EMS must first evaluate the safety of the
Downed power lines, fire, traffic
Is there a need for specialized equipment for
Is there a need for air ambulance
What type of facility is nearby?
Are all patients accounted for. Is there a
possibility of ejected patients.
What type of crew
In Ontario, either Primary Care Paramedic
(PCP) or Advanced Care Paramedic (ACP).
ACP’s have further education and
ACP’s have a wider scope of practice. In
trauma they are able to initiate IV bolus,
perform needle decompression and
endotrachael intubation (with base hospital
ABCD assessment of both patients
Does the mother warrant airway protection
due to GCS?
If there is only one crew on site, who should
be managed first?
Unless extrication causes delay, limit on
scene time to 10 minutes
Airway interventions as per ATLS
More advanced airway interventions are
usually reserved for receiving hospital (if it is
Intubate GCS<8 in field?
(Prehospital Emergency Care, 2011 15 184)
1,555 patients. Chart review.
Intubation attempted in 758 patients
57% mortality, intubation group.
34% mortality, non intubation group
Patients in the intubation group were more
Lower GCS (4.3 vs 5.3)
More SBP<90 (28 % vs 17%)
Probably represents a selection bias whereby
when a decision to intubate is undertaken the
patient is sicker
Morality in Those
Oxygen and ventilatory support are provided
Needle decompression for tension
pneumothorax. This is done in conjunction
with base hospital. Indications are:
Severe shortness of breath
SBP less than 90
Absent breath sounds
Occlusive dressing is placed over an open
Paramedics assess circulation. If systolic
pressure is <100, 20cc/kg IV NS is
Lacerations are bandaged
Unstable Pelvis injuries are tied
MSK injuries are splinted
Extrication with full c-spine precautions
Collar is placed first, then pt is placed on
Board is padded over pressure points
Pt is then placed on a long board
C-spine injury is presumed in any patient
involved in MVC, fall from height, dangerous
mechanism, neck pain, neurological
symptoms or decreased level of
Clearing C-spine in the
Canadian C-spine rule interpreted by
Clinical decision rule is applied, but the
patient remains immobilized
Pt is brought to ER for assessment.
The reliability of rule application is
determined and compared to investigators
Clearing in the Field
1949 patients evaluated
12 c-spine injuries
Paramedics 100% sensitive in identifying
patients with potential injury
Paramedic specificity 43%, versus 38% for
investigators (some overcalling by EMS)
If paramedics were allowed to use rule 62% of
patients would require immobilization in the
field, compared to actual rate of 100%.
This in turn saves ER space, xrays, less time
Advanced care paramedics may administer
analgesia for isolated extremity fractures
Morphine or Fentanyl
For multi-system trauma base hospital is
contacted for analgesia orders
Load and Go Patients
What it sounds like.
In trauma in the setting of severe multi-system
injury (severe chest injuries, head injury with
lateralizing signs, severe abdominal pain post
trauma, unstable pelvis, bilateral femur
Primary assessment performed. Oxygen applied.
Pt is placed on long board with c-spine
immobilization and additional
history/assessment is obtained en route
Dispatch is made aware
Back to Case: Mother
Scene Survey, limit scene time to 10 min
02 applied, ventilation assisted
IV initiated, 20cc/kg NS given
Splint for femur fracture
Benzodiazepines as needed for seizure from
presumed head injury
Secondary survey en route
Three person extrication with full c-spine
Base hospital contacted for analgesia
A before-after controlled clinical trial to
assess the benefit of prehospital advanced
life support program.
1373 BLS patients: 1494 ALS patients
No substantial difference in overall survival to
hospital discharge (81.8% survival BLS,
81.1% survival ALS)
598 patients with GCS<9
Lower survival ALS (50 % survival ) then BLS
(60%). Value was significant (p<0.03)
Authors speculate this may be due to delay in
transfer to hospital
Base Hospital Program.