Annals of emergency medicine
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Comparative Study
Ground versus air transport of trauma victims: medical and logistical considerations.
Emergency aeromedical transport for trauma victims varies widely, from 10% or less in some programs to more than 90% in others. There is the potential in all such programs for dramatic, lifesaving efforts as well as for costly and dangerous overuse. We propose the following preliminary guidelines for emergency aeromedical transport of trauma victims. ⋯ Scene flights should be dispatched within medical guidelines established by the regional emergency medical services system. Emergency aeromedical evacuation of trauma victims should assist the regionalization of trauma care to centers with special capabilities for the management of seriously injured patients. Promulgation of more detailed guidelines will depend on the accumulation of clinical experience and will be possible only if consistent efforts are made to obtain measures of injury severity, categories of injury, and long-term outcomes of management.
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Despite the initial successes achieved in early emergency medical services (EMS) systems, many prehospital care services have developed without the intense involvement of physicians whose interest fueled the first experimental medical programs of prehospital care. Among a myriad of variables affecting EMS is the important element of intense, authoritative physician involvement in education, field supervision, and research. Recognizing this problem, many states now have legislated that EMS systems be closely supervised by medical directors. ⋯ It has been the experience of major urban EMS systems that field participation by physicians has lent irrefutable credibility to the authority of medical directors. Beyond the obvious benefits of quality assurance and supervision, the in-field EMS physician provides the impetus and leadership for EMS research conducted at the street level. Because EMS is the practice of medicine through physician surrogates in a prehospital setting, it sets the stage and tone for subsequent patient care and outcome.(ABSTRACT TRUNCATED AT 250 WORDS)
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The controversies that have surrounded the prehospital management of trauma stem not only from a lack of appropriate evaluation data, but also from a lack of medical accountability and "street-wise," academic physician involvement within emergency medical services (EMS) systems. As a result, the approach to EMS trauma care has often been over-generalized and debated in terms of simplistic, unidimensional concepts, such as "scoop and run" versus "field stabilization," without any regard for the type and anatomic location of injury involved, the efficiency and skill of rescuers, the proximity and actual capabilities of definitive care resources, and the logistics of the prehospital setting. The failure to understand and delineate these variables has led to conflicting studies and has confused the analysis of potential therapeutic modalities and management strategies. ⋯ In all three systems, patients generally are categorized according to three major injury types (penetrating, blunt, and thermal) and then further subcategorized with regard to anatomical involvement, specifically those involving potential (or known) internal truncal injuries versus those with isolated head trauma or isolated extremity injury. For all three, high-flow O2 delivery and aggressive, advanced airway management (by endotracheal intubation whenever feasible) are keystones of management. In cases of potential or known internal truncal injury, the priority is also expeditious transport to facilities with definitive surgical care with the establishment of IV access and rapid fluid infusions en route.(ABSTRACT TRUNCATED AT 250 WORDS)
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The transcutaneous oxygen (PtcO2) monitoring technique uses a Clark electrode applied noninvasively to the skin surface. To obtain PtcO2 values that respond rapidly to physiologic changes, the electrode is heated to 44 to 45 C. Since its introduction in 1972, the PtcO2 sensor has become standard for monitoring oxygenation of neonates in respiratory distress. ⋯ Comparison to an arterial blood gas can easily differentiate whether a low PtcO2 value might be due to hypoxia or to low cardiac output. Other noninvasive monitors (conjunctival oxygen, pulse oximeter, transcutaneous CO2, end-tidal CO2) also show promise. In the emergency department, PtcO2 monitoring is useful in assessing the presence and severity of shock and hypoxia and as a physiologic monitor for titrating resuscitation.
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Acute hemorrhage is a major cause of death in both civilian and military trauma. The suboptimal effect of the volume of standard crystalloids that can be infused during transport has resulted in a need for a more efficacious fluid for the prehospital management of both civilian and military trauma. ⋯ The hypertonic sodium chloride/dextran solution has the potential advantages of improving survival, producing a beneficial hemodynamic effect with smaller fluid volumes, reducing total fluid requirements during resuscitation, and being stored easily. This solution may prove valuable in the early resuscitation of the hypovolemic trauma patient and merits further clinical trials.