Thread by @shaikh_mf

This presentation at Combined @FresnoTrauma / @UCSFFresno EM conference on topic of "CPR in Trauma" generated some good discussion, so I thought I'd share it with #MedTwitter @Me4Trauma @RASACS. Feedback appreciated. cc:@Walid2theED @Alex_KamskyEM (#Tweetorial)

1/ CPR started off as an accidental discovery while studying ⚡️💓 in a 🐶model of cardiac arrest: "Momentary ⬆️ in intra-arterial pressure trace occurred when the heavy electrodes were applied to the chest wall of the 🐶 with V-Fib" bit.ly/2KofXON

2/ High-quality CPR rests on 3 pillars
💖Good depth of compression
💖Good rate of compression
💖Allowing for adequate recoil

Allowing for adequate recoil allows the heart to refill, since cardiac output for CPR in medical cardiac arrest is PRELOAD-dependent

3/ Shock in trauma is hemorrhagic/hypovolemic until proven otherwise. Traumatic cardiac arrest is the *ABSENCE* or severe deficiency of preload

4/ Luna et al (@JTraumAcuteSurg, PMID 2810421) compared CPR in medical arrest (barbiturate OD) vs traumatic arrest (cardiac tamponade & hypovolemia) in baboons🐒:
🍌 CPR 👍 in medical arrest
🍌⬇️(nonperfusing) SBP in trauma
🍌⬇️ DBP during CPR in trauma but not in medical arrest

5/ Recent @FresnoTrauma grad @thejeffcoach et al looked at CPR vs Fluids vs Fluids+CPR in a hemorrhagic traumatic arrest 🐕 model (bit.ly/2YSmuFK, @JTraumAcuteSurg @EAST_TRAUMA)
CPR for Trauma:
🐾⬆️HR⬇️BP
🐾⬆️lactate, worse base deficit
🐾⬇️EF⬆️end organ damage

6/ Watts et al compared resusc w CPR vs whole blood vs crystalloid in hemorrhagic traumatic arrest in a pig 🐖model (PMID 31077754)
🥓CPR alone does not achieve perfusing MAP
🥓CPR does not add to WB or NS to achieve perfusing MAP

7/ These well-designed animal studies are fairly conclusive:

8/ But is there a downside? CPR-related patient injuries are well-documented. Check out Ram et al (PMID 29310980).

9/ Additionally, misguided CPR in traumatic arrest:
💔Impairs proper pt eval
💔Delays necessary procedures
💔Risks injury to health care workers
💔⬇️DBP=⬇️coronary perfusion = missing the point

10/ It feels weird to stop or hold CPR in the pulseless pt, but traumatic arrest is diff from medical arrest and requires diff principles:
⚓️r/o & treat tension PTX &/or tamponade
⚓️establish airway & iv access
⚓️REVERSE HYPOVOLEMIA🌟
⚓️STOP THE BLEED🌟

11-FIN/ This #Tweetorial covered a lot of ground on the role of CPR in Traumatic Arrest; I hope you came to the same one-word conclusion I did:

Sidebar: Who has a good protocol for traumatic arrests? Something more granular than @WesternTrauma EDT guidelines. Trying to reduce variability at my institution (i.e. always IO v Fem line v saph v cutdown??? etc) cc: @EAST_TRAUMA @traumadoctors @ExcelsiorSurg @ACSTrauma