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Major Trauma Outside a Trauma Center Prehospital, Emergency Department, and Retrieval Considerations

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Major Trauma Outside a Trauma Center Prehospital, Emergency Department, and Retrieval Considerations Major Trauma Outside a Trauma Center Prehospital, Emergency Department, and Retrieval Considerations a, b,c Preston J. Fedor, MD, FACEP *, Brian Burns, DipRTM, MSc, MD, FACEM , d Michael Lauria, BA, NRP, FP-C , b,e Clare Richmond, FACEM, MBBS, BSci (Med Sci), Dip IMC KEYWORDS Trauma resuscitation Prehospital trauma Retrieval medicine Resource-limited environment Rural hospital Ultrasound KEY POINTS Incoming Emergency Medical Services crews often have crucial information about trauma mechanism, contributing factors, specific injuries, effect of treatment, key timings, per- sonal details, and more. They also can be an essential extra set of hands in settings with limited resources. Set up the resuscitation area for success and know the equipment and team capabilities. Create and rehearse emergency department and hospital procedures for quickly obtain- ing additional personnel and resources as needed. Extensive radiological and laboratory evaluation is often unnecessary and may delay ac- cess to definitive care. Only obtain studies that may provide actionable results and improve the course of management. Targeted bedside ultrasound can provide rapid and useful answers with appropriate training. An emergency physician must be prepared to provide immediate life, limb, and sight saving interventions when indicated, regardless of the clinical environment. Request transfer/retrieval as soon as the need for higher level of trauma care is presumed. A standard preretrieval process (with checklist) can make the transition of the patient out of the emergency department safer and more efficient. a Department of Emergency Medicine, Division of Prehospital, Austere and Disaster Medicine, University of New Mexico, 1 University of New Mexico, MSC11 6025, Albuquerque, NM 87131- 0001, USA; b Greater Sydney Area HEMS, NSW Ambulance, NSW 2200, Australia; c Sydney Uni- versity, Sydney, NSW, Australia; d Dartmouth-Hitchcock Advanced Response Team (DHART), Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA; e Royal Prince Alfred Hospital, Syd- ney, Australia * Corresponding author. E-mail address: [email protected] Emerg Med Clin N Am 36 (2018) 203–218 https://doi.org/10.1016/j.emc.2017.08.010 emed.theclinics.com 0733-8627/18/ª 2017 Elsevier Inc. All rights reserved. Descargado para Sebastian Betancur ([email protected]) en Hosp Pablo Tobon Uribe de ClinicalKey.es por Elsevier en octubre 19, 2018. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2018. Elsevier Inc. Todos los derechos reservados. 204 Fedor et al PART ONE: PREHOSPITAL TRAUMA: CUTTING-EDGE CARE IN THE FIELD Evolving Practices in Prehospital Care Prehospital care has evolved significantly from its origins in military conflicts to today’s complex Emergency Medical Services (EMS) systems. Highly specialized providers, structured protocols, and a broad scope of practice have contributed to prehospital medicine as a recognized medical specialty.1 High-quality trauma care begins from the point of first medical contact and continues during transport to local hospitals and ultimately to designated trauma centers. Prehospital medicine is now an area of significant and substantive research that has led to important, patient-centered im- provements in processes of care. Thoughtful use of rigid cervical collars and backboards Recent evidence suggests there is little benefit for the routine use of either backboard or cervical spine immobilization in trauma. In fact, neither technique provides effective spine immobilization and may result in patient harm through pain, skin breakdown, and complicating airway management.2–9 Spinal immobilization in penetrating trauma is associated with increased mortality.9,10 Position statements by the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma both recommend attention to spinal protection via “application of a cervical collar, adequate security to a stretcher, minimal movement/transfers, and maintenance of in-line stabilization during any necessary movement/transfer.” Additionally, both groups recommend against immo- bilization for penetrating trauma.11 We anticipate that a selective, rather than “routine” approach to spinal immobilization, will result in fewer patients immobilized without benefit during EMS transport. Increasing use of ultrasound Point-of-care ultrasound improves the diagnostic capability of prehospital physi- cians.12 Non-physician providers can be trained to accurately obtain and interpret ultrasound examinations, such as the Focused Assessment with Sonography for Trauma (FAST) or examination of the abdominal aorta.13 This skill set may improve the ability of EMS teams to assess trauma patients, triage a mass casualty incident, and direct patients to the most appropriate facility.14 In some EMS systems, FAST ex- amination findings directly impact patient care. For example, a shocked trauma pa- tient with a positive prehospital FAST examination may trigger the administration of prehospital blood administration and be directly transported to the operating room of the receiving institution. Prehospital ultrasound is still in its infancy, and further studies will guide its use and establish its impact on patient outcomes. Focus on hemorrhage control using strategies derived from combat medicine Lessons learned from military conflicts have led to substantial developments in trauma management for civilian prehospital practice. Damage control resuscitation (DCR), a treatment paradigm that combines rapid hemorrhage control, minimal crystalloid, and permissive hypotension has become the standard for patients with serious injuries and presumed hemorrhage.15,16 Prehospital clinicians can apply DCR principles by limited crystalloid administration, tourniquet application for extremity bleeding, and massive transfusion protocol initiation.17 The use of blood products in the field is feasible and may improve survival.18,19 Many advanced care EMS organizations now carry blood products, including both packed red blood cells and fresh frozen plasma.20 A more detailed review of DCR principles is outlined in the trauma resusci- tation sections of this issue. Descargado para Sebastian Betancur ([email protected]) en Hosp Pablo Tobon Uribe de ClinicalKey.es por Elsevier en octubre 19, 2018. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2018. Elsevier Inc. Todos los derechos reservados. Major Trauma Outside a Trauma Center 205 A growing number of air and ground EMS organizations administer tranexamic acid (TXA) for select trauma patients.21 TXA represents a feasible therapeutic adjunct for the bleeding patient, particularly for prehospital programs that lack the capability or logistical infrastructure to safely maintain and deliver blood products. Limb tourniquets popularized in military conflicts are now a standard part of civilian EMS practice. They are safe and effective means for controlling hemorrhage from extremity wounds, as demonstrated in both military and civilian prehospital care.22 Similarly, hemostatic dressings were developed from combat medicine, and many civilian EMS organizations include them in their hemorrhage control algo- rithms when pressure dressings fail, or in situations not amenable to tourniquet placement. What Are Unique Aspects of Providing Medical Care Outside of a Hospital? The defining characteristic of prehospital medical care is that it occurs outside of an established medical facility. It is inherently an austere environment spanning situations by the side of a road, the top of a mountain, or the back of a helicopter. Geography does not limit the care prehospital teams provide, but this does result in unique envi- ronmental challenges. EMS providers assess and treat patients in extremes of weather, under threat, and without optimal medical facilities. These challenges may impact what interventions are completed before arrival in the emergency department (ED). What Information Is Critical to Obtain from Prehospital Teams? Prehospital personnel can provide critical information to the team on arrival in the ED.23 In patients with an altered level of consciousness or intubated, the EMS team may be the only source of information regarding the mechanism of injury and preho- spital clinical course. The speed of the vehicle before impact, the immediate clinical status of the patient after injury, and other scene factors can often only be provided by the prehospital team. Several studies highlight the importance of prehospital hypo- tension in predicting clinical course, a finding reliably associated with increased morbidity and mortality.24–26 These findings suggest that the EMS-ED handover include mention of the lowest recorded blood pressure (BP, or if a BP could not be recorded). A structured rapid handover process can lead to a safer and more efficient transition of patient care.27,28 How Should Patient Information from the Field Be Communicated to the Emergency Department Team? EMS reports provide important information to help prioritize and plan care before pa- tient arrival. Key patient data need to be communicated clearly and concisely, and are often relayed remotely by radio, phone, or smart device to an ED charge nurse or physician. Several structured prehospital handover tools have been designed for this purpose, including the MIST report (Mechanism, Injury, Signs and Symptoms, Treatment, and Estimated time of arrival; Box 1).29 The downstream effect of prehospital notification
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