EMS World

FEB 2017

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EMSWORLD.com | FEBRUARY 2017 39 Another study published about the London HEMS system in 2006 showed that prehospital thoracotomy was an inde- pendent predictor of survival. Of patients who received thoracotomy for penetrating trauma, 8.6% survived, and 62.5% of those were neurologically normal. In contrast, there was only a 4.7% survival in penetrat- ing trauma if no prehospital thoracotomy was performed. 41 A review published out of Madrid in 2007 included six patients undergoing prehospi- tal thoracotomy. This study showed a 33% survival, 50% neurologically intact. It is, of course, limited by its small sample size, but its authors noted that their neurologically intact survivors—though located in a city with quoted transport times of less than 10 minutes—would not likely have arrived to the hospital and undergone a thoracotomy in less than 10 minutes from EMS arrival. 42 This paper addresses the question of wheth- er it's still beneficial to perform prehospi- tal thoracotomies in cities where transport times are usually within 10 minutes. Finally a retrospective review published in 2009 out of the Japanese helicopter EMS system looked at 81 patients undergoing thoracotomy for blunt trauma. While 59% achieved ROSC and 34% made it to the ICU, no patients survived to hospital discharge. This study was limited by the long times between EMS arrival and physician arrival at the scene to perform the thoracotomy prior to transport (greater than 19 minutes on average). 43 Prehospital Logistics A prominent factor in patient outcomes is paramedic involvement in the prehospital setting. The "scoop and run" and "stay and play" methods have been studied in the past, leading to the conclusion that "scoop and run" is the preferred technique for penetrat- ing or unstable trauma victims. Studies in the U.S. have shown that patients have a significantly higher chance of survival with immediate transport to the hospi- tal. 44,45 A study from South Carolina also noted that in the "scoop and run" group, 20% of patients lost vital signs between EMS arrival and hospital arrival, versus 40% in the "stay and play" group. This difference may have been a major factor in the groups' mortality rates, as no patients who lost vitals prior to arrival at the hospital survived in this study. 45 These studies may reflect the time-sensitive nature of thoracotomy in traumatic arrest victims. Even though patient survival is increased with rapid transport to the hospital, we know EMS plays a vital role in improving survival for these patients. A 1992 study showed that field intubation in patients with loss of vitals due to penetrating trauma increased the tolerance of CPR time from 4.2 minutes to 9.4 minutes in survivors. 20 Additionally, a German study looking at patients with traumatic arrest requiring thoracotomy showed that the only factor that improved survival was aggressive field care, including chest tube insertion. 13 The NAEMSP currently has a posi- tion paper, Guidelines for Withholding or Termination of Resuscitation in Prehospi- tal Traumatic Cardiopulmonary Arrest. These guidelines, written in 2001 in con- junction with the American College of Surgeons Committee on Trauma, define when prehospital resuscitation efforts should be withheld or discontinued in traumatic arrest patients. 46 A retrospec- tive cohort study published in 2005 col- lected data between 1994–2001 on 184 prehospital traumatic arrest patients. This study showed a 7.6% survival to hospital discharge. When comparing the docu- mented EMS assessments of the survivors to the NAEMSP/ACS guidelines, this study found that if the guidelines had been strict- ly applied, 13 of the 14 survivors would not have been transported to the hospital, and several patients met multiple criteria for withholding resuscitation. Notably, 93% of survivors had CPR times greater than 15 minutes due to the combined on-scene and transport times, although no survivors had transport times greater than 15 minutes. On the converse side of the argument, 111 nonsurvivors would not have been trans- ported to the hospital, which could have freed these EMS teams to transport other patients. This study also noted frequent dis- crepancies between initial EMS assessment and initial ED assessment, concluding that field assessments are often not reliable. 24 The Next Step in the U.S.? While there has been limited success in pre- hospital thoracotomy for blunt trauma, it is clear there is a role for prehospital tho- racotomy in penetrating trauma, especially stabbing victims. And the data shows that thoracotomy is a time-sensitive interven- tion. Based on this evidence, a number of EMS systems across the globe have already adopted prehospital thoracotomy into their current EMS trauma algorithms. But is this something we should be adopting in the United States? In our current EMS system, physicians do not play an integral role in day-to-day patient care and transport. But with the growing popularity of active EMS medi- cal directors and EMS now being a certi- fied medical subspecialty, there are a fair number of EMS systems with emergency medicine-trained physicians available on scenes. Additionally, there are emergency medicine residents and EMS fellows across the country who participate in EMS calls during their training. Is it time to put emergency resuscita- tive thoracotomy into our EMS trauma protocols as the next step in trauma care when physicians are available at the scene? Possibly. It must be recognized that a tho- racotomy is an inherently dangerous pro- cedure. Sharp fractured ribs, bullet frag- ments, scalpels and the austere prehospital environment put the provider at high risk for iatrogenic injury and possible infection with bloodborne pathogens. It is clear that more data is needed to better define which patients, and at what time intervals, can most benefit from emergency resuscitative thoracotomy. Article references available online at EMSWorld.com/12284767. A B O U T T H E A U T H O R S Stephanie Charshafian, MD, is a third-year resident in emergency medicine at Barnes Jewish Hospital in St. Louis. She received her bachelor's degree from the University of Florida and her medical degree from Washington University in St. Louis. Nathan M. Woltman, MD, EMT-T, is an emergency physician and faculty at the Johns Hopkins School of Medicine. He directs the law enforcement and tactical medicine fellowship program at the Johns Hopkins Center for Law Enforcement Medicine and serves as associate medical director for the Johns Hopkins Lifeline critical care transport team. Hawnwan Philip Moy, MD, is an assistant medical director of the St. Louis City Fire Department and emergency medicine clinical instructor and core faculty in the EMS Section of the Division of Emergency Medicine at Washington University in St. Louis.

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