Trauma patient outcome after the Prehospital Trauma Life Support program

Strengthening trauma and critical care globally

PURPOSE OF REVIEW

Trauma is an increasingly significant health problem globally, especially in low-income and middle-income countries. Trauma care is often compromised by economic restrictions. Many capable individuals are attempting to meet this challenge in their own countries, however. This review summarizes such efforts and assesses how they might be expanded in a comprehensive, global fashion.

RECENT FINDINGS

Options for improving trauma care in the prehospital setting have been explored, including strengthening existing, basic formal emergency medical services (including ambulances); instituting new formal emergency medical services, where none had previously existed; and exploring novel ways to strengthen existing, although informal, systems of prehospital care when formal emergency medical services would be unfeasible. Affordable ways by which to strengthen hospital care have been addressed for several specific injuries, including open fractures, burns, and vascular injuries. Especially notable are growing efforts to better monitor outcomes and address factors contributing to preventable deaths. The Essential Trauma Care Project has defined and promoted core essential trauma care services that every injured person in the world realistically can and should be able to receive. This project is a collaborative effort of the World Health Organization and the International Society of Surgery.

SUMMARY

Individual efforts must be built upon to make progress in a comprehensive, global fashion. This review summarizes the background, achievements, and future potential of the Essential Trauma Care Project and several related efforts.

Opinions of Trauma Practitioners Regarding Prehospital Interventions for Critically Injured Patients

BACKGROUND

Significant controversy surrounds the prehospital management of trauma patients.

METHODS

A questionnaire describing clinical scenarios was mailed to a random sample of 345 trauma practitioners.

RESULTS

The 182 trauma practitioners (52.8%) who returned the surveys were predominantly general or trauma surgeons (83.5%) in academic or university practice (68.1%). For a patient with a severe traumatic brain injury, 84.5% of trauma practitioners recommended that emergency medical services personnel attempt intubation at least once when transport time was 20 to 40 minutes. For a patient with a gunshot wound to the epigastrium in decompensated shock, the majority of trauma practitioners believed that a relatively hypotensive state should be maintained, regardless of transport time. Trauma practitioners (52.2%) have recommended the use of the pneumatic antishock garment for transports of 20 to 40 minutes for patients with an unstable pelvic fracture and decompensated shock.

CONCLUSIONS

Most trauma practitioners believe that emergency medical services providers should attempt intubation for a patient with a severe traumatic brain injury, should treat decompensated shock in a patient with penetrating torso trauma but maintain the patient in a relatively hypotensive state, and should apply and inflate the pneumatic antishock garment for a suspected pelvic fracture accompanied by decompensated shock if the patient is 20 to 40 minutes from a trauma center. The recommendations of trauma practitioners regarding appropriate prehospital care are significantly influenced by the time required for transport to the trauma center.

Cost-effectiveness and benefit of alternatives to improve training for prehospital trauma care in Mexico

INTRODUCTION

In Latin America, there is a preponderance of prehospital trauma deaths. However, scarce resources mandate that any improvements in prehospital medical care must be cost-effective. This study sought to evaluate the cost-effectiveness of several approaches to improving training for personnel in three ambulance services in Mexico.

METHODS

In Monterrey, training was augmented with PreHospital Trauma Life Support (PHTLS) at a cost of [US] dollar 150 per medic trained. In San Pedro, training was augmented with Basic Trauma Life Support (BTLS), Advanced Cardiac Life Support (ACLS), and a locally designed airway management course, at a cost of dollar 400 per medic. Process and outcome of trauma care were assessed before and after the training of these medics and at a control site.

RESULTS

The training was effective for both intervention services, with increases in basic airway maneuvers for patients in respiratory distress in Monterrey (16% before versus 39% after) and San Pedro (14% versus 64%). The role of endotrachal intubation for patients with respiratory distress increased only in San Pedro (5% versus 46%), in which the most intensive Advanced Life Support (ALS) training had been provided. However, mortality decreased only in Monterrey, where it had been the highest (8.2% before versus 4.7% after) and where the simplest and lowest cost interventions were implemented. There was no change in process or outcome in the control site.

CONCLUSIONS

This study highlights the importance of assuring uniform, basic training for all prehospital providers. This is a more cost-effective approach than is higher-cost ALS training for improving prehospital trauma care in environments such as Latin America.

Strengthening the prevention and care of injuries worldwide

The global burden of injuries is enormous, but has often been overlooked in attempts to improve health. We review measures that would strengthen existing efforts to prevent and treat injuries worldwide. Scientifically-based efforts to understand risk factors for the occurrence of injury are needed and they must be translated into prevention programmes that are well designed and assessed. Areas for potential intervention include environmental modification, improved engineering features of motor vehicle and other products, and promotion of safe behaviours through social marketing, legislation, and law enforcement. Treatment efforts need to better define the most high-yield services and to promote these in the form of essential health services. To achieve these changes, there is a need to strengthen the capacity of national institutions to do research on injury control; to design and implement countermeasures that address injury risk factors and deficiencies in injury treatment; and to assess the effectiveness of such countermeasures. Although much work remains to be done in high-income countries, even greater attention is needed in less-developed countries, where injury rates are higher, few injury control activities have been undertaken, and where most of the world's population lives. In almost all areas, injury rates are especially high in the most vulnerable sections of the community, including those of low socioeconomic status. Injury control activities should, therefore, be undertaken in a context of attention to human rights and other broad social issues.

Initial management of the poly-trauma patient: a practical approach in an Australian major trauma service

The initial management of the poly-trauma patient is of vital importance to minimizing both patient morbidity and mortality. We present a practical approach to the early management of a severely injured patient as practiced at Liverpool Hospital in Sydney, Australia. Specific attention is paid to innovations in care and specific controversies in early management as well as local solutions to challenging problems.

Improvements in prehospital trauma care in an African country with no formal emergency medical services

BACKGROUND

A large proportion of trauma patients in developing countries do not have access to formal Emergency Medical Services. We sought to assess the efficacy of a program that builds on the existing, although informal, system of prehospital transport in Ghana. In that country, the majority of injured persons are transported to the hospital by some type of commercial vehicle, such as a taxi or bus.

METHODS

A total of 335 commercial drivers were trained using a 6-hour basic first aid course. The efficacy of this course was assessed by comparing the process of prehospital trauma care provided before versus after the course, as determined by self-report from the drivers.

RESULTS

Follow-up interviews were conducted on 71 of the drivers a mean of 10.6 months after the course. Sixty-one percent indicated that they had provided first aid since taking the course. There was considerable improvement in the provision of the components of first aid in comparison to what was reported before the course: crash scene management (7% before vs. 35% after), airway management (2% vs. 35%), external bleeding control (4% vs. 42%), and splinting of injured extremities (1 vs. 16%).

CONCLUSION

Even in the absence of formal Emergency Medical Services, improvements in the process of prehospital trauma care are possible by building on existing, although informal, patterns of prehospital transport.

Trauma education

OBJECTIVE

Trauma is a diverse disease in which time critical decisions and skills affect patient outcome. This review article examines the methods and assessment of education for the management of the trauma patient.

METHOD

Literature review.

RESULTS

Education is a planned experience that leads to a change in behaviour. Adult education methods can be used to improve the knowledge, skills, attitudes and relationships of health care workers. Adult learners need careful consideration of lecture style, small group work, role play and skills stations in order to achieve these aims. These techniques are typically used in short intensive courses such as Advanced Trauma Life Support (ATLS) aimed at the initial care of the trauma patient. There is a relative lack of education directed at definitive care. It is important to assess the impact of trauma education in terms of clinical process, retention of skills/knowledge and the outcome of patients. A generic approach (the ABC approach) is applicable to the care of all critically ill or injured patients. This approach should be taught at junior level.

CONCLUSION

The care of trauma patients can be improved by educating health care workers using adult educational strategies.

Low-cost improvements in prehospital trauma care in a Latin American city

OBJECTIVE

Prehospital care is a critical component of efforts to lower trauma mortality. In less-developed countries, scarce resources dictate that any improvements in prehospital care must be low in cost. In one Latin American city, recent efforts to improve prehospital care have included an increase in the number of sites of ambulance dispatch from two to four and introduction of the Prehospital Trauma Life Support (PHTLS) course.

METHODS

The effect of increased dispatch sites was evaluated by comparing response times before and after completion of the change. The effect of PHTLS was evaluated by comparing prehospital treatment for the 3 months before initiation of the course (n = 361 trauma patients) and the 6 months after (n = 505).

RESULTS

Response time decreased from a mean of 15.5 +/- 5.1 minutes, when there were two sites of dispatch, to 9.5 +/- 2.7 minutes, when there were four sites. Prehospital trauma care improved after initiation of the PHTLS course. For all trauma patients, use of cervical immobilization increased from 39 to 67%. For patients in respiratory distress, there were increases in the use of oropharyngeal airways (16-39%), in the use of suction (10-38%), and in the administration of oxygen (64-87%). For hypotensive patients, there was an increase in use of large-bore intravenous lines from 26 to 58%. The improved prehospital treatment did not increase the mean scene time (5.7 +/- 4.4 minutes before vs. 5.9 +/- 6.8 minutes after). The percent of patients transported who died in route decreased from 8.2% before the course to 4.7% after. These improvements required a minimal increase (16%) in the ambulance service budget.

CONCLUSION

Increase in sites of dispatch and increased training in the form of the PHTLS course improved the process of pre-hospital care in this Latin American city and resulted in a decrease in prehospital deaths. These improvements were low cost and should be considered for use in other less developed countries.