Trauma Management for the Allied Health Professional

A blunt trauma is something hitting or coming into contact with the body and the right speed and angle to cause some form of injury (Dumovich & Singh, 2022). The location(s) and speed of the force will often shed light on the seriousness of the injury. Blunt trauma may occur in any of the following (ENA, 2007):

• Falls
• Motor vehicle accidents
• Assaults
• Pedestrian injuries

In sports, blunt trauma can occur from:

• Collisions
  • Opponent
  • Barriers such as a wall or post
  • Ground
• Hit by projectile object (i.e., a baseball, hockey puck, etc.)

Many injuries in sports can occur as a result of blunt trauma. Some, but not all, are discussed briefly here.

• Abdominal: While abdominal injuries in sports are rare, when they do occur, they may result in potentially life-threatening injuries (Adam & De Luigi, 2018).
  • Spleen: splenic injuries account for 25%  of blunt abdominal trauma.
  • Liver injuries account for 15-20% of blunt abdominal injuries and represent 50% of deaths due to blunt abdominal trauma (Adam & De Luigi, 2018). As with other solid organs, a liver can fracture and cause severe intraabdominal bleeding.
  • A direct blow to the lower back can severely contuse or rupture a kidney.
• Head and Neck
  • Head Injury: Head injury or sport-related concussion is defined as a temporary disturbance of brain function (Hallock et al., 2023). It can be mild, moderate, or severe. In addition to concussion, cerebral edema, focal brain injury, and traumatic hemorrhage (Hallock et al., 2023) can occur from blunt trauma to the head through contact with an opponent, a barrier, or the ground.
  • Spine Injury: Spinal cord injury can occur with a spinal fracture or during axial loading of the spine. The most devastating spinal injuries occur in the cervical spine. When the head is flexed forward approximately 30 degrees, the normal cervical curvature is straightened, which diminishes the ability to dissipate axial force (Hazelden, 2023).
  • Throat Injury: A fracture of the larynx can occur from high trauma caused by a direct hit to the throat with an object, such as a lacrosse ball. Laryngotracheal fracture is extremely rare, but if it does occur, it can be life-threatening. A more likely occurrence is severe contusion, in which case, monitoring for signs of airway compromise is essential.

Axial load of the cervical spine

• Thoracic:
  • Cardiac Injury: Cardiac injuries are rare in sports but can occur following blunt trauma, typically from a high-velocity projectile.
    • Cardiac Tamponade: Cardiac Tamponade occurs when fluid accumulates in the pericardial sac to the point of creating compromised cardiac function. While chest trauma can create cardiac tamponade, many other non-traumatic medical conditions could cause this to develop spontaneously (Phillips & Kunz, 2018).
    • Commotio Cordis: Commotio Cordis occurs after direct trauma to the anterior chest wall, such as a strike by a baseball or lacrosse ball or a punch to the chest in martial arts. If the traumatic impact occurs at a particular portion of the cardiac cycle (t-wave upstroke), it will initiate an arrhythmia leading to ventricular fibrillation. The survival rate is extremely low at 15% and decreases to 3% if the initial attempt at resuscitation is delayed beyond 3 minutes (Tainter & Hughes, 2023). Early defibrillation is critical!
  • Pneumo/Hemothorax: A pneumothorax occurs when air is trapped between the visceral pleura of the lung and the chest wall(Phillips & Kunz, 2018), while a hemothorax is when this space fills with blood.  Pneumothorax, as a result of sports-related trauma, typically is a result of rib fractures that directly injure the pleura. However, there have been incidences of pneumothorax without rib fracture (Phillips & Kunz, 2018).
  • Posterior Sternoclavicular Dislocation: Posterior sternoclavicular dislocation can occur from direct impact to the medial clavicle, potentially creating airway compromise and requiring immediate, emergent reduction (Phillips & Kunz, 2018).
• Orofacial: Orofacial injury rates are estimated at 3-38% of all sport-specific injuries. It is imperative that on-field sports medicine providers, such as athletic trainers, be aware of the evaluation and management of dental injuries. While acute dental trauma occurs, properly worn and well-fitting intraoral protective devices can effectively reduce injury (Gould et al., 2016). Orofacial injuries can include tooth avulsion or fracture, jaw fracture, orbital, and other facial fractures. Direct impact to the eye can cause sudden compression of the eye and damage to the ocular vessels.
• Musculoskeletal
  • Compartment syndrome: Although other factors can lead to compartment syndrome, it can also occur when an impact on a muscle causes bleeding or severe swelling in an area where the fascia cannot expand, leading to excessive pressure buildup. Compartment syndrome is most common in the lower leg, thigh, and forearm, and acute compartment syndrome is considered a medical and surgical emergency (AMSSM. n.d.).

Penetrating trauma is reasonably self-explanatory and is the result of something penetrating the body somewhere(Dumovich & Singh, 2022). Understanding the anatomy and physiology of the human body will help determine the level of injury and potential consequences once the location of the trauma is identified. Hypovolemic shock and, subsequently, death are the worst possible outcome of a penetrating trauma. Penetrating trauma may be classified as low or high velocity and may include (ENA, 2007):

• Stab wounds
• Gunshot wounds
• Explosives

In sports, penetrating trauma can occur from:

• Projectile
  • Javelin/discus
  • Archery
  • Shooting sports
• Shattered eyewear
• Tooth puncture
• Fracture/Laceration

When proper safety precautions are taken, and shatterproof athletic-rated eyewear is utilized, penetrating trauma is rare in sports.

An injury resulting from a sudden stop in motion is termed a deceleration trauma. The brain and aorta are vulnerable to this type of injury(Dumovich & Singh, 2022). For example, in a collision in a high-impact sport, an athlete may strike their head against the ground, causing their brain to hit one side of the skull and may subsequently bounce back and hit the other side of their brain. This type of injury is often seen in shaken baby syndrome.

In sports, deceleration injuries can range from concussions, abrasions, sprains, fractures, and tendon ruptures. While some deceleration injuries can result in severe trauma and need to be managed with proper emergency care, most can be handled through outpatient care.

Common forms of deceleration trauma in sports include, but are not limited to:

• Head Injury: As described above, deceleration head injuries have additive damage to the acceleration injury once there is a sudden stop in motion. In this situation, the brain moving forward suddenly moves in the opposite direction, which may cause traction, torsion, or further compression to the underlying brain tissue. Deceleration injuries can result in bruising, hemorrhage, and shearing injuries deep within the brain (Rush, 2011).
• Cervical injury: Whiplash is when the neck bends forcibly forward and quickly backward (or vice versa). This injury is commonly experienced during a high-velocity collision between players. Whiplash injuries have been reported in most contact sports, such as soccer, basketball, wrestling, etc., and in several non-contact sports, such as diving (Tsoumpos et al., 2013).
• 
  

Hockey Collision

• Dislocations: Sports injuries are one of the top three leading causes of dislocations and almost always happen due to trauma and sports injuries (Cleveland Clinic, n.d.). Most sport-related dislocations involve the upper extremity, with shoulders and fingers being the most common.
• Musculoskeletal trauma:
  • Tendon/ligament ruptures: Tendon and ligament ruptures are, unfortunately, one of the most common injuries in sports. Ligament ruptures often occur due to quick deceleration and change in direction. While the ACL is the most common ligament rupture, ruptures may also involve other knee ligaments, ankle ligaments, quadriceps or patellar tendon, the Achilles, biceps tendon, elbow and finger ligaments, and tendons.
  • Fractures: FOOSH (fall on outstretched hand) injuries are quite common in sports and can cause fractures throughout the wrist, hand, elbow, and shoulder. 

FOOSH Injury

• Abdominal Visceral Injury
  •  Aortic Injury: Aortic Injuries have been described in sports such as rugby and skiing. This injury occurs when a sudden deceleration leads to forces being excessively applied, resulting in tears to the fixed and mobile portions of the aorta(Phillips & Kunz, 2018).

The integumentary system is the most extensive organ system in the human body. Its functions include temperature regulation, external environmental hazard protection, and sensory perception. Burns are a type of injury often caused by chemicals, heat, electricity, or friction, with more than 60% of burn injuries occurring at home (Weaver & Weavind, 2019). Cooking is a common factor in house fires, and substance abuse (primarily alcohol) is a primary factor in up to 40% of fire-related deaths (NFPA, 2018; ENA, 2007).

 In the pediatric population, burns are commonly caused by fire, scalding injuries, or contact with hot surfaces or objects. Burns can be classified into the following primary categories (ENA, 2007): 

• Thermal
• Electrical
• Radiation
• Chemical 

Burns are uncommon in sports; however, chemical powders and spray paint used to mark the lines on an athletic field can be kicked up and get into an athlete's eye. These paints and chemicals may contain acids and alkalis that can irritate and cause burning in the eye until the eye is washed. Still, stronger chemical reactions can cause severe chemical burns and permanent blindness (Keck Medicine of USC, 2022).

Occlusive or obstructive injuries result in a deficiency in oxygen or gas exchange. Examples of these types of injuries include drowning, strangulation, or hanging (ENA, 2007).

Drowning in Sports: In aquatic sports, primary drowning can occur when a participant misjudges their ability or falls into the water while participating in the sport. Other factors may cause an athlete to lose consciousness, resulting in a drowning event (Szpilman & Orlowski, 2016).

When managing trauma, the primary survey is our initial assessment to identify and treat life-threatening injuries quickly (Planas et al. 2023). Due to the significant impact that traumatic injuries can cause, the most common causes of death are related to airway issues, bleeding, shock, brain injury, and respiratory failure (Planas et al., 2023). ABCDE is the acronym often used to complete a primary survey, standing for each of the following (Planas et al., 2023):

Not all trauma scenarios are created equal, so there may be situations where additional examinations or diagnostics are necessary to complete an assessment (Planas et al., 2023). For example:

• Vital signs and family presence (ENA, 2007): most trauma centers and emergency departments have someone act as a family liaison (usually a chaplain); however, athletic trainers function in this role if working closely with a specific team.
• Pain assessment and intervention

If the patient is stable following the primary survey, or once the patient has been stabilized, the healthcare provider can perform a secondary assessment, a more thorough head-to-toe examination. The secondary survey allows providers to gather additional information regarding the accident (or traumatic event) and identify other injuries to help prioritize continued resuscitation and patient care. (Zemaitis et al., 2023). This examination includes additional vital sign monitoring.

The secondary survey should only be performed once the primary survey is complete, resuscitation has begun, the patient is hemodynamically stable, and all life-threatening injuries have been addressed (Zemaitis et al., 2023). Examination for other injuries occurs at this point. Assessment for possible dislocations, fractures, and ligament injuries and gathering additional injury details may help providers in an emergency department if transportation is warranted. A mneumonic to help ensure providers get as much of a history as possible is SAMPLE, which includes (ENA, 2007):

• S → Injury symptoms
• A → Allergies
• M → Current medications
• P → Past medical and surgical history
• L → Last oral intake
• E → Events leading up to the injury

*Pro Tip: During a head-to-toe assessment, if the healthcare provider notices clear drainage from the patient's nose or ears, alert a paramedic, trauma nurse, or physician immediately and be sure not to insert an NG tube or pack the nares (ENA, 2007).

Proper emergency management, including trauma management, is critical and requires preparation, training, proper equipment, and creating an emergency action plan (EAP). An emergency action plan identifies the personnel and qualifications of those involved in the EAP (Andersen et al., 2002). The EAP should be site-specific for each activity venue, determine what emergency care facility is closest to that venue, and identify the necessary equipment required based on the level of training of the personnel involved (Andersen et al., 2002). The EAP should be reviewed and rehearsed annually, although more frequent rehearsals may be warranted. For a complete list of recommendations on what to include in an EAP, please see the National Athletic Trainer’s Association Position Statement: Emergency Planning in Athletics (Andersen et al., 2002).

Emergency Action Plan (EAP)

As vital trauma team members, allied health professionals must effectively assess and manage trauma patients in various settings, from outside athletic fields, ice arenas, indoor courts, snow and slopes for snow sports, aquatic environments, and many more. As a result, specific considerations must be accounted for depending on the location of the traumatic event.

For healthcare professionals providing care for equipment-laden athletes, special considerations must be taken when assessing the injured patient. According to the NATA position statement regarding the acute management of the cervical spine injured athlete (Swartz et al., 2009)

• Because of the risk of unwanted cervical movement of the cervical spine, the removal of athletic equipment such as helmets and shoulder pads should be deferred until transported to an emergency medical facility unless:
  • If the helmet is not properly fitted to prevent movement of the head independent of the helmet.
  • If the equipment prevents natural cervical spine alignment or airway access.
• Independent removal of the helmet or shoulder pads in American Football and ice hockey is not recommended, as removing one and not the other compromises spinal alignment.
• Facemasks may interfere with airway access and should be removed entirely from the helmet by a well-trained healthcare professional with a tool and technique that performs the task quickly and with minimal movement and difficulty. This can be performed with a powered, cordless screwdriver or a cutting tool.

Facemask Cutting Tool 

Electric Screwdriver

Specific skills are required to remove any equipment safely and quickly. Therefore, healthcare professionals should practice regularly. It may also be necessary to practice stabilization procedures in various conditions, such as in a hockey arena, on ice, against the boards, on snow on a ski slope, or in an aquatic environment. Skills decline without regular practice. You do not want to be rusty in your skills when managing an equipment-laden athlete undergoing a potentially life-threatening emergency.

Athletic Trainer Assessing Hockey Injury

Establishing and maintaining an airway, including using Oro and nasopharyngeal airways and supraglottic airways (King LT or Combitude airways), are part of the athletic trainer's educational competencies (NATA, 2011). For other healthcare providers managing acute athletic event emergencies, it depends on the extent of their emergency management education and national/state regulations related to that specific profession. Providers in this setting must have advanced knowledge of the anatomy and physiology of airway management and understand contraindications and potential complications.

Although intubation may be required and is often performed by a physician or emergency medical providers, allied health professionals may be asked to assist in airway management, monitor the patient's vital signs, assess lung sounds, and more.

Like most professionals trained in emergency sports management, all athletic trainers must always maintain Emergency Cardiac Care (ECC) certification. ECC  must include (BOC, n.d.):

• Adult CPR
• Pediatric CPR
• Second Rescuer CPR
• AED
• Airway Obstruction
• Barrier Devices (pocket mask, bag valve mask)
• Must include Demonstrated Skills 

Athletic Trainers are not eligible for ACLS courses without additional certifications, such as EMT-I or EMT-P. As an evidence-based algorithm, ACLS allows trained providers to enact specific responses and interventions in response to a person experiencing a life-threatening event, such as cardiac arrest. The protocols learned in ACLS were developed based on objective evidence, research findings, and expertise, and they are designed to help healthcare team members save lives.

In certain circumstances, trauma patients may require ACLS protocols to be utilized for them to survive. There are also incidences when people suffer catastrophic traumatic injuries that they are not sustainable with life. When these situations occur, difficult decisions may be made by the trauma team to provide the most supportive outcome possible. As a general rule, trauma surgeons and the trauma team will make every attempt physically possible to stabilize and save as many lives as possible.

Any information obtained from the pre-hospital report of incoming trauma will lead the team with clues of potential injuries and severity. Getting advanced insight into the mechanism of injury, specific types of trauma, inhalation or chemical burns, altered mental status, substance use, and breathing difficulties can all assist the trauma team with prioritization of their interventions and potential collaborating services that may be needed (ENA, 2007).

Though traumas can land anywhere, they often need to be transferred to a higher level of care, depending on the severity of the injury. As trauma centers get their designations, it is solely due to the type and amount of resources of care they can provide, with levels I and II being equipped to manage the higher acuity trauma cases (Lundy et al., 2023). Level I and II differ and have specific requirements (Lundy et al., 2023). Level I trauma centers:

• Serve at least 1200 traumas annually or have 240 admissions with a severity score of more than 15
• Must maintain a critical care service managed by a trained surgeon
• A hospital must participate in community outreach, perform trauma research, train residents, and lead in trauma education

Level II trauma centers are typically found in smaller areas and have the resources to stabilize critical traumas before transfer, if necessary (Lundy et al., 2023). Surgeons in level I and II trauma centers must assess trauma patients within 15 minutes of arrival.

Level III trauma centers are limited by the resources available to them (Lundy et al., 2023). However, they can stabilize patients and transfer them to a higher level of care if/when necessary.

Hospitals that become recognized as designated trauma centers come with multiple benefits, both financial and recognition.

The roles and responsibilities will vary based on the hospital, trauma center designation, and available staffing and resources. In general, the primary trauma nurse’s main priority is the patient. There is usually a team leader, often a physician, an advanced practice provider, or a nurse. Their roles may include:

• Keeping the team organized
• Assigning clear roles
• Have the ability to make clear and concise decisions based on assessment findings
• Allow fellow team members to ask questions and voice concerns
• Be a team player
• Maintain situational awareness

Next, there may be a core trauma team. These are the healthcare providers who will be working together to stabilize and treat the patient. Roles and responsibilities may include securing an airway, securing IV access, primary survey, diagnostics, labs, and developing a care plan from when the patient arrives until they are stable and a level of care and disposition is determined (ENA, 2007).

Other support services also play a role in trauma management. These individuals may be charge nurses, chaplains, anesthesiologists, fellow consulting services, pharmacists, etc. All emergency departments should develop trauma policies and protocols based on their ability and resources (ENA, 2007).

Damage control resuscitation (DCR) prioritizes prevention over intervention in patients at risk for presenting in shock or developing shock (ENA, 2007). The trauma team works together to establish damage control in the initial management stages by administering intravenous fluids, blood products, calcium chloride, mass transfusion protocol, tranexamic acid (TXA), and stabilization surgery (ENA, 2007).

The standard of care in a trauma patient is for nursing staff to establish two large-bore intravenous catheters and a bolus of 1-2 liters of isotonic fluids (including prehospital volume), followed by a reassessment and blood products, if indicated. According to experts, administering too much fluids has been shown to contribute to hemodilution and, potentially, poorer outcomes (ENA, 2007).

In traumatic injuries where a large volume of blood loss is suspected, a mass transfusion protocol (MTP) may be ordered. The ratio is 1:1:1 of red blood cells, plasma, and platelets. Calcium chloride infusions are often incorporated to prevent hypocalcemia following the mass transfusion protocol (ENA, 2007).

Tranexamic Acid (TXA) is an antifibrinolytic synthetic variation of lysine, an amino acid. TXA often decreases intraoperative bleeding (ENA, 2007).

Otherwise known as damage control surgery, it is often utilized in major trauma centers. Surgeons will take the patient to the operating room to repair immediate, life-threatening injuries, and it is best not to last more than 90 minutes. Surgeons will then ensure the patient is stabilized and send the patient to the intensive care unit for close monitoring and stabilization until they return to surgery to address the next operation or injury, often the next day. There may be a process of multiple preplanned, staged operations throughout the patients' recovery period. This method has been shown to increase survival rates, rather than have an unstable patient under anesthesia on an operating room table for an extended period (ENA, 2007).

There is a wide variety of potential responses that can occur following a traumatic event, which can be categorized as scary, dangerous, unpredictable, and even life-threatening. Understanding the potential impact that traumatic events can have on patients, their families, and even staff is vital in developing a trauma-informed care approach (ENA, 2007; Mohta, 2003).

Trauma management involves a multidisciplinary approach, prioritizing stabilizing the patient but not forgetting the psychosocial and psychological impact it can have on the patient and others. Psychological stress is bound to be associated with any form of trauma or injury. Some of the causes and feelings related to psychological stress may include(ENA, 2007; Mohta, 2003):

• Feelings of helplessness
• Feelings of humiliation
• Impaired coping mechanisms
• Fear
• Guilt
• Grief

The RESPOND mnemonic (ENA, 2007) is a helpful tool to help both staff and family members assist patients after a traumatic event:

• R→ Reassurance that the patient is safe and is getting the best care is essential after a traumatic event.
• E→ Establishing a good rapport is vital for the patient and family; they must know they can trust their healthcare team.
• S→ Supportive care is necessary after a trauma. If available, allied health providers or hospital staff can contact the chaplain, social worker, or other supportive care staff to assist.
• P→ Allow the patient and family the opportunity to know their care plan, ask questions, and also be sure to manage the patient's pain.
• O→ It is always helpful to offer hope to patients and family members, using caution not to provide false hope.
• N→ Never attempt to deliver a poor prognosis or bad news to a patient or family member alone. Healthcare providers can never anticipate how a family or loved one may react upon receiving bad or scary news.
• D→ Determine the patient's and family's needs and encourage them to express themselves as needed.

Trauma continues to be the leading cause of death in the pediatric population despite all efforts of injury prevention and education. More than 9 million children nationwide receive medical care annually for unintentional injuries. In 2009, more than 200,000 children required inpatient hospitalizations, and 9,000 died from traumatic injuries. Nationally, a large number of emergency departments lack pediatric-specific trauma education, training, or equipment, leading to an increased need for trauma preparedness in pediatric patients (ENA, 2007).

Trauma is one of the top 10 causes of mortality in the geriatric population (Lalwani et al., 2020). Aside from being over the age of 65, most older adults have multiple comorbid conditions that increase their risk for complications, more extended hospitalizations, and even death. The most common mechanisms of injury in this population are falls and motor vehicle collisions (this includes pedestrian accidents). Additional factors to consider in this population include comorbid conditions and medications, as members of the trauma team may easily predict potential complications that may occur. 60% of falls occur in the home, with most being a fall from a standing position (NCOA, 2023). This can sometimes result in improper triage, prolonging adequate treatment (ENA, 2007).

Trauma is said to be the leading cause of death and disability for pregnant women (that is non-obstetric) (Mayo Clinic, 2017). The majority of injuries occur during the third trimester, with up to 7% of traumatic injuries being fatal (Mayo Clinic, 2017).

Hemorrhage and head injuries are the most fatal of traumatic injuries during pregnancy, according to evidence. Preterm delivery and placental abruption are the most common causes of death in the fetus, with the highest risk factor for fetal death being maternal death (ENA, 2007).

Informed consent should be addressed in any healthcare situation (Lin et al., 2019). Only competent individuals can make decisions regarding their healthcare wishes. Some people opt to establish a legal document, such as a living will, or establish a power of attorney, highlighting their wishes and who they elect to decide on their behalf, should they be deemed unable to do so.

Unfortunately, this process is not always clear-cut. For starters, determining competence means that a patient can understand the information being told to them by the healthcare providers and make reasonable decisions based on risk factors, potential consequences, etc. Suppose a person is deemed unable to make decisions and they have a documented power of attorney (or healthcare surrogate). In that case, healthcare providers may have the delegated party as the decision maker. Depending on your state, the laws can be different if individuals do not have any legal documents, especially if they are unmarried and do not have adult children.

If in an emergency, healthcare providers will attempt to gain consent from a family member or other support person as a surrogate. However, sometimes, healthcare providers may have to provide life-saving treatment in an emergency (Lin et al., 2019).