Prehospital accuracy of (H)EMS pelvic ring injury assessment and the application of non-invasive pelvic binder devices

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.

Characteristics of fatal penetrating injury; data from a retrospective cohort study in three urban regions in the Netherlands

INTRODUCTION

Penetrating injury (PI) is a relatively rare mechanism of trauma in the Netherlands. Nevertheless, injuries can be severe with high morbidity and mortality rates. The aim of this study is to assess fatalities due to PI and evaluate the demographic parameters, mechanism of injury and the resulting injury patterns of this group of patients in three Dutch regions.

METHODS

Patients suffering fatal PI (stab- and gunshot injuries), in the period between July 1st 2013 and July 1st 2019, in the region of Amsterdam, Utrecht and The Hague were included. Data were collected from the electronic registration system (Formatus) of the regional departments of Forensic Medicine.

RESULTS

During the study period 283 patients died as the result of PI. The mean age was 44 years (SD 16.9), 83% was male and psychiatric history was reported in 22%. Over 60% of the injuries were due to assault and 35% was self-inflicted. Almost half of the incidents took place at home (47%). Injuries were most frequently to the head (24%) and chest (16%). Mortality was due to exsanguination (chest 27%, multiple body region's 17%, neck 9% and extremities 8%) and traumatic brain injury (21%). Up to 40% of the patients received medical treatment, surgical intervention was performed in 25%. The injuries to the extremities suggest a (potentially) preventable death rate of over 8%. Over 70% of the total population died at the scene.

CONCLUSION

Fatal PI most often involves the relatively young, male, and psychiatric patient. Self-inflicted fatal PI accounted for 35%, addressing the importance of suicide prevention programs. Identification of preventable deaths needs more awareness to reduce the number of fatal PI.

Preventable death in trauma: A systematic review on definition and classification

PURPOSE

Trauma-related preventable death (TRPD) has been used to assess the management and quality of trauma care worldwide. However, due to differences in terminology and application, the definition of TRPD lacks validity. The aim of this systematic review is to present an overview of current literature and establish a designated definition of TRPD to improve the assessment of quality of trauma care.

METHODS

A search was conducted in PubMed, Embase, the Cochrane Library and the Web of Science Core Collection. Including studies regarding TRPD, published between January 1, 1990, and April 6, 2021. Studies were assessed on the use of a definition of TRPD, injury severity scoring tool and panel review.

RESULTS

In total, 3,614 articles were identified, 68 were selected for analysis. The definition of TRPD was divided in four categories: I. Clinical definition based on panel review or expert opinion (TRPD, trauma-related potentially preventable death, trauma-related non-preventable death), II. An algorithm (injury severity score (ISS), trauma and injury severity score (TRISS), probability of survival (Ps)), III. Clinical definition completed with an algorithm, IV. Other. Almost 85% of the articles used a clinical definition in some extend; solely clinical up to an additional algorithm. A total of 27 studies used injury severity scoring tools of which the ISS and TRISS were the most frequently reported algorithms. Over 77% of the panels included trauma surgeons, 90% included other specialist; 61% emergency medicine physicians, 46% forensic pathologists and 43% nurses.

CONCLUSION

The definition of TRPD is not unambiguous in literature and should be based on a clinical definition completed with a trauma prediction algorithm such as the TRISS. TRPD panels should include a trauma surgeon, anesthesiologist, emergency physician, neurologist, and forensic pathologist.

Prehospital time and mortality in polytrauma patients: a retrospective analysis

Background

The time from injury to treatment is considered as one of the major determinants for patient outcome after trauma. Previous studies already attempted to investigate the correlation between prehospital time and trauma patient outcome. However, the outcome for severely injured patients is not clear yet, as little data is available from prehospital systems with both Emergency Medical Services (EMS) and physician staffed Helicopter Emergency Medical Services (HEMS). Therefore, the aim was to investigate the association between prehospital time and mortality in polytrauma patients in a Dutch level I trauma center.

Methods

A retrospective study was performed using data derived from the Dutch trauma registry of the National Network for Acute Care from Amsterdam UMC location VUmc over a 2-year period. Severely injured polytrauma patients (Injury Severity Score (ISS) ≥ 16), who were treated on-scene by EMS or both EMS and HEMS and transported to our level I trauma center, were included. Patient characteristics, prehospital time, comorbidity, mechanism of injury, type of injury, HEMS assistance, prehospital Glasgow Coma Score and ISS were analyzed using logistic regression analysis. The outcome measure was in-hospital mortality.

Results

In total, 342 polytrauma patients were included in the analysis. The total mortality rate was 25.7% (n = 88). Similar mean prehospital times were found between the surviving and non-surviving patient groups, 45.3 min (SD 14.4) and 44.9 min (SD 13.2) respectively (p = 0.819). The confounder-adjusted analysis revealed no significant association between prehospital time and mortality (p = 0.156).

Conclusion

This analysis found no association between prehospital time and mortality in polytrauma patients. Future research is recommended to explore factors of influence on prehospital time and mortality.

Characteristics of helicopter emergency medical services (HEMS) dispatch cancellations during a six-year period in a Dutch HEMS region

Background

For decades, Helicopter Emergency Medical Services (HEMS) contribute greatly to prehospital patient care by performing advanced medical interventions on-scene. Unnecessary dispatches, resulting in cancellations, cause these vital resources to be temporarily unavailable and generate additional costs. A previous study showed a cancellation rate of 43.5% in our trauma region. However, little recent data about cancellation rates and reasons exist, despite revision of dispatch protocols. This study examines the current cancellation rate in our trauma region over a six-year period. Additionally, cancellation reasons are evaluated per type of dispatch and initial incident report, upon which HEMS is dispatched.

Methods

This retrospective study analyzed the data of the Dutch HEMS Lifeliner 1 (North-West region of the Netherlands, covering a population of 5 million inhabitants), analyzing all subsequent cases between April 1st 2013 and April 1st 2019. Patient characteristics, type of dispatch (primary; based on dispatcher criteria versus secondary, as judged by the first ambulance team on site), initial incident report received by the EMS dispatch center, and information regarding day- or nighttime dispatches were collected. In case of cancellation, cancel rate and reason per type of dispatch and initial incident report were assessed.

Results

In total, 18,638 dispatches were included. HEMS was canceled in 54.5% (95% CI 53.8–55.3%) of cases. The majority of canceled dispatches (76.1%) were canceled because respiratory, hemodynamic, and neurologic parameters were stable. Dispatches simultaneously activated with EMS (primary dispatch) were canceled in 58.3%, compared to 15.1% when HEMS assistance was requested by EMS based on their findings on-scene (secondary dispatch). A cancellation rate of 54.6% was found in trauma related dispatches (n = 12,148), compared to 52.2% in non-trauma related dispatches (n = 5378). Higher cancellation rates exceeding 60% were observed in the less common dispatch categories, e.g., anaphylaxis (66.3%), unknown incident report (66.0%), assault with a blunt object (64.1%), obstetrics (62.8%), and submersion (61.9%).

Conclusion

HEMS cancellations are increased, compared to previous research in our region. Yet, the cancellations are acceptable as the effect on HEMS’ unavailbility remains minimized. Focus should be on identifying the patient in need of HEMS care while maintaining overtriage rates low. Continuous evaluation of HEMS triage is important, and dispatch criteria should be adjusted if necessary.

[How can life-threatening external blood loss be stopped? Treatment options in the prehospital phase]

- 3,500 people die of injuries in the Netherlands every year; 40% of the deaths are attributable to bleeding.- Treatment of patients with life-threatening blood loss is part of the trauma care continuum: all the way from incident to hospital treatment.- This article presents an overview of all treatment options for stopping life-threatening external blood loss, divided in medical assistance phases. It also makes a distinction between different types of care providers, based on the presence or absence of their medical skills.

Definition of hemodynamic stability in blunt trauma patients: a systematic review and assessment amongst Dutch trauma team members

INTRODUCTION

Trauma is a great contributor to mortality worldwide. One of the challenges in trauma care is early identification and management of bleeding. The circulatory status of blunt trauma patients in the emergency room is evaluated using hemodynamic (HD) parameters. However, there is no consensus on which parameters to use. In this study, we evaluate the used terms and definitions in the literature for HD stability and compare those to the opinion of Dutch trauma team members.

METHOD

A systematic review was performed to collect the definitions used for HD stability. Studies describing the assessment and/or treatment of blunt trauma patients in the emergency room were included. In addition, an online survey was conducted amongst Dutch trauma team members.

RESULTS

Out of a total of 222, 67 articles were found to be eligible for inclusion. HD stability was defined in 70% of these articles. The most used parameters were systolic blood pressure and heart rate. Besides the variety of parameters, a broad range of corresponding cut-off points is noted. Despite some common ground, high inter- and intra-variability is seen for the physicians that are part of the Dutch trauma teams.

CONCLUSION

All authors acknowledge HD stability as the most important factor in the assessment and management of blunt trauma patients. There is, however, no consensus in the literature as well as none-to-fair consensus amongst Dutch trauma team members in the definition of HD stability. A trauma team ready to co-operate with consensus-based opinions together with a valid scoring system is in our opinion the best method to assess and treat seriously injured trauma patients.

Radiological findings and radiation exposure during trauma workup in a cohort of 1124 level 1 trauma patients

BACKGROUND

During the initial assessment of patients with potential severe injuries, radiological examinations are performed in order to rapidly diagnose clinically relevant injuries. Previous studies have shown that performing these examinations routinely is not always necessary and that trauma patients are exposed to substantial radiation doses. The aim of this study was to assess the amount and findings of radiological examinations during the initial assessment of trauma patients and to determine the radiation doses to which these patients are exposed to.

METHODS

We analyzed the 1124 patients included in a randomized trial. All radiological examinations during the initial assessment (i.e., primary and secondary survey) were assessed. The examination results were categorized as positive findings (i.e., (suspicion for) traumatic injury) and normal findings. The effective radiation doses for the examinations were calculated separately for each patient.

RESULTS

Eight hundred and three patients were male (71 %), median age was 38 years, and 1079 patients sustained blunt trauma (96 %). During initial assessment, almost 3900 X-rays were performed, of which 25.4 % showed positive findings. FAST of the abdomen was performed in 989 patients (88 %), with positive findings in 10.6 %. Additional CT scanning of specific body regions was performed 1890 times in 813 patients (72.1 %), of which approximately 43.4 % revealed positive findings. Hemodynamically stable patients showed more normal findings on the radiographic studies than unstable patients. The mean radiation doses for the total population was 8.46 mSv (±7.7) and for polytraumatized patients (ISS ≥ 16) 14.3 mSv (±9.5).

CONCLUSION

Radiological diagnostics during initial assessment of trauma patients show a high rate of normal findings in our trauma system. The radiation doses to which trauma patients are exposed are considerable. Considering that the majority of the injured patients are hemodynamically stable, we suggest more selective use of X-ray and CT scanning.

The influence of prehospital time on trauma patients outcome: a systematic review

OBJECTIVE

Time is considered an essential determinant in the initial care of trauma patients. Salient tenet of trauma care is the 'golden hour', the immediate time after injury when resuscitation and stabilization are perceived to be most beneficial. Several prehospital strategies exist regarding time and transport of trauma patients. Literature shows little empirical knowledge on the exact influence of prehospital times on trauma patient outcome. The objective of this study was to systematically review the correlation between prehospital time intervals and the outcome of trauma patients.

METHODS

A systematic review was performed in MEDLINE, Embase and the Cochrane Library from inception to May 19th, 2014. Studies reporting on prehospital time intervals for emergency medical services (EMS), outcome parameters and potential confounders for trauma patients were included. Two reviewers collected data and assessed the outcomes and risk of bias using the STROBE-tool. The primary outcome was the influence on mortality.

RESULTS

Twenty level III-evidence articles were considered eligible for this systematic review. Results demonstrate a decrease in odds of mortality for the undifferentiated trauma patient when response-time or transfer-time are shorter. On the contrary increased on-scene time and total prehospital time are associated with increased odds of survival for this population. Nevertheless rapid transport does seem beneficial for patients suffering penetrating trauma, in particular hypotensive penetratingly injured patients and patients with a traumatic brain injury.

CONCLUSION

Swift transport is beneficial for patients suffering neurotrauma and the haemodynamically unstable penetratingly injured patient. For haemodynamically stable undifferentiated trauma patients, increased on-scene-time and total prehospital time does not increase odds of mortality. For undifferentiated trauma patients, focus should be on the type of care delivered prehospital and not on rapid transport.

Morbidity and complications of protective loop ileostomy

OBJECTIVE

The creation of a loop ileostomy is considered suitable to protect a distal anastomosis in colorectal surgery. This technique is, however, associated with failure, complications and even mortality. The aim of this study was to quantify retrospectively the morbidity associated with an ileostomy and its subsequent closure.

METHOD

One hundred and nineteen patients with a temporary loop ileostomy, created between January 2000 and July 2007 were retrospectively analysed from a review of patient records.

RESULTS

All ileostomies were closed after a median period of 106 days (interquartile range: 69-174 days). Stoma-related morbidity occurred in 23 (19%) patients. After ileostomy closure, 16 major complications were seen in 14 (12%) patients and 43 minor complications occurred in 25 (21%) patients. Sixty-three patients (53%) had neither stoma-related morbidity or peri- or postoperative complications after stoma closure.

CONCLUSION

Protective loop ileostomy was found to be associated with a high morbidity. This raises the question of the mode of identifying the specific patients with a low anastomosis who should be provided an ileostomy for protection, set against the potential complications of the formation and closure of the ileostomy.

Preoperative polyethylene glycol versus a single enema in elective bowel surgery

BACKGROUND

At the beginning of 2004, a large Dutch randomized study comparing mechanical bowel preparation with a single preoperative enema reported no differences in anastomotic leakage rates, septic complications, or mortality. On the basis of this study, this institution abandoned the routine practice of bowel preparation with polyethylene glycol and introduced a single preoperative enema.

METHODS

A consecutive series of 78 patients undergoing elective colorectal surgery with mechanical bowel preparation using polyethylene glycol (PG group) was compared to a consecutive series of 71 patients with a single preoperative enema (SE group). The PG group was operated between June 2003 and December 2004, the SE group between January 2005 and January 2006. Mortality, anastomotic leakage, and infectious and noninfectious complications were compared.

RESULTS

Mortality, anastomotic leakage, frequency of reoperations, and hospital stay were comparable for both groups. The overall postoperative morbidity was significantly higher in the SE group (26 vs. 9, p = 0.003). Specifically, the incidence of wound infections was significantly higher in the SE group (7 vs. 1, p = 0.041). Furthermore, a trend was observed in the incidence of intra-abdominal infections which was higher in the SE group (8 vs. 2, p = 0.070). Also a trend toward more extra-abdominal infectious complications was seen in the SE group (11 vs. 4, p = 0.086).

CONCLUSIONS

Based on both the conflicting data currently available from different randomized studies and our results, the preoperative bowel preparation protocol in our institution has been changed. All left-sided colonic resections, in patients who can tolerate mechanical bowel preparation, are prepared with polyethylene glycol.