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Ikram S, Mirtorabi N, Ali D, Aain H, Naumann DN, Dilworth M. Does timely reporting of preoperative CT scans influence outcomes for patients following emergency laparotomy? Ann R Coll Surg Engl 2024. [PMID: 38869096 DOI: 10.1308/rcsann.2023.0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024] Open
Abstract
INTRODUCTION Timely preoperative computed tomography (CT) scans are important for patients requiring emergency laparotomy. United Kingdom guidelines state that a CT scan should be reported within 1h for 'critical' patients (will alter management at the time) and within 12h for 'urgent' patients (will alter management but not necessarily that day). METHODS An observational study included patients who were added to the National Emergency Laparotomy Audit (NELA) at a National Health Service trust from 2014 to 2021. The association of compliance with timings guidance and mortality was investigated. Multivariable logistic regression was used to determine the odds ratio of adherence to guidelines according to age, gender, night time admission, American Society of Anesthesiology (ASA) score, NELA mortality risk and category of scan. Further models determined the influence of adherence to guidelines on mortality, also adjusted for these variables. RESULTS There were 1,299 patients (48% 'critical' and 52% 'urgent' CT scans). Only 360/1,299 (28%) of scans were undertaken with adherence to the timing guidelines. Critical scans were less likely to adhere to guidelines. Although univariable analysis suggested that adherence to guidelines was associated with reduced mortality, this was not the case in the multivariable model: only age, ASA and NELA mortality risk remained significantly associated with mortality. CONCLUSIONS A minority of patients met the recommended preoperative CT report timings, and this was less likely for scans designated 'critical'. This did not appear to affect mortality when adjusted for key variables of risk. This illustrates the phenomenon of guideline adherence appearing to affect patient outcomes as a product of selection bias rather than causality.
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Affiliation(s)
- S Ikram
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - N Mirtorabi
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - D Ali
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - H Aain
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - D N Naumann
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - M Dilworth
- University Hospitals Birmingham NHS Foundation Trust, UK
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Fathi M, Mirjafari A, Yaghoobpoor S, Ghanikolahloo M, Sadeghi Z, Bahrami A, Myers L, Gholamrezanezhad A. Diagnostic utility of whole-body computed tomography/pan-scan in trauma: a systematic review and meta-analysis study. Emerg Radiol 2024; 31:251-268. [PMID: 38396199 PMCID: PMC10995012 DOI: 10.1007/s10140-024-02213-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024]
Abstract
Trauma is a significant cause of mortality and morbidity. It is crucial to diagnose trauma patients quickly to provide effective treatment interventions in such conditions. Whole-body computed tomography (WBCT)/pan-scan is an imaging technique that enables a faster and more efficient diagnosis for polytrauma patients. The purpose of this systematic review and meta-analysis is to evaluate the efficacy of WBCT in diagnosing injuries in polytrauma patients. We will also assess its impact on the mortality rate and length of hospital stay among trauma centers between patients who underwent WBCT and those who did not (non-WBCT). Twenty-seven studies meeting our inclusion criteria were selected among PubMed, Scopus, Web of Science, and Google Scholar. The criteria were centered on the significance of WBCT/pan-scan application in trauma patients. Stata version 15 was used to perform statistical analysis on the data. The authors have also used I2 statistics to evaluate heterogeneity. Egger and Begg's tests were performed to rule out any publication bias. Total of twenty-seven studies including 68,838 trauma patients with a mean age of 45.0 ± 24.7 years were selected. Motor vehicle collisions were the most common cause of blunt injuries (80.0%). Head, neck, and face injuries were diagnosed in 44% (95% CI, 0.28-0.60; I2 = 99.8%), 6% (95% CI, 0.02-0.09; I2 = 97.2%), and 9% (95% CI, 0.05-0.13; I2 = 97.1%), respectively. Chest injuries were diagnosed by WBCT in 39% (95% CI, 0.28-0.51; I2 = 99.8%), abdominal injuries in 23% (95% CI, 0.03-0.43; I2 = 99.9%) of cases, spinal injuries 19% (95% CI, 0.11-0.27; I2 = 99.4%), extremity injuries 33% (95% CI, 0.23-0.43; I2 = 99.2%), and pelvic injuries 11% (95% CI, 0.04-0.18; I2 = 97.4%). A mortality odd ratio of 0.94 (95% CI, 0.83-1.06; I2 = 40.1%) was calculated while comparing WBCT and non-WBCT groups. This systematic review and meta-analysis provide insight into the possible safety, efficacy, and efficiency of WBCT/pan-scan as a diagnostic tool for trauma patients with serious injuries, regardless of their hemodynamic status. In patients with serious injuries from trauma, whether or not there are indicators of hemodynamic instability, our recommended approach is to, wherever possible, perform a WBCT without stopping the hemostatic resuscitation. By using this technology, the optimal surgical strategy for these patients can be decided upon without causing any delays in their final care or greatly raising their radiation dose.
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Affiliation(s)
- Mobina Fathi
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arshia Mirjafari
- Center for Minimally Invasive Therapeutics (C-MIT), University of California, Los Angeles, CA, USA
- Department of Bioengineering, University of California, Los Angeles, CA, USA
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA, USA
| | - Shirin Yaghoobpoor
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Zohre Sadeghi
- Department of Radiology, Imam Khomeini Hospital Complex, Tehran, Iran
| | - Ashkan Bahrami
- Faculty of Medicine, Kashan University of Medical Science, Kashan, Iran
| | - Lee Myers
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ali Gholamrezanezhad
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, USA.
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Tachino J, Seno S, Matsumoto H, Kitamura T, Hirayama A, Nakao S, Katayama Y, Ogura H, Oda J. Association between tranexamic acid administration and mortality based on the trauma phenotype: a retrospective analysis of a nationwide trauma registry in Japan. Crit Care 2024; 28:89. [PMID: 38504320 PMCID: PMC10953216 DOI: 10.1186/s13054-024-04871-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/13/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND In trauma systems, criteria for individualised and optimised administration of tranexamic acid (TXA), an antifibrinolytic, are yet to be established. This study used nationwide cohort data from Japan to evaluate the association between TXA and in-hospital mortality among all patients with blunt trauma based on clinical phenotypes (trauma phenotypes). METHODS A retrospective analysis was conducted using data from the Japan Trauma Data Bank (JTDB) spanning 2019 to 2021. RESULTS Of 80,463 patients with trauma registered in the JTDB, 53,703 met the inclusion criteria, and 8046 (15.0%) received TXA treatment. The patients were categorised into eight trauma phenotypes. After adjusting with inverse probability treatment weighting, in-hospital mortality of the following trauma phenotypes significantly reduced with TXA administration: trauma phenotype 1 (odds ratio [OR] 0.68 [95% confidence interval [CI] 0.57-0.81]), trauma phenotype 2 (OR 0.73 [0.66-0.81]), trauma phenotype 6 (OR 0.52 [0.39-0.70]), and trauma phenotype 8 (OR 0.67 [0.60-0.75]). Conversely, trauma phenotypes 3 (OR 2.62 [1.98-3.47]) and 4 (OR 1.39 [1.11-1.74]) exhibited a significant increase in in-hospital mortality. CONCLUSIONS This is the first study to evaluate the association between TXA administration and survival outcomes based on clinical phenotypes. We found an association between trauma phenotypes and in-hospital mortality, indicating that treatment with TXA could potentially influence this relationship. Further studies are needed to assess the usefulness of these phenotypes.
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Affiliation(s)
- Jotaro Tachino
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan.
| | - Shigeto Seno
- Department of Bioinformatic Engineering, Graduate School of Information Science and Technology, Osaka University, 1-5 Yamada-oka, Suita City, Osaka, Japan
| | - Hisatake Matsumoto
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita City, Osaka, Japan
| | - Atsushi Hirayama
- Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita City, Osaka, Japan
| | - Shunichiro Nakao
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
| | - Yusuke Katayama
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
| | - Jun Oda
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamada-oka, Suita City, Osaka, Japan
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Kiguchi T, Kitamura T, Katayama Y, Hirose T, Matsuyama T, Kiyohara K, Umemura Y, Tachino J, Nakao S, Ishida K, Ojima M, Noda T, Fujimi S. Timing of computed tomography imaging in adult patients with severe trauma: A nationwide cohort study in Japan. Am J Emerg Med 2023; 73:109-115. [PMID: 37647845 DOI: 10.1016/j.ajem.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 07/02/2023] [Accepted: 08/03/2023] [Indexed: 09/01/2023] Open
Abstract
PURPOSE Computed tomography (CT) has become essential for the management of trauma patients. However, appropriate timing of CT acquisition remains undetermined. The purpose of this study was to assess the relationship between time to CT acquisition and mortality among adult patients with severe trauma. METHODS We conducted a retrospective cohort study using data from the Japan Trauma Data Bank, which had 256 participating institutions from all over Japan between 2004 and 2018. Patients were categorized upon arrival as either severe trunk trauma with signs of shock or severe head trauma with coma and separately analyzed. Cases were further divided into three groups based on time elapsed between arrival at hospital and CT acquisition as immediate (0-29 min), intermediate (30-59 min), or late (≥60 min). Primary outcome was mortality on discharge, and multivariate logistic regression with adjusting for confounders was used for evaluation. RESULTS A total of 8467 (3640 in immediate group, 3441 in intermediate group, 1386 in late group) with trunk trauma patients and 6762 (4367 in immediate group, 2031 in intermediate group, 364 in late group) with head trauma patients were eligible for analysis included in the trunk and head trauma groups, respectively. The trunk trauma patients with shock on hospital arrival was 56.4% (4773/8467), and the head trauma patients with deep coma upon EMS arrival was 44.2% (2988/6762). Mortality rate gradually increased from 5.7% to 15.8% with prolonged time to CT imaging among trunk trauma patients. Multivariate logistic regression for death on discharge among trunk trauma patients yielded an adjusted odds ratio of 1.79 (95% confidence interval: 1.42-2.27) for the late group compared to the immediate group. In contrast, among head trauma patients, an adjusted odds ratio was 0.93 (95% confidence interval: 0.71-1.20) for the late group compared to the immediate group. CONCLUSION CT scan at or after 60 min was associated with increased death on discharge among patients with severe trunk trauma but not in those with severe head trauma.
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Affiliation(s)
- Takeyuki Kiguchi
- Department of Emergency and Critical Care, Osaka General Medical Center, 3-1-56, Bandai-Higashi, Sumiyoshi-ku, Osaka, Japan; Department of Preventive Services, Kyoto University School of Public Health, Yoshida-Konoemachi, Sakyo-ku, Kyoto, Japan.
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Japan
| | - Yusuke Katayama
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15, Yamada-oka, Suita, Japan
| | - Tomoya Hirose
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15, Yamada-oka, Suita, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, 465 Kajiicho, Hiroko-ji noboru, Kawaramachi-dori, Kamigyo-ku, Kyoto, Japan
| | - Kosuke Kiyohara
- Department of Food Science, Faculty of Home Economics, Otsuma Women's University Tokyo, 12, Sanban-cho, Chiyoda-ku, Tokyo, Japan
| | - Yutaka Umemura
- Department of Emergency and Critical Care, Osaka General Medical Center, 3-1-56, Bandai-Higashi, Sumiyoshi-ku, Osaka, Japan
| | - Jotaro Tachino
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15, Yamada-oka, Suita, Japan
| | - Shunichiro Nakao
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15, Yamada-oka, Suita, Japan
| | - Kenichiro Ishida
- Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, 2-1-14, Honenzaka, Chuo-ku, Osaka, Japan
| | - Masahiro Ojima
- Department of Acute Medicine and Critical Care Medical Center, Osaka National Hospital, National Hospital Organization, 2-1-14, Honenzaka, Chuo-ku, Osaka, Japan
| | - Tomohiro Noda
- Department of Traumatology and Critical Care Medicine, Osaka Metropolitan University School of Medicine, 1-5-7, Asahi-machi, Abeno-ku, Osaka, Japan
| | - Satoshi Fujimi
- Department of Emergency and Critical Care, Osaka General Medical Center, 3-1-56, Bandai-Higashi, Sumiyoshi-ku, Osaka, Japan
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5
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Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023; 27:80. [PMID: 36859355 PMCID: PMC9977110 DOI: 10.1186/s13054-023-04327-7] [Citation(s) in RCA: 115] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.
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Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| | - Arash Afshari
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Bertil Bouillon
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- grid.424917.d0000 0001 1379 0994Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anaesthesiology and Intensive Care Medicine, Charles University Faculty of Medicine, Simkova 870, CZ-50003 Hradec Králové, Czech Republic
| | - Diana Cimpoesu
- grid.411038.f0000 0001 0685 1605Department of Emergency Medicine, Emergency County Hospital “Sf. Spiridon” Iasi, University of Medicine and Pharmacy ”Grigore T. Popa” Iasi, Blvd. Independentei 1, RO-700111 Iasi, Romania
| | - Nicola Curry
- grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE UK ,grid.4991.50000 0004 1936 8948Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Jacques Duranteau
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- grid.8194.40000 0000 9828 7548Department of Cardiac Anaesthesia and Intensive Care, “Prof. Dr. C. C. Iliescu” Emergency Institute of Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Oliver Grottke
- grid.1957.a0000 0001 0728 696XDepartment of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| | - Lars Grønlykke
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anatole Harrois
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Beverley J. Hunt
- grid.420545.20000 0004 0489 3985Thrombosis and Haemophilia Centre, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Alexander Kaserer
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Radko Komadina
- grid.8954.00000 0001 0721 6013Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty, Ljubljana University, Oblakova ulica 5, SI-3000 Celje, Slovenia
| | - Mikkel Herold Madsen
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Lidia Mora
- grid.7080.f0000 0001 2296 0625Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, ES-08035 Barcelona, Spain
| | - Louis Riddez
- grid.24381.3c0000 0000 9241 5705Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Carolina S. Romero
- grid.106023.60000 0004 1770 977XDepartment of Anaesthesia, Intensive Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, Universidad Europea of Valencia Methodology Research Department, Avenida Tres Cruces 2, ES-46014 Valencia, Spain
| | - Charles-Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre - Université Paris Cité - Cochin Hospital, 27 rue du Faubourg St. Jacques, F-75014 Paris, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Sebastian Wiberg
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Donat R. Spahn
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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Chiu YC, Liang CM, Chung CH, Hong ZJ, Chien WC, Hsu SD. The influence of early selenium supplementation on trauma patients: A propensity-matched analysis. Front Nutr 2022; 9:1062667. [PMID: 36570123 PMCID: PMC9773250 DOI: 10.3389/fnut.2022.1062667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction Oxidative stress is involved in numerous inflammatory diseases, including trauma. Micronutrients, such as selenium (Se), which contribute to antioxidant defense, exhibit low plasma levels during critical illness. This study aimed to investigate the impact of early Se supplementation on trauma patients. Materials and methods A total of 6,891 trauma patients were registered at a single medical center from January 2018 to December 2021. Twenty trauma patients with Se supplemented according to the protocol were included in the study group. Subsequently, 1:5 propensity score matching (PSM) analysis was introduced. These patients received 100 mcg three times a day for 5 days. The primary outcome was overall survival (OS); the secondary outcomes were hospital/intensive care unit (ICU) length of stay (LOS), serologic change, ventilator dependence days, and ventilation profile. Results The hospital LOS (20.0 ± 10.0 vs. 37.4 ± 42.0 days, p = 0.026) and ICU LOS (6.8 ± 3.6 vs. 13.1 ± 12.6 days, p < 0.006) were significantly shorter in the study group. In terms of serology, improvement in neutrophil, liver function, and C-reactive protein (CRP) level change percentile indicated better outcomes in the study group as well as a better OS rate (100 vs. 83.7%, p = 0.042). Longer ventilator dependence was found to be an independent risk factor for mortality and pulmonary complications in 6,891 trauma patients [odds ratio (OR) = 1.262, 95% confidence interval (CI) = 1.039-1.532, p < 0.019 and OR = 1.178, 95% CI = 1.033-1.344, p = 0.015, respectively]. Conclusion Early Se supplementation after trauma confers positive results in terms of decreasing overall ICU LOS/hospital LOS and mortality. Organ injury, particularly hepatic insults, and inflammatory status, also recovered better.
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Affiliation(s)
- Yu-Cheng Chiu
- Division of General Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Ming Liang
- Division of Trauma Surgery and Critical Care Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Hsiang Chung
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Zhi-Jie Hong
- Division of Trauma Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wu-Chien Chien
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Sheng-Der Hsu
- Division of Trauma Surgery and Critical Care Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan,*Correspondence: Sheng-Der Hsu,
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Simultaneous treatment of trauma patients in a dual room trauma suite with integrated movable sliding gantry CT system: an observational study. Sci Rep 2022; 12:16065. [PMID: 36168030 PMCID: PMC9515087 DOI: 10.1038/s41598-022-20491-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/14/2022] [Indexed: 11/24/2022] Open
Abstract
The trauma center of the University Hospital Wuerzburg has developed an advanced trauma pathway based on a dual-room trauma suite with an integrated movable sliding gantry CT-system. This enables simultaneous CT-diagnostics and treatment of two trauma patients. The focus of this study was to investigate the quality of the concept based on defined outcome criteria in this specific setting (time from arrival to initiation of CT scan: tCT; time from arrival to initiation of emergency surgery: tES). We analyzed all trauma patients admitted to the hospital’s trauma suite from 1st May 2019 through 29th April 2020. Two subgroups were defined: trauma patients, who were treated without a second trauma patient present (group 1) and patients, who were treated simultaneously with another trauma patient (group 2). Simultaneous treatment was defined as parallel arrival within a period of 20 min. Of 423 included trauma patients, 46 patients (10.9%) were treated simultaneously. Car accidents were the predominant trauma mechanism in this group (19.6% vs. 47.8%, p < 0.05). Prehospital life-saving procedures were performed with comparable frequency in both groups (intubation 43.5% vs. 39%, p = 0.572); pleural drainage 3.2% vs. 2.2%, p = 0.708; cardiopulmonary resuscitation 5% vs. 2.2%, p = 0.387). At hospital admission, patients in group 2 suffered significantly more pain (E-problem according to Advanced Trauma Life Support principles©; 29.2% vs. 45.7%, p < 0.05). There were no significant differences in the clinical treatment (emergency procedures, vasopressor and coagulant therapy, and transfusion of red blood cells). tCT was 6 (4–10) minutes (median and IQR) in group 1 and 8 (5–15.5) minutes in group 2 (p = 0.280). tES was 90 (78–106) minutes in group 1 and 99 (97–108) minutes in group 2 (p = 0.081). The simultaneous treatment of two trauma patients in a dual-room trauma suite with an integrated movable sliding gantry CT-system requires a medical, organizational, and technical concept adapted to this special setting. Despite the oftentimes serious and life-threatening injuries, optimal diagnostic and therapeutic procedures can be guaranteed for two simultaneous trauma patients at an individual medical level in consistent quality.
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8
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Michael M, Bax S, Finke M, Hoffmann M, Kornstädt S, Kümpers P, Kumle B, Laaf T, Reindl M, Schunk D, Pin M, Bernhard M. Aktuelle Ist-Analyse zur Situation des nichttraumatologischen Schockraummanagements in Deutschland. Notf Rett Med 2022. [DOI: 10.1007/s10049-020-00827-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Zusammenfassung
Einleitung
In Notaufnahmen kommen bundesweit nichttraumatologische kritisch kranke Patienten zur Aufnahme. Zur Struktur, Organisation und Ausstattung des nichttraumatologischen Schockraummanagements ist bisher wenig bekannt. Mittels einer Umfrage sollte daher der Ist-Zustand analysiert werden.
Methodik
Durch die Arbeitsgruppe „Schockraum“ der Deutschen Gesellschaft Interdisziplinäre Notfall- und Akutmedizin (DGINA) wurde mittels E‑Mail den 420 ärztlichen Leiter*Innen des DGINA-Mitgliederregisters eine Onlineumfrage zugesendet. Zwei Wochen nach initialem Anschreiben erfolgte eine Erinnerung. Die Ergebnisse wurden in einer anonymisierten Datenbank extrahiert und ausgewertet.
Ergebnisse
Insgesamt lag die Rücklaufquote mit 131 verwertbaren Antworten bei 31 %. Die Umfrage erfasste Krankenhäuser der Basis- (24 %), erweiterten (39 %) und umfassenden Notfallversorgung (37 %). Korrespondierend zur Versorgungsstufe stiegen die jährlichen Patientenkontakte (21.000 vs. 31.000 vs. 39.000), die Monitorplätze in den Notaufnahmen (9 ± 4 vs. 13 ± 6 vs. 18 ± 10), die Betten der assoziierten Notaufnahmestationen (4 ± 5 vs. 10 ± 17 vs. 13 ± 12), die verfügbaren Schockräume (1 ± 1 vs. 2 ± 1 vs. 3 ± 1) und deren Größe (31 ± 16 vs. 35 ± 9 vs. 38 ± 14 m2) an. Hinsichtlich verschiedener Ausstattungsmerkmale (z. B. Röntgenlafette: 58 vs. 65 vs. 78 %, Computertomographie im Schockraum: 6 vs. 12 vs. 27 %) zeigten sich deutliche Unterschiede in Abhängigkeit von der Versorgungsstufe. Während Kühlungssysteme in 30 % in allen Versorgungsstufen vorgehalten wurden, fanden sich andere Ausstattungsmerkmale (z. B. Videolaryngoskopie: 65 vs. 80 vs. 86 %, Bronchoskopie: 29 vs. 22 vs. 45 %) und spezielle Notfallprozeduren (z. B. REBOA [„resuscitative endovascular balloon occlusion of the aorta“]: 3 vs. 5 vs. 12 %, ACCD [„automated chest compression device“]: 26 vs. 57 vs. 61 %) häufiger in höheren Versorgungsstufen.
Schlussfolgerung
Die vorliegenden Ergebnisse zeigen erstmals den Ist-Zustand der nichttraumatologischen Schockraumversorgung in verschiedenen Versorgungsstufen in Deutschland. Empfehlungen zu Ausstattungsmerkmalen für das nichttraumatologische Schockraummanagement müssen zukünftig formuliert werden.
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Bissoni L, Gamberini E, Viola L, Bergamini C, Russo E, Bolondi G, Agnoletti V. REBOA as a bridge to brain CT in a patient with concomitant brain herniation and haemorrhagic shock - A case report. Trauma Case Rep 2022; 38:100623. [PMID: 35242987 PMCID: PMC8885615 DOI: 10.1016/j.tcr.2022.100623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction The management of complex trauma patient with concomitant brain injury and extra-cranial lesions is challenging since the requirement of a low pressure to limit the bleeding clashes with the need to maintain an adequate cerebral perfusion and to obtain a brain CT-scan. Here we present the use of REBOA as a bridge to CT scan in complex head and torso trauma. Case presentation A 59 years old male patient involved in a road traffic crash was admitted to our hospital after a car accident. He had a GCS of 3 with a left fixed pupil anisocoria. Despite right-sided chest decompression for pneumothorax and massive transfusion protocol for haemoperitoneum, blood pressure remained low; to temporally stabilize the patient and perform a brain CT scan a zone 1 REBOA was inserted and systolic blood pressure rose up from 60 mmHg to 110 mmHg. A brain CT scan highlighted a right subdural hematoma with a 8-mm midline shift. The patient went to the operating room to perform damage control surgery and, subsequently, a decompressive craniotomy. After 96 days of hospital stay, the patient was discharged at home with a complete neurological recovery. Conclusions The achievement of a rapid brain CT scan in traumatic brain injury is often crucial and has a deep impact in changing surgical management; moreover, duration of cerebral herniation is associated with worse outcome and increased mortality. In the light of this, the use of REBOA in selected cases of complex head and torso trauma could allow to gain time to go to the CT room in safe conditions.
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Iacobellis F, Abu-Omar A, Crivelli P, Galluzzo M, Danzi R, Trinci M, Dell’Aversano Orabona G, Conti M, Romano L, Scaglione M. Current Standards for and Clinical Impact of Emergency Radiology in Major Trauma. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19010539. [PMID: 35010799 PMCID: PMC8744756 DOI: 10.3390/ijerph19010539] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 12/17/2022]
Abstract
In industrialized countries, high energy trauma represents the leading cause of death and disability among people under 35 years of age. The two leading causes of mortality are neurological injuries and bleeding. Clinical evaluation is often unreliable in determining if, when and where injuries should be treated. Traditionally, surgery was the mainstay for assessment of injuries but advances in imaging techniques, particularly in computed tomography (CT), have contributed in progressively changing the classic clinical paradigm for major traumas, better defining the indications for surgery. Actually, the vast majority of traumas are now treated nonoperatively with a significant reduction in morbidity and mortality compared to the past. In this sense, another crucial point is the advent of interventional radiology (IR) in the treatment of vascular injuries after blunt trauma. IR enables the most effective nonoperative treatment of all vascular injuries. Indications for IR depend on the CT evidence of vascular injuries and, therefore, a robust CT protocol and the radiologist's expertise are crucial. Emergency and IR radiologists form an integral part of the trauma team and are crucial for tailored management of traumatic injuries.
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Affiliation(s)
- Francesca Iacobellis
- Department of General and Emergency Radiology, “A. Cardarelli” Hospital, A. Cardarelli St. 9, 80131 Naples, Italy; (G.D.O.); (L.R.)
- Correspondence: ; Tel.: +39-339-1026757; Fax: +39-081-0362368
| | - Ahmad Abu-Omar
- Department of Radiology, The James Cook University Hospital, Middlesbrough TS4 3BW, UK; (A.A.-O.); (M.S.)
| | - Paola Crivelli
- Department of Clinical and Experimental Medicine, University of Sassari, Via Roma 151, 07100 Sassari, Italy; (P.C.); (M.C.)
| | - Michele Galluzzo
- Department of Radiology, Azienda Ospedaliera San Camillo Forlanini, C.Ne Gianicolense, 87, 00152 Rome, Italy; (M.G.); (M.T.)
| | - Roberta Danzi
- Department of Radiology, Pineta Grande Hospital, Via Domitiana Km 30, 81030 Castel Volturno, Italy;
| | - Margherita Trinci
- Department of Radiology, Azienda Ospedaliera San Camillo Forlanini, C.Ne Gianicolense, 87, 00152 Rome, Italy; (M.G.); (M.T.)
| | - Giuseppina Dell’Aversano Orabona
- Department of General and Emergency Radiology, “A. Cardarelli” Hospital, A. Cardarelli St. 9, 80131 Naples, Italy; (G.D.O.); (L.R.)
| | - Maurizio Conti
- Department of Clinical and Experimental Medicine, University of Sassari, Via Roma 151, 07100 Sassari, Italy; (P.C.); (M.C.)
| | - Luigia Romano
- Department of General and Emergency Radiology, “A. Cardarelli” Hospital, A. Cardarelli St. 9, 80131 Naples, Italy; (G.D.O.); (L.R.)
| | - Mariano Scaglione
- Department of Radiology, The James Cook University Hospital, Middlesbrough TS4 3BW, UK; (A.A.-O.); (M.S.)
- Department of Radiology, Pineta Grande Hospital, Via Domitiana Km 30, 81030 Castel Volturno, Italy;
- School of Health and Life Sciences, Teesside University, Middlesbrough TS1 3BX, UK
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy
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Ernstberger A, Reske SU, Brandl A, Kulla M, Huber-Wagner S, Popp D, Kerschbaum M, Dendl LM, Braunschweig R, Schreyer AG. Structural and Process Data on Radiological Imaging in the Treatment of Severely Injured Patients - Results of a Survey of Level I and II Trauma Centers in Germany. ROFO-FORTSCHR RONTG 2021; 194:505-514. [PMID: 34911138 DOI: 10.1055/a-1682-7377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Systematic data collection regarding the integration of radiology as well as structural and process characteristics of radiological diagnostics of severely injured patients in Germany using a structured questionnaire. MATERIALS AND METHODS Personal contact with all certified Level I and Level II Trauma Centers in Germany. Data on infrastructure, composition of the trauma room team, equipment, and data on the organization/performance of primary major trauma diagnostics were collected. RESULTS With a participation rate of 46.9 % (n = 151) of all German trauma centers (N = 322), a solid database is available. There were highly significant differences in the structural characteristics incl. CT equipment between the level I and II centers: In 63.8 % of the level II centers, the CT unit was located more than 50 m away from the trauma room (34.2 % in the level I centers). A radiologist was part of the trauma room team in 59.5 % of level II centers (level I 88.1 %). Additionally, highly significant differences were found comparing 24-h provision of other radiologic examinations and interventions, such as MRI (level II 44.9 %, level I 92.8 %) and angiography (level II 69.2 %, level I 97.1 %). CONCLUSION Heterogeneous structural and process characteristics of the diagnosis of severely injured patients in Germany were revealed, with highly significant differences between level I and level II centers. KEY POINTS · This is the first study on the diagnostic reality of radiology in severely injured patients in Germany. Despite a high level of standardization, significant differences were observed.. CITATION FORMAT · Ernstberger A, Reske SU, Brandl A et al. Structural and Process Data on Radiological Imaging in the Treatment of Severely Injured Patients - Results of a Survey of Level I and II Trauma Centers in Germany. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1682-7377.
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Affiliation(s)
- Antonio Ernstberger
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Osnabrücker Zentrum für muskuloskelettale Chirurgie (OZMC), Klinikum Osnabrück GmbH, Osnabrueck, Germany
| | - Stefan Ulrich Reske
- Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Heinrich-Braun-Klinikum gemeinnützige GmbH, Zwickau, Germany
| | - Alexandra Brandl
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Germany
| | - Martin Kulla
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Bundeswehrkrankenhaus Ulm, Germany
| | - Stefan Huber-Wagner
- Klinik für Unfallchirurgie, Wirbelsäulenchirurgie, Alterstraumatologie, Diakonie-Klinikum Schwäbisch Hall gGmbH, Schwabisch Hall, Germany
| | - Daniel Popp
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Germany
| | | | - Lena Marie Dendl
- Institute for Diagnostic and Interventional Radiology, Brandenburg Medical School Theodor Fontane, Brandenburg a.d. Havel, Germany
| | - Rainer Braunschweig
- Direktor (em.) der Klinik für Bildgebende Diagnostik und Interventionsradiologie BG-Klinik Bergmannstrost Halle/S., Vorstandsmitglied der AG MSK der DRG, BG Klinikum Bergmannstrost Halle, 10587 Berlin, Germany
| | - Andreas G Schreyer
- Institute for Diagnostic and Interventional Radiology, Brandenburg Medical School Theodor Fontane, Brandenburg a.d. Havel, Germany
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12
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Cabilan CJ, Eley R, Staib A, Rowney B, Kay P. Effect of computed tomography scanner location on time-to-computed tomography in the emergency department: A before and after study. Emerg Med Australas 2021; 34:370-375. [PMID: 34786840 DOI: 10.1111/1742-6723.13899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 10/12/2021] [Accepted: 10/20/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To compare time metrics associated with a temporary disruption to ED computed tomography (CT) scanner location from adjacent to the ED with direct access from resuscitation rooms, to a location remote to the ED. METHODS A retrospective before and after study was conducted in a public metropolitan ED with over 66 000 presentations annually. Time-to-CT metrics, operational time metrics and ED length of stay were extracted and analysed from presentations between October 2020 and January 2021. RESULTS There were 3031 CT scans during the study period. Overall, the disruption was associated with a significant 27-36 min delay (P < 0.01) in time-to-CT start; these delays were also observed in a subset of trauma patients. In a subset of presumed stroke patients, time-to-brain perfusion was significantly delayed by up to 10 min (P < 0.01). There was a 14% (P < 0.01) greater demand for operational services and a time imposition of up to 8 min (P < 0.01) to transport patients to or from CT scanning when the CT scanner was located away from the ED. ED length of stay was consistent at all time points. CONCLUSION Although rapid, proximate access to CT scanning is often considered desirable in terms of the management of trauma and other time-critical emergencies, the wider time and resource implications demonstrated in this study suggest a potential broader benefit to co-located CT scanning in ED. Our experience could be considered in future re-design of EDs.
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Affiliation(s)
- C J Cabilan
- Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Robert Eley
- Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Andrew Staib
- Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Ben Rowney
- Medical Imaging, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Phillip Kay
- Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Murao S, Yamakawa K, Kabata D, Kinoshita T, Umemura Y, Shintani A, Fujimi S. Effect of Earlier Door-to-CT and Door-to-Bleeding Control in Severe Blunt Trauma: A Retrospective Cohort Study. J Clin Med 2021; 10:jcm10071522. [PMID: 33917338 PMCID: PMC8038745 DOI: 10.3390/jcm10071522] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 01/03/2023] Open
Abstract
Blunt trauma is a potentially life-threatening injury that requires prompt diagnostic examination and therapeutic intervention. Nevertheless, how impactful a rapid response time is on mortality or functional outcomes has not been well-investigated. This study aimed to evaluate effects of earlier door-to-computed tomography time (D2CT) and door-to-bleeding control time (D2BC) on clinical outcomes in severe blunt trauma. This was a single-center, retrospective cohort study of patients with severe blunt trauma (Injury Severity Score > 16). To assess the effect of earlier D2CT and D2BC on clinical outcomes, we conducted multivariable regression analyses with a consideration for nonlinear associations. Among 671 patients with severe blunt trauma who underwent CT scanning, 163 patients received an emergency bleeding control procedure. The median D2CT and D2BC were 19 min and 57 min, respectively. In a Cox proportional hazard regression model, earlier D2CT was not associated with improved 28-day mortality (p = 0.30), but it was significantly associated with decreased mortality from exsanguination (p = 0.003). Earlier D2BC was significantly associated with improved 28-day mortality (p = 0.026). In conclusion, earlier time to a hemostatic procedure was independently associated with decreased mortality. Meanwhile, time benefits of earlier CT examination were not observed for overall survival but were observed for decreased mortality from exsanguination.
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Affiliation(s)
- Shuhei Murao
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
- Department of Emergency Medicine, Osaka Medical College, Takatsuki 569-8686, Japan
- Correspondence: ; Tel.: +81-6-6692-1201; Fax: +81-6-6692-1155
| | - Daijiro Kabata
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka 545-8586, Japan; (D.K.); (A.S.)
| | - Takahiro Kinoshita
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita 565-0871, Japan;
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka 545-8586, Japan; (D.K.); (A.S.)
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
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Teuben MPJ, Mand C, Moosdorf L, Sprengel K, Shehu A, Pfeifer R, Ruchholtz S, Lefering R, Pape HC, Jensen KO. Simultaneous Casualty Admissions-Do they Affect Treatment in the Receiving Trauma Center? World J Surg 2021; 45:2037-2045. [PMID: 33782732 PMCID: PMC8154817 DOI: 10.1007/s00268-021-06074-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2021] [Indexed: 11/27/2022]
Abstract
Background Simultaneous trauma admissions expose medical professionals to increased workload. The impact of simultaneous trauma admissions on hospital allocation, therapy, and outcome is currently unclear. We hypothesized that multiple admission-scenarios impact the diagnostic pathway and outcome. Methods The TraumaRegister DGU® was utilized. Patients admitted between 2002–2015 with an ISS ≥ 9, treated with ATLS®- algorithms were included. Group ´IND´ included individual admissions, two individuals that were admitted within 60 min of each other were selected for group ´MULT´. Patients admitted within 10 min were considered as simultaneous (´SIM´) admissions. We compared patient and trauma characteristics, treatment, and outcomes between both groups. Results 132,382 admissions were included, and 4,462/3.4% MULTiple admissions were found. The SIM-group contained 1,686/1.3% patients. The overall median injury severity score was 17 and a mean age of 48 years was found. MULT patients were more frequently admitted to level-one trauma centers (68%) than individual trauma admissions were (58%, p < 0.001). Mean time to CT-scanning (24 vs. 26/28 min) was longer in MULT / SIM patients compared to individual admissions. No differences in utilization of damage control principles were seen. Moreover, mortality rates did not differ between the groups (13.1% in regular admissions and 11.4%/10,6% in MULT/SIM patients). Conclusion This study demonstrates that simultaneous treatment of injured patients is rare. Individuals treated in parallel with other patients were more often admitted to level-one trauma centers compared with individual patients. Although diagnostics take longer, treatment principles and mortality are equal in individual admissions and simultaneously admitted patients. More studies are required to optimize health care under these conditions.
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Affiliation(s)
- Michel Paul Johan Teuben
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8090 Zurich, Switzerland
- Department of Surgery, Thurgau Cantonal Hospital, Frauenfeld, Switzerland
| | - Carsten Mand
- Department of Trauma-,Hand-, and Reconstructive Surgery, University Clinic Giessen and Marburg, Marburg, Germany
| | - Laura Moosdorf
- Department of Trauma-,Hand-, and Reconstructive Surgery, University Clinic Giessen and Marburg, Marburg, Germany
| | - Kai Sprengel
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8090 Zurich, Switzerland
| | - Alba Shehu
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8090 Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8090 Zurich, Switzerland
| | - Steffen Ruchholtz
- Department of Trauma-,Hand-, and Reconstructive Surgery, University Clinic Giessen and Marburg, Marburg, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8090 Zurich, Switzerland
| | - Kai Oliver Jensen
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8090 Zurich, Switzerland
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15
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Abstract
Supplemental Digital Content is available in the text Background: A declining selenium (Se) status constitutes a characteristic of critical illness and may affect disease course and survival. The dynamics of trauma-induced changes in biomarkers of Se status are poorly characterized, and an association with multiple organ failure (MOF) and mortality can be hypothesized. It was the aim of this study to investigate Se and selenoprotein P (SELENOP) concentrations in major trauma patients during the early posttraumatic period. Patients and Methods: Twenty-four patients after major trauma (ISS ≥16) were included at our level one trauma center. Se supplementation ever during the 90-day observation period was defined as an exclusion criterion. Serum samples were drawn within less than 60 min after trauma, and after 6 h, 12 h, 24 h, 48 h, and 72 h. Serum Se was analyzed by X-ray fluorescence and SELENOP concentrations by ELISA. The data were correlated to clinical parameters, occurrence of MOF defined by MOF and APACHE II score, lung injury defined by Horowitz index and clinical outcome (90-days survival). Results: Serum Se and SELENOP concentrations of the trauma patients were significantly below the average of healthy European subjects (mean ±SD; Se, 41.2±8.1 vs. 84.7±23.3 μg/L, P < 0.001; SePP, 1.5±0.3 vs. 4.3±1.0 mg/L, P < 0.001). A strong deficit was present already at the first time point (Se; 33.6±10.5 μg/L, SELENOP: 1.4±0.5 mg/L). The clinical scores collectively showed an inverse relation between health status and Se biomarkers. Patients who did not survive the 90-day observation period exhibited significantly lower initial post-trauma Se status than the surviving patients (mean±SD; Se, 24.7±7.2 vs. 39.2±8.4 μg/L, P<0.05; SePP, 1.1±0.4 vs. 1.6±0.4 mg/L, P<0.05). Conclusion: Very low Se and SELENOP concentrations occur fast after major trauma and are associated with poor survival odds. These findings support the notion that early Se substitution may constitute a meaningful adjuvant treatment strategy in trauma patients.
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Farris CW, Baghdanian A, Takahashi C, Sung EK, Sakai O, Patel M, Burley H, Rai A, Brahmbhatt T, Adran D, Kim H, Ravilla A, Mian AZ. Implementation of Institutional Triaging Algorithms Decreases Head and Neck MDCT Use in Blunt Trauma. Radiology 2021; 298:622-629. [PMID: 33434109 DOI: 10.1148/radiol.2021201878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Multidetector CT (MDCT) enables rapid and accurate diagnosis of head and neck (HN) injuries in patients with blunt trauma (BT). However, MDCT is overused, and appropriate selection of patients for imaging could improve workflow. Purpose To investigate the effect of implementing clinical triaging algorithms on use of MDCT in the HN in patients who have sustained BT. Materials and Methods In this retrospective study, patients aged 15 years or older with BT admitted between October 28, 2007, and December 31, 2013, were included. Patients were divided into pre- and postalgorithm groups. The institutional trauma registry and picture archiving and communication system reports were reviewed to determine which patients underwent MDCT of the head, MDCT of the cervical spine (CS), and MDCT angiography of the HN at admission and whether these examinations yielded positive results. Injury Severity Score, Acute Physiology and Chronic Health Evaluation II score (only those patients in the intensive care unit), length of hospital stay (LOS), length of intensive care unit stay (ICULOS), and mortality were obtained from the trauma registry. Results A total of 8999 patients (mean age, 45 years ± 20 [standard deviation]; age range, 15-101 years; 6027 male) were included in this study. A lower percentage of the postalgorithm group versus the prealgorithm group underwent MDCT of the head (55.8% [2774 of 4969 patients]; 95% CI: 54.4, 57.2 vs 64.2% [2589 of 4030 patients]; 95% CI: 62.8, 65.7; P < .001) and CS (49.4% [2452 of 4969 patients]; 95% CI: 48.0, 50.7 vs 60.5% [2438 of 4030 patients]; 95% CI: 59.0, 62.0; P < .001) but not MDCT angiography of the HN (9.7% [480 of 4969 patients]; 95% CI: 8.9, 10.5 vs 9.8% [393 of 4030 patients]; 95% CI: 8.9, 10.7; P > .99). Pre- versus postalgorithm groups did not differ in LOS (mean, 4.8 days ± 7.1 vs 4.5 days ± 7.1, respectively; P = .42), ICULOS (mean, 4.6 days ± 6.6 vs 4.8 days ± 6.7, respectively; P > .99), or mortality (2.9% [118 of 4030 patients]; 95% CI: 2.5, 3.5; vs 2.8% [141 of 4969 patients]; 95% CI: 2.4, 3.3; respectively; P > .99). Conclusion Implementation of a clinical triaging algorithm resulted in decreased use of multidetector CT of the head and cervical spine in patients who experienced blunt trauma, without increased adverse outcomes. © RSNA, 2021 See also the editorial by Munera and Martin in this issue.
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Affiliation(s)
- Chad W Farris
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Arthur Baghdanian
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Courtney Takahashi
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Edward K Sung
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Osamu Sakai
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Mrugesh Patel
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Hannah Burley
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Aayushi Rai
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Tejal Brahmbhatt
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Daniel Adran
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Hyunjoong Kim
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Anoop Ravilla
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
| | - Asim Z Mian
- From the Departments of Radiology (C.W.F., A.B., E.K.S., O.S., A. Rai, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston Medical Center, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118; and Departments of Radiology (C.W.F., A.B., E.K.S., O.S., M.P., H.B., A. Rai, D.A., H.K., A. Ravilla, A.Z.M.), Neurology (C.T.), and Surgery (T.B.), Boston University School of Medicine, Boston, Mass
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Munera F, Martin A. Use of Triaging Algorithms to Decrease CT Use Following Blunt Head and Neck Trauma. Radiology 2021; 298:630-631. [PMID: 33439099 DOI: 10.1148/radiol.2021204103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Felipe Munera
- From the Department of Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital/Ryder Trauma Center, 1611 NW 12th Ave, WW-279, Miami, FL 33136
| | - Adam Martin
- From the Department of Radiology, University of Miami Miller School of Medicine, Jackson Memorial Hospital/Ryder Trauma Center, 1611 NW 12th Ave, WW-279, Miami, FL 33136
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Mader MMD, Rotermund R, Lefering R, Westphal M, Maegele M, Czorlich P. The faster the better? Time to first CT scan after admission in moderate-to-severe traumatic brain injury and its association with mortality. Neurosurg Rev 2020; 44:2697-2706. [PMID: 33340052 PMCID: PMC8490239 DOI: 10.1007/s10143-020-01456-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/18/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022]
Abstract
Fast acquisition of a first computed tomography (CT) scan after traumatic brain injury (TBI) is recommended. This study is aimed at investigating whether the length of the period preceding initial CT scan influences mortality in patients with leading TBI. A retrospective cohort analysis of patients registered in the TraumaRegister DGU® was conducted including adult patients with TBI, defined as Abbreviated Injury ScaleHead ≥ 3 and GCS ≤ 13 who had been treated in level 1 or 2 trauma centers from 2007-2016. Patients were grouped according to time intervals either from trauma or from admission to CT. A total of 6904 patients met the inclusion criteria. Mean time period from trauma to hospital admission was 68.8 min. From admission to first CT, a mean of 19.0 min elapsed. Trauma severity was higher in groups with a longer duration from trauma to CT as represented by a mean (± standard deviation) Injury Severity Score (ISS) of 19.8 ± 9.0, 20.7 ± 9.3, and 21.4 ± 7.5 and similar distribution of mortality of 24.9%, 29.9%, and 36.3% in the ≤ 60-min, 61-120-min, and ≥ 121-min groups, respectively. An adjusted multivariable logistic regression model showed a significant influence of the level of the trauma center (p = 0.037) but not for interval from admission to CT (p = 0.528). TBI patients with a longer time span from trauma to first CT were more severely injured and demonstrated a worse prognosis, but received a CT scan faster when duration from admission is observed. The duration until the CT scan was obtained showed no significant impact on the mortality.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Rolf Lefering
- Institute of Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Marc Maegele
- Institute of Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany.,Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Wirth S, Hebebrand J, Basilico R, Berger FH, Blanco A, Calli C, Dumba M, Linsenmaier U, Mück F, Nieboer KH, Scaglione M, Weber MA, Dick E. European Society of Emergency Radiology: guideline on radiological polytrauma imaging and service (short version). Insights Imaging 2020; 11:135. [PMID: 33301105 PMCID: PMC7726597 DOI: 10.1186/s13244-020-00947-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/13/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Although some national recommendations for the role of radiology in a polytrauma service exist, there are no European guidelines to date. Additionally, for many interdisciplinary guidelines, radiology tends to be under-represented. These factors motivated the European Society of Emergency Radiology (ESER) to develop radiologically-centred polytrauma guidelines. RESULTS Evidence-based decisions were made on 68 individual aspects of polytrauma imaging at two ESER consensus conferences. For severely injured patients, whole-body CT (WBCT) has been shown to significantly reduce mortality when compared to targeted, selective CT. However, this advantage must be balanced against the radiation risk of performing more WBCTs, especially in less severely injured patients. For this reason, we recommend a second lower dose WBCT protocol as an alternative in certain clinical scenarios. The ESER Guideline on Radiological Polytrauma Imaging and Service is published in two versions: a full version (download from the ESER homepage, https://www.eser-society.org ) and a short version also covering all recommendations (this article). CONCLUSIONS Once a patient has been accurately classified as polytrauma, each institution should be able to choose from at least two WBCT protocols. One protocol should be optimised regarding time and precision, and is already used by most institutions (variant A). The second protocol should be dose reduced and used for clinically stable and oriented patients who nonetheless require a CT because the history suggests possible serious injury (variant B). Reading, interpretation and communication of the report should be structured clinically following the ABCDE format, i.e. diagnose first what kills first.
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Affiliation(s)
- Stefan Wirth
- European Society of Emergency Radiology, ESER Office, Am Gestade 1, 1010, Vienna, Austria.
- Department of Radiology, LMU University Hospital, Munich, Germany.
- Department of Radiology and Nuclear Medicine, Schwarzwald-Baar-Hospital, Villingen-Schwenningen, Germany.
| | - Julian Hebebrand
- Department of Radiology, LMU University Hospital, Munich, Germany
| | - Raffaella Basilico
- European Society of Emergency Radiology, ESER Office, Am Gestade 1, 1010, Vienna, Austria
- Department of Neurosciences, Imaging and Clinical Science, University of Chieti, Chieti, Italy
| | - Ferco H Berger
- European Society of Emergency Radiology, ESER Office, Am Gestade 1, 1010, Vienna, Austria
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Ana Blanco
- European Society of Emergency Radiology, ESER Office, Am Gestade 1, 1010, Vienna, Austria
- Department of Radiology, University Hospital JM Morales Meseguer, Murcia, Spain
| | - Cem Calli
- European Society of Emergency Radiology, ESER Office, Am Gestade 1, 1010, Vienna, Austria
- Department of Radiology, Ege University Medical Faculty, Izmir, Turkey
| | - Maureen Dumba
- European Society of Emergency Radiology, ESER Office, Am Gestade 1, 1010, Vienna, Austria
- Imperial College NHS Trust, St Mary's Campus, London, UK
| | - Ulrich Linsenmaier
- European Society of Emergency Radiology, ESER Office, Am Gestade 1, 1010, Vienna, Austria
- Department of Diagnostic and Interventional Radiology, Helios Clinic Munich West, Munich, Germany
| | - Fabian Mück
- European Society of Emergency Radiology, ESER Office, Am Gestade 1, 1010, Vienna, Austria
- Department of Diagnostic and Interventional Radiology, Helios Clinic Munich West, Munich, Germany
| | - Konraad H Nieboer
- European Society of Emergency Radiology, ESER Office, Am Gestade 1, 1010, Vienna, Austria
- Department of Radiology, University Ziekenhuis, Vrije University (VUB), Brussels, Belgium
| | - Mariano Scaglione
- European Society of Emergency Radiology, ESER Office, Am Gestade 1, 1010, Vienna, Austria
- James Cook University Hospital, Teesside University, Middlesbrough, UK
- Department of Imaging, Pineta Grande Hospital, Castel Volturno, Italy
| | - Marc-André Weber
- European Society of Emergency Radiology, ESER Office, Am Gestade 1, 1010, Vienna, Austria
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center, Rostock, Germany
| | - Elizabeth Dick
- European Society of Emergency Radiology, ESER Office, Am Gestade 1, 1010, Vienna, Austria
- Imperial College NHS Trust, St Mary's Campus, London, UK
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20
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Amiri F, Hale J, Thiel J, Vo B, Murray J, Winalski J. Improvement in Time to CT Imaging in Trauma Evaluations. Am Surg 2020; 87:1994-1996. [PMID: 32783531 DOI: 10.1177/0003134820940277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Farzad Amiri
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Jessica Hale
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Jordyn Thiel
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Bradley Vo
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Jenny Murray
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Jonathan Winalski
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
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French J, Agius LM, Sandiford NA. Managing the multiply injured patient: the impact of multidisciplinary teams. Br J Hosp Med (Lond) 2020; 80:703-706. [PMID: 31822166 DOI: 10.12968/hmed.2019.80.12.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Management of trauma has been tackled at a national level to improve patient care and mortality. Decision making through a multidisciplinary team approach has resulted in improved patient outcomes through a complex combination of changes. While the focus of trauma care delivery has been towards establishing an effective multidisciplinary trauma service, there are still improvements which can be made. This article reviews the history of trauma care in the UK, and the impact that multidisciplinary teams have had on the management of the multiply injured patient.
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Affiliation(s)
- Jonathan French
- Registrar, Joint Reconstruction Unit, Southland Teaching Hospital, Southern District Health Board, Invercargill, New Zealand
| | - Lewis M Agius
- Registrar, Joint Reconstruction Unit, Southland Teaching Hospital, Southern District Health Board, Invercargill, New Zealand
| | - Nemandra A Sandiford
- Consultant, Joint Reconstruction Unit, Southland Teaching Hospital, Southern District Health Board, Invercargill, New Zealand
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Kippnich M, Schorscher N, Kredel M, Markus C, Eden L, Gassenmaier T, Lock J, Wurmb T. Dual-room twin-CT scanner in multiple trauma care: first results after implementation in a level one trauma centre. Eur J Trauma Emerg Surg 2020; 47:1847-1852. [PMID: 32335685 PMCID: PMC7223892 DOI: 10.1007/s00068-020-01374-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/10/2020] [Indexed: 11/24/2022]
Abstract
Purpose The trauma centre of the Wuerzburg University Hospital has integrated a pioneering dual-room twin-CT scanner in a multiple trauma pathway. For concurrent treatment of two trauma patients, two carbon CT examination and intervention tables are positioned head to head with one sliding CT-Gantry in the middle. The focus of this study is the process of trauma care with the time to CT (tCT) and the time to operation (tOR) as quality indicator. Methods All patients with suspected multiple trauma, who required emergency surgery and who were initially diagnosed by the CT trauma protocol between 05/2018 and 12/2018 were included. Data relating to time spans (tCT and tOR), severity of injury and outcome was obtained. Results 110 of the 589 screened trauma patients had surgery immediately after finishing primary assessment in the ER. The ISS was 17 (9–34) (median and interquartile range, IQR). tCT was 15 (11–19) minutes (median and IQR) and tOR was 96.5 (75–119) minutes (median and IQR). In the first 30 days, seven patients died (6.4%) including two within the first 24 h (2%). There were two ICU days (1–6) (median and IQR) and one (0–1) (median and IQR) ventilator day. Conclusion The twin-CT technology is a fascinating tool to organize high-quality trauma care for two multiple trauma patients simultaneously.
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Affiliation(s)
- Maximilian Kippnich
- Department of Anesthesia and Critical Care, Subsection Emergency- and Disaster Relief Medicine, University Hospital of Wuerzburg, Oberduerrbacherstrasse 6, 97080, Würzburg, Germany.
| | - Nora Schorscher
- Department of Anesthesia and Critical Care, Subsection Emergency- and Disaster Relief Medicine, University Hospital of Wuerzburg, Oberduerrbacherstrasse 6, 97080, Würzburg, Germany
| | - Markus Kredel
- Department of Anesthesia and Critical Care, University Hospital of Wuerzburg, Würzburg, Germany
| | - Christian Markus
- Department of Anesthesia and Critical Care, University Hospital of Wuerzburg, Würzburg, Germany
| | - Lars Eden
- Department of Trauma Surgery, University Hospital of Wuerzburg, Würzburg, Germany
| | - Tobias Gassenmaier
- Department of Diagnostic and Interventional Radiology, University Hospital of Wuerzburg, Würzburg, Germany
| | - Johann Lock
- Department of General and Visceral Surgery, University Hospital of Wuerzburg, Würzburg, Germany
| | - Thomas Wurmb
- Department of Anesthesia and Critical Care, Subsection Emergency- and Disaster Relief Medicine, University Hospital of Wuerzburg, Oberduerrbacherstrasse 6, 97080, Würzburg, Germany
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Abstract
Time to hemorrhage control is critical, as mortality in patients with severe hemorrhage that arrive to trauma centers with sign of life remains over 40%. Prompt identification and management of severe hemorrhage is paramount to reducing mortality. In traditional US trauma systems, the early hospital course of a severely hemorrhaging patient typically proceeds from the trauma resuscitation bay to the operating room or angiography suite with a potential stop for radiological imaging. This protracted journey can prove fatal as it consumes valuable minutes. In contrast to the current US system is a newly developed and increasingly adopted system in Japan called the hybrid emergency room system (HERS). The hybrid ER is equipped to allow resuscitation, imaging, and damage control intervention to occur in the ER without the need to transport the patient to a subsequent destination. The HERS is relatively new and remains restricted to a small number of institutions, limiting the ability to robustly examine impact(s) on patient outcomes. Even if proven to yield superior outcomes, there are significant obstacles to adopting the HERS in the US. Challenges such as the high cost of building and implementing a HER system, return on investment, and the significant differences between the US and Japan in terms of physician training, trauma center, and reimbursement schemes may render the hybrid ER system to be unfeasible in most current trauma centers. Barriers aside, the Japanese hybrid ER system remains the most novel recent advancement in the quest to reduce potentially preventable mortality from hemorrhage.
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Cone J, Ahmed O. Trauma Resuscitation for Interventional Radiologists. Semin Intervent Radiol 2020; 37:103-106. [PMID: 32139976 DOI: 10.1055/s-0039-3401844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Jennifer Cone
- Section of Trauma and Acute Care Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Osman Ahmed
- Section of Interventional Radiology, University of Chicago Medicine, Chicago, Illinois
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The Survival Benefit of a Novel Trauma Workflow that Includes Immediate Whole-body Computed Tomography, Surgery, and Interventional Radiology, All in One Trauma Resuscitation Room: A Retrospective Historical Control Study. Ann Surg 2019; 269:370-376. [PMID: 28953551 PMCID: PMC6325752 DOI: 10.1097/sla.0000000000002527] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Supplemental Digital Content is available in the text Objective: The aim of this study was to evaluate the impact of a novel trauma workflow, using an interventional radiology (IVR)–computed tomography (CT) system in severe trauma. Background: In August 2011, we installed an IVR-CT system in our trauma resuscitation room. We named it the Hybrid emergency room (ER), as it enabled us to perform all examinations and treatments required for trauma in a single place. Methods: This retrospective historical control study conducted in Japan included consecutive severe (injury severity score ≥16) blunt trauma patients. Patients were divided into 2 groups: Conventional (from August 2007 to July 2011) or Hybrid ER (from August 2011 to July 2015). We set the primary endpoint as 28-day mortality. The secondary endpoints included cause of death and time course from arrival to start of CT and surgery. Multivariable logistic regression analysis adjusted for clinically important variables was performed to evaluate the clinical outcomes. Results: We included 696 patients: 360 in the Conventional group and 336 in the Hybrid ER group. The Hybrid ER group was significantly associated with decreased mortality [adjusted odds ratio (OR), 0.50 (95% confidence interval, 95% CI, 0.29–0.85); P = 0.011] and reduced deaths from exsanguination [0.17 (0.06–0.47); P = 0.001]. The time to CT initiation [Conventional 26 (21 to 32) minutes vs Hybrid ER 11 (8 to 16) minutes; P < 0.0001] and emergency procedure [68 (51 to 85) minutes vs 47 (37 to 57) minutes; P < 0.0001] were both shorter in the Hybrid ER group. Conclusion: This novel trauma workflow, comprising immediate CT diagnosis and rapid bleeding control without patient transfer, as realized in the Hybrid ER, may improve mortality in severe trauma.
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26
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Trauma care before and after optimisation in a level I trauma Centre: Life-saving changes. Injury 2019; 50:1678-1683. [PMID: 31337494 DOI: 10.1016/j.injury.2019.07.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/28/2019] [Accepted: 07/09/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The implementation of trauma systems has led to a significant reduction in mortality and length of hospital stay. In our level I trauma centre, 24/7 in-hospital coverage was implemented, and a renovation of the trauma room took place to improve the trauma care. The aim of the present study was to examine the effect of the optimised in-hospital infrastructure in terms of mortality, processes and clinical outcomes. METHODS We performed a retrospective cohort study of prospectively collected data. All adult trauma patients admitted to our trauma centre directly during two time periods (2010-2012 and 2014-2016) were included. Any patients below the age of 18 years and patients who underwent primary trauma screening in another hospital were excluded. Logistic and linear regression were used and adjusted for demographics and characteristics of trauma. The primary endpoint was mortality. The secondary endpoints were subgroups of earlier mortality rates and severely injured patients, processes and clinical outcomes. RESULTS In period I, 1290 patients were included, and in period II, 2421. The adjusted mortality in the trauma room (odds ratio (OR): 0.18; CI: 0.05-0.63) and the total in-hospital mortality (OR: 0.63 CI: 0.42-0.95) showed a significant reduction in period II. The trauma room (TR) time decreased by 30 min (p < 0.001), and the time until CT decreased by 22 min (p < 0.001). The number of delayed diagnoses and complications were significantly lower in the second period, with an OR of 0.2 (CI: 0.1-0.2) and 0.4 (CI: 0.3-0.6), respectively. The hospital length of stay and ICU length of stay decreased significantly, -1.5 day (p = 0.010) and -1.8 days (p = 0.022) respectively. CONCLUSIONS Optimisation of the in-hospital infrastructure related to trauma care resulted in improved survival rates in both severely injured patients as well as in the whole trauma population. Moreover, the processes and clinical outcomes improved, showing a shorter hospital length of stay, shorter TR time, fewer complications and fewer delayed diagnoses.
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The hybrid emergency room system: a novel trauma evaluation and care system created in Japan. Acute Med Surg 2019; 6:247-251. [PMID: 31304025 PMCID: PMC6603312 DOI: 10.1002/ams2.412] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 03/08/2019] [Indexed: 11/06/2022] Open
Abstract
The ultimate trauma management system should allow the completion of all time-consuming life-saving procedures in one trauma resuscitation room. In 2011, the Hybrid Emergency Room System (HERS) was developed in Japan as a novel trauma care system that allows clinicians to perform all life-saving procedures for severely injured patients, including whole-body computed tomography examination, damage control surgery, and transcatheter arterial embolization by interventional radiology, on the same table in the same room without transferring the patient. Since then, the number of HERS installations has rapidly increased around Japan. To promote further innovation and dissemination of this new and creative concept of trauma management, the Japanese Association for Hybrid Emergency Room System was launched on June 21, 2018. In this article, the concept, history, and current evidence behind this new trauma workflow system are summarized. This is the first review to show the next direction of trauma care using HERS.
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 695] [Impact Index Per Article: 139.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Laue F, Ramadanov N, Matthes G. Schockraummanagement beim Schwerverletzten. Notf Rett Med 2019. [DOI: 10.1007/s10049-018-0552-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Whole body computed tomography in multi trauma patients: Review of the current literature. Turk J Emerg Med 2018; 18:142-147. [PMID: 30533556 PMCID: PMC6261098 DOI: 10.1016/j.tjem.2018.09.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 01/29/2023] Open
Abstract
Many authors adopt the Selected Computed Tomography (SCT) approach of the Advanced Trauma Life Support (ATLS) for the management of multiple trauma patients. In the SCT approach, the initial physical examination is followed by conventional radiography (cervical X-ray, chest X-ray, pelvic X-ray and Focused Abdominal Sonography in Trauma (FAST)), and the computed tomography (CT) of the specific body regions if indicated. An alternative to this traditional approach is the Whole-body Computed Tomography (WBCT) protocol, which became widespread all over the world in the last two decades to minimize the rate of missed injuries and decrease the mortality rate. According to the literature, the WBCT approach is superior to the traditional SCT approach in the time of imaging, diagnostic accuracy, and mortality rates. Conversely, WBCT increases the cancer risk due to additional irradiation. Therefore, it is recommended that the WBCT protocol should be reserved for only severe multi-trauma patients. However, further studies to define severe patients, and clinical decision criteria for WBCT are needed.
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Zieleskiewicz L, Fresco R, Duclos G, Antonini F, Mathieu C, Medam S, Vigne C, Poirier M, Roche PH, Bouzat P, Kerbaul F, Scemama U, Bège T, Thomas PA, Flecher X, Hammad E, Leone M. Integrating extended focused assessment with sonography for trauma (eFAST) in the initial assessment of severe trauma: Impact on the management of 756 patients. Injury 2018; 49:1774-1780. [PMID: 30017184 DOI: 10.1016/j.injury.2018.07.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/29/2018] [Accepted: 07/02/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Before total body computed tomography scan, an initial rapid imaging assessment should be conducted in the trauma bay. It generally includes a chest x-ray, pelvic x-ray, and an extended focused ultrasonography assessment for trauma. This initial imaging assessment has been poorly described since the increase in the use of ultrasound. Therefore, our study aimed to evaluate the diagnostic accuracy and therapeutic impact of this initial imaging work-up in severe trauma patients. A secondary aim was to assess the therapeutic impact of a chest x-ray according to the lung ultrasonography findings. METHODS Patients with severe trauma who were admitted directly to our level 1 trauma center were consecutively included in this retrospective single center study. The diagnostic accuracy, therapeutic impact, and appropriate decision rate were calculated according to the initial assessment results of the whole body computed tomography scan and surgery reports. RESULTS Among the 1315 trauma patients admitted, 756 were included in this research. Lung ultrasound showed a higher diagnostic accuracy for haemothorax and pneumothorax cases than the chest x-ray. Sensitivity and specificity of the abdominal ultrasound to detect intraperitoneal effusion were 70% and 96%, respectively. The initial assessment had a therapeutic impact in 76 (10%) of the patients, including 16 (2%) immediate laparotomies and 58 (7%) chest tube insertions. The pelvic x-ray had no therapeutic impact, and when the lung ultrasound was normal, the chest x-ray had a therapeutic impact of only 0.13%. Combining the chest x-ray and lung ultrasound allowed adequate management of all the pneumothorax and haemothorax cases. Only one of the 756 patients had initial management that was judged as inappropriate. This patient had a missed pelvic disjunction with active retroperitoneal bleeding, and underwent an inappropriate immediate laparotomy. CONCLUSIONS In our cohort, the initial imaging assessment allowed appropriate decisions in 755 of 756 patients, with a global therapeutic impact of 10%. The pelvic x-ray had a minimal therapeutic impact, and in the patients with normal lung ultrasounds, the chest x-ray marginally affected the management of our patients. The potential consequences of abandoning systematic chest and pelvic x-rays should be investigated in future randomized prospective studies.
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Affiliation(s)
- Laurent Zieleskiewicz
- Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France; Aix Marseille Univiversity, INSERM, INRA, C2VN, Marseille, France.
| | - Raphaelle Fresco
- Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France
| | - Gary Duclos
- Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France
| | - François Antonini
- Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France
| | - Calypso Mathieu
- Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France; Aix-Marseille University, Marseille, France
| | - Sophie Medam
- Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France
| | - Coralie Vigne
- Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France
| | - Marion Poirier
- Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France
| | - Pierre-Hugues Roche
- Aix-Marseille University, Marseille, France; Department of Neurosurgery, North university hospital, AP-HM, Marseille, France
| | - Pierre Bouzat
- Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, Grenoble, France; Grenoble Alps University, Grenoble, France
| | - François Kerbaul
- Aix-Marseille University, Marseille, France; Pole RUSH, Assistance-Publique Hôpitaux de Marseille, Marseille, France
| | - Ugo Scemama
- Department of Radiology, Hôpital Nord, Marseille, France
| | - Thierry Bège
- Aix-Marseille University, Marseille, France; Department of General Surgery, Marseille, France; Laboratoire de Biomécanique Appliquée, UMR T24, Marseille, France
| | - Pascal Alexandre Thomas
- Aix-Marseille University, Marseille, France; Department of Thoracic and Esophageal Surgery, Hôpital Nord, Marseille, France
| | - Xavier Flecher
- Aix-Marseille University, Marseille, France; Department of Orthopaedic Surgery, Institut du Mouvement et de l'Appareil Locomoteur, UMR CNRS 7287 /AMU, Centre Hospitalo-Universitaire Sud, Hôpital Sainte Marguerite, Marseille, France
| | - Emmanuelle Hammad
- Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France
| | - Marc Leone
- Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France; Aix-Marseille University, Marseille, France; Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes, UMR 63, Marseille, France
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["Everyone talks about quality …"]. Unfallchirurg 2018; 121:772-773. [PMID: 30267236 DOI: 10.1007/s00113-018-0556-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
PURPOSE OF REVIEW To provide an update on the relevant and recent studies on whole-body computed tomography (WBCT) imaging of severely injured patients. RECENT FINDINGS The advantages of WBCT in time saving, diagnostic accuracy and even in survival have been proven in numerous studies. WBCT can also be beneficial in haemodynamically unstable major trauma patients. The CT scanner should be located close to the emergency department or even in the trauma room. The issue of radiation is still quite important, however, iterative as well as split-bolus protocols can nowadays reduce radiation significantly. The question: which trauma patient should receive WBCT and which not is not yet solved sufficiently. Postmortem WBCT has a promising potential to promptly define the definitive cause of death of trauma victims comparably to traditional autopsy. SUMMARY On account of the recent advances, whole-body CT has become a crucial part of the initial in-hospital assessment of severely injured patients. It is recommended as the standard radiological tool for the emergency diagnostic work-up in major trauma patients.
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Kinoshita T, Hayashi M, Yamakawa K, Watanabe A, Yoshimura J, Hamasaki T, Fujimi S. Effect of the Hybrid Emergency Room System on Functional Outcome in Patients with Severe Traumatic Brain Injury. World Neurosurg 2018; 118:e792-e799. [PMID: 30026142 DOI: 10.1016/j.wneu.2018.07.053] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The timely treatment of severe traumatic brain injury (TBI) is essential for limiting the effects of damage; however, there is no consensus regarding an effective method for early intervention. In August 2011, our hospital launched a novel trauma workflow using the hybrid emergency room (ER), consisting of an interventional radiology-computed tomography (CT) unit installed in the trauma resuscitation room to facilitate early interventions. The aim of this study was to evaluate effects of the hybrid ER system on functional outcomes in patients with severe TBI. METHODS We conducted a retrospective historical control study of patients with severe TBI (Glasgow Coma Scale score ≤8) who received conventional treatment (August 2007-July 2011) or treatment in the hybrid ER (August 2011-July 2015). The primary end point was unfavorable outcome at 6 months after injury (death, vegetative state, or lower severe disability) as evaluated by the Glasgow Outcome Scale-Extended. Secondary end points included time from arrival to the start of CT examination and emergency intracranial operation. Potential confounders were adjusted with multivariable logistic regressions. RESULTS Among 158 included patients, 88 were in the conventional group and 70 were in the hybrid ER group. After model adjustment, the hybrid ER group was significantly associated with a reduction in unfavorable outcomes. Times to CT examination and intracranial operation were significantly shorter in the hybrid ER group than that in the conventional group. CONCLUSIONS The hybrid ER system is useful for realizing immediate CT examination and emergency surgery and improving functional outcomes in patients with severe TBI.
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Affiliation(s)
- Takahiro Kinoshita
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Motohisa Hayashi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan.
| | - Atsushi Watanabe
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Jumpei Yoshimura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Toshimitsu Hamasaki
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
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Furugori S, Kato M, Abe T, Iwashita M, Morimura N. Treating patients in a trauma room equipped with computed tomography and patients' mortality: a non-controlled comparison study. World J Emerg Surg 2018; 13:16. [PMID: 29599816 PMCID: PMC5870518 DOI: 10.1186/s13017-018-0176-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/12/2018] [Indexed: 11/16/2022] Open
Abstract
Background To improve acute trauma care workflow, the number of trauma centers equipped with a computed tomography (CT) machine in the trauma resuscitation room has increased. The effect of the presence of a CT machine in the trauma room on a patient’s outcome is still unclear. This study evaluated the association between a CT machine in the trauma room and a patient’s outcome. Methods Our study included all trauma patients admitted to a trauma center in Yokohama, Japan, between April 2014 and March 2016. We compared 140 patients treated using a conventional resuscitation room with 106 patients treated in new trauma rooms equipped with a CT machine. Results For the group treated in a trauma room with a CT machine, the Injury Severity Score (13.0 vs. 9.0; p = 0.002), CT scans of the head (78.3 vs. 66.4%; p = 0.046), CT scans of the body trunk (75.5 vs. 58.6%; p = 0.007), intubation in the emergency department (48.1 vs. 30.7%; p = 0.008), and multiple trauma patients (47.2 vs. 30.0%; p = 0.008) were significantly higher and Trauma and Injury Severity Score probability of survival (96.75 vs. 97.80; p = 0.009) was significantly lower than the group treated in a conventional resuscitation room. In multivariate analysis and propensity score matched analysis, being treated in a trauma room with a CT machine was an independent predictor for fewer hospital deaths (odds ratio 0.002; 95% CI 0.00–0.75; p = 0.04, and 0.07; 0.00–0.98, respectively). Conclusions Equipping a trauma room with a CT machine reduced the time in decision-making for treating a trauma patient and subsequently lowered the mortality of trauma patients.
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Affiliation(s)
- Shintaro Furugori
- 1Department of Emergency Medicine, Yokohama City University, 4-57 Urafunecho, Minamiku, Yokohama City, Kanagawa Prefecture 232-0024 Japan
| | - Makoto Kato
- 2Department of Surgery, Yokohama City University, 4-57 Urafunecho, Minamiku, Yokohama City, Kanagawa Prefecture 232-0024 Japan
| | - Takeru Abe
- 1Department of Emergency Medicine, Yokohama City University, 4-57 Urafunecho, Minamiku, Yokohama City, Kanagawa Prefecture 232-0024 Japan
| | - Masayuki Iwashita
- 1Department of Emergency Medicine, Yokohama City University, 4-57 Urafunecho, Minamiku, Yokohama City, Kanagawa Prefecture 232-0024 Japan
| | - Naoto Morimura
- 3Department of Acute Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033 Japan
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Aarabi B, Sansur CA, Ibrahimi DM, Simard JM, Hersh DS, Le E, Diaz C, Massetti J, Akhtar-Danesh N. Intramedullary Lesion Length on Postoperative Magnetic Resonance Imaging is a Strong Predictor of ASIA Impairment Scale Grade Conversion Following Decompressive Surgery in Cervical Spinal Cord Injury. Neurosurgery 2017; 80:610-620. [PMID: 28362913 DOI: 10.1093/neuros/nyw053] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 11/14/2016] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Evidence indicates that, over time, patients with spinal cord injury (SCI) improve neurologically in various degrees. We sought to further investigate indicators of grade conversion in cervical SCI. OBJECTIVE To detect predictors of ASIA impairment scale (AIS) grade conversion in SCI following surgical decompression. METHODS In a retrospective study, demographics, clinical, imaging, and surgical data from 100 consecutive patients were assessed for predictors of AIS grade conversion. RESULTS American Spinal Injury Association motor score was 17.1. AIS grade was A in 52%, B in 29%, and C in 19% of patients. Surgical decompression took place on an average of 17.6 h following trauma (≤12 h in 51 and >12 h in 49). Complete decompression was verified by magnetic resonance imaging (MRI) in 73 patients. Intramedullary lesion length (IMLL) on postoperative MRI measured 72.8 mm, and hemorrhage at the injury epicenter was noted in 71 patients. Grade conversion took place in 26.9% of AIS grade A patients, 65.5% of AIS grade B, and 78.9% of AIS grade C. AIS grade conversion had statistical relationship with injury severity score, admission AIS grade, extent of decompression, presence of intramedullary hemorrhage, American Spinal Injury Association motor score, and IMLL. A stepwise multiple logistic regression analysis indicated IMLL was the sole and strongest indicator of AIS grade conversion (odds ratio 0.950, 95% CI 0.931-0.969). For 1- and 10-mm increases in IMLL, the model indicates 4% and 40% decreases, respectively, in the odds of AIS grade conversion. CONCLUSION Compared with other surrogates, IMLL remained as the only predictor of AIS grade conversion.
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Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland.,R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles A Sansur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - David M Ibrahimi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - David S Hersh
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Elizabeth Le
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Cara Diaz
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jennifer Massetti
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Noori Akhtar-Danesh
- School of Nursing and Depart-ment of Clinical Epidemiology and Bio-statistics, McMaster University, Hamilton, Ontario, Canada
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Routine versus selective chest and abdominopelvic CT-scan in conscious blunt trauma patients: a randomized controlled study. Eur J Trauma Emerg Surg 2017; 44:9-14. [PMID: 28948295 DOI: 10.1007/s00068-017-0842-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 09/14/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE CT-scan is increasingly used in blunt trauma, but the real impact on patient outcome is still unclear. This study was conducted to assess the effect of performing routine (versus selective) chest and abdominopelvic CT-scan on patient admission time and outcome in blunt trauma. METHODS Conscious and hemodynamically stable high-energy trauma patients were included (n = 140). Routine chest and abdominopelvic CT-scan was requested in addition to the conventional radiography and ultrasound for the intervention group and selective CT-scan according to clinical presentation was done for the control group. Patient admission times in the emergency room and surgery ward, complications, and performed surgical procedures were assessed. "Unsuspected injuries" defined as additional findings on CT-scan, which were not expected before CT-scan, were evaluated. RESULTS Admission time in the emergency ward and admission time in hospital were significantly shorter in the intervention group. Complications were similar in both groups. Abdominopelvic CT-scan in the intervention group revealed nine (7.8%) unsuspected injuries. All of these nine patients had also a positive clinical examination and injuries in other body regions. Chest CT-scan in the intervention group led to additional diagnoses in 17 patients (24.28%) leading to tube thoracostomy in 13 patients (18.57%). CONCLUSION Routine chest and abdominopelvic CT-scan in conscious blunt trauma patients decreases the hospitalization time, but has no impact on patient outcome and probably might lead to overtreatment of occult injuries. The option of using a selective approach should be further evaluated to decrease radiation exposure and facility overuse.
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Wulffeld S, Rasmussen LS, Højlund Bech B, Steinmetz J. The effect of CT scanners in the trauma room - an observational study. Acta Anaesthesiol Scand 2017. [PMID: 28635146 DOI: 10.1111/aas.12927] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND A CT scanner incorporated in the trauma resuscitation bay may benefit trauma patients by fastening work-up times; however, evidence in the area is still sparse. We assessed if time from admission to first CT scan was lower after incorporation of a CT scanner in the resuscitation bay. METHODS We included trauma patients admitted in two 1-year periods, before and after a major rebuilding of the trauma room. Beforehand, one CT scanner was located in an adjacent room. After the rebuilding, two mobile CT scanners were placed in the resuscitation bays, where a moving gantry was combined with a trauma resuscitation table. Subgroup analyses were performed on severely injured and patients with traumatic brain injury. RESULTS We included 784 patients before and 742 patients after the reconstruction. Case-mix differed between study periods as there was a higher proportion of severe injuries, traumatic brain injury and penetrating trauma in the after period. We found a minor increase in time to CT in the after period (20 vs. 21 min, P = 0.008). In a multivariate regression analysis adjusted for differences in case-mix and with time to CT as outcome, period was an insignificant explanatory variable [β (before vs. after): 0.96 min 95% CI: 0.9-1.02, P = 0.3]. In both subgroups, we found no significant difference in time to CT. CONCLUSION We found no reduction in time to CT scan, when comparing a period with mobile CT scanners incorporated in the resuscitation bay to an earlier period with a CT scanner next to the trauma room.
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Affiliation(s)
- S. Wulffeld
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - L. S. Rasmussen
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - B. Højlund Bech
- Department of Diagnostic Radiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - J. Steinmetz
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
- Trauma Centre; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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Abstract
The German Trauma Registry DGU® started in 1993 as an initiative of five dedicated trauma centers and has evolved significantly since then. Data were obtained at four points of time from the site of the accident until discharge from hospital. In the first year (1993), the registry collected data of 260 patients from 5 hospitals. In 2015 more than 38.000 were included from 640 hospitals.This paper focusses on the impact of the trauma registry on the treatment of severely injured patients. Several authors could show that the data can be used by hospitals for benchmarking. This can help to detect problems in individual hospitals and to find solutions that can be implemented into the process of care and its subsequent reevaluation. Due to structural and process-related changes, the time necessary for the management in the emergency room could be reduced significantly. Various scientific analyses of the Trauma Registry DGU® data were implemented in the treatment of severely injured patients. In the prehospital treatment, this changed the criteria for intubation and led to a reduction of volume replacement. In the hospital setting, the analysis influenced the radiologic work-up and the treatment of coagulopathy of severely injured patients. Moreover, the risk-adjusted mortality of severely injured patients in Germany could be continuously reduced over the past 20 years.
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Wynell-Mayow W, Guevel B, Quansah B, O'Leary R, Carrothers AD. Cambridge Polytrauma Pathway: Are we making appropriately guided decisions? Injury 2016; 47:2117-2121. [PMID: 27496722 DOI: 10.1016/j.injury.2016.05.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 05/29/2016] [Indexed: 02/02/2023]
Abstract
Addenbrooke's Hospital, the Major Trauma Centre for the East of England Trauma Network, received 1070 major trauma patients between 1st January and 31st December 2014. In order to improve care, an audit was performed of 59 patients meeting our own selection criteria for orthopaedic polytrauma between 1st January 2013 and 31st December 2013. The Cambridge Polytrauma Pathway was devised through NCEPOD guidelines, literature review, internal and external discussion. It facilitates provision of best practice Early Appropriate Care, encompassing - multidisciplinary consultant decisions around the patient in our Neurological and Trauma Critical Care Unit, early full body trauma CT scans, serial measurements of lactate and fibrinogen levels, and out-of-hours orthopaedic theatre reserved for life-and-limb threatening injuries. Re-audit was conducted of 15 patients meeting selection criteria, admitted between 1st October 2014 and 31st March 2015. Significant improvements in recording of lactate and fibrinogen were demonstrated, both on admission (lactate - p<0.000, fibrinogen - p=0.015), and preoperatively (lactate - p=0.003, fibrinogen - p=0.030). Time to trauma CT was unchanged (p=0.536) with a median time to CT of 0.53h at re-audit (IQR 0.48-0.75). The number of patients receiving definitive orthopaedic intervention out-of-hours reduced from 8 to zero (p=0.195). The approach of facilitating management decisions to be made at early daytime MDT meetings has been adopted. It is anticipated that this pathway will improve outcomes in orthopaedic polytrauma patients and it is recommended that either the GOS-E, or the EQ-5D scoring systems be introduced to assess this.
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Affiliation(s)
- William Wynell-Mayow
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Borna Guevel
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Benjamin Quansah
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Ronan O'Leary
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Andrew D Carrothers
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK.
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Computed tomography in hemodynamically unstable severely injured blunt and penetrating trauma patients. J Trauma Acute Care Surg 2016; 80:597-602; discussion 602-3. [PMID: 26808032 DOI: 10.1097/ta.0000000000000975] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Dynamic and efficient resuscitation strategies are now being implemented in severely injured hemodynamically unstable (HU) patients as blood products become readily and more immediately available in the trauma room. Our ability to maintain aggressive resuscitation schemes in HU patients allows us to complete diagnostic imaging studies before rushing patients to the operating room (OR). As the criteria for performing computed tomography (CT) scans in HU patients continue to evolve, we decided to compare the outcomes of immediate CT versus direct admission to the OR and/or angio suite in a retrospective study at a government-designated regional Level I trauma center in Cali, Colombia. METHODS During a 2-year period (2012-2013), blunt and penetrating trauma patients (≥ 15 years) with an Injury Severity Score (ISS) greater than 15 who met criteria of hemodynamic instability (systolic blood pressure [SBP] <100 mm Hg and/or heart rate >100 beats/min and/or ≥ 4 U of packed red blood cells transfused in the trauma bay) were included. Isolated head trauma and patients who experienced a prehospital cardiac arrest were excluded. The main study outcome was mortality. RESULTS We reviewed 171 patients. CT scans were performed in 80 HU patients (47%) immediately upon arrival (CT group); the remaining 91 patients (53%) went directly to the OR (63 laparotomies, 20 thoracotomies) and/or 8 (9%) to the angio suite (OA group). Of the CT group, 43 (54%) were managed nonoperatively, 37 (46%) underwent surgery (15 laparotomies, 3 thoracotomies), and 2 (5%) underwent angiography (CT OA subgroup). None of the mortalities in the CT group occurred in the CT suite or during their intrahospital transfers. CONCLUSION There was no difference in mortality between the CT and OA groups in HU patients. CT scan was attainable in 47% of HU patients and avoided surgery in 54% of the cases. Furthermore, CT scan was helpful in deciding definitive/specific surgical management in 46% scanned HU patients who necessitated surgery after CT. LEVEL OF EVIDENCE Therapy/care management study, level IV.
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Mattiassich G, Litzlbauer W, Ortmaier R. Voraussetzungen, Erfahrungen und Nutzen des Traumaregisters der DGU in Österreich. Unfallchirurg 2016; 119:613-6. [DOI: 10.1007/s00113-016-0194-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lefering R. [Using data from registries like the TraumaRegister DGU(®) for effectiveness evaluations]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2016; 112 Suppl 1:S11-5. [PMID: 27320022 DOI: 10.1016/j.zefq.2016.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In some situations like a rare disease or an emergency intervention, a randomized controlled trial is rather difficult or even impossible to conduct. In these cases, the use of observational studies or registries for the assessment of effectiveness is discussed. Results from registries, however, are subject to the same methodological limitations as any non-randomized comparison. Specifically, the comparability of selected patient groups is not ensured. Using three examples from the TraumaRegister DGU(®), a nationwide registry for severely injured patients in Germany, the advantages as well as the risks of outcome evaluation with registry data will be discussed: 1) whole-body computed tomography in the early in-hospital phase, 2) pre-hospital volume resuscitation, and 3) surgical treatment according to the principle of damage control. The most important prerequisite for any successful outcome evaluation using registry data is the documentation and availability of so-called confounding variables (prognostic factors), the absence of an accepted standard treatment, i.e., both interventions are routinely applied in similar situations, and, finally, the use of sophisticated statistical methods for multivariate adjustment of results.
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Affiliation(s)
- Rolf Lefering
- Institut für Forschung in der operativen Medizin (IFOM), Universität Witten/Herdecke, Köln, Deutschland.
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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 597] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
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Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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