Prehospital triage of trauma patients before and after implementation of a regional triage guideline

Traumatic cardiac arrest - a nationwide Danish study

BACKGROUND

Cardiac arrest following trauma is a leading cause of death, mandating urgent treatment. This study aimed to investigate and compare the incidence, prognostic factors, and survival between patients suffering from traumatic cardiac arrest (TCA) and non-traumatic cardiac arrest (non-TCA).

METHODS

This cohort study included all patients suffering from out-of-hospital cardiac arrest in Denmark between 2016 and 2021. TCAs were identified in the prehospital medical record and linked to the out-of-hospital cardiac arrest registry. Descriptive and multivariable analyses were performed with 30-day survival as the primary outcome.

RESULTS

A total of 30,215 patients with out-of-hospital cardiac arrests were included. Among those, 984 (3.3%) were TCA. TCA patients were younger and predominantly male (77.5% vs 63.6%, p =  < 0.01) compared to non-TCA patients. Return of spontaneous circulation occurred in 27.3% of cases vs 32.3% in non-TCA patients, p < 0.01, and 30-day survival was 7.3% vs 14.2%, p < 0.01. An initial shockable rhythm was associated with increased survival (aOR = 11.45, 95% CI [6.24 - 21.24] in TCA patients. When comparing TCA with non-TCA other trauma and penetrating trauma were associated with lower survival (aOR: 0.2, 95% CI [0.02-0.54] and aOR: 0.1, 95% CI [0.03 - 0.31], respectively. Non-TCA was associated with an aOR: 3.47, 95% CI [2.53 - 4,91].

CONCLUSION

Survival from TCA is lower than in non-TCA. TCA has different predictors of outcome compared to non-TCA, illustrating the differences regarding the aetiologies of cardiac arrest. Presenting with an initial shockable cardiac rhythm might be associated with a favourable outcome in TCA.

Accuracy of Trauma on Scene Triage Screening Tool (Shock Index, Reverse Shock Index Glasgow Coma Scale and National Early Warning Score) to Predict the Severity of Emergency Department Triage: A Retrospective Cross-Sectional Study

Introduction

Prehospital trauma care includes on-scene assessments, essential treatment, and facilitating transfer to an appropriate trauma center to deliver optimal care for trauma patients. While the Simple Triage and Rapid Treatment (START), Revised Triage Sieve (rTS), and National Early Warning Score (NEWS) tools are user-friendly in a prehospital setting, there is currently no standardized on-scene triage protocol in Thailand Emergency Medical Service (EMS). Therefore, this study aims to evaluate the precision of these tools (SI, rSIG, and NEWS) in predicting the severity of trauma patients who are transferred to the emergency department (ED).

Methods

This study was a retrospective cross-sectional and diagnostic research conducted on trauma patients transferred by EMS to the ED of Ramathibodi Hospital, a university-affiliated super tertiary care hospital in Bangkok, Thailand, from January 2015 to September 2022. We compared the on-scene triage tool (SI, rSIG, and NEWS) and ED triage tool (Emergency Severity Index) parameters, massive transfusion protocol (MTP), and intensive care unit (ICU) admission with the area under ROC (univariable analysis) and diagnostic odds ratio (multivariable logistic regression analysis). The optimal cut-off threshold for the best parameter was determined by selecting the value that produced the highest area under the ROC curve.

Results

A total of 218 patients were traumatic patients transported by EMS to the ED, out of which 161 were classified as ESI levels 1-2, while the remaining 57 patients were categorized as levels 3-5 on the ESI triage scale. We found that NEWS was a more accurate triage tool to discriminate the severity of trauma patients than rSIG and SI. The area under the ROC was 0.74 (95% CI 0.70-0.79) (OR 18.98, 95% CI 1.06-337.25), 0.65 (95% CI 0.59-0.70) (OR 1.74, 95% CI 0.17-18.09) and 0.58 (95% CI 0.52-0.65) (OR 0.28, 95% CI 0.04-1.62), respectively (P-value <0.001). The cut point of NEWS to discriminate ESI levels 1-2 and levels 3-5 was >6 points.

Conclusion

NEWS is the best on-scene triage screening tool to predict the severity at the emergency department, massive transfusion protocol (MTP), and intensive care unit (ICU) admission compared with other triage tools SI and rSIG.

Regional anesthesia and analgesia for trauma: an updated review

PURPOSE OF REVIEW

This narrative review is an updated summary of the value of regional anesthesia and analgesia for trauma and the special considerations when optimizing pain management and utilizing regional analgesia for acute traumatic pain.

RECENT FINDINGS

In the setting of the opioid epidemic, the need for multimodal analgesia in trauma is imperative. It has been proposed that inadequately treated acute pain predisposes a patient to increased risk of developing chronic pain and continued opioid use. Enhanced Regional Anesthesia techniques along with multimodal pain therapies is thought to reduce the stress response and improve patient's short- and long-term outcomes.

SUMMARY

Our ability to save life and limb has improved, but our ability to manage acute traumatic pain continues to lag. Understanding trauma-specific concerns and tailoring the analgesia to a patient's specific injuries can increase a patient's immediate comfort and long-term outcome as well.