Case summary:

 An ALS crew was dispatched for a motor vehicle accident involving a car and a motorcycle.  First responders were already on scene and were also paramedics.  They found a man in his 30s who was lying on the ground and had been riding the motorcycle.  He had reportedly been struck by the other vehicle and had not been wearing a helmet.  He was alert and verbal, but only oriented to self and repeating questions frequently. Bystanders did report a period of loss of consciousness prior to EMS arrival.  The crew performed a quick eval and found that he had a patent airway, non-labored breathing, a weak but regular pulse, an unstable pelvis, perineal laceration, deformity to the left upper arm, right foot deformity and all distal pulses were intact.  First responders placed an IV as transport crew was arriving on scene.  A C collar was placed, and the patient was extricated to the ambulance.  Transport was initiated immediately and vitals were obtained:

Vitals: BP 78/53,  HR 76,  RR 12  Sat 97% RA, GCS 13

The crew hung fluids and gave a 500cc bolus and placed the patient on O2.  The crew also called for a helicopter to be sent to the ED given this patient had poly trauma involving a potential pelvic fracture and hypotension.  The crew arrived and at the receiving hospital and gave hand off to the emergency department team.  Helicopter was in route to the receiving hospital.  Vitals at time of hand off were:

Vitals: BP 84/56  HR 80,  RR 12,  Sat 97% on O2, GCS 13

The crew moved very quickly to get the patient to the definitive care he needed.  Due to the crew requesting a helicopter from the field, the patient left was rapidly transported to a higher level of care.  I included the times below:

Scene time: 6m

Patient contact to ED hand-off: 8m

Injury to ED hand-off: 21m

Patient contact to patient in helicopter: 27m

Highlights of the case:

In trauma, the goal is to transport as soon as possible.

This has been mentioned before, but given how important this concept is, it is worth mentioning again.  In trauma, the priority is rapid transport.  The only exception is airway intervention and stopping bleeding (tourniquet, direct pressure, pelvic binder, ect).  EVERYTHING else, including IV, full vitals, full assessment, etc., should occur after wheels are rolling to the hospital.  This is because trauma patients die of head injury and bleeding, neither of which we can always fix in the field.  For this reason, the goal is to transport to get the patient to the surgeons and blood as soon as possible.  The crew who cared for this patient did exactly this.  They quickly assessed for bleeding and ABCs and then focused on rapid transport and deferred everything else until they were in route.  While an IV is never more important than transport in trauma, this was placed by the first responding crew and it did not delay transport.  First responders should package the patient up as much as possible to decrease the scene time once the transport crew arrives, but it is very reasonable to start thinking ahead to what needs to happen while in route and start that care on scene if still awaiting the transport crew.  The crew also called for a helicopter to be dispatched given the patient met our priority 1 criteria.  This led to the patient being on his way to a level one trauma center within 20 minutes of arriving at the initial emergency department. 

If signs of a pelvic fracture, a pelvic binder should be prioritized over transport.

While the goal in trauma is transport, there are some important exceptions that we have discussed.  One of those is treat any bleeding, both internal and external.  This patient had evidence of a pelvic fracture and was likely bleeding into his pelvis which was why he was hypotensive.  Placing a pelvic binder is critical in these situations and this should be a priority over transport since this can potentially prevent further bleeding in the pelvis.  Commercial pelvic binders are quicker to place and can be placed tighter than using a sheet, but use of a sheet is better than nothing at all.  The key to remember is that the binder must be placed over the greater trochanters on the femur and is not placed over the pelvis itself.  The reason is that this pulls the legs together and closes the pelvis which hopefully will tamponade off the internal bleeding.  This patient would have benefited from a pelvic binder.

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.

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.  This crew noted that the patient had a SBP <90 and gave a 500cc fluid bolus.  If the SBP becomes greater than 90mmHg, no more fluids should be given.

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.  While this crew did not give TXA, they focused on more critical things which included rapid transport to the hospital.  There was only a 2m transport time and the crew correctly focus on fluids and activating a helicopter in that short time frame which was more important than TXA.