Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Trauma and Trauma Systems

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Topics Trauma Trauma Care Systems Trauma Center Designation Trauma triage criteria EMS Roles

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Trauma (1 of 2) Leading killer of persons under 44 in the United States –150,000 deaths annually 44,000 MVC 28,000 GSW Most expensive medical problem in terms of lost wages, initial care, rehabilitation, and lifelong maintenance

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Trauma (2 of 2) Penetrating –Injury caused by an object breaking the skin and entering the body. Blunt –Injury caused by the collision of an object with the body in which the object does not enter the body. Serious/life-threatening problems occur in less than 10% of all trauma patients. –Must recognize difference between serious and non-serious problems and triage your care.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Care System Highway Safety Act of 1966 –Lead to development of EMS –“White Paper” Victims of MVCs suffered from the initial trauma but also from inadequate prehospital care. American College of Surgeons –1990: Trauma Care Systems Planning and Development Act Established guidelines, funding, and state-level leadership for the development of trauma systems.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Designation/Verification of Trauma Centers (1 of 2) National Standard –ACS optimal resource document as a guideline –ACS Committee on Trauma verification/ consultation on site

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Designation/Verification of Trauma Centers (2 of 2) Local Variations –State accreditation

Do Trauma Centers Work? Ann Surg. Oct 2005; 242(4): 512–519. The Effect of Trauma Center Designation and Trauma Volume on Outcome in Specific Severe Injuries Demetrios DemetriadesDemetrios Demetriades, MD, PhD, Mathew Martin, MD, Ali Salim, MD, Peter Rhee, MD, Carlos Brown, MD, and Linda Chan, PhDMathew MartinAli SalimPeter RheeCarlos BrownLinda Chan –Trauma centers are designated by the ACS into different levels on the basis of resources, trauma volume, and educational and research commitment. The criteria for trauma center designation are arbitrary and have never been validated. –A total of 12,254 patients met the inclusion criteria. Overall, level I centers had significantly lower mortality (25.3% vs 29.3%; adjusted odds ratio [OR], 0.81; 95% confidence interval [CI], 0.71–0.94; P = 0.004) and significantly lower severe disability at discharge (20.3% vs 33.8%, adjusted OR, 0.55; 95% CI, 0.44– 0.69; P < 0.001) than level II centers Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Trauma Care System Integration of –EMS –Hospital care Reduces –Cost –Time to surgery –Mortality Proper Care –Immediate surgical intervention to repair hemorrhage sites

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Center Designation Level I –Regional Trauma Center –All types of surgical and medical subspecialty –Research and teaching commitment Level II –Area Trauma Center –Majority of surgical and medical subspecialties available 24/7 Level III –Community Trauma Center –Specialized ED with the majority of surgical and medical subspecialties available 24/7 (on call) Level IV –Rural community hospitals –No immediate surgical intervention necessary –Stabilize and transfer out

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Differences between Level I and II Trauma Centers Level I: –1,200 trauma admissions/year –Pts w/ ISS >15 (240 total or 35 pts/surgeon) –Immediate surgical capability available –In-house trauma surgeon –General surgery residency program or trauma fellowship –Research Level II: –No minimum patient criteria –Surgical capability available in a “reasonably acceptable time” –General surgeon present at resuscitation –Desirable to have residents –No research minimum

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Center Designation Specialty Centers –Neurocenters –Burn Centers –Pediatric Trauma –Hyperbaric Medicine –Microsurgery

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Role of EMS (1 of 2) Trauma Triage Criteria –START –Nearest appropriate facility Mechanism of Injury Analysis (MOI) –Processes and forces that cause trauma –Consider inertial forces Index of Suspicion (IOS) –Anticipation of injury to a body region, organ, or structure based on MOI –Shock and head injury –Frequent reassessment and trending

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Role of EMS (2 of 2) The Golden Hour –Research has shown that the BEST survivability from incident to surgery is 1 hour. (The shorter time, the better!) –Platinum 10 Minutes Scene time limited to 10 minutes –Air Transport Speed vs. need Type of patients transported

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Triage Criteria MOI-Adults (1 of 2) >20’ fall Pedestrian/bicyclist versus auto –Thrown or run over by vehicle –Struck by vehicle traveling >5 mph Motorcycle impact >20 mph Ejected from a vehicle

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Triage Criteria MOI-Adults (2 of 2) Severe vehicle impact –>40 mph –>12” intrusion –>20” vehicle deformity Rollover with signs of serious impact Death of another occupant Extrication time >20 minutes

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Triage Criteria Infants and Children >10’ fall Bicycle collision Vehicle collision at medium speed Any vehicle collision involving an unrestrained infant or child

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Triage Criteria Physical Findings (1 of 2) Revised trauma score <11 Pediatric trauma score <9 Glasgow coma scale <14 Systolic blood pressure <90 Respiratory rate 29

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Trauma Triage Criteria Physical Findings (2 of 2) >2 proximal long bone fractures Flail chest Pelvic fracture Limb paralysis Burn >15% BSA Burn to face or airway Penetrating trunk, neck, or head trauma

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Role of EMS (1 of 3) Decision to Transport –Based upon trauma triage criteria Critical Problems IV Access and other time-consuming procedures en route Err on the side of precaution –If patient DOES NOT fit a trauma triage criteria but has signs and symptoms, RE-EVALUATE!

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Role of EMS (2 of 3) Injury Prevention –Bicycle safety programs –Firearm safety –Boat safety –Child safety seat classes and checking Data and Trauma Registry –Data retrieval system for trauma patient information –Used to evaluate and improve the trauma system

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Role of EMS (3 of 3) Quality Improvement –QI or QM –Examine the system performance and attempt to improve and provide better patient care. –Evaluate calls to determine if standard of care was met. –Accurate and complete documentation.