Paramedics' and pre-hospital physicians' assessments of anatomic injury in trauma patients: a cohort study

Cutoff of the reverse shock index multiplied by the Glasgow coma scale for predicting in-hospital mortality in adult patients with trauma: a retrospective cohort study

BACKGROUND

Early identification of patients at risk of potential death and timely transfer to appropriate healthcare facilities are critical for reducing the number of preventable trauma deaths. This study aimed to establish a cutoff value to predict in-hospital mortality using the reverse shock index multiplied by the Glasgow Coma Scale (rSIG).

METHODS

This multicenter retrospective cohort study used data from 23 emergency departments in South Korea between January 2011 and December 2020. The outcome variable was the in-hospital mortality. The relationship between rSIG and in-hospital mortality was plotted using the shape-restricted regression spline method. To set a cutoff for rSIG, we found the point on the curve where mortality started to increase and the point where the slope of the mortality curve changed the most. We also calculated the cutoff value for rSIG using Youden's index.

RESULTS

A total of 318,506 adult patients with trauma were included. The shape-restricted regression spline curve showed that in-hospital mortality began to increase when the rSIG value was less than 18.86, and the slope of the graph increased the most at 12.57. The cutoff of 16.5, calculated using Youden's index, was closest to the target under-triage and over-triage rates, as suggested by the American College of Surgeons, when applied to patients with an rSIG of 20 or less. In addition, in patients with traumatic brain injury, when the rSIG value was over 25, in-hospital mortality tended to increase as the rSIG value increased.

CONCLUSIONS

We propose an rSIG cutoff value of 16.5 as a predictor of in-hospital mortality in adult patients with trauma. However, in patients with traumatic brain injury, a high rSIG is also associated with in-hospital mortality. Appropriate cutoffs should be established for this group in the future.

Data quality of Glasgow Coma Scale and Systolic Blood Pressure in scientific studies involving physician-staffed emergency medical services: Systematic review

BACKGROUND

Emergency physicians on-scene provide highly specialized care to severely sick or injured patients. High-quality research relies on the quality of data, but no commonly accepted definition of EMS data quality exits. Glasgow Coma Score (GCS) and Systolic Blood Pressure (SBP) are core physiological variables, but little is known about the quality of these data when reported in p-EMS research. This systematic review aims to describe the quality of pre-hospital reporting of GCS and SBP data in studies where emergency physicians are present on-scene.

METHODS

A systematic literature search was performed using CINAHL, Cochrane, Embase, Medline, Norart, Scopus, SweMed + and Web of Science, in accordance with the PRISMA guidelines. Reported data on accuracy of reporting, completeness and capture were extracted to describe the quality of documentation of GCS and SBP. External and internal validity assessment was performed by extracting a set of predefined variables.

RESULTS

We included 137 articles describing data collection for GCS, SBP or both. Most studies (81%) were conducted in Europe and 59% of studies reported trauma cases. Reporting of GCS and SBP data were not uniform and may be improved to enable comparisons. Of the predefined external and internal validity data items, 26%-45% of data were possible to extract from the included papers.

CONCLUSIONS

Reporting of GCS and SBP is variable in scientific papers. We recommend standardized reporting to enable comparisons of p-EMS.

Factors Affecting Treatment with Life-Saving Interventions, Computed Tomography Scans and Specialist Consultations

Background: Emergency treatments determined by emergency physicians may affect mortality and patient satisfaction. This paper attempts to examine the impact of patient characteristics, health status, the accredited level of hospitals, and triaged levels on the following emergency treatments: immediate life-saving interventions (LSIs), computed tomography (CT) scans, and specialist consultations (SCs). Methods: A multivariate logistic regression model was employed to analyze the impact of patient characteristics, including sex, age, income and the urbanization degree of the patient's residence; patient health status, including records of hospitalization and the number of instances of ambulatory care in the previous year; the Charlson Comorbidity Index (CCI) score; the accredited level of hospitals; and the triaged level of emergency treatments. Results: All the patient characteristics were found to impact receiving LSI, CT and SC, except for income. Furthermore, a better health status was associated with a decreased probability of receiving LSI, CT and SC, but the number of instances of ambulatory care was not found to have a significant impact on receiving CT or SC. This study also found no evidence to support impact of CCI on SC. Hospitals with higher accredited levels were associated with a greater chance of patients receiving emergency treatments of LSI, CT and SC. A higher assigned severity (lower triaged level) led to an increased probability of receiving CT and SC. In terms of LSI, patients assigned to level 4 were found to have a lower chance of treatment than those assigned to level 5. Conclusions: This study found that several patient characteristics, patient health status, the accredited level of medical institutions and the triaged level, were associated with a higher likelihood of receiving emergency treatments. This study suggests that the inequality of medical resources among medical institutions with different accredited levels may yield a crowding-out effect.

Isolated blunt severe traumatic brain injury in Bern, Switzerland, and the United States: A matched cohort study

BACKGROUND

The ideal prehospital management of patients with severe traumatic brain injury (TBI) including the impact of endotracheal intubation (ETI) and physicians on scene is unclear. Prehospital management differs substantially in Switzerland and the United States: in Switzerland, there is usually a physician on scene who may provide ETI and other advanced life support procedures, whereas in the United States, prehospital management (including ETI) is performed by paramedics.

METHODS

This is a retrospective cohort-matched study of patients with isolated blunt severe TBI (head Abbreviated Injury Scale [AIS] score, 4-5) and no major extracranial injuries, using Bern University Hospital data from the Swiss PEBITA [Patient-relevant Endpoints after Brain Injury from Traumatic Accidents] (TBI-specific) database and the US National Trauma Data Bank from 2009 to 2010. A 1:4 cohort matching of Bern and US patients was performed. Matching criteria were sex, age (±10 years), exact field Glasgow Coma Scale (GCS) score, exact head AIS score, and injury type (subdural hematoma, epidural hematoma, intraparenchymal hemorrhage, intraventricular hemorrhage, brain edema/swelling, brain stem injury). The matched cohorts were compared with univariable analysis (Fisher's exact test and Mann-Whitney U-test).

RESULTS

Matching of the Bern (n = 128) and US (n = 86,375) cohort resulted in 355 matched cases (71 Bern and 284 US patients). Bern patients had significantly longer scene times (median, 23.0 minutes vs. 9.0 minutes, p < 0.001) and more frequent prehospital ETI (31.0% vs. 18.7%, p = 0.034) and air transportation (39.4% vs. 19.4%, p < 0.001). No significant difference in procedures (craniotomy/craniectomy, intracranial pressure monitoring, tracheotomy), intensive care unit and total hospital lengths of stay, ventilator days, and in-hospital mortality (14.1% vs. 15.8%, p = 0.855) was found between the two cohorts.

CONCLUSION

When taking into account the limitation that patient- and injury-related factors, but not in-hospital treatment variables, were matched, the more frequent prehospital ETI and presence of a physician on scene in the Swiss cohort compared with the US cohort had no significant effect on outcomes, including intensive care unit and total hospital lengths of stay, ventilator days, and in-hospital mortality.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Prehospital Care of Burn Patients and Trajectories on Survival

We sought to identify factors associated with the prognosis and survival of burn patients by analyzing data related to the prehospital treatment of burn patients transferred directly to the burn unit from the accident site. We also aimed to assess the role of prehospital physicians and paramedics providing care to major burn patients. This study included adult burn patients with severe burns treated between 2006 and 2010. Prehospital patient records and clinical data collected during treatment were analyzed, and the Injury Severity Scale (ISS) was calculated. Patients were grouped into two cohorts based on the presence or absence of a physician during the prehospital phase. Data were analyzed with reference to survival by multivariable regression model. Specific inclusion criteria resulted in a sample of 67 patients. The groups were comparable with regard to age, gender, and injury etiology. Patients treated by prehospital physicians (group 1, n = 49) were more severely injured than patients treated by paramedics (group 2, n = 18) in terms of total burn surface area (%TBSA) (32% vs. 17%, p = 0.033), ISS (25 vs. 8, p < 0.000), and inhalation injuries (51% vs. 16%, p = 0.013), and presented with a higher pulse rate, lower systolic blood pressure, and lower median pH. Age, gender, %TBSA, and ISS were significantly associated with survival in both groups. Survival at 30 days was associated with age, gender, the amount of intravenous fluids (in liters) received during the first 24 hours, and the final %TBSA. Variables found to be independently associated by multivariable regression model with 30 day mortality were age, female gender, and final TBSA. We identified prehospital prognostic factors affecting patient outcomes. Based on the results from this study, our current EMS system is capable of identifying seriously injured burn patients who may benefit from physician attendance at the injury scene.

Assessing trauma care provider judgement in the prediction of need for life-saving interventions

INTRODUCTION

Human judgement on the need for life-saving interventions (LSI) in trauma is poorly studied, especially during initial casualty management. We prospectively examined early clinical judgement and compared clinical experts' predictions of LSI to their later occurrence.

PATIENTS AND METHODS

Within 10-15 min of direct trauma admission, we surveyed the predictions of pre-hospital care providers (PHP, 92% paramedics), trauma centre nurses (RN), and attending or fellow trauma physicians (MD) on the need for LSI. The actual outcomes including fluid bolus, intubation, transfusion (<1h and 1-6h), and emergent surgical interventions were observed. Cohen's kappa statistic (K) and percentage agreement were used to measure agreement among provider responses. Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were calculated to compare clinical judgement to actual patient interventions.

RESULTS

Among 325 eligible trauma patient admissions, 209 clinical judgement of LSIs were obtained from all three providers. Cohen's kappa statistic for agreement between pairs of provider groups demonstrated no "disagreement" (K<0) between groups, "fair" agreement for fluid bolus (K=0.12-0.19) and blood transfusion 0-6h (K=0.22-0.39), and "moderate" (K=0.45-0.49) agreement between PHP and RN regarding intubation and surgical interventions, but no "excellent" (K ≥ 0.81) agreement between any pair of provider groups for any intervention. The percentage agreement across the different clinician groups ranged from 50% to 83%. NPV was 90-99% across providers for all interventions except fluid bolus.

CONCLUSIONS

Expert clinical judgement provides a benchmark for the prediction of major LSI use in unstable trauma patients. No excellent agreement exists across providers on LSI predictions. It is possible that quality improvement measures and computer modelling-based decision-support could reduce errors of LSI commission and omission found in resuscitation at major trauma centres and enhance decision-making in austere trauma settings by less well-trained providers than those surveyed.

Accuracy of prehospital diagnosis and triage of a Swiss helicopter emergency medical service

BACKGROUND

Helicopter emergency medical services (HEMSs) have become a standard element of modern prehospital emergency medicine. This study determines the percentage of injured HEMS patients whose injuries were correctly recognized by HEMS physicians.

METHODS

A retrospective level III evidence prognostic study using data from the largest Swiss HEMS, REGA (Rettungsflugwacht/Guarde Aérienne), on adult patients with trauma transported to a Level I trauma center (January 2006-December 2007). National Advisory Committee on Aeronautics (NACA) scores and the Injury Severity Score (ISS) were assessed to identify severely injured patients. Injured body regions diagnosed by REGA physicians were compared with emergency department discharge diagnoses.

RESULTS

Four hundred thirty-three patients were analyzed. Median age was 42.1 years (interquartile range, 25.5-57.9). Three hundred twenty-three (74.6%) were men. Patients were severely injured, with an in-hospital NACA score of 4 or higher in 88.7% of patients and median ISS of 13. REGA physicians correctly recognized injuries to the head in 92.9%, to the femur in 90.5%, and to the tibia/fibula in 83.8% of patients. Injuries to these body regions were overdiagnosed in less than 30%. Abdominal injuries were missed in 56.1%, pelvic injuries in 51.8%, spinal injuries in 40.1%, and chest injuries in 31.2% of patients.

CONCLUSION

This study shows that patients are adequately triaged by REGA physicians reflected by a NACA score 4 or higher in 88.7% of patients and a median ISS of 13. However, recognition of injured body regions seems to be challenging in the prehospital setting. Prospective studies on specific training of HEMS physicians for recognition of these injuries (e.g., portable ultrasonography, telemedicine) might help in the future.

LEVEL OF EVIDENCE

Prognostic study, level III.

Micropower impulse radar: a novel technology for rapid, real-time detection of pneumothorax

Pneumothorax detection in emergency situations must be rapid and at the point of care. Current standards for detection of a pneumothorax are supine chest X-rays, ultrasound, and CT scans. Unfortunately these tools and the personnel necessary for their facile utilization may not be readily available in acute circumstances, particularly those which occur in the pre-hospital setting. The decision to treat therefore, is often made without adequate information. In this report, we describe a novel hand-held device that utilizes Micropower Impulse Radar to reliably detect the presence of a pneumothorax. The technology employs ultra wide band pulses over a frequency range of 500 MHz to 6 GHz and a proprietary algorithm analyzes return echoes to determine if a pneumothorax is present with no user interpretation required. The device has been evaluated in both trauma and surgical environments with sensitivity of 93% and specificity of 85%. It is has the CE Mark and is available for sale in Europe. Post market studies are planned starting in May of 2011. Clinical studies to support the FDA submission will be completed in the first quarter of 2012.