Case summary:

An ALS crew was called to a 50s man who was involved in a motorcycle accident.  He was not wearing a helmet and found 30 feet in front of his bike.  Patient was found lying on the ground, restless and with a trail of blood coming from his head.  The patient was Spanish speaking only so the crew could not communicate well but the patient was speaking to them.  No obvious signs of external bleeding.  The crew placed the patient in a C-collar, moved the patient onto a back board and quickly extricated to the ambulance.  The crew initiated transport to a trauma center as soon as the patient was secured and continued assessment in route.  The crew obtained vitals while working on an IV.  They were not able to get a blood pressure since the patient was agitated and flailing his extremities. 

Vitals: HR 130, RR 22,  Sat 98% on O2

The crew gave fentanyl for analgesia to see if this would help relax the patient.  Given the patients HR and concern for internal bleeding, the crew gave 2g IV tranexamic acid (TXA).  The crew spiked a bag of fluid and had it ready to treat hypotension or hypoperfusion.  While the crew could not get a blood pressure, the patient had a strong radial pulse, so they did not start the fluids to allow for permissive hypotension.  Pelvis was assessed and was stable.  Crew noted bilateral breath sounds and equal chest rise.  Upon re-assessment, the patient was more diaphoretic, and the crew could no longer feel a radial pulse.  Given this, they started fluids and notified the receiving facility of the worsening condition.  Shortly after this, the crew arrived at the trauma center and handed off care to the trauma team.

 Highlights of the case:

 Place spinal motion restriction before extrication

This patient is altered in the setting of blunt trauma with a high mechanism of injury.  This patient is at very high risk for a cervical spine injury and given the patient is altered and likely has a distracting injury, we are unable to clinically clear his cervical spine and he requires cervical motion restriction with a C-collar.  The crew recognized this and placed in the patient in a collar as soon as possible and prior to ever moving the patient.

Transport is the priority in trauma

Trauma patients are load and go patients.  The only exception is airway intervention and stopping bleeding (tourniquet, pelvic binder, ect).  Everything else, including IV, full vitals, full assessment, ect, should occur after wheels are rolling to the hospital.  This is because trauma patients die of head injury and internal bleeding, neither of which we can fix in the field.  For this reason, the goal is transport to get the patient to the surgeons and blood as soon as possible.  Once this patient was extricated, they immediately started transporting leading to the shortest possible scene time.

Tranexamic Acid (TXA) for hemorrhagic shock

TXA works by preventing the breakdown of formed clots.  In the setting of trauma, this can help decrease internal bleeding.  There is a risk of too much clot formation leading to DVTs and PEs, however, the risk of immediate death from massive hemorrhage is much higher than this risk.  Our protocol recommends giving TXA to trauma patient with current or previous uncontrolled bleeding with a HR >120 or SBP <90.  We should never delay transport or more critical interventions to give TXA, but we should attempt to administer it as soon as possible.  This crew correctly gave TXA to a patient that met our inclusion criteria after transport and more critical interventions were performed. 

Permissive hypotension should be used for trauma patients.

In trauma, patients are most often hypotensive from hemorrhage.  Patients are bleeding blood, not crystalloid, therefore we need to replace this volume loss with blood since that is what they are losing.  Unfortunately, most EMS agencies do not carry blood products.  We know that giving too much crystalloid can be harmful for three reasons.  The first reason is that it can dilute out clotting factors leading to increased bleeding.  The second reason is that if there is a hole in a vessel, increased blood pressure speeds up the bleeding through that hole.  Lastly, the body might have formed a semi-stable clot on the injured vessel and increasing the blood pressure knocks the clot off causing more bleeding.  At the same time, hypotension is bad since the body is not delivering oxygen to vital organs.  We balance all this by utilizing the idea of permissive hypotension.  This is where the goal of fluid resuscitation in trauma is to keep the SBP > 90 mmHg.  This way we try to ensure that vital organs are being perfused while minimizing the volume of fluids we are administering to patients.  While this crew could not get a blood pressure due to agitation, they used his radial pulse as a metric for perfusion.  At first, the patient had a radial present, so they hung fluids in preparation for infusion but did not start them.  Once the patient lost his radial pulse, they were already prepared to give fluids.  This crew was thinking ahead and being proactive in their resuscitation which was fantastic EMS care!