Pre-hospital Management of Traumatic Emergencies - An Overview

Introduction:

Trauma is one of the main causes of mortality, especially in the first four decades of life. Successful pre-hospital trauma care management depends on managing the airway, circulation, breathing, fluid resuscitation, and early transport to the trauma center by road or helicopter emergency medical service (HEMS). The management should also identify life-threatening injuries and treat them. Therefore, the total outcome for trauma patients depends on the multidisciplinary approach from both (pre-hospital and hospital) care teams.

What Is the Pre-hospital Management of Traumatic Emergencies?

The main goal of pre-hospital management depends on treating life-threatening injuries, and rapid diagnosis and therapies. The pre-hospital management of traumatic emergencies involves:

1. The Initial Assessment of the Traumatic Patient: Quick management, which can reduce the percentage of preventable deaths, is very important. Initial assessment with the help of the ABCDE approach should be done, which involves:

• Airway: Open airways should be maintained, and the spine should be protected. A partially obstructed airway is diagnosed by a change in voice, stridor (high-pitched breathing), or snoring in the case of an unconscious patient. A completely obstructed airway is diagnosed by paradoxic respiration, in which there is difficulty in breathing. A laryngeal lesion is diagnosed by dysphonia (impaired voice) and hoarseness. Airway obstruction should be treated quickly, or the patient can undergo cardiac arrest. Airway obstruction should be treated by tilting the head and lifting the chin, using suctions to remove obstructions (blood, vomit, or foreign body), giving abdominal thrusting along with back blows, cardiopulmonary resuscitation (mouth-to-mouth breathing and chest compressions), and providing high-flow oxygen at the rate of 15 liters per minute. In the case of unconscious patients, the tongue may fall back, causing difficulty in breathing, and should undergo orotracheal intubation (placement of a tube in the trachea).

• Breathing: Respiratory rate and symmetric movements of the thoracic wall should be diagnosed. Healthcare providers should also check for distended neck veins, cyanosis (bluish discoloration of the skin), and lateralization of the trachea. In the case of tension pneumothorax (a condition where the air is trapped in the outer membranes of the lungs, causing difficulty in cardiac activity), the air should be relieved by inserting a cannula in the second intercostal space. In case of bronchospasm, inhalation should be given. Apart from these, ventilators and bag masks can be used.

• Circulation: Circulation can be assessed by inspecting the skin for signs such as sweating, color changing, and level of consciousness. Blood pressure and electrocardiography (ECG) monitoring should be done. In case of hypovolemia (decreased fluid levels), the patient should be in the supine position, legs should be elevated, and intravenous access should be performed to administer saline.

• Disability: Disability is assessed through the level of consciousness. A low level of consciousness can be due to low glucose levels, which can be corrected with the help of oral glucose.

• Exposure: Skin rashes, needle marks, bleeding, and signs of trauma should be inspected. The skin should be exposed, and body temperature should be maintained.

2. Diagnosis: A complete examination from head to toe and medical history should be carried out. In case of cardiac arrest (decreased blood supply to the heart, which causes loss of function), immediate resuscitation such as chest compressions or ventilation should be carried out. Peri-arrest condition, a condition before going into cardiac arrest, is characterized by decreased blood pressure, absence of pulse, and decreased level of consciousness. The use of focused assessment with sonography in trauma (FAST) helps in diagnosing fluid accumulation in the abdominal cavity called hemoperitoneum and bleeding in the outer membrane of the heart called hemopericardium.

3. Controlling Bleeding: In case of massive bleeding, it should be controlled by applying direct pressure or by using bandages, and early fluid resuscitation should be considered. Tranexamic acid can be given within the first three hours to prevent bleeding.

4. Managing Hypovolemia: It is a condition of decreased fluid volume in the body. The patient presents with tachycardia (increased heart rate), and hypotension (decreased blood pressure). In case of severe fluid loss, the patient can undergo shock. The management includes IV (intravenous) administration of fluids.

5. Transportation of Traumatic Patients to the Hospital: Transferring the patient is a crucial part. Certain positions, such as Trendelenburg position (patient is in supine with legs elevated) in case of shock and Dorsal decubitus (supine position) in case of multiple traumas, can be used. The patient is transferred with the help of a stretcher, brancard, or vacuum mattress. In the case of HEMS transport, a patient with peri arrest (a condition before going into cardiac arrest) should be avoided. Before transporting, an endotracheal tube or orotracheal intubation, which maintains the airway, should be placed. Airway suctioning should be prepared to remove respiratory tract secretions that can block the airway, IV fluid administration, a urine catheter should be placed to monitor urine output, and a gastric tube should be placed in case of gastric distention.

What Are the Conditions That Require Immediate Management in Traumatic Patients?

The conditions that require immediate management include:

1. Tension Pneumothorax: It is a condition in which air is trapped in the outer membranes of the lungs, causing the collapse of the lung, and is accompanied by a shift in mediastinal structures such as the trachea, heart, and great vessels. This occurs due to trauma, which can be penetrating or blunt. The patient presents with sharp pain radiating to the back and shortness of breath. Management includes immediate needle decompression in the second intercostal space, followed by placing a chest drainage tube.

2. Open Pneumothorax: It is a condition that occurs when the air is trapped in the outer membranes of the lungs due to a perforation in the chest wall. The patient presents with rapid and shallow breathing, sudden chest pain, increased heart rate, and hypoxia (decreased oxygen to the body). Management includes three-way dressing (the wound is taped on three sides, which prevents the entry of air into the chest wall) and placing a chest tube.

3. Massive Hemothorax: It is a condition in which blood accumulates in the outer membranes of the lungs (pleural space). Massive hemothorax is diagnosed by the accumulation of more than 1000 milliliters (ml) of blood in the pleural space. Management includes placing a chest drainage tube to collect blood.

4. Flail Chest: It is a traumatic condition in which two or three ribs are broken and causes independent movement of a part of the chest wall from the rest of the chest wall. This causes respiratory disturbance. A CT (computed tomography) scan can help in diagnosing a flail chest. Management includes pain and fluid management, maintaining ventilation, external stabilization (to keep the fractured bones in place), or internal stabilization with the help of metallic wires.

5. Cardiac Tamponade: It is a condition in which fluid accumulates in the outer sacs (pericardial sac) of the heart. The patient presents with chest pain, muffled heart sounds, increasing breathing and heart rate, hypotension, enlargement of veins in the neck, and swelling of limbs. Management includes emergency thoracotomy (incision in the chest wall) or sternotomy (incision on the breastbone to access the heart and its vessels) along with administration of IV fluids. Apart from these, pericardiocentesis (insertion of a needle in the fifth left intercostal space to remove fluid from the pericardial sac) can be performed.

Conclusion:

A systematic approach should be followed in the case of pre-hospital care of trauma patients. The primary assessment is the ABCDE (a systematic approach often used in emergency medicine and first aid to quickly and effectively evaluate and manage patients, especially in critical situations which stands as airway, breathing, circulation, disability, and exposure) approach, after which a complete examination should be carried out and the patient should be transferred safely to a healthcare unit.