Pre

 hospital  care  of  polytrauma  patient:  

Assessment  and  Management  
  Trauma   is   a   leading   cause   of   death   and   disability.   With   increasing   vehicular   population   and  
urbanization   it   is   becoming   more   prevalent.   Presently   Road   Traffic   Accident   (RTA)   is   the   ninth   most  
common  cause  of  death  amongst  all  diseases  in  world  but  as  per  WHO  projections,  by  the  year  2020  it  
will   be   the   third   in   this   list.   Injuries,   whether   due   to   road   traffic   crashes,   violence   or   other   causes,   affect  
not  only  the  immediate  victim,  but  also  his  or  her  family  and  members  of  the  surrounding  community.  
Injuries   exact   a   large   societal   and   economic   toll   on   society.   The   economic   burden   of   injury   is   great   –  
both   in   terms   of   the   direct   costs   of   medical   care   and   the   indirect   economic   costs   of   premature   death  
and  disability.  This  burden  is  magnified  when  one  or  more  family  members  are  forced  to  leave  work  to  
care  for  a  disabled  family  member  or  relative.  Countless  hours  of  productivity  are  lost  as  family,  friends  
and   society   adapt   to   the   death   or   disability   of   loved   ones.   Management   of   a   multiple   injured   or   a  
polytrauma  patient  can  challenge  even  an  astute  clinician.  Most  of  the  times  the  trauma  victim  does  not  
reach   the   hospital   in   time   and   in   many   of   the   hospitals   there   is   a   shortage   of   trained   manpower   and  
resources  to  handle  them.  Therefore,  it  is  imperative  for  all  medical  and  paramedical  personnel  to  gain  
the  knowledge  of  basic  trauma  management  which  can  be  provided  with  the  available  resources,  so  that  
the  patient  receives  the  immediate  care  before  being  shifted  to  a  trauma  centre.  

Deaths  from  trauma  -­‐  "trimodal  distribution"  

This   refers   to   occurrence   of   death   following   trauma   as   a   function   of   time.   Accordingly   these   are  
classified  as:  

Immediate   deaths:   these   occur   within   seconds   to   minutes   after   injury   and   are   due   to   heart   or   major  
vascular  rupture,  brain  stem  injury  or  massive  head  injury.  

Early   deaths:   these   are   the   deaths   which   occur   after   few   minutes   to   hours   after   injury.   Usual   causes   are  
airway  obstruction,  tension  pneumothorax,  closed  head  injury  or  hypovolemic  shock.  

Late   deaths:   these   are   deaths   occurring   days   after   injury,   in   the   intensive   care   units   and   are   due   to  
septicemia,  coagulopathy  and  multiorgan  failure.  

  Immediate   deaths   are   non   salvageable   and   only   preventive   measures   like   following   traffic   rules,  
using   helmets   etc.   can   save   them.   Early   deaths   are   the   preventable   deaths   where   appropriate   diagnosis  
and   treatment   can   make   a   difference   between   survival   and   mortality.   Late   deaths   are   a   consequence   of  
injury   severity   and   inappropriate   initial   care.   Essential   trauma   care   is   all   about   preventing   early   and   late  
deaths.  

  The  survival  of  the  trauma  patient  is  shown  to  be  time  dependent.  The  longer  the  time  taken  for  
providing   appropriate   care,   the   lower   was   the   survival   rate.   This   forms   the   basis   of   the   concept   of  
”Golden  Hour”,  emphasizing  the  need  for  early  treatment  of  these  patients.  The  Golden  hour  starts  from  
the  time  of  injury  and  not  when  the  first  medical  personnel  have  arrived.  

Initial  Assessment  and  Management  of  Patient  

  A  good  pre  hospital  care  is  absolutely  necessary  for  better  survival.  There  is  a  need  to  shift  the  
patient   early   to   an   appropriate   trauma   centre   and   continuous   care   should   be   given   en   route.   This   policy  
is  called”  Load  and  Go”  or  “Scoop  and  Run”,  which  is  being  practiced  in  India.  Another  concept  of  “Stay  
and  Play”  is  in  vogue  in  some  countries  in  Europe  which  implies  that  the  patient  is  treated  and  stabilized  
at  site  of  accident  before  the  transport.  Before  approaching  the  patient  at  site  it  is  essential  that  the  pre  
hospital  team  ensures  that  the  place  is  safe  for  them  to  load  the  patient  and  they  have  their  universal  
precautions   in   place.   Always   approach   the   patient   from   his   front   side   and   address   him   to   elicit   a  
response.   A   patient   who   is   able   to   talk   coherently   -­‐   has   an   intact   airway,   sufficient   oxygenation   and  
adequate  perfusion  of  brain  tissue.  The  EMS  team  should  also  communicate  with  the  receiving  hospital  
so  that  the  trauma  team  is  ready  to  receive  the  patient.  

  The   initial   management   is   divided   into   two   phases;   primary   survey   and   secondary   survey.  
Primary   survey   deals   with   the   management   of   immediate   life   threatening   injuries   while   secondary  
survey  is  comprehensive  management  of  all  injuries.  The  trauma  response  algorithm  is  shown  below.  

 
The  Golden  Principles  of  prehospital  trauma  care  
  A   prehospital   care   provider   needs   to   recognize   and   prioritize   the   treatment   of   patients   with  
multiple  injuries,  following  the  "golden  principles  of  prehospital  trauma  care".  

1.  Ensure  the  safety  of  the  Prehospital  Care  Providers  and  the  Patient.  

Prehospital  care  providers  need  to  ensure  that  scene  safety  remains  their  highest  priority.  This  includes  
not   only   the   safety   of   the   victim,   but   their   own   safety   as   well.   Another   fundamental   aspect   of   safety  
includes   the   use   of   standard   precautions.   Blood   and   other   body   fluids   can   transmit   infections   such   as  
HIV  and  hepatitis  B.  protective  gear  must  always  be  worn,  especially  while  caring  for  trauma  patients  in  
the  presence  of  blood.    

  The  safety  of  the  victim  and  possible  hazardous  situations  should  also  be  assessed.  Even  in  the  
victim  involved  in  a  motor  vehicle  accident  has  no  life-­‐threatening  conditions  identified  in  the  primary  
survey,   rapid   extrication   is   appropriate   if   threats   to   victim   safety   are   noted,   such   as   a   significant  
potential  for  fire  or  a  precarious  vehicle  position.  

2.  Assess  the  scene  situation  to  determine  the  need  for  additional  resources.  

  Examples   of   additional   or   specialized   resources   which   may   be   required   include   additional  

emergency   medical   services   (EMS)   units   to   accommodate   the   number   of   victims,   fire   suppression  
equipment,  special  rescue  teams,  power  company  personnel,  medical  helicopters,  ,  and  physicians  to  aid  
in   triage   of   a   large   number   of   victims.   The   need   for   such   additional   resources   should   be   anticipated   and  
requested  as  soon  as  possible.  

3.  Recognize  the  kinematics  that  produced  the  injuries.  

  As   the   scene   and   the   patient   are   approached,   the   kinematics   of   the   situation   are   noted.  
Understanding   the   principles   of   kinematics   leads   to   the   better   patient   assessment.   Knowledge   of  
specific  injury  patterns  aids  in  predicting  the  injuries  and  knowing  where  to  examine.  

4.  Use  the  primary  survey  approach  to  identify  life-­‐threatening  conditions.  

  The   brief,   primary   survey   allows   vital   functions   to   be   rapidly   assessed   and   life-­‐threatening  
conditions  to  be  identified  through  systematic  evaluation  of  the  ABCDEs  :  Airway,  Breathing,  Circulation,  
Disability,   and   Exposure/Environment.   On   initial   approach   to   the   scene   and   as   field   care   is   provided,   the  
prehospital  care  provider  receives  input  from  several  senses  (sight,  hearing,  smell,  touch)  that  must  be  
sorted  -­‐  placed  in  a  priority  scheme  of  life-­‐threatening  or  limb-­‐threatening  injuries  -­‐  and  used  to  develop  
a  plan  for  correct  management.  

  The  following  are  common  life-­‐threatening  conditions  include:    

(a)  Inadequate  or  threatened  airway    

(b)  Impaired  ventilation  as  demonstrated  by  

 • Abnormally  fast  or  slow  ventilation  rate  
• Hypoxia  (SpO2<95%,  even  with  supplementation  of  oxygen)  
• Dyspnoea  
• Open  pneumothorax  or  flail  chest  
• Suspected  pneumothorax  

(c)    Significant  external  hemorrhage  or  suspected  internal  hemorrhage  

(d)  Shock,  even  if  compensated  

(e)  Abnormal  neurological  status  

• GCS  score  ≤  13  

• Seizure  activity  
• Sensory  or  motor  deficit  

(f)   Penetrating   trauma   of   the   head,   neck,   or   torso,   or   proximal   to   the   elbow   and   knee   in   the  
extremities.  

(g)  Amputation  or  near-­‐amputation  proximal  to  the  fingers  or  toes  

(h)  Any  trauma  in  the  presence  of  the  following:  

• History   of   serious   medical   conditions   (eg,   coronary   artery   disease,   chronic   obstructive  
pulmonary  disease,  bleeding  disorder)  
• Age>55  years  
• Hypothermia  
• Burns  
• Pregnancy  

5.  Provide  appropriate  airway  management  while  maintaining  cervical  spine  stabilization.  

  Maintaining   oxygenation   and   preventing   hypercarbia   are   critical   in   managing   trauma   patients,  
especially  those  who  have  sustained  head  injuries.  Anticipating  vomiting  in  all  injured  patients  and  being  
prepared   to   manage   the   situation   are   very   important.   Because   any   airway   intervention   can   require  
some  neck  motion,  it  is  important  to  maintain  cervical  spine  protection  in  all  patients,  especially  those  
who  are  known  to  have  unstable  cervical  injury  and  those  who  have  been  incompletely  evaluated  and  
are  at  risk.  The  spinal  cord  must  be  protected  until  the  possibility  of  a  spinal  injury  has  been  excluded  by  
clinical  assessment  and  other  appropriate  investigations.    

  Normally,   trauma   patients,   particularly   multiply   injured   patients,   are   immobilized   with   a   neck  
brace   until   a   cervical   spine   fracture   can   be   excluded   by   imaging   technology.   However,   a   correctly  
positioned  cervical  spine  immobilization  device  restricts  the  mouth  opening  and  thus  the  ability  to  insert  
a   laryngoscope   during   an   intubation   maneuver.   The   cervical   spine   immobilization   device   prevents  
reclination   of   the   head.   For   this   reason,   some   users   are   replacing   the   cervical   spine   immobilization  
device  in  endotracheal  intubation  by  manual  in-­‐line  stabilization  (MILS).  In  this  case,  the  cervical  spine  is  
immobilized   by   another   assistant   using   both   hands   to   immobilize   the   cervical   spine   manually.   The  
subsequent  direct  laryngoscopy  under  MILS  was  the  standard  of  care  in  emergency  situations  for  many  
years.   However,   there   is   controversy   surrounding   MILS   and   partially   negative   effects   have   been  
described.   As   an   alternative   to   direct   laryngoscopy,   fiberoptic   intubation   as   the   gold   standard   can   be  
performed  on  alert  and  spontaneously  breathing  patients  in  a  stable  cardiopulmonary  condition  by  an  
experienced  user  in-­‐hospital.  

6.  Support  ventilation  and  deliver  oxygen  to  maintain  an  SpO2  greater  than  95%.  

  If   concern   or   suspicion   exists   about   hypoxia,   oxygen   can   be   administered   through   a  

nonrebreathing   mask   to   the   spontaneously   breathing   patient   or   with   a   bag-­‐mask   connected   to  
supplemental  oxygen  for  those  victims  receiving  assisted  or  total  ventilatory  support.  

7.  Control  any  significant  external  hemorrhage.  

  Because   blood   is   not   available   for   administration   in   the   prehospital   setting,   hemorrhage   control  
becomes   a   paramount   concern   in   order   to   maintain   sufficient   number   of   circulating   RBCs;   every   RBC  
counts.   Most   external   hemorrhage   is   readily   controlled   by   the   application   of   direct   pressure   at   the  
bleeding  site.  Tourniquets  are  routinely  used  in  surgical  procedures,  with  an  excellent  safety  record,  and  
may  be  life-­‐saving  in  the  prehospital  setting.  Extremity  injuries  and  scalp  injuries  such  as  lacerations  and  
partial  avulsions,  may  be  associated  with  life-­‐threatening  blood  loss.  

8.   Provide   basic   shock   therapy,   including   restoring   and   maintaining   normal   body   temperature   and  
appropriately  splinting  musculoskeletal  injuries.  

  Once  primary  survey  is  completed,  the  patient  should  be  covered  adequately  in  order  to  avoid  
hypothermia,   which   can   be   fatal   to   a   critically   injured   patient.   Hypothermia   itself   can   lead   to  
coagulopathy.  Therefore,  it  is  important  to  maintain  and  restore  body  heat  through  the  use  of  blankets  
and  a  warmed  environment  inside  the  ambulance  while  transporting  to  hospital.    

  With   a   critically   injured   trauma   patient,   there   is   no   time   to   splint   each   individual   fracture.  
Instead,   immobilizing   the   patient   to   a   long   backboard   will   splint   virtually   all   fractures   in   an   anatomic  
position  and  diminish  internal  hemorrhage.  The  one  possible  exception  to  this  is  a  mid-­‐shaft  fracture  of  
the  femur.  Because  of  the  spasm  of  the  very  strong  muscles  in  the  thigh,  the  muscles  contract,  causing  
the  bone  ends  to  override  one  another,  thereby  damaging  additional  tissue.  These  types  of  fractures  are  
best  managed  by  use  of  a  traction  splint  if  time  allows  its  application  during  transport.  The  pneumatic  
anti-­‐shock  garment  (PASG),  if  available,  can  be  used  to  splint  and  compress  a  suspected  pelvic  fracture  
when  decompensated  shock  is  present.    

9.  Maintain  manual  spinal  stabilization  until  the  patient  is  immobilized  on  a  long  backboard.  

  When  contact  with  a  trauma  patient  is  made,  manual  stabilization  of  the  cervical  spine  should  
be  provided  and  maintained  until  the  victim  is  either  (a)  immobilized  on  a  long  backboard  or  (b)  deemed  
not   to   meet   indications   for   spinal   immobilization.   Satisfactory   spinal   immobilization   involves  
immobilization  from  the  head  to  the  pelvis.  Immobilization  should  not  interfere  with  victim's  ability  to  
open  the  mouth  and  should  not  impair  the  ventilatory  function.  For  the  victim  of  penetrating  trauma,  
spinal   immobilization   is   performed   if   the   patient   has   spine-­‐related   neurological   complaints   or   if   a   motor  
or  sensory  deficit  is  noted  on  physical  examination.  

10.  For  critically  injured  trauma  patients,  initiate  transport  to  the  closest  appropriate  facility  within  10  
minutes  of  arrival  on  scene.    

  Delays   in   transporting   trauma   patients   to   appropriate   receiving   facilities   lead   to   increases   in  

mortality   rates.   It   may   be   noted   that   the   closest   hospital   may   not   be   the   most   appropriate   receiving  
facility  for  many  trauma  patients.  Those  patients  who  meet  certain  physiologic,  anatomic,  or  mechanism  
of  injury  criteria  benefit  from  being  taken  to  a  trauma  center  -­‐  a  facility  that  has  special  expertise  and  
resources  for  managing  trauma.  Even  if  this  causes  a  moderate  increase  in  transporting  time,  the  time  to  
definitive  care  is  shortened.  

  Most   critically   injured   trauma   victims   are   in   hemorrhagic   shock   and   are   in   need   of   two   things  
that  cannot  be  provided  in  the  prehospital  setting;  blood  and  control  of  internal  hemorrhage.  Crystalloid  
solutions  temporarily  restores  intravascular  volume  but  does  not  replace  the  oxygen-­‐carrying  capacity  of  
RBCs.   Resuscitation   can   never   be   achieved   with   ongoing   internal   hemorrhage.   Control   of   internal  
hemorrhage   almost   always   requires   emergent   surgical   intervention   best   performed   inside   operating  
room.   However,   this   concern   of   limiting   scene   time   should   not   be   constructed   as   a   "scoop-­‐and-­‐run"  
mentality  in  which  no  attempts  are  made  to  address  key  problems  before  initiating  transport.  Instead,  it  
advocates   a   philosophy   of   "limited   scene   intervention",   focusing   on   a   rapid   assessment   aimed   at  
identifying  treats  to  life  and  performing  interventions  that  are  believed  to  improve  outcome.  

  Patients  who  are  critically  injured  should  be  transported  within  10  minutes  of  the  arrival  of  EMS  
on   the   scene   whenever   possible   -­‐   the   "Platinum   10   minutes"   of   the   Golden   period.   Reasonable  
exceptions   to   the   platinum   10   minutes   include   situations   that   require   extensive   extrication   or   time  
needed   to   secure   an   unsafe   scene,   such   as   low   enforcement   ensuring   that   a   perpetrator   is   no   longer  
present.  

11.  Initiate  warmed  intravenous  fluid  replacement  en  route  to  the  receiving  facility.    

  Warmed   solution   is   given   to   aid   in   the   prevention   of   hypothermia.     Volume   resuscitation   is  

individualized  to  the  clinical  situation  and  involves  balancing  the  need  for  the  perfusion  of  vital  organs  
with  risk  of  rebleeding  as  the  blood  pressure  increases.  For  adult  patients  with  suspected  uncontrolled  
hemorrhage  in  the  chest,  abdomen,  or  retroperitoneum,  IV  fluid  therapy  is  titrated  to  maintain  a  mean  
arterial  pressure  of  60  to  65  mmHg  unless  a  CNS  injury  (traumatic  brain  injury  or  spinal  cord  injury)  is  
suspected,   in   which   case   a   target   systolic   blood   pressure   of   at   least   90   mmHg   is   appropriate.   If  
hemorrhage    has  been  controlled,  warmed  IV  fluid  is  provided  in  order  to  return  vitals  to  normal  levels  
unless   the   patient   develops   evidence   of   recurrent   Class   III   or   IV   shock,   in   which   case   fluid   is   titrated   to   a  
mean  arterial  pressure  of  60  to  65  mm  Hg.  
12.   Ascertain   the   patient's   medical   history   and   perform   a   secondary   survey   when   life-­‐threatening  
conditions  have  been  satisfactorily  managed  or  have  been  ruled  out.    

  The   secondary   survey   is   a   systematic,   head-­‐to-­‐toe   physical   examination   that   serves   to   identify  
all   injuries.   At   this   time   a   SAMPLE   history   (Symptoms,   Allergy,   Medications,   Past   medical   history,   Last  
meal,   Events   preceding   the   injury)   is   also   obtained.   For   critically   injured   trauma   victims,   a   secondary  
survey  is  performed  only  if  time  permits  and  once  life-­‐threatening  conditions  have  been  appropriately  
managed.   The   victim   should   be   reassessed   frequently   because   patients   who   initially   present   without  
life-­‐threatening  injuries  may  subsequently  develop  them.  

13.  Provide  thorough  and  accurate  communication  regarding  the  patient  and  the  circumstances  of  the  
injury  to  the  receiving  facility.    

  Communication  about  a  trauma  victim  involves  3  components:  (a)  pre-­‐arrival  warning;  (b)  verbal  
report  upon  arrival;  and  (c)  written  documentation  of  the  encounter  in  the  patient  care  report.  Care  of  
the   trauma   patient   depends   upon   a   team   effort.   The   response   to   a   critical   patient   begins   with   the  
prehospital  provider  and  continues  in  the  hospital.  

14.  Above  all,  do  no  further  harm.  

  The   medical   principle   that   states   "Above   all,   do   no   further   harm"   dates   back   to   the   ancient  
Greek   physician   Hippocrates.   While   caring   for   a   critically   injured   victim,   prehospital   care   providers   need  
to   ask   themselves   if   their   actions   at   the   scene   and   during   transport   will   reasonably   bebefit   the   victim.   If  
the  answer  to  this  question  is  either  "no"  or  "uncertain",  those  actions  should  be  withheld  and  emphasis  
placed   on   transporting   the   trauma   victim   to   the   closest   appropriate   facility.   Interventions   should   be  
limited  to  those  that  prevent  or  treat  physiologic  deterioration.  Trauma  care  must  follow  a  given  set  of  
priorities   that   establish   an   efficient   and   effective   plan   of   action,   based   on   available   time   frames   and   any  
dangers   present   at   the   scene,   if   the   patient   is   to   survive.   Appropriate   intervention   and   stabilization  
should   be   integrated   and   coordinated   between   the   field,   the   emergency   department,   and   the   operating  
room.   It   is   essential   that   every   provider   at   every   level   of   care   and   at   every   stage   of   treatment   be   in  
harmony  with  the  rest  of  the  team.  

Summary  
Pre-­‐hospital   care   is   a   rapidly   developing   and   complex   speciality.   Rapid   identification   of   a   problem   is  
essential   to   guide   extrication   and   evacuation   planning.   It   is   appropriate   to   wait   for   a   controlled   but  
slower  extrication  for  a  trapped  but  clinically  stable  patient.  However,  a  patient  with  airway  compromise  
or  severe  respiratory  difficulties  is  likely  to  require  an  immediate,  and  relatively  uncontrolled,  extrication  
to   allow   medical   intervention.  The   receiving   hospital   should   be   chosen   (where   possible   and   reasonable)  
with   regard   to   the   patient’s   injury   pattern.   The   rescuer   must   perform   frequent   reassessments   of   the  
casualty  especially  after  any  therapeutic  interventions.