1
|
Johnson JP, Oliphant BW, Dodd J, Duckworth RL, Goodloe JM, Lyng JW, Sagraves SG, Fischer PE. Prehospital Antibiotic Administration for Suspected Open Fractures: Joint COT/OTA/ACEP/NAEMSP/NAEMT Position Statement. PREHOSP EMERG CARE 2024:1-13. [PMID: 39356234 DOI: 10.1080/10903127.2024.2409380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 08/29/2024] [Accepted: 09/15/2024] [Indexed: 10/03/2024]
Abstract
One of the primary concerns associated with open fractures is the development of a fracture-related infection (FRI). To minimize the risk of developing an FRI and subsequent morbidity, prophylactic antibiotics should be administered to patients with open fractures as soon as possible. While the antibiotic recommendations for severe open fractures are somewhat debatable, the use of a cephalosporin remains a mainstay of prophylactic treatment. Though administration of prehospital antibiotics does represent an expansion of EMS responsibilities, there have been several other treatment expansions in the prehospital setting, such as the administration of tranexamic acid and the application of pelvic binders. The administration of antibiotics, specifically cefazolin, is inexpensive, technically simple, and does not require special storage. The following recommendations are supported by and represent consensus of the COT, OTA, ACEP, NAEMSP and NAEMT with regards to prehospital antibiotic prophylaxis for suspected fractures:In a responsive patient with no history of penicillin or cephalosporin allergy, the administration by EMS of a 1st generation cephalosporin should be performed after the management of life threats. This intervention should not delay transport.In an obtunded patient, the administration by EMS of a 1st generation cephalosporin should be performed after the management of life-threats. This intervention should not delay transport.In a responsive patient with a documented penicillin allergy, the administration by EMS of a 1st generation cephalosporin should be performed with close monitoring after the management of life-threats. This intervention should not delay transport.
Collapse
Affiliation(s)
- Joey P Johnson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 510 20th St S, Birmingham, AL 35294
| | - Bryant W Oliphant
- Department of Orthopedic Surgery, Detroit Receiving Hospital, 311 Mack Avenue, Detroit, MI 48201
| | - Jimm Dodd
- American College of Surgeons, 633 N St. Clair, Chicago, IL 60611
| | | | - Jeffrey M Goodloe
- Department of Emergency Medicine, University of Oklahoma School of Community Medicine, 4502 E 41st St, Tulsa, OK 74135
| | - John W Lyng
- Department of Emergency Medicine, North Memorial Level 1 Trauma Center, 3300 Oakdale Ave, Robbinsdale, MD 55422
| | - Scott G Sagraves
- Department of Surgery, Baylor College of Medicine, 2401 S. 31st Street, Temple, TX 76508
| | - Peter E Fischer
- Department of Surgery, UTHSC, 910 Madison Ave., #220, Memphis, TN 38163
| |
Collapse
|
2
|
Stevens NM, Tejwani NC. Damage-control orthopedics or early total care: What you need to know. J Trauma Acute Care Surg 2024; 96:694-701. [PMID: 38227676 DOI: 10.1097/ta.0000000000004250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
ABSTRACT Patients with multisystem injuries are defined as multiply injured patients and may need multiple surgical procedures from more than one specialty. The importance of evaluating and understanding the resuscitation status of a multiple-injury patient is critical. Orthopedic strategies when caring for these patients include temporary stabilization or definitive early fixation of fractures while preventing further insult to other organ systems. This article will define multiple injuries and discuss specific markers used in assessing patients' hemodynamic and resuscitation status. The decision to use damage-control orthopedics or early total care for treatment of the patient are based on these factors, and an algorithm is presented to guide treatment. We will also discuss principles of external fixation and the management of pelvic trauma in a multiple-injury patient.
Collapse
Affiliation(s)
- Nicole M Stevens
- From the Department of Orthopedics, NYU Langone Health, East Meadow, New York
| | | |
Collapse
|
3
|
Wend CM, Fransman RB, Haut ER. Prehospital Trauma Care. Surg Clin North Am 2024; 104:267-277. [PMID: 38453301 DOI: 10.1016/j.suc.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Prehospital trauma evaluation begins with the primary assessment of airway, breathing, circulation, disability, and exposure. This is closely followed by vital signs and a secondary assessment. Key prehospital interventions include management and resuscitation according to the aforementioned principles with a focus on major hemorrhage control, airway compromise, and invasive management of tension pneumothorax. Determining the appropriate time and method for transportation (eg, ground ambulance, helicopter, police, private vehicle) to the hospital or when to terminate resuscitation are also important decisions to be made by emergency medical services clinicians.
Collapse
Affiliation(s)
- Christopher M Wend
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street Suite 6-100, Baltimore, MD 21287, USA
| | - Ryan B Fransman
- Department of Trauma, Acute Care Surgery, and Surgical Critical Care, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Jr. Drive, SE, Atlanta, GA 30303, USA
| | - Elliott R Haut
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street Suite 6-100, Baltimore, MD 21287, USA; Department of Surgery, Division of Acute Care Surgery, Johns Hopkins University School of Medicine, Sheikh Zayed 6107C, 1800 Orleans Street, Baltimore, MD 21287, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| |
Collapse
|
4
|
Trentzsch H, Lefering R, Schweigkofler U. Imposter or knight in shining armor? Pelvic circumferential compression devices (PCCD) for severe pelvic injuries in patients with multiple trauma: a trauma-registry analysis. Scand J Trauma Resusc Emerg Med 2024; 32:2. [PMID: 38225602 PMCID: PMC10790519 DOI: 10.1186/s13049-023-01172-z] [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: 08/24/2023] [Accepted: 12/15/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Pelvic Circumferential Compression Devices (PCCD) are standard in hemorrhage-control of unstable pelvic ring fractures (UPF). Controversial data on their usefulness exists. Aim of the study was to investigate whether prehospital application of PCCD can reduce mortality and transfusion requirements in UPF. METHODS Retrospective cohort study. From 2016 until 2021, 63,371 adult severely injured patients were included into TraumaRegister DGU® of the German Trauma Society (TR-DGU). We analyzed PCCD use over time and compared patients with multiple trauma patients and UPF, who received prehospital PCCD to those who did not (noPCCD). Groups were adjusted for risk of prehospital PCCD application by propensity score matching. Primary endpoints were hospital mortality, standardized mortality rate (SMR) and transfusion requirements. RESULTS Overall UPF incidence was 9% (N = 5880) and PCCD use increased over time (7.5% to 20.4%). Of all cases with UPF, 40.2% received PCCD and of all cases with PCCD application, 61% had no pelvic injury at all. PCCD patients were more severely injured and had higher rates of shock or transfusion. 24-h.-mortality and hospital mortality were higher with PCCD (10.9% vs. 9.3%; p = 0.033; 17.9% vs. 16.1%, p = 0.070). Hospital mortality with PCCD was 1% lower than predicted. SMR was in favor of PCCD but failed statistical significance (0.95 vs. 1.04, p = 0.101). 1,860 propensity score matched pairs were analyzed: NoPCCD-patients received more often catecholamines (19.6% vs. 18.5%, p = 0.043) but required less surgical pelvic stabilization in the emergency room (28.6% vs. 36.8%, p < 0.001). There was no difference in mortality or transfusion requirements. CONCLUSION We observed PCCD overuse in general and underuse in UPF. Prehospital PCCD appears to be more a marker of injury severity and less triggered by presence of UPF. We found no salutary effect on survival or transfusion requirements. Inappropriate indication and technical flaw may have biased our results. TR-DGU does not contain data on these aspects. Further studies are necessary. Modular add-on questioners to the registry could offer one possible solution to overcome this limitation. We are concerned that PCCD use may be unfairly discredited by misinterpretation of the available evidence and strongly vote for a prospective trial.
Collapse
Affiliation(s)
- H Trentzsch
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, Ludwig-Maximilians-Universität, Schillerstr. 53, 80336, Munich, Germany.
| | - R Lefering
- Institute for Research in Operative Medicine (IFOM), Faculty of Health, University Witten/Herdecke, Cologne, Germany
| | - U Schweigkofler
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt Am Main Friedberger, Landstr. 430, 60389, Frankfurt am Main, Germany
| |
Collapse
|
5
|
Balet L, Ageron FX, Pasquier M, Zingg T. Performance Assessment of Out-of-Hospital Use of Pelvic Circumferential Compression Devices for Severely Injured Patients in Switzerland: A Nationwide Retrospective Cross-Sectional Study. J Clin Med 2023; 12:5509. [PMID: 37685575 PMCID: PMC10487807 DOI: 10.3390/jcm12175509] [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: 06/22/2023] [Revised: 08/09/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Patients with severe pelvic fractures carry a greater risk of severe bleeding, and pelvic compression devices (PCCD) are used to stabilize the pelvis on the pre-hospital scene. The aim of this study was to describe the use of PCCD in the pre-hospital setting on a nationwide scale (Switzerland) and determine the sensitivity, specificity and rates of over- and under-triage of the current application practices. The secondary objective was to identify pre-hospital factors associated with unstable pelvic fractures. METHODS Retrospective cross-sectional study using anonymized patient data (1 January 2015-31 December 2020) from the Swiss Trauma Registry (STR). Based on AIS scores, patients were assigned a unique principal diagnosis among three categories (unstable pelvic fracture-stable pelvic fracture-other) and assessed for use or not of PCCD. Secondarily, patient characteristics, initial pre-hospital vital signs, means of pre-hospital transport and trauma mechanism were also extracted from the database. RESULTS 2790 patients were included for analysis. A PCCD was used in 387 (13.9%) patients. In the PCCD group, 176 (45.5%) had an unstable pelvic fracture, 52 (13.4%) a stable pelvic fracture and 159 (41.1%) an injury unrelated to the pelvic region. In the group who did not receive a PCCD, 214 (8.9%) had an unstable pelvic fracture, 182 (7.6%) a stable pelvic fracture and 2007 (83.5%) an injury unrelated to the pelvic region. The nationwide sensitivity of PCCD application was 45.1% (95% CI 40.1-50.2), the specificity 91.2% (95% CI 90-92.3), with both over- and under-triage rates of 55%. The prevalence of unstable fractures in our population was 14% (390/2790). We identified female sex, younger age, lower systolic blood pressure, higher shock index, pedestrian hit and fall ≥3 m as possible risk factors for an unstable pelvic fracture. CONCLUSIONS Our results demonstrate a nationwide both over- and under-triage rate of 55% for out-of-hospital PCCD application. Female gender, younger age, lower blood pressure, higher shock index, pedestrian hit and fall >3 m are possible risk factors for unstable pelvic fracture, but it remains unclear if those parameters are relevant clinically to perform pre-hospital triage.
Collapse
Affiliation(s)
- Lionel Balet
- Faculty of Biology and Medicine, University of Lausanne, 1005 Lausanne, Switzerland
| | - François-Xavier Ageron
- Department of Emergency Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Mathieu Pasquier
- Department of Emergency Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Tobias Zingg
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | | |
Collapse
|
6
|
Chu Q, Jin X, Bing H, Zhang C, Bai J, Li F, Lou J, Sun L, Lin L, Li L, Wang H, Zhou Z, Lian H. RESUSCITATIVE RECTAL BALLOON COMPRESSION COMBINED WITH PELVIC BINDER EFFICIENTLY CONTROLLED FATAL VENOUS HEMORRHAGE IN A HEMODYNAMICALLY UNSTABLE PELVIC FRACTURE CANINE MODEL. Shock 2023; 59:912-921. [PMID: 37001912 PMCID: PMC10227942 DOI: 10.1097/shk.0000000000002116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/31/2023] [Indexed: 04/03/2023]
Abstract
ABSTRACT Objective: This study evaluated the feasibility of a combination of pelvic binder and rectal balloon compression in managing fatal venous hemorrhage in a canine model of pelvic fracture. Methods: Rectums from humans (rectal cancer patients), swine, and canines were retrieved to determine their elasticity by measuring their stress and strain. Canines were selected as the animal model in this study because their rectum demonstrated more reversible strain than swine rectum. Doppler ultrasound was used to assess the effect of rectal balloon volume on the blood flow of pelvic iliac blood vessels in three canines. A rectal balloon of 250 mL was chosen to control pelvic venous bleeding as it could provide a peak effect in reducing the blood flow of bilateral internal iliac veins. Then, the open-book pelvic fracture with fatal bleeding of both internal iliac veins animal model was built. The animals were divided into four groups after the modeled surgery to undergo no treatment, pelvic binder, rectal balloon compression, or a combination of pelvic binder and rectal balloon compression. The treatment efficacy was evaluated based on their survival time, survival rate, blood loss, bleeding rate, infusion rate, blood pH, lactate concentration, the stability of hemodynamics, blood loss, and fluid infusion volume. Results: Our results showed that after the reproducible injuries in both internal iliac veins, the combination of pelvic binder and rectal balloon compression was associated with the best survival rate and survival time compared with the other treatment groups. In addition, the combination of pelvic binder and rectal balloon compression exhibited more stable hemodynamics than the pelvic binder or rectal balloon compression treatment alone. Conclusions: This study demonstrated the potential feasibility of using pelvic binder combined with rectal balloon compression to manage the fatal venous bleeding in pelvic fractures.
Collapse
Affiliation(s)
- Qinjun Chu
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Xiaogao Jin
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
- Center for Advanced Medicine, College of Medicine, Zhengzhou University, Zhengzhou, China
- Trauma Research Center, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Hailong Bing
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Chenxi Zhang
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Jingyue Bai
- Department of Peripheral Vascular Intervention, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Fang Li
- Department of Orthopedics, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Junge Lou
- Department of Ultrasound Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, Henan
| | - Liwei Sun
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Lin Lin
- Center for Advanced Medicine, College of Medicine, Zhengzhou University, Zhengzhou, China
- Trauma Research Center, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Liumei Li
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Haibo Wang
- Department of Peripheral Vascular Intervention, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Zhanfeng Zhou
- Department of Orthopedics, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Hongkai Lian
- Department of Orthopedics, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
- Trauma Research Center, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| |
Collapse
|
7
|
Nguyen P, Pokrzywa C, Figueroa J, Jocoy KA, Brandolino A, Karam BS, Schramm AT, Deshpande D, Lawton J, Milia D, Lenz T. Predictive Factors for the Application of Pelvic Binders in the Prehospital Setting. PREHOSP EMERG CARE 2023; 28:425-430. [PMID: 37171847 DOI: 10.1080/10903127.2023.2213316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/08/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVES Early pelvic binder placement in the field stabilizes pelvic fractures and tamponades potential hemorrhage within the pelvis. Despite known risk factors for pelvic fracture, it remains challenging to quickly triage and correctly apply a pelvic binder. We aim to develop a prediction model that exclusively uses prehospital criteria to inform the decision to place a pelvic binder. METHODS The trauma registry was used to identify all trauma patients admitted to an urban Level I trauma center between January 2013 and December 2017. Variables collected included patient demographics, mechanism of injury, prehospital vital signs, and the presence of a pelvic fracture. Participants were randomly assigned to a training group (70%) or a validation group (30%). Univariate analyses were used to identify significant predictors for use in multivariate predictive models. RESULTS A total of 8,480 (65% male; median age 49; median ISS 9) and 3,676 (65% male; median age 48; median ISS 9) trauma patients were randomly assigned to the training and validation groups, respectively. Univariate analysis showed significant likelihood of pelvic fracture associated with female sex, hemodynamic instability (initial systolic blood pressure < 90 mmHg), blunt injury type, specific mechanisms of injury (motor vehicle collision, motorcycle collision, pedestrian struck by motor vehicle, crushing injury, and riding an animal), impact location, and position in vehicle. Multivariate models adjusting for blunt type injury, hemodynamic instability, impact location, and position in vehicle showed that presence of two or more of these risk factors is significantly associated with presence of pelvic fracture. CONCLUSION Establishing select prehospital criteria for the empiric application of pelvic binders for patients in the field with blunt injuries, hemodynamic instability, frontal or side motor vehicle collision impact, and non-front seat passenger may improve outcomes among patients with pelvic fractures.
Collapse
Affiliation(s)
- Peter Nguyen
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Courtney Pokrzywa
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Juan Figueroa
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kathleen A Jocoy
- Department of Psychology, Frostburg State University, Frostburg, Maryland
| | - Amber Brandolino
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Basil S Karam
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andrew T Schramm
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Deshpande
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Joseph Lawton
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Milia
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Timothy Lenz
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| |
Collapse
|