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Scott G.

Sagraves, MD, FACS


Trauma Medical Director
St. Lukes Hospital of Kansas City
No financial relationships creating a conflict
of interest to report
Define the anatomy and physiology of
Traumatic Brain Injury (TBI)

Explain the concept of the Monroe-Kellie
Doctrine

Interpret the Brain Trauma Foundation
guidelines for EMS treatment of TBI
Discuss EMS strategies for managing
injured patients

Compare and contrast City vs. Country
challenges in managing injured patients

Suggest strategies for the EMS
management of trauma patients
Golden hour
30%
late
20%
immediate
50%
0%
20%
40%
60%
80%
100%
120%
0mi n 30mi n 60mi n 120mi n 180mi n
Time (min)
%

D
e
c
l
i
n
e
Urban
Rural
injury related deaths are 40%
higher in rural communities
than in urban areas
Center for Rural Care Fact Sheet University of North Dakota 2003
Methods: Retrospective Review of
Autopsy/ME Database
Comparing outcomes urban SDC vs rural VT
All fatalities were reviewed
ISS
Age
Cause of death
Mechanism of Injury
Comorbidities

Rogers et al, Arch Surg 1997
San Diego Vermont
Cases 248(41%) 103(72%)*
ISS 54 39*
Age 33 45*
Blunt/Pen(%) 69/31 49/51*
Rogers et al, Arch Surg 1997
*p < 0.05
San Diego Vermont
Cases 243(40%) 23(16%)*
ISS 52 33*
Age 33 46*
Blunt/Pen(%) 61/39 96/4*
Rogers et al, Arch Surg 1997
*p < 0.05
Rural patients are more likely to die at
the scene, are less severely injured
and are older

Rural patients surviving 24 hours
before death are older, less severely
injured, have more co-morbidities
and are more likely to die of MOSF
compared to urban patients
Rogers et al, Arch Surg 1997
CITY COUNTRY
911 system local
Paid, staffed vehicles
Trauma Centers close
Training
Lots of resources
Ground transport
ALS
911 system county
Volunteer
Longer distances
Training difficult
Limited resources
Helicopter transport
BLS

CITY COUNTRY
C.A.B.

load n go
A.B.C.D.E.

stay n play
Circulation & Hemorrhage control
Airway
Breathing
AIRWAY & C-spine Control
BREATHING
CIRCULATION & Bleeding Control
DISABILITY - Neurologic Assessment
EXPOSURE - Prevent Hypothermia
www.cdc.gov/Fieldtriage
Visually inspect
Sweep clear with gloved hand
Aggressive suctioning
Avoid Hypoxemia
Severe Trauma
Bleeding -- Consumption
CRYSTALLOIDS TRANSFUSION
DILUTION HYPOTHERMIA
COAGULOPATHY
M J Cohen, UCSF
ACIDOSIS
COAGULOPATHY
HYPOTHERMIA
DEATH
Triad of Death
Maintain mission integrity:
Keep the patient alive

Recognition of the triad

Rapid Transport to the nearest
appropriate hospital (trauma
center)
Preservation
INJURY
Hemorrhage
Control
RESUSCITATION
time
Immediate vs. delayed fluid resuscitation
for hypotensive patients with penetrating
torso injuries
Bickell WH, Wall MH, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL
Dept of Emergency Services, Saint Francis Hospital, Tulsa, OK USA
N Engl J Med 1994 Oct 27;331:1105-9

598 patients; BP < 90; prospective, randomized
Standard vs. limited resuscitation (prior to OR) by EMS
2480 mLs vs. 375 mLs IV fluids
Standard: 38% mortality (p=0.04) & 30% morbidity
Limited: 30% mortality and 23% morbidity
Normotensive = No IV fluids
Hypotensive = IV fluids until
Palpable radial pulse
Improved mentation
MAP ~ 50 mm Hg; SBP ~ 80 mm Hg

Controlled IV fluid boluses
25 500 mL

Hypotension is almost never due to brain
injury or hypovolemia from brain
hemorrhage.

Exsanguination can occur from scalp
laceration

Hypotension (SBP < 90 for 5 min)
doubles brain injury mortality (60% vs. 27%)
additional hypoxia increase mortality to 75%
Goal:
Maintain SBP > 90 mm Hg; MAP > 65
Treatment
Correct hypotension with isotonic fluids
0.9% Normal Saline
Lactated Ringers (LR)

Consider hypertonic saline (3%) if GCS < 8
250 mL 500 mL bolus
Established EMS system with goal of
getting the right patient to the right place
in the right amount of time
Goal
Limit pre-hospital time
Transport vehicle quickest means to closest
center
Transport to facility which has:
CT scan capabilities
ICP monitoring
Neurosurgical Care

The perfect hemostatic
dressing does not exist.
Chitosan (anthropod skeletons)
79 97% success rate
Must adhere well to wound
Is not flexible, difficult to pack
Works best on superficial, flat wounds

Kaolin volcanic rock
Absorbs water in wound
Concentrates factors, platelets
In powder form heat created

Problem solved
Gauze pads impregnated
Require 2-5 mins pressure

Activates factor XII
ONLY PRODUCT ENDORSED BY THE
TACTICAL COMBAT CASUALTY CARE
COMMITTEE OF DoD
MAST
Blanket or Sheet
1 gram over 10 minutes
First dose within 3 hours of injury
Second dose: 1 gram over 8 hours
Trauma=unstable spine injury=spinal cord
injury=permanent neurological deficit=bad.

Any additional movement of the neck/back may
cause an injury that was not present immediately
following the initial traumaor it may worsen an
injury that was there prior to any subsequent
medical intervention.

Further injury is avoided by immobilizing the spine.

Immobilization of the spine is safe.

Medicolegal issues prevent us from changing.

Pressure sores/tissue hypoxia

Good evidence that even short time periods
on a board cause tissue hypoxia at contact
points as well as pressure wounds

Wounds become worse with elderly and
severely injured folks who cant readjust on
board (aka spinal cord injured patient!)
Linares HA, Mawson AR, Suarez E, Biundo JJ. Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics. 1987;10:571-3.
Sheerin F, de Frein R. The occipital and sacral pressures experienced by healthy volunteers under spinal immobilization: a trial of three surfaces. J Emerg Nurs. 2007;33:447-50.
Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995;26:31-36.
Berg G, Nyberg S, Harrison P, Baumchen J, Gurss E, Hennes E. Near-infrared spectroscopy measurement of sacral tissue oxygen saturation in healthy volunteers immobilized on rigid spine boards. Prehosp Emerg Care. 2010;14:419-24.
Walton R, et al. Padded vs. Unpadded Spine Board for Cervical Spine Immobilization. Acad Emerg Med. 1995 Aug;2(8):725-8.
Increased pain
Healthy subjects placed on boards developed
numerous complaints when on boards for short
times (headaches, back, neck pain, dizziness,
nausea)




Barney RN, Cordell WH, Miller E. Pain associated with immobilization on rigid spine boards. Ann Emerg Med. 1989;18:918.
Lerner EB, Billittier AJ, Moscati RM. The effects of neutral positioning with and without padding on spinal immobilization of
healthy subjects. Prehosp Emerg Care. 1998;2:112-6
Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med.
1994;23:48-51



We should NOT be immobilizing
penetrating trauma.

Increases mortality and clear support
from all parties involved (AANS, ACS-COT, NAEMSP,
NAEMT, ATLS/PHTLS etc..)

Rhee P, et al. 2006
57,523 trauma patients
Evaluated by:
Blunt assault
Stab wounds
Gunshot wounds

Rhee P, et al. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating
assault. J Trauma. 2006;61:1166-1170

Rates for C-spine Fx:
GSW (1.35%)
Blunt Assault (0.41%)
Stab Wound (0.12%).
Rates of Spine Cord Inj:
GSW (0.94%)
Blunt Assault (0.14%)
Stab Wound(0.11%)
Rhee P, et al. Cervical spine injury is
highly dependent on the mechanism of
injury following blunt and penetrating
assault. J Trauma. 2006;61:1166-1170

Surgical stabilization:
GSW (26/158 [15.5%])
Blunt Aslt(6/19 [31.6%])
Stab Wnd (3/11 [27.8%])
No patient with
penetrating SCI
regained
significant
neurologic
recovery.


Dont get shot in the spinal cord..
Neurologic deficits from penetrating
assault were established and final at
the time of presentation.
Concern for protecting the neck should
not hinder the evaluation process or life
saving procedures.
Dont waste time on scene
packaging..just go.

There are no data to support routine spine
immobilization in patients with penetrating
trauma to the neck or torso.

There are no data to support routine spinal
mobilization in patients with isolated penetrating
trauma to the cranium.

Spine immobilization should never be done at
the expense of accurate physical examination or
identification and correction of life-threatening
conditions in patients with penetrating trauma.

Stuke LE, Pons PT, Guy JS, Chapleau WP, Butler FK, McSwain NE. Prehospital spine
immobilization for penetrating trauma--review and recommendations from the Prehospital
Trauma Life Support Executive Committee. J Trauma. 2011;71:763-9; discussion 769-70.



Unwarranted spinal immobilization can expose
patients to the risks of iatrogenic pain, skin
ulceration, aspiration and respiratory
compromise, which in turn can lead to multiple
radiographs, resulting in unnecessary radiation
exposure, longer hospital stay and increased
costs. The potential risks of aspiration and
respiratory compromise are of concern because
death from asphyxiation is one of the major
causes of preventable death in trauma patients.
Kwan I, Bunn F, Roberts I. Spinal immobilization for trauma patients. Cochrane Database of Systematic
Reviews. 2009;1:1-15


Reduce amount of on-scene personnel.

Reduce amount of patients lifted from
ground on LSB who are already ambulatory.

Reduce amount of awkward positions
providers place themselves in to extricate
otherwise well patients from vehicles.

Reduce scene times by eliminating time
spent immobilizing to board. (cot straps are
quick!...LSB strapping is NOT quick)
Decreased awkward extrication of stable patients
who could self-extricate
Less resources/manpower needed (two folks and a
cot for most minor MVCs with neck pain).
Less scene time when using cot straps and not
securing head.
More exposure/access to patient enroute.
More comfort for patient.
Saves patient from ED doc who leaves on board in
hospital.
Decrease radiological studies.
Decreases cost.
Decrease in resistance to placing a c-collar in elderly
or borderline patient when not mandated to use LSB.

Despite the long-standing history and
culture of spinal immobilization with a
backboard and cervical collar, using the
best evidence available, many abroad
and in the US believe the risk-benefit
analysis shows that the proven harm is
much worse than the theoretical, but
unproven, benefit of the backboard.