- Email: [email protected]
HEMS and Trauma Patients
Literature Review
Daniel Hankins, MD, FACEP
HEMS 00 Article andtitle Trauma Patients Butler DP, Anwar I, Willett K. Is it the H or the EMS in HEMS that has an impact on trauma mortality? A systematic review of the evidence. Emerg Med J 2010;27:692-701. This systematic review from John Radcliffe Hospital at Oxford University in the United Kingdom looks at all of the population-based studies that consider scene evacuation of trauma patients by helicopter emergency medical services (HEMS). The authors look at papers written between 1980 and 2008. Twenty-three papers were considered to be appropriate for this study; 14 of these studies showed significant improvement in trauma patient mortality when transported by HEMS services. The authors conclude that more study is needed, but they state that randomized studies of air versus ground transport would be hard to do because of significant hurdles, some of which are ethical in nature. The conclusion is that HEMS needs to be considered in the regional EMS system in the context of geography, transport times to the trauma center, and the nature of care rendered. Each regional EMS authority must determine how trauma patients are cared for and transported based on local needs.
(POC) testing has made obtaining a lactate level much easier than the previous cumbersome method, thus making it even more useful in judging where the patient is initially in terms of volume status and in judging the response to resuscitation. These authors looked a group of 149 patients who had a traditional whole blood lactate determination at the same time as a POC lactate determination. The median time of return of the value of the traditional whole blood lactate was 172 minutes, whereas the median time of return of the POC value was 21 minutes. The extrapolation to critical care air and ground transport is obvious: move the POC lactate determination further out from the receiving emergency facility than just triage. An elevated POC lactate determined by the transport crew is a way for the receiving tertiary center to get a more complete picture of just how sick an incoming septic or trauma patient is. Serial determinations of POC lactate are also a way for critical care providers to judge the success of their resuscitative efforts in the field.
Madill J. In-flight thoracic ultrasound detection of pneumothorax in combat. J Emerg Med 2010;39:194-7.
This is a retrospective study of data from the San Diego trauma registry of airway interventions in head-injured trauma (TBI) patients between 1987 and 2003. More than 9,000 TBI patients met the criteria for their study. Scrutiny of the outcomes of these patients showed that intubated TBI patients had a better chance of unpredicted survival compared with nonintubated patient survival. Intubation of TBI patients by air medical providers is associated with better survival than those patients intubated by ground paramedics. As has been shown in other studies, both hyperventilation and hypoventilation were detrimental to TBI patients, leading to poorer rates of unexpected survival. The accompanying commentary by Dr. Norman McSwain summarizes the advantages of HEMS over ground EMS in caring for patients with severe TBI.
Ultrasound (US) machines continue to get smaller, yet with better resolution and cheaper costs. Their use on air and ground vehicles will become more practical. The question is, should we? The exact place for US in out-of-hospital care is still being determined. Is there a cost benefit of these machines that will mean a change of therapy by the medical crew or by personnel at the receiving emergency department? As the author states, US is the only imaging mode available in the austere and difficult conditions often found at scene responses. This paper is a case study from Southwest Asia that looks at a patient with penetrating trauma transported by helicopter. Because of hostile fire, the aircraft had to fly at over 7,000 feet. The patient became hypoxic and deteriorated otherwise. The cause of the deterioration was unclear because of multiple possible origins. The author was able to exclude cardiac tamponade as a reason for the decline and was able to determine not only the presence of a pneumothorax but also which side it was on, and then to treat it appropriately. The author provides a nice discussion on the possible utility of US in the noisy HEMS environment.
Goyal M, Pines JM, Drumheller BC, Gaieski DF. Point of care testing in triage decreases time to lactate level in septic patients. J Emerg Med 2010;38:578-81.
Jorgensen H, Jensen CH, Dirks J. Does prehospital ultrasound improve treatment of the trauma patient? A systematic review. Eur J Emerg Med 2010;17:249-63.
Lactate levels have become increasingly important in the management of fluid resuscitation in trauma and sepsis. Point of care
In the vein of continuing the discussion of US from above, this paper from Denmark is a literature search to determine
Davis DP, Peay J, Sise MJ, Kennedy F, Simon F, Tominaga G, et al. Prehospital airway and ventilation management: A trauma score and injury severity score-based analysis. J Trauma 2010;69:294-301.
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Air Medical Journal 30:1
the extent of papers available that look at US usage in the outof-hospital arena. Twenty-four studies were found, and 14 studies that included 885 patients were used in their study. They found the studies to be heterogeneous and uneven in their approach. The authors were not able to conclude that US was helpful in the care of the trauma patient, but some studies (like the one previously discussed, although not included) showed some change in patient management by use of US. They suggest that more rigorous and formal studies are needed. This is a nice study and review of exactly where US is in out-of-hospital practice currently. Daniel Hankins, MD, FACEP, is a consultant in emergency medicine and medical director, Mayo Medical Transport, Mayo Clinic, in Rochester, MN. He can be reached at [email protected]. 1067-991X/$36.00 Copyright 2011 Air Medical Journal Associates doi:10.1016/j.amj.2010.10.004
January-February 2011
21
Daniel Hankins, MD, FACEP
HEMS 00 Article andtitle Trauma Patients Butler DP, Anwar I, Willett K. Is it the H or the EMS in HEMS that has an impact on trauma mortality? A systematic review of the evidence. Emerg Med J 2010;27:692-701. This systematic review from John Radcliffe Hospital at Oxford University in the United Kingdom looks at all of the population-based studies that consider scene evacuation of trauma patients by helicopter emergency medical services (HEMS). The authors look at papers written between 1980 and 2008. Twenty-three papers were considered to be appropriate for this study; 14 of these studies showed significant improvement in trauma patient mortality when transported by HEMS services. The authors conclude that more study is needed, but they state that randomized studies of air versus ground transport would be hard to do because of significant hurdles, some of which are ethical in nature. The conclusion is that HEMS needs to be considered in the regional EMS system in the context of geography, transport times to the trauma center, and the nature of care rendered. Each regional EMS authority must determine how trauma patients are cared for and transported based on local needs.
(POC) testing has made obtaining a lactate level much easier than the previous cumbersome method, thus making it even more useful in judging where the patient is initially in terms of volume status and in judging the response to resuscitation. These authors looked a group of 149 patients who had a traditional whole blood lactate determination at the same time as a POC lactate determination. The median time of return of the value of the traditional whole blood lactate was 172 minutes, whereas the median time of return of the POC value was 21 minutes. The extrapolation to critical care air and ground transport is obvious: move the POC lactate determination further out from the receiving emergency facility than just triage. An elevated POC lactate determined by the transport crew is a way for the receiving tertiary center to get a more complete picture of just how sick an incoming septic or trauma patient is. Serial determinations of POC lactate are also a way for critical care providers to judge the success of their resuscitative efforts in the field.
Madill J. In-flight thoracic ultrasound detection of pneumothorax in combat. J Emerg Med 2010;39:194-7.
This is a retrospective study of data from the San Diego trauma registry of airway interventions in head-injured trauma (TBI) patients between 1987 and 2003. More than 9,000 TBI patients met the criteria for their study. Scrutiny of the outcomes of these patients showed that intubated TBI patients had a better chance of unpredicted survival compared with nonintubated patient survival. Intubation of TBI patients by air medical providers is associated with better survival than those patients intubated by ground paramedics. As has been shown in other studies, both hyperventilation and hypoventilation were detrimental to TBI patients, leading to poorer rates of unexpected survival. The accompanying commentary by Dr. Norman McSwain summarizes the advantages of HEMS over ground EMS in caring for patients with severe TBI.
Ultrasound (US) machines continue to get smaller, yet with better resolution and cheaper costs. Their use on air and ground vehicles will become more practical. The question is, should we? The exact place for US in out-of-hospital care is still being determined. Is there a cost benefit of these machines that will mean a change of therapy by the medical crew or by personnel at the receiving emergency department? As the author states, US is the only imaging mode available in the austere and difficult conditions often found at scene responses. This paper is a case study from Southwest Asia that looks at a patient with penetrating trauma transported by helicopter. Because of hostile fire, the aircraft had to fly at over 7,000 feet. The patient became hypoxic and deteriorated otherwise. The cause of the deterioration was unclear because of multiple possible origins. The author was able to exclude cardiac tamponade as a reason for the decline and was able to determine not only the presence of a pneumothorax but also which side it was on, and then to treat it appropriately. The author provides a nice discussion on the possible utility of US in the noisy HEMS environment.
Goyal M, Pines JM, Drumheller BC, Gaieski DF. Point of care testing in triage decreases time to lactate level in septic patients. J Emerg Med 2010;38:578-81.
Jorgensen H, Jensen CH, Dirks J. Does prehospital ultrasound improve treatment of the trauma patient? A systematic review. Eur J Emerg Med 2010;17:249-63.
Lactate levels have become increasingly important in the management of fluid resuscitation in trauma and sepsis. Point of care
In the vein of continuing the discussion of US from above, this paper from Denmark is a literature search to determine
Davis DP, Peay J, Sise MJ, Kennedy F, Simon F, Tominaga G, et al. Prehospital airway and ventilation management: A trauma score and injury severity score-based analysis. J Trauma 2010;69:294-301.
20
Air Medical Journal 30:1
the extent of papers available that look at US usage in the outof-hospital arena. Twenty-four studies were found, and 14 studies that included 885 patients were used in their study. They found the studies to be heterogeneous and uneven in their approach. The authors were not able to conclude that US was helpful in the care of the trauma patient, but some studies (like the one previously discussed, although not included) showed some change in patient management by use of US. They suggest that more rigorous and formal studies are needed. This is a nice study and review of exactly where US is in out-of-hospital practice currently. Daniel Hankins, MD, FACEP, is a consultant in emergency medicine and medical director, Mayo Medical Transport, Mayo Clinic, in Rochester, MN. He can be reached at [email protected]. 1067-991X/$36.00 Copyright 2011 Air Medical Journal Associates doi:10.1016/j.amj.2010.10.004
January-February 2011
21