An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma

This report describes the development of an evidence-based guideline for external hemorrhage control in the prehospital setting. This project included a systematic review of the literature regarding the use of tourniquets and hemostatic agents for management of life-threatening extremity and junctional hemorrhage. Using the GRADE methodology to define the key clinical questions, an expert panel then reviewed the results of the literature review, established the quality of the evidence and made recommendations for EMS care. A clinical care guideline is proposed for adoption by EMS systems. Key words: tourniquet; hemostatic agents; external hemorrhage.

Analysis of preventable pediatric trauma deaths and inappropriate trauma care in Montana.

OBJECTIVE: To determine the rates of preventable mortality and inappropriate care, as well as the nature of treatment errors associated with pediatric traumatic deaths occurring in a rural state. METHODS: Retrospective multidisciplinary consensus panel review of deaths attributed to mechanical trauma in children aged 18 years or less, occurring in Montana between October 1, 1989, and September 30, 1992. The care rendered in both preventable and nonpreventable cases was evaluated for appropriateness according to nationally accepted guidelines. Rates of pediatric preventable death and inappropriate care, as well as the nature of inappropriate care, were compared with that of the adult population. RESULTS: One hundred thirty-eight cases were reviewed. One death (less than 1%) was judged frankly preventable, 11 deaths (8%) were judged possibly preventable, giving a total preventability rate of 9% for all cases reviewed. Considering only in-hospital deaths (n = 77), the total preventability rate was 16%. The rate of inappropriate care rendered for all deaths, regardless of preventability, was 36%. The rate of inappropriate care in the prehospital phase was 16%; for in-hospital deaths, it was 47%. In the emergency department (ED), the rate was 36%, and in post-ED care, 22%. In comparison to the adult population, the rates of preventable death (9% vs. 14%) and inappropriate care in the hospital phase (64% vs. 66%) were lower. Inappropriate care for the pediatric group was more prevalent in patients less than or equal to 14 years old. The nature of inappropriate care was most frequently associated with the management of respiratory problems, including airway control and management of chest trauma. CONCLUSION: Preventable mortality from traumatic injuries in children in a rural state appears to be low, and lower than that reported for adult trauma victims in the same state. A preponderance of these preventable deaths occur in the subgroup of children less than or equal to 14 years if age. Inappropriate trauma care in children occurs frequently, particularly in the ED phase of care, and is primarily associated with the management of the airway and chest injuries. Education of ED primary care providers in basic principles of stabilization and initial treatment of the injured child 14 years old or younger may be the most effective method of reducing preventable trauma deaths in the rural setting.

Training for rural prehospital providers: a retrospective analysis from Montana.

OBJECTIVE: This paper provides a retrospective analysis of training methods used by rural Montana's prehospital care providers. Drawn from both published and unpublished sources and spanning the past 25 years, it examines the origins of training in this vast rural state and aims to shed light on successful, nontraditional training delivery methods currently being used. Because volunteer personnel traditionally provide prehospital emergency care in rural areas, development and implementation of effective training programs are generally considered important to helping these practitioners maintain the knowledge and skills they use in their lifesaving work. METHODS: Five different training programs used in Montana were assessed: Train-the-trainer; Local Cluster with videotape and guided practicals; Circuit Rider training with interactive videodisc; interactive video teleconference; and the TENKIDS statewide electronic infrastructure. Strengths and weaknesses of each training program were analyzed. RESULTS: Traditional train-the-trainer methods make training readily accessible, but it is difficult to ensure consistent, top-quality delivery of the materials. Electronic training is popular and effective but can be expensive and difficult to develop and distribute. Establishing an electronic infrastructure allows for easy delivery of high-quality electronic instruction. However, it remains somewhat expensive to develop. CONCLUSIONS: Efforts to improve capabilities of instructors in Montana have had varied success. Studies illustrate that remote training methods that train the providers directly are effective and popular. The application of electronic media and other distance learning techniques have demonstrated a positive impact on the frequency, quality, and standardization of training for volunteer prehospital EMTs.

Changing epidemiology of injury-related pediatric mortality in a rural state: implications for injury control.

STUDY OBJECTIVE: To document the current epidemiology of pediatric injury-related deaths in a rural state and evaluate changes over time. DESIGN: Retrospective review of injury-related deaths in children less than 15 years of age. Data were obtained from death certificates and coroner, autopsy, prehospital, and hospital records. Analysis was done of the mechanism of injury, age, sex, race, location of incident, toxicology, and safety device use. Comparisons with analogous data collected from an earlier time period were made. SETTING: The state of Montana, from October 1989 to September 1992. MEASUREMENTS: Deaths per 100,000 population, intentionality of injury, mechanism of injury, use of protective devices, and comparisons with previous data (1980-1985) collected by Baker and Waller (Childhood injury: State by state mortality facts. Baltimore: Johns Hopkins Injury Prevention Center, 1989;148-152). RESULTS: Of 121 patients reviewed, 56% were male and 44% were female. Mean age was 7.0 years (median, 8.0). Eighty-one percent of patients were Caucasian, and 16% were Native American. The leading cause of injury was motor vehicle crashes, which was followed by drowning, unintentional firearm injuries, deaths related to house fires, homicides, and suicides. Overall, 87% of injuries were unintentional and 13% were intentional, with 62% of these suicides and 38% homicides. When considered independently of intent, firearm-related injuries ranked second. Earlier data showed motor vehicle crashes ranking second, unintentional firearm injuries seventh, and homicide fourth. Comparison of death rates per 100,000 people for the two time periods showed increases in suicide deaths (3.2 vs 0.8) and unintentional firearm injury deaths (2.3 vs 0.6). CONCLUSION: The epidemiology of rural pediatric injury-related deaths has changed. Deaths related to suicide and firearms have increased. Violent deaths related to injuries caused by firearms are at a magnitude approaching all other causes. These findings have implications for public health education and injury control strategies in rural areas.

Analysis of preventable trauma deaths and inappropriate trauma care in a rural state.

OBJECTIVE: The goal of this study was to determine the rate of preventable mortality and inappropriate care in cases of traumatic death occurring in a rural state. DESIGN: This is a retrospective case review. MATERIALS AND METHODS: Deaths attributed to mechanical trauma throughout the state and occurring between October 1, 1990 and September 30, 1991 were examined. All cases meeting inclusion criteria were reviewed by a multidisciplinary panel of physicians and nonphysicians representing the prehospital as well as hospital phases of care. Deaths were judged frankly preventable, possibly preventable, or nonpreventable. The care rendered in both preventable and nonpreventable cases was evaluated for appropriateness according to nationally accepted guidelines. MEASUREMENTS AND MAIN RESULTS: The overall preventable death rate was 13%. Among those patients treated at a hospital, the preventable death rate was 27%. The rate of inappropriate care was 33% overall and 60% in-hospital. The majority of inappropriate care occurred in the emergency department phase and was rendered by one or more members of the resuscitation team, including primary contact physicians and surgeons. Deficiencies were predominantly related to the management of the airway and chest injuries. CONCLUSIONS: The rural preventable death rate from trauma is not dissimilar to that found in urban areas before the implementation of a trauma care system. Inappropriate care rendered in the emergency department related to airway and chest injury management occurs at a high rate. This seems to be the major contributor to preventable trauma deaths in rural locations. Education of emergency department primary care providers in basic principles of stabilization and initial treatment may be the most cost-effective method of reducing preventable deaths in the rural setting.