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4 BLS Versus ALS
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41
patients with Glasgow Coma Scale scores less than 9 had
worse survival during the ALS phase than during the BLS
phase. These ndings support those who believe that denitive trauma care is best provided in the operating theatre and
that prehospital interventions may be associated with
increased complications or may delay transfer to hospital. A
systematic review by Ryynänen etal. came to a similar conclusion. The majority of research into trauma favors BLS in
the case of penetrating trauma and also if the hospital is
close.
Another recently published meta-analysis included two
controlled trials (CTs) and eight observational studies and
came to similar conclusions. Outcomes between the ALS
and BLS groups were not statistically signicant (pooled OR
1.14; 95% CI 0.95–1.36 for mortality, pooled OR 1.12; 95%
CI 0.88–1.42 for good neurological outcomes, pooled mean
difference—0.96; 95% CI—6.64 to 4.72 for on-scene time)
in CTs. In observational studies, ALS prolonged on-scene
time and increased mortality (pooled OR 1.56; 95% CI:
1.31–1.86 for mortality, and pooled mean difference, 1.26;
95% CI: 0.07–2.45 for on-scene time).
In an observational study by Sanghavi etal. prehospital
BLS was compared with prehospital ALS among trauma
patients. In propensity score analyses, survival to 90days
among patients with trauma was higher with BLS than ALS
(6.1% points [95% CI, 5.4% to 6.8% points]).
On the other hand, there are a few studies that favor an
ALS approach over a BLS approach for specic trauma circumstances. In Japan, a registry-based study evaluated 4382
patients with out-of-hospital cardiac arrest following trafc
collision. Patients provided prehospital ALS by a physician
were compared with both patients provided ALS by emergency medical service (EMS) personnel and patients with
only BLS. The highest 1-month survival rate was seen for
ALS by physicians (3.1%), followed by BLS (2.3%) and ALS
by EMS personnel (1.6%). After adjusting for potential confounders using multivariable logistic regression, ALS by physicians was signicantly associated with higher odds for
1-month survival compared with both ALS by EMS personnel and BLS (adjusted OR, 2.13; 95% CI, 1.20–3.78; and
adjusted OR, 1.94; 95% CI, 1.14–3.25; respectively). A propensity score-matched analysis in the ALS cohort showed
that ALS by physicians was associated with increased chance
of 1-month survival compared with ALS by EMS personnel
(risk ratio, 2.00; 95% CI, 1.01–3.97; p=0.04). This association was consistent across a variety of sensitivity analyses. In
line with these ndings, a recently published meta-analysis
reported that the management of major trauma patients by a
prehospital physician is associated with lower mortality rates.
There is another variable that may affect outcomes and
needs to be discussed. If you train a prehospital provider to
perform a skill, they are likely to use that skill. Even under
circumstances where rapid transportation to the hospital
would be more important and in the best interest of the
patient, the skills learned may be applied and delay the
arrival at the hospital.
In summary, the results remain inconsistent, although a
“scoop and run” approach may be preferable, particularly for
penetrating trauma and when the hospital is near. In addition,
there is evidence that ALS by physicians is associated with
better outcomes than with EMS personnel. However, further
studies are required to identify optimal prehospital strategies
(BLS vs. ALS), depending on specic injury patterns and
considering the area where the injury occurs—urban vs.
rural environments with underlying differences in transport
times.
4.6 Outlook withResource Allocation
intheFuture
In the future, prehospital care will evolve to further improve
life support strategies in trauma patients. Efforts have
recently been made (particularly in helicopter EMS operations) to provide advanced life support during the transport
rather than on scene. This approach could also be expanded
to ground base rescue and would combine the fast prehospital times of BLS and the additional options of ALS for optimal patient treatment.
Several additional prehospital interventions have already
been used by ALS crews and some others will be evaluated
in the near future. The use of resuscitative endovascular balloon occlusion of the aorta (REBO) in a prehospital trauma
setting is a promising concept and is being evaluated in different countries. Initial results are promising but it is too
early for a nal conclusion.
Some helicopter programs are already using portable
ultrasound to diagnose hemoperitoneum and hemothorax—
this is currently only observational and there are no data on
the clinical effectiveness of this technique.
Moreover, some programs are starting to use blood products to treat hemorrhagic shock in the prehospital phase.
If any of these additional prehospital interventions were
to be found to improve trauma outcomes, the debate of
whether BLS or ALS should be performed would shift in
favor of ALS.
It is also likely that in the future, specic injury patterns
will more directly dictate prehospital care strategy. Even
today, data suggest that a “scoop and run” approach is preferable for penetrating injuries, whereas on-scene assessment
by a physician, including intubation, may be superior for
trauma-related respiratory failure.
Furthermore, modern trauma triage systems should be
based on easily applicable criteria and ideally be based on
the need for intervention rather than injury severity. This will
likely lead to an adaptation of triage criteria in the future.
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D. A. Jakob and A. K. Exadaktylos
4.7 Conclusion
Specic injury patterns, distance to the hospital, the environment in which the injury occurs as well as the organization of
the EMS system—including the level of training and experience of the EMS provider—all determine the success of prehospital life support strategies. There is no general evidence
that ALS improves outcomes in trauma patients as compared
with BLS.However, in an urban environment, especially in
penetrating trauma the main objective is to transport the
patient to the trauma center in the shortest possible time.
Interventions for external hemorrhage control including the
application of tourniquet and the establishment of a patent
airway (does not necessarily mean intubation) are the only
on-scene interventions that can be clearly recommended to
avoid further delay in transport to a trauma center.
Close collaboration and feedback culture between prehospital providers and in-hospital staff is important to further
improve management strategies. Furthermore, a constant reassessment of the best prehospital care strategy is essential,
because promising interventions such as prehospital use of
REBOA or blood product use are already used by ALS crews
and are currently under evaluation.
Important Points
• BLS is 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 the
case of cardiac arrest.
• ALS provides additional treatment options including the
use of needles for injection, administration of medication,
airway equipment including the possibility to decompress
a pneumothorax or perform a cricothyrotomy.
• Prehospital care in the United States is usually provided
by emergency medical technicians for BLS or trained
paramedics for ALS, whereas in most European coun-
tries, prehospital care is often provided by physicians.
• Prehospital care strategy in the United States more often
follows the “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.
• In the absence of clear evidence, there is no general rec-
ommendation for either BLS or ALS in a prehospital
trauma setting.
• Particularly in penetrating trauma, the main goal is to get
the patient to the trauma center in the shortest possible
time; the number of meaningful interventions that can be
made by prehospital providers is limited.
• There may be other subgroups of patients who benet
from certain prehospital interventions, but these have yet
to be dened.
• If you teach a prehospital provider a skill such as intravenous uid administration or endotracheal intubation, they
are more likely to overuse the skill than underuse the skill.
This may delay the arrival of an exsanguinating patient.
• Prehospital care is constantly evolving. Additional interventions such as REBO or administration of blood products are currently being evaluated for prehospital trauma
management. Constant re-assessment of the best prehospital care strategy is therefore essential.
Suggested Reading
Albrecht R.Handing over the trauma patient from preclinical to clini-
cal care: the pre-clinicians’ perspective. Bern, Switzerland: Swiss
Trauma & Resuscitation Day; 2015.
Cash RE, Panchal AR, Camargo CA Jr. Towards a more uniform
approach to prehospital care in the USA. Eur J Emerg Med.
2020;27(6):400–1.
Choi J, Carlos G, Nassar AK, Knowlton LM, Spain DA. The
impact of trauma systems on patient outcomes. Curr Probl Surg.
2021;58(1):100849.
Clinical governance and prehospital care in the UK.Available from:
https://www.researchgate.net/publication/47621553_Clinical_
governance_and_prehospital_care_in_the_UK. Accessed Jan 07
2022.
Fairhurst R.Pre hospital care in Europe. Emerg Med J. 2005;22(11):760.
Fukuda T, Ohashi-Fukuda N, Kondo Y, Hayashida K, Kukita
I.Association of Prehospital Advanced Life Support by physician
with survival after out-of-hospital cardiac arrest with blunt trauma
following trafc collisions: Japanese registry-based study. JAMA
Surg. 2018;153(6):e180674.
Horst MA, Jammula S, Gross BW, Cook AD, Bradburn EH, Altenburg
J, etal. Undertriage in trauma: does an organized trauma network
capture the major trauma victim? A statewide analysis. J Trauma
Acute Care Surg. 2018;84(3):497–504.
Javaudin F, Penverne Y, Montassier E.Organisation of prehospital care:
the French experience. Eur J Emerg Med. 2020;27(6):404–5.
Knapp J, Haske D, Bottiger BW, Limacher A, Stalder O, Schmid A,
etal. Inuence of prehospital physician presence on survival after
severe trauma: systematic review and meta-analysis. J Trauma
Acute Care Surg. 2019;87(4):978–89.
Kondo Y, Fukuda T, Uchimido R, Kashiura M, Kato S, Sekiguchi
H, et al. Advanced life support vs. basic life support for patients
with trauma in prehospital settings: a systematic review and metaanalysis. Front Med. 2021;8:660367.
Nathens AB, Brunet FP, Maier RV.Development of trauma systems and
effect on outcomes after injury. Lancet. 2004;363(9423):1794–801.
National Association of State EMS Ofcials. 2020 National Emergency
Medical Services Assessment. National Association of State EMS
Ofcials: FC, VA; 2020.
National Emergency Medical Services Information System. EMS Data
Cube - Version 3.
ems- data- cube/. Accessed on September 2, 2020.
H.-J.Oestern O.Trentz, Selman Uranues, W.Arnold, U.Ganzer General
trauma care and related aspects: trauma surgery II.NewYork, NY:
Springer; 2013.
https://nemsis.org/view- reports/public- reports/
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Ryynanen OP, Iirola T, Reitala J, Palve H, Malmivaara A.Is advanced
life support better than basic life support in prehospital care? A systematic review. Scand J Trauma Resusc Emerg Med. 2010;18:62.
Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM.Outcomes of basic
versus advanced life support for out-of-hospital medical emergencies. Ann Intern Med. 2015;163(9):681–90.
Sasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T,
etal. Guidelines for eld triage of injured patients: recommendations of the National Expert Panel on eld triage, 2011. MMWR
Recomm Rep. 2012;61(RR-1):1–20.
Stiell IG, Nesbitt LP, Pickett W, Munkley D, Spaite DW, Banek J, etal.
The OPALS major trauma study: impact of advanced life-support
on survival and morbidity. CMAJ. 2008;178(9):1141–52.
Timmermann A, Russo SG, Hollmann MW.Paramedic versus emer-
gency physician emergency medical service: role of the anaesthesiologist and the European versus the Anglo-American concept. Curr
Opin Anaesthesiol. 2008;21(2):222Y227.
Voskens FJ, van Rein EAJ, van der Sluijs R, Houwert RM, Lichtveld
RA, Verleisdonk EJ, etal. Accuracy of prehospital triage in selecting
severely injured trauma patients. JAMA Surg. 2018;153(4):322–7.
Prehospital Care andTransport
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MichaelA.Frakes andVaheEnder
5
It is clear that trauma outcomes improve when patients are
cared for in organized trauma systems. There is an outcome
benet for penetrating trauma patients taken to veried
trauma centers instead of to non-trauma hospitals, either
directly or with secondary transport, and there is a suggestion of even greater survival advantage for younger and
sicker patients. As the trauma care system does not end with
resuscitation or injury repair, neither does it begin there:
Trauma care begins with the rst responders in the emergency medical services (EMS) system and includes all outof- hospital care components.
The out-of-hospital elements of the trauma system are
important not only as care providers, but also as drivers of
notication and hospital selection, and they may be helpful
in making resource utilization decisions. The system must
also be designed to address access: The last well-described
data show that one in seven Americans does not have access
to a level I or II trauma center within 1 h, and over one quarter of the American population has such access only with
helicopter transport. In addition to the systems providing initial care and transport, inclusive trauma systems must also
integrate interfacility transport systems to effect the movement of patients from non-trauma centers to trauma centers
or to specialty services.
The prehospital emergency care system is largely operated by municipal agencies. In the 200 largest US cities, various public safety entities respond to about 95% of the initial
requests for service and over two-thirds of patient transports
from those requests. Conversely, interfacility transport services, both ground and air, are primarily provided by commercial operators, including hospital-sponsored, for-prot,
and not-for-prot organizations.
Transport providers are generally described as basic life
support, advanced life support, and critical care clinicians.
Basic providers, emergency medical technicians, represent
M. A. Frakes (*) · V. Ender
Boston Med Flight, Bedford, MA, USA
e-mail: Michael.Frakes@bostonmedight.org
about 70% of the over 200,000 working EMS providers in
the United States. They offer stabilization and mostly noninvasive medical care. Paramedics are more advanced providers, with at least 1200h of training in the time-limited care of
patients prior to their initial entry into the inpatient system.
They provide protocol-driven care under the license of a
physician, including invasive therapies such as medication
administration and airway interventions.
Critical care transport teams are often part of air transport
programs transporting patients to trauma centers from more
remote injury sites or, more commonly, moving patients
between facilities for higher levels of care. Increasingly, they
also provide ground-based interfacility critical care transport. These teams are most commonly staffed by a nurse
partnered with a paramedic to leverage the blend of EMS and
in-hospital critical care expertise those providers offer, but
some systems partner a nurse with an in-hospital provider
such as a second nurse, a respiratory therapist, or a physician. The nurses, paramedics, and respiratory therapists on
these teams typically have expanded training and a greater
scope of practice than their non-critical care transport counterparts. There is no optimal out-of-hospital stafng pattern
or system for either EMS or interfacility transport, due in
large part to the diversity of environments in which medical
transportation is provided. Attention to provider quality,
agency infrastructure for performance, oversight, and education, and system utilization is more important than provider
or agency credentials.
The benet of on-scene advanced life support care, either
by paramedics or physicians, remains unclear. Even the oftquoted “Golden Hour of Trauma” is not supported by clear
evidence. There is likely no single best approach. Some subsets of patients, such as those with associated severe brain
injury or those with extended out-of-hospital times, may
benet from greater on-scene intervention while avoiding
unnecessary delays in transport. At the same time, the care of
trauma patients in urban settings may be best served by minimized out-of-hospital intervention. In some reports, urban
trauma transport by non-medical providers is associated with
© 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_5
45
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M. A. Frakes and V. Ender
equal, and perhaps better, outcomes than those transported
by EMS.
When patients are taken to non-trauma centers or require
specialty care, transfer to a higher level center improves outcomes. As patients increase in acuity and complexity, patient
safety during movement requires providers with greater clinical and transport expertise. Even short in-hospital patient
movements are associated with logistical and physiological
complication, and the use of specialty critical care transport
teams during both intra- and interfacility transport is associated with reduced complication rates. Each trauma system
must construct an appropriate model for both transport to the
hospital and, as needed, transport between hospitals.
The EMS management of penetrating trauma outside the
hospital is focused on accessing the patient safely, addressing immediately life-threatening injuries, minimizing secondary injury, and promptly transporting the patient to an
appropriate destination.
In parallel with well-established American College of
Surgeons Advanced Trauma Life Support guidelines, care
begins with ensuring a patent airway. In the overwhelming
majority of cases, this can be achieved with basic life support
techniques such as positioning, suctioning, or the insertion
of an oral airway. At the other end of the spectrum, emergent
cricothyrotomy is rarely indicated: It is performed in 0.004%
of all prehospital advanced life support (ALS) patients and
0.1% of helicopter EMS patients.
Patients with signicant traumatic injury may require
supplemental oxygen, but high-ow oxygen is not required
for all patients, and can have adverse effects. The physiology
of oxygen delivery describes a signicant impact of a high
arterial oxygen tension only in cases of severe anemia.
Supplemental oxygen beyond that necessary to achieve full
saturation is, at best, not benecial. High-ow oxygen does
facilitate a benecial denitrogenation that prolongs the time
to desaturation if airway management procedures are subsequently indicated.
Trauma guidelines historically emphasized the need
empirically to restrict cervical spine motion until physician
and, in patients with distracting injuries, radiologic evaluation. This may be overly dogmatic, and there is evolution
toward less restrictive recommendations. Spinal motion
restriction in penetrating trauma is associated with poorer
outcomes (odds ratio of death 2.06, 95% condence interval
1.35–3.13): The number needed to treat for potential benet
is 1032, while the number needed to harm is 66. Cervical
spine fracture or cervical spinal cord injury is rare with penetrating trauma, occurring in between 0.11% and 1.35% of
patients, and is predictable by mechanism, presentation, and
wound location. These injuries are over eight times more
likely in patients with gunshot wounds than in those with
stabbing injuries, and, in both situations, neurological decit
is almost always evident at the time of initial exam. The
wounds associated with injury in gunshot wound patients are
located between the ears and nipple, and stab wounds associated with cervical injury are those between the mandible and
trapezius muscle. There may be merit in trading time to
denitive trauma care for pro forma attempts at spinal motion
restriction in patients who do not have neurologic decit or
specic injury location.
The immediately life-threatening injuries associated with
breathing addressed in the primary survey are tension pneumothorax and open pneumothorax. A tension pneumothorax
can sometimes be managed with needle decompression;
however, the usual intravenous catheter is too short to reach
the pleural space in up to a third of trauma patients. A catheter of at least 3.25in. in length optimizes success rates. The
out-of-hospital use of “simple” or “nger” thoracostomy is
increasingly accepted as a way to ensure pleural decompression for tension pneumothorax. Physicians and properly
trained ground and ight paramedics have demonstrated procedural success, safety, and acceptably low complication
rates with this procedure. An open pneumothorax can be
covered with a three-sided dressing and the patient monitored carefully for the accumulation of air and subsequent
development of a tension pneumothorax.
One signicant controversy in out-of-hospital trauma care
is the role of airway capture to assist breathing. It is clear that
hypoventilating patients should have assisted ventilation,
and mechanical ventilation in shock states benecially redistributes the cardiac output consumed by work of breathing to
increase mixed venous oxygen saturation independently of
arterial oxygen content. Appropriate ventilation may be
important overall: the mortality of intubated trauma patients,
both with and without brain injury, is signicantly increased
when they arrive at the trauma center with an abnormal
pCO2. The optimal timing and methods for achieving these
goals, however, are less clear.
Endotracheal intubation is a core paramedic skill, but skill
maintenance is difcult. Paramedics in large urban systems
may have only a single intubation opportunity every year,
and the overall success rate for paramedic prehospital intubation may be unsatisfyingly low and accompanied by high
complication rates. Specialty teams with high scrutiny, good
quality improvement programs, and close supervision can be
successful at the invasive airway capture. Procedure success
rates by paramedics with sedation-assisted intubation are
about 77%, rising to 96% with the use of neuromuscularblocking agents.
Although procedural success can be achieved, there is
little certainty of improved outcomes with routine and widespread paramedic out-of-hospital intubation. For example,
the only subgroups of patients shown to have improved outcomes following out-of-hospital intubation for traumatic
brain injury were those subsequently transported by a helicopter critical care transport team. There is no specic
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outcome evaluation of out-of-hospital intubation in patients
with penetrating trauma.
Prevention of adverse events in patients with endotracheal
tubes being placed or in place is essential. The incidence of
hypoxia during paramedic intubation may be as high as 56%.
True procedure success is best viewed not as technical success, but rather as procedural success coupled with the avoidance of peri-procedure hypoxia. The importance of careful
ventilation has already been described. The addition of endtidal carbon dioxide measurement devices for conrming
endotracheal tube placement and for the ongoing monitoring
of correct placement clearly improves out-of-hospital outcomes. Anesthesia standards recommend capnography for
patients with airway appliances and for spontaneously
breathing patients with sedation, yet adherence to this standard of care has signicant room for improvement in the prehospital environment. It may be, ultimately, that the “benet”
of endotracheal intubation comes not from the procedure,
but from patient selection, the prevention of intraprocedure
complications, and careful post-procedure care.
There are a number of blind insertion airways, variations
on an esophageal tube or a laryngeal mask, which can be
used when patients are frankly hypoventilating. These
devices, especially the esophageal tube airways, are designed
to be used by providers trained to basic skill levels, to have
high success rates and to have few complications.
As the primary survey progresses to circulation, the lifesaving intervention is to arrest hemorrhage. Direct pressure
continues to be the primary means of hemorrhage control.
Specialized trauma-dressings for the purpose of providing
effective, continuous direct pressure exist. These dressings
combine an absorbent pad and compression banding to provide direct pressure without relying on caretakers, which
may be a benet for the resource-limited pre-hospital arena.
Penetrating injuries deep within the soft-tissues pose a
particular challenge to achieving hemostasis. Military experience with hemostatic agents has translated into the civilian
environment. These products, initially developed as powders
and pastes, have since evolved into impregnated gauze dressings that encourage clot formation at the site of injury.
Guidelines from civilian medicine, military medicine, and
the Hartford Consensus for public and emergency services
preparedness for active shooter and terrorism incidents recommend the use of tourniquets and hemostatic agents.
In cases where direct pressure fails, placement of a tourniquet is indicated. Tourniquets have played a pivotal role in
reducing battleeld loss of life from injury to under 13%,
with an 85% reduction in death from uncontrolled extremity
bleeding. There is a shift from improvised devices to
purpose- built tourniquets, the most common of which
involves a Velcro® strap combined with a plastic windlass
device. A tourniquet device with a width of at least 1 in.
ensures adequate tamponade deep vasculature while avoid-
ing tissue injury underlying the placement site, and tourniquet placement for up to 16h without long-term complications
may be possible. It is considered best practice to write the
placement time on the device, as well as to convey the information in verbal and written patient handoff.
For vascular injuries that are not amenable to tourniquet
placement due to their location, particularly proximal femoral injuries and penetrating wounds to the pelvis, there is
developmental work on pneumatic compression devices to
occlude vasculature at and below the femoral artery bifurcation. Endovascular interventions, such as Resuscitative
Endovascular Balloon Occlusion of the Aorta (REBOA), are
available at some trauma centers, the procedural challenges
in prehospital use currently reserve it to select physicianstaffed systems. The benet of these interventions remains
unclear.
The question of prehospital uid resuscitation for penetrating trauma appears to have been settled last century and
validated repeatedly since then: there is no benet to prehospital crystalloid resuscitation in trauma patients with bleeding and without brain injury. Mortality is increased in patients
with penetrating trauma or hypotension who receive prehospital crystalloid. Massive crystalloid resuscitation is clearly
associated with coagulopathy, increased hemorrhage, and
the development of the abdominal compartment syndrome.
Uncertainty about uid resuscitation remains for patients
who have associated brain injury or extended out-of-hospital
times. For patients with brain injury, outcomes are clearly
associated with the maintenance of cerebral perfusion pressure, with a goal of maintaining a mean arterial pressure of at
least 80 mmHg. There is a paucity of guidance about the
point at which the deleterious effects of persistent shock
from delayed resuscitation for patients with prolonged outof- hospital times begins to outweigh the hemorrhagic and
coagulopathic risks associated with volume repletion.
Once uid resuscitation is initiated in a patient with penetrating trauma, the question becomes one of ideal uid
choice. Crystalloid uid is the only option for most EMS
providers. Balanced solutions appear to offer a benecial
reduction in coagulopathy, hyperchloremic acidosis, and
renal dysfunction compared with normal saline solution.
When available, blood products are optimal for patients
with ongoing hemorrhage. Overall, guidelines support the
early administration of platelets, fresh frozen plasma, and,
perhaps, cryoprecipitate when more than two units of packed
red blood cells will be rapidly transfused. Some transport
teams have access to plasma, although with less frequency
than access to red cells. When available, transfusion of both
plasma and red cells generates an overall mortality reduction, with a more proven benet in blunt trauma patients or
in those with longer transport times. Despite the cost of additional components, the use of plasma for out-of-hospital
trauma patients appears to be cost-effective. The role of
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M. A. Frakes and V. Ender
unfractionated donor blood (whole blood) offers logistical
advantages and earlier access to mixed component resuscitation; however, there is currently limited evidence to show a
signicant benet compared with component therapy.
For transfused patients, importantly, there is a dosedependent increase in mortality with co-administered crystalloid volume. Transport providers with immediate access
to blood products should use a low/no crystalloid resuscitation strategy for trauma patients.
Tranexamic acid inhibits intrinsic hyperbrinolysis, a
phenomenon particularly associated with trauma-associated
coagulopathy. It is used extensively in orthopedic and obstetric care, and is now ubiquitous in emergency trauma care.
The therapeutic benet appears to be time-dependent, assuredly within the rst 3h of injury, and possibly within the rst
hour, and is greatest in patients with severe shock. It is a
reasonable option for prehospital and resuscitation bay
providers.
The other immediately life-threatening circulatory injury
is pericardial tamponade. Classic management of pericardial
tamponade is emergent pericardiocentesis. This skill is regularly taught to paramedics, but a recent consensus statement
described the absence of evidence to support prehospital
pericardiocentesis and the technical barriers to success.
Aggressive volume resuscitation in this setting may be a
technique with greater likelihood for success outside of the
hospital.
An oft overlooked yet meaningful intervention for the
care of the trauma patient is the mitigation of hypothermia.
The causes two-fold: loss of intrinsic adaptive mechanisms,
such as shivering, suppressed by a shock state, and iatrogenic
causes from the resuscitation. A core body temperature
below 34°C has deleterious effects on clot formation and is
independently associated with an 80% increase in mortality.
Nearly 30% of trauma patients arrive at trauma centers with
a temperature below 35°C.In transport, teams must be attentive to a proper balance of patient exposure and temperature
preservation, a warm environment, and warming resuscitation uids. The use of blankets, lined transport bivvys, and
commercial hypothermia mitigation kits can be helpful.
Although not a life-saving intervention, the provision of
analgesia may be one of the most important out-of-hospital
interventions. Attention to analgesia has historically been
poor in all aspects of the emergency system, from EMS care
through trauma resuscitation. It is clear that out-of-hospital
providers can safely administer short-acting opioid analgesics in systems with protocols and performance improvement systems, and this may be an area in which EMS systems
should consider focused performance improvement efforts.
In addition to rapid, safe transport and the provision of
life-saving interventions, the EMS role is to deliver patients
to the best destination. The concept of direct point of entry
into a trauma center hospital is well established in devel-
oped trauma systems. EMS may also have a benecial role
in determining resource utilization and in-hospital point of
entry, as well. For patients with ST-elevation myocardial
infarction, paramedic acquisition of electrocardiograms
and the use of that information in activating the cardiac
care system or catheterization suite are the standards of
care. For trauma patients, efforts at identifying helpful prehospital triage criteria are so far nonspecic and imperfect,
even as the guidelines are revised. A 6-year case series does
suggest that well-trained critical care transport teams can
appropriately identify patients for direct operating room
admission.
Veried trauma systems include comprehensive outcomes, performance improvement, and data collection components, but the out-of-hospital element of the system often
lags in this area. Optimal system development, resource utilization, and patient care require that EMS and interfacility
transport providers, in collaboration with hospital-based
trauma systems, develop these elements.
The out-of-hospital elements of the trauma system offer
opportunities not only to provide life-saving prehospital
interventions, but also to optimize patient access, resource
utilization, and safety. Mature trauma systems should integrate prehospital and interfacility transport components not
only in clinical care, but also in research, outcomes, and
quality management aspects of the system.
Important Points
• Time to hemorrhage control is a key determinant of out-
come for patients with penetrating traumatic injury.
• Integrated transport systems are essential in trauma care:
Over one quarter of the American population can access a
trauma center within 1h only via helicopter transport, and
interfacility transport to trauma centers also improves
outcomes.
• The use of personnel with expertise in critical care and
transport reduces complications during intra- and interfa-
cility transport of critically ill patients.
• Cervical spinal cord injury is rare in patients with pene-
trating trauma and can be predicted by mechanism, wound
location, and physical examination. There is increased
mortality associated with the routine prehospital applica-
tion of cervical spinal motion restriction devices in pene-
trating trauma patients.
• Prehospital endotracheal intubation for trauma patients is
controversial and, if done, should be performed in sys-
tems with high procedure volume, attentive recurrent edu-
cation and quality improvement processes, and that use
continuous end-tidal carbon dioxide measurements and
mechanical ventilation after intubation.
• Prehospital hemorrhage control is a life-saving interven-
tion. Tourniquet use and the use of hemostatic gauze
5 Prehospital Care andTransport
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should be considered early if initial attempts with direct
pressure fail.
• Prehospital crystalloid administration generally has
greater harm than benet. Conversely, prehospital plasma
and PRBC resuscitation seems benecial.
• Tranexamic acid may be a helpful early consideration,
particularly in severely injured patients.
• There is no evidence supporting prehospital pericardiocentesis for cardiac tamponade.
• There may be inadequate prehospital attention to maintaining patient temperature.
• Transport systems have a proven role in determining destination choice and in-hospital resource activation. There
may be opportunities to expand this role with trauma
patients.
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Prehospital Monitoring During
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Transport
KazuhideMatsushima andHeidiFrankel
6
The principal goal of Emergency Medical Services (EMS)
providers caring for penetrating injury patients in an urban
environment is rapid transport to denitive care while
delivering life-saving interventions. In most circumstances, this is accomplished by ground transport with
Advanced Life Support techniques. Wound location and
hemodynamic information should be communicated
before arrival in a concise report to best prepare the trauma
team to deliver rapid and appropriate denitive care.
Depending on the trauma system, it may be benecial to
transport unstable patients to facilities with in-house
trauma/general surgeons to address torso injuries and neurosurgeons to address brain injuries. Certainly, 24-h immediate access to the operating room, blood bank, and
diagnostic and interventional radiology are optimal in
these patients. Hemodynamically unstable patients may
benet from resuscitative measures delivered during the
transport. These may include establishment and protection
of the airway, decompressive needle thoracostomy, uid
administration, and application of a tourniquet for exsanguinating extremity wounds. If denitive airway is to be
established for head-injured patients, tracheal intubation
with care must be accomplished to protect against hypoventilation and elevations in intracranial pressure. Additional
focus on resuscitative measures, including the administration of blood products to maintain a perfusing pressure and
antibrinolytic agent to correct coagulopathy, may be
required in penetrating injured patients in a rural environment or those with long transport times to the hospital
requiring air transport.
K. Matsushima (*) · H. Frankel
Division of Acute Care Surgery, University of Southern California,
Los Angeles, CA, USA
e-mail: kazuhide.matsushima@med.usc.edu
6.1 Urban Environment
6.1.1 Goal ofEMS Participation
The principal goal of EMS (emergency medical services)
providers caring for penetrating injury patients in an urban
environment is rapid transport to denitive care while
administering life-saving interventions. The prehospital
period involves expeditious evaluation of wounds and
hemodynamics, stabilization and prevention of further
injury, and rapid transportation of the patient to the closest
appropriate facility where denitive care can be delivered.
The care of the patient in the prehospital setting follows
principles set out by the American College of Surgeons
Committee on Trauma (ACS- COT) delineated in Advanced
Trauma Life Support (ATLS) and the Prehospital Trauma
Life Support (PHTLS), both of which are leading international programs of continuing education. The PHTLS course
is taught to EMS providers in over 74 countries worldwide
and complements the ATLS course that is currently taught in
80 countries. Although recent military experiences originate
from an environment that differs from the civilian by the
presence of a hostile setting, mass casualties, less available
resources, and the foremost goal being completion of the
current mission, various battleeld techniques are currently
adapted for civilian use in prehospital setting. The Hartford
Consensus was developed in 2013 after a series of active
shooter events in the United States. The Stop the Bleed
training curriculum has been developed to teach non-professional, civilian rst responders to provide rapid hemorrhage
control, including with tourniquets. As professional rst
responders, EMS providers need to be trained to take appropriate actions, including assessment, triage, and transport of
the victims and further hemorrhage control measures as
needed.
The benets from extensive prehospital intervention for
penetrating trauma, particularly in an urban environment,
remain controversial. In critically injured patients, performance of other than life-saving interventions can delay
© 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_6
51
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