Ace844

Hi All, Rather than continue to hijack the other thread where this started i figured I'd start a new one where we can discuss this issue..... Now let's see what a few studies have to say:::: EMERGENCY MEDICAL VEHICLE COLLISIONS AND POTENTIAL FOR PREVENTIVE INTERVENTION Catherine B. Custalow A1 and Craig S. Gravitz A1 A1 University of Virginia (CBC), Charlottesville, Virginia; and Denver Health Medical Center (CSG), Denver, Colorado. Abstract: Background. Emergency medical vehicle collisions (EMVCs) cause significant injury, death, and property damage every year in the United States and result in significant delays in transporting patients to the hospital. Objective. To identify factors associated with EMVCs that are potentially amenable to preventive intervention. Methods. The authors reviewed data from the Paramedic Division of the Denver Health and Hospital Authority (DHHA) on all EMVCs occurring from 1989 through 1997. Results. A T-bone mechanism, collision at an intersection, and alcohol intoxication of the civilian driver were all significant predictors of collisions resulting in injury (odds ratios of 29.7, 4.3 and 6.1, respectively, p < 0.05, multiple logistic regression). Although only 75% of the division's responses are run with warning lights and sirens (WLS), a disproportionate 91% of response mode collisions were during a WLS response. The responsible EMV driver had a history of multiple EMVCs in 71% of the collisions. Conclusions. Potential interventions suggested by this study include the need for EMV drivers to visually clear the intersection before entering it, alerting other drivers with visual and auditory warning systems, and attempting to make eye contact with them at an intersection. The authors recommend continued public education regarding the risks of drunk driving. The authors feel that the WLS driving mode is best reserved for patients in whom the benefits of shorter response and return times outweigh the risk of collision. Finally, the authors advocate careful review of drivers' collision history, frequent emergency vehicle operator's course retraining, and appropriate discipline when necessary. DO WARNING LIGHTS AND SIRENS REDUCE AMBULANCE RESPONSE TIMES? Lawrence H. Brown A1, Christa L. Whitney A1, Richard C. Hunt A1, Michael Addario A1, Troy Hogue A1 A1 Department of Emergency Medicine (LHB, RCH) and the College of Medicine (CLW), State University of New York Health Science Center at Syracuse, Syracuse, New York; and Rural/Metro Medical Services (MA, TH), Syracuse, New York. Abstract: Objective. To determine the time saving associated with lights and siren (L&S) use during emergency response in an urban EMS system. Methods. This prospective study evaluated ambulance response times from the location at time of dispatch to the scene of an emergency in an urban area. A control group of responses using L&S was compared with an experimental group that did not use L&S. An observer was assigned to ride along with ambulance crews and record actual times for all L&S responses. At a later date, an observer and an off-duty paramedic in an identical ambulance retraced the route--at the same time of day on the same day of the week--without using L&S and recorded the travel time. Response times for the two groups were compared using paired t-test. Results. The 32 responses with L&S averaged 105.8 seconds (1 minute, 46 seconds) faster than those without (95% confidence interval: 60.2 to 151.5 seconds, p = 0.0001). The time difference ranged from 425 seconds (7 minutes, 5 seconds) faster with L&S to 210 seconds (3 minutes, 30 seconds) slower with L&S. Conclusion. In this urban EMS system, L&S reduce ambulance response times by an average of 1 minute, 46 seconds. Although statistically significant, this time saving is likely to be clinically relevant in only a very few cases. A large-scale multicenter L&S trial may help address this issue on a national level. Use of Warning Lights and Siren in Emergency Medical Vehicle Response and Patient Transport National Association of Emergency Medical Services Physicians (NAEMSP) and the National Association of State EMS Directors (NASEMSD) This paper was developed for NAEMSP by the Emergency Medical Response Task Force: Jeff J. Clawson, MD, Chair; Robert Forbuss; Scott A. Hauert; Fred Hurtado; Alexander E. Kuehl, MD; W.H. ABill@ Leonard; Peter A. Maningas, MD; Joseph L. Ryan, MD; and Donald R. Sharpe. It was reviewed and adopted to the position paper format by the NAEMSP Standards and Clinical Practice Committee, Herbert G. Garrison, MD, MPH, Chair. Correspondence: Executive Director, National Association of EMS Physicians, P.O. Box 15945-281, Lenexa, KS 66285-5945. The position paper was approved by the NAEMSP Executive Committee on 18 November 1993, and by the Executive Committee of the National Association of State EMS Directors on 6 January 1994. Published in Prehospital and Disaster Medicine, April-June 1994. Abbreviations: EMS = emergency medical services; EMV = emergency medical vehicle; L&S = lights and siren Introduction The use of warning lights and siren (L&S) by prehospital emergency medical services (EMS) vehicles is a basic component of emergency response and patient transport. This public-safety practice predates modern EMS by 50 years1. Despite the long-term reliance on L&S, it is not a risk-free practice. There are many reports of emergency medical vehicle (EMV) collisions during L&S responses and transports2-4. These collisions often result in tragic consequences for the EMV occupants and those in other vehicles, and may cause significant delays to medical care for the patient the EMV was responding to or transporting5. While there is no systematic collection of EMV collision data, some authors have suggested that the available information underestimates the extent of the problem6,7. In addition, to date there have been few published analyses regarding the effectiveness of L&S as a modality that improves response times or, more important, patient outcome. Despite the lack of data, it generally is accepted that the use of L&S is a privilege granted to emergency medical responders that should be reserved for those situations in which patient welfare is at stake. To provide guidance to the states' EMS medical directors and system managers, the National Association of EMS Physicians (NAEMSP) and the National Association of State EMS Directors (NASEMSD) endorse the following positions regarding the use of warning L&S in EMV response and patient transport. Position Statements 1. Emergency medical services (EMS) medical directors should participate directly in the development of policies governing EMV response, patient transport, and the use of warning lights and siren. Emergency medical vehicle response policy decisions involve many medical care and medical direction issues including patient outcome, quality improvement, patient and emergency medical provider safety, and risk management. Therefore, EMV response and patient transport decisions should be guided, reviewed, and approved by the EMS medical director. 2. The use of warning lights and siren during an emergency response to the scene and during patient transport should be based on standardized protocols that take into account situational and patient problem assessments. Written protocols and guidelines should delineate when to use L&S during scene response and patient transport. These protocols should be based on a reasonable identification of situations for which a reduction in response and transport times might improve patient outcome. The protocols should be developed in conjunction with local emergency response practices and statutes and should receive approval from the EMS medical director. Final protocols should be distributed to all dispatch and EMS entities. Warning lights and siren protocols should be enforced, and inappropriate use of L&S by EMS personnel will be limited. 3. EMS dispatch agencies should utilize an emergency medical dispatch priority reference system that has been developed in conjunction with and approved by the EMS medical director to determine which requests for prehospital medical care require the use of warning lights and siren. Sound dispatch prioritization systems establish a patient’s level of severity, which then allows the determination of the type of vehicle(s) that should respond and the urgency of that response. Emergency medical dispatch centers should institute the protocols and monitor adherence to them. 4. Except for suspected life-threatening, time-critical cases or cases involving multiple patients, L&S response by more than one EMV usually is unnecessary. Guidelines for the multi-EMV L&S response should be outlined in emergency medical response policies and dispatch procedures. 5. The utilization of emergency warning L&S should be limited to emergency response and emergency transport situations only. Alternative practices, such as returning to a station or quarters using warning L&S or using L&S for Astaging@ or moving to designated areas to stand-by for a response, should be discontinued. Exceptions to such a policy would include extraordinary circumstances such as a disaster, or situations in which patient outcome could be affected. 6. All agencies that operate EMVs or are responsible for emergency medical responders should institute and maintain emergency vehicle operation education programs for the EMV operators. Initial and continuing education of EMS personnel should include instruction in safe and appropriate EMV driving techniques and should take place prior to initial EMV operation. Knowledge and demonstrated skill in EMV operation are prerequisites for all public-safety vehicle operators. 7. Emergency medical vehicle-related collisions occurring during an emergency response or transport should be evaluated by EMS system managers and medical directors. Such evaluations should include an assessment of the dispatch process, as well as initial (at the beginning of the transport) and final patient conditions. 8. A national reporting system for EMV collisions should be established. Data are needed regarding the prevalence, circumstances, and causes of EMV collisions, including related injuries and deaths, and "wake effect" collisions. Collection of the information should start at the state and local levels; the information collected should include uniform data elements for tabulation and nationwide comparison. 9. Scientific studies evaluating the effectiveness of warning L&S under specific situations should be conducted and validated. These important research efforts should be supported by both public and private resources. 10. Laws and statutes should take into account prudent safety practices by both EMS providers and the monitoring public. The major emphasis and focus should remain on the exercise of prudent judgment and due regard by EMV operators. Laws and statutes also should emphasize the motoring public's responsibility to clear a lane or access way for EMVs. 11. National standards for safe EMV operation should be developed. Such standards should mandate that EMV operators should approach intersections safely and have a clear view of all lanes of traffic before proceeding through. Standards also should set appropriate speed limits for emergency responses and transports in urban and rural settings, and for responses that occur under adverse road, traffic, and weather conditions. Discussion The Risk of the Emergency Response Response to and transport of emergency patients are integral components of the EMS chain of care. Since the beginning of modern EMS, the usual vehicle response mode has involved the use of L&S. Since this type of response was consistent with the practices of other public-safety agencies that use emergency vehicles (i.e., law enforcement and the fire service), the practice was implemented initially without question. As an understanding of EMS call histories and patient outcomes has evolved, it has become evident that the use of L&S by EMS vehicles is not necessary for every response or patient transport4. There is risk associated with the use of warning L&S: emergency medical vehicles running "hot" (with L&S) have been involved in many collisions that have resulted in injuries and death in a high number of cases2,4,6. The monetary loss derived from EMV collisions, including property damage, increased insurance premiums, and liability payments in some venues, have eclipsed that of any other negligence-related EMS problem7,8. This situation exists at a time when published data demonstrating the use of L&S in response or patient transport is effective in improving patient outcome are lacking. In fact, the U.S. Department of Transportation has reported that sirens may never become an effective warning device9. Even if warning L&S eventually are shown to be useful in certain time-critical situations (e.g., cardiac arrest or penetrating chest injuries), it is unlikely that L&S will be proven beneficial for each and every EMS response and transport. Concern about patient welfare, combined with inadequate information on a patient's actual condition, often pressures emergency medical technicians and paramedics to rush to and from scenes in order to "save lives." As Auerbach5 states, "...loose interpretation of what constitutes an emergency has essentially given [EMV operators permission] to operate their vehicles as they see fit while carrying victims who are essentially stable by anyone's definition." Medical Director Involvement Since EMS response and patient transport are prehospital medical "tools," accountable EMS medical directors should be involved in the development of emergency response and transport policies10. Additionally, EMS medical directors should evaluate EMV collisions for the medical correctness of the dispatch process, the patient's condition on arrival at the scene and when the transport began, and the patient's eventual outcome. For those medical directors who may need assistance with this aspect of prehospital care, advice is available from colleagues in NAEMSP, NASEMSD, and other EMS organizations. Standardized Dispatch, Response, and Transport Sound emergency medical dispatch protocols should be established and used as the basis for determining those situations that would benefit from the appropriate use of warning L&S. Research is emerging that supports the concept that medically sound protocols safely delineate which patients do and do not require emergency advanced life support11, 12. Such protocols, as well as proper emergency medical dispatcher and EMV operator training, should be integral parts of a local dispatch agency's emergency medical dispatch system. The American Society for Testing Materials state in their Standard Practice for Emergency Medical Dispatch document 13 that "this practice may assist in overcoming some of the misconceptions...that red lights, siren, and maximal response are always necessary." Ideally, the use of L&S should be reserved for those situations or circumstances in which response and transport times have been shown to improve a patient's chances for survival or quality of life. Examples of such situations include cardiac or respiratory arrest, airway obstruction, extreme dyspnea, critical trauma, childbirth and problems with pregnancy, drowning, and electrocution. In some of these cases, a rapid response is important (e.g., cardiac arrest), whereas in others rapid transport is necessary (e.g., breech birth). Nevertheless, a large number of calls to 9-1-1 are for non-emergency problems that require neither rapid response nor rapid patient transport14, 15. Systems utilizing non-L&S response modes for such low-priority calls have experienced few problems16. This issue, however, requires more in-depth study in order to determine the specific positive and negative effects of L&S utilization on patient outcome in the various types of high- and low-priority cases. In the typical EMS model, once a patient is evaluated and provided appropriate emergency treatment, transport by an EMV is initiated to move the patient to a definitive care facility. Many patients to whom EMS respond do not require L&S for patient transport. However, many EMS systems do not have protocols governing L&S use during patient transport, and few endorse contact with an on-line medical control base-station for advice or consent on the use of L&S transport. Response of Multiple Emergency Medical Vehicles The use of warning L&S by all EMVs responding to a single incident has been scrutinized in many systems and many of those systems have adopted a modified approach12, 17. From a medical point of view, the response of more than one unit utilizing L&S is necessary only in those situations involving suspected life-threatening, time-critical cases, or multiple patients. Likewise, the practice of returning to a station or quarters using L&S so as to "be in position" for the next call has no support in most responsible public-safety communities. The Emergency Medical Vehicle Operator While prevention of EMV collisions will depend on the application of sound dispatch protocols, dispatcher training, and direct involvement of the EMS medical director in developing dispatch and transport policies, attention also should be directed at the EMV operator. Before a driver of an emergency vehicle takes the wheel, their driving records should be carefully screened, and each should be trained in the proper use of EMVs. Rigorous education and control of EMV drivers should reduce EMV collisions, create a more standard approach and practice to EMV operation, and improve EMV longevity. Fortunately, there are detailed instruction guides for proper EMV operation18, 19. Emergency medical services provider education should include instruction in "low force" driving techniques. In addition, all personnel operating EMS vehicles should be involved in agency quality improvement programs including continuing education courses on EMV operation. Some state laws require that EMV operators exercise what is called "due regard." New Jersey law (N.J.S.A. 39:4-91) states it "...shall not relieve the driver of any authorized emergency vehicle from the duty to drive with due regard for the safety of all persons, nor shall it protect the driver from the consequences of his reckless disregard for the safety of others." Using laws of this nature, a number of prosecutors recently have charged and convicted ambulance operators of involuntary manslaughter14. Most state laws, however, fail to place clear responsibility for the use of L&S on the EMS operators themselves20. While much talk has ensued regarding the public's responsibility to "watch out" or "get out of the way," EMS should not blame the public for the problem of EMV collisions. The EMS Profession Responsibility rests with the EMS profession and local governments to establish minimum standards for the safe operations of EMS vehicles and to monitor the use of such standards. An example of such a standard would be a formal policy stating that EMVs should not exceed the locally posted speed limit in urban settings, should not exceed the speed limit by more than 10 miles per hour in rural areas, and that EMVs should not travel at any speed that is unsafe for current road, traffic, or weather conditions. Nationally, EMS-related organizations should work together in helping to create standards that detail the positions in this document. Organizations that should be involved in a effort to set standards for emergency medical response and transport include the American Ambulance Association, the American College of Emergency Physicians, the Association of Public Safety Officers, the International Association of Fire Chiefs, the International Association of Fire Fighters, the National Association of Emergency Medical Technicians, the National Association of EMS Physicians, the National Association of State EMS Directors, the National Association of State EMS Training Coordinators, the National EMS Alliance, and the National Fire Protection Agency. Reimbursement The reimbursement profiles of many EMS agencies contain an extra charge for the use of warning L&S. This occurs because the federal Health Care Financing Administration reimbursement policies recognize L&S use as a special circumstance. Insurance reimbursement for "emergencies" also may be predicated on L&S use, further perpetuating this problem. Unless these types of policies and profiles are modified by the government, insurance companies, and the EMS profession itself, adjustments in L&S use (as recommended in this document) may be viewed as adversely affecting EMS reimbursement. Therefore, without reimbursement policy modifications, the L&S reform process may be slowed. Emergency Medical Vehicle Collision Reporting The amount of data available on EMV collisions in general is fragmented and has not been obtained using any systematized or scientific format4, 5. The Fatal Accident Reporting System (FARS) may underestimate EMV collision occurrence and outcome. In 1990-1991, a national press clipping service documented 303 EMV collisions in one year resulting in 711 injuries and 78 deaths. (Clawson, unpublished data). The number of fatalities discovered in this newspaper review eclipses those reported by FARS involving EMVs for the same time period. An acknowledged, but little-studied result of L&S use is the "wake effect," in which use of L&S results in collisions that involve only civilian vehicles and not the EMV itself. The ratio of wake effect collisions to those actually involving an EMV may be as high as five to one6. However, this only can be adequately assessed with a comprehensive EMV collision reporting system. There are models for EMV collision reporting systems. The National Fire Protection Agency has had in place a uniform process for reporting and quantifying fire fighting-related collisions and injuries for many years. Utah and Tennessee have "ambulance accident" reporting systems. As Auerbach5 has reported about Tennessee's system: "Before the requirement for accident reporting was imposed, [EMV collisions] analysis would have been impossible. Prehospital [EMV collision] data collection is essential if emergency medical services physicians are to exert reasonable control and make knowledgeable recommendations involving clinical care and professional regulations." Ideally, the federal government will initiate a national reporting system for EMV collisions. Any reporting system should be uniformly structured, track the multiple different types of responding agencies and vehicles including both volunteer and fire-based first responders (not just "ambulances"), and also provide a mechanism for the identification and reporting of wake effect collisions. Research Regrettably, there currently are few published investigations of dispatch protocols for L&S use. Also, there are no published studies attempting to evaluate the effectiveness of L&S use in terms of patient outcome. Worse still, there are no studies in either refereed or public safety trade journals that demonstrate that the use of L&S saves significant time over routine driving methods. In 1987, Auerbach5 demonstrated that the mean delay to hospital care after an EMV collision in Tennessee approached 10 minutes. The use of warning L&S in EMS rests primarily on the unsupported tradition that has evolved from police- and fire-response practices. In some cases, these practices may adversely affect EMS patients and providers. Therefore, a series of objective, well-structured, scientific studies aimed at identifying both the positive and negative effects of L&S use should be pursued. Conclusion In order to ensure that we "first do no harm," 20 sound rationale and corresponding protocols and policies for the use of warning L&S in EMV response and patient transport should be developed and instituted in all EMS systems. All EMV operators should be trained adequately and regulated. The judicious use of warning L&S in the initial response and subsequent transport of patients likely will result in a more balanced system of appropriate care with minimization of iatrogenic injury and death. Also see these studies:: Is Ambulance Transport Time With Lights and Siren Faster Than That Without? Wheels of Fortune Use of Warning Lights and Siren in Emergency Medical Vehicle Response and Patient Transport How to modify the risk-taking behaviour of emergency medical services drivers? Comparison of Crashes Involving Ambulances with Those of Similar-Sized Vehicles A SYSTEMATIC REVIEW OF THE EVIDENCE SUPPORTING THE USE OF PRIORITY DISPATCH OF EMERGENCY AMBULANCES Paramedic Response Time: Does It Affect Patient Survival?

Hi All, I saw this article while I was catching up on my journal reading and after seeing this along with a few others on permissive hypotension. It all got me to thinking, do any of you follow the new evidence in your pre-hospital practice? Has your system adapted at all? If so How??? I'm sure that we all look forward to yuor responses.... Hope these helped, Ace844 http://emj.bmjjournals.com/cgi/content/full/19/6/494 http://www.ncbi.nlm.nih.gov/entrez/query.f...&query_hl=2 http://www.ncbi.nlm.nih.gov/entrez/query.f...&query_hl=2 http://www.ncbi.nlm.nih.gov/entrez/query.f...&query_hl=2 http://www.ncbi.nlm.nih.gov/entrez/query.f...&query_hl=2 http://beta.trauma.org/traumawiki/index.ph...a_Resuscitation http://www.jtrauma.com/pt/re/jtrauma/abstr...9856145!9001!-1 Radial Pulse Character Relationships to Systolic Blood Pressure and Trauma Outcomes John McManus A1, Andrey L. Yershov A1, David Ludwig A2, John B. Holcomb A1, Jose Salinas A1, Michael A. Dubick A1, Victor A. Convertino A1, Denise Hinds A3, Will David A3, Tom Flanagan A3, James H. Duke A3 A1 The U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas A2 The Medical College of Georgia, Augusta, Georgia A3 The University of Texas Health Science Center, Houston, Texas Abstract: Background. Patient measurements that do not require monitoring equipment may be the only way to evaluate casualties in austere conditions to determine treatment and transport priority. Objective. To test the hypothesis that palpable pulse characteristics in the radial artery would estimate systolic blood pressure (SBP) and predict outcome in trauma patients. Methods. Data were analyzed from the medical records of 342 trauma patients ranging from 18 to 50 years of age. Prehospital data were collected by helicopter emergency medical personnel at the scene of the injury. Based on radial pulse character, patients were divided into normal (n = 313) and weak (n = 29) groups. Those whose medical records did not describe pulse characters were not considered. Differences in SBP, mortality, and medical interventions between the radial-pulse-character groups were evaluated. Results. The SBP taken at the scene was a mean of 26 mm Hg lower in those patients with weak radial pulse characters (102 mm Hg versus 128 mm Hg). Similarly, the lowest mean SBPs recorded in the field between the normal- and weak-pulse-character groups were 112 mm Hg and 99 mm Hg, respectively. Patient mortality increased with weak pulse character such that the mortality rats were 3% for the normal-pulse-character group and 29% for the weak-pulse-character-group (odds ratio = 15.2). Conclusions. These preliminary data suggest that a weak radial pulse may be an acceptable method for initial rapid evaluation of trauma patients. This simple and rapid method of pulse evaluation should be considered for the triage of trauma patients in field conditions with limited instrumentation. Key words: pulse character; radial artery; systolic blood pressure; trauma; mortality. Endpoints for Fluid Resuscitation in Hemorrhagic Shock. Journal of Trauma-Injury Infection & Critical Care. 54(5) Supplement:S63-S67, May 2003. Revell, Matthew MD; Greaves, Ian MD; Porter, Keith MD Abstract: Vigorous intravenous fluid resuscitation has become widely accepted as the optimum management of hemorrhagic shock in trauma. There is now, however, sufficient evidence for this position to be reviewed. Hypotensive or delayed resuscitation has been postulated as a means by which the mortality associated with treatment can be reduced. It has been suggested that overresuscitation with intravenous fluids may worsen hemorrhage. This article discusses the possible adverse effects of "conventional" resuscitation and examines the evidence to support alternative treatment modalities. Fluid Resuscitation Improves Hemodynamics without Increased Bleeding in a Model of Uncontrolled Hemorrhage Induced by an Iliac Artery Tear in Dogs. Journal of Trauma-Injury Infection & Critical Care. 52(6):1147-1152, June 2002. Bruscagin, Victor MD; Poli de Figueiredo, Luiz F. MD, PhD; Rasslan, Samir MD; Varicoda, Edson Y. DVM; Rocha e Silva, Mauricio MD, PhD Abstract: Background : Fluid resuscitation administered before hemorrhage control for trauma victims sustaining penetrating abdominal injury is controversial. Our objective was to evaluate intra-abdominal blood loss and hemodynamic and metabolic effects of no fluid resuscitation, small-volume 7.5% sodium chloride/6% dextran-70 (HSD), or large-volume lactated Ringer's (LR) solution during intra-abdominal vascular injury and uncontrolled hemorrhage. Methods : In pentobarbital-anesthetized dogs (n = 26, 17 +/- 0.3 kg), a suture was placed through the common iliac artery to produce a 3-mm tear when the exteriorized suture lines were pulled after incision closure. Dogs were randomized to three groups, according to the treatment used after 20 minutes of uncontrolled hemorrhage: controls, no fluid resuscitation (CT group) (n = 6); the HSD group (4 mL/kg over 4 minutes, n = 6); and the LR group (32 mL/kg over 15 minutes, n = 6). After 40 minutes of uncontrolled bleeding, animals were killed, and intra-abdominal blood loss was measured. Results : Eight dogs died from severe hemorrhagic shock before randomization and were excluded. After 20 minutes, animals presented lower blood pressure (~ 35 mm Hg), low cardiac output (~ 1.0 L/min/m2), and metabolic acidosis (pH ~ 7.23, base excess ~ -9 mmol/L). After HSD and LR solution, arterial pressure presented a transient increase, but remained below baseline. Two animals died before the end of the experiment, both in the LR group. Cardiac index was partially improved in the LR and HSD groups, whereas the CT group sustained a low-flow state. There were no significant differences between groups regarding intra-abdominal blood loss (CT group, 47.8 +/- 5.9 mL/kg; HSD group, 41.7 +/- 2.3 mL/kg; and LR group, 49.4 +/- 0.7 mL/kg). Conclusion : Fluid resuscitation with either large-volume LR solution or small-volume HSD, during uncontrolled hemorrhage from intra-abdominal vascular injury, produced hemodynamic and metabolic benefits, without additional blood loss, whereas no fluid resuscitation was associated with sustained low cardiac output and hypotension. Endpoints for Fluid Resuscitation in Hemorrhagic Shock. Journal of Trauma-Injury Infection & Critical Care. 54(5) Supplement:S63-S67, May 2003. Revell, Matthew MD; Greaves, Ian MD; Porter, Keith MD Abstract: Vigorous intravenous fluid resuscitation has become widely accepted as the optimum management of hemorrhagic shock in trauma. There is now, however, sufficient evidence for this position to be reviewed. Hypotensive or delayed resuscitation has been postulated as a means by which the mortality associated with treatment can be reduced. It has been suggested that overresuscitation with intravenous fluids may worsen hemorrhage. This article discusses the possible adverse effects of "conventional" resuscitation and examines the evidence to support alternative treatment modalities. Fluid Resuscitation of Patients with Multiple Injuries and Severe Closed Head Injury: Experience with an Aggressive Fluid Resuscitation Strategy. Journal of Trauma-Injury Infection & Critical Care. 48(3):376-380, March 2000. York, John MD; Arrillaga, Abenamar MD; Graham, Robin MS; Miller, Richard MD Abstract: Background: Despite increasing experimental and clinical evidence to the contrary, a dichotomy of management strategies of the patient with multiple injuries still exists, based on the presence or absence of traumatic brain injury. Many still advocate fluid restriction or small volume resuscitation if traumatic brain injury is present. Purpose: To demonstrate results of aggressive fluid resuscitation in a prospective case series of patients with multiple injuries and with severe head injury. Methods: Thirty-four patients with Glasgow Coma Scale score <= 8 and Injury Severity Score >= 16 were enrolled into the study over a period of 18 months. Fluid resuscitation was guided in part by cerebral perfusion pressures (mean cerebral perfusion pressures > 80) as well as by hemodynamic monitoring and evidence of end organ perfusion. Overall fluid intake, intensive care unit fluid balance, presence or absence of hypoxia, hypotension, or both, were analyzed. Ninety- and 180-day Glasgow Outcome Scale and Disability Rating Scale scores were also obtained. Results: By using an aggressive fluid resuscitation strategy, secondary insults were avoided in 74% of the patients. A good functional outcome was achieved in 74% and mortality was impressively low at 6%. Conclusion: Fluid restriction is not necessary to achieve good results in the severely injured patient who also has a severe head injury. The epidemiology and modern management of traumatic hemorrhage: US and international perspectives David S Kauvar1 and Charles E Wade2 1Research Fellow, United States Army Institute of Surgical Research, Fort Sam Houston, Texas, USA 2Physiologist, United States Army Institute of Surgical Research, Fort Sam Houston, Texas, USA from Recombinant activated factor VIIa and hemostasis in critical care: a focus on trauma The epidemiology and modern management of traumatic hemorrhage: US and international perspectives David S Kauvar1 and Charles E Wade2 1Research Fellow, United States Army Institute of Surgical Research, Fort Sam Houston, Texas, USA 2Physiologist, United States Army Institute of Surgical Research, Fort Sam Houston, Texas, USA from Recombinant activated factor VIIa and hemostasis in critical care: a focus on trauma Critical Care 2005, 9(Suppl 5):S1-S9 doi:10.1186/cc3779 Published 7 October 2005 -------------------------------------------------------------------------------- Abstract Trauma is a worldwide problem, with severe and wide ranging consequences for individuals and society as a whole. Hemorrhage is a major contributor to the dilemma of traumatic injury and its care. In this article we describe the international epidemiology of traumatic injury, its causes and its consequences, and closely examine the role played by hemorrhage in producing traumatic morbidity and mortality. Emphasis is placed on defining situations in which traditional methods of hemorrhage control often fail. We then outline and discuss modern principles in the management of traumatic hemorrhage and explore developing changes in these areas. We conclude with a discussion of outcome measures for the injured patient within the context of the epidemiology of traumatic injury. Introduction Although it is often thought of as being composed of individual events, traumatic injury is a pandemic disease – one that affects every nation in the world without regard for economic development, racial or religious predominance, or political ideology. The disease is acute in onset but often results in chronic, debilitating health problems that have effects beyond the individual victims. There are identifiable broad trends in the epidemiology of trauma within individual countries and regions, but injury has an impact in every community regardless of demographics [1]. Traumatic hemorrhage accounts for much of the wide ranging international impact of injury, causing a large proportion of deaths and creating great morbidity in the injured. Every individual in the world is at risk for traumatic injury. The etiologies of injury are as diverse as the lifestyles and socioeconomic backgrounds of its victims, ranging from interpersonal violence and terrorism to motor vehicle crashes and occupational accidents. Worldwide, an estimated 5 million people died as a result of injury in 2000, with a mortality rate of 83 per 100,000 of the population. Injury represented 9% of worldwide deaths and 12% of the burden of disease [2]. More than 90% of injury-related fatalities occur in low- and middle-income nations. The highest mortality rates from injury occur in the less wealthy nations in Eastern Europe, with the lowest rates in North America, Western Europe, China, Japan, and Australia [2]. Globally, road traffic injuries result in 1.2 million deaths per year, with an additional 20–50 million injuries. They rank as the 11th leading cause of death overall, accounting for 2.1% of all deaths worldwide and 25% of injury-related deaths [2]. The majority of traffic injuries and fatalities occur in low- to middle-income nations, with some of the highest fatality rates found in European nations [3]. Violence is a large contributor to injury-related fatality as well, with 1.6 million deaths worldwide in 2000, representing 16% of mortality from injury [2]. It is by far the leading cause of death among those aged 15–44 years and is much more prevalent in low- to middle-income countries [4]. Self-inflicted violence represents 16% of injury-related mortality worldwide, with falls and burns accounting for 6% and 5%, respectively [2]. In the USA in 2001, where more than 10% of residents suffered nonfatal injuries, trauma was the third leading cause of death overall and was the leading cause of death among those aged 1–44 years. There were 161,269 deaths from injury in 2002, for an overall rate of 56 per 100,000 residents. Death from injury in the USA results in more years of potential life lost before the age of 75 years than any other cause, accounting for 23% of lost years and illustrating the unequal burden of trauma on young people [5]. In Europe, trauma disproportionately affects the young as well. For example, nearly 40% of the injured in the German trauma registry for 2002 were aged between 20 and 39 years, with the greatest incidence occurring in persons aged between 20 and 24 years. Unintentional injuries account for the majority of trauma in all age groups in the USA. Falls are the leading cause of nonfatal injury in all age groups apart from those aged 15–24 years, and motor vehicle accidents cause the most deaths from injury in all groups apart from infants and the elderly. Although unintentional trauma predominates, homicide is the second leading cause of death in US residents aged 15–34 years, and these fatal injuries result primarily from the use of firearms. In 2002 firearms caused 30,242 deaths for a rate of 10.5 per 100,000 residents. Across all age groups, firearm suicide and homicide were the third and fifth leading causes of overall injury or death, respectively, in 2002 [5]. Firearms cause a smaller proportion of traumatic injury in Europe than in the USA, and this is reflected in lower rates of penetrating trauma. In the USA the rate of penetrating trauma is around 20%, whereas in Germany the rate is less than 5%. Trauma carries with it a great price that is paid at all levels of society – by individuals, families, communities, and nations. The burden of traumatic injury ranges from the significant financial costs of modern trauma care to the emotional distress of having a loved one, especially a young individual, become critically injured or die. The financial costs of road traffic injuries alone can amount to up to 2% of a nation's gross national product [3]. The US Centers for Disease Control and Prevention estimated that, in 2000, US$117 billion was spent on injury-attributable medical care, amounting to approximately 10% of total US medical expenditures [6]. In Germany, the cost of managing a multiply injured patient can exceed €60,000 [7]. The actual economic cost of injury is probably much higher, because the above figures do not include the cost of life and work years lost secondary to injury or death, the loss of property, and indirect costs such as decreased quality of life and mental health concerns. Many victims of trauma in the USA are among those who are without health insurance, and much of the economic cost of trauma care is either reimbursed directly by public funds or is not reimbursed at all, with the cost deferred in other billings. This places a disproportionate burden of the financial costs of injury on taxpayers and on providers of health care, and makes the provision of trauma care financially unattractive to US health care institutions [1]. In addition to the economic cost of traumatic injury, a considerable social burden is associated with it. Despite the acuity of its onset, trauma often becomes a chronic disease with significant long-term functional limitations and decrements in quality of life. In one epidemiologic study [8] 22% of survivors of severe injury suffered permanent disability and 57% had temporary disability. The life and work years lost by the relatively young population of injury victims has high associated costs in lost productivity and work years [9,10]. The impact of the long-term care of trauma patients on families and communities is an aspect of trauma care that vastly increases the cost to society. The accumulated costs of traumatic injury are large and not easily addressed at any single level. Trauma prevention is doubtless the most desirable way to decrease these burdens, and government and private efforts are active in this effort but, as illustrated by the statistics presented above, the problem remains. It is up to those involved in the care of the injured patient to continue striving for ways to optimize care and outcomes. Outline Epidemiology of traumatic fatality and hemorrhage The epidemiology of trauma mortality in the USA has been investigated by a number of population-based studies over the past quarter of a century [11-14]. These and other trauma center-based studies [15,16] have provided a solid base of literature in which to examine the characteristics of injury patterns in the USA. The variety and quality of these investigations allow conclusions to be drawn regarding the epidemiology of traumatic fatality and the role of hemorrhage and hemorrhagic shock. Definitions In order to appreciate fully the epidemiology of trauma and injury, a clear understanding of definitions is necessary. Epidemiologic studies of trauma refer commonly to the terms 'cause of injury' and 'cause of death'. The former represents the mechanism of bodily harm to the patient (gunshot wound, motor vehicle crash, fall, etc.) but it does not account for the injuries sustained or their severity. The cause of death, on the other hand, is the result of the injuries sustained, and represents the proximate event leading to the fatality. Examples include hemorrhage, brain injury, and sepsis. Epidemiologic studies tend to present causes (mechanisms) of injury as being associated with fatality. This type of data focuses efforts on preventing the occurrence of a particular mechanism of injury. Although this is no doubt important, measurable improvements in this area are small over time [12]. As clinicians, those who care for trauma patients must focus their efforts on the causes of traumatic death in order to save lives. Mechanism of injury The proportions of various mechanisms of injury leading to eventual fatality are somewhat inconsistent across epidemiologic studies. In some analyses, penetrating injuries such as gunshot or stab wounds account for as many as 49% of traumatic deaths, whereas in others blunt injuries such as falls and motor vehicle crashes account for up to 60% of deaths [11,13,16]. Penetrating injuries tend to result in earlier fatality, with most deaths occurring during the first 72 hours of hospital admission [11,15]. Cause of death Even with these inconsistent proportions of fatal mechanisms, the same analyses have all demonstrated that injury to the central nervous system (particularly head injury) is the leading overall cause of death in the lethally injured patient, accounting for 40–50% of fatalities. Hemorrhage following traumatic injury accounts for 30–40% of deaths [13]. Fatal traumatic hemorrhage is primarily an acute problem; one epidemiologic study [13] found that 36% of patients who were found or declared dead at the scene of injury had exsanguinated. Bleeding also accounts for a larger share of mortality early on in trauma center admission, with the majority of exsanguinations occurring during the first 48 hours [15]. This pattern implies an intuitive association between penetrating mechanism and severe hemorrhage, given the predominance of early fatality from penetrating injuries. Hemorrhagic shock Hemorrhagic shock, in addition to directly resulting in early fatality, is a predictor of poor outcome in the injured patient. Early hypotension (systolic blood pressure = 90 mmHg) with hemorrhage in the field or at initial hospital evaluation is associated with complications such as eventual organ failure and the development of infections, including sepsis [17,18]. In addition to the consequences of shock itself, the current management of hemorrhagic shock in traumatic injury relies heavily on transfusion of red blood cells (RBCs). These transfusions are associated with the development of multiple organ failure (MOF), increased intensive care unit (ICU) admissions and length of stay, increased hospital length of stay, and mortality [19-22]. As a critically injured patient progresses through the phases of trauma care, death from causes unrelated to specific injuries becomes more common. Infections such as sepsis and pneumonia, systemic inflammatory response syndrome, and MOF become the primary etiologies of traumatic death in the hospitalized trauma patient [11,13,15]. We have established that hemorrhage accounts for a considerable amount of mortality and morbidity among injured patients, and that most severe bleeding occurs during the acute phase of injury, typically as a result of the injuries sustained. We now examine the problem of traumatic hemorrhage in detail, focusing on specific factors that place injured patients at increased risk for severe bleeding and situations in which traditional hemostatic methods may prove inadequate. Surgical bleeding The hemorrhaging trauma patient frequently has injuries that require urgent operation for control of bleeding, and more than 80% of trauma deaths that occur in the operating room do so as a result of hemorrhage [23]. These severe injuries comprise a category known as 'surgical bleeding' and account for about 50% of hypotensive patients. Surgical bleeding is not a well defined term, but it can be described broadly as including those injuries that can only be addressed through direct operative visualization and controlled with suture, packing, pressure, or application of a hemostatic agent. If surgical bleeding is not controlled in this manner, it will likely be fatal. Given the large proportion of operative deaths secondary to hemorrhage, prevention of these fatalities is clearly an area of potential improvement in the care of the injured patient, and early intervention to control bleeding is paramount. Nonsurgical bleeding Not all bleeding can or should be controlled surgically, however, and there are various injuries and situations that fall into the category of 'nonsurgical bleeding'. These are areas in which operative intervention has limited or no ability to control hemorrhage, and in which attempts at surgical control have the potential to exacerbate traumatic hemorrhage and lead to severe bleeding and coagulopathy. Trauma care is constantly evolving, and the trend is toward nonoperative management of hemorrhage that was previously considered 'surgical' in nature. Examples include hemorrhage from pelvic fractures, which may be better addressed with angiographic embolization than laparotomy; and coagulopathic bleeding, which should be addressed by restoring normal hemostatic physiology [24]. Operation for these problems can have disastrous consequences, leading to further blood loss, physiologic derangement, and possibly death. In addition, some instances of intracranial bleeding, including certain intracerebral and subdural hematomas, can be managed nonoperatively [25-30]. Conservative, nonoperative management of splenic and hepatic parenchymal bleeding without operation is well described and studied, and is now standard practice for all but the most severe injuries [24]. Keeping patients with these problems out of the operating room probably reduces morbidity and improves outcomes. Medications The injured patient may be predisposed to bleeding problems over and above those occurring as a result of their injuries. The use of medications that interfere with normal hemostatic physiology is one area in which this is the case, and the use of these medications is increasing. Warfarin and aspirin are commonly used anticoagulants, and their use increases the mortality rate from traumatic brain injuries by fourfold to fivefold [31,32]. Clopidogrel is a commonly used antiplatelet agent and has been shown to increase transfusion requirements in cardiac surgery [33,34]. Ibuprofen, the common nonsteroidal anti-inflammatory medication, is known to interfere with platelet function, and its use has also been shown to increase operative blood loss during hip surgery [35]. Any of these medications may exacerbate bleeding problems in trauma, although little research has been done in this area. Medical conditions Previously existing medical conditions may also predispose a trauma patient to bleeding problems. Patients with hemophilia and other inherited diseases have a tendency toward spontaneous bleeding and to have unexpected hemorrhage with minor trauma. These bleeding diatheses can dramatically compound traumatic hemorrhage. In patients with cirrhosis, failure of the liver to synthesize clotting factors results in coagulopathy and poorer trauma outcomes, especially in the operated patient [36,37]. Patients with renal insufficiency often have platelet dysfunction resistant to platelet transfusion [24]. Alcohol use, so common in trauma patients, is also associated with platelet inhibition, although the effect appears to be transient [38]. Acquired coagulopathy of trauma The acquired coagulopathy of trauma is an important clinical entity that is undergoing intensive study. The phenomenon is responsible for the majority of postoperative traumatic hemorrhagic fatalities, and the onset of an acute coagulopathy is associated with increased overall mortality [39-41]. The development of traumatic coagulopathy is associated with massive transfusion and resuscitation, increased injury severity, and the presence of hemorrhagic shock [42,43]. The sequential and additive effects of the 'lethal triad' of hemodilution, hypothermia, and acidosis on the coagulation cascade produce the 'bloody vicious cycle', and unless intervention is performed to break this cycle it leads rapidly to the demise of the injured patient from coagulopathic exsanguinations [39,43-46]. Attempts to interrupt the vicious cycle have resulted in the development of modern methods of caring for the severely hemorrhaging patient, including 'damage control' surgery, attention to effective resuscitation and rewarming, and appropriate blood and blood product transfusion. These management techniques are discussed below. Current management of traumatic hemorrhage Tables Table 1 Interventions to improve hemostasis in trauma care Prehospital care The development of systematic, regionalized trauma care occurred from the 1970s to the 1980s. In the USA and across Europe, Latin America, Australia, and other developed regions of the world, a number of structured systems exist at regional, national, and local levels to manage prehospital emergency care. A number of epidemiologic studies have demonstrated remarkable improvements in patient survival with the institution of these systematic approaches to prehospital care in the USA and elsewhere [8,47-49]. These systems are focused on trauma centers to which the most severely injured patients are transported either directly from the scene of injury or following stabilization at outlying facilities within a geographic area. The provision of trauma care is integrated from the level of the field emergency service providers through outlying hospitals to the trauma center. Rapid movement of patients from the scene of injury to definitive trauma center care is geared toward providing expeditious treatment of central nervous system injuries and operative intervention for severe hemorrhage. Transport is coordinated through a regional medical command, which allows for appropriate triage, efficient communication between care providers, and standardization of procedures. The principal distinction that can be made between North American (USA and Canada) prehospital care and that in Europe is the proximity of the physician to the injured patient in the field. In North American trauma systems, field care and transport to hospital are performed nearly universally by nonphysician emergency medical services personnel who operate under the direction of a local medical director who is trained in emergency medicine [50]. In Europe, the field of prehospital trauma care has evolved differently, with more use of physicians in the field in many countries. Patients are triaged and treated at the scene of injury by the physician responder and often directly admitted to the hospital for definitive care. By virtue of these differences, field trauma care in Europe tends to be more intensive, and the time to definitive care can be shorter and initial triage more appropriate [51,52]. Phases of care Despite the differences in prehospital care outlined above, the acute management of traumatic hemorrhage is similar around the world and follows well accepted published guidelines [53,54]. In order to explore the management of individual patients with traumatic hemorrhage, it is helpful to define the chronology of a critically injured patient's care as occurring in three, often overlapping segments: the resuscitative, operative, and critical care phases. The diagnosis and control of bleeding should be a high priority during all of the phases of trauma care and is especially important in the patient who is in hemorrhagic shock. Early attempts at hemorrhage control include direct control of visible sources of severe bleeding with direct pressure, pressure dressings, or tourniquets; stabilization of long bone and pelvic fractures; and keeping the patient warm. Table 1 presents a summary of measures to enhance hemostasis throughout the trauma patient's treatment course. Resuscitative phase The resuscitative phase in the care of the hemorrhaging patient begins in the field with the arrival of the first responder. The patient's airway is secured, respiration is assured or provided, and a circulatory assessment is made. A complete head-to-toe evaluation of the patient is undertaken according to the principles of Prehospital Trauma Life Support [53] and Advanced Trauma Life Support (ATLS) [54], life-saving procedures are performed as necessary, and transportation to a hospital is undertaken. Initial intravenous fluid is administered during the resuscitative phase, and fluid resuscitation can continue into and through the subsequent operative phase. It is important to note that attempts to curtail bleeding and prevent coagulopathy, and not just to normalize the patient's vital signs, are essential in the resuscitative care of the hemorrhaging patient. These are key points that can be easily overshadowed in the attempt to aggressively fluid-resuscitate a patient who is in hemorrhagic shock. The principles and practice of resuscitation are changing as more is learned about the physiology of hemorrhagic shock and fluid administration. One aspect in particular flux is the area of resuscitation end-points. For nearly a century, physicians have realized that excessive resuscitation may be detrimental to hemostasis [55]. Current ATLS guidelines call for the replacement of each milliliter of lost blood with three times the amount of isotonic crystalloid, while giving careful attention to the physiologic response of the patient. Attempts to restore 'normal' vital signs in the patient with uncontrolled hemorrhage can be detrimental, producing the consequences of volume overload and rebleeding, leading to coagulopathy and the bloody vicious cycle. A strategy of 'hypotensive resuscitation', whereby fluid is administered with the end-point of a safe but subnormal blood pressure until surgical control of bleeding can be achieved, has been studied in various animal and limited human trials and appears to be a promising way to mitigate some of the problems incurred by more traditional resuscitative strategies [56-62]. Hypotensive resuscitation is probably beneficial for only a limited duration, however, and prompt attention to hemorrhage control is vital. In addition to changing perspectives on the end-points of intravenous fluid resuscitation, the choice of fluid is under investigation as well. There is experimental evidence that, in addition to the detrimental effect of the large volumes administered, the isotonic crystalloids themselves cause undue immune activation and increase regulation of cellular injury markers. These effects are seen with hypertonic and colloid solutions as well [63-65]. These cellular events may predispose patients to poor outcomes, but this has not been directly studied. Various potential replacements for normal saline and Ringer's lactate have been studied, and some are currently in use in various situations. These solutions include hyperosmolar colloid and hypertonic electrolyte compounds. Some, such as the 6% hydroxyethyl starches Hextend® (BioTime, Inc., Emeryville, California, USA) and Hespan® (BraunMedical, Inc., Irvine, California, USA) are approved for use in volume expansion in the USA. These and others such as RescueFlow® (BioPhausia AB, Stockholm, Sweden) and HyperHES® (Vidal, Issy Les Moulineaux, France) are approved and in use in Europe. Hypertonic solutions such as 7.5% saline, HyperHES®, RescueFlow®, and the combination fluid hypertonic saline-dextran have been studied in human resuscitation and found to be safe [66]. The evidence in support of the use of these fluids is not universal, and no study to date has demonstrated a clear positive effect on outcome, and so the debate continues regarding these fluids and their use [67-70]. The transfusion of blood and blood products is a cornerstone of the resuscitation of the severely bleeding patient. ATLS calls for the administration of packed RBCs along with continued isotonic crystalloids if a patient does not respond or responds only transiently to the initial 2 l crystalloid infusion. Hemoglobin-based oxygen carriers are a promising group of compounds that are undergoing study as potential resuscitative fluids or as compounds to limit transfusion [71,72]. Transfusion of blood products such as fresh frozen plasma, cryoprecipitate, and platelet concentrate are used to treat coagulopathy and prevent or interrupt the bloody vicious cycle. Blood and blood product transfusions are discussed further in other articles in this supplement. Operative phase The operative phase follows the initial resuscitative phase, but fluid resuscitation often continues while the patient is in the operating room. Although not all patients undergo an operation, most severe hemorrhages require surgical intervention, and approximately 50% of patients in hemorrhagic shock are moved to the operating room from the emergency department [17]. Efforts to control bleeding and repair damaged tissue surgically are made, and in the critically ill patient an abbreviated 'damage control' procedure is performed, whereby life-threatening injuries are quickly addressed, the patient is taken to the ICU for continued resuscitation and restoration of physiology, and is then returned to the operating room at a later time to complete the procedures [24]. Restoring physiology involves attempts to interrupt the bloody vicious cycle through aggressive rewarming, effective resuscitation, and correction of acidosis. Resuscitation continues in a dynamic fashion with responses to the rapidly changing physiologic status of the patient. Even with aggressive approaches to the correction of the hypothermia and acidosis commonly associated with the coagulopathy of traumatic injury, once the bloody vicious cycle has begun it is exceedingly difficult to salvage the patient [41,44]. Critical care phase The critical care phase in the care of the bleeding trauma patient follows either the operative phase or is a continuation of resuscitation in the ICU. Efforts to attain and preserve normal physiology are initiated and continued, the patient is closely monitored (often invasively), and support is provided as needed as the patient recovers from injury. End-points and goals for the resuscitation of severely injured patients are undergoing constant reappraisal. Standard hemodynamic parameters such as blood pressure and heart rate are no longer regarded as the best measures of physiologic derangement in the critically ill trauma patient. Shock is defined as a state of decreased tissue perfusion, and values that characterize this state more closely represent the status of a patient in and recovering from shock. Examples of these include measures of oxygen delivery, mixed venous oxygen saturation, base deficit and lactate, end-tidal carbon dioxide, gastric tonometry, and more direct measures of peripheral tissue perfusion such as subcutaneous electrode oxygen and carbon dioxide measurements and near infrared spectroscopy. None of these measures is able to predict with perfect reliability the outcome of a patient, but they are more specific measures of physiologic status and research is ongoing to improve them [73]. As the injured patient undergoes the physiologic changes associated with injury and recovery, several complications can arise. The most devastating of these are infections, primarily sepsis, and MOF. These are the leading causes of late traumatic fatality, and much of the ICU care administered to critically ill patients aims at their prevention [13,15,16]. Vigilant attention to all major organ systems and an integrated team approach to patient care involving specialist physicians, nurses, and allied health providers are critical to the achievement of good outcomes. Outline Traumatic hemorrhage therapy and outcome Tables Table 2 Outcome measures for hemostatic interventions in trauma Now that the scope of the problem of traumatic hemorrhage has been defined and current management strategies outlined, we explore the various ways in which the effect of modern developments in trauma care, such as those addressed in this supplement, can be measured. The control of hemorrhage in severe trauma is a complicated issue that is influenced by numerous factors, and likewise measuring outcomes in these patients is not straightforward. The remainder of this review discusses outcome measures that should be part of the evaluation of any proposed hemorrhage control therapy. Table 2 presents such measures. Mortality The most widely used and clinically significant trauma outcome measure is mortality, and we have pointed out that hemorrhage accounts for a large portion of deaths. Saving lives is the ultimate goal of most clinical interventions, and to this end the prospect of reducing mortality from hemorrhage presents great potential benefit to the injured. Because of the wide spectrum of traumatic injuries and their severities, however, it has been difficult to show improvements in mortality with most new interventions. We know of no interventions for the control of bleeding or fluid resuscitation that have been approved based on a reduction in mortality in trauma patients. Mortality in trauma patients occurs throughout the course of treatment. Most deaths that occur early, within 48 hours from injury, are the result of the severity of injuries sustained [13]. This pattern has resulted in the thought that such early deaths are difficult to address and has led to a strong emphasis on preventing later deaths from complications such as sepsis and MOF. The predominance of acute traumatic death from hemorrhage makes hemorrhage control an important area of research if early traumatic deaths are to be prevented. Complications The trauma literature is replete with articles on the development of complications during an injured patient's clinical course. The two most significant complications are organ failure and infections because these are common causes of late traumatic fatality [13,14,16,19]. Various factors have been associated with the development of MOF, including the presence of hypovolemic shock, advanced age, severe injury, and blood transfusion. Therefore, this complication seems to be a reasonable marker for the overall condition of the patient, given their injuries, and thus is an appropriate intermediate outcome measure [18,19,22]. Serious infectious complications such as sepsis and pneumonia are common in the severely injured, especially those who have been in shock, and so this is another reasonable outcome measure for hemorrhage intervention [18]. Intensive care unit and hospital factors Patients who suffer severe hemorrhage and shock are typically critically ill, requiring urgent operation and ICU admission [17]. Their critical care courses can be lengthy and fraught with multiple complications as noted above. Length of stay in the ICU and overall hospital days can be used as global measures of the pace of an injured patient's recovery. Number of days spent on a ventilator may serve as an indicator of the overall progress of the patient, as may the development and course of any pulmonary complications such as acute respiratory distress syndrome. The eventual disposition of an injured patient may also be used as an outcome measure, representing the overall progress of an injured patient at the time of hospital discharge. Patients are discharged home with or without outpatient rehabilitation, or to the various levels of inpatient care. This may take the form of long-term or short-term acute care for those patients who remain significantly debilitated, or of acute or chronic rehabilitation for those patients who are improving but require ongoing therapy following hospital discharge. Laboratory evaluation and transfusion The requirements for RBC and blood product transfusions have been associated with other trauma outcome measures and are important indicators of the severity of hemorrhage and coagulopathy as well as the effectiveness of interventions to improve hemostasis. Reduction in RBC transfusion requirement is a good indicator that a hemostatic intervention is efficacious. Laboratory measures may be used to assess more specifically the performance of techniques used to minimize hemorrhage and especially to address coagulopathy. Laboratory monitoring of traumatic coagulopathy is important in order to address occult hemorrhage in patients whose bleeding has been surgically controlled. In addition to the commonly used prothrombin and partial thromboplastin times, which have been demonstrated to lack accuracy in hypothermic patients [74], thromboelastography – used commonly in cardiac and transplant surgery – is emerging as a potentially useful test in traumatic coagulopathy [75]. Costs The significant financial costs of trauma care are increasing rapidly with improvements in critical care. Critically ill trauma patients are living longer but with increased morbidity, both in the acute and chronic phases of their care and illness. The impact of any proposed intervention in these patients must be weighed carefully against its cost. The patient's prognosis for recovery must be included in the consideration to use a powerful but expensive new intervention. To adopt the use of such methods and agents without consideration of their potential effect on survival or the prevention of complications will inevitably lead to inappropriate use in some cases and increased cost for very little benefit. Conclusion Traumatic injury is an international problem, affecting all nations and people from all walks of life. Hemorrhage is a major contributor to the morbidity and mortality of injury, and attaining and maintaining hemostasis is a key consideration in trauma care. Modern trauma care practices have been developed to expeditiously identify and efficiently treat traumatic hemorrhage, but numerous factors can contribute to severe traumatic hemorrhage and the development of coagulopathy. These can be difficult to treat, and novel methods of hemostasis have the potential to produce great benefit in these cases.

In some places in the US there is no shortage of those.....

Paramedic book????? What's that, I never even had to buy one!!! out here, Ace844

If you don'r like dilaudid, and you can convince them that you're not drug seeking, get them to give you Fentanyl instead...GOOD STUFF!!!!! 8) Ace844

This is part of the reason we as a group recieve the pay, recognition, and poor benefits which we do!! Also, if you note in my post I said,

Hi All, I personally think it has abit to do with a lack of respect, I usually try to give others the benefit of the doubt..Then educate them, but from people who know better it is alot harder to tolerate....These are just a few reasons why I don't like being called an "ambulance driver" As a matter of fact if one were to refer to a cop on the job as a "pig", a fireman "a useless hose dragger" or "bucket head, A RN a "Registered Nobody, or a bed pan attendant", go into a doctors office and say to a podiatrist "hey, where's the real doc..?!?!?" (Just to name a few things off the top of my head); I'm quite sure that they would see it as a total lack of respect, take serious offense, and try to place you in THE UNEMPLOYMENT EXPRESS LANE!!!! So I ask the group then, why would you tolerate it being done in reverse and take the sleight to you?!?!?!? just curious.... I don't know about you, but I worked hard to be skilled, professional, educated, etc....and until I prove I'm unworthy otherwise I expect to be treated in that manner..!!! Ace844

To add to the above post, this drug should also NEVER be taken by a Gravid female.....PERIOD..especially for migraines, etc.... out here, Ace844

"andrean678," If I wanted to argue, I wouldn't have asked for clarification...You made a general statement which wasn't necessarily "the case" which I tried to clarify for you... As far as It was worth your time to post..so that's funny, I'm a fair guy, just don't make statements you can't back up or prove..and we'll be fine...have alot of spirited discussion, besides you posted from an area which i know well and from a state in which i have alot of experience...So Doom on you, this is a discussion board after all... :idea: =P~ :-s out here, Ace844

"andrean678," I am in the area, and I have worked in the state for quite awhile. PB staffing here isn't all that prevelant when compared to other areas across the nation. It was alloewed here to help Als services remain "at the ALS level" when paramedic staffing was hard to come by. OEMS here goes through cycles where they are quite liberal with the application of this "staffing waiver" and others where it revokes and cracks down on them... Any ?'s please see the applicable AR on the MA OEMS website, or post them. Although I am not quite sure what you're trying to assert in your post, so please clarify...!?!??! It's been my experience that they are used here mostly "transfer" and when/if another P is available to staff that ALS truck, the basic gets bumped....I'm quite familiar with both the area and how it works thank you. >>>"Temsp40" It is only one study and until there are more which validate it, I would take it with a "grain of salt" as to their accuracy. Anecdotally I have found them over the years in my practice to be notoriously inaccurate..... out here, Ace844

Yes, but remember there are other factors involved which a thorough H@P will allow you to "dope" out if you will. For example,(just a quick and obvious one off the top of my head) if your patient is on a Beta blocker they will be unable to "show" sympathetic s/s's of pain/shock....that's why it is necessary to look at the whole presentation... Also, the data speaks for itself, we don't adequately treat pain in the pre-hospital environment.... out here, Ace844

I agree with you, I posted it more to get an idea of what peoples opinions on this were and a "hey heads up" this may be coming type of scenario...I'll look into it further...I just don't have "online access to this journal.." hope this helps, Out here

"angel@others," PB= Paramedic/Basic as in the staffing of an ambulance at the ALS level without the use of 2 medics, it is used in my area for both emergent and non-emergent txp's...though it is frowned upon for 911 use...We like to have 2 medics to make an ALS EA here.... Hope this helps, Ace844

"ERdoc," Please see my "edited" post, I found one..As far as "flight physicians...I know that Umass uses them with a flight RN, and I don't know any others up this way.....perhaps other places they are more prevalent..?!!?!? Hope this helps, Ace844

Here's yet another study which shows pre-hospital analgesia to be safe and effective... Hope this helps, Ace844 Impact of Liberalization of Protocols for the Use of Morphine Sulfate in an Urban Emergency Medical Services System James E. Pointer A1 and Kristine Harlan A2 A1 Alameda County EMS, San Leandro, California A2 American Medical Response, Northwest/Plains Division, Roseville, California Abstract: Objective. To investigate the impact of liberalization of paramedic management protocols for the use of morphine sulfate (MS). Methods. A retrospective database analysis tallied and categorized MS use into seven conditions during two intervals—six months before (control) and six months after (study) the protocol change. Results. In the control interval, 760 of 34,020 (2.2%) patients received MS. In the study interval, 999 of 30,320 (3.3%) received the drug, a 50% relative increase in MS use. MS use dramatically increased in two assessment categories: other painful medical conditions (19.0% vs. 2.8% of transports, relative risk [RR] 6.8, 95% confidence interval [CI] 5.2–8.9) and nontraumatic abdominal pain (9.2% vs. 1.9% of transports, RR 4.8, 95% CI 3.3–6.9). Conclusion. Liberalization of pain management protocols resulted in an appreciable increase in the use of MS only in medical categories, predominantly abdominal pain, with no apparent safety or misuse issues.

Hi All, Here's what a recent piece of literature has to say on this.... http://journalsonline.tandf.co.uk/(qsbpkv5...lts,1:112492,1; NEAR-CONTINUOUS, NONINVASIVE BLOOD PRESSURE MONITORING IN THE OUT-OF-HOSPITAL SETTING Stephen H. Thomas A1, A2, Greg Winsor A1, Peter Pang A2, Suzanne K. Wedel A1, A3, Blair Parry A2 A1 Boston MedFlight, Boston, Massachusetts A2 Department of Emergency Services, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts A3 Department of Surgery, Boston Medical Center/Boston University School of Medicine, Boston, Massachusetts Abstract: Objectives. This study was conducted to test out-of-hospital performance of a noninvasive radial artery tonometry device to assess blood pressure (BP), providing readings every 10–12 seconds. The primary objective was to determine the correlation between noninvasive BPs calculated with radial artery tonometry and standard oscillometric cuff methods. The secondary objective was to determine whether the difference observed between the two techniques was consistent over the range of BPs measured. Methods. This prospective trial enrolled adults transported by helicopter (n = 9 patients), fixed-wing airplane (n = 1), or ground vehicle (n = 10) of a single transport service. Patients had BP assessed simultaneously, by both standard automatic cuff and radial artery tonometry device, every 5 minutes. Data were assessed with correlation coefficients, and Bland-Altman techniques were utilized to assess for bias over the range of mean arterial pressures (MAPs) encountered. For all tests, p was set at 0.05. Results. No major problem with radial artery tonometry device field performance was noted. There were 139 pairs of MAP assessments in 20 patients. The correlation coefficient for the two assessment modalities was 0.96. Bland-Altman bias plot and Pitman's test (p = 0.11) revealed good correlation between the two assessment mechanisms over the entire range of MAPs (42 to 163 mm Hg) encountered in the study. Conclusion. The radial artery tonometry device provided MAP assessments that were highly correlated with readings from a standard oscillometric device. The radial artery tonometry device performed well in a variety of patient types and in multiple transport vehicles, and there was no sign that its performance was adversely affected by the out-of-hospital setting. Hope this helps, Ace844

Hi All, I saw this and it made me wonder what you all thought....of the subject of pr-ehospital Chest tubes.... http://www.jtrauma.com/pt/re/jtrauma/abstr...9856145!9001!-1Prehospital Chest Tube Thoracostomy: Effective Treatment or Additional Trauma? Prehospital Chest Tube Thoracostomy: Effective Treatment or Additional Trauma? Journal of Trauma-Injury Infection & Critical Care. 59(1):96-101, July 2005. Spanjersberg, Willem; Ringburg, Akkie; Bergs, Bert; Krijen, Pita; Schipper, Inger SP; Steyerberg, E W.; Edwards, M J.; Schipper, I B.; van Vugt, A B. Abstract: Background: The use of prehospital chest tube thoracostomy (TT) remains controversial because of presumed increased complication risks. This study analyzed infectious complication rates for physician-performed prehospital and emergency department (ED) TT. Methods: Over a 40-month period, all consecutive trauma patients with TT performed by the flight physician at the accident scene were compared with all patients with TT performed in the emergency department. Bacterial cultures, blood samples, and thoracic radiographs were reviewed for TT-related infections. Results: Twenty-two patients received prehospital TTs and 101 patients received ED TTs. Infected hemithoraces related to TTs were found in 9% of those performed in the prehospital setting and 12% of ED-performed TTs (not significant). Conclusion: The prehospital chest tube thoracostomy is a safe and lifesaving intervention, providing added value to prehospital trauma care when performed by a qualified physician. The infection rate for prehospital TT does not differ from ED TT. The Safety and Efficacy of Prehospital Needle and Tube Thoracostomy by Aeromedical Personnel Daniel P. Davis A1, Kelly Pettit A1, Christopher D. Rom A1, Jennifer C. Poste A1, Michael J. Sise A1, David B. Hoyt A1, Gary M. Vilke A1 Abstract: Background.Aeromedical crews routinely use needle thoracostomy (NT) and tube thoracostomy (TT) to treat major trauma victims (MTVs) with potential tension pneumothorax; however, the efficacy of prehospital NT and TT is unclear.Objectives.To explore the efficacy of aeromedical NT and TT in MTVs.Methods.A retrospective chart review was performed using prehospital medical records and the county trauma registry over a seven-year period. All MTVs undergoing placement of NT or TT by aeromedical personnel were included; patients with incomplete data were excluded. Descriptive statistics were used to report the incidence of air release, clinical improvement (improved breath sounds or compliance if intubated, decreased dyspnea if nonintubated), and vital signs improvements (systolic blood pressure [sBP] increase to ≥90 mm Hg or increase by 5 mm Hg if < 90 mm Hg; heart rate improvement to 60–100 beats/min, increase by 10 beats/min if < 60 BPM, or decrease by 10 beats/min if > 100 beats/min; oxygen saturation increase if < 95%) for both NT and TT as documented in prehospital medical records. Survival and improvement in SBP based on trauma registry data were recorded for patients stratified by initial SBP.Results.A total of 136 procedures (89 NTs and 47 TTs) in 81 patients were identified using prehospital medical records over a four-year period. Response rates to NT (60% overall, 32% vital signs) and TT (75% overall, 60% vital signs) were high. Vital signs improvements were observed more often in patients with a pulse and in nonintubated patients. A total of 168 patients were identified in the trauma registry over the seven-year study period. Normalization of SBP was observed in two-thirds of patients with a field SBP ≤ 90 mm Hg and one-third of patients in whom field SBP could not be obtained. A small but significant proportion of patients undergoing prehospital NT and TT, including some with prehospital hypotension and high injury severity, survived to hospital discharge. The incidence of complications was low.Conclusions.Aeromedical crews appear to appropriately select MTVs to undergo field NT or TT. A low incidence of complications and a small but significant group of unexpected survivors support continued use of this procedure by aeromedical personnel.Key words:aeromedical crews; trauma; needle thoracostomy; tube thoracostomy; survival; pneumothorax; efficacy. Chest Tube Decompression of Blunt Chest Injuries by Physicians in the Field: Effectiveness and Complications. Journal of Trauma-Injury Infection & Critical Care. 44(1):98-100, January 1998. Schmidt, Ulf MD; Stalp, Michael MD; Gerich, Thorsten MD; Blauth, Michael MD; Maull, Kimball I. MD; Tscherne, Harald MD Abstract: Objective: Recent literature suggests that patients who undergo emergent tube thoracostomy in the field are at increased risks for complications. This study evaluates indications, complications, and effectiveness of field placement of chest tubes by an aeromedical service. Methods: In a prospective study, 624 consecutive patients with chest injuries (Abbreviated Injury Scale score 1-6) were included. All patients were treated at the scene by a physician-staffed aeromedical service and transported by air to a Level I trauma center. Indications, clinical findings before and after chest tube insertion, and subsequent radiologic diagnosis by chest roentgenography were documented prospectively.Results: Seventy-six chest tubes (50 unilateral, 13 bilateral) were inserted laterally in 63 patients (10%) by blunt dissection. Clinical findings included pneumothorax in 30 patients and hemothorax in 18 patients. In 15 patients receiving field chest tubes, neither pneumothorax nor hemothorax was confirmed. Six patients (<1%) arrived at the trauma center with unsuspected pneumothoraces and required chest tube insertion. No tension pneumothoraces escaped field detection and treatment. Four chest tubes placed in the field required repositioning in the hospital because of malfunction or malpositioning. Radiologic findings excluded intraparenchymal tube placements in all patients. No pleural infections were observed in these 63 patients during their hospital stay. No antibiotics were administered as a result of prehospital chest tube placement. Conclusion: Prehospital chest tube thoracostomy is safe, effective, and associated with low morbidity. Nontherapeutic chest tube placements occurred in 15 of 624 patients (2.4%); missed pneumothoraces occurred in 6 of 624 patients (<1%). Aggressive prehospital physician management of blunt chest trauma leads to an earlier treatment of potentially life-threatening injuries. Significant morbidity can be avoided by prompt pleural decompression using proper techniques Hope this helps, Ace844

"Buddy," I tried your number and keep getting V-mail, I will continue to do so... out here, Ace844

Please refer your doc to the studies above, as well as "Rid" for further education....It seems to me like your law dept...may be getting very busy in the near future..!?!?!?!!? out here, Ace844

"PRPG," I agree with "AZCEP" and will add that they decalibrate easily, as noted are notoriously inaccurate, and not worth the space they take up...as such my choice wasn't listed in your poll so I didn't respond....

More info on this topic can be found here::: Painless MI Hope this helps, Ace844

Hi All, Here's some more "on topic literature" for you all to look at.... Hope this helps, Ace844 EMS Mythology: Part 1 By Bryan E. Bledsoe, DO, FACEP, EMT-P EMS Myth #1: Medical Anti-Shock Trousers (MAST) autotransfuse a significant amount of blood and save lives. Paramedics in the 1970s and 1980s often used Medical Anti-Shock Trousers (MAST), also called the Pneumatic Anti-Shock Garment (PASG), for all forms of trauma. It was the standard of care. On many occasions, I came to believe that I had seen patients pulled from the jaws of death after MAST application. In EMS circles, we told stories about doctors or nurses removing or cutting off MAST in the emergency department, only to have the patient become immediately hypotensive and die. EMS people were not the only true believers in MAST. They were often a common component of trauma resuscitation rooms and operating rooms. Invariably, we would have to retrieve the MAST from the OR, as they remained on the patient until the surgical lesion was repaired. We knew the MAST worked. We had seen it work. But, did the MAST really work? MAST History The concept of the MAST was first described in 1903 by famed surgeon George W. Crile as a "pneumatic rubber suit" to decrease postural hypotension in neurosurgical patients.1,2 During World War II, Crile's suit was used to prevent blackout in pilots who were subjected to high G forces while flying combat aircraft. The National Aeronautics and Space Administration (NASA) claimed responsibility for developing the medical anti-shock trousers at their Ames Research Center in the 1960s.3 MAST were introduced into medical practice during the war in Vietnam and called "Military Anti-Shock Trousers."4 The value of MAST in the military setting was documented when soldiers with massive trauma, previously considered fatal, were able to survive a 45-minute helicopter ride to a definitive care hospital.5 MAST were introduced into civilian EMS in the 1970s.6 It was postulated that the MAST reversed hypotension by three different mechanisms: 1) Increasing peripheral vascular resistance; 2) tamponading of intra-abdominal bleeding; and 3) autotransfusion of blood from the lower extremities and abdomen to the head and upper trunk. Most authorities supported the theory that MAST provided a significant autotransfusion. McSwain estimated the amount of blood autotransfused to be 750–1,000 mL.7 In another paper, McSwain estimated that approximately 20% of a patient's blood volume was autotransfused into the heart, brain and lungs following application of MAST.8 Dillman also estimated the amount of blood autotransfused to be approximately 20% of the total blood volume (approximately 1,200 mL in an 85-kg man).9 Based upon these reports, the EMS textbooks of the era picked up the information on MAST, and it was incorporated into day-to-day EMS teaching. The first paramedic textbook stated: "The pressure applied to the legs squeezes at least 2 units of blood out of these extremities, where it is less critically needed, and into the systemic circulation. The net effect is as if the patient were given a 2-unit transfusion of blood; in a sense, then, it is an AUTOTRANSFUSION, since the patient is transfusing himself with blood from his extremities. (Remember, though, that the converse is also true. When the MAST is deflated, blood returns to the legs, and it is as if the patient suddenly lost 2 units of blood. Thus, the MAST is never deflated until adequate volume replacement has been achieved.)"10 The first edition of Basic Trauma Life Support stated the following: "No one has proven how MAS trousers work, but the most likely mechanism is an increase in peripheral vascular resistance by way of circumferential compression. The important thing is that they do work to improve blood pressure and cerebral circulation in the hemorrhagic or spinal shock victim."11 Likewise, the first edition of Pre-Hospital Trauma Life Support stated, "If the patient is hypotensive or there is suspicion of bleeding within the abdomen, the pneumatic anti-shock garment (PASG) should then be placed on the patient and inflated until an adequate blood pressure is obtained. The early use of the PASG will assist in reducing rapid intra-abdominal bleeding."12 Applying the Scientific Method Later, researchers applied the scientific method to study the effects and effectiveness of the MAST and found that the actual benefits were far less than originally thought. Researchers at Valley Medical Center in Fresno, CA, evaluated the effects of the MAST on healthy volunteers. After removing one liter of blood from the volunteers, the MAST were applied. The amount of blood auto-transfused from the lower extremities and abdomen to the head and upper trunk was measured using sequential radioisotope scans. They found that application of the MAST resulted in an auto-transfusion of less than 5% of the patient's total blood volume. This was approximately 300 mL in an 85 kg man.13 This amount was much less than initial estimates that ranged from 750–1,200 mL. A similar study measured the amount of blood auto-transfused following MAST application to dogs who were suffering hemorrhagic shock following phlebotomy. Again, the amount of blood auto-transfused was approximately 5% of the total blood volume.14 Based on these studies, statements about the auto-transfusion capabilities of the MAST were dropped. Instead, teaching was changed and stated only that MAST increased peripheral vascular resistance. Researchers then began to look at patient outcomes following application of the MAST. The initial study that questioned the benefit of the MAST was conducted in Houston, TX, in 1989 using the Houston Fire Department EMS system. During a 2½-year period, 201 consecutive patients presenting with penetrating anterior abdominal injuries and an initial prehospital systolic blood pressure of 90 mm Hg or less were entered into the study. All prehospital care was provided by the Houston Fire Department and all patients were delivered to the same regional trauma facility (Ben Taub Hospital). The patients were randomized into control and MAST groups by an alternate-day assignment of MAST use. The resulting study groups were found to be well matched for survival probability indices, prehospital response and transport times, and the volume of IV fluids received. The results demonstrated no significant difference in the survival rates of the control and MAST treatment groups. Based on these data, researchers concluded that, contrary to previous claims, the MAST provides no significant advantage in improving survival in urban prehospital management of penetrating abdominal injuries.15 Another prospective, randomized study investigated 291 traumatic shock patients greater than 15 years of age with blunt or penetrating trauma and a systolic blood pressure of 90 mm Hg or less with clinical signs of hypotension. The patients were randomly assigned to a MAST or non-MAST group. The researchers found that there were no significant differences in hospital stay or mortality between MAST and non-MAST patients. Similarly, in the subset of patients with blunt trauma, MAST were not found to be beneficial.16 In a prestigious Cochrane Review, researchers performed a meta-analysis of the two studies described above and found that the duration of Intensive Care Unit (ICU) stay was 1.7 days longer in the MAST-treated group. They concluded that there was no evidence to suggest that MAST/PASG reduce mortality, length of hospitalization or length of ICU stay in trauma patients. In fact, they found, MAST may actually increase these. They concluded that the data do not support the continued use of MAST/PASG in trauma patients.17 Conclusion Based on available data, in 1997 the National Association of EMS Physicians issued a position paper on use of MAST/PASG in modern EMS.18 The association concluded that MAST are definitely beneficial in ruptured abdominal aortic aneurysm and possibly beneficial in hypotension due to pelvic fracture, anaphylactic shock refractory to standard therapy, otherwise uncontrollable lower extremity hemorrhage and severe traumatic hypotension (palpable pulse, no blood pressure).19 Even considering these possibilities, any benefit from application of the MAST may be accomplished through rapid transport to a trauma center. Many EMS services have kept MAST for use in possible pelvic and lower extremity fractures. Patients with femur fractures are best treated with traction splints, while patients with pelvic fractures can be treated with a long backboard or similar device. Furthermore, the MAST are expensive (approximately $500 per pair) and take up valuable storage space on the ambulance. MAST are a relic of our past and belong in EMS museums, not on modern ambulances or rescue vehicles. References 1. Crile GW. Blood Pressure in Surgery: An Experimental and Clinical Research. Philadelphia, PA: JB Lippincott Company, 1903. 2. Crile GW. The Cartwright Prize Essay for 1903. Philadelphia, PA: JB Lippincott Company, 1903. 3. National Aeronautics and Space Administration. 1996 Space Technology Hall of Fame. Innovation 4(2), 1996. 4. Schwab CW, Gore D. MAST: medical antishock trousers. Surgery Annual 15:41–59, 1983. 5. Cutlet BS, Daggett WM. Application of the "G-Suit" to the control of hemorrhage in massive trauma. Ann Surg 173:511–514, 1972. 6. Kaplan BC, Civetti JM, Nagel EL, et al. The military anti-shock trouser in civilian prehospital care. J Trauma 13(10):843–848, 1973. 7. McSwain NE. Pneumatic trousers in the management of shock. J Trauma 17(9):719–724, 1977. 8. McSwain NE. MAST pneumatic trousers: A mechanical device to support blood pressure. Medical Instrumentation 11(6):334–336, Nov–Dec 1977. 9. Dillman PA. The biophysical response to shock trousers. J Emerg Nurs 3(6):21–25, 1977. 10. Caroline NL. Emergency Care in the Streets. Boston, MA: Little, Brown and Company, 1979, p. 86. 11. Campbell JE. Basic Trauma Life Support: Advanced Prehospital Care. Bowie, MD: Brady Communications Company, 1985, p. 54. 12. Butman AE, Paturas JL, McSwain NE, Dineen JP. Pre-Hospital Trauma Life Support. Akron, OH: Emergency Training, 1986, p. 98. 13. Bivins HG, Knopp R, Tiernan C, et al. Blood volume displacement with inflation of antishock trousers. Ann Emerg Med 11(8):409–412, 1982. 14. Lee HR, Blank WF, Massion WH, et al. Venous return in hemorrhagic shock after application of military anti-shock trousers. Am J Emerg Med 1(1):7–11, 1983. 15. Bickell WH, Pepe PE, Bailey ML, et al. Randomized trial of pneumatic antishock garments in the prehospital management of penetrating abdominal injuries. Ann Emerg Med 16(6):653–658, 1987. 16. Chang FC, Harrison PB, Beech RR, Helmar SD. PASG: Does it help in the management of traumatic shock? J Trauma 39(3):453–456, 1995. 17. Dickinson K, Roberts I. Medical anti-shock trousers (pneumatic anti-shock garments) for circulatory support in patients with trauma. Cochrane Review, The Cochrane Library, 2002, p. 4. 18. O'Connor RE, Domeier R. Use of the Pneumatic AntiShock Garment (PASG): NAEMSP Position Paper Prehosp Emerg Care 1(1):32–35, 1997. 19. Chapleau W. PASG: Bad wrap or bad rap? Emerg Med Serv 31(1):75–76, 2002. Also, here's something from "the edumacated" side, A review which most Md's read.... The Cochrane Database of Systematic Reviews 2005 Issue 4 Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Medical anti-shock trousers (pneumatic anti-shock garments) for circulatory support in patients with trauma Dickinson K, Roberts I Plain language summary About one third of injury deaths are due to shock from blood loss. Preventing shock in people with uncontrolled bleeding is therefore vital. Treatment aims to maintain blood pressure, so that tissue damage is minimised. Medical anti-shock trousers (MAST) are believed to increase blood pressure and blood flow to the heart and brain, helping to stabilise the person until they receive further treatment. The review of trials found no evidence that MAST application decreases deaths, with some suggestion that it may even do harm. More research is needed. Abstract Background Medical antishock trousers (MAST) have been used to increase venous return to the heart until definitive care could be given. This, combined with compression of blood vessels, is believed to cause the movement of blood from the lower body to the brain, heart and lungs. However, the equipment is expensive, and may have adverse effects. Objectives To quantify the effect on mortality and morbidity of the use of medical anti-shock trousers (MAST)/ pneumatic anti-shock garments (PASG) in patients following trauma. Search strategy Trials were identified by searches of the Cochrane Injuries Group Trials Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, BIDS ISI Service and Science Citation Index. References in relevant papers identified were followed up. A citation analysis of references to randomised controlled trials was conducted using the Science Citation Index. Authors of identified trials were contacted and asked about any other trials that may have been conducted, whether published or unpublished. Selection criteria Randomised and quasi-randomised trials of MAST/PASG in patients following trauma (excluding fractures of the extremities in which MAST/PASG may be used as a splint). Data collection and analysis Data were extracted independently by two reviewers. Data were collected on mortality, duration of hospitalisation and ICU stay, and quality of allocation concealment. Main results Two trials were identified that met the inclusion criteria. These trials included 1202 randomised patients in total; however, data for only 1075 of these were available. The relative risk of death with MAST was 1.13 (95% CI 0.97 to 1.32). Duration of hospitalisation and of intensive care unit stay was longer in the MAST treated group. The weighted mean difference in the length of intensive care unit stay was 1.7 days (95% CI 0.33 to 2.98). Authors' conclusions There is no evidence to suggest that MAST/PASG application reduces mortality, length of hospitalisation or length of ICU stay in trauma patients and it is possible that it may increase these. These data do not support the continued use of MAST/PASG in the situation described. However, it should be recognised that, due to the poor quality of the trials, conclusions should be drawn with caution.

Hi All, Here's some more "on topic literature" for you all to look at.... Hope this helps, Ace844 EMS Mythology: Part 1 By Bryan E. Bledsoe, DO, FACEP, EMT-P EMS Myth #1: Medical Anti-Shock Trousers (MAST) autotransfuse a significant amount of blood and save lives. Paramedics in the 1970s and 1980s often used Medical Anti-Shock Trousers (MAST), also called the Pneumatic Anti-Shock Garment (PASG), for all forms of trauma. It was the standard of care. On many occasions, I came to believe that I had seen patients pulled from the jaws of death after MAST application. In EMS circles, we told stories about doctors or nurses removing or cutting off MAST in the emergency department, only to have the patient become immediately hypotensive and die. EMS people were not the only true believers in MAST. They were often a common component of trauma resuscitation rooms and operating rooms. Invariably, we would have to retrieve the MAST from the OR, as they remained on the patient until the surgical lesion was repaired. We knew the MAST worked. We had seen it work. But, did the MAST really work? MAST History The concept of the MAST was first described in 1903 by famed surgeon George W. Crile as a "pneumatic rubber suit" to decrease postural hypotension in neurosurgical patients.1,2 During World War II, Crile's suit was used to prevent blackout in pilots who were subjected to high G forces while flying combat aircraft. The National Aeronautics and Space Administration (NASA) claimed responsibility for developing the medical anti-shock trousers at their Ames Research Center in the 1960s.3 MAST were introduced into medical practice during the war in Vietnam and called "Military Anti-Shock Trousers."4 The value of MAST in the military setting was documented when soldiers with massive trauma, previously considered fatal, were able to survive a 45-minute helicopter ride to a definitive care hospital.5 MAST were introduced into civilian EMS in the 1970s.6 It was postulated that the MAST reversed hypotension by three different mechanisms: 1) Increasing peripheral vascular resistance; 2) tamponading of intra-abdominal bleeding; and 3) autotransfusion of blood from the lower extremities and abdomen to the head and upper trunk. Most authorities supported the theory that MAST provided a significant autotransfusion. McSwain estimated the amount of blood autotransfused to be 750–1,000 mL.7 In another paper, McSwain estimated that approximately 20% of a patient's blood volume was autotransfused into the heart, brain and lungs following application of MAST.8 Dillman also estimated the amount of blood autotransfused to be approximately 20% of the total blood volume (approximately 1,200 mL in an 85-kg man).9 Based upon these reports, the EMS textbooks of the era picked up the information on MAST, and it was incorporated into day-to-day EMS teaching. The first paramedic textbook stated: "The pressure applied to the legs squeezes at least 2 units of blood out of these extremities, where it is less critically needed, and into the systemic circulation. The net effect is as if the patient were given a 2-unit transfusion of blood; in a sense, then, it is an AUTOTRANSFUSION, since the patient is transfusing himself with blood from his extremities. (Remember, though, that the converse is also true. When the MAST is deflated, blood returns to the legs, and it is as if the patient suddenly lost 2 units of blood. Thus, the MAST is never deflated until adequate volume replacement has been achieved.)"10 The first edition of Basic Trauma Life Support stated the following: "No one has proven how MAS trousers work, but the most likely mechanism is an increase in peripheral vascular resistance by way of circumferential compression. The important thing is that they do work to improve blood pressure and cerebral circulation in the hemorrhagic or spinal shock victim."11 Likewise, the first edition of Pre-Hospital Trauma Life Support stated, "If the patient is hypotensive or there is suspicion of bleeding within the abdomen, the pneumatic anti-shock garment (PASG) should then be placed on the patient and inflated until an adequate blood pressure is obtained. The early use of the PASG will assist in reducing rapid intra-abdominal bleeding."12 Applying the Scientific Method Later, researchers applied the scientific method to study the effects and effectiveness of the MAST and found that the actual benefits were far less than originally thought. Researchers at Valley Medical Center in Fresno, CA, evaluated the effects of the MAST on healthy volunteers. After removing one liter of blood from the volunteers, the MAST were applied. The amount of blood auto-transfused from the lower extremities and abdomen to the head and upper trunk was measured using sequential radioisotope scans. They found that application of the MAST resulted in an auto-transfusion of less than 5% of the patient's total blood volume. This was approximately 300 mL in an 85 kg man.13 This amount was much less than initial estimates that ranged from 750–1,200 mL. A similar study measured the amount of blood auto-transfused following MAST application to dogs who were suffering hemorrhagic shock following phlebotomy. Again, the amount of blood auto-transfused was approximately 5% of the total blood volume.14 Based on these studies, statements about the auto-transfusion capabilities of the MAST were dropped. Instead, teaching was changed and stated only that MAST increased peripheral vascular resistance. Researchers then began to look at patient outcomes following application of the MAST. The initial study that questioned the benefit of the MAST was conducted in Houston, TX, in 1989 using the Houston Fire Department EMS system. During a 2½-year period, 201 consecutive patients presenting with penetrating anterior abdominal injuries and an initial prehospital systolic blood pressure of 90 mm Hg or less were entered into the study. All prehospital care was provided by the Houston Fire Department and all patients were delivered to the same regional trauma facility (Ben Taub Hospital). The patients were randomized into control and MAST groups by an alternate-day assignment of MAST use. The resulting study groups were found to be well matched for survival probability indices, prehospital response and transport times, and the volume of IV fluids received. The results demonstrated no significant difference in the survival rates of the control and MAST treatment groups. Based on these data, researchers concluded that, contrary to previous claims, the MAST provides no significant advantage in improving survival in urban prehospital management of penetrating abdominal injuries.15 Another prospective, randomized study investigated 291 traumatic shock patients greater than 15 years of age with blunt or penetrating trauma and a systolic blood pressure of 90 mm Hg or less with clinical signs of hypotension. The patients were randomly assigned to a MAST or non-MAST group. The researchers found that there were no significant differences in hospital stay or mortality between MAST and non-MAST patients. Similarly, in the subset of patients with blunt trauma, MAST were not found to be beneficial.16 In a prestigious Cochrane Review, researchers performed a meta-analysis of the two studies described above and found that the duration of Intensive Care Unit (ICU) stay was 1.7 days longer in the MAST-treated group. They concluded that there was no evidence to suggest that MAST/PASG reduce mortality, length of hospitalization or length of ICU stay in trauma patients. In fact, they found, MAST may actually increase these. They concluded that the data do not support the continued use of MAST/PASG in trauma patients.17 Conclusion Based on available data, in 1997 the National Association of EMS Physicians issued a position paper on use of MAST/PASG in modern EMS.18 The association concluded that MAST are definitely beneficial in ruptured abdominal aortic aneurysm and possibly beneficial in hypotension due to pelvic fracture, anaphylactic shock refractory to standard therapy, otherwise uncontrollable lower extremity hemorrhage and severe traumatic hypotension (palpable pulse, no blood pressure).19 Even considering these possibilities, any benefit from application of the MAST may be accomplished through rapid transport to a trauma center. Many EMS services have kept MAST for use in possible pelvic and lower extremity fractures. Patients with femur fractures are best treated with traction splints, while patients with pelvic fractures can be treated with a long backboard or similar device. Furthermore, the MAST are expensive (approximately $500 per pair) and take up valuable storage space on the ambulance. MAST are a relic of our past and belong in EMS museums, not on modern ambulances or rescue vehicles. References 1. Crile GW. Blood Pressure in Surgery: An Experimental and Clinical Research. Philadelphia, PA: JB Lippincott Company, 1903. 2. Crile GW. The Cartwright Prize Essay for 1903. Philadelphia, PA: JB Lippincott Company, 1903. 3. National Aeronautics and Space Administration. 1996 Space Technology Hall of Fame. Innovation 4(2), 1996. 4. Schwab CW, Gore D. MAST: medical antishock trousers. Surgery Annual 15:41–59, 1983. 5. Cutlet BS, Daggett WM. Application of the "G-Suit" to the control of hemorrhage in massive trauma. Ann Surg 173:511–514, 1972. 6. Kaplan BC, Civetti JM, Nagel EL, et al. The military anti-shock trouser in civilian prehospital care. J Trauma 13(10):843–848, 1973. 7. McSwain NE. Pneumatic trousers in the management of shock. J Trauma 17(9):719–724, 1977. 8. McSwain NE. MAST pneumatic trousers: A mechanical device to support blood pressure. Medical Instrumentation 11(6):334–336, Nov–Dec 1977. 9. Dillman PA. The biophysical response to shock trousers. J Emerg Nurs 3(6):21–25, 1977. 10. Caroline NL. Emergency Care in the Streets. Boston, MA: Little, Brown and Company, 1979, p. 86. 11. Campbell JE. Basic Trauma Life Support: Advanced Prehospital Care. Bowie, MD: Brady Communications Company, 1985, p. 54. 12. Butman AE, Paturas JL, McSwain NE, Dineen JP. Pre-Hospital Trauma Life Support. Akron, OH: Emergency Training, 1986, p. 98. 13. Bivins HG, Knopp R, Tiernan C, et al. Blood volume displacement with inflation of antishock trousers. Ann Emerg Med 11(8):409–412, 1982. 14. Lee HR, Blank WF, Massion WH, et al. Venous return in hemorrhagic shock after application of military anti-shock trousers. Am J Emerg Med 1(1):7–11, 1983. 15. Bickell WH, Pepe PE, Bailey ML, et al. Randomized trial of pneumatic antishock garments in the prehospital management of penetrating abdominal injuries. Ann Emerg Med 16(6):653–658, 1987. 16. Chang FC, Harrison PB, Beech RR, Helmar SD. PASG: Does it help in the management of traumatic shock? J Trauma 39(3):453–456, 1995. 17. Dickinson K, Roberts I. Medical anti-shock trousers (pneumatic anti-shock garments) for circulatory support in patients with trauma. Cochrane Review, The Cochrane Library, 2002, p. 4. 18. O'Connor RE, Domeier R. Use of the Pneumatic AntiShock Garment (PASG): NAEMSP Position Paper Prehosp Emerg Care 1(1):32–35, 1997. 19. Chapleau W. PASG: Bad wrap or bad rap? Emerg Med Serv 31(1):75–76, 2002.

Hi All, Here's some more info for you all to consider on this topic..... Hope this helps, Ace844 REVIEW The nasopharyngeal airway: dispelling myths and establishing the facts K Roberts1, H Whalley2 and A Bleetman3 1 Specialist Registrar in General Surgery, Walsall Manor Hospital 2 Senior house officer in Intensive Care Medicine, Birmingham Heartlands Hospital, UK 3 Consultant in Accident and Emergency Medicine, Birmingham Heartlands Hospital, UK Correspondence to: Keith Roberts dr_keith@hotmail.com ABSTRACT The nasopharyngeal airway (NPA) is a simple airway adjunct used by various healthcare professionals. It has some advantages over the oropharyngeal airway (OPA) but despite this it appears to be used less frequently. This may be due to fears over intracranial placement in cases of possible basal skull fracture. This fear, promulgated by training, is based solely on two single case reports and relative risk needs to be put into clinical context. Widely taught methods of sizing NPAs are based upon the width of the patient’s nostril or little finger, MRI data demonstrate that these methods are inaccurate. Ideal NPA length measured at nasal endoscopy correlates with subject height, this is independent of subject sex, and is a far more accurate determinant and easy to use in the clinical setting. Average height females require a Portex size 6 NPA and average height males a size 7 Portex NPA. This knowledge provides a rapid method of NPA selection.

"Buddy" Here's a semi-recent prehospital/ER study which is related to the topic at hand and may bring an interesting perspective... Hope this helps, Ace844 CONCORDANCE OF FIELD AND EMERGENCY DEPARTMENT ASSESSMENT IN THE PREHOSPITAL MANAGEMENT OF PATIENTS WITH DYSPNEA Charles N. Pozner A1, Michael Levine A1, Nathan Shapiro A1, John P. Hanrahan A1 A1 Department of Emergency Medicine (CNP, NS, JPH), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and Finch University and the Chicago Medical School (ML), North Chicago, Illinois. Abstract: Objective. Dyspnea is a common complaint of patients treated by emergency medical services (EMS). Few studies have examined the ability of paramedics to distinguish between etiologies of dyspnea. The authors evaluated the degree of agreement related to cardiac versus noncardiac sources of dyspnea between field and emergency department (ED) assessment of patients transported at the advanced life support level. Methods. This was a retrospective, cohort study of consecutive patients aged ≥35 years transported by paramedics with dyspnea. The authors compared the concordance between the EMS and ED diagnoses. They also investigated whether patients whose assessments were discordant had worse outcomes. Results. Paramedics correctly assessed the cause of dyspnea in 172 of 222 (77%) patients (kappa = 0.60; 95% confidence interval [CI] = 0.51, 0.69). Among single-source (i.e., cardiac or noncardiac) dyspnea patients, prehospital providers correctly assessed 70 of 84 (83%) noncardiac causes and 98 of 114 (86%) cardiac causes (kappa = 0.69; 95% CI = 0.59, 0.79). When the ED diagnosis included both cardiac and noncardiac etiologies, paramedics treated seven of 24 (29%) patients as noncardiac, 13 of 24 (54%) as cardiac, and four of 24 (17%) as combined-source dyspnea.The authors did not observe any statistically significant differences in in-hospital mortality, intubation frequency, or hospital length of stay in patients whose prehospital dyspnea diagnosis was discordant. . Conclusion. The authors conclude that in this EMS system, field assessment of dyspnea by paramedics is in agreement with that arrived at in the ED in a high proportion of patients with dyspnea from a single source. However, field assessment of dyspnea from multiple etiologies is less concordant.