Traumatic cardiac arrest (TCA) in the pre-hospital setting demands immediate, specialized management by paramedics. TCA can result from blunt trauma (e.g., motor vehicle collisions, falls) or penetrating trauma (e.g., stab wounds, gunshot wounds). Management starts with a rapid C-ABCDE assessment to identify life-threatening injuries. Prioritize interventions based on clinical relevance, addressing reversible causes like hypoxia, tension pneumothorax, and hypovolemia per ALS/BLS Patient Care Standards. Airway management, utilizing basic or advanced adjuncts, is crucial but should not delay transport.

Ensure adequate oxygenation and ventilation, addressing tension pneumothorax with needle decompression, if authorized. Bilateral needle thoracentesis should be considered for all traumatic arrests with chest trauma when indications are met. Control hemorrhage with direct pressure, tourniquets, or hemostatic agents, and establish vascular access for fluid therapy where applicable. In blunt TCA, apply a pelvic binder, when indicated, after addressing other reversible causes, or earlier if a pelvic fracture is suspected. Consider an intravenous fluid bolus if it does not delay transport, using large-bore IV or IO access for a 20 mL/kg bolus.

Continuous monitoring of cardiac rhythm, oxygen saturation, and end-tidal CO2 is essential. Consider delaying chest compressions until preload and obstructive causes are addressed. Rapid transport to a trauma center with surgical capabilities is critical for definitive care.

The termination of resuscitation criteria for traumatic cardiac arrest includes specific conditions.

Patients aged 16 or older with no heart rate or breathing, and asystole are generally signs of poor viability and meet the threshold for TOR consideration. Additionally, if there are no detectable pulses, no defibrillation given, and no signs of life since extrication, or signs of life but the nearest hospital is over 30 minutes away, resuscitation efforts may cease following a BHP TOR order. The same applies if the patient presents with pulseless electrical activity (PEA), however, the closest hospital is more than 30 minutes away.

The TOR criteria is designed to help guide paramedics on when to call for TOR consideration, , ensuring resources are used effectively and care aligns with realistic outcomes.

Paramedics are encouraged to utilize the table below to assist in determining if a patient meets TOR criteria.

Hyperkalemia is a life-threatening condition characterized by elevated potassium levels in the blood, which can lead to serious cardiac dysrhythmias and other complications. It often occurs in patients with renal failure, severe dehydration, or those taking certain medications such as potassium-sparing diuretics or ACE inhibitors. Key clinical manifestations include muscle weakness, fatigue, and palpitations. On the physiological level, hyperkalemia affects the electrical conductivity of the heart, leading to characteristic changes on the ECG.

Normal potassium levels are 3.5-5.0 mEq/L. One of the earliest signs of hyperkalemia (high potassium) is peaked T-waves, seen when levels reach 5.5-6.5 mEq/L; these T-waves are tall and tent-shaped. As levels rise to 6.5-7.5 mEq/L, the QRS complex widens due to slower ventricular conduction. The PR interval also lengthens. At very high levels (>7.5 mEq/L), the QRS and T-wave merge into a sine wave pattern, indicating a severe risk of cardiac arrest. Severe hyperkalemia can cause dangerous arrhythmias like bradycardia, ventricular fibrillation, or asystole.

The primary goal in treating hyperkalemia in the prehospital setting is to stabilize the cardiac membrane and shift potassium intracellularly to prevent lethal arrhythmias. This involves using Calcium Gluconate to protect the heart and Salbutamol to promote potassium uptake by cells. It is crucial to consider the patient's comorbidities, such as chronic kidney disease or heart failure, which might influence the treatment approach. Salbutamol may be less effective in patients with underlying respiratory issues or those already on beta-agonists.

Calcium Gluconate protects the heart by counteracting high potassium levels. Salbutamol temporarily lowers potassium by moving it into cells but its mechanism is slow and it may be less effective in frequent beta-agonist users or those with severe respiratory issues. As outlined in the medical directives, consider Calcium Gluconate immediately when hyperkalemia is detected, especially with ECG changes, and use Salbutamol alongside it for potassium reduction. Rapid identification and early treatment can improve outcomes for hyperkalemia patients in prehospital settings.

Please click the link below to join Dr. Jon Smith for an in-depth discussion on hyperkalemia!

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Screening cardiac arrest patients for reversible causes is a critical step in improving survivability and optimizing patient outcomes. By identifying reversible causes, paramedics can implement targeted interventions, or make the determination for early transport, that may significantly increase the chances of successful resuscitation.

The impact of acquiring a well-timed comprehensive event and medical history cannot be overstated, as it allows paramedics, and emergency physicians alike, to tailor treatment strategies based on the specific needs of each patient. For instance, addressing hypoxia through oxygen therapy or correcting electrolyte abnormalities can stabilize the patient's condition and improve the efficacy of interventions like defibrillation and anti-arrhythmic medications.

It is advised to employ a targeted questioning approach during a clinical interview with relatives or bystanders who have knowledge of the patient. This approach will help in obtaining valuable information regarding the events preceding the patient's absence of pulse

Below are examples of targeted questions that could aid in identifying potential reversible factors during the management of a patient in cardiac arrest. It is important to recognize that this compilation serves as a reference and should not be considered an exhaustive checklist. Targeted questions are designed to elicit crucial information for working diagnosis consideration, with further inquiries arising based on the obtained information. Each case is unique, and not all potential causes need exhaustive investigation. The NWRPCP advocates for relying on your clinical expertise and discretion in all instances.

For more information, please review our recent cardiac arrest prerequisite on reversible causes:

Identifying and Treating Reversible Causes of Cardiac Arrest 2024

Vector Change - Refractory VF/Pulseless VT

At any point a patient has had three (3) consecutive defibrillations, paramedics shall consider a vector change prior to the next defibrillation. If the first set of pads applied are placed in the anterior/lateral position, the second set of pads shall be placed in the anterior/posterior position.  Note: the first set of pads may remain in place but need to be disconnected from the monitor.  Once the second set of pads are applied in the anterior/posterior position, ensure that you connect them to the defibrillator. 

Positive Pressure Ventilation

Any patient that needs respiratory support with positive pressure ventilation (PPV) requires the use of a bag valve mask (BVM). In order to ensure this intervention is successful, NWRPCP recommends the following steps: