20082008 דצמבר דצמבר 44תל אביב, תל אביב,

Avraham Rivkind , M.D, F.A.C.SAvraham Rivkind , M.D, F.A.C.SDepartment of General Surgery and Shock Trauma UnitDepartment of General Surgery and Shock Trauma UnitHadassah – Hebrew University Medical CenterHadassah – Hebrew University Medical CenterJerusalem, IsraelJerusalem, Israel

דילמות חילוץ והצלה ממוקדי דילמות חילוץ והצלה ממוקדי תאונותתאונות

““Scoop and Run” vs. “Stay and Play”Scoop and Run” vs. “Stay and Play”

“ “Stay and Play”Stay and Play”

Quo vadis – Were are ere goingQuo vadis – Were are ere going??

““Scoop and RunScoop and Run”” vsvs..

French World War I French World War I

Patients treated 8 hours after injury – 75% mortalityPatients treated 8 hours after injury – 75% mortality

Patients treated 1 hour after injury – 10% mortalityPatients treated 1 hour after injury – 10% mortality

““Golden Hour” the philosophy of modern Golden Hour” the philosophy of modern trauma managementtrauma management

Su

rviv

al %

Survival is related to severity & durationSurvival is related to severity & duration

““Golden Hour” the philosophy of modern Golden Hour” the philosophy of modern trauma managementtrauma management

CAUSES OF TRAUMA DEATHCAUSES OF TRAUMA DEATH

Only prevention efforts might alter the outcomeOnly prevention efforts might alter the outcome

0

5

10

15

20

25

30

35

1 HR 2HR 3 HR 2 WKS 3WKS 4WKS

Immediate:

Brain laceration Brainstem laceration Spinal cord laceration Aorta rupture Heart rupture

Early:

Epi/Subdural hematoma Hemopneumothorax Pelvic/limb fractures Abdominal injuries

Late:

Sepsis Multiple Organ Failure

DE

AT

H

An organized approach to trauma care An organized approach to trauma care Maryland USA Maryland USA

The legacy of R. Adams CowleyThe legacy of R. Adams Cowley

Paramedics at the scene Paramedics at the scene and helicopter which will and helicopter which will

stabilize the patient stabilize the patient en routeen route

1917-19911917-1991

““A critical injured A critical injured patient CANNOT be patient CANNOT be

stabilized in the field”stabilized in the field”

Nancy CarolineNancy Caroline

1944-20021944-2002

Scoop and RunScoop and Run

Emergency Medicine Service SystemEmergency Medicine Service System

Scoop and RunScoop and RunPatient is brought Patient is brought to the doctor by to the doctor by paramedicsparamedics

Responses time:Responses time:

10 min – 80% of cases10 min – 80% of cases

15 min – 95% of cases15 min – 95% of cases

Stay and PlayStay and Play

Doctor is brought to Doctor is brought to the patientthe patient

Longer total prehospital timeLonger total prehospital time

Doctor is brought to Doctor is brought to the patientthe patient

Longer total prehospital timeLonger total prehospital time

Advanced Life Support - ALSAdvanced Life Support - ALS

Paramedic scope of care:Paramedic scope of care:

Endotracheal IntubationEndotracheal Intubation

Intraveous AccessIntraveous Access

Administration of pharmacologic agentsAdministration of pharmacologic agents

Are limited in the type of intervention they Are limited in the type of intervention they can perform prior to arrival to hospitalcan perform prior to arrival to hospital

Sophisticated radiographic investigationSophisticated radiographic investigation

For definitive management of life threatening For definitive management of life threatening injuries are not available in prehospital settinginjuries are not available in prehospital setting

ALS ProvidersALS Providers

Operative interventionOperative intervention

Prehospital ALS has theoretical advantagesPrehospital ALS has theoretical advantages

The evidence supporting its effectiveness The evidence supporting its effectiveness and justification for trauma is limitedand justification for trauma is limited

ALS ProvidersALS Providers

Prehospital procedures before emergemcy Prehospital procedures before emergemcy department thoracotomy: department thoracotomy:

Seamon MJ, Fisher CA, Gaughan J et.al. J Trauma 63:1, 2007Seamon MJ, Fisher CA, Gaughan J et.al. J Trauma 63:1, 2007

““Scoop and Run” saves livesScoop and Run” saves lives

140 min from accident to

hospitalarrival!!!

“Stay and Play”

Patients receiving ALS or BLS demonstrating absence Patients receiving ALS or BLS demonstrating absence of benefit or even the presence of harmof benefit or even the presence of harm

Potter D, el. al. Ann. Emerg. Med. 17:582, 1998 Potter D, el. al. Ann. Emerg. Med. 17:582, 1998

ALS in patients with penetrating injuries had ALS in patients with penetrating injuries had higher than expected mortalityhigher than expected mortality

Cayten CE, J. Trauma 31:440, 1993Cayten CE, J. Trauma 31:440, 1993

A higher risk of death in patients with received A higher risk of death in patients with received pre-hospital ALSpre-hospital ALS

Liberman M, Ann. Surg. 237:153, 2003Liberman M, Ann. Surg. 237:153, 2003

The time required for intravenous placement is The time required for intravenous placement is equivalent to the transport timeequivalent to the transport time

Smith JP, J. Trauma, 25:65, 1985Smith JP, J. Trauma, 25:65, 1985

Advanced Life Support InterventionsAdvanced Life Support Interventions

Interventions fluid resuscitation and attempts at Interventions fluid resuscitation and attempts at field stabilization field stabilization

Bickell WH, Wall MJ Jr, Pepe PE, N. Engl. J. Med., 331:1105, 1994Bickell WH, Wall MJ Jr, Pepe PE, N. Engl. J. Med., 331:1105, 1994

Administration of fluids without hemorrhage Administration of fluids without hemorrhage control only leads to more bleeding control only leads to more bleeding

Negative outcome in patients with penetrating traumaNegative outcome in patients with penetrating trauma

Prehospital interventions might cause harm Prehospital interventions might cause harm and prolong the time to definitive care and prolong the time to definitive care

Berlot G, et. al. Crit. Care. Clin. 22:457, 2006Berlot G, et. al. Crit. Care. Clin. 22:457, 2006

Brambrink AM, et. al. Crit. Care. 8:3, 2004Brambrink AM, et. al. Crit. Care. 8:3, 2004

Bulger EM, Surg. Clin. North. Am. 87:37, 2007Bulger EM, Surg. Clin. North. Am. 87:37, 2007

Physiological normality is NOT a goalPhysiological normality is NOT a goal

ALS and Advanced Life Support interventionsALS and Advanced Life Support interventions

Considerable difficulty to interpreting the published data:Considerable difficulty to interpreting the published data:

Very variable populationVery variable population

Receive dissimilar careReceive dissimilar care

Variable provider typeVariable provider type

Success rates of intubation 33%-100%Success rates of intubation 33%-100%

Endotracheal intubationEndotracheal intubation

A higher risk of death among head injured A higher risk of death among head injured

patients undergoing attempts at field intubationpatients undergoing attempts at field intubation

Pennsylvania StudyPennsylvania Study

Death for patients who underwent intubation in the Death for patients who underwent intubation in the

field is field is 44 times greater times greater

Improved functional outcome in patients that Improved functional outcome in patients that

underwent intubation only after arrival in the ERunderwent intubation only after arrival in the ER

Wang HE, Peitzman AB, Cassoy LD, et.al. Ann. Emerg. Med. 44:439, 2004Wang HE, Peitzman AB, Cassoy LD, et.al. Ann. Emerg. Med. 44:439, 2004

A

B

C

D

E

AA irway / C-spine protection

BB reathing / Life-threatening chest injury

CC irculation / Stop the bleeding

D D isability / Intracranial mass lesion

EE xposure / EEnvironment / Body temp

Initial Assessment and ManagementInitial Assessment and Management

Advanced Trauma Life Support - ATLSAdvanced Trauma Life Support - ATLS

Effect of trauma center care on mortalityEffect of trauma center care on mortality

Efficient transportEfficient transport

Limited BLS intervention an the sceneLimited BLS intervention an the scene

Triage to a designated trauma centerTriage to a designated trauma center

Mackenzie EJ, Rivera FP, Jurkovich GJ, N. Engl. J. Med. 354:366, 2006Mackenzie EJ, Rivera FP, Jurkovich GJ, N. Engl. J. Med. 354:366, 2006

There is not one “golden” medical emergency systemThere is not one “golden” medical emergency system

There is no “golden” timelines There is no “golden” timelines

No “golden” skillsNo “golden” skills

A medical system should be flexible and be A medical system should be flexible and be able to adjust on each specific local situation able to adjust on each specific local situation

Emergency Medicine Service SystemEmergency Medicine Service System

Jerusalem 2008Jerusalem 2008