Prehospital Trauma Care PDF

Preface

On behalf of the International Trauma Anesthesia and Critical Care Society (ITACCS), we are pleased and honored to present Prehospital Trauma Care.

Each of the predominant fields in the care of the injured—anesthesiology, critical care, emergency medicine, and surgery—has an idiosyncratic bias regarding management of the trauma patient. Some of these biases are based on traditional teachings, and others stem from differences reflected in the body of literature accumulated in each specialty. Often, what is well known and accepted in one specialty must be ‘‘rediscovered'' independently by another before becoming part of practice standards (perhaps the most obvious example is the variety of approaches to management of the difficult airway). For these reasons, to the extent possible, we have paired contributors from different specialty backgrounds as author teams, e.g., a surgeon with an anesthesiologist or an emergency medicine physician with a surgeon.

The second aspect that has a profound impact on the way trauma is practiced is geography and culture. Although electronics have made the world a much smaller place, medical practitioners are still largely held to a standard of care that is provincial in nature. A great deal of time and scientific evidence is required to break down the barriers that keep local groups doing things the way the previous generation did, despite the fact that a group elsewhere has developed a better approach to the same issue.

Evidence-based medicine has entered modern medicine at full speed. Hence, we have aimed to include and discuss evidence-based recommendations for clinical care whenever present and feasible. Randomized controlled trials are few, and we know more about what is not useful and may be harmful to the patient than what has been proven beyond doubt to improve survival. Being realistic, we know that in most situations the actual care given to a patient will be based on sound judgment and the experience of the traumatologist involved. Therefore, as editors, one of our goals has been to recruit authors from different parts of the world. In this way, we hope to present various geographic and cultural perspectives within the same context.

Finally, the approach to management of any given clinical problem within the realm of trauma care will differ as a function of the locations in which treatment is undertaken. Trauma care is often viewed as a ‘‘chain of survival,'' stretching from the site of injury in the field to the emergency department, to the operating room, to the intensive care unit, and beyond to the rehabilitation center. How one manages the same problem will vary depending on the point of care. Factors active in this decision-making process include the prevailing environment (lighting, temperature, climate), equipment, distance, and clinical competence. The prehospital arena is considered by many to be the most challenging because of its propensity for adverse factors.

We have attempted to cover the topics within a framework of the highest quality of care and then to qualify this framework within the context of the prehospital environment. Our editorial protocol has been to subject each chapter to two cycles of peer review: the first undertaken by the respective Part editors and the second by each of us as general editors.

The book is divided into four parts. Part A covers the general aspects of prehospital trauma care. It starts with a historic view on scope and practice, then moves to demographics and mechanism of injury. The chapters in this part also focus on the organization of prehospital trauma care in developed societies worldwide. The role of the physician in different systems varies from that of a hospital-based medical director to actually providing care at the scene. The chapters present different configurations of the prehospital trauma team around the world and explain why crew-resource management (CRM), research, and continuous quality improvement are so important.

Part B covers the initial care of the patient; with in-depth discussion on everything from advanced airway management to state-of-the art fluid resuscitation and prevention of hypothermia. A frequently forgotten aspect of high-quality trauma care is the provision of adequate analgesia. This topic is also covered.

Trauma is not a generic disease. Hence, therapy will differ according to the anatomical disruption and physiological consequences of the injury. In Part C, the individual approach is taken one step further. Each chapter presents the clinical challenges and treatment modalities of the different injuries the reader is likely to encounter in his or her practice. The first two chapters of this section explain why blunt and penetrating trauma should be dealt with differently. The following chapters focus on special groups of patients— for example, the traumatized child and the entrapped patient—and special trauma situations—such as chemical injuries and accidental hypothermia.

Part D covers transport issues and special problems, e.g., how to provide high-quality care in rural areas and how to ensure the interactions upon the arrival in the emergency department work to the benefit of the patient. In our experience, both topics present major challenges to a trauma system.

Since improving the trauma chain of survival and securing a continuum of care is the ultimate goal for us all, we felt it was as important to focus on human factors as on specific therapies. Hence, Chapter 40 covers prevention issues, not only how to reduce the number of fatalities caused by car crashes and the use of guns for the wrong purposes, but also how to learn from our own errors and thus improve what we teach the next generation of prehospital care providers. That way, they can do an even better job for the severely injured patient.

In the course of this work, we have learned a great deal and have come to appreciate new methods for dealing with old problems. In an effort to meet the expectations of the broad audience for the book, we have endeavored to fuse the perspectives of a variety of medical specialties as well as geographic and cultural perspectives regarding trauma care. We expect Prehospital Trauma Care to have broad appeal, not only to the range of physicians involved in trauma care but also to the flight nurses and paramedics providing prehospital care to injured patients worldwide. We offer this work to the trauma care community in the spirit of international collegiality, with the hope that the readers will benefit as we have.