Prehospital pearls, pitfalls, and updates

How to modify the risk-taking behaviour of emergency medical services drivers?

High speed and an aggressive style of driving are major risk factors for serious traffic accidents. Consequently, frontline emergency medical services vehicles have an increased collision risk. We report on two studies designed to modify the risk-taking behaviour of emergency medical services drivers. In the first study, we compared the travel intervals for a second tier unit using two different types of vehicles. We found that the replacement of a sports estate by an ambulance, which can be considered more or less as a change from a speedy and aggressive style of driving to a cautious style of driving with respect for the speed limits, resulted in an increase of the travel interval of only 10-20%. In the second study we found that the installation of a 'black box' in an emergency medical services vehicle, combined with well-defined guidelines for the drivers and a close monitoring system, provides fair but still not optimal results with regard to maximum speed and the occurrence of harsh braking events. Despite some limitations in the study designs, we conclude that for second tier units only a small amount of time is gained by high speed and an aggressive style of driving. Furthermore, we are convinced that a 'black box' is a good tool to modify the risk-taking behaviour of emergency medical services drivers.

Factors associated with mortality in patients with penetrating abdominal vascular trauma

OBJECTIVE

Prehospital transport, resuscitation, and operative intervention are all critical to the care of the penetrating trauma victim. We determined which factors most affected mortality in patients with penetrating abdominal vascular injuries.

METHODS

Consecutive patients with penetrating abdominal vascular injuries from an urban Level I trauma center from January 1993 to December 1998 were identified from the trauma registry and their charts reviewed. All patients who died prior to operative intervention were excluded. Data collected included mortality, age, scene time (ST), EMS transport time (TT), time in the emergency department (ED), initial systolic blood pressure in the ED (BP), operating time, intraoperative estimated blood loss (EBL), and worst base deficit in the first 24 h (BD). These variables were compared between nonsurvivors and survivors by univariate ANOVA. Multivariate ANOVA (MANOVA) determined independent effects on mortality.

RESULTS

Forty-six penetrating abdominal vascular injuries were identified in 31 patients, 11 of whom died (38.7%). Examining prehospital parameters, mean ST averaged 16.5 +/- 3.6 min, while TT was 31.8 +/- 7.1 min. For ED parameters, initial BP was 94.8 +/- 6.4 mm Hg and initial heart rate was 109 +/- 7 beats per minute. Mean operative EBL for all patients was 3518 +/- 433 ml. The mean BD for all patients was -12.9 +/- 1.8. Significant differences were noted in the univariate analysis between survivors and nonsurvivors for BD (P < 0.0001), BP (P = 0.0062) and EBL (P = 0.0002). MANOVA revealed that only base deficit (P < 0.0001) had an independent effect on mortality.

CONCLUSIONS

In patients with penetrating abdominal vascular injuries who survive their ED stay, adverse physiologic parameters reflecting the adequacy of resuscitation are more predictive of mortality than identifiable prehospital parameters.

Role of rapid sequence induction for intubation in the prehospital setting: helpful or harmful?

Use of rapid sequence induction for intubation was introduced to the prehospital environment in the hope of enhancing patient outcome by improving early definitive airway management. Varying success has been achieved in both air and ground transport emergency medical services systems, but concern persists about the potential to cause patients harm. Individual emergency medical services systems must determine the need for rapid sequence induction for intubation and their ability to implement a rapid sequence induction for intubation protocol effectively with minimal adverse events. Therefore, the value of rapid sequence induction for intubation is dependent on each emergency medical services system design in their ability to establish personnel requirements and ongoing training, expertise in airway management skills, medical direction and supervision, and a quality assurance program. If these principles are strictly adhered to, rapid sequence induction for intubation may be safely used as an advanced airway management technique in the prehospital setting.