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Prehospital care of the adult trauma patient

Tom Blackwell, MD, FACEP
Section Editor
Maria E Moreira, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM


The concept of emergency medical transport originated from the need to move wounded soldiers from the battlefield to aid stations and other medical facilities [1-3]. In 1865, the first hospital-based ambulance service was developed at the Commercial Hospital in Cincinnati, Ohio. Four years later, New York City's Bellevue Hospital started the first municipal service [1]. During the first half of the 20th century, ambulance services were most often provided by private individuals, particularly morticians as a service to families and to promote their funeral business.

Beginning in the mid-1950s in the United States, emergency medical service (EMS) systems began to mature in parallel with the burgeoning interstate highway system. Excessive speeds coupled with poorly designed vehicles had led to an increase in serious vehicular crashes, and few cities possessed the EMS systems needed to manage such patients. Subsequently, a national effort to develop EMS systems was initiated, and standards for provider education, scope of practice, equipment, vehicles, and system design were introduced [2,4,5]. The result was a dramatic improvement in prehospital care.

This topic review will discuss prehospital care of the adult trauma patient. Discussions of specific procedures are found elsewhere. (See "Basic airway management in adults".)


The priority of any EMS system is to deliver quality patient care in the briefest period of time following injury, regardless of system design or level of care. Wide variation exists in the level and skill of treatment provided in the prehospital setting [6]. Prehospital medicine typically consists of two levels of care: basic life support (BLS) and advanced life support (ALS).

For trauma care, basic skills include airway management (eg, maneuvers to open an airway, oral and nasal airway adjuncts, and bag-mask ventilation), cardiopulmonary resuscitation and automated external defibrillation, hemorrhage control, and fracture and spine immobilization. Emergency medical technicians (EMTs) certified at the basic level (EMT-B) can provide these services.

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Literature review current through: Nov 2017. | This topic last updated: May 15, 2017.
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  1. Barkley KT. Ambulances of the future. In: The Ambulance: The Story of Emergency Transportation of the sick and wounded through the centuries, Kiamesha Lake, New York 1978. p.171.
  2. Brewer LA 3rd. Baron Dominique Jean Larrey (1766-1842). Father of modern military surgery, innovater, humanist. J Thorac Cardiovasc Surg 1986; 92:1096.
  3. Boyd DR. The conceptual development of EMS systems in the United States, Part I. Emerg Med Serv 1982; 11:19.
  4. Law of the 89th Congress: National Highway Safety Act of 1966, Public Law 89-564, Washington, DC, 1966.
  5. Law of the 93rd Congress: Emergency Medical Services Systems Act of 1973, Public Law 93-154, Washington, DC, 1973.
  6. Bulger EM, Nathens AB, Rivara FP, et al. National variability in out-of-hospital treatment after traumatic injury. Ann Emerg Med 2007; 49:293.
  7. Osterwalder JJ. Mortality of blunt polytrauma: a comparison between emergency physicians and emergency medical technicians--prospective cohort study at a level I hospital in eastern Switzerland. J Trauma 2003; 55:355.
  8. Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994; 331:1105.
  9. Stiell IG, Nesbitt LP, Pickett W, et al. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ 2008; 178:1141.
  10. Liberman M, Mulder D, Lavoie A, et al. Multicenter Canadian study of prehospital trauma care. Ann Surg 2003; 237:153.
  11. Smith JP, Bodai BI. The urban paramedic's scope of practice. JAMA 1985; 253:544.
  12. Feero S, Hedges JR, Simmons E, Irwin L. Does out-of-hospital EMS time affect trauma survival? Am J Emerg Med 1995; 13:133.
  13. Gonzalez RP, Cummings GR, Phelan HA, et al. Does increased emergency medical services prehospital time affect patient mortality in rural motor vehicle crashes? A statewide analysis. Am J Surg 2009; 197:30.
  14. McCoy CE, Menchine M, Sampson S, et al. Emergency medical services out-of-hospital scene and transport times and their association with mortality in trauma patients presenting to an urban Level I trauma center. Ann Emerg Med 2013; 61:167.
  15. Brown JB, Rosengart MR, Forsythe RM, et al. Not all prehospital time is equal: Influence of scene time on mortality. J Trauma Acute Care Surg 2016; 81:93.
  16. Gervin AS, Fischer RP. The importance of prompt transport of salvage of patients with penetrating heart wounds. J Trauma 1982; 22:443.
  17. Shafi S, Gentilello L. Pre-hospital endotracheal intubation and positive pressure ventilation is associated with hypotension and decreased survival in hypovolemic trauma patients: an analysis of the National Trauma Data Bank. J Trauma 2005; 59:1140.
  18. Smith JP, Bodai BI, Hill AS, Frey CF. Prehospital stabilization of critically injured patients: a failed concept. J Trauma 1985; 25:65.
  19. Liberman M, Mulder D, Sampalis J. Advanced or basic life support for trauma: meta-analysis and critical review of the literature. J Trauma 2000; 49:584.
  20. Jacobs LM, Sinclair A, Beiser A, D'Agostino RB. Prehospital advanced life support: benefits in trauma. J Trauma 1984; 24:8.
  21. American College of Surgeons Committee on Trauma. Prehospital trauma care. In: Resources for Optimal Care of the Injured Patient. American College of Surgeons, Chicago, IL 2006.
  22. Lerner EB. Studies evaluating current field triage: 1966-2005. Prehosp Emerg Care 2006; 10:303.
  23. Emerman CL, Shade B, Kubincanek J. A comparison of EMT judgment and prehospital trauma triage instruments. J Trauma 1991; 31:1369.
  24. Purtill MA, Benedict K, Hernandez-Boussard T, et al. Validation of a prehospital trauma triage tool: a 10-year perspective. J Trauma 2008; 65:1253.
  25. Sasser SM, Hunt RC, Sullivent EE, et al. Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep 2009; 58:1.
  26. Lerner EB, Schwartz RB, Coule PL, et al. Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep 2008; 2 Suppl 1:S25.
  27. Lipsky AM, Gausche-Hill M, Henneman PL, et al. Prehospital hypotension is a predictor of the need for an emergent, therapeutic operation in trauma patients with normal systolic blood pressure in the emergency department. J Trauma 2006; 61:1228.
  28. Shapiro NI, Kociszewski C, Harrison T, et al. Isolated prehospital hypotension after traumatic injuries: a predictor of mortality? J Emerg Med 2003; 25:175.
  29. Bruns B, Gentilello L, Elliott A, Shafi S. Prehospital hypotension redefined. J Trauma 2008; 65:1217.
  30. Lecky F, Bryden D, Little R, et al. Emergency intubation for acutely ill and injured patients. Cochrane Database Syst Rev 2008; :CD001429.
  31. Winchell RJ, Hoyt DB. Endotracheal intubation in the field improves survival in patients with severe head injury. Trauma Research and Education Foundation of San Diego. Arch Surg 1997; 132:592.
  32. Copass MK, Oreskovich MR, Bladergroen MR, Carrico CJ. Prehospital cardiopulmonary resuscitation of the critically injured patient. Am J Surg 1984; 148:20.
  33. Hedges JR, Feero S, Moore B, et al. Factors contributing to paramedic onscene time during evaluation and management of blunt trauma. Am J Emerg Med 1988; 6:443.
  34. Eckstein M, Chan L, Schneir A, Palmer R. Effect of prehospital advanced life support on outcomes of major trauma patients. J Trauma 2000; 48:643.
  35. Bernard SA. Paramedic intubation of patients with severe head injury: a review of current Australian practice and recommendations for change. Emerg Med Australas 2006; 18:221.
  36. Sen A, Nichani R. Best evidence topic report. Prehospital endotracheal intubation in adult major trauma patients with head injury. Emerg Med J 2005; 22:887.
  37. Davis DP, Peay J, Sise MJ, et al. The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury. J Trauma 2005; 58:933.
  38. Ufberg JW, Bushra JS, Karras DJ, et al. Aspiration of gastric contents: association with prehospital intubation. Am J Emerg Med 2005; 23:379.
  39. Stockinger ZT, McSwain NE Jr. Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation. J Trauma 2004; 56:531.
  40. Wang HE, Yealy DM. Out-of-hospital endotracheal intubation: where are we? Ann Emerg Med 2006; 47:532.
  41. Wirtz DD, Ortiz C, Newman DH, Zhitomirsky I. Unrecognized misplacement of endotracheal tubes by ground prehospital providers. Prehosp Emerg Care 2007; 11:213.
  42. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med 2001; 37:32.
  43. Cobas MA, De la Peña MA, Manning R, et al. Prehospital intubations and mortality: a level 1 trauma center perspective. Anesth Analg 2009; 109:489.
  44. Wayne MA, Friedland E. Prehospital use of succinylcholine: a 20-year review. Prehosp Emerg Care 1999; 3:107.
  45. Krisanda T, Eitel D, Cooley M, et al. Succinylcholine assisted intubation by responding advanced life support ground units: results of a four year plus study for the state of Pennsylvania [abstract]. Acad Emerg Med 1997; 4:460.
  46. Mizelle HL, Rothrock SG, Silvestri S, Pagane J. Preventable morbidity and mortality from prehospital paralytic assisted intubation: can we expect outcomes comparable to hospital-based practice? Prehosp Emerg Care 2002; 6:472.
  47. Davis DP, Ochs M, Hoyt DB, et al. Paramedic-administered neuromuscular blockade improves prehospital intubation success in severely head-injured patients. J Trauma 2003; 55:713.
  48. Ochs M, Davis D, Hoyt D, et al. Paramedic-performed rapid sequence intubation of patients with severe head injuries. Ann Emerg Med 2002; 40:159.
  49. Davis DP, Hoyt DB, Ochs M, et al. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma 2003; 54:444.
  50. Bochicchio GV, Ilahi O, Joshi M, et al. Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury. J Trauma 2003; 54:307.
  51. Murray JA, Demetriades D, Berne TV, et al. Prehospital intubation in patients with severe head injury. J Trauma 2000; 49:1065.
  52. Fakhry SM, Scanlon JM, Robinson L, et al. Prehospital rapid sequence intubation for head trauma: conditions for a successful program. J Trauma 2006; 60:997.
  53. Bair AE, Smith D, Lichty L. Intubation confirmation techniques associated with unrecognized non-tracheal intubations by pre-hospital providers. J Emerg Med 2005; 28:403.
  54. Timmermann A, Russo SG, Eich C, et al. The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians. Anesth Analg 2007; 104:619.
  55. Silvestri S, Ralls GA, Krauss B, et al. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Ann Emerg Med 2005; 45:497.
  56. Education of out-of-hospital emergency medical personnel in pediatrics: report of a National Task Force. Ann Emerg Med 1998; 31:58.
  57. O'Connor RE, Slovis CM, Hunt RC, et al. Eliminating errors in emergency medical services: realities and recommendations. Prehosp Emerg Care 2002; 6:107.
  58. National Association of EMS Physicians. Drug-assisted intubation in the prehospital setting position statement of the National Association of Emergency Physicians. Prehosp Emerg Care 2006; 10:260.
  59. Konrad C, Schüpfer G, Wietlisbach M, Gerber H. Learning manual skills in anesthesiology: Is there a recommended number of cases for anesthetic procedures? Anesth Analg 1998; 86:635.
  60. Matt Ritter E, Bowyer MW. Simulation for trauma and combat casualty care. Minim Invasive Ther Allied Technol 2005; 14:224.
  61. Barsuk D, Ziv A, Lin G, et al. Using advanced simulation for recognition and correction of gaps in airway and breathing management skills in prehospital trauma care. Anesth Analg 2005; 100:803.
  62. Acheson EM, Kheirabadi BS, Deguzman R, et al. Comparison of hemorrhage control agents applied to lethal extremity arterial hemorrhages in swine. J Trauma 2005; 59:865.
  63. Cotton BA, Jerome R, Collier BR, et al. Guidelines for prehospital fluid resuscitation in the injured patient. J Trauma 2009; 67:389.
  64. Frascone RJ, Jensen JP, Kaye K, Salzman JG. Consecutive field trials using two different intraosseous devices. Prehosp Emerg Care 2007; 11:164.
  65. Glaeser PW, Hellmich TR, Szewczuga D, et al. Five-year experience in prehospital intraosseous infusions in children and adults. Ann Emerg Med 1993; 22:1119.
  66. Schwartz D, Amir L, Dichter R, Figenberg Z. The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience. J Trauma 2008; 64:650.
  67. Brown JB, Cohen MJ, Minei JP, et al. Goal-directed resuscitation in the prehospital setting: a propensity-adjusted analysis. J Trauma Acute Care Surg 2013; 74:1207.
  68. Bulger EM, May S, Brasel KJ, et al. Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: a randomized controlled trial. JAMA 2010; 304:1455.
  69. de Crescenzo C, Gorouhi F, Salcedo ES, Galante JM. Prehospital hypertonic fluid resuscitation for trauma patients: A systematic review and meta-analysis. J Trauma Acute Care Surg 2017; 82:956.
  70. Brown LH, Gough JE, Simonds WB. Can EMS providers adequately assess trauma patients for cervical spinal injury? Prehosp Emerg Care 1998; 2:33.
  71. Meldon SW, Brant TA, Cydulka RK, et al. Out-of-hospital cervical spine clearance: agreement between emergency medical technicians and emergency physicians. J Trauma 1998; 45:1058.
  72. Domeier RM, Frederiksen SM, Welch K. Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann Emerg Med 2005; 46:123.
  73. Del Rossi G, Horodyski M, Conrad BP, et al. Transferring patients with thoracolumbar spinal instability: are there alternatives to the log roll maneuver? Spine (Phila Pa 1976) 2008; 33:1611.
  74. White LJ, Cooper JD, Chambers RM, Gradisek RE. Prehospital use of analgesia for suspected extremity fractures. Prehosp Emerg Care 2000; 4:205.
  75. McEachin CC, McDermott JT, Swor R. Few emergency medical services patients with lower-extremity fractures receive prehospital analgesia. Prehosp Emerg Care 2002; 6:406.
  76. Hennes H, Kim MK, Pirrallo RG. Prehospital pain management: a comparison of providers' perceptions and practices. Prehosp Emerg Care 2005; 9:32.
  77. Abbuhl FB, Reed DB. Time to analgesia for patients with painful extremity injuries transported to the emergency department by ambulance. Prehosp Emerg Care 2003; 7:445.
  78. Alonso-Serra HM, Wesley K, National Association of EMS Physicians Standards and Clinical Practices Committee. Prehospital pain management. Prehosp Emerg Care 2003; 7:482.
  79. Garrick JF, Kidane S, Pointer JE, et al. Analysis of the paramedic administration of fentanyl. J Opioid Manag 2011; 7:229.
  80. Soriya GC, McVaney KE, Liao MM, et al. Safety of prehospital intravenous fentanyl for adult trauma patients. J Trauma Acute Care Surg 2012; 72:755.
  81. Thomas SH, Rago O, Harrison T, et al. Fentanyl trauma analgesia use in air medical scene transports. J Emerg Med 2005; 29:179.
  82. Jennings PA, Cameron P, Bernard S, et al. Morphine and ketamine is superior to morphine alone for out-of-hospital trauma analgesia: a randomized controlled trial. Ann Emerg Med 2012; 59:497.
  83. Marcolini EG, Burton JH, Bradshaw JR, Baumann MR. A standing-order protocol for cricothyrotomy in prehospital emergency patients. Prehosp Emerg Care 2004; 8:23.
  84. Holloway VJ, Harris JK. Spontaneous pneumothorax: is it under tension? J Accid Emerg Med 2000; 17:222.
  85. Leigh-Smith S, Davies G. Tension pneumothorax: eyes may be more diagnostic than ears. Emerg Med J 2003; 20:495.
  86. Hannum J, Busko JM, Dix S, et al. Description of 33 prehospital needle chest decompressions for presumed tension pneumothorax [abstract]. Prehosp Emerg Care 2005; 9:125.
  87. Cullinane DC, Morris JA Jr, Bass JG, Rutherford EJ. Needle thoracostomy may not be indicated in the trauma patient. Injury 2001; 32:749.
  88. Eckstein M, Suyehara D. Needle thoracostomy in the prehospital setting. Prehosp Emerg Care 1998; 2:132.
  89. Mines D, Abbuhl S. Needle thoracostomy fails to detect a fatal tension pneumothorax. Ann Emerg Med 1993; 22:863.
  90. Wax DB, Leibowitz AB. Radiologic assessment of potential sites for needle decompression of a tension pneumothorax. Anesth Analg 2007; 105:1385.
  91. Zengerink I, Brink PR, Laupland KB, et al. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? J Trauma 2008; 64:111.
  92. Givens ML, Ayotte K, Manifold C. Needle thoracostomy: implications of computed tomography chest wall thickness. Acad Emerg Med 2004; 11:211.
  93. Stevens RL, Rochester AA, Busko J, et al. Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography. Prehosp Emerg Care 2009; 13:14.
  94. Inaba K, Ives C, McClure K, et al. Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Arch Surg 2012; 147:813.
  95. Schroeder E, Valdez C, Krauthamer A, et al. Average chest wall thickness at two anatomic locations in trauma patients. Injury 2013; 44:1183.
  96. Clemency BM, Tanski CT, Rosenberg M, et al. Sufficient catheter length for pneumothorax needle decompression: a meta-analysis. Prehosp Disaster Med 2015; 30:249.
  97. Aho JM, Thiels CA, El Khatib MM, et al. Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter. J Trauma Acute Care Surg 2016; 80:272.
  98. Hecker M, Hegenscheid K, Völzke H, et al. Needle decompression of tension pneumothorax: Population-based epidemiologic approach to adequate needle length in healthy volunteers in Northeast Germany. J Trauma Acute Care Surg 2016; 80:119.
  99. Beckett A, Savage E, Pannell D, et al. Needle decompression for tension pneumothorax in Tactical Combat Casualty Care: do catheters placed in the midaxillary line kink more often than those in the midclavicular line? J Trauma 2011; 71:S408.
  100. Laan DV, Vu TD, Thiels CA, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury 2016; 47:797.
  101. Inaba K, Karamanos E, Skiada D, et al. Cadaveric comparison of the optimal site for needle decompression of tension pneumothorax by prehospital care providers. J Trauma Acute Care Surg 2015; 79:1044.
  102. Galvagno SM Jr, Thomas S, Stephens C, et al. Helicopter emergency medical services for adults with major trauma. Cochrane Database Syst Rev 2013; :CD009228.
  103. Branas CC, MacKenzie EJ, Williams JC, et al. Access to trauma centers in the United States. JAMA 2005; 293:2626.
  104. Doucet J, Bulger E, Sanddal N, et al. Appropriate use of helicopter emergency medical services for transport of trauma patients: guidelines from the Emergency Medical System Subcommittee, Committee on Trauma, American College of Surgeons. J Trauma Acute Care Surg 2013; 75:734.
  105. Meier, B, Saul, S. Fatal crashes provoke debate on safety of sky ambulances. New York Times, February 28, 2005.
  106. Levin, A, Davis, R. Surge in crashes scars air ambulance industry. USA Today, July 18, 2005.
  107. Isakov AP. Souls on board: helicopter emergency medical services and safety. Ann Emerg Med 2006; 47:357.
  108. Baker SP, Grabowski JG, Dodd RS, et al. EMS helicopter crashes: what influences fatal outcome? Ann Emerg Med 2006; 47:351.
  109. Haller JS Jr. The beginnings of urban ambulance service in the United States and England. J Emerg Med 1990; 8:743.
  110. HAMPTON OP Jr. Transportation of the injured, a report. Bull Am Coll Surg 1960; 45:55.