Prehospital Trauma Life Support Research Articles

International Trauma Anesthesia and Critical Care Society (ITACCS).

International Trauma Anesthesia and Critical Care Society (ITACCS).

Advanced Trauma Life Support System (ATLS) in a Peripheral Hospital.

Dear Editor, It was Dr James Stynor, an American Orthopaedic Surgeon who introduced a structural trauma management training programme, following the death of his wife and serious injury to his 3 children in an air crash in 1970s. This approach is now regarded as gold standard in early trauma, initial assessment and resuscitation. The basic philosophy of the ATLS is to treat lethal injury first, then reassess and treat again. Component steps of ATLS are:- Elements of primary survey are: Airway with cervical spine control Breathing and ventilation Circulation with control of haemorrhage Dysfunction of the central nervous system Exposure in a controlled environment Secondary survey: Head to toe examination of the undressed stable patient The ATLS approach focuses on the second or early death group where death is preventable [1]. At least one in five and possibly as many as one in three, trauma deaths in hospital are preventable [2]. We have adopted ATLS with modification as required for our hospital setting (Table 1). Pre-hospital trauma life support (PHTLS) is essential component of ATLS in which Regimental Medical Officers (RMOs), Nursing Assistants (NAs) and Battlefield Nursing Assistants (BFNAs) are trained in Combat Survival Skills. We have done away with the system of receiving the casualties in Ml Room and shifting them to the ward. We receive our casualties directly in the acute ward, where Nursing officer/NA on duty does the primary survey and sends information quickly to Duty Medical Officer (DMO) and surgical team. In primary survey they carryout ABCD of the ATLS. Doctors do the re-primary survey and secondary survey. In documentation, investigations and required X-rays are carried out in the acute ward itself. Focused abdominal sonogram for trauma (FAST) is done in the ward with portable ultrasound by the surgeon [3]. Triage of mass casualties is carried out by the surgeon. In this small peripheral 49 bedded hospital with limited staff and equipment we have managed 372 battle casualties successfully with no mortality in 2 years. Table 1 Advanced Trauma life Support System (ATLS) Protocol 169 MH Our experience with ATLS is wonderful. It is recommended that all large hospitals should have a trauma wing to handle polytrauma cases and follow ATLS to prevent early deaths. It is also recommended that the concept of PHTLS be taught to all officers of other Arms and Services during their training to enable them to ensure better Combat Survival Skills of their troops.

European comprehensive training course on prehospital advanced trauma life support in adults.

ARAUJO, R.; CORTE, F. DELLA; DICK, W.; DRISCOLL, P.; GIRBES, R.; LORENZO, A.E. HERNANDO; LIPP, M.; NARDI, G.; OAKLEY, P.; SABBE, M. ON BEHALF OF ERC, EUSEM, ITACCS, BTA and ESICM

Improving Capabilities in Prehospital Trauma Life Support

Improving Capabilities in Prehospital Trauma Life Support

Low-cost improvements in prehospital trauma care in a Latin American city.

Prehospital care is a critical component of efforts to lower trauma mortality. In less-developed countries, scarce resources dictate that any improvements in prehospital care must be low in cost. In one Latin American city, recent efforts to improve prehospital care have included an increase in the number of sites of ambulance dispatch from two to four and introduction of the Prehospital Trauma Life Support (PHTLS) course. The effect of increased dispatch sites was evaluated by comparing response times before and after completion of the change. The effect of PHTLS was evaluated by comparing prehospital treatment for the 3 months before initiation of the course (n = 361 trauma patients) and the 6 months after (n = 505). Response time decreased from a mean of 15.5 +/- 5.1 minutes, when there were two sites of dispatch, to 9.5 +/- 2.7 minutes, when there were four sites. Prehospital trauma care improved after initiation of the PHTLS course. For all trauma patients, use of cervical immobilization increased from 39 to 67%. For patients in respiratory distress, there were increases in the use of oropharyngeal airways (16-39%), in the use of suction (10-38%), and in the administration of oxygen (64-87%). For hypotensive patients, there was an increase in use of large-bore intravenous lines from 26 to 58%. The improved prehospital treatment did not increase the mean scene time (5.7 +/- 4.4 minutes before vs. 5.9 +/- 6.8 minutes after). The percent of patients transported who died in route decreased from 8.2% before the course to 4.7% after. These improvements required a minimal increase (16%) in the ambulance service budget. Increase in sites of dispatch and increased training in the form of the PHTLS course improved the process of pre-hospital care in this Latin American city and resulted in a decrease in prehospital deaths. These improvements were low cost and should be considered for use in other less developed countries.

Effect of basic prehospital trauma life support program on cognitive and trauma management skills.

We tested the effectiveness of a basic prehospital trauma life support (PHTLS) program by assessing cognitive performance and trauma management skills among prehospital trauma personnel. Fourteen subjects who completed a standard PHTLS course (group I) were compared to a matched group not completing a PHTLS program (group II). Cognitive performance was assessed on 50-item multiple choice examinations, and trauma skills management was assessed with four simulated trauma patients. Pre-PHTLS multiple choice questionnaire scores were similar (45.8 +/- 9.4% vs. 48.8 +/- 8.9% for groups I and II, respectively), but the post-PHTLS scores were higher in group I (80.4 +/- 5.9%) than in group II (52.6 +/- 4.9%). Pre-PHTLS simulated trauma patient performance scores (standardized to a maximum total of 20 for each station) were similar at all four stations for both groups, ranging from 7.9 to 10.4. The post-PHTLS scores were statistically significantly higher at all four stations for group I (range 16.0-19.0) compared to those for group II (range 8.0-11.1). The overall mean pre-PHTLS score for all four stations was 8.3 +/- 2.1 for group I and 8.8 +/- 2.0 (NS) for group II; the group I post-PHTLS mean score for the four stations was 17.1 +/- 2.7 (p < 0.05) compared to 9.1 +/- 2.3 for group II. Pre-PHTLS Adherence to Priority scores on a scale of 1 to 7 were similar (1.1 +/- 0.9 for group I and 1.2 +/- 1.0 for group II). Post-PHTLS group I Priority scores increased to 5.9 +/- 1.1. Group II (1.1 +/- 1.0) did not improve their post-PHTLS scores. The pre-PHTLS Organized Approach scores in the simulated trauma patients on a scale of 1 to 5 were 2.1 +/- 1.0 for group I and 1.9 +/- 1.2 for group II (NS) compared to 4.2 +/- 0.9 (p < 0.05) in group I and 2.0 +/- 0.8 in group II after PHTLS. This study demonstrates improved cognitive and trauma management skills performance among prehospital paramedical personnel who complete the basic PHTLS program.

Trauma patient outcome after the Prehospital Trauma Life Support program.

We have previously demonstrated a significant improvement in trauma patient outcome after the Advanced Trauma Life Support (ATLS) program in Trinidad and Tobago. In January of 1992, a Prehospital Trauma Life Support (PHTLS) program was also instituted. This study assessed trauma patient outcome after the PHTLS program. Morbidity (length of stay and degree of disability), mortality, injury severity score, mechanism of injury, age, and sex among all adult trauma patients transported by ambulance to the major trauma hospital were assessed between July of 1990 to December of 1991 (pre-PHTLS, n = 332) and January of 1994 to June of 1995 (post-PHTLS, n = 350). Age, sex distribution, percentage blunt injury, and injury severity score were similar for both groups. Mortality pre-PHTLS (15.7%) was greater than post-PHTLS (10.6%). Length of stay and disability were statistically significantly decreased post-PHTLS. Age, injury severity score, and mechanism of injury were positively correlated with mortality in both periods. The previously reported post-ATLS mortality was similar to the pre-PHTLS mortality. Post-PHTLS mortality and morbidity were significantly decreased, suggesting a positive impact of the PHTLS program on trauma patient outcome.

Effect of the prehospital trauma life support program (PHTLS) on prehospital trauma care.

Improvement in trauma patient outcome has been demonstrated after the implementation of the Prehospital Trauma Life Support (PHTLS) program in Trinidad and Tobago. This study was aimed at identifying prehospital care factors that may explain this improvement. All patients transferred by ambulance to the major trauma referral hospital had assessment of airway control, oxygen use, cervical (C)-spine control, and hemorrhage control, as well as splinting of extremities during pre-PHTLS (July of 1990 to December of 1991; n = 332) and post-PHTLS periods (January of 1994 to June of 1995; n = 350). Pre-PHTLS data were compared with post-PHTLS data by chi 2 analysis with a p value < or = 0.05 being considered statistically significant. The frequency (%) increased in the post-PHTLS period for airway control (10 vs. 99.7%), C-spine control (2.1 vs. 89.4%), splinting of extremities (22 vs. 60.6%), hemorrhage control (16 vs. 96.9%), and oxygen use (6.6 vs. 89.5%) when no specific problem was identified. When a specific problem was identified in these areas, the post-PHTLS percentage also increased for airway control (16.2 vs. 100%), C-spine control (25 vs. 100%), splinting of extremities (33.9 vs. 100%), hemorrhage control (18 vs. 100%), and oxygen use (43.2 vs. 98.9%). Prehospital trauma care has changed after the introduction of the PHTLS program as indicated by more frequent airway control, use of oxygen, control of cervical (C)-spine and hemorrhage, as well as splinting of fractures. This finding was evident not only as a routine but particularly when a specific related problem was identified. This change in prehospital care could be responsible for the improved trauma patient outcome after PHTLS.

Emergency ambulance assistance in The Netherlands: is the Dutch situation optimal?

The system of prehospital trauma care in the Netherlands is the subject of great concern. Although many improvements have been achieved in the last decade, there are still some deficits. Legislation concerning the minimal level of education for ambulance attendants was recently upgraded to 'registered nurse', a standard which must be achieved by 1997. Standardization with regard to extrication techniques, equipment and methods of treatment in prehospital trauma care does not yet exist. Although aware of the fact that large regional differences exist throughout the USA, a system of care in accordance with the advanced trauma life support (ATLS) standard of the American College of Surgeons (ACS) and by means of prehospital and advanced trauma life support (PHTLS) given according to the standards of the National Association of Emergency Medical Technicians (NAEMS) was considered to be the 'golden standard'. Nineteen ground ambulance and two helicopter services in different states of the USA, working according to ACS/NAEMS standard, were visited to analyse the system of care, with special reference to (para)medical education, communication, logistics, and immobilization materials and techniques. In the Netherlands all 41 central post ambulance services (CPAs) were asked to return a questionnaire. This resulted in a 90% (37 out of 41) response. The deficits of the Dutch system of care related to the PHTLS/ATLS standard are pointed out, resulting in recommendations to improve the Dutch system. The requirements of the dispatcher are far inferior to the optimal situation, which, together with the lack of technical equipment, results in serious communication problems. The Dutch ambulance attendant education, in which in the present system the education level reaches 'registered nurse' in only 91% and specialized courses are not mandatory, should be upgraded to the PHTLS level of care.

PHTLS Basic and Advanced Pre-Hospital Trauma Life Support Third EditionPHTLS Committee of the NAEMT in Cooperation with The Committee on Trauma of The American College of Surgeons Mosby LifelinePHTLS Basic and Advanced Pre-Hospital Trauma Life Support Third Edition396pp£25.500-8151-6333-90815163339

PHTLS Basic and Advanced Pre-Hospital Trauma Life Support Third EditionPHTLS Committee of the NAEMT in Cooperation with The Committee on Trauma of The American College of Surgeons Mosby LifelinePHTLS Basic and Advanced Pre-Hospital Trauma Life Support Third Edition396pp£25.500-8151-6333-90815163339

Prehospital trauma care

Prehospital trauma care is a very controversial area. The system used in the USA by paramedics is based on the 'scoop and run' theory, which considers prehospital advanced trauma life support to be a waste of time. In many European countries, on the other hand, advanced trauma life support is mandat

Pre-hospital care — current concepts

After a brief outline of past developments in the training of ambulance personnel, this paper traces the adoption in the UK of Pre-Hospital Trauma Life Support (PHTLS) courses from the US. The 1991 World Student Games in Sheffield, UK led to liaison between training staff from South Yorkshire Metropolitan Ambulance and Paramedic Service (SYMAPS) and from Western New York Medical Training Institute. As a result, the trauma care policy of SYMAPS was altered from aiming to stabilise the patient at the scene of the accident to emphasising rapid and thorough assessment, packaging and transport. This is a resume of the scope of the PHTLS provider course. The course concentrates on the principles of PHTLS for the multisystems trauma victim.

Rescue services and prehospital care of multiple-trauma patients

Prehospital trauma care is a very controversial area. The system used in the USA by paramedics is based on the scoop and run theory, which considers prehospital advanced trauma life support (ATLS) to be a loss of time. In many European countries, on the other hand, ATLS is mandatory. The question over which of these systems is best remains an issue of debate. In common with all complex medical controversies there is no straightforward answer: the best system of prehospital trauma care is probably not limited to either of these extremes. In this review we analyse recent developments in the debate.

Basic trauma life support: What is it?

After the National Academy of Science identified trauma as “the neglected disease of modern society” in 1966,’ there has been a massive effort to upgrade emergency medical care in the ‘United States. Early training of paramedics concentrated on field stabilization because of the intense medical scrutiny of lay personnel performing skills previously the prerogative of physicians. The initial success of stabilizing cardiac patients at home by taking an “emergency room on wheels” and in some cases even a physician to the scene, set the trend for emergency medical services (EMSs) of the 1970~.~ We have since realized that serious trauma cannot be stabilized in the field, but needs expeditious supportive care during transport to a facility prepared to immediately treat this surgical emergency. Basic trauma life support (BTLS) has evolved to train prehospital care personnel to properly handle seriously injured patients. In September 1986 at the American College of Emergency Physicians (ACEP) Scientific Assembly in Atlanta, GA, the Board of Directors of the ACEP recommended that BTLS be “endorsed and promulgated” as a course for teaching paramedics advanced trauma care in the pre-hospital setting.3 A similar program, Pre-Hospital Trauma Life Support (PHTLS) has been developed by the American College of Surgeons.4 Emergency physicians, trauma surgeons, and emergency medical service system directors will increasingly be interfacing with prehospital care providers trained by these programs. BTLS incorporates the current fund of knowledge regarding trauma care into a philosophy of prehospital management stressing rapid examination, rapid identification of life threatening problems, and rapid transport to a facility capable of dealing with the multiply injured. It encompasses an educational system for training paramedics, relying heavily on adult education techniques and the development of advanced psychomotor skills, requiring approximately 24 hours of instruction. Heavy emphasis on role playing in moulaged scenarios is used to teach initial assessment. A main component of the course is to teach the student how to perform a rapid physical examination to identify

Prehospital advanced trauma life support for penetrating cardiac wounds

Prehospital advanced trauma life support (ATLS) is controversial because the risks, benefits, and time required to accomplish it remain unknown. We studied 70 consecutive patients with penetrating cardiac injuries to determine the relationships among prehospital procedures, time consumed in the field, and ultimate patient outcome. Thirty-one patients sustained gunshot wounds, and 39 had stab wounds. The mean Revised Trauma Score was 2.8 +/- 0.5. Paramedics spent an average of 10.7 +/- 0.5 minutes at the scene. Seventy-one percent of the patients underwent endotracheal intubation; 93% had at least one IV line inserted; and 57% had two IV lines inserted. Twenty-one (30%) survived. There was no correlation between on-scene time and either the total number of procedures performed (r = .17, P = .17) or IV lines established (r = .06, P = .6). On-scene times did not differ regardless of whether endotracheal intubation or pneumatic antishock garment applications occurred. We conclude that well-trained urban paramedics can perform multiple life-support procedures with very short on-scene times and a high rate of patient survival and that prehospital trauma systems require a minimum obligatory on-scene time to locate patients and prepare them for transport.

Prehospital advanced trauma life support for penetrating cardiac wounds

Prehospital advanced trauma life support for penetrating cardiac wounds

Prehospital advanced trauma life support for critical blunt trauma victims

The ability of paramedics to deliver advanced trauma life support (ATLS) in an expedient fashion for victims of trauma has been strongly challenged. In this study, the records of 114 consecutive victims of blunt trauma who underwent laparotomy or thoracotomy were reviewed. Prehospital care was rendered by paramedics operating under strict protocols. The mean response time (minutes +/- SEM) to the scene was 5.6 +/- 0.27. On-scene time was 13.9 +/- 0.62. The time to return to the hospital was 8.0 +/- 0.4. On-scene time included assessing hazards at the scene, patient extrication, spine immobilization (n = 98), application of oxygen (n = 94), measurement of vital signs (n = 114), splinting of 59 limbs, and the following ATLS procedures: endotracheal intubation (n = 31), IV access (n = 106), ECG monitoring (n = 69), procurement of blood for tests including type and cross (n = 58), and application of a pneumatic antishock garment (PASG) (n = 31). On-scene times were analyzed according to the number of ATLS procedures performed: insertion of one IV line (n = 46), 14.8 +/- 1.03 minutes; two IV lines (n = 28), 13.4 +/- 0.92; one IV line plus intubation (n = 7), 14.0 +/- 2.94; two IV lines plus intubation (n = 9), 17.0 +/- 2.38; and two IV lines plus intubation plus PASG (n = 13), 12.4 +/- 1.36. Of the 161 IV attempts, 94% were completed successfully. Of 36 attempts at endotracheal intubation, 89% were successful.(ABSTRACT TRUNCATED AT 250 WORDS)