Most deaths in trauma occur within the first 5 minutes following the event and most cannot be prevented. There are however the following preventable early deaths in trauma that need to be addressed prior to the conventional teaching of ABCDE.
Trauma patients may initially present with an adequate circulating volume but have haemorrhagic injuries that will lead to cardiac arrest if not treated early. Priority must be given to finding the cause and to STOP THE BLEEDING. Only after interventions are performed should consideration be given towards addressing the airway and breathing, unless there are sufficient people to enable this to be done simultaneously1. The measures mentioned below to control bleeding are only temporising measures and once established, transfer to a hospital with facilities available to manage the critically ill bleeding patient must be initiated. The patient in traumatic cardiac arrest may have little active bleeding, but this may resume on restoration of circulating volume. Haemorrhage control techniques as listed below should be initiated as soon as possible in the resuscitation phase. Restoration of circulating blood volume may be the highest priority for patients in cardiac arrest due to trauma.
External bleeding: restrict movement of the patient, immobilise the affected limb (if applicable), advise the patient to remain at complete rest.
Direct pressure The use of direct pressure is usually the fastest, easiest and most effective way to stop haemorrhage once the bleeding point has been identified. Apply firm, direct pressure using hands or a pad and ensure that the pressure is sufficient and maintained. If bleeding is not controlled then use of a haemostatic dressing if available may be used (i.e. uncontrolled head / trunk wound). Haemostatic dressings act directly on the site to form a clot and reduce active bleeding.
Tourniquet Only to be used for life threatening bleeding from a limb that cannot be controlled by direct pressure. This should be placed 5-7cm above the bleeding point and tight enough to stop all circulation to the injured limb. Once applied it should not be removed until specialist care is available in a controlled environment. Note the time of application.
Indirect pressure Penetrating objects should not be removed as they may be plugging the wound and hence limiting bleeding. Place pads around / above/below the apply pressure over these pads.
Internal bleeding: should be suspected where there are signs and symptoms of shock, particularly with pain, tenderness or swelling over or around an affected area
Pelvic splint application If pelvic fracture is suspected, application of a pelvic binder may temporarily assist to control bleeding until definitive care can be established but should only be applied after other interventions in undifferentiated trauma.
Traction The use of traction in long bone fractures helps to reduce haemorrhage. Therefore, immobilise the limb as soon as possible after other life-saving interventions.
Restoration of Circulating Blood Volume
Restoration of circulating blood volume may be the highest priority for patients in cardiac arrest.
IV or IO access
Should be established as rapidly as possible. Insertion of a peripheral IV cannula may be extremely difficult, especially in the patient who has exsanguinated. Femoral or CVC insertion should be attempted if staff are trained in the procedure. IO access may be more rapidly and reliably achieved, with the humeral head IO achieving more rapid fluid administration than the tibial IO.
An initial fluid bolus of 20ml/kg of crystalloid fluid, ideally warmed, should be rapidly administered to the patient where hypovolaemia is the likely cause of traumatic cardiac arrest. In exsanguinating haemorrhage there should be a 1:1:1 ratio of thawed fresh frozen plasma: packed red blood cells: platelets4. Prehospital administration of blood products may be available and should be initiated in accordance with Ambulance Victoria CPG’s5. Use of other products such as Transexamic acid (TXA), cryoprecipitate and platelets should be guided by each facility’s Massive Transfusion Protocol. Further fluid boluses of 5-10 ml/kg should be given if hypotension is suspected as the primary cause of cardiac arrest. Once there is spontaneous restoration of cardiac output and prior to surgical haemorrhage control and at least for the first hour, fluid should be titrated to a SBP of 90mmHg (permissive hypotension) or to consciousness (as long as there is no traumatic brain injury).6
Tension pneumothorax is the progressive build-up of air within the pleural space, usually due to a lung laceration which allows air to escape but not to return. All patients in cardiac arrest with suspected chest trauma who are not responding to airway opening and restoration of circulating blood volume should have their chest decompressed. Bilateral finger thoracostomy can be quickly performed in the resuscitation phase followed by insertion of an intercostal catheter at a later stage. An alternative that may allow rapid chest expansion is needle decompression, the insertion of a long, wide bore cannula into the pleural cavity to reinflate the collapsed lung and allow air to escape. This technique must always be followed by insertion of an intercostal catheter.
In the trauma patient with the severely compromised airway, it is important to establish and maintain effective oxygenation. Basic airway manoeuvres and supraglottic airway (SGA) devices should be used to maintain oxygenation if tracheal intubation cannot be established immediately. Oxygen should be applied using gentle ventilation as positive pressure ventilation may worsen a tension pneumothorax. ETC02 monitoring using waveform capnography should be established and ventilation adjusted to achieve low or normal ETCO2. Consideration to cervical spine injury should also be taken into account if there is evidence of head trauma.