Reports



REDUCING THE SEVERITY OF ROAD INJURIES THROUGH POST IMPACT CARE


Executive Summary

Full report (.pdf format)

Introduction

Morbidity and mortality due to injuries from road crashes contribute considerably to human suffering amongst victims and their relatives and lead to important socio-economic costs. Many victims belong to younger age groups resulting in many years of life either lost or threatened by severe disability. Despite the fact that the cost of road trauma is larger than from cancer and cardiovascular diseases, the attention and effort paid by health policymakers and by the medical community, to trauma-related care and research has been disproportionately small so far.

The health consequences of road crashes can be influenced by preventative actions before the crash (active or primary safety), during the crash (passive or secondary safety) and post crash (rescue, treatment and rehabilitation). The appropriate management of road casualties following the impact is a crucial determinant of the chance and quality of survival. The ultimate goal of post crash care is, on the one hand, to avoid preventable death and limit the severity of the injury and, on the other, to ensure optimal functioning of the crash victim and re-integration into the community.

This review has brought together medical experts from across the European Union to consider the state of the art of post impact care and the scope for further action. Following an examination of available statistics and epidemiological information, the review looks at the different aspects of post impact care which can be considered as a chain of help given to road crash victims. The review goes on to highlight evidence-based actions for the organisation of optimal trauma care which can be encouraged or undertaken by the European Union. Due to the sparseness of rigorous experimental evidence in trauma care, hard evidence is often lacking and recommendations for further research are made where there seems to be good potential for optimising equipment, procedures, or the organisation of services.

The scope for reducing casualties with post impact care

In EU countries, there are around 43,000 road traffic deaths annually and about 3.5 million casualties when underreporting is taken into account. Some road crash casualties sustain injuries which are unsurvivable in any circumstances and with any type of care. However, the vast majority of crashes are technically survivable.

About 50 per cent of deaths from road traffic collisions occur within minutes at the scene or in transit and before arrival at hospital. For those patients who are taken to hospital, some deaths occur between 1-4 hours after the crash ( 15 per cent) but the majority occur after 4 hours (35 per cent).

Numerous studies of avoidable trauma deaths have suggested that in both the pre-hospital and hospital phases, a proportion of blunt road trauma deaths could be avoided with optimal care. Variations in case fatality ratios for different Member States suggest there may be differences in the effectiveness of post-impact care between countries but it should be emphasised that the available data do not allow firm conclusions to be drawn. It is possible, therefore, that several thousand road traffic deaths in the EU could be prevented by optimal post-impact care. At the same time, poor post impact care could be leading to avoidable injury and disability in survivors. A study conducted in the UK estimated that 12 per cent of patients who had sustained serious skeletal trauma went on to have significant preventable disability.

Detailed information on injury severity in EU countries is needed for a better understanding of the scope for savings through post crash care. It is recommended that:

  • Data should be collected by Member States for auditing the performance of the Emergency Medical Services. The EU-financed European Home and Leisure Accident Surveillance System (EHLASS) would provide one appropriate and possible mechanism for carrying this out.
  • Regulations for performing post mortems or radiological investigations in all road traffic fatalities should be formulated.
  • The Abbreviated Injury Scale (AIS) should be used to record injury severity.
  • The outcomes of road crash survivors need to be measured. Post-injury measures of disability (for example, the Glasgow Outcome Scale) need to be included in routine hospital statistics linked to national crash data.

Chain of help to patients injured in road crashes

The type of help needed by road traffic victims varies with the severity of their injuries. In cases of minor injury patients will often not be hospitalised but will treat themselves or seek the help of a general practitioner. Optimal medical and psychological follow-up care at this level is very important to alleviate pain and distress.

In major injuries the help provided to the victims can be viewed schematically as a chain consisting of different links.. Help starts with (1) action taken by the victims themselves or more often by lay witnesses or bystanders. The subsequent links in the chain are (2) access to the emergency medical system, (3) the help provided by emergency services rescuers, (4) the delivery of medical care before arrival at the hospital, (5) hospital trauma care and (6) rehabilitative psychosocial care. The chain will only be as strong as its weakest link.

Role of bystanders

There is no doubt that lay bystanders can play a crucial role: They can take immediate action by using a fire extinguisher if the vehicle is on fire. When the victim is in a dangerous situation bystanders should be able to take any necessary action to prevent further collisions or damage. Lay bystanders need to be able to recognise unconsciousness and the signs of failing vital functions. Securing a free airway in unconscious victims in a safe way is particularly important to reduce preventable deaths. The presence of gloves in the car to protect the bystander during these actions is desirable. The bystander should know how the emergency services function and especially how to contact them and to give correct and relevant information.

There is no evidence to suggest that first aid kits being made available in cars would help. Indeed, they might confuse bystanders and distract them from the essential action described above.

It is recommended that a description of the important steps to be taken by lay bystanders in the event of a road collision should be included in national Highway Codes and in car manufacturers’ maintenance manuals.

Access to emergency medical system

The European emergency telephone number 112 should be applied by all European countries and publicised so that travellers within the EU are able to contact local emergency services. The time taken to answer emergency calls should be minimised and an EU standard should be devised for call receipt.

Efficient and well-organised emergency medical dispatch is necessary. Calls need to be transferred to a trained dispatcher able to make a layered response of the call using an appropriate dispatch system. The EU could assist in this process by encouraging information exchange on best practice concerning the functioning, type and operation of emergency medical dispatch systems as well as carrying out research.

Emergency services

Fire fighter rescuers and, in some areas, coastguards may arrive at the scene before emergency medical service personnel. It is important that fire fighters be trained in the provision of basic life support techniques and that there is training and close co-operation amongst professionals at the scene with regard to rescue from crash vehicles and safety at the scene. Again, the EU can assist in encouraging information exchange and carrying out research in this area.


Pre-hospital medical care requirements

What treatment should be applied?

There are a range of Basic Life Support techniques (delivered by emergency medical technicians who staff the ambulance, by paramedics, by specialist ‘critical care’ nurses, or physicians in mobile care units) which can be applied at the scene and during transportation to hospital. The particular technique to be applied will depend upon the nature of the trauma. The old method of ‘scoop and run’ without any treatment may be obsolete, but to ‘stay and play’ at the scene before definitive surgical treatment can be started may also be detrimental for the prognosis of the patient. Scientific knowledge about the efficacy of a range of procedures, however, is still in evolution and the optimal approach for different types of trauma patient has yet to be determined. This is an important area for EU research.

Who should deliver the care?

It is not economically feasible to send paramedics, a nurse or a mobile intensive care unit (MICU) to every road collision. A two-tier system with, for example, emergency medical technicians as the first tier and a MICU team as the second has been set up in many European countries. However, the level of training and degree of professionalism varies widely. All too often, the job of emergency medical technician is under-valued. The EU could assist in encouraging greater professionalism and encouraging better standards of training. In addition, the standards for minimum requirements for physicians staffing MICU teams could be developed at EU level.

Who should transport the patients to hospital?

In the majority of road traffic collisions, the patient will be transported with land ambulances. It is recommended that standardised equipment is used in EU countries and guidelines drawn up concerning matters such as occupant restraint. Training standards need to be defined for ambulance drivers.

Helicopters are used widely throughout Europe. Although the small European literature is broadly supportive of claims for benefits such as improving response times, a review of evidence relevant to one Member State concluded that their effectiveness was doubtful. The evidence indicates that if helicopters are operated, this should be on a regional basis in a secondary responder role in response to the request of emergency personnel at the scene or at a primary receiving hospital.

Medical control of pre-hospital care

Since the links in the chain of pre-hospital care are very complex, medical control and medical direction of that care are essential components. Input from a qualified emergency physician is necessary throughout the planning, implementation and evaluation of the emergency medical service. The audit of trauma care should be organised and supervised by all emergency physicians responsible for medical control. The EU should encourage information exchange on best practice in this area.

Organisation of trauma care in major road disasters

The best possible way of providing for adequate medical treatment is through a national or regional trauma system which may include hospital-based mobile medical teams, trained to collaborate with ambulance, police and fire services.

Hospital trauma care

Guidelines need to be formulated at a national and European level in consultation with national scientific medical societies on hospital trauma centres and their organisation and co-ordination. For example, a minimum threshold of basic clinical capabilities for each trauma centre needs to be established and the nature of each hospital and its resources needs to be taken into consideration. Each region should have a list of hospitals with exact details of the services they provide and trauma care should be organised and resourced accordingly.

Trauma teams managing trauma care must have adequate training. The optimal standard is the ATLS course of the American College of Surgeons. In those countries where this course is not applicable each trauma centre must still have a protocol for both the prehospital and hospital phase and will need to organise education and training of the personnel to use such a protocol. The trauma team leader needs to have a specific background in trauma care with certified experience. This experience should include a period sufficient to have managed the treatment of at least 50 major trauma patients in Emergency Department level I/II level trauma centres.

Rehabilitation

Effective trauma care aims to return the injured individual to his or her place in the community. The importance of early rehabilitation in reducing disability has been demonstrated and there is a growing acceptance that rehabilitation specialists should be available as soon as patients are medically and surgically stabilised.

Patients who have sustained traumatic brain injury (TBI) will need additional specialised attention. There is increasing evidence that even relatively "mild TBI" is followed by prolonged disability in a high percentage of cases. Identification of those at special risk in this regard is not yet possible, so research is required in this area. Psychologists should be involved in the "discharge planning" of all patients with TBI and be consulted whenever there is concern about the integration of a patient back into the community.

Post traumatic stress disorder is recognised as a major obstacle to full recovery after injury. It is probable that early assessment and early referral to a psychologist will improve long term outcome and speed up the recovery process. Those care givers responsible for supporting relatives of fatally injured crash victims must have special training and there must be adequate immediate help for these staff who will, in turn, often require support themselves.

Best practice should be identified in treatment programmes in these areas and information exchange between different Member States be encouraged.

Acknowledgements

ETSC gratefully acknowledges the contributions of members of ETSC’s Post Impact Care Working Party to this review:

Working Party Members

Prof. Walter Buylaert (Chairman)
Prof. Anne-Lise Christensen
Prof. Herman Delooz
Prof. R. Jan A. Goris
Prof. Bernard Nemitz
Prof. Michael Nerlich
Prof. Jon Nicholl
Prof. Peter Sefrin
Prof. Franco Servadei
Prof. Hans von Holst
Prof. David Yates