Pre-hospital interventions: introduction to life support systems

B-ENT, 2016, 12, Suppl. 26/1, 41-54

Introduction

Despite initially seeming rather far from thedaily practice of otorhinolaryngology, pre-hospital interventions (PHI) will strongly influence the clinical presentation of the patient at the emergency department (ED) or operation room (OR). The ENT specialist should be aware of the major processes involved in the early assessment and management of casualties by emergency medical services (EMS) or TEMS if available

All around the world, trauma continues to be the main cause of disability and death for people under the age of 40 years.1 In a recent US review of a total of 17,479,328 EMS events, the most common level of PHI was BLS (55.2%). In a large majority (72.3%) of cases, a single patient was involved, while mass casualty incidents only occurred in 0.5% of all events. The most common reported locations of EMS interventions were homes (48.4%), followed by actions on streets or highways (37.0%), and interventions in public buildings (6.3%).2

It is, nowadays, widely recognized that outcomes after injury have been improved by the introduction of efficient pre-hospital life support and early transfer, and completed by a continuum of treatment from the time of injury to the return to the activities of daily life.3

In the initial stages of development of PHI, experts considered that an EMS system with capabilities for rapid response, patient extrication, BLS, ALS, standardized radio communication systems and procedures and transportation should provide appropriate care for a wide spectrum of injured and acutely ill patients.4 Since the 1970s, several treatment protocols have been developed for specific injuries and rapid transport, in order to reduce time at the scene5 and ultimately to improve patient outcomes.6

Finally, the establishment of specialized educa-tional programs, for the conservation of expertise and resources and for the promotion of knowledge and manipulative skill of EMS medics and para-medics, was considered to be pivotal in providing

Pre-hospital interventions: introduction to life support systems

J.-C. de Schoutheete1, S. Hachimi Idrissi2 and J.-B. Watelet3

1Department of Surgery. Queen Astrid Military Hospital, Bruynstraat 1, 1120 Brussels, Belgium; 2Department of Emergency Medicine. Ghent University Hospital, De Pintelaan 185. 9000 Ghent, Belgium; 3Department of Otorhinolaryngology. Ghent University Hospital, De Pintelaan 185. 9000 Ghent, Belgium

Key-words. Emergency medical services; disasters; otorhinolaryngology

Abstract. Pre-hospital interventions: introduction to life support systems. Crucial decisions in pre-hospital emergency care are often made; therefore, a tactical emergency medical support team (TEMS) should maintain the capacity to capture the situation instantaneously and in all circumstances. However, low exposure to severe trauma cases can be a weakness for emergency specialists, which makes pre-hospital assessment more difficult. Pre-hospital interventions (PHI) are usually classified in Western countries into BLS (basic life support) and ALS (ad-vanced life support) levels, according to the methods used. This review introduces tactical combat casualty care for medi-cal personnel (TCCC) guidelines, designed for basic care management under fire or in a hostile environment. The phases of TCCC are: (1) care under fire (or in an unstable environment); (2) tactical field care; and (3) tactical evacuation care, and are mainly dependent on the different hazard zones (hot, warm or cold).In a mass casualty situation due to disaster or cataclysm, standardized protocol and triage are unquestionably required for identifying the environmental risks, for categorizing the casualties in accordance with medical care priorities, and for the initial management of casualty care. When considering conflict situations, or chemical, biological, radiological, or nuclear (CBRN) events, processes always start at the local level. Even before the detection and analysis of agents can be undertaken, zoning, triage, decontamination, and treatment should be initiated promptly. Otorhinolaryngologists should be aware of PHI procedures for completing preliminary assessment and management together with emergency specialists or TEMS.

04-De Schoutheete-.indd 41 4/11/16 17:00

42 J.-C. de Schoutheete

dissemination of the course. ATLS has become the standard for trauma care in American emergency departments and advanced paramedical services, for providing a safe and reliable method for the immediate management of injured patients. Initially, the accumulated data in the literature failed to demonstrate a benefit for on-site ALS provided to trauma patients.18

Similarly, the National Association of Emergency Medical Technicians has developed the pre-hospital trauma life support (PHTLS) course for EMS.19 The mission of PHTLS is to promote excellence in trauma patient management by all providers involved in the delivery of pre-hospital care, through global education. PHTLS courses and training, developed in cooperation with the American College of Surgeons’ Committee on Trauma, aim to improve the quality of trauma care, based on a pre-hospital trauma care philosophy, and stressing the treatment of the multi-system trauma patient as a unique entity with specific needs.

The International Trauma Life Support (ITLS) Committee publishes ITLS Basic and ITLS Advanced courses for pre-hospital professionals as well.Since 1993, combat medical personnel in the US and in many NATO countries are now trained to manage combat trauma on the battlefield using the tactical combat casualty care for medical personnel (TCCC) guidelines adapted per each country. TCCC started as a biomedical research project in the US Special Operations Command, and the original TCCC paper was published in Military Medicine in 1996.20 In the TCCC Guidelines, which are dedicated to basic management for care under fire or in hostile environment,21the recommended attitudes are highly dependent on the tactical situation, the injuries sustained by the casualty, the knowledge and skills of the first responder, and the medical equipment at hand. This approach also serves as a basis for the management of mass casualty incidents. By extension, military procedures have sustained safer and more efficient recommendations in case of industrial disaster, occupational exposure, natural catastrophe, war-fare, or acts of terrorism. A strict zoning, triage, decontamination, and treatment should be prompt-ly initiated, even before the final identification of agents.22 From this military experience emerged a three-fold paradigm:23

close medical supervision and support.7 As in other medical disciplines, the development and dissemi-nation of evidence-based recommendations from trauma practitioners regarding appropriate PHI were justified on basis of the following factors:

- The time required for transportation to the trauma centre, to be as short as possible;8

- The possible dramatic consequences in the case of inadequate PHI9 or patient triage,10

- The enduring and significant emphasis placed by EMS staff on initial impressions and immediately observable information within decision-making, rather than the use of measurable vital parameters.11

Short history of pre-hospital medical interven-tions: civilian and military contributions

Pre-hospital care is typically classified into ALS (advanced life support)12 and BLS (basic life support)13 levels, according to the methods used. Advanced life support (ALS) is a set of life-saving protocols and skills that extend basic life support, in order to further support the circulation and provide an open airway and adequate ventilation.

The type of care to be provided during the pre-hospital period has been debated for a long time. During the early years of PHI development, BLS was considered to be an appropriate system of care for patients at pre-hospital level,14 although today opinions have changed.15 Due to limited financial resources, to the heterogeneity in educational level of the rescue personnel and to a variability of protocols, for some countries, a balance between “scoop and run” (BLS) and “stay and play” (ALS) is probably the best political and operational pre-hospital approach.16

ALS providers may perform more invasive pre-hospital procedures, while BLS providers only offer stabilization care, and often “scoop and run”. The ALS paradigm finally developed into more surgical (advanced trauma life support) or medical (advanced cardiac life support) orientations.

ATLS was developed by the American College of Surgeons (ACS) Committee on Trauma (COT), after its original introduction by James K. Styner, an orthopaedic surgeon, and the Lincoln Medical Education Foundation, who produced the initial ATLS course in 1978.17 In 1980, the American College of Surgeons Committee on Trauma adopted ATLS and began US and international


Pre-hospital Interventions 43

Introducing tactical combat casualty care(tccc)

This review focuses on TCCC for several reasons:- This concept is already in use in several

NATO military structures. TCCC is designed for combat, and is not specifically designed for civilian trauma care; however, it may have applicability in certain settings, and is in use in several civilian organizations such as Fire Departments and civilian protection.

- It integrates the most recent evidence in the field of PHI.

- It considers all aspects of a PHI within hostile environment, from patient status to the safety of health care professionals.

- It provides understandable, accurate and stratified processes.

Goals of TCCC

In contrast to a civilian emergency setting, where the patient is the mission, on the battlefield the care of casualties sustained is only part of the military mission.

The three primary goals of TCCC remain: (1) treat the casualty, (2) prevent additional casualties, (3) complete the mission, in order to accomplish it with minimal casualties and to keep the response team maximally engaged in neutralizing the existing threat. The other goals—to prevent any casualty from sustaining additional injuries and to minimize public harm—are of both military and civilian interest.

Phases and general principles of TCCC

The phases of TCCC are: 1) Care under fire (or in an unstable environment):

the casualty is still under an effectively hostile situation. Available medical equipment is limited to that carried by the individual or by the medical provider in his or her first aid bag. The following items are pivotal during this phase:

- Establishment of a tactical supremacy and deferment of in-depth medical interventions if engaged in an on-going direct threat (e.g., active fire fight, unstable building collapse, dynamic post-explosive scenario, etc.).

- Threat mitigation techniques to minimize the risk to casualties and providers. These should include techniques and tools for rapid casualty access and egress.

- improve immediate care for injuries of any type,24

- increase the capability for recognizing and treating a variety of infectious and other diseases (and by extension, other hazards);

- become the advisor to the unit/team commander in the areas of preventive medicine, medical planning, medical intelligence, logistics, and coordination of evacuation.

This remains the basis for military special operations medical support, and can also be seen in the development of civilian EMS over the past 15 years. Finally, the military medical corps has gathered a great deal of valuable experience in the field of medical evacuation, such as during the current International Security Assistance Force (ISAF) NATO mission in Afghanistan.25

There is a direct line from the evolution of medical support for military special operations forces, especially in the United States of America after World War II, to what is now recognized as tactical emergency medical support (TEMS) in civilian law enforcement and public protection.26 In several countries, professional organizations within law enforcement and emergency medicine have identified and supported the fundamental need for mission safety and the development of a standard model for training and incorporating TEMS into law enforcement special operations. The foundations of TEMS are evidence-based,27,28,29

and its overall objective is to minimize the potential for injury and illness of the people involved, and to promote optimal medical care from the scene of operations to a definitive care facility. Concretely, it (1) reduces the mortality of police staff and the public, (2) positively influences the rescue team (fire crew, police officers, etc.), who know that a trained medical intervention team is quickly available, (3) reduces the feeling of failure in the rescue team, because the responsibility is spread throughout the team, (4) may avoid medical transportations of injured criminals to the nearest non-secured hospital, if medical stabilization by trained staff can take place at the site of contact, and (5) increases the efficiency of the rescue team by this “one head” coordination model. The design, staffing, and implementation of a TEMS program that maximally uses community resources can integrate the previously disparate functions of law enforcement, EMS, and the emergency medical/trauma centre to form a new continuum of care.30



possible life-threatening diagnoses should be systematically investigated, such as costal fracture, flail chest, pulmonary contusion, haemothorax, myocardial contusion, tamponade, heart stunning, aortic dissection, tracheobronchial rupture and diaphragmatic rupture. All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect.

Concerning bleeding, a complete assessment by medics for unrecognized haemorrhage should be performed and all sources of bleeding controlled.

Through an intravenous (IV) access, damage control resuscitation (DCR) can be launched with fluid and pharmacological resuscitation (cfr Chapter 5: Facing coagulation disorders after acute trauma). Prevention of hypothermia, analgesia, initial management of eye trauma, stabilization of fractures, covering of burn area32,33 and even possibly cardiopulmonary resuscitation (CPR)34,35,36

may complete the medical interventions in this phase. Antibiotics are recommended for all open wounds (combat or not).

Finally, clinical assessments, treatments rendered, and changes in the casualty’s stability are documented on a TCCC casualty card (DD Form 1380) for adequate forward to the next level of care (cfr Figure 1).

Phase 3: basic management plan for tactical evacuation care

On a battlefield, the term “tactical evacuation” includes both casualty evacuation (CASEVAC) and medical evacuation (MEDEVAC). In a civilian setting, this refers mainly to casualty evacuation.

At this stage, if not already performed during the previous steps, the entire protocol of Phase 2 is launched. If already completed in Phase 2, the third phase focuses on reassessment and rechecking of aspects such as the vital parameters, the previous medical management of airway disorders, haemorrhages and burn wounds. This view is in line with the ATLS procedures. (1) First detected, first treated. (2) If any change in the vital parameters should occur, a new screening should be performed from the beginning. (3) When primary evaluation is done and the patient stabilized, a secondary survey needs to be performed prior to transferring the patient. If well stabilized, as recommended above, the mode of transport will not influence the clinical outcome of the casualty.37

2) Tactical field care: the patient is no longer under effective hostile fire or environment, and the available medical equipment is still limited to that carried into the field by unit personnel. In the case of multiple casualties, triage can be considered at this phase of care, with prioritization for extraction performed by trained staff,31 based on the available resources and the tactical situation.

3) Tactical evacuation care: i.e., the care rendered once the casualty has been picked up by an aircraft, ground vehicle or boat. Additional medical personnel and equipment that may have been pre-staged should be available in this phase of casualty management.

Phase 1: basic management plan for care under fire

If needed, the medics or paramedics should take cover and direct the casualty to move to cover and apply self-aid if able. This procedure is personal: the casualty should be able to put the tourniquet and stop external bleeding, if necessary and if in a physical state to do so. The objective at this time is to try to keep the casualty from sustaining additional wounds and to move them to a place of relative safety.

The primary medical initiatives by first aiders, paramedics or medics are oriented towards:

a) the control of life-threatening external haemorrhage if tactically feasible, and

b) the best possible protection of the airway. The specific airway management is best deferred until the tactical field care phase.

Phase 2: basic management plan for tactical field care

The first action to be undertaken at this stage is airway management. If the victim is unconscious, without observable airway obstruction, he/she should be placed in the recovery position. In case of airway obstruction or impending airway obstruction, and when conscious, the casualty should assume any position that best protects the airway, to include sitting up.

If the previous measures are unsuccessful, a crico-thyroidotomy may be performed. In a casualty with progressive respiratory distress and known or suspected torso trauma, a tension pneumothorax (simple or open) must be searched for and, if necessary, decompressed. The other



suspect, hostage situation, fire in building, car accident on speedway or flood).

2) Warm zone: The threat level is reduced but not eliminated. A potential threat exists but is not direct or immediate. Firefighters and TEMS may be requested to enter into warm zones but this should only be done with force protection. This zone does not encompass the entire building or area, but expands as the law enforcement sweep progresses. These instances could be utilized for rapid extraction of multiple victims who need immediate assistance. Prior to entering into a warm zone, a risk versus gain analysis should be completed by TEMS, when available.

3) Cold zone: Secure area; outside the area of immediate threat. No significant danger or threat can be reasonably anticipated.

Specific issues

Conflictual context: hot, warm and cold zones

Years of continuous combat operations have enabled the US military and its coalition partners to make a number of major advances in casualty care. The coalition nations have developed efficient combat trauma systems, achieving unprecedented casualty survival rates.

The most visible contribution is the definition of hazard zones. They are defined as followed:

1) Hot zone: Unsecured; the threat continues to be active and immediate. The threat is dynamic and is determined by the complexity and circumstances of the incident (e.g., active shooter, barricaded

Figure 1TCCC Casualty Card (DD Form 1380)



There remains, however, a need to optimize the translation of new battlefield trauma care information, training, and equipment to units and individuals deploying in support of combat operations.39,40,41

In addition, the US Military needs to ensure that these advances are sustained during peace intervals, and that we continue to build upon our successes as we prepare for future conflicts.42,43 The following example is illustrative of the importance of TCCC/TEMS training. Data for casualties from the Vietnam conflict were reviewed in order to determine the potential benefit of cervical spine immobilization on the battlefield. In this population, penetrating cervical cord injury was always fatal and usually immediately so. Only 1.4% of all casualties who were candidates for immobilization might have benefitted from the care. However, the risk of performing immobilization in a hazardous environment is substantial, since about 10% of casualties are incurred while helping other casualties.44 This absolute need for the sustainability of capacities and training is also of importance at a coordination level.45,46 Finally, in terms of mass casualties, several protocols were specifically developed for optimizing pre-hospital triage and management by both military and civilian TEMS.47

Other complicating environmental factors: expo-sure to toxic, bacteriological, chemical and/or radioactive materials

Given the multiple terrorist attacks and industrial tragedies that have occurred in recent years, medical rescue teams and specialized incident assessment teams have been established by many national and international authorities.48 However, medical rescue after nuclear,49 biological,50 and chemical incidents, also called CBRN (chemical, biological, radiological, or nuclear) incidents, remains challenging and is often inefficient.51Toxic injury may require more rapid help than traumatic injury. Moreover, traumatic and toxic injury may co-exist, as in the case of an explosion with toxic emissions.52,53,54 The special skills required are defined in the TOXALS program, a complement to ALS training, and must now become a standard part of the training and practice of pre-hospital medical care.55

As an illustration, the procedure proposed by the Edgewood Chemical Biological Center aims to:56

The EMS response requires close coordination with law enforcement, as illustrated in the FIRESCOPE (FIrefighting RESources of California Organized for Potential Emergencies) protocol for the management of an active shooter incident, under the command of law enforcement officers (LEOs):38

1) First-responding law enforcement officers (LEOs) organize and deploy in small, 2-3 person teams as soon as they arrive on the scene. They move rapidly through unsecured areas toward the sound of the shooting, in an effort to engage the shooter(s) and eliminate the threat. They bypass all victims.

2) First-responding EMS personnel will be organized with the next available law enforcement personnel into warm zone response (WZR) Teams. The WZR Team will move forward into the warm zone, with the goal of providing stabilization care to the wounded. The LEOs will provide front and rear security.

3) Each of the EMS responders will be equipped with a “warm zone response kit” that allows them to work independently to stabilize multiple patients simultaneously. Each EMS responder should be equipped with appropriate insignia that identifies them as an EMS responder. The WZR team moves from casualty to casualty with the EMS responders stabilizing only immediately life threatening wounds, and then moving on. The goal is to stabilize as many casualties as possible. No casualties are evacuated at this point. When the initial WZR team runs out of supplies, they move back through the area, evacuating casualties they have treated to a casualty collection point (CCP), where they can be handed off to transporting EMS units.

4) The WZR team will be capable of radio communication on two tactical call channels (TAC) frequencies simultaneously:

- The LEOs will communicate on a police TAC with law enforcement command.

- EMS responders will communicate on a Fire/EMS TAC with the Fire/EMS Branch Director to report triage information. As resources arrive on scene, additional WZR Teams may be formed, and tasked either with the evacuation of stabilized victims, or with moving deeper into the warm zone in a “stabilize but not evacuate” mode (cfr Figures 2a and 2b). A cache of supplies may be established at the CCP to allow WZR team members to resupply and return to the warm zone.



Figure 2aTactical Law Enforcement Incidents: Initial Response Organization. NB: LEO: Law Enforcement Officer

Figure 2bTactical Law Enforcement Incidents: Reinforced Response Organization. NB: SWAT: Special Weapons and Tactics (Police Intervention Team)



what is necessary; d) decontaminate as far forward as possible.

Following procedures from the Edgewood Chemical Biological Center,52 the method of mass casualty decontamination should include the fol-lowing items:

1) Time is critical in order to save the most lives as possible:

a) Immediate removal of clothing outside the contaminated area for patients who have been visibly contaminated or who have been suspected of having been contaminated; and

b) Processing the victims through a high-volume, low-pressure tepid water shower (~50 to 60 psi) is priority. This may aid in the removal of 80-90% of physical contamination in almost all cases.

2) Provide effective mass casualty deconta-mination, but with particular attention paid to avoiding any further harm (such as adequate cate-gorization, sorting contaminated material or clothes and rewarming casualties). Other activities, such as setting up commercial decontamination tents, tarps, additional decontamination equipment,and/

1) Set up the decontamination and support areas;2) Conduct decontamination triage (for mass

casualty events);3) Decontaminate the victims;4) Segregate victims for observation or treatment;

and5) Release the victims afterwards.The principles for defining the decontamination

zones (DZ) are similar to those described in conflict settings:

- Hot zone: a site of contaminated patients where medical staff must wear personal protection equipment (PPE) for entry into this area;

- Warm zone: medical staff must wear PPE for entry into this area for further patient decontamination;

- Cold zone: where appropriate PPE for medical staff is completed by universal precautions. This zone is dedicated to receive victims and start full pre-hospital medical operations.

The general principles of decontamination are: a) decontaminate as soon as possible; b) decontaminate by priority; c) decontaminate only

Catastrophic compressible haemorrhage [c]

Hot Care under fire

Self /first aider

- Wound packing, - Compressive dressing, - Tourniquet, - Recovery position

None

Airway [a], breathing [b] Warm Tactical field care

Paramedics - QuikClot, - HemCon, - Oropharyngeal airway, - Nasopharyngeal airway, [combi-tube, balloon, crico], collar + head blocks, chest seal, - Needle decompression

- No Quikclot or Hemcon in H/N trauma,- No nasopharyngeal tube, if skull base fractures suspected- In case of maxillofacial fractures, start with crico-thyroidotomy

Circulation [c], disability [d], exposure [e]

Cold Tactical evacuation care

Medics - Intubation, - IV access (+ intraosseous device), - Fluid resuscitation, - Pelvic splint, - Traction splint, - Rewarming

- Tracheotomy- Pharyngeal packing - Proximal oesophageal sealing if rupture

Table 1

Summary of B-ATLS/TCCC principles with possible role for ENT-specialists

NB: B-ATLS: Battlefield Advanced Trauma Life support, TCCC: Tactical Combat Casualty Care, ENT: Otorhinolaryngologist. Quikclot® (Z-Medica, LLC, 4fairfieldBlvd. Wallingford, CT USA 06492). Hemcon® (Hemcon Medical Technologies, INC, 720 SW Washington Street, Suite 200, Portland, Oregon 97205-3504 USA). Oropharyngeal airway: Guedel or Mayo canule. Combitube™ (Covidien, Medtronic, 701 Medtronic Parkway, Minneapolis, MN 55432-5604 USA)



BLS.72 Although they did not always reach such a marked improvement in mortality, several other important studies later confirmed the beneficial effect of pre-hospital ATLS among patients with blunt head injuries or multiple injuries.73,74,75

Finally, an improved outcome in children with severe blunt trauma has been demonstrated when pre-hospital care is provided by physician-staffed ALS units compared with BLS units.76

Does PHTLS have a proven effect on mortality?

The effect of PHI on survival is clearly demonstrated today. In a recent US study, the authors analysed 3,733 consecutive trauma activations in severely injured trauma patients, transported from the scene by air or ground emergency medical service providers. For the most severely injured patients with signs of life who received ALS, the Injury Severity Score and pre-hospital times, and the proportions of traumatic brain injury, blunt trauma, and rates of air transport were similar; however, mortality was significantly lower (43% vs. 23%, p= 0.021).77

Another recent study on all Mobile Emergency Care Unit runs in Odense, Denmark confirmed that anaesthesiologist-administrated pre-hospital therapy increases survival, and thus supports the concept of using specialists in anaesthesiology in the pre-hospital setting, especially when treating patients with cardiac arrest, patients in need of respiratory support and trauma patients.78

Even if these data generally confirm those already obtained around the world,79 the size of the effect of PHI is variable. In an Iraqi study on 205 patients, the mortality rate was eight per cent for patients having been stabilized by PHI, compared to 44% in the control group (BLS).80 In another case-series on 2,788 patients injured by land mines, war, and traffic accidents during a ten-year study period, trauma mortality was reduced from 17% (95% CI 15 -19) to 4% (95% CI 3.5 - 5), survival, and was especially improved in major trauma victims.62,81ALS interventions were associated with positive survival trends when conducted in suburban and out-of-city road locations with long transport times.82

Although PHTLS training has appeared to be associated with a reduction in mortality,83,84 its predicted absolute risk reduction is estimated to correspond to 0.5 lives saved annually per 100,000 population with PHTLS fully implemented.85

or creating a soap-water solution should be accom-plished when time permits.

3) Conduct decontamination triage prior to administering a high-volume, low-pressure water shower.

4) When the contamination involves chemical vapours, or biological or radiological materials, using gentle friction (such as rubbing with hands, a cotton flannel or microfiber cloth, or sponges) is recommended to aid in removal of contamination. Rubbing should start with the head and proceed down the body to the feet. Extra care should be taken to prevent the spread of contamination to the mouth, nose and eyes (such as holding one’s breath to avoid inhalation/close contact).

Results on morbidity and mortality

Is there a need for standardized national or inter-national pre-hospital intervention?

This question was a matter of active debate during the late 1980s and the early 1990s.57,58,59,60 The association between the level of pre-hospital care and risk of mortality was for many years difficult to establish.61Some authors claimed that in urban centres with highly specialized Level I trauma centres there was no proven benefit in having on-site ALS for trauma patients.62 However, after analysis of the survival indicators for the efficacy of PHLS, it rapidly appeared that adequate and sometimes invasive in-place management by medics improves the trauma patient’s survival,63 in contrast to other factors such as an exclusive engagement of modern evacuation vehicles without PHI.64 However, ALS rarely seems to be performed in the trauma paediatric population.65

BLS versus ALS

While not unanimous,66,67 the predominant findings of recent research into the clinical effectiveness of pre-hospital ALS demonstrate improved effectiveness over BLS for patients with traumatic pathologies.68,69,70 The first reports on ATLS were enthusiastic. For example, Potter, in one of the first reports on ATLS, observed that 17 of 37 ALS deaths (36%) occurred within 24 hours of injury, compared with 24 of 33 BLS fatalities (73%) (P less than .05).71 Some years later, Quintans-Rodriquez et al. reported that the survival rate was 48% in patients with pre-hospital ALS and 18% in those receiving



warm zones, but this should only be done with force protection. The specific airway management should be deferred until the tactical field care phase (warm/cold zone). At this stage, a complete evaluation of the damage should take place, such as damage control resuscitation.

2) For CBRN hazards, the decontamination procedure starts in place, in order to avoid any further contamination of other places or secondarily involved people.

3) Each patient coming out of the operation field, after initial damage control resuscitation, would benefit from a complete ENT-examination, including endoscopy when feasible. A systematic screening should track all traumatic injuries of hard/soft tissues, foreign bodies or complicating agents (burns, toxics, surinfection). These initial findings should be fully reported on file. (NB: Specific information on head/neck injury is limited on the TCCC card).

4) The ENT-specialist should be aware that during the PHI, high doses of resuscitation drugs may have been used. Some of these could influence the inflammatory reaction or the coagulation cascade during damage control surgery, and, in the long term, could influence wound healing quality.

5) All patients with laryngeal tube placement during PHI, or with head and neck injury (including those limited in extent or depth) should be systematically monitored by ENT specialists.

Abbreviations

ALS: Advanced Life SupportBLS: Basic Life SupportCBRN: Chemical, Biological, Radiological, or Nu-clearCPR: Cardiopulmonary Resuscitation DCR: Damage Control ResuscitationED: Emergency Department EMS: Emergency Medical ServicesLEO: Law Enforcement OfficersOR: Operation Room PHI: Pre-Hospital Interventions PHTLS: Pre-Hospital Trauma Life Support TCCC: Tactical Combat Casualty Care TEMS: Tactical Emergency Medical Support Team WZR: Warm Zone Response

These observations were found to be similar to those in TEMS for law enforcement86,87 or in extremely hostile environments.88

Does PHTLS have a proven effect on morbidity?

Specific studies on the effect of PHTLS on morbidity are scarce, and usually not independently considered. Pre-hospital resuscitative interventions by ALS units performed on penetrating trauma patients may lengthen on-scene time, but do not significantly increase total pre-hospital time.89 Retrospective information in files from the Swedish National Patient Registry and the Cause of Death Registry on victims of motor-vehicle traffic injuries in Sweden (n = 28,041) show that, after multivariable adjustment, there was no association between PHTLS training and time to return to work (hazard ratio = 0.98; 95% CI, 0.92-1.05).90

Can PHTLS be iatrogenic?

The question of whether PHI can be harmful remains ethically relative in comparison with its proven efficacy on mortality and morbidity as reported above.91 However, this issue is of great interest for ENT specialists, especially with regard to traumatic airway management during PHI.92,93,94,95

In a recent study from Pittsburg, US, pharyngeal reflex or laryngeal spasm (gag reflex), ground (versus air) EMS teams, and male gender were associated with unsuccessful laryngeal tube placement by pre-hospital personnel.96 Traumatic laryngeal tube placement during PHI can induce significant tongue swelling, resulting in life-threatening situations with eventual need for surgical tracheostomy or for crico-thyroidotomy, 97,98 massive distension of the stomach, or significant bleeding from soft tissue injuries.99

conclusions and take-home messages for ent specialists

The aim of this manuscript was to introduce several PHI protocols, which are mainly unknown by ENT specialists. The take-home messages can be identified as follows:

1) Following TCCC procedure, the initial control of life-threatening external haemorrhage, if tactically feasible, should occur in the hot zone. Firefighters and TEMS may sometimes enter into



17. Carmont MR. The Advanced Trauma Life Support course: a history of its development and review of related literature. Postgrad Med J. 2005;81(952):87-91.

18. Liberman M, Mulder D, Sampalis J. Advanced or basic life support for trauma: meta-analysis and critical review of the literature. J Trauma. 2000;49(4):584-599.

19. McSwain NE Jr. Scott B. Frame, MD Memorial Lecture. Judgment based on knowledge: a history of prehospital trauma life support, 1970-2013. J Trauma Acute Care Surg. 2013;75(1):1-7.

20. Butler FK Jr, Hagmann J, Butler EG.Tactical combat casualty care in special operations. Mil Med. 1996;161 Suppl:3-16.

21. National Association of Emergency Medical Technicians (US). TCCC-MP Guidelines and Curriculum; 2015. Available at: http://www.naemt.org/education/TCCC/guidelines_curriculum. Accessed 2016, July 29.

22. Ramesh AC, Kumar S. Triage, monitoring, and treatment of mass casualty events involving chemical, biological, radiological, or nuclear agents. J Pharm Bioallied Sci. 2010;2(3):239-247.

23. Vayer JS, Schwartz RB. Developing a Tactical Emergency Medical Support Program. AdvEmerg Nurse J. 2003:25(4):282-293.

24. Campbell JP, Gratton MC, Salomone JA, Watson WA. Ambulance arrival to patient contact: the hidden component of prehospital response time intervals. Ann Emerg Med. 1993;22(8):1254-1257.

25. Hartenstein I. Medical Evacuation in Afghanistan; RTO-MP-HFM-157; NATO Science and Technology Organization; 2008. Available at: http://natorto.cbw.pl/show_det.php?mx1=7a1a52dc43ef66cd73b6027d2b6a89cc415e53d7&id=4360&mx2=072043e34113884317950a9a5ce49080&l=e&f=A&b=RTO. Accessed 2016, July 29.

26. Llewellyn CH. The Antecedents of Tactical Emergency Medical Support: A Personal Perspective. Adv Emergency Nurse J. 2003;25(4):274–276.

27. Gerhardt R. Impact of emergency medicine specialists in tactical pre-hospital and en route care: what does the available data say? J Trauma. 2007;62(6 Suppl):S11-S12.

28. Gildea JR, Janssen AR. Tactical emergency medical support: physician involvement and injury patterns in tactical teams. J Emerg Med. 2008;35(4):411-414.

29. Young JB, Sena MJ, Galante JM. Physician roles in tactical emergency medical support: the first 20 years. J Emerg Med. 2014;46(1):38-45.

30. Young JB, Sena MJ, Galante JM. Physician roles in tactical emergency medical support: the first 20 years. J Emerg Med. 2014;46(1):38-45.

32. Cupera J, Mannová J, Ríhová H, Brychta P, Cundrle I. Quality of prehospital management of patients with burn injuries--a retrospective study. ActaChirPlast. 2002;44(2):59-62.

33. Singer AJ, Taira BR, Thode HC Jr, McCormack JE, Shapiro M, Aydin A, Lee C. The association between hypothermia, prehospital cooling, and mortality in burn victims.AcadEmerg Med. 2010;17(4):456-459.

34. Alanezi K, Alanzi F, Faidi S, Sprague S, Cadeddu M, Baillie F, Bowser D, McCallum A, Bhandari M. Survival rates for adult trauma patients who require cardiopulmonary resuscitation. CJEM. 2004;6(4):263-265.

References

1. White RD, O’Donovan TP. Prehospital life-support systems in traumaticandcardiacemergencies. Anesth Analg. 1974;53(5):734-743.

2. Aberle SJ, Lohse CM, Sztajnkrycer MD.A Descriptive Analysis of US Prehospital Care Response to Law Enforcement Tactical Incidents. J Spec Oper Med. 2015;15(2):117-122.

3. McMurtry RY, Nelson WR, de la Roche MR. Current concepts in trauma: 1. Principles and directions for development. CMAJ. 1989;141(6):529-533.

4. Blackwell TH. Prehospital care. Emerg Med Clin North Am. 1993;11(1):1-14.

5. Spaite DW, Tse DJ, Valenzuela TD, Criss EA, Meislin HW, Mahoney M, Ross J. The impact of injury severity and prehospital procedures on scene time in victims of major trauma. Ann Emerg Med. 1991;20(12):1299-1305.

6. Roudsari BS, Nathens AB, Cameron P, Civil I, Gruen RL, Koepsell TD, Lecky FE, Lefering RL, Liberman M, Mock CN, Oestern HJ, Schildhauer TA, Waydhas C, Rivara FP. International comparison of prehospital trauma care systems. Injury. 2007;38(9):993-1000.

7. McManus WF, Tresch DD, Darin JC. An effective prehospital emergency system. J Trauma. 1977;17(4):304-310.

8. Salomone JP, Ustin JS, McSwain NE Jr, Feliciano DV. Opinions of trauma practitioners regarding prehospital interventions for critically injured patients. J Trauma. 2005;58(3):509-515.

9. Hohenstein C, Hempel D, Schultheis K, Lotter O, Fleischmann T. Critical incident reporting in emergency medicine: results of the prehospital reports. Emerg Med J. 2014;31(5):415-418.

10. Jones CM, Cushman JT, Lerner EB, Fisher SG, Seplaki CL, Veazie PJ, Wasserman EB, Dozier A, Shah MN. Prehospital Trauma Triage Decision-making: A Model of What Happens between the 9-1-1 Call and the Hospital. PrehospEmerg Care. 2016;20(1):6-14.

11. Liu NT, Holcomb JB, Wade CE, Salinas J. Improving the prediction of mortality and the need for life-saving interventions in trauma patients using standard vital signs with heart-rate variability and complexity. Shock. 2015;43(6):549-555.

12. Gold CR. Prehospital advanced life support vs “scoop and run” in trauma management. Ann Emerg Med. 1987;16(7):797-801.

13. Werman HA, Nelson RN, Campbell JE, Fowler RL, Gandy P. Basic trauma life support. Ann Emerg Med. 1987;16(11):1240-1243.

14. Liberman M, Roudsari BS. Prehospital trauma care: what do we really know? CurrOpinCrit Care. 2007;13(6):691-696.

15. Funder KS, Petersen JA, Steinmetz J. On-scene time and outcome after penetrating trauma: an observational study. Emerg Med J. 2011;28(9):797-801.

16. Arreola-Risa C, Mock C, Herrera-Escamilla AJ, Contreras I, Vargas J. Cost-effectiveness and benefit of alternatives to improve training for prehospital trauma care in Mexico. Prehosp Disaster Med. 2004;19(4):318-325.



methods for sensitivity, specificity, and predictive values. Am J Emerg Med. 2015;33(11):1687-1691

48. Macintyre AG, George W. Christopher GW, Eitzen EJ, Gum R, Weir S, DeAtley G, Tonat K, BArbera JA. Weapons of Mass Destruction Events With Contaminated Casualties: Effective Planning for Health Care Facilities. JAMA. 2000;283(2):242-249.

49. Hogan DE, Kellison T. Nuclear terrorism. Am J Med Sci. 2002;323(6):341-349.

50. Greenfield RA, Brown BR, Hutchins JB, Iandolo JJ, Jackson R, Slater LN, Bronze MS. Microbiological, biological, and chemical weapons of warfare and terrorism. Am J Med Sci. 2002;323(6):326-340.

51. Li HL, Tang WJ, Ma YK, Jia JM, Dang RL, Qiu EC. Emergency response to nuclear, biological and chemical incidents: challenges and countermeasures. Mil Med Res. 2015;2:19.

52. US Department of Transportation, Transport Canada. Emergency Response Guidebook; a guidebook for first Responders during the initial phase of a dangerous goods/hazardous materials transportation incidents. Available at: http://www.firescope.org/specialist-groups/hazmat/ERG2012.pdf. Accessed 2016 July 29.

53. Firescope Board. Chap 14: Hazardous materials and mass decontamination. Field Operations Guide (ICS 420-1). Firefighting Resources of California Organized for Potential Emergencies. www.firescope.org; 2007. Available at: https://www.iafc.org/files/mtlAid_StatePlanCAfieldGuide.pdf. Accessed 2016 July 29.

54. Firescope Board; Chap 17: Terrorism/weapons of mass destruction. Field Operations Guide (ICS 420-1). Firefighting Resources of California Organized for Potential Emergencies. www.firescope.org; 2007. Available at: https://www.iafc.org/files/mtlAid_StatePlanCAfieldGuide.pdf. Accessed 2016 July 29.

55. Baker DJ. Advanced life support for acute toxic injury (TOXALS). Eur J Emerg Med. 1996;3(4):256-262.

56. Lake W, Divarco S, Schulze P, Gougelet R, Army Chemical Biological Radiological Nuclear School Fort Leonard Wood Mo,Eds. Guidelines for Mass Casualty Decontamination During a HAZMAT/Weapon of Mass Destruction Incident. Volumes 1 and 2 (Update) US Army Edgewood Chemical Biological Center (ECBC), Aberdeen MD, 2013.

57. Ummenhofer W, Scheidegger D. Role of the physician in prehospital management of trauma: European perspective. CurrOpinCrit Care. 2002;8(6):559-565.

58. Benitez FL, Pepe PE. Role of the physician in prehospital management of trauma: North American perspective. CurrOpinCrit Care. 2002;8(6):551-558.

59. Dick W. Philosophy of prehospital advanced trauma life support by well-trained emergency physicians is preferred. Prehosp Disaster Med. 1995;10(4):288-289.

60. Hazinski MF. Basic life support: controversial and unresolved issues. J CardiovascNurs. 1996;10(4):1-14.

61. Lee A, Garner A, Fearnside M, Harrison K. Level of prehospital care and risk of mortality in patients with and without severe blunt head injury. Injury. 2003;34(11):815-819.

35. Millin MG, Galvagno SM, Khandker SR, Malki A, Bulger EM; Standards and Clinical Practice Committee of the National Association of EMS Physicians (NAEMSP); Subcommittee on Emergency Services–Prehospital of the American College of Surgeons’ Committee on Trauma (ACSCOT). Withholding and termination of resuscitation of adult cardiopulmonary arrest secondary to trauma: resource document to the joint NAEMSP-ACSCOT position statements. J Trauma Acute Care Surg. 2013;75(3):459-467.

36. Hopson LR, Hirsh E, Delgado J, Domeier RM, McSwain NE, Krohmer J; National Association of EMS Physicians; American College of Surgeons Committee on Trauma. Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest: joint position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. J Am Coll Surg. 2003;196(1):106-112.

37. Bulger EM, Guffey D, Guyette FX, MacDonald RD, Brasel K, Kerby JD, Minei JP, Warden C, Rizoli S, Morrison LJ, Nichol G; Resuscitation Outcomes Consortium Investigators. Impact of prehospital mode of transport after severe injury: a multicenter evaluation from the Resuscitation Outcomes Consortium. J Trauma Acute Care Surg. 2012;72(3):567-573.

38. Firescope Board. Emergency response to tactical law enforcement incidents (ICS 701). Firefighting Resources of California Organized for Potential Emergencies. Version June 23, 2015. www.firescope.org. Available at: http://www.firescope.org/meetings/bod/2015/bod_meeting3/documents/ics 701.pdf. Accessed 2016July 29.

39. Butler FK. Tactical Combat Casualty Care: update 2009. J Trauma. 2010;69Suppl 1:S10-S13.

40. Scope A, Lynn M, Farkash U, Zeev F, Goldberg A, Eldad A. Military trauma life support: a comprehensive training program for military physicians. Mil Med. 2001;166(5):385-388.

41. Husum H. Effects of early prehospital life support to war injured: the battle of Jalalabad, Afghanistan. Prehosp Disaster Med. 1999;14(2):75-80.

42. Butler FK, Smith DJ, Carmona RH. Implementing and preserving the advances in combat casualty care from Iraq and Afghanistan throughout the US Military. J Trauma Acute Care Surg. 2015;79(2):321-326.

43. Dickinson E. Crosshairs on EMS. Responding to MCIs caused by low-tech terrorism. JEMS. 2013;38(9):46-51.

44. Arishita GI, Vayer JS, Bellamy RF. Cervical spine immobilization of penetrating neck wounds in a hostile environment. J Trauma. 1989;29(3):332-337.

45. Jensen J, Thompson S. The Incident Command System: a literature review. Disasters. 2016;40(1):158-182.

46. Xu M, Li SX. Analysis of good practice of public health Emergency Operations Centers. Asian Pac J Trop Med. 2015;8(8):677-682.

47. Bhalla MC, Frey J, Rider C, Nord M, Hegerhorst M. Evaluation of Simple Triage Algorithm and Rapid Treatment and Sort, Assess, Lifesaving, Interventions, Treatment, and Transportation mass casualty triage



severely injured trauma patients. J Trauma Acute Care Surg. 2015;79(2):227-231.

78. Mikkelsen S, Krüger AJ, Zwisler ST, Brøchner AC. Outcome following physician supervised prehospital resuscitation: a retrospective study. BMJ Open. 2015;5(1):e006167

79. Matthes G, Trentzsch H, Wölfl CG, Paffrath T, Flohe S, Schweigkofler U, Ekkernkamp A, Schulz-Drost S;SektionNotfallmedizin, Intensivmedizin und Schwerverletztenversorgung (NIS) der DeutschenGesellschaftfürUnfallchirurgie e. V. Essential measures for prehospital treatment of severely injured patients: The trauma care bundle [in German]. Unfallchirurg. 2015;118(8):652-656.

80. Murad MK, Issa DB, Mustafa FM, Hassan HO, Husum H. Prehospital trauma system reduces mortality in severe trauma: a controlled study of road traffic casualties in Iraq. Prehosp Disaster Med. 2012;27(1):36-41.

81. Murad MK, Husum H. Trained lay first responders reduce trauma mortality: a controlled study of rural trauma in Iraq. Prehosp Disaster Med. 2010;25(6):533-539.

82. HosseinpourM ,Paravar M Mohammadzadeh M , Mirzadeh AS . Prehospital care and in-hospital mortality of trauma patients in Iran.Prehosp Disaster Med. 2014;29(5):1-5.

83. Ali J, Adam RU, Gana TJ, Williams JI.,Trauma patient outcome after the Prehospital Trauma Life Support program. J Trauma. 1997;42(6):1018-1021.

84. Ali J, Adam RU, Gana TJ, Bedaysie H, Williams JI. Effect of the prehospital trauma life support program (PHTLS) on prehospital trauma care. J Trauma. 1997;42(5):786-790.

85. Johansson J, Blomberg H, Svennblad B, Wernroth L, Melhus H, Byberg L, Michaëlsson K, Karlsten R, Gedeborg R. Prehospital Trauma Life Support (PHTLS) training of ambulance caregivers and impact on survival of trauma victims. Resuscitation. 2012;83(10):1259-1264.

86. Pons PT, Jerome J, McMullen J, Manson J, Robinson J, Chapleau W. The Hartford Consensus on Active Shooters: Implementing the Continuum of Prehospital Trauma Response. J Emerg Med.2015;49(6):878-885.

87. Elmqvist C, Brunt D, Fridlund B, Ekebergh M. Being first on the scene of an accident--experiences of ‘doing’ prehospital emergency care. Scand J Caring Sci. 2010;24(2):266-273.

88. Billmann FG, Burnett C, Welke S, Bokor-Billmann T. Effect of advanced trauma life support (ATLS) on the time needed for treatment in simulated mountain medicine emergencies. Wilderness Environ Med. 2013;24(4):407-411.

89. Seamon MJ, Doane SM, Gaughan JP, Kulp H, D’Andrea AP, Pathak AS, Santora TA, Goldberg AJ, Wydro GC. Prehospital interventions for penetrating trauma victims: a prospective comparison between Advanced Life Support and Basic Life Support. Injury. 2013;44(5):634-638.

90. Blomberg H, Svennblad B, Michaelsson K, Byberg L, Johansson J, Gedeborg R. Prehospital trauma life support training of ambulance caregivers and the outcomes of traffic-injury victims in Sweden. J Am Coll Surg. 2013;217(6):1010-9.e1-2.

91. Hoyt D. Prehospital care: do no harm? Ann Surg. 2003;237(2):161-162.

92. Christensen EF, Høyer CC; Danish observational study.Prehospital tracheal intubation in severely injured patients:

62. Liberman M, Mulder D, Lavoie A, Denis R, Sampalis JS. Multicenter Canadian study of prehospital trauma care. Ann Surg. 2003;237(2):153-160.

63. Spaite DW, Criss EA, Valenzuela TD, Meislin HW.Prehospital advanced life support for major trauma: critical need for clinical trials. Ann Emerg Med. 1998;32(4):480-489.

64. Lossius HM, Søreide E, Hotvedt R, Hapnes SA, Eielsen OV, Førde OH, Steen PA.Prehospital advanced life support provided by specially trained physicians: is there a benefit in terms of life years gained? ActaAnaesthesiol Scand. 2002;46(7):771-778.

65. Selig HF, Trimmel H, Voelckel WG, Hüpfl M, Trittenwein G, Nagele P. Prehospitalpediatric emergencies in Austrian helicopter emergency medical service - a nationwide, population-based cohort study. Wien KlinWochenschr. 2011;123(17-18):552-558.

66. Cayten CG, Murphy JG, Stahl WM. Basic life support versus advanced life support for injured patients with an injury severity score of 10 or more. J Trauma. 1993;35(3):460-466.

67. Sampalis JS, Lavoie A, Williams JI, Mulder DS, Kalina M. Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients. J Trauma. 1993;34(2):252-261.

68. Bissell RA, Eslinger DG, Zimmerman L. The efficacy of advanced life support: a review of the literature. Prehosp Disaster Med. 1998;13(1):77-87.

69. Pollack CV Jr. Prehospital fluid resuscitation of the trauma patient.An update on the controversies.Emerg Med Clin North Am. 1993;11(1):61-70.

70. Jones SE, Brenneis AT. Study design in prehospital trauma advanced life support-basic life support research: a critical review. Ann Emerg Med. 1991;20(8):857-860.

71. Potter D, Goldstein G, Fung SC, Selig M. A controlled trial of prehospital advanced life support in trauma. Ann Emerg Med. 1988;17(6):582-588.

72. Quintans-Rodríquez A, Turégano-Fuentes F, Hernández-Granados P, Pérez-Díaz MD, Fuenmayor-Valera ML, Fernández-Moreira C. Survival after prehospital advanced life support in severe trauma.Eur J Emerg Med. 1995;2(4):224-226.

73. Garner A, Crooks J, Lee A, Bishop R. Efficacy of prehospital critical care teams for severe blunt head injury in the Australian setting. Injury. 2001;32(6):455-460.

74. Jacobs LM, Sinclair A, Beiser A, D’Agostino RB. Prehospital advanced life support: benefits in trauma. J Trauma. 1984;24(1):8-13.

75. Ryynänen OP, Iirola T, Reitala J, Pälve H, Malmivaara A. Is advanced life support better than basic life support in prehospital care? A systematic review.Scand J Trauma ResuscEmerg Med. 2010;23(18):62.

76. Suominen P, Baillie C, Kivioja A, Korpela R, Rintala R, Silfvast T, Olkkola KT. Prehospital care and survival of pediatric patients with blunt trauma. J Pediatr Surg. 1998;33(9):1388-1392.

77. Meizoso JP, Valle EJ, Allen CJ, Ray JJ, Jouria JM, Teisch LF, Shatz DV, Namias N, Schulman CI, Proctor KG. Decreased mortality after prehospital interventions in



98. Leibovici D, Fredman B, Gofrit ON, Shemer J, Blumenfeld A, Shapira SC. Prehospitalcricothyroidotomy by physi-cians. Am J Emerg Med. 1997;15(1):91-93.

99. Sunde GA, Brattebø G, Odegården T, Kjernlie DF, Rødne E, HeltneJK.Laryngeal tube use in out-of-hospital cardiac arrest by paramedics in Norway. Scand J Trauma Resusc Emerg Med. 2012;20:84.

J.-C. de SchoutheeteDepartment of Surgery Queen Astrid Military HospitalBruynstraat 11120 Brussels, BelgiumE-mail: [email protected]

a Danish observational study. BMJ. 2003;327(7414):533-534.

93. Adnet F, Lapostolle F, Ricard-Hibon A, Carli P, Goldstein P. Intubating trauma patients before reaching hospital -- revisited. Crit Care. 2001;5(6):290-291.

94. Doran JV, Tortella BJ, Drivet WJ, Lavery RF. Factors influencing successful intubation in the prehospital setting. Prehosp Disaster Med. 1995;10(4):259-264.

95. Brambrink AM, Koerner IP. Prehospital advanced trauma life support: how should we manage the airway, and who should do it? Crit Care. 2004;8(1):3-5

96. Martin-Gill C, Prunty HA, Ritter SC, Carlson JN, Guyette FX. Risk factors for unsuccessful prehospital laryngeal tube placement. Resuscitation. 2015;86:25-30.

97. Marcolini EG, Burton JH, Bradshaw JR, Baumann MR. A standing-order protocol for cricothyrotomy in prehospital emergency patients. PrehospEmerg Care. 2004;8(1):23-28.


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Pre-hospital interventions: introduction to life support systems

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