pre hospital care of acutely injured patient by mohd taofiq et al
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Pre-hospital management of
acutely injured patientGrand Round presentation by:
Dr. Aremu W I
Dr. Mohammed T O
Supervising Consultant: Dr. Aderibigbe AB
Outline
Introduction
Historical background
Epidemiology of trauma
• Organisation of trauma system
• Concept of Pre-hospital care
Pre-hospital trauma care
Nigerian experience
Recommendations
conclusion
Trunkey’s trimodal distribution of deaths from trauma with regard to time:
◦ Immediate deaths-50%,do not reach hospital, not possible to save.
◦ Early deaths-30%,Within the first few hours, many are preventable.
◦ Late deaths -20%,occur as a result of organ failure or sepsis
Introduction
Quite distressing are unexpected loss
of lives or permanent disabilities
caused by physical violence or
accidental injury.
Particularly tragic is the injured but
potentially salvageable patient who
dies needlessly through delay in
retrieval, inadequate assessment or
ineffective treatment.
Appropriate initial care can prevents 2nd and 3rd peak.
The concept of “golden hour’
To describe the urgent need for treatment of trauma patient within the first hour after injury.
Definitions
Trauma-injury to the living tissue that
occurs when a physical force contacts
the body(distortion of human frame
from an extrinsic force)
Pre hospital care refers to out-of-
hospital immediate medical care
rendered to injured patients.
Historical background
The need to move wounded soldiers from battle field to aids station led to the concept of emergency medical transport & use ambulance in military.
Two- or four-wheeled horse-drawn wagons were first used by Dominique Jean Larrey(1766-1842).
In 1865,the first hospital-based ambulance was developed in commercial hospital in Cincinnati, Ohio.
Four years later(1869),New York city’s Bellevue Hospital started first municipal service(out of hospital service with ambulances carrying medical equipments)
In June 1887,St John ambulance brigade was established to provide first aid and ambulance services at public events in London
Rescue society founded in Vienna
after disastrous fire at the Vienna ring
theatre in 1881 was the earliest
emergency medical services reported
1st motorized ambulance came to use
in 1899 donated to Michael Reese
hospital, Chicago.
World’s first component of civilian pre
hospital care on scene began in
1928(Roanoke live saving and first aid
crew in Roanoke, Virginia).
Canadian historian-First formal
training for ambulance attendants was
conducted in city of Toronto in 1892,
During the two world war, advances were made with positive results on patient’s morbidity & mortality.
Modern ambulance design
EMS system design
Epidemiology of trauma
principal cause of death in the first 4 decades
80% of deaths between 15 and 24yr
Every 5min,there is a death from traumatic injury(accidental death)
In USA, unintentional injury was the fifth leading cause of death in 2002.
11th leading cause of death & 6th leading cause of DALY’s loss in Nigeria(WHO,2002).
150,000 deaths annually in the US
18,000 deaths from accident annually in UK
Permanent disability 3 times the mortality rate in the US
> 45m people world wide are left with disability
Globally, injury mortality has M:F of 2:1
Injury accounts for 12% of the world’s burden of disease.
Trauma morbidity & mortality risk is increased by◦ Increasing age
◦ Co morbidity
◦ Obesity
Determinant of injury severity
Force of impact
Duration of impact
Body part involved
Injuring agent
Associated risk factors
Economic burden
Global trauma related cost-- > $500 billion annually
The economic costs associated with RTIs in Africa were estimated to be US$3.7 billion in 2000,
translating to approximately 1–2% of each country’s gross national product.
Significant loss of productive work years
Causes of trauma
RTC-leading cause of traumatic injury
Fall
Industrial/occupational accidents
Disasters
Sport injury
Burns
Assaults
Leading Causes of the Global
burden of TraumaCause of death Individuals killed
Road traffic injuries 1,260,000 (25%)
Other injuries 856,800 (17%)
Suicide 815,000 (16%)
Homicide 520,000 (10%)
Drowning 450,000 (9%)
Poisoning 315,000 (6%)
War 310,000 (6%)
Falls 283,000 (6%)
Burns due to fire 238,000 (5%)
World Health Organization, 2000.
RTI kill 1.3m people annually
80% of global deaths from RTI occur
in developing countries
By 2030, RTI will be 5th leading cause
of death & disability.
The population burden of road traffic
injury is high in Nigeria, at 41 per 1000
population.
◦ Motorcycle injuries comprise over half of
road traffic injuries (54%)
◦ urban VS rural populations –no significant
difference
Federal Road Safety Commission estimates
◦ 5777 deaths in 2004, 0.046 per 1000 population
◦ 4519 deaths occurred in 2005, 0.036 per 1000 population
Organization of trauma
system Trauma system-an organized effort
coordinated by a national or local agency to deliver care(from acute injury to rehabilitation) to injured patient in a defined geographical area.
3 components:◦ Pre hospital care
◦ System wide communication
◦ Appropriately designated hospital Level I
Level II
Level III
Stages of high quality pre hospital
care-star of life
◦ Early detection
◦ Early reporting
◦ Early response
◦ Good on-scene care
◦ Care on transit
◦ Transfer to definitive care
Level of care
BLS & ALS
For trauma care, basic skills include
◦ Basic airway maneuvers
◦ BVM & oxygen
◦ CPR and automated external defibrillation
◦ Hemorrhage control
◦ spine immobilization
◦ Needle decompression of suspected tension pneumothorax
◦ Splinting of major extremity fractures
‘scoop & run’ VS ‘stay & play’
Pre-hospital trauma care
AIM : To provide quality, safe, prompt &
effective health care
Varies from one country to the other
2 levels of care: Basic life support(BLS)
Advance life
support(ALS)
BLS improves outcome in trauma patient
Pre-hospital trauma care
Role of providers :
- Ensure safety of the scene
- For individual victim: Identify life
threatening injuries
Pre-hospital trauma care
• Role of providers :
- For Multiple victim: Triage
- Alert designated trauma
centres/call for help
- Stabilization & transport to
trauma centres
Pre-hospital care
TRIAGE :
- Process of rapidly & accurately
evaluating trauma patient to
determine extent of injuries & the
level of medical care required
- Goal is to transport all seriously
injured patients to appropriate
facility
Pre-hospital care
TRAIGE :
- Depends on a number of variables
- Triage scoring systems
- The Medical Emergency Trial Tags(METTAG)
- black is dead, red is critical, yellow is serious, green is not serious
Pre-hospital care
Initial evaluation / Primary Survey :
- follows the ABCDE pattern
A: Air way & Cervical spine control
B: Breathing
C: Circulation
D: Disability/Neurologic assessment
E: Exposure & enviromental control
Air way control
Assess the airway for patency & protective reflex
Ask patient to open mouth & phonate
Level of consciousness – a 1° indicator of airway stability
Manual in line(MIL) Stabilization of the cervical spine
Air way control
Suction
Chin lift/jaw thrust
Oral/nasal airways
Rescue airways/Airway adjuncts
Air way control
Definitive airways
◦ RSI for agitated patients with c-spine
immobilization
◦ ETI for comatose patients (GCS<8)
◦ Perfomance in the pre-hospital setting is
controversial
Difficult airway
Breathing
Assessed by determining the Patient’s
RR
Palpate,Percuss & Auscultate the
chest
Pulse oximetry is a mandatory adjunct
ETCo2 is becoming a useful adjuncts
Breathing
Oxygen
Control of ventilation
Seal open / sucking chest wound
Chest decompression
Circulation
Evaluate mental status,Skin colour &
temperature
BP & RR – not reliable
Hemorrhagic shock should be
assumed in any hypotensive trauma
patient
Circulation
Direct pressure / pressure dressings
Tourniquet application
Use of pelvic binder
Intravenous / intraosseous line
IV access preferably done enroute
Restricted use of IVF is advocated
Disability
Abbreviated neurological exam
- Level of consciousness
- Pupil size and reactivity
- Motor function
GCS
- Utilized to determine severity of injur
- Guide for urgency of head CT and ICP monitoring
Disability
Spinal cord injury
- High dose steroids if within 8 hours
Elevated ICP
- Head of bed elevated
- Mannitol
- Hyperventilation
- Emergent decompression
Proper Spinal immobilization
Exposure / Enviromental
control Complete disrobing of patient
Logroll to inspect back
Rectal temperature
Warm blankets/external warming
device to prevent hypothermia
Secondary survey
A quick but thorough review of the
body
Aim : to identify missed injuries
Common pitfalls – not inspecting the
back, the axilla, the gluteal region &
the pannicular folds
Others Issues
Fractures
Pain management
Transport
Burns
Extrication – the Kendrick extrication device
Prehospital determination of death
The Nigerian experience
Pre-hospital care of the injured in
south western Nigeria: A hospital
based study of four tertiary hospital in
three states.
• Aim : to determine the level of pre-
hospital care
The Nigerian experience
- A hospital based prospective study
- Information gathered using a one-
page proforma
The Nigerian experience
1996 patients were seen. 1600 – Males & 436 – Females, range : 2 – 80, Mean 30.3 ± 13.3yrs
Most accident occurred on Urban road(49.1%), highways(46.3%)
12,040 accident victims, 1,292(10.7%) immediate fatalities, 80,356(69.4%) injured, 1996(23.9%) seen at the casualty.
The Nigerian experience
172(8.6%) had some form of pre-hospital care
- 17 had wound irrigation
- 5 fracture splinted
- 4 water to drink
- 10 wound cover
The Nigerian experience
wound irrigation
fracture splinted
drinking water
wound coverage
others81(69%)
17(15%)
5(4%)
10(9%)
4(3%
)
Mode of transportation
Treatment at other hospital
584 (29.3%) referred from other
hospitals
300(51.3%) of these were from private
hospitals
Treatment at other hospital
208 (35.6%) from secondary level
government hospitals and 64 (11.0%)
from mission funded hospitals
Significantly higher proportion of those
who had their initial treatment in other
hospitals died in the casualty
Interval between injury and presentation
1,412(70.7%) brought directly to the
hospitals
416 (29.5%) arrived within 30 minutes
while another 392 (27.5%) arrived between
30 minutes and an hour.
Discussion
The overall mean arrival time for all
93.6 minutes.
For those who died in the casualty,
the mean arrival time was 49.8
minutes while it was 96.0 minutes for
those who survived.
Revised trauma score & patient
survival
Disscussion
No organized Pre-hospital care
Some of the bystander PHC were inappropriate
Only 29.5% arrived within 30minutes of injury
Discussion
Make shift transportation
29.3% referred from other hospital
Most of the referred patient died
Study Conclusion
There’s a great need to urgently
review the trauma system in Nigeria
better injury surveillance and the
establishment of hospital and
community based trauma registries as
a first step in improving trauma care in
our environment
Recommendations
Government should recruit & train
volunteers and non-medical
professionals on PHC
Establish trauma centres in the 6 geo-
political zones
Develop a national policy guidelines
on pre-hospital trauma care
Recommendations
Better road design
Compliance with traffic rules
Integration of BLS into school
curriculum
recommendations
The hospital should educate the
populace on Pre-hospital care
Continue to provide an avenue for
learning & research on road safety &
trauma care
All health care professionals to have a
first aid box in their vehicles
Conclusion
The financial and social benefits of
reducing premature death and
minimizing disability
from injury are potentially enormous,
and these benefits may play a major
part in
promoting a nation’s economic and
human development.
THANK YOU
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