Patient Care at Motor Vehicle Crashes

By Mike McEvoy

From the 2010 vehicle extrication e-Newsletter, sponsored by

Death and injuries resulting from motor vehicle crashes are largely responsible for the development of Emergency Medical Services (EMS).1-2 Reducing disability and deaths from roadside trauma continues as a priority for EMS providers today. Firefighters have an enhanced role and added responsibilities at motor vehicle crash scenes because of their rescue and extrication duties. Being familiar with and experienced at working in hostile environments puts the fire service in a leadership role for improving patient outcomes on our roadways.

At any crash scene, priorities include recognizing severe injuries, providing life-saving treatment, and transporting to an appropriate medical facility.
3 Yet despite years of progress and dramatic improvement in outcomes, many prehospital controversies remain. They include appropriate triage and transport decision-making schemes; the role of endotracheal intubation and rapid sequence intubation (RSI), especially in head injured patients; proper techniques for hemorrhage control; the role of spinal immobilization; permissive hypotension; fracture management; the role of air medical services; and appropriate pain management. 

Controversies and Changes

In many ways, the ABC priorities of the past have come full circle. Instead of sequential assessment and treatment of airway, breathing, and circulation, today’s EMS providers are more likely to focus first on circulation, then breathing and airway during medical and trauma resuscitations. The logic behind this seemingly backwards approach to initial assessment is that without circulating blood to carry oxygen, there is little need for an airway or breathing. Hence, the first priority (once an EMS provider ensures that the scene is safe) is immediate assessment and treatment of life-threatening hemorrhage. Next, a rapid assessment for adequacy of breathing should be conducted, including not only chest wall movement but also breath sounds or other evidence that air exchange is occurring. For any patient with questionable breathing, the airway should be evaluated and an airway adjunct such as an oro/nasopharyngeal airway inserted. Any secretions obstructing the airway should be suctioned. If there is evidence of hypoxia, usually determined by measured oxygen saturation less than 92 percent, supplemental oxygen should be administered. There is no evidence of benefit and considerable evidence of harm from routine administration of oxygen to trauma patients who are not hypoxic.
4 

Once an initial assessment is completed and immediate life threats addressed, attention must immediately be focused on determining the scope and severity of injuries followed by selection of the most appropriate destination facility. Years of traumatic injury data were analyzed by the Centers for Disease Control and Prevention (CDC) in 2009 to introduce a comprehensive Trauma Triage Guideline (see www.cdc.gov/fieldtriage). All EMS providers should be familiar with this guideline. Trauma patients transported to a facility equipped and ready to handle their specific injuries have a 20 percent less risk of dying from their injuries.5 The “Golden Hour,” a longstanding fixture in trauma care implying that optimal outcomes are achieved when trauma patients arrive in the operating room within 60 minutes from time of injury, has not been supported by science. Today, evidence suggests that every trauma patient should be seen as a “Golden Opportunity” to provide the best care and transport to the most appropriate facility, recognizing that this will be different in every situation.

Permissive hypotension is a newer concept affecting modern day trauma care. Studies dating back to 1994 demonstrated that large volume intravenous (IV) fluid infusion in hypotensive patients with uncontrolled internal or external hemorrhage directly worsens outcomes.
6    External hemorrhage can now be readily controlled with prompt use of tourniquets and/or application of hemostatic dressings. Internal bleeding requires surgical or radiological intervention. IV fluids given before bleeding is controlled dilute clotting factors and increase blood pressure, leading to greater blood loss. Every EMS service should be equipped with tourniquets and hemostatic dressings, with protocols limiting IV fluids when uncontrolled bleeding is suspected, to provide optimal patient care.

Airway controversies are currently raging in EMS. Depending on where airway management is studied, results seem to be dramatically different. There are some clear conclusions that can guide airway management today. First, trauma patients who can be managed with basic life support (BLS) interventions such as insertion of an oral or nasal airway and bag-valve-mask ventilation have fewer complications and are more likely to survive than if they are electively intubated in the field.7 In head-injured patients, prehospital intubation can increase mortality five-fold over BLS airway management and bag valve mask (BVM) ventilation.8 RSI is controversial, and the jury remains out on whether this practice improves patient outcomes or increases risks. What is crystal clear is that EMS programs using RSI must carefully oversee their providers, train and retrain, practice continually, and limit RSI to a core group who regularly perform the skill.9 Additionally, no EMS provider or program should ever ventilate a patient using any advanced airway device (endotracheal tube, trach, Combitube™, Laryngeal Mask Airway (LMA™), King® Airway, etc.) without continuous waveform capnography attached to the ventilation circuit.10 To use any advanced airway without continuous waveform capnography is malpractice. There is simply too much movement, activity, and potential for tube dislodgement in the prehospital and transport environments not to continuously monitor ventilation at all times.

Spinal immobilization has been in the news lately with findings reported earlier this year that application of a rigid cervical collar or immobilization of trauma patients based on mechanism of injury alone can significantly increase mortality.
11 In fact, one study published in 2009 demonstrated that allowing a collared patient to extract himself from the vehicle resulted in less motion of the cervical spine than extrication by experienced paramedics.
12 Clearly, if you are immobilizing spines on mechanism of injury alone without clear physical exam findings suggestive of spinal injury, your patient outcomes are less than optimal. Logic suggests that spinal injuries occur during crashes that apply far greater forces to the head, neck, and spine than an EMS provider could apply during patient movement. Where and when in the scheme of patient care a provider should consider spinal immobilization is changing.

Using air medical transport seemed for years to be of benefit to trauma patients. Proliferation of services and closer analysis of outcomes have highlighted considerable overuse13 as well as lack of clear benefit to many trauma patients.14 Additionally, although providers often believe that air medical transport results in faster transport times, time studies have repeatedly shown that this is not the case.15 Recent hearings by the National Transportation Safety Board (NTSB) have highlighted the extreme risks of air medical transport, notably that more deaths have occurred in air medical transports than commercial aviation since 2002 despite air medical flying only a fraction of the distance and hours of commercial flights. A flight pilot or crew member with 20 hours per week of flight time over a 20-year career has a 40 percent risk of dying in a crash. These numbers and continued high incidence of mishaps in the air medical industry–many with fatalities–have prompted a call for closer scrutiny of air medical utilization. If your air medical transport policies are not reflective of current trauma triage and transport guidelines, you potentially place patients that you choose to fly at greater risk of death from flight than from their injuries. Every EMS service should have evidence-based air medical use policies with continual quality review to ensure appropriateness of use. Delays in transport using air medical services can result from delayed calls. Given the patient information and crash data collected at our 911 call centers, there is no conceivable reason air medical support should not be placed on standby by protocol at the same time fire and EMS are dispatched to motor vehicle crashes.

Fracture management has evolved relatively little compared to other prehospital treatments for trauma. Stabilization and splinting of fractures are critical before extrication and prior to transport. This reduces pain and minimizes tissue damage in the areas surrounding the fracture. Providers should have adequate stabilizing devices and be well practiced in immobilization techniques.

Prehospital providers commonly fail to provide adequate pain management, and there are innumerable reasons this remains a weakness in patient care.16 Most often, these stem from lack of appropriate protocols or from concern about patient condition. Judicious use of analgesics such as morphine is safe and effective and does not mask significant injuries or result in poor outcomes. There is little to no reason to withhold pain medication, even in seriously injured patients.17 Fentanyl produces less hypotension than morphine and has the added advantage of intranasal administration, eliminating the need for vascular access.

***
The fire service should be taking a lead role in management of trauma at motor vehicle crash scenes. Patient care begins with an initial rapid assessment of circulation with prompt control of severe bleeding using direct pressure, tourniquets, and hemostatic bandages followed by rapid assessment of breathing and airway with immediate insertion of an oral or nasal airway if indicated, suction, and ventilator assistance using a BVM. Measure oxygen saturation and provide supplemental oxygen to hypoxic patients. As disentanglement or extrication progresses, closely monitor the patient, protect him from further injury or loud noises, and control pain by effective use of splinting and narcotic analgesia. Manage anxiety with continued reassurance and sedative drugs, if necessary. Simultaneously, conduct an assessment following a trauma triage guideline to screen for the presence of serious injury and select the most appropriate destination facility. If air medical transport is warranted, select a suitable landing zone.  Multitasking and adapting tactics to hazardous environments are fire service talents. Applying these skills to patient care at motor vehicle crashes promises to improve outcomes and enhance patient comfort.
 
 
Mike McEvoy
is the EMS coordinator for Saratoga County, New York, and the EMS technical editor for Fire Engineering. He is a nurse clinician in the cardiac surgical ICUs at Albany Medical Center and teaches critical care medicine at Albany Medical College in New York. He is a firefighter/paramedic and chief medical officer for West Crescent Fire Department.
 
References

1.      Law of 89th Congress: National Highway Safety Act of 1966, Public Law 89-564, Washington, DC, 1966.

2.
      Law of 93
rd Congress: Emergency Medical Services Systems Act of 1973, Public Law 93-154, Washington, DC, 1973.

3.      Hubble MW, Hubble JP. Principles of advanced trauma care. Albany, New York: Delmar Thomson Learning, 2002.

4.
      Stockinger ZT, McSwain NE. “Prehospital Supplemental Oxygen in Trauma Patients: Its Efficacy and Implications for Military Medical Care.
Mil Med. 2004;169:609-612.

5.      Centers for Disease Control and Prevention. Guidelines for Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage. MMWR 2009;58 (No. RR-1).

6.
      Bickell WH, Wall MJ Jr, Pepe PE, et al. “Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.”
N Eng J Med. 1994;331:1105-9.

7.      Cobas MA, De la Pena MA, Manning R, et al. “Prehospital intubations and mortality: a level 1 trauma center perspective.” Anesth Analg 2009; 109:489.

8.
      Stockinger ZT, McSwain NE Jr. “Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation.” 
J Trauma 2004; 56:531.

9.      Fakhry SM, Scanlon JM, Robinson L, et al. “Prehospital rapid sequence intubation for head trauma: conditions for a successful program.” J Trauma 2006; 60:997.

10. Timmermann A, Russo SG, Eich C, et al. “The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians.” 
Anesth Analg 2007; 104:619.

 

11. Haut ER, Kalish BT, Efron DT, et al. “Spine immobilization in penetrating trauma: more harm than good?”  J Trauma 2010 Jan;68(1):115-20; discussion 120-1.

12. Shafer JS, Naunheim RS. “Cervical spine motion during extrication: a pilot study.” 
W J
Emerg Med 2009; 2:74-78.

13. Shatney CH, Homan SJ, Sherek JP, et al. “The utility of helicopter transport of trauma patients from the injury scene in an urban trauma system.” J Trauma. 2002;53(5):817-22.

14. Braithwaite CE, Roski M, McDowell R, et al. “A critical analysis of on-scene helicopter transport on survival in a statewide trauma system”
J Trauma. 1998;45(1):140-4.

15. Cocanour CS, Fischer RP, Ursie CM. Are scene flights for penetrating trauma justified? J Trauma. 1997;43(1):83-86.

16. Hennes H, Kim MK, Pirrallo RG.” Prehospital pain management: a comparison of providers perceptions and practices.” Prehosp Emerg Care. 2005; 9:32.

17. Also-Serra HM, Wesley K. “Prehospital pain management” Prehosp Emerg Care. 2003; 7:482.

2010 vehicle extrication e-Newsletter sponsored by Holmatro.

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