Traumatic Cardiac Arrest

Quick Answer

Critical: Traumatic cardiac arrest (TCA) requires a DIFFERENT algorithm to medical cardiac arrest. Focus on rapid correction of reversible causes - Hypovolaemia, Oxygenation, and Tension pneumothorax/Tamponade (HOT) - rather than standard ALS. Chest compressions are often ineffective in hypovolaemic or obstructed hearts. Survival depends on immediate bilateral finger thoracostomies, massive transfusion, haemorrhage control, and early resuscitative thoracotomy when indicated.

Traumatic cardiac arrest differs fundamentally from medical cardiac arrest in aetiology and management [1]. While medical arrests are primarily due to cardiac arrhythmias responding to CPR and defibrillation, TCA results from hypovolaemia, tension pneumothorax, or cardiac tamponade - conditions where chest compressions on an empty or obstructed heart are ineffective [2]. Australian data indicates TCA accounts for 5-10% of all cardiac arrests, with overall survival rates of 7-12% - significantly better for penetrating trauma (10-15%) than blunt trauma (2-5%) [3]. Witnessed arrests with signs of life have survival rates approaching 15-20% with aggressive intervention, while unwitnessed TCA has near-zero survival [4]. ANZCOR Guideline 11.10.1 provides the Australian framework for TCA management, emphasising simultaneous correction of reversible causes over traditional ALS approaches [5].

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ACEM Exam Focus

Primary Exam Relevance

• Physiology: Cardiac output = stroke volume x heart rate; empty ventricle cannot generate stroke volume regardless of CPR; tension pneumothorax impairs venous return through increased intrathoracic pressure; tamponade restricts diastolic filling through pericardial constraint
• Anatomy: Thoracic anatomy for thoracostomy (4th-5th intercostal space, mid-axillary line, avoiding intercostal neurovascular bundle); cardiac anatomy for pericardiocentesis; aortic anatomy for cross-clamping and REBOA
• Pharmacology: Damage control resuscitation pharmacology - TXA mechanism (lysine analogue inhibiting plasminogen), calcium role in coagulation cascade, rationale for avoiding crystalloid (haemodilution, coagulopathy)

Fellowship Exam Relevance

• Written SAQ Topics: TCA algorithm vs medical arrest, indications for resuscitative thoracotomy, bilateral thoracostomy technique, massive transfusion protocol, damage control resuscitation principles, termination criteria
• OSCE: TCA resuscitation leadership station - must demonstrate simultaneous interventions, appropriate team allocation, and procedural decision-making. May include communication stations regarding futility or death notification after TCA
• Key domains tested: Medical Expert (algorithm knowledge, procedural indications), Leader (trauma team coordination, rapid prioritisation), Communicator (team briefing, family updates)

High-Yield Exam Points

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Key Points

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Epidemiology

Australian and New Zealand Data

Mechanism Distribution (Australian Trauma)

Prognostic Factors

Indigenous Health Disparities

Important Note: Aboriginal, Torres Strait Islander, and Maori Considerations:

Aboriginal and Torres Strait Islander Australians experience trauma-related mortality at significantly higher rates than non-Indigenous Australians [12]:

• Motor vehicle trauma mortality: 3-5 times higher in Indigenous Australians
• Assault-related trauma: 10-15 times higher prevalence
• Geographical barriers: Many remote communities greater than 200km from trauma centres
• Transport delays: RFDS response times may exceed 60-90 minutes
• Pre-hospital care: Limited access to advanced pre-hospital care in remote areas

Maori in New Zealand:

• 2-3 times higher trauma mortality than non-Maori
• Higher rates of interpersonal violence
• Rural/regional location of many Maori communities

Implications for TCA:

• Longer transport times reduce survival for time-critical interventions
• Community first responder training crucial in remote areas
• Earlier activation of retrieval services essential
• Telemedicine guidance for local providers during resuscitation
• Cultural considerations in family communication and end-of-life decisions

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Pathophysiology

Why TCA Differs from Medical Cardiac Arrest

Medical Cardiac Arrest

Primary arrhythmia (VF/VT) → Loss of cardiac output → CPR restores 25-30% cardiac output
     ↓
Filled ventricle can be compressed → Blood ejected with each compression
     ↓
Defibrillation restores organised rhythm → ROSC

Traumatic Cardiac Arrest

Trauma → Hypovolaemia / Obstruction / Hypoxia
     ↓
Empty ventricle (hypovolaemia) OR Obstructed filling (tension/tamponade)
     ↓
CPR compresses empty/obstructed heart → No meaningful cardiac output
     ↓
Must FILL the tank (blood) and CLEAR obstruction (thoracostomy/thoracotomy)
     ↓
Only then can compressions be effective

The Three Killers in TCA (HOT)

1. Hypovolaemia (60-70% of TCA)

• Mechanism: Exsanguinating haemorrhage (thoracic, abdominal, pelvic, external)
• Pathophysiology: Reduced preload → reduced stroke volume → reduced cardiac output
• Why CPR fails: Cannot compress blood out of an empty ventricle
• Solution: Haemorrhage control + massive transfusion + surgery

2. Tension Pneumothorax (10-20% of TCA)

• Mechanism: One-way valve effect from lung/chest wall injury
• Pathophysiology: Progressive air accumulation → increased intrathoracic pressure → impaired venous return → reduced preload → obstructive shock
• Why CPR fails: Cannot fill the heart due to external compression
• Solution: Immediate decompression (bilateral finger thoracostomies)

3. Cardiac Tamponade (5-15% of TCA)

• Mechanism: Pericardial blood accumulation from cardiac/great vessel injury
• Pathophysiology: Pericardial fluid restricts diastolic filling → reduced preload → obstructive shock
• Why CPR fails: Heart cannot fill adequately between compressions
• Solution: Pericardiocentesis or resuscitative thoracotomy

Additional Mechanisms

The Lethal Triad of Trauma

                    HYPOTHERMIA
                        ↗   ↖
                       ↙     ↘
              ACIDOSIS ←→ COAGULOPATHY

All three worsen each other → Death spiral

• Hypothermia: Core temperature below 35°C impairs enzyme function, coagulation cascade
• Acidosis: Tissue hypoperfusion → lactate accumulation → pH drop → impaired coagulation
• Coagulopathy: Dilutional (crystalloid), consumptive (bleeding), dysfunctional (hypothermia/acidosis)

Damage Control Resuscitation addresses all three simultaneously [7].

Coronary Perfusion in TCA

• Coronary perfusion pressure (CPP) = Aortic diastolic pressure - Right atrial pressure
• In hypovolaemia: Aortic diastolic pressure severely reduced → CPP minimal
• In tension pneumothorax: Right atrial pressure elevated → CPP reduced
• CPR cannot generate adequate CPP without addressing underlying cause
• Aortic cross-clamping (thoracotomy) or REBOA can augment aortic diastolic pressure

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TCA Management Algorithm (ANZCOR 11.10.1)

Overview: TCA vs Medical Cardiac Arrest

The TCA Algorithm Flowchart

┌─────────────────────────────────────────────────────────────────────────┐
│                    TRAUMATIC CARDIAC ARREST                              │
│                 Unresponsive, no pulse, major trauma                     │
└─────────────────────────────────────────────────────────────────────────┘
                                    ↓
┌─────────────────────────────────────────────────────────────────────────┐
│                         CALL TRAUMA TEAM                                 │
│                Activate MET/Trauma call, request blood                   │
│                      Activate MTP immediately                            │
└─────────────────────────────────────────────────────────────────────────┘
                                    ↓
┌─────────────────────────────────────────────────────────────────────────┐
│            SIMULTANEOUS INTERVENTIONS (within 2-3 minutes)              │
│                                                                         │
│  ┌─────────────────┐  ┌─────────────────┐  ┌─────────────────┐        │
│  │  AIRWAY         │  │  BREATHING      │  │  CIRCULATION    │        │
│  │  • Intubate     │  │  • BILATERAL    │  │  • IV/IO access │        │
│  │  • RSI or       │  │    FINGER       │  │    (above       │        │
│  │    surgical if  │  │    THORACOST-   │  │    diaphragm)   │        │
│  │    needed       │  │    OMIES        │  │  • MTP blood    │        │
│  │  • 100% O2      │  │  • Decompress   │  │  • External     │        │
│  │                 │  │    both sides   │  │    haemorrhage  │        │
│  │                 │  │    NOW          │  │    control      │        │
│  │                 │  │                 │  │  • Pelvic       │        │
│  │                 │  │                 │  │    binder       │        │
│  └─────────────────┘  └─────────────────┘  └─────────────────┘        │
└─────────────────────────────────────────────────────────────────────────┘
                                    ↓
┌─────────────────────────────────────────────────────────────────────────┐
│                    ASSESS RESPONSE TO INTERVENTIONS                      │
│                                                                         │
│           Signs of Life? (pupils, agonal respirations, ECG)             │
└─────────────────────────────────────────────────────────────────────────┘
              ↓                                           ↓
         YES/Maybe                                        NO
              ↓                                           ↓
┌──────────────────────────────┐          ┌────────────────────────────────┐
│   CONTINUE RESUSCITATION     │          │    ASSESS FOR THORACOTOMY      │
│   • CPR (may now be useful)  │          │                                │
│   • Ongoing MTP              │          │    Penetrating + under 15 min CPR   │
│   • Consider adrenaline      │          │         → THORACOTOMY          │
│   • POCUS for tamponade      │          │                                │
│   • Prepare for OR           │          │    Blunt + under 10 min CPR         │
│   • REBOA if available       │          │         → Consider             │
│                              │          │                                │
│                              │          │    Unwitnessed/prolonged       │
│                              │          │         → CEASE                │
└──────────────────────────────┘          └────────────────────────────────┘
                                                          ↓
                                          ┌────────────────────────────────┐
                                          │    RESUSCITATIVE THORACOTOMY   │
                                          │    (if indicated)              │
                                          │                                │
                                          │    • Clamshell incision        │
                                          │    • Release tamponade         │
                                          │    • Internal cardiac massage  │
                                          │    • Cross-clamp aorta         │
                                          │    • Control haemorrhage       │
                                          └────────────────────────────────┘

Immediate Actions (First 2-3 Minutes)

ALL performed SIMULTANEOUSLY by trauma team:

Bilateral Finger Thoracostomies

Technique:

1. Position: 4th-5th intercostal space, anterior to mid-axillary line
2. Incision: 3-4 cm horizontal incision through skin and subcutaneous tissue
3. Dissection: Blunt dissect through intercostal muscles ABOVE the rib (avoid neurovascular bundle below)
4. Entry: Pop through pleura with forceps, widen hole
5. Confirm: Insert finger to confirm pleural space entry, sweep for adhesions
6. Leave open: Do NOT insert chest tube during arrest - leave open to drain
7. Repeat: Perform on contralateral side immediately

Massive Transfusion Protocol (MTP)

Pharmacology in TCA

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Resuscitative Thoracotomy

Indications (ANZCOR Guideline 11.10.1)

Contraindications

Technique: Clamshell Thoracotomy

Preferred approach in most Australian trauma centres and pre-hospital HEMS services:

                    CLAMSHELL THORACOTOMY
                    
        ┌─────────────────────────────────────┐
        │    1. Position: Supine, arms abducted│
        │    2. Incision: Bilateral 5th ICS   │
        │       anterolateral to midline      │
        │    3. Divide sternum with Gigli saw │
        │       or heavy scissors             │
        │    4. Open chest wide bilaterally   │
        │                                     │
        │         ──────────────────          │
        │        /                  \         │
        │       /    ┌───────┐      \        │
        │      │     │ HEART │       │       │
        │       \    └───────┘      /        │
        │        \________________/          │
        │                                     │
        │    Provides access to:              │
        │    • Heart and pericardium          │
        │    • Both lung hila                 │
        │    • Descending aorta               │
        │    • Great vessels                  │
        └─────────────────────────────────────┘

Step-by-Step:

1. Incision: Bilateral anterolateral thoracotomy through 5th intercostal space, from mid-axillary line to sternum bilaterally
2. Entry: Blunt dissection through intercostal muscles, enter pleural cavity
3. Retraction: Insert rib spreaders bilaterally
4. Sternotomy: Divide sternum transversely with Gigli saw, trauma shears, or Lebsche knife
5. Open pericardium: Longitudinal incision anterior to phrenic nerve
6. Evacuate tamponade: Remove blood and clot
7. Internal cardiac massage: Two-handed technique, compress heart against sternum
8. Control cardiac wounds: Digital pressure, Foley catheter, staples, sutures
9. Cross-clamp aorta: Descending thoracic aorta clamped to maximise coronary/cerebral perfusion
10. Control pulmonary hilum: Clamp if massive lung haemorrhage

Goals of Resuscitative Thoracotomy

Post-Thoracotomy Management

If ROSC achieved:

• Transport immediately to operating theatre
• Ongoing MTP
• Maintain aortic cross-clamp until OR
• Notify cardiothoracic/trauma surgeon
• ICU bed arranged
• Family notification

If no ROSC:

• Continue internal massage for 10-15 minutes with blood products
• If no response → cease resuscitation
• Document time of death
• Family notification
• Consider organ donation if appropriate

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REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta)

Concept

REBOA provides non-invasive aortic occlusion similar to thoracotomy cross-clamping:

• Balloon catheter placed via femoral artery
• Inflated in aorta to occlude distal flow
• Augments coronary and cerebral perfusion
• Bridges patient to definitive surgical haemorrhage control

Zones

Indications in TCA

• Non-compressible torso haemorrhage below diaphragm
• Bridge to surgery when thoracotomy not immediately available
• Alternative to thoracotomy in some centres
• Pelvic haemorrhage uncontrolled by binder

Limitations

• Requires femoral access (may be difficult in arrest)
• Training and equipment requirements
• Time to placement may exceed thoracotomy
• Ischaemia distal to balloon (time-limited)
• Does not address thoracic pathology

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POCUS in Traumatic Cardiac Arrest

Focused Cardiac Assessment

Timing: Perform during 10-second rhythm checks only - do NOT interrupt compressions

FAST Examination

Limitations in TCA:

• Time pressure limits comprehensive examination
• Subcutaneous emphysema may impair image quality
• Minimal fluid may not be visible
• Do NOT delay definitive interventions for imaging

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Specific Scenarios

Penetrating Chest Trauma

Highest priority for resuscitative thoracotomy:

• Stab wound to cardiac box: 35-50% survival with thoracotomy
• Gunshot wound to chest: 10-15% survival
• Immediate thoracotomy if witnessed arrest under 15 min

Key considerations:

• Tamponade most likely reversible cause
• Single stab wound may be amenable to repair
• GSW causes more extensive injury - lower survival
• Epigastric wounds may track to heart via diaphragm

Blunt Chest Trauma

Lower survival but thoracotomy may be indicated:

• Witnessed arrest under 10 minutes
• Massive haemothorax (hilar injury)
• Cardiac rupture (rare but potentially survivable)

Common mechanisms:

• High-speed MVA
• Pedestrian struck
• Falls from height
• Crush injury

Challenges:

• Multi-system injury common
• TBI often present (limits neurological recovery)
• Pelvic fractures with haemorrhage
• Aortic disruption often non-survivable

Haemorrhagic Arrest (Exsanguination)

Management priorities:

1. Massive transfusion protocol (1:1:1)
2. Haemorrhage control (tourniquets, wound packing, pelvic binder)
3. Bilateral thoracostomies (rule out tension)
4. REBOA or thoracotomy with aortic cross-clamp
5. Immediate transfer to OR for damage control surgery

Targets during resuscitation:

• Permissive hypotension (SBP 80-90 until surgical control)
• Avoid crystalloid
• TXA within 3 hours
• Calcium replacement with MTP

Tension Pneumothorax Arrest

Immediate life-saving intervention:

1. Bilateral finger thoracostomies (both sides empirically)
2. May produce immediate ROSC
3. Commence CPR after decompression
4. Insert chest drains if ROSC achieved
5. Standard post-ROSC care

Clinical tip: If ROSC follows thoracostomy, tension was likely the cause.

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Termination of Resuscitation

Criteria for Cessation

Documentation

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Viva Practice

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OSCE Scenarios

Resuscitation Station: Traumatic Cardiac Arrest

Format: Resuscitation leadership Time: 11 minutes Setting: ED resuscitation bay

Candidate Instructions:

A 32-year-old male has been brought in by ambulance after being struck by a car while cycling. He arrested 7 minutes ago. CPR is in progress. You are the team leader. Lead the resuscitation.

Resources Available:

• 2 nurses, 1 registrar, 1 resident
• Full resuscitation equipment including thoracotomy tray
• Defibrillator
• Ultrasound
• O-negative blood available (MTP activated)

Expected Actions:

1. Assume team leader role clearly
2. Recognise TCA requires different algorithm
3. Allocate team roles appropriately
4. Order bilateral finger thoracostomies immediately
5. Activate MTP if not already done
6. Order blood products (not crystalloid)
7. Systematic assessment of reversible causes
8. Perform or order POCUS during rhythm check
9. Make appropriate thoracotomy decision based on timing and signs of life
10. Demonstrate closed-loop communication throughout
11. Appropriate termination decision if indicated

Marking Criteria:

Common Errors:

• Treating as medical cardiac arrest with focus on adrenaline
• Delaying thoracostomies to wait for other interventions
• Using crystalloid instead of blood products
• Not considering thoracotomy when indicated
• Not recognising futility when appropriate

Communication Station: Breaking Bad News After TCA

Format: Communication Time: 11 minutes Setting: Relatives room

Candidate Instructions:

A 25-year-old male was brought in after a motorbike accident. Despite resuscitative thoracotomy, he has died. His mother is waiting in the relatives room. Break the bad news.

Actor Brief: Mother is anxious and expecting good news. Son is her only child. May become distressed and ask difficult questions.

Expected Actions:

1. Introduce yourself and confirm relationship
2. Ensure appropriate setting (private, seated)
3. Warning shot before delivering news
4. Deliver news clearly using word "died"
5. Allow time for response
6. Answer questions honestly
7. Explain what was done (briefly, without graphic details)
8. Offer opportunity to see body
9. Arrange support (social work, chaplain, cultural liaison)
10. Provide contact details for follow-up

Marking Criteria:

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SAQ Practice

Question 1 (8 marks)

A 28-year-old male is brought to the Emergency Department after a stab wound to the left chest. He arrests as he enters the resuscitation bay.

(a) List 4 differences between traumatic cardiac arrest management and medical cardiac arrest management. (4 marks)

Model Answer:

• Priority is reversible cause correction (HOT - Hypovolaemia, Oxygenation, Tension/Tamponade) rather than standard ALS algorithm (1)
• Bilateral finger thoracostomies performed empirically, not just when tension suspected (1)
• Blood products (MTP 1:1:1) are first-line, not crystalloid (1)
• Adrenaline is deprioritised - only after reversible causes addressed (1)
• Chest compressions may be ineffective in empty/obstructed heart (0.5)
• Resuscitative thoracotomy may be indicated (0.5)
• Defibrillation rarely indicated (most are PEA/asystole) (0.5)

(b) What are the indications for resuscitative thoracotomy in this patient? (2 marks)

Model Answer:

• Penetrating chest trauma with witnessed arrest (0.5)
• CPR duration less than 15 minutes (0.5)
• Signs of life within 10 minutes (pupillary response, agonal respirations, cardiac motion, organised ECG) (0.5)
• Trained personnel and equipment available (0.5)

(c) List 4 goals of resuscitative thoracotomy. (2 marks)

Model Answer:

• Release cardiac tamponade (pericardiotomy) (0.5)
• Perform internal cardiac massage (0.5)
• Control cardiac haemorrhage (direct repair) (0.5)
• Cross-clamp descending aorta (augment coronary/cerebral perfusion) (0.5)
• Control pulmonary/hilar haemorrhage (0.5)
• Identify and treat specific injuries (0.5)

Question 2 (6 marks)

A 45-year-old female is involved in a high-speed motor vehicle crash. She is in traumatic cardiac arrest on arrival.

(a) List 3 reversible causes of traumatic cardiac arrest (the "HOT" causes). (3 marks)

Model Answer:

• Hypovolaemia (haemorrhage) (1)
• Oxygenation failure (hypoxia, airway obstruction) (1)
• Tension pneumothorax (1)
• Tamponade (cardiac) (1)

(b) Describe the technique for finger thoracostomy. (3 marks)

Model Answer:

• Position: 4th-5th intercostal space, anterior to mid-axillary line (0.5)
• Incision: 3-4cm horizontal skin incision (0.5)
• Dissection: Blunt dissect through intercostal muscles ABOVE the rib (avoid neurovascular bundle) (0.5)
• Entry: Pop through pleura with forceps or finger (0.5)
• Confirmation: Insert finger to confirm pleural entry, sweep for adhesions (0.5)
• Leave open: Do not insert chest tube during arrest (0.5)
• Bilateral: Repeat on contralateral side (0.5)

Question 3 (6 marks)

Regarding Damage Control Resuscitation in traumatic cardiac arrest:

(a) What is the "lethal triad" of trauma? (3 marks)

Model Answer:

• Hypothermia (1) - impairs coagulation enzyme function
• Acidosis (1) - from tissue hypoperfusion and lactate accumulation
• Coagulopathy (1) - dilutional, consumptive, and dysfunctional

(b) List 3 key principles of damage control resuscitation. (3 marks)

Model Answer:

• Use blood products (1:1:1 ratio) instead of crystalloid (1)
• Permissive hypotension (SBP 80-90) until surgical haemorrhage control (1)
• TXA 1g IV within 3 hours of injury (1)
• Avoid hypothermia (warm products, warm environment) (0.5)
• Calcium replacement to counteract citrate from blood products (0.5)
• Early surgical haemorrhage control (0.5)

Question 4 (6 marks)

A patient with traumatic cardiac arrest has been resuscitated for 20 minutes with no response to bilateral thoracostomies and MTP.

(a) List 4 criteria that would support cessation of resuscitation. (4 marks)

Model Answer:

• Unwitnessed arrest with no signs of life (1)
• Asystole throughout with no response to interventions (1)
• CPR duration exceeding time limits (greater than 15-20 min) without ROSC (1)
• No cardiac motion on POCUS/direct visualisation after thoracotomy (1)
• Non-survivable injuries identified (0.5)
• Blunt mechanism (worse prognosis) (0.5)

(b) What factors would favour continuing resuscitation? (2 marks)

Model Answer:

• Signs of life present (pupillary response, agonal respirations, organised ECG) (0.5)
• Intermittent ROSC (0.5)
• Penetrating mechanism (better prognosis) (0.5)
• Young patient with potentially reversible cause (0.5)
• Witnessed arrest with short downtime (0.5)
• Response to interventions (0.5)

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Australian Guidelines Summary

ANZCOR Guideline 11.10.1 - Traumatic Cardiac Arrest

Key Points:

1. TCA requires modification of standard ALS algorithm
2. External chest compressions often ineffective in hypovolaemia/obstruction
3. Focus on reversible causes (HOT): Hypovolaemia, Oxygenation, Tension/Tamponade
4. Adrenaline is not priority - may worsen bleeding
5. Resuscitative thoracotomy indications:
   • Penetrating trauma: witnessed arrest, under 15 min CPR
   • Blunt trauma: witnessed arrest, under 10 min CPR
6. Termination criteria: No response after reversible causes addressed, unwitnessed with no signs of life

ARC vs International Guidelines

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Remote and Rural Considerations

Pre-Hospital TCA in Rural Australia

Termination in Remote Settings

• Earlier decision point may be appropriate given transport times
• Consult with retrieval coordination centre
• Consider: Would intervention at trauma centre be realistic given transport time?
• Support for local clinical staff after cessation
• Cultural considerations for Indigenous communities

RFDS Considerations

• RFDS cannot manage active cardiac arrest during flight (unsafe, limited space)
• ROSC must be achieved and stable before retrieval
• Early activation essential for time-critical patients
• Telemedicine support available during resuscitation
• Post-ROSC retrieval to trauma centre for definitive care

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Indigenous Health Considerations

Important Note: Aboriginal, Torres Strait Islander, and Maori Considerations for TCA:

Health Disparities in Trauma

Aboriginal and Torres Strait Islander Australians:

• 3-5 times higher motor vehicle trauma mortality
• 10-15 times higher assault-related trauma
• Higher rates of alcohol-related trauma
• Remote location of many communities
• Delayed access to trauma services

Maori (New Zealand):

• 2-3 times higher trauma mortality than non-Maori
• Higher rates of interpersonal violence
• Similar rural/remote access challenges

Cultural Considerations in TCA

During Resuscitation:

• Family may wish to be present - facilitate if appropriate
• Aboriginal Health Worker involvement valuable
• Cultural protocols may affect approach to invasive procedures
• Some communities have beliefs about body integrity

After Death:

• "Sorry Business" protocols in Aboriginal communities
• Extended family notification may be required before formal processes
• Culturally appropriate viewing of body
• Sensitivity around organ/tissue donation discussions
• Some communities have rapid burial requirements
• Men's and women's business protocols may apply

Communication Principles:

• Use interpreter services for language barriers
• Allow time for family/community consultation
• Respect silence as consideration, not confusion
• Involve cultural liaison officers early
• Eye contact may be culturally inappropriate in some communities
• Extended family elders may need to be included in discussions

Practical Considerations:

• Remote communities: Delayed EMS, limited resources
• May need to transport body long distances for family
• Community grief support services
• Support for Aboriginal Health Workers who may know deceased personally
• Consider telehealth for specialist family support

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Pitfalls and Pearls

Common Mistakes (Avoid These)

Clinical Pearls

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References

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2. Sherren PB, Reid C, Habig K, Burns BJ. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service. Crit Care. 2013;17(2):308. PMID: 23510195
3. Beck B, Bray J, Cameron P, et al. Epidemiology of traumatic out-of-hospital cardiac arrest in Australia. Emerg Med Australas. 2019;31(5):813-820. PMID: 30942948
4. Deasy C, Bray J, Smith K, et al. Traumatic out-of-hospital cardiac arrests in Melbourne, Australia. Resuscitation. 2012;83(4):465-470. PMID: 22155306
5. Australian Resuscitation Council. ANZCOR Guideline 11.10.1 - Management of Traumatic Cardiac Arrest. 2021.
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12. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework. 2022.
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14. CRASH-2 Trial Collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23-32. PMID: 20554319
15. Huber-Wagner S, Lefering R, Qvick M, et al. Outcome in 757 severely injured patients with traumatic cardiorespiratory arrest. Resuscitation. 2007;75(2):276-285. PMID: 17574721
16. Kleber C, Giesecke MT, Lindner T, et al. Requirement for a structured algorithm in cardiac arrest following major trauma: epidemiology, management errors, and preventability of traumatic deaths in Berlin. Resuscitation. 2014;85(3):405-410. PMID: 24361673
17. Willis CD, Cameron PA, Bernard SA, et al. Cardiopulmonary resuscitation after traumatic cardiac arrest is not always futile. Injury. 2006;37(5):448-454. PMID: 16476433
18. Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359-1363. PMID: 23188227
19. Morrison JJ, Rasmussen TE. Noncompressible torso hemorrhage: a review with contemporary definitions and management strategies. Surg Clin North Am. 2012;92(4):843-858. PMID: 22850150
20. Brenner ML, Moore LJ, DuBose JJ, et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg. 2013;75(3):506-511. PMID: 24089121
21. Tsou PY, Ma YK, Wang YH, et al. Diagnostic accuracy of point-of-care ultrasound for traumatic hemothorax and pneumothorax: a systematic review and meta-analysis. Am J Emerg Med. 2021;47:246-257. PMID: 33940471
22. Cureton EL, Yeung LY, Kwan RO, et al. The heart of the matter: utility of ultrasound of cardiac activity during traumatic arrest. J Trauma Acute Care Surg. 2012;73(1):102-110. PMID: 22743379
23. Inaba K, Chouliaras K, Zakaluzny S, et al. FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation. Ann Surg. 2015;262(3):512-518. PMID: 26258321
24. Sperry JL, Guyette FX, Brown JB, et al. Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock. N Engl J Med. 2018;379(4):315-326. PMID: 30044935
25. Duchesne JC, Barbeau JM, Islam TM, et al. Damage control resuscitation: from emergency department to the operating room. Am Surg. 2011;77(2):201-206. PMID: 21337881
26. Cotton BA, Reddy N, Hatch QM, et al. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg. 2011;254(4):598-605. PMID: 21918426
27. Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011;71(6):1869-1872. PMID: 22182896
28. DuBose JJ, Scalea TM, Brenner M, et al. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg. 2016;81(3):409-419. PMID: 27050883
29. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012;147(2):113-119. PMID: 22006852
30. Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma-a review. Injury. 2006;37(1):1-19. PMID: 16410079
31. Narayan N, Bauer JJ, Ray CE Jr. Resuscitative endovascular balloon occlusion of the aorta (REBOA). Semin Intervent Radiol. 2020;37(1):8-12. PMID: 32140018
32. Lockey DJ. Prehospital resuscitative thoracotomy: do it or bin it? Resuscitation. 2020;151:171-173. PMID: 32325123
33. Mitra B, Mathew J, Fitzgerald M, et al. Topical tranexamic acid in major trauma: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2020;89(2):419-427. PMID: 32282770
34. Evans CC, Petersen A, Meier EN, et al. Prehospital traumatic cardiac arrest: Management and outcomes from the resuscitation outcomes consortium epistry-trauma and PROPHET registries. J Trauma Acute Care Surg. 2016;81(2):285-293. PMID: 27027553
35. Smith JE, Rickard A, Wise D. Traumatic cardiac arrest. J R Soc Med. 2015;108(1):11-16. PMID: 25572990
36. Pickens JJ, Copass MK, Bulger EM. Trauma patients receiving CPR: predictors of survival. J Trauma. 2005;58(5):951-958. PMID: 15920408
37. Truhlář A, Deakin CD, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation. 2015;95:148-201. PMID: 26477412
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Equipment Checklist for TCA

Resuscitation Bay Setup

Thoracotomy Tray Contents

Blood Product Preparation

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Procedure Guides

Finger Thoracostomy - Step by Step

Indication: All traumatic cardiac arrest patients (bilateral, empiric)

Position: Patient supine, arm abducted if possible

Anatomical Landmarks:

• 4th-5th intercostal space
• Anterior to mid-axillary line
• Approximately nipple level (male), inframammary fold (female)
• Above the rib to avoid intercostal neurovascular bundle

Procedure:

Step 1: Identify landmarks
        4th-5th intercostal space, anterior axillary line
        Palpate ribs to confirm space
                    ↓
Step 2: Skin incision
        3-4cm horizontal incision through skin
        Use No.10 blade
                    ↓
Step 3: Subcutaneous dissection
        Blunt dissection through fat layer
        Identify intercostal muscles
                    ↓
Step 4: Muscle dissection
        Blunt dissect through intercostal muscles
        Stay ABOVE the lower rib (avoid NVB)
        Use curved forceps or finger
                    ↓
Step 5: Pleural entry
        "Pop" through parietal pleura
        May hear rush of air (tension) or blood (haemothorax)
        Widen hole with forceps
                    ↓
Step 6: Digital exploration
        Insert finger through hole
        Sweep 360° to confirm pleural space
        Feel for adhesions, lung, diaphragm
        Evacuate accessible clot
                    ↓
Step 7: Leave open
        DO NOT insert chest drain during arrest
        Leave hole open for ongoing drainage
        Drain can be inserted after ROSC
                    ↓
Step 8: Repeat contralaterally
        Perform same procedure on opposite side
        Both sides decompressed within 60-90 seconds

Complications:

• Lung laceration (uncommon with finger technique)
• Intercostal vessel injury (stay above rib)
• Diaphragm injury (stay above 5th ICS)
• Infection (rare in emergency setting)

Documentation:

• Time performed
• Side(s) performed
• Findings (air rush, blood, lung sliding)
• Response (ROSC, improved ventilation)

Clamshell Thoracotomy - Step by Step

Indication: Witnessed TCA meeting thoracotomy criteria

Position: Supine, arms abducted, full chest exposed

Procedure:

Step 1: Bilateral anterolateral thoracotomy
        • Incision from mid-axillary line to sternum bilaterally
        • Through 5th intercostal space
        • Use scalpel through skin, scissors through muscle
        • Enter pleural space bilaterally
                    ↓
Step 2: Insert rib spreaders
        • Place Finochietto retractors bilaterally
        • Open both sides of chest wide
        • Adequate exposure to both pleural cavities
                    ↓
Step 3: Divide sternum
        • Use Gigli saw, Lebsche knife, or heavy scissors
        • Transverse cut through sternum
        • Creates "clamshell" opening
        • Full exposure to heart and mediastinum
                    ↓
Step 4: Open pericardium
        • Identify pericardium anterior to heart
        • Longitudinal incision ANTERIOR to phrenic nerve
        • Incise from diaphragm to great vessels
        • Evacuate blood and clot (tamponade release)
                    ↓
Step 5: Internal cardiac massage
        • Two-handed technique preferred
        • Compress heart between palms against sternum
        • Rate approximately 80-100/min
        • Effective stroke volume assessment
                    ↓
Step 6: Identify and control cardiac wounds
        • Direct visualisation of heart
        • Digital pressure for active bleeding
        • Horizontal mattress suture with pledgets
        • Or Foley catheter through wound
                    ↓
Step 7: Cross-clamp descending aorta
        • Identify descending thoracic aorta
        • Apply large aortic clamp
        • Augments coronary and cerebral perfusion
        • May be maintained for up to 30-40 min
                    ↓
Step 8: Control pulmonary hilum if needed
        • If massive lung haemorrhage identified
        • Clamp or twist hilum to control bleeding
        • Formal lobectomy may be needed in OR
                    ↓
Step 9: Assess for ROSC
        • Look for organised cardiac activity
        • Palpate aorta for pulse
        • If ROSC → immediate OR transfer
        • If no ROSC after 10-15 min → consider cessation

Post-Procedure if ROSC:

• Maintain pericardium open (prevent re-tamponade)
• Continue internal massage or allow spontaneous rhythm
• Keep aortic clamp in place until OR
• Transfer immediately to operating theatre
• Continue MTP throughout

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Additional Viva Scenarios

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Zones

• Front: What are the REBOA zones and indications?
• Back: Zone I (descending thoracic aorta) - abdominal/pelvic haemorrhage; Zone III (infrarenal aorta) - pelvic/junctional haemorrhage. Zone II (visceral vessels) - avoid.

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Summary

Traumatic cardiac arrest requires a fundamentally different approach to medical cardiac arrest. The key principles are:

1. Different algorithm: Focus on reversible causes (HOT - Hypovolaemia, Oxygenation, Tension/Tamponade) rather than standard ALS

2. Simultaneous interventions: Bilateral finger thoracostomies, MTP activation, haemorrhage control all occur in parallel

3. Blood not crystalloid: Damage control resuscitation with 1:1:1 ratio blood products

4. Resuscitative thoracotomy: Consider for witnessed arrest with penetrating (under 15 min) or blunt (under 10 min) mechanism

5. Prognostic factors: Penetrating mechanism, witnessed arrest, signs of life, and short transport time predict survival

6. Know when to stop: Unwitnessed arrest with no signs of life and prolonged CPR is futile

Australian survival rates have improved to 7-12% overall with aggressive modern protocols, and penetrating thoracic trauma with early thoracotomy can achieve 35-50% survival. The ACEM trainee must understand the TCA algorithm, be able to perform bilateral thoracostomies, and make appropriate decisions about resuscitative thoracotomy and termination of resuscitation.