Category Archives: Prehospital

Prehospital

Field Amputation Part 2: Indications

Leave a comment

There are basically four indications, two absolute and two relative:

  • Absolute #1: entrapped extremity with a lengthy extrication and a physiologically impaired patient who does not respond to fluids. In this case, there is occult blood loss in other areas that is killing your patient, and they need to get out quickly for definitive management.
  • Absolute #2: entrapped extremity with a lengthy extrication and an unstable physical environment. Examples include entrapment in a structurally damaged building or a vehicle in danger of falling, exploding, etc.
  • Relative #1: entrapped extremity with a lengthy extrication in a patient who was initially hypotensive but responded to IV fluids. Waiting for additional extrication efforts is possible, but vital signs must be monitored closely. At the first sign of recurrent hypotension, it’s time to amputate.
  • Relative #2: entrapped extremity and physiologically normal, but extrication may take many hours or be impossible. Once again, there is time to wait and let rescue workers continue their efforts. However, the more time passes, the less likely the extremity will ultimately be functional.

Obviously, a lot of thought and judgment goes into deciding to amputate. Having another physician to discuss the facts with is helpful, but as the treating trauma professional, the ultimate decision is yours. If appropriate, there may also be an opportunity to discuss with the patient and/or their family.

In the next post in this series, I’ll discuss who performs the field amputation.

Print Friendly, PDF & Email
Prehospital

Field Amputation Part 1: Introduction

Leave a comment

Field amputation is not thought of very often, and for good reason. It is unpleasant, uncommon, and not very safe for trauma professionals due to the austere environment. I will dedicate the next several posts to the topic, starting with some of the facts.

First, let’s start with definitions. Two distinct procedures are discussed here.

The first and most commonly described is field amputation. This is the removal of a body part in a living person to extricate them from a situation in which all other attempts have failed.

The other procedure is field dismemberment. This is the surgical alteration of a dead body to extricate another living person who is entrapped, where there is no other route of egress. This is less taxing, both surgically and psychologically, for all involved. For this reason, I’ll focus on field amputation for the rest of this issue.
In reality, these procedures are discussed much more often than performed. And there are far more papers written than actual documented cases. There is one old paper that is cited frequently which consisted of a survey from 1996! A search of the literature at that time only yielded two case descriptions.

In the 1996 study, surveys were sent out to EMS directors in North America’s 200 largest metropolitan areas. A total of 143 directors responded.

Here are the factoids:

  • There were 26 amputations performed over a five-year period
  • Nine additional cases were identified where it was believed that the procedure was indicated but not performed
  • The most common mechanism was motor vehicle crash (27%), followed by industrial machinery (23%)
  • 53% were (or would have been) performed by a trauma surgeon, 36% by an emergency physician, and a paramedic in 14%. Five respondents had no idea who would do it. (More than one choice was possible, hence total is > 100%)
  • No training was available for this procedure, although a few had training on how to deal with the amputated part
  • Only 2 EMS systems had an existing policy or protocol (1%)

An informal poll of trauma surgeons at a national American College of Surgeons meeting several years ago showed that only five had ever been called to do a field amputation, and only two had actually done it.

Uncommonly performed procedures are always problematic. It is extremely difficult to keep skills sharp (pun) and to remember the protocol, equipment, and where to find them. Furthermore, these procedures are prone to error and pose considerable risk to all involved

And if there are no policies or guidance, it is possible that the procedure may actually not be done in cases where it should. Therefore, effective policies must be put in place to accomplish these five things:

  1. Define situations where in-field amputation may be necessary
  2. Notify online medical direction of possible need for amputation
  3. Notification and mobilization of the appropriate physician
  4. Transport of the response team and equipment to the scene
  5. Transport of the patient to the appropriate receiving facility

In the next post, I’ll review the indications for field amputation.

Reference: In-Field Extremity Amputation: Prevalence and Protocols in Emergency Medical Services. Prehospital and Disaster Medicine 11(1):63-66, 1996

Print Friendly, PDF & Email
Prehospital, What the heck?

What The Heck! You Make The Diagnosis – The Answer

Leave a comment

In my last post, I detailed the following case:

This male patient was brought to the trauma center after a high-speed car crash. He was unresponsive with GCS 3. A bleeding facial laceration was present, as was vomitus in the airway.

Prehospital providers rapidly intubated the patient and inserted an orogastric tube. They rapidly packaged and transported him to the nearest trauma center.  The facial laceration was stapled for bleeding control. The airway was checked with a CO2 color change indicator and was positive. OG was hooked to suction with return of gastric contents.

And here was a lateral cervical spine image:

The main problem is that, if you look closely there are three tubes on the image!

Look carefully at the anterior pharynx and trace the radiopaque markers back. There are two nearly overlapping lines. One extends posteriorly, down into the esophagus. This is the orogastric tube. The distal tip of the other (an endotracheal tube which is only inserted to 12 cm at the teeth) stops where it touches another tube. Another endotracheal tube, the proximal end of which is sitting at the epiglottis!

What the heck??! The medics were interviewed, and the patient was initially intubated successfully. The intubator turned his attention to finding a tube securing device, and when he turned back the tube was gone! So he intubated again but met some resistance. This explained the shallow position of the tube.

The patient was oxygenated well and the “outside” ET tube was removed. Then ring forceps were passed under direct vision and the “inside” tube was removed. A well-positioned ET tube was then reinserted. The patient did well afterwards.

Teaching point: When inserting anything that is partially in and partially out of the body (e.g. guidewires, and now ET tubes) always anchor them with your fingers so they don’t just “disappear.” And if you need more hands, ask for assistance!

Source: personal collection. Not treated at Regions Hospital or even in Minnesota.

Print Friendly, PDF & Email
Abstracts, Prehospital

Best Of EAST 2023 #11: Prehospital Use Of TXA

Leave a comment

More stuff on TXA! I published two posts back in December on TXA hesitancy. This Friday, the trauma group at Wake Forest is presenting an abstract on TXA use by prehospital trauma professionals.

It is very likely that EMS carries tranexamic acid (TXA) in your area. Each agency has its own policy on when to administer, but the primary indication is hemorrhagic shock. A few ALS services may infuse for serious head injury as well.

The Wake Forest group was concerned that TXA administration might be occurring outside of the primary indication, hemorrhagic shock. They reviewed their experience using a six-year retrospective analysis of their trauma registry. The patients’ physiologic state before and after arrival at the hospital was assessed, as were the interventions performed in both settings.

Here are the factoids:

  • Of 1,089 patients delivered by 20 EMS agencies, one-third (406) had TXA initiated by EMS
  • Only 58% of patients who received prehospital TXA required transfusion after arrival
  • TXA administration based on BP criteria were as follows:
  • Similar compliance was noted when examining only high-volume EMS services

The authors concluded that TXA use is common in the prehospital setting but is being used outside of literature-driven indications.

Bottom line: This is an interesting snapshot of TXA use surrounding a single Level I trauma center. As such, it can’t be automatically applied to all. However, my own observations suggest that this drug is being used more liberally nationwide.

Clearly, the prehospital providers are starting TXA on patients who do not fit the category of severe hemorrhagic shock. Only 30% of patients receiving it had SBP < 90. Is this a bad thing? Referring back to my conversation on TXA hesitancy, I think not. But do keep in mind that giving any drug when not indicated adds no benefit and can certainly increase risk. The good news is that TXA is very benign when it comes to side effects.

However, policies are designed for a reason: safety. And if the EMS agency policy says to give TXA only for SBP < x, then that’s when it should be given. The prehospital PI process (or the trauma center’s) should identify variances and work to correct them. If EMS is “overusing” TXA in your area, your trauma center should add this as a new prehospital PI filter and let them know when it happens.

Here are my questions and comments for the presenter/authors:

  • Is using the need for transfusion a valid measure of the need for TXA? You found that half of the patients receiving TXA were not transfused. The decision to transfuse depends on surgeon preference, and they don’t always use objective criteria. And hey! Maybe the TXA worked, obviating the need for blood!

This is a straightforward and intriguing paper. I’m excited to hear more details on how you sliced and diced this data.

Reference: ARE DATA DRIVING OUR AMBULANCES? LIBERAL USE OF TRANEXAMIC ACID IN THE PREHOSPITAL SETTING. EAST 2023 Podium paper #34.

Print Friendly, PDF & Email
Complications, Prehospital

Scoop And Run VS Stay And Play: Part 5

Leave a comment

This is the last piece in my series on whether or not trauma patients should be initially managed with some limited interventions at the scene, vs just getting them into the ambulance and on their way to a trauma center. This article deals specifically with the needs of victims of penetrating trauma in big cities.

The Eastern Association for the Surgery of Trauma (EAST) published the results of a multicenter trial on the utility of prehospital procedures performed by EMTs and medics in this subset of patients. Most of the studies previously reviewed do not show an obvious advantage to dawdling at the scene.

The EAST study took an interesting approach. It limited patients to those in urban locations near trauma centers, which largely eliminated time from the equation. The authors could then attempt to identify any utility in performing procedures prior to trauma center arrival.

This was an observational trial of adults with penetrating injury to the torso or proximal extremity. A total of 25 trauma centers participated for a one-year period. Patients with penetrating injuries above the clavicles or in the distal extremities were excluded.

Here are the factoids:

  • Although 2,352 patients met inclusion criteria, a small number (68) were excluded because the method of transport was missing (!)
  • Type of transport was ALS (63%), private vehicle (17%), police (14%), and BLS (7%)
  • Nearly two-thirds (61%) received some type of prehospital procedure
  • The procedures performed included intubation (6% on scene, 2% in transport), IV access (49% on scene, 42% in transport), IO access (5% on scene, 3% in transport), fluid resuscitation (16% on scene, 32% in transport),application of a pressure dressing (23% on scene, 12% in transport), and tourniquet application (6% on scene, 2% in transport)
  • Patients who received prehospital interventions had significantly longer hospital length of stay (5.6 vs 4 days) and were more likely to develop ARDS, venous thromboembolisms, and urinary tract infections
  • In-hospital mortality was significantly higher in the intervention group (10.3% vs 7.8%)
  • Mortality significantly increased with the number of interventions performed at the scene and enroute to the trauma center
  • Prehospital intubation was strongly correlated with mortality, and the following procedures were also associated with higher mortality: fluid resuscitation, cervical spine immobilization, and pleural decompression
  • Prehospital IV insertion was significantly associated with survival, but tourniquet placement was neutral
  • There was no mortality difference based on the type of transport provided

Bottom line: This is a fascinating paper that applies to a limited subset of patients. Specifically, it only studied patients in urban areas with a trauma center that was presumably very close. Prehospital endotracheal intubation proved to be the most deadly intervention. A few studies have confirmed that intubation further degrades end-organ perfusion further in animals with severe hemorrhagic shock.

The finding that prehospital fluids were associated with higher mortality, but that IV access was not, is puzzling at first. However, there are a number of papers clearly showing that resuscitation without definitive hemorrhage control, can be deadly. This study confirms this fact in humans and lends support to the concept of permissive hypotension in these patients. 

Cervical spine immobilization proved to be a mortality risk. The reasons are not clear, but difficulties in placing an airway and increased intracranial pressure could be factors. The only clear indication would be for stabilization of the neck in patients with cervical cord injuries. However, in such cases the damage is done and collars are likely not of any benefit neurologically.

The biggest flaw in this study was that it did not record transport times. The authors assumed that times were short since the patients were injured in high density urban areas. There was also concern for selection bias, as more severely injured patients were more likely to undergo prehospital intervention.

The takeaway message is that in a setting with very short transport time to a trauma center, hemorrhage control trumps almost everything else. Obtaining IV access or applying a tourniquet may be beneficial, but should only occur once the patient is enroute to minimize time on scene. More advanced maneuvers such as fluid resuscitation, fluid resuscitation, collar placement, or needle decompression of the chest should be delayed for management by the trauma team.

These results cannot be generalized to patients with longer expected transport times, although we don’t have good research yet to back up this assertion. In those patients, it is probably best to adhere to the good old ABCs of ATLS. And of course, until this work is confirmed by more studies, do not go against any policies or procedures established by your prehospital agency!

Reference: An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients. J Trauma 91(1):130-140, 2021.

Print Friendly, PDF & Email