Trauma Codes; To Work or Not.

[AustinSofa]

To all my freinds in EMS, what do your protocols say about working a trauma code? What do you personally do? Would you have worked this or called it as DOS.
Patient; 17 year old female
MOI; one car MVA, vs semi
Injuries; massive facial trauma ( face was unrecognizable), massive chest and internal trauma, both legs amputated below the knees. Heart was in V-fib that very quickly turned into asytole, and she had agonal breathing. Was it even remotely workable?

 

[Akulahawk]

Workable? Sure. You could "work" that code, but understand that it would have likely been nothing more than practice because it sounds like the injuries were incompatible with life. Local protocol would have directed EMS to work that code unless there was actual separation of the brain or heart from the body and because the initial rhythm was not Asystole or PEA (with rate < 40/min). Trauma codes very rarely survive.

 

[Flying]

Massive Chest Trauma + V-fib -> Asystole + Agonal Respirations = Not workable.
Would inform officer of findings to pass onto ME.

Relevant Section in Our Guidelines:

Dead on Arrival
• In order for EMTs to determine a patient is DOA and not attempt resuscitation, one or more of the following
must be present
o Valid DNR or POLST associated with cardiopulmonary arrest
o Rigor Mortis
o Dependent Lividity
o Severe traumatic injuries that would preclude reasonable chance of survival
o Traumatic cardiac arrest in an entrapped patient

 

[OnceAnEMT]

Not workin'.

Patient with injury obviously incompatible with
life meeting Criteria for Death Standard or
Discontinuation of Resuscitation Standard

Criteria for Death

1. Signs of obvious death:
• Rigor mortis and/or dependent lividity;
• Decomposition;
• Decapitation;
• Incineration;
2. Obviously mortal wounds (severe trauma with obvious signs of organ destruction)
3. Patient submersion greater than 20 minutes from arrival of first Public Safety entity until
the patient is in a position for effective resuscitative efforts to begin
4. Fetal death with a fetus < 20 weeks by best age determination available at scene
(considered products of conception and does not require time of death). Fetal death < 20
weeks may be documented on mothers PCR. If ≥ 20 weeks create separate PCR.

Discontinuation of Resuscitation (assuming no medical cause)

1. Any System Credentialed Provider, in the following circumstances, may discontinue
resuscitation efforts without OLMC:
• Resuscitation efforts were inappropriately initiated when criteria outlined in the
Criteria for Death/Withholding Resuscitation Standard were present
• A valid Out of Hospital Do Not Resuscitate Form (OOH-DNR) and/or OOH-DNR ID
device was discovered after resuscitative efforts have been initiated. The form and
device may be from any (US) State (Original or Copy) as defined in the DNR
Standard
2. In addition to the previously stated criteria a Paramedic Credentialed Provider, in the
following circumstances, may discontinue resuscitation efforts without OLMC:
• If the patient suffers a traumatic injury meeting the following criteria:
 The patient is pulseless and apneic on arrival of the first provider on scene AND
 Lacks respiratory effort after basic airway maneuvers AND
 Organized electrical activity on ECG with a rate (less than) < 40.

This one falls under obviously mortal, unfortunately.

I'm curious about lead placement on a massive chest trauma patient

 

[AustinSofa]

Let me throw something else into the mix, say it was a friend of yours, what would you personally do?

 

[gotbeerz001]

Let me throw something else into the mix, say it was a friend of yours, what would you personally do?

Is this an actual call or are you just trying to play with "what if..."?

 

[AustinSofa]

It is a call I ran. I'm just curious to see if anyone would have done anything different.

 

[AustinSofa]

Would anyone have done anything different given the circumstances?

 

[04_edge]

In the county I work, we would have worked her. I agree that there is 0 chance of her surviving this, but being she has agonal respirations, and a shockable rhythm upon arrival, I would prefer to give that responsibility to someone else, particularly because of her age. People like to sue. At the very least it would be good for practice. She sounds like an excellent candidate to cric, bilateral needle decompression and apply tourniquets to both legs.

 

[AustinSofa]

We can't cric on the ground. By the time the ambulances arrived she was already in asystole.

 

[chaz90]

In reality, this patient should not be worked. That's the rational and correct response from a medical standpoint.

If you're asking if an emotionally compromised provider might work this patient for the wrong reasons, the answer may always be yes. If this were my sister involved in an accident and in this condition, I might try to work her but that doesn't make it the right choice or improve her chances at survival.

 

[AustinSofa]

That's why I worked it. She was a friend of mine, a trainer on my football team and she ran Track with me. If it was a stranger, I wouldn't have worked it. She had a shockable rhythm and was breathing. I understand that most protocols would have been to call it, but I still tried because she was a close friend.

 

[Tigger]

Shockable rhythm in a trauma arrest doesn't really indicate anything.

Pulselessness secondary to blunt trauma is not worked here and to do so would likely result in a meeting with the medical director.

Sounds like a terrible call nonetheless.

 

[AustinSofa]

I ran the call as a Volunteer Firefighter. I haven't been in EMS very long, but this was one of the worst things I've saw.

 

[Akulahawk]

Shockable rhythm in a trauma arrest doesn't really indicate anything.

Pulselessness secondary to blunt trauma is not worked here and to do so would likely result in a meeting with the medical director.

Sounds like a terrible call nonetheless.

Fortunately, agonal respirations aren't a part of determination of death criteria. Given the extent of injury and being pulseless upon my arrival, I probably would have searched for a way to not work this one because of the futility of doing so. My suspicion is that she was in VF because of exanguination and shocking that rhythm would have resulted in either a PEA (again, no volume) or asystole. Putting TK's on, decompressing the chest, doing a cric (needle or intubation), establishing large bore lines, infusing massive amounts of blood, wouldn't change the outcome as in my opinion as doing all that is the equivalent of closing the barn door after the horses have bolted for the hills.

To the OP, my condolences. Sometimes you have to go run calls (even bad ones) on people you know and it's tougher when you know it's futile and you should not even begin to provide care.

 

[cruiseforever]

Isolated penetrating trauma? maybe Blunt trauma? no

 

[PotatoMedic]

I ran the call as a Volunteer Firefighter. I haven't been in EMS very long, but this was one of the worst things I've saw.

If you want to talk to anyone about it there are a lot of good resources out there.

 

[WildlandEMT89]

Sorry for your loss op. Those calls are never easy.
If you want to talk to someone and work through it this group is focused solely one helping first responders in this type of situation and you can remain anonymous ifyou so choose.

https://www.facebook.com/pages/Heroes-Cry-Too/1402572360048486

 

[DesertMedic66]

We would have had to work it here. 1) because she is 17 and 2) because she was V-fib on scene.

 

[Jim37F]

First off to the OP, that sounds horrible, I can't imagine responding to a call and finding anyone I know in that condition, much less a close friend, I honestly have no idea what I'd do. But to answer the academic question:

Our County policy for determining death in the field and therefore not requiring a workup:

Determination of Death, Base Hospital Contact Not Required:
A. A patient may be determined dead if, in addition to the absence of respiration, cardiac activity, and neurologic reflexes, one or more of the following physical or
circumstantial conditions exist:
1. Decapitation
2. Massive crush injury
3. Penetrating or blunt injury with evisceration of the heart, lung or brain
4. Decomposition
5. Incineration
6. Pulseless, non-breathing victims with extrication time greater than fifteen minutes, where no resuscitative measures can be performed prior to extrication.
7. Penetrating trauma patients who, based on the paramedic’s thorough assessment, are found apneic, pulseless, asystolic, and without pupillary reflexes upon the arrival of EMS personnel at the scene.
8. Blunt trauma patients who, based on a paramedic’s thorough patient assessment, are found apneic, pulseless, and without organized ECG activity (narrow complex supraventricular rhythm) upon the arrival of EMS personnel at the scene.
9. Pulseless, non-breathing victims of a multiple victim incident where insufficient medical resources preclude initiating resuscitative measures.
10. Drowning victims, when it is reasonably determined that submersion has been greater than one hour.
11. Rigor mortis (requires assessment as described in Section I, B.)
12. Post-mortem lividity (requires assessment as described in Section I, B.)

(I've highlighted the bullets that seem the most applicable here)
So any of the first 10 exist by themselves we can call it and wont work the code, Rigot mortis and/or Post-mortem lividity require a further assessment...but those don't really apply to the scenario. The injuries described sound like an argument can be made for #2 If the patient had to be cut out and it took longer than 15 minutes, no work up. Otherwise, I honestly don't know if V-Fib counts as #8 describes, if so call it, if not we're working it. But we do not transport codes, initiate resuscitation on scene and call base and let the doc at the other end of the line call it.