For rural emergency departments, the decision to transfer a trauma patient to a level one center involves multiple factors including the patient’s hemodynamic stability. Harwell et al. looked at 47 trauma patients transferred from a rural hospital to a level one center. They found: “Overall mortality was significantly different between patients who had damage control laparotomy at a rural hospital (14.3%), were unstable transfer patients (75.0%), and stable transfer patients (3.3%; P < 0.001).” They concluded: “Rural damage control laparotomy may be used as a means of stabilization prior to transfer to a Level 1 center, and in appropriate patients may be life-saving.”
Preplanning with emergency medicine, surgery, radiology, anesthesia, nursing, and the receiving trauma center on how to manage these patients is critical.
In a study looking at 80 blunt trauma patients that died within 1 hour of arrival to a trauma center who underwent a noncontrast post mortem CT scan the following injuries were identified:
-40% traumatic brain injury
-25% long bone fracture
-22.5% hemoperitoneum
-25% cervical spine injury
- 18.8% moderate/large pneumothorax
-5% esophageal intubation
Blunt trauma arrest patients deserve decompression of the chest (preferred method is open with finger sweep). Intubation should be verified with end tidal CO2. Verification on arrival at the trauma center is also prudent.
The authors of this paper suggest the following changes, supported by evidence, to the management of traumatic cardiac arrest:
1. Epinephrine, bicarbonate and calcium have limited if no role in traumatic cardiac arrest.
2. CPR may be harmful in traumatic cardiac arrest. Hypovolemia is the cause of death for most trauma patients and CPR cannot correct this.
3. Blood is the resuscitative fluid to be given and all other fluids do not have a role in traumatic cardiac arrest.
4. Correct hypoxia immediately.
5. Finger thoracostomy to decompress penumothoracies, not needles.
6. Utilize termination of resuscitation protocols to end resuscitations in the field.
In this small propensity matching study looking at prehospital blood transfusion vs. emergency department blood transfusion in trauma patients aged 0-17 these authors found a better 24 and in-hospital mortality for patients who received prehospital blood transfusion compared to those receiving blood on arrival to the emergency department.
“The number needed to transfuse in the prehospital setting to save 1 child's life was 5 (95% CI, 3-10).”
Splenic injury treatment depends on the grade of injury. In general, grades 1 and 2 are non-operatively managed. Grades 4 and 5 tend to be managed operatively. Interventional radiology is used commonly for grade 3 and grades 1 and 2 if active contrast extravasation is seen. Below is a refresher on splenic injury grading.
Table 1
Adaptation of AAST Organ Injury Scale for Spleen
| Grade | Injury type | Description of injury |
|---|---|---|
| I | Hematoma | Subcapsular, <10% surface area |
| II | Hematoma | Subcapsular, 10% to 50% surface area |
| Laceration | Capsular tear, 1 cm to 3 cm parenchymal depth that does not involve a trabecular vessel | |
| III | Hematoma | Subcapsular, >50% surface are or expanding: ruptured subcapsular or parenchymal hematoma: intraparenchymal hematoma_>5 cm or expanding |
| IV | Laceration | Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) |
| V | Laceration | Completely shattered spleen |
Evaluating trauma patients at Level 3 or 4 centers, rural hospitals, and non-trauma centers is difficult. Understanding the amount of work-up to perform prior to transfer is important. Summers, et al suggest less is more when it comes to imaging. The receiving facility often repeats imaging leading to time delays, additional radiation exposure, and increased costs. Chest X-ray and FAST exam may be all that is indicated in centers that do not have the resources to care for injures identified on CT imaging prior to transfer.
This study found that time to intraosseous was faster than time to peripheral IV. This lead to quicker resuscitation time. This was particularly true in pateints that arrived without a pre-hospital IV.
Pelvic fractures can be a major source of life threatening hemorrhage. Suspect fracture with significant force/mechanism. Signs are pelvic tenderness (no need to “rock” the pelvis), bruising at perineum, and hypotension in the setting of major trauma. Major classifications of pelvic fractures are lateral compression, anterior posterior (wide public ramus, open book), and vertical sheer (fall from height). An appropriately applied pelvic binding device can be lifesaving. The biggest mistake in applying these devices is to apply them too high. Maximum pressure is achieved with application directly across the greater trochanters.
Shock index (heart rate/systolic blood pressure) has been used to predict trauma outcomes. This study from American Journal of Emergency Medicine looked at 89,000 pre-hospital patients who had a normal shock index on arrival at an emergency department. They then looked for those with abnormal pre-hospital shock index vs. those without an abnormal shock index and compared outcomes. Those with an abnormal pre-hospital shock index had worse outcomes than those with normal pre-hospital shock index.
Bottom line: A good handoff from pre-hospital to emergency department staff is critical because any abnormal shock index predicts a worse outcome than those with a normal shock index.
Use of intravenous lidocaine has been proposed as an adjunct/replacement for opioids in trauma patients with rib fractures. These small studies show a signal that the use of lidocaine decreased the need for opiate pain medication in this cohort of patients. Larger studies are needed, however, trauma surgeons maybe reaching for intravenous lidocaine in patients they are admitting with rib fractures. Also, transdermal lidocaine patches have been shown to have a similar effect in this patient cohort. “In admitted trauma patients with acute rib fractures not requiring continuous intravenous opiates, lidocaine patch use was associated with a significant decrease in opiate utilization during the patients’ hospital course.” 3
Recognizing that the studies discussing emergency department thoracotomy (ERT) in traumatic injuries are performed at large institutions where surgical back-up is available, emergency physicians should be familiar with the indications of emergency department thoracotomy in the setting of trauma. An informed decision should be made based on resources available along with the limited literature available to make the best decision for the patient and staff present.
Adding to last week’s pearl of no cardiac activity and no pericardial fluid on FAST exam, what else prognosticates intact survival? A 2020 paper concluded “ERT had the highest survival rates in patients younger than 60 years who present with signs of life after penetrating trauma. None of the patients with blunt trauma who presented with no signs of life survived.” 1A review in Trauma last month recommended: “Based on our scoping review of existing literature, we can conclude three major findings in the context of RT: (1) Resuscitative Thoracotomies (RT) performed in the setting of blunt trauma have a worse prognosis compared to patients undergoing RT for penetrating injuries, (2) procedures that have the potential to delay patient transport to hospital, such as intubation, may significantly increase the risk of mortality and (3) the presence of signs of life or hemodynamic stability in the prehospital or in-hospital setting are positive survival predictors in the setting of RT” 2 The best outcome is in patients brought immediately to an ED (preferably a trauma center) with limited on scene time. Police transport had a major association with survival in these patients. Stab wounds have the highest rate of intact survival.
For those at non-trauma centers, have a conversation within your ED group as well as with general surgeons (if available) to decide ahead of time if this procedure will be utilized in the setting of traumatic cardiac arrest and in which patient population.
Bottom Line: Lack of pericardial fluid or cardiac motion on FAST exam leads to no intact survivors for ED RT for trauma.
Zone 1 REBOA may be as good or better than ED RT for those requiring aortic occlusion after trauma.
Intact neurologic survival after emergency department resuscitative thoracotomy (ED RT) for trauma is low. Best outcomes have been shown for stab wounds to the chest with loss of vital signs in the ED or just prior to ED arrival. Worst outcomes are for blunt trauma with loss of vital signs in the field.
Two studies help us further evaluate the use of emergency department resuscitative thoracotomy. Inaba et al. illustrate in patients undergoing a FAST exam prior to or concomitant with ED RT “The likelihood of survival if pericardial fluid and cardiac motion were both absent was zero.” Cralley et al. compared survival after ED RT to Resuscitative Endovascular Balloon Occlusion of the Artery (REBOA) zone 1 (above celiac axis) and found REBOA was as good or better when used in centers with experience with both procedures. They advocate for a randomized trial to compare the two procedures further.
A study looking at 177 trauma patients (predominately skiing injuries) treated with oral trans mucosal fentanyl (600 and 800 mcg dosing) found a statistically and clinically significant reduction in pain. This therapy could be an adjunct to patients who require pain relief but IV access is delayed for various reasons.
This study looked at 20 years of death by firearm and stratified the location of death from urban to rural. The authors concluded:
“Descriptively, in all county types and both decades of the study, per capita gun suicides were more common than per capita gun homicides, and the most rural counties had higher rates of firearm death compared with the most urban counties. Firearm death rates were meaningfully higher in 2011-2020 compared with 2001-2010, primarily because of an increase in gun suicides.”
It is time to abandon the ABC's that ATLS teaches and move to hemorhage control (circulation) as well as resucitation before we deal with airway in the majority of trauma patients. Tounriquets save lives. Pelvic binders save lives. Blood transfusion (whole blood) saves lives. Poisitive presssure ventilation, sedativies, and decreasing sympathetic drive in hypoternsive patients makes their hypotension worse.
Please consider changing to a CAB approach to the hyhpotensive trauma patient.
Delayed sequence intubation can be valuable in the agitated, combative trauma patients who will not tolerate pre-intubation pre-oxygenation. We know peri-intubation hypoxia leads to significant morbidity and mortality. DSI offers us an option to avoid peri-inubation hypoxia.
This study randomized 200 trauma patients into a rapid induction group (Ketamine followed immediately by succinylcholine with immediate intubation) vs. delayed induction group (Ketamine followed by a 3-minute oxygenation period followed by succinylcholine, followed by intubation). The authors found: “Peri-intubation hypoxia was significantly lower in group DSI (8 [8%]) compared to group RSI (35 [35%]; P = .001). First-attempt success rate was higher in group DSI (83% vs 69%; P = .02).”
This extensive review looks at the literature surrounding vasopressors in trauma. Take away points are:
1. Most of the studies were done when the use of crystalloid was still being used as initial resuscitation fluid instead of blood.
2. Use of whole blood and mass hemorrhage protocols are not reflected in the literature regarding vasopressor use.
3. There are physiologic reasons vasopressors could be useful, particularly in head injured patients where we want increased mean arterial pressures.
4. European guidelines include vasopressor use whereas American ones do not.
5. Vasopressin and norepinephrine appear to be the vasopressors of choice if using a vasopressor in a trauma patient.
6. We need better studies looking at this topic
7. We need better studies looking at permissive hypotension in trauma now that our resuscitative strategy emphasizes mass hemorrhage protocol of blood, blood products, TXA and hemorrhage control.
8. As with all things in medicine, never say never.
