Prehospital advanced life support for major trauma: critical need for clinical trials

Advanced Life Support vs. Basic Life Support for Patients With Trauma in Prehospital Settings: A Systematic Review and Meta-Analysis

Background: Advanced Life Support (ALS) is regarded to be associated with improved survival in pre-hospital trauma care when compared to Basic Life Support (BLS) irrespective of lack of evidence. The aim of this study is to ascertain ALS improves survival for trauma in prehospital settings when compared to BLS.

Methods: We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for published controlled trials (CTs), and observational studies that were published until Aug 2017. The population of interest were adults (>18 years old) trauma patients who were transported by ground transportation and required resuscitation in prehospital settings. We compared outcomes between the ALS and BLS groups. The primary outcome was in-hospital mortality and secondary outcomes were neurological outcome and time spent on scene.

Results: We identified 2,502 studies from various databases and 10 studies were included in the analysis (two CTs, and eight observational studies). The outcomes were not statistically significant between the ALS and BLS groups (pooled OR 1.14; 95% CI 0.95 to 1.36 for mortality, pooled OR 1.12; 95% CI 0.88 to 1.42 for good neurological outcomes, pooled mean difference −0.96; 95% CI−6.64 to 4.72 for on-scene time) in CTs. In observational studies, ALS prolonged on-scene time and increased mortality (pooled OR 1.56; 95% CI: 1.31 to 1.86 for mortality, and pooled mean difference, 1.26; 95% CI: 0.07 to 2.45 for on-scene time).

Conclusions: In prehospital settings, the present study showed no advantages of ALS on the outcomes in patients with trauma compared to BLS.

Effects of advanced life support versus basic life support on the mortality rates of patients with trauma in prehospital settings: a study protocol for a systematic review and meta-analysis

INTRODUCTION

Advanced life support (ALS) is thought to be associated with improved survival in prehospital trauma care when compared with basic life support (BLS). However, evidence on the benefits of prehospital ALS for patients with trauma is controversial. Therefore, we aim to clarify if ALS improves mortality in patients with trauma when compared with BLS by conducting a systematic review and meta-analysis of the recent literature.

METHODS AND ANALYSIS

We will perform searches in PubMed, Embase and the Cochrane Central Register of Controlled Trials for published observational studies, controlled before-and-after studies, randomised controlled trials and other controlled trials conducted in humans and published until March 2017. We will screen search results, assess study selection, extract data and assess the risk of bias in duplicate; disagreements will be resolved through discussions. Data from clinically homogeneous studies will be pooled using a random-effects meta-analysis, heterogeneity of effects will be assessed using the χ2 test of homogeneity, and any observed heterogeneity will be quantified using the I2 statistic. Last, the Grading of Recommendations Assessment, Development and Evaluation approach will be used to rate the quality of the evidence.

ETHICS AND DISSEMINATION

Our study does not require ethical approval as it is based on findings of previously published articles. Results will be disseminated through publication in a peer-reviewed journal, presentations at relevant conferences and publications for patient information.

TRIAL REGISTRATION NUMBER

PROSPERO (International Prospective Register of Systematic Reviews) registration number CRD42017054389.

Methodological Challenges in Studies Comparing Prehospital Advanced Life Support with Basic Life Support

Determining the most appropriate level of care for patients in the prehospital setting during medical emergencies is essential. A large body of literature suggests that, compared with Basic Life Support (BLS) care, Advanced Life Support (ALS) care is not associated with increased patient survival or decreased mortality. The purpose of this special report is to synthesize the literature to identify common study design and analytic challenges in research studies that examine the effect of ALS, compared to BLS, on patient outcomes. The challenges discussed in this report include: (1) choice of outcome measure; (2) logistic regression modeling of common outcomes; (3) baseline differences between study groups (confounding); (4) inappropriate statistical adjustment; and (5) inclusion of patients who are no longer at risk for the outcome. These challenges may affect the results of studies, and thus, conclusions of studies regarding the effect of level of prehospital care on patient outcomes should require cautious interpretation. Specific alternatives for avoiding these challenges are presented. Li T , Jones CMC , Shah MN , Cushman JT , Jusko TA . Methodological challenges in studies comparing prehospital Advanced Life Support with Basic Life Support. Prehosp Disaster Med. 2017;32(4):444-450.

Airway management of patients with traumatic brain injury/C-spine injury

Traumatic brain injury (TBI) is usually combined with cervical spine (C-spine) injury. The possibility of C-spine injury is always considered when performing endotracheal intubation in these patients. Rapid sequence intubation is recommended with adequate sedative or analgesics and a muscle relaxant to prevent an increase in intracranial pressure during intubation in TBI patients. Normocapnia and mild hyperoxemia should be maintained to prevent secondary brain injury. The manual-in-line-stabilization (MILS) technique effectively lessens C-spine movement during intubation. However, the MILS technique can reduce mouth opening and lead to a poor laryngoscopic view. The newly introduced video laryngoscope can manage these problems. The AirWay Scope® (AWS) and AirTraq laryngoscope decreased the extension movement of C-spines at the occiput-C1 and C2-C4 levels, improving intubation conditions and shortening the time to complete tracheal intubation compared with a direct laryngoscope. The Glidescope® also decreased cervical movement in the C2-C5 levels during intubation and improved vocal cord visualization, but a longer duration was required to complete intubation compared with other devices. A lightwand also reduced cervical motion across all segments. A fiberoptic bronchoscope-guided nasal intubation is the best method to reduce cervical movement, but a skilled operator is required. In conclusion, a video laryngoscope assists airway management in TBI patients with C-spine injury.

Prehospital response model and time to CT scan in blunt trauma patients; an exploratory analysis of data from the head injury retrieval trial

Background

It has been suggested that prehospital care teams that can provide advanced prehospital interventions may decrease the transit time through the ED to CT scan and subsequent surgery. This study is an exploratory analysis of data from the Head Injury Retrieval Trial (HIRT) examining the relationship between prehospital team type and time intervals during the prehospital and ED phases of management.

Methods

Three prehospital care models were compared; road paramedics, and two physician staffed Helicopter Emergency Medical Services (HEMS) - HIRT HEMS and the Greater Sydney Area (GSA) HEMS. Data on prehospital and ED time intervals for patients who were randomised into the HIRT were extracted from the trial database. Additionally, data on interventions at the scene and in the ED, plus prehospital entrapment rate was also extracted. Subgroups of patients that were not trapped or who were intubated at the scene were also specifically examined.

Results

A total of 3125 incidents were randomised in the trial yielding 505 cases with significant injury that were treated by road paramedics, 302 patients treated by the HIRT HEMS and 45 patients treated by GSA HEMS. The total time from emergency call to CT scan was non-significantly faster in the HIRT HEMS group compared with road paramedics (medians of 1.9 hours vs. 2.1 hours P = 0.43) but the rate of prehospital intubation was 41% higher in the HIRT HEMS group (46.4% vs. 5.3% P < 0.001). Most time intervals for the GSA HEMS were significantly longer with a regression analysis indicating that GSA HEMS scene times were 13 (95% CI, 7–18) minutes longer than the HIRT HEMS independent of injury severity, entrapment or interventions performed on scene.

Conclusion

This study suggests that well-rehearsed and efficient interventions carried out on-scene, by a highly trained physician and paramedic team can allow earlier critical care treatment of severely injured patients without increasing the time elapsed between injury and hospital-based intervention. There is also indication that role specialisation improves time intervals in physician staffed HEMS which should be confirmed with purpose designed trials.

Analysis of remote trauma transfers in South Central Texas with comparison with current US combat operations: results of the RemTORN-I study

BACKGROUND

This study aimed to analyze demographic, epidemiologic, temporal, and outcome data from an integrated trauma registry of patients undergoing initial stabilization and transfer within a mature domestic trauma network; compare data with a companion subset from the Department of Defense Trauma Registry. Texas Trauma Service Area-P is composed of 25 counties, 15 rural Level IV trauma centers (no acute care surgery), and two Level I trauma centers.

METHODS

This study has a retrospective cohort design. We hypothesize that Injury Severity Scores (ISSs), time intervals, and other clinical indicators would be complimentary to contemporary combat casualties. Inclusion criteria include age 18 years to 80 years, transferred from Level IV to Level I trauma center, or expired en route.

RESULTS

A total of 543 subjects (84%) met the criteria and were analyzed. Averages and confidence intervals were as follows: age of 40 years (38-41 years), males at 81%, ISS of 10 (10-11), intensive care unit stay of 2 days (1-3 days), and hospital stay of 5 days (4-6 days). Mechanisms of injury were as follows: penetrating (15%), blunt weapon (19%), stabs (9%), burns (5%), and gunshots (5%). Eight percent received blood within the first 24 hours. Survival was at 98%. Time intervals (95% confidence interval) were as follows: prehospital at 1:43 (1:29-1:58), Level IV dwell time at 3:17 (3:06-3:28), interfacility transfer at 1:43 (1:36-1:49), and total at 6:39 (6:20-6:58). RemTORN cases were older, spent longer time en route to Level I, and had ISS similar to combat casualties. Rates of blood transfusion in the first 24 hours and survival were similar in order of magnitude.

CONCLUSION

The RemTORN platform is operational. Demographic, epidemiologic, and temporal characteristics as observed will support clinical investigations of traumatic coagulopathy, shock, and potential interventions before Level I arrival. Results of such investigations will likely be applicable to the contemporary and future battlefield.

Statement of severe trauma management in France; teachings of the FIRST study

INTRODUCTION

The blunt trauma victim management is still a matter of debate and comparing studies involving different emergency medical services and health care organization remains fictitious. Hence, the French Intensive care Recorded in Severe Trauma (FIRST) was conducted in order to describe the severe blunt trauma management in France. The present paper aimed at recalling the main results of FIRST study.

METHODS

The FIRST study was based on a multicenter prospective cohort of patients aged 18 or over with severe exclusive blunt trauma requiring admission to university hospital care unit within the first 72h and/or managed by medical-Staffed Emergency Mobile Unit (SMUR). Multiple data were collected about patient characteristics, clinical initial status, typology of trauma and the main endpoints were 30-day mortality.

RESULTS

Sixty-one percent of trauma patients were road traffic victims and 30% were domestic, sport or leisure trauma. Patients who benefited from medical pre-hospital management were globally more severely injured than those who received basic life support care by fire brigades. Therefore, they were delivered more aggressive treatment in the pre-hospital setting and the median time for their hospital admission was lengthened. However, their 30-day mortality was significantly reduced. The probability of death was also decreased when casualties were transported by SMUR helicopter directly to the university hospital. In the in-hospital setting, the performance of a whole-body computed tomography (CT) was associated with a significant reduction in the mortality risk compared with a selective CT.

CONCLUSION

The FIRST study suggests the benefit of a medical management in the pre-hospital setting on the survival of trauma patients. The emergency physician (EP) expertise in the pre-hospital and initial hospital phases would lead to the concept of the appropriate care for the appropriate trauma patient. It also highlights the necessity to set up organized regional sectors of care and registries.

Anglo-American vs. Franco-German Emergency Medical Services System

It has been stated that the Franco-German Emergency Medical Services System (FGS) has considerable drawbacks compared to the Anglo-American Emergency Medical Services System (AAS):

1. The key differences between the AAS and the FGS are that in the AAS, the patients is brought to the doctor, while in the FGS, the doctor is brought to the patient.

2. In the FGS, patients with urgent conditions usually are evaluated and treated by general practitioners in their offices or at the patient`s home; initially, very few approach an emergency department.

3. Emergency patients with life-threatening trauma or disease are treated by emergency physicians at the scene and during transport. Paramedics often are first to arrive at the scene, and until the emergency physician arrives at the scene, are allowed to defibrillate, to intubate endotracheal-ly, and to administer life-saving drugs (epinephrine endotracheally, glucose intravenously, etc.).

4. Prehospital emergency physicians treat patients at the scene and during transport.

5. Emergency patients are guaranteed to be reached by an appropriate emergency vehicle and a respective crew within 10 minutes in 80% of the responses and within 15 minutes in 95% of cases.

6. The FGS deploys qualified emergency physicians assisted by qualified paramedics as prehospital intensive care providers; extended immediate care is standard. Total Prehospital Times (TPT) and scene times only are minimally longer than in the AAS.

7. Emergency Medicine is recognized as a supra-specialty to the base specialties. Specific training programs exist for emergency physicians, medical directors of emergency medical services systems (EMSS), and chief emergency physicians (CEP).

8. Resuscitation attempts are carried out not only by anesthesiologists, but also by internists, surgeons, pediatricians, etc. Emergency medicine encompasses cardiopulmonary resuscitation (CPR) and shock cases, and patients with an acute myocardial infarction, stroke, poly-trauma, status asthmaticus, etc. Emergency patients are admitted directly to emergency departments of the hospitals, which, depending upon the size of the hospital.

9. The incidence of life-threatening trauma victims has decreased to <10% in the FGS. Of a total of 830,000 deaths/year, fatal trauma cases ranked the lowest at 4%.

10. Survival figures on cardiac arrest (asystole, ventricular fibrillation/ventricular tachycardia (VF/VT), pulseless electrical activity (PEA), etc.) reported in the German EMSS correspond to those in Europe and the United States.

11. Paramedic training is characterized by a two-year program followed by a theoretical and a practical examination.

12. Paramedics and emergency physicians-in-training are supervised at the scene and during transport. Quality assurance (Q/A) constitutes an integral and legally compulsory part of the EMSS.

13. In the majority of cases, the emergency patients are evaluated and treated by the respective specialties without delays caused by patient transfer to other hospitals.

14. The FGS does not require a greater number of ambulances and/or personnel than does the AAS.

15. The German healthcare system creates less expenses/ capita than the does the U.S. system at a similar level of quality of care.

16. Emergency procedures are carried out by anesthesiologists, emergency physicians, surgeons, internists, and other specialists.

Indicadores clínicos e pré-hospitalares de sobrevivência no trauma fechado: uma análise multivariada

O objetivo do estudo foi identificar os indicadores clínicos e pré-hospitalares associados à sobrevivência de vítimas de trauma fechado. Foram utilizadas a análise de sobrevivência de Kaplan Meier, e de Riscos Proporcionais de Cox, para analisar a associação de 33 variáveis ao óbito precoce e tardio, propondo modelos multivariados. Os modelos finais até 48h pós-trauma evidenciaram altos coeficientes de risco promovidos pelas lesões abdominais, Injury Severity Score >25, procedimentos respiratórios avançados e compressões torácicas pré-hospitalares. No modelo até 7 dias, a pressão arterial sistólica na cena do acidente, se menor de 75mmHg, foi associada a maior risco de óbito e se ausente, foi associada ao mais elevado risco de óbito após 7 dias. A reposição de volume pré-hospitalar apresentou efeito protetor em todos os períodos. Os resultados sugerem que a magnitude da hipoxemia e da instabilidade hemodinâmica diante da hemorragia, influenciaram de forma significante o óbito precoce e tardio desse grupo de vítimas.

[Prognostic factors in chest traumas: a prospective study of 500 patients]

OBJECTIVE

Identify the factors of greatest impact in patients with chest trauma.

PATIENTS AND METHODS

prospective study of 500 patients (425 men and 75 women) with chest trauma treated between January 2006 and December 2008. The parameters assessed include the degree of trauma, the abbreviated injury scale (AIS), the injury severity score (ISS), pre-hospital intubation, duration of mechanical ventilation, stay in the intensive care unit (ICU), number of rib fractures, presence of pulmonary contusion, haemothorax and cardio-pulmonary effects.

RESULTS

The presence of polytrauma, the number of rib fractures, the presence of flail chest, pulmonary contusion, the delay in mechanical ventilation and age were shown to be effective markers of severity.

CONCLUSIONS

Thoracic injuries have a number of indicators of severity. The mortality risk is associated with an ISS >25, the presence of 3 or more rib fractures with flail chest, pulmonary contusion, the development of ARDS, and with an age >55 years.

The Canadian prehospital evidence-based protocols project: knowledge translation in emergency medical services care

OBJECTIVES

The principles of evidence-based medicine are applicable to all areas and professionals in health care. The care provided by paramedics in the prehospital setting is no exception. The Prehospital Evidence-based Protocols Project Online (PEP) is a repository of appraised research evidence that is applicable to interventions performed in the prehospital setting and is openly available online. This article describes the history, current status, and potential future of the project.

METHODS

The primary objective of the PEP is to catalog and grade emergency medical services (EMS) studies with a level of evidence (LOE). Subsequently, each prehospital intervention is assigned a class of recommendation (COR) based on all the appraised articles on that intervention, in an effort to organize the evidence so it may be put into practice efficiently. An LOE is assigned to each article by the section editor, based on the study rigor and applicability to EMS. The section editor committee consists of EMS physicians and paramedics from across Canada, and two from Ireland and a paramedic coordinator. The evidence evaluation cycle is continuous; as the section editors send back appraisals, the coordinator updates the database and sends out another article for review.

RESULTS

The database currently has 182 individual interventions organized under 103 protocols, with 933 citations.

CONCLUSIONS

This project directly meets recent recommendations to improve EMS by using evidence to support interventions and incorporating it into protocols. Organizing and grading the evidence allows medical directors and paramedics to incorporate research findings into their daily practice. As such, this project demonstrates how knowledge translation can be conducted in EMS.

The Utstein template for uniform reporting of data following major trauma: a joint revision by SCANTEM, TARN, DGU-TR and RITG

BACKGROUND

In 1999, an Utstein Template for Uniform Reporting of Data following Major Trauma was published. Few papers have since been published based on that template, reflecting a lack of international consensus on its feasibility and use. The aim of the present revision was to further develop the Utstein Template, particularly with a major reduction in the number of core data variables and the addition of more precise definitions of data variables. In addition, we wanted to define a set of inclusion and exclusion criteria that will facilitate uniform comparison of trauma cases.

METHODS

Over a ten-month period, selected experts from major European trauma registries and organisations carried out an Utstein consensus process based on a modified nominal group technique.

RESULTS

The expert panel concluded that a New Injury Severity Score > 15 should be used as a single inclusion criterion, and five exclusion criteria were also selected. Thirty-five precisely defined core data variables were agreed upon, with further division into core data for Predictive models, System Characteristic Descriptors and for Process Mapping.

CONCLUSION

Through a structured consensus process, the Utstein Template for Uniform Reporting of Data following Major Trauma has been revised. This revision will enhance national and international comparisons of trauma systems, and will form the basis for improved prediction models in trauma care.

Predetermining value analysis of the prehospital phase procedures in trauma victims survival

The aim of this study was to analyze the determining value of the procedures carried out during prehospital care in the survival time of traffic accident victims. Data of 175 victims with Revised Trauma Score £ 11, cared for and transported by advanced life support to tertiary referral hospitals, were submitted to Kaplan-Meier Survival Analysis and to Cox proportional hazards model. Four procedure groups associated with survival were identified: basic circulatory; advanced respiratory; volume replaced and medication. Until hospital discharge, the victims who underwent orotracheal intubation and chest compressions showed 3.6 and 6.4 times higher death hazards, respectively. The need for definitive airway and cardiopulmonary resuscitation in the prehospital phase was predetermining with higher death hazard. The less than 1000ml intravenous fluid replacement was the only predetermining factor with protective power against death hazard.

The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity

BACKGROUND

To date, the benefit of prehospital advanced life-support programs on trauma-related mortality and morbidity has not been established

METHODS

The Ontario Prehospital Advanced Life Support (OPALS) Major Trauma Study was a before-after systemwide controlled clinical trial conducted in 17 cities. We enrolled adult patients who had experienced major trauma in a basic life-support phase and a subsequent advanced life-support phase (during which paramedics were able to perform endotracheal intubation and administer fluids and drugs intravenously). The primary outcome was survival to hospital discharge.

RESULTS

Among the 2867 patients enrolled in the basic life-support (n = 1373) and advanced life-support (n = 1494) phases, characteristics were similar, including mean age (44.8 v. 47.5 years), frequency of blunt injury (92.0% v. 91.4%), median injury severity score (24 v. 22) and percentage of patients with Glasgow Coma Scale score less than 9 (27.2% v. 22.1%). Survival did not differ overall (81.1% among patients in the advanced life-support phase v. 81.8% among those in the basic life-support phase; p = 0.65). Among patients with Glasgow Coma Scale score less than 9, survival was lower among those in the advanced life-support phase (50.9% v. 60.0%; p = 0.02). The adjusted odds of death for the advanced life-support v. basic life-support phases were nonsignificant (1.2, 95% confidence interval 0.9-1.7; p = 0.16).

INTERPRETATION

The OPALS Major Trauma Study showed that systemwide implementation of full advanced life-support programs did not decrease mortality or morbidity for major trauma patients. We also found that during the advanced life-support phase, mortality was greater among patients with Glasgow Coma Scale scores less than 9. We believe that emergency medical services should carefully re-evaluate the indications for and application of prehospital advanced life-support measures for patients who have experienced major trauma.

A Comprehensive Framework for Determining the Cost of an Emergency Medical Services System

To determine the cost of an emergency medical services (EMS) system, researchers, policymakers, and EMS providers need a framework with which to identify the components of the system that must be included in any cost calculations. Such a framework will allow for cost comparisons across studies, communities, and interventions. The objective of this article is to present an EMS cost framework. This framework was developed by a consensus panel after analysis of existing peer-reviewed and non-peer-reviewed resources, as well as independent expert input. The components of the framework include administrative overhead, bystander response, communications, equipment, human resources, information systems, medical oversight, physical plant, training, and vehicles. There is no hierarchical rank to these components; they are all necessary. Within each component, there are subcomponents that must be considered. This framework can be used to standardize the calculation of EMS system costs to a community. Standardizing the calculation of EMS cost will allow for comparisons of costs between studies, communities, and interventions.

Pre-hospital fluid therapy in the critically injured patient--a clinical update

Venous access and fluid therapy should still be considered to be essential elements of pre-hospital advanced life support (ALS) in the critically injured patient. Initiation of fluid therapy should be based on a clinical assessment, most importantly the presence, or otherwise, of a radial pulse. The goal in penetrating injury is to avoid hypovolaemic cardiac arrest during transport, but at the same time not to delay transport, or increase systolic blood pressure. The goal in blunt injury is to secure safe perfusion of the injured brain through an adequate cerebral perfusion pressure, which generally requires a systolic blood pressure well above 100 mmHg. Patients without severe brain injury tolerate lower blood pressures (hypotensive resuscitation). Importantly, using systolic blood pressure targets to titrate therapy is not as easy as it seems. Automated (oscillometric) blood pressure measurement devices frequently give erroneously high values. The concept of hypotensive resuscitation has not been validated in the few studies done in humans. Hence, the suggested targeted systolic blood pressures should only provide a mental framework for the decision-making. The ideal pre-hospital fluid regimen may be a combination of an initial hypertonic solution given as a 10-20 minutes infusion, followed by crystalloids and, in some cases, artificial colloids. This review is intended to help the clinician to balance the pros and cons of fluid therapy in the individual patient.

Development of trauma systems and effect on outcomes after injury

The ideal system for management of trauma remains controversial, especially in respect of prehospital care and regionalisation of trauma-care delivery. To explore these issues, we compare two differing trauma systems--in the USA the focus is on the trauma centre, with a lesser emphasis on prehospital care, whereas in France there is more emphasis on prehospital care coordinated by the Service d'Aide Médicale Urgente. We describe the historical developments, current structure, and major controversies with regard to trauma-care delivery in the two countries. Comparative evidence on the effectiveness of the two systems was obtained through a structured review of databases, but very little evidence permits direct comparison of outcomes across the two systems. Crude injury mortality rates and fatality rates from motor-vehicle accidents (crashes in US usage) are higher in France than in the USA, although adjustment for potential confounders is difficult. Adjusted mortality rates suggest equivalent outcomes among patients who survive to hospital, although these data are confounded by the lack of a contemporaneous comparator population. There are differences in the American and French trauma systems that might translate into measurable differences in trauma-related mortality. However, the lack of data to allow comparison of outcomes between countries significantly impedes the identification and implementation of components of a trauma system that are effective and the discarding of those that offer little benefit.

Rapid response car as a supplement to the helicopter in a physician-based HEMS system

BACKGROUND

The purpose of this study was to describe the use of a rapid response car (RRC) as a supplement to the ambulance helicopter in a mixed urban/rural region in Norway.

METHODS

Data from all the requested missions were collected from standard flight records. Operational factors, patient characteristics, primary diagnosis, treatment and modes of transport were registered and analyzed retrospectively.

RESULTS

In 1999-2001, a total of 4777 requests were included in the study, resulting in the initiation of 3172 helicopter and 752 RRC missions. In the RRC missions, 224 patients received advanced medical treatment that would otherwise not have been provided. For 181 patients, the availability of the RRC was crucial for receiving the treatment of the helicopter emergency medical services (HEMS). The cost of equipping the base with the RRC increased the annual budget by less than one percent.

CONCLUSION

The RRC was essential for solving missions in periods of non-flying conditions. The RRC increased the availability of the advanced prehospital life support offered by the HEMS in this region. Taking the modest increase in cost into consideration, it seems reasonable that this HEMS, covering mixed urban and rural areas, is equipped with such a vehicle.

Prehospital Endotracheal Intubation for Trauma Does Not Improve Survival over Bag-Valve-Mask Ventilation

BACKGROUND

Few data exist supporting a survival benefit to prehospital endotracheal intubation (ETI) over bag-valve-mask ventilation (BVM) in trauma patients.

METHODS

Data were reviewed from all trauma patients transported to our Level I trauma center receiving prehospital ETI or BVM. Mortality was adjusted by age, Revised Trauma Score, Injury Severity Score, and mechanism of injury (penetrating vs. blunt).

RESULTS

Of 5,773 patients, 316 (5.5%) had ETI and 217 (3.8%) had BVM. Patients receiving ETI were significantly more like to die (88.9% vs. 30.9%, p < 0.0001). When corrected for Injury Severity Score, Revised Trauma Score, and mechanism of injury, ETI was associated with similar or greater mortality than BVM. ETI patients had longer prehospital times (22.0 vs. 20.1 minutes, p = 0.0241).

CONCLUSION

In our trauma system, when corrected for mechanism and severity of anatomic and physiologic injury, ETI confers no survival advantage over BVM and slightly increases prehospital time.

"Don't just do something, stand there!": to teach or not to teach, that is the question--intravenous fluid resuscitation training for Combat Lifesavers

Good Level I scientific evidence supporting the efficacy (decreased morbidity and mortality) of prehospital fluid administration by civilian Emergency Medical Services personnel is lacking. The efficacy of this procedure in the hands of army Combat Lifesavers is even less well substantiated. The purpose of this article is to look critically at the skill of intravenous fluid administration that is taught to army Combat Lifesavers and to consider whether or not the application of that skill is actually beneficial to the majority of patients who are recipients of this procedure. A method is described to assist medical educators in making decisions as to which skills should be taught to health care providers, and this method is loosely applied in the following discussion about whether Combat Lifesavers should receive training to start and administer intravenous fluids. Good scientific studies, based on valid data, need to be performed to determine the efficacy of intravenous fluid administration and other combat medical skills.

Role of the physician in prehospital management of trauma: European perspective

Advanced prehospital trauma life support is challenged as a whole. Formerly well-accepted basic principles for stabilizing vital functions of the severely injured patient like volume resuscitation, airway protection, and immobilization have been questioned. In prehospital management of trauma, the role of not only the physician but also the paramedic must be redefined. In the absence of evidence about the effectiveness of advanced trauma life support training for paramedic crews, the needs of trauma victims and capacities of emergency medical systems must be re-evaluated. Assessment of patients' conditions, including mechanism of trauma (blunt vs penetrating), source of hypovolemic shock (controlled vs ongoing hemorrhage), concomitant disease (as in elderly patients), and identification of therapeutic goals (such as for cerebral perfusion pressure or secondary brain damage caused by hypoxia in severe head injury), is a subject of increasing importance. Invasive airway management techniques require skills, expertise, and daily routines available only to experienced in-hospital personnel. The controversial issue of paramedic vs physician-based systems should be abandoned. It is the skill, the technique, the awareness of pitfalls, and the capability to handle complications that makes the difference, not the person in possession of the skill.

[Advanced life support: care provided to motor vehicle crash victims]

OBJECTIVE

To analyze the performance of Advanced Life Support care mode (ALS) applied to car crash victims using indicators by means of the Revised Trauma Score (RTS) in prehospital phase.

METHODS

It were analyzed 643 reports of car crash victims cared by public ALS services that occurred in highways of the city of São Paulo, from April 1999 to April 2000. Time intervals assessed were: response time, on-scene time, transport time, and total time. Correct screening decision analysis considered RTS< or = 1 for tertiary hospitals. Changes in RTS and its parameters were observed using the following equation: RTSfinal - RTSinitial.

RESULTS AND CONCLUSIONS

Of 643 victims, 90.8% were RTS=12 and 5.2% were RTS < or = 0. The response time ranged from 8 to 9 minutes, while on-scene and transport time were higher in RTS < or = 0 cases. Of RTS < or = 0 victims, 45.5% were correctly transported to tertiary hospitals. Screening decision misjudgments were identified. Maintenance or improvement of RTS values occurred in 98.8% of the cases. Respiratory rate was the parameter that showed better improvement followed by systolic blood pressure.

Prehospital advanced life support provided by specially trained physicians: is there a benefit in terms of life years gained?

BACKGROUND

The benefit of prehospital advanced life support (ALS) is disputed, as is the prehospital use of specially trained, hospital-based physicians. The purpose of the study was to assess the health benefit from an anesthesiologist-manned prehospital emergency medical service (EMS), and to separate the benefit of the anesthesiologist from that of rapid transport.

METHODS

The anesthesiologist-manned helicopter and rapid response car service at Rogaland Central Hospital assisted 1106 patients at the scene during the 18-month study period. Two expert panels assessed patients with a potential health benefit for life years gained (LYG) using a modified Delphi technique. The probability of survival as a result of the studied EMS was multiplied by the life expectancy of each patient. The benefit was attributed either to the anesthesiologist, the rapid transport or a combination of both.

RESULTS

The expert panels estimated a benefit of 504 LYG in 74 patients (7% of the total study population), with a median age of 54 years (range 0-88). The cause of the emergency was cardiac diseases (including cardiac arrest) in 61% of the 74 patients, trauma in 19%, and cardio-respiratory failure as a result of other conditions in 20%. The LYG were equally divided between air and ground missions, and the majority (88%) were attributed solely to ALS by the anesthesiologist.

CONCLUSION

The expert panels found LYG in every 14th patient assisted by this anesthesiologist-manned prehospital EMS. There was no difference in LYG between the helicopter and the rapid response car missions. The role of the anesthesiologist was crucial for health benefits.

Can the "golden hour of shock" safely be extended in blunt polytrauma patients? Prospective cohort study at a level I hospital in eastern Switzerland

BACKGROUND

The objective was to test, in this trauma system, the North American hypothesis that exceeding the 60-minute limit for the entire prehospital time ("golden hour of shock") increases mortality of blunt polytrauma patients.

METHODS

In a prospective, observational, cohort study conducted between 1990 and 1996, a severity characterization of trauma (ASCOT) score was used to compare the actual mortality with the predicted mortality in 107 blunt polytrauma patients (Group 1) with prehospital rescue periods < or = 60 minutes (time from accident until arrival at the emergency department). The same comparison was performed for 147 blunt polytrauma patients (Group 2) with rescue periods > 60 minutes. Inclusion criteria were blunt trauma of at least two body sites, an Injury Severity Score (ISS) of > or = 8, and direct admission to the trauma centre. Multivariate regression analysis was performed to test for bias and confounding, and to identify factors that might influence mortality. Odd ratio (OR) and 95% confidence interval (CI) were calculated.

RESULTS

The mortality in Group 1 was 14%, and was not statistically significantly higher than the 10.2% observed for Group 2. 4.8 patients, or 47% more than predicted, died in Group 1 (p = 0.057). The corresponding figures in Group 2 were 4.2 patients or 22% fewer than predicted (p = 0.19). Multivariate logistic regression confirmed this trend with a significant mortality odds ratio of 8 (95% CI 1.7 to 38.5) for Group 1 compared to Group 2. Significantly more patients in Group 2 were treated by emergency physicians.

CONCLUSIONS

It appears in this trauma system, in which emergency physicians often are deployed, that the 'golden hour of shock' can be extended safely in many blunt polytrauma patients, since this was associated with better survival figures than in those patients for whom the time was < 1 hour.

Does prehospital fluid administration impact core body temperature and coagulation functions in combat casualties?

BACKGROUND

Administration of large amounts of fluids to trauma patients, in the absence of surgical control, may increase bleeding, cause hypothermia and coagulopathy which may worsen the bleeding and increase morbidity and mortality. The purpose of our study is to examine the impact of prehospital fluid administration to military combat casualties on core body temperature and coagulation functions.

METHODS

Prospective data were collected on all cases of moderately (9 < or = ISS < or = 14) and severely (ISS > or = 16) injured victims wounded in South Lebanon, treated by Israeli military physicians and evacuated to hospitals in Israel, over a two-year period. Data regarding prehospital phase of injury (timetables, amount of fluids) and upon hospital arrival (initial core body temperature, prothrombin time [PT], partial thromboplastin time [PTT]) were examined for monotonic relation using Spearman's non-parametric test.

RESULTS

Fifty-three moderately injured and 31 severely injured patients were included in the study. The average evacuation time for the moderately injured group was 109.3 +/- 44.8 min, and for the severely injured 100.3 +/- 38.4 min (P value=NS). The mean volume of fluids administered was 2.39 +/- 1.52 and 2.49 +/- 1.47 l, respectively (P=NS). No statistical correlation was found between core body temperature, PT or PTT, measured upon hospital arrival, and prehospital fluid treatment. In addition, no correlation was found between core body temperature on hospital arrival and prehospital time, or between prehospital fluid volumes and prehospital time. The mean core body temperature of the moderately injured patients was 36.8 degrees C, and that of severely injured was 35.8 degrees C (P=0.026).

CONCLUSIONS

With proper control of blood loss and avoidance of excessive fluid administration, moderately and severely injured combat casualties in 'low intensity conflict' in South Lebanon can be resuscitated with fluid volumes that do not result in a coagulation deficit or hypothermia. The core body temperature on arrival at the hospital is related to the severity of the injury.

The death of a Princess and the formulation of medical competence

This study outlines a genealogy of the French and United States' Emergency Medical Service (EMS) systems. This is done to contextualise claims that Princess Diana could have survived had her crash taken place in the USA, and to enrich the EMS debate regarding field-treatment vs. rapid hospital admission for trauma victims. A historical analysis is offered for the disproportionate amount of available data on penetrating trauma, and proportionate deficit of data on blunt trauma with respect to total North American and Western European trauma epidemiology. The impact of US biomedical knowledge and culture on French medical practice is evaluated and used to understand how foreign knowledge is negotiated in local medical practice. The paper concludes by showing how, in response to a challenge by American biomedical standards of practice and formulation of competence, French pre-hospital Emergency Physicians have contextualised the origins of these standards as well as their local relevance in order to preserve an integrated notion of competence.

Epidemiology of severe brain injuries: a prospective population-based study

BACKGROUND

The aim of this prospective study was to estimate annual incidences of hospitalization for severe traumatic brain injury (TBI) (maximum Abbreviated Injury Score in the head region [HAIS] 4 or 5) in a defined population of 2.8 million.

METHODS

Severe TBI patients were included in the emergency departments in the 19 hospitals of the region. A prospective data form was completed with initial neurologic state, computed tomographic scan lesions, associated injuries, length of unconsciousness, and length of stay in acute care centers. Outcome at the time the patient left acute hospitalization was retrospectively assessed from medical notes.

RESULTS

During the 1-year period (1996), 497 residents fulfilled the inclusion criteria, leading to an annual incidence rate of 17.3 per 100,000 population; 58.1% were HAIS5. Mortality rate was 5.2 per 100,000. Men accounted for 71.4% of cases. Median age was 44 years, with a quarter of patients more than 70 years old. Traffic accidents were the most frequent causes (48.3%), but falls accounted for 41.8% of all patients. Age and severity were different according to the major categories of external causes. In HAIS5 patients, 86.5% were considered as comatose (coma lasting more than 24 hours or leading to immediate death) but only 60.9% had an initial Glasgow Coma Scale score < 9. In the HAIS4 group, 7.2% had an initial Glasgow Coma Scale score < 9. Fatality rates were 30.0% in the whole study group, 7.7% in HAIS4, 12.8% in HAIS5 without coma, and 51.2% in HAIS5 with coma.

CONCLUSION

This study shows a decrease in severe TBI incidence when results are compared with another study conducted 10 years earlier in the same region. This is because of a decrease in traffic accidents. However, this results in an increase in the proportion of falls in elderly patients and an increase in the median age in our patients. This increased age influences the mortality rate.

Emergency Medical Services Outcomes Project (EMSOP) II: developing the foundation and conceptual models for out-of-hospital outcomes research

Development of methodologically acceptable outcomes models for emergency medical services (EMS) is long overdue. In this article, the Emergency Medical Services Outcomes Project proposes a conceptual framework that will provide a foundation for future EMS outcomes research. The "Episode of Care Model" and the "Out-of-Hospital Unit of Service Model" are presented. The Episode of Care Model is useful in conditions in which interventions and outcomes, especially survival and major physiologic dysfunction, are linked in a time-dependent manner. Conditions such as severe trauma, anaphylaxis, airway obstruction, respiratory arrest, and nontraumatic cardiac arrest are amenable to this methodology. The Out-of-Hospital Unit of Service Model is essentially a subunit of the Episode of Care Model. It is valuable for evaluating conditions that have minimal-to-moderate therapeutic time dependency. This model should be used when studying outcomes limited to the out-of-hospital interval. An example of this is pain management for injuries sustained in motor vehicle crashes. These models can be applied to a wide spectrum of conditions and interventions. With the scrutiny of health care expenditures ever increasing, the identification of clinical interventions that objectively improve patient outcome takes on growing importance. Therefore, the development, dissemination, and use of meaningful methodologies for EMS outcomes research is key to the future of EMS system development and maintenance.

New equipment and techniques for airway management in trauma

A patent, unobstructed airway is fundamental in the care of the trauma patient, and is most often obtained by placing a cuffed tube in the trachea. The presence of shock, respiratory distress, a full stomach, maxillofacial trauma, neck hematoma, laryngeal disruption, cervical spine instability, and head injury all combine to increase tracheal intubation difficulty in the trauma patient. Complications resulting from intubation difficulties include brain injury, aspiration, trauma to the airway, and death. The use of devices such as the gum-elastic bougie, McCoy laryngoscope, flexible and rigid fiberscopes, intubating laryngeal mask, light wand, and techniques such as rapid-sequence intubation, manual in-line axial stabilization, retrograde intubation, and cricothyroidotomy, enhance the ability to obtain a definitive airway safely. The management of the failed airway includes calling for assistance, optimal two-person bag-mask ventilation, and the use of the laryngeal mask airway, Combitube, or surgical airway. The simulation of airway management using realistic simulator tools (e.g. full-scale simulators, virtual reality airway simulators) is a promising modality for teaching physicians and advanced life support personnel emergency airway management skills.

Advanced or basic life support for trauma: meta-analysis and critical review of the literature

BACKGROUND

The question of whether to use advanced life support (ALS) or basic life support (BLS) for trauma patients in the prehospital setting has been much debated and still lacks a clear answer. The purpose of this study was to conduct a comprehensive critical review of the literature regarding this controversy

METHODS

A total of 174 articles on prehospital ALS or BLS for trauma were reviewed. Fifteen of these studies were found to involve mortality statistics for both ALS- and BLS-treated patients. Odds ratios were calculated for survival in ALS versus BLS and summarized across studies on the basis of multivariate scoring systems that incorporated both design and methodological assessment. Overall odds ratios for all studies were calculated on the basis of both raw data from the papers, and weighted odds ratios were calculated from the scoring systems.

RESULTS

Six studies were scored as being methodologically average (5 favoring BLS and 1 favoring ALS), two were scored as good (1 favoring BLS and 1 favoring ALS), seven as excellent (6 favoring BLS and 1 favoring ALS). Ten studies had an average study design score (6 favoring BLS and 4 favoring ALS) and seven had a good study design score (6 favoring BLS and 1 favoring ALS). Weighted odds ratio for dying was 2.59 for patients receiving ALS compared with those receiving BLS. The crude odds ratio was 2.92.

CONCLUSION

The aggregated data in the literature have failed to demonstrate a benefit for on-site ALS provided to trauma patients and support the scoop and run approach.

Prehospital trauma care

Concepts regarding uniform reporting of data after trauma and regarding treatment of brain trauma patients at the scene have recently been agreed upon in consensus processes. Endotracheal intubation and alternatives are as controversially discussed as fluid resuscitation and helicopter transport of trauma victims. Long-term outcomes of trauma patients should more frequently be studied using the Quality of Wellbeing Scale.

Effectiveness of state trauma systems in reducing injury-related mortality: a national evaluation

BACKGROUND

Regional trauma systems were proposed 2 decades ago to reduce injury mortality rates. Because of the difficulties in evaluating their effectiveness and the methodologic limitations of previously published studies, the relative benefits of establishing an organized system of trauma care remains controversial.

METHODS

Data on trauma systems were obtained from a survey of state emergency medical service directors, review of state statutes and a previously published trauma system inventory. Injury mortality rates were obtained from national vital statistics data, whereas motor vehicle crash (MVC) mortality rates were obtained from the Fatality Analysis Reporting System. Mortality rates were compared between states with and without trauma systems.

RESULTS

As of 1995, 22 states had regional trauma systems. States with trauma systems had a 9% lower crude injury mortality rate than those without. When MVC-related mortality was evaluated separately, there was a 17% reduction in deaths. After controlling for age, state speed laws, restraint laws, and population distribution, there remained a 9% reduction in MVC-related mortality rate in states with a trauma system.

CONCLUSION

These data demonstrate that a state trauma system is associated with a reduction in the risk of death caused by injury. The effect is most evident on analysis of MVC deaths.

The Ontario Prehospital Advanced Life Support (OPALS) study Part II: Rationale and methodology for trauma and respiratory distress patients. OPALS Study Group

The Ontario Prehospital Advanced Life Support (OPALS) Study represents the largest prehospital study yet conducted, worldwide. This study will involve more than 25,000 cardiac arrest, trauma, and critically ill patients over an 8-year period (1994-2002). The current article, Part II, describes in detail the rationale and methodology for major trauma and respiratory distress patients and for an economic evaluation of Advanced Life Support (ALS) programs in the OPALS Study. The OPALS Study, using a rigorous controlled methodology and a large sample size, should clearly indicate the benefit in trauma and respiratory distress patient survival and morbidity that results from the widespread introduction of prehospital ALS programs to communities of many different sizes. [Stiell IG, Wells GA, Spaite DW, Nichol G, O'Brien B, Munkley DP, Field BJ, Lyver MB, Luinstra LG, Dagnone E, Campeau T, Ward R, Anderson S, for the OPALS Study Group: The Ontario Prehospital Advanced Life Support (OPALS) Study Part II: Rationale and methodology for trauma and respiratory distress patients.