1. Yaniv Berliner

2. Scene survey  EMS must first evaluate the safety of the scene.  Downed power lines, fire, traffic  Is there a need for specialized equipment for extrication.  Is there a need for air ambulance  What type of facility is nearby?  Are all patients accounted for. Is there a possibility of ejected patients.

3. What type of crew  In Ontario, either Primary Care Paramedic (PCP) or Advanced Care Paramedic (ACP).  ACP’s have further education and preceptorship.  ACP’s have a wider scope of practice. In trauma they are able to initiate IV bolus, perform needle decompression and endotrachael intubation (with base hospital support)

4. Primary Survey  ABCD assessment of both patients  Does the mother warrant airway protection due to GCS?  If there is only one crew on site, who should be managed first?  Unless extrication causes delay, limit on scene time to 10 minutes

5. Airway  Airway interventions as per ATLS  O2 applied  Jaw thrust  BMV  More advanced airway interventions are usually reserved for receiving hospital (if it is nearby)

6. Intubate GCS<8 in field? (Prehospital Emergency Care, 2011 15 184)  Trauma Registry  1,555 patients. Chart review.  Intubation attempted in 758 patients  57% mortality, intubation group.  34% mortality, non intubation group

7.  Patients in the intubation group were more critically injured.  Lower GCS (4.3 vs 5.3)  More SBP<90 (28 % vs 17%)  Probably represents a selection bias whereby when a decision to intubate is undertaken the patient is sicker

8. SiteIntubation %Overall mortalityMorality in Those Intubated TOR184668 MLW305081 DAL376279 IWA413957 OTT455074 ARC453862 PTL503148 PGH544750 VAN685863 SKC753539

9. Breathing  Oxygen and ventilatory support are provided  Needle decompression for tension pneumothorax. This is done in conjunction with base hospital. Indications are:  Severe shortness of breath  SBP less than 90  Absent breath sounds  Occlusive dressing is placed over an open pneumothorax

10. Circulation  Paramedics assess circulation. If systolic pressure is <100, 20cc/kg IV NS is administered.  Lacerations are bandaged  Unstable Pelvis injuries are tied  MSK injuries are splinted

11. Disability  Extrication with full c-spine precautions  Collar is placed first, then pt is placed on board  Board is padded over pressure points  Pt is then placed on a long board  C-spine injury is presumed in any patient involved in MVC, fall from height, dangerous mechanism, neck pain, neurological symptoms or decreased level of consciousness.

12. Clearing C-spine in the Field  Canadian C-spine rule interpreted by paramedics  Clinical decision rule is applied, but the patient remains immobilized  Pt is brought to ER for assessment.  The reliability of rule application is determined and compared to investigators (ER docs)

13. C-spine rules

14. Clearing in the Field  1949 patients evaluated  12 c-spine injuries  Paramedics 100% sensitive in identifying patients with potential injury  Paramedic specificity 43%, versus 38% for investigators (some overcalling by EMS)

15. Clearing C-spine  If paramedics were allowed to use rule 62% of patients would require immobilization in the field, compared to actual rate of 100%.  This in turn saves ER space, xrays, less time on board.

16. Pain management  Advanced care paramedics may administer analgesia for isolated extremity fractures  Morphine or Fentanyl  For multi-system trauma base hospital is contacted for analgesia orders

17. Load and Go Patients  What it sounds like.  In trauma in the setting of severe multi-system injury (severe chest injuries, head injury with lateralizing signs, severe abdominal pain post trauma, unstable pelvis, bilateral femur fractures)  Primary assessment performed. Oxygen applied. Pt is placed on long board with c-spine immobilization and additional history/assessment is obtained en route  Dispatch is made aware

18. Back to Case: Mother  Scene Survey, limit scene time to 10 min  Primary Survey  Full immobilization  02 applied, ventilation assisted  IV initiated, 20cc/kg NS given  Splint for femur fracture  Transport initiated  Benzodiazepines as needed for seizure from presumed head injury  Secondary survey en route

19. Daughter  Scene Survey  Primary Survey  Collar placed  Three person extrication with full c-spine precaution  Full board  IV initiated  Base hospital contacted for analgesia

20. OPALS  A before-after controlled clinical trial to assess the benefit of prehospital advanced life support program.  1373 BLS patients: 1494 ALS patients  No substantial difference in overall survival to hospital discharge (81.8% survival BLS, 81.1% survival ALS)

21. OPALS  598 patients with GCS<9  Lower survival ALS (50 % survival ) then BLS (60%). Value was significant (p<0.03)  Authors speculate this may be due to delay in transfer to hospital

22. Acknowlegements  Base Hospital Program.  David Vusich  Severo Rodrigues