Missouri EMS Central Region

October 2011 Webinar

Jeffrey Coughenour, MD, FACS

Assistant Professor of SurgeryMedical Director, Missouri EMS Central Region

Purpose

• Monthly educational opportunity for providers within the Central Region

• Focus– Performance improvement, actual case review– Literature review– Discuss practice management guidelines

Performance Improvement

• Review performance and safety of EMS system– Expected or unexpected mortality?– Opportunity for improvement?

• Now the actual work begins…– System or individual?– Preventable or not?– Is the issue open or closed?

Corrective Action

• Develop or revise a guideline• Targeted education• Enhance resources, communication• Counseling• Change in provider privileges or credentials• External review (region, trauma center, etc.)

Results

• Demonstrate that a corrective action has the desired effect by continued evaluation

• Continuous use of your new PIPS process is more important than “loop closure”

Chapter 16, Performance Improvement and Patient Safety, Resources for the Optimal Care of the Injured Patient 2006 Copyright © 2006 American College of Surgeons, Chicago, IL

MVC

• Moderate front-end vehicle damage• 70’s male, presumed intoxicated• Pelvic and arm pain• 100, 16, 184/90, 95% on 2 L NC• Community hospital 5 miles away, trauma

center 95 miles away

Destination?

MVC Chest radiograph

MVCPelvic radiograph

MVC Right rib fractures, small hemothorax, subcutaneous air

MVC Right comminuted iliac crest fracture, retroperitoneal hematoma

MVC

• CT findings and hemoglobin value of 4.8 prompt referral to Level I trauma center

• Intubated, chest tube, pelvic binder placed• Arrival 7 hours after injury

Excessive time to definitive care?What was the indication for intubation?

Does the pelvic injury necessitate pelvic binder?

MVC Increasing subcutaneous air right chest

MVC Residual anterior pneumothorax

MVC Retroperitoneal hematoma has not significantly changed

MVC Atelectasis, resolving right basilar effusion, tube thoracostomy remains

MVC

• Ventilator-associated pneumonia• Transfusion, nutritional supplementation• No operation required for pelvis• Prolonged ICU admission, LTAC transfer with

significant disability

Young and Burgess Classification

• Vector of force, severity, ligamentous disruption, rotational instability

• Grade I-III• Anterior-posterior• Lateral• Vertical shear

Summary Points

• Early referral for extremes of age• Pelvic binder when loss of rotational stability,

most often APC, closes down pelvic volume• If you take the time to scan… do it right– Include entire torso– Use IV contrast– Renal function rarely a consideration

ATV

• ATV rear-ended another ATV• All occupants ejected• Local EMS: Immobilization, supplemental O2,

needle decompression right chest• Flight crew—confused, lethargic, grunting,

attempting to pull oxygen mask off face

Diagnosis?

ATV

• 143, 28, 112/58, 83% on NRB, GCS 11• Ever since RSI medications given, slow decline

in HR, now 45, 0, 0, 60% with BVM, GCS 3TC• Successfully intubated

Diagnosis?

ATVLeft tension PTX, extensive right contusion with subcutaneous emphysema

ATV Bilateral chest tubes placed, resolution of tension physiology, bilateral pulmonary contusions

ATV

Progression of pulmonary contusions, 30 mins after arrival

ATV

Progression of pulmonary contusions, 2 hours after arrival

ATV

• Large air leak from left chest• Inspiratory Tv 570 mL, expiratory Tv 20 mL

• OR for thoracotomy– Progressive hypoxemia, bradyarrythmia– Large laceration at lingula, vascular and bronchial

injury, hilar clamp → total pneumonectomy

MVC

• Passenger side impact from large truck, ejected

• Progressive shortness of breath, bloody, frothy secretions, anxiety/confusion

• Intubated after arrival of flight crew, PEA• Resuscitated, but died shortly after OR

MVCAdmission chest radiograph

MVC

• 1535 Crash• 1540 EMS on-scene,

aircraft requested• 1607 Ground EMS

transporting to closest ED• 1628 Arrive helipad• 1634 Aircraft arrival• 1659 Aircraft departure• 1726 Patient in trauma

resuscitation suite

Scene 64.4 miles from trauma center

1 hour 10 minutes

Benefit of air medical transport: Distance or

critical care?

Summary Points

• Diagnostic dilemma: Problem with A or B?• Pre-hospital care was good• Large air leaks require urgent operative

intervention—delay to OR• Pulmonary contusions, when present soon

after injury, associated with high mortality

Pulmonary Contusion

• Parenchymal hemorrhage, inflammatory destruction of the alveolar-capillary membrane

• Historical mortality rates 40%• Mechanical ventilation, antibiotics, invasive

monitoring MAY improve outcomes (6.5%)• Supportive care

Crash and occupant predictors of pulmonary contusion

O’Conner JV, Scalea TM Crash Injury Research and Engineering Network (CIREN)

J Trauma 2009 Apr 66(4):1091—5

• 2,184 crash occupants• Strong association with higher delta V (severity)• Risk greatly increased with near-side lateral impact, suggests

occupant proximity to force most important• Not an independent marker for mortality

Pulmonary contusion: An update on recent advances in clinical management

Cohn SM, DuBose JJWorld J Surg 2010 Aug 34(8):1959—70

• 47% present on admission• 92% present by 24 hours• 24-48 hour progression• Resolution after 4-6 days• Delay prompts investigation

for infiltrate, fluid overload, TRALI, aspiration

November 2011 Webinar

Pre-Hospital Fluid Management