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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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Hu KM, Brown RM. Resuscitation of the Critically Ill Older Adult. Emerg Med Clin North Am 2021; 39:273-286. [PMID: 33863459 DOI: 10.1016/j.emc.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In 30 years, adults 65 and older will represent 20% of the US population, with increased medical comorbidities leading to higher rates of critical illness and mortality. Despite significant acute illness, presenting symptoms and vital sign abnormalities may be subtle. Resuscitative guidelines are a helpful starting point but appropriate diagnostics, bedside ultrasound, and frequent reassessments are needed to avoid procrustean care that may worsen outcomes. Baseline functional status is as important as underlying comorbid conditions when prognosticating, and the patient's personal wishes should be sought early and throughout care with clear communication regarding prospects for immediate survival and overall recovery.
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Affiliation(s)
- Kami M Hu
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA; Department of Internal Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Robert M Brown
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Carilion Roanoke Memorial Hospital, 1906 Belleview Ave SE, Roanoke, VA 24014, USA
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Smith A, Onyiego A, Duchesne J, Tatum D, Harris C, Moreno-Ponte OI, Strumwasser A, Inaba K, O'Keeffe T, Black J, Quintana MT, Gupta S, Brocker J, Schreiber M, Pickett ML, Cripps MW, Guidry C. A Multi-Institutional Analysis of Damage Control Laparotomy in Elderly Trauma Patients: Do Geriatric Trauma Protocols Matter? Am Surg 2020; 86:1135-1143. [PMID: 32809869 DOI: 10.1177/0003134820943646] [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: 11/15/2022]
Abstract
BACKGROUND Trauma centers are receiving increasing numbers of older trauma patients. There is a lack of literature on the outcomes for elderly trauma patients who undergo damage control laparotomy (DCL). We hypothesized that trauma centers with geriatric protocols would have better outcomes in elderly patients after DCL. METHODS A retrospective chart review of consecutive adult trauma patients with DCL at 8 level 1 trauma centers was conducted from 2012 to 2018. Patients aged 40 or older were included. Age ≥ 55 years was defined as elderly. Demographics, injury information, clinical outcomes, including mortality, and complications were recorded. Univariate and multivariate analyses were performed. RESULTS A total of 379 patients with DCLs were identified with an average age of 54.8 ± 0.4 years with 39.3% (n = 149/379) of patients aged ≥ 55. Geriatric protocols or a consulting geriatric service was present at 37.5% (n = 3/8) of institutions. Age ≥ 55 was a significant risk factor for in-hospital mortality (OR 2, 95% CI 1.0-4.0, P = .04). Institutions without dedicated geriatric trauma protocols/services had higher overall in-hospital mortality on both univariate (57.9% vs 34.3%, P = .02) and multivariate analyses (OR 2.1, 95% CI 1.3-3.4, P < .001). CONCLUSIONS Surgical management of older trauma patients remains a challenge. Geriatric protocols or dedicated services were found to be associated with improved outcomes. Future efforts should focus on standardizing the availability of these resources at trauma centers.
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Affiliation(s)
- Alison Smith
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
| | - Alexandra Onyiego
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
| | - Juan Duchesne
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
| | - Danielle Tatum
- Our Lady of the Lake Trauma Hospital, Baton Rouge, LA, USA
| | - Charles Harris
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
| | | | | | - Kenji Inaba
- University of Southern California, Los Angeles, CA, USA
| | | | | | - Megan T Quintana
- 21668 Shock Trauma Center University of Maryland, Baltimore, MD, USA
| | - Shailvi Gupta
- 21668 Shock Trauma Center University of Maryland, Baltimore, MD, USA
| | - Jason Brocker
- 21668 Shock Trauma Center University of Maryland, Baltimore, MD, USA
| | | | | | | | - Chrissy Guidry
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
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Khoujah D, Martinelli AN, Winters ME. Resuscitating the Critically Ill Geriatric Emergency Department Patient. Emerg Med Clin North Am 2019; 37:569-581. [PMID: 31262422 DOI: 10.1016/j.emc.2019.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The emergency department resuscitation of the critically ill geriatric patient is challenging and can be fraught with peril. The anatomic and physiologic changes that occur with aging can significantly influence the recognition of critical illness and the logistics of resuscitation itself. This article discusses the relevant physiologic changes with aging, the effect of these changes on clinical manifestations of critical illness in older adults, and the core principles of resuscitation in this population, with specific attention to sepsis and trauma care. In addition, end-of-life care is also discussed.
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Affiliation(s)
- Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Ashley N Martinelli
- Emergency Medicine, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Michael E Winters
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
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Affiliation(s)
- D G Nevin
- Department of Anaesthesia and London's Air Ambulance, The Royal London Hospital Major Trauma Centre, Bart's Health NHS Trust, London, UK
| | - K Brohi
- Centre for Trauma Sciences, The Blizard Institute, Queen Mary University of London, London, UK
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Carpenter CR, Arendts G, Hullick C, Nagaraj G, Cooper Z, Burkett E. Major trauma in the older patient: Evolving trauma care beyond management of bumps and bruises. Emerg Med Australas 2017; 29:450-455. [DOI: 10.1111/1742-6723.12785] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 03/19/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Christopher R Carpenter
- Department of Emergency Medicine; Washington University School of Medicine in St. Louis; St. Louis Missouri USA
| | - Glenn Arendts
- Department of Emergency Medicine; The University of Western Australia; Perth Western Australia Australia
- Harry Perkins Institute for Medical Research, Centre for Clinical Research in Emergency Medicine; Perth Western Australia Australia
| | - Carolyn Hullick
- Emergency Department, John Hunter Hospital; Newcastle New South Wales Australia
- Department of Emergency Medicine; Faculty of Health and Medicine, The University of Newcastle; Newcastle New South Wales Australia
| | - Guruprasad Nagaraj
- Department of Emergency Medicine; Liverpool Hospital; Liverpool New South Wales Australia
- Department of Emergency Medicine, School of Medicine; The University of Sydney; Sydney New South Wales Australia
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital; Harvard University School of Medicine; Boston Massachusetts USA
| | - Ellen Burkett
- Princess Alexandra Hospital; Brisbane Queensland Australia
- Department of Emergency Medicine; School of Medicine, The University of Queensland; Brisbane Queensland Australia
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Lai WH, Wu SC, Rau CS, Kuo PJ, Hsu SY, Chen YC, Hsieh HY, Hsieh CH. Systolic Blood Pressure Lower than Heart Rate upon Arrival at and Departure from the Emergency Department Indicates a Poor Outcome for Adult Trauma Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:E528. [PMID: 27231926 PMCID: PMC4923985 DOI: 10.3390/ijerph13060528] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/13/2016] [Accepted: 05/19/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hemorrhage is a leading cause of preventable trauma death. In this study, we used the reverse shock index (RSI), a ratio of systolic blood pressure (SBP) to heart rate (HR), to evaluate the hemodynamic stability of trauma patients. As an SBP lower than the HR (RSI < 1) may indicate hemodynamic instability, the objective of this study was to assess the associated complications in trauma patients with an RSI < 1 upon arrival at the emergency department (ED) (indicated as (A)RSI) and at the time of departure from the ED (indicated as (L)RSI) to the operative room or for admission. METHODS Data obtained from all 16,548 hospitalized patients recorded in the trauma registry system at a Level I trauma center between January 2009 and December 2013 were retrospectively reviewed. A total of 10,234 adult trauma patients aged ≥20 were enrolled and subsequently divided into four groups: Group I, (A)RSI ≥ 1 and (L)RSI ≥ 1 (n = 9827); Group II, (A)RSI ≥ 1 and (L)RSI < 1 (n = 76); Group III, (A)RSI < 1 and (L)RSI ≥ 1 (n = 251); and Group IV, (A)RSI < 1 and (L)RSI < 1 (n = 80). Pearson's χ² test, Fisher's exact test, or independent Student's t-test was conducted to compare trauma patients in Groups II, III, and IV with those in Group I. RESULTS Patients in Groups II, III, and IV had a higher injury severity score and underwent a higher number of procedures, including intubation, chest tube insertion, and blood transfusion, than Group I patients. Additionally, patients of these groups had increased hospital length of stay (16.3 days, 14.9 days, and 22.0 days, respectively), proportion of patients admitted to the intensive care unit (ICU) (48.7%, 43.0%, and 62.5%, respectively), and in-hospital mortality (19.7%, 7.6%, and 27.5%, respectively). Although the trauma patients who had a SBP < 90 mmHg either upon arrival at or departure from the ED also present a more severe injury and poor outcome, those patients who had a SBP ≥ 90 mmHg but an RSI < 1 had a more severe injury and poor outcome than those patients who had a SBP ≥ 90 mmHg and an RSI ≥ 1. CONCLUSIONS SBP lower than heart rate (RSI < 1) either upon arrival at or departure from the ED may indicate a detrimental sign of poor outcome in adult trauma patients even in the absence of noted hypotension.
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Affiliation(s)
- Wei-Hung Lai
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Ta-Pei Road, Niao-Song District, Kaohsiung City 833, Taiwan.
| | - Pao-Jen Kuo
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Yi-Chun Chen
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Hsiao-Yun Hsieh
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Ching-Hua Hsieh
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Ta-Pei Road, Niao-Song District, Kaohsiung City 833, Taiwan.
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