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Taghavi S, Vora HP, Jayarajan SN, Gaughan JP, Pathak AS, Santora TA, Goldberg AJ. Prehospital Intubation Does Not Decrease Complications in the Penetrating Trauma Patient. Am Surg 2020. [DOI: 10.1177/000313481408000107] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intubation in the prehospital setting does not result in a survival benefit in penetrating trauma. However, the effect of prehospital intubation (PHI) on the development of in-hospital complications has yet to be determined. The goal of this study was to determine if PHI in patients with penetrating trauma results in reduced mortality and in-hospital complications. Patient records for all Category 1 trauma activations as a result of penetrating injury admitted to our institution from 2006 to 2010 were reviewed. There were 1615 Category 1 trauma activations with 152 (9.8%) intubated in the field. A total of 1311 survived initial resuscitative efforts to permit hospital admission with 55 (4.2%) being intubated in the field. For patients surviving to admission, pre-hospital intubation was associated with increased mortality (hazard ratio, 8.266; 95% confidence interval [CI, 4.336 to 15.758; P < 0.001). After correcting for Injury Severity Score, PHI was not protective against pulmonary complications (odds ratio [OR], 0.724; 95% CI, 0.229 to 2.289; P = 0.582), deep vein thrombosis/pulmonary embolus (OR, 0.838; 95% CI, 0.281 to 2.494; P = 0.750), sepsis (OR, 0.572; 95% CI, 0.201 to 1.633; P = 0.297), wound infections (OR, 1.739; 95% CI, 0.630 to 4.782; P = 0.286), or complications of any kind (OR, 1.020; 95% CI, 0.480 to 2.166; P = 0.959). For victims of penetrating trauma, immediate transportation by emergency medical personnel may result in improved outcomes.
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Affiliation(s)
- Sharven Taghavi
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
| | - Halley P. Vora
- Temple University School of Medicine, Philadelphia, Pennsylvania
| | | | - John P. Gaughan
- Biostatistics Consulting Center, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Abhijit S. Pathak
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
| | - Thomas A. Santora
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
| | - Amy J. Goldberg
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
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Efficacy of venous access placement at a pre-hospital scene in severe paediatric trauma patients: a retrospective cohort study. Sci Rep 2020; 10:6433. [PMID: 32286495 PMCID: PMC7156689 DOI: 10.1038/s41598-020-63564-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/23/2020] [Indexed: 11/08/2022] Open
Abstract
Purpose: Aside from severe traumatic brain injury, uncontrolled bleeding and corresponding haemorrhage shock are the leading causes of traumatic deaths. No established recommendations exist about venous access placement for severely injured, bleeding children at a pre-hospital scene. This study sought to evaluate the association between pre-hospital venous access placement and mortality in a paediatric trauma population by analysing the Japan Trauma Data Bank (JTDB). Methods: This epidemiologic study compared the outcomes of severe traumatic paediatric patients with or without venous access placement at a pre-hospital scene. Data were obtained from JTDB from 2004 to 2015. Results: Of 4,109 patients who met our inclusion criteria, 144 patients received venous access placement and 3,965 patients did not. The probability of survival was lower in the venous access group than in the no access group (0.90 [0.67–0.97] vs. 0.97 [0.90–0.99], p < 0.01). After multivariable logistic analysis, venous access placement did not improve survival to hospital discharge (odds ratio = 1.40, confidence interval = 0.32–6.15, p = 0.653). Conclusions: The probability of survival was lower in the venous access group than in the no access group. Survival outcome at discharge was not affected by venous access placement at a pre-hospital scene.
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Naumann DN, Hancox JM, Raitt J, Smith IM, Crombie N, Doughty H, Perkins GD, Midwinter MJ. What fluids are given during air ambulance treatment of patients with trauma in the UK, and what might this mean for the future? Results from the RESCUER observational cohort study. BMJ Open 2018; 8:e019627. [PMID: 29362272 PMCID: PMC5786144 DOI: 10.1136/bmjopen-2017-019627] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES We investigated how often intravenous fluids have been delivered during physician-led prehospital treatment of patients with hypotensive trauma in the UK and which fluids were given. These data were used to estimate the potential national requirement for prehospital blood products (PHBP) if evidence from ongoing trials were to report clinical superiority. SETTING The Regional Exploration of Standard Care during Evacuation Resuscitation (RESCUER) retrospective observational study was a collaboration between 11 UK air ambulance services. Each was invited to provide up to 5 years of data and total number of taskings during the same period. PARTICIPANTS Patients with hypotensive trauma (systolic blood pressure <90 mm Hg or absent radial pulse) attended by a doctor. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the number of patients with hypotensive trauma given prehospital fluids. Secondary outcomes were types and volumes of fluids. These data were combined with published data to estimate potential national eligibility for PHBP. RESULTS Of 29 037 taskings, 729 (2.5%) were for patients with hypotensive trauma attended by a physician. Half were aged 21-50 years; 73.4% were male. A total of 537 out of 729 (73.7%) were given fluids. Five hundred and ten patients were given a single type of fluid; 27 received >1 type. The most common fluid was 0.9% saline, given to 486/537 (90.5%) of patients who received fluids, at a median volume of 750 (IQR 300-1500) mL. Three per cent of patients received PHBP. Estimated projections for patients eligible for PHBP at these 11 services and in the whole UK were 313 and 794 patients per year, respectively. CONCLUSIONS One in 40 air ambulance taskings were manned by physicians to retrievepatients with hypotensive trauma. The most common fluid delivered was 0.9% saline. If evidence justifies universal provision of PHBP, approximately 800 patients/year would be eligible in the UK, based on our data combined with others published. Prospective investigations are required to confirm or adjust these estimations.
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Affiliation(s)
- David N Naumann
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James M Hancox
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- West Midlands Ambulance Service NHS Foundation Trust, Brierley Hill, UK
- Midlands Air Ambulance Charity, Stourbridge, West Midlands, UK
| | - James Raitt
- Thames Valley Air Ambulance, RAF Benson, Oxfordshire, UK
| | - Iain M Smith
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
| | - Nicholas Crombie
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | - Mark J Midwinter
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- School of Biomedical Sciences, Faculty of Medicine, University of Queensland, Brisbane, Australia
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Dick WF, Baskett PJF, Grande C, Delooz H, Kloeck W, Lackner C, Lipp M, Mauritz W, Nerlich M, Nicholl J, Nolan J, Oakley P, Parr M, Seekamp A, Soreide E, Steen PA, van Camp L, Wolcke B, Yates D. Recommendations for uniform reporting of data following major trauma - the Utstein style. TRAUMA-ENGLAND 2016. [DOI: 10.1177/146040860000200105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Domingues CDA, Nogueira LDS, Settervall CHC, Sousa RMCD. Desempenho dos ajustes do Trauma and Injury Severity Score (TRISS): revisão integrativa. Rev Esc Enferm USP 2015; 49 Spec No:138-46. [DOI: 10.1590/s0080-623420150000700020] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 08/20/2015] [Indexed: 11/21/2022] Open
Abstract
RESUMO Objetivo identificar estudos que realizaram ajustes na equação do Trauma and InjurySeverity Score (TRISS) e compararam a capacidade discriminatória da equação modificada com a original. Método Revisão integrativa de pesquisas publicadas entre 1990 e 2014 nas bases de dados LILACS, MEDLINE, PubMed e SciELO utilizando-se a palavra TRISS. Resultados foram incluídos 32 estudos na revisão. Dos 67 ajustes de equações do TRISS identificados, 35 (52,2%) resultaram em melhora na acurácia do índice para predizer a probabilidade de sobrevida de vítimas de trauma. Ajustes dos coeficientes do TRISS à população de estudo foram frequentes, mas nem sempre melhoraram a capacidade preditiva dos modelos analisados. A substituição de variáveis fisiológicas do Revised Trauma Score (RTS) e modificações do Injury Severity Score (ISS) na equação original tiveram desempenho variado. A mudança na forma de inclusão da idade na equação, assim como a inserção do gênero, comorbidades e mecanismo do trauma apresentaram tendência de melhora do desempenho do TRISS. Conclusão Diferentes propostas de ajustes no TRISS foram identificadas nesta revisão e indicaram, principalmente, fragilidades do RTS no modelo original e necessidade de alteração da forma de inclusão da idade na equação para melhora da capacidade preditiva do índice.
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Johnson NJ, Carr BG, Salhi R, Holena DN, Wolff C, Band RA. Characteristics and outcomes of injured patients presenting by private vehicle in a state trauma system. Am J Emerg Med 2013; 31:275-81. [PMID: 23000329 DOI: 10.1016/j.ajem.2012.07.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 07/18/2012] [Accepted: 07/27/2012] [Indexed: 11/26/2022] Open
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Still making the case against prehospital intubation: a rat hemorrhagic shock model. J Trauma Acute Care Surg 2012; 73:332-7; discussion 337. [PMID: 22846936 DOI: 10.1097/ta.0b013e3182584447] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prehospital intubation does not appear to result in a survival advantage for patients experiencing penetrating trauma; yet, there is still resistance to the practice of "scoop and run" to speed access to advanced care. An animal model was used to determine whether intubation provides a survival advantage during potentially lethal hemorrhage. METHODS The carotid arteries of Sprague-Dawley rats were cannulated, and mean arterial pressure (MAP) was measured. One group of animals (n = 10) was intubated and placed on a ventilator, whereas the other (n = 9) was administered with 100% oxygen via nose cone. Rats were exsanguinated to a MAP of 40 mm Hg and then bled periodically to maintain a MAP between 40 mm Hg and 45 mm Hg. The primary end-point was time until death. Secondary end-points included lactic acid and base excess levels measured in blood collected at 30-minute intervals after inducing shock. RESULTS There was no significant difference in time until death between the intubated and nose cone groups (85.5 vs. 93.3 minutes, p = 0.60). Intubated animals had higher lactic acid levels at 90 minutes (6.1 vs. 3.5 mmol/L; p = 0.02) and 120 minutes (7.7 vs. 2.6 mmol/L, p = 0.03) after the initiation of shock. In addition, intubated animals had worse base excess at 90 minutes (-13.5 vs. -7.9 mmol/L, p = 0.04). CONCLUSION Intubation does not result in a survival advantage in this rat model of hemorrhagic shock. Positive pressure ventilation may cause decreased venous return and accentuate end-organ hypoperfusion. Large animal studies are needed to further investigate these findings.
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Isenberg DL, Bissell R. Does Advanced Life Support Provide Benefits to Patients?: A Literature Review. Prehosp Disaster Med 2012; 20:265-70. [PMID: 16128477 DOI: 10.1017/s1049023x0000265x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractIntroduction:Emergency medical services have invested substantial resources to establish advanced life support (ALS) programs. However, it is unclear whether ALS care provides better outcomes to patients compared to basic life support (BLS) care.Objective:To evaluate the current evidence regarding the benefits of ALS.Methods:Electronic medical databases were searched to identify articles that directly compared ALS versus BLS care. A total of 455 articles were found. Articles were excluded for the following reasons: (1) the article was not written in English; (2) BLS response was not compared to an ALS response; (3) a physician or nurse was included as part of the ALS response; (4) it was an aeromedical response; or (5) defibrillation was included in the ALS, but not the BLS, scope of care. Twenty-one articles met the inclusion criteria for this literature review.Results:Results were divided into four categories: (1) trauma; (2) cardiac arrest; (3) myocardial infarction; and (4) altered mental status.Trauma:The majority of articles showed that ALS provided no benefits over BLS in urban trauma patients. In fact, most studies showed higher mortality rates for trauma patients receiving ALS care. Further research is needed to evaluate the benefits of ALS for rural trauma patients, and whether ALS care improves outcomes in subgroups of urban trauma patients.Cardiac Arrest:Cardiac arrest studies show that early CPR plus early defibrillation provide the greatest improvement in survival. However, most cardiac arrest research includes defibrillation as an ALS skill which has now moved into the BLS scope of care. The 2004 multi-center OPALS study provided good evidence that ALS does not improve cardiac arrest survival over early defibrillation. Further research is needed to address whether any ALS interventions improve cardiac arrest outcome.Myocardial Infarction:Only one study directly compared the outcome of BLS and ALS care on myocardial infarction. The study found no difference in outcomes between BLS and ALS care in an urban setting.Advanced Life Support:Only one study directly compared the outcome of BLS and ALS care on patients with altered mental status. The study found that the same number of patients had improved to “alert” on arrival at the emergency department, but there was a decreased length of emergency department stay for patients treated by ALS for hypoglycemia.Limitations:This review article does not take into account the benefits of ALS interventions, such as thrombolytics, dextrose, or nitroglycerin, since no studies directly compared these interventions to BLS care. Furthermore, only one study in this literature review was a large, multi-center trial.Conclusions:ALS shows little, if any, benefits for urban trauma patients. Cardiac arrest studies show that ALS does not provide additional benefits over BLS-defibrillation care, but more research is needed in this area. In two small studies, ALS care did not provide benefits over BLS care for patients with myocardial infarctions or altered mental status. Larger-scale studies are needed to evaluate which specific ALS interventions improve patient outcomes.
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Affiliation(s)
- Derek L Isenberg
- Tulane School of Medicine, 1430 Tulane Ave., Box F19, New Orleans, LA 70112, USA.
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Abstract
AbstractIntroduction:Jurisdictions throughout the United States and some other parts of the world have invested substantial time and resources into creating and sustaining a prehospital advanced life support (ALS) system without knowing whether the efficacy of ALS-level care had been validated scientifically. In recent years, it has become fashionable for speakers before large audiences to declare that there is no scientific evidence for the clinical effectiveness of ALS-level care in the out-of-hospital setting. This study was undertaken to evaluate the evidence that pertains to the efficacy of ALS-level care in the current scientific literature.Methods:An extensive review of the available literature was accomplished using computerized and manual means to identify all applicable articles from 1966 to October, 1995. Selected articles were read, abstracted, analyzed, and compiled Each article also was categorized as presenting evidence supporting or refuting the clinical efficacy of ALS-level care, and a list was constructed that pointed to where the preponderance of the evidence lies.Results:Research in this field differs widely in terms of methodological sophistication. Of the 51 articles reviewed, eight concluded that ALS-level care is not any more effective than is basic life support, seven concluded that it is effective in some applications but not for others, and the remainder demonstrated effectiveness. The strongest support for ALS-level care was in the area of responses to victims of cardiac arrest, whereas somewhat more divergent findings related to trauma or non condition-specific studies.Conclusion:While not unanimous, the predominant finding of recent research into the clinical effectiveness of advanced life support demonstrates improved effectiveness over basic life support for patients with certain pathologies. More outcomes-based research is needed.
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Recommendations for Uniform Reporting of Data following Major Trauma — The Utstein Style: An Initiative. Prehosp Disaster Med 2012. [DOI: 10.1017/s1049023x00027473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The document is published in collaboration with the following organisations: the European Society of Emergency Medicine (Leuven); the European Resuscitation Council (Antwerpen); the Air Medical Physician Association (Salt Lake City, US); the German Interdisciplinary Association of Critical Care Medicine; and the German Society of Anaesthesiology and Intensive Care. The document is to be published jointly in the following journals: 1) Trauma Care (ITACCS); 2) Resuscitation; 3) Prehospital and Disaster Medicine; 4) European Journal of Emergency Medicine; 5) Trauma and Emergency Medicine Journal (SA); 6) Emergency Medicine(Norway); 7) JEUR; and 8) Notfall und Rettungsmedizin (Germany).
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Band RA, Pryor JP, Gaieski DF, Dickinson ET, Cummings D, Carr BG. Injury-adjusted mortality of patients transported by police following penetrating trauma. Acad Emerg Med 2011; 18:32-7. [PMID: 21166730 DOI: 10.1111/j.1553-2712.2010.00948.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND More than a decade ago, the city of Philadelphia began allowing police transport of penetrating trauma patients. OBJECTIVES The objective was to determine the relation between prehospital mode of transport (police department [PD] vs. Philadelphia Fire Department (PFD) emergency medical services [EMS]) and survival in subjects with proximal penetrating trauma. METHODS The authors performed a retrospective cohort study of prospectively collected trauma registry data. All subjects who sustained proximal penetrating trauma and who presented to a Level I urban trauma center over a 5-year period (January 1, 2003, to December 31, 2007) were included. Mortality for subjects presenting by EMS was compared to that of those who arrived by PD transport in unadjusted and adjusted analyses. Unadjusted analyses were performed using the chi-square test, Wilcoxon rank sum test, and Student's t-test. Adjusted analyses were performed using logistic regression using the Trauma Injury Severity Score (TRISS) methodology. Data are presented as percentages, odds ratios (ORs), and 95% confidence intervals (CIs). Total hospital length of stay was examined as a secondary outcome. RESULTS Of the 2,127 subjects, 26.8% were transported to the emergency department (ED) by PD, and 73.2% by EMS. The mean(±standard deviation [SD]) age of PD subjects was 26.3 (±9.1) years and 92% were male versus EMS subjects whose mean (±SD) age was 31.5 (±11.8) years and of whom 87% were male. Overall, 70.8% sustained a gunshot wound (GSW), and 29.2% sustained a stab wound (SW). Overall Injury Severity Score (ISS) was 11.21 (ISS for PD, 14.2±17.5; for EMS, 10.1±14.5; p<0.001), and 16.6% of the subjects died (PD, 21.4±0.41%; EMS, 14.8±0.36%; p<0.001). In unadjusted analyses, PD subjects were more likely to die than EMS subjects (OR=1.6, 95% CI=1.2 to 2.0; p<0.001). When adjusting for injury severity using TRISS, there was no difference in survival between PD and EMS subjects (OR=1.01, 95% CI=0.63 to 1.61). Median length of hospital stay was 1 day and did not differ according to mode of prehospital transport (p=0.159). CONCLUSIONS Although unadjusted mortality appears to be higher in PD subjects, these findings are explained by the more severely injured population transported by PD. The current practice of permitting police officers to transport penetrating trauma patients should be continued.
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Affiliation(s)
- Roger A Band
- Department of Emergency Medicine, Division of Trauma and Surgical Critical Care, University of Pennsylvania, Philadelphia, PA, USA.
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Biosurveillance for Pandemic Influenza: US Experience with the H1N1 Outbreak, April–June, 2009. Prehosp Disaster Med 2010. [DOI: 10.1017/s1049023x00022330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
Although the need and benefit of prehospital interventions has been controversial for quite some time, an increasing amount of evidence has stirred both sides into more frequent debate. Proponents of the traditional "scoop-and-run" technique argue that this approach allows a more timely transfer to definitive care facilities and limits unnecessary (and potentially harmful) procedures. However, advocates of the "stay-and-play" method point to improvement in survival to reach the hospital and better neurologic outcomes after brain injury. Given the lack of consensus, the Eastern Association for the Surgery of Trauma convened a Practice Management Guideline committee to answer the following questions regarding prehospital resuscitation: (1) should injured patients have vascular access attempted in the prehospital setting? (2) if so, what location is preferred for access? (3) if access is achieved, should intravenous fluids be administered? (4) if fluids are to be administered, which solution is preferred? and (5) if fluids are to be administered, what volume and rate should be infused?
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LIBERMAN MOISHE, C BRANAS CHARLES, MULDER DAVIDS, LAVOIE ANDRÉ, SAMPALIS JOHNS. Advanced Versus Basic Life Support in the Pre‐Hospital Setting – The Controversy between the ‘Scoop and Run’ and the ‘Stay and Play’ Approach to the Care of the Injured Patient. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/15031430410025515] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
BACKGROUND Time to definitive care is a major determinant of trauma patient outcomes yet little is empirically known about prehospital times at the national level. We sought to determine national averages for prehospital times based on a systematic review of published literature. METHODS We performed a systematic literature search for all articles reporting prehospital times for trauma patients transported by helicopter and ground ambulance over a 30-year period. Forty-nine articles were included in a final meta-analysis. Activation time, response time, on-scene time, and transport time were abstracted from these articles. Prehospital times were also divided into urban, suburban, rural, and air transports. Statistical tests were computed using weighted arithmetic means and standard deviations. RESULTS The data were drawn from 20 states in all four U.S. Census Regions and represent the prehospital experience of 155,179 patients. Average duration in minutes for urban, suburban, and rural ground ambulances for the total prehospital interval were 30.96, 30.97, and 43.17; for the response interval were 5.25, 5.21, and 7.72; for the on-scene interval were 13.40, 13.39, and 14.59; and for the transport interval were 10.77, 10.86, and 17.28. Average helicopter ambulance times were response 23.25, on-scene 20.43, and transport 29.80 minutes. CONCLUSIONS Despite the emphasis on time in the prehospital and trauma literature there has been no national effort to empirically define average prehospital time intervals for trauma patients. We provide points of reference for prehospital intervals so that policymakers can compare individual emergency medical systems to national norms.
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Affiliation(s)
- Brendan G Carr
- Department of Surgery, The Trauma Center at Penn., Hospital of the University of Pennsylvania, Philadelphia 19104, USA.
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O'Brien E, Hendricks D, Cone DC. Field termination of resuscitation: analysis of a newly implemented protocol. PREHOSP EMERG CARE 2008; 12:57-61. [PMID: 18189179 DOI: 10.1080/10903120701707989] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Earlier work has shown the safety of termination-of-resuscitation (TOR) protocols for traumatic and nontraumatic out-of-hospital cardiac arrest (OOHCA). This study examined the implementation of these protocols in one urban/suburban EMS system. The objective was to determine how often patients are transported to the ED despite meeting TOR criteria. METHODS All adult OOHCA patients transported to two EDs during a 3.5-year interval were retrospectively identified through dispatch and hospital records. EMS and ED records were evaluated to assess for the presence of TOR protocol criteria and to determine whether the patients should have been transported or pronounced dead on scene. Records were also examined for documentation of mitigating circumstances that might have prompted transport despite meeting TOR criteria. RESULTS 865 OOHCA patients were identified; 235 met study criteria. Of these, 131 (56%) met TOR criteria but were transported anyway. All expired in the ED or in the hospital (131/131 = 100%, 95% CI: 97.7-100) Of the 43 traumatic OOHCA patients, 27 (63%) met TOR criteria, yet were transported, and all expired in the ED (27/27 = 100%, 95% CI: 89.5-100). Of the 192 nontraumatic OOHCA patients, 104 (54%) met TOR criteria, yet were transported, and all expired in the ED or in the hospital (104/104 = 100%, 95% CI: 97.2-100). In no case was a mitigating circumstance documented to justify transporting a patient meeting TOR criteria. CONCLUSIONS Termination-of-resuscitation protocols are not being implemented as intended in this EMS system: more than half of cardiac arrest patients meeting criteria for termination of resuscitation were transported anyway. These protocol violations result in emergency transport to the ED for a substantial number of patients for whom continued resuscitative efforts are futile: no patient who met TOR criteria in this sample survived to discharge.
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Haas B, Nathens AB. Pro/con debate: is the scoop and run approach the best approach to trauma services organization? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:224. [PMID: 18828868 PMCID: PMC2592727 DOI: 10.1186/cc6980] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
You are asked to be involved in organizing a trauma service for a major urban center. You are asked to make a decision on whether the services general approach to trauma in the city (which does have a well-established trauma center) will be scoop and run (minimal resuscitation at the scene with a goal to getting the patient to a trauma center as quickly as possible) or on-the-scene resuscitation with transfer following some degree of stabilization.
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Affiliation(s)
- Barbara Haas
- Department of Surgery, University of Toronto, St Michael's Hospital, Queen Wing, 3N-073, 30 Bond Street, Toronto, Ontario, Canada M5B 1W8.
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Malvestio MAA, Sousa RMCD. Predetermining value analysis of the prehospital phase procedures in trauma victims survival. Rev Lat Am Enfermagem 2008; 16:432-8. [DOI: 10.1590/s0104-11692008000300016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Accepted: 03/07/2008] [Indexed: 11/22/2022] Open
Abstract
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.
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Stiell IG, Nesbitt LP, Pickett W, Munkley D, Spaite DW, Banek J, Field B, Luinstra-Toohey L, Maloney J, Dreyer J, Lyver M, Campeau T, Wells GA. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ 2008; 178:1141-52. [PMID: 18427089 PMCID: PMC2292763 DOI: 10.1503/cmaj.071154] [Citation(s) in RCA: 191] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- Ian G Stiell
- The Department of Emergency Medicine, University of Ottawa, and the Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ont
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Sugrue M, Balogh Z, Lynch J, Bardsley J, Sisson G, Weigelt J. Guidelines for the management of haemodynamically stable patients with stab wounds to the anterior abdomen. ANZ J Surg 2007; 77:614-20. [PMID: 17635271 DOI: 10.1111/j.1445-2197.2007.04173.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Clinical practice guidelines have been shown to improve the delivery of care. Anterior abdominal stab wounds, although uncommon, pose a challenge in both rural and urban trauma care. A multidisciplinary working party was established to assist in the development of evidence-based guidelines to answer three key clinical questions: (i) What is the ideal prehospital management of anterior abdominal stab wounds? (ii) What is the ideal management of anterior abdominal stab wounds in a rural or urban hospital without an on-call surgeon? (iii) What is the ideal emergency management of stable patients with anterior abdominal stab wounds when surgical service is available? A systematic review, using Cochrane method, was undertaken. The data were graded by level of evidence as outlined by the Australian National Health and Medical Research Council. Stable patients with anterior abdominal stab wounds should be transported to the hospital without delay. Any interventions deemed necessary in prehospital care should be undertaken en route to hospital. In rural hospitals with no on-call surgeon, local wound exploration (LWE) may be undertaken by a general practitioner if confident in this procedure. Otherwise or in the presence of obvious fascial penetration, such as evisceration, the patient should be transferred to the nearest main trauma service for further management. In urban hospitals the patient with omental or bowel evisceration or generalized peritonitis should undergo urgent exploratory laparotomy. Stable patients may be screened using LWE. Abdominal computed tomography scan and plain radiographs are not indicated. Obese and/or uncooperative patients require a general anaesthetic for laparoscopy. If there is fascial penetration on LWE or peritoneal penetration on laparoscopy, then an urgent laparotomy should be undertaken. The developed evidence-based guidelines for stable patients with anterior abdominal stab wounds may help minimize unnecessary diagnostic tests and non-therapeutic laparotomy rates.
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Affiliation(s)
- Michael Sugrue
- Trauma Department, Liverpool Hospital, Sydney, New South Wales, Australia.
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21
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Seamon MJ, Fisher CA, Gaughan J, Lloyd M, Bradley KM, Santora TA, Pathak AS, Goldberg AJ. Prehospital Procedures Before Emergency Department Thoracotomy: “Scoop and Run” Saves Lives. ACTA ACUST UNITED AC 2007; 63:113-20. [PMID: 17622878 DOI: 10.1097/ta.0b013e31806842a1] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The role of prehospital healthcare personnel in the management of acutely injured patients is rapidly evolving. However, the performance of prehospital procedures on unstable, penetrating trauma patients remains controversial. The objective of this study is to test the hypothesis that survival of most critically injured penetrating trauma patients requiring emergency department thoracotomy (EDT) would be improved if procedures were restricted until arrival to the trauma bay. METHODS A retrospective chart review on 180 consecutive penetrating trauma patients (2000-2005) who underwent EDT was performed. Patients were divided into two groups by mode of transportation and compared on the basis of demographics, clinical and physiologic parameters, prehospital procedures, and survival. RESULTS Eighty-eight patients arrived by emergency medical services (EMS), and 92 were brought by police or private vehicle. Groups were similar with respect to demographics. Seven of 88 (8.0%) EMS-transported patients survived until hospital discharge, and 16 of 92 (17.4%) survived after police or private transportation. Overall, 137 prehospital procedures were performed in 78 of 88 (88.6%) EMS-transported patients, but no police- or private-transported patient underwent field procedures. Multivariate logistic regression analyses identified prehospital procedures as the sole independent predictor of mortality. For each procedure, patients were 2.63 times more likely to die before hospital discharge (OR = 0.38, 95% CI = 0.18-0.79, p = 0.0096). CONCLUSIONS The performance of prehospital procedures in critical, penetrating trauma victims had a negative impact on survival after EDT in our study population. Paramedics should adhere to a minimal or "scoop and run" approach to prehospital transportation in this setting.
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Affiliation(s)
- Mark J Seamon
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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22
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Abstract
Emergency medical services (EMS) play a critical role in the trauma system as the point of initial patient care and stabilization and in determining the regional flow of patients and the commitment of resources to the critically injured. Trauma surgeons and emergency physicians need to be involved in the organizational planning of EMS systems to ensure that uniform patient care protocols are developed for triage and treatment. Ongoing efforts should focus on addressing national variability in care provided after injury to ensure optimal outcome for patients in all regions. Through additional research, the best practice and optimal EMS system design will continue to be defined.
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Affiliation(s)
- Eileen M Bulger
- Department of Surgery, University of Washington, Harborview Medical Center, Box 359796, 325 9th Avenue, Seattle, WA 98104, USA.
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23
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Søreide E, Deakin CD. Pre-hospital fluid therapy in the critically injured patient--a clinical update. Injury 2005; 36:1001-10. [PMID: 16098325 DOI: 10.1016/j.injury.2005.01.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2005] [Accepted: 01/10/2005] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Eldar Søreide
- Division of Acute Care Medicine, Stavanger University Hospital, Stavanger, Norway.
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Ehrlich PF, Seidman PS, Atallah O, Haque A, Helmkamp J. Endotracheal intubations in rural pediatric trauma patients. J Pediatr Surg 2004; 39:1376-80. [PMID: 15359393 DOI: 10.1016/j.jpedsurg.2004.05.010] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND/PURPOSE Evidence from urban trauma centers questions the efficacy of pediatric field endotracheal intubations (ETIs). It is recognized that in the rural environment, discovery, transport delays, and a paucity of pediatric expertise contribute to higher pediatric trauma mortality rates compared with urban environments. The purpose of our study was to determine the effectiveness of field ETI in rural pediatric trauma patients. METHODS ETI attempts (field, referring hospital, trauma center [TC]) in trauma patients less than 19 years old were included. Prehospital and TC charts, including demographics, injury mechanism, indication, location, person performing, number of attempts, Glascow Coma Scale (GCS), complications from ETI, and outcome, were assessed. RESULTS Between 1991 and 2000, 105 of 2,907 patients met study criteria. Paramedics, trauma flight nurses (field ETIs), emergency physicians, surgeons, and anesthesiologists performed the ETI. One hundred fifty-five ETIs (1 to 6 per patient) were attempted in 105 children. Fifty-seven percent of the ETIs were attempted in the field, 22% in transferring hospital, and 21% at the TC. Successful intubation on first attempt was 67% (field), 69% (referring hospital), and 95% (TC). Subsequent ETI attempts had failure rates of 50% (field) and 0% (referring hospital, TC). Indication for ETI included fear of losing airway control (37%), closed head injury (36.1%), respiratory rate less than 10 or greater than 40 (11.2%), cardiopulmonary arrest (6.5%), respiratory arrest (4.6%), and airway obstruction 4.6%. Only 9.3% of children could not be oxygenated or ventilated by bag valve mask (BVM) before ETI. Twenty-three percent had complications directly related to ETI (eg, aspiration). The relative risk of an airway complication was 2.5x higher with more then one ETI attempt (P <.05). Four percent of the airway complications occurred in TC, 29% (transferring hospital) and 66% (field, P <.05), respectively. Airway complications and multiple ETIs were associated with transport delay, lower GCS, longer hospital stay, and lower discharge GCS (P <.001) but independent of injury severity score, sex, age, and survival (P >.05). CONCLUSIONS Multiple ETI attempts are associated with significant complications and may offer limited advantage over BVM and possibly may affect outcome. Indications for field intubations may require review especially in rural pediatric trauma.
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Affiliation(s)
- P F Ehrlich
- Department of Pediatric Surgery, West Virginia University School of Medicine, Morgantown, WV, USA
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25
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Stockinger ZT, McSwain NE. Prehospital Endotracheal Intubation for Trauma Does Not Improve Survival over Bag-Valve-Mask Ventilation. ACTA ACUST UNITED AC 2004; 56:531-6. [PMID: 15128123 DOI: 10.1097/01.ta.0000111755.94642.29] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Zsolt T Stockinger
- Department of Surgery SL-22, Tulane University Health Sciences Center, 1430 Tulane Avenue, New Orleans, LA 70112-2699, USA.
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26
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MacFarlane C, Benn CA. Evaluation of emergency medical services systems: a classification to assist in determination of indicators. Emerg Med J 2003; 20:188-91. [PMID: 12642542 PMCID: PMC1726053 DOI: 10.1136/emj.20.2.188] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Emergency medical services (EMS) systems, and prehospital care are difficult to evaluate. Accordingly, the true efficacy and value of such systems are difficult to determine. The multitude of variations and combinations of involved factors makes standardisation and comparison difficult, and universal indicators are hard to develop. Various attempts have been made to determine valid indicators of effectiveness, but there has been little success. Prehospital care has been seen by some as a single entity. As a result, experience from well resourced first world trauma centres has been taken, by many, to be applicable to all prehospital situations. This article attempts to assist in the development of valid EMS indicators of performance and effectiveness by categorising prehospital scenarios into a classification reflecting the reality of their conditions of practice.
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Affiliation(s)
- C MacFarlane
- Emergency Medical Services Training, Gauteng Provincial Government, South Africa.
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27
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Hopson LR, Hirsh E, Delgado J, Domeier RM, Krohmer J, McSwain NE, Weldon C, Friel M, Hoyt DB. Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest. J Am Coll Surg 2003; 196:475-81. [PMID: 12648687 DOI: 10.1016/s1072-7515(03)00229-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Laura R Hopson
- Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, USA
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28
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Abstract
OBJECTIVE To evaluate whether the type of on-site care a trauma patient receives affects outcome. SUMMARY BACKGROUND DATA The controversy regarding the prehospital care of trauma patients between Advanced Life Support (ALS) and Basic Life Support (BLS) is ongoing. Due to this unresolved controversy, as well as historical, cultural, and political factors, there are significant variations with respect to the type of prehospital care available for trauma patients. METHODS This prospective cohort study compared three types of prehospital trauma care systems: Montreal, where physicians provide ALS (MD-ALS); Toronto, where paramedics provide ALS (PMD-ALS); and Quebec City, where emergency medical technicians provide BLS only (EMT-BLS). The study took advantage of this variation to evaluate the association between the type of on-site care and mortality in patients with major life-threatening injuries. All patients were treated at highly specialized tertiary (level I) trauma hospitals. The main outcome measure was death as a result of injury. Follow-up was to hospital discharge. RESULTS The overall mortality rates by type of on-site personnel were physicians 35%, paramedics 24%, and EMTs 18%. For patients with major but survivable trauma, the overall mortality rates were physicians 32%, paramedics 28%, and EMTs 26%. The overall mortality rate of patients receiving only BLS at the scene was 18% compared to 29% for patients receiving ALS. For the subgroup of patients with major but survivable injuries, the mortality rates were 30% for ALS and 26% for BLS. The adjusted increased risk for mortality in patients receiving ALS at the scene was 21%. CONCLUSIONS In urban centers with highly specialized level I trauma centers, there is no benefit in having on-site ALS for the prehospital management of trauma patients.
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Affiliation(s)
- Moishe Liberman
- McGill University, Montreal, Quebec, Montreal General Hospital, Department of Surgery, Canada
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29
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Hopson LR, Hirsh E, Delgado J, Domeier RM, McSwain NE, Krohmer J. Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest: joint position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. J Am Coll Surg 2003; 196:106-12. [PMID: 12517561 DOI: 10.1016/s1072-7515(02)01668-x] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Laura R Hopson
- Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI, USA
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30
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Gwinnutt C, Bethelmy L, Nolan J. Anaesthesia in trauma. TRAUMA-ENGLAND 2003. [DOI: 10.1191/1460408603ta267oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Trauma patients may need to be anaesthetized at the scene of an accident, in the emergency department or most commonly in the operating theatre. The principles of safe management of anaesthesia in each of these very different environments are discussed along with the common anaesthetic problems encountered and advice on their solution.
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31
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Malvestio MAA, de Sousa RMC. [Advanced life support: care provided to motor vehicle crash victims]. Rev Saude Publica 2002; 36:584-9. [PMID: 12471383 DOI: 10.1590/s0034-89102002000600007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Roberts I, Evans P, Bunn F, Kwan I, Crowhurst E. Is the normalisation of blood pressure in bleeding trauma patients harmful? Lancet 2001; 357:385-7. [PMID: 11211015 DOI: 10.1016/s0140-6736(00)03653-9] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- I Roberts
- Department of Epidemiology and Public Health, Institute of Child Health, London, UK.
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33
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Sethi D, Kwan I, Kelly AM, Roberts I, Bunn F. Advanced trauma life support training for ambulance crews. Cochrane Database Syst Rev 2001:CD003109. [PMID: 11406080 DOI: 10.1002/14651858.cd003109] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND There is an increasing global burden of disease from injuries. Models of trauma care initially developed in high-income countries are also being adopted in low and middle-income countries (LMIC). Amongst these ambulance crews with Advanced Life Support (ALS) training are being promoted in LMIC as a strategy for improving outcomes for victims of trauma. However there is controversy as to the effectiveness of this health service intervention, and the evidence has yet to be rigorously appraised. OBJECTIVES To quantify the effectiveness of ambulance crews with ALS training versus crews with any other level of training in reducing mortality and morbidity in trauma patients. SEARCH STRATEGY We searched the Cochrane Controlled Trial Register (CCTR), the specialised register of the Cochrane Injuries Group, MEDLINE, EMBASE, CINAHL, PubMed and the National Research Register. We checked references of background papers and contacted authors to identify additional published or unpublished data. SELECTION CRITERIA Randomised controlled trials, quasi-randomised controlled trials and controlled before-and-after studies comparing effectiveness of ambulance crews with ALS training versus crews with any other levels of training in reducing mortality and morbidity in trauma patients. Studies which compared crews staffed by physicians versus others were excluded. DATA COLLECTION AND ANALYSIS Two reviewers independently applied eligibility criteria to trial reports for inclusion and extracted data. MAIN RESULTS We found one randomised controlled trial, which included 16 trauma cases. However, outcome data were added to the main non-randomised cohort in the analysis, and data on these 16 cases are not yet available. REVIEWER'S CONCLUSIONS In the absence of evidence of the effectiveness of advanced life support, strong argument could be made that it should not be promoted outside the context of a properly concealed and otherwise rigorously conducted randomised controlled trial.
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Affiliation(s)
- D Sethi
- Health Policy Unit, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK, WC1E 7HT.
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Liberman M, Mulder D, Sampalis J. Advanced or basic life support for trauma: meta-analysis and critical review of the literature. THE JOURNAL OF TRAUMA 2000; 49:584-99. [PMID: 11038074 DOI: 10.1097/00005373-200010000-00003] [Citation(s) in RCA: 186] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- M Liberman
- Department of Surgery, McGill University, Montreal, Quebec, Canada
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35
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Eckstein M, Chan L, Schneir A, Palmer R. Effect of prehospital advanced life support on outcomes of major trauma patients. THE JOURNAL OF TRAUMA 2000; 48:643-8. [PMID: 10780596 DOI: 10.1097/00005373-200004000-00010] [Citation(s) in RCA: 164] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Determine whether prehospital advanced life support (ALS) improves the survival of major trauma patients and whether it is associated with longer on-scene times. METHODS A 36-month retrospective study of all major trauma patients who received either prehospital bag-valve-mask (BVM) or endotracheal intubation (ETI) and were transported by paramedics to our Level I trauma center. Logistic regression analysis determined the association of prehospital ALS with patient survival. RESULTS Of 9,451 major trauma patients, 496 (5.3%) had either BVM or ETI. Eighty-one percent received BVM, with a mean Injury Severity Score of 29 and a mortality rate of 67%; 93 patients (19%) underwent successful ETI, with a mean Injury Severity Score of 35 and a mortality rate of 93%. Adjusted survival for patients who had BVM was 5.3 times more likely than for patients who had ETI (95% confidence interval, 2.3-14.2, p = 0.00). Survival among patients who received intravenous fluids was 3.9 times more likely than those who did not (p = not significant). Average on-scene times for patients who had ETI or intravenous fluids were not significantly longer than those who had BVM or no intravenous fluids. CONCLUSION ALS procedures can be performed by paramedics on major trauma patients without prolonging on-scene time, but they do not seem to improve survival.
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Affiliation(s)
- M Eckstein
- University of Southern California School of Medicine, Los Angeles, USA.
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36
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Dick WF, Baskett PJ. Recommendations for uniform reporting of data following major trauma--the Utstein style. A report of a working party of the International Trauma Anaesthesia and Critical Care Society (ITACCS). Resuscitation 1999; 42:81-100. [PMID: 10617327 DOI: 10.1016/s0300-9572(99)00102-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- W F Dick
- Klinik fur Anaesthesiologie, Johannes Gutenberg Universitat, Mainz, Germany
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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. The Ontario Prehospital Advanced Life Support (OPALS) study Part II: Rationale and methodology for trauma and respiratory distress patients. OPALS Study Group. Ann Emerg Med 1999; 34:256-62. [PMID: 10424933 DOI: 10.1016/s0196-0644(99)70241-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- I G Stiell
- Division of Emergency Medicine, Department of Medicine, Loeb Health Research Institute, University of Ottawa, Ontario, Canada
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Eckstein M, Alo K. The effect of a quality improvement program on paramedic on-scene times for patients with penetrating trauma. Acad Emerg Med 1999; 6:191-5. [PMID: 10192669 DOI: 10.1111/j.1553-2712.1999.tb00154.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To decrease paramedic on-scene times (OSTs) for major trauma patients through a focused quality improvement (QI) program. METHODS A prospective study was conducted from 1993 through 1997 to determine the impact of a QI program on paramedic OSTs. All penetrating trauma patients transported by paramedics to Los Angeles County/USC Medical Center, a Level-1 trauma center, were included, and all cases with OSTs > 20 minutes were reviewed in detail for extenuating circumstances. Cases including multiple victims or unsecured scenes were considered "acceptable deviations." All others were considered "fallouts," which prompted extensive review with the paramedics and their field supervisors. RESULTS Prior to the inception of the QI project there was a 4.1% fallout rate of penetrating trauma patients with OSTs > 20 minutes. This fallout rate fell to 1.5% in 1997 (p < 0.01). Mortality rates among these fallouts decreased from 5.1% to 0.8% during the study period (p < 0.01). CONCLUSIONS An intensive QI program can have a significant, positive impact on paramedic OSTs among patients with penetrating trauma.
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Affiliation(s)
- M Eckstein
- University of Southern California School of Medicine and the Los Angeles City Fire Department, USA.
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Stratton SJ, Brickett K, Crammer T. Prehospital pulseless, unconscious penetrating trauma victims: field assessments associated with survival. THE JOURNAL OF TRAUMA 1998; 45:96-100. [PMID: 9680019 DOI: 10.1097/00005373-199807000-00021] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND This study was designed to determine whether out-of-hospital clinical signs could be associated with functional survival for pulseless, unconscious victims of penetrating trauma. METHODS A retrospective review of medical data and outcome for pulseless, unconscious penetrating urban trauma victims during 1993-1994. For comparison with the penetrating study group, data for blunt pulseless, unconscious trauma victims for the same period are reported. Logistic regression, odds ratios, positive predictive values, sensitivity, and specificity were used to determine the possible association of field clinical signs with survival. RESULTS A total of 879 penetrating and blunt trauma victims met criteria of the study. Four of 497 victims of penetrating injury survived. Three of the four survivors were neurologically intact, with the remaining survivor impaired but functional in a supervised work setting. All survivors of penetrating trauma had monitored cardiac electrical (sinus rhythm or sinus tachycardia) activity on presentation in the field, and three were stabbing victims. Age, total field treatment time, spontaneous respiration, reactive pupils, and return of pulse in the field were not found to be associated with survival. Four victims of penetrating injury survived long enough to donate perfused asystolic-sensitive (kidney, liver, lung, and pancreas) organs. There were 382 victims of blunt injury that met study inclusion criteria with five survivors. None of the five survivors of blunt injury had good neurologic function. CONCLUSION Functional survival was rare but did occur with penetrating trauma presenting pulseless and unconscious in the out-of-hospital setting. Although the presence of a pulseless sinus rhythm or tachycardia and stabbing as a mechanism seemed to indicate better survival rates, our study failed to identify reliable out-of-hospital criteria to separate salvageable penetrating trauma victims from those who are nonsalvageable. With this lack of reliable criteria, aggressive prehospital resuscitation efforts and rapid transport to the nearest trauma center for pulseless, unconscious victims of penetrating injury seem indicated.
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Affiliation(s)
- S J Stratton
- Harbor-UCLA Medical Center, Los Angeles, California, USA.
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Abstract
OBJECTIVE To determine whether the provision of advanced life support (ALS) field care has any impact on patient outcome in the urban Canadian environment. METHODS A convenience cohort study was conducted of all emergent ambulance transfers of adults to an urban Canadian hospital from May 22 to July 31, 1996. Data were collected from ambulance call reports regarding presenting complaint and field interventions applied, and from hospital records regarding time in the ED, hospital length of stay (LOS), and discharge disposition. Patient outcomes were compared within 7 presenting complaint groups (chest pain, altered level of consciousness, shortness of breath, abdominal pain, motor vehicle crash, falls, and other) by field care level: level 1--BLS (basic life support) vs levels 2 and 3--ALS. RESULTS The study population consisted of 1,397 patients. No significant differences were seen between BLS and ALS patients on baseline demographics. ED triage score did not depend on field care level for any group, implying that those in the ALS group were not inherently sicker. Outcome measures (ED LOS, admission rates, and hospital LOS) showed no significant differences between BLS and ALS for each presenting complaint group. Discharge dispositions were analyzed by chi2 but were not varied enough to allow reliable analysis. Observation of trends suggested no difference between BLS and ALS. CONCLUSIONS There was no beneficial impact on the measured patient outcomes found in association with the provision of ALS vs BLS field care in Metropolitan Toronto for patients who were brought to a nontrauma center.
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Affiliation(s)
- J S Eisen
- Queen's University Faculty of Medicine, Kingston, Ontario, Canada
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Hauswald M, Yeoh E. Designing a prehospital system for a developing country: estimated cost and benefits. Am J Emerg Med 1997; 15:600-3. [PMID: 9337371 DOI: 10.1016/s0735-6757(97)90167-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Many of the costs associated with prehospital care in developed countries are covered in budgets for fire suppression, police services, and the like. Determining these costs is therefore difficult. The costs and benefits of developing a prehospital care system for Kuala Lumpur, Malaysia, which now has essentially no emergency medical services (EMS) system, were estimated. Prehospital therapies that have been suggested to decrease mortality were identified. A minimal prehospital system was designed to deliver these treatments in Kuala Lumpur. The potential benefit of these therapies was calculated by using statistics from the United States corrected for demographic differences between the United States and Malaysia. Costs were extrapolated from the current operating budget of the Malaysian Red Crescent Society. Primary dysrhythmias are responsible for almost all potentially survivable cardiac arrests. A system designed to deliver a defibrillator to 85% of arrests within 6 minutes would require an estimated 48 ambulances. Kuala Lumpur has approximately 120 prehospital arrhythmic deaths per year. A 6% resuscitation rate was chosen for the denominator, resulting in seven survivors. Half of these would be expected to have significant neurological damage. Ambulances cost $53,000 (US dollars) to operate per year in Kuala Lumpur; 48 ambulances would cost a total of $2.5 million. Demographic factors and traffic problems would significantly increase the cost per patient. Other therapies, including medications, airway management, and trauma care, were discounted because both their additional cost and their benefit are small. Transport of patients (including trauma) is now performed by police or private vehicle and would probably take longer by ambulance. A prehospital system for Kuala Lumpur would cost approximately $2.5 million per year. It might save seven lives, three of which would be marred by significant neurological injury. Developing countries would do well to consider alternatives to a North American EMS model.
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Affiliation(s)
- M Hauswald
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque 87131-5246, USA
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Zalstein S, Cameron PA. Helicopter emergency medical services: their role in integrated trauma care. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1997; 67:593-8. [PMID: 9322693 DOI: 10.1111/j.1445-2197.1997.tb04604.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The role of helicopters in trauma management must be considered in the context of the provision of sophisticated, high-quality trauma care. The present review examines the evolution of systems of trauma care, the value of advanced life support (ALS), and the role of the Helicopter Emergency Medical Service (HEMS) in improving outcomes. Comparison is made of outcomes of patients managed by HEMS and road ambulances, and important aspects of HEMS including staffing and safety are discussed. There is a role for HEMS as part of a modern trauma system, in particular in bringing ALS skills and access to expert medical care to the rural accident scene or hospital at distances of up to 160 km. It is of greatest value when it is integrated into a well-organized ambulance service and emergency system with good triage and close medical supervision.
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Affiliation(s)
- S Zalstein
- Emergency Department, Royal Melbourne Hospital, Parkville, Victoria, Australia
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