The following information is taken from: Varon, Albert J. (2012-06-01). Essentials of Trauma Anesthesia. Cambridge University Press. Kindle Edition.
Airway and ventilation management
Loss of airway or breathing is the most rapid cause of death. Airway management in the field is more difficult than in the hospital owing to the lack of resources, adverse environment, and uncontrolled patient factors in the field. Intubation and alternatives 9LMA, etc.) should be used when necessary. Cervical spine injury should be considered and steps taken to minimize more injury.
The EMS provider administers oxygen and consider assisted ventilation if injury to the chest is suspected. Tracheal intubation is used when spontaneous ventilation is inadequate. Tension pneumothorax is treated with a needle placed into the pleural space via the second intercostal space in the mid-clavicular line. Open pneumothorax is treated by an occlusive dressing taped down on three sides creating a one-way valve that allows air to escape from the pleural space but prevents re-entry.
The EMS provider has two goals: vital organ perfusion and external bleeding controlled. Perfusion is assessed by determining mental status, skin color, and quality of the pulse.
“AVPU” is a mental status mnemonic:
- A = Alert and responsive
- V = Responds only to verbal stimulus
- P = Responds only to pain (trapezius pinch, sternal rub)
- U = Unresponsive
Time should not be wasted determining blood pressure as this may delay patient transport.
Almost all external bleeding may be controlled with direct pressure or tourniquets when direct pressure fails.
Time should not be taken in the exsanguinating patient to establish IV access if this is at the expense of getting the patient to a trauma center in the fastest time possible.
Traditionally, fluid resuscitation has been considered the standard of care in the prehospital setting despite a lack of evidence supporting this practice. IV access should not be performed in the prehospital setting if it delays transport to definitive care. If access is obtained, IV fluid should be withheld until active bleeding has been addressed (particularly for penetrating torso wounds). Fluid should be given in small 250 cc boluses, titrating to a palpable radial pulse, instead of a continuous infusion. Most trauma patients who found in cardiopulmonary arrest in the field have exsanguinated. ACLS algorithms will not help this situation. Futile resuscitation efforts will also place the field healthcare providers at needless risk. The National Association of Emergency Medical Services Physicians and the American College of Surgeons Committee on Trauma have published guidelines for withholding or termination of resuscitation in prehospital traumatic arrest:
1. Resuscitation efforts may be withheld in any blunt trauma patient who, based on out-of-hospital personnel’s thorough primary patient assessment, is found apneic, pulseless, and without organized ECG activity upon the arrival of EMS at the scene.
2. Victims of penetrating trauma found apneic and pulseless by EMS, based on their patient assessment, should be rapidly assessed for the presence of other signs of life, such as pupillary reflexes, spontaneous movement, or organized ECG activity. If any of these signs are present, the patient should have resuscitation performed and be transported to the nearest emergency department or trauma center. If these signs of life are absent, resuscitation efforts may be withheld.
3. Resuscitation efforts should be withheld in victims of penetrating or blunt trauma with injuries obviously incompatible with life, such as decapitation or hemicorporectomy.
4. Resuscitation efforts should be withheld in victims of penetrating or blunt trauma with evidence of a significance time lapse since pulselessness, including dependent lividity, rigor mortis, and decomposition.
5. Cardiopulmonary arrest patients in whom the mechanism of injury does not correlate with clinical condition, suggesting a nontraumatic cause of the arrest, should have standard resuscitation initiated
6. Termination of resuscitation efforts should be considered in trauma patients with EMS-witnessed cardiopulmonary arrest and 15 minutes of unsuccessful resuscitation and cardiopulmonary resuscitation (CPR).
7. Traumatic cardiopulmonary arrest patients with a transport time to an emergency department or trauma center of more than 15 minutes after the arrest is identified may be considered nonsalvageable, and termination of resuscitation should be considered.
8. Guidelines and protocols for TCPA (Traumatic Cardiopulmonary Arrest) patients who should be transported must be individualized for each EMS system. Consideration should be given to factors such as the average transport time within the system, the scope of practice of the various EMS providers within the system, and the definitive care capabilities (that is, trauma centers) within the system. Airway management and intravenous (IV) line placement should be accomplished during transport when possible.
9. Special consideration must be given to victims of drowning and lightning strike and in situations where significant hypothermia may alter the prognosis.
10. EMS providers should be thoroughly familiar with the guidelines and protocols affecting the decision to withhold or terminate resuscitative efforts.
11. All termination protocols should be developed and implemented under the guidance of the system EMS medical director. On-line medical control may be necessary to determine the appropriateness of termination of resuscitation.
12. Policies and protocols for termination of resuscitation efforts must include notification of the appropriate law enforcement agencies and notification of the medical examiner or coroner for final disposition of the body.
13. Families of the deceased should have access to resources, including clergy, social workers, and other counseling personnel, as needed. EMS providers should have access to resources for debriefing and counseling as needed.
14. Adherence to policies and protocols governing termination of resuscitation should be monitored through a quality review system.
The EMS provider should make a rapid determination of the patient’s Glasgow Coma Scale (GCS) score, pupillary response. and gross assessment of extremity motor function. Full spinal immobilization is maintained if there is any suspicion of injury to the spine. A rapid look at the patient’s body completes the primary survey. Transport to definitive care should not be delayed. Time should not be taken to splint fractures at the expense of quickly moving the patient to the trauma center.
The purpose of triage is to match patients with the resources necessary to effectively and efficiently deal with their injuries. Triage protocols should be formulated so that patients are brought to the closest and most appropriate facility. When multiple casualty incidents occur, the goal is to do the most good for the most people.
A widely used triage categorization is ID-ME based on likelihood of survival and degree of injury.
- I = Immediate. The patient has detectable vital signs but will die if they do not receive immediate care within two hours. Examples are head injury with altered mental status, severe respiratory distress, extensive burns, uncontrolled bleeding, decompensated shock, extensive thoracic, abdominal, or pelvic injuries, and traumatic amputation.
- D = Delayed. The patient has a serious injury and obviously needs medical treatment but will not rapidly deteriorate. Examples are moderate dyspnea, compensated shock, moderate to severe bleeding that is controlled, penetrating injury without airway compromise, open fractures, severe abdominal pain with stable vital signs, compartment syndrome, and uncomplicated spine injury.
- M = Minimal. The patient has minor injuries but is fully conscious and able to walk. These patients are often referred to as “walking wounded” and can take care of themselves for extended periods of time. Examples are closed fractures or dislocations without shock, minor to moderate bleeding that is controlled, burns involving less than 20% body surface area (BSA) not involving the airway or joints, strains and sprains, and minor head injury.
- E = Expectant. The patient has little or no chance of survival. Examples are cardiac arrest from any cause, severe head injury, burns larger than 70% BSA, irreversible shock, and gunshot wound to the head with GCS score ≤ 5.
The START triage system (Simple Triage and Rapid Assessment) is commonly used by EMS and military personnel to focus on four specific factors:
- Ability to ambulate
- Respirations (respiratory rate, RR)
- 3. Pulse
- 4. Mental status
If the patient is able to ambulate, they can be removed from the scene. Non-ambulatory patients are then triaged according to the following:
- Respirations (no respirations = Expectant or Deceased; RR > 30 = Immediate; RR < 30 go to next assessment).
- Pulse (no radial pulse or delayed capillary refill > 2 sec = Expectant).
- Mental status (unable to follow commands or unresponsive = Immediate; able to follow commands = Delayed).
Triage is dynamic and changes may occur based on response to simple maneuvers (e.g., chin lift, jaw thrust), availability of additional or more highly trained personnel, and other factors. The patient should be taken to the trauma center within the system that has the most appropriate resources to care for the specific injuries the patient might have.
The goals of the prehospital providers are to prevent further injury, initiate resuscitation, and provide safe and rapid transport of the injured patient.
- While much emphasis is understandably focused on the in-hospital care of the injured patient, injury prevention and prehospital care are essential if the burden of trauma on the individual and on society as a whole is to be diminished.
- Traumatic injuries are the third-leading cause of death in the United States, and for many of these injuries, death occurs within minutes of injury, making injury prevention the only way of treating these patients.
- For those who survive the initial insult, efficient prehospital care is essential in bringing the patient to the most appropriate facility.
- Field time should be minimized so that the potentially exsanguinating patient can be brought to a trauma center as soon as possible, where expeditious operative control of bleeding can be accomplished.