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Category Archives: Trauma Patient

March 13, 2023 SWORBHP Category: Miscellaneous, Trauma Patient | Date: March-13-2023

This is a BLS question. For management of a flail chest, most research suggests that we tape the flail segment in place with a large bulky dressing, bag of saline, Asherman chest seal, etc. I've been hearing from recent PCP graduates that they have been taught to use a bulky dressing, however they mention that they are being taught to do a circumferential wrap around the chest with a triangular bandage or blanket to hold the dressing in place (which I would assume is incorrect) instead of taping a bulky dressing over the flail segment. What would be the preferred method and why?

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September 29, 2022 SWORBHP Category: Hypoglycemia, Immobilization, Trauma Patient | Date: 2022-september-29

I have a question in regards to the hypoglycemia directive. We were dispatched to a patient who suffered a fall, with history of diabetes. Upon assessment the patient was GCS 15, answering questions appropriately and oriented to person, place, time and event, however the patient was unable to move their limbs, and had loss of sensation in portions of the arms, torso, and legs, as well as a depressed skull fracture. The patient was hypovolemic and hypoglycemic at 3.2, stating he has not been eating or drinking fluids all day. Due to a complaint of back pain and paralysis, the a c-dollar was applied and scoop was used to extricate. Because the patient was secured to the stretcher supine, treating with oral gel was not an option, and transport was a priority. Some of the symptoms exhibited by the patient are concurrent with typical signs of hypoglycemia. In this situation where the patient is NOT altered, but hypoglycemic, with sufficient suspicion to suspect that low blood sugar may be causing some of the symptoms, would it be reasonable to treat the patient with IV dextrose? How do we proceed in situations where patients may be hypoglycemic, are not altered (GCS less than 15) but are unable to tolerate oral glucose or carbs? I can see this being the case for traumas.

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November 28, 2017 SWORBHP Category: Trauma Patient | Date: 28-Nov-2017

Question: With the introduction of commercial tourniquets and hemostatic dressings for Soft Tissue Injuries/Uncontrolled bleeds in the BLSPCS 3.0, where does the OBHG and MOH stand on wound packing for hemorrhage control? It is generally accepted among TCCC guidelines as a part of basic hemorrhage control, and even taught as a part of First Aid with some organizations. Unfortunately the BLS 3.0 (or 2.xx as well) do not explicitly mention it as an option, as well it is technically prohibited under the Registered Health Professions Act which lists "Putting an instrument, hand or finger, into an artificial opening in the body" as a delegated act. Is this something that we will see added to our scope in the future? Why or why not?

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Trauma Patient

December 17, 2015 SWORBHP Category: Trauma Patient | Date: 17-Dec-2015

Question: Upon review of the new Field Trauma Triage Guidelines, colleagues and I noticed that those patients who have sustained penetrating trauma to the head/neck or torso (with or without vital signs) should be transported to the lead trauma hospital providing it's within 30 minutes transport. Our question is why is this not the case for blunt trauma patients (in particular, those patients VSA from blunt trauma)?

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Answer:

Good pick-up. This was something that we wanted to stress at your recerts this year in the discussion of the Field Trauma Triage Standard (FTTS) for the reason you mention: these patients are treated differently. So we’re glad you’ve brought this up – so we may highlight why this is the protocol.

The anatomical differences in penetrating vs blunt trauma, lead to differences in ultimate treatment and therefore their initial destination. Penetrating injuries to the chest may be temporarily stabilized by an emergency department thoracotomy (EDT) wherein the patient’s chest is opened and a reparable defect in the heart, major vasculature or lungs is sought. Due to the force of blunt trauma, there is more widespread damage (think about what happens when an orange is crushed vs sliced) and an EDT is unlikely to show a single injury that can be easily be addressed.

The reason for the transport disparity is that thoracotomies are only performed as a salvage technique to buy time to get the patient to definitive management. In the case of penetrating chest trauma, definitive management is a cardiothoracic surgeon. This resource is generally only available at the Lead Trauma Hospital (LTH). Although not a candidate for EDT, blunt traumatic arrests can be treated with needle decompression, chest tube insertion, intubation, fluid/blood resuscitation and other supportive care that can reliably be initiated at the closest hospital.

A very robust systemic review was recently published in July 2015 by the subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma (EAST) on EDT. In which they summarized the results of 72 research papers on EDT to date, finding a 2.3% hospital survival rate in blunt traumatic arrest vs 10.6% survival in penetrating injury (7.2% Gun shot wounds vs 15.8% stab wounds). Unfortunately, not only are patients less likely to survive after EDT for blunt injury but also, when they do survive, they are more likely to be neurologically impaired. Of those that survive blunt traumatic arrest, only 59% are neurologically intact at discharge. This is in contrast to 90% of penetrating traumatic cardiac arrest survivors. This is why the National Association of EMS Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ASCOT) state that “emergency thoracotomy does not appear to have a role in traumatic cardiopulmonary arrest as a result of blunt trauma”.

Bottom line: Due to the anatomical differences in penetrating vs blunt trauma, another level of intervention (EDT) can be performed on penetrating trauma VSAs in a last ditch attempt to stabilize the patient. This intervention will generally only be performed at the LTH. Thus, penetrating traumatic VSAs are brought to the LTH to give them the best chance. Whereas, the best chance for a blunt traumatic arrest is at the closest hospital who can reasonably initiate other life-saving interventions.

References:

Seamon et al. An evidence-based approach to patient selection for emergency department thoractotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015; 79(1):159-73.

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November 22, 2013 SWORBHP Category: CPAP, Trauma Cardiac Arrest, Immobilization, Trauma Patient | Date: 22-Nov-2013

Question: VSA trauma patients - chest compressions and defib is the priority for this patient. C-spine maintained manually. In this scenario, is it mandatory to apply a collar prior to a shock being delivered as the manual c-spine must be removed to deliver the shock?

CPAP- indication b/p 100 or above systolic. Contraindication is hypotension. If CPAP is applied while normotensive, can we leave the device on until they become hypotensive or we must remove when b/p drops below 100? Thanks.

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August 22, 2013 SWORBHP Category: Trauma Patient | Date: 22-Aug-2013

Question: In the BLS Standards I found in Section 1, General Standard of Care, Directive H. Patient Transport, the following statement in subsection 1 "in the absence of direction, transport to the closest or most appropriate hospital emergency unit capable of providing the medical care apparently required by the patient." So one question I have is the trauma patient, if they needed care above the capabilities of the closest hospital emergency unit, do we transport the patient to the closest hospital emergency unit that has these capabilities?

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Answer: Great question! The real issue is how you define the trauma patient. The BLS Patient Care Standards in Section 1- General Standards of Care have described a set of criteria which are known as the Field Trauma Triage Guidelines. The closest most appropriate hospital for on-scene call patients assessed as meeting the Field Trauma Triage Guidelines is the closest Lead Trauma Hospital. The page reference is Section 1-25.

On-scene call patients assessed as meeting the Field Trauma Triage Guidelines (FTTG) will bypass other hospitals to go to the closest Lead Trauma Hospital if the closest Lead Trauma Hospital is less than thirty minutes away by land ambulance. It is essential to note however that the FTTG does not include every patient that has been injured by a traumatic mechanism: there are specific criteria that need to be met and these are described in the BLS PCS.

Note that paramedics will divert to the closest hospital with an emergency department when, in their judgment, the patient could not survive transport to the nearest Lead Trauma Hospital (complete airway obstruction, no spontaneous respirations, no palpable carotid pulse). The 30 minutes in an approximation and includes extrication time, traffic and road/weather conditions, and those factors which affect response/transport time but cannot be predetermined.

One of the confusing components of the BLS PCS is the definition of the Lead Trauma Hospital. Officially at the moment, London Health Sciences Centre (LHSC) Victoria Hospital is considered a Level I LTH and Hotel Dieu in Windsor is considered a Level II. For the majority of paramedics in the Southwest however, the closest ED becomes the destination since these two LTH’s fall outside the 30min transport window. Therefore, in practicality, all hospitals play a role in the management of the trauma patient. It is also essential for paramedics to follow their local destination protocols which may have addressed these scenarios in collaboration with the Base Hospital.

The Trauma Association of Canada, has gone through a two year process where, Accreditation Canada will now accredit the trauma programs through a trauma distinction program. Windsor will be going through the pilot process in November. Interestingly they will be looking at three local hospitals, and the level of trauma care provided.

In the future, it is possible that all of the hospitals will have a level, and paramedics could possibly be bypassing lower level centers for those with a surgeon and scanner in rural areas. This is where destination policies and local trauma networks come into play: stay tuned!

The Ontario Base Hospital Group (OBHG) along with Ornge and the Ontario Trauma Advisory Committee (OTAC) have revised the Field Trauma Triage Guidelines within the last few years. The revised versions of these guidelines are anticipated to be released shortly from the MOHLTC.

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Trauma Patient