Evolution is a natural, and essential, part of medicine. During the 18th century, blowing tobacco smoke into the anus was believed to be an effective treatment for drownings. Whilst this is a time in history where we can look back and question logic – bloodletting was common too – we need not jump onto our high horses about previous practices, but rather stimulate introspection about how we currently practice medicine. Are we ourselves practising medicine in manner that will be considered comical in 100 years’ time?
Historically, traumatic cardiac arrest was mostly thought to be a futile condition. Once a traumatic pathology had progressed to the point of cardiac arrest, it was a common belief that the patient could not survive. However, thanks to the modern era of evidence-based medicine, we have re-shaped our perceptions about these patients – there are survivors. The question remained though, who are they, and how do we save them?
The most compelling arguments originally came from post-mortem studies where the cause of death was derived. The results were profound. What we saw, was that there were a significant cohort of patients who could have been saved. These were the patients who had died from:
- Tension pneumothorax
- Cardiac Tamponade
In modern trauma systems, we are seeing survival rates anywhere from 5% up to 27%. These are big numbers, particularly when we take into account that the vast majority of the trauma patients are younger, fitter and healthier individuals compared with their medical cardiac arrest counterparts.
That being said, we do need to recognise that a large cohort of patients will have catastrophic injuries and will inevitably die. The challenge that has faced clinicians and researchers over the years, is how do we predict patients with such injuries.
What we have learnt is that there are very few predictors of futility in traumatic cardiac arrest. Signs previously thought to be synonymous with death, such as asystole and fixed dilated pupils, have since been debunked. Current recommendations for withholding resuscitation are centred around:
- No signs of life within the preceding 15 minutes;
- Massive trauma incompatible with survival, such as decapitation and loss of brain tissue.
There are some pretty impressive injuries that fall outside of these categories that previously would not have been worked on. It makes you think, doesn’t it?
So what is the paradigm shift? It’s a mentality.
Let’s not throw the baby out with the bathwater. Let’s resuscitate these patients. We’ll throw everything at them and try and capture the ones that can be saved, and accept those that cannot be. Be an advocate for your patient.
To hear more about this, listen to Episode 14: Traumatic Arrest – A Paradigm Shift.