STAB-5: an aide-mémoire for the efficient prehospital management of penetrating trauma by emergency medical services,Critical Care

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STAB-5: an aide-mémoire for the efficient prehospital management of penetrating trauma by emergency medical services
Critical Care ( IF 8.8 ) Pub Date : 2024-08-05 , DOI: 10.1186/s13054-024-05048-1
M Robinson ₁ , F Rath ₁ , C Sutton ₁ , M Kinsella ₁ , E Ter Avest _{2,

3} , L Carenzo ₄

Affiliation

Penetrating trauma represents a significant percentage of the overall trauma case load in many trauma systems.For patients with penetrating injuries, a longer time to hospital is associated with an increase in risk-adjusted odds of death [1, 2]. Therefore, expedited treatment and transport of by Emergency Medical Services (EMS) crews, who are usually the first healthcare practitioners to attend these patients on scene, is warranted.

To expedite decision-making by EMS crews and to improve immediate care for patients withpenetrating torso injuries, a 5-step aide-mémoire was developed based on available literature and expert opinion.

5 key-points are essential in the EMS treatment of patients with (central) stab wounds. They can be remembered by the STAB-5 mnemonic (Fig. 1).

Scene safety

Traditionally, EMS crews are trained to follow a classic approach to scene safety, accessing scene only when deemed safe by the police [3]. In the evolving landscape of emergency response, a shift towards the concept of dynamic risk assessment is emerging worldwide. This approach emphasises the importance of scene assessment by EMS personnel and their ability to swiftly adapt to evolving situations to prevent a therapeutic vacuum.

Triage

Immediately after arrival, crews should establish the location and the severity of the injuries sustained. This should be done succinctly to prevent attention being drawn towards the most obvious injury whilst other sources of significant bleeding or injury are neglected. Clothing should be cut-off to facilitate a quick full-body examination, especially of often neglected areas such as axillae, groin, gluteal cleft and perineum, whilstcare should be taken to maintain dignity to the patient when performing these examinations.

Assertive scene & patient management

An early request for critical care teams capable of performing advanced interventions such as blood transfusion or resuscitative thoracotomy should be made, but crews should NOT wait on scene for their arrival. Focus should be on advancing towards the nearest Major Trauma Center (MTC) unless the patient is peri-arrest (agonal breathing, barely recordable pulses), where diverting to the nearest (trauma) hospital is appropriate. If available and deemed necessary (depending on distance from hospital and the patient’s condition), a Rendezvous Point (RVP) with a criticalcare team can be established en route to hospital. Early communication with dispatch regarding the destination hospital and planned rendez-vous points are key in these instances.

Bleeding control

Direct pressure, wound packing and tourniquet application are the mainstem of bleeding control. In catastrophic extremity bleeding, a tourniquet should be applied immediately and tightened sufficiently to stem arterial bleeding. A second tourniquet may be required if the bleeding continues. Some wounds require packing in addition to direct pressure. The bleeding vessel should be located within the wound, and hemostatic gauze applied directly to the source of the bleed, packing tightly until the wound is filled to provide sufficient pressure. A pressure bandage can then be applied over the top of the haemostatic gauze. For neck wounds direct pressure should be maintained and the need for (early) airway interventions should be considered.

5-min scene time

EMS focus should be to provide immediate life-saving interventions and leave scene towards definite care within 5 min. Patients should be assisted to walk to the ambulance where possible or rapidly extricated by carry-chair or stretcher if necessary. All emphasis should be upon leaving scene with a shared understanding that most intervention can be performed en route to hospital. If vascular (IV/IO) access cannot be gained immediately, additional attempts can be made on route if safe to do so. Tranexamic Acid (IV or IM if no access can be obtained), analgesia and basic monitoring can all be managed en route to hospital and if no reliable blood pressure readings are generated, the patient’s volume status should be assessed and described by peripheral pulses, colour, diaphoresis and respiratory status.

The use of the STAB-5 mnemonic ensures a standardised, rapid delivery of essential interventions in a structured manner for critically unwell patients in the prehospital setting. It emphasises the importance of thorough patient exposure and early haemorrhage control, as various studies have shown that over 50% of in-hospital death after penetrating trauma occur due to exsanguination [4]. STAB-5 differs from the classic “Scoop and run” approach, wherein patients are transported with minimal- or no interventions at all. However, it still urges crews to minimise scene times, as prolonged scene times directly correlate with a higher mortality [1, 2].

Previous research has confirmed the effectiveness of medical mnemonics for recalling information [5]. Based on preliminary feedback received from ambulance crews, we expect the STAB-5 mnemonic introduced in this study may assist and support crews in tailoring their clinical priorities in this patient group, whilst simultaneouslyencouraging them to prioritise hemostatic interventions and short scene times over other treatments. We hope that by formalising these key priorities, clinical innovation and quality improvement projects can have significant impact on (preventable) pre-hospital trauma deaths [6]. Prospective evaluation of the introduction of the mnemonic on scene times and treatments provided is warranted to confirm our hypothesis.

The STAB-5 mnemonic is a standard simple approach for treatment of patients with penetrating injuries by EMS crews, focusing on early haemorrhage control and short on-scene times, which may contribute to better patient outcomes in systems where providers have limited exposure to penetrating injuries.

No datasets were generated or analysed during the current study.

MTC:: Major trauma center
RVP:: Rendezvous point
TU:: Trauma unit

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We are grateful to Mr. Joolz Ingram for his invaluable help in designing the STAB-5 infographic, and would like to thank Dr. Niccolò Stomeo for the French translation of the STAB-5 infographic.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors and Affiliations

Great Western Air Ambulance Charity, Bristol, UK
M. Robinson, F. Rath, C. Sutton & M. Kinsella
Department of Acute Care, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
E. ter Avest
London’s Air Ambulance and Bart’s Health NHS Trust, Royal London Hospital, London, UK
E. ter Avest
Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy
L. Carenzo

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M. RobinsonView author publications
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F. RathView author publications
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C. SuttonView author publications
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M. KinsellaView author publications
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E. ter AvestView author publications
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Contributions

MR, FR, CS and MK developed the concept of STAB-5. Together with LC and EtA they searched the available literature and collected experiences from various pre-hospital services. EtA and LC drafted the manuscript, and all authors revised it critically for important intellectual content. All authors gave final approval of the version to be submitted and agreed to be accountable for all aspects of the work.

Corresponding author

Correspondence to E. ter Avest.

Competing interests

The authors declare no competing interests.

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Robinson, M., Rath, F., Sutton, C. et al. STAB-5: an aide-mémoire for the efficient prehospital management of penetrating trauma by emergency medical services. Crit Care 28, 261 (2024). https://doi.org/10.1186/s13054-024-05048-1

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Received: 21 June 2024
Accepted: 27 July 2024
Published: 05 August 2024
DOI: https://doi.org/10.1186/s13054-024-05048-1

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中文翻译：

STAB-5：紧急医疗服务对穿透伤进行有效院前管理的辅助工具

在许多创伤系统中，穿透伤占总创伤病例量的很大一部分。对于穿透伤患者，住院时间较长与风险调整后死亡几率增加相关 [1， 2]。因此，需要由紧急医疗服务（EMS）工作人员进行快速治疗和转运，他们通常是第一批在现场照顾这些患者的医疗保健从业人员。

为了加快 EMS 工作人员的决策并改善对穿透性躯干损伤患者的即时护理，根据现有文献和专家意见制定了 5 步辅助记忆。

在（中央）刺伤患者的 EMS 治疗中，5 个关键点是必不可少的。它们可以通过 STAB-5 助记符记住（图 1）。

现场安全

传统上，EMS 工作人员接受的培训是遵循经典的现场安全方法，只有在警方认为安全的情况下才能进入现场 [3]。在不断发展的应急响应环境中，全球范围内正在出现向动态风险评估概念的转变。这种方法强调了 EMS 人员进行现场评估的重要性，以及他们迅速适应不断变化的情况以防止治疗真空的能力。

分流

到达后，工作人员应立即确定受伤的位置和严重程度。这应该简洁地进行，以防止将注意力吸引到最明显的损伤上，而忽略了其他严重出血或损伤的来源。应剪掉衣服以方便快速进行全身检查，尤其是经常被忽视的区域，如腋窝、腹股沟、臀裂和会阴，同时在进行这些检查时应注意维护患者的尊严。

自信的场景和患者管理

应尽早要求能够进行高级干预（如输血或复苏开胸手术）的重症监护团队，但工作人员不应在现场等待他们的到来。应重点向最近的重伤中心（MTC）推进，除非患者处于围期停搏（痛苦呼吸、几乎无法记录的脉搏），此时应转移到最近的（创伤）医院。如果可用且认为有必要（取决于与医院的距离和患者的状况），可以在前往医院的途中与重症监护团队建立集合点（RVP）。在这些情况下，与调度人员就目的地医院和计划的集合点进行早期沟通是关键。

出血控制

直接加压、伤口填塞和止血带应用是控制出血的主要因素。在灾难性肢体出血中，应立即使用止血带并充分收紧以阻止动脉出血。如果出血持续，可能需要第二条止血带。除了直接按压外，一些伤口还需要填塞。出血血管应位于伤口内，止血纱布直接涂抹在出血源上，紧紧填塞，直到伤口填满以提供足够的压力。然后可以在止血纱布的顶部贴上压力绷带。对于颈部伤口，应保持直接压力，并应考虑（早期）气道干预的必要性。

5 分钟场景时间

EMS 的重点应该是提供即时挽救生命的干预措施，并在 5 分钟内离开现场进行明确的护理。应尽可能协助患者步行至救护车，或在必要时用手提椅或担架快速解救。所有重点都应该放在离开现场时，并达成共识，即大多数干预可以在前往医院的途中进行。如果无法立即获得血管（IV/IO）通路，在安全的情况下，可以在路线上进行额外的尝试。氨甲环酸（如果无法进入，则静脉注射或肌内注射）、镇痛和基本监测都可以在前往医院的途中进行管理，如果没有产生可靠的血压读数，则应评估患者的容量状态，并通过外周脉搏、颜色、出汗和呼吸状态进行描述。

STAB-5 助记符的使用可确保在院前环境中以结构化的方式为病情危重的患者提供标准化、快速的基本干预措施。它强调了彻底暴露患者和早期出血控制的重要性，因为各种研究表明，超过 50% 的穿透伤后院内死亡是由于失血造成的 [4]。STAB-5 不同于经典的“Scoop and Run”方法，在经典的“Scoop and Run”方法中，患者只需最少的干预或根本没有干预即可转运。然而，它仍然敦促工作人员尽量减少现场时间，因为现场时间延长与更高的死亡率直接相关 [1， 2]。

以前的研究已经证实了医学助记词对回忆信息的有效性 [5]。根据从救护车工作人员那里收到的初步反馈，我们预计本研究中引入的 STAB-5 助记符可以帮助和支持工作人员在该患者群体中定制他们的临床优先事项，同时鼓励他们优先考虑止血干预和短场景时间而不是其他治疗。我们希望通过正式确定这些关键优先事项，临床创新和质量改进项目可以对（可预防的）院前创伤死亡产生重大影响 [6]。有必要对助记符的引入进行现场时间和提供的治疗方法的前瞻性评估，以证实我们的假设。

STAB-5 助记符是 EMS 工作人员治疗穿透伤患者的一种标准简单方法，侧重于早期出血控制和较短的现场时间，这可能有助于在提供者有限暴露于穿透伤的系统中获得更好的患者预后。

在当前研究期间没有生成或分析数据集。

MTC：: 重大创伤中心
RVP：: Rendezvous point
涂：: 创伤科

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文章： PubMed PubMed Central Google Scholar
Holgersson A. 大规模伤亡袭击现场管理综述。J Hum Secur.2016. https://doi.org/10.12924/johs2016.12010091。
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文章 PubMed 谷歌学术
观点：从系统到患者层面改善创伤结果的 11 大优先事项。暴击护理。2022;26:395.https://doi.org/10.1186/s13054-022-04243-2。

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下载参考资料

我们感谢 Joolz Ingram 先生在设计 STAB-5 信息图方面提供的宝贵帮助，并感谢 Niccolò Stomeo 博士对 STAB-5 信息图的法语翻译。

这项研究没有从公共、商业或非营利部门的资助机构获得任何具体资助。

作者和单位

Great Western Air Ambulance Charity，英国布里斯托尔

M. Robinson， F. Rath， C. Sutton & M. Kinsella
荷兰格罗宁根大学格罗宁根大学医学中心急症护理系
E. ter Avest
伦敦空中救护车和 Bart's Health NHS Trust，英国伦敦皇家医院
E. ter Avest
意大利米兰 Rozzano IRCCS Humanitas 研究医院麻醉和重症监护医学科
L. 卡伦佐

作者

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贡献

MR、FR、CS 和 MK 开发了 STAB-5 的概念。他们与 LC 和 EtA 一起检索了现有文献并收集了各种院前服务的经验。EtA 和 LC 起草了手稿，所有作者都对重要的知识内容进行了批判性修改。所有作者都对要提交的版本进行了最终批准，并同意对工作的各个方面负责。

通讯作者

与 E. ter Avest 的通信。

利益争夺

作者声明没有利益冲突。

出版商注

施普林格·自然（Springer Nature）对已发布的地图和机构隶属关系中的管辖权主张保持中立。

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