Lasting Impressions About Hidden Trauma

This article appeared in the EMS World special supplement Combating the Hidden Dangers of Shock in Trauma, developed by Cambridge Consulting Group and sponsored by North American Rescue, LifeFlow by 410 Medical, and QinFlow. Download the supplement here. 

This publication was designed to change the way you think about assessing and treating traumatic injuries. It’s packed with information and links to informative videos that underscore the significant hemorrhage that occurs from hidden traumatic injuries, as well as major fractures that should be splinted to stabilize sharp bone ends and stem bleeding.

While developing its content, trauma surgeon Andrew Dennis, DO, division chief for prehospital and resuscitation at Cook County Health in Illinois and executive medical advisor and associate producer for the television shows Chicago Med and Chicago Fire, stressed to me that we must do a better job educating EMS providers to react to the mechanisms of injury, early vital signs, and gut feelings to detect and treat conditions that can cause shock.

Dennis said he often finds both physicians and EMS providers rely too heavily on the clearly observable injuries as they approach and assess patients. It’s easy to become tunnel-visioned, distracted by grossly obvious deformities or other injuries, to the detriment of nonvisible cavitary hemorrhage. 

All emergency responders, Dennis continued, should read and adopt practices outlined in the book Left of Bang: How the Marine Corps’ Combat Hunter Program Can Save Your Life. He explained that Gen. James Mattis decided too many US Marines were being killed by contacting hidden improvised explosive devices (IEDs) when there were obvious, observable sights, signs, and past incidents that should have set off alarm bells in their brains to react decisively before the bang of the IED. 

Because of this, Mattis ramped up the number of troops in the Marine Corps’ Combat Hunter program, which was developed to make Marines able to recognize and respond to events based on nonverbal and environmental signals before they happen (“left of bang”) instead of after (“right of bang”). The number of Marines killed by IEDs then began to decrease significantly.

Paying attention to a patient’s physiologic “tells,” as Dennis calls the various ways the body compensates for ongoing hemorrhage and shock, allows providers to gauge the degree of compensation and physiologic point of no return—the physiologic “bang.” Recognizing and staying left of physiologic bang can mean the difference between life and death, as it can redirect and refocus the provider on the right interventions for the right time. 

After reading Left of Bang, I came to appreciate Dennis’s point: that the processes discussed in the book present a new way of thinking for emergency personnel. We should instill in them to turn what they have been taught and what they see and sense into the detection of hidden injuries before their patient deteriorates into hemorrhagic shock and crosses the physiologic point of no return. 

Approximately half the more than 60,000 traumatic deaths a year in the US result from hemorrhage that occurs in the prehospital setting. This means emergency medical responders need to be on their A game when confronted with critical trauma patients.¹ 

Most EMTs and paramedics can zero in on patients in shock and preshock states where external hemorrhage exists. Many, however, fall short when confronted with blunt trauma or trauma where there’s little or no blood showing. 

One example is rib fractures: Up to 10% of hospitalized trauma patients have rib fractures.² EMTs and paramedics have traditionally been taught an isolated rib fracture isn’t a big deal in the field because there’s not much they can do for it. But a flail segment—2 or more contiguous rib fractures with 2 or more breaks per rib—is not an isolated rib injury. It’s a big deal because it’s associated with considerable morbidity and mortality when a portion of the chest wall is destabilized, usually from significant blunt force trauma.² 

A flail chest alters the mechanics of breathing, with the floating segment of chest wall and soft tissue moving paradoxically in the opposite direction from the rest of the rib cage. Broken ribs and flail segments, if they aren’t stabilized, can also cause pulmonary complications (eg, pneumothorax, hemothorax, pulmonary contusion, pneumonia, and atelectasis; see Figure 1).³ 

In addition, a flail segment can cause damage to the heart and surrounding muscles and blood vessels, resulting in significant internal bleeding that can be life-threatening.2 As much as 1500 ml of blood can flow into the pleura, the serous membranes lining the thorax and enveloping the lungs, and result in massive hemothorax.^4,5 

To illustrate how much damage can result from hidden injuries such as a flail segment or fractures to the femur and/or pelvis, Scotty Bolleter, BS, EMT-P, and Jennifer Achay, BS, NRP, from the Centre for Emergency Health Sciences in Spring Branch, Texas, created custom videos in a state-of-the-science cadaver lab that are embedded throughout this special publication. They have been created so you can appreciate the need to identify, locate, and stabilize these potentially deadly injuries.

We’ve gathered a team of expert practitioners, medical directors, and educators from across the country to provide you with critical assessment tips to help you stay “left of physiologic bang” and identify trauma patients who may not initially present with visible hemorrhage or other outward signs of trauma but who may be leaking precious blood inside the closed confines of cavities such as the chest, pelvis, and abdomen.

Dennis says playing “trauma poker”—looking for “tells” associated with physiologic compensation—is essential when dealing with blunt trauma, where obvious bleeding may not be so obvious. This is where putting it all together matters: Understanding how these various factors all intertwine—skin color, heart rate, respiratory rate, mentation, and subtle signs such as capillary refill and temperature—forces providers to focus on their training and look for outliers. 

Thinking about the ways the body can compensate for injury and understanding how compensation impacts mortality can help us make timely and appropriate decisions regarding the best intervention.

These advances are important to share to stop hemorrhagic shock from killing our patients. As medical professionals we must be proactive and use our education, past experiences, 6 senses, understanding of vital signs, and gut feelings to recognize when something’s “not quite right” and then act early and confidently to alert and mobilize trauma teams to save the lives of patients who have suffered hidden trauma. 

Video: Anatomy of a Chest Injury

This video shows:

• The anatomy of the thoracic cavity when associated with a flail segment (and its proximity to the lung and other vital thoracic organs)
• The associated trauma and potential for hemorrhage with fractured ribs
• The amount of blood that can accumulate from damaged vessels within the thoracic cavity

Click on the link above to launch and play a video provided by the Centre for Emergency Health Sciences that demonstrates a chest fracture resulting in a flail segment. 

References

1. Mannucci PM, Levi M. Prevention and treatment of major blood loss. N Engl J Med. 2007; 356(22): 2301–11.

2. Flail chest: An adult case study. Accessed April 20, 2022. www.mayo clinic.org/medical-professionals/trauma/news/flail-chest-an-adult-case-study/mcc-20437935

3. Stewart RM, Corneille MG. Common complications following thoracic trauma: Their prevention and treatment. Semin Thorac Cardiovasc Surg. 2008; 20(1): 69–71.

4. Kim M, Moore JE. Chest trauma: Current recommendations for rib fractures, pneumothorax, and other injuries. Curr Anesthesiol Rep. 2020; 10(1): 61–8. 

5. de Lesquen H, Avaro JP, Gust L, et al. Surgical management for the first 48 h following blunt chest trauma: State of the art (excluding vascular injuries). Interact Cardiovasc Thorac Surg. 2015; 20(3): 399–408.

6. Jarraya M, Hayashi D, Roemer FW, et al. Radiographically occult and subtle fractures: A pictorial review. Radiol Res Pract. 2013; 2013: 370169.

AJ Heightman, MPA, EMT-P, is senior advisor and chief development officer for Cambridge Consulting Group. He is best known as editor emeritus of JEMS (the Journal of Emergency Medical Services), where he spent 27 years developing editorial content. He is also an adjunct instructor of clinical research and leadership at George Washington University School of Medicine and Health Sciences and serves as an academic advisor for the San Diego Fire Rescue paramedic program. Contact him at ajheightman@gmail.com.