1. Missouri EMS Central Region October 2011 Webinar Jeffrey Coughenour, MD, FACS Assistant Professor of Surgery Medical Director, Missouri EMS Central Region

2. Purpose Monthly educational opportunity for providers within the Central Region Focus – Performance improvement, actual case review – Literature review – Discuss practice management guidelines

3. Performance Improvement Review performance and safety of EMS system – Expected or unexpected mortality? – Opportunity for improvement? Now the actual work begins… – System or individual? – Preventable or not? – Is the issue open or closed?

4. Corrective Action Develop or revise a guideline Targeted education Enhance resources, communication Counseling Change in provider privileges or credentials External review (region, trauma center, etc.)

5. Results Demonstrate that a corrective action has the desired effect by continued evaluation Continuous use of your new PIPS process is more important than “loop closure” Chapter 16, Performance Improvement and Patient Safety, Resources for the Optimal Care of the Injured Patient 2006 Copyright © 2006 American College of Surgeons, Chicago, IL

8. MVC Moderate front-end vehicle damage 70’s male, presumed intoxicated Pelvic and arm pain 100, 16, 184/90, 95% on 2 L NC Community hospital 5 miles away, trauma center 95 miles away Destination?

9. MVC Chest radiograph

10. MVC Pelvic radiograph

11. MVC Right rib fractures, small hemothorax, subcutaneous air

12. MVC Right comminuted iliac crest fracture, retroperitoneal hematoma

13. MVC CT findings and hemoglobin value of 4.8 prompt referral to Level I trauma center Intubated, chest tube, pelvic binder placed Arrival 7 hours after injury Excessive time to definitive care? What was the indication for intubation? Does the pelvic injury necessitate pelvic binder?

14. MVC Increasing subcutaneous air right chest

15. MVC Residual anterior pneumothorax

16. MVC Retroperitoneal hematoma has not significantly changed

17. MVC Atelectasis, resolving right basilar effusion, tube thoracostomy remains

18. MVC Ventilator-associated pneumonia Transfusion, nutritional supplementation No operation required for pelvis Prolonged ICU admission, LTAC transfer with significant disability

19. Young and Burgess Classification Vector of force, severity, ligamentous disruption, rotational instability Grade I-III Anterior-posterior Lateral Vertical shear

20. Summary Points Early referral for extremes of age Pelvic binder when loss of rotational stability, most often APC, closes down pelvic volume If you take the time to scan… do it right – Include entire torso – Use IV contrast – Renal function rarely a consideration

22. ATV ATV rear-ended another ATV All occupants ejected Local EMS: Immobilization, supplemental O 2, needle decompression right chest Flight crew—confused, lethargic, grunting, attempting to pull oxygen mask off face Diagnosis?

23. ATV 143, 28, 112/58, 83% on NRB, GCS 11 Ever since RSI medications given, slow decline in HR, now 45, 0, 0, 60% with BVM, GCS 3TC Successfully intubated Diagnosis?

24. ATV Left tension PTX, extensive right contusion with subcutaneous emphysema

25. ATV Bilateral chest tubes placed, resolution of tension physiology, bilateral pulmonary contusions

26. ATV Progression of pulmonary contusions, 30 mins after arrival

27. ATV Progression of pulmonary contusions, 2 hours after arrival

28. ATV Large air leak from left chest Inspiratory T v 570 mL, expiratory T v 20 mL OR for thoracotomy – Progressive hypoxemia, bradyarrythmia – Large laceration at lingula, vascular and bronchial injury, hilar clamp → total pneumonectomy

31. MVC Passenger side impact from large truck, ejected Progressive shortness of breath, bloody, frothy secretions, anxiety/confusion Intubated after arrival of flight crew, PEA Resuscitated, but died shortly after OR

32. MVC Admission chest radiograph

33. MVC 1535 Crash 1540 EMS on-scene, aircraft requested 1607 Ground EMS transporting to closest ED 1628 Arrive helipad 1634 Aircraft arrival 1659 Aircraft departure 1726 Patient in trauma resuscitation suite Scene 64.4 miles from trauma center 1 hour 10 minutes Benefit of air medical transport: Distance or critical care?

34. Summary Points Diagnostic dilemma: Problem with A or B? Pre-hospital care was good Large air leaks require urgent operative intervention—delay to OR Pulmonary contusions, when present soon after injury, associated with high mortality

35. Pulmonary Contusion Parenchymal hemorrhage, inflammatory destruction of the alveolar-capillary membrane Historical mortality rates 40% Mechanical ventilation, antibiotics, invasive monitoring MAY improve outcomes (6.5%) Supportive care

36. Crash and occupant predictors of pulmonary contusion O’Conner JV, Scalea TM Crash Injury Research and Engineering Network (CIREN) J Trauma 2009 Apr 66(4):1091—5 2,184 crash occupants Strong association with higher delta V (severity) Risk greatly increased with near-side lateral impact, suggests occupant proximity to force most important Not an independent marker for mortality

37. Pulmonary contusion: An update on recent advances in clinical management Cohn SM, DuBose JJ World J Surg 2010 Aug 34(8):1959—70 47% present on admission 92% present by 24 hours 24-48 hour progression Resolution after 4-6 days Delay prompts investigation for infiltrate, fluid overload, TRALI, aspiration

38. November 2011 Webinar Pre-Hospital Fluid Management