Embed Size (px)
Citation preview
Getting There:Getting There:The Right Place at the Right TimeThe Right Place at the Right Time
Jeffrey P. Salomone, MD, FACS, NREMT-P
Associate Professor of SurgeryEmory University School of Medicine
Co-Director of Trauma andDeputy Chief of Surgery
Grady Memorial Hospital
Goal
10. . . in the right amount of time.
. . . to the right place
Get the right patient . . .
Guiding PrincipleGuiding Principle
Patient destination based upon
medical appropriateness
Accessibility to Trauma CentersAccessibility to Trauma Centers
Branas CC, et al; JAMA, 2005:
Almost 90% of the US population lives in areas accessible to designated trauma care (Level I, II or III centers) within a one hour
period of time
Access to Level I and II TC’s within 60 minsAccess to Level I and II TC’s within 60 minsGround EMS (5% land area, 60 % pop)Ground EMS (5% land area, 60 % pop)
Access to Level I and II TC’s within 60 minsAccess to Level I and II TC’s within 60 minsGround + Air Medical EMS Ground + Air Medical EMS (35% land area, 90% pop)(35% land area, 90% pop)
The RealityThe RealityNathens AB, et al; J Trauma, 2000:
500,000 injured persons in 18 statesFailed to receive care at designated trauma
facilities:– 56% of all trauma patients– 36% of major trauma patients
Access to Level I and II TC’s within 60 minsAccess to Level I and II TC’s within 60 minsGround EMS vs Ground + Air Medical EMSGround EMS vs Ground + Air Medical EMS
Land area 4%; 38% pop Land area 79%; 90% pop
The Right PlaceThe Right Place
Trauma CenterTrauma Center
An institution committed to the care of injured patients, from acute care to rehabilitation
Initial resuscitationOperative managementCritical careContinuing care
Trauma CenterTrauma Center
Immediate availability on a 24-hr basis: Specialized surgeonsPhysician specialistsNursesAllied health personnelResuscitation and life support equipment
TeamworkTeamwork Physicians:
– Surgery – EM– Ortho – etc
Therapists:– Respiratory– Physical– Occupational
Technologists:– Lab– Xray
Nurses: – ED– OR– ICU– Ward– Clinic
Trauma CenterTrauma Center
Trauma program: Trauma service Trauma team Trauma medical
director Coordinator / program
manager Performance
improvement/ registry
Trauma CentersTrauma Centers
Levels- established by ACS-COT:– Level IV– Level III– Level II– Level I
“Designated”- state agency“Verified”- ACS-COT site visit
Level IIILevel III
General Surgery- immediately available*Available 24 hrs: EM, Orthopedics, Plastics,
Radiology, Anesthesia– Neurosurgery is desirable
Required (24 hr) : Xray, CT, PACUDesirable (24 hr): Xray Tech, Resp Tech
* = within 15 minutes of patients arrival in ED
Level IILevel II
Level III Criteria, plus:Physicians*: Neurosurg, Hand, OB/GYN,
Ophth, OMFS, Thoracic, CCM 24 hr OR is desirableInjury Prevention outreach
*Inhouse trauma surgeons NOT required
Level ILevel ILevel II criteria, plus:Physicians*: Cardiac surg, MicrovascularServices: CPB, inhouse OR personnel,
inhouse SICU serviceTeaching facility (Surg residency, ATLS)ResearchAdmissions: 1,200/yr; 240 with ISS > 15Tertiary referral / resource center*Inhouse trauma surgeons NOT required
Exclusive vs InclusiveExclusive vs InclusiveTrauma SystemTrauma System
Level IVLevel IV
24 hrs: ED, LabDoes not need 24 hr Emer MedDesirable: 24 hr Gen Surg, AnesthInitial resuscitation
– Refer to higher level center
Hospitals that “lack a commitment to trauma care” have been associated with a higher incidence of unacceptable care and poor outcomes– Moylan JA, et al., J Trauma, 1976 – Detmer DE, et al., J Trauma, 1977
Lack of Trauma CentersLack of Trauma Centers
Comparison of Trauma SystemsComparison of Trauma SystemsWest JG, et al., Arch Surg, 1979Comparison of trauma patients who died
after arrival at a hospital– Orange Co., closest facility (n = 90) – San Francisco, single trauma center (n = 92)
“Preventable” deaths– Orange Co. 40 of 90 deaths (44%):
20/30 (66%) of non-CNS trauma 20/60 (33%) of CNS trauma pts
– SF: only one (about 1%)
Transfer of trauma patients to designated trauma centers has also been shown to improve outcomes:– West JG, et al., Arch Surg, 1983
Follow up to 1979 study Significant reduction in mortality by regionalization:
overall 20% preventable; TC 9% preventable– Shackford SR, et al., J Trauma, 1986– Waddell TK, et al., J Trauma, 1991
Trauma CentersTrauma Centers
Effect of Trauma-Center Care on Effect of Trauma-Center Care on MortalityMortality
Trauma patients managed at 18 Level I trauma centers compared to 51 non-trauma centers (14 states)
Complete records available for:– 1104 patients who died – 4087 patients discharged alive
CDC funded
MacKenzie EJ, et al, NEJM, 2006
Effect of Trauma-Center Care on Effect of Trauma-Center Care on MortalityMortality
In-hospital mortality :– Trauma center: 7.6%; relative risk 0.80– Non-trauma center: 9.5%
One year mortality rate:– Trauma center 10.4%, relative risk 0.75– Non-trauma center: 13.8%
Differences in mortality rates primarily confined to patients with more severe injuries
You (or your patient) are 25% more likely to survive if taken to a trauma center.
Level I vs Level IILevel I vs Level II
Traditionally outcome between Level II and Level I centers viewed to be equivalent– Criteria for clinical care nearly identical– Level I primarily teaching / research facility
Superiority of Level ISuperiority of Level IRetrospective review using NTDB
– pts > 14 yrs, ISS >15– One of the following injuries:
Aortic vena cava iliac vessels Cardiac Grade IV/V liver injuries quadriplegia complex pelvic fx
Demetriades D, et al., Ann Surg, Oct 2005
Superiority of Level I?Superiority of Level I?
Results– 12,254 pts met inclusion criteria– Level I centers had significantly:
Lower mortality (25.3% vs 29.3%, p = 0.004) Less severe disability at D/C ( 20.3% vs 33.8%, p =
0.001) Higher functional outcome
Trauma Center vs Closest HospitalTrauma Center vs Closest Hospital
Closest Hospital CRASH! 8 minute EMS response 10 min scene time 5 min transport time 10 min ED evaluation 30 min surgeon call-in 30 min OR call-in 5 min transfer to ORTotal Time, injury to OR= 98
mins
Trauma Center CRASH 8 minute EMS response 10 min scene time 15 min transport time 10 min ED evaluation 5 min transfer to ORTotal Time, injury to OR= 48
mins
The Right PatientThe Right Patient
OvertriageOvertriage
Transporting minimally injured trauma patients to a trauma center
Overtriage rate of up to 50% considered acceptable
Often a financial / resource issue
Failure to transport major trauma patients to a trauma center
Undertriage rate of 5 – 10 % considered unavoidable, and is associated with an overtriage rate of 30 – 50%
Often a political issue
UndertriageUndertriage
What is a What is a “Major Trauma Patient”?“Major Trauma Patient”?
Injury Severity Score (ISS) > 15 frequently usedCorrelates well with mortality over a broad range of ages
and injuries Knudson MM, et al., Arch Surg, 1994 Buckley SL, et al., J Pediatr Orthop, 1994 Gustilo RB, et al., Orthop, 1985 Jones JM, et al., J Trauma, 1995 Shedden PM, et al., Pediatr Neurosurg, 1990 Chen RJ, et al., Eur J Surg, 1995
Can’t be calculated in the prehospital setting
Major Trauma Patient
Injury Severity ScoreInjury Severity Score
Region InjuryDescription
AIS SquareTop Three
Head & Neck Cerebral Contusion 3 9
Face No Injury 0
Chest Flail Chest 4 16
Abdomen Minor Contusion of LiverComplex Rupture Spleen
2 5
25
Extremity Fractured femur 3
External No Injury 0
Injury Severity Score: 50
ISS - IssuesISS - Issues
Based primarily on motor vehicle crash data– Not as useful in penetrating trauma
Ignores multiple injuries in the same body region
Trauma Index– Kirkpatrick JR, Youmans RL, J Trauma, 1971
Trauma Score / Revised Trauma Score– Champion HR, et al., Crit Care Med, 1981– Champion HR, et al., J Trauma, 1989
CRAMS scale– Gormican SP, Ann Emerg Med, 1982
Prehospital Index– Koehler JJ, et al, Ann Emerg Med, 1986
Trauma Triage Rule– Baxt WG, et al., Ann Emerg Med, 1990
Each with limitations, lacking clear superiority over others
Other Trauma Scores
Alternatives to ISSAlternatives to ISS
Deaths in the ED or within 24 hrs of ED admission
Resource utilization:– Massive blood transfusions– Rapid operative intervention– Cessation of bleeding by interventional
angiography– Early intensive critical care
All difficult to determine in the field!
Field TriageField Triage
Field TriageField Triage
Committee on Trauma, American College of Surgeons / CDC
Components:– Physiologic– Anatomic– Mechanism of Injury– Special Considerations
CaseCase
29 y/o male fishing in small boat at 1 AM. Boat run over by speedboat.Airway: Intact
Breathing: shallow, 34/min, equal
Circulation: no radial pulses, SBP 80 mm Hg, significant hemorrhage from lower extremities
Disability: GCS 13 (E4, V4, M5)
Expose: No injuries to torso, head, upper extremities
Speedboat vs FishermanSpeedboat vs Fisherman
High flow O2, pulse oximetry
Tourniquets placed to bilateral thighs
Transport initiated Intravenous
resuscitation begun enroute
Physiologic CriteriaPhysiologic Criteria
Take to Trauma Center:Glasgow Coma Scale Score < 13Systolic blood pressure < 90 mm HgRespiratory rate < 10 or > 29
– <20 in infant (under one year of age)– Or need for ventilatory support
Physiologic derangement correlates well with severity of injury and can predict mortality– Baxt WB, et al., Ann Emerg Med, 1989
Patients with significant tachycardia and hypotension have typically lost 30 – 40% of their blood volume and often are in need of emergent transfusion and surgical intervention
Physiologic Criteria
CaseCase
55 y/o male, despondent over relationship, stabs self in left chest with kitchen steak knife
Airway: intact Breathing: 24, equal BS Circulation: HR 58, BP
114/68 Disability: GCS 14 Exposure: No other
injuries
Steak knife vs heartSteak knife vs heart
High flow O2, pulse oximetry
Initiate rapid transport to trauma center
Initiate IV therapy enroute
Anatomic CriteriaAnatomic CriteriaAll penetrating injuries to head, neck, torso
and extremities proximal to elbow or kneeChest wall instability or deformity ( i.e., flail
chestTwo or more proximal long bone fracturesCrush, degloved, mangled or pulselessAmputation proximal to wrist or anklePelvic fracturesOpen or depressed skull fracturesParalysis
Some patients with lethal injury may present with normal vital signs, especially if EMS response has been rapid– Reliance on only physiologic criteria may result in
undertriage
Anatomic Criteria
Several studies have documented noteworthy survival rates in patients with penetrating torso trauma transported to facilities with immediate surgical capabilities
Best survival rates are in patients with stab wounds to the chest that have vital signs upon arrival in the ED– Durham LA, et al., J Trauma, 1992– Velmahos GC, et al., Arch Surg, 1995– Rhee PM, et al., J Am Coll Surg, 2000
Anatomic Criteria:Penetrating Torso Trauma
CaseCase
8 y/o male backseat passenger of vehicle involved in frontal collision. Significant intrusion to passenger compartment
Airway: intact Breathing: RR 28, equal BS Circulation: Pulse 110 Disability: GCS 15 Expose: Seatbelt mark to
abdomen, abdomen tender
Child in MVCChild in MVC
High flow O2, pulse oximetry
Extrication to trauma board, complete spinal immobilization
Rapid transport to trauma center
IV lines initiated enroute
Mechanism of InjuryMechanism of Injury Falls
– Adults > 20 ft (one story is equal to 10 ft)– Children < 15 yrs: > 10 ft or 2-3 X height of the child
High-risk auto crash*– Intrusion, including roof: > 12” occupant site; > 18” any
site– Ejection (partial or complete) from automobile– Death in same passenger compartment– Vehicle telemetry data consistent with high risk of
injury Auto-pedestrian / auto-bicyclist thrown, run over, or with
significant (> 20 mph) impact Motorcycle crash >20 mph
* Removed: rollover, deformation to vehicle
MOI may aid in predicting serious injury– King AI, et al., J Trauma, 1995– Grande CM, et al., Crit Care Clin, 1990– Presswalla FB, Med Sci Law, 1978
MOI correlates least well with the presence of significant injury– Relying on these alone increases overtriage
rate
Mechanism of Injury Criteria
CaseCase 78 y/o restrained
female front seat passenger in high speed motor vehicle crash. PMH of A-fib, on warfarin
Airway: intact Breathing: RR 24,
slightly decreased BS on left
Circulation: HR 110, irreg; BP 148/90
Disability: GCS 15 Expose: multiple
contusions
Elderly female in MVCElderly female in MVC
High-flow O2, pulse oximetry
Spinal immobilization
Initiate transfer to a trauma center
Initiate IV therapy enroute
Special Circumstances
Older adults: – risk of injury death increases after age 55– SBP < 110 may represent shock after age 55– Low impact mechanisms (e.g., ground level falls)
may result in severe injuries Children: should be triaged preferentially to
pediatric-capable trauma center Anticoagulation and bleeding disorders
– Patients with head injury are at high risk for deterioration
Special Circumstances
Burns – Without other trauma: burn facility – With other trauma: trauma center
Pregnancy > 20 weeks EMS provider judgment
Field Triage Mobile AppField Triage Mobile Apphttp://www.cdc.gov/fieldtriage/mobile.htmlhttp://www.cdc.gov/fieldtriage/mobile.html
The Right Amount of TimeThe Right Amount of Time
EMS in PerspectiveEMS in Perspective
U.S.– Medics returning from
Viet Nam– Firefighters trained in
EMS– Seattle, Miami, Denver,
L.A.
Emergency! (1972-77)
Prehospital ALS for TraumaPrehospital ALS for Trauma
Adaptation of ALS care for medical / cardiac patients to trauma care
Management at scene focused on stabilizing the patient
Prehospital ALS for TraumaPrehospital ALS for Trauma
Scene stabilization of trauma patients by ALS crews were disastrous– Improved outcome when
victims of penetrating cardiac trauma were transported by BLS
“scoop and run”5/6 vs 0/7
Gervin A, J Trauma, 1982
Prehospital ALS for TraumaPrehospital ALS for Trauma
Authorities questioned the role of prehospital advanced life support
Is ALS necessary for pre-hospital trauma care?– Trunkey DD, J Trauma, 1984
Prehospital stabilization of critically injured patients: a failed concept– Smith J, et al, J Trauma, 1985
The “Ultimate Stabilization”The “Ultimate Stabilization”
EMS vs Private transportEMS vs Private transport
Los Angeles (USC+LAC)4856 EMS patients vs.
926 non-EMS patientsISS > 15
Demetriades D, Arch Surg, 1996
Above all, do no further harmAbove all, do no further harm
Mortality:– 28.8% EMS
Transport– 14.1% Private
Transport
Scene time– More than 20 mins
for both blunt and penetrating trauma
PreHospital TraumaPreHospital TraumaLife SupportLife Support
Based on ATLS
10
PlatinumPlatinum10 minutes10 minutes
Golden Golden PeriodPeriod
For critically injured patients, initiate transport to the closest appropriate facility within 10 minutes of arrival on scene.
PHTLSPHTLS
Limited, key field interventions:– Airway control– Oxygenation and ventilation support– Hemorrhage control– Spinal Immobilization– Rapid Transport to appropriate facility– Initiate IVs enroute
NOT “scoop and run”
IV FluidsIV Fluids
No data has ever documented improved survival based upon prehospital IV fluid therapy
One study suggests increased mortality rate in hypotensive trauma patients given prehospital fluid
TransportationTransportation
Gasoline (or diesel or JetA) is the most important fluid in prehospital trauma care
PHTLS works!Ali J, J Trauma, 1998
CaseCase
13 y/o male suffers single GSW. EMS called. On arrival:
Airway: intact Breathing: decreased BS on right Circulation: HR 110, strong radial pulse Disability: GCS 15 Exposure: bullet wound 5th ICS left parasternal;
bullet wound right 8th ICS posterior axillary line
13 y/o shot in chest13 y/o shot in chest
EMS treatment– High flow O2– Placed on gurney– Transport initiated ( 1 minute scene time!)– 2 IV lines placed en route
ED evaluation– BP 110/80– Pericardial US positive for fluid
13 y/o shot in chest13 y/o shot in chest
OR findings:– Blood in pericardium– Wound to anterior right ventricle near right
coronary artery (repaired)– Wound to lateral right atrium (repaired)– Normal transesophageal echocardiogram– Right lung repaired– Bleeding diaphragmatic vessel ligated
13 y/o shot in chest13 y/o shot in chest
The Right Patient. . . To the Right Place. . . In the Right Amount of Time
Thanks for your attention!Thanks for your attention!
