ramsey handout als vs bls and hems mcep 2021.ppt
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07/21/2021
The Right Care Via the Right Way Shaun C. Ramsey, DO, FACEP, EMT 1
The Right Care Via the Right WayALS, BLS, and Helicopter EMS in Rural Trauma
Shaun C. Ramsey, DO, FACEP, EMT
Trauma Medical Director, Munson Cadillac & Grayling
Medical Director, North Central MCA
Medical Director, Mobile Medical Response
MCEP SUMMER ASSEMBLY – JULY 21, 2021
No Financial Disclosures
07/21/2021
The Right Care Via the Right Way Shaun C. Ramsey, DO, FACEP, EMT 2
Objectives
Discuss differences in outcomes of trauma patients treated with advanced life support (ALS) or basic life support (BLS) in the prehospital setting.
Identify when helicopter EMS transport is indicated in rural trauma.
Examine EMS protocols
that activate helicopter EMS
early in the rural trauma setting
Rural Trauma
07/21/2021
The Right Care Via the Right Way Shaun C. Ramsey, DO, FACEP, EMT 3
Rural Trauma
Mortality higher in rural setting Newgard et al. JAMA Surgery 2017
– 7 counties in Washington & Oregon– 53,000 patients– 29.4% of rural patients transported directly to
major trauma center• 88.7% urban patients
– Most high risk trauma patients were cared for outside of trauma centers
– Rural mortality highest within 24 hours
Rural Trauma
Jarman et al. JAMA Surgery, 2018– Maryland
– Geocoded incident location in relation to trauma center
– Odds of death highest for:• Patients in communities with higher median age or
lower income
• Locations farthest from level 1 or 2 trauma centers
– Odds of death increased 8% for every 5 miles from trauma center
07/21/2021
The Right Care Via the Right Way Shaun C. Ramsey, DO, FACEP, EMT 4
Rural Trauma
Mortality higher in rural areas– Farther from definitive care
– Must give the best possible care to these pts
– ALS or BLS?
ALS vs. BLS
Liberman Journal of Trauma 2000– Metanalysis – 174 articles
– No benefit to ALS
Many of these urban settings
“Scoop & Run”
07/21/2021
The Right Care Via the Right Way Shaun C. Ramsey, DO, FACEP, EMT 5
ALS vs. BLS
Isenberg, Prehosp Disaster Med, 2005– Comprehensive review
– No benefit to ALS over BLS in URBAN
– Higher mortality in ALS
ALS vs. BLS
OPALS Major Trauma Study– Ontario Prehospital Advanced Life Support
– Canadian Medical Association Journal 2008
– Before-after controlled trial, 2867 pts
– City populations 20,000 to 750,000; 1992-2002
– No difference in morbidity/mortality ALS vs. BLS
– Worse outcomes for pts GCS<9 who received ALS
07/21/2021
The Right Care Via the Right Way Shaun C. Ramsey, DO, FACEP, EMT 6
ALS vs. BLS
Ryynanen, Scand Journ Trauma, Resus, and EM, 2010
– Systematic Review, 46 articles
– Myocardial infarction favors ALS
– Penetrating trauma favors BLS
Multiple injuries and severe brain injuries performed by physician and HEMS favors ALS
ALS vs. BLS
Bakalos, Resuscitation 2011– Meta-analysis of both trauma and cardiac arrest
– No benefit to ALS in trauma
– Only a few good controlled studies
07/21/2021
The Right Care Via the Right Way Shaun C. Ramsey, DO, FACEP, EMT 7
ALS vs. BLS
Seamon, Injury, 2013– Penetrating injuries in urban setting
• Temple University, Philadelphia
– ALS longer on scene times• More interventions
– Total pre-hospital time was same
– Increased mortality in ALS group• ALS survival: 69.5%
• BLS survival: 88.4%
ALS vs. BLS Summary
Penetrating trauma in urban setting– ALS has worse outcomes than BLS
Penetrating trauma needs operating room
Generalize urban data to rural penetrating trauma– Farther from trauma center/operating room
07/21/2021
The Right Care Via the Right Way Shaun C. Ramsey, DO, FACEP, EMT 8
ALS vs. BLS Summary
No difference between ALS & BLS in blunt trauma– GCS<9 has worse outcomes in ALS
– Need more rural studies
Any benefits to ALS?
Even if ALS trained, don’t forget your BLS!
Why do we utilize helicopters?– Ryynanen: Multiple injuries, severe brain
injuries
Helicopter EMS
Brown, Journal Trauma Acute Care Surgery, 2017– External validation of Air Medical Prehospital Triage score
– 222,827 pts in Pennsylvania 2000-13
– HEMS transport was associated with a 6.7% increase in the relative probability of survival
07/21/2021
The Right Care Via the Right Way Shaun C. Ramsey, DO, FACEP, EMT 9
Helicopter EMS
Helicopter EMS
Chen, Journal Trauma Acute Care Surgery, 2018– Pennsylvania State Trauma Registry
– HEMS 13 mins longer prehospital time than ground
– Patients benefit from HEMS transport • Abnormal respiratory rate, GCS 8 or less, hemo/pneumothorax
– Specific patients benefit primarily from HEMS care • Advanced airway and chest trauma management, blood
Speed is not everything!
07/21/2021
The Right Care Via the Right Way Shaun C. Ramsey, DO, FACEP, EMT 10
Helicopter EMS
Michaels, Trauma Surgery and Acute Care Open, 2019– Retrospective review of National Trauma Data Bank in 2014
– 469,407 pts to a trauma center• Large rural population
– Mortality 6.0% in HEMS vs 2.9% ground• When adjusted for age, ISS, gender; pts transferred by HEMS 57%
less likely to die
Helicopter EMS
Subset of patients benefit from HEMS– Multiple injuries
– Head injuries/low GCS
– Needing intervention: intubation, chest tubes, blood
– HEMS expertise comes into play
Go to closest ED?
07/21/2021
The Right Care Via the Right Way Shaun C. Ramsey, DO, FACEP, EMT 11
Helicopter EMS
Auto Launch– Region 7/North Flight Aero Med
– Launch helicopter based on dispatch info
– >30 min ground transport time to trauma center
Helicopter EMS
Auto Launch Criteria– Area inaccessible by ground– Multiple trauma victims (MCI)– Major MVA, rollover, ejection or entrapment,
death in same vehicle– Pedestrian struck with serious injury– Major burns– Drowning– Penetrating trauma– Falls > 20 ft with serious injury (>10 ft peds)
07/21/2021
The Right Care Via the Right Way Shaun C. Ramsey, DO, FACEP, EMT 12
Helicopter EMS
Launches HEMS team early
Can rendezvous at helipad
Can assist in emergency department
Summary
Penetrating trauma– BLS has better outcomes than ALS
Blunt trauma– Majority of patients: no benefit to ALS
– Critically injured patients: benefit from HEMS
– Need more rural studies!
Helicopter EMS– Vital to rural trauma
– Consider Auto Launch protocol
07/21/2021
The Right Care Via the Right Way Shaun C. Ramsey, DO, FACEP, EMT 13
Questions?
sramsey@mhc.net
References
Newgard et al. Evaluation of Rural vs Urban Trauma Patients Served by 9-1-1 Emergency Medical Services, JAMA Surg. 2017;152(1):11-18.
Jarman et al. Associations of Distance to Trauma Care, Community Income, and Neighborhood Median Age With Rates of Injury Mortality, JAMA Surg. 2018;153(6):535-543.
Harmson et al. The influence of prehospital time on trauma patients outcome: A systematic review, Injury, Int. J. Care Injured 46 (2015) 602–609.
Liberman et al. Advanced or Basic Life Support for Trauma: Meta-analysis and Critical Review of the Literature, J Trauma. 2000;49:584–599.
Eisen et al. Advanced Life Support vs Basic Life Support Field Care: An Outcome Study, ACADEMIC EMERGENCY MEDICINE 1998; 5:592-598.
Liberman et al. Multicenter Canadian Study of Prehospital Trauma Care, ANNALS OF SURGERY 2003; 237(2): 153–160.
Isenberg D & Bissell R. Does Advanced Life Support Provide Benefits to Patients?: A Literature Review, Prehosp Disast Med 2005;20(4):265-270.
Stiell et al. The OPALS Major Trauma Study: impact of advanced life support on survival and morbidity, CMAJ 2008;178(9):1141-52.
Cobas et al. Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective, Anesth Analg 2009;109:489 –93.
07/21/2021
The Right Care Via the Right Way Shaun C. Ramsey, DO, FACEP, EMT 14
References
Ryynänen et al.: Is advanced life support better than basic life support in prehospital care? A systematic review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2010 18:62.
Bakalos et al. Advanced life support versus basic life support in the pre-hospital setting: A meta-analysis, Resuscitation 82 (2011) 1130– 1137.
Haut et al. Prehospital Intravenous Fluid Administration Is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis, Ann Surg 2011;253:371–378.
Seamon et al. Prehospital interventions for penetrating trauma victims: A prospective comparison between Advanced Life Support and Basic Life Support, Injury, Int. J. Care Injured 44 (2013) 634–638.
Wandling et al. Police transport versus ground EMS: A trauma system-level evaluation of prehospital care policies and their effect on clinical outcomes, J Trauma Acute Care Surg. 2016;81: 931–935.
Brown et al. External validation of the Air Medical Prehospital Triage score for identifying trauma patients likely to benefit from scene helicopter transport, J Trauma Acute Care Surg. 2017;82: 270–279.
Chen et al. Speed is not everything: Identifying patients who may benefit from helicopter transport despite faster ground transport, J Trauma Acute Care Surg. 2018;84: 549–557.
Michaels et al. Helicopter versus ground ambulance: review of national database for outcomes in survival in transferred trauma patients in the USA, Trauma Surg Acute Care Open 2019;4:e000211.
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