With the recent release of the US DHS Guidance for IED and Active Shooter document, we’re taking a look at some of the key concepts within that document. This week we’re looking at the Trauma Systems roles in preparing for and responding to these events.
To some extent we are lucky. We’re lucky because there are probably few tertiary care trauma centers that don’t have a veteran of Afghanistan or Iraq on their surgical, ICU or resuscitation service. Experience counts, and team leadership is essential in MCI, no matter where they happen. Many hospitals have regular MCI drills, and at the facility level it really doesn’t matter what the incident is. Plane crash? Bus Crash? IED? Unless you move the MCI to the hospital during transport, or the incident targets a health care facility, MCI in hospitals (should be) are very different from the chaos of responding to the incident scene.
“EMS must rapidly and accurately triage casualties at the incident site and expeditiously transport those identified for “immediate care” into an appropriate hospital setting.”
All facilities, not just those designated trauma receiving facilities, need to be ready for an influx of patients. Experience shows that in major events many casualties self-report to the nearest treatment facility if they are capable of doing so. These facilities need to have triage systems in place and EMS needs to stage transport units at these facilities to effect secondary transport. In a major event, secondary transport may include out of region and even out of province transfers. We need to keep in mind that our health care system is currently operating with a very limited surge capacity.
Damage control resuscitation and surgery (DCR/DCS) is the name of the game. Prevent hypothermia, treat with blood products not salt water, and stop ongoing hemorrhage.
DCR is based on the balanced administration of thawed plasma, pRBCs, and platelets in severely injured patients instead of solutions such as normal saline and lactated ringers.9 10 11 12 DCR also includes avoidance of hypothermia and pursuit of other measures to maximize oxygenation and reduce injurious factors in the blast-injured patient.
However, all the surgeons in all the OR’s aren’t much help if you can’t get the patient to them in the right sequence. Triage is one of the most critical elements of any MCI response, and MCI triage is not what you’ve experienced in the Emergency Room during a normal visit. Triage also can’t happen once. Triage should happen at each stage of evacuation, again on arrival at the hospital, and again among the priority patients for surgical priority.
Behind the scenes of any surgery are the hidden experts, radiology, lab techs, blood bank, and all the others without whom a modern OR can’t function, and they each have a job to do. This job will take a finite amount of time, and have a finite amount of stores on hand.
One area where significant efficiencies can be found is the role of the blood bank in trauma resuscitation, particularly development and implementation of Massive Transfusion (MT) Protocols. Fascinating research in MT is ongoing, and developments like rotational thromboelastometry (ROTEM) are offering exciting developments.
Any patient who may require MT should have already received TXA, preferably during tactical field care or casevac care. Despite best efforts, none of the prehospital blood replacements (or even Normal Saline for that matter!) show much benefit in hemorrhagic shock. With that in mind, resuscitation with blood products is the gold standard. Everything infused should be warm, it should be under pressure, and it should either help promote clotting or carry oxygen.
And let’s not forget that when these patients come out of resus and are off to the OR or ICU there is a finite amount of resources available for them even if they’ve made it this far. We know that care of the traumatized patient is a long-term problem that will persist long after the event.
The provider on scene is only the tip of what must be a vast concerted effort of allied health care providers working together towards a common goal: Best care for the patients under less than ideal circumstances.