Noting that a variety of pre-hospital interventions can now be applied to treat traumatic injury, David J Lockey calls for research to determine which of these actually improve survival and reduce ...morbidity.
The purpose of the trauma team is to provide advanced simultaneous care from relevant specialists to the seriously injured trauma patient. When functioning well, the outcome of the trauma team ...performance should be greater than the sum of its parts. Trauma teams have been shown to reduce the time taken for resuscitation, as well as time to CT scan, to emergency department discharge and to the operating room. These benefits are demonstrated by improved survival rates, particularly for the most severely injured patients, both within and outside of dedicated trauma centres. In order to ensure the best possible performance of the team, the leadership skills of the trauma team leader are essential and their non-technical skills have been shown to be particularly important. Team performance can be enhanced through a process of audit and assessment of the workings of the team and the evidence currently available suggests that this is best facilitated through the process of video review of the trauma resuscitation. The use of human patient simulators to train and assess trauma teams is becoming more commonplace and this technique offers a safe environment for the future education of trauma team staff. Trauma teams are a key component of most programmes which set out to improve trauma care. This article reviews the background of trauma teams, the evidence for benefit and potential techniques of performance assessment. The review was written after a PubMed, Ovid, Athens, Cochrane and guideline literature review of English language articles on trauma teams and their performance and hand searching of references from the relevant searched articles.
Current management principles of hemorrhagic shock after trauma emphasize earlier transfusion therapy to prevent dilution of clotting factors and correct coagulopathy. London's Air Ambulance (LAA) ...was the first UK civilian prehospital service to routinely offer prehospital red blood cell (RBC) transfusion (phRTx). We investigated the effect of phRTx on mortality.
Retrospective trauma database study comparing mortality before implementation with after implementation of phRTx in exsanguinating trauma patients. Univariate logistic regression was performed for the unadjusted association between phRTx and mortality was performed, and multiple logistic regression adjusting for potential confounders.
We identified 623 subjects with suspected major hemorrhage. We excluded 84 (13.5%) patients due to missing data on survival status. Overall 187 (62.3%) patients died in the before phRTx period and 143 (59.8%) died in the after phRTx group. There was no significant improvement in overall survival after the introduction of phRTx (P = 0.554). Examination of prehospital mortality demonstrated 126 deaths in the pre-phRTx group (42.2%) and 66 deaths in the RBC administered group (27.6%). There was a significant reduction in prehospital mortality in the group who received RBC (P < 0.001).
phRTx was associated with increased survival to hospital, but not overall survival. The "delay death" effect of phRTx carries an impetus to further develop inhospital strategies to improve survival in severely bleeding patients.
Pre-hospital airway management is a controversial subject, but there is general agreement that a small number of seriously ill or injured patients require urgent emergency tracheal intubation (ETI) ...and ventilation. Many European emergency medical services (EMS) systems provide physicians to care for these patients while other systems rely on paramedics (or, rarely, nurses). The ETI success rate is an important measure of provider and EMS system success and a marker of patient safety.
We conducted a systematic search of Medline and EMBASE to identify all of the published original English-language articles reporting pre-hospital ETI in adult patients. We selected all of the studies that reported ETI success rates and extracted information on the number of attempted and successful ETIs, type of provider, level of ETI training and the availability of drugs on scene. We calculated the overall success rate using meta-analysis and assessed the relationships between the ETI success rate and type of provider and between the ETI success rate and the types of drugs available on the scene.
From 1,070 studies initially retrieved, we identified 58 original studies meeting the selection criteria. Sixty-four per cent of the non-physician-manned services and 54% of the physician-manned services reported ETI success rates but the success rate reporting was incomplete in three studies from non-physician-manned services. Median success rate was 0.905 (0.491, 1.000). In a weighted linear regression analysis, physicians as providers were significantly associated with increased success rates, 0.092 (P=0.0345). In the non-physician group, the use of drug-assisted intubation significantly increased the success rates. All physicians had access to traditional rapid sequence induction (RSI) and, comparing these to non-physicians using muscle paralytics or a traditional RSI, there still was a significant difference in success rate in favour of physicians, 0.991 and 0.955, respectively (P=0.047).
This comprehensive meta-analysis suggests that physicians have significantly fewer pre-hospital ETI failures overall than non-physicians. This finding, which remains true when the non-physicians administer muscle paralytics or RSI, raises significant patient safety issues. In the absence of pre-hospital physicians, conducting basic or advanced airway techniques other than ETI should be strongly considered.
Abstract This report describes the first use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the pre-hospital setting to control catastrophic haemorrhage. The patient, who had ...fallen 15 meters, suffered catastrophic internal haemorrhage associated with a pelvic fracture. He was treated by London's Air Ambulance's Physician-Paramedic team. This included insertion of a REBOA balloon catheter at the scene to control likely fatal exsanguination. The patient survived transfer to hospital, emergency angio-embolization and subsequent surgery. He was discharged neurologically normal after 52 days and went on to make a full recovery. The poor prognosis in catastrophic torso haemorrhage and novel endovascular methods of haemorrhage control are discussed. Also the challenges of Pre-Hospital REBOA are discussed together with the training and governance required for a safe system.
Abstract Background Major trauma is the leading worldwide cause of death in young adults. The mortality from traumatic cardiac arrest remains high but survival with good neurological outcome from ...cardiopulmonary arrest following major trauma has been regularly reported. Rapid, effective intervention is required to address potential reversible causes of traumatic cardiac arrest if the victim is to survive. Current ILCOR guidelines do not contain a standard algorithm for management of traumatic cardiac arrest. We present a simple algorithm to manage the major trauma patient in actual or imminent cardiac arrest. Methods We reviewed the published English language literature on traumatic cardiac arrest and major trauma management. A treatment algorithm was developed based on this and the experience of treatment of more than a thousand traumatic cardiac arrests by a physician – paramedic pre-hospital trauma service. Results The algorithm addresses the need treat potential reversible causes of traumatic cardiac arrest. This includes immediate resuscitative thoracotomy in cases of penetrating chest trauma, airway management, optimising oxygenation, correction of hypovolaemia and chest decompression to exclude tension pneumothorax. Conclusion The requirement to rapidly address a number of potentially reversible pathologies in a short time period lends the management of traumatic cardiac arrest to a simple treatment algorithm. A standardised approach may prevent delay in diagnosis and treatment and improve current poor survival rates.
Mass casualty civilian shootings present an uncommon but recurring challenge to emergency services around the world and produce unique management demands. On the background of a rising threat of ...transnational terrorism worldwide, emergency response strategies are of critical importance. This study aims to systematically identify, describe and appraise the quality of indexed and non-indexed literature on the pre-hospital management of modern civilian mass shootings to guide future practice.
Systematic literature searches of PubMed, Cochrane Database of Systematic Reviews and Scopus were conducted in conjunction with simple searches of non-indexed databases; Web of Science, OpenDOAR and Evidence Search. The searches were last carried out on 20 April 2016 and only identified those papers published after the 1 January 1980. Included documents had to contain descriptions, discussions or experiences of the pre-hospital management of civilian mass shootings.
From the 494 identified manuscripts, 73 were selected on abstract and title and after full text reading 47 were selected for inclusion in analysis. The search yielded reports of 17 mass shooting events, the majority from the USA with additions from France, Norway, the UK and Kenya. Between 1994 and 2015 the shooting of 1649 people with 578 deaths at 17 separate events are described. Quality appraisal demonstrated considerable heterogeneity in reporting and revealed limited data on mass shootings globally.
Key themes were identified to improve future practice: tactical emergency medical support may harmonise inner cordon interventions, a need for inter-service education on effective haemorrhage control, the value of senior triage operators and the need for regular mass casualty incident simulation.
PDF
