pre hospital care of acutely injured patient by mohd taofiq et al

Pre-hospital management of

acutely injured patientGrand Round presentation by:

Dr. Aremu W I

Dr. Mohammed T O

Supervising Consultant: Dr. Aderibigbe AB

Outline

Introduction

Historical background

Epidemiology of trauma

• Organisation of trauma system

• Concept of Pre-hospital care

Pre-hospital trauma care

Nigerian experience

Recommendations

conclusion

Trunkey’s trimodal distribution of deaths from trauma with regard to time:

◦ Immediate deaths-50%,do not reach hospital, not possible to save.

◦ Early deaths-30%,Within the first few hours, many are preventable.

◦ Late deaths -20%,occur as a result of organ failure or sepsis

Introduction

Quite distressing are unexpected loss

of lives or permanent disabilities

caused by physical violence or

accidental injury.

Particularly tragic is the injured but

potentially salvageable patient who

dies needlessly through delay in

retrieval, inadequate assessment or

ineffective treatment.

Appropriate initial care can prevents 2nd and 3rd peak.

The concept of “golden hour’

To describe the urgent need for treatment of trauma patient within the first hour after injury.

Definitions

Trauma-injury to the living tissue that

occurs when a physical force contacts

the body(distortion of human frame

from an extrinsic force)

Pre hospital care refers to out-of-

hospital immediate medical care

rendered to injured patients.

Historical background

The need to move wounded soldiers from battle field to aids station led to the concept of emergency medical transport & use ambulance in military.

Two- or four-wheeled horse-drawn wagons were first used by Dominique Jean Larrey(1766-1842).

In 1865,the first hospital-based ambulance was developed in commercial hospital in Cincinnati, Ohio.

Four years later(1869),New York city’s Bellevue Hospital started first municipal service(out of hospital service with ambulances carrying medical equipments)

In June 1887,St John ambulance brigade was established to provide first aid and ambulance services at public events in London

Rescue society founded in Vienna

after disastrous fire at the Vienna ring

theatre in 1881 was the earliest

emergency medical services reported

1st motorized ambulance came to use

in 1899 donated to Michael Reese

hospital, Chicago.

World’s first component of civilian pre

hospital care on scene began in

1928(Roanoke live saving and first aid

crew in Roanoke, Virginia).

Canadian historian-First formal

training for ambulance attendants was

conducted in city of Toronto in 1892,

During the two world war, advances were made with positive results on patient’s morbidity & mortality.

Modern ambulance design

EMS system design

Epidemiology of trauma

principal cause of death in the first 4 decades

80% of deaths between 15 and 24yr

Every 5min,there is a death from traumatic injury(accidental death)

In USA, unintentional injury was the fifth leading cause of death in 2002.

11th leading cause of death & 6th leading cause of DALY’s loss in Nigeria(WHO,2002).

150,000 deaths annually in the US

18,000 deaths from accident annually in UK

Permanent disability 3 times the mortality rate in the US

> 45m people world wide are left with disability

Globally, injury mortality has M:F of 2:1

Injury accounts for 12% of the world’s burden of disease.

Trauma morbidity & mortality risk is increased by◦ Increasing age

◦ Co morbidity

◦ Obesity

Determinant of injury severity

Force of impact

Duration of impact

Body part involved

Injuring agent

Associated risk factors

Economic burden

Global trauma related cost-- > $500 billion annually

The economic costs associated with RTIs in Africa were estimated to be US$3.7 billion in 2000,

translating to approximately 1–2% of each country’s gross national product.

Significant loss of productive work years

Causes of trauma

RTC-leading cause of traumatic injury

Fall

Industrial/occupational accidents

Disasters

Sport injury

Burns

Assaults

Leading Causes of the Global

burden of TraumaCause of death Individuals killed

Road traffic injuries 1,260,000 (25%)

Other injuries 856,800 (17%)

Suicide 815,000 (16%)

Homicide 520,000 (10%)

Drowning 450,000 (9%)

Poisoning 315,000 (6%)

War 310,000 (6%)

Falls 283,000 (6%)

Burns due to fire 238,000 (5%)

World Health Organization, 2000.

RTI kill 1.3m people annually

80% of global deaths from RTI occur

in developing countries

By 2030, RTI will be 5th leading cause

of death & disability.

The population burden of road traffic

injury is high in Nigeria, at 41 per 1000

population.

◦ Motorcycle injuries comprise over half of

road traffic injuries (54%)

◦ urban VS rural populations –no significant

difference

Federal Road Safety Commission estimates

◦ 5777 deaths in 2004, 0.046 per 1000 population

◦ 4519 deaths occurred in 2005, 0.036 per 1000 population

Organization of trauma

system Trauma system-an organized effort

coordinated by a national or local agency to deliver care(from acute injury to rehabilitation) to injured patient in a defined geographical area.

3 components:◦ Pre hospital care

◦ System wide communication

◦ Appropriately designated hospital Level I

Level II

Level III

Stages of high quality pre hospital

care-star of life

◦ Early detection

◦ Early reporting

◦ Early response

◦ Good on-scene care

◦ Care on transit

◦ Transfer to definitive care

Level of care

BLS & ALS

For trauma care, basic skills include

◦ Basic airway maneuvers

◦ BVM & oxygen

◦ CPR and automated external defibrillation

◦ Hemorrhage control

◦ spine immobilization

◦ Needle decompression of suspected tension pneumothorax

◦ Splinting of major extremity fractures

‘scoop & run’ VS ‘stay & play’


AIM : To provide quality, safe, prompt &

effective health care

Varies from one country to the other

2 levels of care: Basic life support(BLS)

Advance life

support(ALS)

BLS improves outcome in trauma patient


Role of providers :

- Ensure safety of the scene

- For individual victim: Identify life

threatening injuries


• Role of providers :

- For Multiple victim: Triage

- Alert designated trauma

centres/call for help

- Stabilization & transport to

trauma centres

Pre-hospital care

TRIAGE :

- Process of rapidly & accurately

evaluating trauma patient to

determine extent of injuries & the

level of medical care required

- Goal is to transport all seriously

injured patients to appropriate

facility

Pre-hospital care

TRAIGE :

- Depends on a number of variables

- Triage scoring systems

- The Medical Emergency Trial Tags(METTAG)

- black is dead, red is critical, yellow is serious, green is not serious

Pre-hospital care

Initial evaluation / Primary Survey :

- follows the ABCDE pattern

A: Air way & Cervical spine control

B: Breathing

C: Circulation

D: Disability/Neurologic assessment

E: Exposure & enviromental control

Air way control

Assess the airway for patency & protective reflex

Ask patient to open mouth & phonate

Level of consciousness – a 1° indicator of airway stability

Manual in line(MIL) Stabilization of the cervical spine

Air way control

Suction

Chin lift/jaw thrust

Oral/nasal airways

Rescue airways/Airway adjuncts

Air way control

Definitive airways

◦ RSI for agitated patients with c-spine

immobilization

◦ ETI for comatose patients (GCS<8)

◦ Perfomance in the pre-hospital setting is

controversial

Difficult airway

Breathing

Assessed by determining the Patient’s

RR

Palpate,Percuss & Auscultate the

chest

Pulse oximetry is a mandatory adjunct

ETCo2 is becoming a useful adjuncts

Breathing

Oxygen

Control of ventilation

Seal open / sucking chest wound

Chest decompression

Circulation

Evaluate mental status,Skin colour &

temperature

BP & RR – not reliable

Hemorrhagic shock should be

assumed in any hypotensive trauma

patient

Circulation

Direct pressure / pressure dressings

Tourniquet application

Use of pelvic binder

Intravenous / intraosseous line

IV access preferably done enroute

Restricted use of IVF is advocated

Disability

Abbreviated neurological exam

- Level of consciousness

- Pupil size and reactivity

- Motor function

GCS

- Utilized to determine severity of injur

- Guide for urgency of head CT and ICP monitoring

Disability

Spinal cord injury

- High dose steroids if within 8 hours

Elevated ICP

- Head of bed elevated

- Mannitol

- Hyperventilation

- Emergent decompression

Proper Spinal immobilization

Exposure / Enviromental

control Complete disrobing of patient

Logroll to inspect back

Rectal temperature

Warm blankets/external warming

device to prevent hypothermia

Secondary survey

A quick but thorough review of the

body

Aim : to identify missed injuries

Common pitfalls – not inspecting the

back, the axilla, the gluteal region &

the pannicular folds

Others Issues

Fractures

Pain management

Transport

Burns

Extrication – the Kendrick extrication device

Prehospital determination of death

The Nigerian experience

Pre-hospital care of the injured in

south western Nigeria: A hospital

based study of four tertiary hospital in

three states.

• Aim : to determine the level of pre-

hospital care


- A hospital based prospective study

- Information gathered using a one-

page proforma


1996 patients were seen. 1600 – Males & 436 – Females, range : 2 – 80, Mean 30.3 ± 13.3yrs

Most accident occurred on Urban road(49.1%), highways(46.3%)

12,040 accident victims, 1,292(10.7%) immediate fatalities, 80,356(69.4%) injured, 1996(23.9%) seen at the casualty.


172(8.6%) had some form of pre-hospital care

- 17 had wound irrigation

- 5 fracture splinted

- 4 water to drink

- 10 wound cover


wound irrigation

fracture splinted

drinking water

wound coverage

others81(69%)

17(15%)

5(4%)

10(9%)

4(3%

)

Mode of transportation

Treatment at other hospital

584 (29.3%) referred from other

hospitals

300(51.3%) of these were from private

hospitals

Treatment at other hospital

208 (35.6%) from secondary level

government hospitals and 64 (11.0%)

from mission funded hospitals

Significantly higher proportion of those

who had their initial treatment in other

hospitals died in the casualty

Interval between injury and presentation

1,412(70.7%) brought directly to the

hospitals

416 (29.5%) arrived within 30 minutes

while another 392 (27.5%) arrived between

30 minutes and an hour.

Discussion

The overall mean arrival time for all

93.6 minutes.

For those who died in the casualty,

the mean arrival time was 49.8

minutes while it was 96.0 minutes for

those who survived.

Revised trauma score & patient

survival

Disscussion

No organized Pre-hospital care

Some of the bystander PHC were inappropriate

Only 29.5% arrived within 30minutes of injury

Discussion

Make shift transportation

29.3% referred from other hospital

Most of the referred patient died

Study Conclusion

There’s a great need to urgently

review the trauma system in Nigeria

better injury surveillance and the

establishment of hospital and

community based trauma registries as

a first step in improving trauma care in

our environment

Recommendations

Government should recruit & train

volunteers and non-medical

professionals on PHC

Establish trauma centres in the 6 geo-

political zones

Develop a national policy guidelines

on pre-hospital trauma care

Recommendations

Better road design

Compliance with traffic rules

Integration of BLS into school

curriculum

recommendations

The hospital should educate the

populace on Pre-hospital care

Continue to provide an avenue for

learning & research on road safety &

trauma care

All health care professionals to have a

first aid box in their vehicles

Conclusion

The financial and social benefits of

reducing premature death and

minimizing disability

from injury are potentially enormous,

and these benefits may play a major

part in

promoting a nation’s economic and

human development.

THANK YOU

pre hospital care of acutely injured patient by mohd taofiq et al

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