Sometimes, the best medicine is the decision to avoid unnecessary interventions, the authors write. (Photo/Adam Mason)

Prehospital trauma management has changed significantly in the last 30 years. Despite the advances in prehospital medicine, data from evidence-based medicine, and effective hemorrhage control strategies, trauma patients still die from potentially preventable conditions. Specifically, reversible hemorrhage is implicated in a fair amount of preventable trauma-related deaths.1,2,3 Current evidence reveals that many prehospital trauma strategies do not significantly affect morbidity and mortality. Furthermore, “time honored” interventions such as anterior chest wall needle decompression may be ineffective at best.4,5 Intravenous fluid therapy in the unstable penetrating trauma patient contributes to additional call time and portends poorer outcomes.6,7 The very act of establishing intravenous access instead of intraosseous access in the time critical patient is often detrimental.8,9,10

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Counterproductive interventions compounded by other physiology manipulating interventions, such as premature invasive airway management in a hemodynamically unstable patient with an otherwise stable airway, can lead to disastrous consequences. We offer this retrospective review article to teach us to be introspective and disciplined in our prehospital decisions. Prehospital interventions for trauma related injuries should be guided by the ability to meaningfully impact patient morbidity and mortality. Indeed, rapid transport to a facility capable of delivering definitive care can be considered a mortality informed treatment. On occasion, more can be done for our patients when less interventions are performed.

As technology improves, one would expect to see significant improvement in prehospital trauma patient outcomes. In stark contrast, the compelling evidence is that prehospital trauma care beyond the basic life support level is often unnecessary and results in poor patient outcomes.7,11 Previous published studies show higher mortality rates with an increase in prehospital provider skill level.11 A 2016 study with 164,471 patients found that increased response time does not increase patient mortality and increased scene time for extrication does not increase patient mortality.12 However, prolonged EMS treatment scene time was directly associated with increased patient mortality.12 All patients in the study were statistically adjusted for age, sex, comorbidities, mechanism of injury, injury severity score, and other markers. Indeed, survival in trauma may be more related to distance from definitive care and the underlying severity of injury. Studies conducted in urban areas revealed that mortality following penetrating trauma is greater for patients transported by EMS than those transported by law enforcement or privately-owned vehicle.13,14 After patient injuries were adjusted for severity, the researchers found that survival was increased among patients with penetrating trauma if they were not transported by EMS.13

Penetrating trauma and hemorrhagic shock are absolutely time critical diseases, especially in the presence of uncontrolled, internal hemorrhage. Data extrapolated from numerous studies indicates that if a patient suffers a major, yet survivable traumatic injury, their odds of death increase two to four percent every minute until they reach a surgical suite or receive damage control resuscitation/massive transfusion protocol.15,16,17 In combat, mortality was 67% for patients who suffered a major ballistic injury and did not receive basic care or evacuation to definitive care within 30 minutes of injury.16 Therefore, time emerges as one of the most critical variables with respect to treatment decisions. The performance of additional procedures such as intravenous access or airway management must be weighed against the hazards linked to prolonged scene times. Interventions should be linked to a lifesaving imperative.

Prehospital Intravenous Access

For many prehospital systems, intravenous (IV) access remains a priority for major trauma patients. Prehospital providers believe that they must establish IV access while on scene before initiating transport to the hospital. However, prehospital IVs are often difficult to establish in trauma patients, with documented average times to establish between eight and 12 minutes.7 Current data reflects that in situations with short transport times to trauma centers, it is better to rapidly transport the patient to hospital than attempt interventions at the scene.7 The average prehospital IV increases scene time by five minutes.6,9 Tragically, attempts at IV access by prehospital providers on scene are often greater than the total transport time.8 Studies have also found that medical providers are slow to initiate intraosseous access, and often do so only after intravenous access attempts have failed.10

With such focus on prehospital IV access for trauma, responders must consider if IV access is beneficial to the patient. In 2009, the Eastern Association for the Surgery of Trauma reviewed all available literature regarding prehospital vascular access and fluid resuscitation for trauma, written in the English language, and published between 1982 and 2007.18 Their meta-analysis evaluated 3,392 published research articles. Upon review of all published literature, the researchers concluded two key points. First, there is insufficient data to show that trauma patients benefit from crystalloid fluid resuscitation. Second, and more importantly, prehospital providers should never attempt IV access at the cost of delaying patient arrival at definitive care.18

The best available evidence suggests several scenarios that may be appropriate for prehospital intravenous access on scene with major trauma patients. Given the lack of benefit associated with crystalloid infusion, providers must consider when the risks of IV initiation might outweigh the benefits. The following scenarios represent possible indications for initiating trauma patient IV access prior to transport: (1) when advanced airway management is emergently required and cannot be performed en route, (2) when chemical extrication is required, and (3) when blood products are available for immediate transfusion. Medical directors should review current prehospital trauma protocols to see if any other circumstances would prioritize IV access on scene against the known detriment of delaying transport. Indeed, indications for intravenous access should be made weighing the availability to deliver a therapy or medication clinically proven to improve survival (blood products, tranexamic acid, and other evidence-based care).

Prehospital fluid administration has additional side effects apart from the potential to delay arrival at definitive care. Crystalloid infusion directly correlates with an increased incidence of coagulopathy disorder on arrival to the hospitals.19,20 Approximately 28% of trauma patients arrive at the emergency department with traumatic coagulopathy.21 Traumatic coagulopathy is a multifactorial process that results in decreased clotting, autoheparinization and hyperfibrinolysis.22 Coagulopathy upon arrival to the emergency department represents a five-fold increase in mortality of trauma patients with shock.23

In addition to coagulopathy disorder, further research found that fluid resuscitation in hemorrhagic shock is proven to induce moderate (and sometimes severe) hypothermia.24 Several studies have found that ambient temperature fluid resuscitation rather than shock, was the main cause of decreased body temperature in hemorrhagic shock.24,25 Not only does prehospital IV access often delay transport, but the administration of room temperature fluid causes coagulopathy disorder and will likely induce hypothermia. The fluid resuscitation increases intravascular pressure destroying clots and the resuscitation hypothermia also inhibits clotting cascades. The addition of resuscitation hypothermia completes the lethal triad of trauma, skyrocketing the odds ratio of mortality in these patients. A 2016 study by Balvers and colleagues demonstrated hypothermia in trauma patients was associated with a significantly increased mortality both at 24 hours and 28 days.26 The degree of hematologic derangement is usually associated with increased amount of fluid administration.26

Finally, profound hypotension is reliably linked to adverse outcomes such as mortality and increased transfusion requirements.27,28 It is unclear if a targeted fluid bolus for the profoundly hypotensive trauma patient might confer a survival benefit versus no fluids. Perhaps, there is utility in titrating intravenous fluids to markers of peripheral perfusion. Trauma patients with altered mental status and circulatory collapse are at exceedingly high risk for death.27,28 Providers may consider a targeted fluid bolus in scenarios where blood is unavailable and there is evidence of circulatory compromise apart from tachycardia.27,28

Prehospital Airway Management in the Trauma Patient

On scene, advanced airway management for trauma patients is another technique that deserves scrutiny. Aside from the nature of difficult airways often associated with trauma, there is another significant problem seen with rapid sequence induction in trauma patients. Sedation and paralysis can induce cardiac arrest in multi-system trauma patients.29 Sedation and paralytics can blunt the body’s inherent sympathetic responses to trauma. The body’s self-regulated sympathetic surge of epinephrine and norepinephrine “push dose pressor therapy” is keeping the patient alive. Administering high dose sedation to facilitate airway management often reduces the intrinsic production of epinephrine and norepinephrine.30 This sudden decrease in epinephrine and norepinephrine may cause severe hypotension and decreased myocardial effort, resulting in cardiac arrest.

Other physiologic changes are linked to worsened outcomes following prehospital rapid sequence intubation. The rapid change to positive pressure ventilation causes a buildup of intrathoracic pressure. Positive pressure ventilation limits venous return and can further exacerbate hypotension following an intubation attempt. Patients in hemorrhagic shock have limited physiologic reserve. These critically ill patients require a cautious approach to airway management. In the absence of invasive hemodynamic monitoring, ultrasound, or other modalities, prehospital rapid sequence intubation of the patient in hemorrhagic shock remains a high-risk procedure.31,32

Airway management remains a priority, but treatment does not necessary require an invasive strategy. Basic life support airway management remains a very beneficial treatment modality, especially in urban settings. In the hospital or intensive care environment, an intra-arterial catheter or central venous catheter is inserted in hemodynamically unstable patients prior to undergoing anesthesia induction.29 This allows for damage control resuscitation, real time arterial pressure monitoring, and vasopressor therapy either before anesthesia, or in conjunction with anesthesia. Medications can be tailored to the underlying severity of shock and distressed physiology.

One of the most critical prehospital treatment interventions for trauma patients is to limit scene time.14 Prehospital medical directors and prehospital providers should work to identify procedures or activities that increase scene time and have little to no proven benefit to the patient. Every minute that prehospital providers spend on trauma scenes increases patient mortality. Specifically, increased mortality correlated with prolonged scene time in patients with hypotension, penetrating injury, and flail chest.8,28 Except for prehospital blood administration, trauma patients with uncontrolled internal hemorrhage will benefit very little from prehospital treatments other than rapid transport.33 Victims of serious penetrating trauma require damage control resuscitation and trauma surgery.

Treatment of Prehospital Tension Pneumothorax

Another area where prehospital providers may perform unnecessary interventions on scene is the broad application of needle thoracentesis without clinical manifestation of a tension pneumothorax. Decompressing a tension pneumothorax is certainly a life-saving intervention that providers must perform rapidly when indicated. However, the actual prevalence of a tension pneumothorax in thoracic penetrating trauma is quite low. Several published studies found that the prevalence of prehospital tension pneumothoraces was grossly exaggerated by prehospital providers. Some research suggests that the prehospital providers will perform 20 needle thoracenteses before they decompress one tension pneumothorax.34

A 2007 study found that the prevalence of a tension pneumothorax was as low as 0.3% in patients with penetrating chest trauma who were conscious when EMS providers made contact.34 The study’s author even admits that 0.3% is probably an overestimation.34 A similar study by Coats and colleagues in 1995 stated that approximately 60% of prehospital tension pneumothoraces occur with prehospital positive pressure ventilation.35

Many revert to the argument that it is better to decompress a chest that does not need it than to miss decompressing a true tension pneumothorax. While that axiom is true in some scenarios, prehospital providers can significantly reduce the number of iatrogenic pneumothoraces. The above argument possibly has led to the exceptional over-utilization of prehospital needle thoracentesis. With better diagnostic tools and assessment protocols, providers can reduce the number of unnecessary needle thoracentesis on scene, thus reducing scene time.

Prehospital ‘Time Thieving

Numerous studies show prehospital providers continue to perform time thieving, or inappropriate treatments on scene with trauma patients, albeit with best intentions. These time thief treatments include intravenous or intraosseous access, spinal immobilization, cardiac monitoring, needle thoracostomy and others.14,34,36 Again, the decision to perform an intervention must be fully evaluated in the context of expected patient risks and benefits. Currently, interventions associated with improved survival in the setting of hemorrhagic shock include hemorrhage control, expedient transport, and effective airway management. To ensure that providers are limiting scene time and only providing life-saving treatment on scene, any penetrating trauma scene time greater than 10 minutes should have medical director review and an explanation from the prehospital providers as to the delay(s). The ideal scene time interval for blunt trauma patients is not immediately clear, but a similar rationale for timely stabilization and transport applies.

In the interest of “Primum non nocere” (First, do no harm), prehospital providers and medical directors must candidly review their current trauma protocols to ensure compliance with evidence- based practice. Protocols often represent the continuation of dogma and outdated expert recommendations. Incorporation of position statements, review articles and relevant literature should direct the revision and application of treatment practices.

Make no mistake, the article’s authors are staunch advocates for the practice of prehospital medicine. All authors are active in prehospital practice, education and oversight. However, sometimes the best medicine is the decision to avoid unnecessary interventions. Prehospital providers may find that some treatments are indeed time thieves; unnecessary treatments that simply delay arrival to definitive care. With an increase in hostile mass casualty events, multiple after-action reports note that one of the most significant tactical decisions was the rapid transport of patients to area hospitals using any and every means possible.37,38 In many of these cases, best medical practice involved minimal on-scene interventions and rapid transport to definitive care.

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