regional emergency medicine the american experience paul mc quaid nremt-p
Post on 20-Dec-2015
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Implementation
Regional Emergency Medicine The American experience
Paul Mc Quaid NREMT-P
Implementation
South Shore Hospital Level 3 Trauma Center
• Located on Boston’s South Shore
• 436 bed acute general hospital
• 2nd busiest ER in state of Massachussetts
• 78,000 ER visits per year
• Services a population of 1.2 million
• Approx. 38 trauma cases per month
Implementation
South Shore Hospital Emergency Department
• 72 Beds ED providing services in:– Acute– Semi-acute– Urgent Care– Geriatric ER– Paediatric ER– Emergency Dept. Transitional Care Unit
South Shore HospitalParamedic Services
• Non Transporting ALS
• Services 16 towns
• 400 sq mile coverage area
• 3rd busiest in the state of Massachussetts
• 6,800 ALS calls per year
Implementation
Trauma Centre Designation
• Hospitals receive trauma designation as Level 1 - 4 after thorough application and review process carried out by American College of Surgeons.
• Level 1 Trauma facilities must have in house General Surgery, Neurosurgery, Emergency Services and Anaesthesia 24 hours per day.
• Additional medical and surgical sub specialties available on call and promptly available
• active teaching programmes and trauma research programmes.
Implementation
Trauma Centre Designation
• Level 2: Don’t have same teaching or research requirements
• reduced subspecialties on call
• Level 3: 24 hr ED but in-house surgenry not required at all times.
• Level 4: mostly rural hospitals - stabilisation and transport
Implementation
Trauma Team made up of personnel from:
• Anaesthesiology• Critical care • Internal medicine • Paediatrics • Orthopaedics • Respiratory therapy
• Radiology• Cardiology• Neurology• Obstetrics• ICU services• Chaplaincy
Implementation
Level 1 CriteriaAdult & Paediatric
Physiological
• Adult: Confirmed BP<90 at any time
• Respiratory compromise, obstruction and/or intubation
• Resp rate <10 or > 30 (adult)
• Abnormal resp rate for age
• O2 sats <90%
• CPR in the field
• Transfere from other hospitals who are receiving blood to maintain vital signs
• Hypothermia (<30C or 90F)
• Emergency Physician’s discretion
Implementation
Level 1 CriteriaAdult & Paediatric
Anatomical
• All GSW to neck, Chest or abdomen
• All other penetrating injuries to any body region with large blood loss at scene, exsanguiating haemorrhage or expanding haematoma
• Open or suspected depressed skull fractures
• Pelvic fractures
• Major impalement of any body area
• Burns >15% or involving airyay/face
• Blunt or penetrating injury to:
• Neck:
– Air bubbling from wound
– difficulty with phonation
– saliva in wound
– Signs of cerebral infarction
• Chest:
– massive haemothorax (>1500cc/blood)
– massive open wound
• Abdomen:
– evisceration or large open wound
– rapidly expanding abdomen
Anatomical
• All GSW or penetrating trauma to head,neck, thorax or abdomen.
• Open or suspected depressed skull fracture
• Pelvic Fractures
• Burns >15% or involving face/airway
Anatomical
• All other penetrating injuries to any body region with large blood loss at scene
• Exsanguinating haemorrhage or expanding haematoma
• Multiple long-bone fractures
• Amputations
Anatomical
• Neck:
– Air bubbling from wound
– difficulty with phonation
– saliva in wound
– Signs of cerebral infarction
– Spinal chord injury with neurologic deficit
• Chest:
– Massive haemothorax (>1500cc/blood)
– Massive open injury
– Flail Chest
Anatomical
Anatomical
• Abdomen:– Evisceration or large open
wound
– Rapidly expanding abdomen
– Significant blunt trauma with unstable vital signs
Mechanism
Implementation
Mechanism
• Death at the scene• Ejection from vehicle• Falls > 10 - 15 feet• Destruction of the vehicle • Intrusion into passenger compartment
Implementation
Mechanism
• Motorised vehicle v’s pedestrian @ > 20mph and/or significant impact (windscreen broken, pt. thrown or run over)
• All aeromedical evacuations• Near-drowning with associated trauma
Ground v’s Air Transport
• Air:
• Fast
• Transport to Level 1 facilityAccess to Additional interventions, not available on the ground
• Expensive
• Limited by weather conditions
• Max. 2 patients per flight
Ground v’s Air Transport
• Ground:
• Slow, depending on distance
• Traffic
• Some services reluctant to leave their service area
Case # 1
• 16 yo female
• GSW to head
• GCS 3
• Airway Compromised
• HR 100, BP 166/110, RR 10
POSITIVE
TRAUMA
ALERT
Transport to Closest Appropriate facility
Case # 2
• 21 yo male
• Stab wound to left chest
• Airway patent
• GCS 15
• BS on left
• BP 90/P, HR 130
POSITIVE TRAUMA ALERT
Case # 3• 17 year old male• entrapped for 25 mins• open femur fracture• GCS 6• BP 98/60 -HR 116 - RR 6
POSITIVE TRAUMA ALERT
Transport to Closest Appropriate facility
Pt looses pulse en route to LZ
Implementation
Case # 4
• 8 year old near- drowning in pool
• No signs of trauma• Intubated on scene• Normal brachial
pulse• Responsive to deep
pain.
Near Drowning is NOT considered trauma unless
injury accompanies it!
Implementation
Summary
• EMS providers need to be aware of local hospital’s facilities & capabilities
• All significant trauma must be transported to an appropriate trauma centre
• EMS providers must transport to the closest hospital if there is compromise to: Airway, Breathing or Circulation
• Increased survival rates when trauma patients are transported to Trauma Centres.