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. Spinal immobilization in penetrating trauma is associated with increased mortality.

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 immobilization for penetrating trauma. 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 physicians. 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. 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. In some EMS systems, FAST examination findings directly impact patient care. For example, a shocked trauma patient 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. Prehospital clinicians can apply DCR principles by limited crystalloid administration, tourniquet application for extremity bleeding, and massive transfusion protocol initiation. The use of blood products in the field is feasible and may improve survival. Many advanced care EMS organizations now carry blood products, including both packed red blood cells and fresh frozen plasma. A more detailed review of DCR principles is outlined in the trauma resuscitation sections of this issue.

A growing number of air and ground EMS organizations administer tranexamic acid (TXA) for select trauma patients. 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. Similarly, hemostatic dressings were developed from combat medicine, and many civilian EMS organizations include them in their hemorrhage control algorithms when pressure dressings fail, or in situations not amenable to tourniquet placement.

Is there a role for physicians in prehospital trauma care?

Globally, prehospital teams vary tremendously in composition. In Europe and Australia, it is common for a physician to be part of the prehospital helicopter EMS (HEMS) team. In contrast, similar team composition is rare in the United States. Some studies suggest that physician-based HEMS teams may improve survival to hospital discharge and decrease mortality. The generalizability of these findings is difficult, given confounders related to provider skill sets, care pathways, and deployment protocols.

Based on existing evidence and personal experience, we believe that physician-based prehospital teams are valuable to improve patient outcomes in trauma. In circumstances when trauma patients require immediate critical care interventions (eg, rapid sequence intubation, finger thoracostomy, extremity amputation), physician-led teams offer the best opportunity for success. Recent data support that physician prehospital involvement in complex battlefield trauma is beneficial. These physician-led teams provided critical interventions, such as advanced airway management and pediatric resuscitation, that required advance skill sets not possessed by less-experienced military medics. Heroic measures performed by highly trained prehospital physicians, such as resuscitative thoracotomy and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) are both possible and successful.

The inclusion of physicians in prehospital teams offers benefits in clinical and procedural decision making, trauma system knowledge, and integration of EMS-initiated protocols on arrival in the ED (eg, prehospital activation of a massive transfusion protocol). Additionally, there are system-level benefits to physician involvement in EMS, including education and quality assurance opportunities, improved interprofessional relationships, and identifiable opportunities to improve care.

Should endotracheal intubation be performed in the field on trauma patients?

There is conflicting evidence about the utility and patient-oriented outcomes of prehospital intubation. In large metropolitan areas, studies suggest that in the setting of head injury or severe trauma, prehospital intubation confers worse outcomes or equivocal benefit to mortality or morbidity. Most notably, the Ontario Prehospital Advanced Life Support (OPALS) Major Trauma study found increased mortality with intubation of trauma patients in a before-after trial, compared with a group receiving basic life support care. Other largely retrospective studies suggest that patients who undergo prehospital intubation following traumatic brain injury had improved outcomes compared with those for whom airway management was deferred until hospital arrival.

Not surprisingly, success rates for endotracheal intubation are highly dependent on operator experience. Prehospital intubation performed by prehospital physicians or specially trained air medical teams with frequent intubation experience and airway governance may yield mortality benefit, but this has not been conclusively demonstrated. Physician teams can bring critical care skills refined from in-hospital experience to the prehospital setting, including airway management with first-pass success rates similar to those reported in the ED.

Intubation in the prehospital setting can be accomplished safely and effectively by nonphysician providers in high-functioning EMS systems. The procedure itself is well within the scope of practice of paramedics in North America; however, the expertise is variable across jurisdictions and agencies. Airway management is a major focus of initial and ongoing training, as well as quality improvement initiatives. More studies are needed to better identify which patients require prehospital intubation and what degree of training is required to optimize success.

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. Spinal immobilization in penetrating trauma is associated with increased mortality.

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 immobilization for penetrating trauma. 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 physicians. 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. 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. In some EMS systems, FAST examination findings directly impact patient care. For example, a shocked trauma patient 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. Prehospital clinicians can apply DCR principles by limited crystalloid administration, tourniquet application for extremity bleeding, and massive transfusion protocol initiation. The use of blood products in the field is feasible and may improve survival. Many advanced care EMS organizations now carry blood products, including both packed red blood cells and fresh frozen plasma. A more detailed review of DCR principles is outlined in the trauma resuscitation sections of this issue.

A growing number of air and ground EMS organizations administer tranexamic acid (TXA) for select trauma patients. 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. Similarly, hemostatic dressings were developed from combat medicine, and many civilian EMS organizations include them in their hemorrhage control algorithms when pressure dressings fail, or in situations not amenable to tourniquet placement.

Is there a role for physicians in prehospital trauma care?

Globally, prehospital teams vary tremendously in composition. In Europe and Australia, it is common for a physician to be part of the prehospital helicopter EMS (HEMS) team. In contrast, similar team composition is rare in the United States. Some studies suggest that physician-based HEMS teams may improve survival to hospital discharge and decrease mortality. The generalizability of these findings is difficult, given confounders related to provider skill sets, care pathways, and deployment protocols.

Based on existing evidence and personal experience, we believe that physician-based prehospital teams are valuable to improve patient outcomes in trauma. In circumstances when trauma patients require immediate critical care interventions (eg, rapid sequence intubation, finger thoracostomy, extremity amputation), physician-led teams offer the best opportunity for success. Recent data support that physician prehospital involvement in complex battlefield trauma is beneficial. These physician-led teams provided critical interventions, such as advanced airway management and pediatric resuscitation, that required advance skill sets not possessed by less-experienced military medics. Heroic measures performed by highly trained prehospital physicians, such as resuscitative thoracotomy and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) are both possible and successful.

The inclusion of physicians in prehospital teams offers benefits in clinical and procedural decision making, trauma system knowledge, and integration of EMS-initiated protocols on arrival in the ED (eg, prehospital activation of a massive transfusion protocol). Additionally, there are system-level benefits to physician involvement in EMS, including education and quality assurance opportunities, improved interprofessional relationships, and identifiable opportunities to improve care.

Should endotracheal intubation be performed in the field on trauma patients?

There is conflicting evidence about the utility and patient-oriented outcomes of prehospital intubation. In large metropolitan areas, studies suggest that in the setting of head injury or severe trauma, prehospital intubation confers worse outcomes or equivocal benefit to mortality or morbidity. Most notably, the Ontario Prehospital Advanced Life Support (OPALS) Major Trauma study found increased mortality with intubation of trauma patients in a before-after trial, compared with a group receiving basic life support care. Other largely retrospective studies suggest that patients who undergo prehospital intubation following traumatic brain injury had improved outcomes compared with those for whom airway management was deferred until hospital arrival.

Not surprisingly, success rates for endotracheal intubation are highly dependent on operator experience. Prehospital intubation performed by prehospital physicians or specially trained air medical teams with frequent intubation experience and airway governance may yield mortality benefit, but this has not been conclusively demonstrated. Physician teams can bring critical care skills refined from in-hospital experience to the prehospital setting, including airway management with first-pass success rates similar to those reported in the ED.

Intubation in the prehospital setting can be accomplished safely and effectively by nonphysician providers in high-functioning EMS systems. The procedure itself is well within the scope of practice of paramedics in North America; however, the expertise is variable across jurisdictions and agencies. Airway management is a major focus of initial and ongoing training, as well as quality improvement initiatives. More studies are needed to better identify which patients require prehospital intubation and what degree of training is required to optimize success.

Team members and composition

A dedicated trauma team with specific roles is essential to improve team performance and patient safety. The team should be equipped and adequately skilled to effectively manage life-threatening conditions and be able to facilitate definitive care. Preparation should include space, staff, equipment, medications, and agents to assist hemostatic resuscitation.

The composition of trauma teams varies based on local resources: in remote locations, initial care may be undertaken at a nursing outpost, with or without access to an in-house physician. In better resourced facilities, professionals from several distinct disciplines (emergency medicine, anesthesia, surgery, respiratory therapy) are often called on to form ad hoc teams, with the expectation that they will be able to perform as a cohesive unit, despite having few opportunities to practice team-based skills. The trauma team leader (TTL) must balance both operational (resuscitation logistics, procedures) and executive (planning, resource utilization) tasks, particularly when team composition is small. An emergency physician is often best positioned to assume the TTL role, although in some situations this role may be best delegated to another physician team member or senior nurse (registered nurse [RN]). For example, in 2-member MD/RN teams, an RN may be better positioned to maintain overall situation awareness, monitoring, and oversight, particularly at times when the physician is intently and appropriately task-focused. Designating specific roles, specifically team leader and team members, should be based on the skill set of the individual, not that individual’s discipline of training. When teams must assemble ad hoc, institutional guidelines that prespecify roles and expectations for various team members can help improve cohesion, although it should be understood that role assignment is dynamic and depends on the nature of teamwork and task work being undertaken.

What is the best way to prepare the resuscitation space?

In an ideal circumstance, the resuscitation area should be located in close proximity to the ambulance bay, diagnostic imaging, and the operating room. A large resuscitation space with 360-degree access to the patient facilitates a pit crew–like approach whereby each member of the team has a defined role and physical position. EMS prenotification allows the team to anticipate injuries and interventions required. The decision to open the equipment packaging before EMS arrival will depend on the anticipated need, preparation time, and urgency of the planned intervention. In limited resource settings, specifically those without surgical support, preparation should focus on lifesaving interventions and anticipating the need for rapid transfer to a regional trauma center. Early forward communication with the trauma center will aid this process.