Initial Management

Initial management priorities for patients with traumatic arrest or impending arrest include early control of hemorrhage and hemostatic resuscitation as described in the JTS Damage Control Resuscitation CPG.^18,80 The initial focus in patients presenting in profound hemorrhagic shock, to include loss of pulses, is to determine the best resuscitative strategy, and whether resuscitation is appropriate or futile in a moribund patient. The following must be rapidly determined:

• Mechanism and pattern of injury
• Presence of a pulse
• Duration of cardiac arrest
• Presence or absence of an organized, narrow complex cardiac rhythm and/or organized cardiac activity by ultrasound
• Resources available
• Availability of surgical capability for definitive hemorrhage control
• Number of concurrent casualties

Patients exsanguinating from abdominal, pelvic, or junctional lower extremity bleeding may be candidates for REBOA. Such patients are identified by penetrating mechanism of injury to abdomen or pelvis, blast or blunt mechanism with positive FAST or suspected pelvic fracture, or massive proximal lower extremity trauma with signs of impending cardiovascular collapse.

Exsanguinating hemorrhage in the chest must be ruled out prior to placing REBOA—this can be done with bilateral chest tube placement, x-ray, or thoracic ultrasound. In cases of major chest hemorrhage, occlusion of the aorta may increase thoracic bleeding and is thus best addressed via thoracotomy or sternotomy.

A decision algorithm for (RAO) is found in Appendix A. If RAO is performed, concurrent hemostatic resuscitation and closed chest cardiac massage must continue while the procedure is performed.⁵⁰ If RAO is not performed, resuscitative efforts should cease unless there is a compelling reason to consider a non-traumatic arrest.