Intro to EMS and Trauma Systems

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Trauma Anesthesia
Overview of Emergency Medical Services and Trauma
Systems
Jeffrey Groom, PhD, CRNA Chair and Associate
Professor of Anesthesiology Nursing College of
Nursing and Health Sciences - Florida
International University
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TRAUMA

• Epidemiology
• Trauma Systems
• Basic Trauma Life Support

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Trauma Mortality

• Trauma kills more people between the ages of
  1 and 44 than any other disease or illness.
  
• Nearly 100,000 people of all ages in the
  United States die from trauma each year.
• According to the National Center for Heath
  Statistics, trauma (unintentional injuries
  homicides) causes
• 43 of all deaths from age 1 to 4
• 48 of all deaths in ages 5 to 14
• 62 of all deaths in ages 15 to 24

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Trauma Morbidity and Mortality
Epidemiology of Trauma
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Trauma Morbidity
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Trauma Mortality
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Morbidity by Mechanism
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Mortality by Mechanism
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Morbidity by Age and Mechanism
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Morbidity by Age and Mechanism
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Trauma Morbidity
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Trauma Mortality
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Trauma Mortality
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Trauma Morbidity
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Trauma Mortality
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Trauma Morbidity
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Trauma Mortality
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TRAUMA Systems

• Injury Prevention
• Pre-hospital care
• Acute Care Trauma Centers
• Post-trauma Care and Rehabilitation

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TRAUMA Systems

• Injury Prevention
• Pre-hospital care
• Acute Care Trauma Centers
• Post-trauma Care and Rehabilitation

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Trauma Research
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TRAUMA Systems

• Injury Prevention
• Pre-hospital care
• Acute Care Trauma Centers
• Post-trauma Care and Rehabilitation

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History of Emergency Medical Services
1896 Bellevue Hospital was the 1st City Hospital
in the country to dispatch ambulance services.
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Ambulance Service Pre-1960
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Key Points in EMS History

• Accidental Death and Disability The Neglected
  Disease of Modern Society National Academy of
  Sciences, National Research Council 1966.
• Pantridge JF, Geddes JS. A mobile intensive-care
  unit in the management of myocardial infarction.
  Lancet 1967 2(7510)271-273.
• Nagel EL, HirschmanJC, Mayer PW, Dennis F.
  Telemetry of physiologic data an aid to
  fire-rescue personnel in a metropolitan area.
  South Med J 1968 61(6)598-601.

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• 1966 The National Highway Safety Act (P.L.
  89-564) established national standards for
  training emergency medical technicians, and
  minimum ambulance equipment
• Established US Department of Transportation as
  the lead federal agency to advance trauma safety,
  prehospital care, and acute care.

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Public Expectation
EMERGENCY
ER
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Prehospital Emergency Medical Services
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TRAUMA Systems

• Injury Prevention
• Pre-hospital care
• Acute Care Trauma Centers
• Post-trauma Care and Rehabilitation

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TRAUMA CENTERS
LEVEL 1 LEVEL 2 LEVEL 3
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Regional Trauma Systems
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Trauma Scoring Systems
Physiologic scoring index of trauma severity

• TRAUMA SCORE
• BP, Refill, RR, RE, GCS
• GLASGOW COMA SCORE
• Eye Opening, Verbal, Motor
• INJURY SEVERITY SCORE
• Anatomic Severity Rating

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Trauma Scoring Systems

• REVISED TRAUMA SCORE

BP GCS RR VALUE
gt90 13 - 15 10 - 29 4 76 - 89 9 - 12 gt
29 3 50 -75 6 - 8 6 - 9 2 1 - 49 4
- 5 1 - 5 1 0 3 0 0
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Trauma Scoring Systems

• REVISED TRAUMA SCORE

RTS Probability of Survival
8 0.988 6 0.919 4 0.605 2 0.172 1 0
.071 0 0.027
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Trauma Anesthesia
International Trauma Anesthesiaand Critical Care
Society
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TRAUMA Systems
Future of Trauma Systems
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Fate of Trauma Systems in the Future
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Fate of Trauma Systems in the Future
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TRAUMA

• Epidemiology
• Trauma Systems
• Basic Trauma Life Support

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Trauma Mortality
50 40 10
IMMEDIATE HOURS DAYS
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Trauma Patient Profile

• Typical patient 1 - 40 yrs. - healthy
• Age extremes - coexisting diseases
• Increased Anesthesia Risk
• Altered Level of Consciousness
• ETOH and/or Drug Ingestion
• Full Stomach
• Hypovolemia
• Hypothermia
• Hypoxemia

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Trauma Mechanism of Injury

• Patient impacts with something
• Something impacts with patient
• Everything else bites, burns, etc

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All Trauma is not the same

• Blunt vs Penetrating Trauma
• Open vs Closed Head Trauma
• Neck and Airway Trauma
• Thoracic Trauma
• Abdominal Trauma
• Extremity Trauma
• Thermal - Haz Mat - Other

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300 am
Trauma Alert Trauma Alert..
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C Caution R Reconnaissance A Assess P
Proceed
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Trauma Assessment
A Airway B Breathing C
Circulation D Disability E Examine F
FAST G Go
Assess Prioritize Interventions
Reassess
Re-Prioritize
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PRIMARY ASSESSMENT

• AIRWAY
• BREATHING
• CIRCULATION

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INITIAL RESUSCITATION

• AIRWAY
• Position / Suction / Tube
• BREATHING
• Vent / O2 / Seal/Tap Chest
• CIRCULATION
• STOP Severe Bleeding

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SECONDARY ASSESSMENT

• DISABILITY Status
• CNS Function, Pupils, Posture, Movement
• Examine Head to Toe / Front Back

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AIRWAY Management

• AIRWAY Maintenance
• C-Spine Stabilization
• Airway Positioning
• Suction
• Tubes ETT or SGA
• Cricothyrotomy
• EtCO2 Monitoring or Alternative

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Trauma IntubationRapid Sequence Inline
Stabilization
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BREATHING Management

• BREATHING Support
• High flow Supplemental O2
• Assist Ventilation prn
• Seal Open Chest Wound
• Decompress Tension Pneumo
• Stabilize Flail Segment
• Monitor Resp/Breathing/SaO2
• Caution with N2O

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CIRCULATORY Management

• CIRCULATORY Management
• STOP Bleeding
• Vascular Access IV or IO
• Permissive Hypotension Systolic BP lt80-90mmHG
• PRBCs or Blood Substitute or Cell Saver
• Monitor -BP, Pulses, Refill, SaO2, labs

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Intraosseous Vascular Access
EZ IO Insertion Technique Video
EZ-IO Intraosseous Infusion System - Flow Test -
Tibia
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DISABILITY Management

• DISABILITY Status
• CNS Function
• GCS - Eye / Verbal / Motor
• AVPU
• Posture
• Decorticate
• Decerebrate
• Pupils
• Trunk/Extremity Movement

• C-Collar
• Spine Immobilization
• Splints

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Focused Assessment with Sonography for Trauma
http//www.sonoguide.com/FAST.html
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Head Trauma InfraScanner
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Head Trauma InfraScanner
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Pre-Op Preparation for Trauma

• Direct to OR vs ER vs CT/MRI
• History Physical Assessment
• AIRWAY Management
• Damage Control Resuscitation
• Monitoring / Fluids / Blood
• Induction / IntraOp Monitoring
• Emergence / Post-Op Xport

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Preanesthesia History

• Info from and about the scene
• Info about the accident or injury
• Past medical/surgical history
• Current Meds and Allergies
• Substances of abuse
• ETOH -Cocaine -Opioids
• Marijuana -Inhalants -PCP
• Trends in Vital signs and LOC/GCS

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Physical Examination

• Primary Secondary Assessment
• Particular focus on
• AIRWAY- face, mouth, neck
• RESPIRATORY- chest, diaphragm
• CARDIAC- chest, bleeding, IV access
• NEURO- ?LOC, GCS scores, pupils, motor
• LABS
• SMAC, Type Cross, ABG
• C-spine, CXR, CAT, MRI

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MONITORING

• Standard Monitors
• EKG -BP -SaO2 -Temp
• Urine -EtCO2 -NMB -A-line
• Secondary Monitors
• ICP -CVP -PA cath -LABs
• Room set up - Trauma cart
• Monitors -Airway -Warmers -Lines

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Trauma Team Pit Crew
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SIT Awareness Universal Precautions TEAM
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TRAUMA ANESTHESIA

• International Trauma Anesthesia and Critical Care
  Society