1. Pre-hospital management of
acutely injured patient
Grand Round presentation by:
Dr. Aremu W I
Dr. Mohammed T O
Supervising Consultant: Dr. Aderibigbe AB

2. Outline
 Introduction
 Historical background
 Epidemiology of trauma
• Organisation of trauma system
• Concept of Pre-hospital care
 Pre-hospital trauma care
 Nigerian experience
 Recommendations
 conclusion

3.  Trunkey’s trimodal
distribution of deaths from
trauma with regard to time:
◦ Immediate deaths-50%,do
not reach hospital, not
possible to save.
◦ Early deaths-30%,Within the
first few hours, many are
preventable.
◦ Late deaths -20%,occur as a
result of organ failure or
sepsis

4. Introduction
 Quite distressing are unexpected loss
of lives or permanent disabilities
caused by physical violence or
accidental injury.
 Particularly tragic is the injured but
potentially salvageable patient who
dies needlessly through delay in
retrieval, inadequate assessment or
ineffective treatment.

5.  Appropriate initial care can prevents
2nd and 3rd peak.
 The concept of “golden hour’
 To describe the urgent need for
treatment of trauma patient within the
first hour after injury.

6. Definitions
 Trauma-injury to the living tissue that
occurs when a physical force contacts
the body(distortion of human frame
from an extrinsic force)
 Pre hospital care refers to out-of-
hospital immediate medical care
rendered to injured patients.

7. Historical background
 The need to move wounded soldiers
from battle field to aids station led to the
concept of emergency medical transport
& use ambulance in military.
 Two- or four-wheeled horse-drawn
wagons were first used by Dominique
Jean Larrey(1766-1842).
 In 1865,the first hospital-based
ambulance was developed in
commercial hospital in Cincinnati, Ohio.

8.  Four years later(1869),New York city’s
Bellevue Hospital started first
municipal service(out of hospital
service with ambulances carrying
medical equipments)
 In June 1887,St John ambulance
brigade was established to provide
first aid and ambulance services at
public events in London

9.  Rescue society founded in Vienna
after disastrous fire at the Vienna ring
theatre in 1881 was the earliest
emergency medical services reported
 1st motorized ambulance came to use
in 1899 donated to Michael Reese
hospital, Chicago.

10.  World’s first component of civilian pre
hospital care on scene began in
1928(Roanoke live saving and first aid
crew in Roanoke, Virginia).
 Canadian historian-First formal
training for ambulance attendants was
conducted in city of Toronto in 1892,

11.  During the two world war, advances
were made with positive results on
patient’s morbidity & mortality.
 Modern ambulance design
 EMS system design

12. Epidemiology of trauma
 principal cause of death in the first 4
decades
 80% of deaths between 15 and 24yr
 Every 5min,there is a death from
traumatic injury(accidental death)
 In USA, unintentional injury was the fifth
leading cause of death in 2002.

13.  11th leading cause of death & 6th leading cause of
DALY’s loss in Nigeria(WHO,2002).
 150,000 deaths annually in the US
 18,000 deaths from accident annually in UK
 Permanent disability 3 times the mortality rate in the
US
 > 45m people world wide are left with disability

14.  Globally, injury mortality has M:F of 2:1
 Injury accounts for 12% of the world’s burden of
disease.
 Trauma morbidity & mortality risk is
increased by
◦ Increasing age
◦ Co morbidity
◦ Obesity

15. Determinant of injury severity
 Force of impact
 Duration of impact
 Body part involved
 Injuring agent
 Associated risk factors

16. Economic burden
 Global trauma related cost-- > $500 billion
annually
 The economic costs associated with RTIs
in Africa were estimated to be US$3.7
billion in 2000,
 translating to approximately 1–2% of each
country’s gross national product.
 Significant loss of productive work years

17. Causes of trauma
 RTC-leading cause of traumatic injury
 Fall
 Industrial/occupational accidents
 Disasters
 Sport injury
 Burns
 Assaults

18. Leading Causes of the Global
burden of Trauma
Cause of death Individuals killed
 Road traffic injuries 1,260,000 (25%)
 Other injuries 856,800 (17%)
 Suicide 815,000 (16%)
 Homicide 520,000 (10%)
 Drowning 450,000 (9%)
 Poisoning 315,000 (6%)
 War 310,000 (6%)
 Falls 283,000 (6%)
 Burns due to fire 238,000 (5%)
World Health Organization, 2000.

19.  RTI kill 1.3m people annually
 80% of global deaths from RTI occur
in developing countries
 By 2030, RTI will be 5th leading cause
of death & disability.

20.  The population burden of road traffic
injury is high in Nigeria, at 41 per 1000
population.
◦ Motorcycle injuries comprise over half of
road traffic injuries (54%)
◦ urban VS rural populations –no significant
difference

21.  Federal Road Safety Commission
estimates
◦ 5777 deaths in 2004, 0.046 per 1000
population
◦ 4519 deaths occurred in 2005, 0.036 per
1000 population

22. Organization of trauma
system
 Trauma system-an organized effort
coordinated by a national or local agency
to deliver care(from acute injury to
rehabilitation) to injured patient in a
defined geographical area.
 3 components:
◦ Pre hospital care
◦ System wide communication
◦ Appropriately designated hospital
 Level I
 Level II
 Level III

23.  Stages of high quality pre hospital
care-star of life
◦ Early detection
◦ Early reporting
◦ Early response
◦ Good on-scene care
◦ Care on transit
◦ Transfer to definitive care

24. Level of care
 BLS & ALS
 For trauma care, basic skills include
◦ Basic airway maneuvers
◦ BVM & oxygen
◦ CPR and automated external defibrillation

25. ◦ Hemorrhage control
◦ spine immobilization
◦ Needle decompression of suspected tension
pneumothorax
◦ Splinting of major extremity fractures
 ‘scoop & run’ VS ‘stay & play’

26. Pre-hospital trauma care
 AIM : To provide quality, safe, prompt &
effective health care
 Varies from one country to the other
 2 levels of care: Basic life support(BLS)
Advance life
support(ALS)
 BLS improves outcome in trauma patient

27. Pre-hospital trauma care
 Role of providers :
- Ensure safety of the scene
- For individual victim: Identify life
threatening injuries

28. Pre-hospital trauma care
• Role of providers :
- For Multiple victim: Triage
- Alert designated trauma
centres/call for help
- Stabilization & transport to
trauma centres

29. Pre-hospital care
 TRIAGE :
- Process of rapidly & accurately
evaluating trauma patient to
determine extent of injuries & the
level of medical care required
- Goal is to transport all seriously
injured patients to appropriate
facility

30. Pre-hospital care
 TRAIGE :
- Depends on a number of variables
- Triage scoring systems
- The Medical Emergency Trial Tags(METTAG)
- black is dead, red is critical, yellow is
serious, green is not serious

31. Pre-hospital care
 Initial evaluation / Primary Survey :
- follows the ABCDE pattern
 A: Air way & Cervical spine control
 B: Breathing
 C: Circulation
 D: Disability/Neurologic assessment
 E: Exposure & enviromental control

32. Air way control
 Assess the airway for patency &
protective reflex
 Ask patient to open mouth & phonate
 Level of consciousness – a 1° indicator
of airway stability
 Manual in line(MIL) Stabilization of the
cervical spine

33. Air way control
 Suction
 Chin lift/jaw thrust
 Oral/nasal airways
 Rescue airways/Airway adjuncts

35. Air way control
 Definitive airways
◦ RSI for agitated patients with c-spine
immobilization
◦ ETI for comatose patients (GCS<8)
◦ Perfomance in the pre-hospital setting is
controversial

36. Difficult airway

37. Breathing
 Assessed by determining the Patient’s
RR
 Palpate,Percuss & Auscultate the
chest
 Pulse oximetry is a mandatory adjunct
 ETCo2 is becoming a useful adjuncts

38. Breathing
 Oxygen
 Control of ventilation
 Seal open / sucking chest wound
 Chest decompression

39. Circulation
 Evaluate mental status,Skin colour &
temperature
 BP & RR – not reliable
 Hemorrhagic shock should be
assumed in any hypotensive trauma
patient

40. Circulation
 Direct pressure / pressure dressings
 Tourniquet application
 Use of pelvic binder
 Intravenous / intraosseous line
 IV access preferably done enroute
 Restricted use of IVF is advocated

41. Disability
 Abbreviated neurological exam
- Level of consciousness
- Pupil size and reactivity
- Motor function
 GCS
- Utilized to determine severity of
injur
- Guide for urgency of head CT and
ICP monitoring

42. Disability
 Spinal cord injury
- High dose steroids if within 8 hours
 Elevated ICP
- Head of bed elevated
- Mannitol
- Hyperventilation
- Emergent decompression
 Proper Spinal immobilization

43. Exposure / Enviromental
control
 Complete disrobing of patient
 Logroll to inspect back
 Rectal temperature
 Warm blankets/external warming
device to prevent hypothermia

44. Secondary survey
 A quick but thorough review of the
body
 Aim : to identify missed injuries
 Common pitfalls – not inspecting the
back, the axilla, the gluteal region &
the pannicular folds

45. Others Issues
 Fractures
 Pain management
 Transport
 Burns
 Extrication – the Kendrick extrication device
 Prehospital determination of death

46. The Nigerian experience
 Pre-hospital care of the injured in
south western Nigeria: A hospital
based study of four tertiary hospital in
three states.
• Aim : to determine the level of pre-
hospital care

47. The Nigerian experience
- A hospital based prospective study
- Information gathered using a one-
page proforma

48. The Nigerian experience
 1996 patients were seen. 1600 – Males
& 436 – Females, range : 2 – 80, Mean
30.3 ± 13.3yrs
 Most accident occurred on Urban
road(49.1%)
, highways(46.3%)
 12,040 accident victims, 1,292(10.7%)
immediate fatalities, 80,356(69.4%)
injured, 1996(23.9%) seen at the
casualty.

49. The Nigerian experience
 172(8.6%) had some form of pre-
hospital care
- 17 had wound irrigation
- 5 fracture splinted
- 4 water to drink
- 10 wound cover

50. The Nigerian experience
17(15%)
5(4 %)
4(3% wound irrigation
)
10(9%) fracture splinted
drinking water
wound coverage
81(69%) others

51. Mode of transportation

52. Treatment at other hospital
 584 (29.3%) referred from other
hospitals
 300(51.3%) of these were from private
hospitals

53. Treatment at other hospital
 208 (35.6%) from secondary level
government hospitals and 64 (11.0%)
from mission funded hospitals
 Significantly higher proportion of those
who had their initial treatment in other
hospitals died in the casualty

54. Interval between injury and presentation
 1,412(70.7%) brought directly to the
hospitals
 416 (29.5%) arrived within 30 minutes
while another 392 (27.5%) arrived between
30 minutes and an hour.

55. Discussion
 The overall mean arrival time for all
93.6 minutes.
 For those who died in the casualty,
the mean arrival time was 49.8
minutes while it was 96.0 minutes for
those who survived.

56. Revised trauma score & patient
survival

57. Disscussion
 No organized Pre-hospital care
 Some of the bystander PHC were
inappropriate
 Only 29.5% arrived within 30minutes
of injury

58. Discussion
 Make shift transportation
 29.3% referred from other hospital
 Most of the referred patient died

59. Study Conclusion
 There’s a great need to urgently
review the trauma system in Nigeria
 better injury surveillance and the
establishment of hospital and
community based trauma registries as
a first step in improving trauma care in
our environment

60. Recommendations
 Government should recruit & train
volunteers and non-medical
professionals on PHC
 Establish trauma centres in the 6 geo-
political zones
 Develop a national policy guidelines
on pre-hospital trauma care

61. Recommendations
 Better road design
 Compliance with traffic rules
 Integration of BLS into school
curriculum

62. recommendations
 The hospital should educate the
populace on Pre-hospital care
 Continue to provide an avenue for
learning & research on road safety &
trauma care
 All health care professionals to have a
first aid box in their vehicles

63. Conclusion
The financial and social benefits of
reducing premature death and
minimizing disability
from injury are potentially enormous,
and these benefits may play a major
part in
promoting a nation’s economic and
human development.

64. THANK YOU