sagraves ems strategies

8/11/2019 Sagraves Ems Strategies

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Scott G. Sagraves, MD, FACSTrauma Medical Director

St. Lukes Hospital of Kansas City


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No financial relationships creating a conflict

of interest to report


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Define the anatomy and physiology of

Traumatic Brain Injury (TBI)

Explain the concept of the Monroe-Kellie

Doctrine

Interpret the Brain Trauma Foundationguidelines for EMS treatment of TBI


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Discuss EMS strategies for managing

injured patients

Compare and contrast City vs. Country

challenges in managing injured patients

Suggest strategies for the EMSmanagement of trauma patients


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Golden hour

30%

late

20%

immediate

50%


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0%

20%

40%

60%

80%

100%

120%

0min 30min 60min 120min 180min

Time (min)

%D

ecline

Urban

Rural


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injury related deaths are 40%higher in rural communities

than in urban areasCenter for Rural Care Fact Sheet University of North Dakota 2003


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Methods: Retrospective Review of

Autopsy/ME Database

Comparing outcomes urban SDC vs rural VT

All fatalities were reviewed ISS

Age

Cause of death

Mechanism of Injury Comorbidities

Rogers et al, Arch Surg 1997


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San Diego Vermont

Cases 248(41%) 103(72%)*

ISS 54 39*

Age 33 45*

Blunt/Pen(%) 69/31 49/51*


*p < 0.05


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San Diego Vermont

Cases 243(40%) 23(16%)*

ISS 52 33*

Age 33 46*

Blunt/Pen(%) 61/39 96/4*


*p < 0.05


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Rural patients are more likely to die atthe scene, are less severely injuredand are older

Rural patients surviving 24 hoursbefore death are older, less severelyinjured, have more co-morbiditiesand are more likely to die of MOSFcompared to urban patients



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CITY COUNTRY

911 system local

Paid, staffed vehicles Trauma Centers close

Training

Lots of resources

Ground transportALS

911 system county

Volunteer Longer distances

Training difficult

Limited resources

Helicopter transport BLS


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CITY COUNTRY

C.A.B.

load n go

A.B.C.D.E.

stay n play


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Circulation & Hemorrhage control

AirwayBreathing


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AIRWAY & C-spine Control

BREATHINGCIRCULATION & Bleeding Control

DISABILITY - Neurologic AssessmentEXPOSURE - Prevent Hypothermia


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www cdc gov/Fieldtriage


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Visually inspect

Sweep clear with gloved hand

Aggressive suctioning

Avoid Hypoxemia


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http://www.firefightermedic.com/wp-content/uploads/2013/03/bvm3.jpghttp://www.911school.com/store2/product_info.php?cPath=50_53_58&products_id=121&osCsid=9rnqnigb8iteajdd5t201o5e51


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SevereTrauma

Bleeding -- Consumption

CRYSTALLOIDS TRANSFUSION

DILUTION HYPOTHERMIA

COAGULOPATHYM J Cohen, UCSF


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ACIDOSIS

COAGULOPATHY HYPOTHERMIA

DEATH

Triad of Death


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Maintain mission integrity:

Keep the patient alive

Recognition of the triad

Rapid Transport to the nearest

appropriate hospital (trauma

center)


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Immediate vs. delayed fluid resuscitation

for hypotensive patients with penetratingtorso injuries

Bickell WH, Wall MH, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL

Dept of Emergency Services, Saint Francis Hospital, Tulsa, OK USA

N Engl J Med 1994 Oct 27;331:1105-9

598 patients; BP < 90; prospective, randomized Standard vs. limited resuscitation (prior to OR) by EMS

2480 mLs vs. 375 mLs IV fluids

Standard: 38% mortality (p=0.04) & 30% morbidity

Limited: 30% mortality and 23% morbidity


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Normotensive = No IV fluids

Hypotensive = IV fluids until

Palpable radial pulse

Improved mentation MAP ~ 50 mm Hg; SBP ~ 80 mm Hg

Controlled IV fluid boluses

25 500 mL


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Hypotension is almost never due to braininjury or hypovolemia from brainhemorrhage.

Exsanguination can occur from scalplaceration

Hypotension (SBP < 90 for 5 min) doubles brain injury mortality (60% vs. 27%)

additional hypoxia increase mortality to 75%


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Goal:

Maintain SBP > 90 mm Hg; MAP > 65

Treatment

Correct hypotension with isotonic fluids

0.9% Normal Saline

Lactated Ringers (LR)

Consider hypertonic saline (3%) if GCS < 8 250 mL 500 mL bolus


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Established EMS system with goal ofgetting the right patient to the right placein the right amount of time

Goal Limit pre-hospital time

Transport vehicle quickest means to closestcenter

Transport to facility which has: CT scan capabilities

ICP monitoring

Neurosurgical Care


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The perfect hemostatic

dressing does not exist.


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Chitosan (anthropod skeletons) 79 97% success rate

Must adhere well to wound

Is not flexible, difficult to pack

Works best on superficial, flat wounds


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Kaolin volcanic rock Absorbs water in wound

Concentrates factors, platelets

In powder form heat created

Problem solved Gauze pads impregnated

Require 2-5 mins pressure

Activates factor XII


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ONLY PRODUCT ENDORSED BY THE

TACTICAL COMBAT CASUALTY CARE

COMMITTEE OF DoD


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MAST

Blanket or Sheet


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1 gram over 10 minutes

First dose within 3 hours of injury

Second dose: 1 gram over 8 hours


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Trauma=unstable spine injury=spinal cordinjury=permanent neurological deficit=bad.

Any additional movement of the neck/back maycause an injury that was not present immediately

following the initial traumaor it may worsen aninjury that was there prior to any subsequentmedical intervention.

Further injury is avoided by immobilizing the spine.

Immobilization of the spine is safe.

Medicolegal issues prevent us from changing.


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Pressure sores/tissue hypoxia

Good evidence that even short time periodson a board cause tissue hypoxia at contact

points as well as pressure wounds

Wounds become worse with elderly andseverely injured folks who cant readjust onboard (aka spinal cord injured patient!)

Linares HA, Mawson AR, Suarez E, Biundo JJ. Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics. 1987;10:571-3.

Sheerin F, de Frein R. The occipital and sacral pressures experienced by healthy volunteers under spinal immobilization: a trial of three surfaces. J Emerg Nurs. 2007 ;33:447-50.

Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995 ;26:31-36.

Berg G, Nyberg S, Harrison P, Baumchen J, Gurss E, Hennes E. Near-infrared spectroscopy measurement of sacral tissue oxygen saturation in healthy volunteers immobilized on rigid spine boards. Prehosp Emerg Care. 2010;14:419-24.

Walton R, et al. Padded vs. Unpadded Spine Board for Cervical Spine Immobilization. AcadEmerg Med. 1995 Aug;2(8):725-8.


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Increased painHealthy subjects placed on boards developednumerous complaints when on boards for shorttimes (headaches, back, neck pain, dizziness,nausea)

Barney RN, Cordell WH, Miller E. Pain associated with immobilization on rigid spine boards. Ann Emerg Med. 1989;18:918.

Lerner EB, Billittier AJ, Moscati RM. The effects of neutral positioning with and without padding on spinal immobilization ofhealthy subjects. Prehosp Emerg Care. 1998;2:112-6

Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers.Ann Emerg Med.1994;23:48-51


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We should NOTbe immobilizingpenetrating trauma.

Increases mortality and clear supportfrom all parties involved (AANS, ACS-COT, NAEMSP,NAEMT, ATLS/PHTLS etc..)


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Rhee P, et al. 2006

57,523 trauma patients

Evaluated by: Blunt assault

Stab wounds

Gunshot wounds

Rhee P, et al. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating

assault.J Trauma.2006;61:1166-1170


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Rates for C-spine Fx:

GSW (1.35%)

Blunt Assault (0.41%)

Stab Wound (0.12%).

Rates of Spine Cord Inj:

GSW (0.94%)

Blunt Assault (0.14%)

Stab Wound(0.11%) Rhee P, et al. Cervical spine injury is

highly dependent on the mechanism of

injury following blunt and penetrating

assault.J Trauma. 2006;61:1166-1170

Surgical stabilization:

GSW (26/158 [15.5%])

Blunt Aslt(6/19 [31.6%])

Stab Wnd (3/11 [27.8%])

No patient with

penetrating SCI

regained

significantneurologic

recovery.


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Dont get shot in the spinal cord..Neurologic deficits from penetrating

assault were established and final at

the time of presentation.Concern for protecting the neck should

not hinder the evaluation process or life

saving procedures.

Dont waste time on scene

packaging..just go.


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There are no data to support routine spineimmobilization in patients with penetratingtrauma to the neck or torso.

There are no data to support routine spinalmobilization in patients with isolated penetratingtrauma to the cranium.

Spine immobilization should never be done at

the expense of accurate physical examination oridentification and correction of life-threateningconditions in patients with penetrating trauma.

Stuke LE, Pons PT, Guy JS, Chapleau WP, Butler FK, McSwain NE. Prehospital spineimmobilization for penetrating trauma--review and recommendations from the PrehospitalTrauma Life Support Executive Committee.J Trauma.2011;71:763-9; discussion 769-70.


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Unwarranted spinal immobilization can exposepatients to the risks of iatrogenic pain, skinulceration, aspiration and respiratorycompromise, which in turn can lead to multiple

radiographs, resulting in unnecessary radiationexposure, longer hospital stay and increasedcosts. The potential risks of aspiration andrespiratory compromise are of concern because

death from asphyxiation is one of the majorcauses of preventable death in trauma patients.

Kwan I, Bunn F, Roberts I. Spinal immobilization for trauma patients. Cochrane Database of SystematicReviews. 2009;1:1-15


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Reduce amount of on-scene personnel.

Reduce amount of patients lifted fromground on LSB who are already ambulatory.

Reduce amount of awkward positionsproviders place themselves in to extricateotherwise well patients from vehicles.

Reduce scene times by eliminating timespent immobilizing to board. (cot straps arequick!...LSB strapping is NOT quick)


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Decreased awkward extrication of stable patientswho could self-extricate

Less resources/manpower needed (two folks and acot for most minor MVCs with neck pain).

Less scene time when using cot straps and not

securing head. More exposure/access to patient enroute. More comfort for patient. Saves patient from ED doc who leaves on board in

hospital.

Decrease radiological studies. Decreases cost. Decrease in resistance to placing a c-collar in elderly

or borderline patient when not mandated to use LSB.


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Despite the long-standing history and

culture of spinal immobilization with a

backboard and cervical collar, using the

best evidence available, many abroadand in the US believe the risk-benefit

analysis shows that the proven harm is

much worse than the theoretical, butunproven, benefit of the backboard.


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