Transport of the patient with trauma: a narrative review

Venous thromboembolism in transfer trauma patients: A global problem

BACKGROUND

As air travel and immobility are risk factors for venous thromboembolism, we aimed to test the hypothesis that internationally transferred trauma patients have a high incidence of venous thromboembolism on arrival.

METHODS

A prospectively maintained registry of all international transferred trauma patients who presented to our level I trauma center from January 2023 to June 2024 was retrospectively reviewed. Patients with either lower extremity venous duplex ultrasound or computed tomography scan of the chest with contrast on arrival were included. The primary outcome was venous thromboembolism, either deep venous thrombosis or pulmonary embolism.

RESULTS

There were 161 consecutive internationally transferred trauma patients; 93% had a screening venous duplex ultrasound on arrival, and 52% had a computed tomography scan of the chest with contrast. Average time from injury to arrival was 3.3 ± 4.3 days. Of those who had screening imaging, 6% had a deep venous thrombosis and 8.3% had a pulmonary embolism. Average Greenfield risk assessment profile was greater for those with than without deep venous thrombosis (10 vs 8, P = .024) and pulmonary embolism (12 vs 8, P = .001). There was no difference in days from injury or flight time for those with or without deep venous thrombosis or for those with or without pulmonary embolism.

CONCLUSION

To our knowledge, this is the first study to demonstrate a 6-8% incidence of venous thromboembolism on arrival in international transfer trauma patients. New protocols should include risk stratification for early thromboprophylaxis in transferring centers and screening admission venous duplex ultrasound and computed tomography scan of the chest at receiving centers.

Enhancing Trauma Care in Tertiary Hospitals: Addressing Gaps and Pathways to Improvement

Background: Trauma is a major cause of morbidity and mortality globally, with road traffic accidents projected to be the leading cause of death by 2030. In developing countries like Pakistan, trauma patients face significant challenges in receiving timely and effective care. This study aimed to evaluate trauma centers in tertiary care hospitals in the twin cities of Pakistan to highlight gaps and pitfalls in trauma patient management. Methods: A descriptive cross-sectional study was conducted using the World Health Organization's Hospital Emergency Unit Assessment Tool (HEAT) at five major public sector hospitals in Islamabad and Rawalpindi. Data collection involved collaboration between the Violence, Injury Prevention and Disability Unit and key informants, including Emergency Room in-charges and Heads of Departments. Information on trauma protocols and guidelines was gathered. Results: All hospitals provided 24/7 emergency services with access to operating rooms and laboratories. However, significant disparities were found in equipment availability, particularly portable X-rays (40% availability) and RDT/HIV testing (20% availability). Protocol adherence varied, with 80% of hospitals having clinical management protocols but only 20% having specific protocols for conditions like asthma exacerbation and maternal hemorrhage. This study identifies infrastructural deficiencies and highlights systemic barriers that contribute to inadequate trauma care delivery, underscoring the need for targeted reforms. Conclusion: The study highlights significant gaps in trauma care management in Pakistani tertiary care hospitals, including shortages of personnel, infrastructure deficiencies, and lack of standardized protocols. These findings underscore the urgent need for systemic improvements in trauma care delivery. Recommendations include increased investment in medical infrastructure, addressing staffing and training deficiencies, and standardizing clinical management protocols to enhance trauma care outcomes and reduce morbidity and mortality rates in Pakistan. This research contributes novel insights into the specific barriers faced by trauma care systems in Pakistan, which have not been previously addressed in existing literature.

The Role of Medical Helicopter and Ground Medical Crews in Polytrauma Management: An Evaluative Perspective

Introduction

Polytrauma remains a major global health challenge, with rapid intervention being critical for survival, especially during the "Golden Hour". This study examines the impact of Helicopter Emergency Medical Services (HEMS) on procedural care during the transfer of polytraumatized patients to urban hospitals in Romania.

Methods

A retrospective cohort study was conducted at the County Emergency Hospital "St. Ap. Andrei" in Galați, covering January 2020 to October 2021. The study analyzed data from 89 patients transported by the Romania's Mobile Emergency Service for Resuscitation and Extrication (SMURD) Galați air unit. Key parameters included demographics, injury mechanism, vital statistics, and prehospital interventions. Statistical analyses were performed using SPSS, with significance set at p < 0.05.

Results

Out of 89 patients (mean age 21.6 years, 80.3% male), trauma causes were primarily traffic accidents (34.8%) and falls (33.7%). A Glasgow Coma Scale (GCS) score ≤8 was noted in 28.1% of cases, with head trauma observed in 51.6% of patients. HEMS interventions frequently involved oxygen therapy (89.5%) and patient stabilization maneuvers, leading to a mortality rate of 6.7%. Notably, helicopter transport enabled efficient transfer and improved survival outcomes in this cohort.

Discussion

HEMS demonstrated benefits in reducing intervention times and enhancing prehospital care quality for polytrauma patients, especially in hard-to-reach areas. The study aligns with global data on HEMS's role in trauma systems, underlining the importance of multidisciplinary collaboration and rapid transport.

Conclusion

HEMS plays a crucial role in improving survival rates for severely injured patients through timely interventions and specialized care. Further research comparing HEMS and ground services could refine trauma management protocols in similar settings.

Characteristics of trauma patients treated by Helicopter Emergency Medical Service and transported to the hospital by helicopter or ambulance

INTRODUCTION

Trauma patients treated by the Helicopter Emergency Medical Services (HEMS) can be transported to the hospital either by helicopter or by ambulance, in both cases accompanied by the HEMS physician. The objectives of this study are first to compile an overview of patients treated and transported by the HEMS team with either the helicopter (patients transported by helicopter, PTH) or with the ambulance (patients transported by ambulance, PTA). In addition, to evaluate whether the existing information systems obtain relevant data for researching the decision-making process. The second objective is to identify potentially influencing factors that could be significant for further research.

METHODS

All patients in the period from 1 January 2011 until 31 December 2020, treated by HEMS and subsequently transported to hospitals were included in the study. To avoid overrepresentation of the PTA group, a random sample was taken, creating two groups in a 1:2 ratio (PTH n = 724, PTA n = 1448). Differences in patient and treatment characteristics between PTH and PTA were compared using t-tests, Mann-Whitney U tests, and chi-square tests.

RESULTS

PTH accounted for 12.2% of all transports. Approximately two-third of the patients were male and the mean age was around 40 years. PTH had lower iEMV (initial Eye opening, best Motor response, best Verbal response) and iRTS (initial Revised Trauma Score) scores, were more frequently transported to a level 1 trauma centre, underwent more prehospital treatments and were roughly twice as far from their hospital of arrival compared to PTA.

CONCLUSION

The current dataset is, after some modifications, suitable to provide a comprehensive overview of patients treated by HEMS in the Netherlands. A predictive model could be developed using this dataset, which should include factors such as the patient's location, age, distance to the hospital, physician on duty, mechanism of injury and overall injury severity.

Optimizing Medical Care during a Nerve Agent Mass Casualty Incident Using Computer Simulation

INTRODUCTION

Chemical mass casualty incidents (MCIs) pose a substantial threat to public health and safety, with the capacity to overwhelm healthcare infrastructure and create societal disorder. Computer simulation systems are becoming an established mechanism to validate these plans due to their versatility, cost-effectiveness and lower susceptibility to ethical problems.

METHODS

We created a computer simulation model of an urban subway sarin attack analogous to the 1995 Tokyo sarin incident. We created and combined evacuation, dispersion and victim models with the SIMEDIS computer simulator. We analyzed the effect of several possible approaches such as evacuation policy ('Scoop and Run' vs. 'Stay and Play'), three strategies (on-site decontamination and stabilization, off-site decontamination and stabilization, and on-site stabilization with off-site decontamination), preliminary triage, victim distribution methods, transport supervision skill level, and the effect of search and rescue capacity.

RESULTS

Only evacuation policy, strategy and preliminary triage show significant effects on mortality. The total average mortality ranges from 14.7 deaths in the combination of off-site decontamination and Scoop and Run policy with pretriage, to 24 in the combination of onsite decontamination with the Stay and Play and no pretriage.

CONCLUSION

Our findings suggest that in a simulated urban chemical MCI, a Stay and Play approach with on-site decontamination will lead to worse outcomes than a Scoop and Run approach with hospital-based decontamination. Quick transport of victims in combination with on-site antidote administration has the potential to save the most lives, due to faster hospital arrival for definitive care.

Simulation-Based Enhancement of Patient Safety During Intrahospital Transport of Trauma Patients With COVID-19: A Helipad Scenario

Trauma resulting from accidents, violence, or war claims over five million lives annually, with traffic accidents and falls being predominant causes. The COVID-19 pandemic has posed unprecedented challenges in trauma care. Even though the number of injuries decreased during the lockdown period, the transportation of trauma patients became even more challenging due to concerns about infection control and the need for enhanced protective measures. This simulation workshop was conducted in a controlled environment to test and refine protocols for the safe transport of trauma patients with COVID-19. Our goal was to develop comprehensive guidance on the intrahospital transportation of these patients, ensuring the highest level of patient care and safety. We detail a five-step approach from preparation to the pre-landing, initial assessment, patient transfer, and patient handover phases, emphasizing adherence to protocols, equipment readiness, and personal protective equipment (PPE) use. The primary issues we encountered were related to time management, the decision-making process for applying lifesaving procedures in an open environment, and the risk of cross-infection. The workshop underscored the importance of swift and coordinated care, balancing life-saving interventions with efficient transport to a definitive care facility.

Primary care doctors in acute call-outs to severe trauma incidents in Norway - variations by rural-urban settings and time factors

BACKGROUND

A severely injured patient needs fast transportation to a hospital that can provide definitive care. In Norway, approximately 20% of the population live in rural areas. Primary care doctors (PCDs) play an important role in prehospital trauma care. The aim of this study was to investigate how variations in PCD call-outs to severe trauma incidents in Norway were associated with rural-urban settings and time factors.

METHODS

In this study on severe trauma patients admitted to Norwegian hospitals from 2012 to 2018, we linked data from four official Norwegian registries. Through this, we investigated the call-out responses of PCDs to severe trauma incidents. In multivariable log-binomial regression models, we investigated whether factors related to rural-urban settings and time factors were associated with PCD call-outs.

RESULTS

There was a significantly higher probability of PCD call-outs to severe trauma incidents in the municipalities in the four most rural centrality categories compared to the most urban category. The largest difference in adjusted relative risk (95% confidence interval (CI)) was 2.08 (1.27-3.41) for centrality category four. PCDs had a significantly higher proportion of call-outs in the Western (RR = 1.46 (1.23-1.73)) and Central Norway (RR = 1.30 (1.08-1.58)) Regional Health Authority areas compared to in the South-Eastern area. We observed a large variation (0.47 to 4.71) in call-out rates to severe trauma incidents per 100,000 inhabitants per year across the 16 Emergency Medical Communication Centre areas in Norway.

CONCLUSIONS

Centrality affects the proportion of PCD call-outs to severe trauma incidents, and call-out rates were higher in rural than in urban areas. We found no significant difference in call-out rates according to time factors. Possible consequences of these findings should be further investigated.

Spanish vs USA cohort comparison of prehospital trauma scores to predict short-term mortality

BACKGROUND

This study aimed to evaluate three prehospital early warning scores (EWSs): RTS, MGAP and MREMS, to predict short-term mortality in acute life-threatening trauma and injury/illness by comparing United States (US) and Spanish cohorts.

METHODS

A total of 8,854 patients, 8,598/256 survivors/nonsurvivors, comprised the unified cohort. Datasets were randomly divided into training and test sets. Training sets were used to analyse the discriminative power of the scores in terms of the area under the curve (AUC), and the score performance was assessed in the test set in terms of sensitivity (SE), specificity (SP), accuracy (ACC) and balanced accuracy (BAC).

RESULTS

The three scores showed great discriminative power with AUCs>0.90, and no significant differences between cohorts were found. In the test set, RTS/MREMS/MGAP showed SE/SP/ACC/BAC values of 86.0/89.9/89.6/87.1%, 91.0/86.9/87.5/88.5%, and 87.7/82.9/83.4/85.2%, respectively.

CONCLUSIONS

All EWSs showed excellent ability to predict the risk of short-term mortality, independent of the country.

Impact of physician-staffed ground emergency medical services-administered pre-hospital trauma care on in-hospital survival outcomes in Japan

PURPOSE

In Japan, the vehicle used in pre-hospital trauma care systems with physician-staffed ground emergency medical services (GEMS) is referred to as a "doctor car". Doctor cars are highly mobile physician-staffed GEMS that can provide complex pre-hospital trauma management using various treatment strategies. The number of doctor car operations for patients with severe trauma has increased. Considering facility factors, the association between doctor cars and patient outcomes remains unclear. Therefore, this study aimed to examine the relationship between doctor cars for patients with severe trauma and survival outcomes in Japan.

METHODS

A nationwide retrospective cohort study was conducted to compare the impact of the doctor car group with the non-physician-staffed GEMS group on in-hospital survival in adult patients with severe trauma. The data were analyzed using multivariable logistic regression models with generalized estimating equations.

RESULTS

This study included 372,365 patients registered in the Japan Trauma Data Bank between April 2009 and March 2019. Of the 49,144 eligible patients, 2361 and 46,783 were classified into the doctor car and non-physician staffed GEMS groups, respectively. The adjusted odds ratio (OR) for survival was significantly higher in the doctor car group than in the non-physician staffed GEMS group (adjusted OR = 1.228 [95% confidence interval 1.065-1.415]).

CONCLUSION

Using nationwide data, this novel study suggests that doctor cars improve the in-hospital survival rate of patients with severe trauma in Japan. Therefore, doctor cars could be an option for trauma strategies.

Factors Associated With Early Discharge in Pediatric Trauma Patients Transported by Rotor: A Retrospective Analysis

OBJECTIVE

Helicopter emergency medical services (HEMS) play a crucial role in providing timely transport for pediatric trauma patients. This service carries the highest risk of any mode of medical transport and a high financial burden, and patient outcomes are seldom investigated. This study evaluated the characteristics of pediatric trauma patients discharged within 24 hours after transport by HEMS.

METHODS

This was a single-center, retrospective analysis on pediatric trauma patients transported by HEMS from 2019 to 2022. Analyses were performed to identify factors associated with discharge within 24 hours. Factors analyzed included vital signs, Shock Index, Pediatric Age-Adjusted scores, management details, and clinical outcomes.

RESULTS

A total of 466 pediatric trauma patients were transported by HEMS, including 171 patients (36.7%) who were discharged within 24 hours. There were no differences in the rates of blunt and penetrating injury (P = .583). Patients discharged within 24 hours were more likely to have a higher Glasgow Coma Scale score (14 vs. 11, P < .001) and a lower Injury Severity Score (4.9 vs. 14.7, P < .001), required less prehospital fluid resuscitation (5.5 vs. 11.7 mL/kg, P = .039), and had higher levels of serum calcium (9.3 vs. 8.9 mg/dL, P < .001). They were also less likely to meet criteria for level 1 trauma activation (13.0% vs. 40%, P < .001) or to require prehospital respiratory support of any kind (4.1% vs. 31.1%, P < .001). After arrival at the hospital, they were less likely to require blood transfusions (2.9% vs. 29.8%, P < .001) or tranexamic acid (2.9% vs. 11.5%, P = .001).

CONCLUSION

Trauma patients with a high Glasgow Coma Scale score and a low Injury Severity Score who do not require critical care or meet the criteria for high-level trauma activation may be suitable for transportation with lower acuity. Further studies aimed at improving triage and implementing improved criteria for the use of HEMS are paramount.

Prehospital blood gas analyses in acute patients treated by a ground-based physician-manned emergency unit: a cohort study

BACKGROUND

The prehospital patients treated by ambulances and mobile emergency care units (MECU) are potentially critically ill or injured. Knowing the risks of serious outcomes in these patients is important for guiding their treatment. Some settings allow for prehospital arterial blood gas analyses. This study aimed to assess the outcomes of prehospital patients in relation to their prehospitally measured lactate, pH, and CO2 levels. The primary outcome was 7-day mortality.

METHODS

This register-based cohort study included patients with one or more prehospital blood gas analyses during their prehospital treatment by a physician-manned MECU, from January 2015 to December 2018. The blood samples were analyzed on an ABL90 Flex analyzer. Absolute values with percentages and odds ratios (OR) with 95% confidence intervals (CI) were calculated for the primary and secondary outcomes within prespecified subgroups.

RESULTS

The study included 745 patients, with an overall 7-day mortality rate of 20.0%.

LACTATE LEVEL

The 7-day mortality rates were 11.5% in patients with normal lactate levels (< 2.0 mmol/L), 14.4% with intermediate lactate levels (2.0-3.9 mmol/L), and 33.0% with high lactate levels (≥ 4.0 mmol/L). This corresponded to an OR of 1.30 (95% CI: 0.75-2.24) in the intermediate lactate group (2.0-3.9 mmol/L) and an OR of 3.77 (95% CI: 2.44-5.85) in the high lactate group (≥ 4.0 mmol/L), compared to the reference group with normal lactate.

PH LEVEL

The ORs of 7-day mortality rates were 4.82 (95% CI: 3.00-7.75) in patients with blood pH of < 7.35 and 1.33 (95% CI: 0.65-2.72) in patients with blood pH > 7.45, compared to the reference group with normal pH (7.35-7.45). CO2 LEVEL : The ORs of 7-day mortality rates were 2.54 (95% CI: 1.45-4.46) in patients with blood CO2 of < 4.3 kPa and 2.62 (95% CI: 1.70-4.03) in patients with blood CO2 > 6.0 kPa, compared to the reference group with normal CO2 (4.3-6.0 kPa).

CONCLUSIONS

This study found a strong correlation between increasing 7-day mortality rates and high blood lactate levels, low levels of pH, and abnormal CO2 blood levels, in prehospital patients undergoing prehospital blood analysis.

The relationship between acute pain and other types of suffering in pre-hospital trauma victims: An observational study

BACKGROUND

Acute pain is an important complaint reported by trauma victims, however, the relationship between it and other types of discomfort, such as discomfort caused by cold, discomfort caused by immobilization, and psychological distress such as fear, anxiety, and sadness is limitedly studied and documented.

AIM

To assess the relationship between acute trauma pain and other types of suffering in pre-hospital trauma victims.

METHODS

This is a prospective multicentre cohort study conducted in Immediate Life Support Ambulances in Portugal. All adult trauma victims with a mechanism of blunt and penetrating injuries, falls, road accidents and explosions, were included.

RESULTS

605 trauma victims were included, mainly male, with a mean age of 53.4 years. Before the intervention of the rescue teams, 90.5 % of the victims reported some level of pain, 39.0 % reported discomfort caused by cold, while 15.7 % felt fear, 8.4 % sadness, 49.8 % anxiety and 4.5 % apathy. Victims with high discomfort caused by cold tend to have higher pain levels. Significantly higher pain intensity were observed in victims with fear and anxiety. Univariate and multivariate analysis indicates that immobilization is associated with increased pain levels.

CONCLUSIONS

There is a statistically significant relationship between acute trauma pain, anxiety, fear, cold and immobilization.

Factors influencing on-scene time in a physician-staffed helicopter emergency medical service (HEMS): a retrospective observational study

BACKGROUND

For helicopter emergency service systems (HEMS), the prehospital time consists of response time, on-scene time and transport time. Little is known about the factors that influence on-scene time or about differences between adult and paediatric missions in a physician-staffed HEMS.

METHODS

We analysed the HEMS electronic database of Swiss Air-Rescue from 01-01-2011 to 31-12-2021 (N = 110,331). We included primary missions and excluded missions with National Advisory Committee for Aeronautics score (NACA) score 0 or 7, resulting in 68,333 missions for analysis. The primary endpoint 'on-scene time' was defined as first physical contact with the patient until take-off to the hospital. A multivariable linear regression model was computed to examine the association of diagnosis, type and number of interventions and monitoring, and patient's characteristics with the primary endpoint.

RESULTS

The prehospital time and on-scene time of the missions studied were, respectively, 50.6 [IQR: 41.0-62.0] minutes and 21.0 [IQR: 15.0-28.6] minutes. Helicopter hoist operations, resuscitation, airway management, critical interventions, remote location, night-time, and paediatric patients were associated with longer on-scene times.

CONCLUSIONS

Compared to adult patients, the adjusted on-scene time for paediatric patients was longer. Besides the strong impact of a helicopter hoist operation on on-scene time, the dominant factors contributing to on-scene time are the type and number of interventions and monitoring: improving individual interventions or performing them in parallel may offer great potential for reducing on-scene time. However, multiple clinical interventions and monitoring interact and are not single interventions. Compared to the impact of interventions, non-modifiable factors, such as NACA score, type of diagnosis and age, make only a minor contribution to overall on-scene time.