Pre-Hospital Trauma Care

Source: Sabiston Textbook of Surgery, Chapter 36

Overview

The prehospital phase begins immediately after injury. Optimal trauma care is time-dependent, and the prehospital team (including bystanders) plays an integral role.

Key statistics:

~50% of preventable deaths from exsanguination occur before hospital arrival
Analysis of >40,000 torso hemorrhage cases showed mortality rises with longer time to hemorrhage control - risk is highest within 30 minutes
Scene time and prehospital time are independently associated with mortality in penetrating injury (1-2% increase per minute)
Prehospital hypotension (SBP <90 mmHg) + GCS ≥8 = higher mortality with increasing prehospital time

Note: Rapid transport applies most clearly to hemorrhaging patients. For non-hypotensive or undifferentiated trauma, the transport time-mortality relationship is less clear.

Four Key Prehospital Priorities

Evaluate the scene - Safety first (ongoing violence, traffic, fire, chemicals, toxic agents, booby traps)
Perform initial patient assessment
Determine optimal triage and transport
Initiate critical interventions while providing safe transport

Field Assessment: xControl of Hemorrhage (MARCH-E)

The NAEMT Prehospital Trauma Life Support (PHTLS) course is the global standard for prehospital civilian trauma education. The assessment follows the MARCH-E mnemonic (adapted from military TCCC):

Step	Action
M - Massive hemorrhage	Tourniquets, wound packing, direct pressure
A - Airway	Airway assessment and management
R - Respirations	Breathing and ventilation
C - Circulation	Circulation and shock management
H - Hypothermia/Head	Prevent hypothermia; TBI assessment
E - Everything else	Secondary concerns

Hemorrhage Control Tools

Tourniquets - For compressible extremity hemorrhage; first-line in life-threatening limb bleeding
Wound packing + direct pressure - For junctional and truncal wounds
Pelvic binders - For suspected pelvic fracture to reduce pelvic volume
Interosseous (IO) access - Battery-powered device when IV access is unavailable; sites include the humerus (greater tubercle - allows higher flows) and tibia (2-3 cm distal to tibial tuberosity); sternal access requires a specialized device

Field Assessment: Airway

Assess for adequate airway protection: GCS ≥9, sufficient respiratory effort, no active vomiting, no significant oropharyngeal bleeding
If airway is compromised: jaw thrust, chin lift, suction
If obstruction present or GCS ≤8: endotracheal intubation (RSI in capable systems)
Surgical airway if intubation fails
Cervical spine immobilization with in-line stabilization for blunt trauma

Field Assessment: Breathing

Assess oxygenation and ventilation
Look for: unequal breath sounds, tachypnea, cyanosis, accessory muscle use, asymmetric chest wall motion
Tension pneumothorax - needle thoracostomy in the field if suspected
Open chest wounds - seal with vented chest seal
Supplemental oxygen as needed

Field Assessment: Circulation & Transport

Shock recognition in the field:

Tachycardia, hypotension, decreased capillary refill, cool/mottled extremities

Fluid resuscitation:

Two large-bore peripheral IVs or IO access
Balanced/permissive hypotension strategy: target SBP ~90 mmHg in penetrating trauma to avoid "popping the clot" before surgical control
Warm fluids preferred; prevent hypothermia (trauma triad of death: hypothermia + coagulopathy + acidosis)

Tranexamic Acid (TXA):

CRASH-2 trial (>20,000 patients): TXA reduced all-cause mortality and hemorrhage death when given within 3 hours of injury
MATTERS study (military): TXA improved survival, especially when massive transfusion protocol activated
Civilian prehospital dosing: 2 g IV within 3 hours of injury - safe and likely efficacious, particularly in hemorrhagic shock
Recent PATCH-Trauma trial (2024, 1310 patients) found no overall survival difference but no increased thrombotic events; confirmed safety
Most benefit seen in patients with severe shock (SBP ≤70 mmHg) when given within 1 hour

Transport Considerations

Scoop and Run vs. Stay and Play

Approach	When to Use
Rapid transport ("scoop and run")	Penetrating trauma, hemorrhagic shock - minimise scene time
Stabilise on scene ("stay and play")	Cardiac arrest, airway crisis requiring definitive management

Scene time should be minimised for hemorrhaging patients - increased scene time (per minute) independently increases mortality.

Air vs. Ground Transport

Helicopter EMS (HEMS) - indicated for patients likely to benefit; tools like the Air Medical Prehospital Triage (AMPT) score help identify them
Lights & sirens (L&S): per NAEMSP 2022 position - L&S increases crash risk by 50% and nearly triples crash risk during patient transport
2500 emergency vehicle crashes estimated annually; EMS providers are at high injury risk due to low seatbelt compliance while rendering care

Emerging Prehospital Interventions

Prehospital REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) - aortic hemorrhage control
Prehospital FAST - focused abdominal ultrasound
Vasopressin - under evaluation for hemorrhagic shock
External compression devices for truncal hemorrhage

Key Principle: Time Is the Enemy

"Time is the enemy: Mortality in trauma patients with hemorrhage from torso injury occurs long before the 'golden hour'."

Sabiston Textbook of Surgery (citing landmark surgical literature)

The traditional "golden hour" concept has been refined - for torso hemorrhage, the critical window may be as short as 30 minutes. Every prehospital intervention must be weighed against the time cost of performing it on-scene versus during transport.

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