Ground versus air transport of trauma victims: Medical and logistical considerations

Emergency aeromedical transport for trauma victims varies widely, from 10% or less in some programs to more than 90% in others. There is the potential in all such programs for dramatic, lifesaving efforts as well as for costly and dangerous overuse. We propose the following preliminary guidelines for emergency aeromedical transport of trauma victims. Trauma scene flights should be dispatched only for seriously injured patients who are potentially salvageable. Trauma scene flights are not justified if the flight does not significantly reduce the interval between injury and patient arrival at an appropriate hospital (eg, from motor vehicle accident with entrapment) unless the flight delivers needed medical expertise or equipment to the scene. Critically injured patients should be returned to the closest hospital of appropriate capabilities and demonstrated expertise. Flight services should be a public service fully integrated into the metropolitan emergency medical services system. Scene flights should be dispatched within medical guidelines established by the regional emergency medical services system. Emergency aeromedical evacuation of trauma victims should assist the regionalization of trauma care to centers with special capabilities for the management of seriously injured patients. Promulgation of more detailed guidelines will depend on the accumulation of clinical experience and will be possible only if consistent efforts are made to obtain measures of injury severity, categories of injury, and long-term outcomes of management.     

Utilization of medical care in Orange County: the effect of implementation of a regional trauma system

To determine the effect of implementation of a regional trauma system on utilization of medical care we studied ambulance transports, emergency department (ED) visits, and hospital days for trauma and nontrauma patients before and after system implementation. Serious injury affects approximately one of every 1,000 persons each year and accounts for approximately one of every 250 ED visits, one of every 100 hospital days, and one of every 20 ambulance transports. Following system implementation the trauma hospitals experienced insignificant changes in annual percentage of market share of ED visits and hospital days and in annual rate of growth of ED visits and hospital days. We conclude that implementation of a medically directed regional trauma system has resulted in a predictable redistribution of a small number of seriously injured patients, and has not been associated with significant changes in utilization of EDs or hospitals.     

"PALS for life!" A required trauma-oriented pediatric advanced life support course for pediatric and emergency medicine housestaff

While advanced cardiac life support (ACLS) and advanced trauma life support (ATLS) courses have become accepted standards for physicians who care for the critically ill and injured patient, only recently have pediatric advanced life support (PALS) courses been developed. The American Academy of Pediatrics has shown renewed interest in pediatric cardiopulmonary arrest after impressive gains made in adult resuscitation. The American Heart Association filled a void by including new chapters on Pediatric and Neonatal Resuscitation in the Textbook of Advanced Cardiac Life Support, 1981. A joint committee of AHA and AAP is seeking to unify course objectives and materials for standard curriculum. Because trauma is the most common cause of death and disability in children, pediatric trauma life support measures should be incorporated into any program directed toward emergency physicians and pediatricians who function in an emergency department or rural primary care setting. The Department of Pediatrics and Surgery and its division of Emergency Medicine has developed and implemented a PALS curriculum which is different from most other programs in that emphasis has been placed on pediatric trauma in addition to traditional cardiac (ACLS) resuscitation. This 20-hour program combines a modified ACLS curriculum with specific pediatric trauma lectures and laboratory sessions. It includes a canine surgical procedure lab and modified ATLS skill stations. At the completion of the course, students are eligible for ACLS certification. In the two years in which the course was given, 39 pediatric houseofficers were enrolled in the course.(ABSTRACT TRUNCATED AT 250 WORDS)     

The Tuscan Emergency Medicine Initiative

Italy lacks standardized specialty training in emergency medicine. There is no system of national or regional accreditation of the knowledge base or skill set of physicians working in regional emergency departments (ED), which results in variability of emergency medical care delivery not only between hospital EDs but also within individual EDs. To address this need, the Tuscan Minister of Health chose to develop a partnership with emergency medicine specialists from the United States to help expedite the growth of the specialty in Tuscany. The collaboration called the Tuscan Emergency Medicine Initiative consists of the regional health care service, the Tuscan university system, Harvard Medical International, and the Beth Israel Deaconess Medical Center Department of Emergency Medicine. We describe that effort and process, with an expectation of more than 625 physicians completing the program by June 2008.     

Is there evidence to support the need for routine surgeon presence on trauma patient arrival?

The trauma center certification requirements of the American College of Surgeons include the expectation that, whenever possible, general surgeons be routinely present at the emergency department arrival of seriously injured patients. The 2 historical factors that originally prompted this requirement, frequent exploratory laparotomies and emergency physicians without trauma training, no longer exist in most modern trauma centers. Research from multiple centers and in multiple varying formats has not identified improvement in patient-oriented outcomes from early surgeon involvement. Surgeons are not routinely present during the resuscitative phase of Canadian and European trauma care, with no demonstrated or perceived decrease in the quality of care. American trauma surgeons themselves do not consistently believe that their use in this capacity is either necessary or an efficient distribution of resources. There is not compelling evidence to support the assumption that trauma outcomes are improved by the routine presence of surgeons on patient arrival. Research is necessary to clarify which trauma patients require either emergency or urgent unique expertise of a general surgeon during the initial phase of trauma management. Individual trauma centers should be permitted the flexibility necessary to perform such research and to use such findings to refine and focus their secondary triage criteria.     

Effect of antishock trousers on the trauma score: a prospective analysis in the urban setting

This study was designed to determine the effect of military antishock trousers (MAST) use on the presenting emergency center trauma score (TS) in an urban prehospital setting. Sixty-eight patients were assigned randomly to study and control groups in a prospective investigation of the use of MAST on injured patients with hypotension. Thirty-two control patients, whose mean initial systolic BP was 59 +/- 32 mm Hg, and 36 MAST-treated patients, whose mean initial BP was 55 +/- 31 mm Hg, were found to be well matched for age; sex; type and location of injuries; initial field TS; response, field management, and transport times; and the total amount of intravenous crystalloid infused. Our results demonstrated no significant difference between the control and MAST-treated groups in the presenting emergency department TS (9.8 +/- 6.6 vs 10.6 +/- 5.9). These data conflict with the widely accepted belief that MAST will always enhance conventional support for improving the prehospital condition of injured patients with significant hypotension.     

Epidemiology of pediatric prehospital care

Very few studies about prehospital care of pediatric emergencies have been published. With new interest in emergency care of the pediatric population demonstrated by the development of Pediatric Advanced Life Support and Advanced Pediatric Life Support, it is imperative to have data that define the different types of problems encountered in the prehospital care setting and their outcomes. Prehospital assessment forms were reviewed retrospectively over a consecutive 12-month period beginning August 1, 1983. Patients under 19 years of age were studied in a service area with a population of 557,700. A total of 3,184 forms were analyzed, representing approximately 10% of all ambulance runs. This contrasts sharply with the fact that the pediatric age group represents 32% of the population. The major users were the youngest and the oldest of the pediatric population. Of the cases, 54.4% were in the trauma category. The largest trauma group was motor vehicle accidents in the adolescent age group. Male patients predominated in the trauma cases. Medical disorders were the major reason for prehospital care in the very young. The demand for emergency medical services (EMS) occurred mainly during the summer months and on weekends. More than 50 percent of all EMS pediatric cases occurred during the hours of 1:00 PM to 9:00 PM. Advanced life support was associated with prolonged on-scene time and had a relatively low use and success rate in the younger pediatric population. Resuscitation of 23 cases of pediatric prehospital arrest resulted in no survivors to hospital discharge. The appropriateness of prolonged time spent on scene (mean of 18.3 minutes in 1,196 cases) for prehospital pediatric emergencies requires further evaluation.     

Emergency medicine in Southern Brazil

Emergency medicine is developing rapidly in southern Brazil, where elements of both the Franco-German and the Anglo-American models of emergency care are in place, creating a uniquely Brazilian approach to emergency care. Although emergency medical services (EMS) in Brazil have been directly influenced by the French mobile EMS (SAMU) system, with physicians dispatched by ambulances to the scenes of medical emergencies, the first American-style emergency medicine residency training program in Brazil was recently established at the Hospital de Pronto Socorro (HPS) in Porto Alegre. Emergency trauma care appears to be particularly developed in southern Brazil, where advanced trauma life support is widely taught and SAMU delivers sophisticated trauma care en route to trauma centers designated by the state.     

Prevalence of and annual ambulatory health care visits for pediatric arthritis and other rheumatologic conditions in the United States in 2001-2004

OBJECTIVE: To estimate the prevalence of and the annual number of ambulatory health care visits for pediatric arthritis and other rheumatologic conditions. METHODS: We used physician office visit, outpatient department visit, and emergency department visit data from the 2001-2004 National Ambulatory Medical Care Survey and 2001-2004 National Hospital Ambulatory Medical Care Survey to estimate annual visits for the International Classification of Diseases, Ninth Revision, Clinical Modification codes thought to represent significant pediatric arthritis and other rheumatologic conditions (SPARC). We converted visit estimates into prevalence estimates using data on the number of prior annual visits per patient. Synthetic estimates for states were produced using national rates. RESULTS: The average annualized estimate of the number of children with SPARC was 294,000 (95% confidence interval [95% CI] 188,000-400,000). The annualized number of ambulatory health care visits for SPARC was 827,000 (95% CI 609,000-1,044,000). CONCLUSION: Pediatric arthritis estimates have varied widely because it is an umbrella term for which there are many definitions and because it is a relatively uncommon condition from a population surveillance perspective. Our estimates suggest that arthritis-related health care visits impose a substantial burden on the pediatric health care system. One advantage of this surveillance paradigm is that it has established a starting point for tracking the national prevalence of arthritis and rheumatologic conditions in children on an ongoing basis using existing infrastructure rather than expensive new surveys. This surveillance system will help us monitor and predict the health care needs of patients with these conditions.     

Transport of the mechanically ventilated pediatric patient

Children deserve quality care when they are critically ill or injured. Specialized pediatric services may be limited outside major medical centers. Transport by specialized pediatric and neonatal transport teams may be required to deliver patients to tertiary pediatric medical centers. In addition, in the past decade a cost-effective, organized, systematic approach to health care management has assumed greater importance, leading to the concept of the so-called medical home. In this model, a child with a complex medical problem is cared for in the environment in which he or she will receive the best care, with emphasis on providing rehabilitative and long-term care near the child's home. It is likely, then, that the field of pediatric transport medicine will assume greater importance in the coming decade.     

Interfacility transport of the critically ill pediatric patient

Care of the critically ill and injured child has evolved over the last 20 years, with growth of regional pediatric critical care services, attendant subspecialties, and the proliferation of pediatric critical care training programs nationally. Concurrent with this evolution has been recognition of the need for specialty care of the critically ill child during air or ground transport to a regional pediatric center. The American Academy of Pediatrics Section on Transport Medicine has provided standards that have been adopted by many neonatal and pediatric transport teams. Team composition varies, but all share the mission of specialized transport for critically ill and injured children in a safe and expeditious process while ultimately improving patient outcome. Specialized pediatric transport teams are costly to maintain. Declining reimbursement for specialized care and reduced profit margins have resulted in extended roles for transport team members within children's hospitals. More stringent budgetary constraints have created challenges for pediatric transport teams in our constantly changing medical environment.     

The Long Road to Better ACHD Care

The care of adult patients with congenital heart defects in the United States is spotty at best, and needs to improve greatly if the needs of these patients are to be met. The care of American children with congenital heart defects is generally excellent. Pediatric cardiac services are well established and well supported. The care of adults with congenital heart disease (CHD) is well established in only a few American centers. While there are an increasing number of clinics, they are generally poorly resourced with relatively few patients. If located in adult cardiology programs, they are usually minor players. If located in pediatric cardiac programs, they are usually minor players as well. Training programs for adult CHD (ACHD) caregivers are few, informal, and poorly funded. To improve the situation, we need perhaps 25 well-resourced and well-established regional ACHD centers in the United States. We need to stop the loss to care of CHD patients at risk of poor outcomes. We need to educate patients and families about the need for lifelong and skilled surveillance and care. We need to effect an orderly transfer from pediatric to adult care. We need to strengthen the human resource infrastructure of ACHD care through the training and hiring of healthcare professionals of a quality equivalent to those working in the pediatric care environment. We need to demonstrate that adult care is high quality care. We need more high-quality ACHD research. The ACHD community needs to establish its credibility with pediatric cardiac providers, adult cardiology groups, with governments, with professional organizations, and with research funding agencies. Accordingly, there is a need for strong political action on behalf of American ACHD patients. This must be led by patients and families. These efforts should be supported by pediatric cardiologists and children's hospitals, as well as by national professional organizations, governments, and health insurance companies. The goal of this political action should be to see that ACHD patients can receive high-quality lifelong surveillance, that we lose fewer patients to care, and that the staff and other services needed are available nationwide.     

Rural trauma care: a study of trauma care in a rural emergency medical services region

Motor vehicle-related trauma deaths in a 21-county rural emergency medical services (EMS) system are reviewed. Injury severity scores (ISS) and Glasgow coma scores (GCS) were recorded to provide baseline data for future comparison as the system progresses. The majority of deaths (67%) were related to CNS injuries. ISS in this series was similar to data reported from Orange County, California. The average GCS for all patients in this series was 5, indicating the high prevalence and severity of head injuries in motor vehicle deaths. Patients treated only in community hospitals had a low average ISS of 28.5. Those transferred from community hospitals to the regional tertiary care center had an average ISS of 36.2. Those admitted directly to the tertiary center had an ISS of 38.9. The data suggest that the rural trauma system might improve if there were training programs that promote recognition of significant injury, more aggressive resuscitation, and expeditious transfer of the injured patients.     

Prevalence of and annual ambulatory health care visits for pediatric arthritis and other rheumatologic conditions in the United States in 2001–2004

Objective

To estimate the prevalence of and the annual number of ambulatory health care visits for pediatric arthritis and other rheumatologic conditions.

Methods

We used physician office visit, outpatient department visit, and emergency department visit data from the 2001–2004 National Ambulatory Medical Care Survey and 2001–2004 National Hospital Ambulatory Medical Care Survey to estimate annual visits for the International Classification of Diseases, Ninth Revision, Clinical Modification codes thought to represent significant pediatric arthritis and other rheumatologic conditions (SPARC). We converted visit estimates into prevalence estimates using data on the number of prior annual visits per patient. Synthetic estimates for states were produced using national rates.

Results

The average annualized estimate of the number of children with SPARC was 294,000 (95% confidence interval [95% CI] 188,000–400,000). The annualized number of ambulatory health care visits for SPARC was 827,000 (95% CI 609,000–1,044,000).

Conclusion

Pediatric arthritis estimates have varied widely because it is an umbrella term for which there are many definitions and because it is a relatively uncommon condition from a population surveillance perspective. Our estimates suggest that arthritis‐related health care visits impose a substantial burden on the pediatric health care system. One advantage of this surveillance paradigm is that it has established a starting point for tracking the national prevalence of arthritis and rheumatologic conditions in children on an ongoing basis using existing infrastructure rather than expensive new surveys. This surveillance system will help us monitor and predict the health care needs of patients with these conditions.     

Rettungsdienstliche Versorgung beim Massenanfall von Verletzten (MANV)

Preclinical treatment in major emergency incidents with mass casualties is managed by the emergency medical service under the command of a senior emergency physician, who is supported by a senior paramedic. The overall mission command lies with the senior fire officer. According to the number of patients and local conditions, alert stages I–IV are defined. The regular emergency medical service on scene is reinforced by rapid action groups with mobile rescue posts. Rescue from the damage area is usually the task of the fire department. Medical treatment starts at the border of the accident area. At the rescue post, patients are examined, prepared for transport and distributed to local and regional hospitals. At alert stage IV with a large number of patients, this process must be adapted. The tasks of the rescue post are focused on triage and preparation for transport only of severely injured patients. These patients are transported as soon as possible to special near-by hospital called primary care hospitals. The main task of these hospitals is the further stabilization of the patients for in-hospital care or further transport to special clinics. For this purpose, the primary care hospital is reinforced by a clinic support group with a rescue post of the emergency medical service. A detailed and trained hospital emergency plan is imperative to fulfill these requirements.     

Epidemiology of trauma: The civilian perspective

Recent interest in civilian trauma as a public health problem dates from the National Academy of Sciences white paper in 1966. Civilian trauma patterns vary depending on locale--blunt trauma predominates in rural and smaller urban areas (65% to 80% of hospital admissions); penetrating trauma in larger urban areas outweighs blunt trauma by a ratio of 2 to 1. Approximately 50% of trauma deaths occur within minutes of injury, and efforts at prevention and reduction of injury are the only hope for decreasing mortality in this group. Thirty percent of trauma deaths occur in the first few hours, and reducing this rate will require optimization of prehospital and early hospital care. Aggressive efforts at intensive care unit management will be required to reduce the number of later deaths (20%). Several studies suggest that limiting the depth and duration of shock is a major factor in reducing the in-hospital mortality rate. Reducing mortality and morbidity nationwide requires several things. Although it is clear that preventive efforts must focus on legislation and public education, it is also clear that enforcement is a key element (eg, handgun violations, drunk driving). Emphasis in prehospital care probably should remain on field endotracheal intubation and expeditious transport to an appropriate facility. Recent data suggest that organization of in-hospital care of the multiply injured trauma victim along the lines of a dedicated trauma service can lead to reductions in morbidity and mortality from trauma. Finally, the commitment of federal and private agencies to supporting research on all aspects of trauma must be raised to a level commensurate with the seriousness of this major public health problem.     

Injury prevention and emergency medical services for children in a managed care environment

Each year, 1 in 5 US children receives medical care as a result of injury. Injuries are the leading cause of medical spending for children ages 5 to 21 years, accounting for more than 20% of hospital admissions and days spent in the hospital. Pediatric injuries become an important issue for managed care organizations because of concern for member safety and increasing medical costs related to treatment. Because effective prevention decreases health care consumption, injury prevention often costs less than treating injuries. Simple devices, such as bicycle helmets, smoke detectors, and child safety seats, help keep children safe and save money. Appropriate emergency care at the scene of an injury, poison control centers that dispense expert advice over the telephone, and triaged regional trauma systems improve the outcome and save money at the same time. This article continues the white paper series by the Emergency Medical Services for Children Managed Care Task Force.     

Management of major trauma haemorrhage: treatment priorities and controversies

The severely injured trauma patient often arrives in the emergency department bleeding, coagulopathic and in need of a blood transfusion. The diagnosis and management of these patients has vastly improved with a better understanding of acute traumatic coagulopathy (ATC). In the emergency setting, traditional laboratory coagulation screens are of limited use in the diagnosis and management of life-threatening bleeding. Whole blood assays, such as thrombelastography (TEG) and rotational thrombelastometry (ROTEM) provide a rapid evaluation of clot formation, strength and lysis. Rapid diagnosis of ATC and aggressive haemostatic transfusion strategies utilizing early high doses of plasma are associated with improved outcomes in trauma. At present there is no accurate guide for transfusion in trauma, therefore blood and clotting products are administered on an empiric basis. Targeted transfusion therapy for major trauma haemorrhage based on comprehensive and rapid measures of coagulation e.g. TEG/ROTEM may lead to improved outcomes while optimizing blood utilization. Evidence for the clinical application of TEG and ROTEM in trauma is emerging with a number of studies evaluating their ability to diagnose coagulopathy early and facilitate goal-directed transfusion. This review explores current controversies and best practice in the diagnosis and management of major haemorrhage in trauma.