yaniv berliner. scene survey ems must first evaluate the safety of the scene. downed power lines,...
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EMS STABILIZATIONYaniv Berliner
Scene survey
EMS must first evaluate the safety of the scene. Downed power lines, fire, traffic
Is there a need for specialized equipment for extrication.
Is there a need for air ambulance What type of facility is nearby? Are all patients accounted for. Is
there a possibility of ejected patients.
What type of crew
In Ontario, either Primary Care Paramedic (PCP) or Advanced Care Paramedic (ACP).
ACP’s have further education and preceptorship.
ACP’s have a wider scope of practice. In trauma they are able to initiate IV bolus, perform needle decompression and endotrachael intubation (with base hospital support)
Primary Survey
ABCD assessment of both patients Does the mother warrant airway
protection due to GCS? If there is only one crew on site, who
should be managed first? Unless extrication causes delay, limit
on scene time to 10 minutes
Airway
Airway interventions as per ATLS O2 applied Jaw thrust BMV More advanced airway interventions
are usually reserved for receiving hospital (if it is nearby)
Intubate GCS<8 in field?(Prehospital Emergency Care, 2011 15 184)
Trauma Registry 1,555 patients. Chart review. Intubation attempted in 758 patients 57% mortality, intubation group. 34% mortality, non intubation group
Patients in the intubation group were more critically injured. Lower GCS (4.3 vs 5.3) More SBP<90 (28 % vs 17%)
Probably represents a selection bias whereby when a decision to intubate is undertaken the patient is sicker
Site Intubation % Overall mortality
Morality in Those Intubated
TOR 18 46 68
MLW 30 50 81
DAL 37 62 79
IWA 41 39 57
OTT 45 50 74
ARC 45 38 62
PTL 50 31 48
PGH 54 47 50
VAN 68 58 63
SKC 75 35 39
Breathing
Oxygen and ventilatory support are provided
Needle decompression for tension pneumothorax. This is done in conjunction with base hospital. Indications are: Severe shortness of breath SBP less than 90 Absent breath sounds
Occlusive dressing is placed over an open pneumothorax
Circulation
Paramedics assess circulation. If systolic pressure is <100, 20cc/kg IV NS is administered.
Lacerations are bandaged Unstable Pelvis injuries are tied MSK injuries are splinted
Disability
Extrication with full c-spine precautions Collar is placed first, then pt is placed on
board Board is padded over pressure points Pt is then placed on a long board C-spine injury is presumed in any patient
involved in MVC, fall from height, dangerous mechanism, neck pain, neurological symptoms or decreased level of consciousness.
Clearing C-spine in the Field Canadian C-spine rule interpreted by
paramedics Clinical decision rule is applied, but
the patient remains immobilized Pt is brought to ER for assessment. The reliability of rule application is
determined and compared to investigators (ER docs)
C-spine rules
Clearing in the Field
1949 patients evaluated 12 c-spine injuries Paramedics 100% sensitive in
identifying patients with potential injury
Paramedic specificity 43%, versus 38% for investigators (some overcalling by EMS)
Clearing C-spine
If paramedics were allowed to use rule 62% of patients would require immobilization in the field, compared to actual rate of 100%.
This in turn saves ER space, xrays, less time on board.
Pain management
Advanced care paramedics may administer analgesia for isolated extremity fractures
Morphine or Fentanyl For multi-system trauma base
hospital is contacted for analgesia orders
Load and Go Patients
What it sounds like. In trauma in the setting of severe multi-
system injury (severe chest injuries, head injury with lateralizing signs, severe abdominal pain post trauma, unstable pelvis, bilateral femur fractures)
Primary assessment performed. Oxygen applied. Pt is placed on long board with c-spine immobilization and additional history/assessment is obtained en route
Dispatch is made aware
Back to Case: Mother
Scene Survey, limit scene time to 10 min Primary Survey Full immobilization 02 applied, ventilation assisted IV initiated, 20cc/kg NS given Splint for femur fracture Transport initiated Benzodiazepines as needed for seizure
from presumed head injury Secondary survey en route
Daughter
Scene Survey Primary Survey Collar placed Three person extrication with full c-
spine precaution Full board IV initiated Base hospital contacted for analgesia
OPALS
A before-after controlled clinical trial to assess the benefit of prehospital advanced life support program.
1373 BLS patients: 1494 ALS patients
No substantial difference in overall survival to hospital discharge (81.8% survival BLS, 81.1% survival ALS)
OPALS
598 patients with GCS<9 Lower survival ALS (50 % survival )
then BLS (60%). Value was significant (p<0.03)
Authors speculate this may be due to delay in transfer to hospital
Acknowlegements
Base Hospital Program. David Vusich Severo Rodrigues