Prehospital Trauma Care: What should EMS be doing?
Getting There: The Right Place at the Right Time Jeffrey P. Salomone, MD, FACS, NREMT-P Associate Professor of Surgery Emory University School of Medicine Co-Director of Trauma and Deputy Chief of Surgery Grady Memorial Hospital Goal
Get the right patient . . . . . . to the right place 10 . . . in the right amount of time. Guiding Principle Patient destination based upon medical appropriateness Accessibility to Trauma Centers
Branas CC, et al; JAMA, 2005: Almost 90% of the US population lives in areas accessible to designated trauma care (Level I, II or III centers) within a one hour period of time Access to Level I and II TCs within 60 mins Ground EMS (5% land area, 60 % pop) Access to Level I and II TCs within 60 mins Ground + Air Medical EMS
(35% land area, 90% pop) The Reality Nathens AB, et al; J Trauma, 2000: 500,000 injured persons in 18 states Failed to receive care at designated trauma facilities: 56% of all trauma patients 36% of major trauma patients
Access to Level I and II TCs within 60 mins Ground EMS vs Ground + Air Medical EMS Land area 4%; 38% pop Land area 79%; 90% pop The Right Place Trauma Center An institution committed to the care of injured patients, from acute care to rehabilitation
Initial resuscitation Operative management Critical care Continuing care Trauma Center Immediate availability on a 24-hr basis: Specialized surgeons Physician specialists Nurses Allied health personnel
Resuscitation and life support equipment Teamwork Physicians: Surgery EM
Ward Clinic Trauma Center Trauma program: Trauma service Trauma team Trauma medical director Coordinator / program
manager Performance improvement/ registry Trauma Centers Levels- established by ACS-COT: Level IV Level III Level II Level I
Designated- state agency Verified- ACS-COT site visit Level III General Surgery- immediately available* Available 24 hrs: EM, Orthopedics, Plastics, Radiology, Anesthesia Neurosurgery is desirable Required (24 hr) : Xray, CT, PACU
Desirable (24 hr): Xray Tech, Resp Tech * = within 15 minutes of patients arrival in ED Level II Level III Criteria, plus: Physicians*: Neurosurg, Hand, OB/GYN, Ophth, OMFS, Thoracic, CCM 24 hr OR is desirable Injury Prevention outreach *Inhouse trauma surgeons NOT required
Level I Level II criteria, plus: Physicians*: Cardiac surg, Microvascular Services: CPB, inhouse OR personnel, inhouse SICU service Teaching facility (Surg residency, ATLS) Research Admissions: 1,200/yr; 240 with ISS > 15 Tertiary referral / resource center *Inhouse trauma surgeons NOT required
Exclusive vs Inclusive Trauma System Level IV 24 hrs: ED, Lab Does not need 24 hr Emer Med Desirable: 24 hr Gen Surg, Anesth Initial resuscitation Refer to higher level center
Lack of Trauma Centers Hospitals that lack a commitment to trauma care have been associated with a higher incidence of unacceptable care and poor outcomes Moylan JA, et al., J Trauma, 1976 Detmer DE, et al., J Trauma, 1977 Comparison of Trauma Systems West JG, et al., Arch Surg, 1979 Comparison of trauma patients who died
after arrival at a hospital Orange Co., closest facility (n = 90) San Francisco, single trauma center (n = 92) Preventable deaths Orange Co. 40 of 90 deaths (44%): 20/30 (66%) of non-CNS trauma 20/60 (33%) of CNS trauma pts SF: only one (about 1%) Trauma Centers
Transfer of trauma patients to designated trauma centers has also been shown to improve outcomes: West JG, et al., Arch Surg, 1983 Follow up to 1979 study Significant reduction in mortality by regionalization: overall 20% preventable; TC 9% preventable Shackford SR, et al., J Trauma, 1986 Waddell TK, et al., J Trauma, 1991 Effect of Trauma-Center Care on
Mortality Trauma patients managed at 18 Level I trauma centers compared to 51 nontrauma centers (14 states) Complete records available for: 1104 patients who died 4087 patients discharged alive CDC funded MacKenzie EJ, et al, NEJM, 2006
Effect of Trauma-Center Care on Mortality In-hospital mortality : Trauma center: 7.6%; relative risk 0.80 Non-trauma center: 9.5% One year mortality rate: Trauma center 10.4%, relative risk 0.75 Non-trauma center: 13.8% Differences in mortality rates primarily confined
to patients with more severe injuries You (or your patient) are 25% more likely to survive if taken to a trauma center. Level I vs Level II Traditionally outcome between Level II and Level I centers viewed to be equivalent
Criteria for clinical care nearly identical Level I primarily teaching / research facility Superiority of Level I Retrospective review using NTDB pts > 14 yrs, ISS >15 One of the following injuries: Aortic vena cava iliac vessels Cardiac
Grade IV/V liver injuries quadriplegia complex pelvic fx Demetriades D, et al., Ann Surg, Oct 2005 Superiority of Level I? Results 12,254 pts met inclusion criteria Level I centers had significantly: Lower mortality (25.3% vs 29.3%, p = 0.004)
Less severe disability at D/C ( 20.3% vs 33.8%, p = 0.001) Higher functional outcome Trauma Center vs Closest Hospital Closest Hospital CRASH! 8 minute EMS response 10 min scene time 5 min transport time 10 min ED evaluation
30 min surgeon call-in 30 min OR call-in 5 min transfer to OR Total Time, injury to OR= 98 mins Trauma Center CRASH 8 minute EMS response 10 min scene time 15 min transport time
10 min ED evaluation 5 min transfer to OR Total Time, injury to OR= 48 mins The Right Patient Overtriage Transporting minimally injured trauma patients to a trauma center Overtriage rate of up to 50% considered
acceptable Often a financial / resource issue Undertriage Failure to transport major trauma patients to a trauma center Undertriage rate of 5 10 % considered unavoidable, and is associated with an overtriage rate of 30 50% Often a political issue
What is a Major Trauma Patient? Major Trauma Patient Injury Severity Score (ISS) > 15 frequently used Correlates well with mortality over a broad range of ages and injuries
Knudson MM, et al., Arch Surg, 1994 Buckley SL, et al., J Pediatr Orthop, 1994 Gustilo RB, et al., Orthop, 1985 Jones JM, et al., J Trauma, 1995 Shedden PM, et al., Pediatr Neurosurg, 1990 Chen RJ, et al., Eur J Surg, 1995
Cant be calculated in the prehospital setting Injury Severity Score Region Injury Description AIS Square
Top Three Head & Neck Cerebral Contusion 3 Face No Injury
0 Chest Flail Chest 4 16
2 5 25 Abdomen Minor Contusion of Liver Complex Rupture Spleen Extremity
Fractured femur 3 External No Injury 0
Injury Severity Score: 9 50 ISS - Issues Based primarily on motor vehicle crash data Not as useful in penetrating trauma Ignores multiple injuries in the same body
region Other Trauma Scores Trauma Index Kirkpatrick JR, Youmans RL, J Trauma, 1971 Trauma Score / Revised Trauma Score Champion HR, et al., Crit Care Med, 1981 Champion HR, et al., J Trauma, 1989
CRAMS scale Gormican SP, Ann Emerg Med, 1982 Prehospital Index Koehler JJ, et al, Ann Emerg Med, 1986 Trauma Triage Rule Baxt WG, et al., Ann Emerg Med, 1990 Each with limitations, lacking clear superiority over others
Alternatives to ISS Deaths in the ED or within 24 hrs of ED admission Resource utilization: Massive blood transfusions Rapid operative intervention Cessation of bleeding by interventional angiography Early intensive critical care
All difficult to determine in the field! Field Triage Field Triage Committee on Trauma, American College of Surgeons / CDC
Components: Physiologic Anatomic Mechanism of Injury Special Considerations Case 29 y/o male fishing in small boat at 1 AM. Boat run over by speedboat. Airway: Intact
Breathing: shallow, 34/min, equal Circulation: no radial pulses, SBP 80 mm Hg, significant hemorrhage from lower extremities Disability: GCS 13 (E4, V4, M5) Expose: No injuries to torso, head, upper extremities Speedboat vs Fisherman High flow O2, pulse
oximetry Tourniquets placed to bilateral thighs Transport initiated Intravenous resuscitation begun enroute Physiologic Criteria Take to Trauma Center:
Glasgow Coma Scale Score < 13 Systolic blood pressure < 90 mm Hg Respiratory rate < 10 or > 29 <20 in infant (under one year of age) Or need for ventilatory support Physiologic Criteria Physiologic derangement correlates well with severity
of injury and can predict mortality Baxt WB, et al., Ann Emerg Med, 1989 Patients with significant tachycardia and hypotension have typically lost 30 40% of their blood volume and often are in need of emergent transfusion and surgical intervention Case 55 y/o male, despondent
over relationship, stabs self in left chest with kitchen steak knife Airway: intact Breathing: 24, equal BS Circulation: HR 58, BP 114/68 Disability: GCS 14 Exposure: No other injuries
Steak knife vs heart High flow O2, pulse oximetry Initiate rapid transport to trauma center Initiate IV therapy enroute Anatomic Criteria
All penetrating injuries to head, neck, torso and extremities proximal to elbow or knee Chest wall instability or deformity ( i.e., flail chest Two or more proximal long bone fractures Crush, degloved, mangled or pulseless Amputation proximal to wrist or ankle Pelvic fractures Open or depressed skull fractures Paralysis
Anatomic Criteria Some patients with lethal injury may present with normal vital signs, especially if EMS response has been rapid Reliance on only physiologic criteria may result in undertriage Anatomic Criteria:
Penetrating Torso Trauma Several studies have documented noteworthy survival rates in patients with penetrating torso trauma transported to facilities with immediate surgical capabilities Best survival rates are in patients with stab wounds to the chest that have vital signs upon arrival in the ED Durham LA, et al., J Trauma, 1992 Velmahos GC, et al., Arch Surg, 1995 Rhee PM, et al., J Am Coll Surg, 2000
Case 8 y/o male backseat passenger of vehicle involved in frontal collision. Significant intrusion to passenger compartment Airway: intact Breathing: RR 28, equal BS Circulation: Pulse 110
Disability: GCS 15 Expose: Seatbelt mark to abdomen, abdomen tender Child in MVC High flow O2, pulse oximetry Extrication to trauma board, complete
spinal immobilization Rapid transport to trauma center IV lines initiated enroute Mechanism of Injury
Falls Adults > 20 ft (one story is equal to 10 ft) Children < 15 yrs: > 10 ft or 2-3 X height of the child High-risk auto crash* Intrusion, including roof: > 12 occupant site; > 18 any site Ejection (partial or complete) from automobile Death in same passenger compartment
Vehicle telemetry data consistent with high risk of injury Auto-pedestrian / auto-bicyclist thrown, run over, or with significant (> 20 mph) impact Motorcycle crash >20 mph * Removed: rollover, deformation to vehicle Mechanism of Injury Criteria MOI may aid in predicting serious injury King AI, et al., J Trauma, 1995 Grande CM, et al., Crit Care Clin, 1990
Presswalla FB, Med Sci Law, 1978 MOI correlates least well with the presence of significant injury Relying on these alone increases overtriage rate Case
78 y/o restrained female front seat passenger in high speed motor vehicle crash. PMH of Afib, on warfarin Airway: intact Breathing: RR 24, slightly
decreased BS on left Circulation: HR 110, irreg; BP 148/90 Disability: GCS 15 Expose: multiple contusions Elderly female in MVC High-flow O2, pulse oximetry
Spinal immobilization Initiate transfer to a trauma center Initiate IV therapy enroute Special Circumstances Older adults: risk of injury death increases after age 55
SBP < 110 may represent shock after age 55 Low impact mechanisms (e.g., ground level falls) may result in severe injuries Children: should be triaged preferentially to pediatric-capable trauma center Anticoagulation and bleeding disorders Patients with head injury are at high risk for deterioration Special Circumstances
Burns Without other trauma: burn facility With other trauma: trauma center Pregnancy > 20 weeks EMS provider judgment Field Triage Mobile App http://www.cdc.gov/fieldtriage/mobile.html The Right Amount of Time
EMS in Perspective U.S. Medics returning from Viet Nam Firefighters trained in EMS Seattle, Miami, Denver, L.A. Emergency! (1972-77)
Prehospital ALS for Trauma Adaptation of ALS care for medical / cardiac patients to trauma care Management the patient
at scene focused on stabilizing Prehospital ALS for Trauma Scene stabilization of trauma patients by ALS crews were disastrous Improved outcome when victims of penetrating
cardiac trauma were transported by BLS scoop and run 5/6 vs 0/7 Gervin A, J Trauma, 1982 Prehospital ALS for Trauma Authorities questioned the role of prehospital advanced life support Is ALS necessary for pre-hospital trauma
care? Trunkey DD, J Trauma, 1984 Prehospital stabilization of critically injured patients: a failed concept Smith J, et al, J Trauma, 1985 The Ultimate Stabilization
EMS vs Private transport Los Angeles (USC+LAC) 4856 EMS patients vs. 926 non-EMS patients ISS > 15 Demetriades D, Arch Surg, 1996 Above all, do no further harm Mortality: 28.8% EMS
Transport 14.1% Private Transport Scene time More than 20 mins for both blunt and
penetrating trauma PreHospital Trauma Life Support Based on ATLS Golden Period
Platinum 10 minutes 10 For critically injured patients, initiate transport to the closest appropriate facility within 10 minutes of arrival on scene.
PHTLS Limited, key field interventions: Airway control Oxygenation and ventilation support Hemorrhage control Spinal Immobilization Rapid Transport to appropriate facility Initiate IVs enroute
NOT scoop and run IV Fluids No data has ever documented improved survival based upon prehospital IV fluid therapy One study suggests increased mortality rate in hypotensive trauma patients given prehospital fluid
Transportation Gasoline (or diesel or JetA) is the most important fluid in prehospital trauma care PHTLS works!
Ali J, J Trauma, 1998 Case 13 y/o male suffers single GSW. EMS called. On arrival: Airway: intact Breathing: decreased BS on right Circulation: HR 110, strong radial pulse Disability: GCS 15 Exposure: bullet wound 5th ICS left parasternal; bullet wound right 8th ICS posterior axillary line
13 y/o shot in chest EMS treatment High flow O2 Placed on gurney Transport initiated ( 1 minute scene time!)
2 IV lines placed en route ED evaluation BP 110/80 Pericardial US positive for fluid 13 y/o shot in chest OR findings: Blood in pericardium Wound to anterior right ventricle near right
coronary artery (repaired) Wound to lateral right atrium (repaired) Normal transesophageal echocardiogram Right lung repaired Bleeding diaphragmatic vessel ligated 13 y/o shot in chest
The Right Patient. . . To the Right Place. . . In the Right Amount of Time Thanks for your attention!
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