What is the acute prehospital management via rotary wing (helicopter) for a patient with major abdominal blunt trauma?

From the Guidelines

Prehospital rotary wing management of major abdominal blunt trauma should prioritize rapid assessment and stabilization, focusing on airway maintenance, breathing support, and circulation stabilization following ATLS principles, with a target systolic blood pressure of 80-90 mmHg and administration of tranexamic acid 1g IV over 10 minutes within 3 hours of injury if significant hemorrhage is suspected, as recommended by the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1.

Key Management Strategies

• Secure the airway with endotracheal intubation if GCS is less than 8 or airway compromise exists, and provide supplemental oxygen to maintain SpO2 above 94% and ventilatory support as needed.
• Control external hemorrhage with direct pressure and apply pelvic binders for suspected pelvic fractures.
• Establish two large-bore IV access (16-18 gauge) and initiate fluid resuscitation with balanced crystalloids like 0.9% NaCl, avoiding hypotonic solutions such as Ringer's lactate in patients with severe head trauma, and consider the use of blood products if available (1:1:1 ratio of PRBCs, plasma, and platelets) 1.
• For hypotension, target a systolic blood pressure of 80-90 mmHg (permissive hypotension) to prevent clot disruption while maintaining organ perfusion, unless traumatic brain injury is present, in which case a mean arterial pressure of 280 mmHg should be maintained 1.
• Administer tranexamic acid 1g IV over 10 minutes within 3 hours of injury if significant hemorrhage is suspected, followed by an intravenous infusion of 1g over 8 hours 1.
• Pain management should include fentanyl 25-50 mcg IV titrated to effect or ketamine 0.1-0.3 mg/kg IV for hemodynamically stable patients.
• Continuously monitor vital signs, including temperature to prevent hypothermia using warming blankets, and minimize scene time to under 10 minutes when possible, as definitive surgical intervention at a trauma center is the primary determinant of survival for patients with significant abdominal trauma.

Additional Considerations

• The use of whole-body computed tomography (CT) scans in the emergency department can help identify head and chest injuries and other bleeding sources in patients with multiple injuries, and may improve clinically important outcomes in hemodynamically stable patients 1.
• The integration of modern MSCT scanners in the emergency room area allows for immediate assessment of trauma victims following admission, and can help reduce emergency room and operating room time and shorter ICU stays 1.
• Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be considered in patients with noncompressible life-threatening traumatic hemorrhage, and damage-control surgery should be performed in severely injured patients presenting with hemorrhagic shock, signs of ongoing bleeding, coagulopathy, vascular and pancreatic injuries, hypothermia, acidosis, and/or combined abdominal inaccessible major anatomic injury or a need for time-consuming procedures 1.

From the Research

Acute Prehospital Management via Rotary Wing for Major Abdominal Blunt Trauma

• The prehospital management of patients with major abdominal blunt trauma involves determining the mechanism of injury, identifying anatomic involvement, and staging the condition 2.
• For patients with blunt abdominal injuries, on-scene stabilization should precede transport to the hospital, and immediate blood transfusion is recommended for hemodynamically unstable patients upon arrival at the accident and emergency room 3.
• The use of fluid resuscitation in the prehospital setting is still a topic of debate, with some studies suggesting that liberal use of fluid infusions may not be beneficial for patients with uncontrolled internal hemorrhage 2, 4.
• The priority for patients with severe hemorrhage is rapid evacuation to definitive surgical intervention, with airway control and intravenous access provided en route 2.
• Damage Control Resuscitation can reduce mortality drastically in patients with intra-abdominal traumatic injury, and clear communication is essential to provide quality care 5.
• The use of rotational thromboelastometry (ROTEM) can help identify hyperfibrinolysis and afibrinogenaemia, and guide treatment with antifibrinolytic medication and fibrinogen concentrate 6.
• Prehospital assessment of a patient's circulation status and appropriate resuscitation with intravenous fluids plays a critical role in patients with obvious hemorrhage or systolic blood pressure below 90 mm Hg 4.

Key Considerations

• The management of major abdominal blunt trauma requires a multidisciplinary approach, involving prehospital care, emergency medicine, and surgical teams.
• The use of evidence-based guidelines and protocols can help improve patient outcomes and reduce morbidity and mortality.
• Further research is needed to evaluate the effectiveness of different prehospital management strategies for patients with major abdominal blunt trauma.