Yaniv Berliner
EMS STABILIZATION
Scene survey
 EMS must first evaluate the safety of the
scene.
 Downed power lines, fire, traffic
 Is there a need for specialized equipment for
extrication.
 Is there a need for air ambulance
 What type of facility is nearby?
 Are all patients accounted for. Is there a
possibility of ejected patients.
What type of crew
 In Ontario, either Primary Care Paramedic
(PCP) or Advanced Care Paramedic (ACP).
 ACP’s have further education and
preceptorship.
 ACP’s have a wider scope of practice. In
trauma they are able to initiate IV bolus,
perform needle decompression and
endotrachael intubation (with base hospital
support)
Primary Survey
 ABCD assessment of both patients
 Does the mother warrant airway protection
due to GCS?
 If there is only one crew on site, who should
be managed first?
 Unless extrication causes delay, limit on
scene time to 10 minutes
Airway
 Airway interventions as per ATLS
 O2 applied
 Jaw thrust
 BMV
 More advanced airway interventions are
usually reserved for receiving hospital (if it is
nearby)
Intubate GCS<8 in field?
(Prehospital Emergency Care, 2011 15 184)
 Trauma Registry
 1,555 patients. Chart review.
 Intubation attempted in 758 patients
 57% mortality, intubation group.
 34% mortality, non intubation group
 Patients in the intubation group were more
critically injured.
 Lower GCS (4.3 vs 5.3)
 More SBP<90 (28 % vs 17%)
 Probably represents a selection bias whereby
when a decision to intubate is undertaken the
patient is sicker
Site
Intubation %
Overall mortality
Morality in Those
Intubated
TOR
18
46
68
MLW
30
50
81
DAL
37
62
79
IWA
41
39
57
OTT
45
50
74
ARC
45
38
62
PTL
50
31
48
PGH
54
47
50
VAN
68
58
63
SKC
75
35
39
Breathing
 Oxygen and ventilatory support are provided
 Needle decompression for tension
pneumothorax. This is done in conjunction
with base hospital. Indications are:
 Severe shortness of breath
 SBP less than 90
 Absent breath sounds
 Occlusive dressing is placed over an open
pneumothorax
Circulation
 Paramedics assess circulation. If systolic
pressure is <100, 20cc/kg IV NS is
administered.
 Lacerations are bandaged
 Unstable Pelvis injuries are tied
 MSK injuries are splinted
Disability
 Extrication with full c-spine precautions
 Collar is placed first, then pt is placed on
board
 Board is padded over pressure points
 Pt is then placed on a long board
 C-spine injury is presumed in any patient
involved in MVC, fall from height, dangerous
mechanism, neck pain, neurological
symptoms or decreased level of
consciousness.
Clearing C-spine in the
Field
 Canadian C-spine rule interpreted by
paramedics
 Clinical decision rule is applied, but the
patient remains immobilized
 Pt is brought to ER for assessment.
 The reliability of rule application is
determined and compared to investigators
(ER docs)
C-spine rules
Clearing in the Field
 1949 patients evaluated
 12 c-spine injuries
 Paramedics 100% sensitive in identifying
patients with potential injury
 Paramedic specificity 43%, versus 38% for
investigators (some overcalling by EMS)
Clearing C-spine
 If paramedics were allowed to use rule 62% of
patients would require immobilization in the
field, compared to actual rate of 100%.
 This in turn saves ER space, xrays, less time
on board.
Pain management
 Advanced care paramedics may administer
analgesia for isolated extremity fractures
 Morphine or Fentanyl
 For multi-system trauma base hospital is
contacted for analgesia orders
Load and Go Patients
 What it sounds like.
 In trauma in the setting of severe multi-system
injury (severe chest injuries, head injury with
lateralizing signs, severe abdominal pain post
trauma, unstable pelvis, bilateral femur
fractures)
 Primary assessment performed. Oxygen applied.
Pt is placed on long board with c-spine
immobilization and additional
history/assessment is obtained en route
 Dispatch is made aware
Back to Case: Mother
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Scene Survey, limit scene time to 10 min
Primary Survey
Full immobilization
02 applied, ventilation assisted
IV initiated, 20cc/kg NS given
Splint for femur fracture
Transport initiated
Benzodiazepines as needed for seizure from
presumed head injury
 Secondary survey en route
Daughter
 Scene Survey
 Primary Survey
 Collar placed
 Three person extrication with full c-spine
precaution
 Full board
 IV initiated
 Base hospital contacted for analgesia
OPALS
 A before-after controlled clinical trial to
assess the benefit of prehospital advanced
life support program.
 1373 BLS patients: 1494 ALS patients
 No substantial difference in overall survival to
hospital discharge (81.8% survival BLS,
81.1% survival ALS)
OPALS
 598 patients with GCS<9
 Lower survival ALS (50 % survival ) then BLS
(60%). Value was significant (p<0.03)
 Authors speculate this may be due to delay in
transfer to hospital
Acknowlegements
 Base Hospital Program.
 David Vusich
 Severo Rodrigues