7 Advances in Prehospital Trauma Care

1. 7 Advances in Prehospital Trauma Care Derek Isenberg, MD, NREMT-P Medical Director Mercy EMS

2. With the exception of 2 procedures (Needle decompression) (Tracheostomy) trauma is a BLS skill

3. 1. Hypotensive Resuscitation

4. Hypotensive Resuscitation Keep patient hypotensive but perfusing until bleeding can be controlled Evolved from the military model of battlefield resuscitation Assessment for adequate perfusion Awake and alert Radial pulse SBP >90

5. Hypotensive Resuscitation Question: Would you fill your oil tank with water because you ran out of oil?

6. Hypotensive Resuscitation Treatment for hypovolemia secondary to blood loss is Blood Not Saline

7. Hypotensive Resuscitation

8. Hypotensive Resuscitation

9. EMS vs. Homeboy Ambulance UCLA Comparison of severely injured patients transported by EMS versus Relatives, bystanders, or police 4856 EMS patients vs. 926 non-EMS patients Mortality rate: 9.3% in the EMS group and 4.0% in the non-EMS group

10. Hypotensive Resuscitation Normal saline does not save a trauma patient Bleeding needs to be controlled Rapid transport to a trauma center Do not wait on scene starting an IV No IV fluid is needed if patient is Mentating well Has a radial pulse

11. 2. Selective Spinal Immobilization

12. Selective Spinal Immobilization BLS Protocol Based on the NEXUS Study ED population 34000 patients Validated in prehospital population

13. Selective Spine Immobilization All patients with traumatic injury must be immobilized if they have a MOI and: a. Altered mental status (including any patient that is not completely alert and oriented) b. Evidence of intoxication with alcohol or drugs c. A distracting painful injury d. Neurologic deficit (including extremity numbness or weakness- even if resolved) e. Spinal pain or tenderness (in the neck or back)

14. Does Immobilization Do any Good 5-year retrospective chart review Malaysia trauma center and UNM All patients with acute spinal cord injuries 0/120 patients in Malaya had spinal immobilization 334/334 pts at the UNM. Less neurologic disability in the unimmobilized Malaysian patients

15. Negative Effects of Immobilization C-collar increases ICP Reduced FVC by up to 60% in children In healthy adults, average 15% reduction in FVC 30 healthy adults, 100% developed pain in 30 minutes Decreases blood flow to skin->pressure ulcers

16. Immobilization in Penetrating Trauma Do not immobilize patients just because of penetrating injury Multiple studies-all patients with spinal injuries had obvious neurological deficits on exam or were in cardiac arrest Higher mortality with immobilization?

17. 3. Tourniquets

18. Tourniquets Used to treat massive hemorrhage from extremity wounds Standard issue on the battlefield since 2004 Soldiers can apply the tourniquet to themselves Simple to apply to other soldiers Allow prompt treatment of multiple injuries

19. Tourniquets in Battle 2009-Annals of Surgery 232 patients in 7 months (Middle East) 11% mortality when tourniquets applied in field vs. 24% when applied in ED Tourniquets improved mortality when applied BEFORE shock developed Few complications reported 4 patients had transient nerve injury No permanent injuries or amputations

20. Combat Application Tourniquet

21. Tourniquets-How to Apply Place distal to the injury (not over the injury) Never place over a open wound Place just proximal to the injury Tighten to the lowest pressure needed to stop bleeding Must document neurovascular status before placement and every 5 minutes after placement CAT Tourniquet Video

22. Tourniquets-Complications Nerve Injury Muscle death Necrosis of distal body parts Injuries to blood vessels Blood Clots Reperfusion injury

23. Tourniquets Should never be left on more than 2 hours Safe for 60-90 minutes Muscle damage after 120 minutes Should never be covered Should not be released by any provider before speaking with medical command Time of application MUST be written on the tourniquets

24. Tourniquet-Controversies All studies from military populations Time intervals differ in civilian populations Different injury patterns Explosive devices vs. high velocity weapons vs. low velocity weapons

25. 4. Hemostatic Agents

26. Hemostatic Agents (Quik-Clot) Use kaolin (kaolinite-naturally occurring mineral) Activates clotting factors platelets aggregate clot forms Earliest versions were powdered Caused exothermic reaction Interfered with surgery Adhered to wounds Current products embedded in bandages Available over the counter

27. Quik-Clot

28. Hemostatic Agents-PA Protocol Indicated for extremity bleeding 1. Pack wound with approved agent, 2. Apply direct pressure 3.Apply pressure dressing 4. Once applied, do not remove dressing ***Hemostatic dressings should not be applied over each other

29. 5. Traumatic Cardiac Arrest

30. Traumatic Cardiac Arrest Unless the cause of the cardiac arrest is rapidly reversible (e.g. tension PTX), traumatic are arrests are not salvageable.

31. Trauma Resuscitation Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiac : Joint statement from NAEMSP and ACS-COT Obvious signs of death Any trauma patient without signs of life ECG=asystole or idioventricular rhythm ED transport >15 minutes

32. Trauma DOA Unwitnessed cardiac arrest of traumatic cause Traumatic cardiac arrest in entrapped patient with severe injury that is not compatible with life. Submersion greater than 1 hour.

33. Trauma Cardiac Arrest-Destination Contact medical command for possible field termination of resuscitation if [the patient] cannot arrive at the closest receiving facility within 15 minutes. If the patient can arrive at the closest trauma center within 15 minutes, the patient should be taken to the trauma center even if another hospital is closer.

34. 6. Endotracheal Intubation in Trauma

35. Trauma Intubation Has never been shown to improve morbidity, mortality, or neurologic benefits Likely worsens outcomes because of delays to definitive care Most of the studies have been done in TBI

36. ETI vs. BVM in Trauma 316 pts with ETI and 217 with BVM. Mortality rate for ETI (88.9%) vs. BVM (30.9%)

37. ETI In Head Injury 191 pts with head injury and GCS<8 Mortality rate 23% with ETI versus 12.4% without Higher rates of Hospital days ICU days Days on ventilators Higher rates of pneumonia

38. ETI In Head Injury

39. ETI In pediatric patients

40. ETI In pediatric patients

43. ETI in Trauma-Conclusions ETI provides no benefit in trauma patients Likely harms patients, especially with head injury Majority of patients who receive ETI Definitive airway does not need to be placed in the field Consider King-LT or BVM only

44. 7. The Golden Hour

45. Golden Hour-A Myth 3,656 trauma patients available for analysis, 22.0% died Inclusion criteria were SBP <less than or equal to 90 Respiratory rate <10 or > 29 Glasgow Coma Scale score < 13, Advanced airway

46. Golden Hour-A Myth No association between time and mortality for any EMS interval: Response On-scene Transport Total EMS time All transport times were less than 1 hour Conclusion: �In this...sample, there was no association between EMS intervals and mortality�

47. Conclusions 1) IVF does not improve outcomes Delays transport to definitive care It is no longer acceptable to run IVF wide open of every patient 2) Use spinal immobilization carefully and as other other medical intervention Not a benign treatment 3) Tourniquets save lives in penetrating extremity trauma

48. Conclusions 4) Hemostatic agents can effectively stop bleeding 5) ETI has no benefit in trauma and possibly worsens outcome 6) Dead trauma patients are dead 7) Is the golden hour a myth?