Page 106 - 2022 Spring JSOM

Pulseless Arrest After Rapid Sequence Intubation
of the Massively Hemorrhaged Warfighter

A Case Series

Brian Schwarzkoph*; Alec Emerling; Alex Iteen; Travis Deaton;
Jonathan Auten; William Bianchi

ABSTRACT
Management of hemorrhagic shock and airway stabilization pre-intubation volume resuscitation among patients suffering
are two pillars of trauma resuscitation which have a depen- hemorrhagic shock may aid in reducing preventable deaths af-
dent, yet incompletely understood relationship. Patients ter injury.
presenting with traumatic hemorrhage may manifest shock
physiology prior to intubation, conferring a higher risk of Both civilian and military trauma experts have focused on
postintubation hypotension, pulseless arrest, and mortality. the prehospital phase of care for decreasing trauma deaths in
This case series describes of a group of seven US military mem- the joint “Zero Preventable Deaths” initiative. The benefits
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bers with combat-related trauma who experienced pulseless of early blood product administration have an established
arrest after rapid sequence intubation in a role 2 or role 3 mortality benefit in patients suffering from shock due hem-
setting. All except one of the patients had hemodynamics sug- orrhage. A recent historical cohort of trauma patients with
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gesting hemorrhagic shock prior to intubation. This case series hemorrhagic shock requiring intubation revealed that the tim-
highlights the need for further research to define which trauma ing of blood administration, specifically administration prior
patients are at risk of postintubation pulseless arrest. It also to RSI, was found to decrease postintubation hypotension
focuses on the knowledge gap related to the role that delayed and PA. The early recognition of abnormal hemodynamics
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airway management and judicious blood product resuscitation and prioritization of pre-intubation resuscitation may play
may play in preventable death after injury. an underrecognized role in the treatment of patients suffering
from hemorrhagic shock. We hypothesize that calculation of
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Keywords: pulseless arrest; traumatic arrest; rapid sequence in- a preintubation shock index may allow prediction of which
tubation; transfusion; TCCC patients suffering severe traumatic hemorrhagic are at highest
risk for PA following RSI.

Introduction Methods
Hemorrhage is the leading cause of preventable death among We performed a chart review to identify massively hemor-
warfighters who suffer battlefield injuries. Management of rhaged combat trauma victims who experienced PA after RSI.
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hemorrhage and stabilization of the airway are key aspects of After institutional review board approval, we utilized the Ex-
trauma resuscitation, yet there is no clearly defined method peditionary Medical Encounter Database (EMED) located at
for airway management in trauma patients who are hypovole- Naval Health Research Center (NHRC) in San Diego, CA, to
mic due to exanguination. Use of rapid-acting hypnotic and identify cases of PA. Cases include all combat injured US mil-
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neuromuscular blocking agents to facilitate airway placement, itary personnel between 1 January 2004 and 1 January 2019,
commonly referred to as rapid sequence intubation (RSI), is who presented with an injury severity score (ISS) greater than
a procedure known to have potential negative hemodynamic 15, who received blood product transfusion within 24 hours
consequences. A large military prehospital trauma registry of injury, and who underwent RSI. Cases were excluded if
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review found higher mortality in patients undergoing prehos- cardiopulmonary resuscitation was in-progress or performed
pital intubation in comparison to those receiving definitive before arrival, injury was isolated to the head, neck, or face,
airway management in the medical treatment facility. How- or intubation occurred with general anesthesia in the operat-
ever, this review did not detail the role of hemostatic resusci- ing room. Abstracted clinical data included age, sex, gender,
tation with this finding. Patients suffering hemorrhagic shock height, weight, ISS, Glasgow Coma Scale (GCS), branch of
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represent a unique population who may be at higher risk for service, mechanism of injury, facility type in which intubation
pulseless arrest (PA) after RSI given the physiologic changes occurred (role 2 or role 3), time of arrival to facility, time of
that are associated with the procedure. A therapeutic strategy intubation, heart rate (HR), systolic blood pressure (SBP) at
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that balances the need for trauma airway management with presentation, SBP pre-intubation, and SBP post-intubation.
*Correspondence to schwarzkophmd@gmail.com
All authors are from the Emergency Department, Naval Medical Center San Diego, CA.

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