Pre-hospital severe traumatic brain injury - comparison of outcome in paramedic versus physician staffed emergency medical services

Review article: Emergency medical services transfer of severe traumatic brain injured patients to a neuroscience centre: A systematic review

Patients with severe traumatic brain injuries require urgent medical attention at a hospital. We evaluated whether transporting adult patients with a severe traumatic brain injury (TBI) to a Neuroscience Centre is associated with reduced mortality. We reviewed studies published between 2010 and 2023 on severe TBI in adults (>18 years) using Medline, CINAHL, Google Scholar and Cochrane databases. We focused on mortality rates and the impact of transferring patients to a Neuroscience Centre, delays to neurosurgery and EMS triage accuracy. This review analysed seven studies consisting of 53 365 patients. When patients were directly transported to a Neuroscience Centre, no improvement in survivability was demonstrated. Subsequently, transferring patients from a local hospital to a Neuroscience Centre was significantly associated with reduced mortality in one study (adjusted odds ratio: 0.79, 95% confidence interval: 0.64-0.96), and 24-h (relative risk [RR]: 0.31, 0.11-0.83) and 30-day (RR: 0.66, 0.46-0.96) mortality in another. Patients directly transported to a Neuroscience Centre were more unwell than those taken to a local hospital. Subsequent transfers increased time to CT scanning and neurosurgery in several studies, although these were not statistically significant. Additionally, EMS could accurately triage. None of the included studies demonstrated statistically significant findings indicating that direct transportation to a Neuroscience Centre increased survivability for patients with severe traumatic brain injuries. Subsequent transfers from a non-Neuroscience Centre to a Neuroscience Centre reduced mortality rates at 24 h and 30 days. Further research is required to understand the differences between direct transport and subsequent transfers to Neuroscience Centres.

Tick-tock: Prehospital intubation is associated with longer field time without any survival benefit

BACKGROUND

Prehospital endotracheal intubation is a debated topic, and few studies have found it beneficial after trauma. A growing body of evidence suggests that prehospital endotracheal intubation is associated with increased morbidity and mortality. Our study was designed to compare patients with attempted prehospital endotracheal intubation to those intubated promptly upon emergency department arrival.

METHODS

A retrospective review of a single-center trauma research data repository was utilized. Inclusion criteria included age ≥15 years, transport from the scene by ground ambulance, and undergoing prehospital endotracheal intubation attempts or intubation within 10 minutes of emergency department arrival without prior prehospital endotracheal intubation attempt. Propensity score matching was used to minimize differences in baseline characteristics between groups. Standard mean differences are also presented for pre- and post-matching datasets to evaluate for covariate balance.

RESULTS

In total, 208 patients met the inclusion criteria. Of these, 95 patients (46%) underwent prehospital endotracheal intubation, which was successful in 47% of cases. A control group of 113 patients (54%) were intubated within 10 minutes of emergency department arrival. We performed propensity score matching between cohorts based on observed differences after univariate analysis and used standard mean differences to estimate covariate balance. After propensity score matching, patients who underwent prehospital endotracheal intubation experienced a longer time on scene as compared with those intubated in the emergency department (9 minutes [interquartile range 6-12] vs 6 minutes [interquartile range 5-9], P < .01) without difference in overall mortality (67% vs 65%, P = 1.00). Rapid sequence intubation was not used in the field; however, it was used for 58% of patients intubated within 10 minutes of emergency department arrival. After matched analysis, patients with a failed prehospital intubation attempt were equally likely to receive rapid sequence intubation during re-intubation in the emergency department as compared with those undergoing a first attempt (n = 13/28, 46% vs n = 28/63, 44%, P = 1.00, standard mean differences 0.04). Among patients with prehospital arrest (n = 98), prehospital endotracheal intubation was associated with shorter time to death (8 minutes [interquartile range 3-17] vs 14 minutes [interquartile range 8-45], P = .008) and longer total transport time (23 minutes [interquartile range 19-31] vs 19 minutes [interquartile range 16-24], P = .006), but there was no difference in observed mortality (n = 29/31, 94% vs n = 30/31, 97%, P = 1.00, standard mean differences = 0.15) after propensity score matching.

CONCLUSION

Prehospital providers should prioritize expeditious transport over attempting prehospital endotracheal intubation, as prehospital endotracheal intubation is inconsistently successful, may delay definitive care, and appears to have no survival benefit.

Heart Rate Variability Can Detect Blunt Traumatic Brain Injury Within the First Hour

INTRODUCTION

In patients with multi-organ system trauma, the diagnosis of coinciding traumatic brain injury can be difficult due to injuries from the hemorrhagic shock that confound clinical and radiographic signs of traumatic brain injury. In this study, a novel technique using heart rate variability was developed in a porcine model to detect traumatic brain injury early in the setting of hemorrhagic shock without the need for radiographic imaging or clinical exam.

METHODS

A porcine model of hemorrhagic shock was used with an arm of swine receiving hemorrhagic shock alone and hemorrhagic shock with traumatic brain injury. High-resolution heart rate frequencies were collected at different time intervals using waveforms based on voltage delivered from the heart rate monitor. Waveforms were analyzed to assess statistically significant differences between heart rate variability parameters in those with hemorrhagic shock and traumatic brain injury versus those with only hemorrhagic shock. Stochastic analysis was used to assess the validity of results and create a model by machine learning to better assess the presence of traumatic brain injury.

RESULTS

Significant differences were found in several heart rate variability parameters between the two groups. Additionally, significant differences in heart rate variability parameters were found in swine within 1 hour of inducing hemorrhage in those with traumatic brain injury versus those without. These results were confirmed with stochastic analysis and machine learning was used to generate a model which determined the presence of traumatic brain injury in the setting of hemorrhage shock with 91.6% accuracy.

CONCLUSIONS

 Heart rate variability represents a promising diagnostic tool to aid in the diagnosis of traumatic brain injury within 1 hour of injury.

Effect of time intervals in critical care provided by helicopter emergency medical services on 30-day survival after trauma

BACKGROUND

Trauma is the leading cause of death especially in children and young adults. Prehospital care following trauma emphasizes swift transport to a hospital following initial care. Previous studies have shown conflicting results regarding the effect of time on the survival following major trauma. In our study we investigated the effect of prehospital time-intervals on 30-day mortality on trauma patients that received prehospital critical care.

METHODS

We performed a retrospective study on all trauma patients encountered by helicopter emergency medical services in Finland from 2012 to 2018. Patients discharge diagnoses were classed into (1) trauma without traumatic brain injury, (2) isolated traumatic brain injury and (3) trauma with traumatic brain injury. Emergency medical services response time, helicopter emergency medical services response time, on-scene time and transport time were used as time-intervals and age, Glasgow coma scale, hypotension, need for prehospital airway intervention and ICD-10 based Injury Severity Score were used as variables in logistic regression analysis.

RESULTS

Mortality data was available for 4,803 trauma cases. The combined 30-day mortality was 12.1% (582/4,803). Patients with trauma without a traumatic brain injury had the lowest mortality, at 4.3% (111/2,605), whereas isolated traumatic brain injury had the highest, at 22.9% (435/1,903). Patients with both trauma and a traumatic brain injury had a mortality of 12.2% (36/295). Following adjustments, no association was observed between time intervals and 30-day mortality.

DISCUSSION

Our study revealed no significant association between different timespans and mortality following severe trauma in general. Trends in odds ratios can be interpreted to favor more expedited care, however, no statistical significance was observed. As trauma forms a heterogenous patient group, specific subgroups might require different approaches regarding the prehospital timeframes.

STUDY TYPE

prognostic/therapeutic/diagnostic test.

Association between case volume and mortality in pre-hospital anaesthesia management: a retrospective observational cohort

BACKGROUND

Pre-hospital anaesthesia is a core competency of helicopter emergency medical services (HEMS). Whether physician pre-hospital anaesthesia case volume affects outcomes is unknown in this setting. We aimed to investigate whether physician case volume was associated with differences in mortality or medical management.

METHODS

We conducted a registry-based cohort study of patients undergoing drug-facilitated intubation by HEMS physician from January 1, 2013 to August 31, 2019. The primary outcome was 30-day mortality, analysed using multivariate logistic regression controlling for patient-dependent variables. Case volume for each patient was determined by the number of pre-hospital anaesthetics the attending physician had managed in the previous 12 months. The explanatory variable was physician case volume grouped by low (0-12), intermediate (13-36), and high (≥37) case volume. Secondary outcomes were characteristics of medical management, including the incidence of hypoxaemia and hypotension.

RESULTS

In 4818 patients, the physician case volume was 511, 2033, and 2274 patients in low-, intermediate-, and high-case-volume groups, respectively. Higher physician case volume was associated with lower 30-day mortality (odds ratio 0.79 per logarithmic number of cases [95% confidence interval: 0.64-0.98]). High-volume physician providers had shorter on-scene times (median 28 [25th-75th percentile: 22-38], compared with intermediate 32 [23-42] and lowest 32 [23-43] case-volume groups; P<0.001) and a higher first-pass success rate for tracheal intubation (98%, compared with 93% and 90%, respectively; P<0.001). The incidence of hypoxaemia and hypotension was similar between groups.

CONCLUSIONS

Mortality appears to be lower after pre-hospital anaesthesia when delivered by physician providers with higher case volumes.

Dispatch accuracy of physician-staffed emergency medical services in trauma care in south-east Norway: a retrospective observational study

Background

Selection of incidents and accurate identification of patients that require assistance from physician-staffed emergency medical services (P-EMS) remain essential. We aimed to evaluate P-EMS availability, the underlying criteria for dispatch, and the corresponding dispatch accuracy of trauma care in south-east Norway in 2015, to identify areas for improvement.

Methods

Pre-hospital data from emergency medical coordination centres and P-EMS medical databases were linked with data from the Norwegian Trauma Registry (NTR). Based on a set of conditions (injury severity, interventions performed, level of consciousness, incident category), trauma incidents were defined as complex, warranting P-EMS assistance, or non-complex. Incident complexity and P-EMS involvement were the main determinants when assessing the triage accuracy. Undertriage was adjusted for P-EMS availability and response and transport times.

Results

Among 19,028 trauma incidents, P-EMS were involved in 2506 (13.2%). The range of overtriage was 74–80% and the range of undertriage was 20–32%. P-EMS readiness in the event of complex incidents ranged from 58 to 70%. The most frequent dispatch criterion was “Police/fire brigade request immediate response” recorded in 4321 (22.7%) of the incidents. Criteria from the groups “Accidents” and “Road traffic accidents” were recorded in 10,875 (57.2%) incidents, and criteria from the groups “Transport reservations” and “Unidentified problem” in 6025 (31,7%) incidents. Among 4916 patient pathways in the NTR, 681 (13.9%) could not be matched with pre-hospital data records.

Conclusions

Both P-EMS availability and dispatch accuracy remain suboptimal in trauma care in south-east Norway. Dispatch criteria are too vague to facilitate accurate P-EMS dispatch, and pre-hospital data is inconsistent and insufficient to provide basic data for scientific research. Future dispatch criteria should focus on the care aspect of P-EMS. Better tools for both dispatch and incident handling for the emergency medical coordination centres are essential. In general, coordination, standardisation, and integration of existing data systems should enhance the quality of trauma care and increase patient safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00982-3.

Physician-staffed ambulance and increased in-hospital mortality of hypotensive trauma patients following prolonged prehospital stay: A nationwide study

BACKGROUND

The benefits of physician-staffed emergency medical services (EMS) for trauma patients remain unclear because of the conflicting results on survival. Some studies suggested potential delays in definitive hemostasis due to prolonged prehospital stay when physicians are dispatched to the scene. We examined hypotensive trauma patients who were transported by ambulance, with the hypothesis that physician-staffed ambulances would be associated with increased in-hospital mortality, compared with EMS personnel-staffed ambulances.

METHODS

A retrospective cohort study that included hypotensive trauma patients (systolic blood pressure ≤ 90 mm Hg at the scene) transported by ambulance was conducted using the Japan Trauma Data Bank (2004-2019). Physician-staffed ambulances are capable of resuscitative procedures, such as thoracotomy and surgical airway management, while EMS personnel-staffed ambulances could only provide advanced life support. In-hospital mortality and prehospital time until the hospital arrival were compared between patients who were classified based on the type of ambulance. Inverse probability weighting was conducted to adjust baseline characteristics including age, sex, comorbidities, mechanism of injury, vital signs at the scene, injury severity, and ambulance dispatch time.

RESULTS

Among 14,652 patients eligible for the study, 738 were transported by a physician-staffed ambulance. In-hospital mortality was higher in the physician-staffed ambulance than in the EMS personnel-staffed ambulance (201/699 [28.8%] vs. 2287/13,090 [17.5%]; odds ratio, 1.90 [1.61-2.26]; adjusted odds ratio, 1.22 [1.14-1.30]; p < 0.01), and the physician-staffed ambulance showed longer prehospital time (50 [36-66] vs. 37 [29-48] min, difference = 12 [11-12] min, p < 0.01). Such potential harm of the physician-staffed ambulance was only observed among patients who arrived at the hospital with persistent hypotension (systolic blood pressure < 90 mm Hg on hospital arrival) in subgroup analyses.

CONCLUSION

Physician-staffed ambulances were associated with prolonged prehospital stay and increased in-hospital mortality among hypotensive trauma patients compared with EMS personnel-staffed ambulance.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Physician-led prehospital management is associated with reduced mortality in severe blunt trauma patients: a retrospective analysis of the Japanese nationwide trauma registry

BACKGROUND

Although the results of previous studies suggested the effectiveness of physician-led prehospital trauma management, it has been uncertain because of the limited number of high-quality studies. Furthermore, the advantage of physician-led prehospital management might have been overestimated due to the shortened prehospital time by helicopter transportation in some studies. The present study aimed to evaluate the effect of physician-led prehospital management independent of prehospital time. Also, subgroup analysis was performed to explore the subpopulation that especially benefit from physician-led prehospital management.

METHODS

This retrospective cohort study analyzed the data of Japan's nationwide trauma registry. Severe blunt trauma patients, defined by Injury Severity Score (ISS) ≥16, who were transported directly to a hospital between April 2009 and March 2019 were evaluated. In-hospital mortality was compared between groups dichotomized by the occupation of primary prehospital healthcare provider (i.e., physician or paramedic), using 1:4 propensity score-matched analysis. The propensity score was calculated using potential confounders including patient demographics, mechanism of injury, vital signs at the scene of injury, ISS, and total time from injury to hospital arrival. Subpopulations that especially benefit from physician-led prehospital management were explored by assessing interaction effects between physician-led prehospital management and patient characteristics.

RESULTS

A total of 30,551 patients (physician-led: 2976, paramedic-led: 27,575) were eligible for analysis, of whom 2690 propensity score-matched pairs (physician-led: 2690, paramedic-led: 10,760) were generated and compared. Physician-led group showed significantly decreased in-hospital mortality than paramedic-led group (in-hospital mortality: 387 [14.4%] and 1718 [16.0%]; odds ratio [95% confidence interval] = 0.88 [0.78-1.00], p = 0.044). Patients with age < 65 years, ISS ≥25, Abbreviated Injury Scale in pelvis and lower extremities ≥3, and total prehospital time < 60 min were likely to benefit from physician-led prehospital management.

CONCLUSIONS

Physician-led prehospital trauma management was significantly associated with reduced in-hospital mortality independent of prehospital time. The findings of exploratory subgroup analysis would be useful for the future research to establish efficient dispatch system of physician team.

A scoping review of worldwide studies evaluating the effects of prehospital time on trauma outcomes

BACKGROUND

Annually, over 1 billion people sustain traumatic injuries, resulting in over 900,000 deaths in Africa and 6 million deaths globally. Timely response, intervention, and transportation in the prehospital setting reduce morbidity and mortality of trauma victims. Our objective was to describe the existing literature evaluating trauma morbidity and mortality outcomes as a function of prehospital care time to identify gaps in literature and inform future investigation.

MAIN BODY

We performed a scoping review of published literature in MEDLINE. Results were limited to English language publications from 2009 to 2020. Included articles reported trauma outcomes and prehospital time. We excluded case reports, reviews, systematic reviews, meta-analyses, comments, editorials, letters, and conference proceedings. In total, 808 articles were identified for title and abstract review. Of those, 96 articles met all inclusion criteria and were fully reviewed. Higher quality studies used data derived from trauma registries. There was a paucity of literature from studies in low- and middle-income countries (LMIC), with only 3 (3%) of articles explicitly including African populations. Mortality was an outcome measure in 93% of articles, predominantly defined as "in-hospital mortality" as opposed to mortality within a specified time frame. Prehospital time was most commonly assessed as crude time from EMS dispatch to arrival at a tertiary trauma center. Few studies evaluated physiologic morbidity outcomes such as multi-organ failure.

CONCLUSION

The existing literature disproportionately represents high-income settings and most commonly assessed in-hospital mortality as a function of crude prehospital time. Future studies should focus on how specific prehospital intervals impact morbidity outcomes (e.g., organ failure) and mortality at earlier time points (e.g., 3 or 7 days) to better reflect the effect of early prehospital resuscitation and transport. Trauma registries may be a tool to facilitate such research and may promote higher quality investigations in Africa and LMICs.

Comparing the diagnostic concordance of tele-EMS and on-site-EMS physicians in emergency medical services: a retrospective cohort study

In 2014, a telemedicine system was established in 24-h routine use in the emergency medical service (EMS) of the city of Aachen. This study tested whether the diagnostic concordance of the tele-EMS physician reaches the same diagnostic concordance as the on-site-EMS physician. The initial prehospital diagnoses were compared to the final hospital diagnoses. Data were recorded retrospectively from the physicians' protocols as well as from the hospital administration system and compared. Also, all diagnostic misconcordance were analysed and reviewed in terms of logical content by two experts. There were no significant differences between the groups in terms of demographic data, such as age and gender, as well as regarding the hospital length of stay and mortality. There was no significant difference between the diagnostic concordance of the systems, except the diagnosis "epileptic seizure". Instead, in these cases, "stroke" was the most frequently chosen diagnosis. The diagnostic misconcordance "stroke" is not associated with any risks to patients' safety. Reasons for diagnostic misconcordance could be the short contact time to the patient during the teleconsultation, the lack of personal examination of the patient by the tele-EMS physician, and reversible symptoms that can mask the correct diagnosis.

Do pre-hospital physicians improve mortality in major trauma patients? A systematic review

Background

Optimal pre-hospital care systems contribute to improvements in trauma survival. The presence of pre-hospital physicians (PHPs) is reported to increase survival in traumatic brain injury, yet the effects of PHPs on outcomes for all trauma patients is currently unreported. The objective of this systematic review was to compare trauma mortality for patients treated by a PHP with those treated by a non-medical pre-hospital practitioner (NMPHP).

Methods

A systematic literature search (Medline, Embase, and CINAHL) was performed, on 10th March 2020, to identify original studies comparing the mortality for trauma patients treated by a PHP with those treated by a NMPHP published between 1st January 2010 and 31st December 2019. Methodological quality of studies was assessed using Grade of Recommendations, Assessment, Development and Evaluation (GRADE).

Results

The search revealed 6,296 studies and 14 met the inclusion criteria, comprising a total of 42,479 patients. Unadjusted mortality suggested a higher mortality for the physician cohort in four studies and no difference in six. However, patients treated by physicians had higher Injury Severity Scores and where adjusted mortality was provided several studies showed a mortality benefit for physicians.

Conclusion

This systematic review did not demonstrate a mortality benefit from pre-hospital physicians attending major trauma patients. However, those with higher Injury Severity Scores may benefit from the presence of a PHP. Identifying this patient cohort in the pre-hospital setting to ensure appropriate resource use requires further evaluation.

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.

Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis

BACKGROUND

As trauma is one of the leading causes of death worldwide, there is great potential for reducing mortality in trauma patients. However, there is continuing controversy over the benefit of deploying emergency medical systems (EMS) physicians in the prehospital setting. The objective of this systematic review and meta-analysis is to assess how out-of-hospital hospital management of severely injured patients by EMS teams with and without physicians affects mortality.

METHODS

PubMed and Google Scholar were searched for relevant articles, and the search was supplemented by a hand search. Injury severity in the group of patients treated by an EMS team including a physician had to be comparable to the group treated without a physician. Primary outcome parameter was mortality. Helicopter transport as a confounder was accounted for by subgroup analyses including only the studies with comparable modes of transport. Quality of all included studies was assessed according to the Cochrane handbook.

RESULTS

There were 2,249 publications found, 71 full-text articles assessed, and 22 studies included. Nine of these studies were matched or adjusted for injury severity. The odds ratio (OR) of mortality was significantly lower in the EMS physician-treated group of patients: 0.81; 95% confidence interval (CI): 0.71-0.92. When analysis was limited to the studies that were adjusted or matched for injury severity, the OR was 0.86 (95% CI, 0.73-1.01). Analyzing only studies published after 2005 yielded an OR for mortality of 0.75 (95% CI, 0.64-0.88) in the overall analysis and 0.81 (95% CI, 0.67-0.97) in the analysis of adjusted or matched studies. The OR was 0.80 (95% CI, 0.65-1.00) in the subgroup of studies with comparable modes of transport and 0.74 (95% CI, 0.53-1.03) in the more recent studies.

CONCLUSION

Prehospital management of severely injured patients by EMS teams including a physician seems to be associated with lower mortality. After excluding the confounder of helicopter transport we have shown a nonsignificant trend toward lower mortality.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Prehospital Airway Management in Severe Traumatic Brain Injury

OBJECTIVE

Traumatic brain injury (TBI) is a leading cause of death and disability among trauma patients. The final outcome of TBI results from a complex interaction between primary and secondary mechanisms of injury that begin immediately after the traumatic event. The aim of this review was to evaluate the latest evidence regarding the impact of prehospital airway management and the outcome after traumatic brain injury.

METHODS

PubMed, Embase, and Cochrane searches were conducted using the MeSH database. Airway management, traumatic brain injury, pneumonia, and the subheadings of these Medical Subject Headings were combined.

RESULTS

The review is structured into 4 major topics: airway management devices, prehospital pharmacologic management, mortality and neurologic outcomes, and early respiratory infections. The available literature shows a shift toward a more comprehensive view of prehospital airway management, taking into account not only the location where airway management is attempted but also the drugs administered, the airway management devices used, and the skills of the main professional figures attending the scene.

CONCLUSIONS

Literature about this topic is still inconclusive; however, new evidence taking into consideration more complex aspects of airway management rather than orotracheal intubation per se shows improved outcomes with aggressive prehospital airway management.

Early-Onset Ventilator-Associated Pneumonia in Severe Traumatic Brain Injury: is There a Relationship with Prehospital Airway Management?

BACKGROUND

Prehospital airway management in severe traumatic brain injury (TBI) is widely recommended by international guidelines for the management of trauma. Early-onset ventilator-associated pneumonia (EOVAP) is a common occurrence in this population and can worsen mortality and functional outcome.

OBJECTIVES

In this retrospective observational study, we aimed to evaluate the association between different prehospital airway management variables and the occurrence of EOVAP. Secondarily we evaluated the correlation between EOVAP and mortality and neurological outcome.

METHODS

The study retrospectively evaluated 223 patients admitted from 2010 to 2017 in our trauma intensive care unit for severe TBI. The population was divided into three groups on the basis of the airway management technique adopted (bag mask ventilation, laryngeal tube, orotracheal intubation). Uni- and multivariate logistic regression analyses were performed using the occurrence of EOVAP as the dependent variable, to investigate potential associations with prehospital airway management.

RESULTS

A total of 131 episodes (58.7%) of EOVAP were registered in the study population (223 patients). Laryngeal tube and orotracheal intubation were used in patients with significantly lower Glasgow Coma Scale score on scene and a higher Face Abbreviated Injury Scale; advanced airway management significantly increased the total rescue time. The prehospital airway management technique adopted, prehospital type of sedation or use of muscle relaxants, type of transport, and rescue times were not associated with the occurrence of EOVAP.

CONCLUSIONS

Prehospital airway management does not have a significant impact on the occurrence of EOVAP in severe TBI patients. Similarly, it does not have a significant impact on mortality or long-term neurological outcome despite increasing duration of mechanical ventilation, intensive care unit, and hospital stay.

Effect of Physician-Staffed Emergency Medical Services (P-EMS) on the Outcome of Patients with Severe Traumatic Brain Injury: A Review of the Literature

Introduction: Traumatic injury is the fourth leading cause of death in western countries and the leading cause of death in younger age. However, it is still unclear which groups of patients benefit most from advanced prehospital trauma care. A minimal amount is known about the effect of prehospital physician-based care on patients with specifically traumatic brain injury (TBI). The aim of this review is to assess the effect of physician-staffed Emergency Medical Services (EMS) on the outcome of patients with severe TBI. Methods: Literature searches have been performed in the bibliographic databases of PubMed, EMBASE and The Cochrane Library. Data concerning (physician-staffed) prehospital care for patients with severe TBI were only included if the control group was based on non-physician-staffed EMS. Primarily the mortality rate and secondarily the neurological outcome were examined. Additionally, data concerning hypotension, hypoxia, length of stay (hospital and intensive care unit) and the number of required early neurosurgical interventions were taken into account. Results: The overall mortality was decreased in three of the fourteen included studies after the implementation of a physician in the prehospital setting. One study found also a decrease in mortality only for patients with a Glasgow Coma Scale of 6-8. Strikingly, two other studies reported higher mortality, one for all the included patients and one for patients with GCS 10-12 only. Neurological outcome was improved in five studies after prehospital deployment of a physician. One study reported that more patients had a poor neurological outcome in the P-EMS group. Results of the remaining outcome measures differed widely. Conclusion: The included literature did not show a clear beneficial effect of P-EMS in the prehospital management of patients with severe TBI. The available evidence showed contradictory results, suggesting more research should be performed in this field with focus on decreasing heterogeneity in the compared groups.

What is the impact of physicians in prehospital treatment for patients in need of acute critical care? - An overview of reviews

OBJECTIVES

The aim of this overview was to systematically identify and synthesize existing evidence from systematic reviews on the impact of prehospital physician involvement.

METHODS

The Medline, Embase, and Cochrane library were searched from 1 January 2000 to 17 November 2017. We included systematic reviews comparing physician-based with non-physician-based prehospital treatment in patients with one of five critical conditions requiring a rapid response.

RESULTS

Ten reviews published from 2009 to 2017 were included. Physician treatment was associated with increased survival in patients with out-of-hospital cardiac arrest and patients with severe trauma; in the latter group, the result was based on more limited evidence. The success rate of prehospital endotracheal intubation (ETI) has improved over the years, but ETI by physicians is still associated with higher success rates than intubation by paramedics. In patients with severe traumatic brain injury, intubation by paramedics who were not well skilled to do so markedly increased mortality.

CONCLUSIONS

Current evidence is hinting at a benefit of physicians in selected aspects of prehospital emergency services, including treatment of patients with out-of-hospital cardiac arrest and critically ill or injured patients in need of prehospital intubation. Evidence is, however, limited by confounding and bias, and comparison is hampered by differences in case mix and the organization of emergency medical services. Future research should strive to design studies that enable appropriate control of baseline confounding and obtain follow-up data for the proportion of patients who die in the prehospital setting.

Prehospital on-scene anaesthetist treating severe traumatic brain injury patients is associated with lower mortality and better neurological outcome

BACKGROUND

Patients with isolated traumatic brain injury (TBI) are likely to benefit from effective prehospital care to prevent secondary brain injury. Only a few studies have focused on the impact of advanced interventions in TBI patients by prehospital physicians. The primary end-point of this study was to assess the possible effect of an on-scene anaesthetist on mortality of TBI patients. A secondary end-point was the neurological outcome of these patients.

METHODS

Patients with severe TBI (defined as a head injury resulting in a Glasgow Coma Score of ≤8) from 2005 to 2010 and 2012-2015 in two study locations were determined. Isolated TBI patients transported directly from the accident scene to the university hospital were included. A modified six-month Glasgow Outcome Score (GOS) was defined as death, unfavourable outcome (GOS 2-3) and favourable outcome (GOS 4-5) and used to assess the neurological outcomes. Binary logistic regression analysis was used to predict mortality and good neurological outcome. The following prognostic variables for TBI were available in the prehospital setting: age, on-scene GCS, hypoxia and hypotension. As per the hypothesis that treatment provided by an on-scene anaesthetist would be beneficial to TBI outcomes, physician was added as a potential predictive factor with regard to the prognosis.

RESULTS

The mortality data for 651 patients and neurological outcome data for 634 patients were available for primary and secondary analysis. In the primary analysis higher age (OR 1.06 CI 1.05-1.07), lower on-scene GCS (OR 0.85 CI 0.79-0.92) and the unavailability of an on-scene anaesthetist (OR 1.89 CI 1.20-2.94) were associated with higher mortality together with hypotension (OR 3.92 CI 1.08-14.23). In the secondary analysis lower age (OR 0.95 CI 0.94-0.96), a higher on-scene GCS (OR 1.21 CI 1.20-1.30) and the presence of an on-scene anaesthetist (OR 1.75 CI 1.09-2.80) were demonstrated to be associated with good patient outcomes while hypotension (OR 0.19 CI 0.04-0.82) was associated with poor outcome.

CONCLUSION

Prehospital on-scene anaesthetist treating severe TBI patients is associated with lower mortality and better neurological outcome.

Traumatic brain injured patients: primum non nocere

PURPOSE OF REVIEW

Traumatic brain injury (TBI) remains an unfortunately common disease with potentially devastating consequences for patients and their families. However, it is important to remember that it is a spectrum of disease and thus, a one 'treatment fits all' approach is not appropriate to achieve optimal outcomes. This review aims to inform readers about recent updates in prehospital and neurocritical care management of patients with TBI.

RECENT FINDINGS

Prehospital care teams which include a physician may reduce mortality. The commonly held value of SBP more than 90 in TBI is now being challenged. There is increasing evidence that patients do better if managed in specialized neurocritical care or trauma ICU. Repeating computed tomography brain 12 h after initial scan may be of benefit. Elderly patients with TBI appear not to want an operation if it might leave them cognitively impaired.

SUMMARY

Prehospital and neuro ICU management of TBI patients can significantly improve patient outcome. However, it is important to also consider whether these patients would actually want to be treated particularly in the elderly population.

Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury

Traumatic brain injury (TBI) is a major healthcare problem and a major burden to society. The identification of a TBI can be challenging in the prehospital setting, particularly in elderly patients with unobserved falls. Errors in triage on scene cannot be ruled out based on limited clinical diagnostics. Potential new mobile diagnostics may decrease these errors. Prehospital care includes decision-making in clinical pathways, means of transport, and the degree of prehospital treatment. Emergency care at hospital admission includes the definitive diagnosis of TBI with, or without extracranial lesions, and triage to the appropriate receiving structure for definitive care. Early risk factors for an unfavorable outcome includes the severity of TBI, pupil reaction and age. These three variables are core variables, included in most predictive models for TBI, to predict short-term mortality. Additional early risk factors of mortality after severe TBI are hypotension and hypothermia. The extent and duration of these two risk factors may be decreased with optimal prehospital and emergency care. Potential new avenues of treatment are the early use of drugs with the capacity to decrease bleeding, and brain edema after TBI. There are still many uncertainties in prehospital and emergency care for TBI patients related to the complexity of TBI patterns.

Effect of hypoxia on mortality and disability in traumatic brain injury according to shock status: A cross-sectional analysis

OBJECTIVES

This study aimed to test the association between hypoxia level and outcomes according to shock status in traumatic brain injury (TBI) patients.

METHODS

Adult TBI patients transported by emergency medical services in 10 provinces were enrolled. Hypoxia was a main exposure; three groups by oxygen saturation (SaO2, non-hypoxia (≥94%), mild hypoxia (90 ≤ SaO2 < 94%)), and severe hypoxia (<90%). Shock status (<systolic blood pressure 90 mmHg) was an interactive exposure. The outcomes were hospital mortality and worsened disability (a 2-point increase of Glasgow Outcome Scale). Multivariable logistic regression was used to calculate the adjusted odds (AORs) with 95% Confidence intervals (CIs).

RESULTS

Of the 6125 patients, the mortality/disability rates were 49.4%/69.0% in severe hypoxia, 30.7%/46.9% in mild hypoxia, and 18.5%/27.5% in normoxia (p < 0.0001). Mortality/disability rates were 47.1%/57.1% in shock status and 20.5%/31.4% in non-shock status (p < 0.0001). AORs (95% CIs) for worsened disability/mortality compared with normoxia (reference) were 3.23 (2.47-4.21)/2.24 (1.70-2.96) in patients with severe hypoxia and 2.11 (1.63-2.74)/1.84 (1.39-2.45) in those with mild hypoxia. AORs (95% CIs) for worsened disability/mortality was 1.58 (1.20-2.09)/1.33 (1.01-1.76) by severe hypoxia than normoxia in patient with only non-shock status in the interaction analysis.

CONCLUSIONS

There was a trend toward worsened outcomes with mild and severe hypoxia in patient with and without shock, however, the only met statistical significance for patients with both severe hypoxia and non-shock status.

Treatment, transport, and primary care involvement when helicopter emergency medical services are inaccessible: a retrospective study

OBJECTIVE

To examine handling of cancelled helicopter emergency medical services (HEMS) missions with a persisting medical indication.

DESIGN

Retrospective observational study.

SETTING AND SUBJECTS

Cancelled HEMS missions with persisting medical indication within Sogn og Fjordane county in Norway during the period of 2010-2013. Both primary and secondary missions were included.

MAIN OUTCOME MEASURES

Primary care involvement, treatment and cooperation within the prehospital system.

RESULTS

Our analysis included 172 missions with 180 patients. Two-thirds of the patients (118/180) were from primary missions. In 95% (112/118) of primary missions, GPs were alerted, and they examined 62% (70/112) of these patients. Among the patients examined by a GP, 30% (21/70) were accompanied by a GP during transport to hospital. GP involvement did not differ according to time of day (p = 0.601), diagnostic group (p = 0.309), or patient's age (p = 0.409). In 41% of primary missions, the patients received no treatment or oxygen only during transport. Among the secondary missions, 10% (6/62) of patients were intubated or received non-invasive ventilation and were accompanied by a physician or nurse anaesthetist during transport.

CONCLUSIONS

Ambulance workers and GPs have an important role when HEMS is unavailable. Our findings indicated good collaboration among the prehospital personnel. Many of the patients were provided minimal or no treatment, and treatment did not differ according to GP involvement. Key Points Knowledge about handling and involvement of prehospital services in cancelled helicopter emergency medical services (HEMS) missions are scarce. Ambulance workers and general practitioners have an important role when HEMS is unavailable Minimal or no treatment was given to a large amount of the patients, regardless of which health personnel who encountered the patient.

Prevalence of a definitive airway in patients with severe traumatic brain injury received at four urban public university hospitals in India: a cohort study

AIM

To estimate the proportion of patients arriving with a Glasgow Coma Scale (GCS) less than 9 who had a definitive airway placed prior to arrival.

METHODS

We conducted a retrospective analysis of the data from a multicentre, prospective observational research project entitled Towards Improved Trauma Care Outcomes in India. Adults aged ≥18 years with an isolated traumatic brain injury (TBI) who were transferred from another hospital to the emergency department of the participating hospital with a GCS less than 9 were included. Our outcome was a definitive airway, defined as either intubation or surgical airway, placed prior to arrival at a participating centre.

RESULTS

The total number of patients eligible for this study was 1499. The median age was 40 years and 84% were male. Road traffic injuries and falls comprised 88% of the causes of isolated TBI. The number of patients with GCS<9 who had a definitive airway placed before reaching the participating centres was 229. Thus, the proportion was 0.15 (95% CI 0.13 to 0.17). The proportions of patients with a definitive airway who arrived after 24 hours (19%) were approximately double the proportion of patients who arrived within 6 hours (10%) after injury to the definitive care centre.

CONCLUSION

The rates of definitive airway placement are poor in adults with an isolated TBI who have been transferred from another health facility to tertiary care centres in India.

Prehospital Intubation and Outcome in Traumatic Brain Injury-Assessing Intervention Efficacy in a Modern Trauma Cohort

BACKGROUND

Prehospital intubation in traumatic brain injury (TBI) focuses on limiting the effects of secondary insults such as hypoxia, but no indisputable evidence has been presented that it is beneficial for outcome. The aim of this study was to explore the characteristics of patients who undergo prehospital intubation and, in turn, if these parameters affect outcome.

MATERIAL AND METHODS

Patients ≥15 years admitted to the Department of Neurosurgery, Stockholm, Sweden with TBI from 2008 through 2014 were included. Data were extracted from prehospital and hospital charts, including prospectively collected Glasgow Outcome Score (GOS) after 12 months. Univariate and multivariable logistic regression models were employed to examine parameters independently correlated to prehospital intubation and outcome.

RESULTS

A total of 458 patients were included (n = 178 unconscious, among them, n = 61 intubated). Multivariable analyses indicated that high energy trauma, prehospital hypotension, pupil unresponsiveness, mode of transportation, and distance to the hospital were independently correlated with intubation, and among them, only pupil responsiveness was independently associated with outcome. Prehospital intubation did not add independent information in a step-up model versus GOS (p = 0.154). Prehospital reports revealed that hypoxia was not the primary cause of prehospital intubation, and that the procedure did not improve oxygen saturation during transport, while an increasing distance from the hospital increased the intubation frequency.

CONCLUSION

In this modern trauma cohort, prehospital intubation was not independently associated with outcome; however, hypoxia was not a common reason for prehospital intubation. Prospective trials to assess efficacy of prehospital airway intubation will be difficult due to logistical and ethical considerations.

Does prehospital management by doctors affect outcome in major trauma? A systematic review

BACKGROUND

There is substantial variation worldwide in prehospital management of trauma and the role of doctors is controversial. The objective of this review was to determine whether prehospital management by doctors affects outcomes in major trauma, including the prespecified subgroup of severe traumatic brain injuries when compared with management by other advanced life support providers.

METHODS

EMBASE, MEDLINE(R), PubMed, SciELO, Trip, Web of Science, and Zetoc were searched for published articles. HSRProj, OpenGrey, and the World Health Organization International Clinical Trials Registry Platform were searched for unpublished data. Relevant reference lists were hand-searched. There were no limits on publication year, but articles were limited to the English language. Authors were contacted for further information as required. Quality was assessed using the Downs and Black criteria. Mortality was the primary outcome, and disability was the secondary outcome of interest. Studies were subjected to a descriptive analysis alone without a meta-analysis due to significant study heterogeneity. All searches, quality assessment, data abstraction, and data analysis was performed by two reviewers independently.

RESULTS

Two thousand thirty-seven articles were identified, 49 full-text articles assessed and eight studies included. The included studies consisted of one randomized controlled trial with 375 participants and seven observational studies with over 4,451 participants. All included studies were at a moderate to high risk of bias. Six of the eight included studies showed an improved outcome with prehospital management by doctors, five in terms of mortality and one in terms of disability. Two studies found no significant difference.

CONCLUSION

There appears to be an association between prehospital management by doctors and improved survival in major trauma. There may also be an association with improved survival and better functional outcomes in severe traumatic brain injury. Further high-quality evidence is needed to confirm these findings.

LEVEL OF EVIDENCE

Systematic review, level III.

The Neurological Wake-up Test-A Role in Neurocritical Care Monitoring of Traumatic Brain Injury Patients?

The most fundamental clinical monitoring tool in traumatic brain injury (TBI) patients is the repeated clinical examination. In the severe TBI patient treated by continuous sedation in a neurocritical care (NCC) unit, sedation interruption is required to enable a clinical evaluation (named the neurological wake-up test; NWT) assessing the level of consciousness, pupillary diameter and reactivity to light, and presence of focal neurological deficits. There is a basic conflict regarding the NWT in the NCC setting; can the clinical information obtained by the NWT justify the risk of inducing a stress response in a severe TBI patient? Furthermore, in the presence of advanced multimodal monitoring and neuroimaging, is the NWT necessary to identify important clinical alterations? In studies of severe TBI patients, the NWT was consistently shown to induce a stress reaction including brief increases in intracranial pressure (ICP) and changes in cerebral perfusion pressure (CPP). However, it has not been established whether these short-lived ICP and CPP changes are detrimental to the injured brain. Daily interruption of sedation is associated with a reduced ventilator time, shorter hospital stay and reduced mortality in many studies of general intensive care unit patients, although such clinical benefits have not been firmly established in TBI. To date, there is no consensus on the use of the NWT among NCC units and systematic studies are scarce. Thus, additional studies evaluating the role of the NWT in clinical decision-making are needed. Multimodal NCC monitoring may be an adjunct in assessing in which TBI patients the NWT can be safely performed. At present, the NWT remains the golden standard for clinical monitoring and detection of neurological changes in NCC and could be considered in TBI patients with stable baseline ICP and CPP readings. The focus of the present review is an overview of the existing literature on the role of the NWT as a clinical monitoring tool for severe TBI patients.

Factors influencing on-scene time in a rural Norwegian helicopter emergency medical service: a retrospective observational study

Background

Critically ill patients need to be immediately identified, properly managed, and rapidly transported to definitive care. Extensive prehospital times may increase mortality in selected patient groups. The on-scene time is a part of the prehospital interval that can be decreased, as transport times are determined mostly by the distance to the hospital. Identifying factors that affect on-scene time can improve training, protocols, and decision making. Our objectives were to assess on-scene time in the Helicopter Emergency Medical Service (HEMS) in our region and selected factors that may affect it in specific and severe conditions.

Methods

This retrospective cohort study evaluated on-scene time and factors that may affect it for 9757 emergency primary missions by the three HEMSs in western Norway between 2009 and 2013, using graphics and descriptive statistics.

Results

The overall median on-scene time was 10 minutes (IQR 5–16). The median on-scene time in patients with penetrating torso injuries was 5 minutes (IQR 3–10), whereas in cardiac arrest patients it was 20 minutes (IQR 13–28). Based on multivariate linear regression analysis, the severity of the patient’s condition, advanced interventions performed, mode of transport, and trauma missions increased the on-scene time. Endotracheal intubation increased the OST by almost 10 minutes. Treatment prior to HEMS arrival reduced the on-scene time in patients suffering from acute myocardial infarction.

Discussion

We found a short OST in preselected conditions compared to other studies. For the various patient subgroups, the strength of association between factors and OST varied. The time spent on-scene and its influencing factors were dependent on the patient’s condition. Our results provide a basis for efforts to improve decision making and reduce OST for selected patient groups.

Conclusions

The most important factors associated with increased on-scene time were the severity of the patient’s condition, the need for intubation or intravenous analgesic, helicopter transport, and trauma missions.

Electronic supplementary material

The online version of this article (10.1186/s13049-017-0442-5) contains supplementary material, which is available to authorized users.

Physician-staffed helicopter emergency medical service has a beneficial impact on the incidence of prehospital hypoxia and secured airways on patients with severe traumatic brain injury

BACKGROUND

After traumatic brain injury (TBI), hypotension, hypoxia and hypercapnia have been shown to result in secondary brain injury that can lead to increased mortality and disability. Effective prehospital assessment and treatment by emergency medical service (EMS) is considered essential for favourable outcome. The aim of this study was to evaluate the effect of a physician-staffed helicopter emergency medical service (HEMS) in the treatment of TBI patients.

METHODS

This was a retrospective cohort study. Prehospital data from two periods were collected: before (EMS group) and after (HEMS group) the implementation of a physician-staffed HEMS. Unconscious prehospital patients due to severe TBI were included in the study. Unconsciousness was defined as a Glasgow coma scale (GCS) score ≤ 8 and was documented either on-scene, during transportation or by an on-call neurosurgeon on hospital admission. Modified Glasgow Outcome Score (GOS) was used for assessment of six-month neurological outcome and good neurological outcome was defined as GOS 4-5.

RESULTS

Data from 181 patients in the EMS group and 85 patients in the HEMS group were available for neurological outcome analyses. The baseline characteristics and the first recorded vital signs of the two cohorts were similar. Good neurological outcome was more frequent in the HEMS group; 42% of the HEMS managed patients and 28% (p = 0.022) of the EMS managed patients had a good neurological recovery. The airway was more frequently secured in the HEMS group (p < 0.001). On arrival at the emergency department, the patients in the HEMS group were less often hypoxic (p = 0.024). In univariate analysis HEMS period, lower age and secured airway were associated with good neurological outcome.

CONCLUSION

The introduction of a physician-staffed HEMS unit resulted in decreased incidence of prehospital hypoxia and increased the number of secured airways. This may have contributed to the observed improved neurological outcome during the HEMS period.

TRIAL REGISTRATION

ClinicalTrials.gov IDNCT02659046. Registered January 15th, 2016.

Impact of rapid response car system on ECMO in out-of-hospital cardiac arrest: A retrospective cohort study

INTRODUCTION

Extracorporeal life support (ECLS) has been reported to be more effective than conventional cardiopulmonary resuscitation (CPR). In ECLS, a shorter time from arrival to implantation of extracorporeal membrane oxygenation (ECMO; door-to-ECMO) time was predicted to be associated with better survival rates. This study aimed to examine the impact of the physician-based emergency medical services (P-EMS) using a rapid response car (RRC) on door-to-ECMO time in patients with out-of-hospital cardiac arrest (OHCA).

METHODS

In this retrospective cohort study, adult patients with OHCA who were admitted to a Japanese tertiary care hospital from April 2012 to December 2016 and underwent venoarterial ECMO were included. Patients were either transferred by emergency medical service (EMS only group) or RRC (RRC group). Primary outcome was door-to-ECMO time. Wilcoxon rank-sum test was used to compare the outcome between the two groups.

RESULTS

A total of 34 patients were included in this study, and outcome data were available for all patients. The door-to-ECMO time was significantly shorter in the RRC group than in the EMS only group (median, 23min vs. 36min; P=0.006). Additionally, the RRC was also associated with earlier successful intubation and intravenous adrenaline administration.

CONCLUSION

The physician-based RRC system was associated with a shorter door-to-ECMO time and successful advanced procedures in prehospital settings. Combination of the RRC system with ECLS may lead to better outcomes in patients with OHCA.