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Common prehospital complications and pitfalls in the trauma patient
The evolution of prehospital care in this country has an interesting and continually evolving record. Although there is recorded history of wagons and carts being used to transport the sick and injured as early as 900 ace , the term “ambulance” was not used until introduced by Queen Isabella of Spain in the early 15th century. Even at that time, it referred more to military field hospitals and tents for the wounded than to a means of transporting wounded and dead from battlefields. Not until the time of Baron Larrey would the term “ambulance” take up its more current meaning of “a specially equipped motor vehicle, airplane, or ship for carrying sick or injured people, usually to a hospital.”
Baron Dominique-Jean Larrey was Napoleon Bonaparte’s surgeon and developed what was known as “flying ambulances.” Prior to 1792, there was very little organized transportation of the wounded from the battlefield. As is the case with most medical advances, advances in ambulance transportation occurred as a result of military conflict. Throughout the remainder of the 1800s and the conflicts of the early 20th century, ambulances and other means of transporting individuals from the field of battle were employed.
During the 1950s through the 1970s, helicopters were employed to transport the injured from battlefields to MASH (mobile army surgical hospital) units attaining particular effectiveness in the Korean and Vietnam conflicts. Throughout the first several decades of the 20th century, civilian transport for the injured continued to lag behind advances established in the military.
One of the prime factors identified as contributing to the continued reduction in battlefield casualties from 8% in World War I to less than 2% in the Vietnam War was reducing the time from injury to initiation of medical care. On this backdrop, the mid-1960s and early 1970s sought to improve prehospital care, education, equipment, and processes. The early 1960s called for an extension of basic and advanced first aid training to greater numbers of the lay population and preparation of nationally accepted texts, training aids, and courses of instruction for rescue squad personnel, police, firefighters, and ambulance attendants. Ambulance service in the 1960s was very piecemeal and adequate at best. In a few major cities, there were specially equipped ambulances prepared to care for the injured and sick, and trained professional prehospital personnel were available. However, approximately 50% of the country’s ambulance services at that time were provided by over 12,000 morticians mainly because their vehicles were able to accommodate transportation of patients on gurneys or stretchers.
In the mid-1960s, the National Traffic and Motor Safety Act and the Highway Safety Act provided for the establishment of national standards for used motor vehicles, motor vehicle inspections, and emergency services. Communications were also problematic. At a time when the United States had just placed a man on the moon, it was easier in most instances to communicate with that extraterrestrial individual than it was for prehospital providers to communicate with the emergency department where they were headed.
Over the next several decades, the education and provision of specifically equipped vehicles progressed until the mid-1980s when Injury in America: A Continuing Public Health Problem was published. Although the report found that there had been significant progress in the credentialing and education of prehospital care providers, more than 2.5 million Americans died from injuries in the 1966–1985 period. This prompted the expenditure of more federal dollars to study the continuing public health problem, as the report noted and called for the institution of more systems of communication and transportation of the injured to facilities specially equipped for managing critically injured patients.
In 1992, the Model of Trauma Care Systems Plan, developed by Health Resources and Services Administration under the Authority of the Trauma Systems Planning and Development Act of 1990, marked the next major step in the evolution of health policy related to trauma care. This plan emphasized the need for a fully inclusive trauma care system that involved not only trauma centers but also all health care facilities according to availability of trauma resources, including prehospital providers. As a result, the numbers of dedicated trauma centers and state trauma systems increased, although at a still less-than-adequate pace. Trauma centers were charged with becoming resource facilities for emergency medical response agencies. Educational programs such as Prehospital Trauma Life Support, Basic Trauma Life Support, and others were developed with states being empowered to license and credential prehospital providers at various levels.
Today, the initial care of the injured patient continues to reside primarily with trained prehospital providers such as emergency medical technicians, with basic, intermediate, and paramedic levels of instruction, and police and fire departments also trained in basic life support. Increased communication and education with the lay public with regard to cardiac arrest, “Stop the Bleed” campaign, seat belt usage, wearing of helmets, and other prevention initiatives are in place to continue to try to combat the unacceptably high level of death and disability in this country from intentional and unintentional injury.
Along with the ever-evolving technologies available to the prehospital provider come the unintended risk of complications associated with the implementation of these devices and processes. This chapter addresses some of the more common prehospital complications and pitfalls in the trauma patient.
Incidence
According to the National Center for Injury Prevention and Control in 2015 the number one cause of death, both intentional and unintentional, from ages 1 to 46 was trauma. According to the National Highway Transportation Safety Administration, there has been a downward trend in traffic fatalities from 2016 to 2019. According to the Centers for Disease Control, deaths in the United States from 2007 to 2016 among patients greater than or equal to 65 has increased 31%, with the fastest growing rate among people greater than or equal to 85 years of age (3.9% per year), due to falls. The overall distribution of trauma deaths are motor vehicle crashes, gunshot wounds, stab wounds, and falls. Today’s prehospital provider is in a position to be the first responder to the vast majority of injuries at the time of occurrence or shortly after they occur. These injuries are further complicated with advancing age and comorbidities.
The major causes of death of injured patients in the prehospital period are secondary to severe head injury, respiratory compromise, and exsanguinating hemorrhage. Initial and emergent prehospital treatment focuses on the treatment and prevention of these eventualities.
The foundation of Advanced Trauma Life Support of the American College of Surgeons stresses an ABC (airway, breathing, and circulation) approach. Much of the emphasis on prehospital care and subsequent care involves appropriate management of the airway, providing for ventilation by breathing for the patient, and control of circulation consisting of hemorrhage control and restoration of intravascular volume. Not surprisingly, the most common prehospital complications and pitfalls occur in these three areas .
Airway
Ensuring that the trauma victim has a patent airway is the highest management priority. If manual maneuvers (clearing the airway of foreign bodies, jaw thrust, or chin lift) or basic adjuncts (oropharyngeal or nasopharyngeal airways) are not adequate to maintain the airway, then alternate, more invasive methods are required.
Current prehospital techniques used for airway management and ventilation include (1) bag-valve-mask (BVM), (2) supraglottic airway device (King LT, laryngeal mask airway, i-Gel, etc.), (3) endotracheal intubation (with or without the use of paralytics), and (4) emergency cricothyroidotomy (needle or surgical).
BVM can be a temporizing method for providing adequate oxygenation and ventilation of the injured patient but can occasionally be problematic related to obtaining an adequate seal at the mouth, potential for aspiration, problems with bleeding from soft tissue injury, patient cooperation, and the lack of satisfactory ventilation and oxygenation depending on the specific clinical situation. Acute gastric dilatation from overzealous ventilation can also lead to ventilatory impairment from increased intraabdominal pressure, and, in extreme cases, gastric rupture.
The prehospital use of a supraglottic airway device has an advantage over conventional endotracheal intubation related to ease of technique and maintenance of insertion skill. Supraglottic airways are beneficial in an unconscious patient who cannot be adequately ventilated with a BVM device or cannot be successfully intubated. However, because the trachea is not completely protected, the use of a supraglottic airway may result in aspiration. Once a supraglottic airway device is placed, placement should be confirmed by auscultation and waveform capnography should be monitored to evaluate for adequate ventilation. If there is no waveform capnography reading or poor ventilatory compliance, the prehospital provider will need to check insertion depth and cuff pressure of the device. Supraglottic airways must be inserted to the correct depth for the ventilation port to be above the glottic opening. If ventilation continues to be ineffective, the prehospital provider will need to consider other options of airway management. This may include going back to BVM, an endotracheal intubation attempt, or a cricothyrotomy.
The identification of patients requiring definitive airway management may sometimes be problematic based on the patient’s injuries, mental status (secondary to injury, alcohol, or drugs), underlying medical conditions, and the experience of the prehospital provider. Delay of intubation until respiratory arrest increases morbidity and mortality risks and should be avoided if at all possible. Early recognition of the need for intubation is of paramount importance for the prehospital provider.
Late endotracheal intubation may result because of a false sense of security by the provider, the inability to obtain an airway, and/or lack of recognition of likely deterioration in a patient’s ventilatory status (secondary to airway and chest injuries, traumatic brain injury [TBI], alteration in mental status, or the overall complexity of the injuries). Patients with facial burns and maxillofacial trauma may have progression of their underlying injury and may deteriorate secondary to edema or hematoma formation, causing airway obstruction. Intubation of these patients can be a difficult challenge with the potential for disastrous results if proactive intubation is not accomplished. This is especially true if paralytic agents have been used and the vocal cords cannot be easily visualized. Anticipation of this problem along with early intubation may prevent a catastrophe.
The use of paralytic agents for intubation in the prehospital setting results in a quicker and higher success rate of intubation. However, many prehospital providers do not have access to use these agents due to state or local medical direction. Additionally, if paralytic agents are used, it cannot be overemphasized that it is critical that adequate analgesia and sedation are also administered, so that the injured patient is not chemically paralyzed, while awake and hurting. At the time of handoff of the trauma patient from the prehospital provider to the trauma team in the emergency department, it is important that all of the medications that have been administered to the patient prior to arrival are reviewed, so that the emergency physician and trauma surgeon will ensure adequate pain management and sedation, even when the patient is chemically paralyzed.
Successful endotracheal intubation is beneficial for the trauma patient whose airway needs to be secured, but there are potential complications and pitfalls that may occur during the process of intubation, regardless of the expertise of the provider. Prehospital personnel should be aware of these potential complications and how to clinically recognize them if they occur. A recent study identified a prehospital complication rate for tracheal intubation of approximately 17%.
Esophageal intubation is a known complication of intubation and should be quickly recognized by the prehospital provider if it occurs. However, unrecognized paramedic prehospital esophageal intubation has been shown to be as high as 10%. The difficulty of the intubation and in visualizing the vocal cords should increase concerns of an esophageal intubation and warrants aggressive evaluation to ensure adequate placement of the endotracheal tube (ETT). The placement of an esophageal ETT should be clinically evident by routine chest auscultation immediately after intubation. The routine use of end-tidal CO 2 detectors (ETCO 2 ) is beneficial in rapidly detecting the presence of CO 2 in the exhaled air. In addition, prehospital capnographic monitoring of major trauma patients has been shown to result in more appropriate ventilation status for patients at their time of arrival at the trauma center. The colorimetric devices have a chemically treated indicator strip that reflects the CO 2 level. If there is a question of the exact location, visualization of the ETT location with laryngoscopy should be repeated and appropriate location confirmed.
Right mainstem intubation is an occasional complication of intubation that occurs up to 30% of the time in pediatric trauma patients (less frequently in adult trauma patients) and should be detected by physical examination (auscultation) at the time of intubation, with frequent routine clinical reassessments or urgent reassessment if the patient clinically deteriorates. The distance of the tip of the ETT should be evaluated relative to the size of the patient and the expected appropriate distance of ETT. Repositioning of the ETT while auscultating the chest helps in determining the appropriate location of the ETT. Other possible traumatic injuries that may lead to similar clinical findings must also be considered in severely injured patients, including a pneumothorax, hemothorax, pulmonary contusion, or ruptured hemidiaphragm.
Surgical airways are occasionally needed when endotracheal intubation cannot be successfully achieved secondary to facial trauma, anatomic difficulties, and soft tissue injuries. The prehospital paramedic should anticipate the possible need for a cricothyroidotomy if other prehospital airway management techniques are not successful. Although the use of surgical airways in the prehospital setting is controversial because of its infrequent performance and potential risks, local protocols should outline the specific indications and circumstances for their use. Many trauma surgeons, including Norman McSwain, MD, the founder of National Association of Emergency Medical Technicians (NAEMT), and leader in development of the Prehospital Trauma Life Support course, have stressed the importance of adequate training and frequent continuing education for ALS paramedics in the performance of a surgical cricothyroidotomy for this to be a safe prehospital technique for injured patients.
Complications of surgical cricothyroidotomy include false passage into the tissues, hemorrhage or hematoma formation, esophageal laceration, vocal cord paralysis, inadvertent dislodgement, right mainstem intubation, and potential subglottic stenosis/edema. The right mainstem intubation is usually the result of using an ETT and placement is too distal. However, in some patients a tracheostomy tube may also result in a right mainstem intubation, and therefore auscultation of both lungs immediately after the procedure is a necessity. When using an ETT for a surgical cricothyroidotomy, it should not be inserted any further than the proximal portion of the balloon passing into the trachea, to minimize a right mainstem intubation. If a surgical airway is needed, a surgical cricothyroidotomy should be performed. A formal tracheostomy should not be performed by prehospital providers because of the difficulty and length of time needed to successfully accomplish the procedure. A surgical cricothyroidotomy is contraindicated in a pediatric trauma patient under the age of 12, secondary to difficulty in palpating the cricothyroid membrane and the increased risk of damage to the larynx.
If there are no other options, a needle cricothyroidotomy can be performed in order to provide oxygen for a short time (up to 30–45 minutes) while a definitive airway is obtained. During this time the CO 2 will increase, which may be problematic for patients with TBIs. Potential complications of needle cricothyroidotomy include inadequate ventilation resulting in hypercarbia, hypoxia, esophageal laceration, hematoma formation, posterior tracheal wall perforation, thyroid laceration, bleeding, and death.
Video-assisted laryngoscopes have been shown to be beneficial for intubations, especially among nonphysician intubators with less experience than direct laryngoscopy. Video-assisted laryngoscopy may provide a benefit in the prehospital setting, particularly in the rural setting, where call volume and intubation exposure may be limited. Video laryngoscopy has been observed to be beneficial when there is a concern of a possible cervical spine injury. Most video laryngoscopes currently available to purchase are modeled similar to the traditional Macintosh style blade; however, there are some hyperangulated type blades, which will likely result in a steeper learning curve for the user. There are concerns that with increased use of video-assisted laryngoscopy, some prehospital providers may lose their skills with direct laryngoscopy; however, these concerns must be weighed against higher first-pass success rates, especially when using other airway adjuncts in conjunction (i.e., a bougie).
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