Trauma M

1
Trauma MM

• 3/25/08

2
Trauma Arrest

• 3/2/08
• Ambulance called 1403
• EMS arrival 1405
• TH
• 33 y/o F pt found lying supine, unconscious after
  a motorcycle crash
• Pt ejected approximately 50ft from motorcycle
• No known witness of crash

3
EMS report

• Vitals
• Temp- none recorded BP- 50/palp HR 40bpm Resp-6
  (agonal) O2 sat-none recorded
• HEENT- 3 inch Lac over L eye Pupils-
  nonreactive, dilated No JVD, No tracheal
  deviation, Jaw-rigid
• Chest-no deformity
• Lungs-CTAB
• Abd- 10 inch wound with evisceration on left side
• Ext-R open radial/ulnar fx., L Femur fx

4
EMS Report

• Pts c-spine immobilized, placed on backboard,
  unsuccessful intubation (jaw clenched) in
  respiratory arrest upon transfer into ambulance
• Pt with BVM at 20 L/min O2
• IV established 18G Left AC- LR wide open
• Once in ambulance- pt now in full arrest, monitor
  shows PEA. CPR initiated
• 1 mg of IV Epi and 1 mg of IV Atropine given
• Pt continues in PEA
• Due to arrest none of pts injuries are stabilized
• Depart for Sinai Hospital at 1415

5
Sinai Hospital

• Arrival 1419
• Airway-BVM-20L/min O2 jaw clenched
• Breathing-absent
• Circulation- No recordable BP, No palpable
  femoral or carotid pulse Left 18G AC- LR
• Disability/Deformity-
• Deformity
• Right Forearm, Right tibial/fibula, Left femur
• Left LQ evisceration
• Disability
• GCS 3
• Pupils fixed and dilated

6
Sinai Hospital

• Treatments
• Intubated
• CPR continued
• Additional 1 mg of Epi, 1 mg of atropine given
• No pulse noted on exam performed by me
• Trauma attending in Truama Bay at 1425
• Made aware of current status of patient

7
Sinai Hospital

• Treatments
• Discussion about pronouncing patient at that time
• Also, at that time, a person not member of trauma
  team states he feels a femoral pulse
• I examined for any pulse
• No palpable pulse noted
• Pt continues in PEA
• Now hooked up on monitor in trauma bay

8
Sinai Hospital

• Treatments
• CPR continues
• Atropine, Calcium and Bicarbonate given
• 4 L of LR given
• L needle Thoracostomy performed, Left chest tube
  placed, right femoral central line placed
• Pt continues in PEA
• Time of Death at 1450

9
Literature

• Overall Outcome
• Despite a rapid and effective out-of-hospital and
  trauma center response,
• patients with out-of-hospital cardiac arrest due
  to trauma rarely survive.
• Patients with the best outcome from trauma arrest
  generally are
• young,
• have treatable penetrating injuries
• have received early (out-of-hospital)
  endotracheal intubation
• undergo prompt transport (typically 10 minutes)
  to a trauma care facility
• Cardiac arrest in the field due to blunt trauma
  is fatal in all age groups

10
Overall outcome

• Aihara R, Millham FH, Blansfield J, Hirsch EF.
  Emergency room thoracotomy for penetrating chest
  injury effect of an institutional protocol. J
  Trauma. 2001501027-1030.
• 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.
  2001193303-309.
• McLean RF, Devitt JH, Dubbin J, McLellan BA.
  Incidence of abnormal RNA studies and
  dysrhythmias in patients with blunt chest trauma.
  J Trauma. 199131968-970.
• Paone RF, Peacock JB, Smith DL. Diagnosis of
  myocardial contusion. South Med J. 199386867-870

11
CPR in Pre-Hospital Setting

• Alanezi K, Alanzi F, Faidi S, Sprague S, Cadeddu
  M, Baillie F, Bowser D, McCallum A, Bhandari M.
• Survival rates for adult trauma patients who
  require cardiopulmonary resuscitation.CJEM. 2004
  Jul6(4)263-5.
• used 1992-2002 trauma registry data to identify
  all adult trauma patients over the age of 16 who
  required CPR in the pre-hospital setting
• Demographic information, mechanism of injury,
  injury severity score (ISS), vital signs at the
  scene and in the hospital, and mortality were
  obtained from patient charts
• Patients were stratified into 2 groups
• 1)those with absent vital signs in the field who
  required prehospital CPR
• 2)those who lost vital signs within 24 hours of
  arriving at the trauma suite
• RESULTS Of 50 eligible patients, 28 (58) were
  male and 46 (92) sustained blunt trauma. Overall
  mortality was 96 (48/50), and all patients who
  required prehospital CPR died.
• CONCLUSION In this consecutive series of trauma
  victims with cardiopulmonary arrest there were no
  survivors among those who lost vital signs and
  required CPR prior to arriving at the hospital

12
Blunt Trauma-Prehospital PEA

• Martin SK, Shatney CH, Sherck JP, Ho CC, Homan
  SJ, Neff J, Moore EE.
• Blunt trauma patients with prehospital pulseless
  electrical activity (PEA) poor ending assured. J
  Trauma. 2002 Nov53(5)876-80 discussion 880-1
• Examined outcome of patients experiencing
  prehospital pulseless electrical activity (PEA)
  after blunt injury
• retrospective review was performed of all blunt
  trauma victims with prehospital PEA from 1997 to
  2001
• RESULTS One hundred ten patients, 78 men and 32
  women, met study criteria.
• Seventy-nine patients had PEA at the scene, and
  31 experienced PEA en route to a trauma center
• Injury Severity Score of this population was 45.1
  
• Only one patient survived.

13
Blunt Trauma-Prehospital GCS 3

• Tien HC, Cunha JR, Wu SN, Chughtai T, Tremblay
  LN, Brenneman FD, Rizoli SB.
• Do trauma patients with a Glasgow Coma Scale
  score of 3 and bilateral fixed and dilated pupils
  have any chance of survival? J Trauma. 2006
  Feb60(2)274-8. Links
• Low Glasgow Coma Scale score (GCS) and pupillary
  status predict poor outcomes in head injury (HI)
  patients. We compared the mortality of GCS 3
  patients having bilateral fixed and dilated
  pupils (BFDP) with GCS 3 patients having reactive
  pupils (RP)
• Reviewed all adult, blunt HI patients with GCS3.
  January 1, 2001 to December 31, 2003.
  Demographics, injury data, prehospital times,
  procedures, and outcomes were recorded.
• RESULTS 245 patients were admitted with GCS of 3
  
• 173 patients were analyzed, after excluding 23
  patients who were dead-on-arrival, and 45 others,
  who were intoxicated with alcohol, or received
  paralytic agents in the trauma room
• All BFDP patients died, whereas 42.0 of reactive
  pupil (RP) patients died (p lt 0.0001).
• BFDP patients were more likely to be unstable,
  have extra-axial bleeding, and evidence of
  midline shift and/or herniation
• CONCLUSION Patients with GCS of 3 and BFDP have
  a dismal prognosis

14
Blunt Trauma-Prehospital CPR

• Willis CD, Cameron PA, Bernard SA, Fitzgerald M.
• Cardiopulmonary resuscitation after traumatic
  cardiac arrest. Injury. 2006 May37(5)448-54.
  Epub 2006 Jan 20
• Study aimed to describe the outcomes for victims
  of penetrating and blunt trauma who received
  prehospital CPR
• Retrospective review of a statewide major trauma
  registry using data from 2001 to 2004
• Subjects suffered penetrating or blunt trauma,
  received CPR in the field by paramedics and were
  transported to hospital. Demographics, vital
  signs, injury severity, prehospital time, length
  of stay and mortality data were collected and
  analyzed
• RESULTS Eighty-nine patients met inclusion
  criteria. Eighty percent of these were blunt
  trauma victims, with a mortality rate of 97,
  while penetrating trauma patients had a mortality
  rate of 89. The overall mortality rate was 95
• CONCLUSIONS only a small number of penetrating
  and blunt trauma patients receiving CPR survived
  to discharge

15
Summary- Blunt Trauma

• 33 yo female
• Prehospital Traumatic arrest secondary to blunt
  trauma ejected approximately 50 ft
• GCS3, Bilateral Fixed and Dilated Pupils
• Unable to be intubated in field
• Multisystem trauma with evisceration
• PEA in field
• No return of pulse
• Prehospital time was at least 17 minutes
• Injury occurred at no identifiable time