Air Methods Trauma Interview Guide and Clinical Standards

X - Massive Hemorrhage Priority

The absolute first priority in the management of a trauma patient is the control of life-threatening, massive hemorrhage. This is recognized as the "X" or exsanguination phase of the primary survey. External bleeding must be managed immediately before addressing any other physiological needs. Interventions to achieve control include the application of a tourniquet for extremity bleeding, the application of direct pressure, the use of hemostatic gauze for packing wounds in junctional areas, and the application of a pelvic binder if a pelvic fracture is clinically indicated or suspected based on the mechanism of injury.

A - Airway Assessment and Management

During the airway phase of the primary survey, the provider must determine if the patient is able to protect their own airway. While assessing the airway, cervical spine precautions must be maintained at all times. Specific considerations for performing intubation or a definitive airway include a Glasgow Coma Scale (GCS) score of $\le 8$, the presence of severe hypoxia, a general inability of the patient to protect their airway, or the presence of a severe Traumatic Brain Injury (TBI).

If the decision is made to secure the airway, Rapid Sequence Induction (RSI) medications are utilized. The protocol includes the following pharmacological agents and weight-based dosages: Ketamine at a dose of $1-2\,mg/kg$ administered IV, Etomidate at a dose of $0.3\,mg/kg$ administered IV, and Rocuronium at a dose of $1.2\,mg/kg$ administered IV.

B - Breathing and Thoracic Life Threats

The assessment of breathing involves evaluating lung sounds, chest rise and fall, oxygenation status, and End-Tidal Carbon Dioxide ($ETCO_2$) levels. Any life-threatening thoracic injuries must be addressed immediately. A critical concern is a Tension Pneumothorax, which is characterized by the clinical triad of hypotension, respiratory distress, and unilateral (absent or diminished) breath sounds. The indicated treatment for a Tension Pneumothorax is the performance of a needle thoracostomy or a finger thoracostomy, depending on the specific facility or agency protocol.

C - Circulation and Hemorrhagic Shock Management

The circulation assessment focuses on identifying the specific type of shock present; in the vast majority of trauma cases, this is Hemorrhagic Shock. Management priorities emphasize that blood products are preferred over the administration of large volumes of crystalloid fluids. Tranexamic Acid (TXA) is indicated in cases of significant hemorrhage, administered as a $1\,gram$ IV bolus over $10\,minutes$, followed by a second $1\,gram$ IV infusion over the subsequent $8\,hours$.

During a massive transfusion protocol, calcium replacement is vital to counteract the effects of citrate toxicity and maintain myocardial contractility. The replacement guidelines are as follows: Calcium Chloride at a dose of $1\,gram$ IV or Calcium Gluconate at a dose of $3\,grams$ IV. If vasoactive support is required after hemorrhage control and adequate volume resuscitation have been achieved, Norepinephrine can be initiated at a starting dose of $0.05\,mcg/kg/min$ and titrated to effect.

D - Disability and Traumatic Brain Injury (TBI)

The neurological assessment, or disability phase, involves calculating the Glasgow Coma Scale (GCS), evaluating pupil size and reactivity, and assessing motor function. Blood glucose levels should also be checked if clinically indicated. In patients with a suspected Traumatic Brain Injury, specific physiological goals must be maintained to prevent secondary injury. These include keeping oxygen saturation ($SpO_2$) greater than $94\%$, maintaining $ETCO_2$ between $35-40\,mmHg$, and ensuring the Systolic Blood Pressure (SBP) is greater than $100-110\,mmHg$.

Providers must monitor for signs of intracranial herniation, which include a blown pupil, abnormal posturing, bradycardia, and hypertension. To manage increased intracranial pressure or herniation, hypertonic solutions may be used per protocol: either a $250\,mL$ bolus of $3\%$ saline or a $30\,mL$ slow IV administration of $23.4\%$ saline.

E - Exposure and Environmental Management

The patient must be fully exposed by removing all clothing to ensure a comprehensive assessment of all potential injuries. A critical component of this phase is the aggressive prevention of hypothermia. This is essential to prevent the Trauma Lethal Triad, which consists of three interconnected conditions that lead to increased mortality: Hypothermia, Acidosis, and Coagulopathy.

Trauma Interview Verbalization Script

The following is a structured verbalization for the trauma interview process: "My first priority is hemorrhage control. I assess for exsanguinating hemorrhage and control any life-threatening bleeding. I then assess the airway while maintaining cervical spine precautions. If the patient cannot protect their airway, I would perform RSI and secure the airway. Next, I assess breathing and immediately treat life-threatening chest injuries such as tension pneumothorax."

"I evaluate circulation for hemorrhagic shock, establish IV/IO access, initiate blood product resuscitation, administer TXA if indicated, and replace calcium during massive transfusion. I then perform a neurological assessment, monitor for traumatic brain injury, and maintain adequate oxygenation, ventilation, and blood pressure. I fully expose the patient to identify additional injuries while preventing hypothermia. Throughout transport I continuously reassess ABCs, vital signs, mental status, and response to treatment while preparing for rapid transport to definitive trauma care."