Phtls 9th Edition Update 1uu3a
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It is my privilege and honor to welcome our global family of PHTLS instructors to the 9th edition PHTLS Instructor Update. I am humbled by your presence here this afternoon which reminds us why the PHTLS program continues to be the global leader in prehospital trauma education. The great success of our program is directly due to the tremendous dedication and ion of our global PHTLS faculty. You are the ones who are responsible for providing our prehospital practitioners with the knowledge and skills they need to make the best decisions in the field for their patients. On behalf of NAEMT, thank you for being here today and for what you do each and every day for your students and communities.
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You have come from all across the United States and across the globe, representing the 11,222 PHTLS instructors from 69 countries providing PHTLS to prehospital providers in their communities. PHTLS is truly a global movement dedicated to excellence in prehospital trauma care.
NAEMT is honored to the EMS profession through education, advocacy and research. Education is core to our mission. In addition to our outstanding global faculty, NAEMT’s leadership is fully committed to our global education program. NAEMT is led by an elected Board of 15 , who are ed by 17 appointed committees and 16 staff .
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I would like to thank the NAEMT Board of Directors for their unwavering commitment and for PHTLS and our education mission, and for providing the funds necessary to ensure that the 9th edition of PHTLS is the best ever produced. Our Board are here with us today to welcome you and thank you for your service. Board , please stand.
We are honored to welcome Dr. Eileen Bulger, Chair of the ACS Committee on Trauma to our meeting. NAEMT deeply appreciates our strong relationship with the College on PHTLS and other trauma initiatives. Our organizations have an endurable bond based on our shared commitment to the care of trauma patients. Dr. Bulger, please stand so that our attendees can thank you.
We appreciate your leadership and look forward to continuing our work with you and your colleagues on the COT.
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This 9th edition of PHTLS is dedicated to the founder of PHTLS and the father of all NAEMT education……Dr. Norman McSwain. Without Dr. McSwain’s vision, ion, empathy and tenacity, PHTLS would not exist and we would not be gathering here today.
I can honestly tell you that Dr. McSwain has been on the shoulder of every member of our PHT Committee and in the thoughts of every one of our chapter editors and course authors as the 9th edition was created. Each contributor has been motivated by Dr. McSwain’s standards of excellence and committed to ensuring that the 9th edition is a product that Norman would be proud of.
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Norman led PHTLS for over 30 years. He was ed over the decades by many dedicated volunteers who shared his vision and embraced the PHTLS mission. Some of these PHTLS missionaries were instrumental in the development of earlier editions of the textbook. Others were on the road helping to spread PHTLS. NAEMT and the PHT Committee would like to express our thanks to these PHTLS pioneers. PHTLS lives, breathes, and grows because of the efforts of those who volunteered their time to the development of PHTLS.
It is now my great pleasure to introduce to you the of NAEMT’s Prehospital Trauma Committee. Will each member stand as your name is called… Dr. Alex Eastman Dr. Andrew Pollak Mr. John Phelps Dr. J.C. Pitteloud Dr. Faizan Arshad
I ask any and all of past PHTLS Committees, PHTLS chapter editors, contributors and reviewers, to please stand and be recognized.
Dr. Warren Dorlac Mr. Larry Hatfield Dr. Frank Butler
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Thank you, Dennis. As we move into the future with the 9th edition of PHTLS, it is very important for all of us to understand the history of PHTLS, how it developed, and our special relationship with the American College of Surgeons.
It is now my great privilege to introduce my colleague and friend, Dr. Alex Eastman, to take us back to the history of PHTLS, Dr. McSwain’s monumental vision, and the partnership that continues between NAEMT and the American College of Surgeons Committee on Trauma.
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Norman’s surgical expertise early in his career resulted in his induction, in 1973, as a Fellow of the American College of Surgeons. The history of PHTLS begins with its founder, Dr. Norman McSwain. He began his involvement with the COT in 1975 through his work with the Kansas Committee on Trauma. Also at that time, he helped found NAEMT. Four years later he was appointed to the National COT where he led both the Pre-hospital Care Committee and the ATLS Committee. ATLS launched in 1980.
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Shortly thereafter, at the urging of Dr. Norman McSwain, the NAEMT Board authorized development of a non-physician version of ATLS, called Prehospital Trauma Life . Dr. McSwain, representing the ACS-COT, worked with Bob Nelson to develop a prototype of PHTLS under the title “Improved Trauma Management” and introduced it to a packed room at the 1983 NAEMT annual meeting in Dearborn, Michigan.
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Dr. McSwain’s philosophy on prehospital trauma education served as the foundation for the first PHTLS course and continues as the fundamental precept of PHTLS in this 9th edition. His vision - to improve care and increase the survivability of trauma patients through high-quality, evidence-based education that strengthens and enhances the knowledge and skills of prehospital practitioners.
By 1984, the first PHTLS Committee was appointed, with Dr. McSwain serving as the committee’s Medical Director. The first National PHTLS Faculty course was held at Dr. McSwain’s own Tulane University. The first PHTLS provider course was offered in 1985 and the first PHTLS textbook followed in 1986.
His core belief - that given a sound foundation of knowledge and key principles, prehospital practitioners are capable of making reasoned decisions regarding patient care.
And that, my friends, is how it all began.
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Now let’s jump forward 33 years, and today, NAEMT and ACS have a solid and enduring relationship based on our shared vision for trauma care and our mutual respect, thanks to Dr. McSwain’s vision to bring these two organizations together.
Dr. McSwain shepherded NAEMT’s relationship with ACS for over thirty years. Both organizations relied heavily on his leadership and with his ing, we had to feel our way through to a new relationship. I am pleased to inform you that NAEMT’s relationship with ACS has never been stronger. As the PHTLS Medical Director, I serve as NAEMT’s liaison to the ACS-COT. Both Dennis and I participate on ACS’s EMS Committee and on their Stop the Bleed initiative, and Dennis represents NAEMT on ACS’ Injury Prevention Committee.
NAEMT cooperates with the ACS-COT in the development of PHTLS. Drs. Pollak and Dorlac, and myself are all Fellows of ACS, and serve on the PHT Committee at the recommendation of ACS.
NAEMT thanks ACS’ Executive Director Dr. David Hoyt, along with Drs. Michael Rotondo, Ronald Stewart, Mark Gestring and Eileen Bulger for working with Dennis and the Board to strengthen our relationship.
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Its now my great pleasure to introduce our PHTLS 9th edition Medical Editor who led the revision of the PHTLS textbook. Please me in welcoming my colleague and friend, Dr. Andrew Pollak.
PHTLS is also endorsed by several prestigious organizations – the Eastern Association for the Surgery of Trauma (EAST), the American Academy of Orthopedic Surgeons (AAOS), the Special Operations Medical Association (SOMA), and the Trauma Center Association of America (TCAA).
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Hello. It has been a true honor and pleasure to serve as PHTLS Medical Editor for the ninth edition and I’m excited to be here today to share the textbook updates with you.
We were so fortunate to be able to bring together some of the greatest thought leaders in prehospital trauma to work on the 9th edition. Understanding the critical role of the prehospital provider to the survival of the trauma patient, each of our chapter editors applied their expertise to ensure that the full spectrum of trauma care was addressed.
In revising PHTLS, the Committee recruited subject matter experts from around the world, seeking out the best and brightest to review and revise the chapters. As you will see on the next slide, an amazing group of physicians and prehospital practitioners volunteered their time to this revision and poured their ion and expertise into making the 9th edition an exciting, up-to-date, evidence-based resource.
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We are deeply grateful to these outstanding individuals for the time, effort, and expertise they contributed to the 9th edition. Please me in thanking each of our chapter editors.
On behalf of NAEMT and the PHT Committee, I would like to extend my deep appreciation to Dr. Richard Carmona, former Surgeon General of the United States, for the inspiring foreword he wrote for the 9th edition. Our special thanks and gratitude also go to past PHTLS Medical Director Lance Stuke, for his thoughtful and moving dedication to Dr. Norman McSwain.
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The Committee reviewed the 8th edition PHTLS table of contents and streamlined the content to eliminate redundancies and create a more intuitive flow to the chapters. Every chapter in the book has been updated with current data and references.
In preparing to revise PHTLS, the Committee ed our ATLS partners, who provided updated references and a compendium of changes to the 10th edition of ATLS. The Committee met and reviewed these changes for applicability to prehospital trauma care. The Committee also reviewed and considered new evidence from the Department of Defense’s Committee on Tactical Combat Casualty Care. The PHTLS chapters were then sent to the chapter editors with guidance from the Committee.
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There are now 22 chapters in the book. They are:
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Burn Injuries
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PHTLS: Past, Present, and Future
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Pediatric Trauma
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Golden Principles, Preferences, and Critical Thinking
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Geriatric Trauma
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Shock: Pathophysiology of Life and Death
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Injury Prevention
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The Physics of Trauma
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Disaster Management
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Scene Assessment
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Explosions and Weapons of Mass Destruction
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Patient Assessment and Management
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Environmental Trauma I: Heat and Cold
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Airway and Ventilation
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Environmental Trauma II: Drowning, Lightning, Diving, and Altitude
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Head Trauma
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Wilderness Trauma Care
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Spinal Trauma
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Civilian Tactical Emergency Medical (TEMS)
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Thoracic Trauma
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Abdominal Trauma
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Musculoskeletal Trauma
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While every chapter in the 9th edition PHTLS textbook has been revised and updated, there are some significant changes I’d like to highlight today, both throughout the book and in specific chapters.
To start, the Committee decided to move from the ABCDE patient assessment mnemonic to XABCDE, which puts exsanguinating hemorrhage at the forefront of every patient encounter. As we know, it takes 2 minutes or less for a patient to exsanguinate. No other intervention we perform is more time sensitive than stopping that level of bleeding. While this change is not yet reflected in ATLS, it is extremely relevant to prehospital care and it mirrors the MARCH assessment (which stands for Massive hemorrhage, Airway Control, Respiratory , Circulation, Hypothermia management, Head injury mitigation) used in both Tactical Combat Casualty Care and Tactical Emergency Casualty Care. You will see the importance of XABCDE reflected in every PHTLS chapter. Another change incorporated throughout the book is that boluses are now 250 cc each, with a recheck of patient blood pressure and other vital signs between boluses. In the context of a growing body of evidence of the detrimental effects of over-aggressive early fluid resuscitation, we are encouraging practitioners to be thoughtful about fluid resuscitation. There are also new targets for blood pressure with fluid resuscitation.
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Chapters 1 and 2 provide the foundation of PHTLS. Chapter 1 takes the reader through the history of prehospital trauma care and the development and philosophy of PHTLS. Chapter 2 is now a consolidation of two previous chapters: Golden Principles of Prehospital Trauma Care, and The Science, Art, and Ethics of Prehospital Care: Principles, Preferences, and Critical Thinking. Thank you to Rick Ellis and Patrick Wick for their input on Chapter 1 and to Dr. Blaine Enderson for his excellent work on consolidating Chapter 2.
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Dr. Craig Manifold, NAEMT Medical Director, was asked to revise the chapters on Shock and the Physiology of Life and Death. Dr. Manifold streamlined the content into one incredible chapter. Major changes to this chapter include a focus on treating exsanguinating hemorrhage with tourniquets prior to the onset of shock; a discussion of tranexamic acid (or TXA) dosing (if allowed per local protocols); and a suggestion for practitioners to attempt IV access with an 18gauge needle briefly before moving to IO access.
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Drs. Andrew Schmidt and Lauren MacCormick edited Chapter 4: Physics of Trauma, ensuring that references are up to date, statistics are current, and that it contains the latest evidence on air bags, car seats, and motorcycle crashes.
Chapter 5 – Scene Assessment – was edited by Drs. Blaine Enderson and Catherine McKnight. We all know that scene safety is the number one priority in prehospital trauma care – both our own safety and that of those around us. Citing current evidence from NHTSA, OSHA, the CDC, and other national institutions, this chapter covers scene safety considerations ranging from motor vehicle collisions to active shooter events and events involving weapons of mass destruction.
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One of the updates in the 10th edition of ATLS is a change from rapid sequence intubation to drug-assisted intubation. The Committee had an extensive discussion on this issue, as different jurisdictions use different terminology. You will see that the Airway Chapter refers to pharmacologically assisted intubation. The Committee agreed, however, that regardless of terminology, a rapid response is most important. This chapter also includes a great discussion on apneic oxygenation and the addition of the new HEAVEN criteria to the LEMON approach for predicting a difficult airway. Of note, the needle cricothyrotomy technique has been eliminated from the text, given the minimal evidence of its efficacy. Special thanks to Drs J.C. Pitteloud and Bruno Goulesque for their work on this chapter.
Thank you to Drs. Vince Mosesso and Michael Holtz, for their work on Chapter 6: Patient Assessment and Management. This chapter walks the reader through the new XABCDE patient assessment – addressing hemorrhage control first and foremost through tourniquet use, pressure dressing, and manual direct pressure. NAEMSP and ACS-COT revised guidelines for termination of resuscitation are referenced and the editors expanded the section on patient transfer from prehospital care to the trauma team.
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The Head Trauma chapter, edited by Drs. Deborah Stein and Christine Ramirez, includes an updated Glasgow Coma Scale to improve the accuracy and reliability of practitioners when they are describing the severity of traumatic brain injury. The chapter also continues to emphasize the importance of the motor exam component of the Glasgow Scale as a good predictor of TBI severity. In addition, the chapter authors included the following TBI guideline: to maintain systolic blood pressure at greater than or equal to 100 millimeters of mercury for patients who are 50 to 69 years old; or at greater than or equal to 110 millimeters of mercury for patients 15 to 49 years old or over 70 years. These blood pressure guidelines may be considered to decrease mortality and improve outcomes in our patients with traumatic brain injury.
We all know there has been much debate in the field about spinal immobilization and the use of backboards and other immobilizing devices. Throughout the 9th edition, the spinal motion restriction, spinal stabilization, and spinal immobilization are used interchangeably. Further, the Committee neither advocates for the removal of all long backboards nor the unnecessary use of immobilizing devices. In the spirit of Dr. McSwain and the history of PHTLS, the Committee advocates for the use of applied critical thinking when practitioners are faced with a patient who may need spinal immobilization.
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Chapter editors Drs. Steven Ludwig and Luke Brown, with Ian Bussey and Alyssa Nash, reviewed the signs and symptoms of spinal trauma, as well as the criteria necessary to determine when spinal motion restriction is unnecessary. The chapter includes updated evidence on spinal cord injury and no longer s the use of therapeutic hypothermia as a promising treatment, based on the latest evidence.
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The Thoracic Trauma chapter, edited by Dr. Mark Gestring, highlights new needle decompression guidelines, based on recent evidence that s the 5th intercostal space at (or just anterior to) the mid-axillary line as the preferred needle thoracostomy site. However, while this new site is preferred, it is not the only option and the anterior approach is still taught, because PHTLS always upholds principles over preferences.
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An exciting addition to the Abdominal Trauma chapter is the introduction of REBOA – resuscitative endovascular balloon occlusion of the aorta – as a promising technique for managing and mitigating uncontrolled hemorrhage in the torso. Currently, REBOA is only performed by highly trained teams and is not yet available in the United States for prehospital care. The chapter, edited by Drs. Thomas Scalea, Ronald Tesoriero, and Jason Weinberger, also addresses hemodynamically unstable blunt trauma patients with suspected pelvic injury, for whom prehospital providers are advised to stabilize or close the pelvis by securing it with a sheet or by applying a commercial binder.
The Musculoskeletal Trauma chapter, edited by Drs. Robert O’Toole and David Potter, further addresses the use of pelvic binders and the need for prehospital practitioners to employ their use to prevent exsanguination in the context of major pelvic ring disruption.
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The Burn Injuries chapter, edited by Drs. Brian Williams and Spogmai Komak includes an important update on fluid resuscitation guidelines. The change in the 10th edition of ATLS is that fluid resuscitation for patients with deep partial and full thickness burns involving greater than 20 percent of body surface area should begin with 2cc per kilogram of lactated Ringer’s, times the percent of total body surface area burned with subsequent adjustment as indicated by urine output. This is a change from the previous Parkland formula, which started patients with fluid resuscitation at 4cc per kilogram.
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We were fortunate to have four pediatric physicians—Ann Dietrich, David Tuggle, Jessica Naiditch, and Kate Remick—lending their subject matter expertise to the Pediatric Trauma chapter. The first important change is that damage control resuscitation in children now represents a move toward limiting crystalloid resuscitation. In the child with moderate bleeding, no evidence of end-organ hypoperfusion, and normal vital signs, fluid resuscitation should be limited to no more than one or two normal saline boluses of 20 milliliters per kilogram.
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The Pediatric Trauma chapter also encourages providers to strongly consider the risks of endotracheal intubation before attempting the procedure in the field. Attempting advanced airway management is unnecessary and potentially harmful if the child is adequately ventilated and oxygenated using good basic life skills, such as bag-mask ventilation.
Chapter 15 highlights the unique aspects and increased risks of trauma in geriatric patients. It covers factors affecting control of severe external hemorrhage in this population and provides an important reminder that even ground-level falls can cause fracture in elderly patients. Thank you to Drs. Manish Shah, Michael Lohmeier, and Michael Mancera for their updates to this chapter.
Finally, there has been no change in the preferred site for needle decompression in children – it is still the second intercostal space at the midclavicular line.
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Chapter 16 focuses on Injury Prevention. Thank you to Dr. Heidi Abraham and Thomas Colvin for their work on providing the most up-to-date injury statistics, including an important new section on intimate partner violence, and listing key elements from the National EMS Culture of Safety project.
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The Disaster Management Chapter, edited by Dr. Faizan Arshad, has been updated to introduce Psychological First Aid as an alternative resource to address some of the limitations of mandatory Critical Incident Stress Management and provides teams with effective tools for immediate intervention in situations in which providers have psychologically related complaints and are amenable to assistance.
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The chapter on Weapons of Mass Destruction, edited by Drs. Arshad and Daniel Nogee, includes updated information about types of WMD incidents as well as the inclusion of vehicles as a weapon and suicide bombers. The chapter editors offer new data on specialized decontamination agents, and updated data on newer cyanide antidote kits that contain IV hydroxocobalamin, which binds with cyanide to form cyanocobalamin, a nontoxic agent.
The first of the PHTLS Environmental Trauma chapters focuses on heat and cold. Chapter editors Dr. Seth Hawkins and Bryan Simon include an important discussion on hyperthermia, and stress that normal body temperature is a reasonable goal for hyperthermia management. They also include an updated recommendation for prehospital care providers. Regarding your personal hydration, the Wilderness Medical Society recommends that you drink to thirst to ensure proper hydration while preventing excessive fluid intake and onset of exercise-associated hyponatremia. The chapter editors also provide updated factors predisposing to hypothermia.
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The second Environmental Trauma chapter, also edited by Dr. Seth Hawkins, focuses on lightning, drowning, diving, and altitude and includes update protocols in environmental trauma. Recommendations related to long spine board immobilization in and out of water are changing, although spine boards are still very useful as a transportation tool when moving patients. The chapter includes updated protocols on the use of therapeutic hypothermia in drowning patients and Dr. Hawkins provides new material on drowning in submerged vehicles, which s for 10% of drownings in the US.
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The Wilderness Trauma Care chapter acknowledges the premise that just like with tactical medicine, proper care on the street may not be proper care in the wilderness. Wilderness EMS protocols may require an operationally specific scope of practice for optimum patient care. Chapter editors Drs. Will Smith and John Trentini further the discussion on spinal immobilization to note that mechanism of injury alone is not an indication to immobilize a conscious patient with a reliable exam. They also include updated content on improvised tourniquets, with key descriptions of a successful tourniquet.
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It is now my great pleasure to introduce our PHTLS 9th edition Course Editor, John Phelps, who will walk us through all of the changes in the 9th edition course.
The Civilian Tactical Emergency Medical chapter – coedited by Drs. Eastman and Faroukh Mehkri – includes a new remote assessment methodology flowchart and an emphasis on tourniquets placed “high and tight” rather than focused on trying to locate them 2-3 inches above the wound.
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I am so very grateful for the tremendous effort of each of the of the 9th edition course author team. Please me in recognizing and thanking our course authors: Amie Fuller, from Maryland
Good afternoon, everyone. I am truly honored to have been selected to lead the revision of the 9th edition course. I recognize what a great responsibility NAEMT has given to me to ensure that this latest edition of the course is the very best that it can be. Our team of course authors, contributors and reviewers have been hard at work for the past 18 months on this great project.
Dr. J.C. Pitteloud from Switzerland Anthony Harbour from Virginia Dr. Faizan Arshad from Connecticut And Jim McKendry from Canada
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I also want to thank James Bayreuther, Sean Britton, Riana Constantinou, Shawn Couch, Jan Fillipo, Cody Jenkins, James Jensen, Lara Marcelo, Joanne Piccininni,
All NAEMT courses are beta tested before being published. A very special thank you to the two training centers that ran beta tests of the PHTLS course and the students and instructors who provided invaluable . The initial beta was held at University of Texas Health Science Center in San Antonio, a place near and dear to my heart! Thank you to Cody Jenkins and Shawn Couch for helping teach that course.
Dr. Victor Pimentel, Dawn Poetter, Dr. Neil Pryde, Lee Richardson, Sarrissa Ryan, and Patrick Wick for their contributions to the 9th edition.
Jay Gould and his team at VCU Health were incredibly gracious and welcoming and assembled an all-star team of instructors for our second beta. Thank you to Jay and everyone who taught over those two days in July.
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The PHT Committee agreed on the following learning objectives for the 9th edition of the PHTLS course:
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Demonstrate the principle “First, do no harm.”
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Evaluate emergency situations to determine the most appropriate course of action
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Demonstrate safe and effective scene management
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Apply anatomically appropriate hemorrhage control techniques
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Implement principles of evidence-based research to prehospital trauma care
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Conduct a primary survey
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Provide optimum patient care for all trauma patients
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Perform airway management in a critically injured patient
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Correlate patient criticality with transport timing and disposition decisions
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Provide ventilatory for a patient with inadequate breathing
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Communicate pertinent patient information to the receiving facility
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Defend pain management interventions in trauma patients
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Demonstrate best practices in spinal care for trauma patients
Determine appropriate intravenous fluid therapy for trauma patients in the prehospital setting
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Manage shock within the provider’s scope of practice
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Adapt trauma care principles to special populations
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The 9th edition course schedule incorporates time for skill stations on both day 1 and day 2. As practitioners, it is important that we continually hone our skills and build our muscle memory. With the greater emphasis on bleeding control in this edition, tourniquet application has been introduced as a required skill. – every red blood cell counts!!
As you can see, Day 2 incorporates time for either one of the optional PHTLS lessons or additional simulations. Faculty can choose from Kinematics of Trauma, Point of Care Ultrasound, Altitude, Diving, Wilderness, Hypothermia, or Hyperthermia lessons. Additionally, faculty can choose optional skills to augment the selected optional lesson or a skill focusing on organization needs.
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The 9th edition course offers new patient simulations, and an expanded library of optional lessons that gives the faculty the ability to tailor each course to the needs of their community. Baseline patient simulations from the 8th edition will be available to instructors who wish to utilize them, but are not a required part of the course. We have also developed mass-casualty trauma scenarios for training centers that wish to practice triage skills.
Revising the PHTLS course was a true labor of love and we took the team approach very seriously when starting this mission. We carefully considered from you – our PHTLS faculty – and reached out to PHTLS instructors around the world for their input on best PHTLS teaching practices. Lessons now follow a case-based approach that encourages critical thinking and student engagement. Every lesson reflects the new XABCDE patient assessment approach and aligns with updated content from the textbook. This iteration of the course includes mandatory skills stations, and the removal of the final evaluation skill stations to allow more time for patient simulations and individual skill practice.
A very special thanks to Mike Bowen and his colleagues at Fisdap for partnering with NAEMT to create a validated test instrument for the 9th edition of PHTLS. PHTLS is now the ONLY prehospital trauma course with a validated test. Thank you as well to all of the PHTLS faculty who participated in the process. We appreciate your time and dedication.
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An added component to the 9th edition is the PHTLS Course Manual, created to enhance the participant’s course experience.
There are 9 lessons in the 9th edition PHTLS course. Lesson 1 is an introduction to the course and provides an overview of trauma care and PHTLS. In this lesson, we focus on the societal and financial impacts of trauma; explain the goals, philosophy and educational approach of PHTLS; explain the history and evolution of prehospital trauma care; list the three phases of trauma care, and discuss the effects of communication and documentation in trauma care.
The 9th edition PHTLS Textbook will continue as the gold standard reference book containing the full spectrum of medical science of prehospital trauma care. It is designed for use by students and instructors before, during and after the course. The new Course Manual presents content specific to the course lectures and case studies, and highlights key knowledge from the course lessons to give students a deeper understanding of the content. It includes content presented by the instructor during the course so that students can access this information after the course. The PHTLS 9th edition textbook and course manual will be sold as a package. They will NOT be sold separately. The PHT Committee designed the course to utilize both the textbook and the course manual to ensure that students receive the maximum educational benefits before, during and after the 16 hours of classroom content.
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Lesson 2 covers scene management and the primary survey. The learning objectives for this lesson are to:
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In Lesson 3, Airway, we expect that students will learn how to:
• Identify the
scene safety threats that pose a hazard to personnel, patients, and bystanders.
• Discuss the potential causes of airway obstruction. • Demonstrate the steps of a primary and secondary survey of a trauma patient’s airway.
• Develop a patient approach plan using information gathered during the scene size-up.
• Choose the most appropriate airway management intervention based on the patient’s physical findings.
• Describe the integration of assessment and management during the primary survey. • Apply a MUCC-compliant triage method to manage multiple casualty incidents. and • Identify indications of intimate partner violence.
• Describe the structural differences in the anatomy of adults and children.
and
This lesson also introduces the XABCDE patient-assessment approach.
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Lesson 4, Breathing, Ventilation and Oxygenation, looks at:
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A review of the anatomy
Lesson 4 also considers:
• How to choose the most appropriate airway management intervention. • Evaluation of the ventilation and perfusion status of a trauma patient using waveform capnography. • Choosing the most appropriate supplemental oxygen delivery device based on the patient’s signs and symptoms. and • Determining when to ventilate and
and physiology of
breathing. • How to identify inadequate breathing based on trauma patient assessment. and • Management of life-threatening injuries impairing airway and breathing in a trauma patient. 69
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when to oxygenate a trauma patient.
Lesson 5 is Circulation, Hemorrhage, and Shock. The learning objectives here are for the students to: •. Describe shock pathophysiology. • Recognize the clinical signs of shock. • Explain basic shock treatment. • Identify the modalities of fluid replacement. • Explain the role of blood component replacement in the management of hemorrhagic shock. and • Describe special considerations in shock management (age, athletes, hypothermia, medications, pacemakers, and pregnancy).
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Lesson 6 is Secondary Assessment, where we assume we have a bit more time with the trauma patient and can take our assessment skills a step further.
The PHTLS Disability lesson has been broken into two parts. Part 1 focuses on traumatic brain injury. Lesson objectives for part 1 are:
• Identify the signs and symptoms of traumatic brain injury. • Explain the pathophysiology of traumatic brain injury. • Discuss the physics of trauma that cause TBI. • Distinguish primary and secondary brain injuries. and • Demonstrate proper medical
Following this lesson, students will be able to: Explain the purpose and sequencing of performing a secondary survey. Choose the most appropriate secondary survey tool(s) to obtain pertinent physical findings. and Identify transport options for a trauma patient based on assessment findings.
• • •
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management of traumatic brain injuries.
The second part of the disability lesson focuses on spinal injury. Following this lesson, students will be able to: • Identify the signs and symptoms of spinal injury and neurogenic shock. • Describe the pathophysiology of spinal injury and neurogenic shock. • Demonstrate evidence-based care for spinal injury. • Identify the indications for spinal motion restriction. and • Select appropriate pain management interventions.
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Lesson 8 looks at special considerations, such as burns, the unique features of pediatric and geriatric trauma, and pain management. Learning objectives here include the ability to:
Finally, we have lesson 9, the summation. The learning objectives for this lesson are to
• Discuss burn assessment and treatment.
• Discuss the key points in managing a trauma patient, known as the “Golden Principles.”
• Learn to assess and treat pediatric trauma patients.
And to
• Apply adult trauma treatment concepts to pediatric trauma patients.
• Discuss the EMS provider’s role in the nationwide reduction of trauma deaths and disabilities.
• Apply adult trauma treatment concepts to geriatric trauma patients. • Apply adult trauma treatment concepts to obstetric trauma patients and • Choose the most appropriate pain management intervention based on clinical findings.
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Throughout the course, students will participate in skills stations. Skills that are required in the 9th edition of the course are:
Course coordinators and instructors may choose to include additional optional skill stations, such as:
• Trauma assessment
• Supraglottic airway devices
• Needle decompression
• IO access
• Junctional hemorrhage and wound packing
• ALS airway techniques
• Supraglottic airway
• Immobilization
• Tourniquet application
• For example, t, long bone, and traction splinting
• Pelvic binder
and
• Basic airway techniques
• Other optional skills as needed per organization
and • Extrication
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The 9th edition Course author team has begun work on the 9th edition refresher course, which will be available in English by Fall of 2019. All 9th edition PHTLS providers will be eligible to take the 8-hour refresher course.
We are happy to announce that we have new and revised patient simulations for the course. Thank you to everyone who worked on them! The following categories of simulations are available: • Airway • Breathing • Circulation • Disability • Multisystem • Special Considerations And • Mass casualty
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It is now my pleasure to introduce Amie Fuller, author of the PHTLS 9th edition provider course for first responders…
Thank you, John. I am Amie Fuller, and I am a Lieutenant at Frederick County Fire and Rescue in Maryland, a former flight paramedic, and a PHTLS faculty. I am honored to have the opportunity to lead a team to revise PHTLS for First Responders. This is a course that is designed for first responders who are NOT EMTs or paramedics. There is a huge need for this course within the first responder community both domestically and around the globe. This community includes fire fighters, law enforcement officers, EMRs and others. If your training center is not currently offering this course to your community, we strongly encourage you to reach out to your first responders to provide them with this course.
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Thank you to my colleagues on the PHTLS for First Responders author team – Aaron Miranda and Ken Delassandro. I appreciate their extensive subject matter expertise and field experience in developing the curriculum. And of course, thank you to John Phelps for his leadership.
As a team, we looked at the core PHTLS learning objectives and created objectives appropriate for the first responder community. Those learning objectives include: 1.
Demonstrate safe and effective scene management including infection protection practices that apply to all patients
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Evaluate emergency situations and apply the principles of triage to determine the most appropriate course of action
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Demonstrate safe patient movement practices to remove patients from immediate harm and to assist EMS personnel
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Apply anatomically appropriate hemorrhage control techniques
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Conduct a simple primary survey with emphasis on identifying and managing immediate life-threatening injuries within the first responder’s scope of practice
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The remaining learning objectives are to: 6.
Perform basic airway management in a critically injured patient and provide ventilatory as needed
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Provide basic pain management interventions in trauma patients
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Recognize signs and symptoms of shock and provide basic care procedures within the first responder’s scope of practice
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Reassess patient status while waiting for additional EMS providers or transporting agency and communicate pertinent patient information when relinquishing care
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We have been diligently working on the course and expect to have it complete and ready to teach by June 2019. It should be available in Spanish by December 2019. All PHTLS 9th edition instructors are eligible to teach PHTLS for First Responders. NAEMT and Jones & Bartlett will announce when the course is ready and instructors will be able to access the slides and instructional materials through their JBL . Additional course materials, such as a posttest and course evaluations will be available through the NAEMT Education Portal. A course manual designed specifically for the first responder audience will also be available through the Jones & Bartlett website.
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I am happy to now introduce Nancy Hoffmann of NAEMT who will update us on the publication aspects of our new course materials.
Thank you, Amie. In this next part of the Update, I will provide information regarding the pricing, formats, and translations of the 9th edition, and also provide information about the 9th edition Instructor Update.
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Earlier this year, NAEMT met with our PSG partners to discuss pricing for the 9th edition. While recognizing that the price for the 8th edition had not been increased from the 7th edition, both PSG and NAEMT felt that we should try to bring the price of the 9th edition down even further to address any competitive issues with other courses, and make the 9th edition as affordable as possible. We also took into that our students increasingly want options on how they access the course materials, with many students now preferring digital formats.
NAEMT thanks Jones and Bartlett Learning Public Safety Group for their work on the 9th edition. We greatly appreciate the tremendous of Kim Brophy, Jennifer DeForge-Kling, Donna Gridley, Christine Emerton, Robert Furrier, Alison Lozeau, Tiffany Sliter, and the entire PSG team for truly being our partners in this venture, right from the start. We also thank Kristin Parker, JBL’s designer on this project, for all of her great work and the many design samples she provided.
As John mentioned earlier, the textbook and course manual will ONLY be sold as a package. We feel that the 9th edition pricing model will provide our training centers with affordable options for their students. These are the prices for the English student materials in US dollars.
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PHTLS in English will continue to be offered as a 16-hour classroom course, or in a hybrid format, with 8 hours available online to be followed by 8 hours in the classroom. We will also continue to offer 8 hours of PHTLS continuing education online. Those students who choose this option will not receive the PHTLS provider card but they will receive 8 hours of CAPCE credit.
For the ninth edition, translations will include the textbook, course manual, and instructor toolkit. NAEMT and JBL will work with our partners in other countries to determine in which formats – print or digital - course materials will be published. In most cases, the translated versions of the 9th edition will be priced comparably to the English version in the United States. There may be some instances in countries with emerging economies, where the price will be lower.
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The English version of the online instructor update for the 9th edition will be available in December of this year. All current PHTLS instructors will need to complete the update by July 1, 2019 to maintain their instructor status. The online update will be available through JBL’s Public Safety Group at a price of $25. Instructors taking the update will receive four hours of CAPCE continuing education credit.
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The Spanish-language version of the online instructor update for the 9th edition will be available in March 2019. All current Spanish-speaking PHTLS instructors will need to complete the update by October 1, 2019 to maintain their instructor status. The online update will be available through JBL’s Public Safety Group at a price of $25. We are also pleased to announce that a live PHTLS 9th edition Instructor Update will be offered in conjunction with EMS World Americas in Quito Ecuador in March 2019.
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For countries that speak languages other than English and Spanish, NAEMT will send our partners in those countries a copy of today’s PowerPoint presentation. Our partners will translate the PowerPoint and instructor notes into their own language and can then use the materials to and conduct classroom PHTLS 9th edition Instructor Updates.
I would like to now invite Dennis Rowe back to the podium to introduce our next presenter who is held in very high esteem among both civilian and military colleagues…
Of course, our partners are welcome to utilize the online Instructor Update in English or Spanish, as needed.
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Thanks, Nancy. It is now a great privilege to introduce Dr. Frank Butler, Military Medical Advisor of NAEMT’s Prehospital Trauma Committee. Dr. Butler serves as the Chair of the US Department of Defense Committee on Tactical Combat Casualty Care. This committee develops the guidelines and curriculum for the TCCC courses for military personnel and all combatants. Dr. Butler and his team write the military chapters for the PHTLS Military textbook. This afternoon, Dr. Butler will provide us with an overview of the changes in the military textbook and in the TCCC course.
Thank you for that most appreciated introduction, Dennis. And, thanks to all of you for such a warm welcome.
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First and foremost, I want to thank my colleagues and dear friends, retired Master Sergeant Harold Montgomery and Dr. Steven Giebner for the tremendous work they have done on the TCCC curriculum and the PHTLS Military Edition chapters. Without their expertise and dedication, the program would not be what it is today.
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COL Shackelford will soon be the Director of the t Trauma System. Dr. Holcomb is Chief of the Division of Acute Care Surgery at the Univ. of TX Medical School at Houston. Mr. Fisher is an Army Ranger PA and is currently a medical student at Texas A&M.
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Dr. Champion is the Director of the MedStar shock-trauma unit at Washington Hospital Center.
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Dr. Kotwal is an Emergency Medicine consultant at the ISR. COL Mabry is Chief of the Combat Casualty Care Service Line at the Army Medical Command.
COL Gurney is a burn surgeon and trauma surgeon.
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The 8th edition presented TCCC Guidelines dated 181028 that included change 13-04 Triple Option Analgesia. Change 13-05 is the first of several guideline updates that will be reflected in the 9th edition….
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There is the Deployed Medicine website with the TCCC Collection alongside the JTS deployed/combat casualty care collection.
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You can also the Deployed Medicine mobile application to phone or tablet from your respective app store. Just search for “Deployed Medicine”.
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All of the content available on the website is available on the mobile app and vice versa. When any of our education or reference content is published, it is immediately available on both the website and the app.
Currently available on Deployed Medicine, you will find the current TCCC Guidelines, Educational and How-To videos for TCCC concepts and procedures, topic-based podcasts for TCCC and the t Trauma System, and a core TCCC reference material.
The future exception to this might be the instructor collection being developed that would only be available on the website. This is primarily the instructor materials such as large powerpoint files, skill sheets and testing materials that would not be used on mobile devices. AND, those are usually big files that most people don’t want on their phone.
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are developing in-app quizzing and problem-solving that can help instructors assess cognitive retention as well as critical decision-making. We are looking at how we can use the app to record the evaluator’s assessment checklist when the student is performing their hands-on skills assessment.
The next major phase of Deployed Medicine is the development of a adaptive learning and course delivery system focused on the individual. At the operational level, the learning queue can be offered as a pre-training event for new TCCC students. For instance, a school or command can require students to complete a self-paced TCCC online course in a read-ahead pretraining week to better prepare them for focused didactic and practical training conducted the next week. It then becomes “in-hand” reference material for students as they conduct the formal TCCC training. It would also allow local operational units to use the educational content for refresher and sustainment training events, especially when limited time and resources are available. For instance, a combat unit medic team can block 2 hours of sustainment training on Tuesdays and use the DM material as both read-ahead material or quick hip-pocket training references. At the individual level, they can maintain their knowledge and skill awareness at the personal level. Another aspect being developed is the ability for both instructors and students to use the app as part of their assessments, whether cognitive or hands-on. We
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Find and follow TCCC on social media. Look for all major changes, updates, new education materials announced on TCCC and JTS social media.
I will now turn the podium over to Dr. Eastman who will provide an overview of the 2nd edition of NAEMT’s Tactical Emergency Casualty Care course.
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The first edition of our TECC course was developed in 2014. It was a great first effort that provided EMTs and paramedics with tactical emergency medical skills. After the course published, we heard from the field that the course needed to have a greater focus on civilian tactical situations that EMTs and paramedics across the country and around the world might encounter.
It has been an honor to work with such a dedicated group of tactical and instructional experts in developing the 2nd edition of TECC. NAEMT would like to acknowledge the hard work of the 2nd edition TECC author team: William Justice, David Flory, Mark Gibbons, Don Heath, Michael Hunter, Rich Nydam, and Julie Chase.
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We greatly appreciate the work of Drs. Geoff Shapiro and Reed Smith for their expertise in thoroughly reviewing the course materials and providing their insights and recommendations.
NAEMT is committed to field testing all new and revised courses before release to the public. The second edition TECC Course was field tested on four occasions and we would like to thank all involved.
Also thanks to Mike Meoli, Brendan Hartford, and Michael Costanza for their contributions to the course.
We would like to thank the additional instructors who helped teach in Las Vegas: Phil Carey, John Phelps, Lee Richardson, Bob Waddell, and Ron Wenzel. At Tinker Air Force Base in Oklahoma, we thank Chad Beals. For teaching the TECC beta materials to hundreds of providers in Hawaii, we’d like to thank Barbara Brennan, Dr. Elizabeth Char, Mike Jones, David Kingdon, and Jeff Zuckernick. And, through the Indiana Department of Homeland Security, teaching in Greenwood, Indiana, thank you to Mike Brown and Mark Litwinko.
Thank you to Mike Ward to his dedication and hard work on the TECC Course Manual. And, thanks again to Mike Bowen, Christie Morley, and the rest of the Fisdap team, and all volunteers who participated in the validation process for the 2nd Edition TECC exam.
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The content in the second edition NAEMT TECC Course addresses the current TEMS domains and is consistent with the most recently released Committee on TECC guidelines.
The EMS nomenclature of Hot, Warm, and Cold Zones has been integrated with the tactical nomenclature of Direct Threat, Indirect Threat, and Evacuation phases of care.
The author team identified areas to promote practitioner understanding of civilian tactical prehospital casualty care. These areas include breaking down the MARCH assessment into individual lessons to allow greater focus on each component and incorporating immediate action drills into every lesson to ensure that practitioners not only know how to apply a tourniquet, but have the opportunity to build muscle memory around that skill.
This edition of TECC offers all new patient simulations and tactical scenarios. Perhaps the biggest change is the addition of a TECC Course Manual. This manual includes content from the 9th edition PHTLS TEMS chapter and is designed to be a valuable resource to course participants with expanded sections on TECC topics and references for each lesson.
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As there are substantial changes in this 2nd edition of TECC, all current TCCC and TECC instructors will need to take the 2nd edition TECC Instructor Update to teach the 2nd edition of the course. This Update will be offered online in English and Spanish, and as a classroom course in other languages, using the same process that we are using for the PHTLS 9th edition Update.
The course materials and course manual will be available in English in March 2019. The Spanish-language version will follow in summer of 2019. NAEMT partners who are interested in having TECC translated into another language, please Alison Lozeau at JBL.
If you’re currently not a TECC instructor, but want to become one, you will need to follow NAEMT’s standard of process of completing the TECC provider course and the NAEMT Instructor Preparation Course, and teaching your first course monitored by an Faculty. All new TCCC instructors will need to complete the 2nd edition TECC Instructor Update to be recognized as a 2nd edition TECC instructor.
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The 2nd edition TECC Instructor Update will be available online in English February 2019.
I have also had the pleasure of working with my dear friends and colleagues David Flory, Dr. Bruce Cohen, and Brian Lankford on the new TECC for Law Enforcement Officers course.
The Spanish version of this Update will be online by summer 2019. For all other languages, NAEMT will provide the English TECC Instructor Update PowerPoint to our partners for translation. All current TCCC and TECC instructors will have six months from the date of availability of the Update to complete the Update. NAEMT will send out an email notification with this information to all current TCCC and TECC instructors.
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TECC for Law Enforcement Officers is an 8-hour course designed specifically for non-EMS law enforcement officers and other tactical first responders. The content is based on the new 16 hour 2nd edition TECC course, with lessons on hemorrhage control, rescue tactics, and airway procedures. The course will be rich in scenario-based training with a focus on self-aid and buddy aid.
And now, the presenters are happy to take questions from the faculty.
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It is my privilege and honor to welcome our global family of PHTLS instructors to the 9th edition PHTLS Instructor Update. I am humbled by your presence here this afternoon which reminds why the PHTLS program continues to be the global leader in prehospital trauma education. The great success of our program is directly due to the tremendous dedication and ion of our global PHTLS faculty. You are the ones who are responsible for providing our prehospital practitioners with the knowledge and skills they need to make the best decisions in the field for their patients. On behalf of NAEMT, thank you for being here today and for what you do each and every day for your students and communities.
Thank you to the faculty in countries around the world who are working on the translations and localizations of PHTLS course materials.
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We would like to extend our deep appreciation to our PHTLS instructors, coordinators and medical directors for your dedication and commitment to PHTLS, your students, and their patients.
Will the of the PHT Committee, PHTLS chapter editors and course authors, and TCCC and TECC authors please come to the stage. On behalf of NAEMT, thank you for the months and months, in many cases, years and years, of tremendous work that has gone into producing the very best trauma courses in the world. Please me in thanking this incredible group of experts for their leadership on these projects. We are all very grateful for your service. <Applause and everyone stays on the stage>.
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Go Forth and Serve!
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You have come from all across the United States and across the globe, representing the 11,222 PHTLS instructors from 69 countries providing PHTLS to prehospital providers in their communities. PHTLS is truly a global movement dedicated to excellence in prehospital trauma care.
NAEMT is honored to the EMS profession through education, advocacy and research. Education is core to our mission. In addition to our outstanding global faculty, NAEMT’s leadership is fully committed to our global education program. NAEMT is led by an elected Board of 15 , who are ed by 17 appointed committees and 16 staff .
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I would like to thank the NAEMT Board of Directors for their unwavering commitment and for PHTLS and our education mission, and for providing the funds necessary to ensure that the 9th edition of PHTLS is the best ever produced. Our Board are here with us today to welcome you and thank you for your service. Board , please stand.
We are honored to welcome Dr. Eileen Bulger, Chair of the ACS Committee on Trauma to our meeting. NAEMT deeply appreciates our strong relationship with the College on PHTLS and other trauma initiatives. Our organizations have an endurable bond based on our shared commitment to the care of trauma patients. Dr. Bulger, please stand so that our attendees can thank you.
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This 9th edition of PHTLS is dedicated to the founder of PHTLS and the father of all NAEMT education……Dr. Norman McSwain. Without Dr. McSwain’s vision, ion, empathy and tenacity, PHTLS would not exist and we would not be gathering here today.
I can honestly tell you that Dr. McSwain has been on the shoulder of every member of our PHT Committee and in the thoughts of every one of our chapter editors and course authors as the 9th edition was created. Each contributor has been motivated by Dr. McSwain’s standards of excellence and committed to ensuring that the 9th edition is a product that Norman would be proud of.
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Norman led PHTLS for over 30 years. He was ed over the decades by many dedicated volunteers who shared his vision and embraced the PHTLS mission. Some of these PHTLS missionaries were instrumental in the development of earlier editions of the textbook. Others were on the road helping to spread PHTLS. NAEMT and the PHT Committee would like to express our thanks to these PHTLS pioneers. PHTLS lives, breathes, and grows because of the efforts of those who volunteered their time to the development of PHTLS.
It is now my great pleasure to introduce to you the of NAEMT’s Prehospital Trauma Committee. Will each member stand as your name is called… Dr. Alex Eastman Dr. Andrew Pollak Mr. John Phelps Dr. J.C. Pitteloud Dr. Faizan Arshad
I ask any and all of past PHTLS Committees, PHTLS chapter editors, contributors and reviewers, to please stand and be recognized.
Dr. Warren Dorlac Mr. Larry Hatfield Dr. Frank Butler
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Thank you, Dennis. As we move into the future with the 9th edition of PHTLS, it is very important for all of us to understand the history of PHTLS, how it developed, and our special relationship with the American College of Surgeons.
It is now my great privilege to introduce my colleague and friend, Dr. Alex Eastman, to take us back to the history of PHTLS, Dr. McSwain’s monumental vision, and the partnership that continues between NAEMT and the American College of Surgeons Committee on Trauma.
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Norman’s surgical expertise early in his career resulted in his induction, in 1973, as a Fellow of the American College of Surgeons. The history of PHTLS begins with its founder, Dr. Norman McSwain. He began his involvement with the COT in 1975 through his work with the Kansas Committee on Trauma. Also at that time, he helped found NAEMT. Four years later he was appointed to the National COT where he led both the Pre-hospital Care Committee and the ATLS Committee. ATLS launched in 1980.
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Shortly thereafter, at the urging of Dr. Norman McSwain, the NAEMT Board authorized development of a non-physician version of ATLS, called Prehospital Trauma Life . Dr. McSwain, representing the ACS-COT, worked with Bob Nelson to develop a prototype of PHTLS under the title “Improved Trauma Management” and introduced it to a packed room at the 1983 NAEMT annual meeting in Dearborn, Michigan.
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Dr. McSwain’s philosophy on prehospital trauma education served as the foundation for the first PHTLS course and continues as the fundamental precept of PHTLS in this 9th edition. His vision - to improve care and increase the survivability of trauma patients through high-quality, evidence-based education that strengthens and enhances the knowledge and skills of prehospital practitioners.
By 1984, the first PHTLS Committee was appointed, with Dr. McSwain serving as the committee’s Medical Director. The first National PHTLS Faculty course was held at Dr. McSwain’s own Tulane University. The first PHTLS provider course was offered in 1985 and the first PHTLS textbook followed in 1986.
His core belief - that given a sound foundation of knowledge and key principles, prehospital practitioners are capable of making reasoned decisions regarding patient care.
And that, my friends, is how it all began.
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Now let’s jump forward 33 years, and today, NAEMT and ACS have a solid and enduring relationship based on our shared vision for trauma care and our mutual respect, thanks to Dr. McSwain’s vision to bring these two organizations together.
Dr. McSwain shepherded NAEMT’s relationship with ACS for over thirty years. Both organizations relied heavily on his leadership and with his ing, we had to feel our way through to a new relationship. I am pleased to inform you that NAEMT’s relationship with ACS has never been stronger. As the PHTLS Medical Director, I serve as NAEMT’s liaison to the ACS-COT. Both Dennis and I participate on ACS’s EMS Committee and on their Stop the Bleed initiative, and Dennis represents NAEMT on ACS’ Injury Prevention Committee.
NAEMT cooperates with the ACS-COT in the development of PHTLS. Drs. Pollak and Dorlac, and myself are all Fellows of ACS, and serve on the PHT Committee at the recommendation of ACS.
NAEMT thanks ACS’ Executive Director Dr. David Hoyt, along with Drs. Michael Rotondo, Ronald Stewart, Mark Gestring and Eileen Bulger for working with Dennis and the Board to strengthen our relationship.
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Its now my great pleasure to introduce our PHTLS 9th edition Medical Editor who led the revision of the PHTLS textbook. Please me in welcoming my colleague and friend, Dr. Andrew Pollak.
PHTLS is also endorsed by several prestigious organizations – the Eastern Association for the Surgery of Trauma (EAST), the American Academy of Orthopedic Surgeons (AAOS), the Special Operations Medical Association (SOMA), and the Trauma Center Association of America (TCAA).
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Hello. It has been a true honor and pleasure to serve as PHTLS Medical Editor for the ninth edition and I’m excited to be here today to share the textbook updates with you.
We were so fortunate to be able to bring together some of the greatest thought leaders in prehospital trauma to work on the 9th edition. Understanding the critical role of the prehospital provider to the survival of the trauma patient, each of our chapter editors applied their expertise to ensure that the full spectrum of trauma care was addressed.
In revising PHTLS, the Committee recruited subject matter experts from around the world, seeking out the best and brightest to review and revise the chapters. As you will see on the next slide, an amazing group of physicians and prehospital practitioners volunteered their time to this revision and poured their ion and expertise into making the 9th edition an exciting, up-to-date, evidence-based resource.
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We are deeply grateful to these outstanding individuals for the time, effort, and expertise they contributed to the 9th edition. Please me in thanking each of our chapter editors.
On behalf of NAEMT and the PHT Committee, I would like to extend my deep appreciation to Dr. Richard Carmona, former Surgeon General of the United States, for the inspiring foreword he wrote for the 9th edition. Our special thanks and gratitude also go to past PHTLS Medical Director Lance Stuke, for his thoughtful and moving dedication to Dr. Norman McSwain.
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The Committee reviewed the 8th edition PHTLS table of contents and streamlined the content to eliminate redundancies and create a more intuitive flow to the chapters. Every chapter in the book has been updated with current data and references.
In preparing to revise PHTLS, the Committee ed our ATLS partners, who provided updated references and a compendium of changes to the 10th edition of ATLS. The Committee met and reviewed these changes for applicability to prehospital trauma care. The Committee also reviewed and considered new evidence from the Department of Defense’s Committee on Tactical Combat Casualty Care. The PHTLS chapters were then sent to the chapter editors with guidance from the Committee.
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There are now 22 chapters in the book. They are:
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Burn Injuries
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PHTLS: Past, Present, and Future
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Pediatric Trauma
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Golden Principles, Preferences, and Critical Thinking
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Geriatric Trauma
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Shock: Pathophysiology of Life and Death
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Injury Prevention
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The Physics of Trauma
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Disaster Management
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Scene Assessment
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Explosions and Weapons of Mass Destruction
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Patient Assessment and Management
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Environmental Trauma I: Heat and Cold
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Airway and Ventilation
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Environmental Trauma II: Drowning, Lightning, Diving, and Altitude
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Head Trauma
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Wilderness Trauma Care
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Spinal Trauma
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Civilian Tactical Emergency Medical (TEMS)
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Thoracic Trauma
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Abdominal Trauma
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Musculoskeletal Trauma
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While every chapter in the 9th edition PHTLS textbook has been revised and updated, there are some significant changes I’d like to highlight today, both throughout the book and in specific chapters.
To start, the Committee decided to move from the ABCDE patient assessment mnemonic to XABCDE, which puts exsanguinating hemorrhage at the forefront of every patient encounter. As we know, it takes 2 minutes or less for a patient to exsanguinate. No other intervention we perform is more time sensitive than stopping that level of bleeding. While this change is not yet reflected in ATLS, it is extremely relevant to prehospital care and it mirrors the MARCH assessment (which stands for Massive hemorrhage, Airway Control, Respiratory , Circulation, Hypothermia management, Head injury mitigation) used in both Tactical Combat Casualty Care and Tactical Emergency Casualty Care. You will see the importance of XABCDE reflected in every PHTLS chapter. Another change incorporated throughout the book is that boluses are now 250 cc each, with a recheck of patient blood pressure and other vital signs between boluses. In the context of a growing body of evidence of the detrimental effects of over-aggressive early fluid resuscitation, we are encouraging practitioners to be thoughtful about fluid resuscitation. There are also new targets for blood pressure with fluid resuscitation.
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Chapters 1 and 2 provide the foundation of PHTLS. Chapter 1 takes the reader through the history of prehospital trauma care and the development and philosophy of PHTLS. Chapter 2 is now a consolidation of two previous chapters: Golden Principles of Prehospital Trauma Care, and The Science, Art, and Ethics of Prehospital Care: Principles, Preferences, and Critical Thinking. Thank you to Rick Ellis and Patrick Wick for their input on Chapter 1 and to Dr. Blaine Enderson for his excellent work on consolidating Chapter 2.
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Dr. Craig Manifold, NAEMT Medical Director, was asked to revise the chapters on Shock and the Physiology of Life and Death. Dr. Manifold streamlined the content into one incredible chapter. Major changes to this chapter include a focus on treating exsanguinating hemorrhage with tourniquets prior to the onset of shock; a discussion of tranexamic acid (or TXA) dosing (if allowed per local protocols); and a suggestion for practitioners to attempt IV access with an 18gauge needle briefly before moving to IO access.
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Drs. Andrew Schmidt and Lauren MacCormick edited Chapter 4: Physics of Trauma, ensuring that references are up to date, statistics are current, and that it contains the latest evidence on air bags, car seats, and motorcycle crashes.
Chapter 5 – Scene Assessment – was edited by Drs. Blaine Enderson and Catherine McKnight. We all know that scene safety is the number one priority in prehospital trauma care – both our own safety and that of those around us. Citing current evidence from NHTSA, OSHA, the CDC, and other national institutions, this chapter covers scene safety considerations ranging from motor vehicle collisions to active shooter events and events involving weapons of mass destruction.
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One of the updates in the 10th edition of ATLS is a change from rapid sequence intubation to drug-assisted intubation. The Committee had an extensive discussion on this issue, as different jurisdictions use different terminology. You will see that the Airway Chapter refers to pharmacologically assisted intubation. The Committee agreed, however, that regardless of terminology, a rapid response is most important. This chapter also includes a great discussion on apneic oxygenation and the addition of the new HEAVEN criteria to the LEMON approach for predicting a difficult airway. Of note, the needle cricothyrotomy technique has been eliminated from the text, given the minimal evidence of its efficacy. Special thanks to Drs J.C. Pitteloud and Bruno Goulesque for their work on this chapter.
Thank you to Drs. Vince Mosesso and Michael Holtz, for their work on Chapter 6: Patient Assessment and Management. This chapter walks the reader through the new XABCDE patient assessment – addressing hemorrhage control first and foremost through tourniquet use, pressure dressing, and manual direct pressure. NAEMSP and ACS-COT revised guidelines for termination of resuscitation are referenced and the editors expanded the section on patient transfer from prehospital care to the trauma team.
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The Head Trauma chapter, edited by Drs. Deborah Stein and Christine Ramirez, includes an updated Glasgow Coma Scale to improve the accuracy and reliability of practitioners when they are describing the severity of traumatic brain injury. The chapter also continues to emphasize the importance of the motor exam component of the Glasgow Scale as a good predictor of TBI severity. In addition, the chapter authors included the following TBI guideline: to maintain systolic blood pressure at greater than or equal to 100 millimeters of mercury for patients who are 50 to 69 years old; or at greater than or equal to 110 millimeters of mercury for patients 15 to 49 years old or over 70 years. These blood pressure guidelines may be considered to decrease mortality and improve outcomes in our patients with traumatic brain injury.
We all know there has been much debate in the field about spinal immobilization and the use of backboards and other immobilizing devices. Throughout the 9th edition, the spinal motion restriction, spinal stabilization, and spinal immobilization are used interchangeably. Further, the Committee neither advocates for the removal of all long backboards nor the unnecessary use of immobilizing devices. In the spirit of Dr. McSwain and the history of PHTLS, the Committee advocates for the use of applied critical thinking when practitioners are faced with a patient who may need spinal immobilization.
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Chapter editors Drs. Steven Ludwig and Luke Brown, with Ian Bussey and Alyssa Nash, reviewed the signs and symptoms of spinal trauma, as well as the criteria necessary to determine when spinal motion restriction is unnecessary. The chapter includes updated evidence on spinal cord injury and no longer s the use of therapeutic hypothermia as a promising treatment, based on the latest evidence.
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The Thoracic Trauma chapter, edited by Dr. Mark Gestring, highlights new needle decompression guidelines, based on recent evidence that s the 5th intercostal space at (or just anterior to) the mid-axillary line as the preferred needle thoracostomy site. However, while this new site is preferred, it is not the only option and the anterior approach is still taught, because PHTLS always upholds principles over preferences.
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An exciting addition to the Abdominal Trauma chapter is the introduction of REBOA – resuscitative endovascular balloon occlusion of the aorta – as a promising technique for managing and mitigating uncontrolled hemorrhage in the torso. Currently, REBOA is only performed by highly trained teams and is not yet available in the United States for prehospital care. The chapter, edited by Drs. Thomas Scalea, Ronald Tesoriero, and Jason Weinberger, also addresses hemodynamically unstable blunt trauma patients with suspected pelvic injury, for whom prehospital providers are advised to stabilize or close the pelvis by securing it with a sheet or by applying a commercial binder.
The Musculoskeletal Trauma chapter, edited by Drs. Robert O’Toole and David Potter, further addresses the use of pelvic binders and the need for prehospital practitioners to employ their use to prevent exsanguination in the context of major pelvic ring disruption.
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The Burn Injuries chapter, edited by Drs. Brian Williams and Spogmai Komak includes an important update on fluid resuscitation guidelines. The change in the 10th edition of ATLS is that fluid resuscitation for patients with deep partial and full thickness burns involving greater than 20 percent of body surface area should begin with 2cc per kilogram of lactated Ringer’s, times the percent of total body surface area burned with subsequent adjustment as indicated by urine output. This is a change from the previous Parkland formula, which started patients with fluid resuscitation at 4cc per kilogram.
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We were fortunate to have four pediatric physicians—Ann Dietrich, David Tuggle, Jessica Naiditch, and Kate Remick—lending their subject matter expertise to the Pediatric Trauma chapter. The first important change is that damage control resuscitation in children now represents a move toward limiting crystalloid resuscitation. In the child with moderate bleeding, no evidence of end-organ hypoperfusion, and normal vital signs, fluid resuscitation should be limited to no more than one or two normal saline boluses of 20 milliliters per kilogram.
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The Pediatric Trauma chapter also encourages providers to strongly consider the risks of endotracheal intubation before attempting the procedure in the field. Attempting advanced airway management is unnecessary and potentially harmful if the child is adequately ventilated and oxygenated using good basic life skills, such as bag-mask ventilation.
Chapter 15 highlights the unique aspects and increased risks of trauma in geriatric patients. It covers factors affecting control of severe external hemorrhage in this population and provides an important reminder that even ground-level falls can cause fracture in elderly patients. Thank you to Drs. Manish Shah, Michael Lohmeier, and Michael Mancera for their updates to this chapter.
Finally, there has been no change in the preferred site for needle decompression in children – it is still the second intercostal space at the midclavicular line.
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Chapter 16 focuses on Injury Prevention. Thank you to Dr. Heidi Abraham and Thomas Colvin for their work on providing the most up-to-date injury statistics, including an important new section on intimate partner violence, and listing key elements from the National EMS Culture of Safety project.
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The Disaster Management Chapter, edited by Dr. Faizan Arshad, has been updated to introduce Psychological First Aid as an alternative resource to address some of the limitations of mandatory Critical Incident Stress Management and provides teams with effective tools for immediate intervention in situations in which providers have psychologically related complaints and are amenable to assistance.
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The chapter on Weapons of Mass Destruction, edited by Drs. Arshad and Daniel Nogee, includes updated information about types of WMD incidents as well as the inclusion of vehicles as a weapon and suicide bombers. The chapter editors offer new data on specialized decontamination agents, and updated data on newer cyanide antidote kits that contain IV hydroxocobalamin, which binds with cyanide to form cyanocobalamin, a nontoxic agent.
The first of the PHTLS Environmental Trauma chapters focuses on heat and cold. Chapter editors Dr. Seth Hawkins and Bryan Simon include an important discussion on hyperthermia, and stress that normal body temperature is a reasonable goal for hyperthermia management. They also include an updated recommendation for prehospital care providers. Regarding your personal hydration, the Wilderness Medical Society recommends that you drink to thirst to ensure proper hydration while preventing excessive fluid intake and onset of exercise-associated hyponatremia. The chapter editors also provide updated factors predisposing to hypothermia.
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The second Environmental Trauma chapter, also edited by Dr. Seth Hawkins, focuses on lightning, drowning, diving, and altitude and includes update protocols in environmental trauma. Recommendations related to long spine board immobilization in and out of water are changing, although spine boards are still very useful as a transportation tool when moving patients. The chapter includes updated protocols on the use of therapeutic hypothermia in drowning patients and Dr. Hawkins provides new material on drowning in submerged vehicles, which s for 10% of drownings in the US.
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The Wilderness Trauma Care chapter acknowledges the premise that just like with tactical medicine, proper care on the street may not be proper care in the wilderness. Wilderness EMS protocols may require an operationally specific scope of practice for optimum patient care. Chapter editors Drs. Will Smith and John Trentini further the discussion on spinal immobilization to note that mechanism of injury alone is not an indication to immobilize a conscious patient with a reliable exam. They also include updated content on improvised tourniquets, with key descriptions of a successful tourniquet.
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It is now my great pleasure to introduce our PHTLS 9th edition Course Editor, John Phelps, who will walk us through all of the changes in the 9th edition course.
The Civilian Tactical Emergency Medical chapter – coedited by Drs. Eastman and Faroukh Mehkri – includes a new remote assessment methodology flowchart and an emphasis on tourniquets placed “high and tight” rather than focused on trying to locate them 2-3 inches above the wound.
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I am so very grateful for the tremendous effort of each of the of the 9th edition course author team. Please me in recognizing and thanking our course authors: Amie Fuller, from Maryland
Good afternoon, everyone. I am truly honored to have been selected to lead the revision of the 9th edition course. I recognize what a great responsibility NAEMT has given to me to ensure that this latest edition of the course is the very best that it can be. Our team of course authors, contributors and reviewers have been hard at work for the past 18 months on this great project.
Dr. J.C. Pitteloud from Switzerland Anthony Harbour from Virginia Dr. Faizan Arshad from Connecticut And Jim McKendry from Canada
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I also want to thank James Bayreuther, Sean Britton, Riana Constantinou, Shawn Couch, Jan Fillipo, Cody Jenkins, James Jensen, Lara Marcelo, Joanne Piccininni,
All NAEMT courses are beta tested before being published. A very special thank you to the two training centers that ran beta tests of the PHTLS course and the students and instructors who provided invaluable . The initial beta was held at University of Texas Health Science Center in San Antonio, a place near and dear to my heart! Thank you to Cody Jenkins and Shawn Couch for helping teach that course.
Dr. Victor Pimentel, Dawn Poetter, Dr. Neil Pryde, Lee Richardson, Sarrissa Ryan, and Patrick Wick for their contributions to the 9th edition.
Jay Gould and his team at VCU Health were incredibly gracious and welcoming and assembled an all-star team of instructors for our second beta. Thank you to Jay and everyone who taught over those two days in July.
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The PHT Committee agreed on the following learning objectives for the 9th edition of the PHTLS course:
10.
Demonstrate the principle “First, do no harm.”
11.
Evaluate emergency situations to determine the most appropriate course of action
1.
Demonstrate safe and effective scene management
2.
Apply anatomically appropriate hemorrhage control techniques
12.
Implement principles of evidence-based research to prehospital trauma care
3.
Conduct a primary survey
13.
Provide optimum patient care for all trauma patients
4.
Perform airway management in a critically injured patient
14.
Correlate patient criticality with transport timing and disposition decisions
5.
Provide ventilatory for a patient with inadequate breathing
15.
Communicate pertinent patient information to the receiving facility
6.
Defend pain management interventions in trauma patients
16.
7.
Demonstrate best practices in spinal care for trauma patients
Determine appropriate intravenous fluid therapy for trauma patients in the prehospital setting
8.
Manage shock within the provider’s scope of practice
9.
Adapt trauma care principles to special populations
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The 9th edition course schedule incorporates time for skill stations on both day 1 and day 2. As practitioners, it is important that we continually hone our skills and build our muscle memory. With the greater emphasis on bleeding control in this edition, tourniquet application has been introduced as a required skill. – every red blood cell counts!!
As you can see, Day 2 incorporates time for either one of the optional PHTLS lessons or additional simulations. Faculty can choose from Kinematics of Trauma, Point of Care Ultrasound, Altitude, Diving, Wilderness, Hypothermia, or Hyperthermia lessons. Additionally, faculty can choose optional skills to augment the selected optional lesson or a skill focusing on organization needs.
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The 9th edition course offers new patient simulations, and an expanded library of optional lessons that gives the faculty the ability to tailor each course to the needs of their community. Baseline patient simulations from the 8th edition will be available to instructors who wish to utilize them, but are not a required part of the course. We have also developed mass-casualty trauma scenarios for training centers that wish to practice triage skills.
Revising the PHTLS course was a true labor of love and we took the team approach very seriously when starting this mission. We carefully considered from you – our PHTLS faculty – and reached out to PHTLS instructors around the world for their input on best PHTLS teaching practices. Lessons now follow a case-based approach that encourages critical thinking and student engagement. Every lesson reflects the new XABCDE patient assessment approach and aligns with updated content from the textbook. This iteration of the course includes mandatory skills stations, and the removal of the final evaluation skill stations to allow more time for patient simulations and individual skill practice.
A very special thanks to Mike Bowen and his colleagues at Fisdap for partnering with NAEMT to create a validated test instrument for the 9th edition of PHTLS. PHTLS is now the ONLY prehospital trauma course with a validated test. Thank you as well to all of the PHTLS faculty who participated in the process. We appreciate your time and dedication.
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An added component to the 9th edition is the PHTLS Course Manual, created to enhance the participant’s course experience.
There are 9 lessons in the 9th edition PHTLS course. Lesson 1 is an introduction to the course and provides an overview of trauma care and PHTLS. In this lesson, we focus on the societal and financial impacts of trauma; explain the goals, philosophy and educational approach of PHTLS; explain the history and evolution of prehospital trauma care; list the three phases of trauma care, and discuss the effects of communication and documentation in trauma care.
The 9th edition PHTLS Textbook will continue as the gold standard reference book containing the full spectrum of medical science of prehospital trauma care. It is designed for use by students and instructors before, during and after the course. The new Course Manual presents content specific to the course lectures and case studies, and highlights key knowledge from the course lessons to give students a deeper understanding of the content. It includes content presented by the instructor during the course so that students can access this information after the course. The PHTLS 9th edition textbook and course manual will be sold as a package. They will NOT be sold separately. The PHT Committee designed the course to utilize both the textbook and the course manual to ensure that students receive the maximum educational benefits before, during and after the 16 hours of classroom content.
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Lesson 2 covers scene management and the primary survey. The learning objectives for this lesson are to:
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In Lesson 3, Airway, we expect that students will learn how to:
• Identify the
scene safety threats that pose a hazard to personnel, patients, and bystanders.
• Discuss the potential causes of airway obstruction. • Demonstrate the steps of a primary and secondary survey of a trauma patient’s airway.
• Develop a patient approach plan using information gathered during the scene size-up.
• Choose the most appropriate airway management intervention based on the patient’s physical findings.
• Describe the integration of assessment and management during the primary survey. • Apply a MUCC-compliant triage method to manage multiple casualty incidents. and • Identify indications of intimate partner violence.
• Describe the structural differences in the anatomy of adults and children.
and
This lesson also introduces the XABCDE patient-assessment approach.
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Lesson 4, Breathing, Ventilation and Oxygenation, looks at:
•
A review of the anatomy
Lesson 4 also considers:
• How to choose the most appropriate airway management intervention. • Evaluation of the ventilation and perfusion status of a trauma patient using waveform capnography. • Choosing the most appropriate supplemental oxygen delivery device based on the patient’s signs and symptoms. and • Determining when to ventilate and
and physiology of
breathing. • How to identify inadequate breathing based on trauma patient assessment. and • Management of life-threatening injuries impairing airway and breathing in a trauma patient. 69
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when to oxygenate a trauma patient.
Lesson 5 is Circulation, Hemorrhage, and Shock. The learning objectives here are for the students to: •. Describe shock pathophysiology. • Recognize the clinical signs of shock. • Explain basic shock treatment. • Identify the modalities of fluid replacement. • Explain the role of blood component replacement in the management of hemorrhagic shock. and • Describe special considerations in shock management (age, athletes, hypothermia, medications, pacemakers, and pregnancy).
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Lesson 6 is Secondary Assessment, where we assume we have a bit more time with the trauma patient and can take our assessment skills a step further.
The PHTLS Disability lesson has been broken into two parts. Part 1 focuses on traumatic brain injury. Lesson objectives for part 1 are:
• Identify the signs and symptoms of traumatic brain injury. • Explain the pathophysiology of traumatic brain injury. • Discuss the physics of trauma that cause TBI. • Distinguish primary and secondary brain injuries. and • Demonstrate proper medical
Following this lesson, students will be able to: Explain the purpose and sequencing of performing a secondary survey. Choose the most appropriate secondary survey tool(s) to obtain pertinent physical findings. and Identify transport options for a trauma patient based on assessment findings.
• • •
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management of traumatic brain injuries.
The second part of the disability lesson focuses on spinal injury. Following this lesson, students will be able to: • Identify the signs and symptoms of spinal injury and neurogenic shock. • Describe the pathophysiology of spinal injury and neurogenic shock. • Demonstrate evidence-based care for spinal injury. • Identify the indications for spinal motion restriction. and • Select appropriate pain management interventions.
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Lesson 8 looks at special considerations, such as burns, the unique features of pediatric and geriatric trauma, and pain management. Learning objectives here include the ability to:
Finally, we have lesson 9, the summation. The learning objectives for this lesson are to
• Discuss burn assessment and treatment.
• Discuss the key points in managing a trauma patient, known as the “Golden Principles.”
• Learn to assess and treat pediatric trauma patients.
And to
• Apply adult trauma treatment concepts to pediatric trauma patients.
• Discuss the EMS provider’s role in the nationwide reduction of trauma deaths and disabilities.
• Apply adult trauma treatment concepts to geriatric trauma patients. • Apply adult trauma treatment concepts to obstetric trauma patients and • Choose the most appropriate pain management intervention based on clinical findings.
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Throughout the course, students will participate in skills stations. Skills that are required in the 9th edition of the course are:
Course coordinators and instructors may choose to include additional optional skill stations, such as:
• Trauma assessment
• Supraglottic airway devices
• Needle decompression
• IO access
• Junctional hemorrhage and wound packing
• ALS airway techniques
• Supraglottic airway
• Immobilization
• Tourniquet application
• For example, t, long bone, and traction splinting
• Pelvic binder
and
• Basic airway techniques
• Other optional skills as needed per organization
and • Extrication
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The 9th edition Course author team has begun work on the 9th edition refresher course, which will be available in English by Fall of 2019. All 9th edition PHTLS providers will be eligible to take the 8-hour refresher course.
We are happy to announce that we have new and revised patient simulations for the course. Thank you to everyone who worked on them! The following categories of simulations are available: • Airway • Breathing • Circulation • Disability • Multisystem • Special Considerations And • Mass casualty
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It is now my pleasure to introduce Amie Fuller, author of the PHTLS 9th edition provider course for first responders…
Thank you, John. I am Amie Fuller, and I am a Lieutenant at Frederick County Fire and Rescue in Maryland, a former flight paramedic, and a PHTLS faculty. I am honored to have the opportunity to lead a team to revise PHTLS for First Responders. This is a course that is designed for first responders who are NOT EMTs or paramedics. There is a huge need for this course within the first responder community both domestically and around the globe. This community includes fire fighters, law enforcement officers, EMRs and others. If your training center is not currently offering this course to your community, we strongly encourage you to reach out to your first responders to provide them with this course.
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Thank you to my colleagues on the PHTLS for First Responders author team – Aaron Miranda and Ken Delassandro. I appreciate their extensive subject matter expertise and field experience in developing the curriculum. And of course, thank you to John Phelps for his leadership.
As a team, we looked at the core PHTLS learning objectives and created objectives appropriate for the first responder community. Those learning objectives include: 1.
Demonstrate safe and effective scene management including infection protection practices that apply to all patients
2.
Evaluate emergency situations and apply the principles of triage to determine the most appropriate course of action
3.
Demonstrate safe patient movement practices to remove patients from immediate harm and to assist EMS personnel
4.
Apply anatomically appropriate hemorrhage control techniques
5.
Conduct a simple primary survey with emphasis on identifying and managing immediate life-threatening injuries within the first responder’s scope of practice
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The remaining learning objectives are to: 6.
Perform basic airway management in a critically injured patient and provide ventilatory as needed
7.
Provide basic pain management interventions in trauma patients
8.
Recognize signs and symptoms of shock and provide basic care procedures within the first responder’s scope of practice
9.
Reassess patient status while waiting for additional EMS providers or transporting agency and communicate pertinent patient information when relinquishing care
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We have been diligently working on the course and expect to have it complete and ready to teach by June 2019. It should be available in Spanish by December 2019. All PHTLS 9th edition instructors are eligible to teach PHTLS for First Responders. NAEMT and Jones & Bartlett will announce when the course is ready and instructors will be able to access the slides and instructional materials through their JBL . Additional course materials, such as a posttest and course evaluations will be available through the NAEMT Education Portal. A course manual designed specifically for the first responder audience will also be available through the Jones & Bartlett website.
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I am happy to now introduce Nancy Hoffmann of NAEMT who will update us on the publication aspects of our new course materials.
Thank you, Amie. In this next part of the Update, I will provide information regarding the pricing, formats, and translations of the 9th edition, and also provide information about the 9th edition Instructor Update.
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Earlier this year, NAEMT met with our PSG partners to discuss pricing for the 9th edition. While recognizing that the price for the 8th edition had not been increased from the 7th edition, both PSG and NAEMT felt that we should try to bring the price of the 9th edition down even further to address any competitive issues with other courses, and make the 9th edition as affordable as possible. We also took into that our students increasingly want options on how they access the course materials, with many students now preferring digital formats.
NAEMT thanks Jones and Bartlett Learning Public Safety Group for their work on the 9th edition. We greatly appreciate the tremendous of Kim Brophy, Jennifer DeForge-Kling, Donna Gridley, Christine Emerton, Robert Furrier, Alison Lozeau, Tiffany Sliter, and the entire PSG team for truly being our partners in this venture, right from the start. We also thank Kristin Parker, JBL’s designer on this project, for all of her great work and the many design samples she provided.
As John mentioned earlier, the textbook and course manual will ONLY be sold as a package. We feel that the 9th edition pricing model will provide our training centers with affordable options for their students. These are the prices for the English student materials in US dollars.
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PHTLS in English will continue to be offered as a 16-hour classroom course, or in a hybrid format, with 8 hours available online to be followed by 8 hours in the classroom. We will also continue to offer 8 hours of PHTLS continuing education online. Those students who choose this option will not receive the PHTLS provider card but they will receive 8 hours of CAPCE credit.
For the ninth edition, translations will include the textbook, course manual, and instructor toolkit. NAEMT and JBL will work with our partners in other countries to determine in which formats – print or digital - course materials will be published. In most cases, the translated versions of the 9th edition will be priced comparably to the English version in the United States. There may be some instances in countries with emerging economies, where the price will be lower.
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The English version of the online instructor update for the 9th edition will be available in December of this year. All current PHTLS instructors will need to complete the update by July 1, 2019 to maintain their instructor status. The online update will be available through JBL’s Public Safety Group at a price of $25. Instructors taking the update will receive four hours of CAPCE continuing education credit.
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The Spanish-language version of the online instructor update for the 9th edition will be available in March 2019. All current Spanish-speaking PHTLS instructors will need to complete the update by October 1, 2019 to maintain their instructor status. The online update will be available through JBL’s Public Safety Group at a price of $25. We are also pleased to announce that a live PHTLS 9th edition Instructor Update will be offered in conjunction with EMS World Americas in Quito Ecuador in March 2019.
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For countries that speak languages other than English and Spanish, NAEMT will send our partners in those countries a copy of today’s PowerPoint presentation. Our partners will translate the PowerPoint and instructor notes into their own language and can then use the materials to and conduct classroom PHTLS 9th edition Instructor Updates.
I would like to now invite Dennis Rowe back to the podium to introduce our next presenter who is held in very high esteem among both civilian and military colleagues…
Of course, our partners are welcome to utilize the online Instructor Update in English or Spanish, as needed.
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Thanks, Nancy. It is now a great privilege to introduce Dr. Frank Butler, Military Medical Advisor of NAEMT’s Prehospital Trauma Committee. Dr. Butler serves as the Chair of the US Department of Defense Committee on Tactical Combat Casualty Care. This committee develops the guidelines and curriculum for the TCCC courses for military personnel and all combatants. Dr. Butler and his team write the military chapters for the PHTLS Military textbook. This afternoon, Dr. Butler will provide us with an overview of the changes in the military textbook and in the TCCC course.
Thank you for that most appreciated introduction, Dennis. And, thanks to all of you for such a warm welcome.
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First and foremost, I want to thank my colleagues and dear friends, retired Master Sergeant Harold Montgomery and Dr. Steven Giebner for the tremendous work they have done on the TCCC curriculum and the PHTLS Military Edition chapters. Without their expertise and dedication, the program would not be what it is today.
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COL Shackelford will soon be the Director of the t Trauma System. Dr. Holcomb is Chief of the Division of Acute Care Surgery at the Univ. of TX Medical School at Houston. Mr. Fisher is an Army Ranger PA and is currently a medical student at Texas A&M.
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Dr. Champion is the Director of the MedStar shock-trauma unit at Washington Hospital Center.
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Dr. Kotwal is an Emergency Medicine consultant at the ISR. COL Mabry is Chief of the Combat Casualty Care Service Line at the Army Medical Command.
COL Gurney is a burn surgeon and trauma surgeon.
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The 8th edition presented TCCC Guidelines dated 181028 that included change 13-04 Triple Option Analgesia. Change 13-05 is the first of several guideline updates that will be reflected in the 9th edition….
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There is the Deployed Medicine website with the TCCC Collection alongside the JTS deployed/combat casualty care collection.
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You can also the Deployed Medicine mobile application to phone or tablet from your respective app store. Just search for “Deployed Medicine”.
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All of the content available on the website is available on the mobile app and vice versa. When any of our education or reference content is published, it is immediately available on both the website and the app.
Currently available on Deployed Medicine, you will find the current TCCC Guidelines, Educational and How-To videos for TCCC concepts and procedures, topic-based podcasts for TCCC and the t Trauma System, and a core TCCC reference material.
The future exception to this might be the instructor collection being developed that would only be available on the website. This is primarily the instructor materials such as large powerpoint files, skill sheets and testing materials that would not be used on mobile devices. AND, those are usually big files that most people don’t want on their phone.
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are developing in-app quizzing and problem-solving that can help instructors assess cognitive retention as well as critical decision-making. We are looking at how we can use the app to record the evaluator’s assessment checklist when the student is performing their hands-on skills assessment.
The next major phase of Deployed Medicine is the development of a adaptive learning and course delivery system focused on the individual. At the operational level, the learning queue can be offered as a pre-training event for new TCCC students. For instance, a school or command can require students to complete a self-paced TCCC online course in a read-ahead pretraining week to better prepare them for focused didactic and practical training conducted the next week. It then becomes “in-hand” reference material for students as they conduct the formal TCCC training. It would also allow local operational units to use the educational content for refresher and sustainment training events, especially when limited time and resources are available. For instance, a combat unit medic team can block 2 hours of sustainment training on Tuesdays and use the DM material as both read-ahead material or quick hip-pocket training references. At the individual level, they can maintain their knowledge and skill awareness at the personal level. Another aspect being developed is the ability for both instructors and students to use the app as part of their assessments, whether cognitive or hands-on. We
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Find and follow TCCC on social media. Look for all major changes, updates, new education materials announced on TCCC and JTS social media.
I will now turn the podium over to Dr. Eastman who will provide an overview of the 2nd edition of NAEMT’s Tactical Emergency Casualty Care course.
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The first edition of our TECC course was developed in 2014. It was a great first effort that provided EMTs and paramedics with tactical emergency medical skills. After the course published, we heard from the field that the course needed to have a greater focus on civilian tactical situations that EMTs and paramedics across the country and around the world might encounter.
It has been an honor to work with such a dedicated group of tactical and instructional experts in developing the 2nd edition of TECC. NAEMT would like to acknowledge the hard work of the 2nd edition TECC author team: William Justice, David Flory, Mark Gibbons, Don Heath, Michael Hunter, Rich Nydam, and Julie Chase.
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We greatly appreciate the work of Drs. Geoff Shapiro and Reed Smith for their expertise in thoroughly reviewing the course materials and providing their insights and recommendations.
NAEMT is committed to field testing all new and revised courses before release to the public. The second edition TECC Course was field tested on four occasions and we would like to thank all involved.
Also thanks to Mike Meoli, Brendan Hartford, and Michael Costanza for their contributions to the course.
We would like to thank the additional instructors who helped teach in Las Vegas: Phil Carey, John Phelps, Lee Richardson, Bob Waddell, and Ron Wenzel. At Tinker Air Force Base in Oklahoma, we thank Chad Beals. For teaching the TECC beta materials to hundreds of providers in Hawaii, we’d like to thank Barbara Brennan, Dr. Elizabeth Char, Mike Jones, David Kingdon, and Jeff Zuckernick. And, through the Indiana Department of Homeland Security, teaching in Greenwood, Indiana, thank you to Mike Brown and Mark Litwinko.
Thank you to Mike Ward to his dedication and hard work on the TECC Course Manual. And, thanks again to Mike Bowen, Christie Morley, and the rest of the Fisdap team, and all volunteers who participated in the validation process for the 2nd Edition TECC exam.
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The content in the second edition NAEMT TECC Course addresses the current TEMS domains and is consistent with the most recently released Committee on TECC guidelines.
The EMS nomenclature of Hot, Warm, and Cold Zones has been integrated with the tactical nomenclature of Direct Threat, Indirect Threat, and Evacuation phases of care.
The author team identified areas to promote practitioner understanding of civilian tactical prehospital casualty care. These areas include breaking down the MARCH assessment into individual lessons to allow greater focus on each component and incorporating immediate action drills into every lesson to ensure that practitioners not only know how to apply a tourniquet, but have the opportunity to build muscle memory around that skill.
This edition of TECC offers all new patient simulations and tactical scenarios. Perhaps the biggest change is the addition of a TECC Course Manual. This manual includes content from the 9th edition PHTLS TEMS chapter and is designed to be a valuable resource to course participants with expanded sections on TECC topics and references for each lesson.
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As there are substantial changes in this 2nd edition of TECC, all current TCCC and TECC instructors will need to take the 2nd edition TECC Instructor Update to teach the 2nd edition of the course. This Update will be offered online in English and Spanish, and as a classroom course in other languages, using the same process that we are using for the PHTLS 9th edition Update.
The course materials and course manual will be available in English in March 2019. The Spanish-language version will follow in summer of 2019. NAEMT partners who are interested in having TECC translated into another language, please Alison Lozeau at JBL.
If you’re currently not a TECC instructor, but want to become one, you will need to follow NAEMT’s standard of process of completing the TECC provider course and the NAEMT Instructor Preparation Course, and teaching your first course monitored by an Faculty. All new TCCC instructors will need to complete the 2nd edition TECC Instructor Update to be recognized as a 2nd edition TECC instructor.
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The 2nd edition TECC Instructor Update will be available online in English February 2019.
I have also had the pleasure of working with my dear friends and colleagues David Flory, Dr. Bruce Cohen, and Brian Lankford on the new TECC for Law Enforcement Officers course.
The Spanish version of this Update will be online by summer 2019. For all other languages, NAEMT will provide the English TECC Instructor Update PowerPoint to our partners for translation. All current TCCC and TECC instructors will have six months from the date of availability of the Update to complete the Update. NAEMT will send out an email notification with this information to all current TCCC and TECC instructors.
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TECC for Law Enforcement Officers is an 8-hour course designed specifically for non-EMS law enforcement officers and other tactical first responders. The content is based on the new 16 hour 2nd edition TECC course, with lessons on hemorrhage control, rescue tactics, and airway procedures. The course will be rich in scenario-based training with a focus on self-aid and buddy aid.
And now, the presenters are happy to take questions from the faculty.
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It is my privilege and honor to welcome our global family of PHTLS instructors to the 9th edition PHTLS Instructor Update. I am humbled by your presence here this afternoon which reminds why the PHTLS program continues to be the global leader in prehospital trauma education. The great success of our program is directly due to the tremendous dedication and ion of our global PHTLS faculty. You are the ones who are responsible for providing our prehospital practitioners with the knowledge and skills they need to make the best decisions in the field for their patients. On behalf of NAEMT, thank you for being here today and for what you do each and every day for your students and communities.
Thank you to the faculty in countries around the world who are working on the translations and localizations of PHTLS course materials.
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We would like to extend our deep appreciation to our PHTLS instructors, coordinators and medical directors for your dedication and commitment to PHTLS, your students, and their patients.
Will the of the PHT Committee, PHTLS chapter editors and course authors, and TCCC and TECC authors please come to the stage. On behalf of NAEMT, thank you for the months and months, in many cases, years and years, of tremendous work that has gone into producing the very best trauma courses in the world. Please me in thanking this incredible group of experts for their leadership on these projects. We are all very grateful for your service. <Applause and everyone stays on the stage>.
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Go Forth and Serve!
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