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Gaither JB, Spaite DW, Bobrow BJ, Barnhart B, Chikani V, Denninghoff KR, Bradley GH, Rice AD, Howard JT, Keim SM, Hu C. EMS Treatment Guidelines in Major Traumatic Brain Injury With Positive Pressure Ventilation. JAMA Surg 2024; 159:363-372. [PMID: 38265782 PMCID: PMC10809136 DOI: 10.1001/jamasurg.2023.7155] [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: 04/07/2023] [Accepted: 09/13/2023] [Indexed: 01/25/2024]
Abstract
Importance The Excellence in Prehospital Injury Care (EPIC) study demonstrated improved survival in patients with severe traumatic brain injury (TBI) following implementation of the prehospital treatment guidelines. The impact of implementing these guidelines in the subgroup of patients who received positive pressure ventilation (PPV) is unknown. Objective To evaluate the association of implementation of prehospital TBI evidence-based guidelines with survival among patients with prehospital PPV. Design, Setting, and Participants The EPIC study was a multisystem, intention-to-treat study using a before/after controlled design. Evidence-based guidelines were implemented by emergency medical service agencies across Arizona. This subanalysis was planned a priori and included participants who received prehospital PPV. Outcomes were compared between the preimplementation and postimplementation cohorts using logistic regression, stratified by predetermined TBI severity categories (moderate, severe, or critical). Data were collected from January 2007 to June 2017, and data were analyzed from January to February 2023. Exposure Implementation of the evidence-based guidelines for the prehospital care of patient with TBI. Main Outcomes and Measures The primary outcome was survival to hospital discharge, and the secondary outcome was survival to admission. Results Among the 21 852 participants in the main study, 5022 received prehospital PPV (preimplementation, 3531 participants; postimplementation, 1491 participants). Of 5022 included participants, 3720 (74.1%) were male, and the median (IQR) age was 36 (22-54) years. Across all severities combined, survival to admission improved (adjusted odds ratio [aOR], 1.59; 95% CI, 1.28-1.97), while survival to discharge did not (aOR, 0.94; 95% CI, 0.78-1.13). Within the cohort with severe TBI but not in the moderate or critical subgroups, survival to hospital admission increased (aOR, 6.44; 95% CI, 2.39-22.00), as did survival to discharge (aOR, 3.52; 95% CI, 1.96-6.34). Conclusions and Relevance Among patients with severe TBI who received active airway interventions in the field, guideline implementation was independently associated with improved survival to hospital admission and discharge. This was true whether they received basic airway interventions or advanced airways. These findings support the current guideline recommendations for aggressive prevention/correction of hypoxia and hyperventilation in patients with severe TBI, regardless of which airway type is used.
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Affiliation(s)
- Joshua B. Gaither
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Daniel W. Spaite
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Bentley J. Bobrow
- Department of Emergency Medicine, McGovern Medical School at UT Health, Houston, Texas
| | - Bruce Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
| | - Vatsal Chikani
- Department of Public Health, University of Texas at San Antonio
| | - Kurt R. Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Gail H. Bradley
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
- Arizona Department of Health Services, Bureau of EMS, Phoenix
| | - Amber D. Rice
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | | | - Samuel M. Keim
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
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Shafique MA, Haseeb A, Asghar B, Kumar A, Chaudhry ER, Mustafa MS. Assessing the impact of pre-hospital airway management on severe traumatic Brain injury: A systematic review and Meta-analysis. Am J Emerg Med 2024; 78:188-195. [PMID: 38301369 DOI: 10.1016/j.ajem.2024.01.030] [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: 10/13/2023] [Revised: 01/05/2024] [Accepted: 01/15/2024] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVE This study aimed to assess the impact of establishing a pre-hospital definitive airway on mortality and morbidity compared with no prehospital airway in cases of severe traumatic brain injury (TBI). BACKGROUND Traumatic brain injury (TBI) is a global health concern that is associated with substantial morbidity and mortality. Prehospital intubation (PHI) has been proposed as a potential life-saving intervention for patients with severe TBI to mitigate secondary insults, such as hypoxemia and hypercapnia. However, their impact on patient outcomes remains controversial. METHODS A systematic review and meta-analysis were conducted to assess the effects of prehospital intubation versus no prehospital intubation on morbidity and mortality in patients with severe TBI, adhering to the PRISMA guidelines. RESULTS 24 studies, comprising 56,543 patients, indicated no significant difference in mortality between pre-hospital and In-hospital Intubation (OR 0.89, 95% CI 0.65-1.23, p = 0.48), although substantial heterogeneity was noted. Morbidity analysis also showed no significant difference (OR 0.83, 95% CI 0.43-1.63, p = 0.59). These findings underscore the need for cautious interpretation due to heterogeneity and the influence of specific studies on the results. CONCLUSION In summary, an initial assessment did not reveal any apparent disparity in mortality rates between individuals who received prehospital intubation and those who did not. However, subsequent analyses and randomized controlled trials (RCTs) demonstrated that patients who underwent prehospital intubation had a reduced risk of death and morbidity. The dependence on biased observational studies and the need for further replicated RCTs to validate these findings are evident. Despite the intricacy of the matter, it is crucial to intervene during severe airway impairment.
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Affiliation(s)
| | - Abdul Haseeb
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Bushra Asghar
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Aashish Kumar
- Department of Medicine, Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, Pakistan
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Cimino J, Braun C. Clinical Research in Prehospital Care: Current and Future Challenges. Clin Pract 2023; 13:1266-1285. [PMID: 37887090 PMCID: PMC10605888 DOI: 10.3390/clinpract13050114] [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: 08/21/2023] [Revised: 10/08/2023] [Accepted: 10/19/2023] [Indexed: 10/28/2023] Open
Abstract
Prehospital care plays a critical role in improving patient outcomes, particularly in cases of time-sensitive emergencies such as trauma, cardiac failure, stroke, bleeding, breathing difficulties, systemic infections, etc. In recent years, there has been a growing interest in clinical research in prehospital care, and several challenges and opportunities have emerged. There is an urgent need to adapt clinical research methodology to a context of prehospital care. At the same time, there are many barriers in prehospital research due to the complex context, posing unique challenges for research, development, and evaluation. Among these, this review allows the highlighting of limited resources and infrastructure, ethical and regulatory considerations, time constraints, privacy, safety concerns, data collection and analysis, selection of a homogeneous study group, etc. The analysis of the literature also highlights solutions such as strong collaboration between emergency medical services (EMS) and hospital care, use of (mobile) health technologies and artificial intelligence, use of standardized protocols and guidelines, etc. Overall, the purpose of this narrative review is to examine the current state of clinical research in prehospital care and identify gaps in knowledge, including the challenges and opportunities for future research.
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Affiliation(s)
- Jonathan Cimino
- Clinical Research Unit, Fondation Hôpitaux Robert Schuman, 44 Rue d’Anvers, 1130 Luxembourg, Luxembourg
- Hôpitaux Robert Schuman, 9 Rue Edward Steichen, 2540 Luxembourg, Luxembourg
| | - Claude Braun
- Clinical Research Unit, Fondation Hôpitaux Robert Schuman, 44 Rue d’Anvers, 1130 Luxembourg, Luxembourg
- Hôpitaux Robert Schuman, 9 Rue Edward Steichen, 2540 Luxembourg, Luxembourg
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Chee ML, Chee ML, Huang H, Mazzochi K, Taylor K, Wang H, Feng M, Ho AFW, Siddiqui FJ, Ong MEH, Liu N. Artificial intelligence and machine learning in prehospital emergency care: A scoping review. iScience 2023; 26:107407. [PMID: 37609632 PMCID: PMC10440716 DOI: 10.1016/j.isci.2023.107407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Abstract
Our scoping review provides a comprehensive analysis of the landscape of artificial intelligence (AI) applications in prehospital emergency care (PEC). It contributes to the field by highlighting the most studied AI applications and identifying the most common methodological approaches across 106 included studies. The findings indicate a promising future for AI in PEC, with many unique use cases, such as prognostication, demand prediction, resource optimization, and the Internet of Things continuous monitoring systems. Comparisons with other approaches showed AI outperforming clinicians and non-AI algorithms in most cases. However, most studies were internally validated and retrospective, highlighting the need for rigorous prospective validation of AI applications before implementation in clinical settings. We identified knowledge and methodological gaps using an evidence map, offering a roadmap for future investigators. We also discussed the significance of explainable AI for establishing trust in AI systems among clinicians and facilitating real-world validation of AI models.
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Affiliation(s)
- Marcel Lucas Chee
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Mark Leonard Chee
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Haotian Huang
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Katelyn Mazzochi
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Kieran Taylor
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Han Wang
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Mengling Feng
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
- Pre-Hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore, Singapore
| | - Fahad Javaid Siddiqui
- Pre-Hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
- Pre-Hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore, Singapore
| | - Nan Liu
- Pre-Hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore, Singapore
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
- Institute of Data Science, National University of Singapore, Singapore, Singapore
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Benhamed A, Isaac CJ, Boucher V, Yadav K, Mercier E, Moore L, D'Astous M, Bernard F, Dubucs X, Gossiome A, Emond M. Effect of age on the association between the Glasgow Coma Scale and the anatomical brain lesion severity: a retrospective multicentre study. Eur J Emerg Med 2023; 30:271-279. [PMID: 37161755 DOI: 10.1097/mej.0000000000001041] [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: 05/11/2023]
Abstract
Background and importance Older adults are at higher risk of undertriage and mortality following a traumatic brain injury (TBI). Early identification and accurate triage of severe cases is therefore critical. However, the Glasgow Coma Scale (GCS) might lack sensitivity in older patients. Objective This study investigated the effect of age on the association between the GCS and TBI severity. Design, settings, and participants This multicentre retrospective cohort study (2003-2017) included TBI patients aged ≥16 years with an Abbreviated Injury Scale (AIS of 3, 4 or 5). Older adults were defined as aged 65 and over. Outcomes measure and analysis Median GCS score were compared between older and younger adults, within subgroups of similar AIS. Multivariable logistic regressions were computed to assess the association between age and mortality. The primary analysis comprised patients with isolated TBI, and secondary analysis included patients with multiple trauma. Main results A total of 12 562 patients were included, of which 9485 (76%) were isolated TBIs. Among those, older adults represented 52% ( n = 4931). There were 22, 27 and 51% of older patients with an AIS-head of 3, 4 and 5 respectively compared to 32, 25 and 43% among younger adults. Within the different subgroups of patients, median GCS scores were higher in older adults: 15 (14-15) vs. 15 (13-15), 15 (14-15) vs. 14 (13-15), 15 (14-15) vs. 14 (8-15), for AIS-head 3, 4 and 5 respectively (all P < 0.0001). Older adults had increased odds of mortality compared to their younger counterparts at all AIS-head levels: AIS-head = 3 [odds ratio (OR) = 2.9, 95% confidence interval (CI) 1.6-5.5], AIS-head = 4, (OR = 2.7, 95% CI 1.6-4.7) and AIS-head = 5 (OR = 2.6, 95% CI 1.9-3.6) TBI (all P < 0.001). Similar results were found among patients with multiple trauma. Conclusions In this study, among TBI patients with similar AIS-head score, there was a significant higher median GCS in older patients compared to younger patients.
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Affiliation(s)
- Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot-Université Claude Bernard Lyon 1, Lyon, France
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | | | - Valérie Boucher
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | - Krishan Yadav
- Department of Emergency Medicine-University of Ottawa
- Ottawa Hospital Research Institute, Ottawa, Ontario
| | - Eric Mercier
- CHU de Québec-Université Laval Research Centre, Québec, Québec
- Département de médecine d'urgence et médecine familiale, Université Laval
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec
| | | | - Francis Bernard
- Services de soins intensifs, Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM)-Université de Montréal, Montréal, Québec, Canada
| | - Xavier Dubucs
- Service d'urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Amaury Gossiome
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot-Université Claude Bernard Lyon 1, Lyon, France
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | - Marcel Emond
- CHU de Québec-Université Laval Research Centre, Québec, Québec
- Département de médecine d'urgence et médecine familiale, Université Laval
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Davis DP, McKnight B, Meier E, Drennan IR, Newgard C, Wang HE, Bulger E, Schreiber M, Austin M, Vaillancourt C. Higher Oxygenation Is Associated with Improved Survival in Severe Traumatic Brain Injury but Not Traumatic Shock. Neurotrauma Rep 2023; 4:51-63. [PMID: 36726869 PMCID: PMC9886195 DOI: 10.1089/neur.2022.0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Pre-hospital resuscitation of critically injured patients traditionally includes supplemental oxygen therapy to address potential hypoxemia. The objective of this study was to explore the association between pre-hospital hypoxemia, hyperoxemia, and mortality in patients with traumatic brain injury (TBI) and traumatic shock. We hypothesized that both hypoxemia and hyperoxemia would be associated with increased mortality. We used the Resuscitation Outcomes Consortium Prospective Observational Prehospital and Hospital Registry for Trauma (ROC PROPHET) database of critically injured patients to identify a severe TBI cohort (pre-hospital Glasgow Coma Scale [GCS] 3-8) and a traumatic shock cohort (systolic blood pressure ≤90 mm Hg and pre-hospital GCS >8). Arterial blood gas (ABG) obtained within 30 min of hospital arrival was required for inclusion. Patients with hypoxemia (PaO2 <80 mm Hg) and hyperoxemia (PaO2 >400 mm Hg) were compared to those with normoxemia (PaO2 80-400 mm Hg) with regard to the primary outcome measure of in-hospital mortality in both the TBI and traumatic shock cohorts. Multiple logistic regression was used to calculate odds ratios (ORs) after adjustment for multiple covariables. In addition, regression spline curves were generated to estimate the risk of death as a continuous function of PaO2 levels. A total of 1248 TBI patients were included, of whom 396 (32%) died before hospital discharge. Associations between hypoxemia and increased mortality (OR, 1.8; 95% confidence interval [CI], 1.2-2.8; p = 0.008) and between hyperoxemia and decreased mortality (OR, 0.6; 95% CI, 0.4-0.9; p = 0.018) were observed. A total of 582 traumatic shock patients were included, of whom 52 (9%) died before hospital discharge. No statistically significant associations were observed between in-hospital mortality and either hypoxemia (OR, 1.0; 95% CI, 0.4-2.4; p = 0.987) or hyperoxemia (OR, 1.9; 95% CI, 0.6-5.7; p = 0.269). Among patients with severe TBI but not traumatic shock, hypoxemia was associated with an increase of in-hospital mortality and hyperoxemia was associated with a decrease of in-hospital mortality.
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Affiliation(s)
- Daniel P. Davis
- Logan Health EMS, Kalispell, Montana, USA.,Department of Emergency Medicine, UC San Diego Medical Center, San Diego, California, USA.,*Address correspondence to: Daniel P. Davis, MD, Logan Health EMS, 310 Sunnyview Lane, Kalispell, MT 59901, USA;
| | - Barbara McKnight
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Eric Meier
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Ian R. Drennan
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Craig Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Henry E. Wang
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Eileen Bulger
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Martin Schreiber
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Michael Austin
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Anderson J, Ebeid A, Stallwood-Hall C. Pre-hospital tracheal intubation in severe traumatic brain injury: a systematic review and meta-analysis. Br J Anaesth 2022; 129:977-984. [PMID: 36088135 DOI: 10.1016/j.bja.2022.07.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/27/2022] [Accepted: 07/19/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Severe traumatic brain injury (TBI) continues to be a leading cause of death, particularly in young adults. Severe TBI contributes to significant socioeconomic burden secondary to the long-term disability, impacting the individual and their family, and wider society. The aim of this study was to determine whether establishing a pre-hospital definitive airway was beneficial to mortality and morbidity when compared with no pre-hospital airway. METHODS A literature search for all relevant studies was performed in Medline, Embase, Cochrane, EBSCO, and Emcare databases, with studies comparing effects of pre-hospital tracheal intubation vs noninvasive airway management on mortality in non-paediatric patients with severe TBI. There were 1025 studies that had abstracts screened from this search. This study was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS We identified 19 studies that met inclusion criteria. The included studies identified no significant difference in mortality between pre-hospital and no pre-hospital tracheal intubation, with an odds ratio of 1.07 (95% CI, 0.72-1.57; P<0.001). The meta-analysis identified a trend favouring pre-hospital tracheal intubation with respect to long-term morbidity, with an odds ratio of 0.92 (95% CI, 0.51-1.67; P<0.001). CONCLUSIONS Management of traumatic brain injuries is a constantly evolving field, with ever-changing target parameters regarding management. There is growing evidence, based on the RCTs and recent studies, that pre-hospital tracheal intubation in patients with severe TBI is beneficial if performed by well-trained, experienced practitioners in accordance with current TBI guidelines. PROSPERO REGISTRATION CRD42021234439.
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Affiliation(s)
- Jordan Anderson
- University of London/Queen Mary, London, UK; Flinders Medical Centre, Adelaide, Australia.
| | - Annalize Ebeid
- University of London/Queen Mary, London, UK; Royal Adelaide Hospital, Adelaide, Australia
| | - Catrin Stallwood-Hall
- University of London/Queen Mary, London, UK; Flinders Medical Centre, Adelaide, Australia
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Davis D. Tu-be or Not Tu-be…That Is the Question: Commentary on "Prehospital Intubation of Patients with Severe Traumatic Brain Injury". PREHOSP EMERG CARE 2022:1-3. [PMID: 36191305 DOI: 10.1080/10903127.2022.2132566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Carney N, Totten AM, Cheney T, Jungbauer R, Neth MR, Weeks C, Davis-O'Reilly C, Fu R, Yu Y, Chou R, Daya M. Prehospital Airway Management: A Systematic Review. PREHOSP EMERG CARE 2022; 26:716-727. [PMID: 34115570 DOI: 10.1080/10903127.2021.1940400] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/31/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
Objective: To assess comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) used by prehospital emergency medical services (EMS) to treat patients with trauma, cardiac arrest, or medical emergencies, and how they differ based on techniques and devices, EMS personnel and patient characteristics. Data sources: We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020. Review methods: We followed Agency for Healthcare Research and Quality Effective Health Care Program Methods guidance. Outcomes included mortality, neurological function, return of spontaneous circulation (ROSC), and successful advanced airway insertion. Meta-analyses using profile-likelihood random effects models were conducted, with analyses stratified by study design, emergency type, and age. Results: We included 99 studies involving 630,397 patients. We found few differences in primary outcomes across airway management approaches. For survival, there was no difference for BVM versus ETI or SGA in adult and pediatric patients with cardiac arrest or trauma. For neurological function, there was no difference for BVM versus ETI and SGA versus ETI in pediatric patients with cardiac arrest. There was no difference in BVM versus ETI in adults with cardiac arrest, but improved neurological function with BVM or ETI versus SGA. There was no difference in ROSC for patients with cardiac arrest for BVM versus ETI or SGA in adults and pediatrics, or SGA versus ETI in pediatrics. There was higher frequency of ROSC in adults with SGA versus ETI. For successful advanced airway insertion, there was higher first-pass success with SGA versus ETI for all patients except adult medical patients (no difference), and no difference in overall success using SGA versus ETI in adults. Conclusions: The currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion. Strength of evidence was low or moderate; most included studies were observational. This supports the need for high-quality randomized controlled trials to advance clinical practice and EMS education and policy, and improve patient-centered outcomes.
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Radhakrishnan A, McCahill C, Atwal RS, Lahiri S. A systematic review of the timing of intubation in patients with traumatic brain injury: pre-hospital versus in-hospital intubation. Eur J Trauma Emerg Surg 2022; 49:1199-1215. [PMID: 35962218 DOI: 10.1007/s00068-022-02048-0] [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: 01/07/2022] [Accepted: 06/30/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The objective of this systematic review was to examine current evidence on the risks versus benefit of pre-hospital intubation when compared with in-hospital intubation in adult patients with traumatic brain injuries. METHODS We conducted electronic searches of PubMed, Medline, Embase, CIANHL and the Cochrane library up to March 2021. Data extracted compared mortality, length of hospital and intensive care stay, pneumonia and functional outcomes in traumatic brain injured patients undergoing pre-hospital intubation versus in-hospital intubation. The risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation. RESULTS Ten studies including 25,766 patients were analysed. Seven were retrospective studies, two prospective cohort studies and one randomised control study. The mean mortality rate in patients who underwent pre-hospital intubation was 44.5% and 31.98% for in-hospital intubation. The odds ratio for an effect of pre-hospital intubation on mortality ranged from 0.31 (favouring in-hospital intubation) to 3.99 (favouring pre-hospital). The overall quality of evidence is low; however, the only randomised control study showed an improved functional outcome for pre-hospital intubation at 6 months. CONCLUSIONS The existing evidence does not support widespread pre-hospital intubation in all traumatic brain injured patients. This does not, however, contradict the need for the intervention when there is severe airway compromise; instead, it must be assessed by experienced personnel if a time critical transfer to hospital is more advantageous. Favourable neurological outcomes highlighted by the randomised control trial favours pre-hospital intubation, but further research is required in this field.
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Affiliation(s)
| | - Claire McCahill
- Anaesthetic Department, Great Ormond Street Hospital, London, WC1N 3JH, UK
| | | | - Sumitra Lahiri
- Anaesthetic Department, The Royal London Hospital, London, E1 1FR, UK
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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12
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Nadler R, Tsur AM, Lipsky AM, Benov A, Sorkin A, Glassberg E, Chen J. Trends in combat casualty care following the publication of clinical practice guidelines. J Trauma Acute Care Surg 2021; 91:S194-S200. [PMID: 34039926 DOI: 10.1097/ta.0000000000003280] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The current study explores the trends in the application of combat casualty care following the publication of clinical practice guidelines (CPGs) in five domains for 13 years. METHODS The Israel Defense Forces Trauma Registry was used to assess practice and adherence to guidelines in five domains: (a) crystalloid transfusions, (b) tranexamic acid use, (c) freeze-dried plasma use, (d) chest decompression, and (e) airway management. All patients injured between January 2006 and December 2018 were included in the analysis. Trends were analyzed and presented monthly using linear regression and were compared using the Chow test. RESULTS The mean ± SD crystalloid volume transfused decreased from 1,179 ± 653 mL in 2006 to 466 ± 202 mL in 2018 (B = 0.016, 0.006-0.044). The proportion of patients with an indication treated with tranexamic acid dropped from 8% (238 of 2,979 patients) to 2.5% (60 of 2,356 patients) following the stricter guideline's publication. Freeze-dried plasma administration in indicated casualties rose from 12.5% in 2013 to 48% in 2018 (B = 1.63, 1.3-2.05). The overall proportion of casualties undergoing chest decompression rose from 1% (61 of 6,036 casualties) to 1.5% (155 of 10,493 casualties) following the release of a new CPG in 2012 (p = 0.013). There were no significant trends in intubation ratios before (B = 0.987, 0.953-1.02) or after 2012 (B = 10.2, 0.996-1.05). CONCLUSION Some aspects demonstrate the desired trends in response to new CPGs; in others, initial improvement is achieved but followed by stagnation. In some medical care aspects, completely unexpected and undesirable trends are observed. Every change and update in CPGs should be based on reliable data. The effect of every change must be monitored carefully to ensure adequate adherence to lifesaving guidelines. LEVEL OF EVIDENCE Epidemiological study, level IV.
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Affiliation(s)
- Roy Nadler
- From the Trauma and Combat Medicine Branch (R.N., A.M.T., A.B., A.S., E.G., J.C.), Israel Defense Forces, Medical Corps; Department of General Surgery and Transplantation-Surgery B (R.N.), Chaim Sheba Medical Center; Department of Medicine 'B' (A.M.T.), Sheba Medical Center, Tel Hashomer, Ramat Gan; Department of Emergency Medicine (A.M.L.), Rambam Health Care Campus, Haifa; The Azrieli Faculty of Medicine (A.B., E.G.), Bar-Ilan University, Safad, Israel; School of Medicine, Uniformed Services University of the Health Sciences (E.G.), Bethesda, Maryland; and Central Management, Meir Medical Center (J.C.), Kfar Saba; Sackler School of Medicine (J.C.), Tel Aviv University, Tel Aviv, Israel
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13
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Gaither JB, Spaite DW, Bobrow BJ, Keim SM, Barnhart BJ, Chikani V, Sherrill D, Denninghoff KR, Mullins T, Adelson PD, Rice AD, Viscusi C, Hu C. Effect of Implementing the Out-of-Hospital Traumatic Brain Injury Treatment Guidelines: The Excellence in Prehospital Injury Care for Children Study (EPIC4Kids). Ann Emerg Med 2021; 77:139-153. [PMID: 33187749 PMCID: PMC7855946 DOI: 10.1016/j.annemergmed.2020.09.435] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/28/2020] [Accepted: 09/14/2020] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury. METHODS The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders. RESULTS There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100+). CONCLUSION Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.
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Affiliation(s)
- Joshua B Gaither
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ.
| | - Daniel W Spaite
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at UT Health, Houston, TX
| | - Samuel M Keim
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
| | - Bruce J Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ
| | - Vatsal Chikani
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ
| | - Duane Sherrill
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
| | - Kurt R Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Terry Mullins
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ
| | - P David Adelson
- Barrow Neurological Institute at Phoenix Children's Hospital and Department of Child Health/Neurosurgery, College of Medicine, The University of Arizona, Phoenix, AZ
| | - Amber D Rice
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Chad Viscusi
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
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14
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Sumann G, Moens D, Brink B, Brodmann Maeder M, Greene M, Jacob M, Koirala P, Zafren K, Ayala M, Musi M, Oshiro K, Sheets A, Strapazzon G, Macias D, Paal P. Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel. Scand J Trauma Resusc Emerg Med 2020; 28:117. [PMID: 33317595 PMCID: PMC7737289 DOI: 10.1186/s13049-020-00790-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments. Objective To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments. Eligibility criteria All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms. Sources of evidence PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles. Charting methods Evidence was searched according to clinically relevant topics and PICO questions. Results Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland. Conclusions Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
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Affiliation(s)
- G Sumann
- Austrian Society of Mountain and High Altitude Medicine, Emergency physician, Austrian Mountain and Helicopter Rescue, Altach, Austria
| | - D Moens
- Emergency Department Liège University Hospital, CMH HEMS Lead physician and medical director, Senior Lecturer at the University of Liège, Liège, Belgium
| | - B Brink
- Mountain Emergency Paramedic, AHEMS, Canadian Society of Mountain Medicine, Whistler Blackcomb Ski Patrol, Whistler, Canada
| | - M Brodmann Maeder
- Department of Emergency Medicine, University Hospital and University of Bern, Switzerland and Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - M Greene
- Medical Officer Mountain Rescue England and Wales, Wales, UK
| | - M Jacob
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Hospitallers Brothers Saint-Elisabeth-Hospital Straubing, Bavarian Mountain Rescue Service, Straubing, Germany
| | - P Koirala
- Adjunct Assistant Professor, Emergency Medicine, University of Maryland School of Medicine, Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - K Zafren
- ICAR MedCom, Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA.,Alaska Native Medical Center, Anchorage, AK, USA
| | - M Ayala
- University Hospital Germans Trias i Pujol, Badalona, Spain
| | - M Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - K Oshiro
- Department of Cardiovascular Medicine and Director of Mountain Medicine, Research, and Survey Division, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - A Sheets
- Emergency Department, Boulder Community Health, Boulder, CO, USA
| | - G Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,The Corpo Nazionale Soccorso Alpino e Speleologico, National Medical School (CNSAS SNaMed), Milan, Italy
| | - D Macias
- Department of Emergency Medicine, International Mountain Medicine Center, University of New Mexico, Albuquerque, NM, USA
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
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15
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Hilbert-Carius P, Struck MF, Hofer V, Hinkelbein J, Rognås L, Adler J, Christian MD, Wurmb T, Bernhard M, Hossfeld B. Mechanical ventilation of patients in helicopter emergency medical service transport: an international survey. Scand J Trauma Resusc Emerg Med 2020; 28:112. [PMID: 33208195 PMCID: PMC7672415 DOI: 10.1186/s13049-020-00801-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 10/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mechanical ventilation in helicopter emergency medical service (HEMS) environments is a procedure which carries a significant risk of complications. Limited data on the quality and performance of mechanical ventilation in HEMS are available in the literature. METHOD We conducted an international survey to evaluate mechanical ventilation infrastructure in HEMS and collect data of transported ventilated patients. From June 20-22, 2019, the participating HEMS bases were asked to provide data via a web-based platform. Vital parameters and ventilation settings of the patients at first patient contact and at handover were compared using non-parametric statistical tests. RESULTS Out of 215 invited HEMS bases, 53 responded. Respondents were from Germany, Denmark, United Kingdom, Luxembourg, Austria and Switzerland. Of the HEMS bases, all teams were physician staffed, mainly anesthesiologists (79%), the majority were board certified (92.5%) and trained in intensive care medicine (89%) and had a median (range) experience in HEMS of 9 (0-25) years. HEMS may provide a high level of expertise in mechanical ventilation whereas the majority of ventilators are able to provide pressure controlled ventilation and continuous positive airway pressure modes (77%). Data of 30 ventilated patients with a median (range) age of 54 (21-100) years and 53% male gender were analyzed. Of these, 24 were primary missions and 6 interfacility transports. At handover, oxygen saturation (p < 0.01) and positive end-expiratory pressure (p = 0.04) of the patients were significantly higher compared to first patient contact. CONCLUSION In this survey, the management of ventilated HEMS-patients was not associated with ventilation related serious adverse events. Patient conditions, training of medical crew and different technical and environmental resources are likely to influence management. Further studies are necessary to assess safety and process quality of mechanical ventilation in HEMS. TRIAL REGISTRATION The survey was prospectively registered at Research Registry ( researchregistry2925 ).
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Affiliation(s)
- Peter Hilbert-Carius
- BG Klinikum Bergmannstrost Halle gGmbH, Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, and HEMS "Christoph 84" and "Christoph 85", DRF-Luftrettung, Halle (Saale), Germany
| | - Manuel F Struck
- Department of Anesthesiology and Intensive Care Medicine, and HEMS "Christoph 33" and "Christoph 71" Senftenberg, University Hospital Leipzig, Leipzig, Germany.
| | - Veronika Hofer
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Jochen Hinkelbein
- Department of Anesthesiology and Intensive Care Medicine, and HEMS "Christoph Rheinland", University Hospital Cologne, Cologne, Germany
| | | | - Jörn Adler
- Luxembourg Air Rescue A.s.b.l., Sandweiler, Luxembourg
| | | | - Thomas Wurmb
- Department of Anesthesiology, University Hospital Würzburg, Würzburg, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Björn Hossfeld
- Federal Armed Forces Hospital, Ulm, Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, and HEMS "Christoph 22" Ulm, Ulm, Germany
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16
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Whiting MD, Dengler BA, Rodriguez CL, Blodgett D, Cohen AB, Januszkiewicz AJ, Rasmussen TE, Brody DL. Prehospital Detection of Life-Threatening Intracranial Pathology: An Unmet Need for Severe TBI in Austere, Rural, and Remote Areas. Front Neurol 2020; 11:599268. [PMID: 33193067 PMCID: PMC7662094 DOI: 10.3389/fneur.2020.599268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/12/2020] [Indexed: 11/24/2022] Open
Abstract
Severe traumatic brain injury (TBI) is a leading cause of death and disability worldwide, especially in low- and middle-income countries, and in austere, rural, and remote settings. The purpose of this Perspective is to challenge the notion that accurate and actionable diagnosis of the most severe brain injuries should be limited to physicians and other highly-trained specialists located at hospitals. Further, we aim to demonstrate that the great opportunity to improve severe TBI care is in the prehospital setting. Here, we discuss potential applications of prehospital diagnostics, including ultrasound and near-infrared spectroscopy (NIRS) for detection of life-threatening subdural and epidural hemorrhage, as well as monitoring of cerebral hemodynamics following severe TBI. Ultrasound-based methods for assessment of cerebrovascular hemodynamics, vasospasm, and intracranial pressure have substantial promise, but have been mainly used in hospital settings; substantial development will be required for prehospital optimization. Compared to ultrasound, NIRS is better suited to assess certain aspects of intracranial pathology and has a smaller form factor. Thus, NIRS is potentially closer to becoming a reliable method for non-invasive intracranial assessment and cerebral monitoring in the prehospital setting. While one current continuous wave NIRS-based device has been FDA-approved for detection of subdural and epidural hemorrhage, NIRS methods using frequency domain technology have greater potential to improve diagnosis and monitoring in the prehospital setting. In addition to better technology, advances in large animal models, provider training, and implementation science represent opportunities to accelerate progress in prehospital care for severe TBI in austere, rural, and remote areas.
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Affiliation(s)
- Mark D Whiting
- The Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences and National Institutes of Health, Bethesda, MD, United States.,Stephens Family Clinical Research Institute, Carle Foundation Hospital, Urbana, IL, United States
| | - Bradley A Dengler
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Carissa L Rodriguez
- Johns Hopkins University Applied Physics Laboratory, Laurel, MD, United States
| | - David Blodgett
- Johns Hopkins University Applied Physics Laboratory, Laurel, MD, United States
| | - Adam B Cohen
- Johns Hopkins University Applied Physics Laboratory, Laurel, MD, United States.,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | | | - Todd E Rasmussen
- The Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences and National Institutes of Health, Bethesda, MD, United States.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - David L Brody
- The Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences and National Institutes of Health, Bethesda, MD, United States.,Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.,Laboratory of Functional and Molecular Imaging, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
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17
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Brown CVR, Inaba K, Shatz DV, Moore EE, Ciesla D, Sava JA, Alam HB, Brasel K, Vercruysse G, Sperry JL, Rizzo AG, Martin M. Western Trauma Association critical decisions in trauma: airway management in adult trauma patients. Trauma Surg Acute Care Open 2020; 5:e000539. [PMID: 33083558 PMCID: PMC7549454 DOI: 10.1136/tsaco-2020-000539] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/17/2020] [Accepted: 09/03/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Carlos V R Brown
- Department of Surgery, University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Kenji Inaba
- Deparment of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - David V Shatz
- Department of Surgery, UC Davis, Davis, California, USA
| | - Ernest E Moore
- Department of Surgery, Denver Health, Denver, Colorado, USA
| | - David Ciesla
- Department of Surgery, University of South Florida, Tampa, Florida, USA
| | - Jack A Sava
- Department of Surgery, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Hasan B Alam
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Karen Brasel
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Gary Vercruysse
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason L Sperry
- Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anne G Rizzo
- Department of Surgery, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Matthew Martin
- Department of Trauma Surgery, Scripps Mercy Hospital San Diego, San Diego, California, USA
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18
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Rakhit S, Nordness MF, Lombardo SR, Cook M, Smith L, Patel MB. Management and Challenges of Severe Traumatic Brain Injury. Semin Respir Crit Care Med 2020; 42:127-144. [PMID: 32916746 DOI: 10.1055/s-0040-1716493] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro-Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.
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Affiliation(s)
- Shayan Rakhit
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mina F Nordness
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah R Lombardo
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madison Cook
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Meharry Medical College, Nashville, Tennessee
| | - Laney Smith
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Washington and Lee University, Lexington, Virginia
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurosurgery and Hearing and Speech Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, Tennessee.,Surgical Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee
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19
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Gamberini L, Baldazzi M, Coniglio C, Gordini G, Bardi T. Prehospital Airway Management in Severe Traumatic Brain Injury. Air Med J 2019; 38:366-373. [PMID: 31578976 DOI: 10.1016/j.amj.2019.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 05/12/2019] [Accepted: 06/13/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a leading cause of death and disability among trauma patients. The final outcome of TBI results from a complex interaction between primary and secondary mechanisms of injury that begin immediately after the traumatic event. The aim of this review was to evaluate the latest evidence regarding the impact of prehospital airway management and the outcome after traumatic brain injury. METHODS PubMed, Embase, and Cochrane searches were conducted using the MeSH database. Airway management, traumatic brain injury, pneumonia, and the subheadings of these Medical Subject Headings were combined. RESULTS The review is structured into 4 major topics: airway management devices, prehospital pharmacologic management, mortality and neurologic outcomes, and early respiratory infections. The available literature shows a shift toward a more comprehensive view of prehospital airway management, taking into account not only the location where airway management is attempted but also the drugs administered, the airway management devices used, and the skills of the main professional figures attending the scene. CONCLUSIONS Literature about this topic is still inconclusive; however, new evidence taking into consideration more complex aspects of airway management rather than orotracheal intubation per se shows improved outcomes with aggressive prehospital airway management.
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Affiliation(s)
- Lorenzo Gamberini
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy.
| | - Marzia Baldazzi
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Coniglio
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Giovanni Gordini
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Tommaso Bardi
- Division of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
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20
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Spaite DW, Bobrow BJ, Keim SM, Barnhart B, Chikani V, Gaither JB, Sherrill D, Denninghoff KR, Mullins T, Adelson PD, Rice AD, Viscusi C, Hu C. Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study. JAMA Surg 2019; 154:e191152. [PMID: 31066879 PMCID: PMC6506902 DOI: 10.1001/jamasurg.2019.1152] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/03/2019] [Indexed: 12/27/2022]
Abstract
Importance Traumatic brain injury (TBI) is a massive public health problem. While evidence-based guidelines directing the prehospital treatment of TBI have been promulgated, to our knowledge, no studies have assessed their association with survival. Objective To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI. Design, Setting, and Participants The Excellence in Prehospital Injury Care (EPIC) Study included more than 130 emergency medical services systems/agencies throughout Arizona. This was a statewide, multisystem, intention-to-treat study using a before/after controlled design with patients with moderate to critically severe TBI (US Centers for Disease Control and Prevention Barell Matrix-Type 1 and/or Abbreviated Injury Scale Head region severity ≥3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019. Interventions Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension. Main Outcomes and Measures Primary: survival to hospital discharge; secondary: survival to hospital admission. Results Of the included patients, the median age was 45 years, 14 666 (67.1%) were men, 7181 (32.9%) were women; 16 408 (75.1% ) were white, 1400 (6.4%) were Native American, 743 (3.4% ) were Black, 237 (1.1%) were Asian, and 2791 (12.8%) were other race/ethnicity. Of the included patients, 21 852 met inclusion criteria for analysis (preimplementation phase [P1]: 15 228; postimplementation [P3]: 6624). The primary analysis (P3 vs P1) revealed an adjusted odds ratio (aOR) of 1.06 (95% CI, 0.93-1.21; P = .40) for survival to hospital discharge. The aOR was 1.70 (95% CI, 1.38-2.09; P < .001) for survival to hospital admission. Among the severe injury cohorts (but not moderate or critical), guideline implementation was significantly associated with survival to discharge (Regional Severity Score-Head 3-4: aOR, 2.03; 95% CI, 1.52-2.72; P < .001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P = .02). This was also true for survival to discharge among the severe, intubated subgroups (Regional Severity Score-Head 3-4: aOR, 3.14; 95% CI, 1.65-5.98; P < .001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34; P = .02). Conclusions and Relevance Statewide implementation of the prehospital TBI guidelines was not associated with significant improvement in overall survival to hospital discharge (across the entire, combined moderate to critical injury spectrum). However, adjusted survival doubled among patients with severe TBI and tripled in the severe, intubated cohort. Furthermore, guideline implementation was significantly associated with survival to hospital admission. These findings support the widespread implementation of the prehospital TBI treatment guidelines. Trial Registration ClinicalTrials.gov identifier: NCT01339702.
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Affiliation(s)
- Daniel W. Spaite
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Bentley J. Bobrow
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - Samuel M. Keim
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
| | - Bruce Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
| | - Vatsal Chikani
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - Joshua B. Gaither
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Duane Sherrill
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
| | - Kurt R. Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Terry Mullins
- Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
| | - P. David Adelson
- Barrow Neurological Institute at Phoenix Children’s Hospital, Department of Child Health/Neurosurgery, College of Medicine, The University of Arizona, Phoenix
| | - Amber D. Rice
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Chad Viscusi
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
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Gamberini L, Giugni A, Ranieri S, Meconi T, Coniglio C, Gordini G, Bardi T. Early-Onset Ventilator-Associated Pneumonia in Severe Traumatic Brain Injury: is There a Relationship with Prehospital Airway Management? J Emerg Med 2019; 56:657-665. [PMID: 31000428 DOI: 10.1016/j.jemermed.2019.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 01/22/2019] [Accepted: 02/02/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prehospital airway management in severe traumatic brain injury (TBI) is widely recommended by international guidelines for the management of trauma. Early-onset ventilator-associated pneumonia (EOVAP) is a common occurrence in this population and can worsen mortality and functional outcome. OBJECTIVES In this retrospective observational study, we aimed to evaluate the association between different prehospital airway management variables and the occurrence of EOVAP. Secondarily we evaluated the correlation between EOVAP and mortality and neurological outcome. METHODS The study retrospectively evaluated 223 patients admitted from 2010 to 2017 in our trauma intensive care unit for severe TBI. The population was divided into three groups on the basis of the airway management technique adopted (bag mask ventilation, laryngeal tube, orotracheal intubation). Uni- and multivariate logistic regression analyses were performed using the occurrence of EOVAP as the dependent variable, to investigate potential associations with prehospital airway management. RESULTS A total of 131 episodes (58.7%) of EOVAP were registered in the study population (223 patients). Laryngeal tube and orotracheal intubation were used in patients with significantly lower Glasgow Coma Scale score on scene and a higher Face Abbreviated Injury Scale; advanced airway management significantly increased the total rescue time. The prehospital airway management technique adopted, prehospital type of sedation or use of muscle relaxants, type of transport, and rescue times were not associated with the occurrence of EOVAP. CONCLUSIONS Prehospital airway management does not have a significant impact on the occurrence of EOVAP in severe TBI patients. Similarly, it does not have a significant impact on mortality or long-term neurological outcome despite increasing duration of mechanical ventilation, intensive care unit, and hospital stay.
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Affiliation(s)
- Lorenzo Gamberini
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Aimone Giugni
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Serena Ranieri
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Tommaso Meconi
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Carlo Coniglio
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Giovanni Gordini
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Tommaso Bardi
- Division of Anesthesia, Intensive Care, and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
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Pélieu I, Kull C, Walder B. Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury. Med Sci (Basel) 2019; 7:E12. [PMID: 30669658 PMCID: PMC6359668 DOI: 10.3390/medsci7010012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/12/2019] [Accepted: 01/19/2019] [Indexed: 02/06/2023] Open
Abstract
Traumatic brain injury (TBI) is a major healthcare problem and a major burden to society. The identification of a TBI can be challenging in the prehospital setting, particularly in elderly patients with unobserved falls. Errors in triage on scene cannot be ruled out based on limited clinical diagnostics. Potential new mobile diagnostics may decrease these errors. Prehospital care includes decision-making in clinical pathways, means of transport, and the degree of prehospital treatment. Emergency care at hospital admission includes the definitive diagnosis of TBI with, or without extracranial lesions, and triage to the appropriate receiving structure for definitive care. Early risk factors for an unfavorable outcome includes the severity of TBI, pupil reaction and age. These three variables are core variables, included in most predictive models for TBI, to predict short-term mortality. Additional early risk factors of mortality after severe TBI are hypotension and hypothermia. The extent and duration of these two risk factors may be decreased with optimal prehospital and emergency care. Potential new avenues of treatment are the early use of drugs with the capacity to decrease bleeding, and brain edema after TBI. There are still many uncertainties in prehospital and emergency care for TBI patients related to the complexity of TBI patterns.
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Affiliation(s)
- Iris Pélieu
- Division of Anaesthesiology, University Hospitals of Geneva, 12011 Geneva, Switzerland.
| | - Corey Kull
- Division of Anaesthesiology, University Hospitals of Geneva, 12011 Geneva, Switzerland.
| | - Bernhard Walder
- Division of Anaesthesiology, University Hospitals of Geneva, 12011 Geneva, Switzerland.
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23
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Dunn JA, Schroeppel TJ, Metzler M, Cribari C, Corey K, Boyd DR. History and significance of the trauma resuscitation flow sheet. Trauma Surg Acute Care Open 2018; 3:e000145. [PMID: 30402554 PMCID: PMC6203133 DOI: 10.1136/tsaco-2017-000145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 07/25/2018] [Accepted: 08/08/2018] [Indexed: 11/08/2022] Open
Abstract
There is little to no written information in the literature regarding the origin of the trauma flow sheet. This vital document allows programs to evaluate initial processes of trauma care. This information populates the trauma registry and is reviewed in nearly every Trauma Process Improvement and Patient Safety conference when discerning the course of patient care. It is so vital, a scribe is assigned to complete this documentation task for all trauma resuscitations, and there are continual process improvement efforts in trauma centers across the nation to ensure complete and accurate data collection. Indeed, it is the single most important document reviewed by the verification committee when evaluating processes of care at site visits. Trauma surgeons often overlook its importance during resuscitation, as recording remains the domain of the trauma scribe. Yet it is the first document scrutinized when the outcome is less than what is expected. The development of the flow sheet is not a result of any consensus statement, expert work group, or mandate, but a result of organic evolution due to the need for relevant and better data. The purpose of this review is to outline the origin, importance, and critical utility of the trauma flow sheet.
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Affiliation(s)
- Julie A Dunn
- Trauma and Acute Care Surgery, UC Health Medical Center of the Rockies, Loveland, Colorado, USA
| | - Thomas J Schroeppel
- Trauma and Acute Care Surgery, UC Health Memorial Hospital, Colorado Springs, Colorado, USA
| | - Michael Metzler
- Trauma and Acute Care Surgery, UC Health Medical Center of the Rockies, Loveland, Colorado, USA
| | - Chris Cribari
- Trauma and Acute Care Surgery, UC Health Medical Center of the Rockies, Loveland, Colorado, USA
- Trauma and Acute Care Surgery, UC Health Memorial Hospital, Colorado Springs, Colorado, USA
| | - Katherine Corey
- Trauma and Acute Care Surgery, UC Health Medical Center of the Rockies, Loveland, Colorado, USA
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Mohseni M, Khaleghdoust Mohammadi T, Mohtasham-Amiri Z, Kazemnejad E, Rahbar Taramsari M, Kouchaki Nejad-Eramsadati L. Assessment of Care and its Associated Factors in Traumatic Patients in North of Iran. Bull Emerg Trauma 2018; 6:334-340. [PMID: 30402523 PMCID: PMC6215078 DOI: 10.29252/beat-060411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: To determine the status of pre-hospital emergency care and its associated factors in traumatic patients. Methods: In across-sectional study, 577 traumatic patients who were transferred to Poursina hospital by EMS (Emergency Medical Services) personnel were selected by simple random sampling method. Pre-hospital emergency services were observed. Then the mean of taken measures scores for each domain was determined in percent and evaluated in terms of associated factors (age, working experience of staff and number of missions per day) and compared using Spearman's test. Results: Out of 577 patients, 454 were men (78.7%) and 123 women (21.3%). Their mean age was 35.1 years old. Accident (82.7%) was the most common mechanism of injury. Most vehicles involved in the accident were light -weight cars (48.5%) and motorcycles (32.2%). A significant relationship was found between age, general domain (p=0.039) and hemodynamic (p=0.019) as well as between work experience and general domain (p=0.018). Conclusion: Given that pre-hospital emergency services provided in most of the domains are relatively far from world standard, results of this research can provide information for managers to improve strategic planning on care and medical services, appropriation of budget, knowledge of personnel and necessary equipment.
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Affiliation(s)
- Mina Mohseni
- Department of Social Medicine, Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | | | - Zahra Mohtasham-Amiri
- Guilan Road Trauma Research Center, Guilan university of Medical Sciences, Rasht, Guilan, Iran
| | - Ehsan Kazemnejad
- Department of Critical Care Nursing, Guilan Road Trauma Research Center, Guilan university of Medical Sciences, Rasht, Iran
| | - Morteza Rahbar Taramsari
- Department of Medical Statistics, Social Determinants of Health Research Center, Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Leila Kouchaki Nejad-Eramsadati
- Nursing Education (Medical-Surgical), Social Determinants of Health Research Center, Guilan University of Medical Sciences, Rasht, Iran
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25
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Affiliation(s)
- Ahmed Ammar
- Department of Neurosurgery, King Fahd University Hospital, Al Khobar
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26
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Edwards T, Williams J, Cottee M. Influence of prehospital airway management on neurological outcome in patients transferred to a heart attack centre following out-of-hospital cardiac arrest. Emerg Med Australas 2018; 31:76-82. [DOI: 10.1111/1742-6723.13107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/14/2018] [Accepted: 04/24/2018] [Indexed: 11/28/2022]
Affiliation(s)
| | - Julia Williams
- School of Health and Social Work; University of Hertfordshire; Hertfordshire UK
| | - Michaela Cottee
- Hertfordshire Business School; University of Hertfordshire; Hertfordshire UK
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27
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Rubenson Wahlin R, Nelson DW, Bellander BM, Svensson M, Helmy A, Thelin EP. Prehospital Intubation and Outcome in Traumatic Brain Injury-Assessing Intervention Efficacy in a Modern Trauma Cohort. Front Neurol 2018; 9:194. [PMID: 29692755 PMCID: PMC5903008 DOI: 10.3389/fneur.2018.00194] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 03/13/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Prehospital intubation in traumatic brain injury (TBI) focuses on limiting the effects of secondary insults such as hypoxia, but no indisputable evidence has been presented that it is beneficial for outcome. The aim of this study was to explore the characteristics of patients who undergo prehospital intubation and, in turn, if these parameters affect outcome. MATERIAL AND METHODS Patients ≥15 years admitted to the Department of Neurosurgery, Stockholm, Sweden with TBI from 2008 through 2014 were included. Data were extracted from prehospital and hospital charts, including prospectively collected Glasgow Outcome Score (GOS) after 12 months. Univariate and multivariable logistic regression models were employed to examine parameters independently correlated to prehospital intubation and outcome. RESULTS A total of 458 patients were included (n = 178 unconscious, among them, n = 61 intubated). Multivariable analyses indicated that high energy trauma, prehospital hypotension, pupil unresponsiveness, mode of transportation, and distance to the hospital were independently correlated with intubation, and among them, only pupil responsiveness was independently associated with outcome. Prehospital intubation did not add independent information in a step-up model versus GOS (p = 0.154). Prehospital reports revealed that hypoxia was not the primary cause of prehospital intubation, and that the procedure did not improve oxygen saturation during transport, while an increasing distance from the hospital increased the intubation frequency. CONCLUSION In this modern trauma cohort, prehospital intubation was not independently associated with outcome; however, hypoxia was not a common reason for prehospital intubation. Prospective trials to assess efficacy of prehospital airway intubation will be difficult due to logistical and ethical considerations.
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Affiliation(s)
- Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - David W. Nelson
- Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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28
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Speed is not everything: Identifying patients who may benefit from helicopter transport despite faster ground transport. J Trauma Acute Care Surg 2018; 84:549-557. [DOI: 10.1097/ta.0000000000001769] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bendinelli C, Ku D, Nebauer S, King KL, Howard T, Gruen R, Evans T, Fitzgerald M, Balogh ZJ. A tale of two cities: prehospital intubation with or without paralysing agents for traumatic brain injury. ANZ J Surg 2018; 88:455-459. [PMID: 29573111 DOI: 10.1111/ans.14479] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/17/2018] [Accepted: 02/20/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The role of prehospital endotracheal intubation (PETI) for traumatic brain injury is unclear. In Victoria, paramedics use rapid sequence induction (RSI) drugs to facilitate PETI, while in New South Wales (NSW) they do not have access to paralysing agents. We hypothesized that RSI would both increase PETI rates and improve mortality. METHODS Retrospective comparison of adult primary admissions (Glasgow Coma Scale <9 and abbreviated injury scale head and neck >2) to either Victorian or NSW trauma centre, which were compared with univariate and logistic regression analysis to estimate odds ratio for mortality and intensive care unit (ICU) length of stay. RESULTS One hundred and ninety-two Victorian and 91 NSW patients did not differ in: demographics (males: 77% versus 79%; P = 0.7 and age: 34 (18-88) versus 33 (18-85); P = 0.7), Glasgow Coma Scale (3 (3-8) versus 5 (3-8); P = 0.07), and injury severity score (38 (26-75) versus 35 (18-75); P = 0.09), prehospital hypotension (15.4% versus 11.7%; P = 0.5) and desaturation (14.6% versus 17.5%; P = 0.5). Victorians had higher abbreviated injury scale head and neck (5 (4-5) versus 5 (3-6); P = 0.04) and more often successful PETI (85% versus 22%; P < 0.05). On logistic regression analysis, mortality did not differ among groups (31.7% versus 26.3%; P = 0.34; OR = 0.84; 95% CI: 0.38-1.86; P = 0.67). Among survivors, Victorians had longer stay in ICU (364 (231-486) versus 144 (60-336) h), a difference that persisted on gamma regression (effect = 1.58; 95% CI: 1.30-1.92; P < 0.05). CONCLUSION Paramedics using RSI to obtain PETI in patients with traumatic brain injury had a higher success rate. This increase in successful PETI rate was not associated with an improvement in either mortality rate or ICU length of stay.
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Affiliation(s)
- Cino Bendinelli
- John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Dominic Ku
- John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Shane Nebauer
- John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Kate L King
- John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Teresa Howard
- The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | - Russel Gruen
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Tiffany Evans
- Clinical Research Design, Information Technology and Statistical Support, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Mark Fitzgerald
- The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | - Zsolt J Balogh
- John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
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Rouse C, Hayre J, French J, Fraser J, Watson I, Benjamin S, Chisholm A, Sealy B, Erdogan M, Green RS, Stoica G, Atkinson P. A traumatic tale of two cities: does EMS level of care and transportation model affect survival in patients with trauma at level 1 trauma centres in two neighbouring Canadian provinces? Emerg Med J 2017; 35:83-88. [PMID: 29102923 DOI: 10.1136/emermed-2016-206329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 08/05/2017] [Accepted: 10/11/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Two distinct Emergency Medical Services (EMS) systems exist in Atlantic Canada. Nova Scotia operates an Advanced Emergency Medical System (AEMS) and New Brunswick operates a Basic Emergency Medical System (BEMS). We sought to determine if survival rates differed between the two systems. METHODS This study examined patients with trauma who were transported directly to a level 1 trauma centre in New Brunswick or Nova Scotia between 1 April 2011 and 31 March 2013. Data were extracted from the respective provincial trauma registries; the lowest common Injury Severity Score (ISS) collected by both registries was ISS≥13. Survival to hospital and survival to discharge or 30 days were the primary endpoints. A separate analysis was performed on severely injured patients. Hypothesis testing was conducted using Fisher's exact test and the Student's t-test. RESULTS 101 cases met inclusion criteria in New Brunswick and were compared with 251 cases in Nova Scotia. Overall mortality was low with 93% of patients surviving to hospital and 80% of patients surviving to discharge or 30 days. There was no difference in survival to hospital between the AEMS (232/251, 92%) and BEMS (97/101, 96%; OR 1.98, 95% CI 0.66 to 5.99; p=0.34) groups. Furthermore, when comparing patients with more severe injuries (ISS>24) there was no significant difference in survival (71/80, 89% vs 31/33, 94%; OR 1.96, 95% CI 0.40 to 9.63; p=0.50). CONCLUSION Overall survival to hospital was the same between advanced and basic Canadian EMS systems. As numbers included are low, individual case benefit cannot be excluded.
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Affiliation(s)
- Colin Rouse
- Dalhousie Medicine New Brunswick, Saint John, New Brunswick, Canada.,Department of Family Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, New Brunswick, Canada
| | - Jefferson Hayre
- Dalhousie Medicine New Brunswick, Saint John, New Brunswick, Canada.,Department of Family Medicine, McGill University, Jewish General Hospital, Montreal, Quebec, Canada
| | - James French
- Department of Emergency Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, New Brunswick, Canada.,New Brunswick Trauma Program, Saint John, New Brunswick, Canada
| | - Jacqueline Fraser
- Department of Emergency Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada
| | - Ian Watson
- New Brunswick Trauma Program, Saint John, New Brunswick, Canada
| | - Susan Benjamin
- New Brunswick Trauma Program, Saint John, New Brunswick, Canada
| | | | - Beth Sealy
- Nova Scotia Department of Health and Wellness, Trauma Nova Scotia, Halifax, Nova Scotia, Canada
| | - Mete Erdogan
- Nova Scotia Department of Health and Wellness, Trauma Nova Scotia, Halifax, Nova Scotia, Canada
| | - Robert S Green
- Nova Scotia Department of Health and Wellness, Trauma Nova Scotia, Halifax, Nova Scotia, Canada.,Department of Critical Care, Dalhousie University, Halifax, Nova Scotia, Canada
| | - George Stoica
- Research Services, Horizon Health Network, Saint John, New Brunswick, Canada
| | - Paul Atkinson
- Department of Emergency Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, New Brunswick, Canada.,New Brunswick Trauma Program, Saint John, New Brunswick, Canada
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Denninghoff KR, Nuño T, Pauls Q, Yeatts SD, Silbergleit R, Palesch YY, Merck LH, Manley GT, Wright DW. Prehospital Intubation is Associated with Favorable Outcomes and Lower Mortality in ProTECT III. PREHOSP EMERG CARE 2017; 21:539-544. [PMID: 28489506 PMCID: PMC7225216 DOI: 10.1080/10903127.2017.1315201] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/29/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) causes more than 2.5 million emergency department visits, hospitalizations, or deaths annually. Prehospital endotracheal intubation has been associated with poor outcomes in patients with TBI in several retrospective observational studies. We evaluated the relationship between prehospital intubation, functional outcomes, and mortality using high quality data on clinical practice collected prospectively during a randomized multicenter clinical trial. METHODS ProTECT III was a multicenter randomized, double-blind, placebo-controlled trial of early administration of progesterone in 882 patients with acute moderate to severe nonpenetrating TBI. Patients were excluded if they had an index GCS of 3 and nonreactive pupils, those with withdrawal of life support on arrival, and if they had documented prolonged hypotension and/or hypoxia. Prehospital intubation was performed as per local clinical protocol in each participating EMS system. Models for favorable outcome and mortality included prehospital intubation, method of transport, index GCS, age, race, and ethnicity as independent variables. Significance was set at α = 0.05. Favorable outcome was defined by a stratified dichotomy of the GOS-E scores in which the definition of favorable outcome depended on the severity of the initial injury. RESULTS Favorable outcome was more frequent in the 349 subjects with prehospital intubation (57.3%) than in the other 533 patients (46.0%, p = 0.003). Mortality was also lower in the prehospital intubation group (13.8% v. 19.5%, p = 0.03). Logistic regression analysis of prehospital intubation and mortality, adjusted for index GCS, showed that odds of dying for those with prehospital intubation were 47% lower than for those that were not intubated (OR = 0.53, 95% CI = 0.36-0.78). 279 patients with prehospital intubation were transported by air. Modeling transport method and mortality, adjusted for index GCS, showed increased odds of dying in those transported by ground compared to those transported by air (OR = 2.10, 95% CI = 1.40-3.15). Decreased odds of dying trended among those with prehospital intubation adjusted for transport method, index GCS score at randomization, age, and race/ethnicity (OR = 0.70, 95% CI = 0.37-1.31). CONCLUSIONS In this study that excluded moribund patients, prehospital intubation was performed primarily in patients transported by air. Prehospital intubation and air medical transport together were associated with favorable outcomes and lower mortality. Prehospital intubation was not associated with increased morbidity or mortality regardless of transport method or severity of injury.
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Fevang E, Perkins Z, Lockey D, Jeppesen E, Lossius HM. A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:192. [PMID: 28756778 PMCID: PMC5535283 DOI: 10.1186/s13054-017-1787-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 07/05/2017] [Indexed: 11/17/2022]
Abstract
Background Pre-hospital endotracheal intubation is frequently used for trauma patients in many emergency medical systems. Despite a wide range of publications in the field, it is debated whether the intervention is associated with a favourable outcome, when compared to more conservative airway measures. Methods A systematic literature search was conducted to identify interventional and observational studies where the mortality rates of adult trauma patients undergoing pre-hospital endotracheal intubation were compared to those undergoing emergency department intubation. Results Twenty-one studies examining 35,838 patients were included. The median mortality rate in patients undergoing pre-hospital intubation was 48% (range 8–94%), compared to 29% (range 6–67%) in patients undergoing intubation in the emergency department. Odds ratios were in favour of emergency department intubation both in crude and adjusted mortality, with 2.56 (95% CI: 2.06, 3.18) and 2.59 (95% CI: 1.97, 3.39), respectively. The overall quality of evidence is very low. Twelve of the twenty-one studies found a significantly higher mortality rate after pre-hospital intubation, seven found no significant differences, one found a positive effect, and for one study an analysis of the mortality rate was beyond the scope of the article. Conclusions The rationale for wide and unspecific indications for pre-hospital intubation seems to lack support in the literature, despite several publications involving a relatively large number of patients. Pre-hospital intubation is a complex intervention where guidelines and research findings should be approached cautiously. The association between pre-hospital intubation and a higher mortality rate does not necessarily contradict the importance of the intervention, but it does call for a thorough investigation by clinicians and researchers into possible causes for this finding. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1787-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Espen Fevang
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway. .,Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway.
| | - Zane Perkins
- Blizard Institute, Centre for Trauma Sciences, Queen Mary University, London, UK.,London's Air Ambulance, The Royal London Hospital, London, UK
| | - David Lockey
- Blizard Institute, Centre for Trauma Sciences, Queen Mary University, London, UK.,London's Air Ambulance, The Royal London Hospital, London, UK.,Department of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Elisabeth Jeppesen
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Hans Morten Lossius
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Sciences, University of Stavanger, Stavanger, Norway
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Abstract
BACKGROUND Trauma is time sensitive, and minimizing prehospital (PH) time is appealing. However, most studies have not linked increasing PH time with worse outcomes because raw PH times are highly variable. It is unclear whether specific PH time patterns affect outcomes. Our objective was to evaluate the association of PH time interval distribution with mortality. METHODS Patients transported by emergency medical services in the Pennsylvania trauma registry from 2000 to 2013 with a total PH time (TPT) of 20 minutes or longer were included. TPT was divided into three PH time intervals: response, scene, and transport time. The number of minutes in each PH time interval was divided by TPT to determine the relative proportion each interval contributed to TPT. A prolonged interval was defined as any one PH interval contributing equal to or greater than 50% of TPT. Patients were classified by prolonged PH interval or no prolonged PH interval (all intervals < 50% of TPT). Patients were matched for TPT, and conditional logistic regression determined the association of mortality with PH time pattern, controlling for confounders. PH interventions were explored as potential mediators, and PH triage criteria used identify patients with time-sensitive injuries. RESULTS There were 164,471 patients included. Patients with prolonged scene time had increased odds of mortality (odds ratio, 1.21; 95% confidence interval, 1.02-1.44; p = 0.03). Prolonged response, transport, and no prolonged interval were not associated with mortality. When adjusting for mediators including extrication and PH intubation, prolonged scene time was no longer associated with mortality (odds ratio, 1.06; 95% confidence interval, 0.90-1.25; p = 0.50). Together, these factors mediated 61% of the effect between prolonged scene time and mortality. Mortality remained associated with prolonged scene time in patients with hypotension, penetrating injury, and flail chest. CONCLUSION Prolonged scene time is associated with increased mortality. PH interventions partially mediate this association. Further study should evaluate whether these interventions drive increased mortality because they prolong scene time or by another mechanism, as reducing scene time may be a target for intervention. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.
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The Impact of Prehospital Intubation With and Without Sedation on Outcome in Trauma Patients With a GCS of 8 or Less. J Neurosurg Anesthesiol 2017; 29:161-167. [DOI: 10.1097/ana.0000000000000275] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bieler D, Franke A, Lefering R, Hentsch S, Willms A, Kulla M, Kollig E. 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 ®). Injury 2017; 48:32-40. [PMID: 27586065 DOI: 10.1016/j.injury.2016.08.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 08/11/2016] [Accepted: 08/26/2016] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Dan Bieler
- Department of Trauma Surgery and Orthopaedics, Reconstructive Surgery, Hand Surgery and Burn Medicine, German Armed Forces Central Hospital of Koblenz, Ruebenacher Strasse 170, 56072 Koblenz, Germany.
| | - Axel Franke
- Department of Trauma Surgery and Orthopaedics, Reconstructive Surgery, Hand Surgery and Burn Medicine, German Armed Forces Central Hospital of Koblenz, Ruebenacher Strasse 170, 56072 Koblenz, Germany.
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Sebastian Hentsch
- Department of Trauma Surgery and Orthopaedics, Reconstructive Surgery, Hand Surgery and Burn Medicine, German Armed Forces Central Hospital of Koblenz, Ruebenacher Strasse 170, 56072 Koblenz, Germany
| | - Arnulf Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Ruebenacher Strasse 170, 56072 Koblenz, Germany
| | - Martin Kulla
- Department of Anaesthesiology and Intensive Care, German Armed Forces Hospital of Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Erwin Kollig
- Department of Trauma Surgery and Orthopaedics, Reconstructive Surgery, Hand Surgery and Burn Medicine, German Armed Forces Central Hospital of Koblenz, Ruebenacher Strasse 170, 56072 Koblenz, Germany
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- Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU), Germany
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Abstract
Traumatic Brain Injury (TBI) was chosen as an Emergency Neurological Life Support topic due to its frequency, the impact of early intervention on outcomes for patients with TBI, and the need for an organized approach to the care of such patients within the emergency setting. This protocol was designed to enumerate the practice steps that should be considered within the first critical hour of neurological injury.
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Pediatric Airway Management and Prehospital Patient Safety: Results of a National Delphi Survey by the Children's Safety Initiative-Emergency Medical Services for Children. Pediatr Emerg Care 2016; 32:603-7. [PMID: 27253653 PMCID: PMC5008974 DOI: 10.1097/pec.0000000000000742] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this study was to determine what aspects of prehospital pediatric airway management may contribute to patient safety events. METHODS We conducted a 3-phase Delphi survey in prehospital professionals across the United States to identify potential contributors to patient safety events. Respondents ranked how likely factors were to contribute on a 9-point Likert-type scale and were allowed to elaborate through open-ended questions. Analysis was conducted using a mixed-methods approach, including Likert-type responses and open-ended questions which were analyzed for specific themes. RESULTS All 3 phases of the survey were completed by 492 participants; 50.8% of respondents were paramedics, 22% were emergency medical technician-basics/first responders, and 11.4% were physicians. Seventy-five percent identified lack of experience with advanced airway management, and 44% identified medical decision making regarding airway interventions as highly likely to lead to safety events. Within the domain of technical skills, advanced airway management was ranked in the top 3 contributors to safety events by 71% of participants, and bag-mask ventilation by 18%. Qualitative analysis of questions within the domains of equipment and technical skills identified endotracheal intubation as the top contributor to safety events, with bag-mask ventilation second. In the domains of assessment and decision making, respiratory assessment and knowing when to perform an advanced airway were ranked most highly. CONCLUSIONS This national Delphi survey identified lack of experience with pediatric airway management and challenges in decision making in advanced airway management as high risk for safety events, with endotracheal intubation as the most likely of these.
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Prehospital intubation for isolated severe blunt traumatic brain injury: worse outcomes and higher mortality. Eur J Trauma Emerg Surg 2016; 43:731-739. [PMID: 27567923 DOI: 10.1007/s00068-016-0718-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 08/15/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Prehospital endotracheal intubation (ETI) for traumatic brain injury (TBI) is a controversial issue. The aim of this study was to investigate the effect of prehospital ETI in patients with TBI. METHODS Cohort-matched study using the US National Trauma Data Bank (NTDB) 2008-2012. Patients with isolated severe blunt TBI (AIS head ≥3, AIS chest/abdomen <3) and a field GCS ≤8 were extracted from NTDB. A 1:1 matching of patients with and without prehospital ETI was performed. Matching criteria were sex, age, exact field GCS, exact AIS head, field hypotension, field cardiac arrest, and the brain injury type (according PREDOT-code). The matched cohorts were compared with univariable and multivariable regression analysis. RESULTS A total of 27,714 patients were included. Matching resulted in 8139 cases with and 8139 cases without prehospital ETI. Prehospital ETI was associated with significantly longer scene (median 9 vs. 8 min, p < 0.001) and transport times (median 26 vs. 19 min, p < 0.001), lower Emergency Department (ED) GCS scores (in patients without sedation; mean 3.7 vs. 3.9, p = 0.026), more ventilator days (mean 7.3 vs. 6.9, p = 0.006), longer ICU (median 6.0 vs. 5.0 days, p < 0.001) and total hospital length of stay (median 10.0 vs. 9.0 days, p < 0.001), and higher in-hospital mortality (31.4 vs. 27.5 %, p < 0.001). In regression analysis prehospital ETI was independently associated with lower ED GCS scores (RC -4.213, CI -4.562/-3.864, p < 0.001) and higher in-hospital mortality (OR 1.399, CI 1.205/1.624, p < 0.001). CONCLUSION In this large cohort-matched analysis, prehospital ETI in patients with isolated severe blunt TBI was independently associated with lower ED GCS scores and higher mortality.
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Savitsky B, Givon A, Rozenfeld M, Radomislensky I, Peleg K. Traumatic brain injury: It is all about definition. Brain Inj 2016; 30:1194-200. [PMID: 27466967 DOI: 10.1080/02699052.2016.1187290] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND TBI may be defined by different methods. Some may be most useful for immediate clinical purposes, however less optimal for epidemiologic research. Other methods, such as the Abbreviated Injury Score (AIS), may prove more beneficial for this task, if the cut-off-points for their categories are defined correctly. OBJECTIVE To reveal the optimal cut-off-points for AIS in definition of severity of TBI in order to ensure uniformity between future studies of TBI. RESULTS Mortality of patients with TBI AIS 3, 4 was 1.9% and 2.9% respectively, comparing with 31.1% among TBI AIS 5+. Predictive discrimination ability of the model with cut-off-points of 5+ for TBI AIS (in comparison with other cut-off-points) was better. Patients with missing Glasgow Coma Scale (GCS) in the ED had an in-hospital mortality rate of 11.5%. In this group, 25% had critical TBI according to AIS. Normal GCS didn't indicate an absence of head injury, as, among patients with GCS 15 in the ED, 26% had serious/critical TBI injury. Moreover, 7% of patients with multiple injury and GCS 3-8 had another reason than head injury for unconsciousness. CONCLUSIONS This study recommends the adoption of an AIS cut-off ≥ 5 as a valid definition of severe TBI in epidemiological studies, while AIS 3-4 may be defined as 'moderate' TBI and AIS 1-2 as 'mild'.
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Affiliation(s)
- B Savitsky
- a Israel National Center for Trauma and Emergency Medicine Research , Gertner Institute for Epidemiology and Health Policy Research , Tel Hashomer , Ramat Gan , Israel
| | - A Givon
- a Israel National Center for Trauma and Emergency Medicine Research , Gertner Institute for Epidemiology and Health Policy Research , Tel Hashomer , Ramat Gan , Israel
| | - M Rozenfeld
- a Israel National Center for Trauma and Emergency Medicine Research , Gertner Institute for Epidemiology and Health Policy Research , Tel Hashomer , Ramat Gan , Israel.,b Faculty of Medicine , Tel-Aviv University, School of Public Health , Tel-Aviv , Israel
| | - I Radomislensky
- a Israel National Center for Trauma and Emergency Medicine Research , Gertner Institute for Epidemiology and Health Policy Research , Tel Hashomer , Ramat Gan , Israel
| | - K Peleg
- a Israel National Center for Trauma and Emergency Medicine Research , Gertner Institute for Epidemiology and Health Policy Research , Tel Hashomer , Ramat Gan , Israel.,b Faculty of Medicine , Tel-Aviv University, School of Public Health , Tel-Aviv , Israel
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Isolated blunt severe traumatic brain injury in Bern, Switzerland, and the United States: A matched cohort study. J Trauma Acute Care Surg 2016; 80:296-301. [PMID: 26491802 DOI: 10.1097/ta.0000000000000892] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The ideal prehospital management of patients with severe traumatic brain injury (TBI) including the impact of endotracheal intubation (ETI) and physicians on scene is unclear. Prehospital management differs substantially in Switzerland and the United States: in Switzerland, there is usually a physician on scene who may provide ETI and other advanced life support procedures, whereas in the United States, prehospital management (including ETI) is performed by paramedics. METHODS This is a retrospective cohort-matched study of patients with isolated blunt severe TBI (head Abbreviated Injury Scale [AIS] score, 4-5) and no major extracranial injuries, using Bern University Hospital data from the Swiss PEBITA [Patient-relevant Endpoints after Brain Injury from Traumatic Accidents] (TBI-specific) database and the US National Trauma Data Bank from 2009 to 2010. A 1:4 cohort matching of Bern and US patients was performed. Matching criteria were sex, age (±10 years), exact field Glasgow Coma Scale (GCS) score, exact head AIS score, and injury type (subdural hematoma, epidural hematoma, intraparenchymal hemorrhage, intraventricular hemorrhage, brain edema/swelling, brain stem injury). The matched cohorts were compared with univariable analysis (Fisher's exact test and Mann-Whitney U-test). RESULTS Matching of the Bern (n = 128) and US (n = 86,375) cohort resulted in 355 matched cases (71 Bern and 284 US patients). Bern patients had significantly longer scene times (median, 23.0 minutes vs. 9.0 minutes, p < 0.001) and more frequent prehospital ETI (31.0% vs. 18.7%, p = 0.034) and air transportation (39.4% vs. 19.4%, p < 0.001). No significant difference in procedures (craniotomy/craniectomy, intracranial pressure monitoring, tracheotomy), intensive care unit and total hospital lengths of stay, ventilator days, and in-hospital mortality (14.1% vs. 15.8%, p = 0.855) was found between the two cohorts. CONCLUSION When taking into account the limitation that patient- and injury-related factors, but not in-hospital treatment variables, were matched, the more frequent prehospital ETI and presence of a physician on scene in the Swiss cohort compared with the US cohort had no significant effect on outcomes, including intensive care unit and total hospital lengths of stay, ventilator days, and in-hospital mortality. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Strnad M, Borovnik Lesjak V, Vujanović V, Križmarić M. Predictors of mortality in patients with isolated severe traumatic brain injury. Wien Klin Wochenschr 2016; 129:110-114. [PMID: 26968575 DOI: 10.1007/s00508-016-0974-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 02/11/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Many prognostic models predicting mortality in patients with TBI were developed, which also include patients with mild or moderate TBI and patients who suffered major extracranial injuries. METHODS From a prospective database, we conducted a retrospective medical chart review covering the period between January 2000 and December 2012 of patients with isolated severe TBI (Abbreviated Injury Score for head, AISH ≥ 3) without extracranial injuries, who were intubated in the field using the rapid sequence intubation method and were of age 16 or more. Prehospital vital signs, Injury Severity Score (ISS) and laboratory tests were compared in two study groups: survivors (n = 25) and non-survivors (n = 27). Selected variables identified during univariate analysis (p < 0.1) were then subjected to multivariate analysis logistic regression model. RESULTS Univariate analysis showed that in-hospital mortality was statistically significantly associated with male sex (p = 0.040), ISS (p = 0.005) and mydriasis (p = 0.012). For predicting mortality, area under the curve (AUC) was calculated: for ISS 0.76 (95 % confidence interval, CI; 0.63-0.90; p < 0.001) and for initial Glasgow Coma Scale (GCS) 0.64 (95 % CI, 0.49-0.80, p = 0.079). In the multivariate analysis, ISS (odds ratio, OR; 1.19, 95 % CI, 1.06-1.35; p = 0.004) and mydriasis (OR, 5.73; 95 % CI, 1.06-30.88; p = 0.042) were identified as independent risk factors for in-hospital mortality. The AUC for the regression model was 0.83 (95 % CI, 0.71-0.94; p < 0.001). CONCLUSIONS In prehospital intubated patients with isolated severe TBI only ISS and mydriasis were found to be independent predictors of in-hospital mortality.
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Affiliation(s)
- Matej Strnad
- Center for Emergency Medicine, Community Health Center Maribor, Prehospital Unit, Ulica talcev 9, 2000, Maribor, Slovenia. .,Medical Faculty, University of Maribor, Taborska ulica 8, 2000, Maribor, Slovenia.
| | - Vesna Borovnik Lesjak
- Center for Emergency Medicine, Community Health Center Maribor, Prehospital Unit, Ulica talcev 9, 2000, Maribor, Slovenia
| | - Vitka Vujanović
- Center for Emergency Medicine, Community Health Center Maribor, Prehospital Unit, Ulica talcev 9, 2000, Maribor, Slovenia
| | - Miljenko Križmarić
- Medical Faculty, University of Maribor, Taborska ulica 8, 2000, Maribor, Slovenia.,Faculty of Health Sciences, University of Maribor, Žitna ulica 15, 2000, Maribor, Slovenia
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Fang R, Markandaya M, DuBose JJ, Cancio LC, Shackelford S, Blackbourne LH. Early in-theater management of combat-related traumatic brain injury: A prospective, observational study to identify opportunities for performance improvement. J Trauma Acute Care Surg 2016; 79:S181-7. [PMID: 26406428 DOI: 10.1097/ta.0000000000000769] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Combat-related moderate-to-severe traumatic brain injury (CRTBI) is a significant cause of wartime morbidity and mortality. As of August 2014, moderate-to-severe traumatic brain injuries sustained by members of the Department of Defense worldwide since 2000 totaled 32,996 cases. Previously published epidemiologic reviews describe CRTBI management at a "strategic" level, but they lack "tactical" patient-specific data required for performance improvement. In addition, scarce data exist regarding prehospital CRTBI care. METHODS This is a prospective observational study of consecutive CRTBI casualties presenting to US Role 3 medical facilities. Admission variables including demographics, initial clinical findings, and laboratory results were collected. Head computed tomographic scan findings were noted. Interventions in the first 72 postinjury hours were recorded. Early in-theater mortality was noted, but longer-term outcomes were not. RESULTS Casualties were predominately injured by explosive blasts (78.6%). Penetrating injuries occurred in 42.9%. On arrival, Glasgow Coma Scale (GCS) score was less than 8 for 47.7%. Hypothermia (temperature < 95.0°F) was present in 4.5%, and hypotension (systolic blood pressure < 90 mm Hg) in 21.1%. Hypoxia (O2 saturation < 90%) was observed in 52.5%. Both hypercarbia (Paco2 > 45 mm Hg, 50%) and hypocarbia (Paco2 < 36 mm Hg, 20.3%) were common on presentation. Head computed tomographic scan most commonly found skull fracture (68.9%), subdural hematoma (54.1%), and cerebral contusion (51.4%). Hypertonic saline was administered to 69.7% and factor VIIa to 11.1%. Early in-theater mortality at Role 3 was 19.4%. CONCLUSION Avoidance of secondary brain injury by optimizing oxygenation, ventilation, and cerebral perfusion is the primary goal in the contemporary care of moderate-to-severe CRTBI. Ideally, this crucial care must begin as early as possible after injury. Given the frequency of hypotension, hypoxia, and both hypercarbia and hypocarbia upon Role 3 arrival, increased emphasis on prehospital management is indicated. LEVEL OF EVIDENCE Therapeutic study, level IV; epidemiologic study, level III.
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Affiliation(s)
- Raymond Fang
- From the United States Air Force Center for Sustainment of Trauma and Readiness Skills (R.F., J.J.D., S.S.); and R Adams Cowley Shock Trauma Center (M.M.), University of Maryland Medical Center, Baltimore, Maryland; and United States Army Institute for Surgical Research (L.C.C., L.H.B.), Brooke Army Medical Center, Fort Sam Houston, San Antonio, Texas
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Ono Y, Shinohara K, Goto A, Yano T, Sato L, Miyazaki H, Shimada J, Tase C. Are prehospital airway management resources compatible with difficult airway algorithms? A nationwide cross-sectional study of helicopter emergency medical services in Japan. J Anesth 2015; 30:205-14. [PMID: 26715428 PMCID: PMC4819484 DOI: 10.1007/s00540-015-2124-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 12/13/2015] [Indexed: 11/29/2022]
Abstract
Purpose
Immediate access to the equipment required for difficult airway management (DAM) is vital. However, in Japan, data are scarce regarding the availability of DAM resources in prehospital settings. The purpose of this study was to determine whether Japanese helicopter emergency medical services (HEMS) are adequately equipped to comply with the DAM algorithms of Japanese and American professional anesthesiology societies. Methods This nationwide cross-sectional study was conducted in May 2015. Base hospitals of HEMS were mailed a questionnaire about their airway management equipment and back-up personnel. Outcome measures were (1) call for help, (2) supraglottic airway device (SGA) insertion, (3) verification of tube placement using capnometry, and (4) the establishment of surgical airways, all of which have been endorsed in various airway management guidelines. The criteria defining feasibility were the availability of (1) more than one physician, (2) SGA, (3) capnometry, and (4) a surgical airway device in the prehospital setting. Results Of the 45 HEMS base hospitals questioned, 42 (93.3 %) returned completed questionnaires. A surgical airway was practicable by all HEMS. However, in the prehospital setting, back-up assistance was available in 14.3 %, SGA in 16.7 %, and capnometry in 66.7 %. No HEMS was capable of all four steps. Conclusion In Japan, compliance with standard airway management algorithms in prehospital settings remains difficult because of the limited availability of alternative ventilation equipment and back-up personnel. Prehospital health care providers need to consider the risks and benefits of performing endotracheal intubation in environments not conducive to the success of this procedure. Electronic supplementary material The online version of this article (doi:10.1007/s00540-015-2124-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuko Ono
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan. .,Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, Koriyama, Japan.
| | - Kazuaki Shinohara
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Aya Goto
- Department of Public Health, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Tetsuhiro Yano
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Lubna Sato
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Hiroyuki Miyazaki
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Jiro Shimada
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Choichiro Tase
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan
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Abstract
The need for timely and appropriate airway management for trauma patients is widely recognised. There are a small number of severely injured patients who cannot be adequately supported with basic airway manoeuvres, and require early advanced airway management. The way in which this care is provided remains highly controversial. Whilst it is clear that effective airway management remains a priority for all patients and poorly performed pre-hospital anaesthesia may be detrimental to patient outcome, debate remains over exactly which patients will benefit from early advanced airway interventions, and how it should be provided. The evidence base is small and inconsistent, with significant heterogeneity in the reported data, making it impossible to draw meaningful conclusions. Current practice is not standardised, and care is delivered by providers of different abilities using a range of equipment and techniques. Standards of care provided during in-hospital practice relating to these issues of provider competence, equipment, and monitoring should be directly translated into delivery of care outside the hospital, but this is not always the case. The aim of this review is to evaluate the current evidence surrounding pre-hospital advanced airway management.
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Affiliation(s)
- Kate Crewdson
- North Bristol NHS Trust, Southmead Hospital, UK
- London’s Air Ambulance, Royal London Hospital, UK
| | - David Lockey
- North Bristol NHS Trust, Southmead Hospital, UK
- London’s Air Ambulance, Royal London Hospital, UK
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47
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Prehospital interventions in severely injured pediatric patients. J Trauma Acute Care Surg 2015; 79:983-9; discussion 989-90. [DOI: 10.1097/ta.0000000000000706] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Brown CA, Cox K, Hurwitz S, Walls RM. 4,871 Emergency airway encounters by air medical providers: a report of the air transport emergency airway management (NEAR VI: "A-TEAM") project. West J Emerg Med 2015; 15:188-93. [PMID: 24672610 PMCID: PMC3966436 DOI: 10.5811/westjem.2013.11.18549] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 10/03/2013] [Accepted: 11/11/2013] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Pre-hospital airway management is a key component of resuscitation although the benefit of pre-hospital intubation has been widely debated. We report a large series of pre-hospital emergency airway encounters performed by air-transport providers in a large, multi-state system. METHODS We retrospectively reviewed electronic intubation flight records from an 89 rotorcraft air medical system from January 01, 2007, through December 31, 2009. We report patient characteristics, intubation methods, success rates, and rescue techniques with descriptive statistics. We report proportions with 95% confidence intervals and binary comparisons using chi square test with p-values <0.05 considered significant. RESULTS 4,871 patients had active airway management, including 2,186 (44.9%) medical and 2,685 (55.1%) trauma cases. There were 4,390 (90.1%) adult and 256 (5.3%) pediatric (age ≤ 14) intubations; 225 (4.6%) did not have an age recorded. 4,703 (96.6%) had at least one intubation attempt. Intubation was successful on first attempt in 3,710 (78.9%) and was ultimately successful in 4,313 (91.7%). Intubation success was higher for medical than trauma patients (93.4% versus 90.3%, p=0.0001 JT test). 168 encounters were managed primarily with an extraglottic device (EGD). Cricothyrotomy was performed 35 times (0.7%) and was successful in 33. Patients were successfully oxygenated and ventilated with an endotracheal tube, EGD, or surgical airway in 4809 (98.7%) encounters. There were no reported deaths from a failed airway. CONCLUSION Airway management, predominantly using rapid sequence intubation protocols, is successful within this high-volume, multi-state air-transport system.
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Affiliation(s)
- Calvin A Brown
- Brigham and Women's Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Kelly Cox
- University of Illinois-Peoria, Department of Emergency Medicine, Peoria, Illinois
| | - Shelley Hurwitz
- Brigham and Women's Hospital, Harvard Medical School, Department of Medicine, Boston, Massachusetts
| | - Ron M Walls
- Brigham and Women's Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
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49
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Experience in Prehospital Endotracheal Intubation Significantly Influences Mortality of Patients with Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0141034. [PMID: 26496440 PMCID: PMC4619807 DOI: 10.1371/journal.pone.0141034] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 10/02/2015] [Indexed: 11/19/2022] Open
Abstract
Background Patients with severe traumatic brain injury (TBI) are at high risk for airway obstruction and hypoxia at the accident scene, and routine prehospital endotracheal intubation has been widely advocated. However, the effects on outcome are unclear. We therefore aim to determine effects of prehospital intubation on mortality and hypothesize that such effects may depend on the emergency medical service providers’ skill and experience in performing this intervention. Methods and Findings PubMed, Embase and Web of Science were searched without restrictions up to July 2015. Studies comparing effects of prehospital intubation versus non-invasive airway management on mortality in non-paediatric patients with severe TBI were selected for the systematic review. Results were pooled across a subset of studies that met predefined quality criteria. Random effects meta-analysis, stratified by experience, was used to obtain pooled estimates of the effect of prehospital intubation on mortality. Meta-regression was used to formally assess differences between experience groups. Mortality was the main outcome measure, and odds ratios refer to the odds of mortality in patients undergoing prehospital intubation versus odds of mortality in patients who are not intubated in the field. The study was registered at the International Prospective Register of Systematic Reviews (PROSPERO) with number CRD42014015506. The search provided 733 studies, of which 6 studies including data from 4772 patients met inclusion and quality criteria for the meta-analysis. Prehospital intubation by providers with limited experience was associated with an approximately twofold increase in the odds of mortality (OR 2.33, 95% CI 1.61 to 3.38, p<0.001). In contrast, there was no evidence for higher mortality in patients who were intubated by providers with extended level of training (OR 0.75, 95% CI 0.52 to 1.08, p = 0.126). Meta-regression confirmed that experience is a significant predictor of mortality (p = 0.009). Conclusions Effects of prehospital endotracheal intubation depend on the experience of prehospital healthcare providers. Intubation by paramedics who are not well skilled to do so markedly increases mortality, suggesting that routine prehospital intubation of TBI patients should be abandoned in emergency medical services in which providers do not have ample training, skill and experience in performing this intervention.
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Hyldmo PK, Vist GE, Feyling AC, Rognås L, Magnusson V, Sandberg M, Søreide E. Does turning trauma patients with an unstable spinal injury from the supine to a lateral position increase the risk of neurological deterioration?--A systematic review. Scand J Trauma Resusc Emerg Med 2015; 23:65. [PMID: 26382216 PMCID: PMC4573694 DOI: 10.1186/s13049-015-0143-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 08/10/2015] [Indexed: 12/22/2022] Open
Abstract
Background Airway protection and spinal precautions are competing concerns in the treatment of unconscious trauma patients. The placement of such patients in a lateral position may facilitate the acquisition of an adequate airway. However, trauma dogma dictates that patients should be transported in the supine position to minimize spinal movement. In this systematic review, we sought to answer the following question: Given an existing spinal injury, will changing a patient’s position from supine to lateral increase the risk of neurological deterioration? Methods The review protocol was published in the PROSPERO database (Reg. no. CRD42012001190). We performed literature searches in PubMed, Medline, EMBASE, the Cochrane Library, CINAHL and the British Nursing Index and included studies of traumatic spinal injury, lateral positioning and neurological deterioration. The search was updated prior to submission. Two researchers independently completed each step in the review process. Results We identified 1,164 publications. However, none of these publications reported mortality or neurological deterioration with lateral positioning as an outcome measure. Twelve studies used movement of the injured spine with lateral positioning as an outcome measure; eleven of these investigations were cadaver studies. All of these cadaver studies reported spinal movement during lateral positioning. The only identified human study included eighteen patients with thoracic or lumbar spinal fractures; according to the study authors, the logrolling technique did not result in any neurological deterioration among these patients. Conclusions We identified no clinical studies demonstrating that rotating trauma patients from the supine position to a lateral position affects mortality or causes neurological deterioration. However, in various cadaver models, this type of rotation did produce statistically significant displacements of the injured spine. The clinical significance of these cadaver-based observations remains unclear. The present evidence for harm in rotating trauma patients from the supine position to a lateral position, including the logroll maneuver, is inconclusive. Electronic supplementary material The online version of this article (doi:10.1186/s13049-015-0143-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Per Kristian Hyldmo
- Norwegian Air Ambulance Foundation, Department of Research and Development, Drøbak, Norway. .,Department of Anesthesiology and Intensive Care, Sørlandet Hospital, Kristiansand, Norway.
| | - Gunn E Vist
- The Norwegian Knowledge Center for the Health Services, Oslo, Norway.
| | | | - Leif Rognås
- Pre-hospital Critical Care Services, Aarhus, Denmark.
| | - Vidar Magnusson
- Department of Anesthesiology, Landspitalinn University Hospital, Reykjavík, Iceland.
| | - Mårten Sandberg
- Faculty of Medicine, University of Oslo, Oslo, Norway. .,Air Ambulance Department, Oslo University Hospital, Oslo, Norway.
| | - Eldar Søreide
- Network for Medical Sciences, University of Stavanger, Stavanger, Norway. .,Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway.
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