Chapter 27 Sabina A. Braithwaite and Jeffrey M. Goodloe Trauma is a disease whose severity is largely dictated by time and energy kinematics: time to definitive care, including operative intervention when required in a minority of cases, and energy mechanically transferred to the body to produce injury. Appropriate integration of out-of-hospital and in-hospital management of trauma can have a major effect on overall patient morbidity and mortality. Studies continue to clarify which out-of-hospital interventions truly benefit the patient and which interventions may actually worsen outcomes or delay more effective care options. Specifics on how mechanisms of injury, injury severity, available resources (including air medical services), provider training level, and specialty centers affect management and outcome of trauma patients have become clearer in recent years. Controversy exists as how to best balance the need for expeditious patient transfer from the out-of-hospital environment to in-hospital definitive assessment-based care with the patient’s need for critical or time-sensitive interventions prior to hospital arrival. An ever-enlarging body of experience and scientific study is further defining what management options improve outcomes in specific subpopulations of trauma patients. In short, trauma is a multifaceted disease that requires a systems-thinking and systems-operating approach, while incorporating new scientific knowledge to provide optimal patient management in the practice of EMS medicine. Proper assessment and management of blunt traumatic injuries are among the core goals for EMS physicians, paramedics, and EMTs. The physical demands encountered while managing the trauma patient can be considerable for EMS providers. Extrication from adverse environments and working in inclement weather are common. The ability to adapt the core trauma evaluation and management concepts to any given situation is paramount. Emergency medical services system structure elements, including ALS versus BLS, staffing level, and use of air evacuation resources, all contribute to a system’s ability to care for the trauma patient. Scientific comparison of different operational models is just beginning to demonstrate which can provide the greatest benefit to specific patient populations [1]. Long-held notions of the superiority of ALS interventions in the field (such as IV access for fluid resuscitation and endotracheal airway management) have been called into question [2]. It may be that severely injured patients (at least in an urban setting) are best served by primary application of the basic skills of hemorrhage control, airway support, and rapid transport to the appropriate level trauma center. The central concepts for EMS providers caring for trauma patients include the following. Monitoring and reinforcing proper application of these concepts through performance measurement and improvement (see Volume 1, Chapter 72.), together with adequate practice on infrequently used psychomotor skills, are important parts of medical oversight and can have a demonstrated effect on patient morbidity and mortality. Realistic, relevant, integrated assessment and management scenario-based training, potentially including high-fidelity simulation, has been demonstrated to improve skill consistency and retention and may improve providers’ ability to translate didactics into clinical performance [3]. Nationally and internationally recognized courses that incorporate these elements exist and span the spectrum of care. The mechanism of injury, while not entirely predictive of actual injury sustained, often alerts the astute clinician to potential injuries that may be encountered during the assessment and management of the blunt trauma patient in the field. The importance of integration of local EMS and hospital resources, and tailoring guidelines to optimize patient care within these parameters, cannot be overemphasized. Blunt trauma management differs significantly from penetrating trauma, which is addressed in Volume 1, Chapter 29. Emergency medical services systems should strive to limit the time from patient contact to departure from the scene to 10 minutes or less in injuries compatible with life threat. Except for control of life-threatening hemorrhage and support of airway and oxygenation/ventilation, all other interventions should take place en route to definitive care. The goal of the primary survey is to identify and address any immediate life threats while the critical patient is promptly packaged for transport. Assessment can begin before arrival on the scene using dispatch information to prepare anticipated care needs based on patient mechanism of injury, potential notification of additional needed resources, and other local considerations. Once patient contact is safely made, attention to discovering life threats through an organized approach is essential. Attention to arterial hemorrhage control, establishing and/or maintaining airway patency, correcting oxygenation and/or ventilation failure, and improving shock from blunt trauma are key aspects of the primary survey. In the severely injured patient with possible survival, the only survey to be done on-scene is the primary survey. Scene photography may help convey aspects of mechanism of injury to the receiving physician as long as patient confidentiality is respected [4]. Event data recorders (automotive “black boxes”) will increasingly integrate with EMS to provide objective prearrival information in motor vehicle collisions (MVCs), potentially tailoring data-driven resource allocation based on actual mechanism and patient information. Newer telemedicine applications that allow concurrent assessment by EMS and receiving emergency physicians may facilitate triage and expedite care at the receiving facility for a number of time-sensitive medical complaints, including trauma. The secondary survey, like the primary survey, is conducted using an organized, consistent approach. It differs substantially from the primary survey in its detail. The secondary survey is a methodical head-to-toe assessment exam designed to identify many non-life threatening injuries that are easily obscured by visually captivating injury or primary survey life threat discovery. While important for all trauma patients, due to management priorities that are identified in the primary survey and require frequent reassessment, the secondary survey may not be performed until after arrival at the destination trauma center for some patients. Omission of the secondary survey for this reason is not incorrect and in fact, may represent a conscious decision by an astute EMS clinician to focus on immediate life threats identified in the primary survey.
Blunt trauma considerations
Introduction
Effect on emergency medical services
Training for EMS providers
Resuscitation and initial assessment
The primary survey
The secondary survey
The role of Basic Life Support and Advanced Life Support
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