Question: Upon review of the new Field Trauma Triage Guidelines, colleagues and I noticed that those patients who have sustained penetrating trauma to the head/neck or torso (with or without vital signs) should be transported to the lead trauma hospital providing it's within 30 minutes transport. Our question is why is this not the case for blunt trauma patients (in particular, those patients VSA from blunt trauma)?
Good pick-up. This was something that we wanted to stress at your recerts this year in the discussion of the Field Trauma Triage Standard (FTTS) for the reason you mention: these patients are treated differently. So were glad youve brought this up - so we may highlight why this is the protocol.
The anatomical differences in penetrating vs blunt trauma, lead to differences in ultimate treatment and therefore their initial destination. Penetrating injuries to the chest may be temporarily stabilized by an emergency department thoracotomy (EDT) wherein the patients chest is opened and a reparable defect in the heart, major vasculature or lungs is sought. Due to the force of blunt trauma, there is more widespread damage (think about what happens when an orange is crushed vs sliced) and an EDT is unlikely to show a single injury that can be easily be addressed.
The reason for the transport disparity is that thoracotomies are only performed as a salvage technique to buy time to get the patient to definitive management. In the case of penetrating chest trauma, definitive management is a cardiothoracic surgeon. This resource is generally only available at the Lead Trauma Hospital (LTH). Although not a candidate for EDT, blunt traumatic arrests can be treated with needle decompression, chest tube insertion, intubation, fluid/blood resuscitation and other supportive care that can reliably be initiated at the closest hospital.
A very robust systemic review was recently published in July 2015 by the subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma (EAST) on EDT. In which they summarized the results of 72 research papers on EDT to date, finding a 2.3% hospital survival rate in blunt traumatic arrest vs 10.6% survival in penetrating injury (7.2% Gun shot wounds vs 15.8% stab wounds). Unfortunately, not only are patients less likely to survive after EDT for blunt injury but also, when they do survive, they are more likely to be neurologically impaired. Of those that survive blunt traumatic arrest, only 59% are neurologically intact at discharge. This is in contrast to 90% of penetrating traumatic cardiac arrest survivors. This is why the National Association of EMS Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ASCOT) state that emergency thoracotomy does not appear to have a role in traumatic cardiopulmonary arrest as a result of blunt trauma.
Bottom line: Due to the anatomical differences in penetrating vs blunt trauma, another level of intervention (EDT) can be performed on penetrating trauma VSAs in a last ditch attempt to stabilize the patient. This intervention will generally only be performed at the LTH. Thus, penetrating traumatic VSAs are brought to the LTH to give them the best chance. Whereas, the best chance for a blunt traumatic arrest is at the closest hospital who can reasonably initiate other life-saving interventions.
Seamon et al. An evidence-based approach to patient selection for emergency department thoractotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015; 79(1):159-73.