Advances in Field Care of the Trauma Patient

Transcription

1 Warning Am a contributing author and editor of the ITLS text Advances in Field Care of the Trauma Patient Roy L. Alson, PhD, MD, FACEP, FAAEM Emergency Medicine, Wake Forest Baptist Health Medical Director, FCEMS Objective Trauma Care is a Team Sport It begins when the citizen accesses the medical care system It ends with discharge from the hospital or rehabilitation All components of the system To review new techniques and approaches in field care for the trauma patient Apply evidenced based care to improve outcome Have an important role Must do their job to assure good outcomes Trauma is A Disease Trauma is a World Wide Epidemic World Health Organization 2005 Major cause of Morbidity and Mortality Worldwide Leading Cause of Death for Persons under 44 in rth America Key Components Prevention Strategies Organized Care Systems Prehospital Care is an important component WHO: PreHospital Trauma Care Systems Advances in Trauma care tied to Military Medicine As time to definitive care declined from days in the American Civil War, to hours in the Gulf War, survival improved Organized system assures rapid delivery to definitive care 1

2 Trauma Care and Military Medicine are Closely Linked Trauma is A Disease 1966 National Academy of Sciences White Paper Accidental Death and Disability, the Neglected Disease of Modern Society Watershed event for EMS and Trauma Care in US Trauma is a Disease Time Longer energy applied the worse the injury The shorter the time to definitive care the better the outcome Energy External Energy Applied to the body Greater the Energy the worse the injury Golden Hour R. Adams Cowley, MD, FACS Created Maryland Shock Trauma Today some studies question the impact of EMS times on outcome Ample data supports that EMS does influence outcome EMS is the Gatekeeper EMS is a key component. First point of contact with the system. Sets the tone for others to follow Mackenzie et al A National Evaluation of the Effect of Trauma Center Care on Mortality NEJM 354:266, 2006 Reports a 25% reduction in mortality for patient taken DIRECTLY TO A TRAUMA CENTER! Goal for EMS in a Trauma System The Right Patient To the Right Medical Facilty In the Right Time 2

3 Trauma and Burn EMS Triage and Destination Plan Trauma or Burn Patient = Any patient less (regardless of age) with a significant injury or burn Continuously evaluate the EMS System based on rth Carolina s EMS performance measures Acutely Injured or Burned Patient Evidence of extreme shock or un-manageable airway Any Abnormal Vital Signs? Glasgow Coma Score: <13 or intubated Systolic Blood Pressure: <90 mmhg Respiratory Rate: <10 or >29 breaths per min. (<20 in infant aged <1 year) Special Considerations? Anticoagulation and bleeding disorders Pregnancy >20 weeks Trauma Center (Burn Center for isolated Burn Injury) within minutes of EMS Transport? Air Medical SCTP within minutes of patient s location or helipad? Pearls and Definitions All Injury and Burn Patients must be triaged and transported using this plan. This plan is in effect 24/7/365 All Patient Care is based on the EMS Trauma Protocols Designated Trauma Center = a hospital that is currently designated as a Trauma Center by the rth Carolina Office of Emergency Medical Services. Trauma Centers are designated as Level 1, 2, or 3 with Level 1 being the highest possible designation. Free standing emergency departments and satellite facilities are not considered part of the Trauma Center. Transport to the Nearest Hospital for Stabilization Unless Minimal Additional Time to a Trauma Center Transport to closest Trauma Center (Burn Center for isolated Burn) Choose a Level 3 Trauma Center if EMS transport time is less than minutes compared to a Level 1 or 2 Trauma Center Early tification/activation Burn Center = a ABA verified Burn Center co-located with a designated Trauma Center Community Hospital = a local hospital within the EMS System s service area which provides emergency care but has not been designated as a Trauma Center Specialty Care Transport Program = an air or ground based specialty care transport program which can assume care of an acutely injured patient from EMS or a Community Hospital and transport the patient to a designated Trauma Center. This protocol has been developed by the rth Carolina Office of EMS ( Final Version ) Activate Air or Ground SCTP Transport to closest Community Hospital Listed Unless Trauma Center can be reached in a near equal time Early tification/activation 2009 What is Needed: The 4 P s Product Equipment to provide care Personnel Trained to identify critical trauma and provide care Place trauma centers to receive the patient and provide definitive care Plan Trauma System Plan including Protocols Performance assessment The Purpose of this plan is to: Rapidly identify injured or burned patients who call 911 or present to EMS Minimize the time from injury to definitive care for critical injuries or burns Quickly identify life or limb threatening injuries for EMS treatment and stabilization Rapidly identify the best hospital destination based on time of injury, severity of injury, and predicted transport time Early activation/notification to the hospital of a critically injured or burned patient prior to patient arrival Minimize scene time to 10 minutes or less from patient extrication with a load and go approach Provide quality EMS service and patient care to the EMS Systems citizens Critical Injury by Assessment? Penetrating injury to head, neck, torso, or extremities proximal to elbow and knee Flail Chest or Pneumothorax Two or more proximal long-bone fractures Crushed, degloved, or mangled extremity Amputation proximal to wrist and ankle Pelvic fractures Visibly Open or depressed skull fracture Paralysis Critical or Serious Burns (per EMS Burn Protocol) Significant Mechanism? Falls: Adults >20 ft, Children >10 ft. MVC: Intrusion >12 inches occupant side >18 inches any site Ejection Death in same vehicle Vehicle Telemetry with high risk injury Auto vs. pedestrian/bicyclist thrown, run over Motorcycle crash >20 mph Trauma and Burn EMS Triage and Destination Plan EMS and Time Sensitive Conditions Ability of EMS to identify Trauma Patients and route them to trauma centers Basis for STEMI and Stroke Systems in US Level of care: ALS versus BLS is less important than the appropriate destination Lifesaving interventions in field for trauma are basic level skills Airway External Hemorrhage control EMS Role in Trauma System Identify those victims needing care at trauma center Rapidly and safely transport those persons to the trauma center Perform lifesaving interventions Control life threatening external hemorrhage Control the Airway All other interventions in route to Trauma Center What Does EMS Need to Do This Part of a comprehensive Trauma System Guidelines to identify patients who need system Training These components must be Evidenced based Updated regularly System must provide feedback to improve care American College of Surgeons Prehospital Trauma Triage Guidelines 1987 Early were mechanistic based Energy as predictor of injury ISS > 16 to trauma center ISS score retrospective for EMS Must use surrogate measures Mechanism of Injury: Falls, Death of Occupant, Penetrating Trauam Hemodynamic Instability High Risk Injury - Airway ITLS is The Training IDEA FOR A COURSE December of 1980 Dr. Campbell participated in 1st ATLS course taught in the South (the only ED doc there) ACS turned down my request to use the ATLS slides to teach trauma to my paramedic students 3

4 Original Course Objectives Teach hands-on trauma care Teach a target audience of advanced EMS providers Maintain quality but allow for regional differences Keep the course current Keep the course short enough to teach in two days Keep the course simple and practical Keep the course conservative and noncontroversial so the principles taught reflect the standard of care Goal for EMS in a Trauma System The Right Patient To the Right Medical Facility In the Right Time THERE HAVE BEEN CHANGES SINCE 1984 Apply the Science of Medicine to What We Do New Technologies & Research VIRTUALLY ALL ESSENTIAL TRAUMA SKILLS ARE BLS Hemorrhage Control Airway Support Spinal Protection ITLS Focus Appropriate Interven.on in the Field Airway Control Ven.latory support and oxygena.on Control Life Threatening Bleeding Spinal Stabiliza.on / Protec.on Rapid, Safe Transport to Closest appropriate facility ALL OTHER INTERVENTIONS in ROUTE Hemorrhage Control and Shock Serum Lactate as a Field measure for shock Produced by anaerobic metabolism Poor perfusion as in Shock Levels > 4mmol suggest Shock van Beest P, Mulder P, Oetmo S, et al. Measurement of lactate in a prehospital setting is related to outcome. Eur J Emerg Med. 2009;16(6): Device available outside rth America 4

5 Prevent Shock Heomstatic Dressings Control Hemorrhage Early Tourniquets Work Help stop major bleeding not responsive to direct pressure Large irregular wounds Early studies had tissue damage Journal of Trauma-Injury Infection & Critical Care: V 62#2:s28-37 Prehospital Tourniquet Use in Operation Iraqi Freedom: Effect on Hemorrhage Control and Outcomes Beekley, Alec C. MD, FACS and the 31st Combat Support Hospital Research Group Needle Decompression? Cricothyrotomy? Heomstatic Dressings Transfusion E. Darrin Cox, Martin A. Schreiber, John McManus, Charles E. Wade, John B. Holcomb Special Issue: Hemostasis in Trauma Volume 49, Issue Supplement s5, pages 248S 255S,December 2009 Needle decompression: Needles placed incorrectly Needles too short Fancy Valves Crics may help Delay in doing Airway: BLS versus ALS? RSI is a Tool not a result! Mixed results with head injury Hypoxia during intubation Useful but high risk 5

6 Video Laryngoscopy Advantages of Video Laryngoscopy Sakles JC Ann Emerg Med Dec;60(6): First Attempt Success 2x higher with Video Scope versus MAC Direct line of sight not required Can see around the tongue Structures are magnified Less deterioration of image by body fluids (blood, vomit, beer) Higher Success rates with vices Disadvantages COST!!! Thousands of Dollars t an option in most of world Cost Declining Has place especially with anticipated difficult airway TRANEXAMIC ACID TXA TRANEXAMIC ACID Derivative of Amino Acid Lysine Antifibrinolytic effect Competitively inhibits activation of plasminogen by plasmin Reduces Bleeding Used in many countries Does It Have A Place In Trauma? CRASH 2 Study, Lancet 2010: 376: Africa, Asia, Eastern Europe patients Half given TXA < 8 hours Treatment group with drop in mortality by 1.5% Lancet 2011: 377: Same Data Mortality rises if given after 3 hours 6

7 TXA BMC Emerg Med 2012:12,1-7 Decrease bleed mortality by 1/3 WHO feels TXA is essential medication In NHS Trauma Protocol in UK Military Data NATO forces use Arch Surg 2012: 147: MATTERS TXA Use Mortality ISS Massive Transfusion 23.9% % 17.4% % TXA and Trauma If more than one hour from definitive care and less than 3 hours from injury GIVE TXA Minimal Side Effects CHEAP Permissive Hypotension With Bleeding best Resuscitative fluid is BLOOD! Crystalloid just dilutes what is left! If pressure gets to high, clots are pushed off vessels and bleeding resumes. This is more likely to happen when MAP= 64mmHg or SBP = 94mmHg Resuscitation Outcomes Consortium On going study comparing High Volume Saline to Controlled (500 cc) Others Hypertonic Saline benefit over Isotonic Saline Central Pontine Myelinolysis Use of hypertonic saline injection in trauma. Am J Health Syst Pharm v 15;67(22): Patanwala AE, Amini A, Erstad BL. Blood Substitutes Some studies still ongoing Many stopped due to unexpected mortality 7

8 Remember When? Spinal Management Spine board should be a transfer device Longer on board, more likely to have pressure ulcers More focused use of who needs spinal motion restriction Emerg Med J A re-conceptualisation of acute spinal care Mark Hauswald PEC: NAEMSP and COT ACS: EMS SPINAL PRECAUTIONS AND THE USE OF THE LONG BACKBOARD 2013 Ultrasound Smaller and more affordable units Fast Exam IV Access Look for Pneumothorax More used in Europe When To Stop? Termination of Resuscitation Sometimes there is NOTHING we can do Patients with Traumatic Cardiac Arrest Blunt Trauma Arrest Very Poor Outcome Poor Neurological Status At Vancouver ITLS Meeting v 2013 Ultrasound Course Treatable Causes of Trauma Arrest Identify and Correct in Initial Survey Control Exsanguinating Hemorrhage Airway / Ventilation Decompress Tension Pneumothorax Replace Lost Volume If Response Consider Termination of Resuscitation NAEMSP American College of Surgeons ACEP Position Statement on TOR Termination of Resuscitation BLUNT TRAUMA 8

9 Why? Should we risk lives of responders in Ambulance? Should we risk lives of citizens in street? Leading cause of line of duty death for EMS is AMBULANCE WRECKS! 9