Does ALS care improve outcomes in trauma care over BLS? Should paramedics intubate head trauma patients? Does ACLS care improve outcomes in medical

Transcription

1

2

3 Does ALS care improve outcomes in trauma care over BLS? Should paramedics intubate head trauma patients? Does ACLS care improve outcomes in medical (non-trauma)care over BLS? Paramedic triage of MI and stroke to specialty centers Other new stuff

4 Clear airway, oxygen Bag-Valve-Mask Stop obvious bleeding Immobilization C Spine/C collars Backboard Hare traction and basic splints

5 Airway management Treatment of tension pneumothorax and sucking chest wounds IV Fluids Meds Morphine Valium Can clear C spine (NEXUS)

6 OPALS study: 2 phases (BLS then ACLS) 17 cities: 2,867 patients Outcome: survival to hospital discharge No change in survival 81.1% vs 81.8% Lower survival with ALS if GCS < 9 (50.9% vs 60%) Stiell IG. CMAJ 2008:

7 Cayten CG, J Trauma 1993: consec pts with ISS > 10 No benefit of ALS when prehosp time < 35 min Eckstein M, J Trauma 2000: year prospective study ALS did not increase scene time ALS did not improve outcomes Liberman M, Ann Surg 2003: Canadian cities w/ different EMS MD vs Paramedic (ALS) vs BLS on scene No benefit of MD or ALS

8 Bag-Valve-Mask Intubation: nasal and oral Combitube rescue---king LT Needle cricothyrotomy last resort RSI depends on the particular EMS system CPAP device

9

10 Gausche M, JAMA 2000: peds (< 12 yo) alternate day BVM vs Intub Survival: BVM 30% vs Intub 26% Davis DP, J Trauma 2005: Retrospective analysis 14,000 traumatic brain injury Intubation in field decreased survival

11 Sen A, Emerg Med Jour 2005: Best evidence/literature review 9 relevant trials Prehosp intubation in TBI is associated with increased mortality

12 Davis DP, J Trauma 2003: Prospective major trauma could not intub w/o RSI Midazolam and SUX Hand-matched controls (non-intub) Worse mortality with RSI

13 Dunford, Ann Emerg Med 2003: Incidence of desaturation and bradycardia 57% had desaturations with median duration 160 sec 19% had assoc bradycardia (< 50) 84% Paramedics described these as Easy

14

15 Does ACLS care improve outcomes? Meds: NTG, morphine, lasix, resuscitation meds (epinephrine, amiodarone, bicarb, calcium, lidocaine) Airway management ECG interpretation Stroke recognition

16 OPALS study: 2 phases (BLS then ACLS) 15 sites: 8,138 patients Phase 1: BLS Phase 2: 1.4 % intubated, 15% IV meds Mortality decreased from 14.3% to 12.4% Stiell IG. NEJM 2007:

17 More established for pulmonary edema CPAP (PEEP valve) commonly used BiPAP now being used for COPD in some counties Hubble MW. Prehosp Emerg Care 2006:

18 Paramedics can assess stroke symptoms Helps to triage to stroke centers Increases # of stroke patients receiving specialized care including thrombolysis Unclear if impacts mortality Chenkin J. Prehosp Emerg Care 2009:

19 Paramedics can accurately read ST elevation Can help triage to cardiac centers Can decrease door to balloon time Best with set protocol to activate system (not just read the ECG) Chenkin J. Prehosp Emerg Care 2009:

20 High variability in post-arrest survival between counties Unclear reasons possibly due to differences in field care Multi-center examination of differences with goal to improve EMS post cardiac arrest outcomes Nichol G. JAMA 2008:

21 Does longer transport time lead to worse outcome? 2 studies: Arizona and Canadian (OPALS) Both studies found no impact of increased transport time Argues that may be OK to transport to regional specialized centers (hypothermia) Spaite DW. Resuscitation 2008: Spaite DW. Ann Emerg Med 2009: Epub.

22 Compared 2 rules to stop resuscitation and avoid transport Basic Life Support Rule performed better 1)No return of spontaneous circulation prior to transport 2) No shock given (not vfib) 3) Arrest not witnessed by EMS personnel 100% positive pred value and 100% specificity Avoid transport in 54% of patients Morrison LJ. Resuscitation 2009: Epub.

23 Attention to chest compressions over intubation More aggressive chest compression Avoid early intubation worse outcomes Transport to specialized centers Hypothermia

24 ACLS does not improve trauma outcomes over BLS ACLS may improve respiratory distress outcomes Paramedics can accurately assess MI and stroke (helps triage and increase to specialty care sites) Resources can be saved using protocols to terminate resuscitation in field

25

26