What's your attitude in managing a case arrived at ER with cardiac arrest (asystole by ECG monitor) due to major trauma? Do you still do the CPR or just let it be (is it legal)?

Thanks.

Jacky,
That's what they called DOA (death on arrival), no matter how good you are, you can't bring the death back. It would be different if the arrest happens IN the ER , then you must do something and maybe you'll have a patient to work with. Depending on the injuries.

Dr.Lango Obregon
Trauma Surgeon
Mazatlan General Hospital

Dr. Lango Obregon,

For cases of trauma, what do you consider as "DOA" (Death on arrival)? Is a patient with an ECG of asystole considered "DOA" even if he just arrested outside the ER door, pupils not dilated, and with agonal breathing? I wish Jacky had been more explicit in the findings other than "asystole".

May I know from the other list members, what their stance is or how aggressive they are in resuscitation especially in Trauma wherein the patient is young and most probably healthy prior to the trauma.

Teodoro J. Herbosa MD
Department of Emergency Medical Services
Philippine General Hospital
University of the Philippines, Manila

Assuming that the patient arrives in the ED with ACLS being given, it still takes several minutes to "gain control" meaning

check ABC
get the history
transfer all monitoring leads
cut the clothes off

by which time it is usually obvious how big the chances of survival are.

the decision whether or not to continue is then made by the team, not an individual member of staff and unless that decision is unanimous, we continue with resuscitation.

In Trauma: No signs of life after providing an airway you're dead!

Keith Wesley, MD
Director, EMS Education & Trauma Care
Sacred Heart Hospital
Eau Claire, WI

The data is becoming quite clear. For a trauma patient, who is not intubated, I have not been able to find a survivor who has had pre hospital CPR for more than 5 minutes, including our own data going back to 1960 on our trauma registry. If the patient has been intubated and is a victim of trauma and has had prehospital CPR for more than 10 minutes, we have never had a survivor. If the initial pH is 6.8 or less, in a patient with a traumatic arrest, we have not ever had a survivor. ED resuscitations cost almost $5000.00/hr or more. I do not hesitate to spend this money if there is a chance for reversal, but I think we are irresponsible to pour a lot of money down the drain when everyone knows that this patient in front of us has NO chance of survival, and if we do coax the heart back the cost in the expensive care unit for a person with a dead brain, but a beating heart in an intubated patient is awsome. The family comes to begrudge the "wrongful life" and lawsuits have already been filed as wrongful life suits. Death is virtually always inevitable. We cannot and must not use these desparate and futile cases as "practice" either. That is disrespectful of the dead. What I have said here is for trauma patients, but I am not sure that cardiac patients are not far behind is successes.....

k

Generally, if the monitor shows flat-line, we do nothing further. Other factors to consider include whether there were vital signs in the field and how long ago they were, how long the ambulance ride was, and if the trauma was blunt or penetrating.

Blunt trauma has a prohibitably low yield, as well as long ambulance rides, and the absence of vital signs in the field. You are on solid ground if you chose not open the chest in these situations.

Peter Meade, MD
Asst Prof Surgery/ SICU Director
King/Drew Medical Center
Los Angeles

To quote LA COUNTY / USC :

"In traumatic cardiac arrest there is NO place for external cardiac massage. The procedure of choice is a resuscitative thoracotomy."

For a review of the indications for this procedure I suggest you visit their web site for the full protocol:

http://www.usc.edu/hsc/medicine/surgery/trauma/Trauma_Protocols/11EMERTH.html

The sign on our trauma bay says 'Resuscitation Room', NOT 'Resurrection Room'.

Having said that, I'll pull all the stops out for someone apparently dead, especially if they are relatively young (i.e. no more than 20 years older than I am at the time), until it becomes apparent or lack of response to resus. efforts that it is hopeless. Someone with a tension and a bit of hypovolaemia could be effectively dead, but respond dramatically to simple treatment.

On a bit of a side issue, out of the 96 people that died at the Hillsborough disaster, only FOURTEEN ever made it as far as a hospital. 82 were declared 'dead' at the scene, mostly be untrained people (i.e. police officers). I'm always a bit wary of declaring ANYONE life extinct, so I don't know how these folk could have been confident about doing it in the middle of a heaving soccer pitch.

--
Dr. Ed Walker FRCA
Staff Grade Practitioner, A&E
Dewsbury, Yorkshire, UK.

In reference to the thread on DOA, the question was:- For cases of trauma, what do you consider as "DOA" (Death on arrival)?. One reply stated that "That's what they called DOA (death on arrival), no matter how good you are, you can't bring the death back...."

I would make sure the patient was not severely hypothermic before making a decision one way or another. History is of obvious importance, especially mechanism of injury, time of arrest and current therapy / resuscitation efforts. The outcome for patients sustaining blunt trauma and out of hospital cardiac arrest is very poor.

Chuck Smith
Charles E. Smith, MD, FRCPC
Dept of Anesthesia, MetroHealth Medical Center,
2500 MetroHealth Dr., Cleveland, Ohio, USA 44109
Email: ces4@po.cwru.edu

Cardiac arrest from major trauma especially blunt means death. The survival rate is as close to zero as it can get. Only in penetrating trauma, is it worthwhile to try to resuscitate but it must be by thoracotomy.