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

Authors

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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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L. CarenzoView 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性创伤进行院前有效管理的备忘录

在许多创伤系统中，穿透伤占总体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死亡几率增加相关 [1, 2]。因此，紧急医疗服务 (EMS) 人员通常是第一批到达现场照顾这些患者的医疗保健人员，因此有必要加快治疗和运输。

为了加快 EMS 人员的决策并改善对躯干穿透伤患者的即时护理，根据现有文献和专家意见制定了 5 步辅助备忘录。

（中央）刺伤患者的EMS治疗有5个要点。它们可以通过 STAB-5 助记符来记住（图 1）。

现场安全

传统上，急救人员接受过培训，遵循经典的现场安全方法，仅在警方认为安全时才进入现场 [3]。在不断发展的应急响应领域，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 人员现场评估的重要性以及他们快速适应不断变化的情况以防止治疗真空的能力。

分诊

抵达后，工作人员应立即确定受伤的位置和严重程度。应简洁地进行此操作，以防止将注意力吸引到最明显的损伤上，而忽略其他严重出血或损伤的来源。应剪掉衣服，以便于快速进行全身检查，尤其是经常被忽视的部位，如腋窝、腹股沟、臀裂和会阴，同时在进行这些检查时应注意保持患者的尊严。

自信的场景和患者管理

应尽早请求能够执行输血或复苏性开胸手术等高级干预措施的重症监护团队，但工作人员不应在现场等待他们的到来。重点应放在前往最近的重大创伤中心 (MTC) 上，除非患者处于濒临逮捕状态（呼吸困难、几乎无法记录脉搏），此时转移到最近的（创伤）医院是合适的。如果可行且认为有必要（取决于距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一个集合点 (RVP)。在这些情况下，尽早与调度部门沟通目的地医院和计划的集合点是关键。

出血控制

直接加压、伤口填塞和止血带是控制出血的主要方法。在发生灾难性四肢出血时，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，可能需要第二次止血带。有些伤口除了直接加压外还需要包扎。出血血管应位于伤口内，并将止血纱布直接应用于出血源，紧紧包扎直至伤口被填充以提供足够的压力。然后可以将压力绷带应用在止血纱布的顶部。对于颈部伤口，应保持直接压力，并应考虑（早期）气道干预的需要。

5分钟场景时间

EMS 的重点应是立即提供救生干预措施，并在 5 分钟内离开现场进行明确护理。应尽可能协助患者步行至救护车，或在必要时使用携带椅或担架快速将患者救出。所有重点都应该放在离开现场时达成共识，即大多数干预措施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，如果安全的话，可以在途中进行额外的尝试。氨甲环酸（如果无法获得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，如果没有生成可靠的血压读数，则应通过外周脉搏、颜色来评估和描述患者的容量状态、出汗和呼吸状态。

STAB-5 助记符的使用确保以结构化方式为院前环境中的危重患者提供标准化、快速的基本干预措施。它强调了彻底暴露患者和早期控制出血的重要性，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所致 [4]。 STAB-5 不同于经典的“舀起并运行”方法，在这种方法中，患者的运输只需要很少的干预或根本不需要干预。然而，它仍然敦促工作人员尽量减少现场时间，因为延长现场时间与较高的死亡率直接相关 [1, 2]。

先前的研究已经证实了医学助记符对于回忆信息的有效性[5]。根据救护人员的初步反馈，我们预计本研究中引入的 STAB-5 助记符可以帮助和支持救护人员调整该患者组的临床优先事项，同时鼓励他们优先考虑止血干预和短现场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能够对（可预防的）院前创伤死亡产生重大影响[6]。对场景时间和所提供的处理助记符的引入进行前瞻性评估有必要证实我们的假设。

STAB-5 助记符是 EMS 工作人员治疗穿透伤患者的标准简单方法，重点是早期出血控制和缩短现场时间，这可能有助于在提供者接触穿透伤有限的系统中改善患者治疗效果。

当前研究期间没有生成或分析数据集。

机器技术中心：: 重大创伤中心
RVP：: 集合点
TU：: 创伤科

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文章 PubMed 谷歌学术
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下载参考资料

我们感谢 Joolz Ingram 先生在设计 STAB-5 信息图时提供的宝贵帮助，并感谢 Niccolò Stomeo 博士对 STAB-5 信息图的法文翻译。

这项研究没有获得公共、商业或非营利部门资助机构的任何具体资助。

作者和单位

大西部空中救护慈善机构，英国布里斯托尔

M. 罗宾逊、F. 拉斯、C. 萨顿和 M. 金塞拉
急性护理系，格罗宁根大学医学中心，格罗宁根大学，格罗宁根荷兰
E·特尔·阿维斯特
伦敦空中救护车和巴特健康 NHS 信托基金，伦敦皇家医院，英国伦敦
E·特尔·阿维斯特
意大利米兰罗扎诺 IRCCS Humanitas 研究医院麻醉和重症监护医学科
L·卡伦佐

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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。所有作者最终批准了要提交的版本，并同意对工作的各个方面负责。

通讯作者

对应 E.ter Avest。

利益竞争

作者声明没有竞争利益。

出版商备注

施普林格·自然对于已出版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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