Controversies in the prehospital management of major trauma

Abstract

Many traditional therapies in the prehospital management of major trauma may be of little value or may be even harmful. Little scientific evidence exists to support the use of the pneumatic antishock garment, and some studies have shown it to worsen outcome. The traditional role of intravenous fluid resuscitation also has been questioned and, in situations such as penetrating truncal trauma, it may be associated with comparatively worse outcomes. Although some infusion may be appropriate in severe haemorrhage, the clear priority in such patients is evacuation to definitive surgical intervention. Airway control and establishment of intravenous access are recommended en route. Endotracheal intubation may be capable of prolonging the ability to tolerate circulatory arrest, but overzealous ventilation may further compromise cardiac output where there is severe haemodynamic instability. If these procedures delay patient transport, any benefit they may offer could be outweighed by delaying definitive care. Many of the paradigms of prehospital trauma care should be reconsidered and carefully evaluated in future randomized controlled trials.

Sobrevivência após acidentes de trânsito: impacto das variáveis clínicas e pré-hospitalares

“…[8][9][10] However, to statistically verify the association between prehospital interventions and survival has been a diffi cult task for researchers worldwide, creating controversies over this resource's usefulness. 9,14 Instead of the fatality analysis, which examines the "alive or dead" dichotomy, survival analysis has been supported by researchers all over the world 6,7,10,13 to assess the prehospital care phase. Survival analysis considers survival time as a dependent variable and analyzes factors that may interfere with this result as independent variables.…”

“…Among these factors, there are aspects related to the victim and trauma mechanism, in addition to clinical aspects, such as the severity of injuries and their physiological repercussions, as well as the initial care provided. 9,10,[12][13][14] Among the technologies that have been employed in the initial care of the trauma patient, prehospital care stands out, [8][9][10][11] having two categories 11 -Basic Life Support, whose main characteristic is not to perform invasive, life-preserving procedures, and Advanced Life Support, which involves invasive procedures.…”

Predetermining value analysis of the prehospital phase procedures in trauma victims survival

“…to the great number of variables that interfere in the results, along with the difficulty in extracting the impact of one or a specific group (1,(3)(4)(5)(6) .…”

“…In trauma ALS research, there is a trend to focus its influence on closed traumas (1,3,5,7) , the performance of some procedures, such as intubation and volume replacement (5) , and accidents in rural areas, where the distance between the trauma scene and the hospital is further (5) .…”

“…The surveyed factors involve victims' characteristics, trauma type and its mechanisms and the circumstances of the delivered care from the prehospital phase through hospital setting, including the procedures performed in both phases (1)(2)(3) . However, there is difficulty in statistically demonstrating the association between these factors and survival, due…”