EMS Management of the Lethal Triad
There are several simple steps providers can and should follow to battle the lethal triad.
1. The triad begins and ends with bleeding, so find the bleeding and stop it. Hold pressure, use combat gauze, apply a tourniquet, bind the pelvis, etc. (See the article “Training & speed are crucial: Options, issues & training to prevent death from massive blood loss,” by Joe Holley, MD, FACEP, in the JEMS December 2013 supplement, Putting the clamp on hemorrhage: How a simple, effective point-of-injury tool will transform the way bleeding is controlled in the field.)
2. Do not stop your search for bleeding with the first source you find, as others may exist.
3. Always assume your patient’s temperature is dropping right before your eyes, because it is, and much faster than you’d expect.
4. “Strip ‘em and flip ‘em,” but not with reckless abandon. Make every effort to expose only those body parts you’re examining in the moment and keep the remainder of the patient covered.
5. Patients can and will become hypothermic in conditions you consider warm. Prioritize limiting a patient’s exposure to the environment, especially during prolonged extrications.
6. Place a warm blanket between the newly extricated patient and your cold, hard backboard.
7. Turn up the heat in your ambulance. If you aren’t sweating, it’s certainly not warm enough. (Ideally, 27 degrees C.)
8. Promptly remove wet or bloody clothes and replace with a warm blanket. Shivering wastes valuable cellular energy and oxygen in an attempt to stay warm while producing more lactate, contributing to acidosis.
9. We don’t bleed normal saline, so limit crystalloid infusion as much as possible. It contributes to the patient’s acidosis and dilutes the remaining clotting factors in your patient’s blood. IV fluids may improve a number, but may actually hurt your patient in the long run.
10. Except in those patients with a traumatic brain injury, utilize a permissive hypotension resuscitation strategy. Our goal should be to maintain tissue perfusion typically defined as the presence of a radial pulse or normal mental status. We should avoid overly aggressive fluid administration to normalize blood pressure, which can “pop the clot” and worsen hemorrhage. (See “Vital pathways: Detect & treat symptoms related to hemorrhagic shock,” by Peter Taillac, MD, FACEP and Chad
Brocato, DHSC, CFO, JD, from the JEMS October 2012 issue and “Add a little salt: Permissive hypotension in trauma resuscitation,” by Jeff Beeson, DO, FACEP, EMT-P and Trenton Starnes, NREMT-P in the JEMS April 2013 issue.)
11. Whenever possible, administer only warmed fluids. (Ideally 40 degrees C.)
12. Measure prehospital lactate levels when available to more accurately detect cryptic shock in trauma patients with normal vital signs. End-tidal carbon dioxide may also be a useful marker.
13. Monitor and maximize oxygenation.
14. Treat causes of hypoventilation to prevent a respiratory acidosis.
15. Identify high-risk patients with a baseline coagulopathy due to medications or preexisting medical conditions.
16. Administer tranexamic acid (TXA)—an antifibrinolytic that prevents clot breakdown and thus decreases blood loss—if your system permits its use. TXA has been shown to decrease mortality in two large trauma studies. (See “TXA: A difference-maker for trauma patients? Role of tranexamic acid in EMS & preoperative trauma management,” by Jeffrey M. Goodloe, MD, NREMT-P, FACEP; David S. Howerton, NREMT-P; Duffy McAnallen, NREMT-P and Howard Reed, NREMT-P, in the JEMS April 2013 issue.)