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Please share with us. Rita K. Cydulka, David M. Cline, O. John Ma, Michael T. Fitch, Scott A. Staying Alive Matthew Hahn. John Ma. Pathophysiology of Nursing Demystified Helen C. City Life Michael Morse. Prepper Jeff Garrett. As this review points out, these studies frequently used a flawed base on which to build their research, and often report a cause-and-effect rela- tionship between ALS and patient outcome without complete information.
Prehospital trauma care is an important aspect in the development of a trauma system; therefore it is impor- tant that care be taken to develop methodologically sound research that will provide definitive answers to this ongoing debate. Mortality rates editorials Table 1. When the studies with actual data are were also significantly different: The authors concluded that allow- becomes clear that the conclusions generally do not logi- ing ALS procedures in the prehospital environment results cally follow from the data presented.
Group 1 patients had retrospective methodology. The the emergency department. The mean transport interval entire survival difference may be completely explainable in group 2 was 25 minutes. The show that ALS units were sent to more severely injured conclusion of this study was that prompt transport to a patients.
So, the higher mortality is expected! Another hospital, without attempts at field resuscitation, provides unsupported conclusion was that the longer OSIs associ- a better chance for survival among patients with penetrat- ated with ALS were caused by the ALS care. There are a ing heart wounds.
The groups patient access issues, extrication, and time required for were unmatched in many respects. Not all patients arrived at the hospital by relevant.
Two patients in group 1 were actually trans- In a study comparing 2 groups of trauma patients requir- ported by private vehicle. Their conclusion was that, patients in group 2 were in cardiac arrest before arrival at in an urban environment, optimal prehospital management the hospital.
None of the group 1 patients had cardiac of patients in extremis with penetrating thoracic injuries arrest in the out-of-hospital environment. Therefore group 2 should include immediate transportation without attempted included patients that were, in essence, dead on arrival, field stabilization. Their data show that, on average, the patients rospective. Actual times to definitive surgical care were who received prehospital stabilization were more severely not known. The difference in mortality between the groups injured and more of them arrived at the ED without signs of could be attributable to a delay in surgical care after life.
The authors concluded that this was caused by attempts arrival in the ED, so the use of arrival at the ED as syn- at stabilization. In addition, firm this conclusion. As with other studies, the method of there was no trauma system in place at the time of this transport was not the same for all patients. All ALS patients study. A likely bias is that treated by prehospital personnel before adoption of a pol- the patients in this group were actually injured close to the icy that required patients with penetrating trauma be trauma center and thrown in the back of the vehicle rather transported immediately to the trauma center.
Group 2 than wait for EMS. Prehospital data were lacking on most was comprised of 10 patients transported after adoption of the patients in group 2 since the majority were not of the policy. This study was also retrospective. The In an attempt to evaluate prehospital ALS in trauma survival rate for group 1 was 3. Eleven percent of patients in group vascular system.
The authors con- prehospital intervals. The model predicts that prehospital cluded that a policy of rapid transport is appropriate in the intravenous fluids are potentially beneficial only when all of care of patients with penetrating trauma.
In addition, the authors used a historical con- approximately equal to the bleeding rate. The conclusion trol in which system design and protocols were not reached by the author was that intravenous fluids appear to equally matched with prospective data.
First, there are numerous technical limitations. This shift can account for prolonged Some experts believe that a significant number of trauma compensation in otherwise healthy patients. Second, the patients deteriorate or die en route to the hospital from authors fail to acknowledge the ability to infuse large vol- physiologic abnormalities that could potentially be improved umes of fluid through large-bore intravenous lines under by prehospital ALS. They believe that, by adding prehospital pressure.
All of the patients a trauma center with the least possible time in the field. Group 1 contained 62 patients were successful. The mean OSI was actually shorter for Table 1. Comparison of articles arguing against ALS for prehospital care of trauma patients. The receive BLS was not clearly stated and was probably not best correlation with survival was the absence of clinical random. In addi- trauma. Fourteen percent of the BLS-only patients transported by paramedics. The authors con- In a prospective study of severely injured trauma cluded that the improvement in the salvage rate in this patients brought to the Boston City Hospital Trauma patient population was the result of the early interven- Center, 80 received prehospital ALS and 98 received only tions that could be applied by trained paramedics in the BLS interventions.
OSIs limitation as is the use of a historical control. It is possible were no greater for the patients receiving ALS than those that other changes in the system eg, in-hospital care receiving BLS care. They found that a positive change in could explain the improved outcome since the investiga- the prehospital TS was significantly correlated with an tion spanned more than a decade.
They surmised that early nonsurvivors. All of the sur- care rendered after admission to the hospital. Statistically, does have several limitations. The patients in the study endotracheal intubation and intravenous line placement were not randomly assigned to groups. The determination was positively associated with improved survival. Table 2. Comparison of articles arguing for ALS for prehospital care of trauma patients.
On resuscitation, and rapid transport can be effective in average, 1. Eighteen percent of arrest. An increase in blood pressure of 10 mm Hg or patients who were going to survive. The authors the converse. The authors also failed to present a compari- concluded that ALS interventions by well-trained son of survival among patients receiving ALS versus paramedics can be performed efficiently and improve the patients not receiving ALS.
Presumably this was because hemodynamic status of patients with critical penetrating there was no difference between these groups. If this is wounds to the chest or abdomen.
There was also a This study was retrospective and there was no control difference in the type of injuries between the 2 groups. Group 2 associated with falling or jumping from a meter bridge. Thirty-six 2. More patients arrived at the hospital alive in group 2 percent of the ALS patients died within the first 24 hours than in group 1.
The group 2 survived, and the overall survival rate was three- authors also reported an in-hospital rate of respiratory fold greater in group 2 than in group 1. The authors concluded that the intubated at the scene. The authors concluded that pre- improvement in the hour survival rate among those hospital airway control and fluid resuscitation by a physi- patients treated by ALS crews suggested there was some cian-supervised paramedic system can significantly benefit from prehospital resuscitation and stabilization in improve outcome from multiple trauma.
Providing ALS major trauma. The authors provided in different cities. Another limitation is that the failed to account for the implementation of a trauma system, overall mortality for the trauma patients was similar between which could explain the differences in the survival rates. When the authors analyzed the data using Another possible explanation not addressed by the regression analysis, they did not demonstrate that there was authors was that the EMS system was probably faster an effect on length of ICU stay, disability from head injury, after implementation of the Medic One program.
In an analysis of 3 years of trauma deaths from a Finally, the study reported data from a year period. The authors reported OSIs of Although the authors found there were air transport of major trauma patients. The authors concluded flight team. Patients transported by ground had a mortal- that ALS care was directly correlated with a lower county ity that was similar to their predicted rate given the sever- trauma death rate.
In addition, in the counties with ALS care, it is possible Controlling for injury severity, air medical transported that better, more sophisticated trauma systems have devel- patients with a physician—registered nurse transport team oped. This could contribute to the higher survival rate was associated with a significant reduction in mortal- found in the counties with ALS.
Finally, the ALS counties ity…despite the fact that the total prehospital interval was were undoubtedly more urban. Thus closer proximity to a nearly twice as long for these patients. The authors con- trauma center may have actually been the cause of cluded that the type of prehospital ALS care available to decreased mortality. The authors concluded that ALS care for multisys- CARE tem trauma victims of motor vehicle crashes in a rural There is no objective proof that the primary determinant state appears to be beneficial.
Because the data port this relationship are flawed and nearly all are retro- were collected retrospectively, there was no randomization spective. A series of studies by Bickell et al randomly assigned There is also a potential bias introduced by the trauma trauma patients into groups that would, or would not, review committee methodology.
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