Prehospital Procedures Before Emergency Department Thoracotomy: “Scoop and Run” Saves Lives

Outcomes of Trauma "Walk-Ins" in the American College of Surgeons Trauma Quality Program Database

BACKGROUND

Outcomes of trauma "walk-in" patients (using private vehicles or on foot) are understudied. We compared outcomes of ground ambulance vs walk-ins, hypothesizing that delayed resuscitation and uncoordinated care may worsen walk-in outcomes.

METHODS

A retrospective analysis 2020 American College of Surgeons Trauma Quality Programs (ACS-TQP) databases compared outcomes between ambulance vs "walk-ins." The primary outcome was in-hospital mortality, excluding external facility transfers and air transports. Data was analyzed with descriptive statistics, bivariate, multivariable logistic regression, including an Inverse Probability Weighted Regression Adjustment with adjustments for injury severity and vital signs. The primary outcome for the 2019 (pre-COVID-19 pandemic) data was similarly analyzed.

RESULTS

In 2020, 707,899 patients were analyzed, 556,361 (78.59%) used ambulance, and 151,538 (21.41%) were walk-ins. We observed differences in demographics, hospital attributes, medical comorbidities, and injury mechanism. Ambulance patients had more chronic conditions and severe injuries. Walk-ins had lower in-hospital mortality (850 (.56%) vs 23,131 (4.16%)) and arrived with better vital signs. Multivariable logistic regression models (inverse probability weighting for regression adjustment), adjusting for injury severity, demographics, injury mechanism, and vital signs, confirmed that walk-in status had lower odds of mortality. For the 2019 (pre-COVID-19 pandemic) database, walk-ins also had lower in-hospital mortality.

DISCUSSION

Our results demonstrate better survival rates for walk-ins before and during COVID-19 pandemic. Despite limitations of patient selection bias, this study highlights the need for further research into transportation modes, geographic and socioeconomic factors affecting patient transport, and tailoring management strategies based on their mode of arrival.

The Impact of Out-of-Hospital Time and Prehospital Intubation on Return of Spontaneous Circulation following Resuscitative Thoracotomy in Traumatic Cardiac Arrest

INTRODUCTION

Resuscitative thoracotomy (RT) is a critical procedure performed in certain trauma patients in extremis, with extremely low survival rates. Currently, there is a paucity of data pertaining to prehospital variables and their predictive role in survival outcomes in traumatic cardiac arrest (TCA) patients requiring RT. The aim of the study was to determine the impact of prehospital intubation and out-of-hospital time (OOHT) on return of spontaneous circulation (ROSC) and survival in TCA requiring RT.

METHODS

This was a retrospective cohort study of trauma patients presenting to two level-1 trauma centers, St. Michael's Hospital and Sunnybrook Health Sciences Center, in Toronto, Canada (January 1, 2005-December 31, 2020). Our exposures of interest were any prehospital intubation attempt and OOHT. Primary and secondary outcome measures were ROSC post-RT and survival to hospital discharge, respectively, and data analysis was performed using univariate logistic regression.

RESULTS

A total of 195 patients were included, of which 86% were male, and the mean age was 33 years. ROSC and survival to hospital discharge were achieved in 30% and 5% of patients, respectively. Of those who survived to discharge, 89% sustained penetrating trauma. There was no association between OOHT and ROSC (OR = 1.00, 95% CI 0.97-1.03) or survival (OR = 0.99, 95% CI 0.94-1.05). The odds of ROSC were lower in penetrating trauma in the presence of any prehospital intubation attempt (OR = 0.39, 95% CI 0.19-0.82, p = 0.01). ROSC was less likely among all patients with no prehospital signs of life (SOL) compared to those who had prehospital SOL (OR = 0.30, 95% CI 0.13-0.69, p < 0.01).

CONCLUSIONS

There was a significant association between prehospital intubation and lower likelihoods of ROSC in the penetrating TCA population requiring RT, as well as with the absence of prehospital SOL in all patients. OOHT did not appear to significantly impact ROSC or survival.

Prehospital transportation of severe penetrating trauma victims in Sweden during the past decade: a police business?

INTRODUCTION

Sweden is facing a surge of gun violence that mandates optimized prehospital transport approaches, and a survey of current practice is fundamental for such optimization. Management of severe, penetrating trauma is time sensitive, and there may be a survival benefit in limiting prehospital interventions. An important aspect is unregulated transportation by police or private vehicles to the hospital, which may decrease time but may also be associated with adverse outcomes. It is not known whether transport of patients with penetrating trauma occurs outside the emergency medical services (EMS) in Sweden and whether it affects outcome.

METHOD

This was a retrospective, descriptive nationwide study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 registered in the Swedish national trauma registry (SweTrau) between June 13, 2011, and December 31, 2019. We hypothesized that transport by police and private vehicles occurred and that it affected mortality.

RESULT

A total of 657 patients were included. EMS transported 612 patients (93.2%), police 10 patients (1.5%), and private vehicles 27 patients (4.1%). Gunshot wounds (GSWs) were more common in police transport, 80% (n = 8), compared with private vehicles, 59% (n = 16), and EMS, 32% (n = 198). The Glasgow coma scale score (GCS) in the emergency department (ED) was lower for patients transported by police, 11.5 (interquartile range [IQR] 3, 15), in relation to EMS, 15 (IQR 14, 15) and private vehicles 15 (IQR 12.5, 15). The 30-day mortality for EMS was 30% (n = 184), 50% (n = 5) for police transport, and 22% (n = 6) for private vehicles. Transport by private vehicle, odds ratio (OR) 0.65, (confidence interval [CI] 0.24, 1.55, p = 0.4) and police OR 2.28 (CI 0.63, 8.3, p = 0.2) were not associated with increased mortality in relation to EMS.

CONCLUSION

Non-EMS transports did occur, however with a low incidence and did not affect mortality. GSWs were more common in police transport, and victims had lower GCS scorescores when arriving at the ED, which warrants further investigations of the operational management of shooting victims in Sweden.

The Prevalence and Utilization of Prehospital IV Access in Critically Ill Patients in the Emergency Department

BACKGROUND

Despite the pivotality of emergency medical services (EMS) in prehospital care for patient stabilization, prehospital intravenous (IV) access, a standard practice, remains an ambiguity in Saudi Arabia in terms of its prevalence of placement, justification, and utilization.

OBJECTIVES

In this study, we aim to estimate the prevalence and utilization rate of prehospital IV access placement in patients transported to King Khalid University Hospital (KKUH) Emergency Medicine Department in Riyadh by EMS and determine the relationship between the prevalence and utilization rate of prehospital IV access in Canadian Triage and Acuity Scale (CTAS) levels 1 and 2 in trauma and non-trauma patients.

METHODS

This observational cross-sectional study was conducted over six months. A total of 181 cases of CTAS levels 1 and 2 adult patients were included. Data were collected by trained nurses using convenient sampling through an author-developed questionnaire.

RESULTS

 The prevalence of prehospital IV line placement was 28.7%, with a utilization rate of 50%, and was notably higher among CTAS level 1 cases (69.2%). Additionally, trauma cases had a higher prevalence of prehospital IV access (53.5%) compared to medical cases (odds ratio (OR): 4.73, 95% confidence interval (CI): 4.73, 4.73, p<0.05). Among patients with prehospital IV lines, the majority (92.3%) were patent and functional. Upon arrival, 73.1% of patients had their prehospital IV line replaced, with hospital protocol being the most common reason for the replacement (73.7%).

CONCLUSION

A minority of the patients had prehospital vascular access, and of those, half remained unused. Trauma cases and CTAS level 1 patients had a higher prevalence and utilization of prehospital IV access. Furthermore, trauma cases were more associated with prehospital IV access establishment and utilization.

Predictors of survival in trauma patients requiring resuscitative thoracotomy: A scoping review

Introduction

Resuscitative thoracotomy (RT) is an emergent procedure to gain access to the thoracic cavity to control hemorrhage and other life-threatening injuries. Data predicting survival is variable. This review aims to highlight key predictors of survival and mortality following RT.

Methods

The EMBASE database was searched using the following terms: [exp. Thoracotomy] AND [Trauma.mp] AND [exp. Survival OR exp. Mortality]. The search was limited to full-text articles in the English language and publications released up to February 27, 2022. Reference lists of included articles were reviewed to identify other studies meeting inclusion criteria.

Results

Thirty-seven studies were included. Seventy-six outcome predictors were identified. Prehospital outcome predictors included prehospital vital signs, police transport, cardiopulmonary resuscitation, application of a cervical spine collar, and the number of total prehospital procedures performed. In-hospital variables associated with survival included traumatic cardiac arrest (TCA) in the emergency department (ED), initial ED vital signs and cardiac rhythm, Shock Index Pediatric Age-Adjusted score, location of RT, duration of RT, Focused Assessment with Sonography in Trauma findings, amount of blood products, and amount of administered fluids.

Conclusions

Our study highlights the disparity of data regarding prehospital outcome predictors for trauma patients requiring RT. Most studies focus on injury-specific and in-hospital variables and do not explicitly look at the TCA population. Further work is needed to better define specific variables implicated in enhanced survival across different care settings and to inform management guidelines within these clinical areas.

Transport of the patient with trauma: a narrative review

Trauma and injury place a significant burden on healthcare systems. In most high-income countries, well-developed acute pre-hospital and trauma care systems have been established. In Europe, mobile physician-staffed medical teams are available for the most severely injured patients and apply a wide variety of lifesaving interventions at the same time as ensuring patient comfort. In trauma systems providing pre-hospital care, medical interventions are performed earlier in the patient journey and do not affect time to definite care. The mode of transport from the accident scene depends on the organisation of the healthcare system and the level of hospital care to which the patient is transported. This varies from 'scoop and run' to a basic community care setting, to advanced helicopter emergency medical service transport to a level 4 trauma centre. Secondary transport of trauma patients to a higher level of care should be avoided and may lead to a delay in definitive care. Critically injured patients must be accompanied by at least two healthcare professionals, one of whom must be skilled in cardiopulmonary resuscitation and advanced airway management techniques. Ideally, the standard of care provided during transport, including the level of monitoring, should mirror hospital care. Pre-hospital care focuses on the critical care patient, but the majority of injured patients need only close observation and pain management during transport. Providing comfort and preventing additional injury is the responsibility of the whole transport team.

Association Between Geospatial Access to Care and Firearm Injury Mortality in Philadelphia

Importance

The burden of firearm violence in US cities continues to rise. The role of access to trauma center care as a trauma system measure with implications for firearm injury mortality has not been comprehensively evaluated.

Objective

To evaluate the association between geospatial access to care and firearm injury mortality in an urban trauma system.

Design, Setting, and Participants

Retrospective cohort study of all people 15 years and older shot due to interpersonal violence in Philadelphia, Pennsylvania, between January 1, 2015, and August 9, 2021.

Exposures

Geospatial access to care, defined as the predicted ground transport time to the nearest trauma center for each person shot, derived by geospatial network analysis.

Main Outcomes and Measures

Risk-adjusted mortality estimated using hierarchical logistic regression. The population attributable fraction was used to estimate the proportion of fatalities attributable to disparities in geospatial access to care.

Results

During the study period, 10 105 people (910 [9%] female and 9195 [91%] male; median [IQR] age, 26 [21-28] years; 8441 [84%] Black, 1596 [16%] White, and 68 other [<1%], including Asian and unknown, consolidated owing to small numbers) were shot due to interpersonal violence in Philadelphia. Of these, 1999 (20%) died. The median (IQR) predicted transport time was 5.6 (3.8-7.2) minutes. After risk adjustment, each additional minute of predicted ground transport time was associated with an increase in odds of mortality (odds ratio [OR], 1.03 per minute; 95% CI, 1.01-1.05). Calculation of the population attributable fraction using mortality rate ratios for incremental 1-minute increases in predicted ground transport time estimated that 23% of shooting fatalities could be attributed to differences in access to care, equivalent to 455 deaths over the study period.

Conclusions and Relevance

These findings indicate that geospatial access to care may be an important trauma system measure, improvements to which may result in reduced deaths from gun violence in US cities.

Association of Prehospital Needle Decompression With Mortality Among Injured Patients Requiring Emergency Chest Decompression

Importance

Prehospital needle decompression (PHND) is a rare but potentially life-saving procedure. Prior studies on chest decompression in trauma patients have been small, limited to single institutions or emergency medical services (EMS) agencies, and lacked appropriate comparator groups, making the effectiveness of this intervention uncertain.

Objective

To determine the association of PHND with early mortality in patients requiring emergent chest decompression.

Design, Setting, and Participants

This was a retrospective cohort study conducted from January 1, 2000, to March 18, 2020, using the Pennsylvania Trauma Outcomes Study database. Patients older than 15 years who were transported from the scene of injury were included in the analysis. Data were analyzed between April 28, 2021, and September 18, 2021.

Exposures

Patients without PHND but undergoing tube thoracostomy within 15 minutes of arrival at the trauma center were the comparison group that may have benefited from PHND.

Main Outcomes and Measures

Mixed-effect logistic regression was used to determine the variability in PHND between patient and EMS agency factors, as well as the association between risk-adjusted 24-hour mortality and PHND, accounting for clustering by center and year. Propensity score matching, instrumental variable analysis using EMS agency-level PHND proportion, and several sensitivity analyses were performed to address potential bias.

Results

A total of 8469 patients were included in this study; 1337 patients (11%) had PHND (median [IQR] age, 37 [25-52] years; 1096 male patients [82.0%]), and 7132 patients (84.2%) had emergent tube thoracostomy (median [IQR] age, 32 [23-48] years; 6083 male patients [85.3%]). PHND rates were stable over the study period between 0.2% and 0.5%. Patient factors accounted for 43% of the variation in PHND rates, whereas EMS agency accounted for 57% of the variation. PHND was associated with a 25% decrease in odds of 24-hour mortality (odds ratio [OR], 0.75; 95% CI, 0.61-0.94; P = .01). Similar results were found in patients who survived their ED stay (OR, 0.68; 95% CI, 0.52-0.89; P < .01), excluding severe traumatic brain injury (OR, 0.65; 95% CI, 0.45-0.95; P = .03), and restricted to patients with severe chest injury (OR, 0.72; 95% CI, 0.55-0.93; P = .01). PHND was also associated with lower odds of 24-hour mortality after propensity matching (OR, 0.79; 95% CI, 0.62-0.98; P = .04) when restricting matches to the same EMS agency (OR, 0.74; 95% CI, 0.56-0.99; P = .04) and in instrumental variable probit regression (coefficient, -0.60; 95% CI, -1.04 to -0.16; P < .01).

Conclusions and Relevance

In this cohort study, PHND was associated with lower 24-hour mortality compared with emergent trauma center chest tube placement in trauma patients. Although performed rarely, PHND can be a life-saving intervention and should be reinforced in EMS education for appropriately selected trauma patients.

Emergency department thoracotomy in a physician-staffed trauma system: the experience of a French Military level-1 trauma center

PURPOSE

To investigate survival after emergency department thoracotomy (EDT) in a physician-staffed emergency medicine system.

METHODS

This single-center retrospective study included all in extremis trauma patients who underwent EDT between 2013 and 2021 in a military level 1 trauma center. CPR time exceeding 15 minutes for penetrating trauma of 10 minutes for blunt trauma, and identified head injury were the exclusion criteria.

RESULTS

Thirty patients (73% male, 22/30) with a median age of 42 y/o [27-64], who presented mostly with polytrauma (60%, 18/30), blunt trauma (60%, 18/30), and severe chest trauma with a median AIS of 4 3-5 underwent EDT. Mean prehospital time was 58 min (4-73). On admission, the mean ISS was 41 29-50, and 53% (16/30) of patients had lost all signs of life (SOL) before EDT. On initial work-up, Hb was 9.6 g/dL [7.0-11.1], INR was 2.5 [1.7-3.2], pH was 7.0 [6.8-7.1], and lactate level was 11.1 [7.0-13.1] mmol/L. Survival rates at 24 h and 90 days after penetrating versus blunt trauma were 58 and 41% versus 16 and 6%, respectively. If SOL were present initially, these values were 100 and 80% versus 22 and 11%.

CONCLUSION

Among in extremis patients supported in a physician-staffed emergency medicine system, implementation of a trauma protocol with EDT resulted in overall survival rates of 33% at 24 h and 20% at 90 days. Best survival was observed for penetrating trauma or in the presence of SOL on admission.

Variation in on-scene time of emergency medical services and the extent of the difference of on-scene time between genders: a retrospective population-based registry study in Riyadh Province, Saudi Arabia

OBJECTIVES

To identify the intergender variation of on-scene time (OST) for highly urgent emergency cases conveyed by emergency medical services (EMS) in Saudi Arabia and to assess other predictors of OST and hypothesise for possible factors delaying OST.

DESIGN

A retrospective population-based registry study.

SETTING

Riyadh Province is the largest province in terms of population and the second in terms of geographical area.

PARTICIPANTS

All highly urgent transported patients from the scene to emergency departments, be they medical emergencies or trauma emergencies during 2018.

OUTCOME MEASURE

OST difference between men and women transported by EMS.

RESULTS

In total, 21 878 patients were included for analysis: 33.9% women and 66.1% men. The median OST for women was 22 min (IQR 15-30) and 18 min (IQR 11-26) for men (p<0.001); for medical cases, median OST was 23 min (IQR 16-31) for women compared with 20 min (IQR 13 - 29) for men (p<0.001); for trauma cases, the median OST of both sexes was equal. We found the following additional predictors of OST: factors of emergency type, sex, age category, geographical areas, type of ambulance vehicle and hospital type were all significantly associated with OST in the crude or adjusted analyses. Factors of emergency type, sex, age category, geographical areas, type of ambulance vehicle and hospital type were also significantly associated with the odds of OST of more than 15 min in the crude and adjusted regression analyses.

CONCLUSIONS

The median OST was longer than 15 min for more than half of transported cases. For medical cases, women had a longer median OST than men. Additional predictors associated with prolonged OST were the patient's age, area (ie, urban vs rural), type of ambulance vehicle and season. These findings are hypothesis generating and require further studies.

Distribution of wounding patterns in casualties from mass shooting events

Introduction

The incidence and severity of public mass shootings, and mass casualty incidents (MCI), continues to rise. Understanding the wounding pattern and incidence of potentially preventable death after these incidents is key not only to Health System and Trauma Center emergency response planning but also to community outreach and initial emergency interventions.

Methods

A retrospective study of autopsy reports after events with at least 10 fatalities exclusive of the assailants identified via the Federal Bureau of Investigation database from 1 January 1999 to 31 December 2020 was performed. Sites of injury, identification of weaponry, and identification of potentially survivable wounds were compiled.

Results

Nine events including 203 victims were reviewed. Overall, 56% of gunshots were to the head/neck/face; 37% were to the chest; 43% were to the abdomen/torso/back; 31% were to the lower extremity; and 36% were to the upper extremity. On average, there were 29 fatalities per event.

Conclusion

Emergency response disaster care strategy should focus on immediate point of care at the site of wounding by both the civilian population and medical personnel, as well as rapid extrication of victims for definitive medical care. Review of these autopsy results indicates exsanguination, often treatable, is the primary cause of death—supporting community education efforts in hemorrhage control. The location of the wounding patterns seen in this study warrants primary integration of craniomaxillofacial, orthopedic trauma, neurotrauma, and surgical critical care/trauma surgical specialists into the initial response team for MCI.

Impact of a trauma-focused resuscitation protocol on survival outcomes after traumatic out-of-hospital cardiac arrest: An interrupted time series analysis

AIM

In this study, we examine the impact of a trauma-focused resuscitation protocol on survival outcomes following adult traumatic out-of-hospital cardiac arrest (OHCA).

METHODS

We included adult traumatic OHCA patients aged >16 years occurring between 2008 and 2019. In December 2016, a new resuscitation protocol for traumatic OHCA was introduced prioritising the treatment of potentially reversible causes before conventional cardiopulmonary resuscitation (CPR). The effect of the new protocol on survival outcomes was assessed using adjusted interrupted time series regression.

RESULTS

Over the study period, paramedics attempted resuscitation on 996 patients out of 3,958 attended cases. Of the treated cases, 672 (67.5%) and 324 (32.5%) occurred during pre-intervention and intervention periods, respectively. The frequency of almost all trauma interventions was significantly higher in the intervention period, including external haemorrhage control (15.7% vs 7.6; p-value <0.001), blood administration (3.8% vs 0.2%; p-value <0.001), and needle thoracostomy (75.9% vs 42.0%; p-value <0.001). There was also a significant reduction in the median time from initial patient contact to the delivery of needle thoracostomy (4.4 min vs 8.7 min; p-value <0.001) and splinting (8.7 min vs 17.5 min; p-value = 0.009). After adjustment, the trauma-focused resuscitation protocol was not associated with a change in the level of survival to hospital discharge (adjusted odds ratio [AOR] 0.98; 95% confidence interval [CI]: 0.11-8.59), event survival (AOR 0.82; 95% CI: 0.33-2.03), or prehospital return of spontaneous circulation (AOR 1.30; 95% CI: 0.61-2.76).

CONCLUSION

Despite an increase in trauma-based interventions and a reduction in the time to their administration, our study did not find a survival benefit from a trauma-focused resuscitation protocol over initial conventional CPR. However, survival was low with both approaches.

Emergency Department Versus Operating Suite Intubation in Operative Trauma Patients: Does Location Matter?

BACKGROUND

Decreasing the time from patient arrival to definitive surgical care in injured patients requiring an operation improves outcomes. We sought to study the effect of intubation location (emergency department versus operating suite) on time to definitive surgical care. We hypothesized that patients requiring emergency surgical interventions intubated in the emergency department would have shorter times to definitive care when compared to patients intubated in the operating suite.

METHODS

All injured patients with a preoperative emergency department dwell time of less than 30 min and undergoing emergency operative procedures with the trauma surgery service at an urban Level I center (2010-2017) were analyzed. Demographics, clinical variables, and outcomes were assessed in relation to emergency department intubation versus operating suite intubation. The primary study endpoint was time to initiation of definitive surgical care, defined as the total elapsed time from emergency department arrival until operating room incision time. To investigate the relationship between clinical variables and time, multivariable regression was performed.

RESULTS

In total, 241 patients were included. In total, 138 patients were intubated in the emergency department and 103 patients were intubated in the operative suite. There was no difference between patients intubated in the emergency department and those intubated in the operating room with respect to age, gender, injury mechanism, initial heart rate or systolic blood pressure. Emergency department patients were more likely to sustain post-intubation, traumatic cardiopulmonary arrest (8.0 vs. 0.9%; p = 0.014). No statistical difference in total elapsed time from arrival to definitive surgical care was appreciated between study groups (41 vs. 43 min; p = 0.064). After controlling for clinical variables, emergency department intubation was not associated with time to definitive care (p = 0.386) in the multiple variable regression analysis.

CONCLUSION

When emergency department and operative suite intubation patients were compared, emergency department intubation did not decrease total elapsed time until definitive surgery but was associated with post-intubation, traumatic cardiopulmonary arrest.

Why do some trauma patients die while others survive? A matched-pair analysis based on data from Trauma Register DGU®

PURPOSE

The mortality rate for severely injured patients with the injury severity score (ISS) ≥16 has decreased in Germany. There is robust evidence that mortality is influenced not only by the acute trauma itself but also by physical health, age and sex. The aim of this study was to identify other possible influences on the mortality of severely injured patients.

METHODS

In a matched-pair analysis of data from Trauma Register DGU®, non-surviving patients from Germany between 2009 and 2014 with an ISS≥16 were compared with surviving matching partners. Matching was performed on the basis of age, sex, physical health, injury pattern, trauma mechanism, conscious state at the scene of the accident based on the Glasgow coma scale, and the presence of shock on arrival at the emergency room.

RESULTS

We matched two homogeneous groups, each of which consisted of 657 patients (535 male, average age 37 years). There was no significant difference in the vital parameters at the scene of the accident, the length of the pre-hospital phase, the type of transport (ground or air), pre-hospital fluid management and amounts, ISS, initial care level, the length of the emergency room stay, the care received at night or from on-call personnel during the weekend, the use of abdominal sonographic imaging, the type of X-ray imaging used, and the percentage of patients who developed sepsis. We found a significant difference in the new injury severity score, the frequency of multi-organ failure, hemoglobine at admission, base excess and international normalized ratio in the emergency room, the type of accident (fall or road traffic accident), the pre-hospital intubation rate, reanimation, in-hospital fluid management, the frequency of transfusion, tomography (whole-body computed tomography), and the necessity of emergency intervention.

CONCLUSION

Previously postulated factors such as the level of care and the length of the emergency room stay did not appear to have a significant influence in this study. Further studies should be conducted to analyse the identified factors with a view to optimising the treatment of severely injured patients. Our study shows that there are significant factors that can predict or influence the mortality of severely injured patients.

Prehospital Intubation Does Not Decrease Complications in the Penetrating Trauma Patient

Intubation in the prehospital setting does not result in a survival benefit in penetrating trauma. However, the effect of prehospital intubation (PHI) on the development of in-hospital complications has yet to be determined. The goal of this study was to determine if PHI in patients with penetrating trauma results in reduced mortality and in-hospital complications. Patient records for all Category 1 trauma activations as a result of penetrating injury admitted to our institution from 2006 to 2010 were reviewed. There were 1615 Category 1 trauma activations with 152 (9.8%) intubated in the field. A total of 1311 survived initial resuscitative efforts to permit hospital admission with 55 (4.2%) being intubated in the field. For patients surviving to admission, pre-hospital intubation was associated with increased mortality (hazard ratio, 8.266; 95% confidence interval [CI, 4.336 to 15.758; P < 0.001). After correcting for Injury Severity Score, PHI was not protective against pulmonary complications (odds ratio [OR], 0.724; 95% CI, 0.229 to 2.289; P = 0.582), deep vein thrombosis/pulmonary embolus (OR, 0.838; 95% CI, 0.281 to 2.494; P = 0.750), sepsis (OR, 0.572; 95% CI, 0.201 to 1.633; P = 0.297), wound infections (OR, 1.739; 95% CI, 0.630 to 4.782; P = 0.286), or complications of any kind (OR, 1.020; 95% CI, 0.480 to 2.166; P = 0.959). For victims of penetrating trauma, immediate transportation by emergency medical personnel may result in improved outcomes.

Patterns of Early Mortality after Trauma in a Neighborhood Urban Trauma Center: Can We Improve Outcomes?

Even with specialized trauma systems, a significant number of deaths occur within the early postinjury period. Our goal was to examine deaths within this period for cause and determine if care could improve outcomes. A retrospective chart review was performed on all patients who were dead on arrival or died within 4 hours of arrival between January 1, 2005, and December 31, 2011. Survival probabilities and Injury Severity Score (ISS) were calculated. Chart review and trauma review processes were used to determine cases with opportunities for care improvement. Two hundred eighty-nine patients were dead on arrival (DOA), and 176 patients died within 4 hours of arrival. The most common mechanism of injury was gunshot wounds (68.4%). The most common causes of death were uncontrolled hemorrhage (68.2%) and neurologic trauma (23.4%). Average ISS was 32. Twenty-nine patients had survival probability percentages over 50. Ten of 176 (5.7%) deaths were found to have opportunities for care improvement. In three cases (1.7%), errors contributed to death. The majority of trauma patients DOA or dying within 4 hours of hospital arrival have nonsurvivable injuries. Regular trauma review processes are invaluable in determining opportunities for care improvement. Autopsy information increases the reliability of the review process.

Improved medical treatment could explain a decrease in homicides with a single stab wound

Since the 1990s, there has been a reduction in the homicide rate in Denmark and other Western countries. Our hypothesis is that part of the decrease in the sharp force homicide rate can be explained by better and faster medical treatment over time, and we explore this via stab wound homicides, the largest group of homicides in Denmark. To investigate our hypothesis we undertook an epidemiological study of 428 stab wound homicides in Denmark 1992-2016 based on autopsy reports with registration of stab wounds, quantification of injury severity, treatment intensity and survival time. During 1992-2016, there was a significant reduction in the annual number of victims with a single stab wound, but no reduction in victims with multiple stab wounds. Victims with single stab wounds reached the hospital more often, survived longer and had less severe injuries (New Injury Severity Score (NISS)) than victims with multiple stab wounds. Higher NISS correlated with shorter survival time for all the stab wound victims and for the subgroup that underwent medical treatment. During the 25-year study period, the proportion of victims who underwent surgery before dying increased threefold. The victims in the first half of the study period had shorter survival times than the victims in the last half. We concluded that better and faster medical treatment could partly be responsible for the observed decrease in the number of single stab wound homicides and thereby possibly also in the total number of stab wound homicides.

Efficacy of venous access placement at a pre-hospital scene in severe paediatric trauma patients: a retrospective cohort study

Purpose: Aside from severe traumatic brain injury, uncontrolled bleeding and corresponding haemorrhage shock are the leading causes of traumatic deaths. No established recommendations exist about venous access placement for severely injured, bleeding children at a pre-hospital scene. This study sought to evaluate the association between pre-hospital venous access placement and mortality in a paediatric trauma population by analysing the Japan Trauma Data Bank (JTDB). Methods: This epidemiologic study compared the outcomes of severe traumatic paediatric patients with or without venous access placement at a pre-hospital scene. Data were obtained from JTDB from 2004 to 2015. Results: Of 4,109 patients who met our inclusion criteria, 144 patients received venous access placement and 3,965 patients did not. The probability of survival was lower in the venous access group than in the no access group (0.90 [0.67–0.97] vs. 0.97 [0.90–0.99], p < 0.01). After multivariable logistic analysis, venous access placement did not improve survival to hospital discharge (odds ratio = 1.40, confidence interval = 0.32–6.15, p = 0.653). Conclusions: The probability of survival was lower in the venous access group than in the no access group. Survival outcome at discharge was not affected by venous access placement at a pre-hospital scene.

Prehospital Trauma Scene and Transport Times for Pediatric and Adult Patients

Introduction

Increased out-of-hospital time is associated with worse outcomes in trauma. Sparse literature exists comparing prehospital scene and transport time management intervals between adult and pediatric trauma patients. National Emergency Medical Services guidelines recommend that trauma scene time be less than 10 minutes. The objective of this study was to examine prehospital time intervals in adult and pediatric trauma patients.

Methods

We performed a retrospective cohort study of blunt and penetrating trauma patients in a five-county region in North Carolina using prehospital records. We included patients who were transported emergency traffic directly from the scene by ground ambulance to a Level I or Level II trauma center between 2013–2018. We defined pediatric patients as those less than 16 years old. Urbanicity was controlled for using the Centers for Medicare and Medicaid’s Ambulance Fee Schedule. We performed descriptive statistics and linear mixed-effects regression modeling.

Results

A total of 2179 records met the study criteria, of which 2077 were used in the analysis. Mean scene time was 14.2 minutes (95% confidence interval [CI], 13.9–14.5) and 35.3% (n = 733) of encounters had a scene time of 10 minutes or less. Mean transport time was 17.5 minutes (95% CI, 17.0–17.9). Linear mixed-effects regression revealed that scene times were shorter for pediatric patients (p<0.0001), males (p=0.0016), penetrating injury (p<0.0001), and patients with blunt trauma in rural settings (p=0.005), and that transport times were shorter for males (p = 0.02), non-White patients (p<0.0001), and patients in urban areas (p<0.0001).

Conclusion

This study population largely missed the 10-minute scene time goal. Demographic and patient factors were associated with scene and transport times. Shorter scene times occurred with pediatric patients, males, and among those with penetrating trauma. Additionally, suffering blunt trauma while in a rural environment was associated with shorter scene time. Males, non-White patients, and patients in urban environments tended to have shorter transport times. Future studies with outcomes data are needed to identify factors that prolong out-of-hospital time and to assess the impact of out-of-hospital time on patient outcomes.

Comparison of the causes of death and wounding patterns in urban firearm-related violence and civilian public mass shooting events

BACKGROUND

There are no reports comparing wounding pattern in urban and public mass shooting events (CPMS). Because CPMS receive greater media coverage, there is a connation that the nature of wounding is more grave than daily urban gun violence. We hypothesize that the mechanism of death following urban gunshot wounds (GSWs) is the same as has been reported following CPMS.

METHODS

Autopsy reports of all firearm-related deaths in Washington, DC were reviewed from January 1, 2016, to December 31, 2017. Demographic data, firearm type, number and anatomic location of GSWs, and organ(s) injured were abstracted. The organ injury resulting in death was noted. The results were compared with a previously published study of 19 CPMS events involving 213 victims.

RESULTS

One hundred eighty-six urban autopsy reports were reviewed. There were 171 (92%) homicides and 13 (7%) suicides. Handguns were implicated in 180 (97%) events. One hundred eight (59%) gunshots were to the chest/upper back, 85 (46%) to the head, 77 (42%) to an extremity, and 71 (38%) to the abdomen/lower back. The leading mechanisms of death in both urban firearm violence and CPMS were injury to the brain, lung parenchyma, and heart. Fatal brain injury was more common in CPMS events as compared with urban events involving a handgun.

CONCLUSION

There is little difference in wounding pattern between urban and CPMS firearm events. Based on the organs injured, rapid point of wounding care and transport to a trauma center remain the best options for mitigating death following all GSW events.

LEVEL OF EVIDENCE

Epidemiological, level IV.

Fluid resuscitation in trauma: what are the best strategies and fluids?

BACKGROUND

Traumatic injuries pose a global health problem and account for about 10% global burden of disease. Among injured patients, the major cause of potentially preventable death is uncontrolled post-traumatic hemorrhage.

MAIN BODY

This review discusses the role of prehospital trauma care in low-resource/remote settings, goals, principles and evolving strategies of fluid resuscitation, ideal resuscitation fluid, and post-resuscitation fluid management. Management of fluid resuscitation in few special groups is also discussed.

CONCLUSIONS

Prehospital trauma care systems reduce mortality in low-resource/remote settings. Delayed resuscitation seems a better option when transport time to definitive care is shorter whereas goal-directed resuscitation with low-volume crystalloid seems a better option if transport time is longer. Few general recommendations regarding the choice of fluid are provided. Adhering to evidence-based clinical practice guidelines and local modifications based on patient population, available resources, and expertise will improve patient outcomes.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Main Outcome and Measure

In-hospital mortality.

Results

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

Conclusions and Relevance

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

Distance to trauma centres among gunshot wound victims: identifying trauma ‘deserts’ and ‘oases’ in Detroit

Introduction

Among the factors related to survival among individuals with gun shot wounds (GSW) is distance to trauma care. Relatively little is known about neighbourhood-level patterns of GSW mortality and distance to hospitals with trauma centres. This study focuses on distance to the nearest trauma centre as a correlate of survival among GSW victims.

Methods

Fatal and non-fatal shooting incident data for 9,205 victimisation in Detroit, Michigan between 2011 and 2017 were collected. A Bayesian conditional autoregressive model was utilised to estimate block-group levels of GSW mortality. Clustering techniques were used to identify spatially proximate neighbourhoods with higher or lower than expected rates of GSW mortality.

Results

Distance to the nearest trauma centre was associated with a 22% increase in fatal outcomes, per-mile (OR 1.22, 95% CI, 1.06 to 1.40) after adjusting for block-group level covariates. A Getis-Ord Gi* analysis identified 91 block groups with lower than expected rates of GSW mortality and 12 block-groups with higher than expected rates.

Conclusion

Distance to the nearest trauma centre is associated with GSW victim survival. Clusters of block-groups with below-average GSW mortality were observed within close proximity of major trauma centres in Detroit. Improving speed and access to trauma care may play a role in reducing GSW mortality.

Benchmarking emergency department thoracotomy: Using trauma video review to generate procedural norms

INTRODUCTION

Emergency department thoracotomy (EDT) must be rapid and well-executed. Currently there are no defined benchmarks for EDT procedural milestones. We hypothesized that trauma video review (TVR) can be used to define the 'normative EDT' and generate procedural benchmarks. As a secondary aim, we hypothesized that data collected by TVR would have less missingness and bias than data collected by review of the Electronic Medical Record (EMR).

METHODS

We used continuously recording video to review all EDTs performed at our centre during the study period. Using skin incision as start time, we defined four procedural milestones for EDT: 1. Decompression of the right chest (tube thoracostomy, finger thoracostomy, or clamshell thoracotomy with transverse sternotomy performed in conjunction with left anterolateral thoracotomy) 2. Retractor deployment 3. Pericardiotomy 4. Aortic Cross-clamp. EDTs with any milestone time ≥ 75^th percentile of time or during which a milestone was omitted were identified as outliers. We compared rates of missingness in data collected by TVR and EMR using McNemar's test.

RESULTS

44 EDTs were included from the study period. Patients had a median age of 30 [IQR 25-44] and were predominantly African-American (95%) males (93%) with penetrating trauma (95%). From skin incision, median times in minutes to milestones were as follows: right chest decompression: 2.11 [IQR 0.68-2.83], retractor deployment 1.35 [IQR 0.96-1.85], pericardiotomy 2.35 [IQR 1.85-3.75], aortic cross-clamp 3.71 [IQR 2.83-5.77]. In total, 28/44 (64%) of EDTs were either high outliers for one or more benchmarks or had milestones that were omitted. For all milestones, rates of missingness for TVR data were lower than EMR data (p < 0.001).

CONCLUSIONS

Video review can be used to define normative times for the procedural milestones of EDT. Steps exceeding the 75^th percentile of time were common, with over half of EDTs having at least one milestone as an outlier. Data quality is higher using TVR compared to EMR collection. Future work should seek to determine if minimizing procedural technical outliers improves patient outcomes.

Fatal Wounding Pattern and Causes of Potentially Preventable Death Following the Pulse Night Club Shooting Event

BACKGROUND

Mortality following shooting is related to time to provision of initial and definitive care. An understanding of the wounding pattern, opportunities for rescue, and incidence of possibly preventable death is needed to achieve the goal of zero preventable deaths following trauma.

METHODS

A retrospective study of autopsy reports for all victims involved in the Pulse Nightclub Shooting was performed. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author. Wounds were considered fatal if they involved penetration of the heart, injury to any non-extremity major blood vessel, or bihemispheric, mid-brain, or brainstem injury.

RESULTS

There were an average of 6.9 wounds per patient. Ninety percent had a gunshot to an extremity, 78% to the chest, 47% to the abdomen/pelvis, and 39% to the head. Sixteen patients (32%) had potentially survivable wounds, 9 (56%) of whom had torso injuries. Four patients had extremity injuries, 2 involved femoral vessels and 2 involved the axilla. No patients had documented tourniquets or wound packing prior to arrival to the hospital. One patient had an isolated C6 injury and 2 victims had unihemispheric gunshots to the head.

CONCLUSIONS

A comprehensive strategy starting with civilian providers to provide care at the point of wounding along with a coordinated public safety approach to rapidly evacuate the wounded may increase survival in future events.

Analysis of Prehospital Scene Times and Interventions on Mortality Outcomes in a National Cohort of Penetrating and Blunt Trauma Patients

BACKGROUND

Recent studies have suggested improved outcomes in victims of penetrating trauma managed with shorter prehospital times and limited interventions. The purpose of the current study was to perform an outcome analysis of patients transported following penetrating and blunt traumatic injuries.

METHODS

We performed a descriptive retrospective analysis of the 2014 National Emergency Medical Services Information System (NEMSIS) public release research data set for patients presenting after acute traumatic injury.

RESULTS

A total of 2,018,141 patient encounters met criteria, of which 3.9% were penetrating trauma. Prehospital cardiac arrest occurred in 0.5% blunt and 4.2% penetrating trauma patients. Emergency department (ED) mortality was higher in penetrating than blunt trauma patients (4.1% vs. 0.8%). Scene times were 18.1 ± 36.5 minutes for blunt and 16.0 ± 45.3 minutes for penetrating trauma. Mean scene time for blunt trauma patients who died in the ED was 24.9 ± 58.0 minutes compared with 18.8 ± 38.5 minutes for those admitted; for penetrating trauma, scene times were 17.9 ± 23.5 and 13.4 ± 11.6 minutes, respectively. Mean number of procedures performed for blunt trauma patients who died in the ED was 6.5 ± 4.3 compared with 3.1 ± 2.3 for those who survived until admission; for penetrating trauma, the numbers of procedures performed were 5.7 ± 3.4 and 2.6 ± 2.0, respectively.

CONCLUSIONS

Although less frequent than blunt trauma, penetrating trauma is associated with significantly higher prehospital and ED mortality. Increased scene time and number of procedures was associated with greater mortality for both blunt and penetrating trauma. Further study is required to better understand any causal relationships between prehospital times and interventions and patient outcomes.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Resuscitation thoracotomy

Resuscitation thoracotomy is a rarely performed procedure whose use, in France, remains marginal. It has five specific goals that correspond point-by-point to the causes of traumatic cardiac arrest: decompression of pericardial tamponade, control of cardiac hemorrhage, performance of internal cardiac massage, cross-clamping of the descending thoracic aorta, and control of lung injuries and other intra-thoracic hemorrhage. This approach is part of an overall Damage Control strategy, with a targeted operating time of less than 60minutes. It is indicated for patients with cardiac arrest after penetrating thoracic trauma if the duration of cardio-pulmonary ressuscitation (CPR) is <15minutes, or <10minutes in case of closed trauma, and for patients with refractory shock with systolic blood pressure <65mm Hg. The overall survival rate is 12% with a 12% incidence of neurological sequelae. Survival in case of penetrating trauma is 10%, but as high as 20% in case of stab wounds, and only 6% in case of closed trauma. As long as the above-mentioned indications are observed, resuscitation thoracotomy is fully justified in the event of an afflux of injured victims of terrorist attacks.

Not all prehospital time is equal: Influence of scene time on mortality

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.

Prehospital traumatic cardiac arrest: Management and outcomes from the resuscitation outcomes consortium epistry-trauma and PROPHET registries

BACKGROUND

Traumatic arrests have historically had poor survival rates. Identifying salvageable patients and ideal management is challenging. We aimed to (1) describe the management and outcomes of prehospital traumatic arrests; (2) determine regional variation in survival; and (3) identify Advanced Life Support (ALS) procedures associated with survival.

METHODS

This was a secondary analysis of cases from the Resuscitation Outcomes Consortium Epistry-Trauma and Prospective Observational Prehospital and Hospital Registry for Trauma (PROPHET) registries. Patients were included if they had a blunt or penetrating injury and received cardiopulmonary resuscitation. Logistic regression analyses were used to determine the association between ALS procedures and survival.

RESULTS

We included 2,300 patients who were predominately young (Epistry mean [SD], 39 [20] years; PROPHET mean [SD], 40 [19] years), males (79%), injured by blunt trauma (Epistry, 68%; PROPHET, 67%), and treated by ALS paramedics (Epistry, 93%; PROPHET, 98%). A total of 145 patients (6.3%) survived to hospital discharge. More patients with blunt (Epistry, 8.3%; PROPHET, 6.5%) vs. penetrating injuries (Epistry, 4.6%; PROPHET, 2.7%) survived. Most survivors (81%) had vitals on emergency medical services arrival. Rates of survival varied significantly between the 12 study sites (p = 0.048) in the Epistry but not PROPHET (p = 0.14) registries.Patients in the PROPHET registry who received a supraglottic airway insertion or intubation experienced decreased odds of survival (adjusted OR, 0.27; 95% confidence interval, 0.08-0.93; and 0.37; 95% confidence interval, 0.17-0.78, respectively) compared to those receiving bag-mask ventilation. No other procedures were associated with survival.

CONCLUSIONS

Survival from traumatic arrest may be higher than expected, particularly in blunt trauma and patients with vitals on emergency medical services arrival. Although limited by confounding and statistical power, no ALS procedures were associated with increased odds of survival.

LEVEL OF EVIDENCE

Prognostic study, level IV.

Police transport versus ground EMS: A trauma system-level evaluation of prehospital care policies and their effect on clinical outcomes

BACKGROUND

Rapid transport to definitive care ("scoop and run") versus field stabilization in trauma remains a topic of debate and has resulted in variability in prehospital policy. We aimed to identify trauma systems frequently using a true "scoop and run" police transport approach and to compare mortality rates between police and ground emergency medical services (EMS) transport.

METHODS

Using the National Trauma Databank (NTDB), we identified adult gunshot and stab wound patients presenting to Level 1 or 2 trauma centers from 2010 to 2012. Hospitals were grouped into their respective cities and regional trauma systems. Patients directly transported by police or ground EMS to trauma centers in the 100 most populous US trauma systems were included. Frequency of police transport was evaluated, identifying trauma systems with high utilization. Mortality rates and risk-adjusted odds ratio for mortality for police versus EMS transport were derived.

RESULTS

Of 88,564 total patients, 86,097 (97.2%) were transported by EMS and 2,467 (2.8%) by police. Unadjusted mortality was 17.7% for police transport and 11.6% for ground EMS. After risk adjustment, patients transported by police were no more likely to die than those transported by EMS (OR = 1.00, 95% CI: 0.69-1.45). Among all police transports, 87.8% occurred in three locations (Philadelphia, Sacramento, and Detroit). Within these trauma systems, unadjusted mortality was 19.9% for police transport and 13.5% for ground EMS. Risk-adjusted mortality was no different (OR = 1.01, 95% CI: 0.68-1.50).

CONCLUSIONS

Using trauma system-level analyses, patients with penetrating injuries in urban trauma systems were found to have similar mortality for police and EMS transport. The majority of prehospital police transport in penetrating trauma occurs in three trauma systems. These cities represent ideal sites for additional system-level evaluation of prehospital transport policies.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Prehospital Fluid Administration in Trauma Patients: A Survey of State Protocols

OBJECTIVE

The optimal resuscitation approach during the initial treatment of hypotensive trauma patients remains unknown, but some clinical trials have observed a survival benefit from restricting fluid administration prior to definitive hemorrhage control. We sought to characterize emergency medical services (EMS) protocols for the administration of intravenous fluids in this setting.

METHODS

Publicly accessible statewide EMS protocols for the treatment of hypotensive trauma patients were included and characterized by: 1) goal of fluid administration, 2) dosing strategy, 3) maximum dose, 4) type of fluid, and 5) specific protocols for head trauma, if present.

RESULTS

Of the 27 states with a publicly available, statewide protocol, 21 have a numeric systolic blood pressure (SBP) target for resuscitation. Of these, 16 describe a goal of maintaining SBP ≥90 mmHg with or without additional goals, three specify a goal that is less than 90 mmHg, and two specify a goal ≥100 mHg. Dosing strategies also vary and include both standard bolus strategies (200 mL, 250 mL, 500 mL, and 1 L with repeat) as well as weight-based strategies (20 mL/kg). Nine states specify a maximum dose of 2 L without medical control. Fifteen protocols recommend the use of normal saline, 1 recommends the use of lactated Ringer's, and 11 recommend the use of either normal saline or lactated Ringer's. Nine states have distinct protocols for patients with head trauma, all of which indicate maintaining a higher SBP than for trauma patients without head trauma.

CONCLUSION

State EMS protocols for fluid administration for hypotensive trauma patients vary in regard to SBP goal, fluid dose, and fluid type. Clinical trials to determine the optimal use of intravenous fluids for hypotensive trauma patients are needed to define the optimal approach.

A Descriptive Analysis of Tactical Casualty Care Interventions Performed by Law Enforcement Personnel in the State of Wisconsin, 2010-2015

Introduction

Based upon military experience, law enforcement has developed guidelines for medical care during high-threat conditions. The purpose of the current study was to provide a descriptive analysis of reported outcomes of law enforcement medical interventions.

Methods

This was a descriptive analysis of a convenience sample of cases submitted to the Wisconsin Tactical Medicine Initiative (Wisconsin USA), after the provision of successful patient care, between January 2010 and December 2015. The study was reviewed by the Mayo Foundation Institutional Review Board (Rochester, Minnesota USA) and deemed exempt.

Results

Nineteen agencies submitted information during the study period. Of the 56 episodes of care reported, four (7.1%) cases involved care provided to injured officers while 52 (92.9%) involved care to injured civilians, including suspects. In at least two cases, on-going threats existed during the provision of medical care to an injured civilian. Law enforcement rendered care prior to Emergency Medical Services (EMS) arrival in all but two cases.

Conclusions

The current case series demonstrates the life-saving potential for law enforcement personnel trained and equipped under current Tactical Combat Casualty Care (TCCC)/ Committee on Tactical Emergency Casualty Care (C-TECC) tactical casualty care guidelines. Although originally developed to save the lives of wounded combat personnel, in the civilian sector, the training appears more likely to save victims rather than law enforcement personnel.

StilesCM, CookC, SztajnkrycerMD. A descriptive analysis of tactical casualty care interventions performed by law enforcement personnel in the State of Wisconsin, 2010-2015. Prehosp Disaster Med. 2017;32(3):284–288.

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

The pre-hospital management of life-threatening chest injuries: A consensus statement from the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh

‘The pre-hospital management of chest injury: a consensus statement’ was originally published by the Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh in 2007. To update the pre-existing guideline, a consensus meeting of stakeholders was held by the Faculty of Pre-hospital Care in Coventry in November 2013. This paper provides a guideline for the pre-hospital management of patients with the life-threatening chest injuries of tension pneumothorax, open pneumothorax, massive haemothorax, flail chest (including multiple rib fractures), and cardiac tamponade.

Epidemiology of Emergency Medical Services (EMS) Utilization in Four Indian Emergency Departments

Introduction Without a universal Emergency Medical Services (EMS) system in India, data on the epidemiology of patients who utilize EMS are limited. This retrospective chart review aimed to quantify and describe the burden of disease and patient demographics of patients who arrived by EMS to four Indian emergency departments (EDs) in order to inform a national EMS curriculum.

METHODS

A retrospective chart review was performed on patients transported by EMS over a three-month period in 2014 to four private EDs in India. A total of 17,541 patient records were sampled from the four sites over the study period. Of these records, 1,723 arrived by EMS and so were included for further review.

RESULTS

A range of 1.4%-19.4% of ED patients utilized EMS to get to the ED. The majority of EMS patients were male (59%-64%) and adult or geriatric (93%-99%). The most common chief complaints and ED diagnoses were neurological, pulmonary, cardiovascular, gastrointestinal, trauma, and infectious disease.

CONCLUSIONS

Neurological, pulmonary, cardiovascular, gastrointestinal, trauma, and infectious disease are the most common problems found in patients transported by EMS in India. Adult and geriatric male patients are the most common EMS utilizers. Emergency Medical Services curricula should emphasize these knowledge areas and skills. Wijesekera O , Reed A , Chastain PS , Biggs S , Clark EG , Kole T , Chakrapani AT , Ashish N , Rajhans P , Breaud AH , Jacquet GA . Epidemiology of Emergency Medical Services (EMS) utilization in four Indian emergency departments. Prehosp Disaster Med. 2016;31(6):675-679.

Field intubation in civilian patients with hemorrhagic shock is associated with higher mortality

BACKGROUND

Field intubation (FI) by emergency medical service personnel on severely injured trauma patients remains a contentious practice. Clinical studies suggest an association between FI and adverse outcomes in patients with traumatic brain injury. Military tactical emergency casualty care recommends deferring intubation and providing supplemental oxygenation until reaching a more equipped destination. In addition, animal models with penetrating hemorrhagic shock demonstrate increased acidosis with intubation before resuscitation. The purpose of this study was to evaluate the impact of FI on outcomes in trauma patients with hemorrhagic shock requiring massive transfusion.

METHODS

The Los Angeles County Trauma System Database was retrospectively queried for all trauma patients 16 years or older with hemorrhagic shock requiring massive transfusion (≥6 U packed red blood cells in the first 24 hours) between January 1, 2012, and June 30, 2014. Demographics, clinical and transfusion data, and outcomes were compared between patients who received FI and those who did not (NO-FI). Multivariate regression analysis was used to adjust for confounders.

RESULTS

Of 552 trauma patients meeting inclusion criteria, 63 (11%) received FI, and the remaining 489 (89%) were NO-FI. Age, sex, and incidence of blunt injury were similar between the FI and the NO-FI group. The FI cohort presented with a lower median Glasgow Coma Scale (GCS) score (3 vs. 14, p < 0.001), a lower median systolic blood pressure (86 mm Hg vs. 104 mm Hg, p < 0.001), and a higher median Injury Severity Score (ISS) (41 vs. 29, p < 0.001). Mortality was significantly higher in FI patients (83% vs. 43%, p < 0.001). Transfusion patterns and total field times were similar in both groups. After adjusting for confounders, FI patients had increased odds of mortality (adjusted odds ratio, 2.89; 95% confidence interval, 1.08-7.78; p = 0.035). In addition, FI was identified as an independent predictor of mortality (adjusted odds ratio, 3.41; 95% confidence interval, 1.35-8.59; p = 0.009).

CONCLUSION

FI may be associated with higher mortality in trauma patients with hemorrhagic shock requiring massive transfusion. Less invasive airway interventions and rapid transport might improve outcomes for these patients.

LEVEL OF EVIDENCE

Therapeutic study, level IV; epidemiologic study, level III.

Effect of private versus emergency medical systems transportation in trauma patients in a mostly physician based system- a retrospective multicenter study based on the TraumaRegister DGU®

Background

The effects of private transportation (PT) to definitive trauma care in comparison to transportation using Emergency Medical Services (EMS) have so far been addressed by a few studies, with some of them finding a beneficial effect on survival. The aim of the current study was to investigate epidemiology, pre- and in-hospital times as well as outcomes in patients after PT as compared to EMS recorded in the TraumaRegister DGU®.

Methods

All patients in the database of the TraumaRegister DGU® (TR-DGU) from participating European trauma centers treated in 2009 to 2013 with available data on the mode of transportation, ISS ≥ 4 and ICU treatment were included in the study. Epidemiological data, pre- and in-hospital times were analysed. Outcomes were analysed after adjustment for RISC-II scores.

Results

76,512 patients were included in the study, of which 1,085 (1.4 %) were private transports. Distribution of ages and trauma mechanisms showed a markedly different pattern following PT, with more children < 15 years treated following PT (3.3 % EMS vs. 9.6 for PT) and more elderly patients of 65 years or older (26.6 vs 32.4 %). Private transportation to trauma care was by far more frequent in Level 2 and 3 hospitals (41.2 % in EMS group vs 73.7 %). Median pre-hospital times were also reduced following PT (59 min for EMS vs. 46 for PT). In-hospital time in the trauma room (66 for EMS vs. 103 min for PT) and time to diagnostics were prolonged following PT. Outcome analysis after adjustment for RISC-II scores showed a survival benefit of PT over EMS transport (SMR for EMS 1.07 95 % CI 1.05–1.09; for PT 0.85 95 % CI 0.62–1.08).

Discussion

The current study shows a distinct pattern concerning epidemiology and mechanism of injury following PT. PT accelerates the median pre-hospital times, but prolongs time to diagnostic measures and time in the trauma room.

Conclusions

In this distinct collective, PT seemed to lead to a small benefit in terms of mortality, which may reflect pre-hospital times, pre-hospital interventions or other confounders.

Characteristics and Outcomes of Patients Injured in Road Traffic Crashes and Transported by Emergency Medical Services

To investigate the injury characteristics and mortality of patients transported by emergency medical services (EMS) and hospitalized for trauma following a road traffic crash, data obtained from the Trauma Registry System were retrospectively reviewed for trauma admissions between 1 January 2009 and 31 December 2013 in a Level I trauma center. Of 16,548 registered patients, 3978 and 1440 patients injured in road traffic crashes were transported to the emergency department by EMS and non-EMS, respectively. Patients transported by EMS had lower Glasgow coma scale (GCS) scores and worse hemodynamic measures. Compared to patients transported by non-EMS, more patients transported by EMS required procedures (intubation, chest tube insertion, and blood transfusion) at the emergency department. They also sustained a higher injury severity, as measured by the injury severity score (ISS) and the new injury severity score (NISS). Lastly, in-hospital mortality was higher among the EMS than the non-EMS group (1.8% vs. 0.3%, respectively; p < 0.001). However, we found no statistically significant difference in the adjusted odds ratio (AOR) for mortality among patients transported by EMS after adjustment for ISS (AOR 4.9, 95% CI 0.33-2.26), indicating that the higher incidence of mortality was likely attributed to the patients' higher injury severity. In addition, after propensity score matching, logistic regression of 58 well-matched pairs did not show a significant influence of transportation by EMS on mortality (OR: 0.578, 95% CI: 0.132-2.541 p = 0.468).

Indication Bias Explains Some of the Observed Increased Mortality Associated With Use of Prehospital Intravenous Fluids in a Pediatric Trauma Population

OBJECTIVES

Traditionally, in both pediatric and adult trauma patients, management of hemorrhage and shock has included early rapid intravenous fluid (IVF) replacement at the scene or during transport to a definitive care facility. Because prehospital resuscitation can be considered as a lifesaving intervention, severely injured patients are more likely to receive IVF. Observational studies not adequately adjusting for this confounding by indication (indication bias) while evaluating the impact of prehospital IVF on mortality in clinically heterogeneous patient populations are likely to find an increased mortality associated with the use of prehospital IVF, an association that may be spurious even after traditional multivariable risk adjustment. Propensity scores can be used to mitigate the impact of this selection bias on the estimated effect. The authors hypothesized that the effect of IVF on mortality will differ based on whether propensity scores (based on a set of prehospital indications for IVF) are adjusted for in a multivariable outcome model.

METHODS

This was a retrospective cohort study of severely injured pediatric (<18 years) patients consecutively evaluated and treated between January 1, 2008, and June 30, 2011, at Oklahoma's only Level I pediatric trauma center. Patients were divided into those receiving 250 mL or more (GE250 group) and those receiving less (LT250 group) of prehospital IVF based on area under curve (AUC) analysis (AUC = 0.7, 95% confidence interval [CI] = 0.6 to 0.80, sensitivity = 0.81 and specificity = 0.56). Propensity scores were used to minimize confounding by indication of the mortality estimate and were calculated based on measurable prehospital factors. Using Cox's regression to minimize survival bias, the independent effect of prehospital IVF on the risk of 30-day in-hospital mortality was evaluated with and without adjusting for the propensity to receive 250 mL of prehospital IVF.

RESULTS

A total of 482 patients met study criteria. Of these, 46.3% (223 of 449) were in the GE250 group. After adjusting for Injury Severity Score, presence of a severe head injury, shock, and a penetrating injury, all of which were significant predictors of mortality, receiving 250 mL or more of prehospital IVF was significantly associated with an almost threefold increase in the risk of 30-day in-hospital mortality (hazard ratio [HR] = 2.96, 95% CI = 1.1 to 8.2). However, further adjusting for the propensity to be in the GE250 group, in addition to the aforementioned variables, attenuated the effect estimate and resulted in a nonsignificant (p = 0.3408), more precise association between prehospital IVF and mortality (HR = 1.9, 95% CI = 0.6 to 6.6).

CONCLUSIONS

Propensity-adjusted survival analysis suggests that the observed increased risk in mortality associated with use of prehospital IVF replacement may be a spurious association resulting from inadequate control of confounding by indication inherent in observational studies. In the absence of patient subgroup-specific results from well-controlled studies, IVF resuscitation should not be a reason to delay patient transport to a definitive care facility. Randomized trials evaluating the effect of prehospital fluids are warranted in the pediatric trauma population, as such studies have shown clinical significance in the adult trauma population.

Resuscitative thoracotomy in penetrating trauma

The resuscitative thoracotomy (RT) is an important procedure in the management of penetrating trauma. As it is performed only in patients with peri-arrest physiology or overt cardiac arrest, survival is low. Experience is also quite variable depending on volume of penetrating trauma in a particular region. Survival ranges from 0% to as high as 89% depending on patient selection, available resources, and location of RT (operating or emergency rooms). In this article, published guidelines are reviewed as well as outcomes. Technical considerations of RT and well as proper training, personnel, and location are also discussed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Therapeutic study, level IV.

An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Within the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework, we performed a systematic review and developed evidence-based recommendations to answer the following PICO (Population, Intervention, Comparator, Outcomes) question: should patients who present pulseless after critical injuries (with and without signs of life after penetrating thoracic, extrathoracic, or blunt injuries) undergo emergency department thoracotomy (EDT) (vs. resuscitation without EDT) to improve survival and neurologically intact survival?

METHODS

All patients who underwent EDT were included while those involving either prehospital resuscitative thoracotomy or operating room thoracotomy were excluded. Quantitative synthesis via meta-analysis was not possible because no comparison or control group (i.e., survival or neurologically intact survival data for similar patients who did not undergo EDT) was available for the PICO questions of interest.

RESULTS

The 72 included studies provided 10,238 patients who underwent EDT. Patients presenting pulseless after penetrating thoracic injury had the most favorable EDT outcomes both with (survival, 182 [21.3%] of 853; neurologically intact survival, 53 [11.7%] of 454) and without (survival, 76 [8.3%] of 920; neurologically intact survival, 25 [3.9%] of 641) signs of life. In patients presenting pulseless after penetrating extrathoracic injury, EDT outcomes were more favorable with signs of life (survival, 25 [15.6%] of 160; neurologically intact survival, 14 [16.5%] of 85) than without (survival, 4 [2.9%] of 139; neurologically intact survival, 3 [5.0%] of 60). Outcomes after EDT in pulseless blunt injury patients were limited with signs of life (survival, 21 [4.6%] of 454; neurologically intact survival, 7 [2.4%] of 298) and dismal without signs of life (survival, 7 [0.7%] of 995; neurologically intact survival, 1 [0.1%] of 825).

CONCLUSION

We strongly recommend that patients who present pulseless with signs of life after penetrating thoracic injury undergo EDT. We conditionally recommend EDT for patients who present pulseless and have absent signs of life after penetrating thoracic injury, present or absent signs of life after penetrating extrathoracic injury, or present signs of life after blunt injury. Lastly, we conditionally recommend against EDT for pulseless patients without signs of life after blunt injury.

LEVEL OF EVIDENCE

Systematic review/guideline, level III.

The selection of diagnostic modalities in the management of pelvic fracture patients requiring transfers

Introduction

Pelvic fractures can result in life-threatening hemorrhages. Therefore, pelvic fracture patients must usually be transferred to a trauma center for additional management. We attempted to analyze transferred pelvic fracture patients to determine which diagnostic modalities to use in different treatment settings.

Materials and methods

From May 1, 2008, to February 28, 2014, patients with pelvic fractures who were transferred from other local hospitals within 24 hours after the trauma were enrolled. We compared the pre-transfer conditions and pelvic X-ray results from the local hospitals between the group of patients that underwent further angioembolization at the trauma center and the group that did not. The role of computed tomography (CT) in the decision-making process (i.e., regarding additional angioembolization) at the different institutions was discussed.

Results

In total, 751 patients were enrolled in the current study. Of the patients who received further angioembolization at the trauma center, 77.6 % (121/156) had sacro-iliac (SI) joint disruption on their pre-transfer pelvic X-ray; this rate was significantly higher than that of the patients who did not undergo further embolization (77.6 % vs. 25.5 %, p < 0.001). There was no significant difference in the use of pre-transfer CT scans at the local hospitals between the patients who underwent angioembolization and those who did not (53.8 % vs. 50.3 %, p = 0.472). Furthermore, of these patients, there was no significant difference in the length of emergency department stay (from arrival to angioembolization) at the trauma center among the patients who underwent pre-transfer CT scans and those who did not (97.4 ± 69.3 minutes vs. 108.6 ± 21.8 minutes, p = 0.461).

Conclusion

When managing patients with pelvic fractures, the more attention should be paid to those with SI joint disruption on pelvic X-ray. Because these patients are more likely to require further angioembolization, they should be transferred earlier. Additional CT may be performed after the patient’s transfer to the trauma center to determine subsequent treatment.