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Ch 19. Penetrating Trauma

 

The major paradigm within EMS for penetrating trauma is the rapid transport of patients to definitive surgical care – a “load and go” strategy. Prehospital interventions that may delay trans- port should be reserved only for truly immediate life-threatening injuries identified on the primary survey. Note the survey should assess for cavitation, or the rapid expansion and contraction of tissues from the shock wave of the penetrating object.

Epidemiology and General Principles

Penetrating trauma in the United States:

  • ~ 20% of trauma
  • 40-50% of all trauma mortality
  • More likely to cause mortality in the first 72 hours vs. blunt trauma (Table)

 

Penetrating Trauma

Out-of-Hospital Management

PRIMARY SURVEY

Penetrating trauma patients are assessed using “CABC,” or Catastrophic Hemorrhage, Airway, Breathing, Circulation.

C - CATASTROPHIC HEMORRHAGE

Massive external hemorrhage is the first priority in manage- ment, with direct pressure being the mainstay of treatment. Pri- or to riding along, be familiar with the different bandages and supplies carried on board for hemostasis.

Tourniquets

Tip: After tourniquet application, it is normal to see some ooz- ing but not frank arterial spray.

Rapid exsanguination from penetrating isolated extremity trauma accounts for up to 10% of exsanguination deaths.

  • Three-quarters of such wounds will be in the lower extremities.
  • The majority are proximal to the knee or elbow.

Tourniquets improve mortality. Properly used tourniquets:

  • Do not increase permanent neurovascular injury.
  • Do not change ultimate extent of amputation required.

Application Principles:

  • Place 2 or more inches proximal to the point of injury.
  • Device should be wide:
    • Lower extremity bleeding is difficult to control with tourniquets less than 1 inch wide.
    • Increased width may also reduce local tissue damage and complication.
  • Device should be tightened until bleeding stops.
  • Clearly document application time on device.
  • Failure to control bleeding, or loss of previously controlled bleeding, should prompt placement of a second tourniquet more proximal to the first.
    • Note: The first device should not be loosened or removed.
  • Ultimately, rapid transport to obtain an alternative, definitive manner of controlling hemorrhage remains the goal; ideally limit tourniquet time to less than 2hrs.

Topical Hemostatic Agents

Uncontrolled hemorrhage accounts for up to 80% of early civilian trauma deaths; a small percentage of these are from iso- lated extremity injury. Most of the civilian trauma hemorrhage is due to liver and cardiac injuries, with almost one-third involving a major vessel injury.

Topical hemostatic agents are an option for wounds not amenable to tourniquets. These products can be used to rapidly pack penetrating wounds with pulsatile bleeding; in such cases, the source of the bleeding should be visible or accessible with a finger (eg, very proximal femoral artery injuries over the groin, abdominal injuries, etc.).

Tranexamic Acid

  • Tranexamic acid (TXA) may be of benefit for patients at risk for significant internal bleeding, especially if time to definitive care is delayed. TXA is a lysine derivate that prevents plasmin and plasminogen activity, thus reducing clot dissolution.  Two major studies show roughly 10% mortality reduction (penetrating and blunt trauma combined).

TXA is often given as bolus, followed by infusion:

  • 1g over 10 min, then 1g over 8 hrs; best results if given within 3hrs of injury. It is always important to consider the mechanism, patient’s vital signs, and overall clinical scenario prior to administration.
  • Complications potentially include coagulant phenomenon such as MI, PE/DVT; however early studies have not shown increase in mortality from use.

TXA’s role in civilian EMS remains unclear; it is just starting to be integrated into many EMS systems.