ramsey handout als vs bls and hems mcep 2021.ppt

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


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

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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

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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”

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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

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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

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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

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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

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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!

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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?

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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)

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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

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Questions?

[email protected]

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.

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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.

ramsey handout als vs bls and hems mcep 2021.ppt

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