[Out-of-hospital management of elderly patients for trauma injury]

Reality of treatment for severely injured patients: are there age-specific differences?

BACKGROUND

Major trauma and its consequences are one of the leading causes of death worldwide across all age groups. Few studies have conducted comparative age-specific investigations. It is well known that children respond differently to major trauma than elderly patients due to physiological differences. The aim of this study was to analyze the actual reality of treatment and outcomes by using a matched triplet analysis of severely injured patients of different age groups.

METHODS

Data from the TraumaRegister DGU® were analyzed. A total of 56,115 patients met the following inclusion criteria: individuals with Maximum Abbreviated Injury Scale > 2 and < 6, primary admission, from German-speaking countries, and treated from 2011-2020. Furthermore, three age groups were defined (child: 3-15 years; adult: 20-50 years; and elderly: 70-90 years). The matched triplets were defined based on the following criteria: 1. exact injury severity of the body regions according to the Abbreviated Injury Scale (head, thorax, abdomen, extremities [including pelvis], and spine) and 2. level of the receiving hospital.

RESULTS

A total of 2,590 matched triplets could be defined. Traffic accidents were the main cause of severe injury in younger patients (child: 59.2%; adult: 57.9%). In contrast, low falls (from < 3 m) were the most frequent cause of accidents in the elderly group (47.2%). Elderly patients were least likely to be resuscitated at the scene. Both children and elderly patients received fewer therapeutic interventions on average than adults. More elderly patients died during the clinical course, and their outcome was worse overall, whereas the children had the lowest mortality rate.

CONCLUSIONS

For the first time, a large patient population was used to demonstrate that both elderly patients and children may have received less invasive treatment compared with adults who were injured with exactly the same severity (with the outcomes of these two groups being opposite to each other). Future studies and recommendations should urgently consider the different age groups.

Early management of severe pelvic injury (first 24 hours)

OBJECTIVE

Pelvic fractures represent 5% of all traumatic fractures and 30% are isolated pelvic fractures. Pelvic fractures are found in 10 to 20% of severe trauma patients and their presence is highly correlated to increasing trauma severity scores. The high mortality of pelvic trauma, about 8 to 15%, is related to actively bleeding pelvic injuries and/or associated injuries to the head, abdomen or chest. Regardless of the severity of pelvic trauma, diagnosis and treatment must proceed according to a strategy that does not delay the management of the most severely injured patients. To date, in France, there are no guidelines issued by healthcare authorities or professional societies that address this subject.

DESIGN

A consensus committee of 22 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et de Réanimation; SFAR) and the French Society of Emergency Medicine (Société Française de Médecine d'Urgence; SFMU) in collaboration with the French Society of Radiology (Société Française de Radiologie; SFR), French Defence Health Service (Service de Santé des Armées; SSA), French Society of Urology (Association Française d'Urologie; AFU), the French Society of Orthopaedic and Trauma Surgery (Société Française de Chirurgie Orthopédique et Traumatologique; SOCFCOT), and the French Society of Digestive Surgery (Société Française de Chirurgie digestive; SFCD) was convened. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently from any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE^® methodology.

RESULTS

The SFAR Guideline panel provided 22 statements on prehospital and hospital management of the unstable patient with pelvic fracture. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, 11 have a high level of evidence (Grade 1 ± ), 11 have a low level of evidence (Grade 2 ± ).

CONCLUSIONS

Substantial agreement exists among experts regarding many strong recommendations for management of the unstable patient with pelvic fracture.

État des lieux de la prise en charge de la douleur

Le concept d’oligoanalgésie en structure d’urgences reste une réalité en France comme dans de nombreux pays qui publient sur le sujet. Les motifs de cette oligoanalgésie sont multiples, le plus souvent liés à des contraintes organisationnelles plus que médicales. Les solutions existent, et la douleur aiguë persistante ne doit plus être une fatalité en structure d’urgences. L’analyse des raisons de l’oligoanalgésie avec des audits ciblés et la mise en place de protocoles thérapeutiques locaux sont des prérequis à l’amélioration de la prise en charge. Les nouveaux enjeux de la médecine d’urgence, liés à l’augmentation constante de la sollicitation, mais également en lien avec l’évolution des techniques médicales et des compétences des équipes médicales et soignantes, donnent de nouvelles perspectives pour améliorer la qualité–sécurité de la prise en charge de la douleur en structure d’urgences.

Impact of trauma dispatch algorithm software on the rate of missions of emergency medical services

BACKGROUND

Trauma still stands atop of the list of emergencies. Transfer of these patients via Emergency Medical Services (EMS) dispatch is critical with regard to importance of timing. This aspect has achieved greater importance due to population increase and telephone triage.

OBJECTIVES

We aimed to decrease unnecessary Emergency Medical Services (EMS) missions via a computer program designed for an algorithmic approach for trauma care by nurses involved in EMS, to help them evaluate the case more accurately. We named our program "Trauma Dispatch Algorithm".

MATERIALS AND METHODS

First, the most common chief complaints regarding traumatic events were chosen from searching all the calls in December 2008 recorded in Tehran, Iran's EMS center; and then an algorithm approach was written for them. These algorithms were revised by three traumatologists and emergency medicine specialists, after their approval the algorithms were evaluated by EMS dispatch center for their practicality. Finally all data were turned into computer software. The program was used at the Tehran EMS center; 100 recorded calls assessed with each system were selected randomly. They were evaluated by another traumatologist whether it was necessary to send a team to the site or not.

RESULTS

The age average was 26 years in both groups. The "trauma dispatch algorithm" was significantly effective in reducing the unnecessary missions of EMS by 16% (from 42% to 26%) (P = 0.005).

CONCLUSIONS

This program was effective in reducing unnecessary missions. We propose the usage of this system in all EMS centers.