Really useful post—thanks for sharing. I know the subcostal approach is recommended intra-arrest due to ongoing CPR and defib pad positioning but, in a true atraumatic tamponade arrest, would ongoing CPR actually help? I think I’d still start ALS (e.g. airway adjuncts, shock if indicated) and then plan for a brief, timed pause—like for rhythm checks—to prioritise pericardial drainage. It feels counterintuitive to take the most impactful intervention and not only make it more challenging to perform but also less effective. Once the effusion has been aspirated then we could continue with usual ALS protocols? No solid evidence either way that I’ve found, but have personally mental modelled it like that - curious what others think?
Shal cheers for the comment. Couldn't agree more. I think I've mapped it out similarly to you - I would plan a pause, and then go straight for an apical approach. Similarly I would plan a pause to decompress the chest to treat tension pneuomothorax. Challenging to get the whole MDT on on the same page when veering off the standard ALS piste.
All the more reason for an MDT approach to regular HALO simulations as wider awareness of this mental model and team leader practice sharing it with a multidisciplinary arrest team will help at times when bandwidth is low and adrenaline high. Have found that deviations from ALS, when appropriate, can still cause a lot of distress to more junior members of the team/observers unless explained or fully debriefed. Would be good to develop a 'patter' for these situations - I imagine prehospital critical care clinicians are better at this e.g. when stopping established ALS for a thoracotomy?
One needs a well developed “patter” to change the momentum of standard ALS to prioritise meaningful interventions
Not just the Gotterdamerubg of a prehospital thoracotomy for trauma….but simple things like bilateral finger thoracostomy, splint to alignment, volume, airway etc
Really useful post—thanks for sharing. I know the subcostal approach is recommended intra-arrest due to ongoing CPR and defib pad positioning but, in a true atraumatic tamponade arrest, would ongoing CPR actually help? I think I’d still start ALS (e.g. airway adjuncts, shock if indicated) and then plan for a brief, timed pause—like for rhythm checks—to prioritise pericardial drainage. It feels counterintuitive to take the most impactful intervention and not only make it more challenging to perform but also less effective. Once the effusion has been aspirated then we could continue with usual ALS protocols? No solid evidence either way that I’ve found, but have personally mental modelled it like that - curious what others think?
Shal cheers for the comment. Couldn't agree more. I think I've mapped it out similarly to you - I would plan a pause, and then go straight for an apical approach. Similarly I would plan a pause to decompress the chest to treat tension pneuomothorax. Challenging to get the whole MDT on on the same page when veering off the standard ALS piste.
All the more reason for an MDT approach to regular HALO simulations as wider awareness of this mental model and team leader practice sharing it with a multidisciplinary arrest team will help at times when bandwidth is low and adrenaline high. Have found that deviations from ALS, when appropriate, can still cause a lot of distress to more junior members of the team/observers unless explained or fully debriefed. Would be good to develop a 'patter' for these situations - I imagine prehospital critical care clinicians are better at this e.g. when stopping established ALS for a thoracotomy?
Yes indeed
One needs a well developed “patter” to change the momentum of standard ALS to prioritise meaningful interventions
Not just the Gotterdamerubg of a prehospital thoracotomy for trauma….but simple things like bilateral finger thoracostomy, splint to alignment, volume, airway etc