It was a traumatic experience for all of usVivien Spitz
Every time we teach in a trauma course, two of the most frequent questions are:
- What do I do if the patient arrests?
- When should I do a thoracotomy?
Let’s see if we can try to answer this point!
You’re the team leader of a great trauma team and in a few minutes a young motorcyclist will be brought to your ED:
A – 33 years old male;
T – 30 minutes before;
M – Motorcyclist involved in a high-velocity motor vehicle crash; he was found almost 10 m from the bike;
I – Chest pain on the right side and abdominal pain, unstable pelvis;
S – SBP 75/25 mmHg, HR 135 bpm, SatO2 88% in room air increasing to 99% in high flow oxygen;
T – Oxygen, Philadelphia collar, spinal board, IV line, 250ml of clear fluids.
Your team is composed of Mark (anesthetist), John (surgeon), and Armand (surgeon). For each team member, you are happy to have a skilled nurse ready and set up!
The patient arrives, he’s still breathing, the pulse is very weak and there is no external massive bleeding (5 sec round – see team management)
While he’s getting evaluated by the team members you take a full dispatch from the ambulance team.
“The patient arrested!” Mark screams!
Armand is starting the chest compressions and John is watching you, waiting for orders!
What should they do?
What are your priorities in treating this patient?
Time is passing… and progressively running out…
When you have your trauma patient in cardiac arrest, you need to quickly support A, B, and C. As you may imagine, D and E will have to wait.
The reversible causes are hypoxia, tension pneumothorax, thoracic hemorrhage, abdominal hemorrhage, extremities hemorrhage, and pericardial tamponade.
Let’s review quickly what you need to assess and do for each letter:
A – SECURE IT!!! The patient needs to be ventilated and checked as soon as possible (even a sovragloctic mask with the CO2 monitor works perfectly;
B – Open both sides of the thorax, perform a thoracostomy for each side. You need to exclude the presence of an unknown tension pneumothorax and/or massive haemothorax. Remember that each reversible cause of death in the thorax is essentially diagnosed and treated with a drain (the only one not taken into account is the cardiac tamponade);
C – Get venous access (if you have already one get a second, and make it appear quickly!), start fluids and blood, assess the 5 sites of massive bleeding (thorax, abdomen, pelvis, long bones, and “floor”) and treat them properly;
e-FAST – Help the patient with the ultrasound, you NEED it to diagnose a cardiac tamponade, which accounts for more or less 10% of all traumatic cardiac arrests. Ultrasound will also give you other information.
In the meantime, you OBVIOUSLY have someone already on the patient doing the cardiac massage!
Now, ask yourself, is this a traumatic cardiac arrest or is it a “medical” cardiac arrest? Don’t assume the patient is dying due to the trauma when he/she may have a massive pulmonary embolism. So, be ready also for those kinds of protocols!
Let’s get back to our motorcyclist…
“Mark, tube him! John, drain his thorax on both sides! Armand, keep compressing! Nurses, set up the pelvic binder and a second IV line!” you say.
You take the ultrasound and see abundant free fluid in the abdomen, there is cardiac activity without tamponade.
Now, the patient is tubed and ventilated with FiO2 100%, left ICD is empty, right ICD drained a tension hemopneumothorax (750 ml of blood). The second IV line is in place with warm 0 negative blood pushed in. The pelvic binder is on, as well as the urinary catheter (200 cc of bloody urine).
You’ve done everything, but the patient is still in PEA (pulseless electrical activity)… and now?
You know where we are heading…
Firstly, we have to say that an emergency room thoracotomy (ERT) should be done ONLY in the hospital setting (in the emergency room). The only European country studying the possibility of doing a thoracotomy on the street is the UK, and the results are still ongoing.
The ERT is always something it can be extremely scary or exciting to think about, but doing it is something completely different and is not pleasant at all.
Trust us when we say “we hope none of our readers will have to do it”.
To open up a chest in an emergency room is a very stressful situation with extremely low possibilities of patient’s survival. According to the literature, the survival rate after an ERT for a penetrating trauma is around 10%, where after blunt trauma is 2.3% (and only less than 4% of survivors will not have a neurological impairment)!
Last thing you have to remember: ERT IS NOT A DEFINITIVE TREATMENT! It is a bridge therapy to bring the patient to the operating room to “close the tap”! It is useless to open up a patient’s chest, clamp the aorta, and start an internal cardiac massage if you don’t have an operating room ready.
Let’s summarise the STRICT indications to the ERT:
- Penetrating trauma patients with less than 15 minutes of CRP;
- Blunt traumas with less than 10 minutes of CRP;
- Peri-arrest patients (profound refractory shock – SBP <60mmHg) and CPR patients who regained signs of life.
And here is the flow-chart to follow:
And the REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta)?
The REBOA is a “new” technology primarily developed for trauma patients. In our opinion, there are still no proven certainties in its use and indications. Anyhow, we are not going to discuss its possible use and indications here.
Now let’s get back to our patient:
He is in cardiac arrest due to massive subdiaphragmatic bleeding (i.e. abdomen, retroperitoneum, pelvis). The two ICDs in the thorax are “mute”. Now, you have indications for a thoracotomy.
You decide to go for a left anterolateral thoracotomy:
- Cut the skin, subcutaneous tissue, and muscles;
- Open the ribs and put the Finocchietto retractor;
- Cut the inferior pulmonary ligament;
- Find the descending aorta sliding your hand on the posterior ribs and clamp it with your hand;
- Open the pericardium (your cardiac massage and electric shock will perform better with the pericardium open);
- Massage the heart with the other hand.
O negative blood is running and after 3 units you have a pulse back!
You bring the patient and the team to the OR to conclude the damage control phase.
Most of the time an ERT (or a REBOA) may be a futile act on a patient who is already dead. Ultrasound is also capable of helping you decide whether to start or stop the resuscitation. As Cureton et al. concluded in their article: “for patients with prolonged prehospital cardiopulmonary resuscitation, ultrasound evaluation of the cardiac motion in pulseless patients with trauma may be a rapid way to determine which patient has no chance of survival in the setting of lethal injuries, so that futile resuscitations can be stopped”.
Act according to the guidelines… We are treating human beings, not dolls.
To conclude, luckily for us all, the more unstable the patient, the less you will have to evaluate and do. Remember to take a deep breath and jump in!
See you next time!
- European Resuscitation Council and European Society for Trauma and Emergency Surgery. European Trauma Course: the team approach.
- Boffard KD. Manual of Definitive Surgical Trauma Care. 5th Ed. Boca Raton, FL: CRC Press; 2019.
- Charshafian S, et al. Prehospital resuscitative thoracotomy: the next step in improving trauma outcomes? With victims of penetrating trauma, there could be value in bringing the practice to the field. EMS World 2017;46:36-39.
- Teeter W, et al. Updates in traumatic cardiac arrest. Emerg Med Clin North Am 2020;38:891-901.
- Cureton EL, et al. The heart of the matter: utility of ultrasound of cardiac activity during traumatic arrest. J Trauma Acute Care Surg 2012;73:102-10.
How to Cite This Post
Marrano E, Bellio G. My Heart Will Go On. Surgical Pizza. Published on December 5, 2020. Accessed on June 16, 2021. Available at [https://surgicalpizza.org/trauma/my-heart-will-go-on/].