Is it appropriate to initiate Cardiopulmonary Resuscitation (CPR) in a patient with bilateral fixed and dilated pupils (mydriasis) in a blunt trauma-induced cardiac arrest?

From the Guidelines

In a blunt trauma cardiac arrest with bilateral blown pupils, it is still appropriate to initiate CPR. Blown pupils (fixed and dilated) suggest severe brain injury but should not alone determine resuscitation decisions in the acute trauma setting 1. CPR should be started immediately while simultaneously addressing potential reversible causes of arrest such as tension pneumothorax, cardiac tamponade, hypovolemia, or hypoxia.

The standard trauma arrest protocol should be followed, including:

• High-quality chest compressions at a rate of 100-120 per minute
• Securing the airway
• Providing ventilation
• Obtaining IV/IO access
• Administering fluids for volume resuscitation While the prognosis is poor with bilateral blown pupils after trauma, some patients may still have salvageable injuries, particularly younger patients, as suggested by the study published in the Annals of Emergency Medicine in 2014 1.

The decision to terminate resuscitation efforts should be based on multiple factors including:

• Mechanism of injury
• Duration of arrest
• Response to interventions
• Overall clinical picture, not solely on pupillary findings Early consultation with neurosurgery is warranted if ROSC is achieved, as immediate surgical intervention may be necessary. The study emphasizes the importance of considering the circumstances and timing of the traumatic cardiopulmonary arrest, and involving parents and family in the decision-making process with assistance and guidance from medical professionals 1.

From the Research

Bilateral Blown Pupils in Blunt Trauma Cardiac Arrest

• The presence of bilateral blown pupils in a patient with blunt trauma cardiac arrest is a significant indicator of a poor prognosis 2, 3.
• However, the decision to initiate CPR in such cases should not be based solely on the presence of bilateral blown pupils.
• Studies have shown that CPR can be beneficial in certain cases of blunt trauma cardiac arrest, particularly when there is a possibility of reversible causes of cardiac arrest 4, 5.

Factors Influencing CPR Initiation

• The study by 2 found that prolonged time interval to hospital transport and high injury severity score were predictors of failure of CPR.
• Another study by 4 suggested that the use of automated CPR devices and damage control laparotomy may be beneficial in certain cases of blunt trauma cardiac arrest.
• The presence of hypoxia and electrical injury may also be associated with cardiac arrest in blunt trauma patients 5.

Management of Blunt Trauma Cardiac Arrest

• The management of blunt trauma cardiac arrest requires a critical evaluation of the patient's condition and the potential benefits of CPR 3.
• Resuscitative thoracotomy is not always recommended in cases of blunt trauma cardiac arrest, due to the low survival rates and high risk of complications 3.
• Alternative management options, such as automated CPR devices and damage control laparotomy, may be considered in certain cases 4.