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Soni KD, Bansal V, Khajanchi M, Veetil DK, Anderson G, Rayker N, Sarang B, David S, Wärnberg MG, Roy N. Intubation and In-Hospital Mortality After Trauma With Glasgow Coma Scale Score Eight or Less-A Cohort Study. J Surg Res 2024; 299:188-194. [PMID: 38761677 DOI: 10.1016/j.jss.2024.04.014] [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: 04/27/2023] [Revised: 02/24/2024] [Accepted: 04/18/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Most trauma societies recommend intubating trauma patients with Glasgow Coma Scale (GCS) scores ≤8 without robust supporting evidence. We examined the association between intubation and 30-d in-hospital mortality in trauma patients arriving with a GCS score ≤8 in an Indian trauma registry. METHODS Outcomes of patients with a GCS score ≤8 who were intubated within 1 h of arrival (intubation group) were compared with those who were intubated later or not at all (nonintubation group) using various analytical approaches. The association was assessed in various subgroup and sensitivity analyses to identify any variability of the effect. RESULTS Of 3476 patients who arrived with a GCS score ≤8, 1671 (48.1%) were intubated within 1 h. Overall, 1957 (56.3%) patients died, 947 (56.7%) in the intubation group and 1010 (56.0%) in the nonintubation group, with no significant difference in mortality (odds ratio = 1.2 [confidence interval, 0.8-1.8], P value = 0.467) in multivariable regression and propensity score-matched analysis. This result persisted across subgroup and sensitivity analyses. Patients intubated within an hour of arrival had longer durations of ventilation, intensive care unit stay, and hospital stay (P < 0.001). CONCLUSIONS Intubation within an hour of arrival with a GCS score ≤8 after major trauma was not associated with differences in-hospital mortality. The indications and benefits of early intubation in these severely injured patients should be revisited to promote optimal resource utilization in LMICs.
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Affiliation(s)
- Kapil Dev Soni
- Critical and Intensive Care, JPN Apex Trauma Centre, AIIMS, New Delhi, India
| | - Varun Bansal
- Department of General Surgery, Seth. G. S. Medical College & K.E.M. Hospital, Mumbai, India
| | - Monty Khajanchi
- Department of General Surgery, Seth. G. S. Medical College & K.E.M. Hospital, Mumbai, India
| | | | - Geoffrey Anderson
- Division of Trauma, Burn, Surgical Critical Care and Emergency General Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Nakul Rayker
- Division of Trauma and Emergency Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
| | - Bhakti Sarang
- Trauma Research Group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India
| | - Siddharth David
- Doctors For You, Mumbai, India; Health Systems and Policy, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Martin Gerdin Wärnberg
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
| | - Nobhojit Roy
- Trauma Research Group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India; Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
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Li P, Zhang Z, Yu HF, Yao R, Wei W, Nie H. Development and validation of a model to predict the need for artificial airways for acute trauma patients in the emergency department: a retrospective case-control study. BMJ Open 2024; 14:e081638. [PMID: 38889944 PMCID: PMC11191793 DOI: 10.1136/bmjopen-2023-081638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 06/05/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVE To develop scores for predicting the need for artificial airway procedures for acute trauma patients in the emergency department (ED). DESIGN Retrospective case-control. SETTING A tertiary comprehensive hospital in China. PARTICIPANTS 8288 trauma patients admitted to the ED within 24 hours of injury and who were admitted from 1 August 2012 to 31 July 2020. PRIMARY AND SECONDARY OUTCOME MEASURES The study outcome was the establishment of an artificial airway within 24 hours of admission to the ED. Based on the different feature compositions, two scores were developed in the development cohort by multivariable logistic regression. The predictive performance was assessed in the validation cohort. RESULTS The O-SPACER (Oxygen saturation, Systolic blood pressure, Pulse rate, Age, Coma Scale, Eye response, Respiratory rate) score was developed based on the patient's basic information with an area under the curve (AUC) of 0.85 (95% CI 0.80 to 0.89) in the validation group. Based on the basic information and trauma scores, the IO-SPACER (Injury Severity Score, Oxygen saturation, Systolic blood pressure, Pulse rate, Age, Coma Scale, Eye response, Respiratory rate) score was developed, with an AUC of 0.88 (95% CI 0.84 to 0.92). According to the O-SPACER and IO-SPACER scores, the patients were stratified into low, medium and high-risk groups. According to these two scores, the high-risk patients were associated with an increased demand for artificial airways, with an OR of 40.16-40.67 compared with the low-risk patients. CONCLUSIONS The O-SPACER score provides risk stratification for injured patients requiring urgent airway intervention in the ED and may be useful in guiding initial management. The IO-SPACER score may assist in further determining whether the patient needs planned intubation or tracheotomy early after trauma.
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Affiliation(s)
- Ping Li
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Zhuo Zhang
- Emergency Department, West China Hospital, Sichuan University, Chengdu, China
| | - Hai Fang Yu
- Emergency Department, West China Hospital, Sichuan University, Chengdu, China
| | - Rong Yao
- Emergency Department, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Wei
- Emergency Department, West China Hospital, Sichuan University, Chengdu, China
| | - Hu Nie
- Emergency Department, West China Hospital, Sichuan University, Chengdu, China
- West China Xiamen Hospital of Sichuan University, Xiamen, China
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Park FS, Nahmias J, Schubl S, Swentek L, Guner Y, Goodman LF, Emigh B, Grigorian A. Adolescent Trauma Patients With Isolated Head Trauma and Glasgow Coma Scale 6-8: Routine Intubation? Am Surg 2024; 90:882-886. [PMID: 37982759 DOI: 10.1177/00031348231212583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
BACKGROUND Recent evidence suggests that routine intubation upon arrival for adults with isolated head trauma and a depressed Glasgow Coma Scale (GCS) score is associated with increased risk of morbidity and mortality. Whether these outcomes are similar within an adolescent trauma population has not been previously investigated. We hypothesized intubation upon arrival for adolescent trauma patients with isolated head trauma to be associated with a higher risk of death and prolonged length of stay (LOS). METHODS The 2017-2019 TQIP was queried for adolescents (age 12-16) presenting after isolated blunt head trauma (abbreviated injury scale [AIS] <1 spine/chest/abdomen/upper-extremity/lower-extremity) and GCS 6-8 on arrival. Transferred patients, dead-on-arrival, and those undergoing emergent operation from the emergency department were excluded. Patients intubated within one-hour were compared to patients not intubated within one-hour. A multivariable logistic regression analysis was performed adjusting for age, sex, GCS, and AIS-grade for the head. RESULTS From 141 patients, 73 (51.8%) were intubated upon arrival. Intubated patients had a low complication rate (5.6%). Intubated and non-intubated patients had a similar rate and mortality risk (6.8% vs 1.5%, P = .11) (OR 1.84, CI .08-43.69, P = .71) and median length of stay (LOS) (2 days vs 2 days, P = .13). DISCUSSION Unlike adult patients, adolescents with isolated head trauma and a depressed GCS have similar outcomes if they are intubated upon arrival. Utilizing initial GCS score to determine which adolescent trauma patients with isolated head trauma should be intubated appears to be a safe practice.
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Affiliation(s)
- Flora S Park
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine School of Medicine, Orange, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine School of Medicine, Orange, CA, USA
| | - Sebastian Schubl
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine School of Medicine, Orange, CA, USA
| | - Lourdes Swentek
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine School of Medicine, Orange, CA, USA
| | - Yigit Guner
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine School of Medicine, Orange, CA, USA
- Department of Surgery, Division of Pediatric Surgery, Children's Health Orange County, Orange, CA, USA
| | - Laura F Goodman
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine School of Medicine, Orange, CA, USA
- Department of Surgery, Division of Pediatric Surgery, Children's Health Orange County, Orange, CA, USA
| | - Brent Emigh
- Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Areg Grigorian
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine School of Medicine, Orange, CA, USA
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Wend CM, Fransman RB, Haut ER. Prehospital Trauma Care. Surg Clin North Am 2024; 104:267-277. [PMID: 38453301 DOI: 10.1016/j.suc.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Prehospital trauma evaluation begins with the primary assessment of airway, breathing, circulation, disability, and exposure. This is closely followed by vital signs and a secondary assessment. Key prehospital interventions include management and resuscitation according to the aforementioned principles with a focus on major hemorrhage control, airway compromise, and invasive management of tension pneumothorax. Determining the appropriate time and method for transportation (eg, ground ambulance, helicopter, police, private vehicle) to the hospital or when to terminate resuscitation are also important decisions to be made by emergency medical services clinicians.
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Affiliation(s)
- Christopher M Wend
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street Suite 6-100, Baltimore, MD 21287, USA
| | - Ryan B Fransman
- Department of Trauma, Acute Care Surgery, and Surgical Critical Care, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Jr. Drive, SE, Atlanta, GA 30303, USA
| | - Elliott R Haut
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street Suite 6-100, Baltimore, MD 21287, USA; Department of Surgery, Division of Acute Care Surgery, Johns Hopkins University School of Medicine, Sheikh Zayed 6107C, 1800 Orleans Street, Baltimore, MD 21287, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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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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Weigeldt M, Schulz-Drost S, Stengel D, Lefering R, Treskatsch S, Berger C. In-hospital mortality after prehospital endotracheal intubation versus alternative methods of airway management in trauma patients. A cohort study from the TraumaRegister DGU®. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02498-8. [PMID: 38509186 DOI: 10.1007/s00068-024-02498-8] [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: 11/09/2023] [Accepted: 03/10/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE Prehospital airway management in trauma is a key component of care and is associated with particular risks. Endotracheal intubation (ETI) is the gold standard, while extraglottic airway devices (EGAs) are recommended alternatives. There is limited evidence comparing their effectiveness. In this retrospective analysis from the TraumaRegister DGU®, we compared ETI with EGA in prehospital airway management regarding in-hospital mortality in patients with trauma. METHODS We included cases only from German hospitals with a minimum Abbreviated Injury Scale score ≥ 2 and age ≥ 16 years. All patients without prehospital airway protection were excluded. We performed a multivariate logistic regression to adjust with the outcome measure of hospital mortality. RESULTS We included n = 10,408 cases of whom 92.5% received ETI and 7.5% EGA. The mean injury severity score was higher in the ETI group (28.8 ± 14.2) than in the EGA group (26.3 ± 14.2), and in-hospital mortality was comparable: ETI 33.0%; EGA 30.7% (27.5 to 33.9). After conducting logistic regression, the odds ratio for mortality in the ETI group was 1.091 (0.87 to 1.37). The standardized mortality ratio was 1.04 (1.01 to 1.07) in the ETI group and 1.1 (1.02 to 1.26) in the EGA group. CONCLUSIONS There was no significant difference in mortality rates between the use of ETI or EGA, or the ratio of expected versus observed mortality when using ETI.
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Affiliation(s)
- Moritz Weigeldt
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | | | - Dirk Stengel
- BG Kliniken - Hospital Group of the German Federal Statutory Accident Insurance, Leipziger Platz 1, 10117, Berlin, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Faculty of Health, Witten/Herdecke University, 51109, Cologne, Germany
- Committee On Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU), Berlin, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Christian Berger
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
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Krieger JA, Sheehan J, Hernandez MA, Thau MR, Johnson NJ, Robinson BRH. Characteristics of victims of trauma requiring invasive mechanical ventilation with a short stay in critical care. Am J Emerg Med 2024; 77:1-6. [PMID: 38096634 DOI: 10.1016/j.ajem.2023.11.054] [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: 08/29/2023] [Revised: 11/20/2023] [Accepted: 11/25/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Many patients who are admitted to the intensive care unit (ICU) have needs which rapidly resolve and are discharged alive within 24 h. We sought to characterize the outcomes of critically ill trauma victims at our institution with a short stay in the ICU. METHODS We conducted a retrospective cohort study of all critically ill adult trauma victims presenting to our ED between January 1st, 2011 and December 31st, 2019. We included patients who were endotracheally intubated in either the prehospital setting or the ED and were admitted either to the operating room (OR), angiography suite, or ICU. Our primary outcome was the proportion of patients who were discharged alive from the ICU within 24 h. RESULTS We included 3869 patients meeting the criteria above who were alive at 24 h. This population was 78% male with a median age of 40 and 76% of patients suffered from blunt trauma. The median injury severity score (ISS) of the group was 21 [inter-quartile range (IQR) 11-30]. In-hospital mortality amongst the group was 12%. 17% of the group were discharged alive from the ICU within 24 h. Thirty-four percent of the group had an ISS ≤ 15. Of the group which left the ICU alive within 24 h, six patients (0.9%) died in the hospital, 2 % of patients were re-admitted to an ICU, and 0.6% of patients required re-intubation. CONCLUSIONS We found that 17% of patients who were intubated in the prehospital setting or emergency department and subsequently hospitalized were discharged alive from the ICU within 24 h.
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Affiliation(s)
- Joshua A Krieger
- Department of Hospital Care, Section of Critical Care, UCHealth Memorial Hospital Central, Colorado Springs, CO, United States of America.
| | - Jordan Sheehan
- Department of Emergency Medicine, University of Washington Medical Center, Seattle, WA, United States of America.
| | - Michael A Hernandez
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Washington Medical Center, Seattle, WA, United States of America.
| | - Matthew R Thau
- Department of Medicine, Division of Critical Care, Pulmonary and Sleep, University of Texas McGovern Medical School, Houston, TX, United States of America.
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington Medical Center, Seattle, WA, United States of America; Department of Pulmonary, Critical Care and Sleep Medicine, University of Washington Medical Center, Seattle, WA, United States of America
| | - Bryce R H Robinson
- Department of Surgery, University of Washington Medical Center, Harborview Medical Center, Seattle, WA, United States of America.
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Bradford JM, Teixeira PG, DuBose J, Trust MD, Cardenas TC, Golestani S, Efird J, Kempema J, Zimmerman J, Czysz C, Robert M, Ali S, Brown LH, Brown CV. Temporal changes in the prehospital management of trauma patients: 2014-2021. Am J Surg 2024; 228:88-93. [PMID: 37567816 DOI: 10.1016/j.amjsurg.2023.08.001] [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: 05/25/2023] [Revised: 07/24/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023]
Abstract
INTRODUCTION Aggressive prehospital interventions (PHI) in trauma may not improve outcomes compared to prioritizing rapid transport. The aim of this study was to quantify temporal changes in the frequency of PHI performed by EMS. METHODS Retrospective chart review of adult patients transported by EMS to our trauma center from January 1, 2014 to 12/31/2021. PHI were recorded and annual changes in their frequency were assessed via year-by-year trend analysis and multivariate regression. RESULTS Between the first and last year of the study period, the frequency of thoracostomy (6% vs. 9%, p = 0.001), TXA administration (0.3% vs. 33%, p < 0.001), and whole blood administration (0% vs. 20%, p < 0.001) increased. Advanced airway procedures (21% vs. 12%, p < 0.001) and IV fluid administration (57% vs. 36%, p < 0.001) decreased. ED mortality decreased from 8% to 5% (p = 0.001) over the study period. On multivariate regression, no PHI were independently associated with increased or decreased ED mortality. CONCLUSION PHI have changed significantly over the past eight years. However, no PHI were independently associated with increased or decreased ED mortality.
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Affiliation(s)
- James M Bradford
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Pedro G Teixeira
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Joseph DuBose
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Marc D Trust
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Tatiana Cp Cardenas
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Simin Golestani
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Jessica Efird
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - James Kempema
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Jessica Zimmerman
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Clea Czysz
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Michelle Robert
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Sadia Ali
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Lawrence H Brown
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
| | - Carlos Vr Brown
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, United States.
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Catoire P, Roussel M, Teissandier D. Sequence of administration of anesthetic agents during rapid sequence induction for emergency intubation: a French survey on current practices. Eur J Emerg Med 2024; 31:71-73. [PMID: 37792524 DOI: 10.1097/mej.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Affiliation(s)
- Pierre Catoire
- Sorbonne University, Emergency Department, Hopital Pitie-Salpêtrière, Assistance Publique-Hopitaux de Paris, Paris
| | - Mélanie Roussel
- Emergency Department, University Rouen Normandie, CHU Rouen, Rouen, France
| | - Dorian Teissandier
- Sorbonne University, Emergency Department, Hopital Pitie-Salpêtrière, Assistance Publique-Hopitaux de Paris, Paris
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Qasim Z, Perrone J, Delgado MK. The Value of Not Intubating Comatose Patients With Acute Poisoning. JAMA 2023; 330:2253-2254. [PMID: 38019975 DOI: 10.1001/jama.2023.22462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Affiliation(s)
- Zaffer Qasim
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - M Kit Delgado
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Hossain I, Rostami E, Marklund N. The management of severe traumatic brain injury in the initial postinjury hours - current evidence and controversies. Curr Opin Crit Care 2023; 29:650-658. [PMID: 37851061 PMCID: PMC10624411 DOI: 10.1097/mcc.0000000000001094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of recent studies discussing novel strategies, controversies, and challenges in the management of severe traumatic brain injury (sTBI) in the initial postinjury hours. RECENT FINDINGS Prehospital management of sTBI should adhere to Advanced Trauma Life Support (ATLS) principles. Maintaining oxygen saturation and blood pressure within target ranges on-scene by anesthetist, emergency physician or trained paramedics has resulted in improved outcomes. Emergency department (ED) management prioritizes airway control, stable blood pressure, spinal immobilization, and correction of impaired coagulation. Noninvasive techniques such as optic nerve sheath diameter measurement, pupillometry, and transcranial Doppler may aid in detecting intracranial hypertension. Osmotherapy and hyperventilation are effective as temporary measures to reduce intracranial pressure (ICP). Emergent computed tomography (CT) findings guide surgical interventions such as decompressive craniectomy, or evacuation of mass lesions. There are no neuroprotective drugs with proven clinical benefit, and steroids and hypothermia cannot be recommended due to adverse effects in randomized controlled trials. SUMMARY Advancement of the prehospital and ED care that include stabilization of physiological parameters, rapid correction of impaired coagulation, noninvasive techniques to identify raised ICP, emergent surgical evacuation of mass lesions and/or decompressive craniectomy, and temporary measures to counteract increased ICP play pivotal roles in the initial management of sTBI. Individualized approaches considering the underlying pathology are crucial for accurate outcome prediction.
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Affiliation(s)
- Iftakher Hossain
- Neurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Elham Rostami
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala
- Department of Neuroscience, Karolinska institute, Stockholm
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
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Elkbuli A, Breeding T, Ngatuvai M, Patel H, Andrade R, Rosander A, Knowlton LM, Liu H, Ang D. Glasgow Coma Scale Intubation Thresholds and Outcomes of Patients With Traumatic Brain Injury: The Need for Tailored Practice Management Guidelines. Am Surg 2023; 89:6098-6113. [PMID: 37515511 DOI: 10.1177/00031348231192062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
INTRODUCTION This study aims to re-evaluate the GCS threshold for intubation in patients presenting to the ED with a traumatic brain injury to optimize outcomes and provide evidence for future practice management guidelines. METHODS We retrospectively reviewed the ACS-TQIP-Participant Use File (PUF) 2015-2019 for adult trauma patients 18 years and older who experienced a blunt traumatic head injury and received computerized tomography. Multivariable regressions were performed to assess associations between outcomes and GCS intubation thresholds of 5, 8, and 10. RESULTS In patients with a GCS ≤5, there were no differences in mortality (GCS ≤5: 26.3% vs GCS >5: 28.3%, adjusted P = .08), complication rates (GCS ≤5: 9.1% vs GCS >5: 10.3%, adjusted P = .91), or ICU length of stay (GCS ≤5: 5.4 vs GCS >5: 4.7, adjusted P = .36) between intubated and non-intubated patients. Intubated patients at GCS thresholds ≤8 (26.2% vs 19.1%, adjusted P < .0001) and ≤10 (25.6% vs 15.8%, adjusted P < .0001) had significantly higher mortality rates than non-intubated patients. Intubation at all GCS thresholds >5 resulted in higher rates of complications, H-LOS, and ICU-LOS when compared to non-intubated patients with the same GCS score. CONCLUSION A GCS ≤5 was the threshold at which intubation in TBI patients conferred an additional benefit in disposition without worsened outcomes of mortality, H-LOS, or ICU-LOS. Trauma societies and hospital institutions should consider revisiting existing guidelines and protocols concerning the appropriate GCS threshold for safer intubation and better outcomes among these patient population.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | | | | | - Heli Patel
- NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Ryan Andrade
- School of Osteopathic Medicine, A.T. Still University, Mesa, AZ, USA
| | - Abigail Rosander
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ, USA
| | - Lisa M Knowlton
- Department of Surgery, Division of Trauma and Surgical Critical Care, Stanford University Medical Center, Palo Alto, CA, USA
| | - Huazhi Liu
- Department of Surgery, Division of Trauma and Surgical Critical Care, Ocala Regional Medical Center, Ocala, FL, USA
| | - Darwin Ang
- Department of Surgery, Division of Trauma and Surgical Critical Care, Ocala Regional Medical Center, Ocala, FL, USA
- Department of Surgery, University of South Florida, Tampa, FL, USA
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13
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Londoño M, Nahmias J, Dolich M, Lekawa M, Kong A, Schubl S, Inaba K, Grigorian A. Development of a novel scoring tool to predict the need for early cricothyroidotomy in trauma patients. Surg Open Sci 2023; 16:58-63. [PMID: 37808420 PMCID: PMC10550758 DOI: 10.1016/j.sopen.2023.09.017] [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] [Received: 06/01/2023] [Revised: 08/08/2023] [Accepted: 09/17/2023] [Indexed: 10/10/2023] Open
Abstract
Background The lack of a widely-used tool for predicting early cricothyroidotomy in trauma patients prompted us to develop the Cricothyroidotomy After Trauma (CAT) score. We aimed to predict the need for cricothyroidotomy within one hour of trauma patient arrival. Methods Derivation and validation datasets were obtained from the Trauma Quality Improvement Program (TQIP) database. Logistic modeling identified predictors, and weighted averages were used to create the CAT score. The score's performance was assessed using AUROC. Results Among 1,373,823 derivation patients, <1 % (n = 339) underwent cricothyroidotomy within one hour. The CAT score, comprising nine predictors, achieved an AUROC of 0.88. Severe neck injury and gunshot wound were the strongest predictors. Cricothyroidotomy rates increased from 0.4 % to 9.3 % at scores of 5 and 8, respectively. In the validation set, the CAT tool yielded an AUROC of 0.9. Conclusion The CAT score is a validated tool for predicting the need for early cricothyroidotomy in trauma patients. Further research is necessary to enhance its utility and assess its value in trauma care.
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Affiliation(s)
- Mary Londoño
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Jeffry Nahmias
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Matthew Dolich
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Michael Lekawa
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Allen Kong
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Sebastian Schubl
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Kenji Inaba
- University of Southern California, Department of Surgery, Los Angeles, CA, USA
| | - Areg Grigorian
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
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14
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Kim MH, Kim JY, Lee JS, Jo A, Kim DH. A novel technique of handling the blade for videolaryngoscopy intubation in patients with a semi-rigid neck collar: a prospective randomized controlled trial. Korean J Anesthesiol 2023; 76:451-460. [PMID: 36912005 PMCID: PMC10562061 DOI: 10.4097/kja.22733] [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: 11/14/2022] [Revised: 01/26/2023] [Accepted: 02/22/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Semi-rigid neck collars to protect the cervical spine can limit the extent of neck movement and mouth opening; this may further complicate orotracheal intubation. We aimed to compare intubation environments obtained with videolaryngoscopy using the technique of gliding a blade under the epiglottis and that obtained using the conventional Macintosh blade technique of blade tip placement on the vallecula. METHODS This prospective randomized study included patients aged ≥ 20 years with American Society of Anesthesiologists physical status I-III scheduled for cervical spine surgery between October 2020 and August 2021. Patients were divided into two groups according to the placement of the blade of the McGrathTM videolaryngoscope: the gliding and conventional groups. The percentage of glottic opening (POGO) score was the primary endpoint. We also recorded the time to obtain the optimal laryngoscopic view, intubation duration, and ease and satisfaction of the researcher performing intubation. RESULTS Among 176 patients, the POGO scores were significantly higher in the gliding group than in the conventional group (88.9 ± 14.7 vs. 63.8 ± 27.4, P < 0.001). The time to achieve the optimal glottic view for intubation and duration of intubation were also shorter, and ease and satisfaction in performing intubation were better in the gliding group than in the conventional group. CONCLUSION Our findings demonstrated a superior glottic view and more favorable intubation environments when the blade tip was placed under the epiglottis than using the conventional Macintosh technique in patients with immobilized cervical spine.
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Affiliation(s)
- Myoung Hwa Kim
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Young Kim
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Seok Lee
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Arim Jo
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Do-Hyeong Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
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15
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Thomas MB, Urban S, Carmichael H, Banker J, Shah A, Schaid T, Wright A, Velopulos CG, Cripps M. Tick-tock: Prehospital intubation is associated with longer field time without any survival benefit. Surgery 2023; 174:1034-1040. [PMID: 37500409 DOI: 10.1016/j.surg.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/16/2023] [Accepted: 06/18/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Prehospital endotracheal intubation is a debated topic, and few studies have found it beneficial after trauma. A growing body of evidence suggests that prehospital endotracheal intubation is associated with increased morbidity and mortality. Our study was designed to compare patients with attempted prehospital endotracheal intubation to those intubated promptly upon emergency department arrival. METHODS A retrospective review of a single-center trauma research data repository was utilized. Inclusion criteria included age ≥15 years, transport from the scene by ground ambulance, and undergoing prehospital endotracheal intubation attempts or intubation within 10 minutes of emergency department arrival without prior prehospital endotracheal intubation attempt. Propensity score matching was used to minimize differences in baseline characteristics between groups. Standard mean differences are also presented for pre- and post-matching datasets to evaluate for covariate balance. RESULTS In total, 208 patients met the inclusion criteria. Of these, 95 patients (46%) underwent prehospital endotracheal intubation, which was successful in 47% of cases. A control group of 113 patients (54%) were intubated within 10 minutes of emergency department arrival. We performed propensity score matching between cohorts based on observed differences after univariate analysis and used standard mean differences to estimate covariate balance. After propensity score matching, patients who underwent prehospital endotracheal intubation experienced a longer time on scene as compared with those intubated in the emergency department (9 minutes [interquartile range 6-12] vs 6 minutes [interquartile range 5-9], P < .01) without difference in overall mortality (67% vs 65%, P = 1.00). Rapid sequence intubation was not used in the field; however, it was used for 58% of patients intubated within 10 minutes of emergency department arrival. After matched analysis, patients with a failed prehospital intubation attempt were equally likely to receive rapid sequence intubation during re-intubation in the emergency department as compared with those undergoing a first attempt (n = 13/28, 46% vs n = 28/63, 44%, P = 1.00, standard mean differences 0.04). Among patients with prehospital arrest (n = 98), prehospital endotracheal intubation was associated with shorter time to death (8 minutes [interquartile range 3-17] vs 14 minutes [interquartile range 8-45], P = .008) and longer total transport time (23 minutes [interquartile range 19-31] vs 19 minutes [interquartile range 16-24], P = .006), but there was no difference in observed mortality (n = 29/31, 94% vs n = 30/31, 97%, P = 1.00, standard mean differences = 0.15) after propensity score matching. CONCLUSION Prehospital providers should prioritize expeditious transport over attempting prehospital endotracheal intubation, as prehospital endotracheal intubation is inconsistently successful, may delay definitive care, and appears to have no survival benefit.
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Affiliation(s)
- Madeline B Thomas
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO.
| | - Shane Urban
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Heather Carmichael
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO. https://twitter.com/hcarmichaelmd
| | - Jordan Banker
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Ananya Shah
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Terry Schaid
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Angela Wright
- Department of Emergency Medicine, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Catherine G Velopulos
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO. https://twitter.com/CVelopulos
| | - Michael Cripps
- Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO. https://twitter.com/MichaelCrippsMD
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16
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Kim J, Jung K, Moon J, Kwon J, Kang BH, Yoo J, Song S, Bang E, Kim S, Huh Y. Ketamine versus etomidate for rapid sequence intubation in patients with trauma: a retrospective study in a level 1 trauma center in Korea. BMC Emerg Med 2023; 23:57. [PMID: 37248552 DOI: 10.1186/s12873-023-00833-7] [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: 01/24/2023] [Accepted: 05/24/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Ketamine and etomidate are commonly used as sedatives in rapid sequence intubation (RSI). However, there is no consensus on which agent should be favored when treating patients with trauma. This study aimed to compare the effects of ketamine and etomidate on first-pass success and outcomes of patients with trauma after RSI-facilitated emergency intubation. METHODS We retrospectively reviewed 944 patients who underwent endotracheal intubation in a trauma bay at a Korean level 1 trauma center between January 2019 and December 2021. Outcomes were compared between the ketamine and etomidate groups after propensity score matching to balance the overall distribution between the two groups. RESULTS In total, 620 patients were included in the analysis, of which 118 (19.9%) were administered ketamine and the remaining 502 (80.1%) were treated with etomidate. Patients in the ketamine group showed a significantly faster initial heart rate (105.0 ± 25.7 vs. 97.7 ± 23.6, p = 0.003), were more hypotensive (114.2 ± 32.8 mmHg vs. 139.3 ± 34.4 mmHg, p < 0.001), and had higher Glasgow Coma Scale (9.1 ± 4.0 vs. 8.2 ± 4.0, p = 0.031) and Injury Severity Score (32.5 ± 16.3 vs. 27.0 ± 13.3, p < 0.001) than those in the etomidate group. There were no significant differences in the first-pass success rate (90.7% vs. 90.1%, p > 0.999), final mortality (16.1% vs. 20.6, p = 0.348), length of stay in the intensive care unit (days) (8 [4, 15] (Interquartile range)), vs. 10 [4, 21], p = 0.998), ventilator days (4 [2, 10] vs. 5 [2, 13], p = 0.735), and hospital stay (days) (24.5 [10.25, 38.5] vs. 22 [8, 40], p = 0.322) in the 1:3 propensity score matching analysis. CONCLUSION In this retrospective study of trauma resuscitation, those receiving intubation with ketamine had greater hemodynamic instability than those receiving etomidate. However, there was no significant difference in clinical outcomes between patients sedated with ketamine and those treated with etomidate.
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Affiliation(s)
- Jinjoo Kim
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jonghwan Moon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Junsik Kwon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Byung Hee Kang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jayoung Yoo
- Gyeonggi Southern Regional Trauma Centre, Ajou University Hospital, Suwon, Republic of Korea
| | - Seoyoung Song
- Gyeonggi Southern Regional Trauma Centre, Ajou University Hospital, Suwon, Republic of Korea
| | - Eunsook Bang
- Gyeonggi Southern Regional Trauma Centre, Ajou University Hospital, Suwon, Republic of Korea
| | - Sora Kim
- Gyeonggi Southern Regional Trauma Centre, Ajou University Hospital, Suwon, Republic of Korea
| | - Yo Huh
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea.
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Kuupiel D, Jessani NS, Boffa J, Naude C, De Buck E, Vandekerckhove P, McCaul M. Prehospital clinical practice guidelines for unintentional injuries: a scoping review and prioritisation process. BMC Emerg Med 2023; 23:27. [PMID: 36915034 PMCID: PMC10010958 DOI: 10.1186/s12873-023-00794-x] [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: 08/15/2022] [Accepted: 02/22/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Globally, millions of people die and many more develop disabilities resulting from injuries each year. Most people who die from injuries do so before they are transported to hospital. Thus, reliable, pragmatic, and evidence-based prehospital guidance for various injuries is essential. We systematically mapped and described prehospital clinical practice guidelines (CPGs) for injuries in the global context, as well as prioritised injury topics for guidance development and adolopment. METHODS This study was sequentially conducted in three phases: a scoping review for CPGs (Phase I), identification and refinement of gaps in CPGs (Phase II), and ranking and prioritisation of gaps in CPGs (Phase III). For Phase I, we searched PubMed, SCOPUS, and Trip Database; guideline repositories and websites up to 23rd May 2021. Two authors in duplicate independently screened titles and abstract, and full-text as well as extracted data of eligible CPGs. Guidelines had to meet 60% minimum methodological quality according to rigour of development domain in AGREE II. The second and third phases involved 17 participants from 9 African countries and 1 from Europe who participated in a virtual stakeholder engagement workshop held on 5 April 2022, and followed by an online ranking process. RESULTS Fifty-eight CPGs were included out of 3,427 guidance documents obtained and screened. 39/58 (67%) were developed de novo compared to 19 that were developed using alternative approaches. Twenty-five out of 58 guidelines (43%) were developed by bodies in countries within the WHO European Region, while only one guideline was targeted to the African context. Twenty-five (43%) CPGs targeted emergency medical service providers, while 13 (22%) targeted first aid providers (laypeople). Forty-three CPGs (74%) targeted people of all ages. The 58 guidance documents contained 32 injury topics. Injuries linked to road traffic accidents such as traumatic brain injuries and chest injuries were among the top prioritised topics for future guideline development by the workshop participants. CONCLUSION This study highlights the availability, gaps and priority injury topics for future guideline development/adolopment, especially for the African context. Further research is needed to evaluate the recommendations in the 58 included CPGs for possible adaptation to the African context.
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Affiliation(s)
- Desmond Kuupiel
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine & Health Science, Stellenbosch University, Cape Town, 7530, South Africa.
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine & Health Science, Stellenbosch University, Cape Town, 7530, South Africa.
- Faculty of Health Sciences, Durban University of Technology, Durban, 4001, South Africa.
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, 4001, South Africa.
| | - Nasreen S Jessani
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine & Health Science, Stellenbosch University, Cape Town, 7530, South Africa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Jody Boffa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine & Health Science, Stellenbosch University, Cape Town, 7530, South Africa
- The Aurum Institute, Johannesburg, South Africa
| | - Celeste Naude
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine & Health Science, Stellenbosch University, Cape Town, 7530, South Africa
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine & Health Science, Stellenbosch University, Cape Town, 7530, South Africa
| | - Emmy De Buck
- Centre for Evidence-Based Practice, Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Kapucijnenvoer 35 block D, 3000, Leuven, Belgium
- Cochrane First Aid, Motstraat 42, Mechelen, Belgium
| | - Philippe Vandekerckhove
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine & Health Science, Stellenbosch University, Cape Town, 7530, South Africa
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Kapucijnenvoer 35 block D, 3000, Leuven, Belgium
- Belgian Red Cross, Motstraat 42, 2800, Mechelen, Belgium
| | - Michael McCaul
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine & Health Science, Stellenbosch University, Cape Town, 7530, South Africa
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Maurya I, Maurya VP, Mishra R, Moscote-Salazar LR, Janjua T, Yunus M, Agrawal A. Airway Management of Suspected Traumatic Brain Injury Patients in the Emergency Room. INDIAN JOURNAL OF NEUROTRAUMA 2023. [DOI: 10.1055/s-0042-1760416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
AbstractThe patients of trauma offers a special challenge because of the associated head injury, maxillofacial, neck and spine injuries, which puts the airway at imminent risk. The response time for the emergency team to initiate the airway management determines the outcome of the individual undergoing treatment. A judious implementatin of triage and ATLS guidelines are helpful in the allocation of resources in airway management of trauma patients. One must not get distracted with the severity of other organ systems because cerebral tissue permits a low threshold to the hypoxic insults. Adequate preparedness and a team effort result in better airway management and improved outcomes in trauma patients with variable hemodynamic response to resuscitation. All possible efforts must be made to secure a definitive airway (if required) and should be verified clinically as well as with the available adjuncts. The success of a trauma team depends on the familiarity to the airways devices and their discrete application in various situations.
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Affiliation(s)
- Indubala Maurya
- Department of Anaesthesiology, Kalyan Singh Super Specialty Cancer Institute, CG City, Lucknow, Uttar Pradesh, India
| | | | - Rakesh Mishra
- Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | | | - Tariq Janjua
- Department of Critical Care Medicine, Physician Regional Medical Center, Naples, Florida, United States
| | - Mohd Yunus
- Department of Trauma and Emergency Medicine, All India Institute of Medical Sciences, Saket Nagar, Bhopal, Madhya Pradesh, India
| | - Amit Agrawal
- Department of Trauma and Emergency Medicine, All India Institute of Medical Sciences, Saket Nagar, Bhopal, Madhya Pradesh, India
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Stausberg T, Ahnert T, Thouet B, Lefering R, Böhmer A, Brockamp T, Wafaisade A, Fröhlich M. Endotracheal intubation in trauma patients with isolated shock: universally recommended but rarely performed. Eur J Trauma Emerg Surg 2022; 48:4623-4630. [PMID: 35551425 PMCID: PMC9712316 DOI: 10.1007/s00068-022-01988-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/20/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The indication for pre-hospital endotracheal intubation (ETI) must be well considered as it is associated with several risks and complications. The current guidelines recommend, among other things, ETI in case of shock (systolic blood pressure < 90 mmHg). This study aims to investigate whether isolated hypotension without loss of consciousness is a useful criterion for ETI. METHODS The data of 37,369 patients taken from the TraumaRegister DGU® were evaluated in a retrospective study with regard to pre-hospital ETI and the underlying indications. Inclusion criteria were the presence of any relevant injuries (Abbreviated Injury Scale [AIS] ≥ 3) and complete pre-hospital management information. RESULTS In our cohort, 29.6% of the patients were intubated. The rate of pre-hospital ETI increased with the number of indications. If only one criterion according to current guidelines was present, ETI was often omitted. In 582 patients with shock as the only indication for pre-hospital ETI, only 114 patients (19.6%) were intubated. Comparing these subgroups, the intervention was associated with longer time on scene (25.3 min vs. 41.6 min; p < 0.001), higher rate of coagulopathy (31.8% vs. 17.2%), an increased mortality (8.2% vs. 11.5%) and higher standard mortality ratio (1.17 vs. 1.35). If another intubation criterion was present in addition to shock, intubation was performed more frequently. CONCLUSION Decision making for pre-hospital intubation in trauma patients is challenging in front of a variety of factors. Despite the presence of a guideline recommendation, ETI is not always executed. Patients presenting with shock as remaining indication and subsequent intubation showed a decreased outcome. Thus, isolated shock does not appear to be an appropriate indication for pre-hospital ETI, but clearly remains an important surrogate of trauma severity and the need for trauma team activation.
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Affiliation(s)
- Timo Stausberg
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany.
| | - Tobias Ahnert
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Ben Thouet
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
| | - Andreas Böhmer
- Department of Anaesthesiology and Intensive Care Medicine, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Cologne, Germany
| | - Thomas Brockamp
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Arasch Wafaisade
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Matthias Fröhlich
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
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Wu FC, Hung KS, Lin YW, Sung K, Yang TH, Wu CH, Wang CJ, Yen YT. Effectiveness of protocolized management for patients sustaining maxillofacial fracture with massive oronasal bleeding: a single-center experience. Scand J Trauma Resusc Emerg Med 2022; 30:60. [PMID: 36411460 PMCID: PMC9677620 DOI: 10.1186/s13049-022-01047-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 11/08/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Maxillofacial fractures can lead to massive oronasal bleeding; however, surgical hemostasis and packing procedures can be challenging owing to complex facial anatomy. Only a few studies investigated maxillofacial fractures with massive oronasal hemorrhage. However, thus far, no studies have reported a protocolized management approach for maxillofacial trauma from a single center. This study aimed to evaluate the effectiveness of protocolized management for maxillofacial fractures with oronasal bleeding. METHODS Patients were identified from the National Cheng University Hospital trauma registry from 2010 to 2020. We included patients with a face Abbreviated Injury Scale (AIS) score of > 3 and active oronasal bleeding. Patients' characteristics were compared between the angiography and non-angiography groups and between survivors and nonsurvivors. RESULTS Forty-nine patients were included. Among them, 34 (69%) underwent angiography, of whom 21 received arterial embolization. Forty-seven patients (96%) successfully achieved hemostasis by adhering to the treatment protocol at our institution. Compared with the non-angiography group, the angiography group had significantly more patients requiring oral intubation (97% vs. 53%, P < 0.001), Glasgow Coma Scale < 9 (GCS; 79% vs. 27%, P < 0.001), head AIS > 3 (65% vs. 13%, P = 0.001), higher Injury Severity Score (ISS; 43 [33-50] vs. 22 [18-27], P < 0.001), higher incidence of cardiopulmonary resuscitation (CPR; 41% vs. 0%, P = 0.002), higher mortality rate (35% vs. 7%, P = 0.043), and more units of packed red blood cells (PRBC) transfused within 24 h (12 [6-20] vs. 2 [0-4], P < 0.001). The nonsurvivor group had significantly more patients with hypotension (62% vs. 8%; P < 0.001), higher need for CPR (85% vs. 8%; P < 0.001), head AIS > 3 (92% vs. 33%; P < 0.001), skull base fracture (100% vs. 64%; P = 0.011), GCS score < 9 (100% vs. 50%; P = 0.003), higher ISS (50 [43-57] vs. 29 [19-48]; P < 0.001), and more units of PRBC transfused within 24 h (18 [13-22] vs. 6 [2-12]; P = 0.001) than the survivor group. More patients underwent angiography in the nonsurvivor group than in the survivor group (92% vs. 61%; P = 0.043). Among embolized vessels, the internal maxillary artery (65%) was the most common bleeding site. Hypoxic encephalopathy accounted for 92% of deaths. CONCLUSIONS Protocol-guided management effectively optimizes outcomes in patients with maxillofacial bleeding.
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Affiliation(s)
- Fang-Chi Wu
- grid.412040.30000 0004 0639 0054Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Kuo-Shu Hung
- grid.64523.360000 0004 0532 3255Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, Tainan, 704 Taiwan
| | - Yu-Wen Lin
- grid.64523.360000 0004 0532 3255School of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Kang Sung
- grid.412040.30000 0004 0639 0054Department of Medical Imaging, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Tsung-Han Yang
- grid.64523.360000 0004 0532 3255Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, Tainan, 704 Taiwan
| | - Chun-Hsien Wu
- grid.412040.30000 0004 0639 0054Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chih-Jung Wang
- grid.64523.360000 0004 0532 3255Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, Tainan, 704 Taiwan
| | - Yi-Ting Yen
- grid.64523.360000 0004 0532 3255Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, Tainan, 704 Taiwan
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Soni KD, Bansal V, Arora H, Verma S, Wärnberg MG, Roy N. The State of Global Trauma and Acute Care Surgery/Surgical Critical Care. Crit Care Clin 2022; 38:695-706. [PMID: 36162905 DOI: 10.1016/j.ccc.2022.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Trauma is a leading cause of morbidity and mortality globally, with a significant burden attributable to the low- and middle-income countries (LMICs), where more than 90% of injury-related deaths occur. Road injuries contribute largely to the economic burden from trauma and are prevalent among adolescents and young adults. Trauma systems vary widely across the world in their capacity of providing basic and critical care to injured patients, with delays in treatment being present at multiple levels at LMICs. Strengthening existing systems by providing cost-effective and efficient solutions can help mitigate the injury burden in LMICs.
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Affiliation(s)
- Kapil Dev Soni
- Critical & Intensive Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, Ring Road, Raj Nagar, Safdarjung Enclave, New Delhi, Delhi 110029, India
| | - Varun Bansal
- Department of General Surgery, 2nd Floor Registration Building, Seth G.S.M.C. and K.E.M. Hospital, Parel, Mumbai 400012, India
| | - Harshit Arora
- Department of Surgery, Punjab Institute of Medical Sciences, Gadha Road, Jalandhar, Punjab 144006, India
| | - Sukriti Verma
- Department of Blood Bank, Guru Teg Bahadur Hospital, Tahirpur Rd, GTB Enclave, Dilshad Garden, New Delhi, Delhi 110095, India; WHO Collaborating Center for Research on Surgical Care Delivery in LMICs, Department of Surgery, BARC Hospital, Anushaktinagar, Mumbai 400094, India
| | - Martin Gerdin Wärnberg
- Department of Global Public Health, Karolinska Institutet, Tomtebodavägen 18, 171 65 Solna, Stockholm 171 65, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital Solna, SE - 171 76, Stockholm, Sweden
| | - Nobhojit Roy
- WHO Collaborating Center for Research on Surgical Care Delivery in LMICs, Department of Surgery, BARC Hospital, Anushaktinagar, Mumbai 400094, India; The George Institute of Global Health India, F-BLOCK, 311-312, Third Floor, Jasola Vihar, New Delhi, Delhi 110025, India.
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Somwaru B, Grossman D. Intubating Special Populations. Emerg Med Clin North Am 2022; 40:443-458. [DOI: 10.1016/j.emc.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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Chon SB, Lee MJ, Oh WS, Park YJ, Kwon JM, Kim K. A simple and novel equation to estimate the degree of bleeding in haemorrhagic shock: mathematical derivation and preliminary in vivo validation. THE KOREAN JOURNAL OF PHYSIOLOGY & PHARMACOLOGY 2022; 26:195-205. [PMID: 35477547 PMCID: PMC9046898 DOI: 10.4196/kjpp.2022.26.3.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/04/2022] [Accepted: 03/18/2022] [Indexed: 11/18/2022]
Abstract
Determining blood loss [100% – RBV (%)] is challenging in the management of haemorrhagic shock. We derived an equation estimating RBV (%) via serial haematocrits (Hct1, Hct2) by fixing infused crystalloid fluid volume (N) as [0.015 × body weight (g)]. Then, we validated it in vivo. Mathematically, the following estimation equation was derived: RBV (%) = 24k / [(Hct1 / Hct2) – 1]. For validation, non-ongoing haemorrhagic shock was induced in Sprague–Dawley rats by withdrawing 20.0%–60.0% of their total blood volume (TBV) in 5.0% intervals (n = 9). Hct1 was checked after 10 min and normal saline N cc was infused over 10 min. Hct2 was checked five minutes later. We applied a linear equation to explain RBV (%) with 1 / [(Hct1 / Hct2) – 1]. Seven rats losing 30.0%–60.0% of their TBV suffered shock persistently. For them, RBV (%) was updated as 5.67 / [(Hct1 / Hct2) – 1] + 32.8 (95% confidence interval [CI] of the slope: 3.14–8.21, p = 0.002, R2 = 0.87). On a Bland-Altman plot, the difference between the estimated and actual RBV was 0.00 ± 4.03%; the 95% CIs of the limits of agreements were included within the pre-determined criterion of validation (< 20%). For rats suffering from persistent, non-ongoing haemorrhagic shock, we derived and validated a simple equation estimating RBV (%). This enables the calculation of blood loss via information on serial haematocrits under a fixed N. Clinical validation is required before utilisation for emergency care of haemorrhagic shock.
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Affiliation(s)
- Sung-Bin Chon
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
- Department of Emergency Medicine, CHA Bundang Medical Center, Seongnam 13496, Korea
| | - Min Ji Lee
- Department of Emergency Medicine, CHA Bundang Medical Center, Seongnam 13496, Korea
| | - Won Sup Oh
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon 24289, Korea
| | - Ye Jin Park
- Department of Emergency Medicine, CHA Bundang Medical Center, Seongnam 13496, Korea
| | - Joon-Myoung Kwon
- Department of Critical Care and Emergency Medicine, Mediplex Sejong Hospital, Incheon 21080, Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, CHA Bundang Medical Center, Seongnam 13496, Korea
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The Need to Routinely Convert Emergency Cricothyroidotomy to Tracheostomy: A Systematic Review and Meta-Analysis. J Am Coll Surg 2022; 234:947-952. [DOI: 10.1097/xcs.0000000000000114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Posterior Circulation Stroke: Coma (More Than Time) is Brain. J Stroke Cerebrovasc Dis 2022; 31:106313. [PMID: 35093627 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106313] [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: 11/07/2021] [Revised: 12/19/2021] [Accepted: 01/06/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND AND PURPOSE Contrary to anterior circulation, the legitimacy of endovascular treatment in posterior circulation stroke is still being questioned. Finding reliable prognostic factors and determining how patient selection should be done has become top priority. METHODS Observational and retrospective study from two Portuguese hospitals, including all consecutive patients with posterior circulation occlusions who underwent thrombectomy between January 1st 2015 and December 31st 2019. RESULTS Out of a total of 126 patients, the median age was 74 (IQR 61-80) and 39.7% were female. A good clinical outcome (mRS ≤2) was associated with a lower incidence of coma (24,2% vs 66,7%, p < 0,001) and of sudden onset coma (3% vs 18%,=0,04), a lower NIHSS at admission (14 vs 19, p < 0,001), a higher pc-ASPECTS at admission (10 vs 9, p < 0,001) and at 24 h (8 vs 6, p < 0,001) and a higher BATMAN score (7 vs 6, p = 0,017). Differences in the times of symptom-onset-to-recanalization (496 vs 536, p = 0,19) and symptom-onset-to-coma (130 vs 195, p = 0,52) were not remarkable. When excluding NIHSS and pc-ASPECTS at 24 h, coma (p = 0,003; OR=0,22; 95% CI: 0,08-0,59) and the pc-ASPECTS at admission (p = 0,037; OR=1,63; 95% CI: 1,03-2,57) become independent predictors of good outcome. CONCLUSIONS In strokes from the posterior circulation, coma, more than time, appears to be an important prognostic factor. The BATMAN and the pc-ASPECTS scores were also associated with clinical outcome and coma.
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Braithwaite S, Stephens C, Remick K, Barrett W, Guyette FX, Levy M, Colwell C. Prehospital Trauma Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:64-71. [PMID: 35001817 DOI: 10.1080/10903127.2021.1994069] [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] [Indexed: 10/19/2022]
Abstract
Definitive management of trauma is not possible in the out-of-hospital environment. Rapid treatment and transport of trauma casualties to a trauma center are vital to improve survival and outcomes. Prioritization and management of airway, oxygenation, ventilation, protection from gross aspiration, and physiologic optimization must be balanced against timely patient delivery to definitive care. The optimal prehospital airway management strategy for trauma has not been clearly defined; the best choice should be patient-specific. NAEMSP recommends:The approach to airway management and the choice of airway interventions in a trauma patient requires an iterative, individualized assessment that considers patient, clinician, and environmental factors.Optimal trauma airway management should focus on meeting the goals of adequate oxygenation and ventilation rather than on specific interventions. Emergency medical services (EMS) clinicians should perform frequent reassessments to determine if there is a need to escalate from basic to advanced airway interventions.Management of immediately life-threatening injuries should take priority over advanced airway insertion.Drug-assisted airway management should be considered within a comprehensive algorithm incorporating failed airway options and balanced management of pain, agitation, and delirium.EMS medical directors must be highly engaged in assuring clinician competence in trauma airway assessment, management, and interventions.
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A retrospective data analysis on the induction medications used in trauma rapid sequence intubations and their effects on outcomes. Eur J Trauma Emerg Surg 2022; 48:2275-2286. [PMID: 34357407 PMCID: PMC8343213 DOI: 10.1007/s00068-021-01759-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/27/2021] [Indexed: 01/25/2023]
Abstract
PURPOSE Rapid sequence intubation (RSI) in trauma patients is common; however, the induction agents used have been debated. We determined which induction medications were used most frequently for adult trauma RSIs and their associations with hemodynamics and outcomes. We hypothesized that etomidate is the most commonly used induction agent and has similar outcomes to other induction agents. METHODS This retrospective review at two U.S. level I trauma centers evaluated adult trauma patients undergoing RSI within 24 h of admission, between 01/01/2016 and 12/31/2017. We compared patient characteristics and outcomes by induction agent. Comparisons on the primary outcome of in-hospital mortality and secondary outcomes of peri-intubation hypotension, hospital and ICU length of stay (LOS), ventilator days, and complications used logistic regression or negative binomial regression. Regression models adjusted for hospital site, age, patient severity measures, and intubation location. RESULTS Among 1303 trauma patients undergoing RSI within 24 h of admission, 948 (73%) were intubated in the emergency department (ED) and 325 (25%) in the operating room (OR). The most common induction agents were etomidate (68%), propofol (17%), and ketamine (11%). In-hospital mortality was highest in the etomidate group (25.5%), followed by ketamine (17%), and propofol (1.8%). CONCLUSION Etomidate was most commonly used in ED intubations; propofol was most used in the OR. Compared to propofol, patients induced with etomidate had higher mortality and complication rates. Findings should be interpreted with caution given limited generalizability and residual confounding by indication.
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Nannapaneni S, Silvis J, Curfman K, Chung T, Simunich T, Morrissey S, Dumire R. Bronchoscopy Decreases Ventilator-Associated Pneumonia in Trauma Patients. Am Surg 2021; 88:653-657. [PMID: 34879745 DOI: 10.1177/00031348211058639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Health care-associated pneumonias (HAPs) are a significant comorbidity seen in hospitalized patients. Traumatic injury is a known independent risk factor for the development of HAP. Trauma-related injuries also contribute to an increase in the rate of pneumonia in mechanically ventilated patients requiring intensive care unit (ICU) treatment. In 2011, the ventilator-associated pneumonia (VAP) rate among ICU patients at our institution (CMMC) increased dramatically. As a result, our infection control specialists performed a focused review of these patients and found a likely association between these infections and patients requiring pre-hospital intubation. Their determination prompted a July 2012 revision of the CMMC Trauma/Surgery Admission ICU protocol for ventilated patients to include bronchoscopy for all patients who have been intubated pre-hospital providing no contraindications were present. Our aim was to ascertain any influence of the protocol change on the rate of VAP. We conducted a retrospective medical record review of trauma patients who were intubated in the field or ED and seen at our institution (an accredited Level 1 trauma center) from 2012 to 2018. Applying the current definition of VAP from the Centers for Disease Control and Prevention (CDC) to data collected from the CMMC trauma registry, we observed a 13% lower VAP rate in the bronchoscopy group (YB) as compared to the group that did not receive bronchoscopy (NB) (P < .025). Based on our results, we determined that bronchoscopy performed in this setting does support a statistically significant decrease in the rate of ventilator-associated pneumonia.
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Affiliation(s)
| | - Jennifer Silvis
- Department of Surgrey, 21654UConn Health, Farmington, CT, USA
| | - Karleigh Curfman
- Department of Surgrey, 4157Conemaugh Health System, Johnstown, PA, USA
| | - Timothy Chung
- Department of Surgrey, 4157Conemaugh Health System, Johnstown, PA, USA
| | | | - Shawna Morrissey
- Department of Surgrey, 4157Conemaugh Health System, Johnstown, PA, USA
| | - Russell Dumire
- 22465Conemaugh Memorial Medical Center, Johnstown, PA, USA
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Outcomes following traumatic inhalational airway injury - Predictors of mortality and effect of procedural intervention. Injury 2021; 52:3320-3326. [PMID: 34565616 DOI: 10.1016/j.injury.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/19/2021] [Accepted: 09/12/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Study outcomes, predictors of mortality, and effects of procedural interventions on patients following traumatic inhalational airway injury. STUDY Design: Retrospective study. SETTING National Trauma Data Bank METHODS: Patients over the age of eighteen admitted between 2008 and 2016 to NTDB-participating sites were included. In-hospital mortality and length of stay were the primary outcomes. RESULTS The final study cohort included 13,351 patients. History of active smoking was negatively associated with in-house mortality with an OR of 0.33 (0.25-0.44). History of alcohol use, and presence of significant medical co-morbidities were positively associated with in-house mortality with OR of 5.28 (4.32-6.46) 2.74 (19.4-3.86) respectively. There was little to no association between procedural interventions and in-house mortality. Intubation, laryngobronchoscopy, and tracheostomy had OR of 0.90 (0.67-1.20), 1.02 (0.79-1.30), and 0.94 (0.58-1.51), respectively. However, procedural intervention did affect both the median hospital and ICU lengths of stay of patients. Median hospital and ICU length of stay were shorter for patients receiving endotracheal intubation. Median hospital length of stay was longer for patients undergoing bronchoscopy and laryngoscopy, but median ICU length of stay was shorter for patients undergoing bronchoscopy and laryngoscopy. Patients receiving a tracheostomy have both significantly increased median hospital and ICU lengths of stay. CONCLUSIONS Active smoking was associated with decreased odds of in-hospital mortality, while presence of pre-existing medical comorbidities and history of alcohol use disorder was associated with increased odds of in-hospital mortality. Procedural intervention had little to no association with in-hospital mortality but did affect overall hospital and ICU LOS.
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Houska N, Ing RJ, Chatterjee D. Difficult Endotracheal Intubation in Adult Congenital Heart Disease Patients. J Cardiothorac Vasc Anesth 2021; 35:3665-3666. [PMID: 34521581 DOI: 10.1053/j.jvca.2021.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 08/20/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Nicholas Houska
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Richard J Ing
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO.
| | - Debnath Chatterjee
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
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Breindahl N, Baekgaard J, Christensen RE, Jensen AH, Creutzburg A, Steinmetz J, Rasmussen LS. Ketamine versus propofol for rapid sequence induction in trauma patients: a retrospective study. Scand J Trauma Resusc Emerg Med 2021; 29:136. [PMID: 34526085 PMCID: PMC8442378 DOI: 10.1186/s13049-021-00948-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 08/31/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rapid Sequence Induction (RSI) is used for emergency tracheal intubation to minimise the risk of pulmonary aspiration of stomach contents. Ketamine and propofol are two commonly used induction agents for RSI in trauma patients. Yet, no consensus exists on the optimal induction agent for RSI in the trauma population. The aim of this study was to compare 30-day mortality in trauma patients after emergency intubation prehospitally or within 30 min after arrival in the trauma centre using either ketamine or propofol for RSI. METHODS In this investigator-initiated, retrospective study we included adult trauma patients emergently intubated with ketamine or propofol registered in the local trauma registry at Rigshospitalet, a tertiary university hospital that hosts a level-1 trauma centre. The primary outcome was 30-day mortality. Secondary outcomes included hospital and Intensive Care Unit length of stay as well as duration of mechanical ventilation. We analysed outcomes using multivariable logistic regression models adjusting for age, sex, injury severity score, shock (systolic blood pressure < 90 mmHg) and Glasgow Coma Scale score before intubation and present results as odds ratios (ORs) with 95% confidence intervals. RESULTS From January 1st, 2015 through December 31st, 2019 we identified a total of 548 eligible patients. A total of 228 and 320 patients received ketamine and propofol, respectively. The 30-day mortality for patients receiving ketamine and propofol was 20.2% and 22.8% (P = 0.46), respectively. Adjusted OR for 30-day mortality was 0.98 [0.58-1.66], P = 0.93. We found no significant association between type of induction agent and hospital length of stay, Intensive Care Unit length of stay or duration of mechanical ventilation. CONCLUSIONS In this study, trauma patients intubated with ketamine did not have a lower 30-day mortality as compared with propofol.
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Affiliation(s)
- Niklas Breindahl
- Department of Anaesthesia, Section 6011, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, Section 6011, 2100, Copenhagen, Denmark.
| | - Josefine Baekgaard
- Department of Anaesthesia, Section 6011, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, Section 6011, 2100, Copenhagen, Denmark
| | - Rasmus Ejlersgaard Christensen
- Department of Anaesthesia, Section 6011, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, Section 6011, 2100, Copenhagen, Denmark
| | - Alice Herrlin Jensen
- Department of Anaesthesia, Section 6011, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, Section 6011, 2100, Copenhagen, Denmark
| | - Andreas Creutzburg
- Department of Anaesthesia, Section 6011, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, Section 6011, 2100, Copenhagen, Denmark
| | - Jacob Steinmetz
- Department of Anaesthesia, Section 6011, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, Section 6011, 2100, Copenhagen, Denmark.,Danish Air Ambulance, Aarhus, Denmark
| | - Lars S Rasmussen
- Department of Anaesthesia, Section 6011, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, Section 6011, 2100, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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First pass success of tracheal intubation using the C-MAC PM videolaryngoscope as first-line device in prehospital cardiac arrest compared with other emergencies: An observational study. Eur J Anaesthesiol 2021; 38:806-812. [PMID: 32833853 DOI: 10.1097/eja.0000000000001286] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Successful airway management is a priority in the resuscitation of critically ill or traumatised patients. Several studies have demonstrated the importance of achieving maximum first pass success, particularly in prehospital advanced airway management. OBJECTIVE To compare success rates of emergency intubations between patients requiring cardiopulmonary resuscitation (CPR) for cardiac arrest (CPR group) and other emergencies (non-CPR group) using the C-MAC PM videolaryngoscope. DESIGN Ongoing analysis of prospective collected prehospital advanced airway management core variables. SETTING Single helicopter emergency medical service (HEMS) 'Christoph 22', Ulm Military Hospital, Germany, May 2009 to July 2018. PATIENTS We included all 1006 HEMS patients on whom prehospital advanced airway management was performed by board-certified anaesthesiologists on call at HEMS 'Christoph 22'. INTERVENTIONS The C-MAC PM was used as the first-line device. The initial direct laryngoscopy was carried out using the C-MAC PM without the monitor in sight. After scoring the direct laryngoscopic view according to the Cormack and Lehane grade, the monitor was folded within the sight of the physician and tracheal intubation was performed using the videolaryngoscopic view without removing the blade. MAIN OUTCOME MEASURES The primary outcome was successful airway management. Secondary outcomes were the patient's position during airway management, necessity for suction, direct and videolaryngoscopic view according to Cormack and Lehane grading, as well as number of attempts needed for successful intubation. RESULTS A patent airway was achieved in all patients including rescue techniques. There was a lower first pass success rate in the CPR group compared with the non-CPR group (84.4 vs. 91.4%, P = 0.01). In the CPR group, direct laryngoscopy resulted more often in a clinically unfavourable (Cormack and Lehane grade 3 or 4) glottic view (CPR vs. non-CPR-group 37.2 vs. 26.7%, P = 0.0071). Using videolaryngoscopy reduced the clinically unfavourable grading to Cormack and Lehane 1 or 2 (P < 0.0001). The odds of achieving first pass success were approximately 12-fold higher with a favourable glottic view than with an unfavourable glottic view (OR 12.6, CI, 6.70 to 23.65). CONCLUSION Airway management in an anaesthesiologist-staffed HEMS is associated with a high first pass success rate but even with skilled providers using the C-MAC PM videolaryngoscope routinely, patients who require CPR offer more difficulties for successful prehospital advanced airway management at the first attempt. TRIAL REGISTRATION German Clinical trials register (drks.de) DRKS00020484.
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West JR, O'Keefe BP, Russell JT. Predictors of first pass success without hypoxemia in trauma patients requiring emergent rapid sequence intubation. Trauma Surg Acute Care Open 2021; 6:e000588. [PMID: 34263062 PMCID: PMC8246356 DOI: 10.1136/tsaco-2020-000588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 05/26/2021] [Indexed: 11/10/2022] Open
Abstract
Objective The predictors of first pass success (FPS) without hypoxemia among trauma patients requiring rapid sequence intubation (RSI) in the emergent setting are unknown. Methods Retrospective study of adult trauma patients requiring RSI during a 5-year period comparing the trauma patients achieving FPS without hypoxemia to those who did not. The primary outcome was FPS without hypoxemia evaluated by multivariate logistic regression adjusting for the neuromuscular blocking agent used (succinylcholine or rocuronium), hypoxemia prior to RSI, Glasgow Coma Scale (GCS) scores, the presence of head or facial trauma, and intubating operator level of training. Results 246 patients met our inclusion criteria. The overall FPS rate was 89%, and there was no statistical difference between those receiving either paralytic agent. 167 (69%) patients achieved FPS without hypoxemia. The two groups (those achieving FPS without hypoxemia and those who did not) had similar mean GCS, mean Injury Severity Scores, presence of head or facial trauma, the presence of penetrating trauma, intubating operator-level training, use of direct laryngoscopy, hypoxemia prior to RSI, heart rate per minute, mean systolic blood pressure, and respiratory rate. In the multivariate regression analysis, the use of succinylcholine and GCS score of 13–15 were found to have adjusted ORs of 2.1 (95% CI 1.2 to 3.8) and 2.0 (95% CI 1.0 to 3.3) for FPS without hypoxemia, respectively. Conclusion Trauma patients requiring emergency department RSI with high GCS score and those who received succinylcholine had higher odds of achieving FPS without hypoxemia, a patient safety goal requiring more study. Level of evidence IV. Study type Prognostic.
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Affiliation(s)
- Jason Randall West
- Emergency Medicine, NYC Health + Hospitals / Lincoln, Bronx, New York, USA
| | - Brandon P O'Keefe
- Emergency Medicine, NYC Health + Hospitals / Lincoln, Bronx, New York, USA.,Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - James T Russell
- Emergency Medicine, NYC Health + Hospitals / Lincoln, Bronx, New York, USA
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Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Baig S, Stein R, Haymes D, Fiester P, Rao D. Imaging Review of Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema of the Head and Neck. Cureus 2021; 13:e14021. [PMID: 33898114 PMCID: PMC8057747 DOI: 10.7759/cureus.14021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Angiotensin-converting enzyme inhibitors (ACE-i) are commonly used medications to treat hypertension and congestive heart failure. Angioedema is a well-established side effect of ACE-i and most commonly manifests as swelling of the mucosal and extra-mucosal soft tissues in the head and neck. CT with contrast is generally used to evaluate for airway compromise and to exclude other etiologies of edema. Herein we present five cases that illustrate the radiological findings specific to ACE-i-induced angioedema on enhanced CT scans.
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Affiliation(s)
- Saif Baig
- Radiology, Nassau University Medical Center, East Meadow, USA
| | - Rachel Stein
- Neuroradiology, University of Florida Health, Jacksonville, USA
| | - Dalys Haymes
- Neuroradiology, University of Florida Health, Jacksonville, USA
| | - Peter Fiester
- Neuroradiology, University of Florida Health, Jacksonville, USA
| | - Dinesh Rao
- Neuroradiology, University of Florida Health, Jacksonville, USA
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Emergency Department Versus Operating Suite Intubation in Operative Trauma Patients: Does Location Matter? World J Surg 2020; 44:780-787. [PMID: 31741071 DOI: 10.1007/s00268-019-05296-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Merceron TK, Williams RY, Ingram WL, Abramowicz S. Epidemiology and Management of Pediatric Head and Neck Burns: An Institutional Review. Am Surg 2020; 87:741-746. [PMID: 33170752 DOI: 10.1177/0003134820952828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pediatric head and neck burns (HNBs) require special attention due to the potential for long-term disfigurement, functional impairment, and psychosocial stigma. METHODS We performed a retrospective review of patients <18 years old admitted to Grady Memorial Hospital with a diagnosis of HNB from 2009-2017. Demographic data, burn characteristics, management, and hospital course were analyzed. RESULTS Of the 272 patients included, 65.4% were male with a mean age of 63.2 months. Burn mechanism was primarily secondary to scalding liquids (70.2%) or flames (23.9%). The average total body surface area involved was 10.3%, and 3.0% for the head/neck. Average length of stay was 5.2 days and overall mortality was 1.1%. Twenty-five patients (9.2%) required surgery in the acute setting, and 5 (1.8%) required secondary surgery for hypertrophic scarring or contracture. DISCUSSION Pediatric HNBs occur most commonly in males <6 years old secondary to scalding liquids or open flames. Most patients can be managed nonoperatively without long-term sequelae.
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Affiliation(s)
- Tyler K Merceron
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Rachael Y Williams
- Trauma-Surgical Critical Care, Grady Memorial Hospital, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.,Grady Memorial Hospital Burn Unit, Atlanta, GA, USA.,Grossman Burn Centers, Los Angeles, CA, USA
| | - Walter L Ingram
- Trauma-Surgical Critical Care, Grady Memorial Hospital, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.,Grady Memorial Hospital Burn Unit, Atlanta, GA, USA
| | - Shelly Abramowicz
- Division of Oral and Maxillofacial Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.,Section of Oral and Maxillofacial Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Assessment of Nonroutine Events During Intubation After Pediatric Trauma. J Surg Res 2020; 259:276-283. [PMID: 33138986 DOI: 10.1016/j.jss.2020.09.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Intubation in the early postinjury phase can be a high-risk procedure associated with an increased risk of mortality when delayed. Nonroutine events (NREs) are workflow disruptions that can be latent safety threats in high-risk settings and may contribute to adverse outcomes. MATERIALS AND METHODS We reviewed videos of intubations of injured children (age<17 y old) in the emergency department occurring between 2014 and 2018 to identify NREs occurring between the decision to intubate and successful intubation ("critical window"). RESULTS Among 34 children requiring intubation, the indications included GCS≤8 (n = 20, 58.8%), cardiac arrest (n = 6, 17.6%), airway protection (n = 5, 14.7%), and respiratory failure (n = 3, 8.8%). The median duration of the "critical window" was 7.5 min (range 1.4-27.5 min), with a median of six NREs per case in this period (range 2-30). Most NREs (n = 159, 61.9%) delayed workflow, with 31 (12.1%) of these delays each lasting more than one minute. Eighty-seven NREs (33.9%) had a potential for harm but did not lead to direct patient harm. The most common NREs directly related to the intubation process were poor positioning for intubation (n = 23, 8.9%) and difficulty passing the endotracheal tube (n = 5, 1.9%), with most being attributed to the anesthesiologist performing the intubation (n = 51, range 0-7). CONCLUSIONS Workflow disruptions related to nonroutine events were frequent during pediatric trauma intubation and were often associated with delays and potential for patient harm. Interventions for improving the efficiency and timeliness of the critical window should focus on adherence to intubation protocol and improving communication and teamwork related to tasks in this phase.
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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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Park CY, Kim OH, Chang SW, Choi KK, Lee KH, Kim SY, Kim M, Lee GJ. Part 3. Clinical Practice Guideline for Airway Management and Emergency Thoracotomy for Trauma Patients from the Korean Society of Traumatology. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Seo KH, Kim KM, John H, Jun JH, Han M, Kim S. Comparison of C-MAC D-blade videolaryngoscope and McCoy laryngoscope efficacy for nasotracheal intubation in simulated cervical spinal injury: a prospective randomized comparative study. BMC Anesthesiol 2020; 20:114. [PMID: 32408862 PMCID: PMC7227116 DOI: 10.1186/s12871-020-01021-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Immobilization with cervical spine worsens endotracheal intubation condition. Though various intubation devices have been demonstrated to perform well in oral endotracheal intubation, limited information is available concerning nasotracheal intubation (NTI) in patients with cervical spine immobilization. The present study compared the performance of the C-MAC D-Blade videolaryngoscope with the McCoy laryngoscope for NTI in patients with simulated cervical spine injuries. METHODS This was a prospective, randomized, controlled, study done in a tertiary hospital. Ninety-five patients requiring NTI were included in data analysis: McCoy group (group M, n = 47) or C-MAC D-Blade videolaryngoscope group (group C, n = 48). A Philadelphia neck collar was applied before anesthetic induction to immobilize the cervical spine. Single experienced anesthesiologist performed NTI. The primary outcome was duration of intubation divided by three steps: nose to oropharynx; oropharynx into glottic inlet; and glottic inlet to trachea. Secondary outcomes included glottic view as percentage of glottis opening (POGO) score and Cormack-Lehance (CL) grade, modified nasal intubation-difficulty scale (NIDS) rating, hemodynamic changes before and after intubation, and complications. RESULTS Total intubation duration was significantly shorter in group C (39.5 ± 11.4 s) compared to group M (48.1 ± 13.9 s). Group C required significantly less time for glottic visualization and endotracheal tube placement in the trachea. More patients in group C had CL grade I and higher POGO scores (P < 0.001, for both measures). No difficulty in NTI (modified NIDS = 0) was more in group C than group M. Hemodynamic changes and incidence of complications were comparable between groups. CONCLUSION The C-MAC D-Blade videolaryngoscope is an effective tool for NTI in a simulated difficult airway, which improves glottic visualization and shortens intubation time relative to those with McCoy laryngoscope. TRIAL REGISTRATION Clinical Research Information Service of the Korea National Institute of Health, Identification number: KCT 0004535, Registered December 10, 2019, Retrospectively registered, http://cris.nih.go.kr.
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Affiliation(s)
- Kwon Hui Seo
- Department of anesthesiology and pain medicine, Hallym University Sacred Heart Hospital, Hallym University School of Medicine, 22, Gwanpyeong-ro 170 beon-gil, Dong-gu, Anyang-si, Gyeonggi-do, 14068, Republic of Korea
| | - Kyung Mi Kim
- Clinical assistant professor, Department of anesthesiology and pain medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Hyunji John
- Department of anesthesiology and pain medicine, Hallym University Sacred Heart Hospital, Hallym University School of Medicine, 22, Gwanpyeong-ro 170 beon-gil, Dong-gu, Anyang-si, Gyeonggi-do, 14068, Republic of Korea
| | - Joo Hyun Jun
- Department of anesthesiology and pain medicine, Kangnam Sacred Heart Hospital, Hallym University School of Medicine, 12, Siheung-daero 187-gil, Yeongdeungpo-gu, Seoul, 07441, Republic of Korea
| | - Minsoo Han
- Department of anesthesiology and pain medicine, Hallym University Sacred Heart Hospital, Hallym University School of Medicine, 22, Gwanpyeong-ro 170 beon-gil, Dong-gu, Anyang-si, Gyeonggi-do, 14068, Republic of Korea
| | - Soyoun Kim
- Department of anesthesiology and pain medicine, Hallym University Sacred Heart Hospital, Hallym University School of Medicine, 22, Gwanpyeong-ro 170 beon-gil, Dong-gu, Anyang-si, Gyeonggi-do, 14068, Republic of Korea
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Hatchimonji JS, Dumas RP, Kaufman EJ, Scantling D, Stoecker JB, Holena DN. Questioning dogma: does a GCS of 8 require intubation? Eur J Trauma Emerg Surg 2020; 47:2073-2079. [PMID: 32382780 PMCID: PMC7223660 DOI: 10.1007/s00068-020-01383-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/24/2020] [Indexed: 11/26/2022]
Abstract
Background There is no evidence supporting intubation for a Glasgow Coma Scale (GCS) of 8. We investigated the effect of intubation in trauma patients with a GCS 6–8, with the hypothesis that intubation would increase mortality and length of stay. Methods We studied adult patients with GCS 6–8 from the 2016 National Trauma Data Bank. Intubated and non-intubated patients were compared using inverse probability weighted regression adjustment (IPWRA) to control for injury severity and patient characteristics. Outcomes were mortality, intensive care unit length of stay (ICU LOS), and total LOS. Stratified analysis was performed to investigate the effect in patients with and without head injuries. Results Among 6676 patients with a GCS between 6 and 84,078 were intubated within 1 h of arrival to the emergency department. The overall mortality rate was 15.1%. IPWRA revealed an increase in mortality associated with intubation (OR 1.05, 95% CI 1.03, 1.06). The results were similar in patients with head injuries (OR 1.04, 95% CI 1.02, 1.06) and without (OR 1.06, 95% CI 1.03, 1.10). Among the 5,742 patients admitted to the ICU, intubation was associated with a 14% increase in ICU LOS (95% CI 8–20%; 5.5 vs. 4.8 days; p < 0.001). The overall length of stay was 27% longer (95% CI 19.8–34.3%) among intubated patients (mean 7.7 vs 6.0 days; p < 0.001). Conclusion Among patients with GCS of 6 to 8, intubation on arrival was associated with an increase in mortality and with longer ICU and overall length of stay. The use of a strict threshold GCS to mandate intubation should be revisited.
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Affiliation(s)
- Justin S. Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA USA
| | - Ryan P. Dumas
- Division of General and Acute Care Surgery, Department of Surgery, University of Texas Southwestern Medical
Center at Dallas, Dallas, TX USA
| | - Elinore J. Kaufman
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
| | - Dane Scantling
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
| | - Jordan B. Stoecker
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA USA
| | - Daniel N. Holena
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
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Comparison of drugs used for intubation of pediatric trauma patients. J Pediatr Surg 2020; 55:926-929. [PMID: 32067810 DOI: 10.1016/j.jpedsurg.2020.01.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 01/25/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Rapid sequence intubation (RSI) drugs, such as propofol, affect clinical outcomes, but this has not been examined in the pediatric population. This descriptive study compares the outcomes associated with intubation drugs used in pediatric traumatic brain injury (TBI) patients. METHODS A retrospective chart review and descriptive analysis of intubated TBI patients, ages 0-17, admitted to Children's Hospital London Health Sciences Centre (LHSC) from January 2006-December 2016 was performed. RESULTS Out of 259 patients intubated, complete data was available for 107 cases. Average injury severity score was 28; 46 were intubated at LHSC, 55 at primary care site, and 6 on scene. Intubation attempts were recorded in 87 of 107 paper charts. First-pass intubation success rate was 88.5%. Propofol (n = 21), midazolam (n = 31), etomidate (n = 13), and ketamine (n = 7) were the most commonly used intubation drugs. Paralytics were used in 50% of patients. Following use of propofol, Pediatric Adjusted Shock Index was increased as a result of worsening hypotension. Mean total hospital length of stay was 21 days with 7.5 days in ICU. Survival was 87%. CONCLUSION Great variability exists in the use of induction agents and paralytics for RSI. Propofol was commonly used and is potentially associated with poorer clinical outcomes. TYPE OF STUDY Retrospective. LEVEL OF EVIDENCE IV.
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Turner S, Lang ES, Brown K, Franke J, Workun-Hill M, Jackson C, Roberts L, Leyton C, Bulger EM, Censullo EM, Martin-Gill C. Systematic Review of Evidence-Based Guidelines for Prehospital Care. PREHOSP EMERG CARE 2020; 25:221-234. [PMID: 32286899 DOI: 10.1080/10903127.2020.1754978] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Introduction: Multiple national organizations have identified a need to incorporate more evidence-based medicine in emergency medical services (EMS) through the creation of evidence-based guidelines (EBGs). Tools like the Appraisal of Guidelines for Research and Evaluation (AGREE) II and criteria outlined by the National Academy of Medicine (NAM) have established concrete recommendations for the development of high-quality guidelines. While many guidelines have been created that address topics within EMS medicine, neither the quantity nor quality of prehospital EBGs have been previously reported. Objectives: To perform a systematic review to identify existing EBGs related to prehospital care and evaluate the quality of these guidelines using the AGREE II tool and criteria for clinical guidelines described by the NAM. Methods: We performed a systematic search of the literature in MEDLINE, EMBASE, PubMED, Trip, and guidelines.gov, through September 2018. Guideline topics were categorized based on the 2019 Core Content of EMS Medicine. Two independent reviewers screened titles for relevance and then abstracts for essential guideline features. Included guidelines were appraised with the AGREE II tool across 6 domains by 3 independent reviewers and scores averaged. Two additional reviewers determined if each guideline reported the key elements of clinical practice guidelines recommended by the NAM via consensus. Results: We identified 71 guidelines, of which 89% addressed clinical aspects of EMS medicine. Only 9 guidelines scored >75% across AGREE II domains and most (63%) scored between 50 and 75%. Domain 4 (Clarity of Presentation) had the highest (79.7%) and domain 5 (Applicability) had the lowest average score across EMS guidelines. Only 38% of EMS guidelines included a reporting of all criteria identified by the NAM for clinical practice guidelines, with elements of a systematic review of the literature most commonly missing. Conclusions: EBGs exist addressing a variety of topics in EMS medicine. This systematic review and appraisal of EMS guidelines identified a wide range in the quality of these guidelines and variable reporting of key elements of clinical guidelines. Future guideline developers should consider established methodological and reporting recommendations to improve the quality of EMS guidelines.
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Louro J, Dudaryk R, Rodriguez Y, Dutton RP, Epstein RH. Airway management at Level 1 trauma center in the era of video laryngoscopy. Int J Crit Illn Inj Sci 2020; 10:20-24. [PMID: 32322550 PMCID: PMC7170343 DOI: 10.4103/ijciis.ijciis_14_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 12/02/2019] [Accepted: 12/20/2019] [Indexed: 12/30/2022] Open
Abstract
Background Rapid sequence induction and tracheal intubation through direct laryngoscopy (DL) has been the most common approach to secure the airway in trauma patients. The introduction of video laryngoscopy (VL) has changed airway management in many clinical settings. In this retrospective study, we assessed if immediate availability of VL in the trauma suite has changed the approach and outcomes of airway management during acute resuscitation at a dedicated trauma center. Materials and Methods We retrospectively collected data from emergency intubation in the 6 resuscitation bays at a high-volume, academic, Level 1 trauma center over a 42-month period following the introduction of immediately available VL in the resuscitation bay. We divided the data into 13-week bins to assess the trend in the use of VL over time. Our measured outcomes were the incidence of failed intubations requiring a surgical airway and the frequency of VL use for airway management. Results Among 1328 airway management events in the resuscitation bays when intubation was attempted, the failure rate resulting in the placement of a surgical airway was 0.38% (95% confidence interval [CI], 0.12% -0.88%). This was consistent with the surgical airway rate before the introduction of VL into trauma practice (0.3%). VL use (primary or as a rescue technique) throughout the study period was 4.14% (95% CI, 2.76%-5.74%), with no temporal trend. Conclusion The immediate availability of VL in the resuscitation bay has not changed the prevalence of its use during emergency airway management at our trauma center. DL remains a preferred primary modality for airway management by the trauma anesthesiologists working at this facility, with an acceptably low incidence of both primary failure and the need to establish a surgical airway.
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Affiliation(s)
- Jack Louro
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, FL, USA.,Ryder Trauma Center, Jackson Health System, Miami, FL, USA
| | - Roman Dudaryk
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, FL, USA.,Ryder Trauma Center, Jackson Health System, Miami, FL, USA
| | - Yvette Rodriguez
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Richard P Dutton
- US Anesthesia Partners, Dallas, Texas, USA.,Texas A&M School of Medicine, Bryan, Texas, USA
| | - Richard H Epstein
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, FL, USA
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Fort AC, Zack-Guasp RA. Anesthesia for Patients with Extensive Trauma. Anesthesiol Clin 2020; 38:135-148. [PMID: 32008648 DOI: 10.1016/j.anclin.2019.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Trauma anesthesiology is a unique and growing subspecialty. With the growing number of adult and pediatric trauma centers in the United States, a thorough understanding of the early management of severely injured patients with trauma is an important aspect of anesthesia. Trauma anesthesiology requires the ability to adapt to different work environments, including the trauma bay, the operating room, and even the intensive care unit, where a patient room may require conversion to an operating suite for emergencies. This article provides a review of the anesthetic management for patients with extensive trauma, focusing on physiology, pharmacology, and bedside management.
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Affiliation(s)
- Alexander C Fort
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, University of Miami, 1611 Northwest 12th Avenue, Suite C300, Miami, FL 33136, USA.
| | - Richard A Zack-Guasp
- Department of Anesthesiology, Bruce W. Carter Medical Center, Department of Veteran's Health Administration, 1201 Northwest 16th Street, Room B333, Miami, FL 33136, USA
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Dietrich SK, Alnchoukati OK, Dunn JA. Survey of Pharmacologic Agents Used during Rapid Sequence Intubation of Traumatically Injured Patients. Am Surg 2020. [DOI: 10.1177/000313482008600113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Scott K. Dietrich
- Department of Pharmacy University of Colorado Health North Fort Collins, Colorado
| | - Omar K. Alnchoukati
- Department of Trauma Research Medical Center of the Rockies University of Colorado Health North Loveland, Colorado
| | - Julie A. Dunn
- Department of Trauma Surgery Medical Center of the Rockies University of Colorado Health North Loveland, Colorado
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Intubation of emergency traumatic head injury patient outside the operation theatre: Cross-sectional study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Cervical Spine Movement in a Cadaveric Model of Severe Spinal Instability: A Study Comparing Tracheal Intubation with 4 Different Laryngoscopes. J Neurosurg Anesthesiol 2020; 32:57-62. [DOI: 10.1097/ana.0000000000000560] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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