Pre hospital care of acutely injured patient by mohd taofiq et al.
Pre-hospital management ofacutely injured patientGrand Round presentation by:Dr. Aremu W IDr. Mohammed T OSupervising 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 Globalburden of Trauma Cause 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 traumasystem 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’
Pre-hospital trauma care 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
Pre-hospital trauma care Role of providers : - Ensure safety of the scene - For individual victim: Identify life threatening injuries
Pre-hospital trauma care• 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
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 / Enviromentalcontrol 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
The Nigerian experience- A hospital based prospective study - Information gathered using a one- page proforma
The Nigerian experience 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.
The Nigerian experience 172(8.6%) had some form of pre- hospital care - 17 had wound irrigation - 5 fracture splinted - 4 water to drink - 10 wound cover
The Nigerian experience 17(15%) 5(4 %) 4(3% wound irrigation ) 10(9%) fracture splinted drinking water wound coverage 81(69%) others
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.
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.