21yo male, 160kph rollover, ejcted from vehicle. GCS 4 at the scene with obvious head, chest and abdominal injury. Significal fluid and blood resuscitation at the scene. Ongoing haemodynamic instability en route. Output lost just prior to arrival in the department. On arrival in the department, CPR ongoing, intubated, pupils fixed and dilated.
Bilateral chest decompression in the department. Pelvic binder in situ.
However a decision to cease CPR was made based on the EFAST done by Jana.
Subcostal view of the heart taken during a pulse check showing cardiac standstill and no pericardial effusion. Note the spontaneous echo contrast in the RA and RV (see annotated image below).
LUQ view showing large volume haemoperitoneum. Note: most of the blood is between the diaphragm and spleen rather than between spleen and kidney.
RUQ view showing heamoperitoneum in Morrison's pouch.
Traumatic cardiac arrest has a similar or slightly better prognosis when compared to medical causes of arrest(1). Severe exanguination as a cause of traumatic arrest has one of the worst prognoses. One restrospective study showed that the presence of cardiac standstill on ultrasound significantly decreases the probability of survival with a NPV of 99% (2).
The aim of resuscitation in traumatic cardiac arrest is to treat reversible causes as soon as possible. Ultrasound should not delay this. However, once treament has been initiated, cardiac ultrasound can be a useful tool to determine the usefulness of ongoing resuscitation.
Well done Jane for getting such good images and for saving them for teaching!
(1) Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: who are the survivors? Ann Emerg Med. 2006;48:240-244.
(2) Cureton EL, Yeung LY, Kwan RO et al The heart of the matter: Utility of ultrasound of cardiac activity during traumatic arrest. J Trauma Acute Care Surg Volume 73,(1) 102-110.