Takeaways from the NAEMSP Prehospital Trauma Compendium

The recently published NAEMSP Prehospital Trauma Compendium is a powerful resource for EMS clinicians, educators, and leaders. Rather than a single guideline, it is a curated collection of position statements, resource documents, and literature reviews that gather the best available evidence on trauma care and translate it into practical recommendations for the field.

This year’s Compendium spans the range of EMS trauma care, from airway and hemorrhage to spinal injuries and traumatic cardiac arrest. The papers offer a clearer picture of what effective prehospital trauma care looks like in 2025. For this review, we highlight three key papers: the updated guidance on traumatic out-of-hospital circulatory arrest (TOHCA), the position statement and resource document on transfusion of blood products, and a comprehensive review of prehospital spinal cord injury management.

Methods

The Compendium documents follow a consistent development approach. Expert panels from NAEMSP, the American College of Surgeons Committee on Trauma (ACS-COT), and the American College of Emergency Physicians (ACEP) conduct structured literature reviews, synthesize the available evidence, and build consensus recommendations. The depth of literature varies widely across trauma topics, so some papers function as resource documents summarizing what is known, while others provide formal position statements with clear recommendations.  

Across all Compendium documents, the emphasis is the same: evidence where it exists, consensus where evidence is limited, and an honest acknowledgment of the gaps that still need to be filled. The Compendium also provides references to all recommendations and offers resources that point to other national guidance as a best practice.

Key Takeaways from the Three Highlighted Papers

1. Prehospital Management of Adults with Traumatic Out-of-Hospital Circulatory Arrest–A Joint Position Statement and Resource Document of NAEMSP, ACS-COT, and ACEP

The updated position statement on the management of adults with TOHCA is the most extensive of the three reviewed here. Traumatic cardiac arrest has long been associated with poor outcomes, but recent data reveal a  more nuanced picture. Survival is still low, but not uniformly hopeless, and improvement is possible. The authors screened more than 1,000 articles, synthesizing the evidence into pragmatic recommendations from which several themes emerged.

Reversible causes first. TOHCA is often driven by hypoxia, airway obstruction, tension pneumothorax, or massive hemorrhage. The authors emphasize that EMS clinicians should prioritize these life-saving interventions before considering anything else. Airway positioning and basic ventilation, hemorrhage control, and chest decompression, performed when clinically indicated and not universally, take precedence over prolonged CPR.

Chest compressions are not the anchor treatment. Unlike medical arrest, high-quality CPR alone is unlikely to change outcomes in TOHCA unless the underlying cause is corrected. The document reinforces that compressions should occur only after priority interventions and must not delay transport to definitive trauma care.

Epinephrine should not be routinely used. The authors provide substantial evidence that does not support routine epinephrine administration for traumatic cardiac arrest, noting several studies that suggest it may worsen outcomes.

Ultrasound may help determine futility. If cardiac motion is absent on point-of-care ultrasound, especially after priority interventions, the likelihood of meaningful survival is extremely low.

No single factor should determine when to stop. Neither mechanism of injury nor initial rhythm alone should drive termination decisions. While shockable rhythms still have the best outcomes, the paper cautions against relying exclusively on rhythm to determine futility.

Overall, the authors push EMS systems to balance rapid transport with focused, reversible-cause management and to recognize TOHCA as a unique clinical entity that requires its own structured approach.

2. Transfusion of Blood Products in Trauma–A Position Statement and Resource Document of NAEMSP

Hemorrhagic shock remains the leading cause of potentially preventable death, and expanding access to blood products in the field has become common. This document summarizes the evidence and outlines what EMS systems should consider when developing or refining a transfusion program.

Blood products over crystalloids. The authors reinforce that large-volume crystalloids can worsen coagulopathy and acidosis, while early use of blood products may improve outcomes. The overall trend supports blood-first resuscitation in patients with life-threatening bleeding.

Low titer group O whole blood when available. The authors identify low titer group O whole blood (LTOWB) as the preferred product for agencies that can support its use. LTOWB offers balanced resuscitation in a single unit and has demonstrated safety and feasibility in both military and civilian programs.

Clear indications and careful monitoring. The authors encourage EMS systems to base transfusion decisions on meaningful physiologic criteria, such as hypotension, shock index, major hemorrhage, or high-risk injury patterns. They also emphasize the need for protocols to monitor for transfusion reactions.

Collaboration and sustainability. Successful programs depend on strong relationships with trauma centers and blood banks. The paper highlights the importance of reliable supply chains, recycling unused units to reduce waste, and maintaining the training and oversight needed for safe operations.

Overall, this resource guides EMS systems toward thoughtful implementation of blood product administration, recognizing its growing role in improving care for patients with significant hemorrhage.

3. Prehospital Management of Spinal Cord Injuries–A NAEMSP Comprehensive Review and Analysis of the Literature

 After reviewing more than a century of literature, the authors found that the strongest evidence points not to movement as the cause of delayed neurological decline, but to hypoperfusion of the spinal cord. Modern imaging and physiologic studies show that inadequate blood supply is a more meaningful contributor to worsening deficits than a patient turning their head or repositioning on the stretcher.

The authors also remind us that absence of evidence is not evidence of absence. Their findings do not prove that movement can never worsen an injury. Instead, they highlight that decades of research simply have not demonstrated movement as the predictable pathway to paralysis that many of us were taught. What the evidence does show is that restoring and maintaining perfusion makes the greatest difference.

Spinal motion restriction over rigid immobilization. Consistent with this updated understanding, the review reinforces that spine boards and rigid immobilization can create more harm than benefit. Pain, respiratory compromise, increased intracranial pressure, and early skin breakdown all appear as complications. Motion restriction using the stretcher and careful handling aligns better with current evidence.

Patients protect themselves. The authors note that patients with painful injuries naturally avoid movements that worsen pain. This challenges the old belief that a patient might turn their head, become paralyzed, and die. In many cases, attempts to force rigid immobilization create more movement than allowing the patient to settle into a position of comfort.

Airway and perfusion come first. Because hypoperfusion is a primary driver of secondary injury, the review emphasizes that airway management, oxygenation, and maintaining adequate blood pressure take priority over preventing every degree of movement.

Selective use of collars and devices. The evidence supports a risk-based approach rather than universal collar application. Many low-risk or ambulatory patients do not benefit from collars, and studies show no increase in delayed neurologic injury when they are omitted.

Overall, this paper guides EMS toward spinal care that focuses on perfusion, airway protection, patient comfort, and thoughtful risk assessment. It encourages clinicians to worry less about preventing every small movement and more about supporting the physiology that truly impacts long-term outcomes.

Discussion

Together, this Compendium shows how far we have come in grounding trauma care in thoughtful, evidence-based practice.  The authors challenge long-standing assumptions, clarify where the science truly points, and help us frame our decisions in ways that support the best possible outcomes for patients. The Trauma Compendium is fully open access, and I encourage readers to explore the complete collection to better understand the depth of work behind these recommendations.  It is a great appreciation we owe to the authors for their time, discussion, and leadership on advancing EMS through these publications.

References

1. Breyre, A. M., George, N., Nelson, A. R., Ingram, C. J., Lardaro, T., Vanderkolk, W., & Lyng, J. W. (2024). Prehospital Trauma Compendium: Prehospital Management of Adults with Traumatic Out-of-Hospital Circulatory Arrest–A Joint Position Statement and Resource Document of NAEMSP, ACS-COT, and ACEP. Prehospital Emergency Care, 1-15.

2. Brown, J. B., Yazer, M. H., Kelly, J., Spinella, P. C., DeMaio, V., Fisher, A. D., ... & Guyette, F. X. (2025). Prehospital Trauma Compendium: Transfusion of Blood Products in Trauma–A Position Statement and Resource Document of NAEMSP. Prehospital Emergency Care, 1-10.

3. Millin, M. G., Innes, J. C., King, G. D., Abo, B. N., Kelly, S. M., Knoles, C. L., ... & Gallagher, J. M. (2025). Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries–A NAEMSP Comprehensive Review and Analysis of the Literature. Prehospital Emergency Care, 1-13.

About the Author

Michael Kaduce, MPS, NRP, is director of the Falck Health Institute, West Coast Board Director for the National Association of EMTs, and a research associate for the UCLA Prehospital Care Research Forum.