Traumatic Cardiac Arrest – A paradigm shift: Part 2

You arrive on scene to find a car that has had a frontal impact with a gum tree. The engine bay is wrapped around the tree trunk, horn blaring. The patient is slumped over the steering wheel, with a weak carotid pulse that dissipates immediately. Are you confident with your next step? What are the priorities here? Do we declare them or work on them? Well, luckily, you’ve read Traumatic Cardiac Arrest Part 1, so you know that this is game on.

We know that there are four primary pathologies that we can potentially treat. But how do we do this?

Hypoxia is the end result of a broad range of underlying insults. However, it doesn’t matter whether the cause is airway obstruction, brain impact apnoea, or a lung pathology, the fix all starts the same – basics. The term basic, however, is a misnomer. The ability to use a bag-valve mask effectively is a skill that will serve you well in your career, whether it be a failed airway algorithm or trying to judge your priorities in a traumatic cardiac arrest. Practise this skill ‘til no end. Whilst these patients do benefit from a definitive airway, the initial goal is all about air in and out.

The management of tension pneumothorax and cardiac tamponade conceptually is easy…decompress them. However, pre-hospital medicine is far from simple. Anyone can be taught how to place a needle into a set location. But what happens when it does not work? Mastering your practice is more than learning the fundamental skill. It is about understanding when to do it. It is about picking up on the cues that suggest that it will be ineffective. It is about knowing what the patient needs, and the options that are available to get the patient what they need – even if it is not in your tool kit. So how do we deal with these pathologies? We know our equipment, we know our procedures, we know our fail safes, and most importantly, we know our limitations.

Bleeding is undoubtedly the elephant in the room. It causes the greatest number of traumatic deaths that were potentially reversible. Therefore, we need to be experts at dealing with it. Many ambulance services now have a repertoire of options to treat external haemorrhages. Ranging from basic and modified pad and bandages, to haemostatic dressings and tourniquets. Junctional haemorrhage is an important subgroup of these patients that we are learning a lot from the military. They present a unique challenge due to the pairing of vulnerable major vessels with inconvenient locations. However, let us not forget about internal haemorrhages. Potentially amenable locations include long bones and pelvic regions. However, looking to the future, and in some cases the present, we have more dramatic methods of controlling other forms of internal haemorrhage such as REBOA and thoracotomy.

There is ongoing controversy about the role of cardiac compressions and adrenaline in the traumatic arrest patient. On one hand, it makes no physiological sense to perform compressions, and doing so may interrupt more important interventions. The counter to this is that not all traumatic deaths are equal, and it’s hard to generalise the priority of an intervention, with such vast aetiologies. Arguably, the greatest concern is if this apparent traumatic arrest, actually had a medical origin. Isn’t that one to think about. That patient that wrapped his car around the tree… could he have had crushing chest pain and a VF arrest prior to the car leaving the road?

Bias – Does it influence your judgement?

Does this sound familiar?

It is 4am and the pager goes off. You see “75-year-old with a sore leg” or “65-year-old vomiting and diarrhoea” or an 18-year-old female “drunk”.

What would be your immediate reaction?

Be honest….

You probably, (myself included) have descended into the five stages of grief. Denial, anger, bargaining, depression, and hopefully, acceptance. Why? Because, whether we are aware of it or not, we believe that jobs like these aren’t what we should be going to. When university courses, TV shows, news articles and self-proclaimed “health advocates” on twitter focus so much on the high end of our work, why should we?

We believe our role, where we can practice our craft, is in the big work. We start to perceive our identity based on this belief.

When we associate this identity with an expectation and that isn’t met, we become discouraged, demotivated, and a little angry. And who do we blame? The person responsible for creating that feeling…the patient who called us.

So why could this be detrimental to our patient care?

An internal dialogue that starts with “We shouldn’t be going to this”, can easily lead to “I don’t think this patient requires an ambulance”. And because they don’t require an ambulance, my next thought might be, “this patient can’t be sick”.

This is the kicker. Based on little information, we have concluded that “this patient is not sick”

This is dangerous. This is bias.

Bias stops us from considering all the possibilities. Bias stops us from looking further once we have reached a decision. Bias makes us focus on the variables that affirm our belief that someone isn’t sick and ignore the variables that contradict it.

The sore leg can be septic cellulitis, the diarrhoea and vomiting can be acute adrenal crisis, and the drunk teenager can be having a stroke.

I’m no saint, and I will happily put my hand on my heart and say I am guilty of this. But being aware of your thoughts is the first step to correcting them. So next time you get a sore leg, or drunk at 4am, pause, acknowledge the bias, and try and approach the patient with an open mind.

Remember, to you it’s just another job. To the patient it may be the worst day of their lives.

To learn more about bias,

Check out Episode 5 – Deadly D and V