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Damage Control Resuscitation
https://t.me/medicina_free
inPenetrating Trauma: Rules
oftheGame
ChristopherReed, AdrianCamarena, andSureshAgarwal
3
3.1 Introduction
Penetrating wounds tend to span surgical disciplines and anatomic boundaries with impunity. Surgeons who treat trauma
are the only physicians who might reasonably and routinely
be faced with a patient in hemorrhagic shock who is suffering
from complicated and concurrent injuries to the neck, head,
chest, spine, major abdominal vasculature, hepatobiliary system, aerodigestive tract, and extremities. Among the most
important and difcult dilemmas posed to the modern trauma
surgeon is identifying which patients should undergo denitive surgical management of their traumatic injuries at initial
presentation and which patients should instead have their
denitive repair delayed in order to maximize the chance of
saving life and limb. The philosophy of delaying denitive
management while arresting life- threatening hemorrhage and
controlling ongoing contamination has become known as
damage control and represents an area of ongoing progress
since its rst widespread description in the 1980s.
In the 1990s, Rotondo and colleagues outlined three key
“phases” of damage control strategy for exsanguinating
trauma, which have since been addended by others to include
considerations in the pre-hospital setting and then again after
denitive reoperation. These phases are generally considered
prehospital, operative, resuscitation, reoperation, and
abdominal reconstruction.
3.2 History
Although formal descriptions of hepatic packing and temporary abdominal closure for traumatic injury date back at least to
World War I, such practices were largely abandoned before the
Vietnam War due to associated complications and the percep-
C. Reed · A. Camarena · S. Agarwal (*)
Division of Trauma, Acute & Critical Care Surgery, Department of
Surgery, Duke University School of Medicine, Durham, NC, USA
e-mail: christopher.reed2@duke.edu; adrian.camarena@duke.edu;
suresh.agarwal@duke.edu
tion that foregoing denitive operation at the time of presentation indicated a decit of surgical skill. In the 1970s, nonsurgical
coagulopathic bleeding was identied as a major culprit in
potentially survivable traumatic deaths, in the newly coined
“lethal triad.” This represented a fundamental change in the
treatment strategy of severe traumatic hemorrhage that underpins damage control strategy. Specically, trauma surgeons
began to forego denitive management of all anatomic and
mechanical lesions in the acute setting in favor of reversing
life-threatening physiologic disturbances (acidosis, coagulopathy, hypothermia) in the ICU before returning for surgical treatment of injuries. Although several groups
disseminated supportive descriptions of damage control techniques (i.e., abbreviated or conservative laparotomy with temporary packing) during this time, it was not until the 1980s that
Stone’s seminal description of the “frustrating experience” of
encountering frank coagulopathy during initial laparotomy
ultimately resulted in widespread acceptance of damage control techniques for civilian trauma across North America.
The 1990s saw considerable interest in formalizing and
studying outcomes in damage control techniques, with
extension to other surgical disciplines involved in stabilizing
the severely injured trauma patient. In particular, temporary
external xation of pelvic and long bone injuries gained
favor and description in orthopedic trauma. Since that time,
focus has been particularly intense on optimizing resuscitation, identifying patients who will benet from damage control strategies to prevent over- or misapplication, and
prehospital interventions to improve identication and outcomes of severely injured patients.
3.3 Rule #1: Damage Control
inPrehospital Care Is aFast-Moving
Field
North American prehospital emergency medical services
were early in applying damage control principles in the management of trauma patients on scene, and this trend has since
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_3
31
32
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C. Reed et al.
been enduring. The concept of “scoop and run,” practiced
and modeled by North American emergency medical services, generally favors rapid transport to a capable trauma
center for the arrest of hemorrhage compared to the European
“stay and play” model. The history of scoop and run for
trauma patients in particular parallels the popularization of
damage control techniques for in-hospital care, and the techniques have evolved contemporaneously. Although the evolution of prehospital care for penetrating trauma patients will
be covered in detail elsewhere, it is worthwhile to reiterate
that damage control resuscitation starts in the prehospital
setting with deference to the same principles that guide inhospital resuscitation: Limit resuscitation volume, minimize
or eliminate crystalloid, and expedite all efforts to arrive at
surgical control of hemorrhage.
3.4 Rule #2: Minimize or Eliminate
Crystalloid inthePre- andin-Hospital
Resuscitation Phases
Historical experience with resuscitation in animal models
demonstrated improvement in short-term outcomes with
aggressive crystalloid resuscitation. Early American College
of Surgeons Advanced Trauma Life Support (ATLS) protocols for trauma resuscitation stressed the need for early,
aggressive volume replacement with crystalloid regardless
of injury mechanism. The vestiges of this practice can still be
detected in most pre-hospital protocols in which hypotensive
patients receive 1–2L of lactated Ringer’s solution prior to
blood products regardless of their injury pattern, physiologic
status, or availability of blood products. The most recent
ATLS approach has been updated to consider the patient’s
injury severity and likelihood of hemorrhagic shock, suggesting that more severe physiologic derangements be
treated with blood product-based resuscitation.
Enthusiasm for crystalloid-based resuscitation in patients
with hemorrhagic shock has appropriately waned after the
recognition and description of the lethal triad and, specically, the contribution of exogenous dilutional coagulopathy
to mortality. An independent association between infusion of
large volumes of crystalloid and mortality has been demonstrated in trauma patients, and balanced (or whole blood)
resuscitation strategies have been associated with improved
coagulation and survival. Crystalloid infusion, particularly in
the prehospital setting where uids may not be warmed prior
to infusion, aggravates the lethal triad both through dilutional coagulopathy and by exacerbation of hypothermia.
The role in hypothermia of aggravating coagulopathy is well
established, and such risks are sufcient to avoid cold crystalloid in an actively hemorrhaging patient altogether.
Finally, crystalloid does not improve oxygen-carrying capac-
ity of blood directly. The theoretical improvement in tissue
perfusion associated with crystalloid infusion relies on its
ability to expand circulating volume and perfusion pressure
of affected tissue beds without increasing red cell mass.
Although the benets of blood-based resuscitation have
been well established in the emergency and operative settings over the past decades, the role of prehospital hemostatic resuscitation for trauma patients is an area of explosive
interest. Only recently has there been prospective investigation into the potential benets of blood- and plasma-based
resuscitation in this setting. The PAMPer trial was a seminal
phase 3, multi-centered, cluster randomized control trial that
demonstrated a signicant improvement in 30-day mortality
(23% vs. 33%) in hemorrhaging patients that were administered plasma in the prehospital setting as opposed to standard
of care resuscitation with crystalloid. Patients resuscitated
with plasma also had improved survival at 24 h. This
improvement in in mortality was not associated with any signicant harm to the patient, as transfusion reactions were
rare and mild. Administration of plasma in the pre-hospital
setting could be life saving for trauma patients presenting
with hemorrhagic shock in need of pre-hospital resuscitation, and efforts continue to delineate the role of blood products in prehospital transfusion protocols.
3.5 Rule #3: Avoid Over-Resuscitation
Historically, prehospital and emergency department resuscitation protocols after penetrating injury aimed to restore normal blood pressures in an attempt to maximize tissue
perfusion; i.e., conventional resuscitation. Although restoration of mean arterial pressure to physiologic levels sufcient
to support tissue perfusion is ultimately a goal of all resuscitation efforts in penetrating trauma, there has been increased
interest in delaying the achievement of normotension until
after hemorrhage control has been achieved. This concept
has been termed “permissive hypotension,” or hypotensive
resuscitation, and is emerging as a cornerstone of an overall
damage control strategy in the appropriate context. Several
studies have identied that relative hypotension (variably
dened as systolic blood pressure 70–90 mmHg, or MAP
50–60 mmHg) may be associated with improved survival
and decreased blood loss. It is difcult to evaluate the contribution of blood pressure goals to mortality independent of
crystalloid infusion, which is typically used to achieve pressure goals in the prehospital setting. However, increasing
hemorrhage occurring in concert with increasing blood pressure is a familiar sight to many surgeons from intraoperative
experience, and the dangers of crystalloid resuscitation in
hemorrhagic shock are best avoided regardless. Therefore, a
conservative transfusion strategy in penetrating trauma
3 Damage Control Resuscitation inPenetrating Trauma: Rules oftheGame
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33
patients with a good response to initial resuscitation ts well
with a broader damage control strategy aimed at rapid arrest
of life-threatening hemorrhage prior to denitive injury
management.
It is important to note that hypotensive resuscitation is
most often appropriate in patients with a penetrating mechanism, who arrive in hemorrhagic shock and are unlikely to
have associated signicant traumatic brain injury. Although
select blunt trauma patients with exsanguinating injuries
may theoretically benet from the strategy for the same reasons (i.e., prevention of rebleeding and aggravation of coagulopathy), severely injured patients after blunt trauma more
frequently have associated brain and spinal cord injuries that
may benet from greater perfusion pressures.
3.6 Rule #4: Give Blood toTreat Lost
Blood
Blood is a complex tissue composed of protein-rich acellular
plasma and an intricate, interactive network of different cell
types that promote hemostasis in concert with the endothelium. Generally, bleeding trauma patients who have lost
whole blood should receive attempts at the replacement of
whole blood. The most common and best-studied means to
achieve this goal in modern trauma centers is the use of 1:1:1
packed red blood cells, fresh-frozen plasma, and platelets.
The PROPPR randomized clinical trial is one of the most
accepted and highly cited examples of how even subtle alterations of this now-familiar formula may lead to inferior outcomes. Empiric administration of balanced red cells, plasma,
and platelets forms the foundation for most massive transfusion protocols, with cryoprecipitate or brinogen concentrate, tranexamic acid, calcium, and prothrombin complex
concentrates as potential adjuncts. Achievement of 1:1:1
ratio is associated with improved survival among severely
injured trauma patients, a testament to the importance of all
the available components of blood in the complex process of
coagulation.
It is important to note that blood products transfused in a
balanced ratio, while demonstrating a measurable improvement over unbalanced ratios, do not completely recapitulate
the patient’s fresh whole blood that has been lost. The
oxygen- carrying capacity of red cells degrades over time and
platelets become less efcient at clotting. Calcium chelators,
which prevent clotting of blood products during storage, can
cause severe derangements in circulating cations in critically
injured and ill patients. Potassium and innate immuneactivating damage-associated molecules in stored cellular
products are inevitable. Therefore, replacement of ongoing
hemorrhagic losses with blood products is never an adequate
substitute for denitive hemostasis.
3.6.1 Whole Blood
The demonstration of improved outcomes with balanced
hemostatic resuscitation in a ratio that approximates whole
blood has reignited interest in whole blood transfusion for
civilian trauma. The use of whole blood transfusion actually
long precedes the more storage-friendly component therapy
that is stocked in blood banks and available to most trauma
centers. In fact, for most of the history of transfusion medicine, only whole blood was available. Whole blood remains
the standard transfusion product available in military medicine, where it has been described and studied since World
War I.Over the past 20 years, several high-volume trauma
centers have described their experience with reinstituting
whole blood transfusion for civilian trauma patients with
hemorrhagic shock, with most reports demonstrating noninferiority compared to component transfusions. The potential
benets of whole blood include less mechanical and chemical manipulation of blood cells and retention of blood constituents that may be diluted or lost in adjuncts (i.e.,
bronectin and von Willebrand factor). The components of
donor whole blood more closely resemble those lost during
hemorrhage than component therapy. The role for whole
blood transfusion in civilian trauma and its head-to-head
comparison with more familiar component-based strategies
is still being dened.
3.7 Rule #5: Use Laboratory Tests
asAdjuncts toGuide Resuscitation
Historically, conventional coagulation and hematologic tests
(partial thromboplastin time, prothrombin time, and quantitative brinogen/platelet count) were used to assess for
reversible coagulation decits. Given the complexity of the
hemostatic system and associated derangements in trauma,
there has been considerable interest in identifying a single
rapid test that could provide a global assessment of hemostatic capacity and assess parameters not reected in conventional tests. Thromboelastography (TEG) and rotational
thromboelastometry (ROTEM), collectively known as viscoelastic hemostatic tests, analyze the clotting kinetics and efciency of whole blood with a variety of activation agents.
These tests are increasingly used in the trauma resuscitation
setting with some trauma centers employing point-of-care
TEG or ROTEM analysis to assist in evaluating trauma
patients in real time.
Many centers integrate viscoelastic hemostatic testing
into massive transfusion protocols. Besides providing rapid
and actionable evaluation of whole blood hemostatic potential, the tests evaluate several parameters that are medically
addressable and are not described with conventional tests
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C. Reed et al.
(i.e. brinolysis, platelet dysfunction). Therefore, these tests
represent an additional tool in the trauma surgeon’s perioperative armamentarium for the evaluation and treatment of
coagulopathy. It is worth noting that viscoelastic hemostatic
tests, similar to conventional tests, are run in buffered solutions containing excess calcium at 37 degrees Celsius and
therefore will not reect contributions of acidosis, hypocalcemia, or hypothermia to coagulation status, respectively.
3.8 Rule #6: Avoid Unnecessary
Procedures Preoperatively
The central tenet of damage control resuscitation is to minimize the time between injury and surgical hemorrhage control. Only a handful of procedures are necessary to stabilize
or otherwise prepare the patient for surgery prior to the operating room. Early airway control with intubation as indicated
by the patient’s mental status and physiology allows better
control of cardiopulmonary and acid-base physiology. When
indicated, intubation in the emergency department or the
operating room should be performed concurrent with the
acquisition of peripheral intravenous access. Finally, immediately reversible, non-hemorrhagic causes of shock (tension
pneumothorax, pericardial tamponade) should be rapidly
evaluated and treated contemporaneously. Although these
fundamental concepts form the basis of the Advanced
Trauma Life Support evaluation, the importance of rapidly
completing the evaluation and minimizing time with unnecessary diagnostic and treatment maneuvers cannot be overstated when damage control techniques are indicated.
Common pre-surgical time-wasting pitfalls include arterial and central venous access procedures, which may be performed during surgery and are not necessary to pursue
surgical hemorrhage control. The cost (in terms of time and
procedural risk) and benet must be carefully considered for
any procedure prior to denitive hemorrhage control in the
operating room.
3.9 Rule #7: Surgical Goals Are to(1)
Arrest Hemorrhage and(2) Control
Contamination
The operative strategy in the initial, abbreviated laparotomy
for penetrating injury to the abdomen can be simplied to
three goals. First, major hemorrhage should be arrested or
controlled through surgical means, including temporary
packing or shunting. Second, ongoing contamination should
be controlled, most commonly by temporary closure of
digestive tract injuries, i.e. with surgical staplers. Third and
nal, a temporary abdominal coverage device should be used
to rapidly complete the abbreviated laparotomy and transfer
the patient to the ICU for the treatment of acidosis, coagu-
lopathy, and hypothermia. Time is one of the most precious
resources in this setting, and the surgeon must balance the
patient’s physiologic reserve with the goals of the operation.
In complex trauma patients for whom multiple teams will
provide care, careful and complete documentation is
extremely important. Although the electronic medical record
has streamlined some aspects of sharing information across
multidisciplinary teams, the amount of data recorded and
reported for critically ill patients can overwhelm relevant
details. The injuries identied during the initial procedure as
well as all surgical interventions should be documented in
the operative report, and relevant physiologic and laboratory
variables that informed damage control decision-making
should similarly be included.
3.9.1 Temporary Abdominal Closure
Temporary abdominal closure is useful in scenarios when the
fascia cannot be closed. The primary goal of a temporary
abdominal closure in the acute setting after damage control
laparotomy is to prevent evisceration of bowels, prevent
increased insensible losses by the provision of moisture barrier, prevent the contamination of the peritoneal cavity, and
remove excess uid. With repeat laparotomies and in the
subacute phase, temporary abdominal coverage may also
aim to reapproximate the edges of the fascia and provide tension to counter the inevitable loss of abdominal domain
encountered in such patients. Loss of domain is the result of
forces of the unopposed lateral abdominal wall musculature
and makes delayed closure much more difcult. There are
both static and dynamic therapies, with sequential tightening
of the abdominal wall with temporary abdominal closure
techniques being favored in recent years.
Types of static therapies for temporary abdominal closure
include sequential primary closure, negative pressure wound
therapy (NPWT), and mesh bridging. When performing a
sequential primary closure, a large abdominal incision is
assessed at each re-operation and may be partially closed
from either the caudal or cephalad end using a slowly absorbable suture. Negative pressure wound therapy is a vacuumassisted dressing that utilizes an intraabdominal protective
and non-adherent layer, followed by a uid- and airpermeable sponge, and nally followed by an adhesive bandage with a small opening for a drain with continuous
suction. Absorbable mesh bridging utilizes an absorbable
biologic or synthetic mesh placed as an interposition graft
between fascial edges, limiting loss of domain and encouraging later skin grafting and reconstruction. This may be
thought of as a type of temporary abdominal wound closure
in a situation requiring a planned hernia with the intent to
provide denitive repair in the post-acute setting.
Types of dynamic therapies include mesh-mediated fascial traction (MMFT) and dynamic retention sutures or
3 Damage Control Resuscitation inPenetrating Trauma: Rules oftheGame
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35
abdominal re-approximation anchor (ABRA). In MMFT,
mesh is sewn to opposite ends of the fascia and sequentially
tightens the anterior abdominal wall. An example of MMFT
is the Wittman patch (Starsurgical, Burlington, Wisconsin).
Dynamic retention sutures or ABRA (CJMedical, Cornwall,
England) utilizes plastic tubes that are inserted through the
abdominal wall away from the fascial edge and are held in
place with adhesive buttons. These can be sequentially tightened to minimize loss of domain. An advantage to this technique is that it preserves the fascial edge for the delayed
closure. Randomized control trials have demonstrated that
either of the dynamic techniques coupled with NPWT for
temporary abdominal closure is more effective than NPWT
alone. More recently a metanalysis concluded that NPWT +
ABRA achieved 93% fascial closure compared to 72% fascial closure with NPWT + MMFT.
3.9.2 Temporary Chest Closure
After sternotomy or thoracotomy for penetrating trauma,
temporary chest closure may be utilized for rapid termination of the abbreviated procedure and transfer to the ICU in
preparation for planned second look or denitive procedure.
The indications for this unusual but ultimately inevitable circumstance are similar to those for damage control laparotomy with delayed abdominal closure (coagulopathy and
metabolic disturbance, extensive injury burden, concern for
thoracic compartment syndrome). Two general techniques
have been described for temporary chest closure, the latter of
which utilizes principles and supplies from the elective cardiac and thoracic surgical settings. First, primary closure of
skin (with or without intrathoracic packing) for the coverage
of the lung parenchyma without re-approximation of the
deeper muscular and fascial layers provides a rapid and reliable temporary closure. This technique is rapid and does not
rely on the availability of any specic expertise or supplies in
temporary chest closure. Alternatively, a silastic sheet may
be used to provide temporary coverage, held in place at the
level of the skin or fascia either with sutures or adhesive
strips. This technique has the benet of providing a clear
window for examination into the thoracic cavity to allow
monitoring of ongoing hemorrhage. Given that neither technique allows for passive or active drainage of blood, wide
pleural drainage with thoracostomy is imperative.
3.10 Rule #8: Return totheOperating
Room forDenitive Operation
assoon asFeasible
The decision to return to the operating room for denitive
surgical management of injuries should be based on the
patient’s physiology and coagulation status. As soon as
resuscitation is adequate, coagulopathy and acidosis are
reversed, and normothermia is achieved, the patient
should return to the operating room with the intent to
complete all indicated procedures and for attempted fascial closure. There is no minimum amount of time for
resuscitation prior to returning to the operating room, and
the patient should undergo denitive management of
remaining injuries as soon as appropriate to prevent ongoing derangements associated with temporary abdominal
closure.
Some patients may still have ongoing hemorrhage, contamination, or physiologic disturbance at this point. If the
source of these derangements is reversible but this is not feasible at the second laparotomy, additional reoperations may
be required. In this case, the abdomen is again temporarily
closed.
3.11 Rule #9: Do Not Over- or Misapply
Damage Control Techniques
There are numerous potential complications associated with
temporary abdominal closure, multiple laparotomies, and
temporary diversion of the gastrointestinal and pancreaticobiliary. Fluid management is challenging with temporary
abdominal closure, despite advances in coverage systems
that allow better retention of moisture and quantication of
losses (i.e., via a wound VAC device or similar). Insensible
losses are greatly increased with an open abdomen, similar
to those expected during laparotomy. Proteins are lost in
ascitic uid in addition to free water, and greater losses are
expected with longer lengths of time open (and additional
exploratory procedures).
The risk of GI stula has been estimated to be 20% after
damage control laparotomy for trauma, and some reports
have suggested that it may be even higher when a gastrointestinal anastomosis has been created. There are likely to be
differing rates of stula formation depending on the wound
management system used, and there have been substantial
efforts in the past 20 years to improve such systems. The
morbidity associated with such complications is heavily
dependent upon which parts of the GI system are involved,
as well as the overall physiology of the patient. Infection
from contamination with exogenous bacteria due to loss of
the skin’s barrier function or from repeated laparotomies is
similarly a constant threat to the patient with an open
abdomen.
Finally, loss of abdominal domain and some rate of ventral hernia formation are essentially inevitable in patients
with multiple injuries requiring temporary abdominal closure. In the handful of long-term studies available on the subject, incisional hernia rates vary from 50% to 70%. In patients
with major abdominal contamination, loss of domain, or
other comorbidities leading to high-risk abdominal closure,
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C. Reed et al.
incisional hernia may be a planned and inevitable event with
absorbable mesh and skin coverage as a temporary or destination closure. Regardless of the variability in reported outcomes and management techniques, it is clear that damage
control strategy is associated with the risk of incisional hernia formation.
Taken together, it is well accepted that damage control
strategies are life- and limb-saving in appropriately selected
patients with major physiologic disturbances and attendant
coagulopathy. However, delayed abdominal closure and
multiple laparotomies can have predictable negative consequences, and in lieu of prospective studies to determine the
perfect candidates for damage control techniques, trauma
surgeons must continue to thoughtfully assess patients for
appropriateness on an individual basis. A thorough understanding of the patient’s physiologic parameters, injury
severity, and coagulation status is crucial to guiding these
decisions.
3.12 Rule #10: Keep It Simple
The fundamental goal of damage control resuscitation is to
expedite arrival at denitive surgical hemorrhage control
and then to reverse metabolic and coagulation derangements in preparation for denitive operation. The single
key tenet of this strategy is ultimately doing less in the prehospital, preoperative, and operative phases: fewer emergency procedures, less (or no) crystalloid, less aggressive
preoperative resuscitation goals, and less time in the operating room. The guiding perspective of the trauma surgeon
in a damage control situation should generally be that all
supportive therapies are eventually destined to fail until
hemorrhage control is obtained. Only after arresting life-
threatening hemorrhage should physiologic normality
be pursued.
Important Points
• Avoid or eliminate crystalloids in prehospital and preoperative resuscitation efforts for penetrating trauma.
• Transfuse whole blood or blood cells, plasma, and platelets in a 1:1:1 ratio in the actively bleeding patient.
• Use physiologic and laboratory adjuncts to guide hemostatic resuscitation.
• Avoid over-resuscitation.
• Expedite all efforts to arrive at denitive surgical control
of hemorrhage.
• In the operating room, abbreviate the abdominal and/or
chest explorations and focus on management of lifethreatening hemorrhage and control of ongoing
contamination.
• Utilize temporary abdominal and/or chest coverage techniques to expedite transfer to the ICU.
• Avoid over- or misapplication of damage control techniques, which have potential complications.
Suggested Reading
Bickell WH, et al. Immediate versus delayed uid resuscitation for
hypotensive patients with penetrating torso injuries. Boca Raton,
Florida: CRC Press; 1994.
CRASH-2 Trial Collaborators. Effects of TXA on death, vascular
occlusive events, and blood transfusion in trauma patients with signicant hemorrhage (CRASH-2): a randomized, placebo-controlled
trial.
Diaz JJ, et al. Open abdomen in trauma and emergency general sur-
gery, management: part 1. J Trauma. 2010;68(6):1425–38. EAST
guidelines.
practice- management- guidelines/details/open- abdomen- in- traumaand- emergency- general- surgery- management- of- part- 1
Holcomb JB.Transfusion of plasma, platelets, and red blood cells in a
1:1:1 vs. a 1:1:2 ratio and mortality in patients with severe trauma:
the proppr randomized clinical trial. JAMA. 2015;313(5):471–82.
Rotondo MF, et al. Damage control’: an approach for improved sur-
vival in exsanguinating penetrating abdominal injury. J Trauma.
1993;35(3):375–82.
Sperry JL.Prehospital Plasma during Air Medical Transport in Trauma
Patients at Risk for Hemorrhagic Shock: PAMPER trial. N Engl J
Med. 2018;379(18):1783.
https://www.east.org/education- career- development/
BLS Versus ALS
https://t.me/medicina_free
DominikA.Jakob andAristomenisK.Exadaktylos
4
4.1 BLS andALS
Basic life support (BLS) and advanced life support (ALS)
were both designed for prehospital life support and patient
transportation to the hospital. Both concepts have been
shown to improve patient outcomes and are widely used
around the world. Contemporary models of emergency medical services (EMS), particularly in the United States,
encounters simultaneous response of providers capable of
BLS care with those capable of ALS.
As the term BLS indicates, this support is restricted to
basic non-invasive procedures without the administration of
medications. Basic providers are restricted to splinting, bandaging, alignment of displaced limbs, the administration of
oxygen including bag valve mask ventilation, chest compression, and the use of an automated external debrillator
(AED) in patients with cardiac arrest. However, especially in
the United States, many BLS providers possess an intermediate level certication (EMT-I) of life support; these indi-
viduals may start with intravenous uids and achieve a more
denitive airway by using a combitube or even by performing endotracheal intubation. These emergency medical technicians are said to deliver “basic life support”—BLS for
short. Around the world, BLS is commonly provided by reghters, police ofcers, or other rst responders. A 120–
150h training course is required to become a certied BLS
provider.
On the other hand, ALS provides additional treatment
options, including the use of needles for injection and
administration of medication. ALS also includes monitors
for manual cardioversion or debrillation and glucose testing devices. In addition, airway equipment for intubation
is ready for use—including the option to decompress a
pneumothorax or perform a cricothyrotomy. ALS is generally provided by doctors, nurses, or paramedics (advanced
prehospital providers) and requires 1200–1800 h of
training.
Table 4.1 indicates differences between BLS and ALS
D. A. Jakob · A. K. Exadaktylos (*)
Department of Emergency Medicine,
Inselspital University Hospital of Bern, Bern, Switzerland
e-mail: Dominik.Jakob@insel.ch;
Aristomenis.Exadaktylos@insel.ch
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_4
37
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D. A. Jakob and A. K. Exadaktylos
Table 4.1 Differences between BLS and ALS in trauma according to
the primary survey
Primary survey
A: Airway
and C-spine
protection
B: Breathing Oxygen
C: Circulation Hemorrhage control BLS,
D: Disability Options to decrease
E: Exposure Warm the patient BLS,
Additional
management
BLS basic life support, ALS advanced life support, ICP intracranial
pressure, EMS emergency medical service
a
There is variation in whether BLS can provide these skills. This is
dependent upon EMS system and local medical protocols
Airway control
without intubation
(chin lift maneuver,
insertion of a
Wendel tube, etc.)
Laryngeal mask,
intubation
Cricothyrotomy ALS Surgical airway
C-spine protection BLS,
administration
Needle chest
decompression,
nger thoracostomy
Sucking chest
wound
Intravenous uids BLS
Administration of
tranexamic acid
ICP
Splinting/bandaging
limbs
Stabilization for
transport
BLS/
ALS Comment
BLS,
No secured
ALS
airway, aspiration
possible
a
BLS
,
Complications
ALS
documented in
literature
Should not be
ALS
applied in
penetrating neck
trauma
BLS,
Usually, high ow
ALS
oxygen by
protocol
ALS Potentially
immediately
life-saving
maneuver in
tension
pneumothorax
ALS,
Occlusive dressing
BLS
to chest wound
Tourniquets and
ALS
bleeding control
bandages
a
,
Takes a few
ALS
minutes. Plasma
and blood
administration
being considered
ALS Increasingly used
in prehospital
setting
ALS Mannitol,
hypertonic saline
administration,
sedation, etc.
Essential for
ALS
coagulopathy
BLS,
No option of
ALS
analgesia
administration in
BLS
BLS,
Placed on a
ALS
backboard
4.2 Organization ofEMS Worldwide
andtheImpact onBLS Versus ALS
The organization of emergency medical services (EMS),
including the allocation of differently qualied and trained
care providers, is a key factor that determines whether BLS
or ALS is performed in the prehospital setting. The following
paragraph therefore discusses differences in the organization
of prehospital trauma systems around the world.
The organization of prehospital trauma systems varies
widely around the world. In many middle- to low-income
countries, there are no organized prehospital trauma systems
on a national scale. Field-to-hospital transport is often undertaken in non-EMS specialized vehicles by individuals who
lack certied training.
High-income countries have national EMS systems with
certied rst responders who are capable of providing basic
or advanced life support. These trauma systems incorporate
comprehensive infrastructures to provide optimal care for
injured patients and encompass a wide spectrum that ranges
from efforts to prevent injury and an integrated network of
trauma centers to concerted research agendas.
Over the past decade, the United States has made great
strides toward a uniform “basic” EMS model that can still be
tailored to different local needs. Approximately 10,000
emergency medical services (EMS) agencies respond to
requests for emergency 911 services. The structures of EMS
agencies are highly variable and include a wide range of
models, such as re departments, municipal “third party”
(i.e. not embedded in a police or re department), and private
companies. The system relies on non-medical EMS providers operating under a physician as a medical director. As a
result, prehospital care is usually provided by emergency
medical technicians for BLS or trained paramedics for
ALS. Even in helicopter-based transport, the EMS team
includes an emergency physician in only 5% of cases.
In Europe, prehospital care is organized even more heterogeneously, to differences in the EMS systems in various
countries. However, compared to the United States, prehospital care in most European countries is often provided by
physicians. The EMS team in German-speaking countries
includes an anesthesiologist or emergency physician, who
may provide endotracheal intubation and other advanced life
support procedures on scene. Throughout the United
Kingdom, doctors and other healthcare professionals respond
to requests for assistance from the ambulance service on a
4 BLS Versus ALS
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39
voluntary basis. In France, mobile ICU teams—including a
physician—can be dispatched on scene if required by the
severity of the trauma.
In accordance with these differences between the
American and European EMS systems, the US prehospital
care strategy follows more a “scoop and run” approach and
prioritizes rapid patient transport to trauma centers. In
Europe, the priority lies more on eld triage, on-scene
assessment, and initiation of procedures by physicians, also
known as the “stay and play” approach. This also explains
the tendency for prolonged on scene times in Europe compared to the United States.
4.3 Ambulance Response, Triage,
andTransportation totheHospital
Rapid transportation of severely injured patients to a trauma
center remains a key aspect in prehospital care. Although the
process of ambulance response may differ slightly in highincome countries all over the world, the following process is
a typical example for the United States and many European
countries. A citizen dials the number to activate emergency
response (911in the United States), and this is answered at a
public service answering point. Here the dispatcher will ask
a series of protocol-driven questions to determine if re,
ambulance, or police dispatch—or a combination—is
required. In a typical case, the exact location of the caller is
immediately available to the dispatcher from a computerized
directory. In the United States, many EMS system responses
are tiered—the dispatcher will request the closest BLS
ambulance to the scene to respond and simultaneously dispatch the closest ALS unit. Because there are more BLS
responses required than ALS, a typical ratio for a metropolitan area is to have four BLS ambulances to provide an immediate response with a single ALS ambulance covering the
same area. For example, a patient who has fallen but not lost
consciousness and has a suspected ankle fracture will only
be sent a BLS ambulance; a patient who has been hit by a car
and is unconscious will receive a BLS and an ALS response.
A typical response would be 3–4min for a BLS ambulance
in an urban area with an ALS ambulance available in
4–8min. Once on the scene, the patient will have to be evaluated, potentially placed on a backboard, have intravenous
lines initiated, and then be transported to the hospital. The
ALS ambulance will occasionally rendezvous with the BLS
ambulance during transport—the so-called ALS intercept—
and provide additional care capability if needed. Data would
suggest that the ALS intercept model provides little additional care to the patient; over 60% of intercepts provided no
ALS treatment, and in 11%, the only additional care was
morphine administration. Transport times in urban areas are
typically short, usually less than 10min. In more sophisti-
cated systems, the ambulances are equipped with GPS location equipment, and the whole process is computerized—a
computer-aided dispatch (CAD) system. In the United States,
the ambulance reporting system has moved to a standardized
format—the National Emergency Medical Services
Information System (NEMSIS)—which allows improved
evaluation of the efciency and effectiveness of prehospital
care delivery. More than 30 million EMS activations from
more than 10,000 agencies across the United States are submitted to the NEMSIS Database each year.
EMS personnel will not enter a scene that is potentially
dangerous until it has been deemed safe—usually by the
police department. This may mean that victims of penetrating trauma from gunshot wounds may not receive immediate
treatment at the scene because this would place the EMS providers at risk. However, a new paradigm has been developed
through a group called the Hartford Consensus. This group
was initiated by the American College of Surgeons (ACS)
and brought together senior leaders in emergency medicine,
anesthesiology, and trauma surgery. The purpose of this consensus was to promote local, state, and national policies to
improve survival in active shooter events. The Hartford
Consensus recommends that an integrated active shooter
response should include the critical actions contained in the
acronym THREAT: threat suppression, hemorrhage control,
rapid extrication to safety, assessment by medical providers,
and transport to denitive care. The use of THREAT and a
more integrated response by law enforcement, re/ rescue,
and EMS offers communities a strategy to minimize loss of
life in these incidents. In particular, the use of a tourniquet
for hemorrhage control have been shown to decrease mortality and has therefore been implemented in the last several
years. Nowadays, many law enforcement ofcials and re
ghters are equipped with tourniquets and are trained to perform effective external hemorrhage control.
The main objective of prehospital trauma triage is to
transport the patient to the most appropriate level of care.
Under-triage is associated with increased mortality, and
over-triage results in signicant overuse of resources.
Although, several guidelines exist [in the United States from
the Center of Disease Control (CDC)], the on-scene decision
of triage remains a signicant challenge, as information on
the patients may be limited, as is the available time. The
guidelines recommend that all penetrating injuries to head,
neck, torso, and extremities proximal to elbow or knee
should be triaged to a trauma center, because the likelihood
that these patients will require surgery is high, and treatment
in trauma centers for those injuries has been shown to be
associated with improved outcomes. However, substantial
numbers of severely injured trauma patients are still managed at hospitals outside the trauma system. It is obvious that
a well-trained ALS responder may make better triage decisions than a less well-trained basic responder.
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D. A. Jakob and A. K. Exadaktylos
In the United States and Europe, both BLS and ALS are
generally associated with prehospital notication given to
the emergency department. This information usually includes
estimated time of arrival, mechanism of injury, gender, age,
and vital signs, including GCS.This information can be used
for proper allocation of in-hospital resources. In low- and
middle-income countries, prehospital notication is not
always guaranteed—especially when prehospital care is provided by non-EMS certied individuals or rst aid responders in private vehicles.
4.4 BLS vs ALS Debate andtheEMS
Paradox
BLS consists of non-invasive interventions that are easy to
perform, require little added on-scene time, and can often be
performed en route by minimally trained emergency medical
staff. As a consequence, BLS is associated with lower cost
per provider, which can result in more people being trained
and this may further shorten response times. The treatment
of penetrating trauma is especially time-sensitive because it
is often associated with hemorrhage. For those patients,
rapid transportation to the hospital is essential, because inhospital surgery is typically needed for hemorrhage control.
Therefore, many true emergencies may benet from “scoop
and run” rather than “stay and play,” which may clearly favor
a BLS approach.
On the other hand, ALS response includes the recognition
of several immediately life-threating conditions, including
options for immediate treatment, such as endotracheal intubation, needle chest decompression, and administration of
medication. These additional procedures can delay denitive
in-hospital care compared to BLS.However, it may also be
life-saving and associated with improved patient outcomes.
For example, if a patient has an obstructed airway due to
severe facial fractures, a cricothyrotomy can be ultimately
life-saving, as can chest decompression for an imminent tension pneumothorax. In these situations, a delay caused by
transportation to the hospital may have devastating consequences. Another advantage of ALS vs BLS may be the early
administration of uids for resuscitation or the use of
tranexamic acid, a medication with antibrinolytic activity
that is used to treat or prevent excessive blood loss. Early use
of tranexamic acid has been shown to improve survival following major trauma. Finally, ALS responders have a deeper
understanding of the “why” behind the sick patient, which
may not only mean improved on-scene management but can
also lead to better prehospital triage decisions.
Especially for longer transports, the time-saving aspect of
BLS becomes less important and the additional options of
ALS may improve patient outcomes. However, at this point
it is important to mention the EMS paradox that can be
observed in the United States and Europe. Paramedics or
physicians are normally located in high-volume (urban)
environments, where the transport times to hospitals are
relatively short. Basic EMTs are more likely to be found in a
rural environment where the transport times to denitive care
might be an hour or more; the sparse population will only
generate a small number of ambulance calls, and response
and transport times are much more likely to be prolonged.
Skill maintenance is also an issue although simulation training might help. Neither paid nor volunteer paramedics are
likely to maintain skills that are only utilized once or twice a
year. The paradox is that in a rural environment with a prolonged transport time, interventions such as needle decompression of the chest, endotracheal intubation, and
intravenous resuscitation (all paramedic skills) might be
associated with improved patient outcomes. However, in
these areas, often only BLS response is available.
4.5 Discussion oftheData
Uncontrolled hemorrhage remains the most frequent preventable cause of death in trauma. As a consequence, rapid
transportation to the hospital remains a cornerstone in the
treatment of trauma patients. This is particularly true for the
treatment of penetrating injury, as the number of meaningful
interventions that can be performed by prehospital providers
is limited and in-hospital surgery is typically needed for
these patients. The decision to pursue a BLS or ALS approach
determines whether advanced medical procedures associated
with prolonged prehospital time are performed at the scene.
In this context it is important to emphasize that the injury
demographics differ substantially between the United States
and Europe, especially in regard to penetrating trauma.
While penetrating trauma is common in the United States,
especially in urban settings, it is rarely encountered in
Western Europe. The “scoop and run” approach, which
focuses on rapid transport to the hospital with limited action
at the scene, may therefore be the best approach for urban
settings in the United States. In Europe, where blunt trauma
is predominant, the assumption may not be equally true that
shorter prehospital times with limited on-scene interventions
are associated with better outcomes.
The question of whether ALS or BLS should be performed in a prehospital trauma setting remains controversial.
In a large before-after controlled clinical trial, two 36month
long phases of BLS followed by ALS were compared.
Overall, 1373 adult patients in the BLS group were enrolled
and 1494 adult patients in the ALS group. Despite the large
sample, controlled design and multiple approaches to the
analysis, no evidence was found that the implementation of
full prehospital ALS was associated with lower mortality in
major trauma. On the contrary, the evidence suggested that
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