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Serial killers: Trauma

Assessing for the 5 things that can kill people emergently when they suffer major trauma


AP Photo/John Minchillo

We often start with a diagnosis and teach from there – we’ve attempted to flip this script with our initial serial killer series, which included chest pain, shortness of breath and altered mental status. However, we concentrated primarily on medical serial killers during those episodes and, honestly, we didn’t include trauma. So, in this episode, we’re going to discuss the trauma serial killers

When people suffer major trauma – what things can kill them emergently?

  1. Hemorrhagic shock
  2. Obstructive shock – Tension PTX/tamponade
  3. Hypoxemia (high C-spine injury)
  4. Closed head injury
  5. DIC

Where to start?

  • En route: always approach trauma calls considering the killer 5 diagnoses first
  • Vitals are vital (don’t forget the ETCO2/shock index/kids will compensate, beware of trauma plus tachycardia in pediactrics)
  • Exam: pupils are overrated! GCS motor is likely more reliable
  • Mind your scene time
  • To care for trauma patients, we must gain control – respect traumatic thrash

This episode includes:

  • Hemorrhage. Think through all the spots blood can hide
  • Obstructive shock. Tension PTX and tamponade
  • Hypoxemia. BVM, SGA or ETT
  • Closed head injury. GCS motor
  • DIC. Don’t forget to warm these patients

Take home points

  • Always expose and control the patient – we can’s assess things we can’t see and it’s impossible to care for a sick trauma patient while wrestling them
  • Less scene time = quicker time to surgeon
  • TXA 2g – while en route
  • Needle T in the fourth ICS AAL
  • Avoid and prevent hypoxia and hypotension in CHI
  • Warm your trauma patients


  1. Childress K, et al. Prehospital End-tidal Carbon Dioxide Predicts Mortality in Trauma Patients. Prehosp Emerg Care. 2018 Mar-Apr;22(2):170-174.
  2. Androski CP Jr, et al. Case Series on 2g Tranexamic Acid Flush From the 75th Ranger Regiment Casualty Database. Journal of Special Operations Medicine : a Peer Reviewed Journal for SOF Medical Professionals. 2020 ;20(4):85-91. 
  3. Taghavi S, et al. An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients. J Trauma Acute Care Surg. 2021 Jul 1;91(1):130-140. 
  4. Sims CA, et al. Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock: A Randomized Clinical Trial. JAMA Surg. 2019 Nov 1;154(11):994-1003. 
  5. Kupas DF, et al. Glasgow Coma Scale Motor Component (“Patient Does Not Follow Commands”) Performs Similarly to Total Glasgow Coma Scale in Predicting Severe Injury in Trauma Patients. Ann Emerg Med. 2016 Dec;68(6):744-750.
  6. Rankin CJ, et al. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg. 2020 Mar;88(3):434-439. 
  7. Laan DV, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2016 Apr;47(4):797-804. 

The MCHD Paramedic Podcast was launched in early 2018 in an effort to provide easily consumable core-content EMS education and insights from prehospital care thought leaders. The Clinical Services Department of The Montgomery County Hospital District EMS service developed the podcast as a tool to better engage and disseminate continuing education to our MCHD medics as well as first responders and EMS professionals nationwide.

Dr. Casey Patrick is the assistant medical director for Montgomery County Hospital District EMS and is a practicing emergency physician in multiple community emergency departments across Greater Houston. His EMS educational focus is on innovative paramedic teaching via the MCHD Paramedic Podcast. Dr. Patrick’s prehospital clinical research involves the investigation of paramedic use of bolus dose intravenous nitroglycerin for acute pulmonary edema and the implementation of lung protective ventilation strategies for intubated EMS patients. Casey and his wife, Alyssa, work and live in Conroe, Texas, and Spokane, Washington. Together they have five children: Mia, Ainsley, Brock, Dean and Will.

Dr. Dickson graduated with honors from the University of Texas Health Science Center San Antonio in 2001 and completed emergency medicine training at Indiana University in 2004. He serves as the EMS medical director at Montgomery County Hospital District EMS and an assistant professor of emergency medicine at Baylor College of Medicine in Houston, Texas. His academic interests include systems of care in stroke and other time-sensitive emergencies, neurologic emergencies and education. He is board certified in emergency medicine in both the U.S. and Australasia, and has subspecialty board certification in EMS medicine. He has authored multiple professional articles and presented at regional, national and international conferences on emergency medicine and EMS topics.