EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.
Issue link: https://emsworld.epubxp.com/i/53080
TRAUMA CARE Figure 2: The crew initiates cervical-spinal immobilization as they rapidly assess the patient and address his ABCs. The man appears to have a significant head injury as well as right chest wall inju- ries. Bystanders report he has a history of diabetes, congestive heart failure and high blood pressure, and is also a smoker. He has been noncompliant with his medications. The crew continues to treat the patient while simultaneously preparing for transport to the local trauma center. They load him into the ambulance and start intravenous lines. The patient remains unconscious. En route to the hospital, his vital signs are heart rate 120, EKG showing sinus tachycardia; blood pressure 70/30; respiratory rate 10 and still sonorous. At the hospital the patient is trans- ferred to emergency department and admitted to the CCU in critical condition. Two weeks later he expires. It is noted that the patient experienced hypoxia, acidosis, hypothermia and dissemi- nated intravascular coagulation (DIC). The emergency physician provides this follow-up to the crew and observes that the patient appears to have experienced the trauma triad of death. Overview Prehospital care providers respond to a variety of calls, ranging from relatively benign to life-threatening. Providers need to maintain a core working knowledge of anatomy and physiology, as well as confidence with the assessment and treatment of all patients, regardless of situation. This is especially important in situations where multiple diseases or injuries may be involved, such as the Figure 1: Trauma Triad of Death HYPOTHERMIA COAGULOPATHY Frontal lobes Olfactory bulbs Hypothalamus Thalamus Hippocampus Amygdala Hypothalamus case of the multiple-trauma patient. Trauma scenarios require providers to consider the immediate needs of the patient while simultaneously anticipating what treatment they may require in the future. A variety of tools and resources can be used to support the provider in providing optimal care. The Golden Hour suggests the critical trauma patient has 60 minutes from the time of injury to reach definitive care. This concept has influenced approaches to trauma resus- citation, such as the goal of reducing the time from injury to incision,1–4 and in recent years the idea has been applied to settings beyond the field, including the emergency department, operating room and ICU. Decreased myocardial performance In the ED and OR environments, the critical parameter is the time the patient spends there before certain clinical conditions develop. These condi- tions include hypothermia, acidosis and coagulopathy. Jointly they comprise the trauma triad of death (see Figure 1). While the prehospital treat- ment of hypothermia, acidosis and coagu- lopathy is predomi- nantly supportive, it is important for prehos- pital providers to be familiar with the indi- vidual components of this condition; METABOLIC ACIDOSIS care given in the prehospital setting can help reduce the likelihood a patient succumbs to the trauma triad of death.5–9 Hypothermia Hypothermia occurs when the body's mechanisms for temperature regulation are overwhelmed. The brain's hypothal- amus produces hormones that influence a variety of bodily functions, including body temperature. Core body tempera- ture normally ranges between 36.5– 37.5°C (see Table 1). Hypothalamic control of temperature occurs through several mechanisms, including heat conservation with peripheral vasocon- striction and heat production through shivering, influenced by epinephrine (Figure 2). Heat production increases with muscle contractions and shivering. Some consider shivering one of the last resorts by which the body attempts to maintain temperature.1–7,10–14 Heat loss occurs through several mechanisms. The most significant in the trauma setting is often radiation, which can account for more than half of total heat loss. Conduction and convec- tion, which involve the direct transfer of heat to another object or circulating air, are the most common causes of acci- dental hypothermia. Heat loss through conduction in water is significant, as the thermal conductivity of water can be over 25 times greater than that of air. Other sources of heat loss include respiration EMSWORLD.com | FEBRUARY 2012 45 Lactic acidosis Halt coagulation cascade Fran Milner, www.franimation.com