Prehospital Trauma Care

Good Clinical Practice (GCP) Guideline: Key recommendations for airway [1]

Grade (GoR)

Emergency medical services personnel must be regularly trained in emergency anesthesia, endotracheal intubation, and alternative ways of securing an airway (bag-valve-mask, supraglottic airway devices, emergency cricothyroidotomy)

GoR A

Multiply injured patients with apnoe or a respiratory rate below 6 must be anesthetized, intubated endotracheally, and ventilated in the prehospital setting

GoR A

Emergency anesthesia, endotracheal intubation, and ventilation should be carried out in the prehospital phase in multiply injured patients with the following indications:

GoR B

Hypoxia (SpO₂ < 90 %) despite oxygenation after exclusion of a tension pneumothorax

Severe traumatic brain injury (GCS < 9)

Trauma-associated hemodynamic instability (BP_sys < 90 mmHg)

Severe chest injury with respiratory insufficiency (respiratory rate > 29 breaths per minute)

The multiply injured patient must be preoxygenated before anesthesia

GoR A

After more than three attempts of endotracheal intubation, alternative methods must be considered for ventilation and securing an airway

GoR A

Alternative methods for securing an airway must be available when anesthetizing and endotracheally intubating a multiply injured patient

GoR A

When endotracheal intubation and emergency anesthesia are performed, electrocardiogram, blood pressure measurement, pulse oxymetry, and capnography must be used to monitor the patient

GoR A

During endotracheal intubation in the prehospital and in-hospital setting, capnometry/capnography must be used for monitoring tube placement and ventilation

GoR A

Normoventilation must be carried out in endotracheally intubated and anesthetized trauma patients

GoR A

For endotracheal intubation in multiply injured patients, emergency anesthesia must be carried out as rapid sequence induction because of the usual lack of a fasting state and risk of aspiration

GoR A

Manual in-line stabilization should be carried out for endotracheal intubation with the cervical spine immobilization device temporarily removed

GoR B

Life threatening “B” problems that must be detected are a tension pneumothorax or relevant pneumothorax or hemothorax that result in cardiorespiratory impairment. A tension pneumothorax will usually show reduced breath sounds, a reduced oxygen saturation, distended neck veins, and dyspnoea if the patient is awake. The treatment of choice for a tension pneumothorax or a relevant pneumothorax or hemothorax is placement of a thoracic drain. In case of a tension pneumothorax, fast needle decompression can be a good option, followed by placement of a thoracic drain. It is important to reevaluate breath sounds and oxygen saturation after the intervention to ensure that the treatment has a positive effect. In patients with a suspected minor pneumothorax without cardiorespiratory impairment, close reevaluation of the patient is appropriate.

GCP Guideline: Key recommendations for breathing [1]	Grade (GoR)
A suspected diagnosis of pneumothorax and/or hemothorax must be made if breath sounds are weaker or absent on one side (after checking correct placement of the tube). Absence of such auscultation largely rules out a larger pneumothorax, especially if the patient is normopneic and has no chest pain	GoR A
The potential progression of a small pneumothorax that cannot initially be diagnosed in the prehospital phase should be taken into consideration	GoR B
A suspected diagnosis of tension pneumothorax should be made if auscultation of the lung reveals no breath sounds unilaterally (after checking correct placement of the tube) and, in addition, typical symptoms are present, particularly, severe respiratory disorder or distended neck veins, in combination with arterial hypotension	GoR B
A clinically suspected tension pneumothorax must be decompressed immediately	GoR A
A tension pneumothorax should be decompressed by needle decompression, followed by placement of a chest drain	GoR B
A pneumothorax diagnosed on the basis of auscultation in patients not on ventilation should usually be managed by close clinical observation	GoR B
A pneumothorax diagnosed on the basis of auscultation in a patient with positive pressure ventilation should be decompressed	GoR B
A pneumothorax should be treated with a chest drain provided the indication exists	GoR B

Life-threatening “C” problems that must be detected are sources of uncontrolled bleeding. The variables used to check if the patient has a “C” problem are blood pressure, pulse rate, and capillary refill. A systolic blood pressure below 90 mm Hg and tachycardia above 100 beats per minute indicate presence of shock. Shock in trauma patients is usually a result of bleeding. Typical bleeding sources are abdominal injuries, thoracic injuries, pelvic and long bone fractures, and open wounds with arterial bleeding. If the bleeding source is detected, the emergency personnel must check if control of the bleeding is possible. Bleeding from extremity injuries can be controlled by pressure or application of tourniquets. Bleeding from pelvic injuries can often be controlled by application of simple pelvic binders combined with fixed inner rotation of the legs. Abdominal or thoracic bleeding usually cannot be controlled. Limited application of fluids and a rapid transportation to a facility that can provide surgical control of the bleeding in the operating room is important. Administration of large amounts of fluids has been shown to deteriorate outcome by increasing blood loss because of increased blood pressure and impaired coagulation.

GCP Guideline: Key recommendations for circulation [1]	GoR
Volume replacement should be initiated in multiply injured patients. In patients with uncontrolled bleeding, volume replacement should be performed at a reduced level	GoR B
In hypotensive patients with traumatic brain injury, volume replacement should be carried out with the goal of restoring normotension	GoR B
Normotensive patients do not require volume replacement, but venous lines should be started	GoR B
Crystalloids should be used for volume replacement in trauma patients	GoR B
Anti-shock trousers must not be used for circulatory support in multiply injured patients	GoR A

Life-threatening “D” problems that must be detected are clinical signs of increased cranial pressure as a result of intracranial bleeding. Any deterioration in the patient’s consciousness and abnormal pupillary reaction are important clinical signs that necessitate rapid transportation to an institution that allows rapid evaluation of the cranium with computed tomography. If a patient is unconscious and if the GCS is 8 or lower, the patient by definition, has an “A” problem and needs endotracheal intubation.

Glasgow Coma Scale (GCS) [10]

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