Circulation Problem

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Massive hemothorax:

Penetrating injury to chest and lost pulses en route to or in the ED:

Massive hemorrhage:

Resuscitation is a key component of the ED evaluation of a patient with penetrating injuries. When a GSW patient presents with hypotension, resuscitation should begin with blood, not crystalloid fluids, because crystalloid administration can cause hemodilution and worsen coagulopathy. Whole blood or packed red blood cells (PRBCs) (O-negative for women who are of child-bearing age) should be used for initial resuscitation. If a patient is likely to need multiple transfusions, activation of a massive transfusion protocol (MTP) should be considered. Criteria for initiation of MTP varies by institution but is typically based on gestalt, taking into consideration the following questions:

If the answer to any of these questions suggests the need for transfusion of a large volume of blood, then MTP is likely indicated. Guided by the 2015 PROPPR trial, MTP currently consists of transfusion of PRBCs, fresh frozen plasma (FFP), and platelets at a ratio of 1:1:1. Laboratory work is not useful in this setting, as the blood loss is acute and will not be reflected accurately in the results. Additionally, the acute resuscitation is guided by hemodynamic response, rather than any specific laboratory value.

An important consideration for hemorrhaging patients and their resuscitation is management of calcium levels. Calcium is important for cardiac contractility and platelet function. The citrate in blood products binds to calcium and leads to hypocalcemia and worsening coagulopathy. A 2021 systematic review studied 3 different cohort studies with a total of 1213 trauma patients and showed increased mortality in those who were hypocalcemic compared with those who were normocalcemic. The only widespread standardized protocol for calcium administration with MTP in the United States is from the military sector. A 2018 review recommends administering 1 g calcium chloride IV for patients in hemorrhagic shock after transfusion of 4 units of blood products. Repeat doses of IV calcium chloride should be considered for ongoing resuscitation.

Pericardial effusion and cardiac tamponade are best identified on the E-FAST examination. Classic clinical findings of tamponade are the Beck triad: muffled heart sounds, distended neck veins, and hypotension, though all 3 of these are often not present. Other than using ultrasound to identify cardiac tamponade, tachycardia and narrowing of pulse pressure plus a thoracoabdominal GSW should raise concern for this injury. In a hemodynamically stable patient with tamponade identified on ultrasound, pericardiocentesis may be indicated, but only as a temporizing measure if the operating room is not immediately available.

Indications for ED thoracotomy include patients with a penetrating injury to the chest who are hemodynamically unstable, who previously had signs of life (on scene/en route/in the ED) but then lost pulses. This procedure can be life-saving but will likely have poor outcomes if the patient was in asystole the entire time without cardiac tamponade, if there is prolonged pulselessness (>15 min), or if there are other nonsurvivable injuries (eg, massive head trauma). A prospective study of 187 patients undergoing resuscitative thoracotomy showed that none survived if their ultrasound showed no cardiac activity, making this a vital early adjunct to decision-making. Furthermore, this procedure should be performed only if there is immediate access to a trained surgeon and a properly equipped operating room.