First clinical experiences of concurrent bleeding control and intracranial pressure monitoring using a hybrid emergency room system in patients with multiple injuries

Effective use of the hybrid emergency Department system in the treatment of non-traumatic critical care diseases

BACKGROUND

The hybrid emergency room (ER) system can provide resuscitation, computed tomography imaging, endovascular treatment, and emergency surgery, without transferring the patient. However, although several reports have demonstrated the effectiveness of the hybrid ER for trauma conditions, only a few case reports have demonstrated its usefulness for non-traumatic critical diseases. In this observational cohort study, we aimed to identify endogenous diseases that may benefit from treatment in the hybrid ER.

METHODS

We retrospectively reviewed the clinical characteristics of patients with non-traumatic conditions treated in a hybrid ER between August 2017 and July 2022 at our institution. Patients who underwent surgery, endoscopy, or interventional radiology (IR) in the hybrid ER were selected and pathophysiologically divided into a bleeding and non-bleeding group. The rate of shock or cardiac arrest, blood transfusion, and death within 24 h of admission or in-hospital death were compared among the groups using Fisher's exact test. Multivariable logistic regression analysis was performed to confirm the relationships among in-hospital mortality, transfusion, and hemorrhagic conditions in patients who underwent endoscopy and IR.

RESULTS

Among the 726 patients with non-traumatic conditions treated in a hybrid ER system, 50 (6.9%) experienced cardiac arrest at or before admission to the hybrid ER, 301 (41.5%) were in shock, 126 (17.4%) received blood transfusions, 42 (5.8%) died within 24 h of admission to the hybrid ER, and 141 (19.4%) died in the hospital. Emergency surgery was performed in 39 patients (7 in the bleeding group and 32 in the non-bleeding group). Significantly more blood transfusions were administered in the bleeding group (71.4% vs. 18.8%, P = 0.01); there were no significant differences in the rate of shock or cardiac arrest, death within 24 h, or in-hospital death between groups. Endoscopy was performed in 122 patients (80 in the bleeding group and 42 in the non-bleeding group). The bleeding group had a significantly higher rate of shock or cardiac arrest (87.5% vs. 66.7%, P = 0.008) and rate of blood transfusion (62.5% vs. 4.8%, P < 0.0001); there was no significant difference in death within 24 h and in-hospital death between groups. IR was performed in 100 patients (68 in the bleeding group and 32 in the non-bleeding group). Significantly more blood transfusions were administered in the hemorrhage group (67.7% vs. 12.5%, P < 0.0001); there was no difference in the rate of shock or cardiac arrest, death within 24 h, or in-hospital death between groups. Multivariable analysis in patients who underwent endoscopy showed a trend toward more in-hospital deaths in non-hemorrhagic conditions than in hemorrhagic conditions (odds ratio = 3.8, 95% confidence interval: 0.88-17, P = 0.073); however, no significant relationship with in-hospital death was observed for any of the adjusted variables.

CONCLUSION

Among endogenous diseases treated in the hybrid ER, there is a possible association between in-hospital mortality and hemorrhagic conditions. Future studies are needed to focus on diseases to demonstrate the effectiveness of the hybrid ER.

Hybrid emergency room: Installation, establishment, and innovation in the emergency department

A novel trauma workflow system called the hybrid emergency room (Hybrid ER) that combines a sliding computed tomography (CT) scanning system with interventional radiology features was first installed in Osaka General Medical Center in 2011. The Hybrid ER enables CT diagnosis and emergency therapeutic interventions without transferring the patient to another examination room. In this article, the history of CT in trauma care, the world's first installation of the Hybrid ER, clinical experiences, and evidence for the Hybrid ER in trauma workflow and nontrauma fields are summarized, and the future and innovation of the Hybrid ER are reviewed.

Achieving good neurological outcome by combining decompressive craniectomy for acute subdural hematoma and transarterial embolization of intraperitoneal injured arteries for multiple severe trauma: a case report

A 22-year-old woman jumped from the 4th floor of her apartment in an attempt to commit suicide. Whole-body computed tomography showed multiple injuries, including right acute subdural hematoma, left hemopneumothorax, several fractures, intraperitoneal hemorrhage, and spleen injury. Her consciousness deteriorated rapidly, and her right pupil was dilated. Furthermore, she had unstable vital signs including blood pressure of approximately 70/40 mmHg, pulse about 150/minute, respiratory rate 25/minute, and percutaneous oxygen saturation of 90% on 10 L oxygen. Intratracheal intubation and insertion of a thoracostomy tube were performed in the emergency room. Due to concomitant brain herniation and hemorrhagic shock, simultaneous decompressive craniectomy for acute subdural hematoma and transarterial embolization of intraperitoneal injured arteries were performed in our hybrid operating room. Despite rapid blood transfusions, the blood pressure did not increase. After starting embolization of the injured arteries of the spleen, the blood pressure increased, thereby making it possible to remove the acute subdural hematoma, and hemostasis was then achieved. Four hours later, the acute subdural hematoma and intracranial pressure increased again, and re-operation was performed in the normal operating room. Cranioplasty and clavicular fracture reduction were performed 14 days later. She recovered enough to talk and walk, and her consciousness stabilized. Interviews with her and her family by a psychiatrist determined that abnormal behaviors had first appeared 2 months earlier. She was diagnosed with acute and transient psychotic disorders, and treatment was started. The patient was discharged home 1 month later with mild disability of her higher-order brain function.

Direct to OR resuscitation of abdominal trauma: An NTDB propensity matched outcomes study

BACKGROUND

Direct to operating room resuscitation (DOR) is used by some trauma centers for severely injured trauma patients as an approach to minimize time to hemorrhage control. It is unknown whether this strategy results in favorable outcomes. We hypothesized that utilization of an emergency department operating room (EDOR) for resuscitation of patients with abdominal trauma at an urban Level I trauma center would be associated with decreased time to laparotomy and improved outcomes.

METHODS

We included patients 15 years or older with abdominal trauma who underwent emergent laparotomy within 120 minutes of arrival both at our institution and within a National Trauma Data Bank sample between 2007 to 2019 and 2013 to 2016, respectively. Our institutional sample was matched 1:1 to an American College of Surgeons National Trauma Databank sample using propensity score matching based on age, sex, mechanism of injury, and abdominal Abbreviated Injury Scale score. The primary outcome was time to laparotomy incision. Secondary outcomes included blood transfusion requirement, intensive care unit (ICU) length of stay (LOS), ventilator days, hospital LOS, and in-hospital mortality.

RESULTS

Two hundred forty patients were included (120 institutional, 120 national). Both samples were well balanced, and 83.3% sustained penetrating trauma. There were 84.2% young adults between the ages of 15 and 47, 91.7% were male, 47.5% Black/African American, with a median Injury Severity Score of 14 (interquartile range [IQR], 8-29), Glasgow Coma Scale score of 15 (IQR, 13-15), 71.7% had an systolic blood pressure of >90 mm Hg, and had a shock index of 0.9 (IQR, 0.7-1.1) which did not differ between groups (p > 0.05). Treatment in the EDOR was associated with decreased time to incision (25.5 minutes vs. 40 minutes; p ≤ 0.001), ICU LOS (1 vs. 3.1 days; p < 0.001), transfusion requirement within 24 hours (3 units vs. 5.8 units packed red blood cells; p = 0.025), hospital LOS (5 days vs. 8.5 days, p = 0.014), and ventilator days (1 day vs. 2 days; p ≤ 0.001). There were no significant differences in in-hospital mortality (22.5% vs. 15.0%; p = 0.14) or outcome-free days (4.9 days vs. 4.5 days, p = 0.55).

CONCLUSION

The use of an EDOR is associated with decreased time to hemorrhage control as evidenced by the decreased time to incision, blood transfusion requirement, ICU LOS, hospital LOS, and ventilator days. These findings support DOR for patients sustaining operative abdominal trauma.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level III.

Image-guided procedures in the hybrid operating room: A systematic scoping review

Background

The shift from open to minimally invasive procedures with growing complexity has increased the demand for advanced intraoperative medical technologies. The hybrid operating room (OR) combines the functionality of a standard OR with fixed advanced imaging systems to facilitate minimally invasive image-guided procedures.

Objective

This systematic scoping review provides an overview of the use of the hybrid OR over the years, and reports on the encountered advantages and challenges.

Methods

We conducted a systematic search in PubMed, Embase, Web of Science, and Cochrane library databases for studies that described procedures being performed with the aid of 3D imaging in the hybrid OR.

Results

The search identified 123 studies that described 44 distinct procedures, divided over nine clinical disciplines. The number of studies increased from two in 2010 to 15 in the first five months of 2020. Ninety-nine (80%) of the studies described how 3D imaging was performed in the hybrid OR; 95 (96%) used cone-beam CT; four (4%) used multi-detector CT. Advantages and challenges of the hybrid OR were described in 94 (76%) and 34 (35%) studies, respectively. The most frequently reported advantage of using a hybrid OR is the achievement of more accurate treatment results, whereas elongation of the procedure time is the most important challenge, followed by an increase in radiation dose.

Conclusion

In conclusion, the growing number of clinical disciplines that uses the hybrid OR shows its wide functionality. To optimize its use, future comparative studies should be conducted to investigate which procedures really benefit from being performed in the hybrid OR.

Perioperative Management of Polytrauma Patients with Severe Traumatic Brain Injury Undergoing Emergency Extracranial Surgery: A Narrative Review

Managing the acute phase after a severe traumatic brain injury (TBI) with polytrauma represents a challenging situation for every trauma team member. A worldwide variability in the management of these complex patients has been reported in recent studies. Moreover, limited evidence regarding this topic is available, mainly due to the lack of well-designed studies. Anesthesiologists, as trauma team members, should be familiar with all the issues related to the management of these patients. In this narrative review, we summarize the available evidence in this setting, focusing on perioperative brain protection, cardiorespiratory optimization, and preservation of the coagulative function. An overview on simultaneous multisystem surgery (SMS) is also presented.

Endovascular Resuscitation and Trauma Management (EVTM)-Practical Aspects and Implementation

ABSTRACT

In recent years there has been a tremendous increase in hemorrhage control by endovascular methods. Traumatic and non-traumatic hemorrhage is being more frequently managed with endografts, embolization agents, and minimal invasive methods. These methods initially were used in hemodynamically stable patients only, whereas now these are being implemented in acute settings and hemodynamically unstable patients. The strategy of using endovascular and combined open-endo methods approach for hemodynamic instability in trauma and non-trauma patients has been named EVTM- EndoVascular resuscitation and Trauma Management. The EVTM concept will be presented in this article, describing how it is developed and used, as well as its limitations and future aspects.

Hybrid emergency rooms reduce the requirement of blood transfusion in patients with severe trauma

Background

A hybrid emergency room (ER) is defined as an emergency unit with four functions—performing resuscitation, computed tomography (CT), surgery, and angiography. However, the safety and efficacy of performing CT in a hybrid ER are unclear in primary surveys. Therefore, this study aimed to evaluate the safety and clinical effects of hybrid ERs.

Methods

This retrospective observational study used data from the Shimane University Hospital Trauma Database from January 2016 to February 2019. Hospitalized patients with severe trauma and an injury severity score of ≥ 16 were divided into the non-hybrid ER group (n = 134) and the hybrid ER group (n = 145). The time from arrival to CT and interventions and the number of in-hospital survivors, preventable trauma deaths (PTD), and unexpected survivors (US) were assessed in both groups. Further, the amount of blood transfused was compared between the groups using propensity score matching.

Results

The time from arrival to CT and interventions was significantly reduced in the hybrid ER group compared to that in the non-hybrid ER group (25 vs. 6 min; p < 0.0001 and 101 vs. 41 min; p = 0.0007, respectively). There was no significant difference in the rate of in-hospital survivors (96.9% vs. 96.3%; p = 0.770), PTD (0% vs. 0%), and US (9.0 vs. 6.2%; p = 0.497) between the groups. The amount of blood transfused was significantly lower in the hybrid ER group than in the non-hybrid ER group (whole blood 14 vs. 8, p = 0.004; red blood cell 6 vs. 2, p = 0.012; fresh frozen plasma 9 vs. 6, p = 0.021). This difference was maintained after propensity score matching (whole blood 28 [10–54] vs. 6 [4–16.5], p = 0.015; RBC 8 [2.75–26.5] vs. 2 [0–8.5], p = 0.020, 18 [5.5–27] vs. 6 [3.5–7.5], p = 0.057).

Conclusions

The study results suggest that trauma treatment in a hybrid ER is as safe as conventional treatment performed in a non-hybrid ER. Further, hybrid ERs, which can reduce the time for trauma surveys and treatment, do not require patient transfer and can reduce the amount of blood transfused during resuscitation.

Chinese Cerebrovascular Neurosurgery Society and Chinese Interventional & Hybrid Operation Society, of Chinese Stroke Association Clinical Practice Guidelines for Management of Brain Arteriovenous Malformations in Eloquent Areas

Aim: The aim of this guideline is to present current and comprehensive recommendations for the management of brain arteriovenous malformations (bAVMs) located in eloquent areas. Methods: An extended literature search on MEDLINE was performed between Jan 1970 and May 2020. Eloquence-related literature was further screened and interpreted in different subcategories of this guideline. The writing group discussed narrative text and recommendations through group meetings and online video conferences. Recommendations followed the Applying Classification of Recommendations and Level of Evidence proposed by the American Heart Association/American Stroke Association. Prerelease review of the draft guideline was performed by four expert peer reviewers and by the members of Chinese Stroke Association. Results: In total, 809 out of 2,493 publications were identified to be related to eloquent structure or neurological functions of bAVMs. Three-hundred and forty-one publications were comprehensively interpreted and cited by this guideline. Evidence-based guidelines were presented for the clinical evaluation and treatment of bAVMs with eloquence involved. Topics focused on neuroanatomy of activated eloquent structure, functional neuroimaging, neurological assessment, indication, and recommendations of different therapeutic managements. Fifty-nine recommendations were summarized, including 20 in Class I, 30 in Class IIa, 9 in Class IIb, and 2 in Class III. Conclusions: The management of eloquent bAVMs remains challenging. With the evolutionary understanding of eloquent areas, the guideline highlights the assessment of eloquent bAVMs, and a strategy for decision-making in the management of eloquent bAVMs.

Combined brain and thoracic trauma surgery in a hybrid emergency room system: a case report

Background

A novel trauma workflow system called the hybrid emergency room (Hybrid ER), which combines a sliding CT scanner system with interventional radiology features (IVR-CT), was initially instituted in our emergency department in 2011. Use of the Hybrid ER enables CT diagnosis and emergency therapeutic interventions without transferring the patient to another room. We describe an illustrative case of severe multiple blunt trauma that included injuries to the brain and torso to highlight the ability to perform multiple procedures in the Hybrid ER.

Case presentation

A 46-year-old man sustained multiple injuries after falling from height. An early CT scan performed in the Hybrid ER revealed grade IIIa thoracic aortic injury, left lung contusion, and right subdural haematoma and subarachnoid haemorrhage. Without relocating the patient, all definitive procedures, including trepanation, total pneumonectomy, and thoracic endovascular aneurysm repair were performed in the Hybrid ER. At 5.72 h after definitive surgery was begun, the patient was transferred to the intensive care unit.

Conclusions

The Hybrid ER has the potential to facilitate the performance of multiple definitive procedures in combination to treat severe multiple blunt trauma including injuries to the brain and torso. Emergency departments with more than one resuscitation room would benefit from a Hybrid ER to treat complex emergency cases.

Effectiveness and Usage Trends of Hemorrhage Control Interventions in Patients with Pelvic Fracture in Shock

BACKGROUND

Hemorrhage control for pelvic fractures remains challenging. There are several kinds of hemostatic interventions, including angiography/angioembolization (AG/AE), external fixation (EF), and resuscitative endovascular balloon occlusion of the aorta (REBOA). However, no large studies have been conducted for the comparative review of each intervention. In this study, we examined the usage trend of therapeutic interventions in Japan for patients with pelvic fractures in shock and the influence of these interventions on mortality.

METHODS

Data of adult patients with pelvic fracture who were in shock were obtained from the Japanese Trauma Data Bank (2004-2014). The primary endpoint was the influence of each intervention (AG/AE, EF, and REBOA) on in-hospital mortality. We also investigated the frequency of each intervention.

RESULTS

A total of 3149 patients met all our inclusion criteria. Specifically, 1131 (35.9%), 496 (15.8%), and 256 (8.1%) patients underwent AG, EF, and REBOA interventions, respectively. Therapeutic AE was performed in 690 patients who underwent AG (61.0%). The overall mortality rate was 31.4%. Multiple regression analysis identified that AG/AE (OR 0.64, 95% CI 0.52-0.80) and EF (OR 0.75, 95% CI 0.58-0.98) were significantly associated with survival, whereas REBOA (OR 4.17, 95% CI 3.00-5.82) was significantly associated with worse outcomes.

CONCLUSIONS

In Japan, patients with pelvic fracture who were in shock had high mortality rates. AG/AE and EF were associated with decreased mortality. AG may benefit from the early detection of arterial bleeding, leading to decreased mortality of patients with pelvic fracture in shock.

Cost-effectiveness of a hybrid emergency room system for severe trauma: a health technology assessment from the perspective of the third-party payer in Japan

Background

Hybrid emergency room (ER) systems, consisting of an angiography-computed tomography (CT) machine in a trauma resuscitation room, are reported to be effective for reducing death from exsanguination in trauma patients. We aimed to investigate the cost-effectiveness of a hybrid ER system in severe trauma patients without severe traumatic brain injury (TBI).

Methods

We conducted a cost-utility analysis comparing the hybrid ER system to the conventional ER system from the perspective of the third-party healthcare payer in Japan. A short-term decision tree and a long-term Markov model using a lifetime time horizon were constructed to estimate quality-adjusted life years (QALYs) and associated lifetime healthcare costs. Short-term mortality and healthcare costs were derived from medical records and claims data in a tertiary care hospital with a hybrid ER. Long-term mortality and utilities were extrapolated from the literature. The willingness-to-pay threshold was set at $47,619 per QALY gained and the discount rate was 2%. Deterministic and probabilistic sensitivity analyses were conducted.

Results

The hybrid ER system was associated with a gain of 1.03 QALYs and an increment of $33,591 lifetime costs compared to the conventional ER system, resulting in an ICER of $32,522 per QALY gained. The ICER was lower than the willingness-to-pay threshold if the odds ratio of 28-day mortality was < 0.66. Probabilistic sensitivity analysis indicated that the hybrid ER system was cost-effective with a 79.3% probability.

Conclusion

The present study suggested that the hybrid ER system is a likely cost-effective strategy for treating severe trauma patients without severe TBI.

Hybrid emergency room management of a ruptured abdominal aortic aneurysm

Patients with a ruptured abdominal aortic aneurysm (rAAA) still have high mortality. Rapid diagnosis and treatment are vital for improving survival outcomes. rAAA management has evolved regarding these factors. We have reported the case of a 70-year-old man with an rAAA that was rapidly diagnosed and treated in a hybrid emergency room (ER). A hybrid ER is an integrated ER capable of computed tomography scanning, interventional radiology, and surgery in one place. In the present case, the door-to-intervention time was 35 minutes. The use of hybrid ERs has the potential to enhance the speed and quality of diagnostic and definitive treatment of rAAAs.

Preserve encephalus in surgery of trauma: online survey. (P.E.S.T.O)

Background

Traumatic brain injury (TBI) is a global health problem. Extracranial hemorrhagic lesions needing emergency surgery adversely affect the outcome of TBI. We conducted an international survey regarding the acute phase management practices in TBI polytrauma patients.

Methods

A questionnaire was available on the World Society of Emergency Surgery website between December 2017 and February 2018. The main endpoints were the evaluation of (1) intracranial pressure (ICP) monitoring during extracranial emergency surgery (EES), (2) hemodynamic management without ICP monitoring during EES, (3) coagulation management, and (4) utilization of simultaneous multisystem surgery (SMS).

Results

The respondents were 122 representing 105 trauma centers worldwide. ICP monitoring was utilized in 10–30% of patients at risk of intracranial hypertension (IH) undergoing EES from about a third of the respondents [n = 35 (29%)]. The respondents reported that the safest values of systolic blood pressure during EES in patients at risk of IH were 90–100 mmHg [n = 35 (29%)] and 100–110 mmHg [n = 35 (29%)]. The safest values of mean arterial pressure during EES in patients at risk of IH were > 70 mmHg [n = 44 (36%)] and > 80 mmHg [n = 32 (26%)]. Regarding ICP placement, a large percentage of respondents considered a platelet (PLT) count > 50,000/mm³ [n = 57 (47%)] and a prothrombin time (PT)/activated partial thromboplastin time (aPTT) < 1.5 times the normal control [n = 73 (60%)] to be the safest parameters. For craniotomy, the majority of respondents considered PLT count > 100,000/mm³ [n = 67 (55%)] and a PT/aPTT < 1.5 times the normal control [n = 76 (62%)] to be the safest parameters. Almost half of the respondents [n = 53 (43%)], reported that they transfused red blood cells (RBCs)/plasma (P)/PLTs at a ratio of 1/1/1 in TBI polytrauma patients. SMS was performed in 5–19% of patients, requiring both an emergency neurosurgical operation and EES, by almost half of the respondents [n = 49 (40%)].

Conclusions

A great variability in practices during the acute phase management of polytrauma patients with severe TBI was identified. These findings may be helpful for future investigations and educational purposes.

Electronic supplementary material

The online version of this article (10.1186/s13017-019-0229-2) contains supplementary material, which is available to authorized users.