Professional Documents
Culture Documents
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INTRODUCTION
Trauma is the leading cause of death in people younger than
45 years of age and fourth leading cause of death for all
ages. Approximately 5 million people died worldwide as a
result of injury in 1990 and this is expected to rise to 8.4
million by 2020. Though blunt trauma due to road traffic
accidents is the leading cause of death in Europe, penetrating
injuries such as gunshot and stab injuries have become the
main cause of death in some states of USA.
Two people will be killed, 350 will have a disabling injury
and approximately 78,00,0000 dollars will be spent on the
unintentionally injured patients in the USA in the time taken
for one to finish reading this chapter. Approximately 60
million injuries occur annually in the USA. Trauma related
dollar costs exceed 400 billion dollars annually.
One-third of prehospital deaths may be preventable by
providing appropriate prehospital trauma care. But the
quality of care provided is highly variable and there is often
a controversy about what is optimum care. The average
prehospital time taken by the paramedics in UK is 45 to 50
minutes. The so called Golden Hour after injury is a
prehospital event and the prehospital trauma care should
be considered as the start of a continuum of care. The Golden
Hour is an unproven concept but is a good yardstick by
which resuscitative measures can be assessed.
The main aim of prehospital trauma care is to promote
functioning of vital organs and preservation of blood clot,
while transporting the injured patient quickly to the nearest
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The prehospital care for trauma patients in the industrialized countries is provided by the Emergency Medical
Systems (EMSs). These systems are predominantly
paramedic based in UK and USA (the Anglo-American
system), whereas in continental Europe and Scandinavia,
physicians become an important member of the prehospital
trauma care team (Franco-German system).1,2
The method of providing prehospital care took a more
organized form after the introduction of the Advanced
Trauma and Life Support Course, the first of which was
held in 1978. The stimulus to set-up this type of organized
system was the tragedy that befell an Orthopedic Surgeon
while piloting his own plane in February 1976. The surgeon
crashed in a rural Nebraska cornfield sustaining serious
injuries himself. In addition, three of his children suffered
critical injuries, his wife died instantly and one child suffered
minor injuries. The surgeon in spite of his injuries is reported
to have provided and given the instructions for the initial
resuscitation of his family in the cornfield.
The surgeon commented that, When I can provide
better care in the field with limited resources than what my
children and I received at the primary care facility, there is
something wrong with the system and the system has to be
changed.
In the aftermath of this tragedy, a group of surgeons and
physicians in Nebraska, the Lincoln Medical Education
Foundation, Lincoln Area Mobile Heart Team Nurses along
Extensive experience
Better adapted to prehospital care
Optimum care with limited resources
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Pain Management
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CONCLUSION
Prehospital trauma care is continuously evolving specialty.
There are no universally accepted guidelines to deliver this
care. The main aim is to promote oxygenation and
preservation of blood clot with rapid transport of the patient
to a hospital with appropriate facilities to provide definitive
care. Management of obstructed airway takes top priority
as it is the major cause of preventable death in trauma. Fluid
replacement in prehospital care continues to be a source of
controversy and should be used with great caution in patients
with head injury and penetrating injuries. Supplemental
oxygen should be given to all trauma patients and hypoxia
should be avoided by administering 100% oxygen. Spinal
immobilization is widely practiced and secondary spinal cord
injury should be avoided. Pain relief is often neglected and
undertreated and appropriate pain relief should be
administered to all trauma patients.
Overall in addition to the qualitative aspects of prehospital care coordination with the intrahospital element
of the care is essential.
Funding of trauma care is another complex issue with
the trend in recent years shifting this responsibility to
insurance companies rather than being state funded.
REFERENCES
1. David Hoyt-Editorial. Prehospital care: do no harm? Ann
Surg 2003;237(2):161-2.
2. Erika Frischknecht Christensen, Claus Christian Schovsbo
Hoyer. Pretracheal intubation in severely injured patients:
A Danish observational study. BMJ 2003;327:533-4.
3. Frederic Adnet, Frederic Lapostolle, Agnes Richard-Hibon,
Pierre Carli, Patrick Goldstein. Intubating trauma patients
before reaching hospitalRevisited. Critical Care 2001;
5(6):290-1.
4. Kwann I, Bunn F, Roberts I. Timing and volume of fluid
administration for patients with bleeding following trauma.
In the Cochrane Library, issue 2. Oxford; Update Software
2002.
5. Lockey D, Davies G, Coates T. Survival of trauma patients
who have prehospital tracheal intubation without anaesthesia
and muscle relaxants: Observational study. BMJ 2001;
323:141.
6. Moische Liberman, David Mulder, Andre Lavoie, Ronald
Denis, John S Sampalis. Multicenter Canadian study of
prehospital trauma care. Ann Surg 2003; 237(2):153-60.
7. Paul E Pepe, Vincent N Mosesso Jr, Jay L Falk. Prehospital
fluid resuscitation of the patient with major trauma.
Prehospital Emergency Care 2002;6(1):81-91.
8. Ravell M, Porter K, Greaves I. Fluid resuscitation in
prehospital trauma care: A consensus view. Emerg Med J
2002;19:494-8.
9. Wolfgang F Dick. Anglo-American vs. Franco-German
Emergency medical services system. Prehospital and Disaster
Medicine 2003;18(1):29-37.
10. Wolfgang Ummenhofer, Daniel Scheidegger. Role of the
physician in prehospital management of trauma: European
perspective. Current Opinion in Critical Care 2002;8:55965.