple pressure dressings, and silk tape.
- Connect clamped end to drainage system, then unclamp.
- Obtain AP CXR and identify radio-opaque line which contains proximal drainage hole. Ensure it is located inside pleural space.
Needle Thoracostomy Placement
- Immediate decompression is necessary for high suspicion of tension pneumothorax.
- 14-16 gauge angiocatheter attached to 5-10 mL syringe (found in drawer below chest tube tray)
- Superior margin of 2nd- 3rd rib in midclavicular line or at location of standard chest tube (4th-5th intercostal space at the anterior axillary line)
- Advance while aspirating until air aspirated
- Withdraw needle from angiocatheter, rush of air indicates partial or complete conversion to simple pneumothorax
- Place thoracostomy tube as above
Indications for Operative Thoracotomy
- Immediate drainage of >1 L of blood or 20 mL/kg
- Accumulation of >3 mL/kg per hour of blood or 150-200 mL/h for 2-4 hours
- Persistent blood transfusions to maintain hemodynamic stability
- NEJM Chest Tube Insertion (16 min video): http://www.youtube.com/watch?v=NiDFYGQts5c
- Doelken, Peter, MD. "Placement and Management of Thoracostomy Tubes." Placement and Management of Thoracostomy Tubes. UpToDate, 7 Aug. 2013. Web. 08 Dec. 2013. <http://www.uptodate.com/contents/placement-and-management-of-thoracostomy-tubes?source=search_result>.
- Brunett PH, Yarris LM, Cevik AA. Chapter 258. Pulmonary Trauma. In: Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=6389704. Accessed December 10, 2013.
Resuscitation and IV Access
Establishing adequate venous access is prudent in any trauma patient, and is obviously more so for the unstable traumatic patient. Large-bore peripheral IVs may be adequate if two or more can be secured. If peripheral access is not easily obtainable, there should be consideration of central access via large catheter introducer (8F to 9F) or intraosseous access. This can typically be the femoral vein as the subclavian and jugular veins may be partially collapsed with significant hypovolemia, and iatrogenic pneumothorax would cause further hemodynamic decompensation. However, vascular access above the diaphragm is preferred if there is concern of major vascular injury in the area of the abdomen or pelvis.In general, the rate at which crystalloid can be infused is dependent on the catheter diameter and the driving pressure.  This is based on Poiseuille’s Law which is arguable not applicable to in-vivo use given the non-laminar flow.Nevertheless, theoretical infusion rates are in the table below for comparison purposes. Flow rates via intraosseous access are less well established, but are thought to be comparable to peripheral access. Some studies have shown that the humeral site compared to tibial access allows for more rapid infusion; however, the studies are flawed and are either small, biased or based on animal models.[4-5]Theoretical Infusion Rates based on Poiseuille’s Law :
- Li SF, Cole M, Forest R, Chilstrom M, Reinersman E, Jones MP, Zinzuwadia S, King S, Yadav K. Are 2 smaller intravenous catheters as good as 1 larger intravenous catheter? Am J Emerg Med. 2010 Jul;28(6):724-7. doi: 10.1016/j.ajem.2009.05.003. Epub 2010 Mar 25. PubMed PMID: 20637391.
- Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. Judith E. Tintinalli, J. Stephan Stapczynski, David M. Cline, O. John Ma, Rita K. Cydulka, and Garth D. Meckler. The American College of Emergency Physicians. 2011.
- McPherson D, Adekanye O, Wilkes AR, Hall JE. Fluid flow through intravenous cannulae in a clinical model. Anesth Analg. 2009 Apr;108(4):1198-202. doi: 10.1213/ane.0b013e3181966451. PubMed PMID: 19299786.
- Lairet J, Bebarta V, Lairet K, Kacprowicz R, Lawler C, Pitotti R, Bush A, King J. A comparison of proximal tibia, distal femur, and proximal humerus infusion rates using the EZ-IO intraosseous device on the adult swine (Sus scrofa) model. Prehosp Emerg Care. 2013 Apr-Jun;17(2):280-4. doi: 10.3109/10903127.2012.755582. Epub 2013 Jan 18. PubMed PMID: 23331182.
- Miller L, Philbeck T, Montez D and Puga T A two-phase study of fluid administration measurement during intraosseous infusion Annals of Emergency Medicine 2010; 56(3):S151
Indications for ED Thoracotomy
The potential benefits of an ED thoracotomy (EDT) need to be carefully balanced with the potential harmful exposure of health care personnel to blood-borne pathogens.  It is performed on patients who have just sustained or are on the verge of cardiac arrest, and is done to evacuate a pericardial tamponade, temporarily repair a myocardial wound, cross-clamp the descending thoracic aorta (to prevent exsanguinating abdominal hemorrhage and improve coronary/cerebral flow), and to allow for internal cardiac massage.Overall mortality is high, where only 1.4% of blunt trauma patients undergoing EDT will survive. Survival is higher for penetrating trauma, 16.8% and 4.3% for stab wounds and gunshot wounds, respectfully. According to the Practice Management Guidelines published by the American College of Surgeons Committee on Trauma, indications for EDT include the following: 
- EDT is best applied to patients sustaining penetrating cardiac injuries who arrive at trauma centers after a short scene and transport time with witnessed or objectively measured physiologic parameters showing signs of life.
- EDT should be performed in patients sustaining penetrating noncardiac thoracic injuries, but these patients generally experience a low survival rate. Because it is difficult to ascertain whether the injuries are noncardiac thoracic versus cardiac, EDT can be used to establish the diagnosis.
- EDT should be performed rarely in the patient sustaining cardiopulmonary arrest secondary to blunt trauma because of its very low survival rate and poor neurologic outcomes. It should be limited to patients who arrive with vital signs at the trauma center and experience witnessed cardiac arrest.
- EDT should be performed in patients sustaining exsanguinating abdominal vascular injuries, but these patients generally experience a low survival rate.
CURRENT EAST GUIDELINES ON RESUSCITATIVE THORACOTOMY IN TRAUMA (JULY 2015, FREE OPEN ACCESS)
- Mollberg NM, Glenn C, John J, Wise SR, Sullivan R, Vafa A, Snow NJ, Massad MG. Appropriate use of emergency department thoracotomy: implications for the thoracic surgeon. Ann Thorac Surg. 2011 Aug;92(2):455-61. doi: 10.1016/j.athoracsur.2011.04.042. Epub 2011 Jun 25. PubMed PMID: 21704969.
- Practice management guidelines for emergency department thoracotomy. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons-Committee on Trauma. J Am Coll Surg. 2001;193(3):303.
Should Advanced Life Support be Initiated or Continued?
Research Arguing For or Against Currently Accepted Guidelines
Traumatic cardiac arrest: Should advanced life support be initiated?According to the article by Leis et al. (J Trauma Acute Care Surg, Volume 74 Number 2, Pages 634-638), ALS should be initiated regardless of the initial cardiac rhythm in a traumatic cardiac arrest (TCA), realizing that the highest survival rates are those presenting in VF or PEA and children.His group performed a retrospective cohort study between 2006-2009 of an urban-based EMS two-tier response system, meaning that both BLS and ALS ambulances were present at each scene with a rapid response time of 7-9 minutes. A physician-in-charge as well as an ambulance physician were also present on-scene and during transfer to level 1 trauma reference centers. All TCA patients received ALS on-scene including intubation, IV access, fluid and drug therapy, POC blood analysis, and procedures such as chest drain insertion, pericardiocentesis, and FAST exam. The study objective: describe survival results and compare them with other published series to determine which factors could be associated with return of spontaneous circulation (ROSC) and complete neurological recovery (CNR).They evaluated patients at three points in time: when initial patient contact was made; when ALS was terminated; and when the patient was discharged from the ICU. They found that of 167 patients included in the study, ROSC was obtained in 49.1% with 6.6% achieving CNR. The survival rate was 23.1% in children, 5.7% in adults, and 3.7% in the elderly. The etiology included 40.1% traffic accidents, ; 15.6% assaults, stab wounds, or GSWs; 16.8% falls; and the other group being drowning, electrocution, self-harm, railroad or underground accidents, etc. There was no significance in ROSC regarding the type of ambulance to arrive first. There was, however, a significant difference between response times and survival with CNR; if >10 minutes passed, none of the patients achieved CNR. They also found that the rate of ROSC was greater if TCA was witnessed or patients received more fluid replacement. These, along with other findings, led them to conclude that ALS should be initiated in TCA regardless of the initial cardiac rhythm.
When Should Efforts be Terminated in Resuscitation of Blunt Agonal Arrests?
The Consequences of Noncompliance With Guidelines for Withholding or Terminating Resuscitation in Traumatic Cardiac Arrest in Patients
Mollberg, et al. would argue otherwise (The Journal of TRAUMA Injury, Infection, and Critical Care, Volume 71, Number 4, October 2011, Pages 997-1002). They studied the consequences of violating the published guidelines by The National Association of Emergency Medical Services Physicians and American College of Surgeons Committee on Trauma (NAEMSP/ACS-COT) for withholding or terminating resuscitation in prehospital traumatic cardiopulmonary arrest (TCPA). Also studied was whether EMS personnel were able to accurately identify patients in TCPA. This was done via a retrospective review of all patients with TCPA managed by the Chicago Fire Department and transported to Mount Sinai Hospital during an eight year time period, composing the largest series to date on this topic.
Of the 294 patients identified who met criteria for withholding or terminating resuscitation, 0.3% survived with a GCS of 6. Their outcomes were dismal with four being declared brain dead, one having life support withdrawn, two passing away in <24 hours, and the lone survivor being discharged to a long term care facility. Total costs incurred were $3,852,446.65, excluding those associated with intubation and ACLS medications in the field and ambulance transportation. There was 100% agreement between BLS and ACLS teams on the presence or absence of a pulse for 39.8% of patients. The study excluded those patients younger than 18, those who arrested secondary to drowning, strangulation, hypothermia, electrocution, fire, when a nontraumatic cause proceeded the arrest, as well as anyone transported by another agency.
They concluded that strict adherence to the current guidelines should be maintained with little risk of loss of neurologically intact survivors in a system where no physicians are on scene to provide advanced care such as a thoracotomy or pericardiocentesis. Upholding the guidelines will result in significant cost savings within the medical system and for the patients’ families as well as reduce the burden placed on families and care facilities whom must provide for individuals no longer capable of performing activities of daily living.
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