key: cord-0918302-4um2mvo8
authors: Mazzoli, C.A.; Tartaglione, M.; Gamberini, L.; Lupi, C.; Semeraro, F.; Chiarini, V.; Coniglio, C.; Gordini, G.
title: Pre-Hospital Trauma Care in the COVID-19 era
date: 2020-07-25
journal: Air Med J
DOI: 10.1016/j.amj.2020.07.009
sha: d2a4da62200507d10999bc50963359e099714c77
doc_id: 918302
cord_uid: 4um2mvo8

During the COVID-19 pandemic, a health emergency scenario quickly emerged and put the Italian National Health System to the test. The Pre-hospital Emergency Care has undergone several changes to cope with this situation, several Authors and Scientific Societies have addressed the peculiar aspects of cardiological emergencies but, until now, little has been written about pre-hospital trauma care. In this letter, we discuss all the aspects and changes derived from the experience of the Maggiore Hospital Trauma Center. Regardless of how this pandemic will evolve, the new peculiarities of the trauma patient approach could be permanently changed.

The first appearance of COVID-19 1 in Italy was reported on January 30th, 2020 with the discovery of two positive Chinese tourists in Rome. Less than one month later, on February 21 st , a new outbreak was reported in Lombardy 2 , Northern Italy. In the following weeks, there was an exponential surge in the number of patients with respiratory failure who entered to ED and requiring ICU admission, putting the Italian Health System to the test.

In this framework of a health emergency, the pre-hospital emergency system had to undergo profound changes too, partly due to logistical needs, secondary to the overloading of hospital facilities, and partly caused by the complete subversion of the epidemiology of pre-hospital emergency cases.

Several Authors have dealt with the peculiarities of pre-hospital management of acute coronary syndromes 3 or cardiac arrest in the COVID-19 era and Scientific Societies have drawn up dedicated guidelines 4 .

Several observations have been addressed to the remodeling of emergency departments 5 (ED) which, on the one hand, had to manage a flow of patients with respiratory failure that was enormous and disproportionate to the available resources and, on the other hand, had to ensure the care of patients who normally enter the ED for emergencies of different kinds 6 .

Little has been written about how this pandemic has entailed in the care of trauma patients in the pre-hospital setting and this letter is the result of the different experiences and consequent considerations that a highvolume trauma system such as Maggiore Hospital Trauma Center has experienced during this period.

The first fundamental point is the safety of the health-care workers (HCWs) involved in the rescue of a traumatized patient and this aspect is influenced by several human factors.

First of all we have to take into account the level of stress to which HCWs are subjected during the rescue, which is aggravated by the additional stress caused by the fear of being infected and infecting their families.

The management of stress among HCWs is a rather debated topic at the moment 7 .

Therefore, the obstacles caused by the PPEs must be taken into account, the fogging of the goggles can impair the view of both the patient and the scene putting HCWs at risk. Wearing two or more pairs of gloves inevitably leads to a loss of sensitivity of the hands, which is crucial during the detection of subcutaneous emphysema or arterial pulse, the limitation in terms of fineness of movement can also be perceived when performing maneuvers such as intubation, finger thoracostomy or REBOA catheter placement.

A further aspect is a prostration caused by PPEs due to excessive fluid loss through sweating and which, with the physical effort often required during the rescue of a traumatized patient, are certainly accentuated with an increased risk of fainting.

When it comes to maneuvers, these add risk factors for HCWs. The two above-mentioned are certainly the riskiest in terms of contamination. As far as intubation is concerned, the use of a video laryngoscope is recommended 8 , but in patients with a large amount of blood or vomit in the oral cavity, it may not be usable.

Moreover, once intubated, these patients often need to repeat suctions through the ETT because of aspiration even during transport, with consequent multiple disconnections of the respiratory circuit which, in an emergency context, may not always be performed with all the appropriate precautions.

Decompression or drainage of tension pneumothorax may involve the leak of pressure air from the pleural cavity, the air comes from lacerations of the pulmonary parenchyma and therefore potentially carries a high viral load.

Logistics issues also play an important role in this scenario, the first consideration is that in case of a trauma call, it is difficult for the Dispatch Center to screen for suspected COVID-19 patients 9 because the eye witness often does not know the victim and can't provide any recent medical history. Then, on the scene, the victims may be multiple and the need for HCWs to evaluate each one at the same time as an initial triage brings with it risks of contamination given the impossibility of fully changing PPEs during such hectic phases.

The second consideration concerns the professional figures involved on the scene, together with HCWs there are firefighters and police officers, very often they are personally involved in the rescue phases where physical distancing is almost impossible. Working hand in hand is a characteristic and also a typical need in the care of trauma victims in the pre-hospital setting more than in other types of medical emergencies and, in a historical moment like this, it is certainly risky despite the use of PPEs.

The last logistical aspect is the decontamination of the vehicles, ambulance and helicopter are the final vectors with which these patients will be transported to the ED and need an extensive and treated sanitization that can increase the time to restore the full operation of the vehicle. This may cause delays and missed missions.

Going back to Italy's situation, due to the exponential increase in the number of cases and the high rate of hospitalization among COVID19 patients, the Italian Government imposed a national lockdown on March 9th and then eased restrictions as of the second half of May.

During this period we have witnessed a vertical collapse of trauma emergency calls 6 , as already reported by several Authors, making trauma management less problematic given the small number of cases. At the moment we are witnessing an equally sudden increase in cases due to the resumption of the circulation of people, the reopening of workplaces and sports activities.

No one knows what will happen in the future, whether we will be overwhelmed by a second wave or whether the pandemic will gradually disappear, but this experience has had a profound impact on all aspects of the pre-hospital management of trauma patients, as shown in Fig.1 , which may not be the same from now on.

A novel coronavirus from patients with pneumonia in China

Covid -19 epidemic in Italy : evolution , projections and impact of government measures

Covid-19 : implications for prehospital , emergency and hospital care in patients with acute coronary syndromes

European resuscitation council COVID-19 guidelines executive summary

Critical Care Utilization for the COVID-19 Outbreak in

Variation in volumes and characteristics of trauma patients admitted to a level one trauma centre during national level 4 lockdown for COVID-19 in New Zealand

Mental Health Strategies to Combat the Psychological Impact of Coronavirus Disease 2019 ( COVID-19 ) Beyond Paranoia and Panic

Consensus guidelines for managing the airway in patients with COVID-19