Traumatic cardiac arrest (TCA) is a condition in which the

heart The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide to ...

has ceased to beat due to

blunt Blunt may refer to: * Blunt (surname), a surname (and list of people with the name) * Blunt (cigar), a term used in the cigar industry to designate blunt-tipped, usually factory-rolled cigars * Blunt (cannabis), a slang term used in cannabis cu ...

or penetrating trauma, such as a

stab wound A stab wound is a specific form of penetrating trauma to the skin that results from a knife or a similar pointed object. While stab wounds are typically known to be caused by knives, they can also occur from a variety of implements, including brok ...

to the thoracic area. It is a medical emergency which will always result in death without prompt advanced medical care. Even with prompt medical intervention, survival without

neurological Neurology (from el, νεῦρον (neûron), "string, nerve" and the suffix -logia, "study of") is the branch of medicine dealing with the diagnosis and treatment of all categories of conditions and disease involving the brain, the spinal c ...

complications is rare. In recent years, protocols have been proposed to improve survival rate in patients with traumatic cardiac arrest, though the variable causes of this condition as well as many coexisting injuries can make these protocols difficult to standardize. Traumatic cardiac arrest is a complex form of

cardiac arrest Cardiac arrest is when the heart suddenly and unexpectedly stops beating. It is a medical emergency that, without immediate medical intervention, will result in sudden cardiac death within minutes. Cardiopulmonary resuscitation (CPR) and possi ...

often derailing from

advanced cardiac life support Advanced cardiac life support, advanced cardiovascular life support (ACLS) refers to a set of clinical guidelines for the urgent and emergent treatment of life-threatening cardiovascular conditions that will cause or have caused cardiac arrest, ...

in the sense that the emergency team must first establish the cause of the traumatic arrest and reverse these effects, for example hypovolemia and haemorrhagic shock due to a penetrating injury.

Mechanism

Traumatic cardiac arrest can occur in patients following any severe blunt or penetrating injury to the chest. Following the traumatic event, the heart ceases to pump blood through the body. Unlike medical cardiac arrest, there are several potentially reversible causes that may result in cardiac arrest in the setting of trauma. Clinicians will rapidly assess for these causes, and interventions will be directed to the specific cause.

Massive hemorrhage

In both blunt and penetrating trauma, massive

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or external bleeding may decrease the volume of blood is available to be pumped by the heart to the body. This is considered preload dependent arrest.

Tension pneumothorax

Tension pneumothorax is caused when air is able to enter the space between the lung and the

chest wall The thoracic wall or chest wall is the boundary of the thoracic cavity. Structure The bony skeletal part of the thoracic wall is the rib cage, and the rest is made up of muscle, skin, and fasciae. The chest wall has 10 layers, namely (from sup ...

, but is not able to escape. The increasing pressure within the chest cavity prevents blood from returning from the body to fill the heart.

Hemothorax

Hemothorax A hemothorax (derived from hemo- lood+ thorax hest plural ''hemothoraces'') is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may in ...

occurs when injury to the chest results in bleeding into the thoracic cavity. Similar to tension pneumothorax, increasing pressure prevents the return of blood from circulation to the heart.

Cardiac tamponade

In the setting of trauma,

cardiac tamponade Cardiac tamponade, also known as pericardial tamponade (), is the buildup of fluid in the pericardium (the sac around the heart), resulting in compression of the heart. Onset may be rapid or gradual. Symptoms typically include those of obstructi ...

results from an acute

pericardial effusion A pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. The pericardium is a two-part membrane surrounding the heart: the outer fibrous connective membrane and an inner two-layered serous membrane. The two layers of t ...

, the accumulation of blood within the sac that surrounds the heart. As this sac is filled with fluid, the pressure on the heart is increased, and the chambers of the heart are unable to fill with blood.

Hypoxia

Inability to maintain oxygenation in trauma patients may be a result of

airway The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa. Air is breathed in through the nose t ...

compromise due to mechanical injury or obstruction or due to loss of the respiratory drive from

cervical spine In tetrapods, cervical vertebrae (singular: vertebra) are the vertebrae of the neck, immediately below the skull. Truncal vertebrae (divided into thoracic and lumbar vertebrae in mammals) lie caudal (toward the tail) of cervical vertebrae. In sau ...

peripheral nerve injury Nerve injury is an injury to nervous tissue. There is no single classification system that can describe all the many variations of nerve injuries. In 1941, Seddon introduced a classification of nerve injuries based on three main types of nerve f ...

. These conditions result in the hypoxia that may lead to cardiac arrest.

Signs and symptoms

Patients will present following a traumatic event most often with

pulseless electrical activity Pulseless electrical activity (PEA) refers to cardiac arrest in which the electrocardiogram shows a heart rhythm that should produce a pulse, but does not. Pulseless electrical activity is found initially in about 55% of people in cardiac arrest. ...

(PEA). Patients will exhibit low blood pressure with pulses that cannot be palpated. Patients will progress into

asystole Asystole (New Latin, from Greek privative a "not, without" + ''systolē'' "contraction") is the absence of ventricular contractions in the context of a lethal heart arrhythmia (in contrast to an induced asystole on a cooled patient on a heart-lung ...

if the underlying condition is not reversed. Other non-specific signs and symptoms associated with impending traumatic cardiac arrest may include sweating,

altered mental status An altered level of consciousness is any measure of arousal other than normal. Level of consciousness (LOC) is a measurement of a person's arousability and responsiveness to stimuli from the environment. A mildly depressed level of consciousne ...

rapid Rapids are sections of a river where the river bed has a relatively steep gradient, causing an increase in water velocity and turbulence. Rapids are hydrological features between a ''run'' (a smoothly flowing part of a stream) and a '' cascade' ...

or slow breathing, and signs of trauma (bruising,

laceration A wound is a rapid onset of injury that involves lacerated or punctured skin (an ''open'' wound), or a contusion (a ''closed'' wound) from blunt force trauma or compression. In pathology, a ''wound'' is an acute injury that damages the epid ...

, fractures, etc.).

Diagnosis

Diagnosis of traumatic cardiac arrest is initially made with electrocardiogram with EMS or in the emergency department. Clinicians will also order diagnostic testing that may include

chest x-ray A chest radiograph, called a chest X-ray (CXR), or chest film, is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common film taken in me ...

, bedside ultrasound and echocardiogram, and blood gas levels. A type and cross will be ordered to match the patient to receive blood transfusion if necessary. Other work-up involved in diagnosis of a trauma patient may include e-FAST, RUSH exam, CBC, pelvic X-ray, and CT of the head, neck, chest, abdomen, and pelvis.

Treatment

Treatment of traumatic cardiac arrest is guided by advanced trauma life support guidelines. Standard advanced cardiac life support guidelines are inappropriate for use in traumatic cardiac arrest, as they are directed primarily at treating pathology originating within the heart itself. As clinicians begin to intervene, they will simultaneously seek reversible causes of the arrest. Management begins by establishing multiple points of IV access and evaluating the patient's airway and breathing. Other interventions may include

thoracostomy A thoracostomy is a small incision of the chest wall, with maintenance of the opening for drainage. It is most commonly used for the treatment of a pneumothorax. This is performed by physicians, paramedics, and nurses usually via needle thoracosto ...

and

thoracotomy A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons (emergency physicians or paramedics under certain circumstances) to gain access to the thoracic organs, most commonly the he ...

, as well as treatment of the underlying cause of arrest.

Basic life support

Basic life support Basic life support (BLS) is a level of medical care which is used for patients with life-threatening illnesses or injuries until they can be given full medical care by advanced life support providers (paramedics, nurses, physicians). It can be pr ...

is commonly initiated by bystanders and first responders, but the role of basic life support in traumatic cardiac arrest is unclear. Basic life support is targeted to maintain oxygenation and circulation throughout the body, which can be lifesaving in cases of medical cardiac arrest, but does not address the frequent large volume blood loss encounters in many cases of traumatic cardiac arrest.

Chest compressions

Chest compressions Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spont ...

are considered the most important initial intervention in cases of medical cardiac arrest, however studies evaluating their efficacy have excluded patients with traumatic cardiac arrest. Chest compressions work to replace the cardiac function of pumping blood throughout the body, however cases where the heart is either unable to fill with blood or the total blood volume is depleted, this intervention may be ineffective. Additionally, as many of the interventions targeted at specific causes of arrest are centered around procedures performed around the patient's chest, head, and neck, compressions may interfere with definitive management.

Management of reversible causes

Future directions

Current guidelines tailored to treatment of specific causes of traumatic cardiac arrest have improved outcomes for patients, however these guidelines may be difficult to apply in a standardized manner due to differences in pre-hospital care and the wide variety of causes of traumatic cardiac arrest compared to medical cardiac arrest. Evolving algorithms are directed at quickly identifying incidences of cardiac arrest with a traumatic source and rapidly intervening to address reversible causes.

Prognosis

Historically, traumatic cardiac arrest was thought to lead invariably to death. More recently, evolutions of advanced trauma life support guidelines and improved understanding of the underlying causes of traumatic cardiac arrest have improved outcomes for patients. Recent studies suggest that the survival rate for traumatic cardiac arrest is similar to that of all-cause cardiac arrest. There is wide variability in the estimated survival rate based on factors that include initiation of pre-hospital care and nature of injury. Many patients who survive traumatic cardiac arrest may develop long-term neurological damage resulting from lack of circulation to the nervous system during the arrest. This damage may range from moderate disability to a persistent vegetative state. A 2012 review suggests that while survival rates of traumatic cardiac arrest are higher in children, so is the incidence of neurological complication.

References

{{DEFAULTSORT:Traumatic Arrest Heart diseases Medical emergencies Chest trauma Traumatology