AUTISMO TEA PDF

AUTISMO TEA PDF
TRASTORNO ESPECTRO AUTISMO y URGENCIAS PDF

ULTIMO SOBRE 2019-nCoV

ULTIMO SOBRE 2019-nCoV
CORONAVIRUS covid-19

VISITAS RECIENTES

We Support The Free Share of the Medical Information

EMS SOLUTIONS INTERNATIONAL

Facebook Dr. Ramon Reyes, MD

6 años con el Sello HONcode

6 años con el Sello HONcode
Health on the Net

Nota Importante

Aunque pueda contener afirmaciones, datos o apuntes procedentes de instituciones o profesionales sanitarios, la información contenida en el blog EMS Solutions International está editada y elaborada por profesionales de la salud. Recomendamos al lector que cualquier duda relacionada con la salud sea consultada con un profesional del ámbito sanitario. by Dr. Ramon REYES, MD

sábado, 24 de febrero de 2018

Integrated Tourniquet System (I.T.S.) SISTEMA DE TORNIQUETE INTEGRADO


Integrated tourniquet system

Actualmente, y debido a los nuevos sistemas de protección pasiva que portan las tropas, se ha conseguido disminuir la incidencia de lesiones en tórax y abdomen, pero no así las posibilidades de morir como consecuencia de las heridas en las extremidades. En el campo de batalla de hoy, el uso de artefactos explosivos improvisados ha demostrado cuán peligrosas pueden ser las lesiones por metralla. Una laceración de las principales arterias situadas en los miembros superiores o inferiores puede causar la muerte rápidamente, a menos que se aplique de modo precoz un torniquete. Lo más novedoso en relación a este tema es el ITS, desarrollado por una empresa norteamericana. La idea básicamente es la de integrar torniquetes en el uniforme del combatiente, disminuyendo considerablemente el tiempo de aplicación de éstos.


El diseño que actualmente se encuentra en fase de experimentación, consta de 2 torniquetes en cada manga de la camisa y otros 2 en cada pernera del pantalón (fig. 7). De este modo, se facilita el rápido control de la hemorragia, si se produjera, por parte del mismo combatiente herido o ayudado por un compañero, ahorrando un tiempo muy valioso en el tratamiento de las lesiones, probablemente aumentando la supervivencia y disminuyendo las pérdidas por sangrado.

 Integrated Tourniquet System (I.T.S.)


Blackhawk's Integrated Tourniquet System (I.T.S.) is part of the new Warrior Wear apparel line with life-saving potential. Four tourniquets in the pants and four tourniquets in the shirt (two in the short sleeve version) are correctly positioned and oriented to the upper and lower extremities for immediate access under existing gear and can be operated by the wearer, their buddy, or a medic. Immediate application minimizes loss of blood, the single greatest medical problem resulting in death from injuries sustained to the extremities. An additional feature includes a design that allows users to train with the system over and over rather than having to replace each tourniquet after a single use.


 Integrated Tourniquet System (I.T.S.)
 Integrated Tourniquet System (I.T.S.)

 Integrated Tourniquet System (I.T.S.)

 Integrated Tourniquet System (I.T.S.)
Curso TECC TACTICAL EMERGENCY CASUALTY CARE. TACMED Tactical Medicine

viernes, 23 de febrero de 2018

50 years 911 emergency number / 50 años numero de emergencias 911

50 years 911 emergency number / 50 años numero de emergencias  911
50 años del 911

Les esperamos en Nuestro Grupo en TELEGRAM 
Sociedad Iberoamericana de Emergencias https://t.me/joinchat/FpTSAEHYjNLkNbq9204IzA


El Numero 911 nacio el 16 de Febrero del año 1968, en Haleyville. Alabama EUA. 

 50 years of 911: The small town that revolutionized emergency response
"Hello?" answered Alabama Rep. Tom Bevill on Feb. 16, 1968, during the first-ever test call of the 911 emergency system that's now been in use for decades nationwide.
By Daniel Uria  |  Feb. 16, 2018 
50 years 911 emergency number / 50 años numero de emergencias  911

The president of a rural telephone company took the initiative to establish the first 911 emergency system in a small northwest Alabama town exactly 50 years ago Friday.

At 2 p.m. on Feb. 16, 1968, in Haleyville, Ala., Speaker of the Alabama House Rankin Fite made the first 911 call -- from Haleyville Mayor James Whitt's office to U.S. Rep. Tom Bevill, who answered the test call with a "hello?" on a bright red phone in the police station.

The call was the very first use of the now-universal three-digit emergency number that quickly connects Americans in distress to dispatchers and first responders.

"It doesn't matter where you are from or where you are at -- 911 is the universal emergency phone number," Haleyville Chamber of Commerce President Mike Evans told UPI. "Personally, I think all Alabamians -- especially in Haleyville -- swell with pride knowing that the work and ingenuity to make this idea a reality came to fruition here."

After settling on the numbers "9-1-1" -- three digits that weren't already in use for any phone number or area code -- the U.S. Federal Trade Commission and carrier AT&T set out to build the first emergency phone system in Huntington, Ind.

Bob Gallagher, president of Alabama Telephone Co., read about the FTC-AT&T plan in the Wall Street Journal and decided it was Haleyville -- a town of about 4,000 residents located 65 miles northwest of Birmingham -- that should try the system first.

"Bob was a little offended because the independent telephone companies had not been included in the decision," Haleyville Mayor Ken Sunseri, James Whitt's son-in-law, told Alabama Newscenter. "He got with his inside plant manager, Robert Fitzgerald, and they evaluated the company's 27 phone systems and chose Haleyville as the site where it made sense to make the first 911 call."

After quick approval from Continental Telephone and the Alabama Public Service commissioner, Gallagher announced on Feb. 9, 1968, that the Alabama Telephone Company would make history.

Fitzgerald and his team traveled from Fayette to Haleyville, where they worked overnight throughout the following week to lay the foundation for the system that would revolutionize emergency response services -- and become a household number nationwide.

Nome, Alaska, was next to implement a 911 service on Feb. 22, 1968 -- and in March 1973, the White House's Office of Telecommunications issued a national policy statement encouraging nationwide adoption of 911, according to the National Emergency Number Association.

"I don't think that anybody realized the effect that it would have nationwide," Sunseri told UPI. "There's over 200 million 911 calls made yearly. When people are in need, whether they need police, fire, ambulance or medical, this is the first line they call in some of the worst times people have in their lives."

"In the decades since the first 911 call, emergency communications services have improved and expanded to better respond to accidents, disasters, public safety threats, health emergencies, and other life-threatening situations," the White House said Friday in a presidential message commemorating 911 Telecommunicators Day. "Today, 911 services are available to roughly 97 percent of the geographic United States. Advances in technology have made this system more widespread, precise, and efficient -- enabling dispatchers to provide rapid response and timely assistance when the difference between life and death can be only a matter of seconds.

"Though we rarely see these heroes, we witness their around-the-clock devotion, and we owe them our deepest gratitude and appreciation for all that they do."

Nearly five decades after it made history, Haleyville again found itself at the center of another advancement in 911 technology. Last October, it placed the first call of Alabama's statewide Internet protocol-based Next Generation 911 network.

"Alabama has always been on the forefront when it comes to 911," Winston County 911 Communications Director James Webb, whose uncle laid telephone line for the first 911 system, said. "We count that kind of a unique opportunity to be part of history being made again in the same place where it started 50 years ago."

To mark its role in history, Haleyville holds a "911 Festival" every year during the first weekend in June. The event remembers the historic call and celebrates its local first responders.

"Many of our local companies and employers are local families that stepped out with a spirit of adventure and were driven by a good idea and the desire to succeed," Evans said. "We like to think that innovation is not reserved for a special part of the country -- and not limited by the grandeur of the vision, but the lack thereof." 

50 years 911 emergency number / 50 años numero de emergencias  911


 https://www.upi.com/50-years-of-911-The-small-town-that-revolutionized-emergency-response/3811518491798/

jueves, 22 de febrero de 2018

Unidades de Neonatología Estándares y recomendaciones de calidad


Unidades de  Neonatología  Estándares y recomendaciones de calidad 
Ministerio de Sanidad, Servicios Sociales e Igualdad. España 2014

Grupo en TELEGRAM Sociedad Iberoamericana de Emergencias
https://t.me/joinchat/FpTSAEHYjNLkNbq9204IzA

Enlace para descargar PDF gratis 


miércoles, 21 de febrero de 2018

Farmacocinetica y Farmacodinamica Presentacion PDF


La farmacocinética es la rama de la farmacología que estudia los procesos a los que un fármaco es sometido a través de su paso por el organismo. Trata de dilucidar qué sucede con un fármaco desde el momento en el que es administrado hasta su total eliminación del cuerpo.
Para ello, se han desarrollado diferentes modelos que simplifiquen los numerosos procesos que tienen lugar entre el organismo y el fármaco. Aun cuando dentro de los mismos el modelo policompartimental es el más próximo a la realidad, la complicación que conlleva ha hecho que sean los modelos monocompartimental y en todo caso el bicompartimental los más usados. Desde esos prismas, el estudio detallado de los sucesivos pasos que atraviesa el fármaco en el organismo, se agrupan con el acrónimo LADME:
  • Liberación del producto activo,
  • Absorción del mismo,
  • Distribución por el organismo,
  • Metabolismo o inactivación, al ser reconocido por el organismo como una sustancia extraña al mismo, y
  • Excreción del fármaco o los residuos que queden del mismo.
Estas distintas fases, implican la utilización y manejo de conceptos básicos para comprender la dinámica instaurada. Así, las propiedades de las sustancias que actúan como excipientes, las características de las membranas biológicas y la forma en que las sustancias pueden atravesarlas, o las características de las reacciones enzimáticas que inactivan al fármaco, son de necesario conocimiento para la correcta comprensión de la cinética del fármaco.
Todos estos conceptos se pueden representar mediante fórmulas matemáticas que tienen su correspondiente representación gráfica. De esta manera se puede conocer tanto las características de una molécula, como la manera en que se comportará determinado fármaco conociendo algunas de sus características básicas. Así, el conocimiento del pKa, su biodisponibilidad o hidrosolubilidad, orienta sobre su capacidad de absorción o distribución en el organismo.
Las gráficas resultantes del estudio de un fármaco tienen valor trascendente en aplicaciones en la industria (cálculos de bioequivalencia en el diseño de fármacos genéricos, por ejemplo) o en la aplicación clínica de los conceptos farmacocinéticos. En efecto, la farmacocinética clínica provee abundantes pautas de actuación para el correcto manejo de los fármacos, buscando el máximo de efectividad y utilidad para los profesionales de la medicina humana y veterinaria.


martes, 20 de febrero de 2018

H VENT Vented Chest Seal Winner of 2017 EMSWORLD Innovation Award!

H&H Medical introduces the newest product in our line of hydrogel chest dressings, the H*VENT vented chest dressing. Like our world-class Bolin Chest Seal, the H*VENT has been designed to work to relieve pressure from an open chest wound due to air in the chest (pneumothorax) or bodily fluid (hemothorax). 
Key features of the H*VENT include:
  1. A unique multi-directional vented dressing. This allows the fluids to “Drain towards gravity”. Important because that means casualty can be transported on their side, etc.
  2. The design helps prevent occlusion. This provides a backup fail-safe system since there are 6 ports. Even if 5 become obstructed, the vent will remain fully operational.
  3. The unique dome membrane design creates a complete seal around the wound area, ensuring a complete seal around the wound and reducing the risk of air or fluid finding alternate paths.
  4. Large vent openings on the H*VENT allows for visual monitoring of the wound. The dome design gives quick indication of air or fluid leaving the chest (billows up) or when the seal is in place (sucks down).
  5. Proven in internal testing to retain a seal during inhalation and to maintain a sustainable negative pressure (below ambient pressure) within the pleural space.
  6. Lowest profile of any vented chest seal and easy to fold.
The H*VENT vented chest dressing will be sold in single packs and a twin-pack.


H VENT Vented Chest Seal Winner of 2017 EMSWORLD Innovation Award!


The Trip Report: Pediatric Education in EMS by EMSWORLD.com

The Trip Report: Pediatric Education in EMS by EMSWORLD.com

Grupo en TELEGRAM Sociedad Iberoamericana de Emergencias https://t.me/joinchat/FpTSAEHYjNLkNbq9204IzA

Download in PDF for free


The Trip Report: Pediatric Education in EMS


Turning Research Into Practice: Dr. Seth Brown and his coauthors recently published a manuscript examining pediatric education for EMS providers. This is a great opportunity to discuss a study design not often utilized in EMS or medical literature: the qualitative study. www.emsworld.com/12319193

REVIEWED THIS MONTH: Brown SA, Hayden TC, Randell KA, Rappaport L, Stevenson MD, Kim IK. Improving Pediatric Education for Emergency Medical Services Providers: A Qualitative Study. Prehosp Disaster Med, 2017 Feb; 32(1): 20–26.
This month is dedicated to educational research. Dr. Seth Brown and his coauthors recently published a manuscript examining pediatric education for EMS providers. This is a great opportunity to discuss a study design not often utilized in EMS or medical literature: the qualitative study.
Most research published in EMS and other medical literature involves quantitative studies. Quantitative studies rely on numbers to examine statistical significance. Qualitative studies don't rely on calculations; they gather information from unstructured interviews, focus groups, diaries and other methods. The information is explained, contextualized and often grouped into categories. Qualitative studies often generate hypotheses that can be tested in future quantitative studies.
Examining Education
As we are all well aware, pediatric patients make up a very small number of 9-1-1 calls. While it's fantastic that children aren't often sick or injured enough to account for a large percentage of EMS calls, this does leave us at a disadvantage when we're asked to care for a child. Many EMS providers just don't have the field experience, which makes our initial and continuing education on pediatric care that much more important.
With that in mind, the authors of this study utilized focus groups to understand how EMS providers in Kentucky felt about deficits in EMS pediatric education. They also sought to come up with suggestions on ways to improve pediatric education and training. They worked with the state EMS system to identify focus group participants. Training officers were contacted by the study team and asked to invite potential participants from their agency.
The authors chose to have separate focus groups for EMS providers who worked in urban, suburban and rural areas. They also held separate focus groups for administrative and nonadministrative personnel. We all know there are urban and rural differences, and a paramedic might not be so open to identifying deficits (in other words, criticizing) the con ed provided by their agency with their boss in the room.
They had a total of six focus groups (one for administrators and one for field providers in each of the three community types). They limited the focus groups to a maximum of 10 participants. This was also a good idea; it can get very difficult to moderate a focus group with too many participants. The focus groups lasted a total of 90 minutes and were audio-recorded and professionally transcribed.
Now, you might be thinking a maximum of 10 participants each in six focus groups would mean the study drew conclusions from just 60 people. In fact, the total number of participants was 42. Yes, compared to most EMS literature we will review here, that is a very small number. You may remember a couple months ago we reviewed a study with over 2,000 cases. Qualitative studies don't need to rely on large numbers. Actually, they typically never have a study population that is very large. This study design allows you to get a lot of in-depth information from a small number of participants.
One really interesting part of this study was that they used a "professional moderator." This was a great way to prevent any bias the study team may have from their familiarity with EMS pediatric education from altering the opinions of the focus group participants. This often adds cost to the study.
Analyzing the Data
Now we'll discuss the most difficult part of qualitative research, data analysis. In quantitative research, when you are ready to analyze your data, what is probably the most difficult part of the study (obtaining enough data to analyze) is over. In qualitative research, you have to review every focus group meeting multiple times and read notes and transcripts to come up with consistent messages, themes and categories. Luckily this is a science, so there are tested methods and strategies to analyze qualitative data. We don't have enough space to review each of these here, but an overly simplified explanation is that the authors listened to every audio recording and read every transcript multiple times until they could identify overarching categories. They drilled down on these categories to combine ideas and thoughts that were very similar. Finally they took some steps to make sure that they all agreed on the results.
When all that work was done, they were left with four major themes for deficits in pediatric EMS education: 1) suboptimal previous pediatric training and training gaps in continuing education; 2) opportunities for improved interactions with ED staff, including case-based feedback on patient care; 3) barriers to optimal pediatric prehospital care; and 4) proposed pediatric training improvements.
Under the theme of suboptimal previous pediatric training and training gaps in continuing education, the authors found PowerPoint may be overused in pediatric education, and participants reported that educators are often not very familiar with the material or how care is provided to peds in the prehospital environment.
The theme of opportunities for improved interactions with ED staff focused largely on the desire of EMS providers to know the outcomes of the patients they cared for and the difficulty with obtaining that information from the ED.
The barriers to optimal pediatric prehospital care simply restated that EMS providers don't see children very often, and when they did the focus group participants didn't feel like they were provided enough guidance on how to care for complicated patient scenarios.
Finally, proposed pediatric training improvements included increasing the frequency of training, increasing hands-on time with pediatric patients, more shadowing and observation of pediatric emergency care providers, and increasing specific content areas of medication dose calculations and administrations, IV access, airway management and resuscitation.
From these four themes the authors came up with five hypotheses they felt could improve pediatric patient care:
  • More online training may help fulfill training needs;
  • Obtaining more feedback in the ED;
  • Implementing a more standardized pediatric training;
  • Increasing training in airway maintenance, IV access, drug calculations and medication administration;
  • Targeted education on special-needs and medically fragile children.
Interestingly, the authors also stated that this study was the first to identify and publish that there are concerns regarding patient handoffs from EMS providers to ED staff. This is an unfortunate error and highlights the importance of a thorough literature review. Patient handoffs have been addressed in medical literature prior to the publication of this study. The American College of Emergency Physicians has discussed the importance of an appropriate patient handoff, and we even reviewed a paper on patient handoffs in this column last month. It is possible the authors' claim was true in 2013 when the focus groups took place, but in 2017, when this paper was published, this study is not the first to discuss the importance of patient handoffs.
Finally, the authors stated that they used a professional moderator and a professional to transcribe the meetings. Unless the group of MDs and PhDs that authored this study have had this professional training, they had to pay someone. Since they specifically state these services were used to reduce bias, it's unlikely the authors did this work. They do not list a funding source for the study. Specifying a funding source, if one was used, is extremely important to put these results into context. If this study was funded by a company that produces standardized online pediatric training, we might think differently about its conclusions. I am not suggesting the authors are trying to hide anything, but I am suggesting this information should have been included in the manuscript.
Antonio R. Fernandez, PhD, NRP, FAHA, is the research director at the EMS Performance Improvement Center and an assistant professor in the Department of Emergency Medicine at the University of North Carolina–Chapel Hill. He has been a nationally certified paramedic since 2005 and completed the EMS Research Fellowship at the National Registry of Emergency Medical Technicians.

sábado, 17 de febrero de 2018

Prehospital Traumatic Cardiac Arrest "An Evidence-Based Review" By Matthew Chinn, MD , M. Riccardo Colella, DO, MPH

Prehospital Traumatic Cardiac Arrest "An Evidence-Based Review"
By Matthew Chinn, MD , M. Riccardo Colella, DO, MPH
Blog by Dr. Ramon Reyes, MD

Photo courtesy Dave Rynders An Evidence-Based Review of Prehospital Traumatic Cardiac Arres

An Evidence-Based Review of Prehospital Traumatic Cardiac Arrest



 By  , 
"Medic 1, please respond to 123 Maple Tree Drive for a gunshot wound."
After a short drive, you arrive at a scene that has been secured by police to see a young male lying supine in the middle of the road with several gunshot wounds to his chest. He yells "help me" several times before going unresponsive. You check for a pulse and find none.
What interventions should be considered? Are advanced cardiac life support (ACLS) medications and guidelines appropriate to follow? Should you transport the patient in cardiac arrest if the nearest trauma center is five minutes away? What about 20 minutes away?

Current Guidelines

Unintentional injuries are the fourth most common cause of death among all, and the most common among children and young adults.1 Although many systems have established trauma care guidelines, the management of traumatic cardiac arrest often is inconsistent and variable. The issue of futility in the resuscitation of a traumatic cardiac arrest is one that is often brought up when discussing the merits of resuscitation.
The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma (NAEMSP/ASCOT) stated in their consensus guidelines in 2012 that "termination of resuscitation may be considered when there are no signs of life and there is no return of spontaneous circulation despite appropriate field EMS treatment that includes minimally interrupted cardiopulmonary resuscitation (CPR)."2

Airway management and fluid administration are generally considered standard of care; however, the NAEMSP/ASCOT recommendations are limited by the fact that "further research is appropriate to determine the optimal duration of CPR prior to terminating resuscitative efforts" and that "appropriate field EMS treatment" isn't uniformly defined. This often leaves field providers with a conundrum of what to do on scene when patients undergo traumatic cardiac arrest.2
The NAEMSP/ASCOT guidelines do offer some objective guidance on withholding resuscitation in patients with "... blunt trauma who, on the arrival of EMS personnel, are found to be apneic, pulseless, and without organized electrocardiographic activity," and in penetrating trauma when "… on the arrival of EMS personnel, are found to be pulseless and apneic and there are no other signs of life, including spontaneous movement, electrocardiographic activity, and pupillary response."3 However, providers will often encounter a patient who doesn't meet these stringent withholding guidelines upon arrival, as they're in pulseless electrical activity (PEA) or have other signs of life, or they may begin treatment on a patient who will then undergo a witnessed cardiac arrest and thus fall into the termination guidelines which are far less well defined.
The lack of adherence to guidelines and provider uncertainty with resuscitation is best highlighted with a study from 2010, which showed that seven (21%) of 33 of the nation's largest cities EMS systems would transport an "asystolic blunt trauma patient emergently" or "leave the transport decision to paramedic judgment" and 15 (46%) would transport an "asystolic penetrating trauma patient." The study also found that 27 (82%) would transport penetrating trauma patients and 20 (61%) would transport blunt trauma patients with persistent ECG activity but no palpable pulses.4
The vagueness in the guidelines combined with competing evidence discussed in this article drives field provider and medical director uncertainty regarding the appropriate field management of traumatic cardiac arrest.


Background

Much of the early prehospital research would seem to show that outcomes of patients in traumatic cardiac arrest were dismal. A study from 1982 found no survivors from blunt or penetrating truncal trauma who underwent CPR for more than three minutes in the prehospital setting.5 In 1993, another study found no survivors from traumatic cardiac arrest who had CPR performed at the scene or during transport. The authors argued that "the wisdom of transporting trauma victims suffering cardiopulmonary arrest at the scene or during transport must be questioned."6 Another study, published in 2003, concluded that patients who had a "combination of no respiratory rate, no systolic blood pressure, and a Glasgow Coma Score of 3 should be declared dead on scene."7
With the published literature arguing against the transport of traumatic cardiac arrest patients, many EMS services took a less aggressive approach to resuscitating patients in traumatic cardiac arrest.
Other studies, however, supported better outcomes for traumatic cardiac arrest patients. A 2007 study reported a survival rate of 19.5% of patients who underwent CPR on scene from traumatic arrest with ROSC and 17.2% in all traumatic cardiac arrest patients. Impressively, the authors also found a survival rate of 7.7% on patients with circulatory and respiratory arrest and a Glasgow coma score of 3 on scene. It's important to note that the German EMS system from which the data were abstracted from utilizes physicians on scene. Also worth considering is that the large proportion of these traumatic arrests (94.3%) were from blunt trauma-interesting given the perceived better outcomes of penetrating trauma that will be discussed later.8
A 2006 study from London Air Ambulance found that 7.5% of patients who underwent traumatic cardiac arrest on scene survived to hospital discharge. The authors argued that under the 2003 NAESMP/ASCOT guidelines, several of their survivors would have met termination criteria, concluding that "outcome [for patients in traumatic cardiac arrest] is still poor but, for reasons that are unclear, better than previously described." It's worth noting that this service also utilizes physicians on scene and several patients underwent scene thoracotomies.9
A 2004 study reviewing patients who underwent traumatic cardiac arrest and were subsequently transported to the ED found that 7.6% of the patients survived to discharge. They also found that "three of our survivors (21.4%) had EMS CPR times greater than 15 minutes, and 93% of survivors exceeded the recommended 15-minute total transportation time." The authors concluded that "the survival of traumatic cardiopulmonary arrest patients cannot be predicted in the urban prehospital setting," and "guidelines may not be applicable to urban systems with rapid transport to a Level 1 trauma center."10
What's important to recognize regarding traumatic arrest is that "survival rates are highly variable depending on the etiology, and traumatic pathologies associated with an improved chance of successful resuscitation include hypoxia, tension pneumothorax and cardiac tamponade."11
Finally, a study from Madrid, Spain, found that return of spontaneous circulation was obtained in 49.1% of traumatic cardiac arrest patients, of which 6.6% obtained a complete neurological recovery. As with other European studies, physicians were integrated into the prehospital response in this study.12
These studies reflect significantly improved survival rates that approach or eclipse the national average for medical cardiac arrests, for which there's little argument about aggressive initial resuscitation. They make the strong argument that more aggressive resuscitation may be supported for traumatic cardiac arrest.
The management futility of traumatic cardiac arrest seems to be more complex than early published guidelines would suggest, and the literature is inconclusive in establishing perfectly sensitive markers for withholding or terminating resuscitation. This competing literature likely leads to the current state of management of traumatic cardiac arrest.

Characteristics

Penetrating vs. blunt traumatic cardiac arrest: Historically, one of the most important factors that should be considered in the management of traumatic cardiac arrest is the etiology of the traumatic cardiac arrest. Penetrating trauma-gunshot wounds and stab wounds in particular-have much better outcomes than blunt traumatic arrest. In fact, the trauma surgical societies' thoracotomy guidelines are notably more aggressive with penetrating trauma than they are with blunt trauma. The Eastern Association for the Surgery of Trauma's guidelines has their strongest recommendation for thoracotomy for penetrating trauma to the thoracic area. The Western Trauma Association's guidelines extend the downtime for consideration of thoracotomy from 10 minutes with blunt trauma to 15 minutes with penetrating trauma. As such, more consideration should be given to load and go transport to a trauma center if penetrating trauma is the etiology, in particular if isolated to the thoracic area and in close proximity to a trauma center.13,14 It should be noted however that there are studies which don't show significant differences or demonstrate similar survival rates in blunt trauma, and that both U.S. trauma surgery guidelines still even suggest thoracotomy as a possible intervention for blunt traumatic arrest patients.8,10,12-14
Rhythm analysis: Traditionally, a patient in asystole has had an extremely poor outcome from traumatic cardiac arrest. The 2013 NAEMSP/ASCOT paper states that "... analysis of the existing literature demonstrates that patients in an asystolic rhythm have extremely low odds of survival (<1 style="border: 0px; font-family: inherit; font-size: 16px; font-style: inherit; font-weight: inherit; margin: 0px; outline: 0px; padding: 0px;" sup="">15
 However, one recent study showed a survival rate of 2.7% in patients with an initial rhythm of asystole, much less than other rhythms, but higher than suggested previously. Other studies show isolated cases of survival as well.10 Certainly these rates are much lower than other rhythms and a few isolated cases do not necessarily refute the general consensus, but they should be noted for completion sake.12
Additionally, several studies show poor outcome in patients with PEA at initial rates< 40 beats per minute with a rate > 40 beats per minute shown to be an independent predictor of survival.10 Patients in wide complex rhythms should be treated with defibrillation as per the American Heart Assocation (AHA) guidelines.16 Significant consideration should be given to medical causes of arrest as well when considering termination in these patients. Outcomes for patients in these wide complex rhythms have been shown to be significantly better than those in asystole or slow PEA.12
Witnessed vs. unwitnessed: Given the above information, unwitnessed traumatic cardiac arrest patients who present in asystole after either blunt or penetrating trauma are unlikely to survive and the current guidelines support withholding resuscitation. Witnessed traumatic cardiac arrest patients will benefit from aggressive attempts at resuscitation on scene including fluids, CPR, and procedural interventions as discussed below, and potentially rapid transport to a trauma center for a select subset of patients. Distance and time to a trauma center for witnessed arrest patients is vital to the decision to transport, as those patients who have extended transport times (i.e., > 10-15 minutes) will likely not fit into the guidelines for thoracotomy. It may be reasonable to manage all unwitnessed traumatic arrest patients on scene due to the inability to establish a downtime and thus the likelihood that they won't not be a candidate for thoracotomy based on U.S. guidelines.

Clinical Controversies

Role of epinephrine: The 2010 AHA Guidelines for CPR and Emergency Cardiovascular Care makes no mention of the use of ACLS drugs in the section on cardiac arrest associated with trauma. Even within the realm of all causes of cardiac arrest, there's much dispute on the efficacy of epinephrine.16
A single randomized controlled trial conducted on the use of epinephrine for all-cause out of hospital cardiac arrest found that patients receiving epinephrine had higher rates of ROSC with no statistically significant improvement in survival to hospital discharge, despite overall higher rates of survival to discharge (1.9% vs. 4.0%). There were several limitations to the study and its authors were unable to recruit their full sample size potentially leading to the lack of statistical significance in their survival to discharge rates. Additionally, this was an all-cause out-of-hospital study of cardiac arrest, with the majority of patients with a cardiac cause cited.17
In a meta-analysis on prehospital use of epinephrine in cardiac arrest, the authors noted increased prehospital ROSC with the use of epinephrine, but no improvement in overall ROSC, hospital admission or survival to discharge.18
A retrospective review on epinephrine administration in children with traumatic cardiac arrest-an isolated study looking at traumatic causes only-found increased rates of ROSC, but no improvement in survival or good neurological outcome.19
Some literature would even suggest a negative effect on tissue perfusion in hemorrhagic shock with the use of epinephrine, and that given the natural rise in catecholamines in hemorrhagic shock, additional vasopressors would be unjustified.20
The evidence on epinephrine use in medical cardiac arrest is equivocal at best, and with the characteristics of traumatic cardiac arrest being very different, it's likely that there's limited to no role for epinephrine in the management of traumatic cardiac arrest.
Role of external compressions: Since the 1960s, external compressions have been the hallmark of management of cardiac arrest. However, much of the early data have been obtained on medical cardiac arrests. Little to no literature currently exists looking at patients in traumatic cardiac arrest.
A study in baboons found that external cardiac compressions increased the systolic blood pressure (BP) in the setting of hemorrhagic shock and in cardiac tamponade. However, these increases in BP were significantly less than the response to their subjects with non-traumatic, normovolemic cardiac arrest. Since the cause of traumatic arrests involve more commonly hemorrhagic shock for which there was less effect, it's thought that more emphasis should be placed on procedural interventions and resuscitation than external cardiac compressions. Additionally, the use of external cardiac compressions on a patient with cardiac tamponade may worsen the cardiac output by increasing the intrapericardial pressure.21,22
A recent best evidence report on the efficacy of chest compressions in children in traumatic cardiac arrest found no direct evidence to answer the question.23 However, the NAEMSP/ASCOT guidelines clearly state that CPR is an integral part of in the management of traumatic arrest.2 At this time, while external cardiac compression has become standard of care and recommended by the national guidelines, there's no direct evidence to support its use and they shouldn't impede procedural interventions in patients with traumatic cardiac arrest which may be of more help.
Transport guidelines: Transportation of patients in cardiac arrest comes with many risks to providers, the patient and the public. The management of medical cardiac arrest patients is relatively uniform and there are minimal differences in the resuscitation of patients in the field vs. in an ED; therefore, it often doesn't make sense to transport medical cardiac arrest patients given the risks of expedient transport and the difficulty of managing a resuscitation in the back of an ambulance.
However, there may be some special circumstances for traumatic arrest patients that suggest transport is beneficial. A 1982 study, for example, found that the prompt transport of patients with penetrating heart injuries resulted in higher rates of survival than those who received resuscitation on scene.24
The argument of transportation revolves around the surgical interventions that may be available in a hospital that aren't available to prehospital providers in the field, such as ED thoracotomy and chest tube insertion. This may be reflected in the improved survival of traumatic arrest patients from the recent European studies which utilize physician providers in the field performing some of these procedures within a short time of cardiac arrest.8,9,12
In the U.S., ED thoracotomy is the surgical procedure of choice for traumatic arrest and something that's rarely an option in the prehospital setting. Although local resources and policy, in particular closeness of a trauma center, should dictate the protocols surrounding the transportation of patients in cardiac arrest, it should be recognized that there may be a role for very selective emergent transportation of patients in traumatic cardiac arrest to hospitals to potentially undergo this procedure. It's reasonable to consider rapid transportation in a subset of patients whose etiology and characteristics include: witnessed arrest, penetrating trauma of thoracic location, and close (10-15 minute) proximity to a trauma center.13,14

Procedural Interventions

Needle thoracostomy: It seems reasonable to strongly consider needle thoracostomy in traumatic cardiac arrest. The incidence of tension pneumothorax in one study of traumatic arrest patients was 5.7%, and the placement of a chest tube was detected as statistically significant in increasing the probability of survival. The authors recommend on-scene chest decompression for patients in traumatic cardiac arrest.8 This was supported by another study that also recommended chest decompression in traumatic cardiac arrest as part of the resuscitation effort.25
The length and size of the catheter is an area of debate regarding this procedure. The traditional use of 14-gauge IV catheters at the standard midclavicular line has come under scrutiny. One study showed that a 5.0 cm catheter would be unlikely to access the pleural cavity in half of adult patients in the standard position. They also found that the 5th intercostal space, midaxillary line was a better option for placement.26 This is supported by a study that showed that a 4.4 cm catheter would be unsuccessful in 50% of trauma patients determined by CT in the standard location.27 Another study showed that the fifth intercostal space was statistically thinner than the traditional second intercostal space in adult cadavers. If using a standard 5.0 cm angiocath, the study's authors found that only 58% of placement at the traditional site would have been successful vs. 100% success at the alternate site.28
Therefore, it should be recommended that providers ensure that they have longer needles than the standard 14-gauge angiocath and access to alternate sites, such as the mid- or anterior axillary line, of decompression to ensure penetration into the pleural cavity. There's also literature to support the more aggressive use of needle decompression in traumatic cardiac arrest as part of the standard resuscitation effort.
Resuscitative thoracotomy: In a review of the current literature in the U.S. regarding resuscitative thoracotomies, the current guidelines suggest that a patient may be a candidate for this procedure if presented within 10-15 minutes of the time of traumatic cardiac arrest and based on mechanism and signs of life.
The Western Trauma Association's data suggests that there were no survivors of blunt trauma with > 10 minutes of prehospital CPR and penetrating trauma with > 15 minutes of prehospital CPR. They support consideration of thoracotomy within that timeframe. They also recognize that case reports exist outside of their data of patient survival beyond their studies time end points and go so far as to criticize the 2003 NAEMSP/ASCOT guidelines as "excessively restrictive."13
The Eastern Association for the Surgery of Trauma published guidelines that remove any time durations of CPR and instead rely on signs of life. They suggest that a thoracotomy is either strongly or conditionally recommended for patients with penetrating injuries both with and without signs of life and blunt trauma with signs of life only.14
These guidelines would seem to support the transport of patients in traumatic cardiac arrest who reside in a short geographical distance from trauma centers with prompt surgical intervention available. For those services with access to physicians in the prehospital setting, as in many of the European literature, prehospital thoracotomy may be supported.8,9,12
Pericardiocentesis: Pericardiocentesis is within the scope of practice of many paramedics. In the setting of pericardial tamponade, it may be used as a temporizing procedure until definitive surgical intervention is made. The available literature is limited in applicability as most literature is hospital based. One study concluded that there remains a limited role for pericardiocentesis in non-trauma centers. This study isn't directly applicable to prehospital providers. For many EDs, the broad application of ultrasound to evaluate the pericardium has led to a decrease in empiric pericardiocentesis. Additionally, it isn't without iatrogenic injury risk, including injury to the myocardium, diaphragm and lung among others.29 The routine application of pericardiocentesis in traumatic cardiac arrest isn't supported in the literature, but should be considered for isolated chest wounds, in particular from stabbing mechanisms.
Ultrasound: The application of ultrasound in the treatment of prehospital traumatic arrest lies in its abilities to diagnose cardiac tamponade, evaluate cardiac activity and evaluate for other chest or abdominal injury. The enhanced focused assessment with sonography in trauma (eFAST) exam includes cardiac, thoracic and abdominal views which may show tamponade, intra-abdominal hemorrhage and even pneumothorax. Additionally, ultrasound may be able to quantify fluid status that may suggest a hypovolemic state and the need for further crystalloid or colloid resuscitation.22 It may also be used to evaluate for cardiac standstill and confirm the decision to terminate resuscitation.
In the U.S., paramedic providers aren't traditionally trained in the use of ultrasound in the field. Recent advances in technology, however, have made ultrasound more accessible to prehospital providers, and several EMS systems around the country have adopted the technology and trained providers. In many countries where physicians are a standard part of the prehospital response, ultrasound has demonstrated clinical advantages that may aid in treatment and assessment of patients in traumatic cardiac arrest.12 It has been shown to be feasible and more reliable in the detection of intra-abdominal hemorrhage and cardiac tamponade compared with standard physical exam and vital sign assessment. Despite this, it should be noted that there's currently no literature that correlates the use of ultrasound to improvement in treatment of
trauma patients.30
Point of care (POC) testing: POC testing is available to limited EMS services in the U.S. Various devices can assess hemoglobin, blood gases, lactic acid, coagulation measures, including thromboelastography, and other lab values. The utility of these devices is limited in traumatic cardiac arrest. They may, however, be useful in monitoring the resuscitation of trauma patients prior to arrest and during resuscitation. TEG and coagulation testing, lactate and other measures have been used as markers of resuscitation for many years to guide a more thoughtful approach to resuscitation of the traumatically injured, however, in the setting of traumatic arrest, there's no current literature to support the use of these tests in the acute prehospital management of the patient.
POC testing may also distract providers from focusing on other tangible interventions. Very few studies can be found looking at the prehospital application of POC devices as a monitor of resuscitation in the prehospital setting with most exploring the feasibility and not patient outcomes.31 Additionally, end-tidal carbon dioxide (EtCO2) has been used to try to predict survival with values < 10 mmHg indicating poor outcomes, albeit with most literature being in medical cardiac arrest. This may be a useful measure as a monitor of resuscitation, with down trending or low levels (< 10mmHg) indicating worsening patient outcomes.

Conclusion & Sample Pathway

Recent literature would suggest that certain patients may benefit from aggressive resuscitation and rapid transport while in traumatic cardiac arrest. There exists some data that offer similar survival rates to those with medical causes of cardiac arrest, albeit many studies done in a different prehospital environment.
Penetrating trauma patients in particular may benefit from load-and-go treatment in some circumstances. Asytolic and slow PEA are indicators of worse outcome; wide complex rhythms should be managed with defibrillation and strong consideration of a medical cause. These rhythms have the highest rates of survival. There's no evidence to support the routine use of epinephrine in traumatic cardiac arrest. External cardiac compressions are standard of care, however, they shouldn't impede the performance of procedural interventions and fluid resuscitation.
The transport of patients in traumatic cardiac arrest is not always contraindicated, and in the right circumstances may offer potential benefit to the patient. At this time, the more aggressive use of needle thoracostomy is supported by evidence. The use of larger angiocaths and alternate sites of approach should be strongly considered to ensure penetration.
Within the areas of ultrasound and point of care testing, there may be future implications, but currently there's a sparse amount of literature to support its regular use in the prehospital setting outside of evaluation for cardiac standstill. There's still a lack of a completely sensitive time frame for which to terminate resuscitation.
We propose a sample pathway based on the evidence, with the understanding that it may not account for isolated cases of survival discussed in the article:
1. Patients meeting the NAEMSP/ASCOT withholding resuscitation guidelines may have no resuscitation started and be declared immediately on scene.
2. If patient develops traumatic arrest from penetrating trauma to thorax, transport immediately to trauma center if within 10 minutes.
3. If patient presents with penetrating traumatic arrest or develops penetrating traumatic arrest not meeting this strict guideline above for transport, initiate resuscitation on scene and transport only with ROSC.
4. If patient presents with blunt traumatic arrest or develops blunt traumatic arrest, initiate resuscitation on scene and transport only with ROSC.
5. Standard resuscitation should include: fluid bolus, procedural interventions (e.g., needle thoracostomy, pericardiocentesis, thoractomy, etc.) as indicated, external cardiac compressions, airway management, and medical direction consultation as per protocol for further management and/or termination order.
6. Consider consultation for termination if all indicated procedural interventions are completed, airway is managed, fluid bolus is administered, the rhythm changes to or is asystole or slow (< 40 beats per minute) PEA, EtCO2 is < 10 mmHg, and/or downtime is > 15 minutes.

Case Conclusion

What interventions should be considered? Needle decompression, airway management, and rapid fluid administration should be considered.
Are ACLS medications and guidelines appropriate to follow? No, there's no established role for epinephrine in the treatment of this patient and the cause of cardiac arrest is different than a medical arrest.
Should you transport the patient in cardiac arrest if the nearest trauma center is 5 minutes away? Yes. Transport in this case may provide benefit to the patient as they may be a candidate for thoracotomy or other advanced surgical procedures.
What about 20 minutes away? Likely no. The patient is unlikely to be a candidate for thoractomy and aggressive resuscitation should be done on scene with transport only with ROSC due to the risk to providers and predicted worse outcome.

References

1. Heron M. Deaths: Leading causes for 2013. Natl Vital Stat Rep. 2016;65(2):1-95.
2. National Association of EMS Physicians, American College of Surgeons. Termination of resuscitation for adult traumatic cardiopulmonary arrest. Prehosp Emerg Care. 2012;16(4):571.
3. National Association of EMS Physicians, American College of Surgeons. Withholding of resuscitation for adult traumatic cardiopulmonary arrest. Prehosp Emerg Care. 2013;17(2):291.
4. Brywczynski J, McKinney J, Pepe PE, et al. Emergency medical services transport decisions in posttraumatic circulatory arrest: Are national practices congruent? J Trauma. 2010;69(5):1154-1160.
5. Mattox KL, Feliciano DV. Role of external cardiac compression in truncal trauma. J Trauma. 1982;22(11):934-936.
6. Rosemurgy AS1, Norris PA, Olson SM, et al. Prehospital traumatic cardiac arrest: The cost of futility. J Trauma. 1993;35(3):468-474.
7. Stockinger ZT, McSwain NE Jr. Additional evidence in support of withholding or terminating cardiopulmonary resuscitation for trauma patients in the field. J Am Coll Surg. 2004;198(2):227-231.
8. 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.
9. Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: who are the survivors? Ann Emerg Med. 2006;48(3):240-244.
10. Pickens JJ, Copass MK, Bulger EM. Trauma patients receiving CPR: Predictors of survival. J Trauma. 2005;58(5):951-958.
11. Sherren PB, Reid C, Habig K, et al. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service. Crit Care. 2013;17(2):308.
12. Leis CC, Hernández CC, Blanco MJ, et al. Traumatic cardiac arrest: Should advanced life support be initiated? J Trauma Acute Care Surg. 2013;74(2):634-638.
13. Adler E. Defining the limits of resuscitative emergency department thoracotomy: A contemporary Western Trauma Association perspective. Journal of Emergency Medicine. 2011;41(2):231-232.
14. Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;79(1):159-173.
15. Millin MG, Galvagno SM, Khandker SR, et al. Withholding and termination of resuscitation of adult cardiopulmonary arrest secondary to trauma: resource document to the joint
NAEMSP-ACSCOT position statements. J Trauma Acute Care Surg. 2013;75(3):459-467.
16. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: Cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):
S829-S861.
17. Jacobs IG, Finn JC, Jelinek GA, et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation. 2011;82(9):1138-1143.
18. Atiksawedparit P, Rattanasiri S, McEvoy M, et al. Effects of prehospital adrenaline administration on out-of-hospital cardiac arrest outcomes: A systematic review and meta-analysis. Crit Care. 2014;18(4):463.
19. Lin YR, Syue YJ, Buddhakosai W, et al. Impact of different initial epinephrine treatment time points on the early postresuscitative hemodynamic status of children with traumatic out-of-hospital cardiac arrest. Medicine (Baltimore). 2016;95(12):e3195.
20. Sperry JL, Minei JP, Frankel HL, et al. Early use of vasopressors after injury: Caution before constriction. J Trauma. 2008;64(1):9-14.
21. Luna GK, Pavlin EG, Kirkman T, et al. Hemodynamic effects of external cardiac massage in trauma shock. J Trauma. 1989;29(10):1430-1433.
22. Smith JE, Rickard A, Wise D. Traumatic cardiac arrest. J R Soc Med. 2015;108(1):11-16.
23. Bowles F, Rawlinson K. BET 3: The efficacy of chest compressions in paediatric traumatic arrest. Emerg Med J. 2016;33(5):368.
24. Gervin AS, Fischer RP. The importance of prompt transport of salvage of patients with penetrating heart wounds. J Trauma. 1982;22(6):443-448.
25. Mistry N, Bleetman A, Roberts KJ. Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest. Emerg Med J. 2009;26(10):738-740.
26. Akoglu H, Akoglu EU, Evman S, et al. Determination of the appropriate catheter length and place for needle thoracostomy by using computed tomography scans of pneumothorax patients. Injury. 2013;44(9):1177-1182.
27. Stevens RL, Rochester AA, Busko J, et al. Needle thoracostomy for tension pneumothorax: Failure predicted by chest computed tomography. Prehosp Emerg Care. 2009;13(1):14-17.
28. Inaba K, Branco BC, Eckstein M, et al. Optimal positioning for emergent needle thoracostomy: A cadaver-based study. J Trauma. 2011;71(5):1099-1103.
29. Lee TH, Ouellet JF, Cook M, et al. Pericardiocentesis in trauma: a systematic review. J Trauma Acute Care Surg. 2013;75(4):543-549.
30. Jørgensen H, Jensen CH, Dirks J. Does prehospital ultrasound improve treatment of the trauma patient? A systematic review. Eur J Emerg Med. 2010;17(5):249-253.
31. Schött U. Prehospital coagulation monitoring of resuscitation with point-of-care devices. Shock. 2014;41 Suppl 1:26-29.