Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Potentially Reversible Causes of Cardiac Arrest and the Futility of CPR for Trauma Arrest

One caveat. This does not apply to a medical cardiac arrest that coincidentally has some trauma associated with it. V Fib (Ventricular Fibrillation) while driving leading to a car crash. That is not a trauma arrest.

What is the purpose of CPR in trauma arrest?

To put on a show.

[youtube]e7mmrF-4rUE[/youtube]

Bullwinkle is infinitely more likely to pull a rabbit out of that hat, than CPR is likely to resuscitate a cardiac arrest due to trauma.

Play the video again, it might work.

Almost.

Keep trying.

Nearly had it.

Don’t give up.

You were so close.

Maybe this time.

There was tremendous improvement on that attempt.

Never say die.

Couldn’t you feel that it was there?

Under no circumstances will we admit that our magic is futile!

Keep trying. I know you can do it. You can find that card, Charlie Brown will kick that ball, and nobody ever dies. 😉


Picture credit.

Part 12.8: Cardiac Arrest Associated With Trauma

BLS and ACLS for the trauma patient are fundamentally the same as that for the patient with primary cardiac arrest, with focus on support of airway, breathing, and circulation. In addition, reversible causes of cardiac arrest need to considered. While CPR in the pulseless trauma patient has overall been considered futile, several reversible causes of cardiac arrest in the context of trauma are correctible and their prompt treatment could be life-saving. These include hypoxia, hypovolemia, diminished cardiac output secondary to pneumothorax or pericardial tamponade, and hypothermia.[1]

While CPR in the pulseless trauma patient has overall been considered futile, several reversible causes of cardiac arrest in the context of trauma are correctible and their prompt treatment could be life-saving.

This is a non sequitur.

Where is there any evidence that CPR in any pulseless trauma patients is not futile?

There isn’t any.

None. That is why CPR for pulseless patients is considered futile.

This is just a case of treatment based entirely on What if . . . ?

This is alternative medicine. This is not medicine.

Here is our good friend naloxone (Narcan) to explain the non sequitur

While CPR in the pulseless trauma patient has overall been considered futileWhile naloxone in the pulseless trauma patient has overall been considered futile, several reversible causes of cardiac arrest in the context of trauma are correctible and their prompt treatment could be life-saving.

Or –

While CPR in the pulseless trauma patient has overall been considered futile, several reversible causes of cardiac arrest in the context of trauma are correctible and their prompt treatment could be life-saving naloxone can cause withdrawal in opioid addicts.

Are we harming trauma patients by not using naloxone?

What does naloxone have to do with traumatic arrest?

Not a thing.

What does any futile treatment for pulseless trauma patients have to do with reversible causes of cardiac arrest?

But it is only considered futile!

That is because of the difficulty in proving a negative. Hume’s problem of induction does not mean that we should assume that anything that has a snowball’s chance of working actually does work.[2]

Should we try Reiki, because What if . . . ?

Should we try acupuncture, because What if . . . ?

Should we try a medicine dance, because What if . . . ?

Should we try therapeutic phlebotomy bleeding the patient to remove the bad humors, because What if . . . ?

Should we sing silly songs, because What if . . . ?

What is the cause of pulselessness in trauma patients?

There are 2 possibilities –

1. Obstruction of circulation –

Tension pneumothorax kills by preventing circulation, not by interfering with breathing.

Cardiac tamponade also kills by preventing circulation.

2. Nothing to circulate –

Hypovolemic arrest kills because there is not enough blood to produce a palpable pulse, even though the heart is beating as well as can be expected.

If the compressions do not produce any circulation, what is the point of CPR?

Let’s not forget spinal immobilization combined with CPR for traumatic arrest –


Picture credit. Still no rabbit.

BLS Modifications
When multisystem trauma is present or trauma involves the head and neck, the cervical spine must be stabilized.
[1]

Is the outcome from traumatic arrest so good that we need to throw in this ritual? Or is it so bad, that it does not matter what we do to keep up appearances?

If we have time to strap a patient to a backboard, then we might as well just get out a shovel and have the funeral right there. Nothing says permanently dead as clearly as putting spinal immobilization and CPR for trauma together.

There must be a rabbit in here somewhere.

It works in the scenarios in school.

Footnotes:

[1] Part 12.8: Cardiac Arrest Associated With Trauma
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 12: Cardiac Arrest in Special Situations
Free Full Text Article with links to Free Full Text PDF download

[2] Problem of induction
Wikipedia
Article

.

Comments

  1. Anoxia can also be reversed in some cases.

    Now, reversing anoxia doesn’t often lead to survival-to-discharge. (“Doesn’t often”=”Never”) But restoring circulation by correcting anoxia can sometimes lead to temporary survival, which can then allow the family more time with their loved one prior to death, and can also lead to the possibility of organ donation. Yes, none of these directly help the patient himself. But they do lend a societal benefit, especially the latter.

    • PJ,

      Anoxia can also be reversed in some cases.

      Yes, hanging would be one traumatic cause of anoxia. After the noose (or whatever) is released, the trauma is no longer present and it should be treated as a medical arrest.

      Now, reversing anoxia doesn’t often lead to survival-to-discharge. (“Doesn’t often”=”Never”) But restoring circulation by correcting anoxia can sometimes lead to temporary survival, which can then allow the family more time with their loved one prior to death, and can also lead to the possibility of organ donation. Yes, none of these directly help the patient himself. But they do lend a societal benefit, especially the latter.

      The organ donation can lead to societal benefit.

      Time with the brain dead family member being worth something depends on the family.

      How do we know that the family wants to be given false hope?

      We don’t.

      Why should we assume that the family has the money to spend for this false hope?

      Maybe the money that was going to pay for a child to go to college is now going to have to go to pay for this time that the family never wanted.

      We should not assume that we know what is best for others. Maybe they have the money for this. Maybe they will benefit psychologically from this false hope.

      However, this is just the mantra of the people who keep pushing the idea of “At least we did everything we could.” These are people who keep our standards low and our EMS education pathetically inadequate.

      We could also fly every patient, just to give the family the impression that there is hope. We could continue CPR until rigor mortis becomes obvious, just to give the family hope. We should ask, where does “At least we did everything we could,” end and unethical behavior begin? However, it is probably more accurate to ask how much overlap there is with the two.

      We should not presume to make this judgment for anyone.

      I can’t read the minds of the family members, so I do not pretend that I can.

      .

      • Time with the brain dead family member being worth something depends on the family.

        How do we know that the family wants to be given false hope? We don’t.

        Exactly, which is why we leave the option open to them.

        We should not assume that we know what is best for others. Maybe they have the money for this. Maybe they will benefit psychologically from this false hope.

        The family can (and often do) decide to terminate efforts in the ED. If yours is a progressive system, you may even be able to take such direction form a family member on scene. Either way, the direction should come from a family member, preferably one who is well-informed of the possible outcomes, etc.

        I can’t read the minds of the family members, so I do not pretend that I can.

        Then let them decide, and until they do, keep their (reasonable) options open. For some families (yours?), that will be field termination of efforts. For other families (mine?), that will be exhausting efforts in favor of organ donation, but no farther. For other families (someone’s?) that will be exhausting all reasonable efforts towards survival. But it’s mighty difficult to define “reasonable” at the side of the road at 0300. What looks like a traumatic cardiac arrest may not be.

        • PJ,

          I don’t pretend to have all of the answers, but our attempt at an ethical approach to resuscitation has been inappropriately biased toward Do everything!

          This is not to satisfy patients, but to satisfy those who do the resuscitation. We don’t want to feel useless.

          We need to have a discussion with people to find out what a reasonable approach is for patients. We need to stop imposing our values on patients, especially when that is so expensive and painful for so many families.

          We need to ridicule the idiocy of Sarah Palin and Senator Grassley to discourage any discussion of this.

          We need to have full discussions of what people want. All who oppose that should be made to pay for all of the care of all of those resuscitated with severe neurological deficits.

          .

  2. I went to a presentation by a HEMS team (a helicoptor medical team in the UK, which generally carries a doctor and a paramedic with extended skills). Unfortunately I don’t have a copy, so don’t have the references, but they addressed this very topic.

    The consultant’s point was that we usually think traumatic arrest is indeed futile, but that their research, in conjunction with London HEMS showed that very early intervention could save lives at a reasonable percentage. Much of this intervention was surgical, mainly either thoracotomy or thoracostomy, both of which are performed “in the field” by the HEMS team. I believe the survival to discharge figure quoted for field thoracotomy was around 17% (based on published research).

    My understanding of the US system is that these options are unlikely to be available, but traumatic arrest is survivable, especially with early surgical intervention.

    • Jess,

      I went to a presentation by a HEMS team (a helicoptor medical team in the UK, which generally carries a doctor and a paramedic with extended skills). Unfortunately I don’t have a copy, so don’t have the references, but they addressed this very topic.

      The consultant’s point was that we usually think traumatic arrest is indeed futile, but that their research, in conjunction with London HEMS showed that very early intervention could save lives at a reasonable percentage. Much of this intervention was surgical, mainly either thoracotomy or thoracostomy, both of which are performed “in the field” by the HEMS team. I believe the survival to discharge figure quoted for field thoracotomy was around 17% (based on published research).

      Yes, decompressing a tension pneumothorax, or a cardiac tamponade will allow the heart to beat again. If the brain is still working, that can result in the patient leaving the hospital.

      That has nothing to do with CPR. If anything, CPR may make these conditions less likely to respond to treatment.

      Similarly, if we come up with a fluid that effectively transports oxygen to the tissues, then that would be an effective treatment and replacing the fluid should allow the still beating heart to circulate the fluid all by itself. No CPR needed. If the heart is no longer beating, then CPR would be indicated once oxygen transporting fluid is added. Also, open chest cardiac massage is something that works, but cracking the chest should decompress any tension pneumothorax and working on a cardiac tamponade would not work well with someone trying to squeeze the heart (which should still be trying to contract on its own, if the patient is viable).

      My understanding of the US system is that these options are unlikely to be available, but traumatic arrest is survivable, especially with early surgical intervention.

      My point is that the CPR does nothing to improve the patient’s ability to survive traumatic arrest.

      Go listen to this podcast.

      EMCrit Podcast 36 – Traumatic Arrest

      .

  3. the only thing with which i disagree in this article is calling cpr in a trauma arrest alternative medicine. it is not alternative medicine-it is simply bad medicine.

    • SEAN,

      the only thing with which i disagree in this article is calling cpr in a trauma arrest alternative medicine. it is not alternative medicine-it is simply bad medicine.

      I fail to see the distinction.

      As has been put so eloquently by Tim Minchin (and probably many others) –

      “Alternative Medicine”, I continue
      “Has either not been proved to work,
      Or been proved not to work.
      You know what they call “alternative medicine”
      That’s been proved to work?
      Medicine.

      http://www.youtube.com/watch?v=HhGuXCuDb1U

      Alternative medicine is an alternative to medicine that works.

      Alternative medicine includes magic, witchcraft, Reiki, acupuncture, the “Golden Hour,” Trendelenburg position for shock, John Edwards talking with the dead, and an abundance of other treatments that are at best placebos, but may also be categorized as frauds. I do not include any of the magic by magicians who are honest in telling the audience that they are deceiving the audience – only those magicians who pretend that what they do is real.

      I consider alternative medicine to be worse than bad medicine.

      .

  4. I think you are setting up a straw man with your naloxone argument. There is not even biomedical plausibility for the scenario you describe. There is no RCT to say that oxygenation is good for cardiac arrest but there is a good physiological rationale for it. I presume you don’t withhold that?

    I appreciate the issue of withholding ECM for traumatic arrest. It was raised at ICEM 2012 by Prof Harris of HEMS and he quoted animal studies with the argument the heart in hypovolaemic PEA is maximally hyper-dynamic and further mechanical augmentation is unlikely to improve output. But again no RCTs or human studies to support this.

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