Resuscitation and transfer of trauma patients: a prospective study

Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity

BACKGROUND

Although the benefits of acute stabilization of long bone fractures are recognized, the role of early fixation of unstable pelvis and acetabular fractures is not well-defined. The purpose of this study was to review complications and hospital course of patients treated surgically for pelvis and acetabulum fractures. We hypothesized that early definitive fixation would reduce morbidity and decrease length of stay.

METHODS

Six hundred forty-five patients were treated surgically at a level I trauma center for unstable fractures of the pelvic ring (n = 251), acetabulum (n = 359), or both (n = 40). Mean age was 40.5 years, and mean Injury Severity Score (ISS) was 25.6 (range 9-66). They were retrospectively reviewed to determine complications including acute respiratory distress syndrome (ARDS), pneumonia, deep vein thrombosis, pulmonary embolism, multiple organ failure (MOF), infections, and reperations.

RESULTS

Definitive fixation was within 24 hours of injury in 233 patients (early, mean 13.4 hours) and >24 hours in 412 (late, mean 99.2 hours). Twenty-nine patients (12.4%) had complications after early fixation versus 81 (19.7%) after late, p = 0.006. Length of stay and intensive care unit days were 10.7 days versus 11.6 days (p = 0.26) and 8.1 days versus 9.9 days (p = 0.03) for early and late groups, respectively. With ISS >18 (n = 165 early [ISS 32.7]; n = 253 late [ISS 33.1]), early fixation resulted in fewer pulmonary complications (12.7% versus 25%, p = 0.0002), less ARDS (4.8% versus 12.6%, p = 0.019), and less MOF (1.8% versus 4.3%, p = 0.40). Rates of complications, pulmonary complications, deep vein thrombosis, and MOF were no different for patients with pelvis versus acetabulum fractures. In patients receiving ≥ 10U packed red blood cells (n = 41 early, n = 56 late) early fixation led to fewer pulmonary complications (24% versus 55%, p = 0.002), less ARDS (12% versus 25%, p = 0.09), and MOF (7.3% versus 14%, p = 0.23). Two hundred ten patients had some chest injury (32.6%). Chest injury with Abbreviated Injury Scores ≥ 3 was present in 46 (19.7%) of early and 78 (18.9%) of late patients (p = 0.44) and was associated with pulmonary complications in 26.1% versus 35.9%; ARDS in 15.2% versus 23.1%; and MOF in 6.5% versus 6.4%, respectively (all p > 0.20). However, chest injury with Abbreviated Injury Scores ≥ 3 was independently associated with more complications including ARDS (20.2% versus 3.3%, p < 0.0001), other pulmonary complications (32.3% versus 10.4%, p < 0.0001), and MOF (6.5% versus 1.2%, p = 0.0016), regardless of timing of fixation.

CONCLUSIONS

Early fixation of unstable pelvis and acetabular fractures in multiply injured patients reduces morbidity and length of intensive care unit stay, which may decrease treatment costs. Further study to ascertain the effects of associated systemic injuries and the utility of physiologic and laboratory parameters during resuscitation may delineate recommendations for optimal surgical timing in specific patient groups.

Compliance with protocols in transferring emergency patients to a tertiary care centre

STUDY OBJECTIVES

We evaluated compliance with standard patient transfer protocols in a pre- and post-interventional study among patients transferred from other hospitals to our tertiary care university hospital.

METHODS

In the first phase, transfer information was recorded on the arrival in 174 consecutive patients transferred to our emergency department (ED) over a 2-month period in 1999. Emergency caregivers throughout the province then received education about proper transfer procedures. This training was provided through monthly citywide co-ordination and co-operation meetings among the physicians of the emergency medical services (EMS) and the emergency departments of the hospitals in the city and the nearby counties. Fifteen months after the beginning of these educational efforts, the second observational phase was implemented. Over a period of 2 months in early 2001, information was recorded from 180 consecutive patients transferred to our ED. Presence of patient medical records, laboratory results, and X-rays; clearly delineated reason for transfer; prior notification of transfer; and appropriate care during transport from the initial facility were the parameters compared in the pre- and post-intervention periods.

RESULTS

Patients in phase-II were found to have had more appropriate care in some respects, such as presence of cervical collar and proper airway management, during transport from the initial facility than patients in phase-I (P < 0.05). However, other parameters were not significantly different between the two phases.

CONCLUSION

We have concluded that our monthly meetings and conferences have made a positive impact on compliance with some of the standard transfer protocols. We must however, continue our efforts to increase compliance with other aspects of standard patient transfer guidelines.

Reduction of time to definitive care in trauma patients: effectiveness of a new checklist system

This study evaluated the feasibility of establishing a new trauma transfer checklist and assessed its impact on trauma-related interhospital transfers. A standard envelope with a printed checklist (N.E.W.S.) incorporating four key concepts in the care and transfer of trauma patients was used. A prospective comparison of consecutive interhospital trauma transfers to the major trauma service between July 1999-May 2000 (pre-N.E.W.S.) and August 2000-November 2000 (post-N.E.W.S.) was made. Changes in management satisfaction were assessed by a Likert scale (1=poor to 5=excellent). Pre-N.E.W.S., 88 trauma patients were transferred and 20 trauma transfers were recorded post-N.E.W.S. The time to definitive care pre-N.E.W.S. was 443+/-322 min, and 339+/-108 min (P=0.014) post-N.E.W.S. The time in the referring hospital was also reduced from 343+/-310 min pre-N.E.W.S. to 197+/-90 min post-N.E.W.S (P=0.0002). The checklist system prompted changes in the management of the trauma patient in 20% of the cases and there was a high level of satisfaction expressed by users of the checklist (4.6+/-0.7). The N.E.W.S. checklist is effective in facilitating the interhospital transfer of trauma patients by shortening the time to definitive care.

Impact of level III verification on trauma admissions and transfer: comparisons of two rural hospitals

PURPOSE

To study the impact of Level III verification and other changes in rural hospitals on trauma delivery and to examine factors affecting transfer to a Level I trauma center.

SETTING

Two rural Kentucky hospitals and a Level I trauma center.

METHOD OF REVIEW

Concurrent review of all trauma patients in 1988 and re-review of the same parameters in 1995.

FINDINGS

In 1988, both hospitals had similar management practices in trauma care. A significant number of patients were transferred for (a) patient choice, (b) serious and/or multiple trauma, (c) specialty care in non-life threatening situations, and (d) to exclude a potentially serious problem seen on radiologic evaluation (usually questionable cervical spine or widened mediastinum). Both hospitals had major changes in trauma delivery. One hospital received Level III verification, and the other had changes that lessened the general surgeon's involvement with initial evaluation and treatment. A re-review in 1995 disclosed major changes at both institutions. Transfers to exclude radiologic abnormalities had virtually disappeared. The Level III status had increased the surgical involvement in that hospital; there was actually an increase in patients transferred to the Level I hospital and an increase in patient acuity. More operations were performed locally, and the care was more efficiently delivered. The other hospital had a large increase in transfers and decreased admissions locally as general surgical involvement decreased.

CONCLUSIONS

The factors related to patient transfer for trauma care are complex and require careful elucidation to improve care. The development of a Level III trauma service appeared to increase the number of seriously injured patients treated in the rural hospital and the efficiency of the care delivered.

Interhospital transfer of the critically ill trauma patient: the potential role of a specialist transport team in a trauma system

A specialist transfer team based in the regional intensive therapy unit (ITU) at the Western Infirmary, Glasgow, acts as a central interhospital retrieval team for Glasgow and the west of Scotland. The establishment of trauma systems has been proposed. This paper describes the activities of the specialist transfer team to illustrate the potential role of a central retrieval team within such a system.

Stabilization of rural multiple-trauma patients at level III emergency departments before transfer to a level I regional trauma center

STUDY OBJECTIVE

To determine whether triage and stabilization of severely injured rural trauma victims in outlying Level III emergency departments before transfer to Level I trauma centers results in outcomes similar to national normative data.

DESIGN

Retrospective review of trauma transfers and deaths during a 4-year period.

SETTING

Two Level III EDs in rural, upstate New York and an urban Level I regional trauma center.

PARTICIPANTS

Fifty multiple-trauma victims with a Trauma Triage Score (T-RTS) of < or = 11 or less. Forty-three patients were stabilized before transfer, and 7 died in the rural Level III ED.

RESULTS

There were 45 blunt injuries and 5 penetrating injuries. Mean patient age was 34 years (range, 9 months to 97 years). The Revised Trauma Score (RTS) on admission to the Level III ED was calculated for each patient (median score, 5.97; interquartile range (IQR), 4.09 to 6.90), as was the ultimate Injury Severity Score (ISS) (median score, 23; IQR, 13 to 29). With TRISS methodology, probabilities of survival (Ps) and death (Pd) were calculated. Results were compared with the Major Trauma Outcome Study (MTOS) by use of current coefficients derived from Walker-Duncan regression analysis of MTOS data. The predicted number of deaths was 13.5, whereas the actual number was 12, Z statistic, -.710. There were two unexpected survivors and three unexpected deaths. The 43 patients who were stabilized and transferred had a median RTS of 5.97 (IQR, 4.30 to 6.90) and an ISS of 18 (IQR, 12 to 25). The median interval in the Level III ED before transfer was 1 hour 43 minutes (IQR, 1 hour 11 minutes to 2 hours 40 minutes). There were two unexpected survivors (Ps = .32, Ps = .49) and 1 unexpected death (Ps = .52). The predicted number of deaths was 8.1, whereas the actual number was 5. The 7 patients who died in the rural Level III ED had a median RTS of 4.41 (IQR, 2.98 to 4.71) and a median ISS of 50 (IQR, 44 to 65). The median interval in the Level III ED before death was 42 minutes (IQR, 41 minutes to 1 hour 20 minutes). There were 2 unexpected deaths (Ps = .66, Ps = .55). The predicted number of deaths was 5.4 whereas the actual number was 7.

CONCLUSION

Triage and stabilization of severely injured rural trauma victims at Level III EDs before Level I transfer provide outcomes similar to national results. Unexpected death of severely injured trauma victims remains a problem in rural Level III EDs.

A comparison study of chest tube thoracostomy: air medical crew and in-hospital trauma service

Chest tube thoracostomy (CTT) is not frequently performed by non-physician-staffed air medical crews (AMC) due to concern regarding safety, efficiency and training requirements. This study compared two groups of patients requiring CTT, one group with insertion performed by an AMC and the other by a physician trauma service (TS) in the emergency department on patient arrival. The CTT of 172 patients managed at a Level I trauma center between October 1988 and September 1990 were reviewed. Seventy-two patients were managed by the AMC and received CTT in a prehospital setting; the air medical personnel placed the chest tube cleanly in all cases. Chest tubes placed by AMC were removed within 48 hours of transport to minimize infection risk. One hundred patients requiring CTT in the hospital setting were randomly selected from the trauma registry during a similar time span. The study compared the patients' Injury Severity Scores (ISS), and trauma scores, any placement complications and the overall mortality. While the AMC often treated patients with higher acuity, as reflected by ISS and trauma scores and overall higher mortality, the rate of complications between CTT performed by AMC and TS was similar. Appropriately trained AMC can safely perform CTT without putting patients at increased risk.

The organization of a pediatric critical care transport program

Highly specialized pediatric critical care centers have matured significantly over the past two decades; however, access to this care is limited to tertiary care facilities and constrained by geography. With the advances of transport medicine, great distances can be spanned to bring critical care to the patient and provide effective treatment and safe transport systems where specialized care was previously unavailable. A patchwork of diverse transport systems perform pediatric transports with significant differences in the level of pediatric critical care. The optimal transport system has yet to be fully defined, but many successful systems share fundamental elements of organization.

Impact of helicopters on trauma care and clinical results

This report reviews the history of the development of civilian helicopter ambulance program as a component of a total emergency medical services (EMS) system. Current literature demonstrates significant reduction in trauma mortality for those patients transported by air either from the scene of the accident or from an outlying hospital to a trauma center. The primary factor is not the speed of the transport but administration of life-saving care by the helicopter medical crew at the scene of the accident or at the outlying hospital. Regulations have been developed to assure proper patient selection, quality care, safety, and minimization of misuse of this expensive resource.

Brain resuscitation and protection

No drug that is used for brain protection after global brain ischaemia as a result of cardiac arrest has been shown to be of benefit. Barbiturate agents have been proved not to be beneficial whereas studies of calcium-channel blocking drugs are inconclusive. Hypothermia, haemodilution and mechanical hyperventilation are not of proven benefit. Immediate defibrillation with rapid restoration of blood pressure is the best method to improve the neurological outcome after a cardiac arrest. After severe head injury, prompt emergency care to restore ventilation, oxygenation and blood pressure improves the neurological outcome. The early evacuation of extracerebral intracranial haematomas also improves the outcome. Corticosteroid therapy does not improve the outcome. The monitoring of intracranial pressure and the control of increased intracranial pressure by hyperventilation, cerebrospinal-fluid drainage and mannitol, frusemide and barbiturate therapy appear to improve the outcome after a severe head injury, although this has not been proved by randomized controlled studies.

Stabilization of patients prior to interhospital transfer

With regionalization of specialized health care services, some patients must be transferred between hospital to receive needed care. The authors evaluated 100 transfers to their emergency department as to the adequacy of stabilization prior to transport. Problems were identified in the areas of communication (nine cases), oxygenation (two cases), cardiac monitoring (one case), intravenous lines (eight cases), airway (two cases), ventilation (one case), equipment and personnel accompanying the patient (one case), bladder catheterization (four cases), nasogastric suctioning (one case), radiographs (nine cases), and spinal immobilization (seven cases). Because more than one error occurred in some patients, the total number of patients having problems with stabilization was 28. The authors also compared the reimbursement status of transferred patients with that of the region's and emergency department's patient populations. No evidence was found that financially undesirable patients were being preferentially transferred. Thus, even when transfers are not made because of unfavorable reimbursement status, many errors in stabilization occur. A review of the literature shows that inadequacies in stabilization for transfer are widespread. This may be improved through physician education, use of transport teams, and judicious use of interhospital transport. The indications and responsibilities of transfer are discussed.

Rural interhospital helicopter transport of motor vehicle trauma victims: causes for delays and recommendations

One hundred twenty-six consecutive ACS Category I motor vehicle trauma patients transported by helicopter from 25 hospitals to a regional trauma center in rural Pennsylvania during a 14-month period were reviewed retrospectively. The overall mortality was 13%. Average round-trip distance was 79 miles. Interventions by the medical flight team (emergency physician/nurse) included endotracheal intubation, tube thoracostomy, and/or central venous access in 42 patients (33%) prior to lift-off. Ground time at the referring facility, from landing to lift-off, when no interventions were required of the flight team, averaged 31.2 minutes (baseline). Ground time when major therapeutic interventions were required (principally airway management), however, averaged 57.4 minutes, an 84% increase over baseline (P less than .01). A major cause of the excessive ground times was the lack of standardized diagnostic workup and stabilization of patients prior to arrival of the flight team. Recommendations for standardized emergency department preparation of trauma victims requiring aeromedical evacuation are made.