Case summary:

An ALS first responder crew and an ALS transport crew were dispatched to the scene to a middle-aged man who was reportedly stabbed in the face.  Local law enforcement secured the scene and then EMS approached the patient to render care.  They found the patient covered in blood and holding two dish towels to his face which were soaked in blood.  The patient was talking and denied loss of consciousness, dizziness or difficulty breathing.  The patient did endorse being on a blood thinner.  EMS assessed the wound and noted pulsatile bleeding, so the wound was covered with a large dressing.  The crews on scene requested an aircraft be dispatched as they loaded the patient into the transport unit.  Scene time was 4 minutes.

Transport was initiated immediately with the medic from the transport crew and two first responders for extra support given acuity.  Team re-assessed the dressing in route and notices the dressing was soaked with blood but airway remained clear and patient was awake and talking.  Dressing was removed and wound was packed with quick clot and direct pressure was applied to the wound by multiple providers.  Despite this, blood continues to soak through the dressing.  Third provider in squad places an IV.  Crew arrives at ED 4m after leaving scene and 16m after the stabbing occurred.  Care handed off to ED with helicopter still in route.  Vitals were not obtained but patient was still talking and maintaining his airway.

Highlights of the case:

Calling for a helicopter in the field

The golden hour of trauma is the idea that what happens in the first one hour after the traumatic injury largely determines if a patient will live or die.  Much of what happens in the golden hour of trauma is dictated by the decisions of EMS providers.  One critical decision is mobilization of an aircraft to speed up transport to the highest-level trauma center in the region.  Helicopter EMS is a limited and costly resource, so we want to make sure that we are requesting it for patients who truly will benefit from it.  In terms of requesting a helicopter for trauma, we should defer to local protocols.  In Northeast Ohio, we utilize the Northeast Ohio Trauma System (NOTS) trauma field triage to determine when a helicopter should be considered.  For any patient with injuries or vitals that are listed in the red boxes, it would be reasonable to consider calling for a helicopter in the field.  This is potentially true even if there is a nearby lower-level trauma center since the goal is to get this patient to the highest-level trauma center in the region.  There is some nuance to this, so it is best to discuss this with your own medical director to see what the recommendation is where you practice.  A picture of the red criteria are included below.  If you look at these criteria, you will notice that mechanism of injury alone does not get you into the red criteria.  This means that no matter who bad the trauma looks, that in itself does not trigger a helicopter.  For the patient in this case, he had penetrating trauma to the face (which is on the head) so this meets criteria for a helicopter and the crew did the correct thing mobilizing this resource as quickly as possible.

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

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 assessed the patient airway and noted no bleeding or expanding hematoma as well as re-evaluated the airway throughout transport.  Keeping the patient talking the entire time is a good way to do this.  They also attempted to control the bleeding.  Their times from patient contact to transport were very quick, which is best practice in trauma care.

Hemorrhage control

Hemorrhage control is the most important aspect of trauma care and for this reason is listed first in almost every modern trauma treatment algorithm.  We should have low thresholds to place tourniquets for bleeding coming from the extremities as well as pelvic binders if there is any suspicion for a pelvic fracture.  Treating bleeding coming from the torso, head and neck can be more difficult.  Direct pressure is our best means for hemorrhage control, but this needs to be point pressure.  A single finger over the source of bleeding is much more effective than a bulky pad or the palm of a hand.  The patient in this case had known arterial bleeding coming from a laceration to the face.  The best way to control the bleeding would have been to to expose the wound and put one or two fingers directly over the pulsatile bleeding.  Gauze can then be used to clean up the extra blood to ensure that the bleeding is control and if not, another finger can be placed over the additional source of bleeding.  Once bleeding is controlled, pressure is maintained until a physician tells you to move your finger.  We never want to check to “see if the bleeding has stopped” because most likely it has not and there is a chance once we lose control that we will never gain control again.

Once this patient arrived in the emergency department, the emergency physician removed all the dressing and noted persistent arterial bleeding from what was likely the mental artery and another venous bleed.  He used two fingers, one on the artery and another on the vein and was able to get complete control of the bleeding.  Remember, a single finger is far more powerful than an entire hand when it comes to hemorrhage control.