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

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

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

“Golden Hour” the philosophy of modern trauma management

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

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

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

“A critical injured patient CANNOT be stabilized in the field” Nancy Caroline Scoop and Run

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

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

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

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

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

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

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

Prehospital interventions might cause harm and prolong the time to definitive care 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 Physiological normality is NOT a goal

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

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

A B C D E A A irway / C-spine protection B B reathing / Life-threatening chest injury C C irculation / Stop the bleeding D D isability / Intracranial mass lesion E E E xposure / Environment / Body temp Initial Assessment and Management Advanced Trauma Life Support - ATLS

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

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 Emergency Medicine Service System

Jerusalem 2008