patient in traumatic cardiac arrest - trauma centre diversion

Question

QUESTION AT THE BOTTOM

I am from Hong Kong and for injured patients who are treated by paramedics and need transport to hospital for treatment they have a trauma diversion guide. This is for patients with major trauma, designed to go direct to a trauma centre, instead of the nearest hospital.

The trauma diversion guide is as follows: If the patient is in cardiac arrest OR cannot maintain airway or breathing they are to go to the CLOSEST hospital regardless if it is a trauma centre or not.

If patient is not in cardiac arrest and can maintain airway or breathing, physiological and anatomical criteria will be applied to decide if they need to go to a trauma centre. If they fit ANY of the criteria below, they will be transported to a trauma centre.

Physiological Criteria:

1. GCS < 14
2. systolic BP < 90
3. Respiratory rate < 10 or > 29 per minute

Anatomical Criteria:

1. Flail chest
2. 2 or more long bone fractures
3. amputation proximal to wrist or ankle
4. penetrating trauma to head, neck or torso
5. limb paralysis
6. pelvic fracture
7. combined trauma/burn (equal to or greater than 2nd degree or equal to or greater than 20%)

My question is, if the patient is in cardiac arrest why does the Hong Kong trauma diversion guide state that they need to go to the closest hospital? Wouldn't it be better for them to travel to a hospital in which a resuscitative thoracotomy can be performed?

Answer 1

The reasons can be found in the training of Hong Kong paramedics. Their training is roughly comparable to the EMT-Intermediate level in the US. According to the Hong Kong Fire Service, which provides emergency medical services (EMS) in the city, their capabilities are as follows:

https://www.hkfsd.gov.hk/eng/source/safety/paramedic_amb.html

• Defibrillator To salvage patients in non-traumatic cardiac arrest.

• Nitroglycerin (NTG) To reduce angina pain.

• Ventolin & Atrovent To ease shortness of breath in patients having asthma / emphysema / chronic bronchitis.

• Intravenous infusion of Dextrose 10% in Water (D10W) To correct the decreased level of consciousness in patients suffering from hypoglycemia.

• Glucagon To correct the decreased level of consciousness in patients suffering from hypoglycemia.

• Intravenous infusion of Normal Saline To replenish body fluid in patients suffering from severe blood loss in accidents or other medical emergencies.

• Entonox To reduce pain through patient-controlled inhalation.

• Naloxone To revive patients suffering from narcotic overdose.

In addition, some ambulances are equipped with more sophisticated drugs and equipment:

• Adrenaline To treat anaphylaxis through correcting shock and breathing difficulty.

• Valium To treat convulsion in epileptic children.

• Laryngeal-Mask Airway and Combitube To provide better airway management and artificial ventilation for patients in cardiac arrest.

You'll notice that what's missing from the list are intubation and cricothyroidotomy, so they're not well prepared to handle a trauma arrest. The logic behind diverting to the nearest hospital is that without definitive airway control the patient is unlikely to survive a trip any longer than absolutely necessary.

There is an interesting review of traumatic arrest literature that draws this conclusion:

Should you transport the patient in cardiac arrest if the nearest trauma center is 5 minutes away? Yes. Transport in this case may provide benefit to the patient as they may be a candidate for thoracotomy or other advanced surgical procedures.

What about 20 minutes away? Likely no. The patient is unlikely to be a candidate for thoractomy and aggressive resuscitation should be done on scene with transport only with ROSC due to the risk to providers and predicted worse outcome.

It's worth noting that even though American paramedics are trained to perform endotracheal intubation and cricothyroidotomy, trauma arrests are often not transported at all. Where I live, an adult arrest due to blunt or penetrating injury will generally receive three rounds of ACLS on scene. If no pulse is restored, they are not transported.