What Direction is Pre-Hospital Traumatology Going?

My Top 15 Recent Articles

At the Colloque intercollégial en Soins préhospitalier d’urgence held in Shawinigan, Quebec on January 25, 2020, I had the privilege of presenting on the future of pre-hospital traumatology around the world. The conference included a popularized version of 15 recent scientific articles intended to familiarize conferencegoers in the relevant scientific literature and to garner their appreciation for the successes that lie ahead.

First, I’d like to address what qualifies me to speak on this matter. I have been a certified athletic therapist since 2013 and I am also a master’s student at Laval University in pre-hospital identification of intra-thoracic and intra-abdominal lesions in trauma patients. I am also an examiner for the Prehospital Evidence-Based Practice program and a coordinator for the International Trauma Life Support program and Quebec’s Stop the Bleed program. I continue to practice athletic therapy in the field and as a first responder for the city of Côte-St-Luc and I also provide training to first responders and through Sports First Responder.

• Prehospital services and medical-legal systems are very different around the world and are not always comparable from one country to the next;
• You should avoid getting too excited about new tools that appear highly effective. The majority of popular products are scientifically unproven;
• In trauma, the vast majority of data stems from the military context, and the military does not accurately represent the views of the general public;
• A common mistake is to extrapolate from data or results that have not yet been published. An example of this is assuming that a pediatric treatment is equally effective in adults;
• Make sure that you read all the details! Everyone who gets interested in scientific literature should read the two studies below:
• Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial (BMJ 2018)¹
• Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials (BMJ 2003)²

According to the American government some of the problems to rectify in pre-hospital traumatology over the next decade are:

• The appropriate destination for patients with severe trauma (the nearest hospital vs. tertiary trauma centre)
• More adequate use of helicopter transportation
• Acknowledgement of the importance of first responders on the mortality of patients and how to adapt trainings. The Stop the Bleed program is the best example of this
• Ensure that protocols are based on the best available data and not only the opinions of experts
• The best use of technologies including cell phones, telemedicine, portable ultrasound machines, etc.
• Ensure better physical and psychological safety for medical practitioners. This should come in the way of ambulances, bulletproof vests, peer/support-worker programs, etc.
• Managing emergency transportation using private vehicles and police rather than traditional ambulance-based transportation vehicles in specific situations.

Here now are the 15 studies that I chose to include in my summary of the upcoming changes in pre-hospital traumatology:

1. The use of lactate as an early identifier of shock in non-hypotensive patients is a highly interesting avenue. Before the patient deteriorates, a single sample of lactate (no more complicated that glycemia) can indicate whether or not the patient’s state will worsen. This tool has already been proven in patients with hypotension, but unfortunately it remains inconclusive in non-hypotensive patients. The shock index (pulse/systolic blood pressure) is simpler and more precise (89.9% accuracy vs. 66.9% for lactate)³.

2. In the worse cases of trauma to the lower limbs, hemorrhaging can be difficult and even impossible to control. A new, very promising tool on the market is the abdominal and junction aorta tourniquet! This tourniquet compresses the abdomen until the aorta has been completely occluded, allowing the patient to get to a hospital and into surgery to control the hemorrhage. It has been proven safe for use up to 4 hours!⁴

3. For years, the traditional tourniquet was demonized but has since proven effective. According to this study out of Louisiana, it would reduce the number of reduce blood transfusions and days in hospital. More importantly, there were less complications in the group that used the tourniquet than those that did not. And to think that people continue to hesitate to use it⁵.

4. REBOA is an amazing tool with great potential. This minimally-invasive technique consists in inflating a balloon in the aorta to control hemorrhaging in the pelvis and the lower limbs. Data from this British study appear to favour its use. However, the study included only 21 patients, representing only 0.003% of severely injured patients in London⁶.

5. This was certainly the most talked-about study to come out of the pre-hospital milieu in 2018. The mortality of 103,029 patients was lower in those that were transported via private vehicle than by ambulance! Does this mean that everyone should always try to get themselves to the hospital? No! The caveat is that the study accounted only for patients that had experienced a penetrating injury. And these cases require emergency surgery, so the patients always need to get to the hospital as quickly as possible, regardless of the means!⁷

6. One of the vital emergency health issues in traumatology is the pressure pneumothorax. The technique currently being used is pin decompression, however, many practitioners agree that catheters are too small to ensure good decompression. A group in Texas attempted to use thoracostomies (i.e. an incision between two ribs to release trapped air), however, statistically, this technique has not had a positive impact. In clinical settings, however, more patients survived in the experimental group. In addition, the thoracostomy was found to be safer for patients than pin decompression⁸.

7. This study was conducted by an American athletic therapist! It involved comparing whether patients immobilized in the traditional manner (board, straps, blocks, cervical collar) moved less during transportation than patients placed on a stretcher with only a cervical collar. Unsurprisingly, there was no difference between the two groups. So why waste time putting patients on a board or vacuum mattress? In the end “scooping” was considered the better option⁹.

8. This is another study on spinal injuries, this time on the geriatric population. The researchers analyzed a new protocol for making immobilization decisions, but in patients over 60 years of age, which was relatively rare and innovative. Upon implementing the new protocol, less patients were immobilized (59.4% vs. 28.1%) while maintaining a small proportion of patients with neurological deficits (6.5% vs. 5.3%). It was therefore considered safe to establish triage protocols for geriatric patients in contrast to what is stated in the Canadian rules and it harkens back to the question of why to immobilize patients at all?¹⁰

9. Star Trek technology is on the horizon! Using portable ultrasound machines in pre-hospital settings is currently very trendy, but, above all, these machines are accurate! They are used in trauma situations along with complex medical cases (intubation, CPR, etc.) and help assess and decide whether or not transportation is necessary. The drawbacks? It’s tough to keep skills up-to-date with the small number of machines available in pre-hospital settings, making it necessary to visit a hospital to practice with them¹¹.

10. Another study on ultrasound here, this time investigating triage situations in situations such as the Berlin Truck Attack. The technology is found to improve triage, reduce the number of scans required and wait times before moving to the operating ward. However, the currently available technology cannot be used for long periods of time¹².

11. In patients that have lost a lot of blood before they reach the hospital, it is difficult to administer blood products. In addition, we know that traditional administering of NaCl solution increases mortality rates (owing to acidosis, hypothermia and coagulopathy). The French and Israeli armies have adopted a new technique: lyophilized plasma. This is human blood plasma that has been reduced into a powder. It just needs to be mixed with sterile water and shaken thoroughly for 2 minutes to reconstitute the solution. It can be administered quickly in a pre-hospital setting and appears very promoising¹³.

12. Keeping with patients with significant hemorrhaging, in 2013 the use of tranexamic acid, an antifibrinolytic medication that has long been used in hospital settings, was proven to be effective in the first 3 hours after the trauma. Administering of this product by paramedics in California led to a decrease in mortality rate, the use of blood products and the length of hospitalization in the experimental group, with no further complications!¹⁴

13. Do advanced life support helicopter teams, like the ones that we often see in Europe, improve the survival rate of patients in critical cardiac arrest? According to the authors of this study, yes, but the results are not very convincing. In fact, there are very few studies that have demonstrated the added value of helicopter services in prehospital settings, especially when the immense costs are taken into account. They are great for television, but these services require better oversight¹⁵.

14. With the increase in violence and active shooters across the world, emergency services need to find strategies to safely access patients more quickly. The most popular method, i.e. rescue task forces, consist in sending teams of 3-4 police officers along with 2 paramedics into a “warm” zone, which is an area in which the threat is no longer present. Once on site, the police officers ensure safety while the paramedics carry out an initial triage before evacuating victims to a buffer zone where other teams are waiting to transfer the patients to a treatment area. According to the study, respondents can easily be trained in this approach and in short order, however, remaining safe while using effective means of communication must remain the priority. Police units in Quebec have already begun training their respondents!¹⁶

15. Following the horrible Pulse Bar shootout in Orlando, a group investigated the mechanisms of injury that led to death. The results were striking: of the 49 deaths, 336 wounds were identified, i.e. 6.9 per patient. 46% of the wounds were to the extremities, while 41% of deaths were caused by injuries to the thorax. If we consider previous studies on the matter, the initial triage and rapid transportation to trauma centres were the most important factors in victim survival. The use of tourniquets on the extremities was also a priority considering the percentage of wounds to the extremities and the average number in each patient, i.e. it is impossible to treat 6-7 wounds at the same time¹⁷.

In closing, I would mention the following important points:

1. The survival of trauma patients in Quebec is the highest among all Canadian provinces. Let’s stop denigrating the work of respondents and our province’s system. Obviously, there is room for improvement, but it works very well!
2. Cooperation among professional is critical and our work as athletic therapists in the field helps save lives and reduces morbidity in patients. However, we can’t do it alone and knowledge transfer and collaboration with our paramedic colleagues means that patient welfare remains our main concern
3. Make sure you are always questioning, reading scientific articles and encouraging discussion and pushing for change!

I could have raised a multitude of other matters, but time is limited, so I’ll keep them in mind for a future presentation! To keep the discussion going, please follow me on Instagram or on Facebook. You can also email me.

Marc-Antoine Doré, CAT (C)
Special Collaborator

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