Introduction

Trauma is one of the main causes of death in patients under the age of 40 and estimated five
million people all around the world die annually from the causes of traumatic injury (WHO,
2014). According to World Health Organization (WHO), the best response time is equal or
less than 8 minutes (Nogueira LC et al., 2016). Lawner et al. (2015) state that based on the
secondary outcomes, that is including changes in other main ambulance response interval
(time taken from ambulance send off and arrive to the scene) and total out-of-service interval
(the total of time that the ambulance unable to respond other incident). According to Vile et
al. (2015), Welsh Ambulance Service Trust (WAST) that is the only organization that
provide urgent paramedical care services across entire region of Wales, response time is
important to provide good indication of the quality and timeliness of care that resulting the
response time is one of the Key Performance Indicator of Welsh Ambulance Service Trust
(WAST).

The goal of trauma patient management is to identify and priority treatment first life-
threatening injuries in order for the prevention of exacerbation existing injuries or the
presentation of additional injuries (Truhlar A. et al., 2015). Prehospital Emergency Care
Services (EMS) function as the transportation of emergency cases to the hospital or medical
care facilities for resuscitation purpose therefore is important in emergency trauma care
(Williamson K. et al., 2011). The crucial parameter of Emergency Medical Services (EMS) in
prehospital time consists of response time, on scene time, and transporting time may
conceivably affect victim/patient results. Numerous factors may potentially effect on
prehospital time such as, the response speed of Emergency Medical Services (EMS), various
environment factors, severity of patient condition, and on scene patient management (Bigdeli
M. et al., 2010).

In spite of the fact that there have been huge advances in resuscitation, circulatory
access, airway management, and haemorrhagic management as the prehospital management
provided by paramedic and the team, on scene management can increase the prehospital time
(Williamson K. et al., 2011). The issues of shorter prehospital time by rapid transportation
can lower the mortality cases remain discussed (Roger FB. et al., 2015). Numerous studies
made for the determination of correlation between prehospital time and the outcome, but
most of the studies showing uncertain result (Harmsen et al., 2015). Some of the studies show
that there is no significant association or even the less prehospital time related to poorer
patient outcomes (Newgard et al., 2010). Other than that, some studies did show the
advantages of the shorter prehospital time or transportation especially in penetrating injury
(Mccoy et al., 2013). Harmsen et al (2015) from his systemic review stated that for patient
with neurotrauma and penetrating injury along with unstable hemodynamic characteristic,
rapid transportation is very important (Harmsen et al., 2015).

The importance of prehospital time for the treatment of severely injured patient

There is a common thinking of the importance of “golden hour” immediately

following of injury or trauma, during the time of resuscitation; stabilization and
transportation to the hospital/medical facilities propose better chance of survival to the patient
(Harmsen et al., 2015). When the prehospital time is reducing, further advanced medical
management can be providing earlier, thus react the goal to reduce the mortality rate. In any
case, there is an absence of conclusive research on whether the term “golden hour” is
significant for all type of injuries. There are cases in which the injured patients need to be
treating immediately before transferring to the medical facilities/hospital, particularly if a
necessary treatment conceded for getting the patient to the medical facilities as soon as
possible. Moreover, it is likely that reducing prehospital time under a specific limit will
prompt to affecting the patient survival. For instance, understanding results might be
comparable for prehospital times under 15 minutes, implying that a reduction in prehospital
time from 15 minutes to 10 minutes may not change patient results enough to legitimize the
cost of the reduction.

Various studies use response time, the time between Emergency Medical Services
(EMS) dispatch and arrival in the scene, as an indicator of whole process of prehospital time
and a measurement of Emergency Medical Services (EMS) performance. According to
Blackwell and Kaufman (2002), responses time only improved survival rate of the patient
when the EMS team arrive at scene less than five minutes. There is a study perform in Korea
to identify the correlation between severely injured patient to the prehospital time, the result
of the study is there is no effect on mortality and that mortality diminished when scene time
were longer than six minutes (Kim J. et al., 2015). Sanchez Mansas et al (2010) state that a
study of Motor Vehicles Accident (MVA) in Spain found that when responses times reduce
from 25 minutes to 15 minutes, the possibilities of fatality diminished by one third. Another
study perform and found that when the prehospital time increase especially in rural areas, the
higher mortality rates resulted in which means that the Emergency Medical Services (EMS)
responses time higher than 14 minutes (Gonzalez et al., 2009). Al shaqsi (2010) state that
some options for diminished prehospital time have restrictive expenses, yet increment the risk
of safety of the victims, Emergency Medical Services (EMS) team, and the public because of
the higher risk of collision rate of the ambulance.

Al shaqsi (2010) further state that patient outcome must be the main goal of
Emergency Medical Services (EMS) performance. Furthermore, response time may also have
various impacts relying on upon the sort of emergency, most studies on the effect of
prehospital time have focused on cardiac arrest of cardiac patient due to higher mortality
cases reported because of cardiac problem (Wilde E.T et al., 2013). According to Wilde
(2013), previous studies neglected to represent the endogeneity that may have brought about
in biased estimates of the impacts of prehospital time decreasing toward finding no effects.
At this point, when Wilde represented this endogeneity by utilizing an instrument variables,
which influences the explanatory variables, but has no independent impacts on the dependent
variables, Wilde found that a one minutes increasing of response time prompted an eight to
seventeen per cent expansion in mortality (Wilde E.T et al., 2013).

A study conducted by Dharap et al (2017) for the important for the best outcome and
survival of the patient, a significant component of the study is that it was conducted over an
extensive period of 12 months and a large number of injury patient (1181) were selected for
analysis. From the study, only 352 (29.8%) had been admitted to the medical facilities
directly from the accident site, and this group had a fundamentally lower mortality in spite of
having more patients with serious injury. Mortality rate was significantly higher (odds ratio =
1.869, 95% confidence interval = 1.233-2.561, P = 0.005) in the group of 829 (70.2%)
patients who had been moved to the facilities after stabilization at another facilities which
may not having modern equipment for managing trauma patient and that too regardless of
this group having less patient with severe trauma.

Dharap et al (2017) states that the mortality not related with prehospital time nor with
time to tertiary care but with age, mechanism of injury, shock, Glasgow coma Scale (GCS)
less than 9, severity of injury score over or equal to 16, and needs for immediate endotracheal
intubation and ventilator support on arrival (Dharap et al., 2017). Roger F.B et al (2015) state
that the concern of time in the management of severe trauma is obvious, but in recent time, it
is being in increasingly perceived that the acclaimed “golden hour” is not generally a medical
dogma, particularly for patient who are hemodynamically stable. A prospective observational
study in 2010 conducted in Taiwan with smaller sample size (231 severe trauma patients, 75
of the patient were transfer patient) and found that there is no distinction of endurance
between the injury patients directly moved to their facilities and those transferred for further
management, after stabilization at another medical facility of hospital (Hsiao et al., 2013).

Trauma management of patient with chest pain based on the importance of prehospital
time

Management of the chest pain of the patient that involve in trauma divided into three
levels of care; pre-hospital trauma life support, in-hospital or emergency room trauma life
support and surgical trauma life support. For every level of care, acknowledgement of
thoracic injury is essential for the later result. The earlier management of chest pain of the
patient that involve in trauma based on the protocols from the Advance Trauma Life Support
(ATLS, 2013). After performing a primary survey, life-threatening injuries should be
excluding or treat for example:

1. Flail chest
2. Airway obstruction
3. Open pneumothorax
4. Tension pneumothorax
5. Massive haemothorax
6. Cardiac tamponade

After primary survey perform, secondary survey made to provide information on potentially
life threatening trauma:

1. Oesophageal disruption
2. Tracheobronchial disruption
3. Traumatic diaphragramtic rupture
4. Aortic disruption
5. Pulmonary contusion
6. Myocardial contusion
 The assessment of breathing and clinical examinations of the chest (chest movement and
nature of breath) are important to perceive major thoracic injuries, for examples, tension
pneumothorax, open pneumothorax, massive haemothorax, flail chest and pulmonary
contusion. Performing IPPA (inspection, percussion, palpation and auscultation) will
providing information of the presentation of pneumothorax and was 98% specificity, 90%
sensitivity (Waydhas and Sauerland, 2007).

If the clinical diagnosis of pneumothorax confirmed, it needs immediate intervention such

as needle decompression of the pleura space. If the method is not effective and there is a
proof of pneumothorax, chest tube insertion must apply. Repeated examination is compulsory
to avoid neglect of progression of a pneumothorax. As tension pneumothorax is the incessant
reversible reason for mortality in injury patient with cardiac arrest (Mistry et al., 2009).

The initial management and primary survey

Life threatening injuries related to thoracic injuries regularly distinguished in the

primary survey via evaluating the patients ABCDEs. These injuries normally require
interventions, for example, endotracheal intubation, tubethoracostomy, pericardiocentesis, or
needle decompression. These type of life threatening condition and relate issues are resolved
after discovered. Chest injury patient can present to the Emergency and Trauma Department
(ETD) through Emergency Medical Services (EMS), frequently positioned on a backboard as
in a cervical collar.

Furthermore, prehospital treatment of penetrating thoracic injury patient can treat by

needle decompression, intravenous fluid resuscitation and three sided occlusive dressing of
the wound site. Patient with the injuries can also walk into the Emergency and Trauma
Department (ETD), in which case it is necessary to promptly apply a C-spine collar and
continue with Advance Trauma Life Support (ATLS) interventions.

All injury patients must manage according to the Advance Trauma Life Support (ATLS,
2013) algorithm:

A (airway with c-spine protection) – is the patient taking in full sentences?

B (breathing and ventilation) – is the breathing sound symmetrical or present bilaterally?

C (circulation and haemorrhage control) – are the pulses present and regular? Skin colour of
the patient (cold clammy, warm well-perfuse)
D (disability) - calculate the Glasgow coma scale and the examination of upper and lower
extremities

E (exposure/environment control) – expose patient to detect any abnormalities

Earlier interventions for the trauma patient with chest pain

Intravenous infusion – two large-bores (minimum 18 gauges) at the Antecubital site

Oxygen – via nasal cannula or facemask

Monitor – applying the cardiac monitor-to-monitor patient continuously

Rapid chest trauma management can be conventional (with invasive or non-invasive

mechanical ventilation, aggressive respiratory and pain therapy, lung toilet) or operation
(surgical intervention fixation or open reduction in the case of flail chest) (Kourouche et al.,
2018). According to Majercik et al (2017), conventional treatment is typically the treatment
of decision such as, endotracheal intubation and invasive mechanical ventilation for severely
injured patient, or non-invasive mechanical ventilation for patient that less injured. For the
chest pain management of the patient that involve in trauma, the analgesia management
consist of Epidural Analgesia (EA), Intrapleural analgesia and Intravenous analgesia (IV).

Epidural Analgesia (EA)

Epidural Analgesia (EA) is amazingly compelling in acute pain treatment; it improves

pulmonary functions test (Functional Residual Capacity (FRC), lung compliance, airway
resistance reduction, vital capacity and respiratory exchange enhancement) and patient
involvement to physiotherapy with an increase number of deep breathing and more
effectiveness in coughing. Epidural Analgesia (EA) first recommended in blunt chest injury
patients, either with lumbar or thoracic approach relying on the injury site; for patient with
bilateral rib fracture Epidural Analgesia (EA) is the suitable choice of the pain management.
Normally, Local Anaesthesia (LA) with or without adjuvants (clonidine, opioids) are provide
in boluses or continuous infusions (Malekpour et al., 2017).
Intrapleural Analgesia

Intrapleural Analgesia is the application of analgesia through transcutaneous catheter

and it is obtain unilateral Intercostal Nerve Block (ICNB) through Local Anaesthesia (LA)
diffusion in pleural space. Patient must in supine position for the Local Anaesthesia diffusion
and multiple unilateral dermatomes block, which is not ideal in a patient with compromised
respiratory mechanic; additionally, with the Intrapleural Analgesia, there is a chance of
diaphragmatic function bargain with respiratory capacity exacerbating. Conceivable result are
Intraparenchymal or extrapleural catheter localization, pneumothorax and chest wall
misplacement; besides, high plasma concentration through pleural absorption has been
reported, along with high risk of Local Anaesthesia toxicity (Ho A.M et al., 2013).

Intravenous Analgesia (IV)

Intravenous Analgesia is a choice for the patient that not eligible for neuraxial or
regional anaesthesia. The intravenous administration is with opioids (with or without patient
controlles anaesthesia (PCA)) supported with non-steroidal anti-inflammatory drugs
(NSAIDs) and acetaminophen (Galvagno et al., 2016). At the point when it is necessary and
conceivable, Intravenous Analgesia can be administer through Intramuscular (IM), trans-
dermal or oral routes (Kourouche et al., 2018).

Conclusion

Prehospital time is importance in trauma scene, but in aspect of measuring service

effectiveness, they are a part of measure only. Reducing prehospital time may improve the
patient outcomes following by Motor Vehicles Accident (MVA). The presence of well train
Emergency Medical Services team has a beneficial effect on reducing prehospital time and on
achieving appropriate patient triage for the proper management plan. This also include that
Emergency Medical Services (EMS) team identify the severity of the injuries more quickly in
the most-severely injured patient and the proper management plan. Prehospital time consists
of the time between the incident and Emergency Medical Services (EMS) notify, the time
between Emergency Medical Services (EMS) dispatch and arrive at the scene, the total time
spent at the scene, and the travelling time from the scene to the medical facilities or hospital.
Because of the importance of the topic, it is important to invigorate the advancement of
various study that look to comprehend the variables associated with the prehospital time,
which will allow an experimentally validated understanding of what we need to do to
overcome the issues.