[Analysis of indications fo interhospital transfer]

Évaluation de la pertinence d'un projet de réseau de santé prenant en charge les urgences neurotraumatiques graves

The aim of the study was to realise a strategic analysis of the feasibility of implementing a health care network for the management of severely head-injured patients in the Alpine region. We conducted face-to-face semi-structured interviews. Manual and computerized analysis of interviews was realized. Textual analysis was performed using the ALCESTE software package. A strategic analysis according to Crozier and Friedberg was performed. Eighteen interviews were realised: 13 physicians, 3 hospital directors and 2 head nurses. We identified 5 types of problems in the management of severely head-injured patients: the lack of human and material resources (33.1% of the variance), problems of communication (12.2%) and surgical competence (24.00), trajectory of care influenced by the concurrence between hospitals (18.0%) and relationship between professionals (12.6%). The stabilisation of process of cooperation was expected by all the professionals and a health care network seemed to be adapted as a coordination tool. Its implementation needed to take into account 3 individual representations: the will for collaboration--cooperation (23.3%), the negotiation (48.4%) and the contracts of the cooperation (28.3%). This study confirms that actors noted the need for improving the management of severely head-injured patients in the Alpine region. However, negotiation to express and solve controversies appears being a precondition to prevent from the blocking of the network by resistances to change.

[Medical prehospital rescue in head injury]

OBJECTIVE

To evaluate the effectiveness of prehospital medical care in head-injured patients.

PATIENTS AND METHODS

All head-injured patients admitted in Bicêtre hospital from 1995 to 1999 were retrospectively studied. Glasgow Coma Scale (GCS) score, mean arterial pressure (MAP) and SpO(2) measured on the field were compared to GCS, MAP and SpO(2) on arrival in the hospital. All treatments given during transport and first data recorded in the hospital were noted. Each parameter was compared to outcome at 6 months. Then, significant parameters were compared with a multivariate analysis.

RESULTS

Three hundred and four patients were included, 80% had a GCS <or= 8 and 45% a GCS = 3. At 6 months, 43% of the patients had no or mild sequelae and 45% died. Prehospital time was 2 h 55 min +/- 1 h 40 min. During transport, 75% of hypoxemic events were corrected, but GCS and MAP decreased significantly. None of the patients with non-reactive mydriasis received any osmotherapy and all patients with non-reactive mydriasis until hospital admission died (n = 55). After multivariate analysis, parameters significantly related to outcome were, on the field, MAP (p < 0.025) and at hospital SAPS II (p < 0,001), GCS (p < 0.001), non-reactive mydriasis (p < 0.025), hyperglycemia (p < 0.025) and low haemoglobinemia (p < 0.001).

CONCLUSION

Respect of guidelines is important to improve medical care. Prehospital management corrected hypoxemia but not hypotension. The lack of osmotherapy after mydriasis cannot be explained and is probably an error. Patient route must be simplified to decrease time delay from field to hospital. Improvement in prehospital care may decrease mortality in head-injured patients.

[Strategies diagnosis of polytraumatized adult patients with coma]

OBJECTIVE

To review the diagnostic strategy of management of multiple trauma patient during the first hours.

DATA SOURCES

Extraction from Pubmed database of French and English articles on the management of multiple trauma patient published for ten years.

DATA SELECTION

The collected articles were reviewed and selected according to their quality and originality. The more recent data were selected.

DATA SYNTHESIS

The first hours of management of multiple trauma patients are a particular challenge. The first dilemma is to drive the patient toward an adequate structure. In case of poor haemodynamic tolerance, the patient will be drive in the nearest hospital. When haemodynamic parameters are restored, multiple trauma patient has to be receive in a high level hospital by a trained medical team with an anesthesiologist, intensivist, neurosurgeon, general surgeon and radiologist. The initial assessment may have two priorities: quality and speed. The total body CT scan is actually the answer to these priorities.