G Model RESUS-5953; No. of Pages 1
ARTICLE IN PRESS Resuscitation xxx (2014) xxx.e1
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Reply to Letter: Requirement for a structured algorithm in cardiac arrest following major trauma: Epidemiology, management errors, and preventability of traumatic deaths in Berlin Sir, It was with great interest we read the paper by Kleber et al. presenting an algorithm in cardiac arrests following major trauma.1 We would like to thank the research group for demonstrating the usefulness of treatment of traumatic cardiac arrest (tCA) and for the presentation of data supporting this statement. Their investigation of causes of cardiac arrest gives insight into underlying clinical disease and possible treatment options. There are a number of details that we feel should be discussed. In the article, the majority of patients with fatal tCA had treatment stopped in the prehospital setting before presentation to the Emergency Department. This is understandable if prehospital care and treatment options are similar to those in the hospital setting and when no meaningful treatment options remain to save the patient. On-scene availability of diagnostic tools like portable ultrasound devices can simplify and speed up diagnosing treatable causes of cardiac arrest and guide therapeutic interventions e.g., pericardial drainage in case of tamponade.2 The suggested needle decompression of cardiac tamponade is not without risks and demands training and skills.3 Even when the needle is in the correct position, it is debatable if the cumulated clotted blood can be aspirated adequately. Needle pericardiocentesis provides no definitive treatment unlike clot removal by thoracotomy.4 The use for this procedure in tCA in our opinion is therefore limited especially for an experienced physician staffed prehospital emergency service. In the case of severe hypovolaemic shock, the algorithm suggests bleeding control and the use of a pelvic binder in combination with fluid resuscitation and permissive hypotension. If hypovolaemia is the (probable) cause of a tCA the possibility to administer type O negative blood and plasma, if available, can be considered. In our prehospital setting blood can be obtained from local hospitals. This is transported to the accident location or is given during transport to a trauma center.5 In the future, freeze dried plasma or (artificial) oxygen carriers may become available for these patients. The authors have demonstrated that more patients could survive if one is able to diagnose and treat a tension pneumothorax as the cause of tCA. In these cases, point-of-care ultrasound may
contribute to early decision making. When time is of the essence, as it is in every CPR setting, the suggested bilateral chest drain insertion may be simplified by performing bilateral thoracostomies. This efficiently deflates intra thoracic overpressure on the affected side of the thorax and is a lot quicker to perform than chest tube insertion. We agree with the authors that tCA is not a hopeless situation. Indeed, to further improve diagnosis and treatment to consequently improve patient survival and quality of life, further research is warranted. If a multicenter study starts in a European prehospital context, we suggest that the widespread use of ultrasound machines should be an integral part of the protocol. Conflict of interest statement We hereby state that all the listed authors, contributed substantially to this letter as stated in your “Guide for authors”. There are no conflicts of interest. References 1. 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;85:405–10. 2. Ketelaars R, Hoogerwerf N, Scheffer GJ. Prehospital chest ultrasound by a Dutch helicopter emergency medical service. J Emerg Med 2013;44:811–7. 3. Loukas M, Walters A, Boon JM, et al. Pericardiocentesis: a clinical anatomy review. Clin Anat 2012;25:872–81. 4. Lee TH, Ouellet JF, Cook M, et al. Pericardiocentesis in trauma: a systematic review. J Trauma Acute Care Surg 2013;75:543–9. 5. Barkana Y, Stein M, Maor R, et al. Prehospital blood transfusion in prolonged evacuation. J Trauma 1999;46:176–80.
Joost H. Peters ∗ Jan Biert Rein Ketelaars Radboud University Medical Center, Helicopter Emergency Medical Service, Geert Grooteplein Zuid 10, 6525GA Nijmegen, Netherlands ∗ Corresponding author. E-mail addresses: [email protected] (J.H. Peters), [email protected] (R. Ketelaars)
1 March 2014
http://dx.doi.org/10.1016/j.resuscitation.2014.03.310 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Peters JH, et al. Reply to Letter: Requirement for a structured algorithm in cardiac arrest following major trauma: Epidemiology, management errors, and preventability of traumatic deaths in Berlin. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.03.310
ARTICLE IN PRESS Resuscitation xxx (2014) xxx.e1
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Reply to Letter: Requirement for a structured algorithm in cardiac arrest following major trauma: Epidemiology, management errors, and preventability of traumatic deaths in Berlin Sir, It was with great interest we read the paper by Kleber et al. presenting an algorithm in cardiac arrests following major trauma.1 We would like to thank the research group for demonstrating the usefulness of treatment of traumatic cardiac arrest (tCA) and for the presentation of data supporting this statement. Their investigation of causes of cardiac arrest gives insight into underlying clinical disease and possible treatment options. There are a number of details that we feel should be discussed. In the article, the majority of patients with fatal tCA had treatment stopped in the prehospital setting before presentation to the Emergency Department. This is understandable if prehospital care and treatment options are similar to those in the hospital setting and when no meaningful treatment options remain to save the patient. On-scene availability of diagnostic tools like portable ultrasound devices can simplify and speed up diagnosing treatable causes of cardiac arrest and guide therapeutic interventions e.g., pericardial drainage in case of tamponade.2 The suggested needle decompression of cardiac tamponade is not without risks and demands training and skills.3 Even when the needle is in the correct position, it is debatable if the cumulated clotted blood can be aspirated adequately. Needle pericardiocentesis provides no definitive treatment unlike clot removal by thoracotomy.4 The use for this procedure in tCA in our opinion is therefore limited especially for an experienced physician staffed prehospital emergency service. In the case of severe hypovolaemic shock, the algorithm suggests bleeding control and the use of a pelvic binder in combination with fluid resuscitation and permissive hypotension. If hypovolaemia is the (probable) cause of a tCA the possibility to administer type O negative blood and plasma, if available, can be considered. In our prehospital setting blood can be obtained from local hospitals. This is transported to the accident location or is given during transport to a trauma center.5 In the future, freeze dried plasma or (artificial) oxygen carriers may become available for these patients. The authors have demonstrated that more patients could survive if one is able to diagnose and treat a tension pneumothorax as the cause of tCA. In these cases, point-of-care ultrasound may
contribute to early decision making. When time is of the essence, as it is in every CPR setting, the suggested bilateral chest drain insertion may be simplified by performing bilateral thoracostomies. This efficiently deflates intra thoracic overpressure on the affected side of the thorax and is a lot quicker to perform than chest tube insertion. We agree with the authors that tCA is not a hopeless situation. Indeed, to further improve diagnosis and treatment to consequently improve patient survival and quality of life, further research is warranted. If a multicenter study starts in a European prehospital context, we suggest that the widespread use of ultrasound machines should be an integral part of the protocol. Conflict of interest statement We hereby state that all the listed authors, contributed substantially to this letter as stated in your “Guide for authors”. There are no conflicts of interest. References 1. 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;85:405–10. 2. Ketelaars R, Hoogerwerf N, Scheffer GJ. Prehospital chest ultrasound by a Dutch helicopter emergency medical service. J Emerg Med 2013;44:811–7. 3. Loukas M, Walters A, Boon JM, et al. Pericardiocentesis: a clinical anatomy review. Clin Anat 2012;25:872–81. 4. Lee TH, Ouellet JF, Cook M, et al. Pericardiocentesis in trauma: a systematic review. J Trauma Acute Care Surg 2013;75:543–9. 5. Barkana Y, Stein M, Maor R, et al. Prehospital blood transfusion in prolonged evacuation. J Trauma 1999;46:176–80.
Joost H. Peters ∗ Jan Biert Rein Ketelaars Radboud University Medical Center, Helicopter Emergency Medical Service, Geert Grooteplein Zuid 10, 6525GA Nijmegen, Netherlands ∗ Corresponding author. E-mail addresses: [email protected] (J.H. Peters), [email protected] (R. Ketelaars)
1 March 2014
http://dx.doi.org/10.1016/j.resuscitation.2014.03.310 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Peters JH, et al. Reply to Letter: Requirement for a structured algorithm in cardiac arrest following major trauma: Epidemiology, management errors, and preventability of traumatic deaths in Berlin. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.03.310
