06/03/2018 Prehospital care of the adult trauma patient - UpToDate

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Prehospital care of the adult trauma patient

Author: Tom Blackwell, MD, FACEP

Section Editor: Maria E Moreira, MD
Deputy Editor: Jonathan Grayzel, MD, FAAEM

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2018. | This topic last updated: May 15, 2017.

INTRODUCTION — The concept of emergency medical transport originated from the need to move wounded
soldiers from the battlefield to aid stations and other medical facilities [1-3]. In 1865, the first hospital-based
ambulance service was developed at the Commercial Hospital in Cincinnati, Ohio. Four years later, New York
City's Bellevue Hospital started the first municipal service [1]. During the first half of the 20th century,
ambulance services were most often provided by private individuals, particularly morticians as a service to
families and to promote their funeral business.

Beginning in the mid-1950s in the United States, emergency medical service (EMS) systems began to
mature in parallel with the burgeoning interstate highway system. Excessive speeds coupled with poorly
designed vehicles had led to an increase in serious vehicular crashes, and few cities possessed the EMS
systems needed to manage such patients. Subsequently, a national effort to develop EMS systems was
initiated, and standards for provider education, scope of practice, equipment, vehicles, and system design
were introduced [2,4,5]. The result was a dramatic improvement in prehospital care.

This topic review will discuss prehospital care of the adult trauma patient. Discussions of specific procedures
are found elsewhere. (See "Basic airway management in adults".)

EMERGENCY MEDICAL SERVICE (EMS) SYSTEM DESIGN — The priority of any EMS system is to deliver
quality patient care in the briefest period of time following injury, regardless of system design or level of care.
Wide variation exists in the level and skill of treatment provided in the prehospital setting [6]. Prehospital
medicine typically consists of two levels of care: basic life support (BLS) and advanced life support (ALS).

For trauma care, basic skills include airway management (eg, maneuvers to open an airway, oral and nasal
airway adjuncts, and bag-mask ventilation), cardiopulmonary resuscitation and automated external
defibrillation, hemorrhage control, and fracture and spine immobilization. Emergency medical technicians
(EMTs) certified at the basic level (EMT-B) can provide these services.

Systems functioning at the ALS level provide more comprehensive management, including advanced airway
interventions (eg, endotracheal intubation, cricothyroidotomy), intravenous line placement and fluid
administration, medication administration, cardiac monitoring and defibrillation, and needle thoracostomy.
Providers certified at the paramedic level (EMT-P) can perform any of these interventions, while providers
certified at the intermediate level (EMT-I) can perform a select subset. While EMS systems in most urban and
suburban areas function at the ALS level of care, debate continues concerning the effectiveness of ALS
interventions for traumatic emergencies [7-10].

An EMS medical director is a clinician who has undertaken specialized training and has an understanding of
the capacity and extent of prehospital medical management. Directors oversee all aspects of EMS including:
communications, clinical management, education, and quality improvement.

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One important duty of the medical director is to develop patient care protocols, which serve as practice
guidelines and standards of care for specific illnesses or injuries. Protocols may include standing orders,
which enable prehospital providers to perform specified procedures or to administer medications for
predefined conditions without a delay to obtain permission from a clinician.

The medical director typically also has the responsibility to develop protocols for triage and hospital
notification. Such protocols ensure that receiving hospitals are adequately prepared to mobilize the resources
needed to efficiently address any critically ill or injured patients being transported.

PREHOSPITAL TRAUMA CARE

Overview — Three critical tasks must be rapidly performed by prehospital providers caring for trauma
victims:

● For the individual victim: examination with recognition of severe injuries and injuries with potential to
cause rapid decompensation

● For multiple victims: triage with initiation of life-saving treatment

● Stabilization and transport to a hospital capable of addressing the identified injuries

Rapid transport to the hospital is critically important, and prehospital providers must do all they can to
minimize the amount of time spent on scene [11-15]. Conflicting data exist concerning the relative importance
of specific procedures in trauma management, but evidence suggests that patient mortality is lower when
invasive procedures are performed in the hospital rather than en route [16-19]. Assuming comparable
transport times, studies suggest trauma victims do better when cared for by ALS providers [20].

Triage — Many forms of triage exist and a full discussion is beyond the scope of this review. Below, we
provide an overview of important concepts and scoring systems used for prehospital triage of adult trauma
patients. Triage of pediatric patients is reviewed separately. (See "Classification of trauma in children".)

Triage of trauma victims is the process of rapidly and accurately evaluating patients to determine the extent
of their injuries and the appropriate level of medical care required. The goal is to transport all seriously injured
patients to medical facilities capable of providing appropriate care, while avoiding unnecessary transport of
patients without critical injuries to trauma centers. Overall, triage tools should err on the side of reducing
under-triage (ie, increasing sensitivity), at the risk of encouraging over-triage (ie, decreasing specificity).
According to the American College of Surgeons, 5 percent is an acceptable under-triage rate, while
acceptable over-triage rates may be as high as 50 percent [21].

Appropriate prehospital triage of trauma victims depends on a number of variables, including the nature of
the incident, the number of victims, available resources, transport time, and the judgment of prehospital
caretakers. As an example, triage for a motor vehicle accident with multiple victims involves determining
which patients are most severely injured and ensuring that they are immediately transported to a trauma
center. Priorities change during a mass casualty incident capable of overwhelming local healthcare
resources. In such a circumstance, priority is placed on providing care to victims most likely to survive;
victims with such severe injuries that they are unlikely to survive are given low priority because they consume
a disproportionate share of resources.

Triage scoring systems have been developed to aid prehospital personnel. The ideal prehospital triage tool is
simple to use, results in consistent findings when applied by different clinicians, and accurately differentiates
between victims with major and minor injuries. No single best scoring system exists: the scoring system
selected is based upon the type of incident, personnel, available resources, and the preference of emergency
medical service (EMS) directors. Most scoring systems incorporate several types of criteria to differentiate
major from minor trauma, including:

● Physiologic (eg, blood pressure, level of consciousness)

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● Anatomic (eg, long bone fracture, surface area of burn)

● Mechanistic (eg, height of fall, pedestrian hit by car)

● Age and comorbidities

Over the past two decades, trauma specialists have developed a number of prehospital triage scoring
systems [22]. Most incorporate simple assessments of neurologic, respiratory, and circulatory function.
Examples of such triage scoring tools include the Prehospital Index, Revised Trauma Score, CRAMS score
(Circulation, Respiration, Abdomen/Thorax, Motor, Speech), and MGAP (Mechanism, GCS, Age, arterial
Pressure) (table 1).

Field personnel created START (Simple Triage and Rapid Treatment) for use as a prehospital triage system
utilizing assessment of ambulation, respiration, perfusion, and mental status in a stepwise fashion to
determine which victims require immediate transport for definitive care. START is easy to apply and designed
for mass casualty incidents when time for comprehensive evaluation is nonexistent.

Paramedic judgment is an important component of triage. One observational study found that assessment by
experienced urban paramedics is as accurate in identifying critically ill trauma patients as three commonly
used scoring systems [23]. Another observational study concluded that prehospital personnel can use a
trauma triage tool to identify major trauma victims accurately [24].

For mass casualty incidents, prehospital triage planning should incorporate an identification system. The
Medical Emergency Triage Tags (METTAG™) system is perhaps best known, and is widely used across the
United States. The system uses color-coded tags to identify patients and to designate their triage category:
black is dead, red is critical, yellow is serious, green is not serious.

The United States Centers for Disease Control and Prevention (CDC) has developed guidelines for mass
casualty triage to promote consistent management. The CDC's SALT approach (Sort, Assess, Lifesaving
interventions, Treatment and transport) was developed on the basis of available evidence and expert
consensus, and incorporates variables from several triage systems (algorithm 1) [25,26].

Regardless of the triage system adopted, all prehospital personnel must be familiar with the system and must
participate in periodic exercises to retain knowledge and skill.

Initial evaluation — Once triage is complete, the sickest viable patients are managed first. The Advanced
Trauma Life Support (ATLS) evaluation guidelines put forward by the American College of Surgeons can be
usefully applied in the field: primary (focused) assessments are followed by secondary (detailed)
assessments. Primary assessment (ie, primary survey) follows the ABCDE pattern: Airway, Breathing,
Circulation, Disability (Neurologic status), Exposure.

The prehospital provider's first task is to secure the patient's airway. If it is not secure, emergent basic airway
management is performed. Interventions may include maneuvers to open and maintain the airway. Manual in-
line stabilization of the cervical spine should be performed simultaneously. Airway adjuncts, such as
oropharyngeal or nasopharyngeal airways, and suctioning, can be used. If breathing is labored or absent,
assisted ventilations should be provided using a bag-valve mask device and high-flow oxygen. (See "Basic
airway management in adults".)

Once the airway and breathing are secure, providers must manage any uncontrolled hemorrhage using direct
pressure. Once hemorrhage is controlled, neurologic status is assessed. One simple assessment scheme is
AVPU: Alert, responds to Voice, responds to Pain, or Unresponsive. Spinal immobilization is continuously
maintained.

Next, prehospital personnel place definitive spinal immobilization (ie, rigid cervical collar and backboard).
Various techniques may be used to attach the backboard, including the figure-of-eight, where straps are
placed diagonally across the chest and lower extremities, or the transverse, where straps are placed straight

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across the torso and lower extremities. Two points bear emphasis: the immobilization technique must firmly
secure the patient to the board such that they (backboard and patient) can be rolled with minimal if any
patient movement. Rolling may be needed to prevent aspiration, should the patient vomit. A clinician must
perform manual in-line stabilization of the cervical spine while others secure the patient's body to the
backboard. Once the body is secured, prehospital personnel may definitively secure the patient's head to the
backboard.

Patients trapped in a vehicle pose challenging problems for safe extrication. Special care must be taken with
patients who have suspected spinal injuries, including those with an altered level of consciousness. For such
patients, prehospital personnel can use special devices, such as the Kendrick Extrication Device. These
short backboards effectively immobilize the mid-back and cervical region prior to moving the trapped patient.
Although use of these devices may prolong scene time, the benefit may outweigh the risk for patients with
potentially unstable spinal injuries.

Prehospital providers obtain vital signs as part of their assessment of patient circulation. Ideally, blood
pressure measurements are obtained in each arm. Several observational studies suggest that prehospital
hypotension is associated with an increased need for emergent surgery and with increased mortality [27-29].
The presence of prehospital hypotension must be clearly communicated to the emergency department
clinicians assuming care of the patient.

The final primary assessment is an evaluation of the entire patient. Prehospital providers must be compulsive
about removing enough clothing to assess critical areas of the body for obvious and occult injuries.

Secondary survey — After completion of the initial assessment and stabilizing treatments, the prehospital
provider performs a quick but thorough review of the entire body, referred to as the secondary survey. The
goal is to discern and manage as appropriate any injuries missed during the primary survey.

Common pitfalls include not thoroughly inspecting the back, the axillae, the gluteal region, and pannicular
folds. Such inspection is particularly important if the clinician suspects penetrating trauma. Providers must
also assess for pelvic instability and, if present, attempt to provide stability and control retroperitoneal
hemorrhage by applying a pelvic binder. A binder can be a prefabricated device or something as simple as a
sheet wrapped tightly around the patient's pelvis and tied in place. (See "Pelvic trauma: Initial evaluation and
management".)

Following the secondary survey, the patient should be prepared for transport. Performing full spinal
immobilization is prudent; prolonging scene time to initiate intravenous lines, bandage non-hemorrhaging
wounds, or splint minor fractures is unnecessary and potentially deleterious.

Airway support

Controversies and guidelines — Airway management techniques are discussed elsewhere. (See "Basic
airway management in adults" and "Rapid sequence intubation for adults outside the operating room" and
"Direct laryngoscopy and endotracheal intubation in adults".)

While basic measures to protect the airway are valuable, definitive airway control with endotracheal
intubation (ETI) is often needed for severely injured patients. Whether ETI should be performed in the
prehospital setting is controversial. A systematic review found a dearth of rigorous studies addressing ETI in
acutely ill and injured patients and concluded that there is "no imperative" to the performance of prehospital
intubation in urban trauma patients [30].

Some researchers claim prehospital ETI improves outcomes. In one retrospective case-control study
performed in a large urban emergency medical services (EMS) system, researchers found that field
intubation was associated with a decrease in mortality among 671 patients with severe head injury [31]. In
this study researchers stratified patients by their Glasgow Coma Scale (GCS), but did not adjust for their

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Injury Severity Score, or comparable measures. A small number of studies have found a similar association
between field ETI and improved survival [32].

However, many researchers have found increased morbidity and mortality among patients intubated in the
field and question the benefit of this practice [17,33-43]. They attribute worse outcomes to delays in transport,
improperly placed endotracheal tubes, improper ventilation, aspiration, and other complications. One
retrospective review of 496 patients who received airway support from paramedics working in a major urban
EMS system found that patients assisted with bag mask ventilation (BMV) were more likely to survive than
those treated with ETI [34]. After controlling for injury severity, these researchers found the survival rate of
patients receiving ventilation by BMV to be 5.3 times higher than patients managed with ETI (95 percent CI
2.3-14.2). Others have found similar results [39].

Whether drug-assisted intubation (DAI) or rapid sequence intubation (RSI) should be performed in the
prehospital environment also remains controversial. RSI is commonly performed by air medical programs and
is used successfully by some ground EMS systems [31,44-48]. Nevertheless, several studies have noted
many of the same complications observed with standard ETI in patients receiving RSI [37,49-51]. As an
example, one prospective study of prehospital RSI in patients with severe head injury, performed in a major
urban EMS system, compared 209 patients treated with RSI to 627 matched controls [49]. The authors found
a significant increase in mortality and morbidity among patients managed with RSI. (See "Rapid sequence
intubation for adults outside the operating room".)

Controversy about whether to perform prehospital RSI, particularly where transport times are brief, will likely
persist until large prospective randomized controlled trials are conducted to determine how the technique
affects patient outcomes. Until then, EMS programs incorporating RSI into their management protocols
should strive to ensure their paramedics perform the procedure properly. Effective training and regular
retraining, close monitoring, and regular performance of the procedure by a core group of paramedics can
help accomplish this [52]. (See 'Airway training for EMS providers' below.)

EMS systems that permit prehospital ETI, especially those incorporating RSI, must include protocols with
procedures for confirmation of proper tube placement in the airway. Paramedics often confirm placement by
auscultating bilateral breath sounds and noting absent gastric sounds, but this approach is often inaccurate
and difficult to perform in the austere prehospital environment [53]. End-tidal CO2 (either qualitative by color
change or quantitative measurement using numerical values or waveforms from in-line or side-stream
devices) provides a more accurate assessment [54,55]. Pulse oximetry is also important. (See "Carbon
dioxide monitoring (capnography)".)

Prehospital ETI protocols must include a rescue device for failed airway management. Examples include the
Combitube™ and the Laryngeal Mask Airway (LMA™). Paramedics must maintain skill in employing the
selected rescue device and should not hesitate to implement it should they encounter a difficult airway or fail
at three attempts to place an endotracheal tube. The dangers of delayed transport and prolonged hypoxia
argue against prolonged prehospital attempts at ETI.

Providing appropriate respiratory rates and tidal volumes is crucial for all trauma patients. Hyperventilation
can result in hyperinflated lungs, which decreases preload and compromises cardiac output [17].
Hyperventilation can also cause or exacerbate elevated airway pressures, predisposing to pneumothorax.
(See "Basic airway management in adults", section on 'Ventilation volumes, rates, and cadence'.)

Head injury — Patients with blunt head injury pose special problems, and debate continues concerning
whether these patients should be intubated outside the hospital [31,35-37,49]. Most important in the
prehospital setting is to protect the airway and control the ventilation of head-injured patients in the least
invasive manner, thereby minimizing elevations in intracranial pressure. If transport time is brief, often bag-
mask ventilation (BMV) alone is sufficient. Successful BMV is critical: it provides immediate oxygenation and
ensures that ventilation can be maintained should attempts at more invasive airway management fail. (See
"Basic airway management in adults".)

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Should prehospital providers encounter a head-injured patient with a clenched jaw or other airway-
compromising conditions, the first step is to perform manual maneuvers (eg, jaw thrust) to open the airway
and then provide adequate BMV. Nasal or oropharyngeal airways can help maintain airway patency. Care
must be taken to maintain cervical immobilization.

In EMS systems with protocols for prehospital intubation, paramedics may determine that endotracheal
intubation is needed. Intubation should be performed with speed and finesse in the head-injured patient in
order to minimize airway manipulation, which can elevate intracranial pressure and exacerbate the underlying
head injury.

In addition to airway protection, head-injured patients are intubated in order to control their ventilation rates
and maintain their end-tidal CO2 levels between 33 and 35 mmHg. Doing so prevents elevations in
intracranial pressure (ICP), thereby helping to maintain adequate cerebral perfusion pressure. Previously,
hyperventilation was thought necessary to lower ICP, but this is not so. Ventilation rates typically less than 15
breaths per minute are sufficient [56].

Moving intubated patients — The intubated patient should be moved carefully with special attention paid
to preventing displacement of the endotracheal tube (ETT) and intravenous lines. The provider in charge of
the airway orchestrates all patient movement. Many endotracheal tubes have been removed or displaced into
the esophagus from failure to coordinate patient transport appropriately [57]. Proper technique for transferring
the intubated patient includes:

● Limited hyperventilation prior to moving

● Removing the bag-valve mask device prior to moving

● Holding the tube securely at the lips throughout the move

● Using clear, verbal commands to coordinate the move

● Immediately reattaching the bag-valve mask after the move

● Reassessing ETT placement once the move is complete (see "Carbon dioxide monitoring
(capnography)")

Airway training for EMS providers — Successful prehospital advanced airway management depends
upon proper training and oversight. EMS directors must design and implement educational and quality
management programs for advanced airway management that are comprehensive and stringent [52,58].

To be successful in advanced airway management, prehospital advanced life support (ALS) providers need
cognitive and technical skills, and must understand the following:

● Airway assessment

● Indications for endotracheal intubation (ETI)

● Common clinical scenarios in which ETI is needed

● Major complications of ETI

● A range of airway management techniques, including bag-mask ventilation, ETI, and rescue airways

● Confirmation of proper endotracheal tube placement

The number of supervised endotracheal intubations (ETI) a paramedic should perform before operating
independently is unknown. Furthermore, no universal training standards exist for paramedics, despite their
being charged with managing the airway under the most difficult conditions [46,56,57,59].

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Prehospital providers should learn basic technical skills in airway management during classroom training
sessions taught by experienced airway managers. Additional skill can be gained by performing techniques on
patients in the operating room under the supervision of anesthesiologists. Such opportunities may be limited,
however, and alternative experiences such as high-fidelity simulation (HFS), can be extremely useful in
developing cognitive and technical airway management skills [60,61]. Regular retraining using HFS can help
prehospital providers maintain competency.

Experience in airway management is best provided to paramedic trainees in the emergency department,
which more closely approximates the clinical conditions found outside the hospital (eg, combative patients,
blood and vomit in the airway). In addition to basic airway procedures and endotracheal intubation, ALS
providers must be facile with airway adjuncts (eg, Laryngeal mask airway, LMA™) and able to confirm proper
placement of the endotracheal tube using end-tidal CO2 detectors and other techniques. (See "Carbon
dioxide monitoring (capnography)".)

Hemorrhage control — Basic measures for controlling hemorrhage consist of direct pressure to the wound
followed by pressure dressings, with elevation and pressure points used as adjuncts. When penetrating
trauma occurs to certain anatomic areas, hemorrhage control may be difficult with pressure dressings alone.
As an example, gross hemorrhage may not be apparent with gunshot wounds to the thigh. In such
circumstances, direct manual pressure must be applied throughout the prehospital phase of care to ensure
that occult, internal bleeding is controlled as well as possible. In uncommon instances (eg, injury from an
explosion, traumatic near or complete limb amputation), application of a tourniquet may be necessary to
control life-threatening bleeding from a severe extremity wound. The use of tourniquets in this setting is
reviewed separately. (See "Severe extremity injury in the adult patient", section on 'Control of hemorrhage'.)

Tranexamic acid (TXA) is an antifibrinolytic agent that reduces mortality in select trauma patients. In the
prehospital setting, TXA may benefit trauma patients whose systolic blood pressure is less that 75 mmHg if it
can be administered within one hour of injury. Cost and administration parameters (1 g IV over 10 minutes)
may be prohibitive for many systems. For bleeding or hemodynamically unstable trauma patients known to
be taking anticoagulants, administration of reversal agents may be helpful if available and circumstances are
appropriate. (See "Management of bleeding in patients receiving direct oral anticoagulants", section on 'Major
bleeding' and "Reversal of anticoagulation in warfarin-associated intracerebral hemorrhage" and "Initial
management of moderate to severe hemorrhage in the adult trauma patient", section on 'Antifibrinolytic
agents'.)

A number of topical hemorrhage control agents are being developed, but they require further study before
widespread use in civilian populations can be recommended [62]. (See "Initial evaluation of shock in the adult
trauma patient and management of NON-hemorrhagic shock".)

Unstable pelvic injuries, such as "open-book" fractures involving disruption of the sacroiliac joints, are
associated with retroperitoneal hemorrhage. Prehospital treatment for this injury consists of "closing" the
fracture by securing a pelvic binder or sheet tightly around the pelvis. Serial exams of pelvic fractures should
NOT be performed in order to avoid exacerbating retroperitoneal hemorrhage. (See "Pelvic trauma: Initial
evaluation and management".)

Intravenous (IV) fluids — When the need for fluid resuscitation or intravenous (IV) medications is apparent
or anticipated, EMS personnel should place two large-bore (16 gauge or larger) IV catheters. If possible,
placement should be performed during transport to avoid prolonging scene times [63]. When peripheral IV
access is difficult or impossible, an intraosseous (IO) line may be used for adults or children. Preliminary
observational data suggest that several devices are effective at establishing IO access in the prehospital
setting [64-66]. (See "Intraosseous infusion".)

According to a systematic review of studies of prehospital fluid resuscitation, weak evidence suggests that
trauma patients with signs of hypovolemic shock are best treated with a discrete bolus of IV fluid (eg, 250 mL
of isotonic saline) [63]. EMS personnel can give repeat boluses to maintain an adequate pulse and blood

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pressure. However, excessive IV fluid infusion may lead to adverse outcomes including coagulopathy and
death [67]. When infused fluid volumes exceed 500 mL, it is crucial that providers closely observe the
patient’s response. Alternative markers for blood pressure (eg, mental status, quality of pulse) should be
monitored closely, particularly during prolonged transports, and additional IV fluid boluses given if necessary.
Pressure bags or rapid infusion pumps should not be used [63]. The recognition and management of trauma-
related shock is reviewed separately. (See "Initial evaluation of shock in the adult trauma patient and
management of NON-hemorrhagic shock".)

The treatment of hemodynamic instability from traumatic injury with high-volume IV fluid resuscitation has
been standard in most EMS systems. However, the use of copious IV fluid replacement to achieve normal or
near-normal blood pressures for uncontrolled hemorrhagic shock is controversial and evidence supporting
this approach is scant for both blunt and penetrating trauma [63].

Some researchers question the need for prehospital high-volume resuscitation and advocate restricted use of
IV fluids. They theorize that increasing mean arterial pressure to near-normal levels with aggressive IV fluid
replacement, prior to achieving surgical hemostasis, may result in hemodilution, decreased oxygen-carrying
capacity, dilution of clotting factors, and disruption of tenuous clots at sites of injury. An alternative approach,
termed limited volume or "hypotensive" resuscitation in trauma, is discussed in detail separately. (See "Initial
evaluation of shock in the adult trauma patient and management of NON-hemorrhagic shock" and "Initial
management of moderate to severe hemorrhage in the adult trauma patient", section on 'Delayed fluid
resuscitation/controlled hypotension'.)

While the importance of maintaining end-organ and cerebral perfusion remains unquestionable, the ideal
mean arterial pressure to achieve this goal without causing potential harm is unknown. Maintaining such an
ideal blood pressure, even if it were known, would be extremely difficult in the prehospital setting. In addition,
much may depend upon the clinical scenario. As examples, larger IV fluid volumes may be needed to raise
the blood pressure and ensure adequate cerebral perfusion in a head-injured patient, while such volumes
may be harmful in a young healthy patient with an isolated stab wound of the abdomen. Pending further
research, we believe it is reasonable to withhold IV fluid during brief prehospital transport in patients with
isolated penetrating torso injuries whose systolic blood pressure is ≥90 mmHg [63].

Hypertonic crystalloid has been used for the resuscitation of trauma patients, primarily in combat settings,
because it is easy to store (does not require refrigeration and has a long shelf life) and entails smaller fluid
loads. Hypertonic saline has shown some promise for the resuscitation of patients with traumatic brain injury
because it maintains cerebral perfusion without increasing intracranial pressure. Examples of such fluids
include 3 percent hypertonic saline, 5 percent hypertonic saline, and the combination of hypertonic saline and
6 percent dextran-70. While hypertonic saline may be useful in the military environment where austere
conditions often prevail, evidence supporting this approach in the civilian environment is lacking. The
Resuscitation Outcomes Consortium (ROC) trial, which compared hypertonic saline, hypertonic saline-
dextran, and isotonic saline for prehospital treatment of patients with traumatic brain injury, was stopped early
using prespecified criteria because treatment with hypertonic saline failed to improve neurologic outcome or
survival [68]. A systematic review of nine randomized trials involving 3490 trauma patients concluded that
prehospital fluid resuscitation using hypertonic saline does not improve survival compared to resuscitation
using isotonic crystalloid [69].

The type of IV fluid most suitable for the initial resuscitation of trauma patients in hemorrhagic shock is
discussed in detail separately. (See "Initial management of moderate to severe hemorrhage in the adult
trauma patient", section on 'Intravenous fluid resuscitation'.)

Spinal immobilization — In most EMS systems, paramedics do not perform prehospital clearance of
cervical spine injury. Some EMS systems use clinical criteria, such as those from the National Emergency X-
Ray Utilization Study (NEXUS) or Canadian C-spine rule, to rule out cervical spine injury in the prehospital
setting. These criteria and spinal immobilization of pediatric patients are discussed in detail separately. Spinal
immobilization is often not necessary in the setting of penetrating trauma, and this issue too is reviewed
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separately. (See "Evaluation and acute management of cervical spinal column injuries in adults" and
"Pediatric cervical spinal motion restriction" and "Penetrating neck injuries: Initial evaluation and
management", section on 'Cervical spine immobilization'.)

Observational studies of interrater reliability between emergency clinicians and prehospital providers in the
application of clinical guidelines to rule out cervical spine injury have shown mixed results [70-72]. Should
EMS directors decide to incorporate prehospital clearance of cervical injury, they must ensure their
prehospital providers are knowledgeable and skilled in the application of clinical criteria to avoid missing
spinal injuries.

Proper spinal immobilization includes placement of a hard cervical collar, barriers to lateral head movement
(eg, foam pads, rolled towels), and a long backboard. When rolling patients to place them on the long board,
providers should inspect the back and palpate the spinal column for step-off and tenderness. Alternative
transfer techniques, such as the lift-and-slide, may reduce spine motion in patients with suspected
thoracolumbar injury [73]. (See 'Initial evaluation' above.)

Fractures — If time allows, long-bone fractures can be stabilized or splinted during transport. By splinting
and applying traction to obvious femur fractures, providers may reduce pain and minimize soft tissue damage
and bleeding.

Pain management — Prehospital providers often fail to provide adequate analgesia [74-76]. Providing
analgesics en route to the hospital is important not only for immediate pain relief, but also because it may
improve pain treatment in the emergency department [77]. Reluctance to provide analgesia in the prehospital
setting may stem from a lack of adequate, age-appropriate assessment protocols, or from concern about the
patient's condition. Concerns may include:

● Contributing to diagnostic uncertainty by masking symptoms

● Exacerbating hemodynamic instability

● Blunting respiratory drive in a patient with breathing difficulty

● Exacerbating the condition of a patient with an altered level of consciousness following an injury

Despite these concerns, judicious use of short-acting opioids for patients in obvious pain is generally safe
and effective, and will not mask significant injuries or alter outcome. There is no reason to withhold pain
medications for conditions such as isolated extremity injuries [78].

Fentanyl is a short-acting opioid with rapid onset of effect and is less likely to cause hypotension than other
opioids and so is the preferred agent in the trauma patient at risk for hemodynamic instability; doses up to
100 or 150 micrograms IV or IM can be used in patients without hypotension. The results of several
observational studies suggest that fentanyl can be given safely to trauma patients in the prehospital setting
[79-81]. Morphine may be used but it has a longer duration of effect and is more likely to cause hypotension;
doses up to 10 or 15 mg IV or IM can be used in patients without hypotension.

For patients in severe pain but with hemodynamic instability, paramedics can give 25 mcg doses of fentanyl
(or 2 mg doses of morphine) approximately every 10 minutes, while being prepared to give an IV fluid bolus
for hypotension. Judicious use of naloxone may be needed for refractory hypotension. Prehospital providers
should carefully monitor the respiratory and hemodynamic status of all patients receiving opioids.

Ketamine is being studied as an analgesic for trauma patients in the prehospital setting [82]. However, we
believe the potential risks associated with ketamine, including general disorientation and possibly acute
elevations in the intracranial pressure of patients with head injuries, are too great. Pending further research,
we do not suggest it be used in the prehospital treatment of trauma-related pain. The effect of ketamine on
intracranial pressure is discussed separately. (See "Induction agents for rapid sequence intubation in adults
outside the operating room", section on 'Elevated intracranial pressure'.)

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Transport — Once prepared for transport, providers must determine which hospital is most appropriate for
the patient. Most metropolitan area ambulance services have access to level one, level two, and level three
trauma centers. The American College of Surgeons has established these hospital designations based on
specific criteria (eg, availability of neurosurgery or pediatric surgery) to improve the care of trauma victims.
Level one and level two centers are comparable in their clinical capacities; level one centers are generally
academic institutions with additional research and educational obligations.

Little research has been done to determine which patients are best served by direct transport to a level one
trauma center, and guidelines are often determined locally. Among the general indications are the following:

● Hemodynamic instability in a patient with blunt or penetrating injuries to the torso or head

● Significant burns (eg, greater than 25 percent body surface area, inhalation injury, high voltage electrical
source)

● Spinal injury with a neurologic deficit

● Significant upper or lower extremity amputation

● Injury severity score ≥15

Providers should notify the receiving facility as early as possible to ensure that hospital staff have adequate
time to warn needed personnel (eg, surgeons, interventional radiologists) and prepare equipment (eg, airway
devices, operating rooms, CT scanners). This is especially important for systems using trauma teams.

During hospital transport, providers should continuously reassess the patient's vital signs and clinical status
until arrival at the hospital. Three-lead cardiac and pulse oximetry monitoring should be continuously
performed en route. End-tidal CO2 readings of intubated patients should be continuously monitored to help
maintain proper ventilation. (See "Carbon dioxide monitoring (capnography)".)

SPECIALIZED PROCEDURES

Needle and surgical cricothyroidotomy — Needle cricothyroidotomy, which permits percutaneous

transtracheal ventilation, may be necessary as a last resort to provide oxygenation and ventilation when
conventional means of airway support have failed or cannot be performed. As an example, in the presence of
massive facial trauma, providers may not be able to discern anatomic landmarks or maintain an adequate
mask seal. Copious amounts of blood or secretions can interfere with airway procedures, and may
necessitate cricothyroidotomy.

For needle cricothyroidotomy, a standard 14-gauge angiocath is acceptable for most adults. The skin over the
insertion site should be cleaned with providine-iodine. Once the catheter is properly inserted and the needle
removed, ventilation is performed. Should a prefabricated jet ventilation system be unavailable, emergency
medical service (EMS) providers may use a bag-valve mask device connected to a 3.0 or 3.5 mm pediatric
endotracheal tube adapter. This alternative is a less satisfactory means of ventilation. (See "Needle
cricothyroidotomy with percutaneous transtracheal ventilation".)

Cricothyroidotomy enables the clinician to maintain oxygenation, but hypercapnea develops after
approximately 20 minutes. Complications of needle cricothyroidotomy include improper catheter placement,
bleeding, barotrauma, and infection [83].

Surgical cricothyroidotomy poses greater risks and potential complications because it is more invasive. With
greater availability of effective airway adjuncts (eg, Laryngeal Mask Airway™, Pharyngeal Tracheal Lumen
(PTL®) airway, and Combitube™), EMS providers may have less need to resort to needle and surgical
cricothyrotomy. Maintaining adequate skill can be problematic for many prehospital providers, and as skills
decline, so do patient outcomes. (See "Emergency cricothyrotomy (cricothyroidotomy)".)

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Needle chest decompression — Needle thoracostomy may be life-saving for patients in shock from a
tension pneumothorax. However, the procedure increases morbidity if performed when tension
pneumothorax is suspected but absent.

In the field, prehospital providers may have difficulty confirming the presence of a tension pneumothorax. The
mechanism of injury may be suggestive, but physical findings such as diminished breath sounds, distended
neck veins, and tracheal deviation, can be unreliable [84,85]. A patient with a tension pneumothorax may
tolerate the condition until arrival at the hospital, where clinical examination or a chest radiograph will discern
its presence. If there is high clinical suspicion of a tension pneumothorax (eg, unrestrained driver with rib
fractures and dyspnea) and the patient develops significant hypotension, the EMS provider should perform
emergent needle thoracostomy.

Several studies have evaluated the utility of prehospital needle decompression for suspected tension
pneumothorax [86-88]. In a large, prospective, observational study, researchers at a major urban trauma
center assessed the frequency and utility of needle thoracostomy in over 6000 trauma patients and found
that the procedure, while seldom performed, may improve outcome in a small number of patients [88].

Other studies have questioned the utility of the procedure in the prehospital setting. Of over 2000 trauma
patients in another observational study, 19 received prehospital needle decompression after trauma, but only
four showed evidence of tension physiology, defined by the presence of a pneumothorax with an air leak after
tube thoracostomy [87]. The authors concluded that needle thoracostomy is often ineffective and may be
overused. A study of 33 medical and trauma patients who received needle decompression found that 14
patients who presented in cardiac arrest had no change in outcome, and only 10 patients had clinical
evidence of a pneumothorax [86]. None of the four patients who survived had hemodynamic or respiratory
instability prior to decompression.

Based on these studies, we recognize it can be difficult to determine when prehospital needle thoracostomy
should be performed, but suggest the procedure is most likely to be useful under the following conditions:

● Mechanism of injury suggests the likelihood of pneumothorax

● Patient is in respiratory distress, based on clinical signs and symptoms, and low pulse oximetry despite
supplemental oxygen

● Hemodynamic instability is present

● Transport time is prolonged

Providers should be aware that a tension pneumothorax can be localized, and that needle thoracostomy may
not be effective in such circumstances [89].

Acceptable sites for insertion of a 14-gauge angiocatheter include the second or third intercostal space in the
midclavicular line, or the fifth intercostal space in the anterior or mid-axillary line. Depending on the patient’s
body habitus, needles as long as 8 cm may be required to perform the technique effectively [90-98]. We
suggest using the anterior site for prehospital treatment. Direct stabilization and continued observation can
be performed more easily in a moving ambulance using the anterior site; catheters placed at the lateral site
may be dislodged by the patient's arm, and may be more prone to obstruction [99]. However, axillary
placement may be easier to perform [100,101]. The skin should be cleaned with providine-iodine prior to
insertion of the needle.

Following needle chest decompression, general thoracostomy is typically performed. (See "Placement and
management of thoracostomy tubes".)

SPECIAL ISSUES

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Air medical services — The use of air transport of patients dates to World War I, but its role was expanded
dramatically during the Korean and Vietnam conflicts. The first hospital-based air medical service began in
Denver at St. Anthony hospital in 1972. Helicopters are used to transport patients between hospitals and
from trauma scenes; fixed-wing aircraft are used for long-distance transports. Studies of air transport are
limited and additional research is needed [102].

The advantages of medical transport by helicopter may include providing a higher level of care at the scene
of trauma and improving access to trauma centers [103]. Helicopter-based emergency medical service (EMS)
also provides critical care capabilities during inter-facility transport from community hospitals to trauma
centers.

Effective use of helicopter services for trauma depends on the ground responder's ability to determine
whether the patient's condition warrants air medical transport [104]. Protocols and training must be developed
to ensure appropriate triage criteria are applied. Excessively stringent criteria can prevent rapid care and
transport of trauma victims; lax criteria can result in the embarrassing and costly situation of transporting a
patient by helicopter only to have the patient discharged in good condition from the emergency department.

Crew and patient safety is the single most important factor to be considered when deciding whether to
transport a patient by helicopter. Weather, air traffic patterns, and distances (eg, from trauma scene to closest
level one trauma center) must also be considered.

Some have questioned the safety of air medical services [105,106]. While the number of crashes may be
increasing, the number of programs and use of services has also increased [107]. Factors associated with
fatal crashes of medical transport helicopters include flying at night and during bad weather, and post-crash
fires [108].

Burn management — Prehospital treatment of burn patients begins with stabilization of the airway,
breathing, and circulation. Patients with signs of active or impending airway compromise should be treated
with immediate endotracheal intubation. Allowing airway swelling from inhalational injury to progress without
intervention can create extraordinarily difficult airway management situations, leading to increased morbidity
and possibly death. Treatment of major burns is discussed in detail elsewhere. (See "Emergency care of
moderate and severe thermal burns in adults".)

Common signs of significant smoke inhalation injury and the potential need for intubation include:

● Persistent cough, stridor or wheezing

● Hoarseness

● Deep facial or circumferential neck burns

● Nares with inflammation or singed hair

● Carbonaceous sputum or burnt matter in mouth or nose

● Blistering or edema of the oropharynx

● Depressed mental status, including evidence of drug or alcohol use

● Respiratory distress

● Hypoxia or hypercapnia

Providers should determine the severity (eg, full-thickness versus partial-thickness) and extent (ie, percent
body surface area) of the burn. These calculations are used to determine the amount of intravenous (IV) fluid
resuscitation required. Aggressive fluid resuscitation should begin immediately for any patient with burn
shock or major burns.

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According to the Parkland (or Baxter) formula, the fluid requirement during the initial 24 hours of treatment is
4 mL/kg of body weight for each percent of TBSA burned, given IV. Superficial burns are excluded from this
calculation. One-half of the calculated fluid need is given in the first eight hours. IV fluid boluses to maintain
blood pressure are given in addition to the calculated fluid requirements based on burn size.

Other treatments to consider, if time is available, include wound cooling and dressing. While rapid cooling is
desirable and must be performed within 30 minutes to be effective, it may result in hypothermia if performed
over an extensive surface area. Isolated extremity burns may be cooled immediately; more extensive burns
should be covered with dry, clean sheets or other appropriate dressings. The ambulance should be heated to
help prevent hypothermia. (See "Treatment of minor thermal burns".)

Patients with significant burns should be transported directly to facilities capable of providing comprehensive
burn care. If no such facility exists locally, the patient is brought to the closest hospital able to provide initial
stabilization and arrange secondary transport to a designated referral burn center. According to the American
Burn Association, significant burns include:

● Burns covering over 20 percent of total body surface area in adults, or over 10 percent in young children
or the elderly

● Full-thickness burns covering over 5 percent of total body surface area

● Burns involving the face, eyes, ears, hands, feet, or perineum

● Burns crossing major joints or circumferential extremity burns

● High voltage electrical burns

Patients with burns from suspected abuse or burns associated with major trauma, and patients with
comorbidities increasing the risk of infection (eg, diabetes mellitus), should be hospitalized.

Prehospital determination of death — Prehospital providers may withhold life support in certain situations.
As an example, providers need not provide care to patients with injuries that are incompatible with life (eg,
burned beyond recognition, decapitated, blunt trauma to the abdomen and/or chest without vital signs), or
those with obvious signs of death (eg, postmortem lividity, rigor mortis, or gross decomposition). Caution
should be exercised when developing protocols paramedics can use to withhold care. Some states may have
regulations that limit the prehospital provider's ability to make such determinations.

After resuscitation has been initiated, there may be circumstances when it is reasonable for prehospital
providers to cease their efforts and pronounce the patient dead. Clinical circumstances (eg, blunt versus
penetrating trauma) play a role in such decisions [109,110].

In all cases where prehospital providers pronounce death after stopping resuscitative efforts, they should
perform and record the following:

● Complete set of vital signs

● Cardiac monitor rhythm strip from multiple leads, including printed copies

SUMMARY AND RECOMMENDATIONS

● Three critical tasks must be rapidly performed by prehospital providers caring for trauma victims (see
'Overview' above):

• For the individual victim: examination with recognition of severe injuries and injuries with potential to
cause rapid decompensation

• For multiple victims: triage with initiation of life-saving treatment (see 'Triage' above)

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• Stabilization and transport to a hospital capable of addressing the identified injuries. Prehospital
providers must do all they can to minimize the amount of time spent on scene. (See 'Transport'
above.)

● Assessment and stabilization of the trauma victim follow the ABCDE pattern: Airway, Breathing,
Circulation, Disability (Neurologic status), Exposure. The prehospital provider's first task is to secure the
patient's airway. If it is not secure, emergent basic airway management is performed. Once the airway
and breathing are secure, providers manage any uncontrolled hemorrhage using direct pressure. The
cervical spine is immobilized to prevent injury. Proper spinal immobilization includes placement of a hard
cervical collar, barriers to lateral head movement (eg, foam pads, rolled towels), and a long backboard.
Vital signs are obtained. (See 'Initial evaluation' above and 'Spinal immobilization' above and "Basic
airway management in adults".)

● After completion of the initial assessment and stabilizing treatments, the prehospital provider performs a
quick but thorough review of the entire body to discern and manage any injuries missed during the
primary survey. Common pitfalls include not thoroughly inspecting the back, the axillae, the gluteal
region, and pannicular folds. (See 'Secondary survey' above.)

● Prehospital endotracheal intubation (ETI) is controversial. EMS systems that permit prehospital ETI,
especially those incorporating rapid sequence intubation (RSI), must include protocols and equipment
(eg, End-tidal CO2 monitor) for confirmation of proper tracheal tube placement, and a rescue device for
failed airway management. Paramedics must maintain skill in employing the selected rescue device and
should use it if they encounter a difficult airway or fail at three attempts to place a tracheal tube. The
dangers of delayed transport and prolonged hypoxia argue against prolonged prehospital attempts at
ETI. (See 'Airway support' above.)

● Providing appropriate respiratory rates and tidal volumes is crucial for all trauma patients.
Hyperventilation can result in hyperinflated lungs, which decreases preload and compromises cardiac
output. (See 'Airway support' above.)

● Basic measures for controlling hemorrhage consist of direct pressure followed by pressure dressings,
with elevation and pressure points used as adjuncts. (See 'Hemorrhage control' above and 'Intravenous
(IV) fluids' above.)

● Unstable pelvic injuries, such as "open-book" fractures involving disruption of the sacroiliac joints, are
associated with retroperitoneal hemorrhage. Prehospital treatment for this injury consists of "closing" the
fracture by securing a pelvic binder or sheet tightly around the pelvis. (See 'Hemorrhage control' above
and 'Intravenous (IV) fluids' above.)

● Burn patients with signs of airway compromise or impending compromise should be treated with
immediate tracheal intubation, if the prehospital provider is skilled in the procedure. Signs of airway
compromise are described in the text. Severe burn victims require aggressive fluid resuscitation. (See
'Burn management' above.)

● Prehospital providers often fail to provide adequate analgesia. Judicious use of short-acting opioids (eg,
IV fentanyl up to 100 or 150 mcg, or IV morphine up to 10 or 15 mg) for patients in obvious pain is
generally safe and effective, and will not mask significant injuries or alter outcome. Paramedics may treat
patients with severe pain and hemodynamic instability with 25 mcg doses of IV fentanyl (or 2 mg doses
of IV morphine) approximately every 10 minutes, while being prepared to give an IV fluid bolus.
Paramedics should carefully monitor the respiratory and hemodynamic status of any patient receiving
opioids. (See 'Pain management' above.)

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Topic 347 Version 29.0

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GRAPHICS

Examples of prehospital triage scoring systems

Name Parameters Notes

Prehospital Index Systolic BP Scale is 0 to 24 (>3: major trauma)
Pulse rate
Respiratory rate
Consciousness
Penetrating wounds
(chest or abdomen)

CRAMS (Circulation, Respiration, Systolic BP or capillary Scale is 0 to 10 (<8: major trauma)

Abdomen/Thorax, Motor, Speech) refill Each parameter rated as normal, mildly
Respirations abnormal, or highly abnormal
Examination of trunk
Motor function
Speech pattern

Revised Trauma Score Systolic BP 0 to 7.8408 (<4: major trauma)

Respiratory rate GCS more heavily weighted
GCS

START (Simple triage and rapid Ambulation Stepwise algorithm designed for ease of use
treatment) Respiratory rate in mass casualty incident

Capillary refill
Consciousness

GCS (Glasgow Coma Scale) Eye response Scale is 3 to 15 (<8: severe brain injury)
Verbal response
Motor response

MGAP (Mechanism, GCS, Age, arterial Mechanism (blunt) Scale is 3 to 29 (<18: high risk)
Pressure) GCS
Age (60 years)
Systolic BP

Graphic 79522 Version 1.0

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US 2011 trauma field triage algorithm

EMS: emergency medical services.

* The upper limit of respiratory rate in infants is >29 breaths per minute to maintain a higher level of overtriage for
infants.
Δ Trauma centers are designated Level I-IV. A Level I center has the greatest amount of resources and personnel for
care of the injured patient and provides regional leadership in education, research, and prevention programs. A Level II
facility offers similar resources to a Level I facility, possibly differing only in continuous availability of certain
subspecialties or sufficient prevention, education, and research activities for Level I designation; Level II facilities are
not required to be resident or fellow education centers. A Level III center is capable of assessment, resuscitation, and

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emergency surgery, with severely injured patients being transferred to a Level I or II facility. A Level IV trauma center
is capable of providing 24-hour physician coverage, resuscitation, and stabilization to injured patients before transfer to
a facility that provides a higher level of trauma care.
◊ Any injury noted in Step two or mechanism identified in Step three triggers a "yes" response.
§ Age <15 years.
¥ Intrusion refers to interior compartment intrusion, as opposed to deformation which refers to exterior damage.
‡ Includes pedestrians or bicyclists thrown or run over by a motor vehicle or those with estimated impact >20 mph
with a motor vehicle.
† Local or regional protocols should be used to determine the most appropriate level of trauma center within the
defined trauma system; need not be the highest-level trauma center.
** Age >55 years.
ΔΔ Patients with both burns and concomitant trauma for whom the burn injury poses the greatest risk for morbidity
and mortality should be transferred to a burn center. If the nonburn trauma presents a greater immediate risk, the
patient may be stabilized in a trauma center and then transferred to a burn center.
◊◊ Patients who do not meet any of the triage criteria in Steps one through four should be transported to the most
appropriate medical facility as outlined in local EMS protocols.

Reproduced from: Sasser SM, Hunt RC, Faul M, et al. Guidelines for field triage of injured patients: Recommendations
of the National Expert Panel on Field Triage, 2011. MMWR 2012; 61:1.

Graphic 81002 Version 3.0

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