EDITOR'S NOTE: Special thanks to our guest blogger, Bob Sullivan. Bob Sullivan, MS, NRP, is a paramedic instructor at Delaware Technical Community College. He has been in EMS since 1999, and has worked as a paramedic in private, fire-based, volunteer, and municipal EMS services, and is an ally to Pulsara. Contact info for Bob can be found on his blog, The EMS Patient Perspective. Enjoy!
~ Kris
Trauma is a leading cause of death for all age groups. EMS plays a pivotal role in trauma systems of care through assessment, treatment, and transport to the most appropriate trauma-care facility. Here are the top 10 things you need to know about multi-system trauma to save lives:
Definitive care for multi-system trauma patients is surgery at a trauma center, and time to surgery is critical for those with serious injuries. Interventions on scene should be limited to a rapid head-to-toe exam that identifies severe injuries and the need to control of severe external bleeding, manage the airway, and ventilate or oxygenate the patient. Unless a patient is trapped, most other interventions are done during transport.
EMS transport of severely injured patients to Level I and Level II trauma centers, which have specialists and emergency surgery available, has proven to be lifesaving. Not every trauma patient requires transport to a Level I or II trauma center, though, and over-triage can overwhelm the finite resources at those hospitals. Use the CDC field triage guidelines to determine which patients can be safely taken to Level III and IV trauma centers to better distribute patient load. However, err on the side of over triage and transport to the higher-level center if there is any concern about the severity of the patient’s injuries.[1]
External hemorrhage control begins by applying pressure to the wound with a dressing. Hold the dressing tightly on the wound, directly on the injured blood vessel. If that does not quickly control bleeding, apply a tourniquet ‘high and tight’ proximal to the wound. Adjust the pressure of a commercial device or inflate a blood pressure cuff until the bleeding stops. If bleeding continues after the maximum amount of pressure is reached, a second tourniquet may be applied proximal to the first. There is no nerve damage or risk of limb loss from tourniquets for at least two hours after application.[2]
Traumatic injury to the lung can cause a tension pneumothorax, in which air leaks into the space between the lung and chest wall and compresses the lung, heart, and blood vessels. This compromises both ventilation and cardiac output and can quickly lead to death.
Auscultate for silent or decreased breath sounds on one side, tachycardia, altered mental status, and hypotension during the primary assessment, and treat a tension pneumothorax as soon as it is recognized. This is done through placement of a needle into the second intercostal space at the mid-clavicular line of the chest, which relieves pressure in the chest and increases the size of the lung. The needle should be large bore (14 gauge or higher), and at least two inches long to ensure penetration of the chest wall. Assess for a rush of air and change in vital signs after needle placement.
Waveform capnography is an indirect measurement of a patient’s perfusion status. David Page describes capnography as the “smoke of metabolism.” The amount of carbon dioxide exhaled is related to cellular metabolism, which decreases in shock states. Consider internal bleeding or another cause of shock when end-tidal CO2 readings are below 35 mmHG and monitor for trends.
As internal bleeding progresses to shock, the combination of hypothermia, acidosis, and coagulopathy worsen bleeding. Even mild hypothermia impairs the body’s clotting mechanisms. Acidosis occurs when tissue demand for oxygen exceeds the available supply, and anaerobic metabolism is needed to produce energy. Both contribute to coagulopathy, where blood clots are broken down and the body is unable to form new ones.
Use blankets and heat in the ambulance to keep trauma patients as warm as possible, even in warm ambient temperatures. Administer 100% oxygen via NRB mask or bag-valve-mask to maximize oxygen delivery to tissues. Tranexamic acid impedes the breakdown of formed clots, and has been shown to reduce mortality in certain trauma patients when administered early.[2] This medication is being adopted by some EMS systems for hemorrhagic shock.
The once taught practice of infusing normal saline or lactated ringers to increase the blood pressure in hemorrhagic shock patients is now believed to cause harm. IV fluids dilute the body’s natural clotting factors and contribute to acidosis, and higher pressure may cause the existing clots to “pop.” If used, administer only enough fluid to maintain a radial pulse and mentation.
Patients taking blood thinners, such as Coumadin and Plavix, have impaired clotting capability and are at risk of internal bleeding from relatively minor injuries. Beta-blockers, including atenolol and metoprolol, may mask the signs of tachycardia and diaphoretic skin seen in patients in shock. It is important to know what medications are in these classes and consider their effects in your assessment findings.
Positioning patients flat on a spine board reduces respiratory capacity, causes pain, and increases the likelihood of pressure ulcers. An assessment of spinal pain and neurologic deficits should be used to determine if spinal immobilization is needed rather than just considering the mechanism of injury.
Many EMS systems have stopped using a long spine board and rigid cervical collar for spinal immobilization, even if a spinal injury is detected, and transport patients in a position of comfort with a soft cervical collar. Follow local protocols regarding spinal immobilization and be ready for changes in the near future.
Acute pain damages the immune system, hinders wound healing, and can lead to chronic pain, in addition to the suffering it causes.[3] Administration of fentanyl has been shown to effectively reduce pain, and does not cause hypotension or respiratory depression associated with other narcotics.[4] Deliver pain medications by IV, IO, or IN routes and reassess the patient’s pain. Early pain management by EMS can mitigate this harm, as well as improve the patient’s experience.
A two-minute exam with an ultrasound probe is commonly used in hospital to detect internal abdominal bleeding and collapsed lungs. Anaerobic metabolism in shock states produces lactic acid, which can be detected with point-of-care lactate meters before other vital sign changes. Both ultrasound and lactate have been incorporated into some EMS systems to identify these conditions, initiate treatment, and determine the most appropriate hospital destination. Look for wider adoption of these assessment tools in the near future.
1. Sasser SM, Hunt RC, Faul M., et al. Guidelines for field triage of injured pateints: recommendations of the National Expert Panel on Field Triage, 2011. CDC MMWR 2012, January 13; 61(1): 1-23.
2. Prehospital Trauma Life Support Committee of the National Association of Emergency Medical Technicians in cooperation with the Committee on Trauma of the American College of Surgeons. PHTLS: Prehospital Trauma Life Support. 8th ed. Burlington, MA: Jones and Bartlett
3. Thomas SH, Shewakramani S. Prehospital trauma analgesia. J Emerg Med 2008; 35(1): 45–57.
4. Krauss WC, Shah S, Thomas SH. Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia. J Emerg Med, 2011; 40(2): 182–7.
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