1993-2008

FIFTEEN YEARS
OF INDEPENDENT
INFORMATION

Drug and Therapeutics Bulletin of Navarre. Spain VOL 16, No 3 SEPTEMBER 2008

Prehospital management
of trauma patients
CLINT JEAN LOUISa,b
CARLOS BEAUMONT CAMINOSa,b
BERNABÉ FERNÁNDEZ ESAINa,b,c
DIEGO REYERO DÍEZb
TOMÁS BELZUNEGUI OTANOa

(a) EMERGENCY DEPARTMENT. HOSPITAL DE NAVARRA. PAMPLONA. SPAIN

(b) PREHOSPITAL TRAUMA LIFE SUPPORT (PTLS) INSTRUCTOR
(c) ADVANCED TRAUMA LIFE SUPPORT (ATLS) INSTRUCTOR

OBJECTIVES CONCLUSIONS

To describe the most relevant aspects of the manage- The management steps taken during the critical period
ment of trauma victims in the prehospital setting. condition the survival and posterior morbidity of trauma
patients. Life should take priority over function and this
MATERIALS AND METHODS over aesthetics. The primary survey is the key to detect
and treat life threatening injuries. Definitive treatment is
A review was carried out of all relevant secondary sour- nearly always hospital based and therefore transfer
ces such as UpToDate database (Prehospital manage- should not be delayed. The absence of a definitive diag-
ment of the adult trauma patient) and publications of the nosis should not impede the application of therapeutic
American College of Surgeons (Advanced Trauma Life measures. Psychological suffering and pain should not
Support program for doctors 7th Ed) and the European be left unattended and the principle of primum non noce-
resuscitation Council (Avanced Life Support, 5th Ed). re should always be taken into account.

RESULTS

A description of the adequate approach to evaluate trau-

ma patients is made with an emphasis on the primary
survey, whose objective is to rule out and treat life threa-
tening injuries. The secondary survey, immobilisation
and transfer is also discussed.
38 DRUG AND THERAPEUTICS BULLETIN OF NAVARRE. SPAIN

One Sunday morning a young couple decide to take a secondary route to avoid a police check for alco-
hol, after a night at a discoteque in a rural setting. While on duty at a rural emergency service, you receive
a call at 6.30 am from the emergency call center indicating that you should first attend to an accident sce-
ne in your area. At the scene of the accident you find a car crashed into a tree. There are two passengers.
The driver does not move or respond to verbal commands and seems to be dead. The copilot looks se-
verely injured, is conscious, confused, and you see her with some breathing difficulty. She is actively ble-
eding from the scalp. A few minutes later she becomes even more confused, and her breathing difficulty
increases….

What are the first measures to take at the scene of an accident? What evaluation must you carry out on
the patient? What would make you think she is critical? What vital injuries could place her life in danger?
How should you initially manage and treat your patient? How should you manage a patient in shock? Is
the patient critical? Should you transfer immediately? What interventions can you carry out at the scene?
If she is not critical what steps should you take next? How would you immobilise her and prepare for
transport? What transfer options do you have?

Introduction rupture and other great vessel injury. Very few of

these patients survive. These deaths are hardly
Epidemiology of trauma salvageable and here lies the importance of pre-
ventive measures and health education.
The World Health Organization defined trauma in
1958 as any fortuitous event caused by an exter- The second phase corresponds to the first hours
nal force that acts quickly and results in physical after the incident and death occurs due to subdu-
or mental injury. Each day nearly 16,000 people ral or/and epidural haemorrhage, haemo-pneu-
die from all types of trauma1. mothorax, spleen or liver injury, pelvic fractures or
multiple injuries associated with severe haemor-
In Spain, accidents are the fourth cause of overall rhage. This group comprises 30% of trauma vic-
mortality in all ages and the first in those under 45 tims and death can be prevented by an adequate
years. With regard to morbidity accidents are the prehospital and hospital emergency system. For
first cause of loss of potential life years. Eight per- this reason, the first professional who assists a
cent of discapacity in the general population is victim has the possibility to influence either positi-
caused by accidents, 50% of which occur in peo- vely or negatively in the final outcome.
ple under 30 years of age2.
In the third phase, death occurs days to weeks af-
Mortality in trauma victims ter the incident and is greatly caused by sepsis or
multiorgan failure.
The distribution of mortality caused by trauma fo-
llows a tri-modal distribution3. In the early phase, Critical period
in a 50 % of the trauma patients, death occurs in
the first seconds to minutes after the event, and The “Golden Hour” is defined as the period of one
generally is due to brain lacerations, brain stem hour between the moment of the traumatic event
damage, high spinal trauma, cardiac injury, aortic and definitive surgical care. Dr. Adams Cowley de-
 PREHOSPITAL MANAGEMENT OF TRAUMA PATIENTS 39

veloped the concept of “Golden hour” in trauma

and noted that if tissue oxygenation was not rees-
tablished within an hour of injury the possibility of The aim of the primary
survival would be scarce. The Golden hour is now
referred to as the “critical period” because some survey is to detect and
patients have less than one hour to receive medi- treat life-threatening
cal assistance while others may have a more pro-
longed critical period. Within the critical period injuries.
prehospital assistance at the site of the event
should not take longer than 10 minutes if the pa-
tient is critical, what some authors refer to as the
platinum 10 minutes4.

The objective of the present review is to offer,

through a series of principles, a guideline for pre-
hospital management of trauma victims. All critical Evaluation of the severe trauma patient
patients are managed following the same syste-
matic approach. This approach, regardless of the WHAT ARE THE FIRST STEPS TO TAKE AT THE
injury is based on a wider concept of maintaining SCENE OF AN ACCIDENT?
life, securing correct oxygenation, breathing and
perfusion: the ABCDE of the primary evaluation
within a limited period. We hope the paper will be a Evaluation of the scene. Safety and situation
useful tool for health care providers in pre-hospital
care as a guide to approach these patients in an As soon as an emergency call has been made, he-
orderly fashion. alth care providers should analyse the initial infor-
mation obtained, and integrate new data once
Physiopathology of injury. arriving at the scene (what happened? how many
Mechanism of injury victims are there? what are their ages?, what injury
mechanism was involved?, etc.). The sum of this
Knowledge of the physiopathology of trauma information should help to determine whether the
could be the key to discovering or suspecting any scene is safe.
inadvertent injury. Trauma can be classified as
contuse or penetrating. A single contuse or pene- Safety at the scene is a requirement for all health
trating injury could affect multiple systems. The care providers. An orderly approach to the victims
exchange of energy involved in both types of trau- at the scene should include the following:
ma is similar, but differ in the penetration across
the skin. Universal precautions

Contuse trauma occuring after traffic accidents The use of gloves is fundamental to protect one-
can involve various injury mechanisms (head on self from the transmission of some infections (HIV,
collision, lateral and rear impact, with rotation or hepatitis). Besides nitrile gloves, kevlar gloves
rollover collisions). Other accidents include falls, (made of resistant material to fire and cuts) are
runovers, and sports related injuries. Penetrating useful to avoid cuts and abrasions while getting
trauma includes injuries due to blunt trauma or fi- access to the patient and can be removed once
rearms with entrance and exit orifices. used5. Eye protection and masks are also univer-
sal precautions to take into account. The helmet,
The injury mechanism can orient the health provi- resistant footwear and intervention gear are ele-
der to suspect injuries in organs or systems. This ments not to be obviated.
orientation could lead us to suspect internal and
hidden injuries when possibly no external signs Safety at the scene
are evident. For example, in the case of a fall, inte-
grating injury physiopathology in our thinking im- Prudence and prevision of possible threats before
plies that we ask ourselves about the factors invol- arriving at the scene contributes to a safe inter-
ved: the height of the fall, the relation between the vention. In the context of a possible crime scene
height of the patient and the distance of the fall, the presence of the police may be warranted.
the type of landing surface, etc. This could help us
suspect internal organ injury or spinal injury and Elements of passive safety on vehicles such as the
establish priorities in our management. airbag that did not open after a collision, could do
40 DRUG AND THERAPEUTICS BULLETIN OF NAVARRE. SPAIN

so at any time during the intervention in the vehicle

and produce serious injuries to the victim or heath
care providers. The medical team should first put
A
Airway and cervical spine
themselves in the hands of the rescue team (fire-
men, etc.). A patent airway is a priority in the management of
all trauma victims8. All actions taken or the use of
Safety of the patient any method to manage the airway should be done
under the assumption that a cervical spine fractu-
Protection screens are available and if not a blan- re exists. Thus airway patency will be explored un-
ket could be enough. In critical situations, such as der strict control of the cervical spine (manual in-li-
fire or a dangerous position of a vehicle, rapid ex- ne stabilisation –MILS– in neutral position).
trication should be employed. If the victim is trap-
ped priorities with the rescue team should be ma- To evaluate the airway (A) the first thing to do is to
de for a quick and safe liberation of the patient. ask the patient a question to evaluate response. If
the patient is able to speak then patency is ascer-
tained. If the patient is unconscious or does not
respond, the airway should be assessed and pa-
HOW SHOULD THE PATIENT BE EVALUATED? tency should be secured. Noisy breath sounds or
WHAT INJURIES COULD PLACE THE LIVES diminished air entry could indicate a parcial obs-
OF THE VICTIMS IN DANGER? HOW DOES ONE truction of the airway. The main maneuvres to
DECIDE WHETHER A PATIENT IS CRITICAL open, assess and maintain a patent airway include:
OR NOT?

MANUAL CLEARING OF THE AIRWAY

Primary survey
If any foreign object is observed (teeth, food, pros-
The objective is to detect and treat life-threatening theses, etc.) this should be removed with forceps
injuries. The primary survey follows the ABCDE (such as Magill forceps) or with a finger sweep.
approach of the ATLS (Advanced Trauma Life
Support program) under the American College of
Sugeons6,7. This brief exploration allows us to MANUAL MANEUVRES TO OPEN THE AIRWAY
systematically examine the airway (A), breathing
(B), circulation (C), disability, mental status and In unconscious patients (supine position), the ton-
neurological status (D) and exposure (E) of the pa- gue loses its muscle tone and may be displaced
tient to detect any other obvious injuries. Treat- towards the posterior pharyngeal wall causing air-
ment of injuries detected in the primary survey way obstruction. Recent studies in anesthesized
should not be delayed but rather treated as they patients have shown that the site of airway obs-
are found (treat as you go). truction more frequently occurs at the soft palate
and epiglotis and not the tongue9. To avoid this,
That is, if during the primary survey we detect an two techniques can be applied: mandible displa-
obstruction of the airway, then this should be trea- cement (head-chin tilt lift or modified triple maneu-
ted immediately before moving on to the next step. ver without cervical spine extension) along with a
An airway problem can cause death in seconds, a manual in-line stabilisation of the head and neck
breathing problem in minutes and a circulation pro- by an assistant, and the jawthrust maneuver.
blem in hours. Thus we should not be easily “dis-
tracted” with the reduction of a fractured limb, if we Both techniques displace the jaw bone forward,
have not acted upon the airway, breathing and cir- lifting the tongue and separating it from the poste-
culation. Life prevails over function and function rior pharyngeal wall, thus opening the airway.
over aesthetics. The ABCDE scheme helps to
identify whether patients are critical or not. In case
of a critical patient, an on-scene time of less than SUCTION
10 minutes is recommended.
In occasions, the presence of blood or vomit, may
be the cause of airway obstruction. Vigorous and
prolonged suctioning can cause or worsen hypo-
xemia. Wide bore rigid suckers are preferable
(Yankauer) to fine bore flexible soft suction cathe-
 PREHOSPITAL MANAGEMENT OF TRAUMA PATIENTS 41

ters. The sucker is introduced in the mouth up to

the desired area to suck and suction is carried out
as the catheter is pulled out from the mouth and
In the management of the
for not more than 15 seconds. airway and breathing, the
main aim is not intubation
USE OF OROPHARYNGEAL but rather oxygenation
AND NASOPHARYNGEAL AIRWAYS
(and ventilation if required)
Both are employed to maintain an open airway but
they do not prevent bronchoaspiration as they do
not seal the airway. The nasopharyngeal airway is
contraindicated in patients with suspected skull
base fractures.
should be removed between 1-2 cm and ventila-
tion verified in both sides of the chest. When a fai-
TRACHEAL INTUBATION led intubation occurs or an intubation is not per-
formed due to inexperience or difficulty, there are
This is perceived as the optimal method to mana- other alternatives to maintain the airway secured
ge and secure the airway. It is indicated in patients (though not completely) and the patient ventilated
unable to maintain an open airway on their own, and oxygenated.
including those with Glasgow coma scale (GCS)
scores of <9 points, patients with airway burns,
etc.
Table 1. Drug assisted intubation (DAI) including rapid
It is important to check and prepare the material sequence intubation (RSI).
beforehand (ensure functioning of the laryngosco-
pe´s light source and battery, tube cuff, etc). In the PREPARATION
prehospital environment, drug-assisted intubation
Evaluation of the airway and plan for the procedure.
(DAI)10 can prove useful, which may include the Indications, risks and alternatives (in case of failed intubation).
use of opioids, and a rapid sequence induction Preparation and verify functioning of material.
(RSI) to avoid bronchoaspiration (table 1). After a PREOXYGENATION
period of pre-oxygenation with 100% oxygen, se-
100% Oxygen for 3-5 minutes.
dative (etomidate can be useful as it does not pro- 4-8 inspirations maximum (FiO2: 1).
duce hypotension as with midazolam) and paraly- Ventilate only if pulsioximetry ≤ 90%.
tic agents (succinylcholine) are introduced in
PREMEDICATION
tandem to improve laryngoscopy and facilitate in-
Sedatión-Analgesia-Amnesia. Opioids: fentanyl (1-2 mcg/kg).
tubation. In cases where intubation is decided it is Defasciculatión: succinilcholine (1-1.5 mg/kg).
important to know the GCS score before adminis- Optional: lidocaine (1 mg/kg). Useful in head injury or increase in
tering sedative agents (see section D, neurological intracraneal pressure.
evaluation). The main characteristics of the most Optional: atropine (children).
common sedative agents employed are shown in PARALYSIS WITH SEDATION
table 2. The use of DAI requires training and it is Inductor in bolus (table 2).
highly recommended that guidelines be establis- Paralytic agent (succinilcholine: 1-2 mg/kg; rocuronium 0.6-0.9
hed in accordance with the characteristics of the mg/kg).
prehospital care system10. PROTECTION
Sellick maneuver (cricoid pressure).
From the moment the patient loses the ability to Correct positioning of the patient.
maintain and protect the airway, the Sellick mano- Ventilation only if pulsioximetry SatO2 ≤ 90%.
euvre should be applied (pressure over the cricoid PASS THE TUBE-INTUBATION
cartilage) to avoid gastric reflux. Correct insertion Laryngoscope and intubation.
of the endotracheal tube (ETT) should be carried Verify position of endotracheal tube.
out, by auscultating both sides of the thorax (api- Inflate cuff.
cal, axilar regions, bases and epigastrium), moni- POSTINTUBATION MANAGEMENT
toring the end tidal CO2 and having directly visuali- Release cricoid pressure.
sed the tube go pass the vocal cords11. In cases of Fix tube.
selective right bronchus intubation, the ETT Sedation and adequate relaxation.
42 DRUG AND THERAPEUTICS BULLETIN OF NAVARRE. SPAIN

Intubation adjuncts ProSeal laryngeal mask

Guides
It permits the use of a nasogastric catheter to
The Eschmann and Frova tracheal tube introdu- drain gastric content. The double cuff design pro-
cers are widely used. The latter is provided with a vides better seal pressure than the classical laryn-
lumen that permits a brief period of ventilation. geal mask.
Under direct vision with a laryngoscope, these de-
vices are first introduced passed the glottis (the FasTrach laryngeal mask airway
Eschmann has a 45º angulated tip to facilitate its
introduction) after which a standard ETT is passed This carries a metallic handle to facilitate manipu-
over the introducer. lation. Once placed and the cuff inflated, bag ven-
tilation can be carried out. In addition, an ETT can
Optic larygoscope (AirtrachTM) be advanced through the lumen (figure 3).

A single use device that allows direct visualisation The I-GEL airway mask
of the glottis. The device contains two conduits,
one with an optic apparatus and the other through It is a novel device made of a non-inflammable
which the ETT is placed. Mobilisation of the cervi- thermoplastic polymer that adapts to the laryngeal
cal spine is not needed, and given the ease of pla- anatomy of the patient providing a nearly comple-
cing the tube, this device is an attractive alternati- te seal of the airway. Moreover, it allows for an ETT
ve in cases of failed intubations (figure 1). and gastric drain to be advanced through it12,13.

Supraglottic devices In cases when intubation is not possible due to in-

experience or difficult airway or there are no other
When intubation is indicated but is not possible for alternatives, then bag-mask ventilation should be
some cause (inexperience, failed technique, etc.) carried out until more expertise is available for in-
there are other alternative devices to ventilate the tubation.
patient such as the laryngeal mask airway (ProSe-
alTM, FastrachTM), combitube (dual lumen dual cuff
airway) and the laryngeal tube (figure 2).

All these devices offer air/oxygen flow above the

B
Breathing
glottis not reaching past the vocal cords. They do
not completely eliminate the possibility of inflating Hypoxia is caused by insufficient supply of oxygen
the oesophagus and the passage of gastric con- due to tissue hypoperfusion or because arterial
tent into the airway. As for the laryngeal mask air- blood is not sufficiently oxygenated.
way it is important to verify its functioning before
use (inflation-deflation). There are several varia- The administration of 100% oxygen is absolutely
tions including: primordial in the trauma patient. The first observa-

Table 2. Principle sedatives used in intubation.

MIDAZOLAM ETOMIDATE KETAMINE PROPOFOL

(DormicumTM) (HypnomidateTM) (KetolarTM) (DiprivanTM)
Variability among different Hypnosis en 30-60 seg. Dissociative state Rapid action (60 seconds).
patients in effects. Duration of effect: 5-10 Potent analgesia Short duration (5-10 min. after
Maximum effect in 3 minutes. minutes. Broncodilator bolus)
Rapid and predictable intra- Cardiovascular stability Useful in asthma, burns Pharmokinetics unaffected by
muscular absortion (>80%). Neuroprotection. Increase in intracraneal renal or liver impairment.
Moderate hemodynamic Spontaneous movements, pressure (ICP). Decreases ICP
repercussion. mioclony. Dose: 1-2 mg/kg iv., 3 mg/kg Cardiovascular depression.
Not an anesthetic induction Dose: 0.3 mg/kg i.m. Dose: 2-2.5 mg/kg
agent.
Dose: 0.1-0.4 mg/kg
(variability)
 PREHOSPITAL MANAGEMENT OF TRAUMA PATIENTS 43

Figure 1. Optical laryngoscope AirtrachTM

1
Figure 2. Supraglottic devices:
(Left to right): Combitube, laryngeal mask,
laryngeal tube, I-GEL.
Figure 3. Fastrach maskTM

tion to make is whether the patient is breathing or Effective bag mask ventilation (BMV) is not as easy
not. If not, then cardiorespiratory resuscitation as it may seem. It is important to obtain a proper
should be initiated. If the patient is breathing then seal with the mask on the face of the patient to
we should evaluate the work of breathing, chest avoid air leaks. Two handed mask ventilation is
motion movements, use of accessory muscles, preferable to single handed ventilation, as the for-
etc. In a first inspection we should look for open or mer generates superior tidal volumes and peak
sucking wounds, abrasions or signs of contusion pressure. One person is in charge of applying the
in the neck and thorax. Some very important signs mask to the patients face while the other ventilates
should not be overlooked in the neck such as sub- (approximately 10-12 ventilations per minute).
cutaneous crepitation (possible underlying pneu-
mothorax), open wounds, laryngeal crepitation In the evaluation of breathing, the potential injuries
(laryngeal rupture), tracheal deviation (tension that can be ruled out are as follows:
pneumothorax), and jugular ingurgitation (tension
pneumothorax, cardiac tamponade).
FLAIL CHEST
In the thorax, observe for asymmetry in the chest
wall and paradoxical chest motion. Palpation of the This consists of a fracture of two or more ribs in
chest should be carried out to find painful areas, two different sites, resulting in a segment that re-
subcutaneous crepitation, as well as auscultation mains free from the rest of the chest wall. The seg-
of all lung fields and heart (diminished heart ment moves freely in inspiration and expiration in
sounds, displacement of heart sounds, etc.). the opposite direction to the rest of the chest wall
(paradoxical movement). There is a reduction in vi-
If the patient is breathing, oxygen should be ap- tal capacity, increase in work of breathing, pain
plied via Venturi mask or a nonrebreather mask and this implies underlying pulmonary contusion
with an oxygen reservoir. If ventilatory support is which could require ventilatory support with bag
needed, then bag mask ventilation (AmbuTM) con- mask, or early intubation.
nected to a 100% oxygen supply should be given
until a definitive airway is secured.
44 DRUG AND THERAPEUTICS BULLETIN OF NAVARRE. SPAIN

OPEN PNEUMOTHORAX blood pressure by >10-15 mmHg during inspira-

tion), jugular ingurgitation, and diminished heart
Here both atmospheric and intrathoracic pressures sounds. Rapid transfer to an emergency room
are equalised. It is estimated that if the defect in the with supportive measures is fundamental, where
chest wall is 2/3 the size of the trachea, then air will pericardiocentesis can be perfomed before defini-
enter the pleural space (negative intrathoracic pres- tive surgical repair.
sure) with each inspiratory effort, resulting in pneu-
mothorax. Management involves, besides 100% In summary, the objective of the management of
oxygen supplementation, the application of an oc- the airway and breathing is not intubation, but ra-
clusive dressing over the wound. One side of the ther provide adequate oxygenation (and ventila-
dressing should be left untaped to act as a flap-val- tion if required). Though intubation is the most ef-
ve to allow air to escape from the pneumothorax fective method to maintain and secure the airway,
during expiration, but not to enter during inspira- it should not be made an obsession. The trauma
tion. Commercial dressings such as the Asherman patient needs oxygenation/ventilation and this can
seal are available. be achieved by alternative methods. Even though
these alternatives do not completely secure the
airway, they allow for a more than acceptable
TENSION PNEUMOTHORAX supply of oxygen and ventilation of the patient.

One hemithorax is not ventilated, as the pleural

space fills up with air, and collapses the lung.
When the pressure in the pleural space exceeds
the atmospheric pressure, the mediastinum (heart
and great vessels) are displaced to the opposite si-
de. Ventilation becomes more difficult as intratho-
C
Circulation and hemorrhage control
racic pressure increases, followed by a reduction
in venous return, cardiac filling and cardiac output, The objectives of the “C” step of the primary sur-
resulting in shock. Symptoms and signs of tension vey are to evaluate the circulatory status and to
pneumothorax include important work of brea- detect and control hemorrhage (external and evi-
thing and extreme anxiety (if conscious), cyanosis, dent or internal and occult), determine whether the
taquipnoea, tachycardia, jugular ingurgitation (due patient is in shock and if so, determine the type
to increase in intrathoracic pressure), hypotension, (hypovolemic, cardiogenic, etc.) and severity, and
subcutaneous emphysema, and absence of venti- initiate treatment as soon as possible.
lation sounds on auscultation. Tracheal deviation
can appear in occasions, but at later stages. If sus- What defines shock? Inadequate oxygen delivery
pected, then tension pneumothorax should be im- to tissues produced mainly by hypoperfusion (re-
mediately decompressed with needle thoracos- duced blood flow) results in shock. If not treated,
tomy. An intravenous cannula (12 or 14G) is this process progresses to an anaerobic state with
inserted into the second rib space (mid-clavicular the production of lactate and pyruvate, resulting in
line), over the superior edge of the third rib to avoid acidosis and finally cell death.
damaging the neurovascular bundle14.
Identification of shock. In the prehospital context
the identification of patients in shock is a clinical
MASSIVE HEMOTHORAX diagnosis. An overall judgement should be made
after exploring pulse (quality and rate, regularity)
This is the accumulation of blood in the pleural capillary refill, skin (aspect, color and temperatu-
space (up to 2.5-3 litres). Symptoms develop from re), rate and work of breathing, and mental status.
the resulting hypovolemia and to a lesser extent Table 3 shows the ATLS classification of hemor-
due to the associated lung collapse. rhagic shock7.

CARDIAC TAMPONADE If taken individually, the outlined clinical signs are

hardly sensitive and specific. However, if evalua-
It occurs mainly in penetrating trauma. If the peri- ted as a whole then the sensitivity and specificity
cardial sac is filled with blood (200-300 ml is suffi- increases considerably. For example, a patient un-
cient), myocardial distension is limited producing der treatment with betablockers in a state of
reduced cardiac filling leading to a situation of low shock, could possibly not show tachycardia, but
cardiac output and shock arises. Classical signs could be cold, pale, and breathe rapidly and su-
include the presence of a paradoxical pulse (fall of perficially. Thus as a general norm, any patient that
 PREHOSPITAL MANAGEMENT OF TRAUMA PATIENTS 45

is cold, pale, sweaty and with a fast heart rate is in

shock.
All trauma victims that
All these changes are a consequence of compen- are cold, pallid, sweaty
sating mechanisms that eventually are exhausted
if the patient is not treated promptly and adequa- and with tachycardia are
tely, resulting in sharp fall in blood pressure (Grade in shock
III). This state is known as uncompensated shock
and can be recognised in the prehospital scene as
the loss of radial pulse.

CONFOUNDING FACTORS

Age sion of the uterus by the great vessels in supine

position could result in hypotension. Therefore
Elderly patients have poorer compensation me- pregnant women should be placed in the left late-
chanisms due to physiological changes related to ral tilt position.
aging, or to medication (for example betabloc-
kers). This means that they could present a fall in Previous disease
blood pressure and a loss of radial pulse with a
15% blood loss. On the contrary, children com- A reduction in cardiopulmonary reserve may occur
pensate well by increasing their heart rate and in COPD or cardiac disease.
maintain their blood pressure at normal levels until
blood loss reaches 45%. Medication

Athletes Certain drugs can contribute to a decrease in blo-

od pressure (antihypertensive drugs) or facilitate
They usually present a greater capacity for com- bleeding (antiplatelet and anticoagulation agents).
pensation and tachycardia may not appear in the The use of pacemakers could interfere with the
initial stages of shock. heart rate.

Pregnancy Time between injury and treatment

The increase in cardiac output, blood volume and During the period between the accident and the
heart rate related to this state contributes to the first medical attention the injuries continue their
fact that signs of shock do not appear until blood evolution, such that a patient with a ruptured spleen
loss reaches 30%, despite the presence of fetal seen in the first minutes after the incident occurred
distress. Moreover in the third trimester compres- could still be hemodynamically stable at this point.

Table 3. Classification of shock (adapted from the American College of Surgeons ATLS, 1997).

CLASS I CLASS II CLASS III CLASS IV

Volumen of blood loss (% total) < 750 ml 750-1,500 ml 1,500-2,000 ml > 2,000 ml
(< 15%) (15-30%) (30-40%) (> 40%)

Heart rate (beats per minute) Normal > 100 > 120 > 140

Respiratory rate (rpm) Normal 20-30 30-40 > 35

Systolic Blood pressure (mm Hg) Normal Normal Reduced Reduced

Palpable pulse Radial palpable Radial palpable Radial pulse not palpable Carotid palpable +/-

Neurological status Alert Anxious Confused Lethargic

Urine output (ml/h) Normal 20-30 5-15 Minimum

46 DRUG AND THERAPEUTICS BULLETIN OF NAVARRE. SPAIN

The most frequent cause of shock is hemorrhage lling of the left ventricle. Exemplary injuries that
(cause of early and preventable mortality) though follow this mechanism include tension pneumo-
other types of shock also should be considered thorax and cardiac tamponade.
and could appear concurrently in the same patient:

Neurogenic shock
Hypovolemic shock
This type of shock is associated with spinal trau-
Mainly reflects blood loss which can be estimated ma affecting the cervical spine or high thoracic
by the ATLS classification (table 3). It is important vertebral column. The clinical condition involves
to identify the site of the bleeding: extenal hemor- the suppression of sympathetic innervation of blo-
rhage (visual diagnosis) and/or internal in one or od vessels and the heart leading to peripheral va-
more of the four cavities: sodilation (relative hypovolemia, dry flushed skin)
and bradycardia (a confounding factor). A high in-
· Pleural-thoracic. It may cause a massive hemo- dex of suspicion is important in this type of shock
thorax (look, listen and feel) because initially it is not outrightly manifest, and
often causes difficulty to evaluate hypovolemic
· Peritoneal. One should suspect organ damage. shock (due to bradycardia) and evaluate pain
Initially there may be scarce symptoms until a blo- when exploring the abdomen, pelvis or long bo-
od loss of 2,000-3,000 mL. The abdominal exami- nes. In case of spinal injury with neurological com-
nation is of little value. If the patient is in shock promise, it is primordial to rule out bleeding, im-
then we should first suspect an abdominal injury mobilise the patient and arrange early transfer.
until ruled out by imaging such as focussed as-
sessment with sonography for trauma (FAST) or
computed tomography. MANAGEMENT OF PATIENTS IN SHOCK

· Retroperitoneal–pelvic. This is associated with The aim of management of shock is to provide

unstable fractures of the pelvis, with arterial or oxygen supply to tissues reversing metabolism
more frequently venous blood loss, soft tissue and from anaerobic to aerobic. The following indica-
bone damage (in the latter 80% damage can be tions are useful in treating these patients:
reduced with closing of the pelvis). A high index of
suspicion could be obtained from the injury me- · Guarantee a secured airway and correct ventila-
chanism and the physical examination (pain, equi- tion.
mosis in the perineal region and scrotum, rotation · Control bleeding. Control of hemorrhage is the
and deformity in the lower extremity). Currently, all most effective way to adequately manage shock. In
maneuvers to establish stability of the pelvis are case of external hemorrhage, this should be carried
not recommended as they are hardly specific and out in tandem according to the site of bleeding:
increase the probability of further bleeding. If an
open pelvic fracture is suspected then the pelvis - Direct pressure over the wound with sterile
should be “closed” (immobilised) until ruled out by padding or bandage.
diagnostic radiological imaging15,16. - Elevation of the limb, if the wound is located in
a non fractured extremity.
· Long bones-soft tissue. Femur fractures can - Pressure at a proximal site to the wound to
cause blood loss of up to 1,500 mL17. compress the responsable artery pressure
points (axilary, femoral)
- Torniquet. It should be the final resort when all
Cardiogenic shock else fails and is used in amputations.

This can be due to intrinsic or extrinsic causes re- In case of internal hemorrhage, the majority of ble-
sulting in cardiac pump failure. eds require surgical control and/or angiography.
Supportive treatment with blood products to rees-
· Intrinsec. This may be due to contuse cardiac in- tablish delivery of oxygen may also be needed.
jury after chest trauma with an alteration in con-
tractility, arrhythms (which guides the diagnostic - Pleura-thorax: aggressive management of the
suspicion) and mechanical complications (ventri- airway and ventilation, and consideration of chest
cular or valve rupture). decompression by tube thoracostomy in cases of
massive hemothorax or needle thoracostomy in
· Extrinsic. Here increased intrathoracic or intra- tension pneumothorax.
percardial pressure causes diminished cardiac fi- - Abdomen: early transfer to a trauma center.
 PREHOSPITAL MANAGEMENT OF TRAUMA PATIENTS 47

- Retroperitoneum-pelvis: by simply “closing” the tion of an inflammatory systemic response. More-

pelvis, venous bleeding, soft tissue and bone in- over, the correction of blood pressure levels did
jury can be reduced. This can be done applying a not necessarily guarantee adequate perfusion of
sheet, or an inverted FernoKed, or the vacuum tissues, especially if bleeding was still uncontro-
Mattress, or commercial devices available which lled. Currently, the tendency in prehospital scenes
should be maintained until a pelvic radiograph is is to titrate fluid therapy indistinctly in blunt trauma
obtained to confirm or rule out injury15. and mostly in penetrating trauma.
- Long bones: like the femur, which requires ade-
quate immobilisation (preferably splints with trac- Different fluids can be used, although none posses-
tion). ses the capability of transporting oxygen. These
fluids differ in expansion of volemia, permanence in
· Hypothermia. The most important aspect in the the intravascular compartment and in adverse e-
management of hypothermia is prevention. Hypo- ffects.
thermia can produce myocardial dysfunction, va-
soconstriction, electrolyte disturbances and coa- · Crystalloids / Ringer lactate solution. These are
gulopathy, contributing to the trauma triad of safe and not expensive. However, only 33% of the
death (acidosis, hypothermia and coagulopathy) solution remains in the intravascular compartment
that augments considerably mortality in these pa- thus large volumes are required.
tients. All wet and humid clothes should be remo- · Colloids. These remain longer periods in the intra-
ved and the patient well covered, while the interior vascular compartment and less quantities are nee-
of the ambulance or room should be conditioned ded. The most recommended today is HES 6%
to a temperature of 29ºC. Fluid and blood derived (Hydroxyethyl Starch, VoluvenTM). Maximum daily
products should also be warm. dose: 50 mL/kg.
· Hypertonic saline 7.5%. This is particularly benefi-
· Fluid resuscitation. Currently no solution is ca- cial in patients with head injury. Perfusion improves
pable of transporting oxygen (except blood) and with a reduction in cerebral oedema, and intracra-
thus in the prehospital environment the term repla- neal pressure but, in cases of vascular lesions, ble-
cement of volume is more adequate, ie: without eding may be increased due to an osmotic effect.
the possibility of transporting oxygen to tissues. · Oxygen Carriers. Purified artificial hemoglobin of
Transfer to a hospital should not be delayed by in- bovine origin HBOC-20121.
itiating fluid resuscitation at the scene of an acci- · Solutions with anti-inflammatory properties and
dent18,19. The normalisation of vital parameters Ringer ethyl pyruvate solution (experimental).
should not be the aim of an aggressive approach
to fluid replacement (what are the really “normal”
vital signs of a patient?) Aggressive and excessive Estimated blood loss can be evaluated with the
fluid replacement has its risks which include a di- response to the volume of fluid administered.
lutional coagulopathy, “concealing” the state of Three situations can occur:
shock (with normalised vital signs but with preca-
rious oxygen transport) and the pop the clot phe- · The patient improves. This suggests that there
nomenon causing new internal bleeding by dislod- has been a loss of up to 30% of volemia and the
ging a clot. Permissive hypotension however has rate of resuscitation is greater than the loss. These
been gaining weight in recommendations on fluid patients may need blood posteriorly.
management of the trauma patient. A maximum li- · The patient initially improves but later deteriora-
mit for systolic blood pressure of 90 mmHg (pal- tes. In this case there may be an increase in the rate
pable radial pulse) is a guide to fluid resuscita- of blood loss or a new site of bleeding appears or
tion16,20. there is a loss in hemostasis at the inicial site of blee-
ding (pop a clot phenomenon). The latter may be due
to aggressive approach in fluid resuscitation. The
Fluid therapy should be administered via wide bo- majority of these patients require surgery and blood.
re intravenous access (ideally 12-14G). Two reaso- · The patient does not improve at all. This means
nable attempts to obtain an intravenous access that the patient loses more blood than what is ad-
should be performed before opting for an alterna- ministered or that the patient may not also be suf-
tive access (for example intraosseous). Currently fering from hemorrhagic shock. The former may
there is a debate on the automatic initiation of fluid have lost >40% of their volemia (Grade IV) and re-
replacement. Previously, the tendency was to ad- quire urgent surgery or embolisation with blood
minister 2,000 mL of crystalloids in 10-15 minutes derived products.
(ATLS, 1997)7. However, it was seen that aggressi-
ve resuscitation produced dislodging of clots (pop Considerations from a consensus on fluid mana-
a clot phenomenon), hypothermia and the activa- gement:
48 DRUG AND THERAPEUTICS BULLETIN OF NAVARRE. SPAIN

· Transfer of patients should not be delayed by IS THE PATIENT IN A CRITICAL CONDITION?

cannulation of intravenous lines. IS RAPID TRANSFER REQUIRED? WHAT
· Crystalloids should be considered as first choice. INTERVENTIONS SHOULD BE APPLIED
· According to the severity of shock, boluses of AT THE SCENE?
500 mL-1,000 mL of warmed cristalloids should
be administered until a radial pulse is palpated. The primary survey is usually carried out at the sce-
ne (except in cases of imminent danger). However
interventions at the scene should be limited. During
and after the primary survey, primary resuscitation
measures are carried out such as opening of the

D
Discapacity
airway, administration of high concentrated oxy-
gen, (FiO2>0.85), bag mask ventilatory support,
compression of external bleeding, and fluid repla-
cement may be initiated. In circumstances where
The level of conscious (LOC) of the patient, pupils there is a risk of death as in tension pneumothorax,
and signs of lateralisation should be evaluated at needle thoracostomy may be requiered urgently to
this point. The Glasgow Coma scale (GCS), provi- avoid early death. In a non-critical patient, splinting
des information on cerebral function and progno- of isolated fractures, dressing of wounds and pain
sis (table 4). A score between 14-15 correlates management, etc., may be performed.
with a mild head injury; 9-13, moderate and <8
with a severe head injury. However, the majority of injuries will need hospital
care and it is therefore important to reduce prehos-
It is convenient to carry out this neurological eva- pital delay within the critical period to increase the
luation every 5 minutes to detect changes in the posibilities of survival of the trauma patient. Once
level of consciousness. It is important to remem- the health care provider determines that the patient
ber that a GCS <9 is an indication for endotrache- is critical, then prompt transfer to an appropriate
al intubation and that a low level of consciuosness center becomes a foremost priority. Cannulation of
could be due to cerebral hypoxia, injuries in the intravenous access should not delay transfer and
central nervous system, drugs or alcohol, or meta- can be carried out en route.
bolic disturbances (hypoglycemia, seizures).

The size and reactivity of pupils to light and acco-

modation should be examined. A dilated pupil or Table 4. Glasgow Coma scale (GCS).
bilateral dilation or fixed pupils could indicate ce-
rebral herniation and require prompt surgical inter-
vention to reduce intracraneal pressure (ICP). RESPONSE SCORE
Aniscoric pupils in a conscious patient do not indi- Eye opening
cate increased ICP. No eye opening 1
To pain 2
To speech 3
Spontaneously 4

Best verbal response

None 1

E
Exposure
Incomprehensible sounds
Inappropriate words
Patient confused
2
3
4
Patient oriented 5

In the last step of the primary survey, all clothing Best motor response
should be removed to examine the patient entirely. None 1
Extensor response to painful stimulus 2
This should be carried out respecting the dignity
Flexion to painful stimulus 3
of the patient and in a way that prevents hypother- Withdraws from pain 4
mia. Once performed, the patient is covered to Localizes to pain stimulus 5
conserve body warmth and prevent hypothermia. Obeys commands 6
 PREHOSPITAL MANAGEMENT OF TRAUMA PATIENTS 49

Ideally, interventions at the scene should not take

more than 10 minutes. In rural or distant areas, he-
alth care providers who arrive at an accident scene
The majority of vital
should carry out an initial triage of patients and so- injuries require hospital
licit more resources depending on the type of acci-
dent, the number and severity of those victims in-
care and thus prehospital
volved. Once it is determined that a patient is management should not
critical and more resources are solicited for early
transfer, then primary resuscitation measures can delay transfer
be performed and a secondary survey completed,
while awaiting an ambulance or helicopter. Reeva-
luation of the patient involves detection of changes
in LOC, clinical condition, vital signs, management
of fluid therapy and analgesia, splinting of fractu-
res. All these measures may facilitate smooth han-
ding over of the patient once transfer commences.
WHERE SHOULD THE PATIENT BE
Transfer may occur from the scene of the accident, TRANSFERRED TO? HOW SHOULD THE PATIENT
local primary care centre, or secondary transfer BE IMMOBILISED?
from one hospital when more specialised care is
needed. Transfer is a delicate link in the manage- Immobilisation of the spinal column
ment of these patients and close vigilance of the
patients condition may be jeopardised. Thus du- Once access is made to the trauma victim, stabili-
ring transfer of the patient the patient should be re- sation of he cervical spine should be performed.
evaluated frequently especially after any changes The reason for this is to prevent, if not already oc-
in the clinical condition. A secondary survey can al- curred, any spinal injury. In-line immobilisation of
so be performed if time allows and other therapeu- the cervical column is carried out and maintained
tic measures should be carried out depending on with no traction until a cervical collar is placed.
the duration of transfer. The cervical collar however does not completely
relieve us of stabilising the neck. It should be reca-
lled that the cervical collar limits flexo-extension
and lateral movements but does not provide
IF THE PATIENT IS NOT CRITICAL, HOW SHOULD 100% immobilisation. The collar should not inter-
WE PROCEED? fere with the ability of the patient to open the
mouth or breathe13.
Secondary survey
Maneuvers to extricate the patient from the vehi-
Anamnesis and directed physical examination cle should be carried out with the cervical collar in
place and manual in-line stabilisation maintained.
The prehospital health care professional should Once the patient is placed on a long spinal board,
complete the primary survey, identify potentially then complementary head blocks should be ad-
mortal injuries and initiate treatment and evalute ded with strapping. Cervical spine immobilisation
the efectiveness of these interventions. Once the should also be accompanied by full spinal column
primary survey is completed then a secondary sur- immobilisation on a long spinal board.
vey which consists of a brief head-to-toe examina-
tion of the patient is performed. The responsibility of cervical spine immobilisation
should be assumed by one of the members of the
The objective of the secondary survey is to identify rescue team. Preferably, neither the physician nor
problems that are not potentially vital, using the lo- the nurse should be given this responsibilty, but
ok, listen and feel technique in all regions of the rather ideally could be handed over to the ambu-
body. A summary of the secondary survey is lance technician who, by doing so, frees the rest of
shown in table 5. the team to focus on other aspects of manage-
ment.

In victims of penetrating trauma, cervical immobi-

lisation should be performed in cases of neurolo-
gical abnormalities during the physical examina-
tion. In blunt trauma, spinal immobilisation is
50 DRUG AND THERAPEUTICS BULLETIN OF NAVARRE. SPAIN

Table 5. Secondary evaluation.

Anatomical area Signs Notes

Head Evaluate scalp. open wounds, bleeding, bone Skull base fractures: early signs: (hemotypanum,
displacement. Careful palpation of bone margins. oto-rhino cerebro spinal fluid, conjuntival hemor-
rhage) and late signs: (racoon eyes, Battle sign).

Neck Pain, crepitus, deformity and echimosis, Mantain in-line neutral stabilisation.
emphysema at neck. Suspect pneumothorax if subcutaneous emphy-
Jugular vein distension. Ausculate carotid arteries sema. If jugular vein distension, and tracheal de-
for murmurs (possible dissection). viation (suspect tension pneumothorax or cardiac
Open or penetrating wounds. tamponade).

Spine Echimosis, pain, crepitus. Auscultate posterior chest.

Paralysis, paresthesia, rectal tone. To evaluate the spine, turn the patient on the side
with coordination with the team.

Thorax Pain, open rounds, abrasions, deformities and Open pneumothorax.

abnormal movements or assymetry in the chest Tension pneumothorax.
wall. Bone crepitation, and subcutaneous Cardiac tamponade.
emphysema. Hemothorax.
Seat Belt injuries.
Auscultate anterior y lateral sides of chest.

Abdomen Hematoma. Distension, abrasions and echimosis. Seat belt sign: suspect injury to duodenum and
Abdominal guarding on palpation: low sensitivity lumbar spine fractures (Chance fracture)
and specificity. Abdominal auscultation has little value.

Pelvis Suggestive signs of pelvic fracture: pain, abdomino- Hematoma in expansion.

pelvic distension, and unstability. Hemorrhage in If suspected pelvic fracture, do not palpate: immo-
urethral meatus, hemorrage in scrotum, defomities bilise, and wait to cofirm or rule out fracture from
in lower extremities with shortening and external radiology.
rotation, palpation of bone fragments in vagina and
rectum. Ascended prostate gland.

Extremities Pallor, pulses, weakness or paralysis, sensitivity. Repeat examination and check pulse, etc., alter
any maneuver or immobilisation of a limb.

Neurological examniation Glasgow coma scale. In case of neurological deficit, suspect spinal in-
Pupils (size, symmetry, and response to light). jury, immobilise and transfer.
Sensory-motor examination (dermatomes-
myotomes).

History (AMPLE) Allergies. Vital signs:

Vital signs Medications. Blood pressure, heart and respiratory rate, tempe-
Past medical history: COPD, heart failure rature, pulsioximetry, colour, GCS with re-evalua-
(reduced cardiorespiraory reserve). tions every 5-10 minutes and at lesser intervals if
Last meal changes are observed.
Event.
 PREHOSPITAL MANAGEMENT OF TRAUMA PATIENTS 51

carried out in patients with abnormal level of cons-

ciousness (GCS<15), anatomical abnormality, mo- Transfer of the patient
tor or sensitive deficit, and pain on spinal percus-
sion22,23. Immobilisation is also indicated when the
should be made to an
injury mechanism is preoccupying, if there are appropriate centre, that is
signs of alcohol or drug intoxication, or in the pre-
sence of any distracting injuries (due to pain or one which will resolve the
profuse bleeding) or in case of inability for com-
munication (due to age, disease or lack of fluency
majority if not all major
in the spoken tongue). In any case, the prehospital injuries of the patient
health provider should use careful judgement and
in case of doubt apply spinal immobilisation where
deemed necessary.

tanyl or morphine chloride administered intrave-

Transfer nously and in progressive doses (for example,
successive 2 mg doses up to a total of 10-15 mg
In patients in critical condition, early transfer is the of morphine chloride) will provide safe pain relief,
foremost priority at the scene. Delay in initiating making the transfer more bearable for the pa-
the transfer of critical patients should not be cau- tient25. A professional approach and constant
sed by any technique which can be performed en communication with the patient throughout mana-
route. gement can transmit confidence and contribute to
collaboration on the part of the patient and family
Transfer of critical patients should be made to “ap- members.
propriate centres”, that is where both specialist
and technical resources are available to manage Lastly, it is important communicate with the recei-
the majority, if not all the injuries adequately. The ving centre. The prehospital professional should
availability of specialists in neurosurgery, thoracic alert and inform the receiving centre as soon as
and vascular surgery, etc., are often vital to resolve possible of the patient and an approximate time of
the problems of the trauma patient and thus the arrival. It is crucial that the receiving centre is pre-
latter should be transferred to a center where the- pared beforehand. Once the patient is brought in,
se resources are available. Timing is also an im- handing over should be accompanied by both ver-
portant factor the prehospital provider should bal and written information. In the prehospital me-
consider in relation with the condition of the pa- dical report, the injury mechanism and a complete
tient. It may occur that a patient may require trans- account of events, time intervals, treatments and
fer to a district hospital where initially life saving response to treatments should be detailed. In ad-
surgical intervention and control of internal blee- dition this medical report should serve as an indi-
ding can be performed. Once resolved secondary cator of the quality of prehospital management as
transfer may be needed to a tertiary hospital to co- well as a legal document relating all measures ca-
ver all the needs of the patient. rried out during management. It is useful to re-
member that “whatever is not recorded in the me-
During transfer, after a primary survey and initial dical report was not done at all”.
resuscitation measures, the patient should be
continually monitored and vital signs recorded.
The primary survey should be repeated during the Final note
journey and after any change in the condition of
the patient. The re-evaluation of the ABCDE can The introduction of the Advanced Trauma Life Sup-
help discover any other injury not detected earlier, port (ATLS) courses is a landmark in the manage-
or any change in the clinical condition of the pa- ment of trauma victims7. The principles applied in-
tient. clude first treating injuries that most threaten
survival of the patient, and applying therapeutic
Two fundamental aspects in the management and measures to injuries without a definitive diagnosis.
transfer of patients are pain management and The ATLS has been directed principally by colleges
psychological support. Infrequent use of opiod of surgeons and the courses have extended world-
derivatives and fear that they may worsen respira- wide. A great part of the contents of the present ar-
tion or cause hemodynamic instability limits the ticle has been based on ATLS principles and me-
use of the agents. Drugs such as tramadol24, fen- thodology.
52 DRUG AND THERAPEUTICS BULLETIN OF NAVARRE. SPAIN

Table 6. Summary of the management of prehospital trauma patients.

Priority actions Evaluation Indicators of severity

Safety at the scene Need for more resources Some indications for airway intervention:
Glasgow<8, Severe head injury
Extreme agitation
Primary survey Airway compromised
A Airway C-spine control, oxygen Hemodynamically unstable
B Breathing Detect signs of shock Hipoxia depsite high flow oxygen
C Circulation and control Glasgow, pupils, neurological deficit Respiratory fatigue
of bleeding Control temperature Inhaled burns
D Discapacity Critical: Primary resuscitation,
E Exposure immobilisation, and early transfer Possible interventions in situ:
Non critical: secondary survey, transfer Tension pneumothorax: needle decompression
Open pneumothorax: occlusive dressing (3 sides)
Cardiac tamponade: early transfer
Decision Head-to-toe, not forgetting spine Hemothorax: volume replacement, early transfer

Findigs that indicate probability of severe trauma

Evaluación secundaria Alergies, Medicacion, Personal history, which may require early transfer:
AMPLE Last meal, Event
Age and previous co-morbidity

Immobilisation Transfer to an appropriate centre and early Anatomical:

Transfer communication Facial injury (threatens airway)
Pain management Flail chest
Re-evaluation Amputation
Suspected pelvic fracture
Neurological deficit
Other associated injuries: burns
Moderate-severe head injury

Physiological:
Respiratory rate <10 or >30
Glasgow<14
Systolic BP<90 mmHg
Loss of radial pulse

Injury mechanism:
High energy and velocity
Ejection from vehicle
Death of accompanying passenger
Fall > x2 patients’ height
Complicated extrication
Penetrating trauma
 PREHOSPITAL MANAGEMENT OF TRAUMA PATIENTS 53

However, in the last few years the adaptability of Conclusions

the ATLS to health systems in European countries
and the rest of the world has been questioned,
with the exception of the USA26,27. The critics con- Management of trauma patients should be
sider that management of severe trauma patients guided by some principles among which
in Europe is much more multidisciplinary involving include:
professionals ranging from primary care, medicali-
sed ambulances, emergency physicians, anaes- The sum of actions carried out during the
thesiology, thoracic surgery, general surgery, in- critical period is a determining factor in the
tensive care, to traumatology and orthopedics. short and long term survival of patients and
Thus they propose collaboration from all the impli- posterior morbidity. Lost time consumes
cated parts in the elaboration of a multidisciplinary lives.
approach. Since 2006, the European Resuscita-
tion Council (ERC) in collaboration with other Eu- Priorities in management should be clear.
ropean scientific societies have initiated the Euro- Life prevails over function and this over
pean Trauma course that intends to cover the aesthetics.
exposed deficiencies28. The impact of this course
in the European context is yet to be seen. The aim of the primary survey is to detect
(and treat) life-threatening injuries.
In any case there is no doubt that an early respon-
ding, fast and systematic approach in prehospital Treatment of the critical patient is nearly
management is necessary in whatever system as always hospital based and transfer to an
this greatly determines survival. appropriate center should not be delayed.

The absence of a definitive diagnosis should

not impede the application of therapeutic
measures.

Psychological suffering and pain should not

be left unattended.

In all aspects of management take in to

account the basic principle: primum non
nocere.
54 DRUG AND THERAPEUTICS BULLETIN OF NAVARRE. SPAIN

References

1. Informe sobre la salud en el mundo 2001. Salud 15. Lee C and Potter K. The prehospital management
mental: nuevos conocimientos, nuevas esperanzas. Gi- of pelvis fractures. Emerg Med J 2007;24:130-133.
nebra, Organización Mundial de la Salud, 2001. 16. Sukumaran S, Henry J, Beard D et al. Prehospital
2. Prada C, Prada R, del Río MC, Alvarez FJ. Acciden- trauma management: a national study of paramedic ac-
tes de Tráfico en la población española. Med Clin (Bar) tivities Emerg Med J 2005;22:60-63.
1995;11;105(16):601- 4. 17. Lee C and Potter K. Prehospital management of
3. Trunkey DD. Trauma. Sci Am 1983;249:28-35. lower limb fractures. Emerg Med J 2005;22:660-663.
4. Lerner EB, Moscati RM. The golden Hour: scientific 18. Revell M, Porter K and Greaves I. Fluid resuscita-
fact or medical urban legend? Acad Emerg Med tion in prehospital trauma care: a consensus view
2001;8(7):758-760. Emerg Med J 2002;19:494-498.
5. Claudon L. Influence on grip of knife handle surface 19. Bickell WH, Wall MJ, Pepe PE, Martin RR, Ginger
characteristics and wearing protective gloves. Appl Er- VF, Allen MK et al. Immediate versus delayed fluid re-
gon 2006;37(6):729-35. suscitation for hypotensive patientes with penetrating
6. American College of Surgeons. Advanced Trauma torso injuries N Eng J Med 1994;331(17):1105-9.
Life Support Program for doctors. 7Th Ed. Chicago: 20. Salomone JP, Ustin JS, McSwain NE and Feli-
American College of Surgeons; 2007. ciano DV. Opinions of trauma practitioners regarding
7. Prehospital Trauma life Support Comittee of the prehospital interventions for critically injured patients.
Nacional Association of Emergency Medical Techni- Journal of Trauma-Injury Infection & Critical Care
cians in collaboration with The Committee on Trauma of 2005;58(3):509-517.
the American College of Surgeons. PHTLS Soporte vital 21. Cohnheim RL and Haras BA Haemoglobin thera-
Básico y Avanzado en el trauma prehospitalario. 6ª Ed. peutics in hemorrhagic shock. Current Opinion in Criti-
Madrid: Elselvier Mosby; 2008. cal Care 1998;4:442-446.
8. Bierge Ruiz A, Siles Suarez L. Revisión. Manejo 22. Chan D, Goldberg R, Tascone A, Harmon S and
prehospitalario de la via aérea en el paciente politrau- Chan L. The effect of spinal inmobilization on healthy
matizado. Emergencias 1999;11:47-53. volunteers. Ann Emerg Med 1994;23(1):48-51.
9. European Resuscitation Council. Airway manage- 23. Ross SE, O´Malley KF, De Long WG, Born CT and
ment. In: European Resuscitation Council. Advanced Schwab CW. Clinical predictors of unstable cervical
Life Support. 5th Edition. London: Resuscitation Coun- spine injury in multiply injured patients. Injury 1992;
cil (UK); 2006. p. 41. 23(5):317-9.
10. Drug-Assisted Intubation in the pre-hospital set- 24. Vergnion M, Degesves S, Garcet L and Magot-
ting. Ann Emerg Med 2005;46(2):214. teaux V. Tramadol, an alternative to morphine for treat-
11. Grmec S, Mally S. Pre-hospital determination of ing posttraumatic pain in the prehospital setting. Anesth
tracheal tube placement in severe head injury Emerg Analg 2001;92(6);1543-1546.
Med J 2004;21;518-520. 25. Alonso-Serra HM and Wesley K. Prehospital pain
12. Bamgbade O, Macnab W and Khalaf W. Evalua- management. Prehosp Emerg Care 2003;7(4):482-8.
tion of the i-gel in 300 patients. Eur J Anaesthesiol. 2008 26. McKeown D. Should the UK develop and run its
Jun 6:1-2 (Epub, doi:10.1017/S0265021508004511). own advanced trauma course? (Ed). Emerg Med J
13. Dinsmore J, Maxwell W and Ickeringill M. Early ex- 2005;22:2-3.
perience with the iGEL. Resuscitation 2007;74(3): 574 - 27. Southern D and Sen A. Training for Trauma (Ed).
575. Anaesthesia 2007;62(9):865-867.
14. Eckstein M and Suyehera S. Needle thoracosto- 28. Nolan J. Training in trauma care moves on the Eu-
my in the prehospital setting. Prehosp Emerg Care ropean Trauma Course. Resuscitation 2007;74(1):7-12.
1998;2(2):132-5.
ISSN EDITORIAL BOARD
1138-1043 Isabel Martín Montaner (chairwoman)
Cristina Agudo Pascual
COPYRIGHT Mª José Ariz Arnedo
NA-1263/1997 Jesús Berjón Reyero
INFORMATION AND SUSCRIPTION José Ignacio Elejalde Guerra
Servicio Navarro de Salud / Osasunbidea Idoia Gaminde Inda
Plaza de la Paz, s/n Maite Hermoso de Mendoza
31002 Pamplona Rodolfo Montoya Barquet
T +34 848429047 Lourdes Muruzábal Sitges
F +34 848429010 Mercedes Noceda Urarte
E-mail Javier Lafita Tejedor
farmacia.atprimaria@cfnavarra.es Cristina Ibarrola Guillén
Juan Erviti López (coordinator)

WEB PAGE
http://www.cfnavarra.es/WebGN/SOU/publicac/BJ/sumario.htm