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תל אביב, 4 דצמבר 2008

דילמות חילוץ והצלה ממוקדי תאונות. “Scoop and Run” vs. “Stay and Play”. Avraham Rivkind , M.D, F.A.C.S Department of General Surgery and Shock Trauma Unit Hadassah – Hebrew University Medical Center Jerusalem, Israel. תל אביב, 4 דצמבר 2008. Quo vadis – Were are ere going?.

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תל אביב, 4 דצמבר 2008

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  1. דילמות חילוץ והצלה ממוקדי תאונות “Scoop and Run” vs. “Stay and Play” Avraham Rivkind , M.D, F.A.C.S Department of General Surgery and Shock Trauma Unit Hadassah – Hebrew University Medical Center Jerusalem, Israel תל אביב, 4 דצמבר 2008

  2. Quo vadis – Were are ere going? “Stay and Play” “Scoop and Run” vs.

  3. French World War I Patients treated 8 hours after injury – 75% mortality Patients treated 1 hour after injury – 10% mortality

  4. “Golden Hour” the philosophy of modern trauma management

  5. Survival % “Golden Hour” the philosophy of modern trauma management Survival is related to severity & duration

  6. Immediate: Brain laceration Brainstem laceration Spinal cord laceration Aorta rupture Heart rupture Late: Sepsis Multiple Organ Failure Early: Epi/Subdural hematoma Hemopneumothorax Pelvic/limb fractures Abdominal injuries DEATH CAUSES OF TRAUMA DEATH Only prevention efforts might alter the outcome

  7. The legacy of R. Adams Cowley An organized approach to trauma care Maryland USA Paramedics at the scene and helicopter which will stabilize the patient en route 1917-1991

  8. Scoop and Run “A critical injured patient CANNOT be stabilized in the field” Nancy Caroline 1944-2002

  9. Emergency Medicine Service System Scoop and Run Stay and Play Patient is brought to the doctor by paramedics Doctor is brought to the patient Doctor is brought to the patient Responses time: 10 min – 80% of cases 15 min – 95% of cases Longer total prehospital time Longer total prehospital time

  10. Advanced Life Support - ALS Paramedic scope of care: • Endotracheal Intubation • Intraveous Access • Administration of pharmacologic agents

  11. ALS Providers Are limited in the type of intervention they can perform prior to arrival to hospital Sophisticated radiographic investigation Operative intervention For definitive management of life threatening injuries are not available in prehospital setting

  12. ALS Providers Prehospital ALS has theoretical advantages The evidence supporting its effectiveness and justification for trauma is limited Prehospital procedures before emergemcy department thoracotomy: “Scoop and Run” saves lives Seamon MJ, Fisher CA, Gaughan J et.al. J Trauma 63:1, 2007

  13. “Stay and Play” 140 min from accident to hospital arrival !!!

  14. Patients receiving ALS or BLS demonstrating absence of benefit or even the presence of harm Potter D, el. al. Ann. Emerg. Med. 17:582, 1998 ALS in patients with penetrating injuries had higher than expected mortality Cayten CE, J. Trauma 31:440, 1993 A higher risk of death in patients with received pre-hospital ALS Liberman M, Ann. Surg. 237:153, 2003 The time required for intravenous placement is equivalent to the transport time Smith JP, J. Trauma, 25:65, 1985

  15. Advanced Life Support Interventions Interventions fluid resuscitation and attempts at field stabilization Negative outcome in patients with penetrating trauma Administration of fluids without hemorrhage control only leads to more bleeding Bickell WH, Wall MJ Jr, Pepe PE, N. Engl. J. Med., 331:1105, 1994

  16. Prehospital interventions might cause harm and prolong the time to definitive care Physiological normality is NOT a goal Berlot G, et. al. Crit. Care. Clin. 22:457, 2006 Brambrink AM, et. al. Crit. Care. 8:3, 2004 Bulger EM, Surg. Clin. North. Am. 87:37, 2007

  17. ALS and Advanced Life Support interventions Endotracheal intubation Considerable difficulty to interpreting the published data: • Very variable population • Receive dissimilar care • Variable provider type Success rates of intubation 33%-100% A higher risk of death among head injured patients undergoing attempts at field intubation

  18. Pennsylvania Study • Death for patients who underwent intubation in the field is 4 times greater • Improved functional outcome in patients that underwent intubation only after arrival in the ER Wang HE, Peitzman AB, Cassoy LD, et.al. Ann. Emerg. Med. 44:439, 2004

  19. Advanced Trauma Life Support - ATLS Initial Assessment and Management A Airway / C-spine protection B Breathing / Life-threatening chest injury C Circulation / Stop the bleeding D D isability / Intracranial mass lesion E Exposure / Environment / Body temp

  20. Effect of trauma center care on mortality • Efficient transport • Limited BLS intervention an the scene • Triage to a designated trauma center Mackenzie EJ, Rivera FP, Jurkovich GJ, N. Engl. J. Med. 354:366, 2006

  21. Emergency Medicine Service System There is not one “golden” medical emergency system There is no “golden” timelines No “golden” skills A medical system should be flexible and be able to adjust on each specific local situation

  22. Jerusalem 2008

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