Tag Archives: EMS

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AAST 2011: Patients Evaluated But Not Transported By EMS

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Injured patients transported to the ED are just the tip of the iceberg. There are some patients who are evaluated by EMS, either at the scene or in their home, but never transported. These patients do not appear in any trauma registry and little information is known about how they do after their evaluation.

Stanford University reviewed county data and found 5,865 patients out of 69,000 who were evaluated by EMS but not transported (3 counties, 3 years of data). Over a quarter (29%) presented to an ED later and 92 were admitted (2% of the total). By linking available vital statistics data, at least 7 were found to have died.

Bottom line: Patients who are evaluated by EMS but ultimately not transported to a hospital may have unsuspected problems. The mortality is very low (0.14%) but these may represent preventable deaths. It is not practical to force everyone to go to the ED. However, it should be cost-effective to at least make a followup call the next day on these select patients to see if they should be urged to get further evaluation in the ED.

Reference: The forgotten trauma patient: outcomes for injured patients evaluated by EMS but not transported. AAST 2011 Annual Meeting, Oral Paper 46.

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Is The Glasgow Coma Scale (GCS) Getting Too Old?

Traumatic brain injury (TBI) is one of the leading causes of death from trauma worldwide. The assessment of TBI was revolutionized in 1976 when the GCS scale was first introduced. Shortly after its introduction, it was found to be predictive of outcome after brain injury. But it does have some drawbacks: it is somewhat complicated, and interrater reliability is low.

Interestingly, a number of studies have shown that the motor component of GCS is nearly as accurate as the full score in predicting survival. Thus, the Simplified Motor Score (SMS) was introduced as a possible substitute for the GCS in 2007. It was found to be equivalent for predicting survival when applied in the ED.

SMS scoring:

  • Obeys commands = 2
  • Localizes pain = 1
  • Withdraws (or less) to pain = 0

So can this scale be validated in the field when applied by prehospital providers?

Nearly 10 years of data (almost 20,000 patients) from the Denver Health trauma registry was analyzed to attempt to validate SMS when used by EMS. Although the statistics were not perfect, they found that GCS and SMS were equivalent for predicting the presence of a brain injury, need for emergency intubation, need for neurosurgical intervention, and death. Interestingly, they found that both SMS and GCS were not quite as good at predicting overall outcomes as previously thought.

Bottom line: The simplified motor score is a simple system that has now been shown to be as accurate as GCS in predicting severity and outcome from head injury. To be clear, though, neither is a perfect system. They must still be combined with clinical and radiographic assessments to achieve the best accuracy. But SMS can and should be used both in-hospital and prehospital to get a quick assessment, and may help determine early intervention and need for activating the trauma team.

References:

  • Assessment of coma and impaired consciousness: a practical scale. Lancet 2:81-84, 1976.
  • Assessment and prognosis of coma after head injury. Acta Neurochir (Wien) 34:45-55, 1976.
  • Validation of the simplified motor score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury. Ann Emerg Med, in press, Aug 2011.
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Hare Traction – Putting It On, Taking It Off

Femoral traction devices have been around for a long time. One reader has asked about the timing of removal of these devices after they arrive at the hospital. I learned a number of things while reviewing the literature to answer this question.

Most importantly, there is really only one indication for applying a traction splint to the femur: an isolated, relatively mid-shaft femur fracture. Unfortunately, there are lots of contraindications. They consist of other injuries or fractures that could sustain further damage from traction. Specifically, these include:

  • Pelvic or hip fracture
  • Hip dislocation
  • Knee injury
  • Tib/fib, ankle or foot fracture

I did find one interesting study from 1999 that looked at how useful these splints really were. Of 4,513 EMS runs, only 16 had mid-thigh trauma and 5 of these appeared to have a femur fracture. Splint application was attempted in 3, and only 2 were successful. This was the experience in only one city (Evanston, IL) for one year. However, it mirrors what I see coming into our trauma center.

Unfortunately, when it comes to removal, there are very few guidelines out there. My advice is to have your orthopedic surgeon evaluate as soon as imaging is complete. They can help decide whether converting to some type of definitive traction is necessary, or whether it can be changed to a more conventional splint. In any case, the objective is to minimize the total amount of time in the traction splint to avoid any further injury to other structures.

Reference: Prehospital midthigh rauma and traction splint use: recommendations for treatment protocols. Am J Emerg Med, 19:137-140, 2001.

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    Helicopter Transport of Trauma Patients Saves Lives

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    Helicopter EMS (HEMS) transport of trauma patients is used primarily to decrease the amount of time between injury and arrival at the trauma center. Unfortunately, efficacy studies have provided conflicting answers as to whether this is actually true. Last year, the CDC completed a large sample study of this issue using the National Trauma Data Bank (NTDB) in an attempt to determine if HEMS flights are effective.

    Using almost 150,000 entries in the NTDB for 2007, they were able to isolate over 56,000 adult records with complete data points. They looked for mortality patterns based on age, injury severity, and revised trauma score, comparing patients who were transported by air vs ground.

    They found the following:

    • Odds of dying in-hospital were 39% lower overall when transported by helicopter
    • This survival advantaged disappeared for patients age 55 and older, possibly because of decreased reserve, comorbidities, more complications, or medications that interfere with successful resuscitation
    • Regardless of type of transport, males always fared worse than females

    Bottom line: This is a large and intriguing study. About 85% of the US population has access to a Level I or II trauma center within an hour. However, a third of those can only get there in that period of time if transported by air. This mode of transport has a significantly lower mortality rate. However, there are cost and safety considerations as well. The key now is to figure out which patients will have the best outcomes after air transport. This will require more work, looking at more than just mortality (e.g. disability, complications).

    Reference: Reduced mortality in injured adults transported by helicopter emergency medical services. Prehospital Emerg Care 15(3):295-302, 2011.

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    Ambulance 2.0: The “Super Ambulance” of the Future

    Lifebot Technology has been working to upgrade the prehospital environment and connect it more closely with trauma professionals in the trauma center. They have done this by developing a so-called “super ambulance.” These ambulances are outfitted with new variations of tried and true technology. This includes a special Hewlett-Packard Slate tablet computer, multiple cameras inside the ambulance, cameras that are wearable by medics, and a state-of-the-art telemedicine system.

    The Slate tablet allows for hand-held patient monitoring, GPS positioning, high resolution imaging via its built-in camera, patient medical record charting, and connection to the trauma center base station. At the base, the emergency physician or trauma surgeon can view monitoring information, control any camera in the ambulance to focus in on the action, and even draw on the Slate’s screen to show the crew areas of interest (telestration).

    The system is pricey ($50,000 US), but is extremely valuable in rural areas where the nearest trauma center may be quite far away. In theory, a doctor could walk a medic through a procedure to resolve a problem that may kill their patient before they can get to the hospital. The system is already in use in select areas in Arizona, Florida and Texas.

    Reference: Displayed at the HIMSS 2011 (Healthcare Information and Management Systems Society) annual meeting, February 20-24, 2011 in Orlando, FL.

    Disclosure: I have no financial interest in Lifebot Technology or Hewlett Packard

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