41 YOM - Traumatic Arrest - Obvious Death or Begin Resuscitation?

[NYMedic828]

had this call about a week ago now and its been bugging me.

Story:

41 y/o male, found supine on ground post gunshot to left chest. Patient was working under his car when someone walked up and shot him at close range. Called in by a bystander no further info could be obtained on-scene.

When my partner and I arrived, the BLS unit had already begun CPR and c-spine.

Assessment:

-Pulseleness Apneic.
-Single GSW to left chest, roughly one inch inferior and medial to the the left nipple.
-No exit wound
-Absolutely no blood from the wound or anywhere for that matter.
-Possible non-tension hemo-pnuemothorax to left side.
-Idioventricular PEA on the monitor at a rate of <20 complexes per min.


Since CPR was already started, in the NYC 911 system, you must continue until a physician takes over either via telemetry or hospital and takes responsibility for pronouncement.

We ran it as a PEA arrest,

EJ to the left jugular, giving vasopressin followed by Q5 epi.

Tubed the patient no problem, frothy pink secretions in tube (hence hemo-pnuemo)

CPR throughout.

We gave a notification to the trauma hospital and upon arrival they took over CPR for about 3 minutes until the trauma surgeon walked in gave the "We're done here" look once he saw where the wound was and they called it.

My question is, would you have arrived on-scene and began CPR, or would you call it an obvious death and write up a pronouncement on-scene, leaving the crime-scene in tact as well.

The shirt had burn marks on it, the wound had no bleeding leading me to believe immediate cessation of blood flow. The bullet was directly in the anatomical location of the left ventricle and probably went through to the left lung.

What would you have done if you were first on-scene?

[Aidey]

+ YouTube Video

*ahem*

Sorry, couldn't resist.

I would have worked him, but not transported. Given the location of the wound and the PEA it is very likely that there massive damage to the heart. Since I don't have an ultrasound on scene I can't prove that, but if we don't get anywhere after 3 rounds we're done.

And c-spine????

[Smash]

He's dead where he lays, it's not appropriate to attempt resus.

And I'll second the "huh?" when it comes to c-spine.

[Medic Tim]

DId you take c spine because it was a gsw?

Where I work we would call it right there.

[NYMedic828]

In NYC C-spine is a requirement for any penetrating trauma to the thorax. Its really annoying to be honest.

I wanted to get on the horn to pronounce but my partner said it didn't qualify for obvious death... I thought it was pretty obvious lol.

[Rocketmedic40]

In my system, barring size/distance/time challenges, we need asystole to halt resuscitation.

[SanDiegoEmt7]

No c-spine,

For us ALS gets to re-evaluate the indications for CPR regardless of first responder actions.

For us that wouldn't qualify as injuries incompatible with life (decapitation, brain matter showing, entire body charred etc.)

PEA less than 20 gets transported only if we are within 10 minutes of a hospital. (asystole gets 1 min of CPR if its still asystole after that its terminated, all other rhythms are transported)

[Smash]

Originally Posted by NYMedic828

In NYC C-spine is a requirement for any penetrating trauma to the thorax. Its really annoying to be honest.

That is annoying.

I wanted to get on the horn to pronounce but my partner said it didn't qualify for obvious death... I thought it was pretty obvious lol.

What, the fact that he is dead doesn't qualify as obvious death?

EDIT:

I thought I should throw in some references, just because I haven't for a while. C-Spine for penetrating trauma is not just dumb, it is probably harmful. For this case, it is probably a moot point, however it is still bad: "The number needed to treat with spine immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66"

Pretty poor numbers there.

Spine Immobilization in Penetrating Trauma: More Harm Than Good? Haut et al, Johns Hopkins. J Trauma 68(1): 115-121, 2010.

Transporting traumatic arrests is also bad: The consequences of noncompliance with guidelines for withholding or terminating resuscitation in traumatic cardiac arrest patients. Molberg et al, J Trauma, 2011

[usalsfyre]

Originally Posted by SanDiegoEmt7

For us that wouldn't qualify as injuries incompatible with life (decapitation, brain matter showing, entire body charred etc.)

While in most systems that's the case, a bullet that sounds like it fairly neatly transacted the LV is pretty much incompatible with life.

I think a pretty good case could be made for at least phoning a doc.

[DrParasite]

Originally Posted by NYMedic828

Assessment:

-Pulseleness Apneic.
-Single GSW to left chest, roughly one inch inferior and medial to the the left nipple.
-No exit wound
-Absolutely no blood from the wound or anywhere for that matter.
-Possible non-tension hemo-pnuemothorax to left side.
-Idioventricular PEA on the monitor at a rate of <20 complexes per min.

doesn't scream obvious death to me. really bad, yeah, likely to die, probably, should I call a priest for him for last rights, I would think so.

brain matter showing, decapitation, rigor mortis, asystole in 3 leads with pupils fixed and dilated pupils are those signs of obvious death. This guy, although he sounds really messed up, probably wouldn't qualify (although as the trauma surgeon said, even in a trauma center was beyond care), but that's the doctor's call as they have more flexibility than a medic in what they can do.

Originally Posted by NYMedic828

The shirt had burn marks on it, the wound had no bleeding leading me to believe immediate cessation of blood flow. The bullet was directly in the anatomical location of the left ventricle and probably went through to the left lung.

PEA is pulseless electrical activity. so the heart isn't pumping (hence the CPR), but it is still sending signals to try to get it to pump. that could have explained the cessation of blood flow, because the heart wasn't pumping.

Originally Posted by NYMedic828

In NYC C-spine is a requirement for any penetrating trauma to the thorax. Its really annoying to be honest.

I was taught the same thing back in the 90s. the latest edition of PHTLS says it's no longer needed, but I still see many many experienced EMTs and paramedics still doing it. But I would have still put him on a board to aid in carrying him to the cot and transfer him to the ER bed, if we were going to transfer him.