PREHOSPITAL AND RETRIEVAL MEDICINE
RETRIEVAL
PromptPros and cons of road vs helo transfer
ResponseRoad
Slower Speed
Required vehicular access to site
Subject to traffic and road conditions
Limited range
Helicopter
Weather dependant
Subject to atmospheric changes
Limited interventions possible in flight
Landing site required
Capacity/weight limited
Noise and vibration
Prolonged launch time
Higher cost
Slower Speed
Required vehicular access to site
Subject to traffic and road conditions
Limited range
Helicopter
Weather dependant
Subject to atmospheric changes
Limited interventions possible in flight
Landing site required
Capacity/weight limited
Noise and vibration
Prolonged launch time
Higher cost
PromptWho is prioritised in extraction of multiple entrapped patients
ResponseHaemodynamically compromised and most likely to be time critical.
Needs immediately airway Mx due to cyanosis.
Needs immediately airway Mx due to cyanosis.
PromptDifficulties that may be encountered in the prehospital environment
ResponseUnfamiliar environment - exposed to elements, variable light, noisy, terrain rough and uneven
Distressed, intoxicated or angry family members / bystanders
Working on casualties on the ground
Hazards of incident
Site appears disorganised
Information unavailable, inconsistent or incorrect
Inadequate staff, equipment, resources
Different hierarchical systems
Distressed, intoxicated or angry family members / bystanders
Working on casualties on the ground
Hazards of incident
Site appears disorganised
Information unavailable, inconsistent or incorrect
Inadequate staff, equipment, resources
Different hierarchical systems
PromptHitory/examination suggesting threat to staff during transport
ResponseThreats of violence
Active thought disorder
Inability to follow commands
Current intoxication
History of violence
Evidence of significant self-harm
Lots of others acceptable
Active thought disorder
Inability to follow commands
Current intoxication
History of violence
Evidence of significant self-harm
Lots of others acceptable
PromptManagement strategies for aggressive patient
ResponseSedation:
- Diazepam 10mg oral prn
- Ketamine 20mg aliquots prn, or infusion
- Droperidol 10mg IM
- Avoid air transport altogether – ground transport
- Employ police / security to travel with pt
- Intubate for transfer / general anaesthesia
PromptList interventions which have proven benefit in prehospital environment
Responsefinger (+/- tube) thoracostomy
Blood transfusion
RSI (essential if only doing a finger thoracostomy)
Analgesia
Pelvic binding
Femoral traction
CPR
Early defib (1min delay = 10% incr mortality)
Needle decompression of pneumothorax
Basic airway
Nitrates/GTN in LVF (improves recovery and mortality)
Thrombolytics for MI with long transport time (decr time to thrombolysis by 30-45mins; 15- 30% false positives, 5% false negatives)
RSI if long transport time (if not mentioned above)
ECG pre-hospital (get ECG 30mins earlier, show dynamic changes; adds 5mins to scene time)
Resuscitative thoracotomy (controversial however data from London HEMS suggests increased survival)
Emergency amputation – for extraction from a life-threatening scene when trapped with a devitalised limb
Escharotomies if long transport time to ED / burns centre
Blood transfusion
RSI (essential if only doing a finger thoracostomy)
Analgesia
Pelvic binding
Femoral traction
CPR
Early defib (1min delay = 10% incr mortality)
Needle decompression of pneumothorax
Basic airway
Nitrates/GTN in LVF (improves recovery and mortality)
Thrombolytics for MI with long transport time (decr time to thrombolysis by 30-45mins; 15- 30% false positives, 5% false negatives)
RSI if long transport time (if not mentioned above)
ECG pre-hospital (get ECG 30mins earlier, show dynamic changes; adds 5mins to scene time)
Resuscitative thoracotomy (controversial however data from London HEMS suggests increased survival)
Emergency amputation – for extraction from a life-threatening scene when trapped with a devitalised limb
Escharotomies if long transport time to ED / burns centre
PromptPros/cons of mechanism as part of triage tool
ResponseHigh degree of sensitivity but poor specificity for predicting severe trauma. Results in significant over-triage
PromptPros/cons of trauma bypass
ResponseAdvantages: shown to reduce mortality, concentrate resources, provides sufficient number of cases to justify having full services, sufficient cases for staff exposure/training, staff satisfaction/retention
Disadvantages: over-triage places unnecessary load on MTS, de-skilling of non-MTS staff – they are then not as practised when self-presenting trauma arrives, staff dissatisfaction, longer transit times – deterioration en route, removal of patient further from normal domicile/family supports
Disadvantages: over-triage places unnecessary load on MTS, de-skilling of non-MTS staff – they are then not as practised when self-presenting trauma arrives, staff dissatisfaction, longer transit times – deterioration en route, removal of patient further from normal domicile/family supports
PromptEvidence for permissive hypotension in prehospital setting
ResponseMost of the evidence comes from animal studies & the Bickell study (1994) – and that evidence which exists supports permissive hypotension mostly in the context of (a) penetrating injury and (b) short transit times to definitive care.
Patients with head injury excluded from this & other trials.
No good data to support this in blunt trauma.
Patients with head injury excluded from this & other trials.
No good data to support this in blunt trauma.
PromptMonitoring modalities required for safe transport
ResponseContinuous ECG
Pressure monitoring – invasive and non-invasive
Patient Oxygenation with continuous pulse oximetry
Patient Ventilation with wave form capnography
Ventilator alarms including high pressure and disconnection
Pressure monitoring – invasive and non-invasive
Patient Oxygenation with continuous pulse oximetry
Patient Ventilation with wave form capnography
Ventilator alarms including high pressure and disconnection
PromptNon-Clinical equipment that may be needed for retrieval
ResponseCommunication – phones
Documentation and pens
Taxi vouchers
Spare batteries for equipment
Torches and/or head torches
Documentation and pens
Taxi vouchers
Spare batteries for equipment
Torches and/or head torches
PromptClinical governance required in retrieval (ie: what should be reviewed)
ResponseTasking
Staffing mix and seniority
Equipment performance
Clinical decisions and patient outcomes
Closed loop of feedback to staff and to inform future practice
Staffing mix and seniority
Equipment performance
Clinical decisions and patient outcomes
Closed loop of feedback to staff and to inform future practice