Introduction
Each year civilian trauma accounts for 35 million emergency department (ED) evaluations and 1.9 million hospital discharges admissions across the United States. It is the leading cause of death in individuals ages 1 to 44 years (47% of the deaths) and the third leading cause of death overall, covering all age groups with 180,811 deaths in 2011. The leading mechanism of civilian injury deaths is motor vehicle crashes, 26%; firearms, 18%; poisoning, 17.8%; and falls, 11.4%. Thirty percent of life-years lost are due to trauma followed by cancer (16%) and heart disease (12%). The economic burden is enormous ($400 billion) in both health care costs and loss of productivity.
The Department of Defense (DoD) reports U.S. deaths from Operation Enduring Freedom and Operation Iraqi Freedom, including military and DoD civilians, at 6651 with those wounded in action totaling 50,602. The mechanism of military injuries is 67% penetrating, 38% blunt, and 3% burns. Leading causes of injury including battle and non–battle related, are improvised explosive device (IED), 52%; gunshot wounds, 28%; other, 13.8%; and motor vehicle crashes, 5.9%, which is in contrast to civilian injuries causes of falls, 40%; motor vehicle crashes, 28%; and firearms, 4.35%.
The concept of a trimodal distribution of death after injury has been popularized in both civilian and military settings. This trimodal distribution of deaths associated with civilian trauma is categorized as immediate, early, and late. Immediate deaths occur as a result of brain or spinal cord injury, major vessel injury, or cardiac injury; prevention is the best approach in reducing these fatalities, particularly from the military perspective. At the other end of the spectrum, late deaths occur several days to weeks after admission. Organ failure and sepsis are the most common cause of late deaths. Fifty percent of trauma deaths occur within 12 hours of injury, and 74% die within 48 hours, emphasizing the need for expedient and definitive intervention. Deaths within 1 to 24 hours after injury occur from hemorrhage in the first 6 to 12 hours and severe brain injury in the 12- to 24-hour period. The military died-of-wounds rate (deaths that occur after reaching the first level of medical care) have also been investigated and categorized in nonsurvival (NS) and potential survival (PS). The predominant mechanism of death in NS group was overwhelming traumatic brain injury (83%) and hemorrhage (16%). However, in the PS group, the percentage is reversed with hemorrhage as the leading cause of death at 80%. These data underscore the necessity for initiatives to mitigate bleeding, particularly in the prehospital environment.
A general understanding of trauma systems, prehospital care, Advanced Trauma Life Support (ATLS) assessment, and a brief overview of initial injury management are critical in the understanding of how we might mitigate injury-related complications and mortality in multi-injured trauma patients.
Trauma Systems
In 1966, the landmark article “Accidental Death and Disability: The Neglected Disease of Modern Society” was published by the National Academy of Sciences. The publication emphasized the need for an organized approach to the treatment of injured patients. A decade later, the American College of Surgeons (ACS) Committee on Trauma published “Optimal Hospital Resources for the Care of the Seriously Injured,” which became the framework for modern-day U.S. trauma systems.
The Trauma Care Systems and Development Act created guidelines for the development of an inclusive trauma system integrated with the emergency medical services (EMS) system to meet the needs of acutely injured patients. The objective of the system is to match the needs of patient to the most appropriate level of care through a well-organized approach of care delivery to the injured within a community. The process of designation of trauma centers as level I, II, III, or IV depends on the commitment and resources of the medical staff and administration to trauma care at facilities seeking designation. Trauma centers may be designated either by a state or regional trauma system authority or by the ACS verification process. The verification process evaluates several key factors, including (1) the institutional commitment to injured patients; (2) injury volume and acuity; (3) facility layout, dedicated material, and human resources; (4) operation of the clinical trauma program; and (5) trauma performance improvement program. The relationship between the formal verification of a trauma center and the improved outcomes has been demonstrated across a number of quality indicators, including in-hospital mortality, length of stay, lethal injury complex outcomes, and resource uses.
Although the development of the civilian trauma system has been closely tied to the lessons learned by the U.S. military during conflicts over the past two centuries, the U.S. military trauma system stagnated in the 1980s and was initially unprepared for the number of casualties incurred during Operations Enduring Freedom and Iraqi Freedom. The Joint Theater Trauma System (JTTS) was developed by military medical leaders to provide a systematic approach to battlefield care resulting in mitigating mortality and morbidity. The JTTS was based on U.S. civilian trauma systems with further refinement in creating a continuum of care from the battlefield care to rehabilitation through levels of care in 2004. The Joint Theater Trauma Registry (JTTR), which included a comprehensive injury and outcome database, was developed to account for ongoing performance improvement and research. This database has had a significant impact on the care of wounded warriors through the development of evidence-based clinical practice guidelines.
The general thrust of both civilian and military trauma systems is a paradigm of the right patient, right injury, right care, and right time.
Prehospital Evaluation and Care
Major studies of both civilian and military trauma epidemiology suggest that the majority of deaths in injured patients occurs in the prehospital phase. Whereas nearly 50% of civilian injury-related deaths occur within the first 12 hours, 50% of current U.S. military combat-related deaths occur within the first 6 hours. Death and late complications have been linked to the timeliness and appropriateness of early interventions, including airway management, hemorrhage control, and resuscitation. Thus, the development of prehospital treatment and resuscitation algorithms has the great potential to improve mortality and morbidity.
In every system, the goal of evaluation and treatment of a trauma patient in the field is to evaluate airway, breathing, and circulation (ABCs); provide spinal immobilization; initiate appropriate resuscitation; perform a secondary survey; properly prepare the patient for transport; and minimize the time on the scene. The specific standards or protocols are determined by the regulatory agency governing that region and local medical control.
Prehospital Personnel
The on-scene evaluation and treatment of trauma patients can be widely variable and are dependent on the level of training of the provider, local standards and protocols, and available resources. Each EMS system has a unique structure, but in general, there are four levels of providers: first responder, emergency medical technician (EMT), paramedic, and prehospital critical care provider. Prehospital critical care providers include critical care–trained paramedics, nurses, respiratory therapists, and physicians. These providers operate in ground and air transport systems.
Although local protocols often follow nationally accepted standards, there may be small variations for each specific protocol based on regional need or the local medical director’s preference. In general, more densely populated areas have a greater number of EMS providers and resources. Unfortunately, as the population density decreases, EMS resources often decrease. In rural areas, there may be only one ambulance and a basic EMT team for a large geographic area.
Each level of prehospital provider has specific required training that increases in conjunction with the number and complexity of the available protocols and interventions to be performed. The U.S. Department of Transportation (DOT) establishes the National Standard Curricula (NSC) as the minimum standards for each level and recommends the range of required training hours.
Prehospital and En Route Critical Care Providers
This category of provider covers a wide range of disciplines, including critical care–trained paramedics, respiratory therapists, nurses, and physicians. These providers are often required to have a certain amount of in-hospital critical care experience before joining a transport team. Commonly, they receive further training, both didactic and practical, as part of an orientation to the transport program; most advanced teams receive 2 to 6 months of training after joining the transport team.
This group of practitioners provides the highest level of care outside of the hospital setting. The assessment of a trauma patient is generally the same as done by other prehospital medics but involves more attention to detail. The interventions follow the same general principles but are often more aggressive, including intravenous (IV) fluid resuscitation and administration of analgesia. The same principles for immobilization are used, and the patient is transported to the hospital.
A paradigm shift in the U.S. military during the cold war necessitated the development and heavy reliance on specialized teams of en route critical personnel. Military operations became smaller and more mobile, leading to a shift from fixed combat support hospitals to scalable deployable assets with forward surgical operations providing damage control surgery. With this new paradigm of surgical care, a gap existed in the transfer of intensive care level (ICU) of treatment in the patient who may be stable but not appropriate for the standard military aeromedical evacuation system. Some of the teams created include the U.S. Army Burn Flight Team (1950s), the U.S. Air Force (USAF) Critical Care Air Transport Team (1990s), and the USAF Acute Lung Rescue Team (2005). These specialized teams impact military care and civilian care via augmentation during disasters.
Airway Control
The first objective is to evaluate, manage, and secure the airway. Inspection of the airway for foreign bodies such as broken teeth, foodstuff, emesis, and clotted blood is essential before an artificial airway is placed. In all Basic Life Support courses, the emphasis on chin lift and jaw thrust cannot be overemphasized as the initial treatment. This simple maneuver moves the tongue away from the back of the throat and in many instances reestablishes a patent airway. At this point, an oral airway may need to be placed. Appropriate size selection is essential to prevent the complication of airway obstruction. The nasopharyngeal airway may also be placed through the nasal passage into the back of the oropharynx to prevent the tongue from occluding the airway.
After this maneuver has been performed, the airway may need to be definitively controlled in patients who are unresponsive or have an altered mental status (Glasgow Coma Scale [GCS] score <8), are hemodynamically unstable, or have multiple injuries including the head and neck. Of importance remains cervical spine protection while the optimal airway is maintained, with in-line cervical spine stabilization. This maneuver minimizes iatrogenic injuries to the spine and spinal cord during the process of definitive airway control.
Prehospital endotracheal intubation remains a controversial intervention because of the success rate and amount of time required to perform the definitive airway. The EMS systems with the highest endotracheal intubations rate have very stringent requirements for certification (i.e., 20 live intubation or a minimum of 12 field intubations annually). Neuromuscular blockade increases the success rate (97%), but the current use is limited to a few ground EMS systems and aeromedical agencies under direct medical control.
Besides direct endotracheal intubation there are other airway adjuncts available. The use of the laryngeal mask airway (LMA) has gained popularity because of the relative ease of placement and relatively low cardiovascular stress that the patient undergoes compared with standard endotracheal intubation. It must be remembered that the LMA does not technically protect the airway from aspiration and was designed for use in spontaneously breathing patients. The LMA may be used emergently for a patient to whom a paralytic agent has been given but successful intubation has not been achieved or before the injection of the paralytic agent if mask ventilation is not adequate
The King LT is a commonly used rescue technique to manage the airway in the prehospital setting. The King LT is a single-use supraglottic airway that uses two cuffs to create a supraglottic ventilation seal at the pharynx and esophagus. It has a single ventilation port and a single valve and pilot balloon that go to both the pharyngeal balloon and the esophageal balloon. Although it is possible to insert the distal tip of the King LT directly into the trachea instead of the esophagus, its overall short length and preformed curve makes this very unlikely. Several studies have shown the King LT to have a higher rate for success for airway control in the prehospital setting compared with other supraglottic airways or endotracheal intubation.
Whenever the decision is made to emergently secure an airway, it must be accomplished as quickly and safely as possible. Pharmacologic agents must be chosen that will allow the safe placement of an airway while minimizing the risk to the patient. The most rapidly acting agents with the shortest duration (i.e., etomidate for sedation and succinylcholine for paralysis) along with an acceptable side effect profile should be chosen. In all circumstances, the practitioner must avoid the situation in which a long-acting agent has been given and the airway cannot be intubated or ventilated with a bag mask device.
In the case of the standard rapid sequence induction, the patient should be preoxygenated, and a hypnotic agent should be given and immediately followed by the paralytic agent. Mask ventilation is not attempted (it may induce aspiration), and it is hoped that the immediate successful placement of the endotracheal tube will proceed. Proper placement is verified by auscultation of the lungs bilaterally, lack of gastric sounds with ventilation, and the presence of end-tidal carbon dioxide at the proximal end of the endotracheal tube.
Thermal injuries to the airway initially may not be symptomatic or present as hypoxia for some time after the insult. During the initial survey, documentation of singed hair, soot, or burns around the air passages should be noted. The decision may be made to secure an airway with an endotracheal tube prophylactically before significant edema and swelling may make securing the airway much more difficult.
As the anesthetic induction is begun, an assistant should apply enough pressure onto the cricoid cartilage so as to occlude the esophagus, which lies directly posterior. It should be remembered that trauma, pain, and the use of narcotics may all delay gastric emptying. Release of cricoid pressure occurs only after proper positioning of the endotracheal tube has been verified.
Hemorrhage Control
Uncontrolled hemorrhage is the second leading cause of death in civilian trauma and the leading cause of death in military trauma. Compression of hemorrhage is one of the first priorities for prehospital personnel in the care of injured patients, and on the battlefield, it takes precedence in Tactical Combat Casualty Care. When direct pressure cannot control hemorrhage, advanced maneuvers are needed, including the use of tourniquets and hemostatics as adjuncts for control.
Extremity hemorrhage is common with penetrating trauma and especially during wartime. Despite previous debate concerning the use of tourniquets in the prehospital setting, recent experience and research in combat causalities have led to a dramatic increase in the use of tourniquets. Current literature suggests that tourniquets are strongly associated with survival when applied early and have a low morbidity risk without amputations resulting solely from their application. Although all military personnel deployed to combat are provided tourniquets with training, the use of tourniquets in the civilian prehospital setting is not common. One recent review of community experience of isolated exsanguinating extremity hemorrhage noted that more than 50% of patients who died had a bleeding site anatomically amenable to tourniquet control. Based on military experience and improvements in tourniquet technology, emergency medical personnel are now being trained in the application of the tourniquet, and it is endorsed by Prehopital Trauma Life Support (PHTLS). Universal acceptance, indications, and application of the use of tourniquets might benefit in disaster or mass casualty situations.
The role of topical hemostatic agents in control of hemorrhage has been predominately in combat resuscitation but is becoming more common in civilian practice. The compounds in general are most useful in curtailing hemorrhage associated with broad or deep wounds, particularly in junctional areas. The ideal agent would be package ready, light weight, simple to apply, work rapidly, and control both arterial and venous bleeding. Although no agent currently meets these requirements, the three most common classes include mucoadhesive agents (WoundStat, HemCon, and Celox), procoagulant supplementors (QuikClot Combat Gauze), and clotting factor concentrators (QuikClot Zeolite granular and QuikClot ACS+). All agents have shown benefit over traditional field dressings in animal models of hemorrhage. Although these agents have demonstrated efficacy, there are some safety concerns. Similar to tourniquet application, the use of hemostatic agents is currently limited in civilian prehospital care by scope and application compared with military use.
Resuscitation
A primary goal of prehospital providers in conjunction with airway and hemorrhage control is the restoration of perfusion. Prompt and appropriate access to intravascular space is critical, and the placement of large-bore peripheral catheters is still the standard. However, rapid access is not always easily achievable, and an alternate approach with placement of intraosseous (IO) devices has steadily increased. IO devices can be placed in children and adults in a variety of locations, but caution must be used because each IO device is specifically designed for age group (pediatric vs. adult) and specific anatomic location (sternal vs. tibia).
The traditional prehospital resuscitation treatment regimen of 2 L of crystalloid fluid to achieve a minimum systolic blood pressure of 90 mm Hg has been reduced to 1 L of crystalloid with the 9th Edition of the Advanced Trauma Life Support (ATLS) course based on growing evidence that aggressive crystalloid resuscitation may not be beneficial. The concept of withholding resuscitation and allowing permissive hypotension with ongoing hemorrhage dates back to World War I and has been uniformly adopted in the current management of gastrointestinal (GI) hemorrhage and aortic aneurysm rupture. In selected groups of trauma patients, it has been shown to increase survival. This concept of controlled resuscitation has already been adopted by the military with limited administration of fluids (maximum of two 500-mL boluses of Hextend a minimum of 30 minutes apart). The rationale for this recommendation is based on limited resources on the battlefield and the cumulative literature regarding limited resuscitation.
The deployment of blood components and fresh whole blood in the prehospital realm is becoming more frequent, particularly with prehospital critical care providers on both rotary wing and ground transports. Currently, several air services carry packed red blood cells, and a few carry plasma.
Tranexamic acid (TXA) is an antifibrinolytic agent that has been used since the 1960s to control bleeding from blood dyscrasias, heavy menstrual bleeding, and GI bleeding and is now also being evaluated in trauma patients as part of the resuscitation. In a very large multicenter, randomized, double-blind, placebo-controlled trial, trauma patients who received TXA had a significant reduction in all-cause mortality and an overall reduction in death secondary to hemorrhage. Those who benefited the most received TXA within 3 hours of injury. The military recently, in a retrospective study, compared combat-injured patients who received TXA with those who did not, demonstrating improved survival in the group that received TXA. Current efforts are under way to study the use of TXA in the prehospital setting to assess if earlier administration of the drug would extend the benefits previously seen in the hospital treatment.
Hospital Evaluation and Care
Trauma Team
The configuration of the trauma team receiving patients is variable but includes emergency medicine physicians, nurses, allied health personnel, and the trauma surgeon as the team leader. Various subspecialists in surgery, orthopedics, neurosurgery, cardiothoracic surgery, anesthesia, and pediatrics are readily available at a level I center. The receiving facility should have a dedicated area for the resuscitation of trauma patients as well as a dedicated operating room (OR) available 24 hours a day. A resuscitation room should be well equipped with devices for the warming of fluid, rapid infusers, and appropriate surgical supplies for the performance of lifesaving procedures. Permanently fixed radiographic equipment expedites the evaluation of injured patients in the resuscitation room. Staffing in the trauma room should be limited to those with experience in trauma resuscitation, and their duties should follow the guidelines outlined in the ACS Committee on Trauma Resources for Optimal Care of the Trauma Patient 2010.
After the acute phase of resuscitation and operative intervention, a level I trauma facility maintains a highly trained staff of surgical intensivists. The staff provides 24-hour coverage of the intensive care unit (ICU). These patients are susceptible to complications such as sepsis, acute respiratory distress syndrome (ARDS), and multisystem organ failure, which require the technical support provided by a level I center. Intermediate care units provide intensive supervision of the patient before placement on the trauma floor, which is critical for the recovery of the patient. During this time, patients receive rehabilitation to prepare for dealing with disabilities and limitations that may have changed their lives owing to their injury. The patient’s physical and emotional health is evaluated, and treatment is initiated. Patients who have sustained significant injury will have special nutritional needs, given their increased caloric demands. The patient’s nutritional status is assessed by nutritional services and a recommendation made to the trauma service. As the patient nears discharge, arrangements for home needs and potential placement are made by social services and case care coordinators. The availability of and relationships with rehabilitation centers and chronic nursing facilities are essential for injured patients.
Assessing the Severity of Injury
Several scoring systems have been developed in an attempt to triage and classify patients both in the field and at the receiving hospital. Champion and coworkers have classified the scoring systems into physiologic and anatomic types. The GCS for brain injury is perhaps the most widely accepted physiologic score. This scale ranges from 3 to 15, with 15 being normal. Each section, with its weighted score, is as follows: eye movement (4 points maximum), verbal response (5 points maximum), and motor response (6 points maximum) ( Table 9-1 ). The GCS is a part of the Revised Trauma Score (RTS), which allows inferences to patient outcome as a result of these scores. This score comprises the GCS score, systolic blood pressure, and respiratory rate ( Table 9-2 ).
| Response | Score |
|---|---|
| A. Eye Opening | |
| Spontaneous | 4 |
| To voice | 3 |
| To pain | 2 |
| None | 1 |
| B. Verbal Response | |
| Oriented | 5 |
| Confused | 4 |
| Inappropriate words | 3 |
| Incomprehensible sounds | 2 |
| None | 1 |
| C. Motor Response | |
| Obeys commands | 6 |
| Localized pain | 5 |
| Withdraw to pain | 4 |
| Flexion to pain | 3 |
| Extension to pain | 2 |
| None | 1 |
| Response | Variables | Score |
|---|---|---|
| A. Respiratory Rate (breaths/min) | ||
| 10–29 | 4 | |
| >29 | 3 | |
| 6–9 | 2 | |
| 1–5 | 1 | |
| 0 | 0 | |
| B. Systolic Blood Pressure (mm Hg) | ||
| >89 | 4 | |
| 76–89 | 3 | |
| 50–75 | 2 | |
| 1–49 | 1 | |
| 0 | 0 | |
| C. Glasgow Coma Scale Score Conversion | ||
| 13–15 | 4 | |
| 9–12 | 3 | |
| 6–8 | 2 | |
| 4–5 | 1 | |
| 3 | 0 | |
| Revised Trauma Score = Total of A + B + C |
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
