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Coulombe P, Malo C, Robitaille-Fortin M, Nadeau A, Émond M, Moore L, Blanchard PG, Benhamed A, Mercier E. Identification and Management of Pelvic Fractures in Prehospital and Emergency Department Settings. J Surg Res 2024; 300:371-380. [PMID: 38843724 DOI: 10.1016/j.jss.2024.05.006] [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: 01/19/2024] [Revised: 05/03/2024] [Accepted: 05/08/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION This study aims to describe the characteristics of patients with a pelvic fracture treated at a level 1 trauma center, the proportion of prehospital undertriage and the use of pelvic circumferential compression device (PCCD). METHODS This is a retrospective cohort study. Prehospital and inhospital medical records of adults (≥16 y old) with a pelvic fracture who were treated at Hopital de l'Enfant-Jesus-CHU de Québec (Quebec City, Canada), a university-affiliated level 1 trauma center, between September 01, 2017 and September 01, 2021 were reviewed. Isolated hip or pubic ramus fracture were excluded. Data are presented using proportions and means with standard deviations. RESULTS A total of 228 patients were included (males: 62.3%; mean age: 54.6 [standard deviation 21.1]). Motor vehicle collision (47.4%) was the main mechanism of injury followed by high-level fall (21.5%). Approximately a third (34.2%) needed at least one blood transfusion. Compared to those admitted directly, transferred patients were more likely to be male (73.0% versus 51.3%, P < 0.001) and to have a surgical procedure performed at the trauma center (71.3% versus 46.9%, P < 0.001). The proportion of prehospital undertriage was 22.6%. Overall, 17.1% had an open-book fracture and would have potentially benefited from a prehospital PCCD. Forty-six transferred patients had a PCCD applied at the referral hospital of which 26.1% needed adjustment. CONCLUSIONS Pelvic fractures are challenging to identify in the prehospital environment and are associated with a high undertriage of 22.6%. Reducing undertriage and optimizing the use of PCCD are key opportunities to improve care of patients with a pelvic fracture.
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Affiliation(s)
- Pascale Coulombe
- VITAM - Centre de Recherche en Santé Durable de l'Université Laval, Québec, Canada
| | - Christian Malo
- Axe Santé des Populations et Pratiques Optimales en Santé, Unité de Recherche en Traumatologie - Urgences - Soins Intensifs, Centre de Recherche du CHU de Québec - Université Laval, Québec, QC, Canada; Département de Médecine Familiale et de Médecine D'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | | | - Alexandra Nadeau
- VITAM - Centre de Recherche en Santé Durable de l'Université Laval, Québec, Canada; Axe Santé des Populations et Pratiques Optimales en Santé, Unité de Recherche en Traumatologie - Urgences - Soins Intensifs, Centre de Recherche du CHU de Québec - Université Laval, Québec, QC, Canada
| | - Marcel Émond
- VITAM - Centre de Recherche en Santé Durable de l'Université Laval, Québec, Canada; Axe Santé des Populations et Pratiques Optimales en Santé, Unité de Recherche en Traumatologie - Urgences - Soins Intensifs, Centre de Recherche du CHU de Québec - Université Laval, Québec, QC, Canada; Département de Médecine Familiale et de Médecine D'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Lynne Moore
- Département de Médecine Préventive, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Pierre-Gilles Blanchard
- VITAM - Centre de Recherche en Santé Durable de l'Université Laval, Québec, Canada; Axe Santé des Populations et Pratiques Optimales en Santé, Unité de Recherche en Traumatologie - Urgences - Soins Intensifs, Centre de Recherche du CHU de Québec - Université Laval, Québec, QC, Canada; Département de Médecine Familiale et de Médecine D'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Axel Benhamed
- Axe Santé des Populations et Pratiques Optimales en Santé, Unité de Recherche en Traumatologie - Urgences - Soins Intensifs, Centre de Recherche du CHU de Québec - Université Laval, Québec, QC, Canada; Département de Médecine Familiale et de Médecine D'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada
| | - Eric Mercier
- VITAM - Centre de Recherche en Santé Durable de l'Université Laval, Québec, Canada; Axe Santé des Populations et Pratiques Optimales en Santé, Unité de Recherche en Traumatologie - Urgences - Soins Intensifs, Centre de Recherche du CHU de Québec - Université Laval, Québec, QC, Canada; Département de Médecine Familiale et de Médecine D'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada.
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Durrands TH, Murphy M, Wohlgemut JM, De'Ath HD, Perkins ZB. Diagnostic accuracy of clinical examination for identification of life-threatening torsos injuries: a meta-analysis. Br J Surg 2023; 110:1885-1886. [PMID: 37847819 DOI: 10.1093/bjs/znad285] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 10/19/2023]
Affiliation(s)
- Thomas Harry Durrands
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- The Central London School of Anaesthesia, London, UK
| | - Mark Murphy
- Department of Anaesthesia, Frimley Health NHS Foundation Trust, UK
| | - Jared M Wohlgemut
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Henry D De'Ath
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Zane B Perkins
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- London's Air Ambulance, Royal London Hospital, Barts Health NHS Trust, London, UK
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Balet L, Ageron FX, Pasquier M, Zingg T. Performance Assessment of Out-of-Hospital Use of Pelvic Circumferential Compression Devices for Severely Injured Patients in Switzerland: A Nationwide Retrospective Cross-Sectional Study. J Clin Med 2023; 12:5509. [PMID: 37685575 PMCID: PMC10487807 DOI: 10.3390/jcm12175509] [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: 06/22/2023] [Revised: 08/09/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Patients with severe pelvic fractures carry a greater risk of severe bleeding, and pelvic compression devices (PCCD) are used to stabilize the pelvis on the pre-hospital scene. The aim of this study was to describe the use of PCCD in the pre-hospital setting on a nationwide scale (Switzerland) and determine the sensitivity, specificity and rates of over- and under-triage of the current application practices. The secondary objective was to identify pre-hospital factors associated with unstable pelvic fractures. METHODS Retrospective cross-sectional study using anonymized patient data (1 January 2015-31 December 2020) from the Swiss Trauma Registry (STR). Based on AIS scores, patients were assigned a unique principal diagnosis among three categories (unstable pelvic fracture-stable pelvic fracture-other) and assessed for use or not of PCCD. Secondarily, patient characteristics, initial pre-hospital vital signs, means of pre-hospital transport and trauma mechanism were also extracted from the database. RESULTS 2790 patients were included for analysis. A PCCD was used in 387 (13.9%) patients. In the PCCD group, 176 (45.5%) had an unstable pelvic fracture, 52 (13.4%) a stable pelvic fracture and 159 (41.1%) an injury unrelated to the pelvic region. In the group who did not receive a PCCD, 214 (8.9%) had an unstable pelvic fracture, 182 (7.6%) a stable pelvic fracture and 2007 (83.5%) an injury unrelated to the pelvic region. The nationwide sensitivity of PCCD application was 45.1% (95% CI 40.1-50.2), the specificity 91.2% (95% CI 90-92.3), with both over- and under-triage rates of 55%. The prevalence of unstable fractures in our population was 14% (390/2790). We identified female sex, younger age, lower systolic blood pressure, higher shock index, pedestrian hit and fall ≥3 m as possible risk factors for an unstable pelvic fracture. CONCLUSIONS Our results demonstrate a nationwide both over- and under-triage rate of 55% for out-of-hospital PCCD application. Female gender, younger age, lower blood pressure, higher shock index, pedestrian hit and fall >3 m are possible risk factors for unstable pelvic fracture, but it remains unclear if those parameters are relevant clinically to perform pre-hospital triage.
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Affiliation(s)
- Lionel Balet
- Faculty of Biology and Medicine, University of Lausanne, 1005 Lausanne, Switzerland
| | - François-Xavier Ageron
- Department of Emergency Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Mathieu Pasquier
- Department of Emergency Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Tobias Zingg
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
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Gende A, Roesly H. Acute Hemorrhage on the Playing Field. Clin Sports Med 2023; 42:401-408. [PMID: 37208055 DOI: 10.1016/j.csm.2023.02.005] [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: 05/21/2023]
Abstract
Acute hemorrhage in sport is a common issue for the sideline professional. The severity of bleeding ranges from mild to severe and life- or limb-threatening. The mainstay of management of acute hemorrhage is achieving hemostasis. Hemostasis is frequently accomplished via direct pressure but may require more invasive management including tourniquet use or pharmacologic management. With concerns for internal bleeding, dangerous mechanism of injury, or signs of shock, prompt activation of the emergency action plan is required.
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Affiliation(s)
- Alecia Gende
- Department of Emergency Medicine, Mayo Clinic Health System, 700 West Avenue, La Crosse, WI 54601, USA; Department of Sports Medicine, Mayo Clinic Health System, 700 West Avenue, La Crosse, WI 54601, USA.
| | - Heather Roesly
- Emergency Medicine Faculty, University of Colorado, Aurora, CO, USA; UC Health Highlands Ranch Hospital, 1500 Central Drive, Highlands Ranch, CO 80129-6688, USA
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Wohlgemut JM, Marsden MER, Stoner RS, Pisirir E, Kyrimi E, Grier G, Christian M, Hurst T, Marsh W, Tai NRM, Perkins ZB. Diagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patients. Scand J Trauma Resusc Emerg Med 2023; 31:18. [PMID: 37029436 PMCID: PMC10082501 DOI: 10.1186/s13049-023-01083-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/31/2023] [Indexed: 04/09/2023] Open
Abstract
BACKGROUND Timely and accurate identification of life- and limb-threatening injuries (LLTIs) is a fundamental objective of trauma care that directly informs triage and treatment decisions. However, the diagnostic accuracy of clinical examination to detect LLTIs is largely unknown, due to the risk of contamination from in-hospital diagnostics in existing studies. Our aim was to assess the diagnostic accuracy of initial clinical examination for detecting life- and limb-threatening injuries (LLTIs). Secondary aims were to identify factors associated with missed injury and overdiagnosis, and determine the impact of clinician uncertainty on diagnostic accuracy. METHODS Retrospective diagnostic accuracy study of consecutive adult (≥ 16 years) patients examined at the scene of injury by experienced trauma clinicians, and admitted to a Major Trauma Center between 01/01/2019 and 31/12/2020. Diagnoses of LLTIs made on contemporaneous clinical records were compared to hospital coded diagnoses. Diagnostic performance measures were calculated overall, and based on clinician uncertainty. Multivariate logistic regression analyses identified factors affecting missed injury and overdiagnosis. RESULTS Among 947 trauma patients, 821 were male (86.7%), median age was 31 years (range 16-89), 569 suffered blunt mechanisms (60.1%), and 522 (55.1%) sustained LLTIs. Overall, clinical examination had a moderate ability to detect LLTIs, which varied by body region: head (sensitivity 69.7%, positive predictive value (PPV) 59.1%), chest (sensitivity 58.7%, PPV 53.3%), abdomen (sensitivity 51.9%, PPV 30.7%), pelvis (sensitivity 23.5%, PPV 50.0%), and long bone fracture (sensitivity 69.9%, PPV 74.3%). Clinical examination poorly detected life-threatening thoracic (sensitivity 48.1%, PPV 13.0%) and abdominal (sensitivity 43.6%, PPV 20.0%) bleeding. Missed injury was more common in patients with polytrauma (OR 1.83, 95% CI 1.62-2.07) or shock (systolic blood pressure OR 0.993, 95% CI 0.988-0.998). Overdiagnosis was more common in shock (OR 0.991, 95% CI 0.986-0.995) or when clinicians were uncertain (OR 6.42, 95% CI 4.63-8.99). Uncertainty improved sensitivity but reduced PPV, impeding diagnostic precision. CONCLUSIONS Clinical examination performed by experienced trauma clinicians has only a moderate ability to detect LLTIs. Clinicians must appreciate the limitations of clinical examination, and the impact of uncertainty, when making clinical decisions in trauma. This study provides impetus for diagnostic adjuncts and decision support systems in trauma.
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Affiliation(s)
- Jared M Wohlgemut
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK.
- Ward 12D, Trauma Service, Royal London Hospital, Barts NHS Health Trust, Whitechapel Road, London, E1 1FR, UK.
| | - Max E R Marsden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- Ward 12D, Trauma Service, Royal London Hospital, Barts NHS Health Trust, Whitechapel Road, London, E1 1FR, UK
- Academic Department of Military Surgery and Trauma, Royal Centre of Defence Medicine, Birmingham, UK
| | - Rebecca S Stoner
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- Ward 12D, Trauma Service, Royal London Hospital, Barts NHS Health Trust, Whitechapel Road, London, E1 1FR, UK
| | - Erhan Pisirir
- Department of Electrical Engineering and Computer Science, Queen Mary University of London, London, UK
| | - Evangelia Kyrimi
- Department of Electrical Engineering and Computer Science, Queen Mary University of London, London, UK
| | - Gareth Grier
- London's Air Ambulance, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Michael Christian
- London's Air Ambulance, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Thomas Hurst
- London's Air Ambulance, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - William Marsh
- Department of Electrical Engineering and Computer Science, Queen Mary University of London, London, UK
| | - Nigel R M Tai
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- Ward 12D, Trauma Service, Royal London Hospital, Barts NHS Health Trust, Whitechapel Road, London, E1 1FR, UK
- Academic Department of Military Surgery and Trauma, Royal Centre of Defence Medicine, Birmingham, UK
| | - Zane B Perkins
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- Ward 12D, Trauma Service, Royal London Hospital, Barts NHS Health Trust, Whitechapel Road, London, E1 1FR, UK
- London's Air Ambulance, Royal London Hospital, Barts Health NHS Trust, London, UK
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Carvalho Mota MT, Goldfinger VP, Lokerman R, Terra M, Azijli K, Schober P, de Leeuw MA, van Heijl M, Bloemers FW, Giannakopoulos GF. Prehospital accuracy of (H)EMS pelvic ring injury assessment and the application of non-invasive pelvic binder devices. Injury 2023; 54:1163-1168. [PMID: 36801132 DOI: 10.1016/j.injury.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 01/04/2023] [Accepted: 02/05/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Pre-hospital application of a non-invasive pelvic binder device (NIPBD) is essential to increase chances of survival by limiting blood loss in patients with an unstable pelvic ring injury. However, unstable pelvic ring injuries are often not recognized during prehospital assessment. We investigated the prehospital (helicopter) emergency medical services ((H)EMS)' accuracy of the assessment of unstable pelvic ring injuries and NIPBD application rate. METHODS We performed a retrospective cohort study on all patients with a pelvic injury transported by (H)EMS to our level one trauma centre between 2012 and 2020. Pelvic ring injuries were included and radiographically categorized using the Young & Burgess classification system. Lateral Compression (LC) type II/III -, Anterior-Posterior (AP) type II/III - and Vertical Shear (VS) injuries were considered as unstable pelvic ring injuries. (H)EMS charts and in-hospital patient records were evaluated to determine the sensitivity, specificity and diagnostic accuracy of the prehospital assessment of unstable pelvic ring injuries and prehospital NIPBD application. RESULTS A total of 634 patients with pelvic injuries were identified, of whom 392 (61.8%) had pelvic ring injuries and 143 (22.6%) had unstable pelvic ring injuries. (H)EMS personnel suspected a pelvic injury in 30.6% of the pelvic ring injuries and in 46.9% of the unstable pelvic ring injuries. An NIPBD was applied in 108 (27.6%) of the patients with a pelvic ring injury and in 63 (44.1%) of the patients with an unstable pelvic ring injury. (H)EMS prehospital diagnostic accuracy measured in pelvic ring injuries alone was 67.1% for identifying unstable pelvic ring injuries from stable pelvic ring injuries and 68.1% for NIPBD application. CONCLUSION The (H)EMS prehospital sensitivity of unstable pelvic ring injury assessment and NIPBD application rate is low. (H)EMS did not suspect an unstable pelvic injury nor applied an NIPBD in roughly half of all unstable pelvic ring injuries. We advise future research on decision tools to aid the routine use of an NIPBD in any patient with a relevant mechanism of injury.
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Affiliation(s)
- M T Carvalho Mota
- Department of Trauma Surgery, Amsterdam University Medical Centres, Room 7F-002, De Boelelaan 1117, 1081 HV, the Netherlands.
| | - V P Goldfinger
- Department of Emergency Medicine, Amsterdam University Medical Centres, Room 7F-002, De Boelelaan 1117, 1081 HV, the Netherlands
| | - R Lokerman
- Department of Surgery, University Medical Centre Utrecht, the Netherlands
| | - M Terra
- Department of Trauma Surgery, Amsterdam University Medical Centres, Room 7F-002, De Boelelaan 1117, 1081 HV, the Netherlands
| | - K Azijli
- Department of Emergency Medicine, Amsterdam University Medical Centres, Room 7F-002, De Boelelaan 1117, 1081 HV, the Netherlands
| | - P Schober
- Department of Anaesthesiology, Amsterdam University Medical Centres, Room 7F-002, De Boelelaan 1117, 1081 HV, the Netherlands
| | - M A de Leeuw
- Department of Anaesthesiology, Amsterdam University Medical Centres, Room 7F-002, De Boelelaan 1117, 1081 HV, the Netherlands
| | - M van Heijl
- Department of Surgery, University Medical Centre Utrecht, the Netherlands; Department of Surgery, Diakonessenhuis Utrecht, the Netherlands
| | - F W Bloemers
- Department of Trauma Surgery, Amsterdam University Medical Centres, Room 7F-002, De Boelelaan 1117, 1081 HV, the Netherlands
| | - G F Giannakopoulos
- Department of Trauma Surgery, Amsterdam University Medical Centres, Room 7F-002, De Boelelaan 1117, 1081 HV, the Netherlands
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Predictive value of computed tomography for short-term mortality in patients with acute respiratory distress syndrome: a systematic review. Sci Rep 2022; 12:9579. [PMID: 35689019 PMCID: PMC9185136 DOI: 10.1038/s41598-022-13972-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 05/31/2022] [Indexed: 11/20/2022] Open
Abstract
The best available evidence and the predictive value of computed tomography (CT) findings for prognosis in patients with acute respiratory distress syndrome (ARDS) are unknown. We systematically searched three electronic databases (MEDLINE, CENTRAL, and ClinicalTrials.gov). A total of 410 patients from six observational studies were included in this systematic review. Of these, 143 patients (34.9%) died due to ARDS in short-term. As for CT grade, the CTs used ranged from 4- to 320-row. The index test included diffuse attenuations in one study, affected lung in one study, well-aerated lung region/predicted total lung capacity in one study, CT score in one study and high-resolution CT score in two studies. Considering the CT findings, pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were 62% (95% confidence interval [CI] 30–88%), 76% (95% CI 57–89%), 2.58 (95% CI 2.05–2.73), 0.50 (95% CI 0.21–0.79), and 5.16 (95% CI 2.59–3.46), respectively. This systematic review revealed that there were major differences in the definitions of CT findings, and that the integration of CT findings might not be adequate for predicting short-term mortality in ARDS. Standardisation of CT findings and accumulation of further studies by CT with unified standards are warranted.
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