Hostname: page-component-586b7cd67f-r5fsc Total loading time: 0 Render date: 2024-11-24T01:17:12.612Z Has data issue: false hasContentIssue false
  • English
  • Français

Evolving Challenges in Prehospital Trauma Services: Current Issues and Suggested Evaluation Tools

Published online by Cambridge University Press:  17 February 2017

Paul E. Pepe  and
Ronald F. Maio
Paul E. Pepe*
Affiliation:
Departments of Medicine, Surgery, and Pediatrics, Baylor College of Medicine; City of Houston, Emergency Medical Services, Houston, Tex.; NAEMSP
Ronald F. Maio
Affiliation:
Section of Emergency Medicine, Department of Surgery, University of Michigan, Ann Arbor, Mich.
*
City of Houston, Center for Resuscitation and Emergency Medical Services, 410 Bagby, Suite 300, Houston, TX 77002-1595
Get access Rights & Permissions [Opens in a new window]

Abstract

For the past two decades, prehospital trauma care has been addressed almost generically in terms of the related approaches to epidemiology, research, and management. However, evolving directions in research have helped emergency medical services (EMS) practitioners to delineate more focused treatment strategies according to the mechanism of injury, anatomic involvement, and the patient's clinical condition. Recent studies in the areas of trauma-associated circulatory arrest, severe blunt head injury, and post-traumatic hemorrhage following penetrating truncal injury suggest that current standard approaches to patient care should be reconsidered. In turn, this need for re-examination of trauma management strategies calls for the development of appropriate evaluation tools within EMS systems. Proper research design is dependent upon several key issues including: 1) the type of study (system study versus examination of a specific intervention); 2), the population under study; 3) physiological and anatomical scoring method; 4) prospective definitions of interventions and meaningful outcome variables (both morbidity and mortality; 5) relative outcome compared to known standards; and 6) prospective determination of statistical requirements.

Keywords

Emergency Medical ServicesEMSTraumaTrauma ServicesResearchEMS ResearchClinical TrialsTrauma ClassificationsTrauma CareHead InjuryShockSkeletal ImmobilizationEvaluation TestsStudy DesignStudy ElementsPopulationsSeverity ScoresData SourcesInterventionsRandomizationMissing DataClinical SignificanceStatistical SignificanceFeasibility
Type
Research Article
Information
Prehospital and Disaster Medicine , Volume 8 , supplement S1: Research in Prehospital Care Systems , March 1993 , pp. S25 - S34
Copyright
Copyright © World Association for Disaster and Emergency Medicine 1993

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Pepe, PE, Bonnin, MJ, Mattox, KL: Regulating the scope of EMS. Prehospital and Disaster Medicine 1990;5:59.CrossRefGoogle Scholar
2. American College of Surgeons' Committee on Trauma: Advanced Trauma Life Support Course, Instructor Manual. Chicago, American College of Surgeons, 1989.Google Scholar
3. Campbell, JE: Basic Trauma Life Support, 2d ed. American College of Emergency Physicians, Alabama Chapter 1988;205:567–2000.Google Scholar
4. Border, JR, Lewis, FR, Aprahamian, C, et al: Prehospital trauma care—stabilization or scoop and run. J Trauma 1983;23:708.CrossRefGoogle ScholarPubMed
5. Smith, JP, Bodai, BI, Hill, AS, et al: Prehospital stabilization of critically injured patients: A failed concept. J Trauma 1985;25:65.Google Scholar
6. Pepe, PE, Copass, MK: Prehospital care. In: Moore, EE (ed): Early Care of the Injured Patient. 4th ed. Toronto, BC Decker, 1990, p. 34.Google Scholar
7. Pepe, PE, Bass, RR, Mattox, KL: Clinical trials of the pneumatic antishock garment in the urban prehospital setting. Ann Emerg Med 1986;15:1407.CrossRefGoogle ScholarPubMed
8. Bickell, WH, Pepe, PE, Bailey, ML, et al: Randomized trial of pneumatic antishock garments in the prehospital management of penetrating abdominal injuries. Ann Emerg Med 1987;16:653.Google Scholar
9. Mattox, KL, Bickell, WH, Pepe, PE, et al: Prospective MAST study in 911 patients. J Trauma 1989;29:1104.Google Scholar
10. Maningas, PA, Mattox, KL, Pepe, PE, et al: Hypertonic salinc-dextran solutions for the prehospital management of traumatic hypotension. Am J Surg 1989;157:528.CrossRefGoogle ScholarPubMed
11. Mattox, KL, Maningas, PA, Moore, EE, et al: Prehospital hypertonic saline/dextran infusion for post-traumatic hypotension—The U.S.A. multi-center trial. Ann Snrg 1991;213:482.Google Scholar
12. Martin, RR, Bickell, WH, Mattox, KL, et al: Prospective evaluation of preoperative volume resuscitation in hypotensive patients with penetrating truncal injuries—Preliminary report. J Trauma 33:354–361.CrossRefGoogle Scholar
13. Copass, MK, Oreskovich, MR, Bladergroen, MR, et al: Prehospital cardiopulmonary resuscitation of the critically injured patient. Am J Surg 1984;148:20.CrossRefGoogle ScholarPubMed
14. Durham, LA, Richardson, RJ, Wall, MJ, et al: Emergency center thoracotomy: Impaci of prehospital resuscitation. J Trauma 32:775–779.Google Scholar
15. Gervin, AS, Fisher, RP: The importance of prompt transport in salvage of patients with penetrating heart wounds. J Trauma 1982;22:443–446.CrossRefGoogle ScholarPubMed
16. Marnar, TJ, Oreskovich, MR, Copass, MK, et al: Role of emergency thoracotomy in the resuscitation of moribund trauma victims. Amer J Surg 1981;142:96.Google Scholar
17. Cogbill, TH, Moore, EE, Millikan, JS, et al: Rationale for selective application of emergency department thoracotomy in trauma. J Trauma 1983;23:453.CrossRefGoogle ScholarPubMed
18. Rohman, M, Ivatury, RR, Steichen, FM, et al: Emergency room thoracotomy for penetrating cardiac injuries. J Trauma 1983;23:570.Google Scholar
19. Ivatury, RR, Shalt, PM, Ito, K, et al: Emergency room thoracotomy for the resuscitation of patients with “fatal’ penetrating injuries of the heart. Ann Thame Surg 1981;32:377.CrossRefGoogle ScholarPubMed
20. Mattox, KL, Beall, AC, Jordan, GL, et al: Cardiorrhaphy in the emergency center. J Thorac Cardiovasc Surg 1974;68:886.CrossRefGoogle ScholarPubMed
21. Pepe, PE, Wyatt, CH, Bickell, WH, et al: Use of MAST in penetrating cardiac injuries. Chest 1986;89(suppl):452 (abstract).Google Scholar
22. Wall, MJ, Pepe, PE, Mattox, KL. Successful roadside thoracotomy. J Trauma 1993 (in press).Google Scholar
23. Miller, JD, Butterworth, JF, Gudeman, SK, et al: Further experience in the management of severe head injury. J Neurosurg 1981;54:289.CrossRefGoogle ScholarPubMed
24. Bowers, SA, Marshall, LP: Outcome in 200 consecutive cases of severe head injury treated in San Diego county: A prospective analysis. Neurosurgery 1980:6:237.Google Scholar
25. Stone, JL, Lowe, RJ, Jonasson, O, et al: Acute subdural hematoma: Direct admission to a trauma center yields improved results. J Trauma 1986;26:445.CrossRefGoogle ScholarPubMed
26. Pepe, PE, Copass, MK, Joyce, TH: Prehospital endotracheal intubation—Rationale for training emergency medical personnel. Ann Emerg Med 1985;14:1085.CrossRefGoogle ScholarPubMed
27. Gildenberg, PL, Makela, M: The effect of early intubation and ventilation on outcome following head trauma. In: Dacey, RG, Winn, HR, Rimmell, RW, et al (eds): Trauma of the Central Nervous System. New York: Raven Press, 1985, p 79.Google Scholar
28. Jones, PW: Hyperventilation in the management of cerebral oedema. Intensive Crit Care Dig 1982;1:17.Google Scholar
29. McGillicuddy, JE: Cerebral protection: Pathophysiology and treatment of increased intracranial pressure. Chest 1985;87:85.CrossRefGoogle ScholarPubMed
30. Thompson, JD, Fish, S, Ruiz, E: Succinykholine for endotracheal intubation. Ann Emerg Med 1982;11:526–529.Google Scholar
31. Bickell, WH, Shaftan, GW, Mattox, KL: Intravenous fluid administration and uncontrolled hemorrhage. J Trauma 1989;29:409.CrossRefGoogle ScholarPubMed
32. Bickell, WH, Bruttig, SP, Millnamoro, GA, et al: The detrimental affects of intravenous crystalloid after aortotomy in swine. Surgery 1991;110:529.Google Scholar
33. Bickell, WH, Bruttig, SP, Millnamow, GA, O'Benar, J, Wade, CE: Use of hypertonic saline/dextran versus lactated Ringer's solution as a resuscitation fluid alter uncontrolled aortic hemorrhage in anesthetized swine. Ann Emerg Med 1992;21:1077–1085.CrossRefGoogle Scholar
34. Honigman, B, Lowenstein, SR, Moore, EE, et al: The role of the pneumatic antishock garment in penetrating cardiac wounds. JAMA 1991;266:2398–2401.Google Scholar
35. Berendt, BM, van Niewerburgh, P: Survival not improved by MAST use in ITEC trauma registry. The ITEC Newsletter. Valhalla, NY, Institute for Trauma and Emergency Care, New York Medical College, fall/winter 1991;16:6.Google Scholar
36. Cook, TD, Campbell, DT: Quasi-Expertmentation: Design and Analysis Issues for Eield Settings. Boston: Houghton Mifflin Company, 1979.Google Scholar
37. Freidman, LM, Furberg, CD, DeMcts, DL: Fundamentals of Clinical Trials, 2d ed. Littleton, Mass: PSG Publishing Company, Inc., 1985.Google Scholar
38. Kleinbaum, DO, Kuper, LL, Morgenstern, H: Epidemiological Research: Principles and Quantitative Methods. New York: Van Nostrand Reinhold Company, 1982.Google Scholar
39. Potter, D, Goldstein, G, Fung, SC, et al: A controlled trial of prehospital Advanced Life Support in trauma. Ann Emerg Med 1988;17:582–588.Google Scholar
40. Apprahamian, C, Thompson, BM, Towne, JB, Darin, JC: The effect of a paramedic system on mortality of major intra-abdominal vascular trauma. J Trauma 1983;23:687–691.Google Scholar
41. Hedges, JR, Sacco, WJ, Champion, HR: An analysis of prehospital care of blunt trauma. J Trauma 1982;22:989–993.CrossRefGoogle ScholarPubMed
42. Honigman, B, Rohweder, K, Moore, EE, et al: Prehospital advanced life support for penetrating cardiac wounds. Ann Emerg Med 1990;19:145–151.CrossRefGoogle ScholarPubMed
43. Pons, PT, Honigman, B, Moore, EE, et al: Prehospital advanced life support for critical penetrating wounds to the thorax and abdomen. J Trauma 1985;25:828–832.CrossRefGoogle Scholar
44. Jones, SE, Nesper, TP, Alcouloumre, E: Prehsopital line placement: A prospective study. Ann Emerg Med 1989;18:244–247.Google Scholar
45. Johannigman, JA, Branson, RD, Davis, K Jr., Hurst, JM: Techniques of emergency ventilation: A model to evaluate tidal volume, airway pressure, and gastric insufflation. J Trauma 1991;31:93–98.CrossRefGoogle Scholar
46. Wears, RL, Winton, CN: Load and go versus stay and play: Analysis of prehospital IV fluid therapy by computer simulation. Ann Emerg Med 1990;19:163–168.CrossRefGoogle ScholarPubMed
47. Maio, RF, Burney, RE, Lazzara, S, et al: Correlation between motor vehicle mortality rate and density of medical resources. Prehospital and Disaster Medicine 1990;5:335–339.CrossRefGoogle Scholar
48. The impact of emergency medical services on the morbidity and mortality of trauma patients. Prepared for The Pennsylvania Trauma Systems Foundation, Pittsburgh, Pennsylvania: The Pittsburgh Research Institute Center for Health Services Research, 12 13, 1989.Google Scholar
49. Mattox, KL, Bickell, WH, Pepe, PE, et al: Prospective randomized evaluation of anti-shock MAST in post-traumatic hypotension. J Trauma 1986;26:779–786.Google Scholar
50. Pepe, PE, Mattox, KL, Fischer, RP, et al: Geographic patterns of urban trauma according to mechanism and severity of injury. J Trauma 1990;30:1125.Google Scholar
51. Jones, SE, Brenneis, AT: Study design in prehospital trauma advanced life support—basic life support research. Ann Emerg Med 1991;20:857–860.CrossRefGoogle ScholarPubMed
52. Pepe, PE, Wyatt, CH, Bickell, WH, et al: The relationship between total prehospital time and outcome in hypotensive patients with penetrating trauma. Ann Emerg Med 1987;16:293.Google Scholar
53. American College of Surgeons Committee on Trauma: Hospital and Prehospital Resources for Optimal Care of the Injured Patient and appendices A-J. Chicago: American College of Surgeons, 1987.Google Scholar
54. Burney, RE, Passini, L, Hubert, D, Maio, RF: Comparison of aeromedical crew performance by patient severity and outcome. Ann Emerg Med 1992;21:375–378.CrossRefGoogle ScholarPubMed
55. Baxt, WG, Moody, P: The impact of a physician as part of the aeromedical prehospital team in patients with blunt trauma. JAMA 1987;257:3246–3250.CrossRefGoogle ScholarPubMed
56. Taillac, PP, Pepe, PE, Zachariah, BS and Curka, PA: The epidemiology, type and severity of pediatric gunshot wounds in a large urban center. Ann Emerg Med 1992;21:1045.Google Scholar
57. Morris, JA, MacKenzie, EJ, Damiano, AM, Bass, SM: Mortality in trauma patients: the interaction between host factors and severity. J Trauma 1990;30:1476–1482.CrossRefGoogle Scholar
58. McClain, PW, Pollock, DA: A microcomputer program for coiling cause of injury. J Trauma 1989;29:55–58.Google Scholar
59. Snizek, JE, Finklea, JF, Graitcer, PL: Injury coding and hospital discharge data. JAMA 1989;262:2270–2272.Google Scholar
60. Champion, HR, Sacco, WJ: Trauma severity scales. In Maull, KI, Cleveland, HC, Strauch, GO, et al (eds): Advances in Trauma. Chicago: Year Book Medical Publishers, 1986, Vol. 1, p. 1–19.Google Scholar
61. Boyd, CR, Tolson, MA, Copes, WS: Evaluating trauma care: The TRISS method. J Trauma 1987;27:370–378.Google Scholar
62. Champion, HR, Sacco, WJ, Lepper, RL, et al: An anatomic index of injury severity. J Trauma 1980B;20:197–202.CrossRefGoogle ScholarPubMed
63. The Abbreviated Injury Scale. 1990 revision, Association for the Advancement of Automotive Medicine, Park Ridge, Illinois.Google Scholar
64. Baker, SP, O'Neill, B, Haddon, W, et al: The injury severity score: A method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187–196.CrossRefGoogle ScholarPubMed
65. Baker, SP, O'Neill, B: The injury severity score: An update. J Trauma 1976;16:882–885.CrossRefGoogle ScholarPubMed
66. TRI-CODE: Injury coding software, Tri-Analytics, Inc., Bel Air, Md.Google Scholar
67. MacKenzie, EJ, Steinwachs, DM, Shankar, BS: Classifying severity of trauma based on hospital discharge diagnoses: Validation of an ICD-9 CM to AIS-85 conversion table. Medical Care 1989;27:412–422.Google Scholar
68. Copes, WS, Champion, HR, Sacco, WJ, et al: Progress in characterizing anatomic injury. J Trauma 1990;30:1200–1207.Google Scholar
69. Baxt, WG, Upenieks, V: The lack of full correlation between the injury severity score and the resource needs of injured patients. Ann Emerg Med 1990;19:1396–1400.CrossRefGoogle ScholarPubMed
70. Tepas, JJ, Grooms, , Mollitt, DL, et al: Inter-rater reliability of the injury severity score and abreviated injury scale. Proceedings of the 33rd Annual Meeting of the Association for the Advancement of Automotive Medicine. 1989; pp 183–190.Google Scholar
71. Champion, HR, Sacco, WJ, Carnazzo, AJ, et al: Trauma score. Crit Care Med 1981;9:672–676.Google Scholar
72. Champion, HR, Sacco, WJ, Copes, WS, et al: A revision of the Trauma Score. J Trauma 1989;29:623–629.Google Scholar
73. Champion, HR, Sacco, WJ, Hannan, DS, et al: Assessment of injury severity: the Triage Index. Crit Care Med 1980a;8:201–208.Google Scholar
74. Ramenofsky, ML, Ramenofsky, MB, Jurkovich, GJ, et al: The predictive validity of the Pediatric Trauma Score. J Trauma 1988;28:1038–1042.Google Scholar
75. Tepas, JJ, Ramenofsky, ML, Mollitt, DL, et al: The Pediatric Trauma Score as a predictor of injury severity: An objective assessment. J Trauma 1988;28:425–429.CrossRefGoogle ScholarPubMed
76. Tepas, JJ, Mollitt, DL, Talbert, JL, et al: The Pediatric Trauma Score as a predictor of injury severity in the injured child. J Ped Surg 1987;22:14–18.Google Scholar
77. Nayduch, DA, Moylan, J, Rutledge, R, et al: Comparison of the ability of adult and pediatric trauma scores to predict pediatric outcome following major trauma. J Trauma 1991;31:452–458.CrossRefGoogle ScholarPubMed
78. Eichelberger, MR, Gotschall, CS, Sacco, WJ, et al: A comparison of the Trauma Score, the Revised Trauma Score and the Pediatric Trauma Score. Ann Emerg Med 1989;18:1053–1058.Google Scholar
79. Gormican, SP: CRAMS Scale: Field triage of trauma victims. Ann Emerg Med 1982;11:132–136.Google Scholar
80. Koehler, JJ, Baer, LJ, Malafa, SA, et al: Prehospital index: A scoring system for field traigc of trauma victims. Ann Emerg Med 1986;15:178–182.CrossRefGoogle ScholarPubMed
81. McAnena, OJ, Moore, FA, Moore, EE, Mattox, KL, Marx, JA, Pepe, P: Invalidation of the APACHE II scoring system for patients with acute trauma. J Trauma 1992;33:504–507.CrossRefGoogle ScholarPubMed
82. Report from the 1988 Trauma Registry Workshop, including recommendations for hospital-based trauma registries. J Trauma 1989;29:827–834.CrossRefGoogle Scholar
83. Waller, JA: Methodological issues in hospital-based injury research. J Trauma 1988;28:1632–1636.Google Scholar
84. Cales, RH: Trauma Registries. Trauma Quarterly 1989;5:1–8.Google Scholar
85. Sacco, WJ, Jameson, JW, Copes, WS, et al: Partition: A quantitative method for evaluating prehospital services for trauma patients. Comp Biol Med 1988;221–227.Google Scholar
86. Moreau, M, Garner, PS, Champion, HR, et al: Application of the trauma score in the prehospital setting. Ann EJmerg Med 1985;14:1049–1054.Google Scholar
87. Keene, RA, Cullen, DJ: Therapeutic Intervention Scoring System: Update 1983. Crit Care Med 1983;11:1–3.Google Scholar
88. Gales, RH: Trauma mortality in Orange County: The effect of a regional trauma system. Ann Emerg Med 1984; 13:1–10.Google Scholar
89. Kreis, DJ, Plasencia, G, Augenstein, D, et al: Preventable trauma deaths: Dade County, Florida. J Trauma 1990;30:1524–1532.Google Scholar
90. Moylan, JA, Detmer, DE, Rose, J, et al: Evaluation of the quality of hospital care for major trauma. J Trauma 1976;16:517–523.Google ScholarPubMed
91. West, JG, Trunkey, DD, Lim, RC: Systems of trauma care: A study of two counties. Arch Surg 1979;114:455–460.Google Scholar
92. West, JG, Williams, MJ, Trunkey, DD: Trauma systems: Current status-future challenges, JAMA 1988;259:3597–3600.CrossRefGoogle ScholarPubMed
93. Trunkey, DD: Bay area trauma care. San Francisco Med 1982;55:22–25.Google Scholar
94. Salmi, LR, Williams, JI, Guibert, R, et al: Preventable deaths and the evaluation of trauma programs: Flawed concepts and methods. Proceedings of the 30th Annual Meeting of the American Association for Automotive Medicine 1986; 179–195.Google Scholar
95. Wesson, DE, Williams, JI, Salmi, LR, et al: Evaluating a pediatric trauma program: Effectiveness versus preventable death rate. J Trauma 1988;28:1226–1231.CrossRefGoogle ScholarPubMed
96. Wilson, DS, McElligot, J, Fielding, LP: Identification of preventable deaths: Confounded inquiries? J Trauma 1992;32:45–49.Google Scholar
97. Dykes, EH, Spence, LJ, Bohn, DJ, et al: Evaluation of pediatric care in Ontario. J Trauma 1989;29:724–729.CrossRefGoogle ScholarPubMed
98. Dykes, EH, Spence, LJ, Young, JG, et al: Preventable pediatric trauma deaths in a metropolitan region. J Pediatr Surg 1989;24:107–111.Google Scholar
99. Kaufmann, CR, Maier, RV, Kaufmann, EJ, et al: Validity of applying adult TRISS analysis to injured children. J Trauma 1991;31:691–698.Google Scholar
100. Champion, HR, Copes, WS, Sacco, WJ, et al: The Major Trauma Outcome Study: Establishing national norms for trauma care. J Trauma 1990;30:1356–1365.Google Scholar
101. Committee on Trauma, American College of Surgeons. Quality assurance in trauma care. In: Resources for the Optimal Care of the Trauma Patient. Chicago: American College of Surgeons, 1990, pp 67–75.Google Scholar
102. Cayten, CG, Stahl, WM, Murphy, JG, et al: Limitations of the TRISS method for interhospital comparisons: A multi-hospital study. J Trauma 1991;31:471–482.CrossRefGoogle Scholar
103. Kearney, PA, Terry, L, Burney, RE: Outcome of patients with blunt trauma transferred after diagnostic procedures or four hour delay. Ann Emerg Med 1991;9:882–886.Google Scholar
104. Champion, HR, Copes, WS, Sacco, WJ, et al: A new characterization of Injury Severity. J Trauma 1990;30:539–545.Google Scholar
105. Shires, GT: Evolution of trauma and trauma research. J Trauma 1991;31:S107–S115.Google Scholar
106. Smith, JS, Martin, LF, Young, WW, Macioce, DP: Do trauma centers improve outcome over non-trauma centers: The evaluation of regional trauma care using discharge abstract data and patient management categories. J Trauma 1990;30:1533–1538.Google Scholar
107. Morris, JA Jr., Sanchez, AA, Bass, SM, MacKenzie, EJ: Trauma patients return to productivity. J Trauma 1991;31:827–834.Google Scholar
108. Young, WW, Macioce, DP: PMCs-An alternative to DRGs for trauma care reimbursement. J Trauma 1991;31:459–470.Google Scholar
109. MacKenzie, EJ, Morris, JA Jr., Smith, GS, et al: Acute hospital costs of trauma in the United States: Implication for regionalized systems of care. J Trauma 1990;30:1096–1103.Google Scholar
110. Maio, RF, Amato, DA: Ambulance randomization for prehospital clinical trials. Ann Emerg Med 1988;7:75.Google Scholar
111. Cornfield, J: Randomization by Group: A Formal Analysis. Am J Epidemiology 1978;108:100–102.CrossRefGoogle Scholar
112. Donner, A, Birkett, N, Buck: Randomization by cluster: Sample size requirements and analysis. Am J Epidemiology 1981;114:906–914.CrossRefGoogle ScholarPubMed
113. Freiman, JA, Chalmers, TC, Smith, H, Kuebler, RR: The importance of Type II error and sample size in the design and interpretation of the randomized control trial. N Engl J Med 1978;299:690–693.Google Scholar
114. Gaddis, GM, Gaddis, ML: Introduction to Bio-statistics: Part 5, Statistical inference techniques for hypothesis testing with nonpara-metric data. Ann Emerg Med 1990; 19:1054–1060.CrossRefGoogle Scholar
115. Mendenhall, W: The Normal Probability Distribution. In: Mendenhall, W (ed). Introduction to Probability and Statistics, 6th ed. Boston: PWS Publishers, 1983, pp 220–233.Google Scholar