Multicenter Canadian study of prehospital trauma care

A Ten-Year Retrospective Cohort Study on Neck Collar Immobilization in Trauma Patients with Head and Neck Injuries

Background and Objectives: In the context of prehospital care, spinal immobilization is commonly employed to maintain cervical stability in head and neck injury patients. However, its use in cases of unclear consciousness or major trauma patients is often precautionary, pending the exclusion of unstable spinal injuries through appropriate diagnostic imaging. The impact of prehospital C-spinal immobilization in these specific patient populations remains uncertain. Materials and Methods: We conducted a retrospective cohort study at Taipei Tzu Chi Hospital from January 2009 to May 2019, focusing on trauma patients suspected of head and neck injuries. The primary outcome assessed was in-hospital mortality. We employed multivariable logistic regression to investigate the relationship between prehospital C-spine immobilization and outcomes, while adjusting for various factors such as age, gender, type of traumatic brain injury, Injury Severity Score (ISS), Revised Trauma Score (RTS), and activation of trauma team. Results: Our analysis encompassed 2733 patients. Among these, patients in the unclear consciousness group (GCS ≤ 8) who underwent C-spine immobilization exhibited a higher mortality rate than those without immobilization. However, there was no statistically significant difference in mortality among patients with alert consciousness (GCS > 8). Multivariable logistic regression analysis revealed that advanced age (age ≥ 65), unclear consciousness (GCS ≤ 8), major traumatic injuries (ISS ≥ 16 and RTS ≤ 7), and the use of neck collars for immobilization (adjusted OR: 1.850, 95% CI: 1.240-2.760, p = 0.003) were significantly associated with an increased risk of mortality. Subgroup analysis indicated that C-spine immobilization was significantly linked to an elevated risk of mortality in older adults (age ≥ 65), patients with unclear consciousness (GCS ≤ 8), those with major traumatic injuries (ISS ≥ 16 and RTS ≤ 7), and individuals in shock (shock index > 1). Conclusions: While our findings do not advocate for the complete abandonment of neck collars in all suspected head and neck injury patients, our study suggests that prehospital cervical and spinal immobilization should be applied more selectively in certain head and neck injury populations. This approach is particularly relevant for older individuals (age ≥ 65), those with unclear consciousness (GCS ≤ 8), individuals experiencing major traumatic injuries (ISS ≥ 16 or RTS ≤ 7), and patients in a state of shock (shock index ≥ 1). Our study employs a retrospective cohort design, which may introduce selection bias. Therefore, in the future, there is a need for confirmation of our results through a two-arm randomized controlled trial (RCT) arises, as this design is considered ideal for addressing this issue.

Prehospital clinical practice guidelines for unintentional injuries: a scoping review and prioritisation process

BACKGROUND

Globally, millions of people die and many more develop disabilities resulting from injuries each year. Most people who die from injuries do so before they are transported to hospital. Thus, reliable, pragmatic, and evidence-based prehospital guidance for various injuries is essential. We systematically mapped and described prehospital clinical practice guidelines (CPGs) for injuries in the global context, as well as prioritised injury topics for guidance development and adolopment.

METHODS

This study was sequentially conducted in three phases: a scoping review for CPGs (Phase I), identification and refinement of gaps in CPGs (Phase II), and ranking and prioritisation of gaps in CPGs (Phase III). For Phase I, we searched PubMed, SCOPUS, and Trip Database; guideline repositories and websites up to 23^rd May 2021. Two authors in duplicate independently screened titles and abstract, and full-text as well as extracted data of eligible CPGs. Guidelines had to meet 60% minimum methodological quality according to rigour of development domain in AGREE II. The second and third phases involved 17 participants from 9 African countries and 1 from Europe who participated in a virtual stakeholder engagement workshop held on 5 April 2022, and followed by an online ranking process.

RESULTS

Fifty-eight CPGs were included out of 3,427 guidance documents obtained and screened. 39/58 (67%) were developed de novo compared to 19 that were developed using alternative approaches. Twenty-five out of 58 guidelines (43%) were developed by bodies in countries within the WHO European Region, while only one guideline was targeted to the African context. Twenty-five (43%) CPGs targeted emergency medical service providers, while 13 (22%) targeted first aid providers (laypeople). Forty-three CPGs (74%) targeted people of all ages. The 58 guidance documents contained 32 injury topics. Injuries linked to road traffic accidents such as traumatic brain injuries and chest injuries were among the top prioritised topics for future guideline development by the workshop participants.

CONCLUSION

This study highlights the availability, gaps and priority injury topics for future guideline development/adolopment, especially for the African context. Further research is needed to evaluate the recommendations in the 58 included CPGs for possible adaptation to the African context.

International comparison of injury care structures, processes, and outcomes between integrated trauma systems in Québec, Canada, and Victoria, Australia

BACKGROUND

Quality improvement activities in trauma systems are widely based on comparisons between trauma centers within the same system. Comparisons across different trauma systems may reveal further opportunities for quality improvement.

OBJECTIVES

This study aimed to compare the integrated trauma systems in Québec, Canada and in Victoria, Australia, regarding their structures, care processes and patient outcomes.

METHODOLOGY

The elements recommended by the American College of Surgeons were used to compare trauma systems structures. Comparisons of care processes and patient outcomes were based on data from major trauma admissions extracted from trauma registries (2013 and 2017). Care processes included time to reach a definitive care facility, time spent in the emergency department, and time lapsed before the first head computed tomography (CT) scan. These care processes were compared using a z-test of log-transformed times. Hospital mortality and hospital length of stay (LOS) were compared using indirect standardization based on multiple logistic and linear regression.

RESULTS

Major differences in trauma system structure were Advanced Trauma Life Support at the scene of injury (Victoria), the use of validated prehospital triage tools (Québec), and mandatory accreditation of all trauma centers (Québec). Patients in Québec arrived at their definitive care hospital earlier than their counterparts in Victoria (median: 1.93 vs. 2.13 h, p = 0.002), but spent longer in the emergency department (median: 8.23 vs. 5.15 h, p<0.0001) and waited longer before having their first head CT (median: 1.90 vs. 1.52 h, p<0.0001). In-hospital mortality and hospital LOS were higher in Québec than in Victoria (standardized mortality ratio: 1.15, 95% CI: 1.09 - 1.20; standardized LOS ratio: 1.10, 95% CI: 1.09 - 1.11).

CONCLUSION

We observed important differences in the structural components and care processes in Québec and Victoria's trauma systems, which might explain some of the observed differences in patient outcomes. This study shows the potential value of international comparisons in trauma care and identifies possible opportunities for quality improvement.

Talk and Die: A Descriptive Analysis of Penetrating Trauma Patients

INTRODUCTION

"Talk and die" traditionally described occult presentations of fatal intracranial injuries, but we broaden its definition to victims of penetrating trauma.

METHODS

We conducted a descriptive analysis of patients with penetrating torso trauma who presented with a Glasgow Coma Scale verbal score ≥3 and died within 48 h of arrival from 2008 to 2018.

RESULTS

Sixty patients were identified. Eighteen (30.0%) required resuscitative thoracotomy with 7 (11.7%) dying in the trauma bay. Fifty-three (86.9%) patients went to the operating room, and 35 (66.0%) required multicavitary exploration. The most common injuries were hollow viscous (58.5%), intra-abdominal vascular (49.0%), liver (28.3%), pulmonary (26.4%), intrathoracic vascular (18.9%), and cardiac (15.75) injuries. Twenty-three (43.4%) patients survived their initial operation, but died in the first 48 h postoperatively.

CONCLUSIONS

Patients who "talk and die" most frequently have intra-abdominal vascular injures and require multicavitary exploration.

Association between Mode of Transportation and Survival in Adult Trauma Patients with Penetrating Injuries: Matched Cohort Study between Police and Ground Ambulance Transport

INTRODUCTION

Police transport (PT) of penetrating trauma patients has the potential to improve survival rates. There are no well-established guidelines for PT of penetrating trauma patients.

STUDY OBJECTIVE

This study examines the association between survival rate to hospital discharge of adult penetrating trauma patients and mode of transport (PT versus ground ambulance [GA]).

METHODS

A retrospective, matched cohort study was conducted using the United States (US) National Trauma Data Bank (NTDB). All adult penetrating injury patients transported by police to trauma centers were identified and matched (one-to-four) to patients transported by GA for analysis. Descriptive analysis was carried out. The patients' demographic and clinical characteristics were tabulated and stratified by the transport mode.

RESULTS

Out of the 733 patients with penetrating injuries, ground Emergency Medical Services (EMS) transported 513 patients and police transported 220 patients. Most patients were 16-64 years of age with a male (95.6%) and Black/African American race (79.0%) predominance. Firearm-related injuries (68.8%) were the most common mechanism of injury with the majority of injuries involving the body extremities (62.9%). Open wounds were the most common nature of injury (75.7%). The overall survival rate to hospital discharge was similar for patients transported by GA and by police (94.5% versus 92.7%; P = .343).

CONCLUSION

In this study, patients with penetrating trauma transported by police had similar outcomes to those transported by GA. As such, PT in penetrating trauma appears to be effective. Detailed protocols should be developed to further improve resource utilization and outcomes.

Disparity in prehospital scene time for geriatric trauma patients

BACKGROUND

Geriatric patients face disparities in prehospital trauma care. We hypothesized that geriatric trauma patients are more likely to experience prolonged prehospital scene time than younger adults.

METHODS

Retrospective analysis of the 2017 National Emergency Medical Services Information System. Patients who met anatomic or physiologic trauma criteria based on national triage guidelines were included (n = 16,356). Geriatric patients (age≥65, n = 3594) were compared to younger adults (age 18-64). The primary outcome was prolonged scene time (>10 min). Multivariable logistic regression was performed, controlling for patient demographics, on-scene treatments, and injury severity.

RESULTS

Geriatric patients were more likely to experience prolonged scene time than younger adults after controlling for other factors (OR 1.78, 95% CI 1.57-2.04, p < 0.001). The likelihood of prolonged scene time reached OR 2.29 (95% CI 1.85-2.84) for patients age 70-79 and OR 2.66 (95% CI 2.07-3.42) for patients age 80-89, relative to age 18-29.

CONCLUSIONS

Geriatric trauma patients are more likely than younger adults to have prolonged prehospital scene time. This disparity may be caused by delayed recognition of injury severity or age-related cognitive biases.

Advanced Life Support vs. Basic Life Support for Patients With Trauma in Prehospital Settings: A Systematic Review and Meta-Analysis

Background: Advanced Life Support (ALS) is regarded to be associated with improved survival in pre-hospital trauma care when compared to Basic Life Support (BLS) irrespective of lack of evidence. The aim of this study is to ascertain ALS improves survival for trauma in prehospital settings when compared to BLS.

Methods: We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for published controlled trials (CTs), and observational studies that were published until Aug 2017. The population of interest were adults (>18 years old) trauma patients who were transported by ground transportation and required resuscitation in prehospital settings. We compared outcomes between the ALS and BLS groups. The primary outcome was in-hospital mortality and secondary outcomes were neurological outcome and time spent on scene.

Results: We identified 2,502 studies from various databases and 10 studies were included in the analysis (two CTs, and eight observational studies). The outcomes were not statistically significant between the ALS and BLS groups (pooled OR 1.14; 95% CI 0.95 to 1.36 for mortality, pooled OR 1.12; 95% CI 0.88 to 1.42 for good neurological outcomes, pooled mean difference −0.96; 95% CI−6.64 to 4.72 for on-scene time) in CTs. In observational studies, ALS prolonged on-scene time and increased mortality (pooled OR 1.56; 95% CI: 1.31 to 1.86 for mortality, and pooled mean difference, 1.26; 95% CI: 0.07 to 2.45 for on-scene time).

Conclusions: In prehospital settings, the present study showed no advantages of ALS on the outcomes in patients with trauma compared to BLS.

Association Between Mode of Transportation and Outcomes in Penetrating Trauma Across Different Prehospital Time Intervals: A Matched Cohort Study

BACKGROUND

National guidelines do not provide recommendations concerning optimal dispatch time for helicopter emergency medical services (HEMS) in the United States.

OBJECTIVES

This study describes the association between mode of transport (ground vs. helicopter) and survival of patients with penetrating injury across different prehospital time intervals and proposes evidence-based time-related dispatch criteria for HEMS.

METHODS

A retrospective matched cohort study was conducted using the 2015 National Trauma Data Bank. Adult patients (age ≥ 16 years) with penetrating injuries were included. Patients transported via HEMS were selected and matched (1 to 1) for 17 variables to patients transported by ground ambulance (GEMS). Bivariate analyses were conducted to compare characteristics and outcomes (survival to hospital discharge) of patients across different prehospital time intervals.

RESULTS

Each group consisted of 949 patients. Overall survival rate was similar in both groups (90.6% for HEMS vs. 87.9% for GEMS, p = 0.054). Patients transported by HEMS had significantly higher survival compared with those transported by GEMS (92.5% for HEMS vs. 87.0% for GEMS, p = 0.002) in the 0-60-min time interval from dispatch to arrival to hospital, and more specifically, in the 31-60-min interval (92.2% vs. 85.2%, p = 0.001). No difference in survival between the two groups was observed in the shortest (0-30 min) or in the extended prehospital time intervals (>60 min).

CONCLUSION

In adult patients with penetrating trauma, HEMS transport was associated with improved survival in a specific total prehospital time interval (31 to 60 min). This finding can help emergency medicine service administrators develop evidence-based HEMS dispatch criteria.

Patient Contact Time and Prehospital Interventions in Hypotensive Trauma Patients: Should We Reconsider the "ABC" Algorithm When Time Is of the Essence?

INTRODUCTION

There is disagreement in the trauma community concerning the extent to which emergency medical services (EMS) should perform on-scene interventions. Additionally, in recent years the "ABC" algorithm has been questioned in hypotensive patients. The objective of this study was to quantify the delay introduced by different on-scene interventions.

METHODS

A retrospective analysis of hypotensive trauma patients brought to an urban level 1 trauma center by EMS from 2007 to 2018 was performed, and patients were stratified by mechanism of injury and new injury severity score (NISS). Independent samples median tests were used to compare median on-scene times.

RESULTS

Among 982 trauma patients, median on-scene time was 5 minutes (interquartile range 3-8). In penetrating trauma patients (n = 488) with NISS of 16-25, intubation significantly increased scene time from 4 to 6 minutes (P < .05). In penetrating trauma patients with NISS of 10-15, wound care significantly increased scene time from 3 to 6 minutes (P < .05). Tourniquet use, interosseous (IO) access, intravenous (IV) access, and needle decompression did not significantly increase scene time.

CONCLUSION

Understanding that intubation increases scene time in penetrating trauma, while IV and IO access do not, alterations to the traditional "ABC" algorithm may be warranted. Further investigation of prehospital interventions is needed to determine which are appropriate on-scene.

Diversity of Spectrum and Management of Animal-Inflicted Injuries in the Pediatric Age Group: A Prospective Study from a Pediatric Surgery Department Catering Primarily to the Rural Population

Introduction:

Animal-inflicted injuries continue to be a major health problem worldwide. In developing countries, the outcome of such injuries, especially in children may be poor.

Aim:

The study aimed to evaluate the diversity of spectrum and management of animal-inflicted injuries in the pediatric age group.

Materials and Methods:

This was a prospective study on animal-inflicted injuries in children between 1 to 15 years of age over a period of 12 months. Data on various parameters such as age and sex, animal species involved, provoked/unprovoked, mechanism of injury, time of injury, prehospital care, injury-arrival interval, pattern and type of injury, trauma score, body region injured, treatment given and complications were collected and analyzed.

Results:

Fifty-two children with animal-inflicted injuries were included, constituting <1% of all trauma cases seen during the study period (male:female = 2:1). The mean age of the cohort was 9.65 years. Domestic animals were responsible in 41 children (78.84%) and wild animals in 11 children (21.16%). Dog bite was the most common (57.69%). Penetrating injury was observed in 40 (76.9%) and blunt injury was observed in 12 (23.1%). The musculoskeletal system was the most common organ-system injured affecting 36 children (69.23%). Thirty-five children (67.3%) after minor treatment were discharged. Seventeen children (32.7%) required admission. Thirty-four children (65.38%) underwent surgical procedures. Wound debridement was the most common procedure performed. Wound infection was observed in 20 children (38.46%) and was significantly higher (P < 0.01) in delayed presenters. The length of hospital stay for the admitted children ranged from 3 to 28 days.

Conclusion:

Animal-inflicted injuries are rare in children and have a wide spectrum of presentation. Severe injuries require extensive resuscitation and expert surgical care. Mild injuries can be managed conservatively with the use of proper dressings, antibiotics, and analgesics.

Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis

BACKGROUND

As trauma is one of the leading causes of death worldwide, there is great potential for reducing mortality in trauma patients. However, there is continuing controversy over the benefit of deploying emergency medical systems (EMS) physicians in the prehospital setting. The objective of this systematic review and meta-analysis is to assess how out-of-hospital hospital management of severely injured patients by EMS teams with and without physicians affects mortality.

METHODS

PubMed and Google Scholar were searched for relevant articles, and the search was supplemented by a hand search. Injury severity in the group of patients treated by an EMS team including a physician had to be comparable to the group treated without a physician. Primary outcome parameter was mortality. Helicopter transport as a confounder was accounted for by subgroup analyses including only the studies with comparable modes of transport. Quality of all included studies was assessed according to the Cochrane handbook.

RESULTS

There were 2,249 publications found, 71 full-text articles assessed, and 22 studies included. Nine of these studies were matched or adjusted for injury severity. The odds ratio (OR) of mortality was significantly lower in the EMS physician-treated group of patients: 0.81; 95% confidence interval (CI): 0.71-0.92. When analysis was limited to the studies that were adjusted or matched for injury severity, the OR was 0.86 (95% CI, 0.73-1.01). Analyzing only studies published after 2005 yielded an OR for mortality of 0.75 (95% CI, 0.64-0.88) in the overall analysis and 0.81 (95% CI, 0.67-0.97) in the analysis of adjusted or matched studies. The OR was 0.80 (95% CI, 0.65-1.00) in the subgroup of studies with comparable modes of transport and 0.74 (95% CI, 0.53-1.03) in the more recent studies.

CONCLUSION

Prehospital management of severely injured patients by EMS teams including a physician seems to be associated with lower mortality. After excluding the confounder of helicopter transport we have shown a nonsignificant trend toward lower mortality.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Automatic acoustic gunshot sensor technology's impact on trauma care

INTRODUCTION

As cities nation-wide combat gun violence, with less than 20% of shots fired reported to police, use of acoustic gunshot sensor (AGS) technology is increasingly common. However, there are no studies to date investigating whether these technologies affect outcomes for victims of gunshot wounds (GSW). We hypothesized that the AGS technology would be associated with decreased prehospital transport time.

METHODS

All GSW patients from 2014 to 2016 were collected from our institutional registry and cross-referenced with local police department data regarding times and locations of AGS alerts. Each GSW incident was categorized as related or unrelated to an AGS alert. Admission data, trauma outcomes, and prehospital time were then compared.

RESULTS

We analyzed 731 patients. Of these, 192 were AGS-related (26%) and 539 were not (74%). AGS-related patients were more likely to be female (p < 0.01), have a higher injury severity score (ISS) (p < 0.01), and require an operation (p = 0.03). Ventilator days (p < 0.05) and hospital length of stay (p < 0.01) was greater in the AGS cohort. Mortality, however, did not differ between groups (p = 0.5). On multivariable analysis, both total prehospital time and on-scene time were lower in the AGS group (p < 0.01).

CONCLUSION

Our study suggests reduced transport times, decreased prehospital and emergency medical service on-scene times with AGS technology. Additionally, despite higher ISS and use of more hospital resources, mortality was similar to non-AGS counterparts. The potential of AGS technology to further decrease prehospital times in the urban setting may provide an opportunity to improve outcomes in trauma patients with penetrating injuries.

Association of Prehospital Mode of Transport With Mortality in Penetrating Trauma: A Trauma System-Level Assessment of Private Vehicle Transportation vs Ground Emergency Medical Services

Importance

Time to definitive care following injury is important to the outcomes of trauma patients. Prehospital trauma care is provided based on policies developed by individual trauma systems and is an important component of the care of injured patients. Given a paucity of systems-level trauma research, considerable variability exists in prehospital care policies across trauma systems, potentially affecting patient outcomes.

Objective

To evaluate whether private vehicle prehospital transport confers a survival advantage vs ground emergency medical services (EMS) transport following penetrating injuries in urban trauma systems.

Design, Setting, and Participants

Retrospective cohort study of data included in the National Trauma Data Bank from January 1, 2010, through December 31, 2012, comprising 298 level 1 and level 2 trauma centers that contribute data to the National Trauma Data Bank that are located within the 100 most populous metropolitan areas in the United States. Of 2 329 446 patients assessed for eligibility, 103 029 were included in this study. All patients were 16 years or older, had a gunshot wound or stab wound, and were transported by ground EMS or private vehicle.

Main Outcome and Measure

In-hospital mortality.

Results

Of the 2 329 446 records assessed for eligibility, 103 029 individuals at 298 urban level 1 and level 2 trauma centers were included in the analysis. The study population was predominantly male (87.6%), with a mean age of 32.3 years. Among those included, 47.9% were black, 26.3% were white, and 18.4% were Hispanic. Following risk adjustment, individuals with penetrating injuries transported by private vehicle were less likely to die than patients transported by ground EMS (odds ratio [OR], 0.38; 95% CI, 0.31-0.47). This association remained statistically significant on stratified analysis of the gunshot wound (OR,  0.45; 95% CI, 0.36-0.56) and stab wound (OR,  0.32; 95% CI, 0.20-0.52) subgroups.

Conclusions and Relevance

Private vehicle transport is associated with a significantly lower likelihood of death when compared with ground EMS transport for individuals with gunshot wounds and stab wounds in urban US trauma systems. System-level evidence such as this can be a valuable tool for those responsible for developing and implementing policies at the trauma system level.

Effect of requiring a general practitioner at scenes of serious injury: A systematic review

BACKGROUND

In Norway, each municipality is responsible for providing first line emergency healthcare, and it is mandatory to have a primary care physician/general practitioner on call continuously. This mandate ensures that a physician can assist patients and ambulance personnel at the site of severe injuries or illnesses. The compulsory presence of the general practitioner at the scene could affect different parts of patient treatment, and it might save resources by obviating resources from secondary healthcare, like pre-hospital anaesthesiologists and other specialized resources. This systematic review aimed to examine how survival, time spent at the scene, the choice of transport destination, assessment of urgency, the number of admissions, and the number of cancellations of specialized pre-hospital resources were affected by the presence of a general practitioner at the scene of a suspected severe injury.

METHODS

We searched for published and planned systematic reviews and primary studies in the Cochrane Library, Medline, Embase, OpenGrey, GreyLit and trial registries. The search was completed in December 2017. Two individuals independently screened the references and assessed the eligibility of all potentially relevant studies.

RESULTS

The search for systematic reviews and primary studies identified 5981 articles. However, no studies met the pre-defined inclusion criteria.

CONCLUSION

No studies met our inclusion criteria; consequently, it remains uncertain how the presence of a general practitioner at the injury scene might affect the selected outcomes.

Impact of Trauma System Structure on Injury Outcomes: A Systematic Review and Meta-Analysis

BACKGROUND

The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes.

METHODS

We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria.

RESULTS

We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization.

CONCLUSIONS

This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.

The Association of Prehospital Intravenous Fluids and Mortality in Patients with Penetrating Trauma

BACKGROUND

The optimal approach to prehospital care of trauma patients is controversial, and thought to require balancing advanced field interventions with rapid transport to definitive care.

OBJECTIVE

We sought principally to examine any association between the amount of prehospital IV fluid (IVF) administered and mortality.

METHODS

We conducted a retrospective cohort analysis of trauma registry data patients who sustained penetrating trauma between January 2008 and February 2011, as identified in the Pennsylvania Trauma Systems Foundation registry with corresponding prehospital records from the Philadelphia Fire Department. Analyses were conducted with logistic regression models and instrumental variable analysis, adjusted for injury severity using scene vital signs before the intervention was delivered.

RESULTS

There were 1966 patients identified. Overall mortality was 22.60%. Approximately two-thirds received fluids and one-third did not. Both cohorts had similar Trauma and Injury Severity Score-predicted mortality. Mortality was similar in those who received IVF (23.43%) and those who did not (21.30%) (p = 0.212). Patients who received IVF had longer mean scene times (10.82 min) than those who did not (9.18 min) (p < 0.0001), although call times were similar in those who received IVF (24.14 min) and those who did not (23.83 min) (p = 0.637). Adjusted analysis of 1722 patients demonstrated no benefit or harm associated with prehospital fluid (odds ratio [OR] 0.905, 95% confidence interval [CI] 0.47-1.75). Instrumental variable analysis utilizing variations in use of IVF across different Emergency Medical Services (EMS) units also found no association between the unit's percentage of patients that were provided fluids and mortality (OR 1.02, 95% CI 0.96-1.08).

CONCLUSIONS

We found no significant difference in mortality or EMS call time between patients who did or did not receive prehospital IVF after penetrating trauma.

Effects of advanced life support versus basic life support on the mortality rates of patients with trauma in prehospital settings: a study protocol for a systematic review and meta-analysis

INTRODUCTION

Advanced life support (ALS) is thought to be associated with improved survival in prehospital trauma care when compared with basic life support (BLS). However, evidence on the benefits of prehospital ALS for patients with trauma is controversial. Therefore, we aim to clarify if ALS improves mortality in patients with trauma when compared with BLS by conducting a systematic review and meta-analysis of the recent literature.

METHODS AND ANALYSIS

We will perform searches in PubMed, Embase and the Cochrane Central Register of Controlled Trials for published observational studies, controlled before-and-after studies, randomised controlled trials and other controlled trials conducted in humans and published until March 2017. We will screen search results, assess study selection, extract data and assess the risk of bias in duplicate; disagreements will be resolved through discussions. Data from clinically homogeneous studies will be pooled using a random-effects meta-analysis, heterogeneity of effects will be assessed using the χ² test of homogeneity, and any observed heterogeneity will be quantified using the I² statistic. Last, the Grading of Recommendations Assessment, Development and Evaluation approach will be used to rate the quality of the evidence.

ETHICS AND DISSEMINATION

Our study does not require ethical approval as it is based on findings of previously published articles. Results will be disseminated through publication in a peer-reviewed journal, presentations at relevant conferences and publications for patient information.

TRIAL REGISTRATION NUMBER

PROSPERO (International Prospective Register of Systematic Reviews) registration number CRD42017054389.

Otolaryngological Presentations in Times of Terror: Profile from a Tertiary Health Center in North-Central Nigeria

OBJECTIVES

To report the incidence, socio-demographic characteristics, otorhinolaryngological presentations and outcomes of management of patients at the Jos University Teaching Hospital following terror attacks.

METHODS

A prospective descriptive hospital based study of consecutive patients presenting with ear, nose and throat injuries as a result of bomb blasts and ethno-religious crises within a six-year period and managed at the Jos University Teaching Hospital were studied for age, gender, ear, nose and throat presentations, injury mechanism, interventions and outcome of interventions. A designed proforma was used for data collection.

RESULTS

There were 107 ear, nose and throat injuries from a total 468 terror-related injuries consisting of 66 (61.7%) males and 41 (38.3%) females (M:F ratio of 1.6:1), aged between 5 and 77 years (mean= 36.7 years; SD= +/- 16.2). Two peak age incidences of injuries in the first and third decades were recorded. The commonest source of injuries was bomb blasts in 47 (44%) patients. Multiple facial fractures with soft tissue injuries were the commonest seen in 78 (72.9%) patients. The commonest associated injuries were head injuries (n= 36). Ninety-four (87.9%) patients presented via the Accident and Emergency department, 16 (15%) received pre-hospital care. Patients with multiple injuries stayed longer in the hospital (p-value= 0.028). Complications were recorded in 19 (17.8%) patients. A case fatality rate of 5.6% was recorded.

CONCLUSION

Bomb blasts were the major form of terror attacks in our region. The presence of multiple injuries is a significant negative predictor of patient outcomes.

Methodological Challenges in Studies Comparing Prehospital Advanced Life Support with Basic Life Support

Determining the most appropriate level of care for patients in the prehospital setting during medical emergencies is essential. A large body of literature suggests that, compared with Basic Life Support (BLS) care, Advanced Life Support (ALS) care is not associated with increased patient survival or decreased mortality. The purpose of this special report is to synthesize the literature to identify common study design and analytic challenges in research studies that examine the effect of ALS, compared to BLS, on patient outcomes. The challenges discussed in this report include: (1) choice of outcome measure; (2) logistic regression modeling of common outcomes; (3) baseline differences between study groups (confounding); (4) inappropriate statistical adjustment; and (5) inclusion of patients who are no longer at risk for the outcome. These challenges may affect the results of studies, and thus, conclusions of studies regarding the effect of level of prehospital care on patient outcomes should require cautious interpretation. Specific alternatives for avoiding these challenges are presented. Li T , Jones CMC , Shah MN , Cushman JT , Jusko TA . Methodological challenges in studies comparing prehospital Advanced Life Support with Basic Life Support. Prehosp Disaster Med. 2017;32(4):444-450.

Does the presence of an emergency physician influence pre-hospital time, pre-hospital interventions and the mortality of severely injured patients? A matched-pair analysis based on the trauma registry of the German Trauma Society (TraumaRegister DGU®)

PURPOSE

The role of emergency physicians in the pre-hospital management of severely injured patients remains controversial. In Germany and Austria, an emergency physician is present at the scene of an emergency situation or is called to such a scene in order to provide pre-hospital care to severely injured patients in approximately 95% of all cases. By contrast, in the United States and the United Kingdom, paramedics, i.e. non-physician teams, usually provide care to an injured person both at the scene of an incident and en route to an appropriate hospital. We investigated whether physician or non-physician care offers more benefits and what type of on-site care improves outcome.

MATERIAL AND METHODS

In a matched-pair analysis using data from the trauma registry of the German Trauma Society, we retrospectively (2002-2011) analysed the pre-hospital management of severely injured patients (ISS ≥16) by physician and non-physician teams. Matching criteria were age, overall injury severity, the presence of relevant injuries to the head, chest, abdomen or extremities, the cause of trauma, the level of consciousness, and the presence of shock.

RESULTS

Each of the two groups, i.e. patients who were attended by an emergency physician and those who received non-physician care, consisted of 1235 subjects. There was no significant difference between the two groups in pre-hospital time (61.1 [SD 28.9] minutes for the physician group and 61.9 [SD 30.9] minutes for non-physician group). Significant differences were found in the number of pre-hospital procedures such as fluid administration, analgosedation and intubation. There was a highly significant difference (p<0.001) in the number of patients who received no intervention at all applying to 348 patients (28.2%) treated by non-physician teams and to only 31 patients (2.5%) in the physician-treated group. By contrast, there was no significant difference in mortality within the first 24h and in mortality during hospitalisation.

CONCLUSION

This retrospective analysis does not allow definitive conclusions to be drawn about the optimal model of pre-hospital care. It shows, however, that there was no significant difference in mortality although patients who were attended by non-physician teams received fewer pre-hospital interventions with similar scene times.

Global trends in trauma

Injuries cause about 10% of all deaths worldwide, with road traffic accidents, self-inflicted injuries, violence and war injuries being the most common causes of traumatic deaths. There is an anticipated increase in all of these categories by the year 2020. In addition to the increasing global incidence of trauma, other major trends in trauma and its management identified in this review include the growing emphasis on prevention and public health aspects of trauma, the globalization of trauma practices due to the rapid access to new information, a critical emphasis on organizational aspects of trauma care and education, the prominent role of efficacious and cost effective management practises, a shift to gentler treatment methods with less interference in the physiological recovery mechanisms, and at the same time, extreme care and the management of its consequences. In order to fight the global epidemic of trauma, it is the duty and the privilege of health care professionals to take the leadership in this task by ‘thinking globally and acting locally’ but most importantly by working together and sharing their expe riences (the successes and the failures) and by knowing that they can make a difference.

The evil of good is better: Making the case for basic life support transport for penetrating trauma victims in an urban environment

BACKGROUND

Controversy remains over the ideal way to transport penetrating trauma victims in an urban environment. Both advance life support (ALS) and basic life support (BLS) transports are used in most urban centers.

METHODS

A retrospective cohort study was conducted at an urban Level I trauma center. Victims of penetrating trauma transported by ALS, BLS, or police from January 1, 2008, to November 31, 2013, were identified. Patient survival by mode of transport and by level of care received was analyzed using logistic regression.

RESULTS

During the study period, 1,490 penetrating trauma patients were transported by ALS (44.8%), BLS (15.6%), or police (39.6%) personnel. The majority of injuries were gunshot wounds (72.9% for ALS, 66.8% for BLS, 90% for police). Median transport minutes were significantly longer for ALS (16 minutes) than for BLS (14.5 minutes) transports (p = 0.012). After adjusting for transport time and Injury Severity Score (ISS), among victims with an ISS of 0 to 30, there was a 2.4-fold increased odds of death (95% confidence interval [CI], 1.3-4.4) if transported by ALS as compared with BLS. With an ISS of greater than 30, this relationship did not exist (odds ratio, 0.9; 95% CI, 0.3-2.7). When examined by type of care provided, patients with an ISS of 0 to 30 given ALS support were 3.7 times more likely to die than those who received BLS support (95% CI, 2.0-6.8). Among those with an ISS of greater than 30, no relationship was evident (odds ratio, 0.9; 95% CI, 0.3-2.7).

CONCLUSION

Among penetrating trauma victims with an ISS of 30 or lower, an increased odds of death was identified for those treated and/or transported by ALS personnel. For those with an ISS of greater than 30, no survival advantage was identified with ALS transport or care. Results suggest that rapid transport may be more important than increased interventions.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies

BACKGROUND

Most Medicare patients seeking emergency medical transport are treated by ambulance providers trained in advanced life support (ALS). Evidence supporting the superiority of ALS over basic life support (BLS) is limited, but some studies suggest ALS may harm patients.

OBJECTIVE

To compare outcomes after ALS and BLS in out-of-hospital medical emergencies.

DESIGN

Observational study with adjustment for propensity score weights and instrumental variable analyses based on county-level variations in ALS use.

SETTING

Traditional Medicare.

PATIENTS

20% random sample of Medicare beneficiaries from nonrural counties between 2006 and 2011 with major trauma, stroke, acute myocardial infarction (AMI), or respiratory failure.

MEASUREMENTS

Neurologic functioning and survival to 30 days, 90 days, 1 year, and 2 years.

RESULTS

Except in cases of AMI, patients showed superior unadjusted outcomes with BLS despite being older and having more comorbidities. In propensity score analyses, survival to 90 days among patients with trauma, stroke, and respiratory failure was higher with BLS than ALS (6.1 percentage points [95% CI, 5.4 to 6.8 percentage points] for trauma; 7.0 percentage points [CI, 6.2 to 7.7 percentage points] for stroke; and 3.7 percentage points [CI, 2.5 to 4.8 percentage points] for respiratory failure). Patients with AMI did not exhibit differences in survival at 30 days but had better survival at 90 days with ALS (1.0 percentage point [CI, 0.1 to 1.9 percentage points]). Neurologic functioning favored BLS for all diagnoses. Results from instrumental variable analyses were broadly consistent with propensity score analyses for trauma and stroke, showed no survival differences between BLS and ALS for respiratory failure, and showed better survival at all time points with BLS than ALS for patients with AMI.

LIMITATION

Only Medicare beneficiaries from nonrural counties were studied.

CONCLUSION

Advanced life support is associated with substantially higher mortality for several acute medical emergencies than BLS.

PRIMARY FUNDING SOURCE

National Science Foundation, Agency for Healthcare Research and Quality, and National Institutes of Health.

Helicopter versus ground emergency medical services for the transportation of traumatically injured children

BACKGROUND

Helicopter emergency medical services (HEMS) are a common mode of transportation for pediatric trauma patients. We hypothesized that HEMS improve outcomes for traumatically injured children compared to ground emergency medical services (GEMS).

METHODS

We queried trauma registries of two level 1 pediatric trauma centers for children 0-17 years, treated from 2003 to 2013, transported by HEMS or GEMS, with known transport starting location and outcome. A geocoding service estimated travel distance and time. Multivariate regression analyses were performed to adjust for injury severity variables and travel distance/time.

RESULTS

We identified 14,405 traumatically injured children; 3870 (26.9%) transported by HEMS and 10,535 (73.1%) transported by GEMS. Transport type was not significantly associated with survival, ICU length of stay, or discharge disposition. Transport by GEMS was associated with a 68.6%-53.1% decrease in hospital length of stay, depending on adjustment for distance/time. Results were similar for children with severe injuries, and with propensity score matched cohorts. Of note, 862/3850 (22.3%) of HEMS transports had an ISS<10 and hospitalization<1 day.

CONCLUSIONS

HEMS do not independently improve outcomes for traumatically injured children, and 22.3% of children transported by HEMS are not significantly injured. These factors should be considered when requesting HEMS for transport of traumatically injured children.

Trauma patterns in patients attending the Emergency Department of Jazan General Hospital, Saudi Arabia

BACKGROUND

Modern civilization and the sharp rise in living standards have led to dramatic changes in trauma pattern in Saudi Arabia. This study aimed to describe the different patterns of injuries of patients attending the Emergency Department of Jazan General Hospital (JGH) in the southwest corner of Saudi Arabia.

METHODS

A total number of 1 050 patients were enrolled in the study. A pre-organized data sheet was prepared for each patient attended the Emergency Department of JGH from February 2012 to January 2013. It contains data about socio-demographics, trauma data, clinical evaluation results, investigations as well as treatment strategies.

RESULTS

The mean age of the patients was 25.3±16.8 years. Most (45.1%) of the patients were at age of 18-30 years. Males (64.3%) were affected by trauma more common than females. More than half (60.6%) of the patients were from urban areas. The commonest kind of injury was minor injury (60%), followed by blunt trauma (30.9%) and then penetrating trauma (9.1%). The mean time from the incident to arrival at hospital was 41.3±79.8 minutes. The majority (48.2%) of the patients were discharged after management of trivial trauma, whereas 2.3% were admitted to ICU, 7.7% transferred to inpatient wards, and 17.7% observed and subsequently discharged. The mortality rate of the patients was 2.6%.

CONCLUSION

Trauma is a major health problem, especially in the young population in Saudi Arabia. Blunt trauma is more frequent than penetrating trauma, with road traffic accidents accounting for the majority.

A pathway care model allowing low-risk patients to gain direct admission to a hospital medical ward--a pilot study on ambulance nurses and Emergency Department physicians

A pathway care model allowing low-risk patients to gain rapid admission to a hospital medical ward - a pilot study on ambulance nurses and Emergency Department physicians.

BACKGROUND

Patients with non-urgent medical symptoms who nonetheless require inpatient hospital treatment often have to wait for an unacceptably long time at the Emergency Department (ED). The purpose of this study is to evaluate the feasibility and effect on length of delay of a pathway care model for low-risk patients who have undergone prehospital assessment by an ambulance nurse and ED assessment by a physician within 10 minutes of arrival at the ED.

METHODS

The pilot study comparing two low-risk groups took place in western Sweden from October 2011 until January 2012. The pathway model for low-risk patients was used prospectively in the rapid admission group (N = 51), who were admitted rapidly after being assessed by the nurse on scene and then assessed by the ED physician on ED admission. A retrospectively assembled control group (N = 51) received traditional care at the ED. All p-values are age-adjusted.

RESULTS

Patients in the rapid admission group were older (mean age 80 years old) than patients in the control group (mean age 73 years old) (p = 0.02). The median delay from arrival at the patient's side until arrival in a hospital medical ward was 57 minutes for the rapid admission group versus 4 hours 13 minutes for the control group (p < 0.0001). However, the median delay time from the ambulance's arrival at the patient's side until the nurse was free for a new assignment was 77 minutes for the rapid admission group versus 49 minutes for the control group (p < 0.0001). The 30-day mortality rate was 20% for the rapid admission group and only 4% for the control group (p = 0.16).

CONCLUSION

The pathway care model for low-risk patients gaining rapid admission to a hospital medical ward shortened length of delay from the first assessment until arrival at the ward. However, the result was achieved at the cost of an increased workload for the ambulance nurse. Furthermore patients who were rapidly admitted to a hospital ward had a high age level and a high early mortality rate. Patient safety in this new model of fast-track assessment needs to be further evaluated.

Retrospective study of the incidence of unstable and shock patients presenting to the emergency room

BACKGROUND

Over a period of three decades, medical personnel working in our emergency room observed that fewer severe cases presented to the emergency department. The objective of this study is to assess whether a genuine change in the presentation rates of clinically unstable non-trauma patients to the emergency room indeed exists.

METHODS

We conducted a retrospective review of patients treated in the shock room. Patients' demographic data, diagnoses and outcomes were accessed. Populations of patients presenting to the shock room over a span of four seasons, in two separate periods eight years apart were compared. This rate was compared with the complementary bulk rate of patients presenting to the emergency room at the center.

RESULTS

While absolute rates of emergency room utilization rose, the rate of unstable patients demanding urgent intensive care showed a clear decline. An absolute reduction of close to 50% across the different seasons of the examined years was found. Per patient, the proportion of those requiring artificial respiration and urgent hemodialysis remained uniform in both periods. All parameters of patient outcomes were similar in both periods of the study.

CONCLUSION

This unexplored aspect of emergency care demonstrates a dramatic decline in the incidence of unstable patients. While we should continue to reinforce delivery of superior care, our medical educational system should adapt itself to compensate for the diminished exposure of our trainees to emergencies. Further research in this field should explore whether the trend we observed exists in other geographical locations and whether this parameter can be utilized as a quality measure of medical systems.

Evaluation and treatment of trauma related collapse in athletes

Although blunt traumatic injuries are common in athletes, life-threatening trauma is fortunately rare. Most current literature has focused on nontraumatic causes of athlete death though traumatic injuries may be more common. Although prevention of these injuries may be more difficult than nontraumatic causes, prompt recognition and treatment is paramount. Common traumatic causes of collapse athlete generally involve the head, neck, and trunk and are more frequent in collision sports. Other higher risk sports include track and field, cheerleading, snow sports, and those involving motorized vehicles. Health care providers who participate in sports coverage should be aware of the potential for these injuries as emergency treatment is required to maximize outcomes. Emergency action plans allow providers to expediently activate emergency management services while providing treatment and stabilization.

Increased mortality associated with EMS transport of gunshot wound victims when compared to private vehicle transport

BACKGROUND

Recent studies suggest that mode of transport affects survival in penetrating trauma patients. We hypothesised that there is wide variation in transport mode for patients with gunshot wounds (GSW) and there may be a mortality difference for GSW patients transported by emergency medical services (EMS) vs. private vehicle (PV).

STUDY DESIGN

We studied adult (≥16 years) GSW patients in the National Trauma Data Bank (2007-2010). Level 1 and 2 trauma centres (TC) receiving ≥50 GSW patients per year were included. Proportions of patients arriving by each transport mode for each TC were examined. In-hospital mortality was compared between the two groups, PV and EMS, using multivariable regression analyses. Models were adjusted for patient demographics, injury severity, and were adjusted for clustering by facility.

RESULTS

74,187 GSW patients were treated at 182 TCs. The majority (76%) were transported by EMS while 12.6% were transported by PV. By individual TC, the proportion of patients transported by each category varied widely: EMS (median 78%, interquartile range (IQR) 66-85%), PV (median 11%, IQR 7-17%), or others (median 7%, IQR 2-18%). Unadjusted mortality was significantly different between PV and EMS (2.1% vs. 9.7%, p<0.001). Multivariable analysis demonstrated that EMS transported patients had a greater than twofold odds of dying when compared to PV (OR=2.0, 95% CI 1.73-2.35).

CONCLUSIONS

Wide variation exists in transport mode for GSW patients across the United States. Mortality may be higher for GSW patients transported by EMS when compared to private vehicle transport. Further studies should be performed to examine this question.

Advanced training in trauma life support for ambulance crews

BACKGROUND

There is an increasing global burden of injury especially in low- and middle-income countries (LMICs). To address this, models of trauma care initially developed in high income countries are being adopted in LMIC settings. In particular, ambulance crews with advanced life support (ALS) training are being promoted in LMICs as a strategy for improving outcomes for victims of trauma. However, there is controversy as to the effectiveness of this health service intervention and the evidence has yet to be rigorously appraised.

OBJECTIVES

To quantify the impact of ALS-trained ambulance crews versus crews without ALS training on reducing mortality and morbidity in trauma patients.

SEARCH METHODS

The search for studies was run on the 16th May 2014. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (Ovid), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), CINAHL Plus (EBSCO), PubMed and screened reference lists.

SELECTION CRITERIA

Randomised controlled trials, controlled trials and non-randomised studies, including before-and-after studies and interrupted time series studies, comparing the impact of ALS-trained ambulance crews versus crews without ALS training on the reduction of mortality and morbidity in trauma patients.

DATA COLLECTION AND ANALYSIS

Two review authors assessed study reports against the inclusion criteria, and extracted data.

MAIN RESULTS

We found one controlled before-and-after trial, one uncontrolled before-and-after study, and one randomised controlled trial that met the inclusion criteria. None demonstrated evidence to support ALS training for pre-hospital personnel. In the uncontrolled before-and-after study, 'a priori' sub-group analysis showed an increase in mortality among patients who had a Glasgow Coma Scale score of less than nine and received care from ALS trained ambulance crews. Additionally, when the pre-hospital trauma score was taken into account in logistic regression analysis, mortality in the patients receiving care from ALS trained crews increased significantly.

AUTHORS' CONCLUSIONS

At this time, the evidence indicates that there is no benefit of advanced life support training for ambulance crews on patient outcomes.

Trends in trauma: a rural experience

In last 20 years a progressive increase in the cases of road traffic accidents is seen in the institution. In this study efforts have been made to study epidemiology of trauma & how to help the trauma victims in a better way. To study the changing trends in incidence & presentation of trauma victims. To recommend preventive measures based on the analysis. The present study was carried out in MGIMS, Sewagram, Wardha from 2001 to 2003. For this study which is retrospective and prospective, a total of 986 cases of surgical trauma were studied. Present study showed that in this rural area accidents account for maximum trauma admissions & major trauma only in 20 %. Out of 986 patients, 78.8 % required repair of wounds, 3.8 % required exploratory laparotomy and 16.3 % had orthopedic interventions. Overall mortality rate was 2.9 %. It was found that general care in wards was good in terms of trauma results of rural areas. These results may vary when compared with specialized trauma centers in cities; however after a period of few years cost effectiveness of trauma centers in terms of benefits needs an assessment*.

Surgical management in treatment of Jehovah's witness in trauma surgery in Indian subcontinent

The Jehovah's Witness religion is a Christian movement, founded in the US in the 1870s, with 7 million followers worldwide with only 0.002% in India. There is minimal to complete absence of awareness about the existence of this community in our society. Astonishing is that fact that among medical professionals, there is almost no awareness about this unique population, regarding the fact that they completely refuse of blood transfusion even if it leads to their death. This is integral to their faith. Besides legal and ethical issues in treating these group of patients, the biggest challenge exist even in the western world is their management in trauma scenario where few options exist. We have discussed the issues and recommendations in management in trauma scenario in our Indian subcontinent.

Prehospital versus Emergency Room Intubation of Trauma Patients in Qatar: A-2-year Observational Study

Background:

The impact of prehospital intubation (PHI) in improving outcome of trauma patients has not been adequately evaluated in the developing countries.

Aims:

The present study analyzed the outcome of PHI versus emergency room intubation (ERI) among trauma patients in Qatar.

Materials and Methods:

Data were retrospectively reviewed for all intubated trauma patients between 2010 and 2011. Patients were classified according to location of intubation (PHI: Group-1 versus ERI: Group-2). Data were analyzed and compared.

Results:

Out of 570 intubated patients; 482 patients (239 in group-1 and 243 in group-2) met the inclusion criteria with a mean age of 32 ΁ 14.6 years Head injury (P = 0.003) and multiple trauma (P = 0.004) were more prevalent in group-1, whereas solid organ injury predominated in group-2 (P = 0.02). Group-1 had significantly higher mean injury severity scoring (ISS), lower Glasgow coma scale (GCS), greater head abbreviated injury score and longer activation, response, scene and total emergency medical services times. The mortality was higher in group-1 (53% vs. 18.5%; P = 0.001). Multivariate analysis showed that GCS [odds ratio (OR) 0.78, P = 0.005) and ISS (OR 1.12, P = 0.001) were independent predictors of mortality.

Conclusions:

PHI is associated with high mortality when compared with ERI. However, selection bias cannot be ruled out and therefore, PHI needs further critical assessment in Qatar.

Propensity for performing interventions in pre-hospital trauma management - a comparison between physicians and non-physicians

Background

In 2005, the Advanced Life Support (ALS) teams delivering pre-hospital care in RegionSkane in southern Sweden received additional support by physicians, who were part of “Pre-hospital acute teams” (PHAT). The study objective is to compare the incidence of pre-hospital medical interventions for trauma-patients cared for by conventional ALS teams and patients who received additional support by PHAT.

Methods

Trauma patients with Injury Severity Score (ISS) >9 were identified retrospectively in the national quality registry KVITTRA at three hospitals in RegionSkane, for the time period October 2005 to December 2008. Interventions include e.g. tracheal intubation, administration of i.v. fluids, neck immobilization and spine board usage. Confounding effects from trauma severity, trauma mechanism, vital parameters, age and sex were addressed in multivariate models.

Results

Data from 202 cases was included. 9 pre-hospital interventions were assessed. The incidence of endotracheal intubation and immobilisation of extremities was higher among patients in the PHAT-group compared to the ALS-only group (16.3% vs. 6.9%, p = 0.034) and (12.8% vs. 4.3%, p = 0.027) respectively. PHATs presence remained a significant predictor of these interventions also after taking confounding factors into account (OR 5.5, CL 1.5-19.7) and (OR 3.2 CI 1.0-9.8).

PHAT was involved in a greater proportion of cases with <50.0% of survival (19.8% vs. 12.1%, p = 0.134). The average ISS was higher among cases receiving PHAT support in strata ISS 16-24 and ISS > 24 than cases in corresponding strata cared for by ALS teams alone (ISS 20.0 vs. 17.0, p = 0.048 and ISS 34.0 vs. 29.0, p = 0.019).

Conclusions

The incidence of endotracheal intubation and immobilization of extremities was greater among patients supported by PHAT, compared to patients cared for by ALS teams alone. This finding has to be interpreted in the light of a selection-bias where PHAT support was directed to more severely injured patients.

Severity-adjusted mortality in trauma patients transported by police

STUDY OBJECTIVE

Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the association between mode of out-of-hospital transport (police department versus emergency medical services [EMS]) and mortality among patients with penetrating trauma in Philadelphia.

METHODS

This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal penetrating trauma and presented to any Level I or II trauma center in Philadelphia between January 1, 2003, and December 31, 2007, were included. Analyses were conducted with logistic regression models and were adjusted for injury severity with the Trauma and Injury Severity Score and for case mix with a modified Charlson index.

RESULTS

Four thousand one hundred twenty-two subjects were identified. Overall mortality was 27.4%. In unadjusted analyses, patients transported by police were more likely to die than patients transported by ambulance (29.8% versus 26.5%; OR 1.18; 95% confidence interval [CI] 1.00 to 1.39). In adjusted models, no significant difference was observed in overall mortality between the police department and EMS groups (odds ratio [OR] 0.78; 95% CI 0.61 to 1.01). In subgroup analysis, patients with severe injury (Injury Severity Score >15) (OR 0.73; 95% CI 0.59 to 0.90), patients with gunshot wounds (OR 0.70; 95% CI 0.53 to 0.94), and patients with stab wounds (OR 0.19; 95% CI 0.08 to 0.45) were more likely to survive if transported by police.

CONCLUSION

We found no significant overall difference in adjusted mortality between patients transported by the police department compared with EMS but found increased adjusted survival among 3 key subgroups of patients transported by police. This practice may augment traditional care.

Demographic and geographical characteristics of pediatric trauma in Scotland

BACKGROUND

Trauma systems reduce mortality and improve functional outcomes. The aim of this study was to analyse the demographic and geospatial characteristics of pediatric trauma patients in Scotland, and determine the level of destination healthcare facility which injured children are taken to, to determine the need for, and general feasibility, of developing a pediatric trauma system for Scotland.

METHODS

Retrospective analysis of incidents involving children aged 1-14 attended to by the Scottish Ambulance Service between 1 November 2008 and 31 October 2010. A subgroup with physiological derangement was defined. Incident location postcode was used to determine incident location by health board region, rurality and social deprivation. Destination healthcare facility was classified into one of six categories.

RESULTS

Of 10,759 incidents, 72.3% occurred in urban areas and 5.8% in remote areas. Incident location was associated with socioeconomic deprivation. Of the patients, 11.6% were taken to a pediatric hospital with pediatric intensive care facilities, 21.8% to a pediatric hospital without pediatric intensive care service, and 50.2% to an adult large general hospital without pediatric surgical service.

CONCLUSIONS

The majority of incidents involving children with injuries occurred in urban areas. Half were taken to a hospital without pediatric surgical service. There was no difference between children with normal and deranged physiology.

Prehospital interventions for penetrating trauma victims: a prospective comparison between Advanced Life Support and Basic Life Support

BACKGROUND

Advanced Life Support (ALS) providers may perform more invasive prehospital procedures, while Basic Life Support (BLS) providers offer stabilisation care and often "scoop and run". We hypothesised that prehospital interventions by urban ALS providers prolong prehospital time and decrease survival in penetrating trauma victims.

STUDY DESIGN

We prospectively analysed 236 consecutive ambulance-transported, penetrating trauma patients an our urban Level-1 trauma centre (6/2008-12/2009). Inclusion criteria included ICU admission, length of stay >/=2 days, or in-hospital death. Demographics, clinical characteristics, and outcomes were compared between ALS and BLS patients. Single and multiple variable logistic regression analysis determined predictors of hospital survival.

RESULTS

Of 236 patients, 71% were transported by ALS and 29% by BLS. When ALS and BLS patients were compared, no differences in age, penetrating mechanism, scene GCS score, Injury Severity Score, or need for emergency surgery were detected (p>0.05). Patients transported by ALS units more often underwent prehospital interventions (97% vs. 17%; p<0.01), including endotracheal intubation, needle thoracostomy, cervical collar, IV placement, and crystalloid resuscitation. While ALS ambulance on-scene time was significantly longer than that of BLS (p<0.01), total prehospital time was not (p=0.98) despite these prehospital interventions (1.8 ± 1.0 per ALS patient vs. 0.2 ± 0.5 per BLS patient; p<0.01). Overall, 69.5% ALS patients and 88.4% of BLS patients (p<0.01) survived to hospital discharge.

CONCLUSION

Prehospital resuscitative interventions by ALS units performed on penetrating trauma patients may lengthen on-scene time but do not significantly increase total prehospital time. Regardless, these interventions did not appear to benefit our rapidly transported, urban penetrating trauma patients.

Ear, nose and throat injuries at Bugando Medical Centre in northwestern Tanzania: a five-year prospective review of 456 cases

Background

Injuries to the ear, nose and throat (ENT) regions are not uncommon in clinical practice and constitute a significant cause of morbidity and mortality in our setting. There is dearth of literature on this subject in our environment. This study was conducted to describe the causes, injury pattern and outcome of these injuries in our setting and proffer possible preventive measures.

Methods

This was a descriptive prospective study of patients with ear, nose and throat injuries managed at Bugando Medical Centre between May 2007 and April 2012. Ethical approval to conduct the study was sought from relevant authorities. Statistical data analysis was performed using SPSS computer software version 17.0.

Results

A total of 456 patients were studied. The median age of patients at presentation was 18 years (range 1 to 72 years). The male to female ratio was 2:1. The commonest cause of injury was foreign bodies (61.8%) followed by road traffic accidents (22.4%). The ear was the most common body region injured accounting for 59.0% of cases. The majority of patients (324, 71.1%) were treated as an outpatient and only 132(28.9%) patients required admission to the ENT wards after definitive treatment. Foreign body removal and surgical wound debridement were the most common treatment modalities performed in 61.9% and 16.2% of cases respectively. Complication rate was 14.9%. Suppurative otitis media (30.9%) was the commonest complication in the ear while traumatic epistaxis (26.5%) and hoarseness of voice (11.8%) in the aero-digestive tract were commonest in the nose and throat. The overall median length of hospital stay for in-patients was 8 days (range 1 to 22 days). Patients who developed complications and those who had associated injuries stayed longer in the hospital (P < 0.001).

Mortality rate related to isolated ENT injuries was 1.3% (6 deaths). The majority of patients (96.9%) were treated successfully and only 3.1% of cases were discharged with permanent disabilities.

Conclusion

Injuries to the ENT regions are not uncommon in our environment and foreign bodies constitute a significant cause of injury. Majority of these injuries can be prevented through public enlightenment campaigns.

Animal-related injuries in a resource-limited setting: experiences from a Tertiary health institution in northwestern Tanzania

Background

Animal related injuries are a major but neglected emerging public health problem and contribute significantly to high morbidity and mortality worldwide. No prospective studies have been done on animal related injuries in our setting. This study was conducted to determine the management patterns and outcome of animal related injuries and their social impact on public health policy in the region.

Methods

This was a descriptive prospective study of animal related injury patients that presented to Bugando Medical Centre between September 2007 and August 2011. Statistical data analysis was done using SPSS computer software version 17.0.

Results

A total of 452 (8.3%) animal-related injury patients were studied. The modal age group was 21-30 years. The male to female ratio was 2.1:1. Dog-bites (61.1%) were the most common injuries. Musculoskeletal (71.7%) region was the most frequent body region injured. Soft tissue injuries (92.5%) and fractures (49.1%) were the most common type of injuries sustained. Only 140 (31.0%) patients were hospitalized and most of them (97.1%) were treated surgically. Wound debridement was the most common procedure performed in 91.2% of patients. Postoperative complication rate was 15.9%, the commonest being surgical site infections (SSI) in 55.1% of patients. SSI was significantly associated with late presentation and open fractures (P < 0.001). The overall median duration of hospitalization was 16 days. Patients who had severe injuries, long bone fractures and those with hemiplegia stayed longer in the hospital (P < 0.001). Mortality rate was 10.2% and was significantly high in patients with severe injuries, severe head injury, tetanus and admission SBP < 90 mmHg (P < 0.001). The follow up of patients was poor.

Conclusion

Animal related injuries constitute a major public health problem in our setting and commonly affect the young adult male in their economically productive age-group. Measures towards prevention and proper treatment and follow up are important in order to reduce morbidity and mortality resulting from this form of trauma

Prehospital care in patients with severe traumatic brain injury: does the level of prehospital care influence mortality?

INTRODUCTION AND PURPOSE

The controversy between the "scoop and run" versus the "stay and play" approach in severely injured trauma patients has been an ongoing issue for decades. The present study was undertaken to investigate whether changes in prehospital care for patients with severe traumatic brain injury in the Netherlands have improved outcome.

METHODS

In this retrospective study, files (n = 60) were analyzed from a prospectively collected database including all patients admitted to one of six hospitals in the Limburg region in the Netherlands with a Glasgow Coma Scale (GCS) score ≤8 on admittance over the period from January 2006 to December 2008. All patients had traumatic brain damage proven on computed tomography (CT) or magnetic resonance imaging (MRI). Relevant prehospital and clinical data from the present cohort were compared to data from a similar study (n = 30) conducted 20 years ago. The primary outcome assessed was mortality.

RESULTS

The two study groups had similar characteristics with regard to the GCS score. In the historic cohort, Basic Life Support (BLS) and the "scoop and run" approach in patients with major traumatic brain injury was common, with an average time on scene of 7.5 min. Currently, prehospital care is performed mainly on the level of prehospital Advanced Life Support (ALS), with the average time on scene being about four times as long as in the historic cohort. However, the overall mortality rate for the current cohort compared to the historic cohort has not changed.

CONCLUSION

Despite more on-site ALS in severely head injured patients nowadays compared to the historic cohort, there was no reduction in mortality.

Does Advanced Life Support Provide Benefits to Patients?: A Literature Review

Introduction:

Emergency medical services have invested substantial resources to establish advanced life support (ALS) programs. However, it is unclear whether ALS care provides better outcomes to patients compared to basic life support (BLS) care.

Objective:

To evaluate the current evidence regarding the benefits of ALS.

Methods:

Electronic medical databases were searched to identify articles that directly compared ALS versus BLS care. A total of 455 articles were found. Articles were excluded for the following reasons: (1) the article was not written in English; (2) BLS response was not compared to an ALS response; (3) a physician or nurse was included as part of the ALS response; (4) it was an aeromedical response; or (5) defibrillation was included in the ALS, but not the BLS, scope of care. Twenty-one articles met the inclusion criteria for this literature review.

Results:

Results were divided into four categories: (1) trauma; (2) cardiac arrest; (3) myocardial infarction; and (4) altered mental status.

Trauma:

The majority of articles showed that ALS provided no benefits over BLS in urban trauma patients. In fact, most studies showed higher mortality rates for trauma patients receiving ALS care. Further research is needed to evaluate the benefits of ALS for rural trauma patients, and whether ALS care improves outcomes in subgroups of urban trauma patients.

Cardiac Arrest:

Cardiac arrest studies show that early CPR plus early defibrillation provide the greatest improvement in survival. However, most cardiac arrest research includes defibrillation as an ALS skill which has now moved into the BLS scope of care. The 2004 multi-center OPALS study provided good evidence that ALS does not improve cardiac arrest survival over early defibrillation. Further research is needed to address whether any ALS interventions improve cardiac arrest outcome.

Myocardial Infarction:

Only one study directly compared the outcome of BLS and ALS care on myocardial infarction. The study found no difference in outcomes between BLS and ALS care in an urban setting.

Advanced Life Support:

Only one study directly compared the outcome of BLS and ALS care on patients with altered mental status. The study found that the same number of patients had improved to “alert” on arrival at the emergency department, but there was a decreased length of emergency department stay for patients treated by ALS for hypoglycemia.

Limitations:

This review article does not take into account the benefits of ALS interventions, such as thrombolytics, dextrose, or nitroglycerin, since no studies directly compared these interventions to BLS care. Furthermore, only one study in this literature review was a large, multi-center trial.

Conclusions:

ALS shows little, if any, benefits for urban trauma patients. Cardiac arrest studies show that ALS does not provide additional benefits over BLS-defibrillation care, but more research is needed in this area. In two small studies, ALS care did not provide benefits over BLS care for patients with myocardial infarctions or altered mental status. Larger-scale studies are needed to evaluate which specific ALS interventions improve patient outcomes.

Role of Air-Medical Evacuation in Mass-Casualty Incidents—A Train Collision Experience

Background:

On 21 June 2005, a passenger train collided with a truck near Revadim, Israel.The collision resulted in a multiple-scene mass-casualty incident in an area characterized by difficult access and a relatively long distance from trauma centers. A major disaster response was initiated by civilian and military medical forces including the Israeli Air Force (IAF) Search and Rescue teams. The air-medical evacuation from the accident site to the trauma centers, the activities of the airborne medical teams, and the lessons learned from this event are described in this report.

Methods:

A retrospective analysis of data gathered from relevant elements that participated in management, treatment, and evacuation from the accident site was conducted.

Results:

The accident resulted in 289 injured passengers and seven of the injured were killed. Six helicopters (performing nine sorties) participated. Helicopters evacuated trauma victims and aided in transporting air-medical teams to the site of the collision.Overall, 35 trauma victims (10 urgent) were evacuated by air to trauma centers. The length of time between the first helicopter landing and completion of the air evacuation was 83 minutes. The airmedical evacuation operation was controlled by the commander of the IAF Search and Rescue. Different crew compositions were set in real time.

Conclusions:

Air-medical evacuation during this unique event enabled prompt transportation of casualties from the scene to trauma centers and provided reasonable distribution of patients between various centers in the region.This operation highlighted the necessity for flexibility in medical decision-making and the need for non-conventional solutions regarding crew compositions during management of an airborne evacuation in similar settings. Air-medical evacuation should be considered as a part of responses to mass-casualty incidents, especially when the site is remote or characterized by accessibility difficulties.

A comparison of outcomes of out-of-hospital cardiac arrest with non-cardiac etiology between emergency departments with low- and high-resuscitation case volume

OBJECTIVES

It is unclear whether outcome after out-of-hospital cardiac arrest (OHCA) of non-cardiac etiology (NCE) is associated with the volume of patients with OHCA received annually at the emergency department (ED) where they receive treatment. This study evaluated whether the volume of patients treated is associated with better outcomes for non-cardiac OHCA patients.

METHODS

This study was performed in an emergency medical service (EMS) system with a single-tiered basic-to-intermediate service level and approximately 410 destination hospitals for eligible OHCA cases. A nationwide OHCA database (2006-2008), constructed from EMS run sheets, and a hospital medical record review were used. OHCA was defined as pulseless and unresponsive in the field. Included in the study were cases treated with OHCA whose etiology was non-cardiac. Excluded were cases with unknown hospital outcome. The cutoff number for a high volume (HV) versus a low volume (LV) of cardiopulmonary resuscitation (CPR) cases was calculated using a threshold model. The primary end points were survival to admission and survival to discharge. The adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) for the endpoints were calculated, adjusting for potential predictors.

RESULTS

There were 10,425 eligible patients (trauma 5735; drowning 98; poisoning 684; asphyxia 1413; and hanging 1605). The survival-to-admission and the survival-to-discharge rates of the study participants were 9.6% and 2.4%, respectively. The cutoff number for case volume was 38 per year. The rates of survival to admission and survival to discharge were significantly higher in the HV (18.6% and 5.1%, respectively) group when compared to the LV group (5.9% and 1.3%, respectively). For the treated, non-cardiac OHCA patients, the adjusted ORs in the HV group compared to the LV group were 2.16 for survival to admission (95% CI: 1.84-2.55) and 2.58 for survival to discharge (95% CI: 1.90-3.52). The survival-to-discharge rate was significantly higher in the HV group than in the LV group for each cause: trauma 2.1% vs. 0.6%, drowning 6.8% vs. 1.9%, poisoning 8.6% vs. 1.7%, asphyxia 13.5% vs. 3.8%, and hanging 5.2% vs. 1.3%, respectively.

CONCLUSION

This national cohort study suggests that greater survival to admission as well as discharge for patients with OHCA of NCE is associated with greater annual volume of patients with OHCA treated at that hospital.

Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis

OBJECTIVE

Prehospital intravenous (IV) fluid administration is common in trauma patients, although little evidence supports this practice. We hypothesized that trauma patients who received prehospital IV fluids have higher mortality than trauma patients who did not receive IV fluids in the prehospital setting.

METHODS

We performed a retrospective cohort study of patients from the National Trauma Data Bank. Multiple logistic regression was used with mortality as the primary outcome measure. We compared patients with versus without prehospital IV fluid administration, using patient demographics, mechanism, physiologic and anatomic injury severity, and other prehospital procedures as covariates. Subset analysis was performed based on mechanism (blunt/penetrating), hypotension, immediate surgery, severe head injury, and injury severity score.

RESULTS

A total of 776,734 patients were studied. Approximately half (49.3%) received prehospital IV. Overall mortality was 4.6%. Unadjusted mortality was significantly higher in patients receiving prehospital IV fluids (4.8% vs. 4.5%, P < 0.001). Multivariable analysis demonstrated that patients receiving IV fluids were significantly more likely to die (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.05–1.17). The association was identified in nearly all subsets of trauma patients. It is especially marked in patients with penetrating mechanism (OR 1.25, 95% CI 1.08–1.45), hypotension (OR 1.44, 95% CI1.29–1.59), severe head injury (OR 1.34, 95% CI 1.17–1.54), and patients undergoing immediate surgery (OR 1.35, 95% CI 1.22–1.50).

CONCLUSIONS

The harm associated with prehospital IV fluid administration is significant for victims of trauma. The routine use of prehospital IV fluid administration for all trauma patients should be discouraged.