Sechs Jahre Advanced Trauma Life Support (ATLS) in Deutschland

Development of a New Emergency Medicine Spinal Immobilization Protocol for Pediatric Trauma Patients and First Applicability Test on Emergency Medicine Personnel

OBJECTIVES

The purpose of this study was to (i) develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) perform an applicability test on emergency medicine personnel.

METHODS

A structured search of the literature published between 1980 and 2019 was performed in MEDLINE using PubMed. Based on this literature search, a new Emergency Medicine Spinal Immobilization Protocol for pediatric trauma patients (E.M.S. IMMO Protocol Pediatric) was developed. Parameters found in the literature, such as trauma mechanism and clinical findings that accounted for a high probability of spinal injury, were included in the protocol. An applicability test was administered to German emergency medicine personnel using a questionnaire with case examples to assess correct decision making according to the protocol.

RESULTS

The E.M.S. IMMO Protocol Pediatric was developed based on evidence from published literature. In the applicability test involving 44 emergency medicine providers revealed that 82.9% of participants chose the correct type of immobilization based on the protocol. A total of 97.8% evaluated the E.M.S. IMMO Protocol Pediatric as helpful.

CONCLUSIONS

Based on the current literature, the E.M.S. IMMO Protocol Pediatric was developed in accordance with established procedures used in trauma care. The decision regarding immobilization is made on based on the cardiopulmonary status of the patient, and life-threatening injuries are treated with priority. If the patient presents in stable condition, the necessity for full immobilization is assessed based upon the mechanisms of injury, assessment of impairment, and clinical examination.

[Development and first application testing of a new protocol for preclinical spinal immobilization in children : Assessment of indications based on the E.M.S. IMMO Protocol Pediatric]

BACKGROUND

To protect the spine from secondary damage, spinal immobilization is a standard procedure in prehospital trauma management. Immobilization protocols aim to support emergency medicine personnel in quick decision making but predominantly focus on the adult spine; however, trauma mechanisms and injury patterns in adults differ from those in children and applying adult prehospital immobilization protocols to pediatric patients may be insufficient. Adequate protocols for children with spinal injuries are currently unavailable.

OBJECTIVE

The aim of this study was (i) to develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) to perform a first analysis of the quality of results if the protocol is used by emergency personnel.

MATERIAL AND METHODS

Based on a structured literature search a new immobilization protocol was developed. Analysis of the quality of results was performed by a questionnaire containing four case scenarios in order to assess correct decision making. The decision about spinal immobilization was made without and with the utilization of the protocol.

RESULTS

The E.M.S. IMMO Protocol Pediatric was developed based on the literature. The analysis of the quality of results was performed involving 39 emergency medicine providers. It could be shown that if the E.M.S. IMMO Protocol Pediatric was used, the correct type of immobilization was chosen more frequently. A total of 38 out of 39 participants evaluated the protocol as helpful.

CONCLUSION

The E.M.S. IMMO Protocol Pediatric provides decision-making support whether pediatric spine immobilization is indicated with respect to the cardiopulmonary status of the patient. In a first analysis, the E.M.S. IMMO Protocol Pediatric improves decision making by emergency medical care providers.

Teaching Advanced Trauma Life Support (ATLS): A nationwide retrospective analysis of 8202 lessons taught in Germany

OBJECTIVE

To examine whether faculty who teach the Advanced Trauma Life Support (ATLS) course would improve with experience and, correspondingly, ratings from course evaluations would increase.

DESIGN

Retrospective analysis of student evaluations of 262 ATLS courses held between 2008 and 2012.

SETTING

All ATLS courses held between 2008 and 2012 nationwide in Germany.

PARTICIPANTS

All ATLS student course evaluations covering 8202 lessons, 81 instructors, 36 course directors, and 5 coordinators.

RESULTS

ATLS courses in Germany attained high levels of student satisfaction. Satisfaction levels increased steadily over the 5-year period studied. The entire staff influenced this finding. Teaching quality improved the most within the first 100 lessons taught. Skill stations received better evaluations than lectures, and local courses were less satisfactory than national course formats. The 2 demonstrations that open the course were the top rated events. Skill stations, including a human phantom, were highly rated; the cricothyrotomy station was top rated.

CONCLUSION

The German ATLS course evaluations indicated steady improvement over the 5-year study. The level of experience of course coordinators, directors, and instructors influenced this finding. Teaching quality improved most within the first 100 lessons taught, and then reached a steady state. Skill stations received better evaluations than lectures, and local courses were less satisfactory than national course formats.

In view of standardization Part 2: Management of challenges in the initial treatment of burn patients in Burn Centers in Germany, Austria and Switzerland

INTRODUCTION

Initial therapy of severe burns in specialized burn trauma centers is a challenging task faced by the treating multi-professional and interdisciplinary team. A lack of consistent operating procedures and varying structural conditions was recently demonstrated in preliminary data of our group. These results raised the question on how specific treatment measures in acute burn care are met in the absence of standardized guidelines.

MATERIAL AND METHODS

A specific questionnaire containing 57 multiple-choice questions was sent to all 22 major burn centers in Germany, Austria and Switzerland. The survey included standards of airway management and ventilation, fluid management and circulation, body temperature monitoring and management, topical burn wound treatment and a microbiological surveillance. Additionally, the distribution of standardized course systems was covered.

RESULTS

17 out of 22 questionnaires (77%) were returned completed. Regarding volume resuscitation, results showed a similar approach in estimating initial fluid while discrepancies persisted in the use of colloidal fluid and human albumin. Elective tracheostomy and the need for bronchoscopy with suspected inhalation injury were the most controversial issues revealed by the survey. Topical treatment of burned body surface also followed different principles regarding the use of synthetic epidermal skin substitutes or enzymatic wound debridement. Less discrepancy was found in basic diagnostic measures, body temperature management, estimation of the extent of burns and microbiological surveillance.

CONCLUSION

While many burn-related issues are clearly not questionable and managed in a similar way in most participating facilities, we were able to show that the most contentious issues in burn trauma management involve initial volume resuscitation, management of inhalation trauma and topical burn wound treatment. Further research is required to address these topics and evaluate a potential superiority of a regime in order to increase the level of evidence.

Evaluating trauma nursing education: An integrative literature review

OBJECTIVE

A review of the current literature evaluating trauma nursing education.

BACKGROUND

A variety of trauma nursing courses exist, to educate nurses working in trauma settings, and to maintain their continuing professional development. Despite an increase in the number of courses delivered, there appears to be a lack of evidence to demonstrate the effectiveness of trauma nursing education and in particular the justification for this resource allocation.

DESIGN

Integrative literature review.

DATA SOURCES

A search of international literature on trauma nursing education evaluation published in English from 1985 to 2015 was conducted through electronic databases CINAHL Plus, Google Scholar, PubMed, Austhealth, Science Citation Index Expanded (Web of Science), Sciverse Science Direct (Elsevier) & One file (Gale). Only peer reviewed journal articles identifying trauma course and trauma nursing course evaluation have been included in the selection criteria.

REVIEW METHODS

An integrative review of both quantitative and qualitative literature guided by Whittemore and Knafl's theoretical framework using Bowling's and Pearson's validated appraisal checklists, has been conducted for three months.

RESULTS

Only 17 studies met the inclusion criteria, including 14 on trauma course evaluation and 3 on trauma nursing course evaluation. Study findings are presented as two main themes: the historical evolution of trauma nursing education and evaluation of trauma nursing education outcomes.

CONCLUSION

Trauma nursing remains in its infancy and education in this specialty is mainly led by continuing professional development courses. The shortage of evaluation studies on trauma nursing courses reflects the similar status in continuing professional development course evaluation. A trauma nursing course evaluation study will address the gap in this under researched area.

Surgical fixation of sternal fractures: preoperative planning and a safe surgical technique using locked titanium plates and depth limited drilling

Different ways to stabilize a sternal fracture are described in literature. Respecting different mechanisms of trauma such as the direct impact to the anterior chest wall or the flexion-compression injury of the trunk, there is a need to retain each sternal fragment in the correct position while neutralizing shearing forces to the sternum. Anterior sternal plating provides the best stability and is therefore increasingly used in most cases. However, many surgeons are reluctant to perform sternal osteosynthesis due to possible complications such as difficulties in preoperative planning, severe injuries to mediastinal organs, or failure of the performed method.

This manuscript describes one possible safe way to stabilize different types of sternal fractures in a step by step guidance for anterior sternal plating using low profile locking titanium plates. Before surgical treatment, a detailed survey of the patient and a three dimensional reconstructed computed tomography is taken out to get detailed information of the fracture’s morphology. The surgical approach is usually a midline incision. Its position can be described by measuring the distance from upper sternal edge to the fracture and its length can be approximated by the summation of 60 mm for the basis incision, the thickness of presternal soft tissue and the greatest distance between the fragments in case of multiple fractures.

Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates prevents injuries to mediastinal organs and vessels.

Transverse fractures and oblique fractures at the corpus sterni are plated longitudinally, whereas oblique fractures of manubrium, sternocostal separation and any longitudinally fracture needs to be stabilized by a transverse plate from rib to sternum to rib. Usually the high convenience of a patient is seen during follow up as well as a precise reconstruction of the sternal morphology.

[Emergency room management of multiple trauma : ATLS® and S3 guidelines]

Trauma management in the emergency room is an important part of the treatment chain of the severely injured. Important decisions with respect to diagnostics and treatment must be made under time pressure. Successful trauma management in the emergency room requires a hospital tailored treatment protocol. This written protocol needs consent from all participating disciplines and must be known by all members of the resuscitation team. The ATLS® and the recently published clinical practice guidelines on multiple trauma can be of help in order to establish or update such protocols. In order to continuously evaluate and improve performance in the emergency room local quality circles are needed that truly follow that aim. Important factors are reliability of agreement between the different disciplines and continuous communication of results to the team members. In order to be successful such quality circles need people that care.

Epidemiology and management of trauma patients in a Greek multispecialty hospital in the absence of a dedicated trauma center

PURPOSE

In the absence of dedicated trauma centers, surgical emergency departments in hospitals assigned as trauma centers accept a huge load of trauma patients. In this audit, we aim to document and assess the epidemiologic data of trauma patients and their injuries in order to give a picture of the impact of trauma in the workload of a surgical department in the Greek healthcare system.

METHODS

During a period of 2 years, we managed 6,041 trauma patients in the accident and emergency (A&E) department based on the Advanced Trauma Life Support (ATLS) protocols. We retrospectively reviewed the emergency department registry and the admissions.

RESULTS

47.56 % of the patients seen in the A&E department were trauma patients. The mean age of the trauma patients was 44.52 years (range 15-106 years). The majority were men (60.4 %). The leading cause of trauma was motor and vehicle accidents, followed by slip and fall accidents, physical assault, fall from height, and vehicle pedestrian accidents. The majority of the patients were discharged from the hospital. Only 29 (4.6 %) out of 624 patients who were admitted to the general surgery department underwent an operation, while the rest were admitted for observation. On the other hand, patients were admitted to other departments only when surgical treatment was necessary.

CONCLUSIONS

In the absence of level one trauma centers, in multispecialty urban hospitals, the coordination of trauma burdens the general surgery team. This has financial and administrative implications. The collection of important epidemiologic data from these hospitals is mandatory in order to develop national prevention measures against injuries.