Notes – General Trauma Management

General Trauma Management

Patient Safety Considerations

  1. Life-threatening injuries identified on primary survey should be managed immediately with rapid transport to a trauma center, while the secondary survey is performed enroute
  2. Monitor patient for deterioration over time with serial vital signs and repeat neurologic status assessment [see Appendix VII]
    1. Patients with compensated shock may not manifest hypotension until severe blood loss has occurred
    2. Patients with traumatic brain injury may deteriorate as intracranial swelling and hemorrhage increase
  3. Anticipate potential for progressive airway compromise in patients with trauma to head and neck

Notes/Educational Pearls

Key Considerations

  1. Optimal trauma care requires a structured approach to the patient emphasizing ABCDE (Airway, Breathing, Circulation, Disability, Exposure)
  2. Target scene time less than 10 minutes for unstable patients or those likely to need surgical intervention
  3. Provider training should include the CDC Guidelines for Field Triage of Injured Patients
  4. Frequent reassessment of the patient is important
    1. If patient develops difficulty with ventilation, reassess breath sounds for development of tension pneumothorax
    2. If extremity hemorrhage is controlled with pressure dressing or tourniquet, reassess for evidence of continued hemorrhage
    3. If mental status declines, reassess ABCs and repeat neurologic status assessment [see Appendix VII]

Traumatic Arrest: Withholding and Termination of Resuscitative Efforts

Resuscitative efforts should be withheld for trauma patients with the following:

  1. Decapitation
  2. Hemicorpectomy
  3. Signs of rigor mortis or dependent lividity
  4. Blunt trauma: apneic, pulseless, no organized cardiac activity on monitor
    1. Note – Adult and Pediatric: Resuscitative efforts may be terminated in patients with traumatic arrest who have no return of spontaneous circulation after 15-30 minutes of resuscitative efforts, including airway management, evaluation/treatment for possible tension pneumothorax, fluid bolus, and minimally interrupted CPR

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914207 – General Trauma Management

Key Documentation Elements

  • Mechanism of injury
  • Primary and secondary survey
  • Serial vital signs and neurologic status assessments
  • Scene time
  • Procedures performed and patient response

Performance Measures

  • Monitor scene time for unstable patients
  • Monitor appropriateness of procedures
  • Monitor appropriate airway management
  • EMS Compass® Measures (for additional information, see http://www.emscompass.org)
  • PEDS-03: Documentation of estimated weight in kilograms. Frequency that weight or length-based estimate are documented in kilograms
  • Trauma-01: Pain assessment of injured patients. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain
  • Trauma-02: Pain re-assessment of injured patients. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain
  • Trauma-04: Trauma patients transported to trauma center. Trauma patients meeting Step 1 or 2* or 3** of the CDC Guidelines for Field Triage of Injured Patients are transported to a trauma center
    • *Any value documented in NEMSIS eInjury.03 – Trauma Center Criteria
    • **8 of 14 values under eInjury.04 – Vehicular, Pedestrian, or Other Injury Risk Factor match Step 3, the remaining 6 value options match Step 4

References

  1. American College of Surgeons Committee on Trauma; American College of Emergency Physicians Pediatric Emergency Medicine Committee; National Association of EMS Physicians; American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics. 2014;133(4):e1104.Bickell WH, Wall MJ Jr., Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331:1105-9.
  2. Cullinane DC, Schiller HJ, Zielinski MD, et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture – update and systematic review. J Trauma. 2011;71(6):1850-68.
  3. Guidelines for the Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage, 2011. Washington, DC: Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report; 2012;61(RR01):1-20.
  4. Harris T, Rhys Thomas G, Brohi K. Early fluid resuscitation in severe trauma. BMJ. 2012;345:e5752.
  5. Millin M, Galvagno SM, Khandker SR, et al. Withholding and termination of resuscitation of adult cardiopulmonary arrest secondary to trauma: Resource document to the joint NAEMSP-ACS (COT) position statements. J Trauma Acute Care Surg. 2013;75(3):459-67.
  6. Morrison C, Carrick M, Norman M, et al. Hypotensive resuscitation strategy reduces transfusion requirements and sever postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial. J Trauma. 2011;70(3):652-63.
  7. Prehospital Trauma Life Support, 8th Edition. Burlington, MA: Jones & Bartlett; 2016.
  8. Truhlar A, Deakin C, Soar J, et al. European resuscitation council guidelines for resuscitation 2015: section 4. Cardiac arrest in special circumstances. Resuscitation. 2015;95:148-201.