One of the critical maneuvers that EMS providers perform is establishing initial vascular access. This IV is important for administering medications and for initiating volume resuscitation in trauma patients. Prehospital Trauma Life Support guidelines state that every trauma patient should receive two large bore IV lines. But is this really necessary?
The upside of having two IVs in the field is that the EMS provider can give lots of volume. However, a growing body of literature tells us that pushing systolic blood pressure up to “normal” levels in people (or animals) with an uncontrolled source of bleeding can increase mortality and hasten coagulopathy.
The downside of placing two lines is that it is challenging in a moving rig, sterility is difficult to maintain, and the chance of a needlestick exposure is doubled. So is it worth it?
A group at UMDNJ New Brunswick did a retrospective review of 320 trauma patients they received over a one year period who had IV lines established in the field. They found that, as expected, patients with two IVs received more fluid (average 348ml) before arriving at the hospital. There was no increase in systolic blood pressure, but there was a significant increase in diastolic pressure with two lines. The reason for this odd finding is not clear. There was no difference in the ultimate ISS calculated, or in mortality or readmission.
Bottom line: This study is limited by its design. However, it implies that the second field IV is not very useful. The amount of extra fluid infused was relatively small, not nearly enough to trigger additional bleeding or coagulopathy. So if another IV does not deliver significant additional fluid and could be harmful even if it did, it’s probably not useful. Prehospital standards organizations should critically look at this old dogma to see if it should be modified.
Study of placing a second intravenous line in trauma. Prehospital Emerg Care 15:208-213, 2011.
The San Ramon Valley Fire Protection District has released an iPhone app that gives users a window into their 911 dispatch center. When you install the app, you can indicate that you are trained in CPR. Your phone then provides your GPS location, and you can be notified of any sudden cardiac arrest events in your area. You can then proceed to the incident and render assistance, if appropriate.
App users can view all active incidents and the status of dispatched units. If an ambulance passes you or you are stuck in a traffic jam, just tap the screen to find out the details. They can also be notified of incidents by type, and monitor live emergency radio traffic.
The only downside is that leaving GPS location apps active in the background can significantly shorten your battery life. I think we can expect more communities to begin offering services like this in the near future.
The original chest tube collection system traditionally consisted of three chambers. The picture above shows the classic three bottle system (which I actually remember using during residency). On the left is the suction control bottle that determines how much suction is applied to the patient. The middle bottle provides one way flow of air out of the patient, the so-called water seal bottle. Finally, the right bottle collects any fluid from the pleural space.
Collection systems used in hospitals are much more tidy than this, wrapping all three into one modular unit. However, if you look closely you can identify parts of the system that correspond to each of the bottles.
The problem with the older systems is that they typically require water in the “water-seal” chamber to maintain one-way flow out of the patient. If this chamber is compromised by knocking the system over (see this post), air may be able to enter the patient’s chest, giving them a big pneumothorax.
Management of chest tube collection systems by EMS is tough. It’s very easy to tip the system during air or ground ambulance runs, putting the patient at risk. Some manufacturers have developed so called “dry-seal” systems that use a mechanical one-way valve to avoid this problem.
I have not been able to use one of these systems yet. Here is my take on the pros and cons:
Pro – immune to tip-over and malfunction of the water-seal chamber
Con – more difficult to detect an air leak. Current models require either injection of a small quantity of water, tipping the system, or converting to a water-seal system.
Con – no literature regarding safety of this relatively new technology
Bottom line: Looks like a great idea to me, especially for EMS use. Once they get to the hospital, the unit can be changed to a water-seal system or a larger dry-seal system with the water injection port inthe dry-seal chamber.
After my discourses on under- and over-triage in the last week, I received an interesting question from a reader: although undertriage seems bad from a theoretical standpoint, are there any objective negative consequences?
As you might imagine, there is little literature on this topic. The incidence is low, so it’s tough to design a study with enough power to come to any solid conclusions. There are two studies that I can cite that shed as much light on the subject as possible.
The first looks at system undertriage at the EMS level. A Canadian study looked at patients with severe injuries (identified by ISS>15 after admission) who were taken to trauma centers (correct triage) vs non-trauma centers (undertriage). After solid statistical analysis of over 11,000 patients, they found that mortality in the undertriage group was 24% higher than the correctly triaged patients.
A second study looked at undertriage in one trauma center (1,424 patients) using their standard triage criteria, not ISS. The undertriage group had a significantly lower ISS (17 vs 25). The correctly triaged patients were more frequently intubated in the ED, more likely to be admitted to the ICU, and had longer ICU and hospital stays. Mortality was not significantly different. The problem with this study is that most of the undertriage group probably did not need a trauma activation, based on their lower ISS. The higher ISS patients (who met triage criteria) needed an airway earlier and required critical care more often. These data show that the institution probably needs to adjust its triage criteria!
Bottom line: The Canadian study shows the danger of undertriage prior to reaching definitive care. There is no good literature that illustrates its danger once the patient is at a trauma center. But there is support for the converse idea that appropriately triaged patients get definitive management sooner (airway, critical care). Any takers for designing the study to answer this question?
Survival of the fittest: the hidden cost of undertriage of major trauma. J Amer Col Surgeons, 211:804-811, Dec 2010.
Outcome assessment of blunt trauma patients who are undertriaged. Surgery 148(2): 239-245, Aug 2010.
Every trauma professional knows that seat belts save lives. Numerous studies have borne out the survival benefits of wearing them. But do those same professionals practice what they preach?
A recent study by NHTSA study showed that at least 42% of police officers killed in car crashes were not wearing their seat belts. The number of officers killed in traffic accidents in 2010 has increased by 43% over 2009 numbers. Possible reasons may be that seat belts impede the process of getting into and out of the car quickly, and that the belt may get tangled in utility and gun belts.
What about paramedics and EMTs? I couldn’t find any studies looking at this group. However, observation tells me that medics in the patient care compartment don’t always buckle up. The reason typically given is that wearing a belt may compromise patient care by limiting access to equipment, using the radio, or performing CPR. However, I think that patient care is even more limited if the EMS professional is disabled or killed in a rig crash. The patient is much more likely to survive such a crash since they are firmly strapped into place.
How can you stay safe in the back?
Make a commitment to your colleagues (and family) to always belt in
If appropriate, try to do as much of your assessment and interventions as possible before moving
Organize your work area so that commonly used and critical equipment is within easy reach
Use a cell phone for communication if the radio mic is too far away
If you absolutely do need to unbelt, try to do so only when the rig is stopped at a light or stop sign.
I’m interested in your comments about how common of a problem this really is. Unfortunately, I don’t think NHTSA will be doing any studies on this one.
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