Problem of the Month: CPR on penetrating trauma.

[WAS967 97]

Okay. In an effort to liven up discussion here in the training forum and to make you think a little, I want to introduce a new concept to the forum (appologies if someone else thought of this earlier and mentioned it, I don't recall). We can call it the Problem of the Month. This one came to me while sitting in a PHTLS class this past weekend in Westport, CT.

You are called to the scene of a hunting accident. It is in the middle of bow hunting season and someone has been accidentally shot with an aluminum rod arrow. You arrive to see the man's hunting buddies running around frantic, not sure what to do.They just look at you and yell "HELP HIM". You approach the man to find him unconscious on the ground, not breathing (apneic) and pulseless. There is an aluminum arrow sticking out of the center of his chest. Exposing the chest reveals the arrow has penetrated the center of chest, right in the spot where you would normally place your hands to do CPR. His friends say the incident happened 5 minutes before they called, about 11 minutes ago. What do you do now? (A cop is there with you and secures the scene.) [My focus is on the obstruction and how do you do a resusitation in this case. Don't get off on a tanget about how you think one of his buddies shot him on purpose, etc etc]

[mikerabbit 2]

Obviously follow protocol secure airway etc, put him on monitor and hope defib works gains a pulse back so compressions wont be necessary?

[WAS967 97]

And if pulses are not returneds? Then what? Also, protocol is to do CPR until the defib is attached. Do you skip the initial CPR and go right to the defib?

[mikerabbit 2]

Well I guess you have to do CPR... and rapid infusion NS in addition to acls meds

[tbendick 27]

do CPR until the defib is attached

This would depend on the local protocols of the area you are in. See the NYC Protocol below. I know this is a Westchester board, but had to put this in just to make everyone think.

THE REGIONAL EMERGENCY MEDICAL SERVICES COUNCIL OF NEW YORK CITY, INC.

EMERGENCY MEDICAL TECHNICIAN PROTOCOLS

420

TRAUMATIC CARDIAC ARREST

1. Simultaneously begin transportation of the patient and Basic Cardiac Life Support procedures, as circumstances permit.

NOTE:TRAUMATIC CARDIAC ARREST IS A CRITICAL, LIFE-THREATENING EMERGENCY AND SHOULD BE TRANSPORTED IMMEDIATELY.

2. Observe spinal injury precautions, if appropriate. (See Protocol #421.)

3. Request Advanced Life Support assistance.

NOTE:DO NOT USE THE AUTOMATED EXTERNAL DEFIBRILLATOR FOR TRAUMATIC CARDIAC ARREST.

[WAS967 97]

Very interesting, yet very appropriate. Okay. So you do CPR. How? Where do you put your hands since there is an arrow sticking out of the guy where you would normally place them.

[tbendick 27]

Well I will say that I like the way the NYC Protocol reads..

Basic Cardiac Life Support procedures, as circumstances permit.

I would say you get as close as you can and do CPR and transport. Reading the NYC protocol looks like someone took into account that things like this could happen

[x635 4,066]

good scenario!!!

Hmm, I liked MikeRabbits way of thinking lol.

I'd ask the medic. Oh, wait a second! Darn!!

Uh, according to some texts I read, you have to remove the object if it interferes with CPR.

That does make sense, since you'd problay be repeatedly stabbing the guy if you did CPR around it. It's a double edged sword (The scenario, not the object,lol) Also to note, if you're not going to do CPR, dont do ACLS meds. They won't get circulated. Even though, chances are, where the location of the injury is, they will get bled out before they do any good.

Easy way out, I'd contact Medical Control.

I'm curious why FDNY does not allow the AED for traumatic arrest? I have some ideas. Do they allow regular defib for traumatic arrests?

[WAS967 97]

I think the big thing the NYC protocols are hitting at is the idea of not wasting time on scene with defibrillation cause even if it does work, you need to get the heck out of dodge. Calling medical control seems to be a viable option, tho I would NOT contact the local medical control, I would call MC at the trauma center since they would have the best idea as to what to do, and if needed, could put you on the line with a trauma surgeon whom you could consult with. I don't believe for us removign the object would be a viable option. I would see if I could do CPR as best as possible around the object possibly with fingers interlaced around the shaft of the arrow to half stabilize while still compressing. If it is in a major vessel or in the heart, removing it will only exacerbate the problem. It's one of those problems that really doesn't have one correct answer. Perhaps if someone is friendly with a surgeon that could help us out, they could inquire about the problem.

[x635 4,066]

If you do a google search about this, the protocols that I found that addressed situations like this stated to only remove an impaled object if it intereferes with CPR and/or the airway.

If you think about it though, if the object is lodged in a major vessel, and you do CPR , what damage are you doing to that vessel in the process...so it is a double edged sword in a way.

I will try and find out from a real trauma team and trauma surgeons next time I am in Worcester.

[Remember585 815]

MEDIC!!!!!!!!!!!!!! That's my answer....

[Guest alsfirefighter]

Take a kelly day? lol.

1. They are normally fiberglass shanks. Cut the arrow as far down as you can. And then see if you can go slightly above, below or put the arrow between your fingers. ACLS protocol either way according to heart rhythem.

OR

Attach the monitor. Hope for asystole. If not...I would call medical control while bls does some not so "textbook" cpr. If he's lucky its perforating and you can unscrew the arrow and med control may want you to yank it out. Before anyone cries the we aren't supposed to pull things out battle cry. Keep in mind we aren't really supposed to have an arrow sticking out of our chest and just hope the med control line tape is fresh.

As far as defib with traumatic arrest. WAS is speaking from ALS point of view I want to take it. We still attach out monitor or defib or whatever someone else wants to call it. BLS protocol is not to use it on traumatic arrests. Which 9 out of 10 times you couldn't anyway being PEA is the most common traumatic arrest rhythem.

[WAS967 97]

I attach them monitor too on most traumas. But it's done absolutely last generally. Unless it's a code of course, cause hey, you never know what you're gonna get. And unfortunatly even if we did have Asystole in this case, we can't declare traumatic arrests in the field. :cry:

[STAT213 332]

Leave him there, because he is dead. Check the box for obvious death on the PCR, cause that's why its there. All the toys you have ain't bringing anyone with these injuries back.

THEY ARE DEAD.

[mikerabbit 2]

Public Place must transport cant terminate onscn.

Mike

[N1Medic 69]

How is it "Obvious Death" ????

[Guest DADAY]

yank it out and do CPR, what the worst thats gonna happen, he dies?

[Guest alsfirefighter]

To try to answer or put it my way on a few comments,

First, WAS your partly correct, we cannot terminate efforts on a traumatic patient. Keywords: terminate resusitive efforts.

KEEP READING ON: THIS PATIENT IS DOA

You may not be able to just pull it out depending on what type of tip is on that arrow. In game, its not easy so you may be better off cutting the shaft.

This shot is center mass, the heart, lungs and several major blood vessels are all in that area, that is why military, police officers etc are taught to aim for "center mass." Not to mention the fact it is the biggest target area on the human body. Part of Obvious Death.

Second, according to WREMSCO Policy 01-01 "Pronouncement of Death," Pre hospital providers may be pronounced and unable to be resusitated when prehospital providers have found, in addition to apnea and pulselessness, that one or more of the following conditions exists:

Tissue decomposition

Rigor Mortis

Extreme Dependant Lividity

OBVIOUS MORTAL INJURY

A valid DNR

In addition to these conditions prehospital providers should attempt to determine:

Confirmation with AED (EKG) of no shock advised or asystole in more then 1 lead

ANY SIGNIFICANT MEDICAL HISTORY OR TRAUMATIC EVENT

Time elapsed since patient last seen alive.

This patient is and can be pronounced dead by the paramedic under that policy being: he is pulseless and apneic, has significant traumatic injury and if you put him on a monitor he has a high likeliness to be PEA or aystolic. Call the ME's office. The PCR you can check off Obvious Death and document the same just posted. As well as penetrating tauma, respiratory arrest, cardiac arrest, unconscious/unresponsive, major trauma. Great call STAT.