Major Trauma Outside a Trauma Center




Care of the critically injured begins well before the patient arrives at a large academic trauma center. It is important to understand the continuum of care from the point of injury in the prehospital environment, through the local hospital and retrieval, until arrival at a trauma center capable of definitive care. This article highlights the important aspects of trauma assessment and management outside of tertiary or quaternary care hospitals. Key elements of each phase of care are reviewed, including management pearls and institutional strategies to facilitate effective and efficient treatment of trauma patients from the point of injury forward.


Key points








  • Incoming Emergency Medical Services crews often have crucial information about trauma mechanism, contributing factors, specific injuries, effect of treatment, key timings, personal 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 obtaining additional personnel and resources as needed.



  • Extensive radiological and laboratory evaluation is often unnecessary and may delay access 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.






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. 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 improvements 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. 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.


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 environmental 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. 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 prehospital 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 hypotension in predicting clinical course, a finding reliably associated with increased morbidity and mortality. 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.


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 patient 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 ).



Box 1


Car 222 is coming in with a 37-year-old male




  • Mechanism




    • High-speed motor vehicle accident




  • Injury




    • Head, chest, and pelvic injuries




  • Signs and Symptoms




    • GCS 8, HR 120, O2 saturation 90% on non-rebreather, BP 90/60, RR 30, decreased air entry on left, pupils equal and reactive.




  • Treatment




    • IV, 20 mg ketamine, cervical spine collar, pelvic binder, IV fluids 250-mL bolus.




  • Estimated time of arrival




    • 5 minutes




Abbreviations: BP, blood pressure; GCS, Glasgow Coma Scale; HR, heart rate; IV, intravenous; RR, respiratory rate.


Sample radio call: MIST (Mechanism, Injury, Signs and Symptoms, Treatment, and Estimated time of arrival) report


The downstream effect of prehospital notification can be lifesaving, allowing trauma teams to prepare equipment, free up operating room resources, call in off-site consultants (eg, neurosurgery, interventional radiology), or notify the blood bank. EDs should work with their local EMS providers to develop protocols and standard operating procedures for communication with the prehospital team, emphasizing the importance of standardized language and concise, structured reporting.


Controversies in Prehospital Trauma Management


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.




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. 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 improvements 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. 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.


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 environmental 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. 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 prehospital 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 hypotension in predicting clinical course, a finding reliably associated with increased morbidity and mortality. 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.


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 patient 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 ).



Box 1


Car 222 is coming in with a 37-year-old male




  • Mechanism




    • High-speed motor vehicle accident




  • Injury




    • Head, chest, and pelvic injuries




  • Signs and Symptoms




    • GCS 8, HR 120, O2 saturation 90% on non-rebreather, BP 90/60, RR 30, decreased air entry on left, pupils equal and reactive.




  • Treatment




    • IV, 20 mg ketamine, cervical spine collar, pelvic binder, IV fluids 250-mL bolus.




  • Estimated time of arrival




    • 5 minutes




Abbreviations: BP, blood pressure; GCS, Glasgow Coma Scale; HR, heart rate; IV, intravenous; RR, respiratory rate.


Sample radio call: MIST (Mechanism, Injury, Signs and Symptoms, Treatment, and Estimated time of arrival) report


The downstream effect of prehospital notification can be lifesaving, allowing trauma teams to prepare equipment, free up operating room resources, call in off-site consultants (eg, neurosurgery, interventional radiology), or notify the blood bank. EDs should work with their local EMS providers to develop protocols and standard operating procedures for communication with the prehospital team, emphasizing the importance of standardized language and concise, structured reporting.


Controversies in Prehospital Trauma Management


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.




Part two: major trauma at a nontrauma center


Most modern, regionalized trauma systems in Europe, North America, and Australia involve set protocols that establish under what circumstances EMS providers can bypass a local hospital and proceed directly to a level 1 trauma center. This strategy, paired with regional systems that concentrate trauma expertise and resources in a select number of hospitals, is associated with a 25% reduction in injury-related mortality. In situations involving prolonged transport times or in the presence of immediately life-threatening injuries, trauma patients may still be transported to a local hospital for initial assessment and stabilization. Although immediate priorities remain the same regardless of the initial point of contact, the nature, extent, and timing of diagnostic testing and therapeutic interventions will vary depending on local resources and access to interfacility transport.


How Should Ad Hoc Trauma Teams Prepare and Assemble?


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.


The Emergency Medical Services Crew Has Arrived with the Patient: Now What?


To ensure critical information is communicated, a “hands-off, eyes on” approach to the EMS-ED clinical handover is suggested. The patient remains on the EMS stretcher during handover, which should typically be between 30 and 60 seconds. The astute TTL will observe the patient while listening intently to the EMS handover. A whiteboard can serve as a visible repository of patient information that can be referred to periodically as the case progresses, or as new team members enter the resuscitation environment.


A structured, uninterrupted handover will allow the team to hear the required information in a succinct manner. In Australia, it is common for EMS to use the format I-MIST-AMBO ( Box 2 ). A common structure reduces the overall time to handover, and increases retention of the information. Minimal interruptions during handover ensure that the EMS team can complete the transfer of care efficiently and without missing information. If immediate patient interventions are required, the handover can be limited to the crucial I-MIST, with AMBO being delayed until later.


Dec 1, 2017 | Posted by in Uncategorized | Comments Off on Major Trauma Outside a Trauma Center

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