Prehospital Trauma Management Research Articles

Does prehospital management by doctors affect outcome in major trauma? A systematic review.

There is substantial variation worldwide in prehospital management of trauma and the role of doctors is controversial. The objective of this review was to determine whether prehospital management by doctors affects outcomes in major trauma, including the prespecified subgroup of severe traumatic brain injuries when compared with management by other advanced life support providers. EMBASE, MEDLINE(R), PubMed, SciELO, Trip, Web of Science, and Zetoc were searched for published articles. HSRProj, OpenGrey, and the World Health Organization International Clinical Trials Registry Platform were searched for unpublished data. Relevant reference lists were hand-searched. There were no limits on publication year, but articles were limited to the English language. Authors were contacted for further information as required. Quality was assessed using the Downs and Black criteria. Mortality was the primary outcome, and disability was the secondary outcome of interest. Studies were subjected to a descriptive analysis alone without a meta-analysis due to significant study heterogeneity. All searches, quality assessment, data abstraction, and data analysis was performed by two reviewers independently. Two thousand thirty-seven articles were identified, 49 full-text articles assessed and eight studies included. The included studies consisted of one randomized controlled trial with 375 participants and seven observational studies with over 4,451 participants. All included studies were at a moderate to high risk of bias. Six of the eight included studies showed an improved outcome with prehospital management by doctors, five in terms of mortality and one in terms of disability. Two studies found no significant difference. There appears to be an association between prehospital management by doctors and improved survival in major trauma. There may also be an association with improved survival and better functional outcomes in severe traumatic brain injury. Further high-quality evidence is needed to confirm these findings. Systematic review, level III.

Hypothermia in trauma victims at first arrival of ambulance personnel: an observational study with assessment of risk factors

BackgroundHypothermia is common in trauma victims and is associated with increased mortality, however its causes are little known. The objective of this study was to identify the risk factors associated with hypothermia in prehospital management of trauma victims.MethodsThis was an ancillary analysis of data recorded in the HypoTraum study, a prospective multicenter study conducted by the emergency medical services (EMS) of 8 hospitals in France. Inclusion criteria were: trauma victim, age over 18 years, and victim receiving prehospital care from an EMS team and transported to hospital by the EMS team in a medically equipped mobile intensive care unit. The following data were recorded: victim demographics, circumstances of the trauma, environmental factors, patient presentation, clinical data and time from accident to EMS arrival. Independent risk factors for hypothermia were analyzed in a multivariate logistic regression model.ResultsA total of 461 trauma patients were included in the study. Road traffic accidents (N = 261; 57%) and falls (N = 65; 14%) were the main causes of trauma. Hypothermia (<35 °C) was present in 136/461 cases (29%). Independent factors significantly associated with the presence of hypothermia were: a low GCS (Odds Ratio (OR) = 0,87 ([0,81-0,92]; p < 0.0001), a low air temperature (OR = 0,93 [0,91-0,96]; p < 0.0001) and a wet patient (OR = 2,08 [1,08-4,00]; p = 0.03).ConclusionThe incidence of hypothermia was high on EMS arrival at the scene. Body temperature measurement and immediate thermal protection should be routine, and special attention should be given to patients who are wet.Level of evidenceProspective, multicenter, open, observational study; Level IV.

Expertise of German paramedics concerning the prehospital treatment of patients with spinal trauma.

Spinal immobilization is a standard procedure in emergency medicine. Increasing awareness of complications associated with immobilization of trauma patients leads to controversial discussions in the literature. Current guidelines require to include considerations of accident mechanism, an assessment of the patient's condition and an examination of the spine in the decision-making process if immobilization of the spine should be performed. This requires sound knowledge of assessing these parameters. The aim of the current study is to analyze German paramedics' subjective uncertainty in terms of their prehospital assessment and treatment of patients suffering from spine injuries. Over a period of 17months participants in a trauma course were asked to complete a standardized anonymous questionnaire about subjective uncertainty of prehospital assessment and management of spinal trauma before participation in that course. Questions about the frequency of application of different immobilization tools and skills training on spinal immobilization were also asked. A total of 465 paramedics were surveyed. The participants did not indicate any uncertainty about the prehospital diagnosis and treatment of spinal injuries. The feeling of confidence was significantly greater in participants who had already attended another course on structured trauma care before. The participants agreed with the statements that standardized algorithms facilitate teamwork and that there is a need for a protocol for the prehospital treatment of spinal injuries. Paramedics do not feel uncertain about the prehospital assessment and treatment of spinal injuries. The feeling of confidence in participants who had already attended a course on the treatment of trauma patients before was significantly higher.

Strategically Leapfrogging Education in Prehospital Trauma Management: Four-Tiered Training Protocols.

Trauma-related injury in fast developing countries are linked to 90% of international mortality rates, which can be greatly reduced by improvements in often non-existent or non-centralized emergency medical systems (EMS)-particularly in the pre-hospital care phase. Traditional trauma training protocols-such as Advanced Trauma Life Support (ATLS), International Trauma Life Support (ITLS), and Basic Life Support (BLS)-have failed to produce an effective pre-hospital ground force of medical first responders. To overcome these barriers, we propose a new four-tiered set of trauma training protocols: Massive Open Online Course (MOOC) Trauma Training, Acute Trauma Training (ATT), Broad Trauma Training (BTT), and Cardiac and Trauma Training (CTT). These standards are specifically differentiated to accommodate the educational and socioeconomic diversity found in fast developing settings, where each free course is taught in native, lay language while ensuring the education standards are maintained by fully incorporating high-fidelity simulation, video-recorded debriefing, and retraining. The innovative pedagogy of this trauma education program utilizes MOOC for global scalability and a "train-the-trainer" approach for exponential growth-both components help fast developing countries reach a critical mass of first responders needed for the base of an evolving EMS.

Injury risk for matched front and rear seat car passengers by injury severity and crash type: An exploratory study

BackgroundThe risk of serious injury or death has been found to be reduced for some front compared to rear seat car passengers in newer vehicles. However, differences in injury severity between car occupants by seating position has not been examined. This study examines the injury severity risk for rear compared to front seat car passengers. MethodA retrospective matched-cohort analysis was conducted of vehicle crashes involving injured rear vs front seat car passengers identified in linked police-reported, hospitalisation and emergency department (ED) presentation records during 2001–2011 in New South Wales (NSW), Australia. Odds ratios were estimated using an ordinal logistic mixed model and logistic mixed models. ResultsThere were 5419 front and 4588 rear seat passengers in 3681 vehicles. There was a higher odds of sustaining a higher injury severity as a rear-compared to a front seat car passenger, with a higher odds of rear seat passengers sustaining serious injuries compared to minimal injuries. Where the vehicle occupant was older, travelling in a vehicle manufactured between 1990 and 1996 or after 1997, where the airbag deployed, and where the vehicle was driven where the speed limit was ≥70km/h there was a higher odds of the rear passenger sustaining a higher injury severity then a front seated occupant. ConclusionRear seat car passengers are sustaining injuries of a higher severity compared to front seat passengers travelling in the same vehicle, as well as when travelling in newer vehicles and where the front seat occupant is shielded by an airbag deployed in the crash. Rear seat occupant protective mechanisms should be examined. Pre-hospital trauma management policies could influence whether an individual is transported to a hospital ED, thus it would be beneficial to have an objective measure of injury severity routinely available in ED records. Further examination of injury severity between rear and front seat passengers is warranted to examine less severe non-fatal injuries by car seating position and vehicle intrusion.

Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting: A critical appraisal of the medical literature and available alternatives.

Hemorrhage remains the leading cause of preventable trauma-associated mortality. Interventions that improve prehospital hemorrhage control and resuscitation are needed. Tranexamic acid (TXA) has recently been shown to reduce mortality in trauma patients when administered upon hospital admission, and available data suggest that early dosing confers maximum benefit. Data regarding TXA implementation in prehospital trauma care and analyses of alternatives are lacking. This review examines the available evidence that would inform selection of hemostatic interventions to improve outcomes in prehospital trauma management as part of a broader strategy of "remote damage-control resuscitation" (RDCR). The medical literature available concerning both the safety and the efficacy of TXA and other hemostatic agents was reviewed. TXA use in surgery was studied in 129 randomized controlled trials, and a meta-analysis was identified. More than 800,000 patients were followed up in large cohort study. In trauma, a large randomized controlled trial, the CRASH-2 study, recruited more than 20,000 patients, and two cohort studies studied more than 1,000 war casualties. In the prehospital setting, the US, French, British, and Israeli militaries as well as the British, Norwegian, and Israeli civilian ambulance services have implemented TXA use as part of RDCR policies. Available data support the efficacy and the safety of TXA. High-level evidence supports its use in trauma and strongly suggests that its implementation in the prehospital setting offers a survival advantage to many patients, particularly when evacuation to surgical care may be delayed. TXA plays a central role in the development of RDCR strategies.

Prehospital trauma care education for first responders in India

BackgroundA major factor contributing to global trauma mortality and morbidity is the lack of effective prehospital trauma services in developing settings. We developed a 2-d training course for nondoctor first responders featuring high-fidelity simulation and video-assisted debriefing, self-directed learning videos, and native language instruction. Materials and methodsA pilot session was conducted in Jodhpur, Rajasthan. Eighteen local instructors were recruited to train 48 layperson first responders in 10 essential subjects. Didactic sessions of 15–20 min consisting of self-directed learning videos were followed by 30–40 min skill sessions featuring high-fidelity simulation, and concluded with 15–20 min video-debriefing periods. Changes in competence were evaluated using pretraining and posttraining surveys. ResultsResults demonstrated that statistically significant competence increases in all areas of trauma management assessed: airway (t[46] = 7.30, P < 0.000), hemorrhage (t[46] = 9.96, P < 0.000), fractures (t[46] = 9.22, P < 0.000), cervical spine injury (t[46] = 12.12, P = 0.000), chest injury (t[46] = 7.84, P < 0.000), IV line placement (t[46] = 4.36, P < 0.000), extrication (t[46] = 2.81, P < 0.005), scene assessment (t[46] = 7.06, P < 0.000), triage (t[46] = 5.92, P < 0.000), and communication (t[46] = 5.56, P < 0.000). Highest increases in competence were observed in cervical spine injury and hemorrhage management, with lowest increases in IV line placement and extrication. ConclusionsResults suggest this approach may be effective in imparting prehospital trauma management concepts to layperson first responders. This study highlights an innovative educational avenue through which trauma management capacity can be enhanced in developing settings.

Propensity for performing interventions in pre-hospital trauma management – a comparison between physicians and non-physicians

BackgroundIn 2005, the Advanced Life Support (ALS) teams delivering pre-hospital care in RegionSkane in southern Sweden received additional support by physicians, who were part of “Pre-hospital acute teams” (PHAT). The study objective is to compare the incidence of pre-hospital medical interventions for trauma-patients cared for by conventional ALS teams and patients who received additional support by PHAT.MethodsTrauma patients with Injury Severity Score (ISS) >9 were identified retrospectively in the national quality registry KVITTRA at three hospitals in RegionSkane, for the time period October 2005 to December 2008. Interventions include e.g. tracheal intubation, administration of i.v. fluids, neck immobilization and spine board usage. Confounding effects from trauma severity, trauma mechanism, vital parameters, age and sex were addressed in multivariate models.ResultsData from 202 cases was included. 9 pre-hospital interventions were assessed. The incidence of endotracheal intubation and immobilisation of extremities was higher among patients in the PHAT-group compared to the ALS-only group (16.3% vs. 6.9%, p = 0.034) and (12.8% vs. 4.3%, p = 0.027) respectively. PHATs presence remained a significant predictor of these interventions also after taking confounding factors into account (OR 5.5, CL 1.5-19.7) and (OR 3.2 CI 1.0-9.8).PHAT was involved in a greater proportion of cases with <50.0% of survival (19.8% vs. 12.1%, p = 0.134). The average ISS was higher among cases receiving PHAT support in strata ISS 16-24 and ISS > 24 than cases in corresponding strata cared for by ALS teams alone (ISS 20.0 vs. 17.0, p = 0.048 and ISS 34.0 vs. 29.0, p = 0.019).ConclusionsThe incidence of endotracheal intubation and immobilization of extremities was greater among patients supported by PHAT, compared to patients cared for by ALS teams alone. This finding has to be interpreted in the light of a selection-bias where PHAT support was directed to more severely injured patients.

Retrospective Autopsy Based Study of Fatal Road Traffic Accidents in Fiji

Objective: To describe the demographic profile and distribution of injuries from autopsy cases due to fatal Road Traffic Accidents (RTA) in Fiji. Methods: This is a retrospective autopsy based study consisting of 102 medico-legal autopsies performed by the Fiji Institute of Forensic Science, Fiji Police Force during the period of two calendar years from January 1st 2011 to December 31st 2012. Results: Out of the 1454 medico-legal autopsies performed during the study period, 102 (7%) were due to fatal RTA. There were 72 (70.5%) males and 30 (29.5%) female fatalities with an overall male and female ratio of 2.3:1 and the 30 to 44 years age group showed highest number of victims of 30 (29.4%). The months of October in 2011 and August in 2012 took the maximum toll of road traffic deaths of 9 (8.8%) and 12 (11.6%) respectively. The highest number within the road user group were the passengers of 53 (51.9%) followed by the pedestrians and drivers of 32 (31.2%) and 16 (15.6%) respectively. Human behavioural errors or factors by all the road users of 95 (93.1%) was the highest contributing factor and pre-hospital mortality was most common, particularly road traffic death at the scene (51.9%) and those whilst en route to hospital (29.4%). Highest number of injuries were head injuries of 67 (65.7%), followed by multiple injuries of 57 (55.6%), thoracic injuries of 56 (54.9%), abdominal injuries of 31 (30.3%), vertebral injuries 21 (20.5%) and major vessel injuries of 12 (11.7%). The most common mechanism of death was haemorrhagic shock of 90 (88.2%) followed by asphyxia of 7 (6.8%), arrhythmias of 3 (2.9%) and finally septic shock of 2 (1.9%). Conclusion: This study emphasizes the need for better pre-hospital and hospital trauma management, improved traffic law enforcement, effective traffic related and health policy creation, and the establishment of a national traffic traumatic injury surveillance registry in Fiji.

Permissive Hypotension in Bleeding Trauma Patients: Helpful or Not and When?

Severity of hemorrhage and rate of bleeding are fundamental factors in the outcomes of trauma. Intravenous administration of fluid is the basic treatment to maintain blood pressure until bleeding is controlled. The main guideline, used almost worldwide, Advanced Trauma Life Support, established by the American College of Surgeons in 1976, calls for aggressive administration of intravenous fluids, primarily crystalloid solutions. Several other guidelines, such as Prehospital Trauma Life Support, Trauma Evaluation and Management, and Advanced Trauma Operative Management, are applied according to a patient's current condition. However, the ideal strategy remains unclear. With permissive hypotension, also known as hypotensive resuscitation, fluid administration is less aggressive. The available models of permissive hypotension are based on hypotheses in hypovolemic physiology and restricted clinical trials in animals. Before these models can be used in patients, randomized, controlled clinical trials are necessary.

Requirement for a structured algorithm in cardiac arrest following major trauma: Epidemiology, management errors, and preventability of traumatic deaths in Berlin

BackgroundDespite continuous innovation in trauma care, fatal trauma remains a significant medical and socioeconomic problem. Traumatic cardiac arrest (tCA) is still considered a hopeless situation, whereas management errors and preventability of death are neglected. We analyzed clinical and autopsy data from tCA patients in an emergency-physician-based rescue system in order to reveal epidemiologic data and current problems in the successful treatment of tCA. Material and methodsEpidemiological and autopsy data of all unsuccessful tCPR cases in a one-year-period in Berlin, Germany (n=101, Group I) and clinical data of all cases of tCPR in a level 1 trauma centre in an 6-year period (n=52, Group II) were evaluated. Preventability of traumatic deaths in autopsy cases (n=22) and trauma-management failures were prospectively assessed. ResultsIn 2010, 23% of all traumatic deaths in Berlin received tCPR. Death after tCPR occurred predominantly prehospital (PH;74%) and only 26% of these patients were hospitalized. Of 52 patients (Group II), 46% required tCPR already PH and 81% in the emergency department (ED). In 79% ROSC was established PH and 53% in the ED. The survival rate after tCPR was 29% with 27% good neurological outcome. Management errors occurred in 73% PH; 4 cases were judged as potentially or definitive preventable death. ConclusionTrauma CPR is beyond routine with the need for a tCPR-algorithm, including chest/pericardial decompression, external pelvic stabilization and external bleeding control. The prehospital trauma management has the highest potential to improve tCPR and survival. Therefore, we suggested a pilot prehospital tCPR-algorithm.

Retrospective review of image quality of CT in polytrauma patients: comparison of patients scanned using a scoop stretcher and without a scoop stretcher

Increasingly pre-hospital trauma management involves transfer of patients using a scoop stretcher; a number of computed tomography (CT) compatible scoops have recently appeared on the market. We sought to evaluate any differences in image quality in polytrauma patients scanned in a scoop stretcher. CT studies of 234 consecutive patients presenting between December 2011 and August 2012 at our regional level 1 tertiary trauma centre were retrospectively reviewed. Patients were allocated into two groups: those scanned with a scoop stretcher and without. CTs were reviewed by a consultant radiologist and two senior radiology trainees and graded separately for quality/artefact. A scale of 1-5 was employed: 1-uninterpretable, 2-borderline image quality, 3-acceptable, 4-good, 5-excellent. A total of 128 (54.7 %) patients were scanned in a scoop stretcher and 106 (45.3 %) were scanned without, 183 males and 51 females (average age, 46 (16-94) years; SD, 20). The average quality grading for the patients scanned in the scoop was 4.64 compared to 4.68 in those without the scoop. There was no significant grading difference between the groups, consultant (p = 0.096) and trainees (p = 0.782). No artefacts were attributable to the scoop stretcher 0/128 (0 %). Following our experience, the use of scoop stretchers is recommended for efficient, safe and practical management of trauma patients and in terms of imaging, with no detrimental effect on image quality.

Trauma‐related Preventable Deaths in Berlin 2010: Need to Change Prehospital Management Strategies and Trauma Management Education

Fatal trauma is one of the leading causes of death in Western industrialized countries. The aim of the present study was to determine the preventability of traumatic deaths, analyze the medical measures related to preventable deaths, detect management failures, and reveal specific injury patterns in order to avoid traumatic deaths in Berlin. In this prospective observational study all autopsied, direct trauma fatalities in Berlin in 2010 were included with systematic data acquisition, including police files, medical records, death certificates, and autopsy records. An interdisciplinary expert board judged the preventability of traumatic death according to the classification of non-preventable (NP), potentially preventable (PP), and definitively preventable (DP) fatalities. Of the fatalities recorded, 84.9 % (n = 224) were classified as NP, 9.8 % (n = 26) as PP, and 5.3 % (n = 14) as DP. The incidence of severe traumatic brain injury (sTBI) was significantly lower in PP/DP than in NP, and the incidence of fatal exsanguinations was significantly higher. Most PP and NP deaths occurred in the prehospital setting. Notably, no PP or DP was recorded for fatalities treated by a HEMS crew. Causes of DP deaths consisted of tension pneumothorax, unrecognized trauma, exsanguinations, asphyxia, and occult bleeding with a false negative computed tomography scan. The trauma mortality in Berlin, compared to worldwide published data, is low. Nevertheless, 15.2 % (n = 40) of traumatic deaths were classified as preventable. Compulsory training in trauma management might further reduce trauma-related mortality. The main focus should remain on prevention programs, as the majority of the fatalities occurred as a result of non-survivable injuries.

Factors Affecting Front Line Casualty Care in Afghanistan

Objective: Limited research has been undertaken to assess the effectiveness of pre-hospital care given at the point of wounding, nor how battlefield conditions affect the implementation of Battlefield Advanced Trauma...

Postgraduate training in anaesthesiology, pain and intensive care

Postgraduate training in anaesthesiology, pain and intensive care

Assessment and treatment of trauma: an international course

Assessment and treatment of trauma (ATT) is a brand new international continuing education course from the American Academy of Orthopaedic Surgeons (AAOS) that represents the state-of-the-art in prehospital trauma assessment and management. Based on the most current medical information and best practices, this concise and highly interactive continuing education course covers the critical knowledge and skills necessary to rapidly evaluate, stabilize, and transport the trauma patient. The: lBasic ATT is geared toward the emergency medical responder and emergency medical technician lAdvanced ATT is geared toward the advanced emergency medical technician, paramedic, and other advanced life support providers.

Prehospital trauma management: a fluid opinion

Prehospital trauma management: a fluid opinion

(P1-46) A Model of Mass Casualty Management Education: The Prehospital Mass Casualty Exercise and Trauma Management Course

IntroductionIn this article, we aimed to share “the prehospital mass casualty exercise and trauma management course” which is performed at the 10th European Congress of Trauma &amp; Emergency Surgery as a model.Methods and MaterialsThe preparation, format, participant properties and the discussion of the course were evaluated.ResultsThe course performed in 4 parts. On the first part, a panel discussion including opening, targets of course and a conference was performed. On the second part, the prehospital mass casualty exercise was performed. On the third part, the participants discussed in different 4 workshops. On the last part, basic discussion results were declared. At the mass casualty exercise, the scenario was adapted from bus bombing which was in Diyarbakir on 03.01.2010, 6 deaths, 96 wounded. Field and injury simulations were performed. We trained 15 paramedic volunteers to act as wounded patients. Moulage and make-ups were made due to previously defined injuries as in Diyarbakir. The victims were placed in simulated maneuvers field. Participants were accepted in five each groups to the maneuvers field and they were requested to manage the scene, triage, first aid. After the exercise, 4 workshops themed as Scene Medical Management, Ground and Air Evacuations, Preparedness of the E D's and Preparedness of the OR's, and ICU's were performed. The results of the workshops were presented at the last part.Discussion and ConclusionThe participants expressed that observing and experiencing the chaos circumstances during the maneuvers are the most important things in scene management and these must be considered in preparedness and planning phases.

Improving prehospital trauma management for skiers and snowboarders - need for on-slope triage?

BackgroundInjuries from skiing and snowboarding became a major challenge for emergency care providers in Switzerland. In the alpine setting, early assessment of injury and health status is essential for the initiation of adequate means of care and transport. Nevertheless, validated standardized protocols for on-slope triage are missing. This article can assist in understanding the characteristics of injured winter sportsmen and exigencies for future on-slope triage protocols.MethodsSix-year review of trauma cases in a tertiary trauma centre. Consecutive inclusion of all injured skiers and snowboarders aged >15 (total sample) years with predefined, severe injury to the head, spine, chest, pelvis or abdomen (study sample) presenting at or being transferred to the study hospital. Descriptive analysis of age, gender and injury pattern.ResultsAmongst 729 subjects (total sample) injured from skiing or snowboarding, 401 (55%, 54% of skiers and 58% of snowboarders) suffered from isolated limb injury. Amongst the remaining 328 subjects (study sample), the majority (78%) presented with monotrauma. In the study sample, injury to the head (52%) and spine (43%) was more frequent than injury to the chest (21%), pelvis (8%), and abdomen (5%). The three most frequent injury combinations were head/spine (10% of study sample), head/thorax (9%), and spine/thorax (6%). Fisher's exact test demonstrated an association for injury combinations of head/thorax (p < 0.001), head/abdomen (p = 0.019), and thorax/abdomen (p < 0.001).ConclusionThe data presented and the findings from previous investigations indicate the need for development of dedicated on-slope triage protocols. Future research must address the validity and practicality of diagnostic on-slope tests for rapid decision making by both professional and lay first responders. Thus, large-scale and detailed injury surveillance is the future research priority.

Prehospital Management of Pediatric Trauma

A limited body of literature about pediatric prehospital trauma care exists to date. Topics that have been studied include delaying transport to initiate treatment on-scene, the use of advanced life support or basic life support resources, identifying high-risk pediatric trauma patients, optimal airway management, obtaining intravenous or intraosseous access, immobilization of the cervical spine, optimal management of traumatic brain injury, and the assessment and management of pain. Translating the best available evidence into clinical practice is important to providing quality prehospital pediatric trauma care. This article will review the literature regarding the risks and benefits of various aspects of pediatric trauma care in the prehospital setting.