Tag Archives: prehospital

General

Violating Resuscitation Guidelines for Prehospital Traumatic Arrest

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Eight years ago, the National Association of Emergency Medical Services Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ACS-COT) released guidelines regarding withholding or terminating resuscitation in traumatic cardiopulmonary arrest (TCPA). Survival rates were extremely low (<2%) and were thought to have poor outcomes. But validation of the guidelines has been challenging, and some even doubted that EMS personnel could accurately assess these patients in the field!!

Researchers at Mt. Sinai Hospital in Chicago performed a large retrospective study of all patients in TCPA brought to their hospital by the Chicago Fire Department over at 7.5 year period. These patients met exclusion criteria but had been resuscitated anyway. Their series was relatively large (294 patients), and looked not only at the ultimate outcome, but also at EMS performance and cost.

They found that field assessments by EMS were very accurate and consistent. Violation of the guidelines resulted in only 6 survivors, and they all were resuscitated to a neurologically devastated state (4 brain dead, 1 family withdrew support, 1 sent to TCU with long-term GCS 6). No loss of neurologically intact survivors would have occurred if the guidelines were followed. Finally, the cost of trying to resuscitate these patients was $385,000 per year.

Bottom line: EMS can and should apply the NAEMSP/ACS-COT criteria for traumatic cardiopulmonary arrest and withhold resuscitation for these patients. Tragically, it is an expensive waste of time to try to bring them back. 

To review the NAEMSP guidelines, click here.

Reference: The consequences of violating current guidelines regarding resuscitation of patients in prehospital traumatic arrest. Presented at the 34th annual Residents Trauma Paper Competition at the 89th Annual Meeting of the ACS Committee on Trauma, March 10, 2011.

General

The EMS Second IV In Trauma

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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.

Reference:

  • Study of placing a second intravenous line in trauma. Prehospital Emerg Care 15:208-213, 2011.
General

Scoop and Run or Stay and Play for Trauma Care?

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Scoop and run vs stay and play are traditionally EMS concepts. Do I stay at the scene to perform invasive procedures, or do I perform the minimum I can and get to the nearest hospital?

For trauma patients time is the enemy and there is a different flavor of scoop and run vs stay and play. Do I take the patient to a nearby hospital that is not a high level trauma center to stay and play, or do I scoop and run to the nearest Level I or II center?

Admissions to a group of 8 trauma centers were analyzed over a 3 year period. A total of 1112 patients were studied. Patients were divided into two groups: those who were taken directly to a Level I trauma center (76%), and those who were transferred from another hospital (24%). 

Patients who were taken to a non-trauma center first received 3 times more IV crystalloid, 12 times more blood, and were nearly 4 times more likely to die!

Obviously, the cause of this increased mortality cannot be determined from the data. The authors speculate that patients may undergo more aggressive resuscitation with crystalloid and blood at the outside hospital making them look better than they really are, and then they die. Alternatively, they may have been under-resuscitated at the outside hospital, making it more difficult to ensure survival at the trauma center.

Bottom line: this is an interesting paper, but there are a number of flaws that prevent us from mandating that all trauma patients should go directly to the trauma center. The authors never really define a “nontrauma hospital.” Does a Level III or IV center count? How did patients who stayed at the outside hospital do?

A lot of work needs to be done to add detail to this work. In the meantime, we have to trust our experienced prehospital providers to determine who really needs to go to the closest appropriate center, and what that really is.

Reference: Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer’s effect on mortality. J Trauma 69(3):595-601, 2010.

General

How Accurate is EMS at Estimating Blood Loss in the Field?

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EMS providers are the trauma professional’s eyes and ears when providing transportation from the scene of an accident. We rely on their assessment of the mechanism of injury and the amount of blood lost. We tend to believe in the accuracy of those assessments.

A study was carried out that tested EMS personnel on their ability to accurately estimate specific amounts of blood that were left at a simulated accident scene. The blood volumes tested were 500cc, 1000cc, 1500cc and 2100cc. A total of 92 professionals participated, and there was an even split into basic EMTs (34%), intermediate/critical care EMTs (33%) and paramedics (31%). Experience levels were as follows: 0-5 years 43%, 6-10 years 30%, >10 years 31%.

The results were as follows:

  • 87% underestimated the quantity of blood
  • 9% overestimated
  • 4% guessed the exact amount
  • Experience or credentialing level did not matter

Only 8% of the subjects were within 20% of the actual volume, and an additional 19% were within 50%. In general, most medics underestimated the amount of blood lost, and their guesses were worse with higher volumes. The median guess for the 2100cc loss group was only 700cc!

EMS Blood Loss Estimates

The bottom line: Visual estimates of blood loss are extremely inaccurate, and are most likely  underestimates. Physicians in the ED should rely on exam and physiology to help determine the amount of blood loss. For safe measure, multiply the reported blood loss of the EMT or paramedic by 2 or 3 to get a realistic number.

Reference: Patton et al. Accuracy of Estimation of External Blood Loss by EMS Personnel. J Trauma 50(5), 914, 2001.