EMS in the field and physicians in the ED are faced with rapidly assigning some degree of stability to the patients they treat. What exactly are the shades of stability, and what considerations are there for each degree?

In my mind, there are three levels of “stability”:

• Unstable - this one is easy to figure out. The patient has obvious physiologic compromise, which may be objective (low blood pressure, low GCS or poor neuro exam, etc) or subjective (just plain looks bad). 
  EMS: These patients need transport to an appropriate level trauma center (I or II) immediately. If they need airway control or IV access that can’t be obtained in the field, stop at the nearest Level III or IV for assist, then continue on your way FAST. 
  ED: These patient must be a trauma activation. If not activated as your top-tier trauma, activate or upgrade now! These patients must be seen by a trauma surgeon immediately, and can only go to the OR. No diagnostics outside the resuscitation room are allowed unless they can be converted into one of the two stability levels below.
• Stable - this one is usually easy to figure out, too. These patients look good, have good vitals, and a low to moderate energy mechanism for their trauma. Look out for those few patients that may be hiding something like moderate bleeding into some body cavity.
  EMS: Follow your usual transport protocols to select the closest, appropriate hospital.
  ED: Follow your standard protocols for trauma activation if needed. Transport for standard imaging is fine.
•  Metastable - this is a term I invented. It describes patients who have evidence of ongoing volume loss that can be controlled with infusion of crystalloid and/or blood products. It is possible to maintain a certainly level of stability using higher than normal volume infusions. This allows physicians to consider diagnostics or interventions outside of an OR.
  EMS: Ensure adequate IV access and give fluids and/or blood per your local protocols. Transport to a Level I or II trauma center as quickly as possible.
  ED: Activate or upgrade to your highest level of trauma activation. The trauma surgeon needs to be present to help direct diagnostics or interventions. These patients may go to CT, IR or other appropriate areas with nurse and physician accompaniment to diagnose and possibly treat bleeding. If the patient changes to unstable at any point, they must immediately be taken to the OR.

Pelvic Fractures: OR vs Angio In The Unstable Patient

One of the cardinal rules of trauma care is that hemodynamically unstable patients can only go the the operating room from the ED. No trips to CT, xray, etc. Trauma professionals occasionally try to make exceptions to the rule, but it usually doesn’t work out.

Well, what about the patient with severe pelvic fractures who is or becomes unstable? Pelvic fracture bleeding is not always easy or even possible to control in the OR, and angiography offers a way to identify and stop the bleeding, right?

The trauma group at Ryder in Miami did a lengthy (13 year) retrospective review of their experience with these patients. They looked at every patient who underwent angiography, then identified the subset that went to the OR followed by angiography. There were 134 angio patients and 49 OR to angio patients on whom they based their analysis. Obviously, there is plenty of opportunity for bias in this study, and many of the study patients identified had to be excluded due to incomplete records.

Patients who went to the OR first tended to have similar injury severity but were sicker than the angio alone group. Crystalloid and blood resuscitation volumes were significantly higher in the OR group as well. Most of these patients underwent a laparotomy, and 64% had active intra-abdominal bleeding. None died in OR, and most were left with a damage control abdominal closure.

In the angio group, there were really 2 subsets: angio alone, and angio followed by OR. Mortality in the angio alone group was similar to the OR-angio group. But deaths skyrocketed in those who went from angio to OR (67% vs 20%). This is likely due to them failing angiographic management of bleeding. Three patients died in the angio suite.

Bottom line: There’s a lot of data in this paper, and some of the results can be explained by selection bias. However, they appear to support algorithms released by EAST and the WTA (see diagram above). In general, a trauma patient with severe pelvic fractures and hemodynamic instability needs to go to OR to identify and treat any source of intra-abdominal bleeding. If pelvic bleeding remains a problem, preperitoneal packing may be considered, followed by a trip to angio at that point. The rule that unstable patients should only go to OR (or an ambulance bound for a trauma center if there is no OR) still holds!

Reference: Operating room or angiography suite for hemodynamically unstable pelvic fractures? J Trauma 72(2):364-372, 2012.

Quiz: There is just one extremely rare reason that I know of to move to CT with a hemodynamically unstable trauma patient. Leave a comment with your guess.

EMS in the field and physicians in the ED are faced with rapidly assigning some degree of stability to the patients they treat. What exactly are the shades of stability, and what considerations are there for each degree?

In my mind, there are three levels of “stability”:

• Unstable - this one is easy to figure out. The patient has obvious physiologic compromise, which may be objective (low blood pressure, low GCS or poor neuro exam, etc) or subjective (just plain looks bad). 
  EMS: These patients need transport to an appropriate level trauma center (I or II) immediately. If they need airway control or IV access that can’t be obtained in the field, stop at the nearest Level III or IV for assist, then continue on your way FAST. 
  ED: These patient must be a trauma activation. If not activated as your top-tier trauma, activate or upgrade now! These patients must be seen by a trauma surgeon immediately, and can only go to the OR. No diagnostics outside the resuscitation room are allowed unless they can be converted into one of the two stability levels below.
• Stable - this one is usually easy to figure out, too. These patients look good, have good vitals, and a low to moderate energy mechanism for their trauma. Look out for those few patients that may be hiding something like moderate bleeding into some body cavity.
  EMS: Follow your usual transport protocols to select the closest, appropriate hospital.
  ED: Follow your standard protocols for trauma activation if needed. Transport for standard imaging is fine.
•  Metastable - this is a term I invented. It describes patients who have evidence of ongoing volume loss that can be controlled with infusion of crystalloid and/or blood products. It is possible to maintain a certainly level of stability using higher than normal volume infusions. This allows physicians to consider diagnostics or interventions outside of an OR.
  EMS: Ensure adequate IV access and give fluids and/or blood per your local protocols. Transport to a Level I or II trauma center as quickly as possible.
  ED: Activate or upgrade to your highest level of trauma activation. The trauma surgeon needs to be present to help direct diagnostics or interventions. These patients may go to CT, IR or other appropriate areas with nurse and physician accompaniment to diagnose and possibly treat bleeding. If the patient changes to unstable at any point, they must immediately be taken to the OR.

I am interested in other opinions on this as well. Please post your comments!