criteria in consultation with medical control
and therefore also did not include those patients
who were terminated in the field. The Lockey
et al. study did include those patients that were
confirmed dead on scene and not transported;
Leis et al. also included all patients attended to
in the prehospital setting. Each of these studies
certainly has their limitations and it’s difficult to
make apples-to-apples comparisons, but we do
feel that providing all the literature for review
gives the most complete picture on the current
state of traumatic arrest resuscitation.
IMMEDIATE TRANSPORT
This article glosses over one of the most important considerations for urban penetrating trauma
management—immediate transport to a Level
1 trauma center. One study of patients who
received ED thoracotomies showed that each
prehospital procedure performed (e.g., spinal
immobilization, IV access, intubation, etc.) was
associated with increased mortality. The patients
most likely to survive were transported by civil-
ians or police, who rarely had CPR started
before arriving at the hospital.
Peter C.
Via Facebook
AUTHORS MATTHEW CHINN,
MD, & M. RICCARDO COLELLA,
DO, MPH, RESPOND:
We certainly agree that it may be reasonable to
consider rapid transportation (i.e., load and go)
in a subset of patients whose etiology and characteristics include: witnessed arrest, penetrating
trauma of thoracic location, and close proximity
( 10–15 minute) to a trauma center.
We also include the load-and-go recommen-
dation as the second bullet point of our example
pathway. This practice would generally be most
applicable to those services in urban settings
as you suggest, given their higher likelihood
of access to a close Level 1 or 2 trauma center.
There are several studies looking at police or
other non-medical personnel vs. EMS transport
and also BLS vs. ALS level of care in trauma
that seem to imply that the rapidity of trans-
port to an appropriate hospital may play a role.
We do know that often the opportunity for
surgical intervention is within a finite time window and that longer downtimes lead to worse
outcomes. This is why we agree with your argument and would recommend for those patients
that are transported by this load-and-go practice that procedures are performed in route and
don’t delay expeditious transport.
CORRECTION
In this article, the NAEMSP was referred to
incorrectly as an association of EMS medical
directors. The correct name is the National
Association of EMS Physicians. We regret
the error.
