Much different than distributive, obstructive, or cardiogenic shock that frequently uses pressor agents, like your push dose epinephrine, with hypovolemic shock, pressor agents are never the answer. In trauma, the cause of hypovolemic shock is hemorrhagic events. The cure for hemorrhagic shock is blood products and early surgical intervention as needed. The stages of hemorrhagic shock can help you in the evaluation of your trauma patient with some key points for care. The take-home is that even one hypotensive episode in a trauma patient is significant, even if corrected with minimal fluid resuscitation.

Stage I Hemorrhagic Shock is a blood loss of up to 750cc or 15% of total blood volume in the average adult. Some expectations:

         A) Heart Rate will be less than 100.

         B) Blood Pressure will be normal

         C) Pulse pressure will be normal.

         D) Respiratory Rate will be 14-20/minute.

         E) Urine Output >30cc/Hr.

         F) Mental status may show a patient who is slightly anxious.

Stage II Hemorrhagic Shock is a blood loss between 750cc-1500cc or between 15-30% of total blood volume. Some expectations:

• Heart rate will be 100-120 beats per minute.

• Blood pressure still is normal.

• Pulse pressure will narrow (normal 30-50, now 20 or less).

• Respiratory rate 20-30/minute.

• Urine output between 20-30cc/Hr.

• Mental status is mildly anxious.

Stage III Hemorrhagic Shock is blood loss of 1500-2000cc or 30-40% of total blood volume. Some expectations:

• Heart rate 120-140 beats per minute.

• Blood pressure decreased (note this is the first time you’ll see hypotension Critical Moment).

• Pulse pressure will be narrow <20.

• Respiratory rate 30-40/minute.

• Urine output 5-15cc/hr.

• Mental status anxious and confused.

Stage IV Hemorrhagic Shock is >2000cc or more than 40% total blood volume loss. Some expectations:

• Heart rate greater than 140 beats per minute.

• Blood pressure Decreased.

• Pulse pressure will be narrow <20.

• Respiratory rate >35/minute.

• Urine output negligible.

• Mental status: Confused and lethargic.

To summarize hemorrhagic shock, hypotension from bleeding with even one reading demonstrates a significant blood loss in a trauma patient. The second critical point is a lethargic trauma patient is near death, and aggressive measures need to be initiated. As always, get the patient to the right place for proper care.  Thanks for fighting the good fight and saving lives.

Don Spaner, MD

TXA - May 10, 2021

Hello Providers,

This week’s hot topic is trauma use of TXA. Last year the providers were hampered with an hour time frame of transportation, prohibiting the use of TXA in almost every situation. This year we now have removed the time restriction, thanks to the NOTS Board recommendation. That means we need you to start TXA in the pre-hospital arena. In fact, if the adult trauma patient (patients 16 years of age or older) are hypotensive, meaning a MAP of less than 65, or systolic less than 90, and a heart rate greater than 120 beats per minute, caused by traumatic blood loss, should receive TXA as soon as possible. The provider will take the 1GM vial and put it in the 100cc D5W bag and run it over ten minutes. Opening it up faster could cause hypotension. Always watch for signs of allergic reaction and treat accordingly. The trauma centers will start a second dose of 1 GM infusion over an 8-hour period. This is an agent that does not form clots. It stabilizes the clots formed by inhibiting plasminogen from converting to plasmin. Plasmin is a chemical used by the body to absorb clots. This is important in the long run, but minimizing plasmin formation during the acute hemorrhagic event should help maintain clot integrity. Thrombosis formation is still a listed side effect but this is an acceptable risk under the situation of traumatic hemorrhagic shock. Also, watch for nausea or vomiting and utilize Zofran as an antiemetic. Thanks for fighting the good fight and for all the lives you help save. Stay strong and healthy.

Don Spaner, MD

Trauma Triage - May 17, 2021

Hello Providers,

This week’s trauma topic is trauma triage. Our goal is always to get the right patient to the right place at the right time. Our protocol is in coordination with the regional and NOTS recommendations. NOTS has even presented this to the state EMS Board and their hard work has influenced the state’s recommendations. The idea is that the most critical patients should go to the highest level trauma centers, and less critical can go to lower-level centers. The beauty of these guidelines is, how crisp and clear the recommendations are. Notice the red boxes are considered Level I trauma patients unless it adds more than 15 minutes of transportation time to the traumatic event. Then, the provider should go to the next lowest level trauma center available. The red zone is separated as physiologic findings and anatomic findings.

Physiologic red zones:

1. Glasgow Coma Scale less than 13.

2. Systolic blood pressure less than 90mmHg

3. Respiratory rate <10 or >29 BPM or patient requiring ventilation or airway support

Anatomic red zones:

1. Significant penetrating injuries to the head, neck, torso, or extremities proximal to the elbow or knee.

2. Flail chest

3. Two or more proximal long bone fractures

4. Crushed, degloved, or pulseless threatened extremities

5. Amputation proximal to the wrist or ankle

6. Pelvic fractures

7. Open or depressed skull fractures

8. Paralysis

These physiologic or anatomic findings deserve an effort of the highest level trauma centers unless a delay of more than 15 minutes of transport time occurs, and then the next highest center available should be sought out.

The yellow zone is separated by mechanisms or special populations or circumstances. These patients lacking the physiologic or anatomic findings still deserve trauma care, but one should be comfortable in level IIs or IIIs. The guidelines list the following albeit in greater detail, but the following lists the yellow zone trauma candidates.

• Falls adults greater than 10 feet.

• High-risk crashes.

• Auto vs. pedestrian or bicyclist.

• Motorcycle >20mph.

• Other motorized events with a potentially significant injury.

• GCS 12-14 with other traumatic injuries.

• >65 years of age with trauma.

• Anticoagulated.

• Burns not covered in the red zone.

• Open fractures.

• Pregnancy trauma >20 weeks gestation.

• Remember EMS judgment alone can warrant a trauma center delivery.

If the patient does not meet physiologic, anatomic, or mechanism events for trauma, delivery to the nearest emergency department is appropriate.  

We all know the 5 exceptions to the Ohio Trauma Law. If immediate stabilization requires stopping at a nearby emergency department so the patient will make it to a trauma center that is appropriate and must be documented. Weather is a poor reason not to go to a trauma center as the emergency department you go to that is not a trauma center, still has to figure out a way to get them to a trauma center. In addition, utilizing mutual aid should negate the exception of putting your community at risk by leaving to transport to a trauma center. The northeast Ohio trauma centers do not divert trauma patients, so the fourth exception should be a moot point. Lastly, if the patient refuses to go to the trauma center, attempt to educate, document their decision and capacity to make decisions, and get them to a hospital. Thanks again for fighting the good fight and always helping to save lives.

Don Spaner, MD

SMR - May 24, 2021

Hello Fellow Providers,

This week’s trauma topic is spinal motion restriction.

We all remember the decades of placing patients on backboards for everything. I remember being in an ambulance crash as a paramedic, in which I had to lay on a backboard for over 4 hours. It took me a week to get over the pain from the backboard. I was 23 years of age at the time. If it happened now, I might never get over it. Fortunately, outside of extrication, backboards and KEDs have minimal use. That does, however, put a whole lot more onus on you, the provider. Sure it was easy to put someone on a board and move them anywhere. Now it takes teamwork and coordination to do this correctly. The following points are what I think helps in moving these patients according to our guidelines.

1. Follow the above categories and key points. Even if one is in the first category and there is no tenderness or pain complaint, transporting them in a neutral position is critical. Not everyone feels these initial injuries, especially with the high adrenaline one feels in a traumatic event.

2. Have a plan and execute it as a team. The movement of these patients requires teamwork, counting, and coordination. Since we’re only using boards to extricate, we need to become specialists in moving these patients from cart to cart.

3. Pain or tenderness requires collars and neutral positions. Collars provide almost no safe immobilization if the patient is sitting up on the cart.

4. Don’t place collars on patients in their cars and then have them stand and lay on the cart. Proper extrication is critical and then proper controlled log roll to get them off the board can be done safely.

5. Always document neuro checks before and after movement.

6. Significant findings like paralysis or paresthesia or even any altered mental state from trauma or intoxication require the third column of care. Many of you have moved to vacuum mattresses, and this is very acceptable. Keep them neutral, collared, and utilize teamwork for any movement.

Keep up the good fight and thank you for helping us save lives.

Don Spaner, MD