Prehospital care, importance of early intervention on outcome

The improvement of rescue systems and on-scene therapy has lead to a significant reduction of early posttraumatic death. It was the goal of this study to critically analyse the value of prehospital care in respect to early but also to delayed complications (single = SOF or multiple organ failure = MOF) In a retrospective analysis 1223 polytraumatized patients treated during 1984 and 1994, with an injury severity of more than 20 points according to the Injury Severity Score = ISS, on-scene therapy ("field stabilization") was evaluated. We could show that a sufficient preclinical airway management has major influence on late prognosis (MOF). We therefore definitely recommend early intubation at the scene in these patients. The intravenous access at the emergency place is always necessary independent whether the patient is in hemorrhagic shock or not. Loss of time can increase shock mechanisms making intravenous access even more difficult. If there is already a peripheral vasoconstriction and the localisation of an peripheral vein renders more difficult, one possibility is a venae section to get safe access. Concerning the amount of preclinical infusion controverse opinions exist. Our evaluation could not give an satisfactory statement because of a differing high incidence of mass bleeding in the groups with low (< 1000 ml) and high (> 2000 ml) preclinical infusion. The improvement of rescue systems and on-scene therapy has lead to a significant reduction of early posttraumatic death. Especially in those injuries, that are directly associated with the development of early death, i.e. intracranial bleeding, massive hemorrhage from thoracic and intraabdominal lesions these regimens on scene improved survival significantly (Fig 1) (Trunkey 1983). Nevertheless it is still discussed whether a longer rescue time is then justified to intensify on scene therapy. Recent publications demonstrate for instance that infusion therapy beginning on scene is not always necessary and sometimes especially in severe hemorrhagic shock can even aggrevate bleeding (Bickell 1989, Bickell 1991, Bickell 1993, Crawford 1991, Gross 1988, Stern 1993). On the other hand the value of on scene intubation and ventilation and chest tubing in these patients is critically discussed (Mattox 1989). Most of these studies however have their origin in the USA and are related exclusively to penetrating trauma (knife and gunshot wounds), which is completely different from underlying pathomechanisms (pure hemorrhagic shock). Only one reports of the same experience with blunt trauma (Barone 1986). Thus for severe blunt trauma the question is still open: "field stabilization" or "load and go" (Krausz 1992). A decision that always has to be related to the definite rescue time (Smith 1985). It was the goal of this study to critically analyse the value of prehospital care in respect to early but also to delayed complications (single = SOF or multiple organ failure = MOF).