#EmergencyInsights - Mastering the Essentials: A Comprehensive Guide to Trauma Care in EMS

Trauma care is a critical aspect of emergency medical services (EMS), encompassing the immediate and systematic response to injuries sustained through accidents, violence, or other forms of trauma. For seasoned EMS professionals and newcomers alike, understanding the foundational principles of trauma care is essential to provide efficient and effective treatment to patients in need.

The Importance of Trauma Care

Trauma is a leading cause of death and disability worldwide, particularly among individuals aged 1 to 44. Prompt and accurate trauma care can significantly improve patient outcomes, reducing mortality and long-term disability. EMS professionals are often the first responders to trauma scenes, and their ability to rapidly assess, stabilize, and transport patients to appropriate medical facilities is crucial.

Primary Assessment

The initial assessment in trauma care involves a systematic approach to identify and manage life-threatening conditions quickly. This process is commonly referred to as the primary survey, which follows the ABCDEs of trauma care:

Airway with Cervical Spine Protection

The priority in trauma care is ensuring the patient has a patent airway. This includes:

• Checking for obstruction by blood, vomit, or foreign bodies.

• Performing a jaw thrust or chin lift to open the airway.

• Use suction if necessary.

• Inserting an oropharyngeal or nasopharyngeal airway if the patient is unconscious.

Additionally, cervical spine protection is paramount in trauma patients, as there may be an undiagnosed cervical spine injury. Use manual in-line stabilization and apply a cervical collar.

Breathing and Ventilation

Assess the patient’s breathing by looking, listening, and feeling for respiratory effort. Interventions may include:

·      Providing supplemental oxygen via a non-rebreather mask.

·      Assisting ventilation with a bag-valve mask if the patient is not breathing adequately.

·      Recognizing and managing life-threatening conditions like tension pneumothorax or flail chest.

Circulation with Hemorrhage Control

Evaluate the patient's circulatory status by checking for:

• Pulse presence, rate, and quality.

• Skin color, temperature, and capillary refill.

• Identifying and controlling external bleeding using direct pressure, tourniquets, or hemostatic agents.

Neurological Status

Conduct a quick neurological assessment using the AVPU scale (Alert, responds to Verbal stimuli, responds to Painful stimuli, Unresponsive) and the Glasgow Coma Scale (GCS) to determine the level of consciousness and neurological status.

Exposure and Environmental Control

Completely expose the patient to identify hidden injuries while preventing hypothermia by covering the patient with blankets or using warming devices.

Secondary Assessment

Once the primary assessment and initial stabilization are complete, the secondary assessment involves a more thorough head-to-toe examination to identify additional injuries. This includes:

• Detailed examination of the head, neck, chest, abdomen, pelvis, extremities, and back.

• Reassessment of vital signs.

• Take a patient history using the SAMPLE mnemonic (Signs and symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading up to the injury).

Trauma Management and Interventions

Airway Management

Advanced airway management techniques, such as endotracheal intubation, may be necessary for patients who cannot maintain their airway. Rapid Sequence Intubation (RSI)  or Delayed Sequence Intubation (DSI) can be performed if the patient is at risk of aspiration or airway compromise.

Breathing Interventions

In cases of respiratory distress or failure, EMS professionals may need to perform needle decompression for tension pneumothorax or place a chest seal on open chest wounds. In cases where the respiratory distress is caused by medical reasons rather than trauma, continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) may be used.

Circulatory Support

Establishing intravenous or intraosseous access to administer fluids and medications is crucial for patients in shock. Fluid resuscitation should be guided by the type of shock and the patient's condition. In cases of hemorrhagic shock, permissive hypotension (maintaining a lower-than-normal blood pressure) may be employed to reduce the risk of exacerbating bleeding until definitive surgical control can be achieved.

Pain Management

Effective pain management is an essential component of trauma care. Options include:

• Administration of analgesics such as morphine or fentanyl.

• Non-pharmacological methods like splinting fractures and applying ice packs are used.

Spinal Motion Restriction

Current guidelines emphasize the importance of avoiding unnecessary spinal immobilization. Spinal motion restriction techniques tailored to the patient’s condition should be used, and backboards should be employed primarily for extrication and transport rather than prolonged immobilization.

Special Considerations

Pediatric Trauma

Children are not just small adults; their anatomical and physiological differences require specialized approaches. Use age-appropriate equipment and medication dosages, and maintain a high index of suspicion for non-accidental trauma.

Geriatric Trauma

Elderly patients often have comorbid conditions and may present atypically. Pay close attention to their baseline functional status and be cautious with fluid resuscitation to avoid fluid overload.

Obstetric Trauma

Pregnant patients present unique challenges, as trauma can affect both the mother and the fetus. Ensure proper maternal positioning to avoid compressing the inferior vena cava and monitor fetal well-being when feasible.

Transport and Handoff

Rapid transport to an appropriate trauma center is crucial for patients with severe injuries. During transport, continuous monitoring and reassessment are necessary. Effective communication with the receiving facility, including a concise handoff report, ensures that critical information is conveyed.

The MIST Format

Use the MIST format (Mechanism of injury, Injuries found and suspected, Signs and symptoms, Treatments initiated) for structured handoff communication.

Conclusion

Trauma care is a dynamic and challenging field within EMS, requiring rapid assessment, critical thinking, and precise interventions. By mastering the basics of trauma care, EMS professionals can significantly impact patient outcomes. Continuous education, training, and adherence to updated protocols are essential for maintaining and improving trauma care skills.

 References

• American College of Surgeons Committee on Trauma. (2018). Advanced Trauma Life Support (ATLS): Student Course Manual. 10th ed. American College of Surgeons.

• National Association of Emergency Medical Technicians (NAEMT). (2018). Prehospital Trauma Life Support (PHTLS). 9th ed. Jones & Bartlett Learning.

• Centers for Disease Control and Prevention (CDC). (2020). Field Triage Decision Scheme: The National Trauma Triage Protocol. Retrieved from (https://www.cdc.gov/).

• Tintinalli, J. E., Ma, O. J., & Cline, D. M. (2016). Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. McGraw-Hill Education. 

By staying informed and continually honing their skills, EMS professionals can provide the best possible care for trauma patients, ultimately saving lives and improving recovery outcomes.