Roundtable – Trauma Cardiac Arrest

Trauma Cardiac Arrest

Okay, for anyone here who has not met Dr. Phillips, Dr. Phillips is our Associate Medical Director for Texas. He helps Dr. Frayn with a lot of stuff. He is the Medical Director for the EMS up in Parker County, he’s Medical Director for one out in Midland, one in Albany, and he was a paramedic himself before he, or was it before you became a doc or while you were a doc? Before.

Okay, there you go. So he understands you and his lectures are always very, very good. So I’m going to keep recording, but mute my microphone and I’ll be monitoring as well as I can for participation as well.

In about five minutes, I’ll… Okay, I think she went dark there on us. Oops, sorry. There you go.

Yeah, so if you get bumped off, you may not be able to get back in. Just be aware of that. All right, Dr. Phillips, it’s all yours.

Okay. So what actually kind of has occurred that led to this particular presentation is that we were contacted, when I say we, all of the EMS Medical Directors around the Tarrant County area were contacted by John Peter Smith Hospital or JPS, that is our level one trauma center in that side of DFW, because they wanted to make some changes and information flows very slowly in a lot of cases. And I think I’ve talked to you guys previously about a concept called knowledge translation.

And what that is, is moving information from the journals to actual practice. And in general, it takes about 10 years or up until recently, it has taken about 10 years to get a concept from journal article that’s landmark to actually being used on a day-to-day basis. And so we’re trying to reduce that knowledge translation time to less than a year.

Well, you’re going to see the reference or a reference in here that led to some of these changes and it’s 2015. So this is not a new concept and it may already be in place in some areas of the country. And it is a little bit controversial, but not that controversial.

And I really feel like, let’s go ahead and bring you guys up to speed with some of the stuff. And in a way, this is also kind of behind the times in some areas of the country too. So we’ll talk about those as we go along.

Again, same thing that Jane said, if at any point you have any question, preferably unmute your mic and stop me right there, let’s take care of that right then. I like questions, I like for you to ask questions because good questions help me to learn more as well. And as a professor said one time, I want to continue learning until I die.

So without further ado, I’m going to start out by showing you, this is actually the JPS level one trauma activation criteria. Now, every facility has different things in these activation criteria. And so I’ve showed this to you because it’s important that you have some idea of what is going to cause an activation in your system.

And to that end, kind of dovetailing with the previous round table that we had about communication is, if you know what the trauma activation criteria is and you’re calling in a patient for an activation report, it’s helpful for you to say right up front, you know, this is medic 13 and we’re in route with a level one trauma, and then tell them what’s going on because that way they’re already listening and they’re already looking at that list of criteria to be sure that you’re hitting something that’s on that list. Now, JPS has also added burn care to their armamentarium. And so those are some of the things that are in red down there at the bottom.

So the next one, I think that this is actually interesting because it actually got a separate category where it was usually just a line somewhere is geriatric trauma. So you know, once again, I show you these things, not because this is a big deal in this particular lecture, but it’s important that you understand the trauma activation criteria for your area, wherever you’re working, and use those guidelines to help to communicate what you have. So mechanisms of injury.

Okay. Now, this is data that they gave us from JPS, and this was only for 2020. And 2020, we were in the middle of a pandemic.

And so you can see now the absolute numbers were lower, but they pointed out to us that actually the number of penetrating injuries that they had received had gone up compared to previous years during the pandemic. I don’t know if it’s that they’re shooting people so that they maintain social distancing as opposed to running their car directly into them. But you can see that there are some numbers there.

Gunshot wounds represent 10% of all of the trauma that JPS is seeing for their trauma activations. 10%, that’s a lot. And then stab wounds come up to 4.28%. Now I’m not sure, I would tell you that I believe that, let’s say that you’re in a car accident and you have something penetrates you.

That is probably going to end up getting bunched in with the MVCs rather than with the other reasons for the trauma. So I point out to everyone that just because you’re in something like a car accident or a fall doesn’t mean that you can’t have a penetrating injury as well. So you have to look for all of those things.

So they brought up, and in the paper that we’re going to give you the reference for in a little bit, they bring up signs of life. And this is a rather important concept and we haven’t really focused on these things for any time at all. This is a relatively new concept.

And so what they’re wanting us to do is they’re wanting us to look for these specific signs of life. And if they are present, they would like EMS to go ahead and bring those people to them, even if they’re doing CPR. So what are those signs of life? So reactive pupillary response, you know, it’s one of those, especially on a bright sunny day that’s sometimes difficult to assess, but you do need to look and see if they have reactive pupils, because that means that they still have some cortical function in their brain.

Spontaneous ventilation. They would say even agonal respirations are a reason to go ahead and assist that patient, begin resuscitation and bring them to the trauma center. Well, presence of a carotid pulse, they’re not a cardiac arrest at that point, I’m not really sure that that’s a big change, but they’re emphasizing that as one of the things.

Any measurable or palpable blood pressure. So even if it’s 20 over 10, that’s a reason to transport that person. And extremity movement.

Now being a firefighter, of course, when I was talking with some of my EMS crews about this, one of the firefighters brought up, well, what if the arm’s across the room and it’s still twitching and the patient is over in front of you? So, you know, that’s a different thing. So I’m seeing Ruben has here, there is no level one trauma center or that consideration could be available for this trauma scenario on the new guidelines that is considered a change. What I would say is that, first off, you don’t have to have a level one trauma center to do an ED thoracotomy.

And so we’ll show you that in a little bit, but this is something that can be done at outside facilities, although it’s very rare that it’s performed at a facility that does not have cardiothoracic surgery. So that’s really the main thing. And that’s where knowing your individual area and knowing what the capabilities of the facilities that you’re going to be carrying your patients to is so important.

So good question. Now, David, blood pressure being produced by our car. I’m assuming that you mean that because the EM, the truck vibrates that, oh, by CPR.

Well, yeah, they’re talking about before you begin CPR, looking for these signs of life. So we all know that the person loses their pulse and they still have four to six minutes where they’re salvageable. And during that time, they may have some signs of life, especially pupillary response.

So yeah, I’m glad you clarified that. I was thinking that you were talking about because the vehicle moving can sometimes cause an erroneous blood pressure reading. Dr. Phillips Hudson wanted to know, will the use of a Lucas or other device change how you assess for signs of life? Well, first off, once again, we’re talking about doing this assessment for signs of life before you begin CPR.

So that’s really the important thing. We’re talking about starting the process. We’re not talking about where do you end the process.

We’ll get to that in just a little bit. So once again, assessing for the signs of life, and once again, we’re talking about penetrating or any trauma mechanism. In those cases where you come up on the scene and they’re like, I think they’re dead.

Well, you can’t just feel for a carotid pulse. You have to do more of an assessment than that. And focus especially on these particular items.

So the next one is, yes, you’re going to have to get the monitor and you’re going to have to put it on them to see if there is organized cardiac electrical activity. So a wide bazaar QRS is not organized cardiac electrical activity there. You’re looking for something that is sharper.

You may look for a pacer spike that may show that. Yeah, there is some cardiac activity, but eventually after the heart dies, the pacer spikes will still be there, but there’s no activity with that. So you do have to get the monitor out.

You do have to put the patient on it to assess for that. And then now I’m adding on to this list. Pre-hospital ultrasound, looking for any cardiac activity when you’re assessing the heart for trauma windows.

So we’re not going to get into how do you do an ultrasound assessment of the heart, but just suffice it to say, I really think that in the future, pre-hospital ultrasound is going to become the norm rather than a rarity. So James, when you say that it’s very minimal, what is very minimal? I don’t know if you’re talking about the palpable pulse, minimal blood pressure, minimal pupillary response. James, you can unmute your microphone and ask.

It might be easier than typing. I guess just if it’s kind of debatable between like two different paramedics, if they notice movement or reactive pupillary response, if that would be considered minimal. If there’s two different, I guess, opinions.

Well, really, if you think about it, though, a reactive pupillary response, it’s either there or it isn’t. If there’s no reaction at all, if the pupil doesn’t move when you shine light into it, that’s non-reactive. If there’s any movement at all, then that’s reactive.

It’s a yes, no question. There’s not a real grading to it. Spontaneous ventilation, very similarly, most of us will realize that towards the end of a person’s life, they tend to have some gasping type responses.

You know, presence of a carotid pulse, it’s there or it isn’t. Measurable blood pressure. Once, okay, somebody would probably say zero over zero is a measure.

But you know what we mean by that. So, you know, I would tell you that I would err, I want my paramedics to err on the side of saying, okay, maybe I don’t agree with you that there’s something there, but since you believe that there is, let’s go ahead and err on the patient’s side and let’s take them to the hospital. So that would be my preference, would be if there’s a debate about whether or not something is there, err on the side of being an advocate for the patient.

You mean all this, like in the chance you pull up to a scene of a trauma and you’re looking for the signs of life, not like you’ve done CPR on this trauma patient and you’re looking for those signs of life afterward, right? This is an assessment before you begin CPR. Hopefully you’re feeling for a pulse and you’re assessing for breathing before you start CPR every time. So, you know, this is just a little bit extra that the trauma literature would say that we should do.

Gotcha. So you kind of flip this around and say, if you were considering not starting CPR because of the trauma, they would need to have a negative for all of this. So you could kind of flip it around looking at it that way.

Correct. Very, very well stated. So let’s say I’m looking at Hudson’s thing with this type of patient when calling a report ideally a patient that EMS would take directly to surgery in a level one, or would you stop in the ER? They’re going to stop in the ER.

They’re not going to the operating room with these people directly. And yes, the facility that I work at does not do the same thing. But I believe that it’s probably something where if you have a discussion with the trauma medical director for a facility and take the paper to them, you know, print up the paper from 2015 and say, you know, this is kind of what is considered the most recent standard.

You know, that usually is enough to sway the opinion or at least let them, you know, look it over and say, OK, you know, it’s not just some stupid ER doctor, stupid paramedic that is trying to give me this stuff, you know, let them have some time to chew on it. So Ruben says, yes, the pupillary response can be affected by substances, many substances, not only illegal or alcohol. But that’s why we’re looking at more than just one thing.

So yeah, very well stated. But that’s why we’re looking at a lot of different things. And once again, in the future, I see that we’re probably going to have pre-hospital ultrasound.

And ultimately, it’ll be you putting the probe over the heart and looking to see if there’s cardiac activity or not, if there’s organized and if there’s a suspected any organized cardiac electrical activity. So it’s faster to put the ultrasound on than it is put all the leads on in most cases. So eating thoracotomy indications.

Now, this is for John Peter Smith. Now, I heard a heard a voice there. Yeah, Dr. Phillips, I was just curious if during transport, the signs of life that you indicated become no longer present, should we still continue with transport or initiate resuscitation wherever we happen to be? Well, you would initiate the resuscitation wherever you are.

You know, if it’s indicated to resuscitate the patient, and I assume you mean CPR, then you begin that wherever you are at the moment that you diagnose that. So Hudson, go ahead. OK, Hudson.

So I’ll just tell you that, first off, ER doctors are a lot like so many other people. And that is you have so many different opinions about things. And I advocate for the local EMS here on a pretty regular basis, especially with a couple of the doctors who are like, oh, my God, they bring everything here.

You don’t know what they’re bringing to the other hospital. So I would tell you that the best way to approach someone, if these sort of things that you’re describing happen, is first off, follow your chain of command, OK? Don’t try to go up to Dr. Smith and have it out with him in the ER. That’s not the place to do that.

The place and time is to go to your supervisor or your administrator and say, you know, this happened and I’m concerned. And here’s what I believe is the data to show that we should have brought this patient to you and they didn’t even do anything. But that’s something where if you get into a discussion one on one with an ER doctor or a surgeon or even a nurse, it’s not going to be good.

And so it’s always better if you, you know, just the same as in the fire service, police service, you follow the chain of command. So you go to your supervisor or your administrator and you bring up the concerns and then allow them to decide how that needs to go from there and indicate to them, hey, yeah, I’m willing to sit down and talk to Dr. Phillips and tell him why I believe that we did the right thing. So that’s an excellent question.

So any thoracotomy indications. Now, once again, this is for that one facility, but it’s kind of become more of a likely thing that we’re going to start seeing this because it’s been six years now since this paper was published. Penetrating mechanism of injury with patient who presents pulses with signs of life.

So this is what they’re teaching their trauma residents. This is what they’re teaching the emergency medicine residents. If you have a penetrating injury and they’re in cardiac arrest and they have any signs of life, do it.

Any patient who loses their signs of life while they’re in the ER, once again, same sort of thing. You’re kind of looking at a little further down the line than the same patient. So I think that what they’re talking about primarily is somebody that has a measurable blood pressure and then they lose it due to a penetrating trauma.

Don’t fiddle around with external compressions as much and cut their chest open. Let’s see. Took ATLS.

Yeah, I actually. Yeah, the question, Hudson, that you’re asking actually was part of the topic that I gave in the last roundtable regarding loss is more in trauma, and so warmed fluids do make a difference because it increases cold fluids and high volume of fluids will induce coagulopathy. So, but that’s, you know, if you don’t have a pulse, you know, that’s kind of a small secondary sort of thing.

Blunt mechanism of injury. So in these cases with blunt trauma, it’s a patient who presents with signs of life, and then they lose them in the ED. So that’s, those are their only indications for ED thoracotomy at that particular facility.

So I’m going to show you their protocol that they have promulgated, not for pre-hospital use, but that they use day to day. So if they have penetrating trauma and there’s less than 15 minutes of pre-hospital CPR, they’re immediately going to cut their chest open. If they have greater than 15 minutes of pre-hospital CPR, which is going to be every case that I’m going to bring them, then immediately on arrival, they’re going to put ultrasound on their heart, and they’re going to assess for any cardiac activity at all.

If they have cardiac activity on the ultrasound, they’re going to cut them open. And if they don’t, everything stops right then. Now, I want to point out that the trauma medical director, when he was talking about this, he said, you know, I really want you to make a point of telling your EMS folks that if they do CPR and everything on this person, that they’ve had cardiac arrest in their presence even, and they get to us and it’s been 15 minutes since they started CPR, and we put a wand on their chest and they don’t have any cardiac activity and we stop, that is not an indictment of them.

That is just based on the statistics. And so back to the earlier question, you know, that may be one of the reasons why somebody would, you know, you would bring in somebody that got shot or stabbed, and you’ve done CPR and it’s been 20 minutes, and there’s no cardiac activity when they get there. That may be one of the reasons why.

And, you know, obviously every doctor is a little bit different, but most of the crews around here in Texarkana, if they have a question like that, they’re going to come up to me and they’re going to ask, and obviously I’m going to sit there and I’m going to explain it to them. And I’m going to talk to them on a very professional level. Some of my colleagues, unfortunately, are not that way.

So it’s important that you understand that, but I think it’s still reasonable for you to come up and say, just curious, what was the reason that you stopped? So blunt trauma, not suspected to be of medical origin. So in other words, you have somebody that crashed their car and they’re in a cardiac arrest. If it’s an 87-year-old gentleman that has heart disease and, you know, he, you know, somebody said that they saw him slumped over the wheel before he hit anything, that’s probably a medical cardiac arrest, and that needs to be run the same way that we would any other cardiac arrest.

But we’re talking about a blunt trauma that, you know, they fell from a height and it was a suicide or whatever, and they hit the ground, they had a pulse, and then they lose it. Those are different. And in those cases, they’re going to immediately do a cardiac ultrasound.

And if there’s activity, they’re going to cut them. And if there’s not, they stop. So as you can see, the ultrasound is becoming a very, very indispensable tool, and I really think that we’re going to see that be the case pre-hospital very soon.

I’m not sure if you can hear my microphone. It’s not usually working like right off the bat. Okay, cool.

So regarding if there’s no cardiac activity at all, is the reason that you guys are stopping just because, like, you’re most likely not going to get any cardiac activity back, or is it similar to, like, something like hypothermia, where you fall below a certain percentage and you’re basically just going to die of organ failure, even if they get you back? No, actually, in those cases in trauma, where there is no cardiac activity, the heart is already dead. All right, so we’re just assuming at that point that there’s no reason to even try to get it back outside of the pre-hospital environment? Correct. Awesome, thank you.

I had a question, because we did get Ross en route to the hospital, but once we got to the hospital, they had to stop CPR, and they just called it. Is that the same reasoning there, even though we had just, like, five minutes ago? Well, part of, you know, what was the whole scenario? Was it blunt trauma or penetrating? On this one, it was just a medical call. Okay.

She was found out. We don’t know how long she was down, but we did get a pulse on scene, and we got her blood pressure en route, and we got some kind of rhythm on the monitor, and then when we got on scene, we got to the hospital, which was, like, an eight-minute drive from hospital to from the home, and they had to stop. They didn’t find a rhythm, so they called it.

And so, was there any cardiac activity when they stopped CPR there? At the time when they stopped us from doing CPR, they didn’t find anything. It was a systole. But we did get something en route, and we had proof of it on the EKG, but they still called it.

Right, but when you arrived there, the patient was in a systole, correct? Right. Okay. Because a systole is terminal rhythm.

Early on with cardiac arrest, medical cardiac arrest, you’ll have ventricular fibrillation most of the time, and then it will deteriorate into a systole. So, I’m sure that the assumption was that whatever the cause was for the cardiac arrest, even with the ROSC, that there had been so much damage either to the pump or to the brain that it would not be survivable. And they would use also the total cardiac downtime.

You know, I’ve had multiple incidents where I’ve had ROSC and, you know, say 10 minutes into an arrest, you get return of circulation, and then they lose it. And even a couple of times that they got it back several times, but eventually they deteriorated from having organized cardiac activity into a systole and may have passed through several phases to that point. But then when they get to a systole and you’ve done effective compressions and they’ve had appropriate medical therapy, then you get to a point where it’s still non-salvageable.

And so, it’s futile to continue that. And I would also recommend to everyone, a good website to look for some of these things and it’s evidence-based is, and this is, you have to type the whole thing out all together, dnnt.com. And it stands for the number needed to treat. And interestingly, if you look at the cardiology section, the very first question on there is, what drugs are effective in cardiac arrest? And the answer is none.

Absolutely none of the drugs really have been shown to improve survival from cardiac arrest itself. So, you know, it’s, then they give you citations for all the stuff. So, and yes, Hudson, that is the website.

So, interesting website to look at. Obviously, don’t try to access that while you’re doing patient care. But the drugs for cardiac arrest really don’t do much at all.

But we’re still kind of required to do those. So, let’s talk about, go ahead. Oh, no, I was saying, thank you.

Oh, okay. So, let’s talk about what exactly an ED thoracotomy is. And in this particular case, I’m going to describe just one particular approach.

If you go online, there is a video out of, I want to say it’s Ben Taub in Houston. From their trauma bay, they have cameras in the trauma bay, and they do an ED thoracotomy on a young man that had a gunshot wound to the chest. And they begin by doing a left-sided approach, a left-lateral approach.

And then they extend it into this clamshell. And they end up actually getting a pulse back on the kid. And he was discharged neurologically intact.

And the paper that I refer you to gives you a lot of good data about survival in these patients and tells you, you know, in patients with signs of life, what their survival is versus those that don’t have signs of life. Some of them do get pulses back, even without signs of life, but it’s a dismal low number. So, this particular article, and at the end of this, it’s going to have the reference for the article.

That particular article is out of the British Medical Journal. And in Europe, understand that there are a lot of physicians that are providing pre-hospital response, sometimes in ambulance, sometimes in a second vehicle. But they, in a lot of cases, have a higher level of care in the pre-hospital environment because they do have physicians that are dedicated to that particular response.

So, I throw this out there, and this is actually an article talking about doing thoracotomies in the pre-hospital environment specifically. Obviously, that is not something that we do in the United States at this time. But clamshell procedure, and we do have some pictures as well, no video.

So, start out by doing bilateral, and I made a typo there, mid-axillary four centimeter thoracostomies. So, what that means is that at the mid-axillary line in the fifth intercostal space, you take a scalpel and you make a four centimeter incision, and you dissect down with blunt forceps until you’re into the pleural space. And important to note, if you suddenly relieve a tension pneumothorax and you get a return of pulse, stop.

So, obviously, a tension pneumothorax is why they had their cardiac arrest with that. Once again, this is something that if you have pre-hospital ultrasound, that should not surprise you because you can see a pneumothorax with an ultrasound and it’s very easy to do. So, the next step is that they’re going to take the scalpel and they’re going to connect those two thoracostomies all the way across from one side to the other, they say with a deep skin incision.

So, in other words, you’re going to end up cutting out as deep as you can into the muscle and everything else with this one incision that goes from one thoracostomy to the other. The next is, you’re going to push in two fingers and push the lung away and then go up through all of the remaining tissue, once again, staying in that one intercostal space all the way around with large scissors until you get to the sternum. And then they’re saying either cut through the sternum with your large scissors or with a wire saw.

Once again, there’s pictures to follow this. I was actually kind of amazed, but it’s there. Then you’re going to open the clamshell or open those two sides of the incision, either with a self-retaining retractor that opens up or gloved assistance, one or two people.

It may take two people because, believe it or not, it’s actually hard to open that chest up and keep it open. So, and then they talk about sometimes extending back further if you need to. The ones that I’ve done, we actually go all the way back to the bed when we make our first incision.

And then finding the pericardium and opening up fully, so top to bottom, not a small nick in a longitudinal manner. Now, they actually recommend in this article in more detail, actually picking it up on the anterior surface of the pericardium and incising it from top to bottom. The reason that we do that is you have this nerve called the phrenic nerve that runs along the medial and lateral aspect of the pericardium that give you diaphragmatic innervation.

So, in other words, if you cut that nerve, trying to cut open the pericardium, then their diaphragm is not going to work again. And it does happen sometimes accidentally even, but that’s something that you need to keep in mind. And then here’s the reference for that paper, and I’m not sure exactly how you would get that link other than copying it and pasting it, but that will actually link you to this particular article.

If you notice, that’s not a really complicated procedure to do. They do go into detail about finding where the patient has a hole in their heart and either sewing it or patching it with a finger or even putting a Foley catheter into it. So, once again, I bring it up more because of awareness more than trying to teach you how to do this.

So, going back here. Dr. Phillips. Yeah, let me answer Andrew’s right quick.

So, slightly off topic, does the use of out-of-hospital physicians for emergency care actually decrease morbidity and mortality? That’s a million-dollar question because nobody really knows. And I’ll tell you that the reason that it’s not more common in the United States is that we have not had enough physicians to fully staff most things in the hospital, and also there’s just not that many physicians in America that want to get their hands dirty or go out on a cold winter night. Okay, what was the next question there? Dr. Phillips, that was from me.

Given this procedure, looking at it from my viewpoint, in a good hospital, how long does this take to actually do? You’d actually be surprised how quickly it can be done because, once again, you’re not talking about doing fine incisions and making sure that it’s going to be cosmetically correct. You’re not even worrying about sterility that much. And so, the first one that I did from the time that I made my initial incision until I was visualizing, in that case, the actual myocardium, not the pericardium because the pericardium had already been shredded, it took probably about 15 seconds, 30 seconds.

It didn’t take long because you’re just cutting. You make a quick cut and then you make another quick cut the other direction along the rib cage and then you can put your hands in and retract it very easily at first and see what you need to see. And in that case with that kid, as soon as I saw his heart was in pieces and there was no motion, it was like, okay, we’re done.

But the actual procedure getting to the heart does not take long at all. Good question. I’ve got a quick question on that, too.

So, the purpose of that procedure is mainly for visualization so you kind of know what you’re dealing with? Well, the ED thoracotomy is… So, your goal with that is to find a hole in the heart and to plug that up. Now, the other part of that, if you’re doing the traditional ED thoracotomy, is that you’re going to go down and cross-clamp the aorta below where the carotid arteries and everything come off. And so, that is not in this particular description because, once again, they’re describing this for a pre-hospital setting.

They’re talking about somebody that we’re just trying to get to where they have a pulse back. And so, of course, in Britain and some of those places, they’re more likely to be stabbed than they are to be shot. Bullets go all over the place.

Knives generally go in one direction only, and they don’t go as deep or cause as much massive damage as a bullet does. So, they’re talking about trying to find where the injury is, stop the bleeding from that, and then get cardiac activity back. So, Miranda asked about, is CPR going on while the procedure is being performed? No, it’s not.

You can’t do that while you’re doing CPR. So, you have to get your stuff together and then say, okay, stop. And then, if you’re trying to be sterile, you throw some betadine on their chest, just pour it on, and then you make your cuts.

So, it can go very quickly, but you can’t do CPR while you’re doing that. Now, once you get to the heart, you can do intrathoracic compressions with two hands. I hate showing myself on video.

That’s a lot with my question, actually. How does this relate to the cardiac massage? Is that what… That’s what we’re talking about. Okay.

So, once you have finally stopped bleeding, in this case, one hand goes in underneath the myocardium, and then the other one lays on top. You don’t spread your fingers, but you’re just doing this motion, like this. And that’s the compressions.

But, ultimately, if they don’t respond quickly to that, then you’re done. It just doesn’t keep going on forever. At what point are you wanting to do this? They’ve been trying to resuscitate this person for a while, or is it just major trauma? Okay.

Wrong direction. So, edthoracotomy. Okay.

Penetrating trauma less than 15 minutes pre-hospital CPR. They still don’t have a pulse. They’re doing this procedure, edthoracotomy.

If they come in and they have activity on ultrasound with more than 15 minutes, then they’re doing an edthoracotomy, just like we talked about. If they don’t have cardiac activity, they’re stopping. If they have blunt trauma suspected, not suspected to be of a medical origin, then they’re doing the ultrasound.

If there’s activity, they’re cutting their chest open. So, the entire lecture pretty much has been about getting to this point of doing an edthoracotomy. Okay, gotcha.

I guess I didn’t read all that. That makes sense now. I just didn’t know when your last option would be that, but I get it now.

Yeah, it is pretty much the last option. So, in relation with gunshot wounds, and this could be suspicious if other factors are provoking to have no cardiac activity, not related directly. So, in other words, you’re saying they were drugged or something and then shot.

Once again, if they’re bleeding in their chest, you got to stop that. So, you know, other factors until you get a pulse back don’t really matter. I really want to get to these photos.

I’m excited about it. Just have to ask, what are the odds that somebody wakes up during this? They’re not going to. They do talk in this article about that, obviously, you have to have an airway already when you’re doing this.

And they talk about that if the patient wakes up after you’ve reestablished a pulse, and that does sometimes happen that you have to be prepared to provide anesthesia for them. So, I’m thinking they’re probably going to get paralytics and some kind of sedation at that point. I’m thinking ketamine.

Personally, if I’m doing it, they’re going to get ketamine and rocuronium. Yeah, sure. That’s a good point.

The advanced airway being a prerequisite, I think is probably a good start to that question. I just couldn’t imagine that. But all right.

Thanks. No problem. So, this is the picture from that particular journal article of what they say, these are the tools that you need to perform this procedure.

Trauma shears? I’ve never thought about trauma shears for that. So, I’m like, you know, okay. Now, the saw that you see on the left, the wire saw, that is a special sort of thing.

And it obviously has special parts to it. But they describe in that paper how you’re going to use that long pair of forceps to tunnel underneath the sternum. If you can’t cut through the sternum with your trauma shears, I’ve never seen something that trauma shears won’t cut.

But they talk about taking that saw and it has a special name for it. I think it’s Geary Saw. And you will run the forceps underneath and grab the wire and pull it through and then connect it to the handles.

It is a bone saw, yes. So, oh, thanks Hudson for going ahead and putting that up. That’s helpful.

So, here’s where they say you’re going to start the incision and go all the way across. And so, unfortunately, I have yet to find patients to come in with those dots already on them. But it would be nice if they would.

Yeah, they won’t cut a lot of Kevlar, but at the same time, they also won’t cut a lot of fiberglass either when we’re making splints. And it really, really dulls your blade really fast. But, you know, a lot of times things, especially like bone that are crunching when you will try to cut those, I see those sort of things is actually that cuts those easier than than things like Kevlar or fiberglass.

Now, once fiberglass hardens, it goes right through that. So, this is obviously an actual patient that they have done an ED thoracotomy on. And you can see the self-retaining retractor in place there.

And the exposure is so much better than going in the lateral side. If you go just on the left lateral approach, you really can’t get those the incision open more than about the size of your hand. And so it’s very, very cramped and it’s hard to work.

And you’re only going to have one set of hands in there. And you’re having to push the left lung out of the way, because every time that they bag the patient, it will inflate and come in the way. This way by doing this, you can actually pull the heart out of the pericardium and set it on top of it.

And it’s beside the lungs. It’s not being covered by the lungs as it would be anatomically coming from the lateral approach. So, well, it’s one of those where I’ve never actually seen it done, but I’ve seen lots of pictures of it.

And it looks like it’s probably a better way. So Olivia is asking, next step in treatment for our traumatic arrest patients. Well, first off, I don’t think that this is going to be coming into pre-hospital arena for a long, long, long time, if ever.

And then it’ll probably be physicians that will be doing it or physician’s assistants that would be doing it. But I believe that getting them to a place where this can happen is a good idea. Now, let’s change the setting a little bit.

And let’s put this traumatic arrest patient coming into a small rural ER. I used to staff at Graham, Texas, which is an hour from Wichita Falls, an hour and a half from Fort Worth, and about an hour and a half from Abilene. So no trauma services other than us being a level four trauma center, which means most of the time we can go, oh, that looks like trauma.

Yes, we should send that. We’re not going to cut open somebody’s chest at that facility, more than likely, because we can’t do what they really need. And by the time they would get to that definitive care, they probably have died again.

So this is one of those where if you’re in a very rural area, I’m not sure that this is going to change your practice a lot. But if you’re in a suburban or urban area, I think that this probably is going to change practice. Now, the next question would be, what about if low titer O positive whole blood is available and TXA? Maybe that might change, and I don’t know the answer.

I think that the wars tend to give us a lot of advances in medicine, and this war has been no different. So, you know, it’s something where right now, I don’t think that we’re at a point that we can say one way or the other. So obviously, if you’re to answer David’s question, I think that he or somebody else asked the same question earlier about, okay, so they survived.

Yeah, they’re going to the operating room. They’ve got to have a definitive treatment on whatever their injury was. And then obviously, they’re going to have to have wound closure.

So, you know, that’s going to require a thoracic surgeon to do. And they’re also going to have to put in chest tubes, both sides. And there may be more than one.

So it’s nice in the ER when you get a pulse back on these because you go, okay, that’s your problem now, take them to the OR. But yeah, there’s a lot more that’s going to have to happen with this patient. So Andrew, to answer your question, if they don’t have a pulse, then the blood transfusions and TXA aren’t going to do anything.

So if they are a traumatic arrest, and they lose a pulse, blood transfusions and TXA aren’t going to do anything. You have to stop the bleeding. So it’s not a matter of the jury being out.

It’s more a matter of do you have the thoracic surgeon or the hospital’s capabilities to be able to do that. But yeah, in conjunction with doing an ED thoracotomy, you really do have to have massive transfusions available. And you have to have the TXA available.

So these are just a few of my thoughts about where I see some of this stuff. I don’t really see us doing EMS field thoracotomies, at least not for a long, long time. And I feel that ultrasound is really going to be coming very fast and hard.

Even within the next five years, I think that you’re going to see a lot more services adopting ultrasound. And I think that we’re going to see that it’s going to change some of our decision matrices around certain items, and trauma being one of those. I think that we’re going to start getting more good data about low, tight, or O positive whole blood.

And that will make a decision whether or not we need to make this more of a national standard. Obviously, it’s an expensive proposition. It’s going to take a long time for that to spread.

TXA should be given to these patients. And I believe that the literature now supports giving two grams in your initial bolus and be done with it. Combat Casualty Care has switched their protocol to they just give them a two gram bolus over 10 minutes, rather than doing the bolus and then having to get the infusion over eight hours.

I think that especially as our society has gotten larger and larger, doing fingertip thoracotomies or needle, some sort of needle thoracostomies with like a cook catheter set where you have a tube that’s this long, rather than one that’s that long, that you’re trying to get into the chest. I see those being performed more and more, especially the finger thoracotomies. I really think that those will be coming more likely as we go forward.

And I would also point out and I kept biting my tongue on this one. I’ve been doing emergency medicine 30 years and counting my EMS time 40 years. And I’ve seen two ED thoracotomies.

So it’s not something that happens often. Now, since I’m working a night shift tonight in Texarkana, I, since I prepared this lecture, now I’m thinking, yeah, I’ll probably end up with one tonight. But at the same time, you know, this is not something that’s going to happen very often.

Any other questions? That’s actually the end. I have a couple of folks here who haven’t participated. Zach and Jennifer.

I was actually getting ready to ask a question right now. When you’re talking about the needle thoracotomy, is that going to be the same thing as a pericardiocentesis or no? No, no. A pericardiocentesis is a totally different approach.

And with that, you’re usually using a spinal needle in order to get to that area. What we’re talking about with the needle thoracotomy is one of two approaches. And once again, because of the size of our population these days, we’re using, I really, I’m wanting to switch over to the Cook set for catheters or for needle thoracotomies.

And it’s a nine French catheter. So it’s about that big. And it comes on a trocar, which think of that as basically a sword.

It has a special tip on it. You actually cannot just poke that through the skin very easily. You have to make a nick in the skin.

But you put it in either in the traditional location of the second intercostal space, or you come in at the fifth intercostal space laterally. So that is one option. Now, if you’re doing a pericardiocentesis, just as not trying to show you anything more, but my xiphoid is right here.

In that particular procedure, you actually go in just under the rib cage and you direct it at the left shoulder. And actually you’re going for the tip of the shoulder blade and aspirating as you go in. And you do need a long needle.

It needs to be usually a spinal needle in order to get into that place. If you watch the old emergency series from the 70s, they were using intracardiac epinephrine. The needle on the thing was six inches.

So yeah, but that was designed to get into the pericardium and into the heart itself. And they were putting that into the left ventricle. That was their goal with that was to put that into the ventricular circulation.

Okay, well, that makes sense. What else? Dr. Phillips, in the setting of pediatric traumatic arrest, are the same principles that we’re putting here going to be used or is there going to be a different? Well, I think actually the answer to your question is more with the statement of try to stop somebody from transporting those kids. Yes, if it’s penetrating trauma, that’s a law enforcement situation.

That’s a crime scene. But I think that you’d be hard pressed to find somebody that is not going to transport a child that has suffered that other than if they’re obviously dead. If they’re obvious signs incompatible with life, you shouldn’t be doing this stuff anyway.

Interestingly, in preparing for this, I did actually look up some of the information about pediatric trauma and doing ED thoracotomies. And they basically mirrored the same indications. And the survival rates essentially the same as an adult.

Now, they’re talking about for kids 11 and under. And whereas I think it’s interesting, pediatricians consider over 11 as basically treat them like adults. Aren’t they just little adults anyway? Don’t let St. Fisher hear you.

You’re kind of cutting in and out there. Don’t let St. Fisher on Facebook hear you say that. I know.

I know. Sometimes I like to antagonize pediatricians and say that anyway. Okay.

Anything else? I actually seen a story in EMS1. They posted about an EMS service that took a pediatric patient, I believe, to a pediatric hospital that was 15 more minutes out than the level one trauma facility that was in the town, which was, I believe, maybe 10 minutes away. I just didn’t know if you heard about it and what you thought.

No. When it comes to pediatrics and knowing which hospital to go to. Since we’re going on to pediatrics, sorry.

Yeah. I guess that in a way I’m kind of lucky in that with the services that I’ve got, Fort Worth is where the big trauma centers are. Cook Children’s is directly across the street from the level two trauma center.

And the level one trauma center is actually about another, maybe a mile further away from Cook. But we actually got quite a few pediatric patients at JPS when I was there. And so that’s not unheard of to take them to an adult trauma center, stabilize them, and then transfer them after that.

The other service area that I’ve got primarily is Shackleford County. And everything goes to Abilene. And they only have Hendrick and now Hendrick South.

It used to be Abilene Regional. So everything’s kind of going to one place there. But that to me is a matter of you have to know the capabilities within your service area and have a presence to understand where you are physically in relation to those facilities and which one’s going to be closer.

Okay. I was just wondering because that service is actually under investigation because of that. I believe the pediatric did die.

And so I think one of the biggest things was that the other hospital was wanting them to divert to them because of money and whatnot. And so the service was actually telling their AMS crews, hey, you guys need to go here before you go there. And that was one of the topics of it.

Yeah. And not to get into the political sort of stuff. But right now, trauma centers in general are being scrutinized because they are claiming trauma activations, perhaps for things that don’t really meet trauma criteria.

And so and they’re billing huge amounts. I mean, huge amounts as a result of that. And so there’s sadly there are some other reasons that facilities and systems will ask for certain things.

Okay. Well, I got to go get ready for a night shift now. Thank you so much, Dr. Phillips.

We had a great time. It was a good session. Yeah, I enjoyed it.

And I only had, what, 12 slides and still took an hour. Yeah, it was great. We appreciate it.

And I just sent an email out to see if you had some time for us before we go off on winter break for another session, if you don’t mind. Yeah, I will look at the calendar. I know that