How 2018 changed my pre-hospital care

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scanFOAM

Prof. Richard Lyon MBE at The Big Sick 2019. Full talk w video and notes at https://scanfoam.org/

Health & Medicine

!10
CV physiology in patients with isolated TBI
HR < 100
BP > 100
56 %
44 %
Gavrilovski, Injury 2018

!11
CV physiology in patients with isolated TBI
HR < 100
BP > 100
32 %56 %
HR > 100
BP > 100
HR < 100
BP < 100
HR > 100
BP < 100
Gavrilovski, Injury 2018
3 % 9 %

!12
NEJM 2018: 379
Prehospital plasma during air
medical transport in trauma
patients at risk for
haemorrhagic shock
Sperry et al, on behalf of PAMPer Study Group
501
trauma
BP<90 HR>100

!15
TBI present
No pre-hospital packed cells

100% O2
EtCO2 35-40
SBP>90
BM 5-10
Head up 30°

!20
Lancet 2018: 391
25 trials
16,037 patients

!21
Liberal
oxygen
Conservative
oxygen
Mortality
(in hospital)
3.7% 3.0%

!22
Favours less oxygenFavour more oxygen
1.0 2.0 5.00.50.2
In-hospital mortality, overall (p=0.02)
30-day mortality, overall (p=0.033)
Mortality at longest follow-up (p=0.044)

!23
Favours less oxygenFavour more oxygen
1.0 2.0 5.00.50.2
In-hospital mortality, overall (p=0.02)
30-day mortality, overall (p=0.033)
Mortality at longest follow-up (p=0.044)
NN to harm = 71

Aim to achieve SaO2 96-98%
12 L O2/min at 10 breaths/min 100% O2
SaO2 > 96%
Reduce to 4 L O2/min 60% O2
Reduce to 2 L O2/min 40% O2
SaO2 > 96%
Reduce to 0.5 L O2/min 30% O2
SaO2 > 96%
Reduce to air 21% O2
SaO2 > 96%

!28
Mortality & prehospital blood pressure in patients with major traumatic
brain injury: implications for the hypotension threshold
JAMA Surg 2017; 152

!31
1389 aged ≥ 65 years
45% TBI
28% had neurosurgery
Traumatic brain injuries in older adults—6 years
of data for one UK trauma centre: retrospective
analysis of prospectively collected data
Hawley, EMJ 2017

!32
1389 aged ≥ 65 years
45% TBI
28% had neurosurgery
78 % survived TBI
57 % had a good outcome - GOS
Traumatic brain injuries in older adults—6 years
of data for one UK trauma centre: retrospective
analysis of prospectively collected data
Hawley, EMJ 2017

ETI
ﬁrst
4410
9296 patients
SGA ﬁrst
4886

ETI
ﬁrst
4410
9296 patients
SGA ﬁrst
4886
mRS (0-3)
6.4%
mRS (0-3)
6.8%

!46
Association of Prehospital Mode of Transport With Mortality
in Penetrating Trauma: A Trauma System-Level Assessment
of Private Vehicle Transportation vs Ground EMS
103 ,029 patients
Wandling et al, JAMA Surg. 2018

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