Prehospital Trauma Compendium: Prehospital Management of Adults with Traumatic Out-of-Hospital Circulatory Arrest - A Joint Position Statement and Resource Document of NAEMSP, ACS-COT, and ACEP.

IF 2.1 3区 医学 Q2 EMERGENCY MEDICINE
Amelia M Breyre, Nicholas George, Alexander R Nelson, Charles J Ingram, Thomas Lardaro, Wayne Vanderkolk, John W Lyng
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引用次数: 0

Abstract

The National Association of Emergency Medical Services Physicians (NAEMSP), American College of Surgeons Committee on Trauma (ACS-COT), and American College of Emergency Physicians (ACEP) believe that evidence-based, pragmatic, and collaborative protocols addressing the care of patients with traumatic out-of-hospital circulatory arrest (TOHCA) are needed to optimize patient outcomes and clinician safety. When the etiology of arrest is unclear, particularly without clear signs of life-threatening trauma, standard basic and advanced cardiac life support (BCLS/ACLS) treatments for medical cardiac arrest is appropriate. Traumatic circulatory arrest may result from massive hemorrhage, airway obstruction, obstructive shock, respiratory disturbances, cardiogenic causes or massive head trauma. While resuscitation and/or transport is appropriate for some populations, it is appropriate to withhold or discontinue resuscitation attempts for TOHCA patients for whom these efforts are non-beneficial. This position statement and resource document were written as an update to the 2013 joint position statements.

NAEMSP, ACEP, and ACS-COT recommend:EMS resuscitation of adults with TOHCA should:Prioritize prompt identification of patients who may benefit from transport to definitive care at trauma centers when safe and appropriate.Emphasize the identification of reversible causes of traumatic circulatory arrest and timely use of clinically indicated life-saving interventions (LSIs) within the EMS clinician's scope of practice. These include:External hemorrhage control with direct pressure, wound packing, and tourniquetsAirway management using the least-invasive approach necessary to achieve and maintain airway patency, oxygenation, and adequate ventilation.Chest decompression if there is clinical concern for a tension pneumothorax. Empiric bilateral decompression, however, is not indicated in the absence of suspected chest trauma.External chest compressions may be considered but only secondary to other LSIs.Epinephrine should not be routinely used, and if used should not be administered before other LSIs.If point-of-care ultrasound (POCUS) demonstrates no evidence of cardiac motion, this may have utility in TOHCA management for prognostication.Emphasize that placement of cardiac monitors and/or use of POCUS should occur after indicated LSIs have been appropriately performedConditions where resuscitation attempts should be withheld, include TOHCA patients with:Injuries that are incompatible with life (e.g., decapitation, hemi-corpectomy, incineration, open skull injury with extruding brain matter).Evidence of prolonged circulatory arrest (e.g., rigor mortis, dependent lividity, decomposition).Advance care planning documents that indicate Do Not Resuscitate (DNR)/ Do Not Attempt Resuscitation (DNAR)/Allow Natural Death medical orders.Conditions where resuscitation attempts are discontinued for TOHCA patients should recognize:Mechanism of injury should not be used as the sole determinant to discontinue resuscitation efforts.Electrical rhythm should not be used as the sole determinant to discontinue resuscitation efforts. Of note, non-shockable rhythms (Pulseless Electrical Activity/Asystole) are associated with an extremely low likelihood of return of spontaneous circulation (ROSC) or survival with neurologic recovery.There is insufficient evidence to support any specific universal standardized time-based cutoffs to discontinue resuscitation efforts based on the duration of resuscitation or transport times to definitive care. EMS decisions to transport or discontinue resuscitation should be locally determined based on EMS and trauma system resources and proximity.Implementation of protocols for TOHCA should consider:Risks and benefits of resuscitation attempts and transport for public safety and EMS clinician safety.Individual patient cost and organ donation should not be a factor in EMS clinical decision-making on-scene.Local provisions for specific clinical resources (e.g. regional trauma capabilities), environmental (e.g. avalanche, etc.), or population-based situations are important and require active EMS physician oversight in collaboration with local trauma system stakeholders.

院前创伤纲要:外伤性院外循环骤停成人的院前管理——NAEMSP、ACS-COT和ACEP的联合立场声明和资源文件。
美国急诊医师协会(NAEMSP)、美国外科医师学会创伤委员会(ACS-COT)和美国急诊医师学会(ACEP)认为,创伤性院外循环骤停(TOHCA)患者的护理需要循证、务实和协作的协议,以优化患者的预后和临床医生的安全。当心脏骤停的病因不清楚,特别是没有危及生命的创伤的明显迹象时,适用标准的基本和高级心脏生命支持(BCLS/ACLS)治疗药物心脏骤停。创伤性循环骤停可能由大出血、气道阻塞、阻塞性休克、呼吸障碍、心源性原因或大面积头部创伤引起。虽然复苏和/或转运对某些人群是合适的,但对于TOHCA患者,如果这些努力对其无益,则应暂停或停止复苏尝试。本立场声明和参考文件是对2013年联合立场声明的更新。NAEMSP、ACEP和ACS-COT建议:成人TOHCA的EMS复苏应:优先考虑在安全、适当的情况下将患者转移到创伤中心进行最终治疗。强调识别创伤性循环骤停的可逆原因,并在EMS临床医生的实践范围内及时使用临床指示的救生干预措施(LSIs)。这些措施包括:外部出血控制,直接加压,伤口填塞和止血带;气道管理,使用必要的微创方法来实现和维持气道通畅,氧合和适当的通气。如果临床表现为紧张性气胸,应进行胸部减压。经验双侧减压,然而,不适合在没有怀疑胸部创伤。胸外按压可以考虑,但只能继发于其他lsi。肾上腺素不应常规使用,如果使用,不应在其他lsi之前给药。如果即时超声(POCUS)没有显示心脏运动的证据,这可能在TOHCA的预后管理中有实用价值。强调心脏监护仪的放置和/或POCUS的使用应在适当实施lsi后进行。应保留复苏尝试的情况,包括TOHCA患者:与生命不相容的损伤(例如,斩首,半椎体切除术,焚烧,开放性颅骨损伤伴脑物质突出)。长时间循环停止的证据(例如,尸僵,依赖性血渍,腐烂)。预先护理计划文件,注明“不复苏”(DNR)/“不尝试复苏”(DNAR)/“允许自然死亡”医嘱。在停止复苏尝试的情况下,TOHCA患者应认识到:损伤机制不应作为停止复苏努力的唯一决定因素。电节律不应作为停止复苏努力的唯一决定因素。值得注意的是,非电击性节律(无脉性电活动/无搏动)与自发性循环(ROSC)恢复的可能性极低或与神经系统恢复相关。没有足够的证据支持任何具体的、通用的、基于时间的、基于复苏持续时间或运送到最终护理时间的停止复苏努力的标准。EMS决定转运或停止复苏应根据EMS和创伤系统的资源和邻近程度在当地决定。实施TOHCA方案应考虑:复苏尝试和运输的风险和益处,以确保公共安全和EMS临床医生的安全。患者个人费用和器官捐赠不应成为EMS现场临床决策的一个因素。当地对特定临床资源(如区域创伤能力)、环境(如雪崩等)或基于人群的情况的规定很重要,需要EMS医生与当地创伤系统利益相关者合作积极监督。
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来源期刊
Prehospital Emergency Care
Prehospital Emergency Care 医学-公共卫生、环境卫生与职业卫生
CiteScore
4.30
自引率
12.50%
发文量
137
审稿时长
1 months
期刊介绍: Prehospital Emergency Care publishes peer-reviewed information relevant to the practice, educational advancement, and investigation of prehospital emergency care, including the following types of articles: Special Contributions - Original Articles - Education and Practice - Preliminary Reports - Case Conferences - Position Papers - Collective Reviews - Editorials - Letters to the Editor - Media Reviews.
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