What are the key assessment questions for a patient with penetrating trauma for Emergency Medical Services (EMS)?

From the Guidelines

When assessing penetrating trauma as an EMS provider, the primary goal is to rapidly identify and transport patients to a trauma center while addressing life-threatening injuries, following the guidelines outlined by the national expert panel on field triage, 2011 1. The assessment process begins with scene safety evaluation, followed by a primary survey using the ABCDE approach:

• Airway (establish and maintain)
• Breathing (assess and support with oxygen if needed)
• Circulation (control hemorrhage with direct pressure, wound packing, or tourniquets as appropriate)
• Disability (brief neurological assessment)
• Exposure (examine for additional injuries) For penetrating chest trauma, apply occlusive dressings to prevent tension pneumothorax, leaving one side unsealed to allow air escape, as recommended in the guidelines for field triage of injured patients 1. The guidelines also emphasize the importance of assessing anatomy of injury, including all penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee, and other specific criteria such as chest wall instability or deformity, amputation proximal to wrist or ankle, and pelvic fractures 1. Transport to a trauma center is recommended for patients with severe injuries, as identified by the guidelines, and when in doubt, transport to a trauma center is the safest option 1. Key considerations in the assessment and transport of penetrating trauma patients include:
• Measure vital signs and level of consciousness, using the Glasgow Coma Scale, systolic blood pressure, and respiratory rate to guide decision-making 1
• Assess mechanism of injury and evidence of high-energy impact, including falls, high-risk auto crashes, and motorcycle crashes 1
• Consider special patient or system considerations, such as older adults, children, anticoagulants, and bleeding disorders 1
• Administer tranexamic acid (TXA) 1g IV over 10 minutes within 3 hours of injury for significant hemorrhage, as recommended by the guidelines 1
• Monitor vital signs continuously and document wound characteristics, including location, size, and potential trajectory 1

From the Research

Penetrating Trauma Assessment and Management

• The initial assessment of a patient with penetrating trauma should include evaluation of airway, breathing, and circulation (ABCs) 2
• Patients with hemodynamic instability, evisceration, significant gastrointestinal bleeding, peritoneal signs, gunshot wounds with peritoneal violation, and type 2 and 3 shotgun wounds should undergo emergency laparotomy 2
• The use of tourniquets in prehospital settings has been shown to be effective in controlling bleeding in major extremity penetrating trauma, with no increased risk of major complications 3, 4

Fluid Resuscitation and Hemorrhage Control

• Intravenous fluid resuscitation should be limited in patients with potentially uncontrollable internal hemorrhage, particularly in those with penetrating truncal injury being transported immediately to a trauma center 5
• The use of hemostatic agents, such as tourniquets and hemostatic chitosan-based wound packings, has been shown to be effective in controlling bleeding in trauma patients 3, 6
• Tranexamic acid (TXA) has been used as a hemostatic adjunct in prehospital settings, with liberal use in patients with unproven hemorrhage 6

Prehospital Tourniquet Use

• Prehospital tourniquet use has been associated with increased systolic blood pressure on arrival to the ED, decreased blood product utilization, and decreased incidence of limb-related complications 3
• The use of tourniquets in prehospital settings has been shown to be safe and effective, with no increased risk of major complications 3, 4
• Patients who may have potentially benefited from tourniquet application, such as those with extremity injury and shock index ≥1, should be identified and considered for tourniquet use 4

Outcomes and Survival

• Prehospital tourniquet use by EMS in the United States has been associated with lower scene-time and improved survivability to hospital 4
• The use of hemostatic adjuncts, such as tourniquets and TXA, has been shown to be effective in improving outcomes and reducing mortality in trauma patients 3, 6, 4