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Sun Jun 4 11:41:24 BST 2006

What are the conditions or circumstances in a non-trauma patient in which 
chest compression has proven benefits, or is advocated by authorities?

Is it possible that these conditions be present in a "trauma" patient 
concurrently, and is the actual cause of the arrest? (e.g. VF, drug 
intoxication, hyperkalemia)

In practice, how can one be sure in trauma emergencies, in applying the 
blanket statement:"closed chest massage has no place in trauma" ?

Dr. Stewart Chan
Senior Medical Officer
Dept. of Accident & Emergency
Prince of Wales Hospital

>From: "Hall, John R" <John_R_Hall at Wellmont.org>
>Reply-To: "Trauma &amp; Critical Care mailing list" 
><trauma-list at trauma.org>
>To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
>Subject: RE: Closed chest compressions for traumatic arrest
>Date: Sun, 4 Jun 2006 06:06:15 -0400
>
>There was an article in the j of trauma (j of ACS ) not so long ago.  They 
>did open chest in almost everybody.  Like Babe Ruth, they had the largest 
>number of no help (strike outs) - but also a few survivors without 
>neurologic injury (home runs).
>
>Closed chest massage has no place in trauma (and probably mi) - the only 
>way you are going to perfuse the heart and brain (and r/o other fixable 
>cardiac injuries) is open chest
>
>________________________________
>
>De: trauma-list-bounces at trauma.org en nombre de docrickfry at aol.com
>Enviado el: sáb 03/06/2006 22:11
>Para: trauma-list at trauma.org
>Asunto: Re: Closed chest compressions for traumatic arrest
>
>
>
>  Of course, once again, it is not appropriate to ask for evidence AGAINST 
>doing CPR in trauma--the burden of anyone performing the intervention is to 
>FIRST prove it has benefit--it is NOT the burden of the rest of us to prove 
>it does not!  I know of no proven benefit for doing it--that is sufficient 
>for NOT having any justification to do it, unless of course, evidence has 
>no place in your practice.
>ERF
>
>-----Original Message-----
>From: oded private <tangentcarrot at hotmail.com>
>To: trauma-list at trauma.org
>Sent: Sat, 3 Jun 2006 23:59:11 +0300
>Subject: Re: Closed chest compressions for traumatic arrest
>
>
>As cardiac massage, be open or close, is ment to keep cerebral and 
>myocardial perfusion in order to prevent irreversible damage and restore 
>cardiac activity- it is clear thata brain injury fatal for itself is brings 
>indication to no treatment what so ever.
>
>I myself said "a brain dead patient is an all dead pateint"
>
>But when teaching medics, who have basics skill and equipment and can never 
>"call off a code" unless the patient is OBVIOUSLY dead, we need to give 
>them clear-cut answers.
>
>For years they have been taught to perform CPR for the patient with an 
>isolated head injury who arrests. As I understand,the claim is that the 
>arrest dosen't have to be due to primary respiratory arrest resulting from 
>injury to the brain stem, but might also be the result of upper airway 
>obstruction due to depressed LOC and loss of pharyngeal tone, which leads 
>to hypoxemia and resultant respiratory and cardiac arrest. In this case, 
>opening the airway may accomplished manually (jaw thrust) or by 
>endotracheal intubation, and hypoxia may be corrected by ventilating with 
>100% 02 and performing chest compressions (well, you want that blood to 
>reach the alveolies to get oxygenated).
>
>I raised the issuse here not becuase I'm looking for reassurance that it is 
>right- but becuase I'm looking for some solid facts regarding it. By the 
>way, I believe these facts will show the other way around from what we 
>teach now, meaning- there is no indication to perform CPR.
>
>Say- in your hospital,is every patient with a head injury that comes into 
>the rsuscitation area in arrest immediatly Xed?
>
> >From: docrickfry at aol.com
> >Reply-To: "Trauma & Critical Care mailing list" ><trauma-list at trauma.org>
> >To: trauma-list at trauma.org
> >Subject: Re: Closed chest compressions for traumatic arrest
> >Date: Sat, 03 Jun 2006 09:34:21 -0400
> >
> >Neither closed chest compressions NOR open thoracotomy have any value in 
>an >arrest due to fatal brain injury--nor do they for airway obstruction, 
> >please elaborate on your rationale for saying that?
> >ERF
> >
> >-----Original Message-----
> >From: oded private <tangentcarrot at hotmail.com>
> >To: trauma-list at trauma.org
> >Sent: Sat, 3 Jun 2006 16:17:45 +0300
> >Subject: RE: Closed chest compressions for traumatic arrest
> >
> >
> >First, thank you for the comperhensive summary
> >
> >As I see it, we keep on bagging the same issues-
> >1. closed chest compressions are fultile for the patient with little or 
>no >preload, that is a patient arresting from hemorrhagic shock, or 
>compressive >shock resulting from precardial temponade or T/P, and these 
>pateints >require either a thoracotomy, pleural decompression, or, more 
>commonly, a >black polyethen bag. Where I teach, closed chest compressions 
>are >contra-indicated for most trauma patients (the exceptions be 
>electrocution >and a blunt sternal thump)
> >2. The patient who's is brain dead is all dead
> >3. There are few traumatic cases in which closed chest compressions are 
> >clearly indicated- such as commotio cordis, electrocution, or 
>pre-traumatic >arrest
> >
> >But two questions remain open to me:
> >1. Should CPR be performed in the head-traumatized patient by the medic 
>who >is not authorized "to call off a code"? assuming that, a. The arrest 
>could >have developed becuase of an obstructed airway resulting from 
>depressed LOC >rather then by a devastating brain stem injury, 2. the head 
>trauma patient >has a "full" circulation (even if he has a concomitant 
>torso trauma, the >medic can't surley know wether it cuased exsanguination 
>or not)
> >2. Does prehospital CPR actually worsen outcome of thoracotomy? I 
> >understand the physiological grounds to this claim, but have not yet seen 
>a >study supprting it
> >
> >
> > >From: bensonblues at comcast.net
> > >Reply-To: "Trauma & Critical Care mailing list" 
> ><trauma-list at trauma.org>
> > >To: trauma-list at trauma.org
> > >Subject: Closed chest compressions for traumatic arrest
> > >Date: Fri, 02 Jun 2006 18:53:10 +0000
> > >
> > >"I'd like to hear your opinion on closed chest compressions in face of 
> > >traumatic arrest resulting from hypoxemia."
> > >
> > >Oded: Finally, an issue that I am qualified to address (that is, if you 
> > >believe my CV). I'll respond with several points:
> > >
> > >1) The current thinking regarding blood flow during closed chest > 
> >compressions involves the redistribution of blood from the venous > 
> >(capacitance) side of the pulmonary circuit to the systemic circulation. 
> > >Angiographic and hemodynamic studies show that the greatest volumes of 
> > >blood are moved through the heart during the first few compressions 
>after > >arrest. Experimental support of this theory is that simulataneous 
> > >ventilation and compression of the chest generate the greatest > 
> >extrathoracic/cerebral blood flows (but the least pressure diferentials 
> >and >thus flow to intrathoracic organs such as the heart). After blood 
>has >been >displaced out of the pulmonary capacitance vessels, some flow 
>does >occur >from the arterial side of the circuit through the lung 
>capillaries, >but the >amounts are small. This theory (the thoracic pump 
>theory) is >compared with >previous thinking that the heart was squeezed 
>between the >sternum and >spine, thus generating flow wit
>  h the heart acting as
> > the pump.
> > >
> > >2) In either theory (and if fact there may be situations where one or 
>the > >other or both mechanisms are involved in generating blood flow), 
>blood >flow >requires that blood be present in the circuit. Thus, my 
>feeling (and >of >others) is that closed chest compressions in trauma is 
>useless, since >in >hemorrhage, the pulmonary and systemic capacitance 
>vessels are >bloodless. >In fact, many authorities believe, as I do, that 
>closed >compressions are >contraindicated in hemorrhagic/traumatic arrest, 
>and may >worsen injuries in >the torso if they in fact exist.
> > >
> > >3) That being said, medics in Detroit will perform closed chest > 
> >compressions on a pulseless trauma victim on the scene until they pakage 
> > >them up and get on the road. Their justification is simple: the folks > 
> >gathering at these "neighborhood events" are often hostile, and failure 
> >to >appear as if you are doing all you can may result in a riot and 
>bodily >harm >to the medics. Pitiful, isn't it?
> > >
> > >4) There are several scenarios where cardiac arrest in the 
>non-exsanguine > >trauma victim may benefit from chest compressions. First, 
>some victims >have >their dysrhythmia then crash their cars. The presence 
>of non-bleeding > >lacerations or no bruising where there should be may be 
>evidence for the > >medic that this is the case. Another is the phenomenon 
>of commotio cordis >- >blunt chest injury that induces dysrhythmia. 
>Further, after >exsanguination >and arrest, let's say from hemorrhage from 
>an extremity >wound, if >hemostasis and aggressive volume resuscitation can 
>be achieved, >closed >chest compression may be of benefit. Lastly, 
>traumatic aphyxia is a > >condition where, if you can get the out of 
>control Rap concert crowd (or > >the BMW, etc) off of the poor guy's chest 
>in time, closed chest may be of > >benefit.
> > >
> > >5) If, in the resuscitation room, the victim arrived with blood in 
>their > >jugulars and arrests, I would perform chest compressions while 
>trying to > >exclude and immediately treat cardiac tamponade or tension 
>pneumothorax. >If >these things can be excluded, again, this is evidence 
>for a medical > >condition or traumatic aphyxia and closed chest 
>compressions are probably > >indicated. Even in this scenario, studies 
>support my contention that the > >best CPR in terms of neurologic recovery 
>for all-comers is open-chest > >(references available on request).
> > >
> > >To summarize: Blood flow during closed chest compressions in the 
>sanguine > >non-trauma patient is at best 10% (some say up to 30% in 
>special cases) >of >normal. Thus, compressions can be expected to produce 
>sub-viable flow >in >the hemorrhaged, and may worsen intrathoracic injury. 
>In general, the >type >of CPR indicated for traumatic arrest is open-chest 
>with aortic > >cross-clamping and (God willing) hemostasis.
> > >
> > >DB
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Closed chest compressions for traumatic arrest