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Prehospital care and movement of critically injured penetrat­ing trauma patients are key components of an effective sys­tem of trauma care.

The care of critically ill penetrating trauma patients begins before the time of injury. Emergency Medical Services (EMS) leaders need to develop clear advance plans for the management of these challenging patients. Scene security and safety of EMS personnel is paramount, and clear guide­lines should direct medical teams to stay out of dangerous situations until the scene is controlled by law enforcement. Joint training exercises with law enforcement are encour­aged to optimize the response to mass shooting events. Even after law enforcement control is attained, providers should maintain situational awareness and strive for rapid departure from the location of the incident.

There are no universally accepted guides or formulas regarding adequate stafng to care for a critically ill patient; one philosophy is to consider the time-critical nature of pen­etrating trauma to be akin to a building on re. Severity of illness continues to grow and the time window for interven­tion continues to close with every minute. In cardiac arrest, survival improves with seven or more prehospital providers on-scene within the rst 10min. Many medical providers are

needed immediately, and it is better to assign more than the usual number of staff, with the option to reduce staff as able.

Patients with absent respirations or pulse, those with tachypnea, and unconscious patients should be given highest priority and the most resources. Ringburg conrmed this in a systematic review of dispatch criteria. The criterion “loss of consciousness” had a sensitivity of 93–98% and a specicity of 85–96% in this review. The anatomic criteria of “penetrat­ing injury to the torso, neck, head” should capture the high­est risk victims of penetrating trauma. In a retrospective review of trauma deaths in the rst hour, 31% of the penetrat­ing trauma deaths were a result of GSWs to the chest, and 21% from GSWs to the head. Thus any penetrating injury in these areas should prompt the highest level of response.

In a cross-sectional investigation of the relationship of prehospital time to mortality, Baez and colleagues used logistic regression to demonstrate that longer prehospital time correlated signicantly with hospital length of stay and complications, but not with mortality among young patients. In elderly trauma patients prehospital time had no signicant predictive effect on length of stay, complications, or mortality.

1.018–1.076; p<0.01), or non-extremity rearm injury (OR,

In an observational study using the National Trauma Databank (NTDB), Wandling et al. identied adult gunshot and stab wound patients presenting to Level 1 or 2 trauma centers from 2010 to 2012. Frequency of police transport was evaluated, identifying trauma systems with high utiliza­tion. Of 88,564 total patients, 86,097 (97.2%) were trans­ported by EMS and 2467 (2.8%) by police. Unadjusted mortality was 17.7% for police transport and 11.6% for ground EMS.After risk adjustment, patients transported by police were no more likely to die than those transported by EMS (OR = 1.00, 95% CI: 0.69–1.45). In Philadelphia, Pennsylvania police transport penetrating trauma patients frequently. In a cohort study, after coarsened exact matching (870 patients in each transport cohort), there was no differ­ence in mortality at 24hours (210 [24.1%] vs. 212 [24.4%]; odds ratio, 0.95; 95% CI, 0.59–1.52; p=0.91) or at any other time point. On subgroup analysis, patients with severe inju­ries transported by police were less likely to be dead on arrival compared with matched patients transported by EMS (64 of 194 [33.0%] vs. 79 of 194 [40.7%]; odds ratio, 0.48; 95% CI, 0.24–0.94; p=0.03).

The Eastern Association for the Surgery of Trauma exam­ined the practice of police transport and found overall mor­tality by propensity matching was not different between cohorts (15.6 ALS vs. 15.0% PT, p = 0.82). In severely injured patients (ISS ≥ 16), mortality did not differ between PT and ALS transport (38.8% vs. 36.0% respectively; p = 0.68). Cox regression analysis controlled for relevant factors revealed no association with a mortality benet in patients transported by ALS. They conclude that police transport of penetrating trauma patients in urban locations results in similar outcomes compared to ALS care. Any

Airway management is one area of controversy in prehospi­tal care. Failure to correctly control the patient’s airway in trauma is a leading cause of preventable death. Early imple­mentation of bag-valve-mask-assisted ventilation with high­ow oxygen is a key step to initiating the resuscitation of the critically injured patient. This should be followed closely by the placement of a denitive airway with an endotracheal tube. However, prehospital intubation has been associated with impaired outcome in some studies. This association between airway management and outcome has been refuted by two important studies.

It is important to maximally saturate hemoglobin and ensure adequate oxygen content; oxygen delivery is impaired by shock or loss of hemoglobin with hemorrhage. There are no convincing data whether to use or not to use oxygen, but a reasonable approach would be to use the highest concentra­tion possible to maintain oxygen saturation (SpO2) of >98% or to use maximal concentration (FIO2) when SpO2 is not measurable.

Effective alveolar excretion of carbon dioxide is depen­dent on robust pulmonary circulation. Trauma patients with chest injury or hypoperfusion may not be able to effectively deliver CO2 to the lungs or to excrete it appropriately. A recent study of the correlation of EtCO2 and PaCO2 in intu­bated trauma patients found poor correlation. Patients arriv­ing at the trauma center with EtCO2 in the recommended range of 35–40 mmHg were hypoventilated with PaCO

>40mmHg in 80% of the cases and severely under-

If the primary goal of prehospital trauma treatment is to minimize eld time and expedite transportation to a trauma center, does the initiation of IV uid therapy impede this goal? There exists great variation in the amount of time required to place an IV. Some authors report as little as 2–4 min and others much longer, 14–16min. Paramedics need to place IVs during transport and not delay transport for the initiation of IV uid resuscitation. Due to brief transport times in the urban environment, the amount of uid given prior to ED arrival is often quite small. In one review on this topic, the average amount of uid given in 14 studies was 959mL. Even though the amount of uid may be inadequate, there is a non-statistically signicant trend toward prehospi­tal uid being associated with a 3.9- fold increase in survival. Fluid is the primary therapy that may account for improve­ment in blood pressure and heart rate in one comparison of prehospital and ED vital signs in trauma patients. In a series of 19,409 patients, Arbabi described 31% of patients having an increase in their systolic blood pressure in the ED com­pared to the eld.

Patients with uncontrolled hemorrhage represent a unique and special challenge when deciding how much IV uid resuscitation to deliver. One working model is that the deliv­ery of large volumes of non-oxygen carrying uid cools the patient, impairs oxygen delivery, and dilutes clotting. There is also animal data that suggests partially controlled bleed­ing or temporarily clotted aortic injury in pigs re-bleeds when the systolic blood pressure is raised above 94mmHg. Cannon rst described limiting IV uid administration on the battleelds of WWI: “Injection of a uid that will increase blood pressure has dangers in itself. Hemorrhage in a case of shock may not have occurred to a marked degree because blood pressure has been too low and the ow too scant to overcome the obstacle offered by the clot. If the pressure is raised before the surgeon is ready to check any bleeding that may take place, blood that is sorely needed may be lost”. To prevent these deleterious effects, they established a target systolic blood pressure range of 70–80mmHg.

Two randomized controlled trials of hypotensive resusci­tation in penetrating trauma patients with uncontrolled hem­orrhage have been performed. Bickell and group performed a prospective trial comparing immediate and delayed uid resuscitation in 598 adults with penetrating torso injuries who presented with a prehospital systolic blood pressure 90 mmHg. The immediate resuscitation group received an average of 870mL of Lactated Ringer’s solution compared to 92mL in the delayed group. Twelve percent of the patients died before reaching the operative intervention, and the sys­tolic blood pressure was improved on arrival to the operating room in both groups. Among the 289 patients who received delayed uid resuscitation, 203 (70%) survived to hospital discharge, as compared with 193 of the 309 patients (62%) who received immediate uid resuscitation (p = 0.04). Intraoperative blood loss and complications were not differ­ent between the groups. There are several limitations to this study, most notably that it was unblinded and that there may be survival bias: patients surviving (despite minimal uids) to the OR were less sick than those surviving with uid ther­apy to the OR.This study was also limited to an urban envi­ronment with short transport times to a Level 1 trauma facility. In a more recent randomized trial performed by the Resuscitation Outcomes Group, patients presenting with systolic BP<90 were randomized to low crystalloid strategy of 250mL uid to attain SBP 70mmHg or radial pulse vs. 2 L crystalloid with the SBP goal of 110mmHg. Overall 24-h mortality was less in the controlled resuscitation group (5.2% vs. 14.7%), but this difference was not present in the penetrating trauma patients in the study. This study may be underpowered to draw conclusions on the penetrating sub­group of 65 patients. The effects of uid restriction during longer transport times remain to be determined.