DEFINING THE PROBLEM
Hemorrhage, and particularly noncompressible torso hemorrhage (NCTH) remains a leading cause of potentially preventable prehospital death from trauma in the United States (US) and globally (1). Three decades of improvements in hospital definitive trauma care have shown substantial improvements in injury survival, but primarily benefit the patient if they reach the hospital in a state where they are able to be saved (2–8). A subset of severely injured patients either die in the field or develop irreversible hemorrhagic shock before they can receive hospital definitive care, resulting in poor outcomes (9).
The focus of this opinion paper is to delineate
- (a) the need for existing trauma systems to adapt so that potentially life-saving advanced resuscitation and truncal hemorrhage control interventions can be delivered closer to the point-of-injury (POI) in select patients, and
- (b) a possible mechanism through which select trauma systems can train and incorporate specialist multidisciplinary teams to deliver those interventions.
THE EVIDENCE FOR CHANGE
The 2016 National Academies of Sciences, Engineering, and Medicine (NASEM) report emphasized that approximately 20% of civilian prehospital traumatic deaths (about 30,000 patients based on the over 150,000 deaths per year ascribed to injury) are potentially preventable (10). Recent literature shows this may be an underestimate and supports three key findings (Table 1) (2, 11–18):
- 1. The proportion of potentially preventable prehospital and early (within 1 h) in-hospital death is likely higher than previously understood (typically >21% and as high as 45%), emphasizing the need to refocus care.
- 2. Patients most likely to benefit from rapid intervention have NCTH (isolated or combined chest, abdominal, or pelvic hemorrhage) where prehospital interventions and resuscitation focused solely on extremity hemorrhage may not be sufficient.
- 3. Severity of injury and time from injury are inextricably linked to death from hemorrhage. High-grade NCTH deaths occur within 30 min of injury. An early peak of in-hospital death from hemorrhage occurs within the first 1 or 2 h. Based on multicenter study data from US trauma systems, the time from POI to surgical hemorrhage control is a median 128 min (Fig. 1) (10, 19). Thus in-hospital hemorrhage control for these patients is often being applied beyond the point of irreversible hemorrhagic shock.
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Fig. 1: The advanced resuscitative care continuum from prehospital point-of-injury extending en-route to definitive care. IR indicates interventional radiology; OR, operating room; SPARC, selective prehospital advanced resuscitative care.
Table 1 -
Summary of evidence evaluating prehospital potentially preventable deaths
| Author/publication year |
Level of evidence |
Key methods and findings |
| Davis et al. (11)/2014 |
V |
Review of medical examiner reports of all 2011 trauma deaths in Miami-Dade County, FLHemorrhage accounted for 34% of deathsRegions affected: brain (59%), chest (54%), abdomen (35%)Potentially preventable prehospital deaths: 29% – primarily from hemorrhage and chest injuriesPotentially preventable early in-hospital deaths: 62.9% |
| Smith et al. (12)/2016 |
IV |
Retrospective autopsy review of 139 fatalities of 12 civilian public mass shootingsInjuries sustained: head 29%; face/neck 9%; chest 29%; abdomen 14%; extremity 20%Patients with potentially survivable injuries: 7%, primarily with chest injuries (89%) |
| Alarhayem et al. (13)/2016 |
III |
Review of NTDB data (2,523,394 patients) from 2012 to 201442,135 patients identified for inclusionIncluded patients with thorax AIS ≥ 4 or abdomen AIS ≥ 5, prehospital time, prehospital SBP ≤ 110 mm Hg, mortalityOverall mortality: 7.9%Precipitous increase in mortality for torso AIS ≥ 4 patients within 15–30 min of injury |
| Oyeniyi et al. (2)/2017 |
III |
Retrospective review of urban level 1 trauma center records over two time periods (2005–2006 and 2012–2013) to determine temporal distribution of trauma-related deaths and factors characterizing this distributionVolume and mortality increased over time periods – 7080 patients (498 deaths) to 8767 patients (531 deaths)TBI and hemorrhage-related deaths accounted for >91% of all deathsBoth time periods showed peak time to death within 1 h of hospital arrival in 26%Median time of death for all was 1.65 h without a second or third peakHemorrhage-related deaths decreased from 36% to 25%Unadjusted mortality decreased from 7% to 6.1% |
| Smith et al. (14)/2018 |
IV |
Retrospective autopsy review of victims of the Pulse Nightclub shootingInjuries sustained: extremity 90%, chest 78%, abdomen/pelvis 47%, head 39%Patients with potentially survivable injuries: 32%, primarily with torso injuries (56%) |
| Henry et al. (15)/2019 |
III |
Retrospective cohort study incorporating autopsy data of all patients presenting in traumatic arrest from NCTH to a level-1 trauma center from January 2014 to March 2018Logistic regression to identify prehospital factors for REBOA candidacy198 patients included with median ISS 22Patients with potentially preventable NCTH: 13.6% |
| Drake et al. (16)/2020 |
IV |
Retrospective review of all 1848 trauma-related mortality records in 2014 in Harris County, TXAll reviewed cases assigned a trauma preventable/potentially preventable death rate (PPPDR)Overall PPPDR was 36.2%Prehospital deaths: 46% of with PPPDR of 11.1–55.1% from hemorrhageEarly in-hospital (within 1 h) PPPDR: 44.4% – majority from hemorrhage |
| Kalkwarf et al. (17)/2020 |
IV |
Retrospective review of all patients who died of hemorrhage from 1848 trauma-related mortality records in 2014 in Harris County, TXTotal deaths from uncontrolled hemorrhage – 305Potentially preventable deaths – 137 (44.9%)Preventable deaths occurring prehospital deaths – 35.8%Preventable deaths occurring early in-hospital (within 1 h) – 20.4%Sources of potentially preventable hemorrhage: truncal bleeding – 74.5% [isolated chest 21.6%, isolated abdomen 15.7%, combined chest and abdomen 38.2%] |
| Carroll et al. (18)/2020 |
III |
Retrospective analysis of autopsy and hospital records of prehospital and early (within 1 h) in-hospital deaths in 2017 in Jefferson County, ALEvaluated potential mortality benefit of an advanced prehospital DCR teamOf 316 trauma deaths: 9% were survivable with hospital care, 14% were survivable with advanced prehospital DCR, 4% survivable with basic prehospital careCombining physiologic and anatomic parameters – 12% were possibly preventable |
AIS, Abbreviated Injury Severity Score; DCR, damage control resuscitation; ISS, injury severity score; NCTH, noncompressible torso hemorrhage; NTDB, National Trauma Database; REBOA, resuscitative endovascular balloon occlusion of the aorta; SBP, systolic blood pressure; TBI, traumatic brain injury.
Shortening EMS prehospital times (the “scoop-and-run” approach) is in our opinion one-dimensional, often not geographically possible in both rural and/or dense urban US locations (where for example in Houston and Los Angeles despite relatively short distances traffic congestion can hamper ground transport), and, outside of possible gain from using alternative transport methods such as the police in some regions, has not shown much benefit (20–22). A multi-dimensional approach will consider specific injury patterns and a system's needs, with consideration of moving advanced resuscitation and hemorrhage control near POI.
SHAPING A STRATEGY
Learning from the military
In 1996, an evidence-based review of battlefield trauma care recommendations conducted jointly by the US Special Operations Command and the Uniformed Services University resulted in the creation of a set of best-practice evidence-based POI trauma care guidelines customized for the battlefield, termed Tactical Combat Casualty Care (TCCC). This led to a significant decrease in potentially preventable combat trauma death especially from extremity and junctional hemorrhage and tension pneumothoraces (23).
The recommendation of shifting the emphasis of hemorrhage management from the hospital to POI and en-route settings reflects a careful recent analysis of how to further reduce preventable death in combat casualties by the Committee on TCCC. Studies using military autopsy and registry data continue to show that a majority of all military injury mortality occurred prior to reaching a medical treatment facility (MTF) with almost a quarter being potentially survivable, largely from NCTH (24, 25). Across a decade, several investigators showed the benefit of using whole blood over component therapy to reduce hemorrhagic shock mortality both in MTFs and prehospital, especially when transfused within 36 min of injury (26–28).
TCCC recently recommended adding far-forward resuscitation of casualties with NCTH by using whole blood, with zone 1 resuscitative endovascular balloon occlusion of the aorta being utilized for non-responders (29). Termed advanced resuscitative care, this has shown proof of concept in its use by a US Air Force Special Operations Surgical Team working at a far-forward MTF to stabilize 20 critically injured casualties (30). Separately, advanced resuscitative care resulted in the long-term survival of a severely injured soldier with NCTH whose initial injury severity score was 66 (31).
The one-dimensional “scoop and run” philosophy is challenged by the military's capacity to deliver far-forward and en-route advanced critical care. The UK military's Medical Emergency Response Team-Enhanced aeromedical platform is composed of a physician (from emergency medicine, critical care, or anesthesiology), nurse, and paramedic. This model utilized a Chinook helicopter to rapidly retrieve critically injured soldiers. The multidisciplinary clinical team provided en-route advanced resuscitation and hemorrhage control including but not limited to advanced airway management, chest decompression, tourniquet application, intravenous and intraosseous access, and blood product transfusion (32). Such advanced retrieval capability and en-route critical care most benefited casualties with high injury severity and has been implemented successfully by both Special Operations and Marine Corps units (33, 34).
Military–civilian partnership
The NASEM report outlines a National Trauma Action Plan encouraging civilian–military partnership and the use of data-driven decision-making to rapidly translate knowledge rapidly into actionable change (35). Key lessons from the military (blood resuscitation and stopping NCTH close to POI, and prehospital and en-route critical care advanced resuscitation) can augment existing civilian prehospital EMS capability. Local system support, anatomic location, and physiologic consequence of injury, risks, clinician expertise, and evolving data will guide decision-making.
The effects of hemorrhagic shock (oxygen debt, endothelial damage, and coagulopathy) can be exacerbated by crystalloids, and should be mitigated by the early use of whole blood (or in its absence, blood component therapy) along with TXA (1, 5, 36, 37).
Hemorrhage control measures should be directed anatomically – extremity, junctional, or NCTH (abdominal, pelvic, or thoracic). Extremity or junctional hemorrhage control can incorporate hemostatic dressings and/or extremity and junctional tourniquets. Pelvic fractures of appropriate anatomical configuration benefit from the early application of a pelvic binder. Abdominal or abdomino-pelvic NCTH may benefit from approved therapies actively being investigated such as the abdominal aortic junctional tourniquet or resuscitative endovascular balloon occlusion of the aorta. At the time of writing, while we acknowledge high-quality evidence of benefit is limited, resuscitative endovascular balloon occlusion of the aorta is the only FDA-approved modality for this indication. Other modalities such as intracavitary foam may evolve as an option in the future (38–40). Thoracic hemorrhage may require open/finger thoracostomy drainage for massive hemothorax. Witnessed traumatic arrest where the etiology is likely tamponade (as following a stab wound to the chest) may benefit from field resuscitative thoracotomy (41).
Precedent for civilian systems providing prehospital advanced resuscitation teams come from Europe, including London's Air Ambulance (LAA) and the Paris Service d’Aide Medicale Urgente. Both physician-staffed services work in dense urban environments, play key roles in daily trauma care as well as during civilian mass-casualty incidents, and work within a supportive trauma system that has a robust governance structure. LAA utilizes its rotary-wing asset for rapid critical care team insertion (to overcome the ground transport time limitations in this densely populated city), who then provide on-scene and en-route advanced resuscitative interventions (including airway management, blood, and prehospital resuscitative endovascular balloon occlusion of the aorta) similar to the Medical Emergency Response Team-Enhanced model (5, 38, 42).
Developing Selective Prehospital Advanced Resuscitative Care (SPARC) teams within select trauma systems can allow the delivery of a robust “scoop-and-control” approach emphasizing early near POI advanced hemorrhage resuscitation and control while maintaining the momentum to transport to in-hospital operative care (Fig. 1).
IMPLEMENTING THE SPARC STRATEGY
Needs assessment
Needs assessments must guide the decision-making of individual trauma systems to include and appropriately use a service that has high complexity but may be utilized infrequently. The quoted papers from Los Angeles, Houston, Alabama, and Miami are examples of these, although they may not fully represent rural trauma systems (15–18). Civilian trauma systems would do well to follow the direction of the military in incorporating autopsy data of both prehospital and in-hospital deaths so as not to inadvertently exclude those patients who never reached the hospital.
Augmenting, not negating, existing resources
Mechanisms that should continue to be emphasized include injury prevention programs; bystander training in prehospital hemorrhage control through initiatives such as Stop the Bleed; and the ready public-space availability of hemorrhage control kits including tourniquets and hemostatic dressings.
Law-enforcement officers can form a key part in the trauma chain-of-survival. Methods include early POI tourniquet application and rapid police transport of penetrating trauma patients to the nearest trauma center as in Philadelphia (22).
Team composition
Team composition must be dictated by individual trauma systems. This reflects the current environment of US trauma prehospital care, which remains heterogenous in its approach.
SPARC teams should be small, scalable, and multidisciplinary. They can incorporate physicians (from specialties including emergency medicine, surgery, anesthesiology, and/or critical care), nurses, advanced practice providers, paramedics, and/or certified registered nurse anesthetists in varying combinations depending on local resources, training, and need. Small teams within a system have a higher chance of maintaining their skills through continued exposure.
Personnel could originate from multiple sources including level-1/level-2 trauma centers, non-trauma centers, existing EMS resources (such as community paramedicine services or EMS supervisors), and critical care transport services. One or two clinicians may in some systems continuously staff an existing prehospital transport unit. Systems must ensure availability when required, balanced with other duties that team members need to undertake.
Tactical EMS teams (physicians and/or paramedics) may be able to function as a SPARC service. They use either TCCC or its the civilian derivative, Tactical Emergency Casualty Care, are trained to safely work in hostile environments, and already support police operations in a number of communities. Further training can extend their capability to more advanced resuscitative care.
Early, appropriate patient triage
The allocation of appropriate resources to a prehospital incident is a critical part of any EMS system. This has remained a particular challenge in the US due in part to the vast disparity in EMS systems, sometimes even within one city, leading to a lack of standardization in terms of training, personnel availability, and criteria for activation of resources. We cannot, however, emphasize enough that early, rapid, and appropriate triage of the patient who would most benefit from a SPARC team is crucial, and this aspect should form an integral part of discussions with senior clinical and administrative personnel within a trauma system.
Criteria must be agreed in advance for dispatch of this limited resource. Dispatch center staff must be trained to determine which patient is appropriate, and can be assisted by having senior clinicians (paramedics or physicians) integrated into the center. Options for auto-launching the SPARC team and/or staging such a team close to the incident soon after the initial 911 call in appropriate cases should be considered.
Wearable telecommunication technology and automated decision support tools that include geospatial positioning for casualty location, video call capability, and even transmission of physiologic trends can allow real-time scene assessment by SPARC team members. Constant communication between on-scene personnel and a trauma center physician or surgeon may allow not only early patient identification, but also ongoing support for clinical decision-making and procedures. These have already shown benefit in medical cardiac arrests and can be adapted to trauma scenes (43).
Trauma system integration
Prehospital blood administration capability is the most rapidly achievable integration of SPARC within existing systems. Civilian POI blood use, especially when transport times exceed 20 min, has shown benefit in many studies (5, 36, 44). While we recommend whole blood, packed red cells, and liquid plasma are preferred to crystalloids (1). International experience with lyophilized plasma has been positive but awaits Food and Drug Administration approval for US use at the time of writing (45). While some US EMS agencies have been able to incorporate prehospital blood in their systems, we acknowledge challenges including appropriate patient selection, cost, storage, regulations regarding administration and monitoring for complications. Therefore, many US EMS systems still have not implemented this modality. A SPARC team can augment services in both instances, although a continued emphasis must be placed on facilitating the provision of prehospital blood availability and administration within existing EMS systems.
Rapid insertion of the critical care asset by ground, rotary-wing, or even fixed-wing methods requires careful planning based on geographical situation. Time benchmarks must incorporate loading, launching, landing, and off-loading. Basing the team at a community location may actually allow more rapid scene response. Other options include utilizing state resources such as the police aviation service (46).
Level-4 centers without immediate surgical support and those level-3 centers where surgical support may be available but not immediately may specifically benefit from a SPARC team. Instead of the Advanced Trauma Life Support focus of secondary transfer, a patient could be met at a level-4 center by the SPARC team, who can assist with advanced initial resuscitative care at that facility then continue critical care en-route to the higher-level center. If feasible, transport vehicles could be adapted with the equipment to allow evaluation and operative intervention by the team. A precedent for this has been development of an extracorporeal membrane oxygenation (ECMO) truck in Minnesota to provide diagnostic and therapeutic intervention to the field.
Incorporating a SPARC strategy must not negate what the patient ultimately requires – rapid delivery to appropriate operative capability (34). This trajectory must be maintained. One option to truncate time is by bypassing the ED and taking the patient directly to the OR. This may improve survival, especially for high-risk subgroups such as those with penetrating trauma and highest-severity injuries, but requires careful planning and protocols for integration (46, 47). Along with refining triage and implementing prehospital blood, a direct-to-OR policy may be the two most logistically and financially achievable portions of a SPARC strategy.
Training the SPARC team
High-level clinical decision-making, technical skill, and knowledge of trauma/critical care principles will be required of SPARC team members, in addition to the ability to safely work in the prehospital environment.
Training should be sustainable, up-to-date, achieve a curriculum standard, and be subject to peer-review and modification. It will, at least initially, be best aimed at multidisciplinary clinician groups from various backgrounds possessing a solid foundation of experience in prehospital and/or trauma medicine. Examples of existing military and civilian training options include the Valkyrie whole blood training program, the Anesthesia, Trauma, and Critical Care course (www.atacc.co.uk), the LAA Prehospital and Emergency Endovascular Resuscitation course (www.iophc.co.uk/education/pre-hospital-and-emergency-endovascular-resuscitation), and the Resuscitation Adjuncts: Prehospital Transfusion and REBOA course (www.raptorcourse.com). The latter is an example of a military–civilian training collaboration as suggested in the NASEM report and by the Office of the Assistant Secretary for Preparedness and Response.
System-level support
None of this is possible without system-level buy-in and administrative, logistical and financial support. This is complicated further by the current heterogenous approach to US prehospital care within individual trauma systems. Significant differences can exist in systems that are adjacent to each, which makes a one-size-fits-all approach difficult for us to prescribe.
Our proposed model echoes the recently described Minnesota mobile extracorporeal cardiopulmonary resuscitation consortium which saw significant benefits in out-of-hospital cardiac arrest (48, 49). EMS would appropriately identify patients in the field and transport them to one of three hospitals where small, trained mobile ECMO teams would rendezvous, initiate extracorporeal cardiopulmonary resuscitation, and continue critical care management until the patient reached a central ECMO ICU. The consortium maintains regular team assessment of skills, and has been transparent in reporting outcomes. It is an example of how teams moved the needle for an entire community by obtaining buy-in between different health systems, EMS agencies, and city government to achieve markedly improved outcomes.
Cost implications
To augment existing trauma systems with SPARC teams, it is imperative to discuss potential cost implications. Financial implications affect both the agency providing the service as well as ultimately the patient. The Airline Deregulation Act has prevented the Department of Transportation regulating costs associated with air ambulance use in the United States, sometimes resulting in staggering costs to the patient, sometimes exceeding tens of thousands of dollars. This is often based on the typical configuration of air ambulance crews of a flight nurse and paramedic. To add additional specialists such as physicians may lead this cost to increase. The exact additional cost is difficult to ascertain due to the vast disparity of billing practice and insurance reimbursement across the country.
Alternative models do exist. Some agencies are set up as charitable organizations relying on donations from the public to fund physician-level care without billing the patient. This is akin to several air ambulance charities in the United Kingdom. The Maryland State Police Aviation Command funds aeromedical patient care and transport through a small surcharge all Maryland residents pay when renewing their vehicle registration. Thus, the patient is not charged at the time their services are needed. Finally, federal reimbursement may change as a new initiative termed the Emergency Triage, Treat, and Transport Model, is rolled out. This changes the reimbursement mandate from only prehospital transport to the actual quality of care delivered by prehospital personnel. Regardless, it is imperative for individual systems to factor specific cost (and factors to potentially mitigate this) into their decision to successfully implement a SPARC strategy, and whether the benefit to their population outweighs this additional expense.
Ongoing research and quality assurance
We acknowledge that recommendations made in this opinion paper are based on levels III to V evidence. It therefore behooves SPARC teams to report their experience and outcomes so that the benefit (or otherwise) of such an approach can be critically evaluated. These teams must be held to a high standard through initial training and regular reassessment, and must be open to robust internal performance improvement and external quality assurance. Every trauma death must undergo a preventable death review to determine which may have benefitted from SPARC activation, and historical lessons must be scrutinized to ensure errors in medical or logistical management are not repeated (50).
CONCLUSION
Trauma systems have not yet adequately addressed potentially preventable prehospital deaths from truncal hemorrhage resulting in hemorrhagic shock and coagulopathy, which is costing civilian lives. Hemorrhagic shock survival is inextricably related to injury severity and time to hemorrhage control. Decreasing transport times alone is a one-dimensional approach to a multi-dimensional problem with challenges in both dense urban and rural US locations. Based on our expert opinion and the current available military and civilian evidence, we have proposed an opportunity for selected existing trauma systems to achieve marginal gains in addressing this problem by bringing SPARC teams to the patient in the field or smaller referral centers. We emphasize this is based on low-level existing evidence, and any changes must be subject to critical review of outcomes. Improving care will require moving out of our comfort zones. This is about delivering the right care to the right patient at the right time. We cannot continue to do things the same way and expect different results.
Acknowledgments
The authors gratefully acknowledge the review and suggested comments from Jeremy W. Cannon, MD FACS (Perelman School of Medicine at the University of Pennsylvania), Joseph DuBose, MD FACS (University of Maryland School of Medicine), Andrew D. Fisher, MD LP (University of New Mexico School of Medicine), Matthew S. Harmon, NRP FP-C (Classic Air Medical, Utah), John A. Harvin, MD MS (The University of Texas Medical School at Houston), Kenji Inaba, MD FACS (University of Southern California, LAC+USC Medical Center), Donald H. Jenkins, MD FACS (University of Texas at San Antonio Health System), Kyle J. Kalkwarf, MD FACS (University of Arkansas Medical System), Charles W. Mains, MD FACS (Surgical Specialists of Colorado), Ernest E. Moore, MD FACS (University of Colorado, Denver), Jonathan J. Morrison, MD (University of Maryland School of Medicine), Wayne Papalski, NR-P FP-C (Navy Liaison Officer Joint Trauma System), Mark Seamon, MD FACS (Perelman School of Medicine at the University of Pennsylvania), Martin A. Schreiber, MD FACS (Oregon Health and Science University), David K. Tan, MD FAEMS (Washington University School of Medicine), RDML Darin K. Via, MD (Commander, Naval Medical Forces Atlantic), Rebecca Vogel, MD FACS (St. Anthony Hospital).
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