Click to goto CDHA Public Site Click to goto DivEMS Dal Public Site Click to goto EHS Nova Scotia

General Major Trauma Care

Date Last Search Run: Feb 01, 2022
Table last updated: Sep 29, 2022
Data last added: Sep 25, 2022

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)    
2 (fair evidence exists)
3 (weak evidence exists)  


Interventions

Acetaminophen IV
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Pain score measured on a visual analogue scale Patient ED-MD Craig M., Jeavons R., Probert J., Benger J. Randomised comparison of intravenous paracetamol and intravenous morphine for acute traumatic limb pain in the emergency department. Emerg Med J 2012; 29(1):37-9. Medline
III Supportive (Green) Pain relief (NRS or VAS) Patient PH-Paramedic Dijkstra BM., Berben SA., van Dongen RT., Schoonhoven L. Review on pharmacological pain management in trauma patients in (pre-hospital) emergency medicine in the Netherlands. Eur J Pain 2013; 18(1):3-19. Medline

Acetaminophen PO
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Pain relief (NRS or VAS) Patient PH-Paramedic Dijkstra BM., Berben SA., van Dongen RT., Schoonhoven L. Review on pharmacological pain management in trauma patients in (pre-hospital) emergency medicine in the Netherlands. Eur J Pain 2013; 18(1):3-19. Medline

ALS
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Trauma centre mortality Patient Gomes E., Araujo R., Carneiro A., Dias C., Costa-Pereira A., Lecky FE. The importance of pre-trauma centre treatment of life-threatening events on the mortality of patients transferred with severe trauma. Resuscitation 2010; 81(4):440-5. Medline
II Supportive (Green) Survival to hospital Patient PH-Paramedic Rouse C., Hayre J., French J., Fraser J., Watson I., Benjamin S., et al. A traumatic tale of two cities does EMS level of care and transportation model affect survival in patients with trauma at level 1 trauma centres in two neighbouring Canadian provinces? EMJ 2018; 35(2) 83-8. Medline
II Neutral (Yellow) In-hospital mortality Patient PH-Paramedic & MD Kondo Y, Fukuda T, Uchimido R, Kashiura M, Kato S, Sekiguchi H, et al. Advanced Life Support vs. Basic Life Support for Patients With Trauma in Prehospital Settings: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:660367. Medline
II Neutral (Yellow) Survival to 30 days Patient PH-Paramedic Sanghavi P., Jena A., Newhouse J., Zaslavsky A. Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies. Ann Int Med 2015; 163(9):681-91. Medline

Benzodiazepines
Level Direction Primary Outcome Patient/Process Setting Reference
II Opposes (Red) Analgesia Patient PH-Paramedic Auffret Y., Gouillou M., Jacob GR., et al. Does midazolam enhance pain control in prehospital management of traumatic severe pain? Am J Emerg Med 2014; 32(6):655-9. Medline

Blood Glucose Monitoring
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Prediction of traumatic shock Patient PH-Paramedic & MD Kreutziger J, Lederer W, Schmid S, Ulmer H, Wenzel V, Nijsten MW, et al. Blood glucose concentrations in prehospital trauma patients with traumatic shock: A retrospective analysis. Eur J Anaesthesiol 2018; 35(1):33-42. Medline
II Supportive (Green) association with traumatic shock. Process PH-MD & CCT Kreutziger J, Lederer W, Schmid S, Ulmer H, Wenzel V, Nijsten MW, et al. Blood glucose concentrations in prehospital trauma patients with traumatic shock: A retrospective analysis. Eur J Anaesthesiol 2018; 35(1):33-42. Medline

ETCO2
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) ETCO2 to predict future care needs Patient PH-Paramedic BR W, Bruno J, Duckwitz M, Akers N, Jeanmonod D, Jeanmonod R. Prehospital end-tidal CO2 as an early marker for transfusion requirement in trauma patients. Am J Emerg Med 2021; 45:254–7. Medline
II Supportive (Green) All cause mortality Patient PH-Paramedic Bryant MK, Portelli Tremont JN, Patel Z, Cook N, Udekwu P, Reid T, et al. Low initial pre-hospital end-tidal carbon dioxide predicts inferior clinical outcomes in trauma patients. Injury 2021; 52(9):2502–7. Medline
II Supportive (Green) Mortality Patient PH-Paramedic Campion EM, Cralley A, Sauaia A, Buchheit RC, Brown AT, Spalding MC, et al. Prehospital end-tidal carbon dioxide is predictive of death and massive transfusion in injured patients: An Eastern Association for Surgery of Trauma multicenter trial. J Trauma Acute Care Surg 2022; 92(2):355–61. Medline
II Supportive (Green) Prognostication of mortality Patient ED-Paramedic & MD Childress K., Arnold K., Hunter C., Ralls G., Papa L., Silvestri S. Prehospital End-tidal Carbon Dioxide Predicts Mortality in Trauma Patients. PEC; 22(2) 170-4. Medline
II Supportive (Green) mortality Patient PH-MD & CCT Willis RG, Cunningham KW, Troia PA, Gutierrez AS, Christmas AB, Brintzenhoff R, Sing RF. Prehospital End-Tidal CO(2): A Superior Marker for Mortality Risk in the Acutely Injured Patient. Am Surg 2021; 31348211023401. Medline
II Supportive (Green) Need for transfusion Patient PH-Paramedic & MD Wilson BR, Bruno J, Duckwitz M, Akers N, Jeanmonod D, Jeanmonod R. Prehospital end-tidal CO2 as an early marker for transfusion requirement in trauma patients. Am J Emerg Med 2020. Medline

Fentanyl
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Reduction in pain Patient ED-MD Farahmand S., Shiralizadeh S., Talebian MT., et al. Nebulized fentanyl vs intravenous morphine for ED patients with acute limb pain: A randomized clinical trial. Am J Emerg Med 2014; 32(9):1011-5. Medline
I Supportive (Green) Pain relief using the visual analog scale score Patient PH-Paramedic Galinski M., et al. A randomized double-blind study comparing morphine with fentanyl in prehospital analgesia. Am J Emerg Med 2005; 23:114-9. Medline
I Supportive (Green) Pain relief Patient Niemi-Murola L., Unkuri J., Hamunen K. Parenteral opioids in emergency medicine - A systematic review of efficacy and safety. Scandinavian journal of pain 2017; 2(4):187-94. Medline
I Supportive (Green) Pain score reduction Patient ED-MD Shear ML., Adler JN., Shewakramani S., et al. Transbuccal fentanyl for rapid relief of orthopedic pain in the ED. Am J Emerg Med 2010; 28(8):847-852. Medline
II Supportive (Green) Change in pain score Patient Bronsky E.S., Koola C., Orlando A., Redmond D., D'Huyvetter C., Sieracki H., Tanner II A., Fowler R., Mains C., Bar-Or D., Intravenous Low-Dose Ketamine Provides Greater Pain Control Compared to Fentanyl in a Civilian Prehospital Trauma System: A Propensity Matched Analysis, 2019; Prehospital Emergency Care, 23:1, 1-8, DOI: 10.1080/10903127.2018.1469704 Medline
II Neutral (Yellow) Adverse events Patient ED-MD Bible L, Obaid O, Khurrum M, Goh M, Hammad A, Kitts DJ, et al. Pre-Hospital Administration of Opioids in Trauma Patients: Is Dose Associated With Outcomes? J Surg Res 2021; 268:634–42. Medline
III Supportive (Green) Pain relief (NRS or VAS) Patient PH-Paramedic Dijkstra BM., Berben SA., van Dongen RT., Schoonhoven L. Review on pharmacological pain management in trauma patients in (pre-hospital) emergency medicine in the Netherlands. Eur J Pain 2013; 18(1):3-19. Medline
III Supportive (Green) Pain rating using NRS Patient Frakes MA., Lord WR., Kociszewski C., Wedel SK. Efficacy of fentanyl analgesia for trauma in critical care transport. Am J Emerg Med 2006; 24(3):286-9. Medline
III Supportive (Green) Pain Relief Patient PH-Paramedic Park CL., Roberts DE., Aldington DJ., Moore RA. Prehospital analgesia: systematic review of evidence. J R Army Med Corps 2010; 156(4 S1):295-300. Medline
III Supportive (Green) Analgesia Patient PH-Paramedic Rickard C., et al. A RCT of intranasal fentanyl vs intravenous morphine for analgesia in the prehospital setting. Am J Emerg Med 2007; 25:911-7. Medline
X Not Yet Graded (White) - Patient Soriya GC., McVaney KE., Liao MM., et al. Safety of prehospital intravenous fentanyl for adult trauma patients. J Trauma Acute Care Surg 2012; 72(3):755-759. Medline

HEMS
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Survival Patient PH-Paramedic Brown JB., Gestring ML., Guyette FX., et al. Helicopter transport improves survival following injury in the absence of a time-saving advantage. Surgery. 2016;159(3):947-59. Medline
II Supportive (Green) Survival Patient PH-Paramedic Brown JB., Gestring ML., Stassen NA., et al. Geographic variation in outcome benefits of helicopter transport for trauma in the united states: A retrospective cohort study. Ann Surg. 2016;263(2):406-12. Medline
II Supportive (Green) Survival Patient PH-MD & CCT Frankema SP, Ringburg AN, Steyerberg EW, Edwards MJ, Schipper IB, van Vugt AB. Beneficial effect of helicopter emergency medical services on survival of severely injured patients. Br J Surg. 2004 Nov;91(11):1520-6. doi: 10.1002/bjs.4756. PMID: 15455361. Medline
II Supportive (Green) Survival Patient Giannakopoulos GF., Kolodzinskyi MN., Christiaans HM., et al. Helicopter emergency medical services save lives: Outcome in a cohort of 1073 polytraumatized patients. Eur J Emerg Med 2013; 20(2):79-85. Medline
II Supportive (Green) Mortality Patient Other Haas B, Stukel TA, Gomez D, Zagorski B, De Mestral C, Sharma SV, Rubenfeld GD, Nathens AB. The mortality benefit of direct trauma center transport in a regional trauma system: a population-based analysis. J Trauma Acute Care Surg. 2012 Jun;72(6):1510-5; discussion 1515-7. doi: 10.1097/TA.0b013e318252510a. PMID: 22695414. Medline
II Supportive (Green) Time saved Process Other JY J, WK K, Roh H, JH M, JS H, YJ K, et al. Time-saving effects using helicopter transportation: comparison to a ground transportation time predicted using a social navigation software. Med 2021; 100(27):e26569. Medline
II Supportive (Green) Survival Patient PH-Paramedic & MD Kushida Y, Jitsuiki K, KI M, Ikegami S, Nagasawa H, Takeuchi I, et al. A comparison of physician-staffed helicopters and ground ambulances transport for the outcome of severe thoracic trauma patients. Am J Emerg Med 2021; 45:358–60. Medline
II Supportive (Green) Mortality Process Other Maddry JK., Mora AG., Savell S., Reeves LK., Perez CA., Bebarta VS. Combat MEDEVAC: A comparison of care by provider type for en route trauma care in theater and 30-day patient outcomes. The journal of trauma and acute care surgery. 2016;81(5):S104-S110. Medline
II Supportive (Green) Time to care Process PH-Paramedic MR B, Iora P, AC D, RDL F, CER F, MDB C, et al. Helicopter Transportation of Brazilian Trauma Patients: A Comparison of Times to Care. Air Med J 2021; 40(4):259–63. Medline
II Supportive (Green) Survival to discharge Patient PH-MD & CCT Oppe S, De Charro FT. The effect of medical care by a helicopter trauma team on the probability of survival and the quality of life of hospitalised victims. Accid Anal Prev. 2001 Jan;33(1):129-38. doi: 10.1016/s0001-4575(00)00023-3. PMID: 11189116. Medline
II Supportive (Green) 6 month neurological outcome Patient PH-Paramedic & MD Pakkanen T., Kamarainen A., Huhtala H., Silfvast T., Nurmi J., Virkkunen I., et al. Physician-staffed helicopter emergency medical service has a beneficial impact on the incidence of prehospital hypoxia and secured airways on patients with severe traumatic brain injury. Scandinavian journal of trauma, resuscitation and emergency medicine 2017; 25(1) 94. Medline
II Supportive (Green) mortality Patient PH-Paramedic Pham H., Puckett Y., Dissanaike S. Faster on-scene times associated with decreased mortality in Helicopter Emergency Medical Services (HEMS) transported trauma patients. Trauma surgery & acute care open 2017; 2(1) e000122. Medline
II Supportive (Green) Survival Patient Other Schneider AM, Ewing JA, Cull JD. Helicopter Transport of Trauma Patients Improves Survival Irrespective of Transport Time. Am Surg 2021; 87(4):538. Medline
II Supportive (Green) Mortality Process Other Stewart K, Garwe T, Oluborode B, Sarwar Z, Albrecht RM. Association of Interfacility Helicopter versus Ground Ambulance Transport and in-Hospital Mortality among Trauma Patients. PEC 2020:1-9. Medline
II Supportive (Green) Mortality Patient In-Patient Stewart K, Garwe T, Oluborode B, Sarwar Z, Albrecht RM. Association of Interfacility Helicopter versus Ground Ambulance Transport and in-Hospital Mortality among Trauma Patients. PEC 2020:1-9. Medline
II Supportive (Green) out of hospital time Process ED-Paramedic & MD Stowell A, Bobbia X, Cheret J, Genre Grandpierre R, Moreau A, Pommet S, et al. Out-of-hospital Times Using Helicopters Versus Ground Services for Emergency Patients. Air Med J 2019; 38(2):100-5. Medline
II Supportive (Green) Inhospital Mortality Patient PH-Paramedic & CCT Werman HA., Darbha S., Cudnik M., Caterino J. Do Trauma Patients Aged 55 and Older Benefit from Air Medical Transport? PEC; 21(4) 461-5. Medline
II Neutral (Yellow) Survival Patient Ahmed N. Survival of Trauma Victims Transported by Helicopter Who Required Cardiopulmonary Resuscitation Within the First Hour of Hospital Arrival. South Med J; 109(4):213-9. Medline
II Neutral (Yellow) 1-year mortality Patient Other Alstrup K, Rognås L, Sollid S, Johnsen SP, Valentin JB, Petersen JAK. Association of Helicopter vs Ground Emergency Medical Transportation With 1-Year Mortality in Denmark. JAMA Netw Open 2021; 4(1):e2033318. Medline
II Neutral (Yellow) In-hospital mortality. Patient Al-Thani H., El-Menyar A., Pillay Y., Mollazehi M., Mekkodathil A., Consunji R. Hospital Mortality Based on the Mode of Emergency Medical Services Transportation. Air Med J 2017; 36(4):188-92. Medline
II Neutral (Yellow) Survival Patient Buntman AJ., Yeomans KA. The effect of air medical transport on survival after trauma in johannesburg, south africa. S Afr Med J 2002; 92(10):807-11. Medline
II Neutral (Yellow) Patients requiring a procedure from a trauma surgeon or specialist within 1 hour of arrival Patient PH-Paramedic Horwood CR, Ricci K, Sobol CG, Evans D, Eiferman D. Stop Flying the Patients! Evaluation of the Overutilization of Helicopter Transport of Trauma Patients. J Surg Res 2020; 256:290-4. Medline
II Neutral (Yellow) Mortality Patient Other Sborov KD, Gallagher KC, Medvecz AJ, Brywczynski J, Gunter OL, Guillamondegui OD, et al. Impact of a New Helicopter Base on Transport Time and Survival in a Rural Adult Trauma Population. J Surg Res 2020; 254:135-41. Medline
II Neutral (Yellow) Mortality Patient PH-Paramedic & MD Tsuchiya A., Tsutsumi Y., Yasunaga H. Outcomes after helicopter versus ground emergency medical services for major trauma--propensity score and instrumental variable analyses: A retrospective nationwide cohort study. Scandinavian journal of trauma, resuscitation and emergency medicine. 2016;24(1):140. Medline
III Supportive (Green) Hospital resource utilization, ICU admission, mortality Patient PH-MD & CCT Sebastian C., Collopy K., Clancy TV., Acquista E. Analysis of Helicopter-Transported Trauma Patients at a Regional Trauma Center. Am Surg 2018; 84(6) 952-8. Medline
III Neutral (Yellow) Mortality Patient PH-Paramedic & CCT Björkman J, Laukkanen-Nevala P, Olkinuora A, Pulkkinen I, Nurmi J. Short-term and long-term survival in critical patients treated by helicopter emergency medical services in Finland: a registry study of 36 715 patients. BMJ Open 2021; 11(2):e045642. Medline
III Neutral (Yellow) Description of interventions performed Process PH-Paramedic & MD Boyd LR, Borawski J, Lairet J, Limkakeng AT Jr. Critical Care Air Transport Team severe traumatic brain injury short-term outcomes during flight for Operation Iraqi Freedom/Operation Enduring Freedom. J R Army Med Corps. 2017;163(5):342–346. Medline
III Neutral (Yellow) Percentage of patients requiring intervention Patient PH-MD & CCT Gavrilovski M, Griggs JE, Ter Avest E, Lyon RM. The contribution of helicopter emergency medical services in the pre-hospital care of penetrating torso injuries in a semi-rural setting. Scand J Trauma Resusc Emerg Med 2021; 29(1):112. Medline
X Not Yet Graded (White) - Galvagno SM Jr., Haut ER., Zafar SN., et al. Association between helicopter vs ground emergency medical services and survival for adults with major trauma. JAMA 2012; 307(15):1602-10. Medline
X Not Yet Graded (White) - Hannay RS., Wyrzykowski AD., Ball CG., Laupland K., Feliciano DV. Retrospective review of injury severity, interventions and outcomes among helicopter and nonhelicopter transport patients at a level 1 urban trauma centre. Can J Surg 2014;.57(1):49-54. Medline

Intubation
Level Direction Primary Outcome Patient/Process Setting Reference
II Opposes (Red) Mortality Patient PH-Paramedic Chou D., Harada MY., Barmparas G., et al. Field intubation in civilian patients with hemorrhagic shock is associated with higher mortality. The journal of trauma and acute care surgery. 2016;80(2):278-82. Medline
II Opposes (Red) Mortality Patient ED-Paramedic & MD Hatchimonji JS, Dumas RP, Kaufman EJ, Scantling D, Stoecker JB, Holena DN. Questioning dogma: does a GCS of 8 require intubation? Eur J Trauma Emerg Surg 2021; 47(6):2073–9. Medline

IV access
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) in hospital mortality Patient PH-Paramedic Bores SA., Pajerowski W., Carr BG., Holena D., Meisel ZF., Mechem CC., et al. The Association of Prehospital Intravenous Fluids and Mortality in Patients with Penetrating Trauma. J Emerg Med 2018; 54(4) 487-99.e6. Medline

Ketamine
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Adverse events Patient ED-MD Cevik E., Bilgic S., Kilic E., Cinar O., Hasman H., Acar AY., et al. Comparison of ketamine-low-dose midozolam with midazolam-fentanyl for orthopedic emergencies: a double-blind randomized trial. Am J Emerg Med 2013; 31(1):108-13. Medline
II Supportive (Green) Change in pain score Patient Bronsky E.S., Koola C., Orlando A., Redmond D., D'Huyvetter C., Sieracki H., Tanner II A., Fowler R., Mains C., Bar-Or D., Intravenous Low-Dose Ketamine Provides Greater Pain Control Compared to Fentanyl in a Civilian Prehospital Trauma System: A Propensity Matched Analysis, 2019; Prehospital Emergency Care, 23:1, 1-8, DOI: 10.1080/10903127.2018.1469704 Medline
II Neutral (Yellow) Chronic Pain Patient PH-Paramedic Jennings PA., Cameron P., Bernard S., et al. Long-term pain prevalence and health-related quality of life outcomes for patients enrolled in a ketamine versus morphine for prehospital traumatic pain randomised controlled trial. Emerg Med J 2014; 31(10):840-3. Medline
III Supportive (Green) Reduction in pain Patient ED-MD Goltser A., Soleyman-Zomalan E., Kresch F., Motov S. Short (low-dose) ketamine infusion for managing acute pain in the ED: Case-report series. Am J Emerg Med 2015; 33(4):e5-7. Medline
III Neutral (Yellow) Pain Relief Patient PH-Paramedic Jennings PA., Cameron P., Bernard S. Ketamine as an analgesic in the pre-hospital setting: a systematic review. Acta Anaesthesiol Scand 2011; 55(6):638-43. Medline

Ketorolac (Toradol)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Pain level Patient ED-MD Turner NJ, Long DA, Bongiomo JR, Katoski TP, Jin LM, Horsch JP, et al. Comparing two doses of intramuscular ketorolac for treatment of acute musculoskeletal pain in a military emergency department. Am J Emerg Med 2021; 50:142–7. Medline
II Supportive (Green) Pain level Patient ED-MD Buccelletti F., Marsiliani D., Zuccala G., et al. Paracetamol-codeine compared to ketorolac for pain control in the emergency department. Eur Rev Med Pharmacol Sci 2014; 18(20):3139-43. Medline

Manual Intraosseous Insertion
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) First attempt success Patient Sunde G., Heradstveit B., Vikenes B., HeltneJ. Emergency intraosseous access in a helicopter emergency medical service: a retrospective study. Scan J Trauma, Resus and Emerg Med 2010; 18:52. Medline
III Supportive (Green) Insertion time Process Hartholt KA., van Lieshout EM., Thies WC., Patka P., Schipper IB. Intraosseous devices: A randomized controlled trial comparing three intraosseous devices. Prehosp Emerg Care 2010; 14(1):6-13. Medline
III Supportive (Green) Successful placement Process ED-MD Leidel BA., Kirchhoff C., Bogner V., Braunstein V., Biberthaler P., Kanz KG. Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation 2012; 83(1):40-5. Medline
III Supportive (Green) Time to blood Process PH-Paramedic Olaussen A., Williams B. Intraosseous access in the prehospital setting: Literature review. Prehosp Disaster Med 2012; 27(5):468-72. Medline
III Neutral (Yellow) Number of attempts required Process SIM Brenner T., Bernhard M., Helm M., Doll S., Völkl A., Ganion N., Friedmann C., Sikinger M., Knapp J., Martin E., Gries A. Comparison of two intraosseous infusion systems for adult emergency medical use. Resuscitation 2008; 78:314-9. Medline

Mechanical Intraosseous Insertion
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Successful placement Process Dolister M., Miller S., Borron S., et al. Intraosseous vascular access is safe, effective and cost less than central venous catheters for patients in the hospital setting. J Vasc Access 2013; 14(3):216-24. Medline
II Supportive (Green) First attempt success Patient Sunde G., Heradstveit B., Vikenes B., HeltneJ. Emergency intraosseous access in a helicopter emergency medical service: a retrospective study. Scan J Trauma, Resus and Emerg Med 2010; 18:52. Medline
II Neutral (Yellow) 30-day in-hospital mortality Patient ED-MD Tan BK., Chong S., Koh ZX., Ong ME. EZ-IO in the ED: An observational, prospective study comparing flow rates with proximal and distal tibia intraosseous access in adults. Am J Emerg Med 2012; 30(8):1602-1606. Medline
III Supportive (Green) Cervical-spine movement Process OR Brenner T., Bernhard M., Helm M., Doll S., Völkl A., Ganion N., Friedmann C., Sikinger M., Knapp J., Martin E., Gries A. Comparison of two intraosseous infusion systems for adult emergency medical use. Resuscitation 2008; 78:314-9. Medline
III Supportive (Green) Success of EZ-IO insertion Process Davidoff J., Fowler R., Gordon D., et al. Clinical evaluation of a novel intraosseous device for adults: Prospective, 250-patient, multi-center trial. JEMS 2005; 30(10):s20-30. Medline
III Supportive (Green) Success rate on first attempt Process Gazin N., Auger H., Jabre P., et al. Efficacy and safety of the EZ-IO intraosseous device: Out-of-hospital implementation of a management algorithm for difficult vascular access. Resuscitation 2011; 82(1):126-9. Medline
III Supportive (Green) Insertion time Process Hartholt KA., van Lieshout EM., Thies WC., Patka P., Schipper IB. Intraosseous devices: A randomized controlled trial comparing three intraosseous devices. Prehosp Emerg Care 2010; 14(1):6-13. Medline
III Supportive (Green) Time (seconds) for successful access Process Lamhaut L., Dagron C., Apriotesei R., et al. Comparison of intravenous and intraosseous access by pre-hospital medical emergency personnel with and without CBRN protective equipment. Resuscitation 2010; 81(1):65-68. Medline
III Supportive (Green) Successful insertion Process Levitan RM., Bortle CD., Snyder TA., Nitsch DA., Pisaturo JT., Butler KH. Use of a battery-operated needle driver for intraosseous access by novice users: Skill acquisition with cadavers. Ann Emerg Med 2009; 54(5):692-4. Medline
III Supportive (Green) Validity Process ICU Olaussen A., Williams B. Intraosseous access in the prehospital setting: Literature review. Prehosp Disaster Med 2012; 27(5):468-72. Medline
III Supportive (Green) First attempt success Process SIM Ong ME., Ngo AS., Wijaya R. An observational, prospective study to determine the ease of vascular access in adults using a novel intraosseous access device. Ann Acad Med Singapore 2009; 38:121-4. Medline
III Supportive (Green) Success rate Process PH-Paramedic Santos D., Carron PN., Yersin B., Pasquier M. EZ-IO(®) intraosseous device implementation in a pre-hospital emergency service: A prospective study and review of the literature. Resuscitation 2013; 84(4):440-5. Medline
III Supportive (Green) Overall placement success Process PH-Paramedic Schalk R., Schweigkofler U., Lotz G., Zacharowski K., Latasch L., Byhahn C. Efficacy of the EZ-IO needle driver for out-of-hospital intraosseous access--a preliminary, observational, multicenter study. Scand J Trauma Resusc Emerg Med 2011; 19:65-7241-19-65. Medline
III Neutral (Yellow) First attempt success Process ED-MD Leidel BA., Kirchhoff C., Bogner V., Braunstein V., Biberthaler P., Kanz KG. Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation 2012; 83(1):40-5. Medline

Methoxyflurane (Penthrox)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Analgesia Patient ED-MD Fabbri A, Borobia AM, Ricard-Hibon A, Coffey F, Caumont-Prim A, Montestruc F, et al. Low-Dose Methoxyflurane versus Standard of Care Analgesics for Emergency Trauma Pain: A Systematic Review and Meta-Analysis of Pooled Data. J Pain Res 2021; 14:93-105. Medline
I Neutral (Yellow) Reduction in pain after 30 minutes Patient ED-MD Bond C, Westafer L, Challen K, Milne WK. Hot off the press: the RAMPED trial-methoxyflurane for analgesia in the emergency department. Acad Emerg Med 2021; 28(10):1179–82. Medline
II Supportive (Green) Pt perception of pain Patient Other Johansson A, Svensson A, Wihlborg J. Pain management with methoxyflurane (Penthrox®) in Swedish ambulance care - An observational pilot study. Int Emerg Nurs 2021; 59:101076. Medline
III Supportive (Green) Decrease in pain scale Patient PH-Paramedic Ozainne F, Cottet P, Lojo Rial C, von During S, Fehlmann CA. Methoxyflurane in Non-Life-Threatening Traumatic Pain-A Retrospective Observational Study. Healthc 2021; 9(10). Medline

Morphine
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Pain Scale Patient ED-MD Birnbaum A., Esses D., Bijur PE., Holden L., Gallagher EJ. Randomized double-blind placebo-controlled trial of two intravenous morphine dosages (0.10 mg/kg and 0.15 mg/kg) in emergency department patients with moderate to severe acute pain. Ann Emerg Med 2007; 49(4):445-53. Medline
I Supportive (Green) Pain score measured on a visual analogue scale Patient ED-MD Craig M., Jeavons R., Probert J., Benger J. Randomised comparison of intravenous paracetamol and intravenous morphine for acute traumatic limb pain in the emergency department. Emerg Med J 2012; 29(1):37-9. Medline
I Supportive (Green) Reduction in pain Patient ED-MD Farahmand S., Shiralizadeh S., Talebian MT., et al. Nebulized fentanyl vs intravenous morphine for ED patients with acute limb pain: A randomized clinical trial. Am J Emerg Med 2014; 32(9):1011-5. Medline
I Supportive (Green) Reduction in pain Patient ED-MD Furyk JS., Grabowski WJ., Black LH. Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: A randomized controlled trial. Emerg Med Australas 2009; 21(3):203-9. Medline
I Supportive (Green) Pain relief using the visual analog scale score Patient PH-Paramedic Galinski M., et al. A randomized double-blind study comparing morphine with fentanyl in prehospital analgesia. Am J Emerg Med 2005; 23:114-9. Medline
I Supportive (Green) Pain relief Patient ED-MD Miller JP., Schauer SG., Ganem VJ., Bebarta VS. Low-dose ketamine vs morphine for acute pain in the ED: A randomized controlled trial. Am J Emerg Med 2015; 33(3):402-8. Medline
I Supportive (Green) VAS scores Patient ED-MD Miner JR., Moore J., Gray RO., Skinner L., Biros MH. Oral versus intravenous opioid dosing for the initial treatment of acute musculoskeletal pain in the emergency department. Acad Emerg Med 2008; 15(12):1234-40. Medline
I Supportive (Green) Pain relief Patient Niemi-Murola L., Unkuri J., Hamunen K. Parenteral opioids in emergency medicine - A systematic review of efficacy and safety. Scandinavian journal of pain 2017; 2(4):187-94. Medline
I Supportive (Green) Efficacy Patient PH-Paramedic Vergnion M., Degesves S., Garcet L., Magotteaux V. Tramadol, an alternative to morphine for treating posttraumatic pain in the prehospital situation. Anesth Analg 2001; 92(6):1543-1546. Medline
II Supportive (Green) Analgesia Patient PH-Paramedic Ricard-Hibon A., et al. Compliance with a morphine protocol and effect on pain relief in out-of-hospital patients. J Emerg Med 2008; 34:305-10. Medline
II Neutral (Yellow) Adverse events Patient ED-Paramedic & MD Bible L, Obaid O, Khurrum M, Goh M, Hammad A, Kitts DJ, et al. Pre-Hospital Administration of Opioids in Trauma Patients: Is Dose Associated With Outcomes? J Surg Res 2021; 268:634–42. Medline
II Neutral (Yellow) Chronic Pain Patient PH-Paramedic Jennings PA., Cameron P., Bernard S., et al. Long-term pain prevalence and health-related quality of life outcomes for patients enrolled in a ketamine versus morphine for prehospital traumatic pain randomised controlled trial. Emerg Med J 2014; 31(10):840-3. Medline
II Neutral (Yellow) Likelihood of receiving analgesic Patient PH-Paramedic Michael GE., Sporer KA., Youngblood GM. Women are less likely than men to receive prehospital analgesia for isolated extremity injuries. Am J Emerg Med 2007; 25:901-6. Medline
III Supportive (Green) Pain relief (NRS or VAS) Patient PH-Paramedic Dijkstra BM., Berben SA., van Dongen RT., Schoonhoven L. Review on pharmacological pain management in trauma patients in (pre-hospital) emergency medicine in the Netherlands. Eur J Pain 2013; 18(1):3-19. Medline
III Supportive (Green) Time to morphine administration Process PH-Paramedic Fullerton-Gleason L., Crandall C., Sklar D. Prehospital Administration of Morphine for Isolated Extremity Injuries: A Change in Protocol Reduces Time to Medication. Prehospital Emergency Care 2002; 6(4):411-6. Medline
III Supportive (Green) Pain Relief Patient PH-Paramedic Park CL., Roberts DE., Aldington DJ., Moore RA. Prehospital analgesia: systematic review of evidence. J R Army Med Corps 2010; 156(4 S1):295-300. Medline
III Supportive (Green) Analgesia Patient PH-Paramedic Rickard C., et al. A RCT of intranasal fentanyl vs intravenous morphine for analgesia in the prehospital setting. Am J Emerg Med 2007; 25:911-7. Medline
III Neutral (Yellow) Administration of analgesics Patient PH-Paramedic White LJ., Cooper JD., Chambers RM., Gradisek RE. Prehospital use of analgesia for suspected extremity fractures. PEC 2000; 4:205-08. Medline

Nitrous Oxide
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Pain at 15 minutes Patient PH-Paramedic Ducasse JL., Siksik G., Durand-Bechu M., Couarraze S., Valle B., Lecoules N., et al. Nitrous oxide for early analgesia in the emergency setting: a randomized, double-blind multicenter prehospital trial. Acad Emerg Med 2013; 20(2):178-84. Medline
III Supportive (Green) Patient satisfaction Patient PH-Paramedic Johnson JC., Atherton Gl. Effectiveness of Nitrous Oxide in a rural EMS System. The Journal of Emergency Medicine 1991; 9:45-53. Medline
III Neutral (Yellow) Administration of analgesics Patient PH-Paramedic White LJ., Cooper JD., Chambers RM., Gradisek RE. Prehospital use of analgesia for suspected extremity fractures. PEC 2000; 4:205-08. Medline

NSAIDs
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Change in Faces Pain Scale over time Patient ED-MD Koller DM., Myers AB., Lorenz D., Godambe SA. Effectiveness of oxycodone, ibuprofen, or the combination in the initial management of orthopedic injury-related pain in children. Pediatr Emerg Care 2007; 23(9):627-33. Medline
III Neutral (Yellow) pain relief (NRS or VAS) Patient PH-Paramedic Dijkstra BM., Berben SA., van Dongen RT., Schoonhoven L. Review on pharmacological pain management in trauma patients in (pre-hospital) emergency medicine in the Netherlands. Eur J Pain 2013; 18(1):3-19. Medline

Optimal Trip Destination
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Survival Patient ED-MD Ashley DW., Pracht EE., Medeiros RS., et al. An analysis of the effectiveness of a state trauma system: Treatment at designated trauma centers is associated with an increased probability of survival. J Trauma Acute Care Surg 2015; 78(4):706-14. Medline
II Supportive (Green) In-hospital mortality Process In-Patient CA S, BY G, Nieboer D, Steyerberg EW, Den Hartog D, D Van Klaveren. Identifying trauma patients with benefit from direct transportation to Level-1 trauma centers. BMC Emerg Med 2021; 21(1):93. Medline
II Supportive (Green) Survival Patient PH-Paramedic Garwe T., Cowan LD., Neas BR., Sacra JC., Albrecht RM. Directness of transport of major trauma patients to a level I trauma center: A propensity-adjusted survival analysis of the impact on short-term mortality. J Trauma 2011; 70(5):1118-27. Medline
II Supportive (Green) 30 Day mortality and function Patient PH-Paramedic Kelly ML., Roach MJ., Banerjee A., Steinmetz MP., Claridge JA. Functional and long-term outcomes in severe traumatic brain injury following regionalization of a trauma system. J Trauma Acute Care Surg 2015; 79(3):372-7. Medline
II Supportive (Green) In-hospital mortality. Patient Mans S., Reinders FE., de Jongh MA., Lansink KW. Direct transport versus inter hospital transfer of severely injured trauma patients. Injury 2016; 47(1):26-31. Medline
II Supportive (Green) Mortality Patient ED-MD Morshed S., Knops S., Jurkovich GJ., Wang J., MacKenzie E., Rivara FP. The impact of trauma-center care on mortality and function following pelvic ring and acetabular injuries. J Bone Joint Surg Am 2015; 97(4):265-72. Medline
II Neutral (Yellow) Overall Mortality Process ED-MD Billeter AT., Miller FB., Harbrecht BG., et al. Interhospital transfer of blunt multiply injured patients to a level 1 trauma center does not adversely affect outcome. Am J Surg 2014; 207(4):459-66. Medline
II Neutral (Yellow) In-hospital mortality Patient PH-Paramedic Hill AD., Fowler RA., Nathens AB. Impact of interhospital transfer on outcomes for trauma patients: A systematic review. J Trauma 2011; 71(6):1885-900. Medline
II Neutral (Yellow) Percentage of patients diagnosed with TBI on CT scan Patient PH-Paramedic Lecky FE., Russell W., McClelland G., Pennington E., Fuller G., Goodacre S., et al. Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial. BMJ open 2017; 7(10) e016355. Medline
II Neutral (Yellow) Duration of hospital stay Patient ED-MD Metcalfe D., Bouamra O., Parsons NR., Aletrari MO., Lecky FE., Costa ML. Effect of regional trauma centralization on volume, injury severity and outcomes of injured patients admitted to trauma centres. Br J Surg 2014; 101(8):959-64. Medline
II Neutral (Yellow) Mortality Patient ED-MD Tallon JM., Fell DB., Ackroyd-Stolarz S., Petrie D. Influence of a new province-wide trauma system on motor vehicle trauma care and mortality. J Trauma 2006; 60:1-5. Medline
II Neutral (Yellow) Mortality (at 24 hours and 30 days) Patient van der Wilden GM., Janjua S., Wedel SK., et al. Multi-institutional comparison of helicopter transfers directly to the operating room versus the pit stop in the emergency department. Am Surg 2013; 79(9):939-943. Medline
III Supportive (Green) Mortality Patient PH-Paramedic Sanson G., Di Bartolomeo S., Nardi G., et al. Road traffic accident with vehicular entrapment: incidence of major injuries and need for advanced life support. Eur J Emerg Med 1999; 6(4):285-91. Medline
X Not Yet Graded (White) - Candefjord S, Asker L, Caragounis EC. Mortality of trauma patients treated at trauma centers compared to non-trauma centers in Sweden: a retrospective study. Eur J Trauma Emerg Surg 2022; 48(1):525–36. Medline
X Not Yet Graded (White) - Rogers FB, Morgan ME, Brown CT, Vernon TM, Bresz KE, Cook AD, et al. Geriatric Trauma Mortality: Does Trauma Center Level Matter? Am Surg 2021; 87(12):1965–71. Medline
X Not Yet Graded (White) - Wong TH., Lumsdaine W., Hardy BM., Lee K., Balogh ZJ. The impact of specialist trauma service on major trauma mortality. J Trauma Acute Care Surg 2013; 74(3):780-784. Medline

Oxygen
Level Direction Primary Outcome Patient/Process Setting Reference
III Neutral (Yellow) Trauma mortality relative to hyper-oxyemia Patient ED-MD Baekgaard JS, Abback P, Boubaya M, Moyer J, Garrigue D, Raux M, et al. Early hyperoxemia is associated with lower adjusted mortality after severe trauma: results from a French registry. Critical Care 2020; 24(1). Medline
III Neutral (Yellow) Oxygenation status Patient PH-Paramedic & MD Eskesen TG., Baekgaard JS., Christensen RE., Lee JM., Velmahos GC., Steinmetz J., et al. Supplemental oxygen and hyperoxemia in trauma patients A prospective, observational study. Acta Anaesthesiol Scand 2018. Medline

Oxygen-high flow
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Incidence of hyperoxemia Process PH-Paramedic Leitch P, Hudson AL, Griggs JE, Stolmeijer R, Lyon RM, Ter Avest E. Incidence of hyperoxia in trauma patients receiving pre-hospital emergency anaesthesia: results of a 5-year retrospective analysis. Scand J Trauma Resusc Emerg Med 2021; 29(1):134. Medline
II Opposes (Red) All cause mortality Patient In-Patient Baekgaard J, Siersma V, Christensen RE, Ottosen CI, Gyldenkærne KB, Garoussian J, Baekgaard ES, Steinmetz J, Rasmussen LS. A high fraction of inspired oxygen may increase mortality in intubated trauma patients - A retrospective cohort study. Injury 2022; 53(1):190–7. Medline

Oxygen-titrated
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Hyperoxia Patient ED-Paramedic & MD Leitch P, Hudson AL, Griggs JE, Stolmeijer R, Lyon RM, Ter Avest E. Incidence of hyperoxia in trauma patients receiving pre-hospital emergency anaesthesia: results of a 5-year retrospective analysis. Scand J Trauma Resusc Emerg Med 2021; 29(1):134. Medline

Point of Care Lactate
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Trauma centre need Patient Brown JB., Lerner EB., Sperry JL., Billiar TR., Peitzman AB., Guyette FX. Prehospital lactate improves accuracy of prehospital criteria for designating trauma activation level. The journal of trauma and acute care surgery 2016; 81(3):445-52. Medline
II Supportive (Green) Prediction of need for resuscitative care Process PH-Paramedic Guyette FX., Meier EN., Newgard C., et al. A comparison of prehospital lactate and systolic blood pressure for predicting the need for resuscitative care in trauma transported by ground. J Trauma Acute Care Surg 2015; 78(3):600-6. Medline
II Supportive (Green) Utility Process Lewis CT., Naumann DN., Crombie N., Midwinter MJ. Prehospital point-of-care lactate following trauma: A systematic review. The Journal of Trauma and Acute Care Surgery 2016; 81(4):748-55. Medline
II Neutral (Yellow) Detection of early hemorrhagic shock Process PH-Paramedic & MD Galvagno S Jr, Sikorski RA, Floccare DJ, Rock P, Mazzeffi MA, DuBose JJ, et al. Prehospital Point of Care Testing for the Early Detection of Shock and Prediction of Lifesaving Interventions. Shock 2020; 54(6):710-6. Medline
II Neutral (Yellow) Prediction of need for resuscitative care Process PH-Paramedic St JA, McCoy AM, Moyes AG, Guyette FX, Bulger EM, Sayre MR. Prehospital Lactate Predicts Need for Resuscitative Care in Non-hypotensive Trauma Patients. The western journal of emergency medicine 2018; 19(2):224-31. Medline
III Supportive (Green) Need for resuscitative care Patient PH-Paramedic St JA, McCoy AM, Moyes AG, Guyette FX, Bulger EM, Sayre MR. Prehospital Lactate Predicts Need for Resuscitative Care in Non-hypotensive Trauma Patients. The western journal of emergency medicine 2018; 19(2):224-31. Medline

Temperature Monitoring
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Mortality rate Patient ED-MD Balmer JC, Hieb N, Daley BJ, Many HR, Heidel E, Rowe S, McKnight CL. Continued Relevance of Initial Temperature Measurement in Trauma Patients. Am Surg 2022; 88(3):424–8. Medline
II Supportive (Green) Identification of coagulopathy risk factors Patient Wafaisade A., Wutzler S., Lefering R., et al. Drivers of acute coagulopathy after severe trauma: A multivariate analysis of 1987 patients. Emerg Med J 2010; 27(12):934-939. Medline
II Neutral (Yellow) MODS and mortality Patient ED-MD Beilman GJ., Blondet JJ., Nelson TR., et al. Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality. Ann Surg 2009; 249(5):845-50. Medline
II Neutral (Yellow) Sensitivity and Specificity Process Niven DJ., Gaudet JE., Laupland KB., Mrklas KJ., Roberts DJ., Stelfox HT. Accuracy of Peripheral Thermometers for Estimating Temperature: A Systematic Review and Meta-analysis. Ann Intern Med 2015; 163:768-77. Medline

Thermostasis
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Thermostasis Patient PH-Paramedic Watts DD., Roche M., Tricarico R., et al. The Utility of traditional prehospital intervention in maintaining thermostasis. Prehospital Emerg Care 1999; 3:115-122. Medline
II Supportive (Green) Hypothermia prevalence; discomfort management; rewarming outcomes Patient PH-Paramedic Mota MAL, Santos MR, Santos EJF, Henriques C, Matos A, Cunha M. Trauma Prehospital Hypothermia Prevention and Treatment: An Observational Study. J Trauma Nurs 2021; 28(3):194-202. Medline

Trauma Team Activation
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Overall (<30 days) and early (<24 hours) mortality Patient PH-Paramedic & CCT Synnot A., Karlsson A., Brichko L., Chee M., Fitzgerald M., Misra MC., et al. Prehospital notification for major trauma patients requiring emergency hospital transport A systematic review. Journal of evidence-based medicine 2017; 10(3) 212-21. Medline


[ PEP Database - Table of Contents ] [ Email: PEP@Dal.ca ]