Navy corpsmen listens for the correct tube placement on an intubated trauma victim during a search and rescue exercise Typical trauma room Pre-hospital The pre-hospital use of stabilization techniques improves the chances of a person surviving the journey to the nearest trauma-equipped hospital. Emergency medicine services determines which people need treatment at a trauma center as well as provide primary stabilization by checking and treating airway, breathing, and circulation as well as assessing for disability and gaining exposure to check for other injuries. Spinal motion restriction by securing the neck with a cervical collar and placing the person on a long spine board was of high importance in the pre-hospital setting, but due to lack of evidence to support its use, the practice is losing favor. Instead, it is recommended that more exclusive criteria be met such as age and neurological deficits to indicate the need of these adjuncts. This may be accomplished with other medical transport devices, such as a Kendrick extrication device, before moving the person. It is important to quickly control severe bleeding with direct pressure to the wound and consider the use of hemostatic agents or tourniquets if the bleeding continues. Conditions such as impending airway obstruction, enlargening neck hematoma, or unconsciousness require intubation. It is unclear, however, if this is best performed before reaching hospital or in the hospital. Rapid transportation of severely injured patients improves the outcome in trauma. Helicopter EMS transport reduces mortality compared to ground-based transport in adult trauma patients. Before arrival at the hospital, the availability of advanced life support does not greatly improve the outcome for major trauma when compared to the administration of basic life support. Evidence is inconclusive in determining support for pre-hospital intravenous fluid resuscitation while some evidence has found it may be harmful. Hospitals with designated trauma centers have improved outcomes when compared to hospitals without them, and outcomes may improve when persons who have experienced trauma are transferred directly to a trauma center. In-hospital Management of those with trauma often requires the help of many healthcare specialists including physicians, nurses, respiratory therapists, and social workers. Cooperation allows many actions to be completed at once. Generally, the first step of managing trauma is to perform a primary survey that evaluates a person's airway, breathing, circulation, and neurologic status. These steps may happen simultaneously or depend on the most pressing concern such as a tension pneumothorax or major arterial bleed. The primary survey generally includes assessment of the cervical spine, though clearing it is often not possible until after imaging, or the person has improved. After immediate life threats are controlled, a person is either moved into an operating room for immediate surgical correction of the injuries, or a secondary survey is performed that is a more detailed head-to-toe assessment of the person. Indications for intubation include airway obstruction, inability to protect the airway, and respiratory failure. Examples of these indications include penetrating neck trauma, expanding neck hematoma, and being unconscious. In general, the method of intubation used is rapid sequence intubation followed by ventilation, though intubating in shock due to bleeding can lead to arrest, and should be done after some resuscitation whenever possible. Trauma resuscitation includes control of active bleeding. When a person is first brought in, vital signs are checked, an ECG is performed, and, if needed, vascular access is obtained. Other tests should be performed to get a baseline measurement of their current blood chemistry, such as an arterial blood gas or thromboelastography. In those with cardiac arrest due to trauma chest compressions are considered futile, but still recommended. Correcting the underlying cause such as a pneumothorax or pericardial tamponade, if present, may help. A FAST exam may help assess for internal bleeding. In certain traumas, such as maxillofacial trauma, it may be beneficial to have a highly trained health care provider available to maintain airway, breathing, and circulation. Intravenous fluids Traditionally, high-volume intravenous fluids were given to people who had poor perfusion due to trauma. This is still appropriate in cases with isolated extremity trauma, thermal trauma, or head injuries. In general, however, giving lots of fluids appears to increase the risk of death. Current evidence supports limiting the use of fluids for penetrating thorax and abdominal injuries, allowing mild hypotension to persist. Targets include a mean arterial pressure of 60 mmHg, a systolic blood pressure of 70–90 mmHg, or the re-establishment of peripheral pulses and adequate ability to think. Hypertonic saline has been studied and found to be of little difference from normal saline. As no intravenous fluids used for initial resuscitation have been shown to be superior, warmed Lactated Ringer's solution continues to be the solution of choice. If blood products are needed, a greater use of fresh frozen plasma and platelets instead of only packed red blood cells has been found to improve survival and lower overall blood product use; a ratio of 1:1:1 is recommended. The success of platelets has been attributed to the fact that they may prevent coagulopathy from developing. Cell salvage and autotransfusion also may be used. Blood substitutes such as hemoglobin-based oxygen carriers are in development; however, as of 2013 there are none available for commercial use in North America or Europe. These products are only available for general use in South Africa and Russia. Medications Tranexamic acid decreases death in people who are having ongoing bleeding due to trauma, as well as those with mild to moderate traumatic brain injury and evidence of intracranial bleeding on CT scan. It only appears to be beneficial, however, if administered within the first three hours after trauma. For severe bleeding, for example from bleeding disorders, recombinant factor VIIaa protein that assists blood clottingmay be appropriate. While it decreases blood use, it does not appear to decrease the mortality rate. In those without previous factor VII deficiency, its use is not recommended outside of trial situations. Other medications may be used in conjunction with other procedures to stabilize a person who has sustained a significant injury. While positive inotropic medications such as norepinephrine sometimes are used in hemorrhagic shock as a result of trauma, there is a lack of evidence for their use. Therefore, as of 2012 they have not been recommended. Allowing a low blood pressure may be preferred in some situations. Surgery The decision whether to perform surgery is determined by the extent of the damage and the anatomical location of the injury. Bleeding must be controlled before definitive repair may occur. Damage control surgery is used to manage severe trauma in which there is a cycle of metabolic acidosis, hypothermia, and hypotension that may lead to death, if not corrected. The main principle of the procedure involves performing the fewest procedures to save life and limb; less critical procedures are left until the victim is more stable. Approximately 15% of all people with trauma have abdominal injuries, and approximately 25% of these require exploratory surgery. The majority of preventable deaths from trauma result from unrecognised intra-abdominal bleeding.
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