Ho, Andrew Fu Wah; Chew, David; Wong, Ting Hway; Ng, Yih Yng; Pek, Pin Pin; Lim, Swee Han; Anantharaman, Venkataraman; Hock Ong, Marcus Eng
Prehospital emergency care in Singapore has taken shape over almost a century. What began as a hospital-based ambulance service intended to ferry medical cases was later complemented by an ambulance service under the Singapore Fire Brigade to transport trauma cases. The two ambulance services would later combine and come under the Singapore Civil Defence Force. The development of prehospital care systems in island city-state Singapore faces unique challenges as a result of its land area and population density. This article defines aspects of prehospital trauma care in Singapore. It outlines key historical milestones and current initiatives in service, training, and research. It makes propositions for the future direction of trauma care in Singapore. The progress Singapore has made given her circumstances may serve as lessons for the future development of prehospital trauma systems in similar environments. Key words: Singapore; trauma; prehospital emergency care; emergency medical services.
For the German speaking countries, Tscherne's definition of "polytrauma" which represents an injury of at least two body regions with one or a combination being life-threatening is still valid. The timely and adequate management including quick referral of the trauma patient into a designated trauma center may limit secondary injury and may thus improve outcomes already during the prehospital phase of care. The professional treatment of multiple injured trauma patients begins at the scene in the context of a well structured prehospital emergency medical system. The "Primary Survey" is performed by the emergency physician at the scene according to the Prehospital Trauma Life Support (PHTLS)-concept. The overall aim is to rapidly assess and treat life-threatening conditions even in the absence of patient history and diagnosis ("treat-first-what-kills-first"). If no immediate treatment is necessary, a "Secondary Sur- vey" follows with careful and structured body examination and detailed assessment of the trauma mechanism. Massive and life-threatening states of hemorrhage should be addressed immediately even disregarding the ABCDE-scheme. Critical trauma patients should be referred without any delay ("work and go")toTR-DGU® certified trauma centers of the local trauma networks. Due to the difficult pre- hospital environment the number of quality studies in the field is low and, as consequence, the level of evidence for most recommendations is also low. Much information has been obtained from different care systems and the interchangeability of results is limited. The present article provides a synopsis of rec- ommendations for early prehospital care for the severely injured based upon the 2011 updated multi- disciplinary S3-Guideline "Polytrauma/Schwerstverletzten Behandlung", the most recently updated European Trauma guideline and the current PHTLS-algorithms including grades of recommendation whenever possible.
Moscote-Salazar, Luis Rafael; M Rubiano, Andres; Alvis-Miranda, Hernando Raphael; Calderon-Miranda, Willem; Alcala-Cerra, Gabriel; Blancas Rivera, Marco Antonio; Agrawal, Amit
Traumatic brain injury is a leading cause of death in developed countries. It is estimated that only in the United States about 100,000 people die annually in parallel among the survivors there is a significant number of people with disabilities with significant costs for the health system. It has been determined that after moderate and severe traumatic injury, brain parenchyma is affected by more than 55% of cases. Head trauma management is critical is the emergency services worldwide. We present a review of the literature regarding the prehospital care, surgical management and intensive care monitoring of the patients with severe cranioecephalic trauma.
Moscote-Salazar, Luis Rafael; M. Rubiano, Andres; Alvis-Miranda, Hernando Raphael; Calderon-Miranda, Willem; Alcala-Cerra, Gabriel; Blancas Rivera, Marco Antonio; Agrawal, Amit
Traumatic brain injury is a leading cause of death in developed countries. It is estimated that only in the United States about 100,000 people die annually in parallel among the survivors there is a significant number of people with disabilities with significant costs for the health system. It has been determined that after moderate and severe traumatic injury, brain parenchyma is affected by more than 55% of cases. Head trauma management is critical is the emergency services worldwide. We present a review of the literature regarding the prehospital care, surgical management and intensive care monitoring of the patients with severe cranioecephalic trauma. PMID:27162922
da Silva, Hilderjane Carla; Pessoa, Renata de Lima; de Menezes, Rejane Maria Paiva
Objective: to identify the prevalence of trauma in elderly people and how they accessed the health system through pre-hospital care. Method: documentary and retrospective study at a mobile emergency care service, using a sample of 400 elderly trauma victims selected through systematic random sampling. A form validated by experts was used to collect the data. Descriptive statistical analysis was applied. The chi-square test was used to analyze the association between the variables. Results: Trauma was predominant among women (52.25%) and in the age range between 60 and 69 years (38.25%), average age 74.19 years (standard deviation±10.25). Among the mechanisms, falls (56.75%) and traffic accidents (31.25%) stood out, showing a significant relation with the pre-hospital care services (p<0.001). Circulation, airway opening, cervical control and immobilization actions were the most frequent and Basic Life Support Services (87.8%) were the most used, with trauma referral hospitals as the main destination (56.7%). Conclusion: trauma prevailed among women, victims of falls, who received pre-hospital care through basic life support services and actions and were transported to the trauma referral hospital. It is important to reorganize pre-hospital care, avoiding overcrowded hospitals and delivering better care to elderly trauma victims. PMID:27143543
Background The goal of this study was to examine PHTLS Provider courses in Germany and to proof the assumption that formation of physicians and paramedics in prehospital trauma care can be optimized. Methods PHTLS participants were asked to fill out standardized questionnaires during their course preparation and directly after the course. There were some open questions regarding their professional background and closed questions concerning PHTLS itself. Further questions were to be answered on an analog scale in order to quantify subjective impressions of confidence, knowledge and also to describe individual levels of education and training. Results 247 questionnaires could be analyzed. Physicians noted significant (p < 0.001) more deficits in their professional training than paramedics. 80% of the paramedics affirmed to have had adequate training with respect to prehospital trauma care, all physicians claimed not to have had sufficient training for prehospital trauma care situations at Medical School. Physicians were statistically most significant dissatisfied then paramedics (p < 0.001). While most participants gave positive feedback, anesthetists were less convinced of PHTLS (p = 0.005), didn’t benefit as much as the rest (p = 0.004) and stated more often, that the course was of less value for their daily work (p = 0.03). After the course confidence increased remarkably and reached higher rates than before the course (p < 0.001). After PHTLS both groups showed similar ratings concerning the course concept indicating that PHTLS could equalize some training deficits and help to gain confidence and assurance in prehospital trauma situations. 90% of the paramedics and 100% of the physicians would recommend PHTLS. Physicians and especially anesthetists revised their opinions with regard to providing PHTLS at Medical School after having taken part in a PHTLS course. Conclusion The evaluation of PHTLS courses in Germany indicates the necessity for special prehospital
Objectives Pre-hospital care (PH) in Brazil is currently in the phase of implementation and expansion, and there are few studies on the impacts of this public health service. The purpose of this study is to assess the quality of care and severity of trauma among the population served, using trauma scores, attendance response times, and mortality rates. This work compares two pre-hospital systems: the Mobile Emergency Care Service, or SAMU 192, and the Fire Brigade Group, or CB. Method Descriptive study evaluating all patients transported by both systems in Catanduva, SP, admitted to a single hospital. Results 850 patients were included, most of whom were men (67.5%); the mean age was 38.5 ± 18.5 years. Regarding the use of PH systems, most patients were transported by SAMU (62.1%). The trauma mechanisms involved motorcycle accidents in 32.7% of cases, transferred predominantly by SAMU, followed by falls (25.8%). Regarding the response time, CB showed the lowest rates. In relation to patient outcome, only 15.5% required hospitalization. The average score on the Glasgow Coma Scale was 14.7 ± 1.3; average RTS was 7.7 ± 0.7; ISS 3.8 ± 5.9; and average TRISS 97.6 ± 9.3. The data analysis showed no statistical differences in mortality between the groups studied (SAMU - 1.5%; CB - 2.5%). The trauma scores showed a higher severity of trauma among the fatal victims. Conclusion Trauma victims are predominantly young and male; the trauma mechanism that accounted for the majority of PH cases was motorcycle accidents; CB responded more quickly than SAMU; and there was no statistical difference between the services of SAMU and CB in terms of severity of the trauma and mortality rates. PMID:23531089
Timbi-Sisalima, Cristian; Rodas, Edgar B; Salamea, Juan C; Sacoto, Hernán; Monje-Ortega, Diana; Robles-Bykbaev, Vladimir
According to facts given by the World Health Organization, one in ten deaths worldwide is due to an external cause of injury. In the field of pre-hospital trauma care, adequate and timely treatment in the golden period can impact the survival of a patient. The aim of this paper is to show the design of a complete ecosystem proposed to support the evaluation and treatment of trauma victims, using standard tools and vocabulary such as OpenEHR, as well as mobile systems and expert systems to support decision-making. Preliminary results of the developed applications are presented, as well as trauma-related data from the city of Cuenca, Ecuador.
Background Road traffic injuries are a major global public health problem. Improvements in pre-hospital trauma care can help minimize mortality and morbidity from road traffic injuries (RTIs) worldwide, particularly in low- and middle-income countries (LMICs) with a high rate of RTIs such as Iran. The current study aimed to explore pre-hospital trauma care process for RTI victims in Iran and to identify potential areas for improvements based on the experience and perception of pre-hospital trauma care professionals. Methods A qualitative study design using a grounded theory approach was selected. The data, collected via in-depth interviews with 15 pre-hospital trauma care professionals, were analyzed using the constant comparative method. Results Seven categories emerged to describe the factors that hinder or facilitate an effective pre-hospital trauma care process: (1) administration and organization, (2) staff qualifications and competences, (3) availability and distribution of resources, (4) communication and transportation, (5) involved organizations, (6) laypeople and (7) infrastructure. The core category that emerged from the other categories was defined as "interaction and common understanding". Moreover, a conceptual model was developed based on the categories. Conclusions Improving the interaction within the current pre-hospital trauma care system and building a common understanding of the role of the Emergency Medical Services (EMS) emerged as key issues in the development of an effective pre-hospital trauma care process. PMID:21059243
Use of respiratory impedance in prehospital care of hypotensive patients associated with hemorrhage and trauma: A case series Victor A. Convertino...J.Z., D.L.), Toledo , Ohio; Cypress Creek Emergency Medical Services (K.T., L.V.), Spring, Texas; Em- press EmergencyMedical Services (D.B.), Yonkers...Minneapolis, Minnesota. Address for reprints: Victor A. Convertino, PhD, United States Army Institute of Surgical Research, 3698 Chambers Pass, Fort Sam
Norouzpour, Amir; Khoshdel, Ali Reza; Modaghegh, Mohammad-Hadi; Kazemzadeh, Gholam-Hossein
Background Prehospital management of gunshot-wounded (GW) patients influences injury-induced morbidity and mortality. Objectives To evaluate prehospital management to GW patients emphasizing the protocol of patient transfer to appropriate centers. Patients and Methods This prospective study, included all GW patients referred to four major, level-I hospitals in Mashhad, Iran. We evaluated demographic data, triage, transport vehicles of patients, hospitalization time and the outcome. Results There were 66 GW patients. The most affected body parts were extremities (60.6%, n = 40); 59% of cases (n = 39) were transferred to the hospitals with vehicles other than an ambulance. Furthermore, 77.3% of patients came to the hospitals directly from the site of event, and 22.7% of patients were referred from other medical centers. EMS action intervals from dispatchers to scene departure was not significantly different from established standards; however, arrival to hospital took longer than optimal standards. Additionally, time spent at emergency wards to stabilize vital signs was significantly less in patients who were transported by EMS ambulances (P = 0.01), but not with private ambulances (P = 0.47). However, ambulance pre-hospital care was not associated with a shorter hospital stay. Injury Severity was the only determinant of hospital stay duration (β = 0.36, P = 0.01) in multivariate analysis. Conclusions GW was more frequent in extremities and the most patients were directly transferred from the accident site. EMS (but not private) ambulance transport improved patients' emergency care and standard time intervals were achieved by EMS; however more than a half of the cases were transferred by vehicles other than an ambulance. Nevertheless, ambulance transportation (either by EMS or by private ambulance) was not associated with a shorter hospital stay. This showed that upgrade of ambulance equipment and training of private ambulance personnel may be needed. PMID:24350154
anddisplay prehospital and hospital physiologic data in real time on a handheld computer and in the trauma bay.Multivariate logistic regression...Wilkins) LEVEL OF EVIDENCE: Therapeutic/care management, level IV. KEY WORDS: Prehospital physiologic data; lifesaving interventions; vital signs; signal...and interfaces (i.e., ‘‘smart device’’ or non-SVSMs) capable of supplying the medic with constant physiologic observations and datamay enhance the care
What makes military medicine unique? 2. Why do military medical providers exist? 3. What is the leading cause of death on the battlefield? 4. Where do...the advocate for medics and pre-hospital battlefield trauma care? 13. Who owns battlefield medicine ? Unclassified 3 Unclassified SECTION II. EXECUTIVE...customized for use on the battlefield. [Maughon JS. An inquiry into the nature of wounds resulting in killed in action in Vietnam. Military Medicine 1970; 135
Alisic, Eva; Tyler, Mark P.; Giummarra, Melita J.; Kassam-Adams, Rahim; Gouweloos, Juul; Landolt, Markus A.; Kassam-Adams, Nancy
ABSTRACT Background: Pre-hospital providers, such as paramedics and emergency medical technicians, are in a position to provide key emotional support to injured children and their families. Objective: Our goal was to examine (a) pre-hospital providers’ knowledge of traumatic stress in children, attitudes towards psychosocial aspects of care, and confidence in providing psychosocial care, (b) variations in knowledge, attitudes, and confidence according to demographic and professional characteristics, and (c) training preferences of pre-hospital providers regarding psychosocial care to support paediatric patients and their families. Method: We conducted a cross-sectional, online survey among an international sample of 812 pre-hospital providers from high-income countries. The questionnaire was adapted from a measure for a similar study among Emergency Department staff, and involved 62 items in 7 main categories (e.g. personal and work characteristics, knowledge of paediatric traumatic stress, and confidence regarding 18 elements of psychosocial care). The main analyses comprised descriptive statistics and multiple regression analyses. Results: On average, respondents answered 2.7 (SD = 1.59) out of seven knowledge questions correctly. Respondents with higher knowledge scores were more often female, parent of a child under 17, and reported that at least 10% of their patients were children. A majority of participants (83.5%) saw all 18 aspects of psychosocial care as part of their job. Providers felt moderately confident (M = 3.2, SD = 0.45) regarding their skills in psychosocial care, which was predicted by gender (female), having more experience, having a larger proportion of child patients, and having received training in psychosocial care in the past five years. Most respondents (89.7%) wanted to gain more knowledge and skills regarding psychosocial care for injured children. In terms of training format, they preferred an interactive website or a one
Saver, Jeffrey L.; Starkman, Sidney; Lees, Kennedy R.; Endres, Matthias
Brain cells die rapidly after stroke and any effective treatment must start as early as possible. In clinical routine, the tight time–outcome relationship continues to be the major limitation of therapeutic approaches: thrombolysis rates remain low across many countries, with most patients being treated at the late end of the therapeutic window. In addition, there is no neuroprotective therapy available, but some maintain that this concept may be valid if administered very early after stroke. Recent innovations have opened new perspectives for stroke diagnosis and treatment before the patient arrives at the hospital. These include stroke recognition by dispatchers and paramedics, mobile telemedicine for remote clinical examination and imaging, and integration of CT scanners and point-of-care laboratories in ambulances. Several clinical trials are now being performed in the prehospital setting testing prehospital delivery of neuroprotective, antihypertensive, and thrombolytic therapy. We hypothesize that these new approaches in prehospital stroke care will not only shorten time to treatment and improve outcome but will also facilitate hyperacute stroke research by increasing the number of study participants within an ultra-early time window. The potentials, pitfalls, and promises of advanced prehospital stroke care and research are discussed in this review. PMID:23897876
Jones, Jerrilyn; Lawner, Benjamin J
Prehospital care providers are tasked with the delivery of time-sensitive care, and emergency medical services (EMS) systems must match patients to appropriate clinical resources. Modern systems are uniquely positioned to recognize and treat patients with sepsis. Interventions such as administration of intravenous fluid and transporting patients to the appropriate level of definitive care are linked to improved patient outcomes. As EMS systems refine their protocols for the recognition and stabilization of patients with suspected or presumed sepsis, EMS providers need to be educated about the spectrum of sepsis-related presentations and treatment strategies need to be standardized.
Pitt, E; Pusponegoro, A
Current system: Hospitals of varying standards are widespread but have no system of emergency ambulance or patient retrieval. Indonesia's only public emergency ambulance service, 118, is based in five of the biggest cities and is leading the way in paramedic training and prehospital care. Challenges and developments: There are many challenges faced including the culture of acceptance, vast geographical areas, traffic, inadequate numbers of ambulances, and access to quality training resources. Recently there have been a number of encouraging developments including setting up of a disaster response brigade, better provision of ambulances, and development of paramedic training. Conclusions: An integrated national regionalised hospital and prehospital system may seem fantastic but with the enthusiasm of those involved and perhaps some help from countries with access to training resources it may not be an unrealistic goal. PMID:15662073
Background Accidents are the leading cause of death in adults prior to middle age. The care of severely injured patients is an interdisciplinary challenge. Limited evidence is available concerning pre-hospital trauma care training programs and the advantage of such programs for trauma patients. The effect on trauma care procedures or on the safety of emergency crews on the scene is limited; however, there is a high level of experience and expert opinion. Methods I – Video-recorded case studies are the basis of an assessment tool and checklist being developed to verify the results of programs to train participants in the care of seriously injured patients, also known as “objective structured clinical examination” (OSCE). The timing, completeness and quality of the individual measures are assessed using appropriate scales. The evaluation of team communication and interaction will be analyzed with qualitative methods and quantified and verified by existing instruments (e.g. the Clinical Team Scale). The developed assessment tool is validated by several experts in the fields of trauma care, trauma research and medical education. II a) In a German emergency medical service, the subjective assessment of paramedics of their pre-hospital care of trauma patients is evaluated at three time points, namely before, immediately after and one year after training. b) The effect of a standardized course concept on the quality of documentation in actual field operations is determined based on three items relevant to patient safety before and after the course. c) The assessment tool will be used to assess the effect of a standardized course concept on procedures and team communication in pre-hospital trauma care using scenario-based case studies. Discussion This study explores the effect of training on paramedics. After successful study completion, further multicenter studies are conceivable, which would evaluate emergency-physician staffed teams. The influence on the patients
Military medical revolution: Prehospital combat casualty care Lorne H. Blackbourne, MD, David G. Baer, PhD, Brian J. Eastridge, MD, Bijan Kheirabadi...sur- vival for patients with combat-related traumatic injuries. J Trauma. 2009;66(suppl 4):S69 S76. 33. Eastridge BJ, Hardin M, Cantrell J, Oetjen
Boyington, T; Williams, D
After a brief outline of past developments in the training of ambulance personnel, this paper traces the adoption in the UK of Pre-Hospital Trauma Life Support (PHTLS) courses from the US. The 1991 World Student Games in Sheffield, UK led to liaison between training staff from South Yorkshire Metropolitan Ambulance and Paramedic Service (SYMAPS) and from Western New York Medical Training Institute. As a result, the trauma care policy of SYMAPS was altered from aiming to stabilise the patient at the scene of the accident to emphasising rapid and thorough assessment, packaging and transport. This is a resume of the scope of the PHTLS provider course. The course concentrates on the principles of PHTLS for the multisystems trauma victim.
Zhang, Zhan; Sarcevic, Aleksandra; Burd, Randall S.
Pre-hospital communication is a critical first step towards ensuring efficient management of critically injured patients during trauma resuscitation. Information about incoming patients received from the field and en route serves a critical role in helping emergency medical teams prepare for patient care. Despite many efforts, inefficiencies persist. In this paper, we examine the pre-hospital communications between pre-hospital and hospital providers, including the types of information transferred during en-route calls, as well as the information needs of trauma teams. Our findings show that Emergency Medical Services (EMS) teams report a great deal of information from the field, most of which match the needs of trauma teams. We discuss design implications for a computerized system to support the use and retention of pre-hospital information during trauma resuscitation. PMID:24551428
Tiska, M; Adu-Ampofo, M; Boakye, G; Tuuli, L; Mock, C
Methods: Over 300 commercial drivers attended a first aid and rescue course designed specifically for roadway trauma and geared to a low education level. The training programme has been evaluated twice at one and two year intervals by interviewing both trained and untrained drivers with regard to their experiences with injured persons. In conjunction with a review of prehospital care literature, lessons learnt from the evaluations were used in the revision of the training model. Results: Control of external haemorrhage was quickly learnt and used appropriately by the drivers. Areas identified needing emphasis in future trainings included consistent use of universal precautions and protection of airways in unconscious persons using the recovery position. Conclusion: In low income countries, prehospital trauma care for roadway casualties can be improved by training laypersons already involved in prehospital transport and care. Training should be locally devised, evidence based, educationally appropriate, and focus on practical demonstrations. PMID:14988361
Abraham, Rohit; Vyas, Dinesh; Narayan, Mayur; Vyas, Arpita
Trauma-related injury in fast developing countries are linked to 90% of international mortality rates, which can be greatly reduced by improvements in often non-existent or non-centralized emergency medical systems (EMS)-particularly in the pre-hospital care phase. Traditional trauma training protocols-such as Advanced Trauma Life Support (ATLS), International Trauma Life Support (ITLS), and Basic Life Support (BLS)-have failed to produce an effective pre-hospital ground force of medical first responders. To overcome these barriers, we propose a new four-tiered set of trauma training protocols: Massive Open Online Course (MOOC) Trauma Training, Acute Trauma Training (ATT), Broad Trauma Training (BTT), and Cardiac and Trauma Training (CTT). These standards are specifically differentiated to accommodate the educational and socioeconomic diversity found in fast developing settings, where each free course is taught in native, lay language while ensuring the education standards are maintained by fully incorporating high-fidelity simulation, video-recorded debriefing, and retraining. The innovative pedagogy of this trauma education program utilizes MOOC for global scalability and a "train-the-trainer" approach for exponential growth-both components help fast developing countries reach a critical mass of first responders needed for the base of an evolving EMS.
Abraham, Rohit; Vyas, Dinesh; Narayan, Mayur; Vyas, Arpita
Trauma-related injury in fast developing countries are linked to 90% of international mortality rates, which can be greatly reduced by improvements in often non-existent or non-centralized emergency medical systems (EMS)—particularly in the pre-hospital care phase. Traditional trauma training protocols—such as Advanced Trauma Life Support (ATLS), International Trauma Life Support (ITLS), and Basic Life Support (BLS)—have failed to produce an effective pre-hospital ground force of medical first responders. To overcome these barriers, we propose a new four-tiered set of trauma training protocols: Massive Open Online Course (MOOC) Trauma Training, Acute Trauma Training (ATT), Broad Trauma Training (BTT), and Cardiac and Trauma Training (CTT). These standards are specifically differentiated to accommodate the educational and socioeconomic diversity found in fast developing settings, where each free course is taught in native, lay language while ensuring the education standards are maintained by fully incorporating high-fidelity simulation, video-recorded debriefing, and retraining. The innovative pedagogy of this trauma education program utilizes MOOC for global scalability and a “train-the-trainer” approach for exponential growth—both components help fast developing countries reach a critical mass of first responders needed for the base of an evolving EMS. PMID:27419222
Asbjørnsen, Helge; Habiba, Samer; Sunde, Geir Arne; Wester, Knut
Abstract The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars. PMID:23962031
Adam, R; Stedman, M; Winn, J; Howard, M; Williams, J I; Ali, J
Identification of trauma as a major cause of morbidity and mortality in Trinidad and Tobago prompted the establishment of a training programme aimed at improving trauma care in this developing country. An Advanced Trauma Life Support (ATLS) programme for physicians, funded through the Canadian International Development Agency resulted in a statistically significant improvement of in-hospital trauma patient outcome at the Port-of-Spain General Hospital (observed to expected mortality ratio of 3.16 pre-ATLS compared to 1.94 post-ATLS). A recent analysis of all motor vehicle injuries for a shorter period did not confirm this positive impact of the ATLS programme, primarily because a large number of these patients died in the pre-hospital period. Pre-hospital trauma care therefore required urgent attention to complement the positive in-hospital impact of the ATLS programme. A second training programme (the Pre-Hospital Trauma Life Support or PHTLS) for paramedical personnel was thus instituted in 1990. Over 250 physicians have been trained in the ATLS programme and to date over 100 paramedical personnel have been trained in the PHTLS programme. Attempts have also been made to equip the ambulances with more appropriate resuscitative devices in order to improve pre-hospital care. The combination of the PHTLS and the ATLS programme should result in further improvement in the care of patients sustaining major injuries in Trinidad and Tobago.
Trauma is the leading cause of death in the United States for those younger than 35 years and injuries sustained from trauma are a significant source of moderate to severe disability. The inability to establish, secure, or maintain a definitive airway is a major cause of preventable death and secondary injury due to inadequate oxygenation and ventilation. Prehospital airway management is an essential skill of any prehospital care provider. A critical component to providing excellent airway management is the ability of the provider to quickly establish endotracheal intubation without complications such as hypoxia, hyper/hypocapnea, or hypotension. These complications have been shown to cause increased morbidity and mortality, especially in patients suffering from traumatic brain injury. This article presents some of the challenges faced by flight nurses in the air medical environment and how Airlift Northwest has developed a structured, standardized approach to airway management both in training and it the prehospital setting. We will discuss the process improvements that lead to the implementation of video laryngoscopy as our first-line intubation tool. The ultimate goal of any air medical or prehospital emergency medical services program is to manage 100% of airways without complications, which will decrease morbidity and mortality, ultimately improving patient outcomes.
Robertson-Steel, I; Edwards, S; Gough, M
This article seeks to discover and recognize the importance of clinical governance within a new and emerging quality National Health Service (NHS) system. It evaluates the present state of prehospital care and recommends how change, via clinical governance, can ensure a paradigm shift from its currently fragmented state to a seamless ongoing patient care episode. Furthermore, it identifies the drivers of a quality revolution, examines the monitoring and supervision of quality care, and evaluates the role of evidence-based practice. A frank and open view of immediate care doctors is presented, with recommendations to improve the quality of skill delivery and reduce the disparity that exists. Finally, it reviews the current problems with pre-hospital care and projects a future course for quality and patient care excellence. PMID:11383428
Prehospital blood transfusion in the en route management of severe combat trauma: A matched cohort study David J. O’Reilly, FRCS, Jonathan J...BACKGROUND: The value of prehospital blood transfusion (PHBTx) in the management of severe trauma has not been established. This study aimed to evaluate the...prehospital interventions, reached hospital more quickly, and had lower heart rate at admission (all p G 0.05). Matched recipients received more red blood
Cone, David C; Brooke Lerner, E; Band, Roger A; Renjilian, Chris; Bobrow, Bentley J; Crawford Mechem, C; Carter, Alix J E; Kupas, Douglas F; Spaite, Daniel W
This article summarizes the discussions of the emergency medical services (EMS) breakout session at the June 2010 Academic Emergency Medicine consensus conference "Beyond Regionalization: Integrated Networks of Emergency Care." The group focused on prehospital issues such as the identification of patients by EMS personnel, protocol-driven destination selection, bypassing closer nondesignated centers to transport patients directly to more distant designated specialty centers, and the modes of transport to be used as they relate to the regionalization of emergency care. It is our hope that the proposed research agenda will be advanced in a way that begins to rigorously approach the unanswered research questions and that these answers, in turn, will lead to an evidence-based, cohesive, comprehensive, and more uniform set of guidelines that govern the delivery and practice of prehospital emergency care.
Ali, J; Adam, R U; Gana, T J; George, B; Taylor, A; Patino, T; West, U; Ali, E; Bedaysie, H
The impact of the Prehospital Trauma Life Support (PHTLS) programme, introduced in Trinidad and Tobago in 1992, was assessed by questionnaires completed by 26 medical personnel (MP); 71 ambulance personnel (AP); and 50 non ambulance paramedical personnel (NAP). Of the 23 MP, 45 AP and 38 NAP who were aware of the programme, 19 (82.6%) MP, 40 (88.9%) AP and 25 (65.8%) NAP were able to differentiate personnel that had taken the PHTLS programme based on their performance. 32 (71.1%) of the AP were PHTLS trained. 24 (53.3%) and 4 (9%) of the AP identified poor equipment and poor supervision, respectively, as reasons for difficulty in applying PHTLS principles. Improvements observed among those completing the PHTLS programme were: improved resuscitation techniques by 20 (86.9%) MP, 38 (84.4%) AP and 27 (71.1%) NAP; better vital signs recording by 8 (34.8%) MP, 27 (60%) AP and 8 (21.1%) NAP; improved immobilization by 23 (100%) MP, 40 (88.9%) AP and 33 (86.8%) NAP; better haemorrhage control by 22 (95.6%) MP, 40 (88.9%) AP and 24 (63.2%) NAP; appropriate splinting of fractures by 23 (100%) MP, 40 (88.9%) AP and 32 (84.2%) NAP; and increased utilization of oxygen by 15 (65.2%) MP, 31 (68.9%) AP and 21 (55.3%) NAP. 32 (71.1%) AP with PHTLS training indicated improvement in their ability to resuscitate and transport trauma victims, with 42 (93.3%) reporting improvement in overall prehospital care. Medical, paramedical and ambulance personnel all perceive a significant positive impact of PHTLS training on prehospital trauma care. Although improvements in supervision, documentation and equipment are still required, improved trauma resuscitative techniques after PHTLS training should improve trauma patient outcome in Trinidad and Tobago.
Lo, C B; Lai, K K; Mak, K P
A quick and efficient prehospital emergency response depends on immediate ambulance dispatch, patient assessment, triage, and transport to hospital. During 1999, the Ambulance Command of the Hong Kong Fire Services Department responded to 484,923 calls, which corresponds to 1329 calls each day. Cooperation between the Fire Services Department and the Hospital Authority exists at the levels of professional training of emergency medical personnel, quality assurance, and a coordinated disaster response. In response to the incident at the Hong Kong International Airport in the summer of 1999, when an aircraft overturned during landing, the pre-set quota system was implemented to send patients to designated accident and emergency departments. Furthermore, the 'first crew at the scene' model has been adopted, whereby the command is established and triage process started by the first ambulance crew members to reach the scene. The development of emergency protocols should be accompanied by good field-to-hospital and interhospital communication, the upgrading of decision-making skills, a good monitoring and auditing structure, and commitment to training and skills maintenance.
There are many names and places that space will not allow here. In the future, I hope to write about these places one at a time and give more detailed reports on the people all over the world who are our brothers and sisters in EMS, covering the places they work and how they provide care. In any event, with each opportunity, we learn about people, ourselves and how small a place the world has become. We are reminded not to approach people and places with belligerence, implying that we have all the answers. By considering the culture and environment in which care is provided, we learn to bring the same open-mindedness back home to help when addressing the problems we face every day. What our neighbors have to teach us may be the next big step in our development.
Smith, R Malcolm; Conn, Alasdair K T
Improved training and expertise has enabled emergency medical personnel to provide advanced levels of care at the scene of trauma. While this could be expected to improve the outcome from major injury, current data does not support this. Indeed, prehospital interventions beyond the BLS level have not been shown to be effective and in many cases have proven to be detrimental to patient outcome. It is better to "scoop and run" than "stay and play". Current data relates to the urban environment where transport times to trauma centres are short and where it appears better to simply rapidly transport the patient to hospital than attempt major interventions at the scene. There may be more need for advanced techniques in the rural environment or where transport times are prolonged and certainly a need for more studies into subsets of patients who may benefit from interventions in the field.
A variety of point-of-care monitors for the measurement of hematocrit, hemoglobin, blood gas with electrolytes, and lactate can be used also in the prehospital setting for optimizing and individualizing trauma resuscitation. Point-of-care coagulation testing with activated prothrombin test, prothrombin test, and activated coagulation/clotting time tests is available for prehospital use. Although robust, battery driven, and easy to handle, many devices lack documentation for use in prehospital care. Some of the devices correspond poorly to corresponding laboratory analyses in acute trauma coagulopathy and at lower hematocrits. In trauma, viscoelastic tests such as rotational thromboelastometry and thromboelastography can rapidly detect acute trauma coagulopathy and give an overall dynamic picture of the hemostatic system and the interaction between its different components: coagulation activation, fibrin polymerization, fibrin platelet interactions within the clot, and fibrinolysis. Rotational thromboelastometry is shock resistant and has the potential to be used outside the hospital setting to guide individualized coagulation factor and blood component therapies. Sonoclot and Rheorox are two small viscoelastic instruments with one-channel options, but with less documentation. The point-of-care market for coagulation tests is quickly expanding, and new devices are introduced all the time. Still they should be better adopted to prehospital conditions, small, robust, battery charged, and rapid and use small sample volumes and whole blood.
Background High energy trauma is rare and, as a result, training of prehospital care providers often takes place during the real situation, with the patient as the object for the learning process. Such training could instead be carried out in the context of simulation, out of danger for both patients and personnel. The aim of this study was to provide an overview of the development and foci of research on simulation in prehospital care practice. Methods An integrative literature review were used. Articles based on quantitative as well as qualitative research methods were included, resulting in a comprehensive overview of existing published research. For published articles to be included in the review, the focus of the article had to be prehospital care providers, in prehospital settings. Furthermore, included articles must target interventions that were carried out in a simulation context. Results The volume of published research is distributed between 1984- 2012 and across the regions North America, Europe, Oceania, Asia and Middle East. The simulation methods used were manikins, films, images or paper, live actors, animals and virtual reality. The staff categories focused upon were paramedics, emergency medical technicians (EMTs), medical doctors (MDs), nurse and fire fighters. The main topics of published research on simulation with prehospital care providers included: Intubation, Trauma care, Cardiac Pulmonary Resuscitation (CPR), Ventilation and Triage. Conclusion Simulation were described as a positive training and education method for prehospital medical staff. It provides opportunities to train assessment, treatment and implementation of procedures and devices under realistic conditions. It is crucial that the staff are familiar with and trained on the identified topics, i.e., intubation, trauma care, CPR, ventilation and triage, which all, to a very large degree, constitute prehospital care. Simulation plays an integral role in this. The current state of
We Don’t Know: Prehospital Data in Combat Casualty Care 11 COL Brian J. Eastridge; LTC Robert Mabry; COL Lorne H. Blackbourne; CAPT (Ret) Frank K...trauma care. COL Brian Eastridge and his team examined the differences between the advances of military trauma care in the hospital setting and that...constant in the under- We Don’t Know What We Don’t Know: Prehospital Data in Combat Casualty Care COL Brian J. Eastridge, MC, USA LTC Robert Mabry, MC
Smith, Iain M.; James, Robert H.; Dretzke, Janine; Midwinter, Mark J.
ABSTRACT Introduction: Administration of high ratios of plasma to packed red blood cells is a routine practice for in-hospital trauma resuscitation. Military and civilian emergency teams are increasingly carrying prehospital blood products (PHBP) for trauma resuscitation. This study systematically reviewed the clinical literature to determine the extent to which the available evidence supports this practice. Methods: Bibliographic databases and other sources were searched to July 2015 using keywords and index terms related to the intervention, setting, and condition. Standard systematic review methodology aimed at minimizing bias was used for study selection, data extraction, and quality assessment (protocol registration PROSPERO: CRD42014013794). Synthesis was mainly narrative with random effects model meta-analysis limited to mortality outcomes. Results: No prospective comparative or randomized studies were identified. Sixteen case series and 11 comparative studies were included in the review. Seven studies included mixed populations of trauma and non-trauma patients. Twenty-five of 27 studies provided only very low quality evidence. No association between PHBP and survival was found (OR for mortality: 1.29, 95% CI: 0.84–1.96, P = 0.24). A single study showed improved survival in the first 24 h. No consistent physiological or biochemical benefit was identified, nor was there evidence of reduced in-hospital transfusion requirements. Transfusion reactions were rare, suggesting the short-term safety of PHBP administration. Conclusions: While PHBP resuscitation appears logical, the clinical literature is limited, provides only poor quality evidence, and does not demonstrate improved outcomes. No conclusions as to efficacy can be drawn. The results of randomized controlled trials are awaited. PMID:26825635
Ali, J; Adam, R; Josa, D; Pierre, I; Bedsaysie, H; West, U; Winn, J; Ali, E; Haynes, B
We tested the effectiveness of a basic prehospital trauma life support (PHTLS) program by assessing cognitive performance and trauma management skills among prehospital trauma personnel. Fourteen subjects who completed a standard PHTLS course (group I) were compared to a matched group not completing a PHTLS program (group II). Cognitive performance was assessed on 50-item multiple choice examinations, and trauma skills management was assessed with four simulated trauma patients. Pre-PHTLS multiple choice questionnaire scores were similar (45.8 +/- 9.4% vs. 48.8 +/- 8.9% for groups I and II, respectively), but the post-PHTLS scores were higher in group I (80.4 +/- 5.9%) than in group II (52.6 +/- 4.9%). Pre-PHTLS simulated trauma patient performance scores (standardized to a maximum total of 20 for each station) were similar at all four stations for both groups, ranging from 7.9 to 10.4. The post-PHTLS scores were statistically significantly higher at all four stations for group I (range 16.0-19.0) compared to those for group II (range 8.0-11.1). The overall mean pre-PHTLS score for all four stations was 8.3 +/- 2.1 for group I and 8.8 +/- 2.0 (NS) for group II; the group I post-PHTLS mean score for the four stations was 17.1 +/- 2.7 (p < 0.05) compared to 9.1 +/- 2.3 for group II. Pre-PHTLS Adherence to Priority scores on a scale of 1 to 7 were similar (1.1 +/- 0.9 for group I and 1.2 +/- 1.0 for group II). Post-PHTLS group I Priority scores increased to 5.9 +/- 1.1. Group II (1.1 +/- 1.0) did not improve their post-PHTLS scores. The pre-PHTLS Organized Approach scores in the simulated trauma patients on a scale of 1 to 5 were 2.1 +/- 1.0 for group I and 1.9 +/- 1.2 for group II (NS) compared to 4.2 +/- 0.9 (p < 0.05) in group I and 2.0 +/- 0.8 in group II after PHTLS. This study demonstrates improved cognitive and trauma management skills performance among prehospital paramedical personnel who complete the basic PHTLS program.
Saving Lives on the Battlefield (Part II) - One Year Later: A Joint Theater Trauma System and Joint Trauma System Review of Prehospital Trauma Care in Combined Joint Operations Area-Afghanistan (CJOA-A)
another location, a unit company grade commander would not allow medics to carry morphine outside the COP because “they are close enough to the aid...routinely issued and available to medics on patrol. 5. There are no published evidence-based studies regarding morphine intramuscular injection for...trauma patients. Morphine is NOT a recom- mended battlefield analgesic in the TCCC Guidelines. 6. Represents the use of non-TCCC Guideline systemic
Hampton, David A.; Fabricant, Löic J.; Differding, Jerry; Diggs, Brian; Underwood, Samantha; De La Cruz, Dodie; Holcomb, John B.; Brasel, Karen J.; Cohen, Mitchell J.; Fox, Erin E.; Alarcon, Louis H.; Rahbar, Mohammad H.; Phelan, Herb A.; Bulger, Eileen M.; Muskat, Peter; Myers, John G.; del Junco, Deborah J.; Wade, Charles E.; Cotton, Bryan A.; Schreiber, Martin A.
Background Delivery of intravenous crystalloid fluids (IVF) remains a tradition-based priority during pre-hospital resuscitation of trauma patients. Hypotensive and targeted resuscitation algorithms have been shown to improve patient outcomes. We hypothesized that receiving any pre-hospital IVF is associated with increased survival in trauma patients compared to receiving no pre-hospital IVF. Methods Prospective data from ten Level 1 trauma centers were collected. Patient demographics, pre-hospital IVF volume, pre-hospital and Emergency Department vital signs, life-saving interventions, laboratory values, outcomes and complications were collected and analyzed. Patients who did or did not receive pre-hospital IVF were compared. Tests for non-parametric data were utilized to assess significant differences between groups (p ≤ 0.05). Cox regression analyses were performed to determine the independent influence of IVF on outcome and complications. Results The study population consisted of 1245 trauma patients; 45 were removed due to incomplete data; 84% (n=1009) received pre-hospital IVF, and 16% (n=191) did not. There was no difference between the groups with respect to gender, age, and Injury Severity Score. The on-scene systolic blood pressure (SBP) was lower in the IVF group (110 vs. 100 mmHg, p<0.04) and did not change significantly after IVF, measured at ED admission (110 vs. 105 mmHg, p=0.05). Hematocrit/hemoglobin, fibrinogen, and platelets were lower (p<0.05), and Prothrombin Time/International Normalized Ratio and Partial Thromboplastin Time were higher (p<0.001) in the IVF group. The IVF group received a median fluid volume of 700ml (IQR: 300-1300). The Cox regression revealed that pre-hospital fluid administration was associated with increased survival, Hazard Ratio: 0.84 (95% Confidence Interval: 0.72, 0.98; p=0.03). Site differences in ISS and fluid volumes were demonstrated (p<0.001). Conclusions Pre-hospital IVF volumes commonly used by PROMMTT
prehospital endotracheal intubation . Hypoxemia occurred in 86 (38.4%), paramedics suspected traumatic brain injury in 22 (9.8%), and 20 (8.9%) were...admitted; 36.2% sustained a penetrating injury. None underwent prehospital endotracheal intubation . Hypoxemia occurred in 86 (38.4%), paramedics...36.2% sustained a penetrating injury. No subject underwent endotracheal intubation in the pre hospital setting; 7 (3.1%) underwent intubation in the
Kuzma, Kristin; Lim, Andrew George; Kepha, Bernard; Nalitolela, Neema Evelyne; Reynolds, Teri A
Objectives We sought to characterise the prehospital experience of Tanzanian trauma patients, and identify barriers and facilitators to implement community-based emergency medical systems (EMS). Settings Our study was conducted in the emergency department of an urban national referral hospital in Tanzania. Participants A convenience sample of 34 adult trauma patients, or surrogate family members, presenting or referred to an urban referral emergency department in Tanzania for treatment of injury, participated in the study. Interventions Participation in semistructured, iteratively developed interviews until saturation of responses was reached. Outcomes A grounded theory-based approach to qualitative analysis was used to identify recurrent themes. Results We characterised numerous deficiencies within the existing clinic-to-hospital referral network, including missed/delayed diagnoses, limited management capabilities at pre-referral facilities and interfacility transfer delays. Potential barriers to EMS implementation include patient financial limitations and lack of insurance, limited public infrastructure and resources, and the credibility of potential first aid responders. Potential facilitators of EMS include communities’ tendency to pool resources, individuals’ trust of other community members to be first aid responders, and faith in community leaders to organise EMS response. Participants expressed a strong desire to learn first aid. Conclusions The composite themes generated by the data suggest that there are myriad structural, financial, institutional and cultural barriers to the implementation of a formal prehospital system. However, our analysis also revealed potential facilitators to a first-responder system that takes advantage of close-knit local communities and the trust of recognised leaders in society. The results suggest favourable acceptability for community-based response by trained lay people. There is significant opportunity for care
Pre-hospital emergency care (PHEC) in the military has undergone major changes during the last 10 years of warfighting in the land environment. Providing this care in the maritime environment presents several unique challenges. This paper examines the clinical capabilities required of a PHEC team in the maritime environment and how this role can be fulfilled as part of Role 2 Afloat. It applies to Pre-hospital emergency care projected from a hospital not to General Duties Medical Officers at Role 1.
Pladec, Boris Martin le; Menoret, Romuald; Rodes, Raphaël
In collaboration with the ambulance driver and the emergency doctor, the prehospital nurse provides care in a universe which is often difficult and sometimes hostile. Whether they are a nurse from the Samu (urgent medical aid service) or from the Paris fire service, how are they recruited and what training do these emergency care professionals receive?
Maghaminejad, Farzaneh; Adib-Hajbaghery, Mohsen
Background Circulatory management is a critical issue in pre-hospital transportation phase of multiple trauma patients. However, the quality of this important care did not receive enough attention. Objectives The aim of this study was to investigate the quality of pre-hospital circulatory management in patients with multiple trauma. Patients and Methods This was a cross-sectional study conducted in 2013. The study population consisted of all patients with multiple trauma who had been transferred by emergency medical services (EMS) to the central trauma department in Kashan Shahid Beheshti medical center, Kashan, Iran. We recruited a convenience sample of 400 patients with multiple trauma. Data were collected using the circulatory assessment questionnaire and controlling hemorrhage (CAQCH) that were designed by the researchers and were described by using frequency tabulations, central tendency measures, and variability indices. The chi-square test was used to analyze the data. Results The study sample consisted of 263 males (75.2%); 57.75% had lower levels of education and 28.75% were workers. The most common mechanism of trauma was traffic accident (85.4%). We found that the quality of circulatory management was unfavorable in 61% of the cases. A significant relationship was observed between the quality of circulatory management and type of trauma and staff’s employment status. Conclusions The quality of pre-hospital circulatory management provided to patients with multiple trauma was unfavorable. Therefore, establishment of in-service training programs on circulatory management is recommended. PMID:27556056
Patel, Archita D.; Meurer, David A.; Shuster, Jonathan J.
Introduction. Limited evidence is available on simulation training of prehospital care providers, specifically the use of tourniquets and needle decompression. This study focused on whether the confidence level of prehospital personnel performing these skills improved through simulation training. Methods. Prehospital personnel from Alachua County Fire Rescue were enrolled in the study over a 2- to 3-week period based on their availability. Two scenarios were presented to them: a motorcycle crash resulting in a leg amputation requiring a tourniquet and an intoxicated patient with a stab wound, who experienced tension pneumothorax requiring needle decompression. Crews were asked to rate their confidence levels before and after exposure to the scenarios. Timing of the simulation interventions was compared with actual scene times to determine applicability of simulation in measuring the efficiency of prehospital personnel. Results. Results were collected from 129 participants. Pre- and postexposure scores increased by a mean of 1.15 (SD 1.32; 95% CI, 0.88–1.42; P < 0.001). Comparison of actual scene times with simulated scene times yielded a 1.39-fold difference (95% CI, 1.25–1.55) for Scenario 1 and 1.59 times longer for Scenario 2 (95% CI, 1.43–1.77). Conclusion. Simulation training improved prehospital care providers' confidence level in performing two life-saving procedures. PMID:27563467
Background A common feature of prehospital emergency care is the short and fragmentary patient encounters with increased demands for efficient and rapid treatment. Crucial decisions are often made and the premise is the specialist ambulance nurse’s ability to capture the situation instantaneously. The assessment is therefore a pre-requisite for decisions about appropriate actions. However, the low exposure to severe trauma cases in Sweden leads to vulnerability for the specialist ambulance nurse, which makes the assessment more difficult. Our objective was to describe specialist ambulance nurses’ perceptions of assessing patients exposed to severe trauma. Methods This study had a phenomenographic approach and was performed in 2011 as an interview study. 15 specialist ambulance nurses with a minimum of 2.5 years of experience from praxis were included. The analysis of data was performed using phenomenography according to Marton. Results The perceptions of assessing patients exposed to severe trauma were divided into: To be prepared for emergency situations, Confidence in one’s own leadership and Developing professional knowledge. Conclusions This study reveals that the specialist ambulance nurse, on the scene of accident, finds the task of assessment of severe trauma patients difficult and complicated. In some cases, even exceeding what they feel competent to accomplish. The specialist ambulance nurses feel that no trauma scenarios are alike and that more practical skills, more training, exercise and feedback are needed. PMID:22985478
Nesbitt , DSc, PA-C, Amelia M. Duran-Stanton, PhD, PA-C, and Robert T. Gerhardt, MD, MPH, FACEP Background: Prehospital care of combat casualties is a...5c. PROGRAM ELEMENT NUMBER 6. AUTHOR(S) Therien S. P., Nesbitt M. E., Duran-Stanton A. M., Gerhardt R. T., 5d. PROJECT NUMBER 5e. TASK NUMBER 5f
Sampalis, J S; Lavoie, A; Williams, J I; Mulder, D S; Kalina, M
A sample of 360 severely injured patients was selected from a cohort of 8007 trauma victims followed prospectively from the time of injury to death or discharge. A case referent study was used to test the association between on-site care, total prehospital time, and level of care at the receiving hospital with short-term survival. Multiple logistic regression analyses showed that use of Advanced Life Support (ALS) at the scene was not associated with survival, whereas treatment at a level I compatible hospital was associated with a 38% reduction in the odds of dying, which approached statistical significance. Total prehospital time over 60 minutes was associated with a statistically significant adjusted relative odds of dying (OR = 3.0). The results of this study support the need for regionalization of trauma care and fail to show a benefit associated with ALS.
Holsträter, Thorsten; Holsträter, Susanne; Rein, Daniela; Helm, Matthias; Hossfeld, Björn
Explosion injuries are not restricted to war-like military conflicts or terrorist attacks. The emergency physician may also encounter such injuries in the private or industrial fields, injuries caused by fireworks or gas explosions. In such cases the injury patterns are especially complex and may consist of blunt and penetrating injuries as well as thermal damage. Emergency medical personnel must be prepared to cope with explosion trauma not only in individual cases but also in major casualty incidents (MCI). This necessitates a sound knowledge about the mechanisms and processes of an explosion as well as the particular pathophysiological relationships of explosion injuries in order to be able to initiate the best possible, guideline-conform trauma therapy.
Brown, Heather A; Douglass, Katherine A; Ejas, Shafi; Poovathumparambil, Venugopalan
Most low- and middle-income countries (LMICs) have struggled to find a system for prehospital care that can provide adequate patient care and geographical coverage while maintaining a feasible price tag. The emergency medical systems of the Western world are not necessarily relevant in developing economic systems, given the lack of strict legislation, the scarcity of resources, and the limited number of trained personnel. Meanwhile, most efforts to provide prehospital care in India have taken the form of adapting Western models to the Indian context with limited success. Described here is a novel approach to prehospital care designed for and implemented in the State of Kerala, India. The Active Network Group of Emergency Life Savers (ANGELS) was launched in 2011 in Calicut City, the third largest city in the Indian State of Kerala. The ANGELS integrated an existing fleet of private and state-owned ambulances into a single network utilizing Global Positioning System (GPS) technology and a single statewide call number. A total of 85 volunteer emergency medical certified technicians (EMCTs) were trained in basic first aid and trauma care principles. Public awareness campaigns accompanied all activities to raise awareness amongst community members. Funding was provided via public-private partnership, aimed to minimize costs to patients for service utilization. Over a two-year period from March 2011 to April 2013, 8,336 calls were recorded, of which 54.8% (4,569) were converted into actual ambulance run sheets. The majority of calls were for medical emergencies and most patients were transported to Medical College Hospital in Calicut. This unique public-private partnership has been responsive to the needs of the population while sustaining low operational costs. This system may provide a relevant template for Emergency Medical Services (EMS) development in other resource-limited settings. Brown HA , Douglass KA , Ejas S , Poovathumparambil V . Development and
Wilson, Mark H; Habig, Karel; Wright, Christopher; Hughes, Amy; Davies, Gareth; Imray, Chirstopher H E
Pre-hospital care is emergency medical care given to patients before arrival in hospital after activation of emergency medical services. It traditionally incorporated a breadth of care from bystander resuscitation to statutory emergency medical services treatment and transfer. New concepts of care including community paramedicine, novel roles such as emergency care practitioners, and physician delivered pre-hospital emergency medicine are re-defining the scope of pre-hospital care. For severely ill or injured patients, acting quickly in the pre-hospital period is crucial with decisions and interventions greatly affecting outcomes. The transfer of skills and procedures from hospital care to pre-hospital medicine enables early advanced care across a range of disciplines. The variety of possible pathologies, challenges of environmental factors, and hazardous situations requires management that is tailored to the patient's clinical need and setting. Pre-hospital clinicians should be generalists with a broad understanding of medical, surgical, and trauma pathologies, who will often work from locally developed standard operating procedures, but who are able to revert to core principles. Pre-hospital emergency medicine consists of not only clinical care, but also logistics, rescue competencies, and scene management skills (especially in major incidents, which have their own set of management principles). Traditionally, research into the hyper-acute phase (the first hour) of disease has been difficult, largely because physicians are rarely present and issues of consent, transport expediency, and resourcing of research. However, the pre-hospital phase is acknowledged as a crucial period, when irreversible pathology and secondary injury to neuronal and cardiac tissue can be prevented. The development of pre-hospital emergency medicine into a sub-specialty in its own right should bring focus to this period of care.
Pino Sánchez, F I; Ballesteros Sanz, M A; Cordero Lorenzana, L; Guerrero López, F
Traumatic disease is a major public health concern. Monitoring the quality of services provided is essential for the maintenance and improvement thereof. Assessing and monitoring the quality of care in trauma patient through quality indicators would allow identifying opportunities for improvement whose implementation would improve outcomes in hospital mortality, functional outcomes and quality of life of survivors. Many quality indicators have been used in this condition, although very few ones have a solid level of scientific evidence to recommend their routine use. The information contained in the trauma registries, spread around the world in recent decades, is essential to know the current health care reality, identify opportunities for improvement and contribute to the clinical and epidemiological research.
Amadi-Obi, Ahjoku; Gilligan, Peadar; Owens, Niall; O'Donnell, Cathal
The right person in the right place and at the right time is not always possible; telemedicine offers the potential to give audio and visual access to the appropriate clinician for patients. Advances in information and communication technology (ICT) in the area of video-to-video communication have led to growth in telemedicine applications in recent years. For these advances to be properly integrated into healthcare delivery, a regulatory framework, supported by definitive high-quality research, should be developed. Telemedicine is well suited to extending the reach of specialist services particularly in the pre-hospital care of acute emergencies where treatment delays may affect clinical outcome. The exponential growth in research and development in telemedicine has led to improvements in clinical outcomes in emergency medical care. This review is part of the LiveCity project to examine the history and existing applications of telemedicine in the pre-hospital environment. A search of electronic databases including Medline, Excerpta Medica Database (EMBASE), Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for relevant papers was performed. All studies addressing the use of telemedicine in emergency medical or pre-hospital care setting were included. Out of a total of 1,279 articles reviewed, 39 met the inclusion criteria and were critically analysed. A majority of the studies were on stroke management. The studies suggested that overall, telemedicine had a positive impact on emergency medical care. It improved the pre-hospital diagnosis of stroke and myocardial infarction and enhanced the supervision of delivery of tissue thromboplasminogen activator in acute ischaemic stroke. Telemedicine presents an opportunity to enhance patient management. There are as yet few definitive studies that have demonstrated whether it had an effect on clinical outcome.
Van Meter, Keith
Most commercial diving operations and naval operations have 24/7, on-site availability of hyperbaric oxygen therapy to perform routine surface decompression or immediate treatment of arterial gas embolism or decompression sickness. Availability and prompt use of hyperbaric oxygen therapy in the field for treatment of divers with dysbaric conditions has demonstrated its efficacy in acute, co-morbid conditions such as acute exsanguination, blast injury, crush injury, and cardiopulmonary arrest affecting those same divers. Hyperbaric oxygen therapy applied in these cases has demonstrated its utility to augment the efficacy of conventional, pre-hospital advanced cardiac life support and advanced trauma life support. Case studies gleaned from actual experience with the diving industry illustrate the use of hyperbaric oxygen therapy in these conditions. The unexpectedly favorable results have been replicated by controlled laboratory animal studies. The deck decompression or saturation multiplace chambers used by offshore diving operations can easily and quickly be converted for use as medical field resuscitative units. Lightweight and mobile hyperbaric chambers can be outfitted for use in ambulances or helicopters to address civilian street injury or military "far-forward" injury. These transport chambers are compact in design to be efficient transport stretchers designed to hold both the patient and the medical support clinician. It is hoped that hyperbaric oxygen therapy will gain an increasing role as an adjunct to pre-hospital advanced cardiac life support and advanced trauma life support resuscitative efforts as a low-cost, high-yield intervention. In this regard HBO as applied to ATLS/ACLS in civilian and military medical systems may be a productive, disruptive new application of technology.
Kietzmann, Diana; Hannig, Christian; Schmidt, Silke
This study was designed to explore the views of migrants and professionals on culturally sensitive pre-hospital emergency care in order to adapt such care to migrants' needs. Interviews were conducted with 41 migrants who had received direct (as a patient) or indirect (as a significant other) pre-hospital emergency care. Furthermore, 20 professionals in the field of pre-hospital emergency care were interviewed. The content analysis showed five distinguishable categories based on the statements by the migrants and six categories based on the statements by the professionals. While migrants gave priority to basic proficiencies of first responders such as 'social/emotional competencies' and 'communication skills', the professionals considered '(basic) cultural knowledge', 'awareness' and 'attitude' the most important. Furthermore, migrants provided practical indications, e.g. regarding areas of cultural knowledge, whereas professionals seemed to view the issue of culturally pre-hospital emergency care from a more theoretical perspective. The issues of the culturally sensitive pre-hospital emergency care itself, as well as the varying points of view of the two groups interviewed, resulted in eight recommendations for culturally sensitive pre-hospital emergency care.
Methods: Soft systems methodology was used to develop and critically appraise the prehospital practitioner model as an alternative to existing models. This approach started from the philosophical viewpoint that prehospital services should be patient centred. Soft systems methodology was used to structure the elements of prehospital systems and the relations between them into metaphors and pictures that could be analysed. Results: This analysis showed that the most powerful reason for advocating the prehospital practitioner model is that it places prehospital systems within a symbiotic relationship with the healthcare system. Unlike the existing emergency service models or the "chain of survival" model, it is an integrated system that provides a range of services at multiple points during the patient care cycle. Thus, the prehospital practitioner would have roles in the prevention of injury and illness, responding to emergencies, facilitating recovery, and planning future strategies for a healthy community. Conclusions: Implementing this new model would see the prehospital system using its available capacity more effectively to fulfill broader public health and primary care outreach roles than is currently the case. Patients would be referred or transported to the most appropriate and cost effective facility as part of a seamless system that provides patients with well organised and high quality care. PMID:12642545
Ntakiyiruta, Georges; Wong, Evan G.; Rousseau, Mathieu C.; Ruhungande, Landouald; Kushner, Adam L.; Liberman, Alexander S.; Khwaja, Kosar; Dakermandji, Marc; Wilson, Marnie; Razek, Tarek; Kyamanywa, Patrick; Deckelbaum, Dan L.
Background Trauma remains a leading cause of death worldwide. The development of trauma systems in low-resource settings may be of benefit. The objective of this study was to describe operative procedures performed for trauma at a tertiary care facility in Kigali, Rwanda, and to evaluate geographical variations and referral patterns of trauma care. Methods We retrospectively reviewed all prospectively collected operative cases performed at the largest referral hospital in Rwanda, the Centre Hospitalier Universitaire de Kigali (CHUK), between June 1 and Dec. 1, 2011, for injury-related diagnoses. We used the Pearson χ2 and Fisher exact tests to compare cases arising from within Kigali to those transferred from other provinces. Geospatial analyses were also performed to further elucidate transfer patterns. Results Over the 6-month study period, 2758 surgical interventions were performed at the CHUK. Of these, 653 (23.7%) were for trauma. Most patients resided outside of Kigali city, with 337 (58.0%) patients transferred from other provinces and 244 (42.0%) from within Kigali. Most trauma procedures were orthopedic (489 [84.2%]), although general surgery procedures represented a higher proportion of trauma surgeries in patients from other provinces than in patients from within Kigali (28 of 337 [8.3%] v. 10 of 244 [4.1%]). Conclusion To our knowledge, this is the first study to highlight geographical variations in access to trauma care in a low-income country and the first description of trauma procedures at a referral centre in Rwanda. Future efforts should focus on maturing prehospital and interfacility transport systems, strengthening district hospitals and further supporting referral institutions. PMID:26812407
The recent bus crash in Switzerland involving many children provides several lessons for the pre-hospital care community. The use of multiple helicopters that are capable of flying at night and that carry advanced medical pre-hospital teams undoubtedly saved lives following the tragedy. We describe the medical response to the incident and the lessons that can be learned for emergency medical services. PMID:22784360
Al-Naami, Mohammed Y.; Arafah, Maria A.; Al-Ibrahim, Fatimah S.
Saudi Arabia is undergoing a rapid population growth that along with improved socioeconomics has led many individuals to own a car or even a number of cars per family, resulting in a greater number of vehicles on the roads. The reduced focus on good public transportation systems and the dependence on cars for transportation have created a diversity of drivers who are unfamiliar with the local driving rules and lack the basic skills for safe driving. This is in addition to some young drivers who frequently violate traffic laws and tend to speed most of the time. This unplanned expansion in road traffic has resulted in more car accidents, injuries, disabilities, and deaths. Accompanying that is an increased socioeconomic burden, depletion of human resources, emotional and psychological stress on families, and a strain on healthcare facilities. If this continues without prompt intervention, it will lead to increased insurance premiums and may become unmanageable. To minimize this impact, a national or regional multidisciplinary trauma system has to be developed and implemented. A trauma system is a preplanned, comprehensive, and coordinated regional injury response network that includes all facilities with the capability to care for the injured. Essential components of the system include trauma prevention, prehospital care, hospital care, rehabilitation, system administration, trauma care education and training, trauma care evaluation and quality improvement, along with the participation of society. Research has documented a significant decrease in morbidity and mortality from trauma after the implementation of such systems, depending on their efficiency. The purpose of this review is to discuss the problem of road traffic accidents in this country and address the trauma care system as an effective solution. PMID:20103958
Hornez, Emmanuel; Maurin, Olga; Mayet, Aurélie; Monchal, Tristan; Gonzalez, Federico; Kerebel, Delphine
AIM: To evaluate the performance of the specific French Vittel “Pre-Hospital (PH) resuscitation” criteria in selecting polytrauma patients during the pre-hospital stage and its potential to increase the positive predictive value (PPV) of pre-hospital trauma triage. METHODS: This was a monocentric prospective cohort study of injured adults transported by emergency medical service to a trauma center. Patients who met any of the field trauma triage criteria were considered “triage positive”. Hospital data was statistically linked to pre-hospital records. The primary outcome of defining a “major trauma patient” was Injury Severity Score (ISS) > 16. RESULTS: There were a total of 200 injured patients evaluated over a 2 years period who met at least 1 triage criterion. The number of false positives was 64 patients (ISS < 16). The PPV was 68%. The sensitivity and the negative predictive value could not be evaluated in this study since it only included patients with positive Vittel criteria. The criterion of “PH resuscitation” was present for 64 patients (32%), but 10 of them had an ISS < 16. This was statistically significant in correlation with the severity of the trauma in univariate analysis (OR = 7.2; P = 0.005; 95%CI: 1.6-31.6). However, despite this correlation the overall PPV was not significantly increased by the use of the criterion “PH resuscitation” (68% vs 67.8%). CONCLUSION: The criterion of “pre-hospital resuscitation” was statistically significant with the severity of the trauma, but did not increase the PPV. The use of “pre-hospital resuscitation” criterion could be re-considered if these results are confirmed by larger studies. PMID:25379459
Nielsen, Katie; Mock, Charles; Joshipura, Manjul; Rubiano, Andres M.; Zakariah, Ahmed; Rivara, Frederick
Objectives Injury and other medical emergencies are becoming increasingly common in low- and middle-income countries (LMICs). Many to most of the deaths from these conditions occur outside of hospitals, necessitating the development of prehospital care. Prehospital capabilities are inadequately developed to meet the growing needs for emergency care in most LMICs. In order to better plan for development of prehospital care globally, this study sought to better understand the current status of prehospital care in a wide range of LMICs. Methods A survey was conducted of emergency medical services (EMS) leaders and other key informants in 13 LMICs in Africa, Asia, and Latin America. Questions addressed methods of transport to hospital, training and certification of EMS providers, organization and funding of EMS systems, public access to prehospital care, and barriers to EMS development. Results Prehospital care capabilities varied significantly, but in general, were less developed in low-income countries and in rural areas, where utilization of formal emergency medical services was often very low. Commercial drivers, volunteers, and other bystanders provided a large proportion of prehospital transport and occasionally also provide first aid in many locations. Although taxes and mandatory motor vehicle insurance provided supplemental funds to EMS in 85% of the countries, the most frequently cited barriers to further development of prehospital care was inadequate funding (36% of barriers cited). The next most commonly sited barriers were lack of leadership within the system (18%) and lack of legislation setting standards (18%). Conclusions Expansion of prehospital care to currently under- or un-served areas, especially in low-income countries and in rural areas, could make use of the already existing networks of first responders, such as commercial drivers and lay persons. Efforts to increase their effectiveness, such as more widespread first aid training, and better
Mohta, Medha; Sethi, A K; Tyagi, Asha; Mohta, Anup
The clinician manages trauma patients in the emergency room, operation theatre, intensive care unit and trauma ward with an endeavour to provide best possible treatment for physical injuries. At the same time, it is equally important to give adequate attention to behavioural and psychological aspects associated with the event. Knowledge of the predisposing factors and their management helps the clinician to prevent or manage these psychological problems. Various causes of psychological disturbances in trauma patients have been highlighted. These include pain, the sudden and unexpected nature of events and the procedures and interventions necessary to resuscitate and stabilise the patient. The ICU and trauma ward environment, sleep and sensory deprivation, impact of injury on CNS, medications and associated pre-morbid conditions are also significant factors. Specific problems that concern the traumatised patients are helplessness, humiliation, threat to body image and mental symptoms. The patients react to these stressors by various defence mechanisms like conservation withdrawal, denial, regression, anger, anxiety and depression. Some of them develop delirium or even more severe problems like acute stress disorder or post-traumatic stress disorder. Physical, pharmacological or psychological interventions can be performed to prevent or minimise these problems in trauma patients. These include adequate pain relief, prevention of sensory and sleep deprivation, providing familiar surroundings, careful explanations and reassurance to the patient, psychotherapy and pharmacological treatment whenever required.
Watts, Sarah; Nordmann, Giles; Brohi, Karim; Midwinter, Mark; Woolley, Tom; Gwyther, Robert; Wilson, Callie; Poon, Henrietta; Kirkman, Emrys
ABSTRACT Acute trauma coagulopathy (ATC) is seen in 30% to 40% of severely injured casualties. Early use of blood products attenuates ATC, but the timing for optimal effect is unknown. Emergent clinical practice has started prehospital deployment of blood products (combined packed red blood cells and fresh frozen plasma [PRBCs:FFP], and alternatively PRBCs alone), but this is associated with significant logistical burden and some clinical risk. It is therefore imperative to establish whether prehospital use of blood products is likely to confer benefit. This study compared the potential impact of prehospital resuscitation with (PRBCs:FFP 1:1 ratio) versus PRBCs alone versus 0.9% saline (standard of care) in a model of severe injury. Twenty-four terminally anesthetised Large White pigs received controlled soft tissue injury and controlled hemorrhage (35% blood volume) followed by a 30-min shock phase. The animals were allocated randomly to one of three treatment groups during a 60-min prehospital evacuation phase: hypotensive resuscitation (target systolic arterial pressure 80 mmHg) using either 0.9% saline (group 1, n = 9), PRBCs:FFP (group 2, n = 9), or PRBCs alone (group 3, n = 6). Following this phase, an in-hospital phase involving resuscitation to a normotensive target (110 mmHg systolic arterial blood pressure) using PRBCs:FFP was performed in all groups. There was no mortality in any group. A coagulopathy developed in group 1 (significant increase in clot initiation and dynamics shown by TEG [thromboelastography] R and K times) that persisted for 60 to 90 min into the in-hospital phase. The coagulopathy was significantly attenuated in groups 2 and 3 (P = 0.025 R time and P = 0.035 K time), which were not significantly different from each other. Finally, the volumes of resuscitation fluid required was significantly greater in group 1 compared with groups 2 and 3 (P = 0.0067) (2.8 ± 0.3 vs. 1.9 ± 0.2 and 1.8 ± 0.3 L, respectively). This difference was
Watts, Sarah; Nordmann, Giles; Brohi, Karim; Midwinter, Mark; Woolley, Tom; Gwyther, Robert; Wilson, Callie; Poon, Henrietta; Kirkman, Emrys
Acute trauma coagulopathy (ATC) is seen in 30% to 40% of severely injured casualties. Early use of blood products attenuates ATC, but the timing for optimal effect is unknown. Emergent clinical practice has started prehospital deployment of blood products (combined packed red blood cells and fresh frozen plasma [PRBCs:FFP], and alternatively PRBCs alone), but this is associated with significant logistical burden and some clinical risk. It is therefore imperative to establish whether prehospital use of blood products is likely to confer benefit. This study compared the potential impact of prehospital resuscitation with (PRBCs:FFP 1:1 ratio) versus PRBCs alone versus 0.9% saline (standard of care) in a model of severe injury. Twenty-four terminally anesthetised Large White pigs received controlled soft tissue injury and controlled hemorrhage (35% blood volume) followed by a 30-min shock phase. The animals were allocated randomly to one of three treatment groups during a 60-min prehospital evacuation phase: hypotensive resuscitation (target systolic arterial pressure 80 mmHg) using either 0.9% saline (group 1, n = 9), PRBCs:FFP (group 2, n = 9), or PRBCs alone (group 3, n = 6). Following this phase, an in-hospital phase involving resuscitation to a normotensive target (110 mmHg systolic arterial blood pressure) using PRBCs:FFP was performed in all groups. There was no mortality in any group. A coagulopathy developed in group 1 (significant increase in clot initiation and dynamics shown by TEG [thromboelastography] R and K times) that persisted for 60 to 90 min into the in-hospital phase. The coagulopathy was significantly attenuated in groups 2 and 3 (P = 0.025 R time and P = 0.035 K time), which were not significantly different from each other. Finally, the volumes of resuscitation fluid required was significantly greater in group 1 compared with groups 2 and 3 (P = 0.0067) (2.8 ± 0.3 vs. 1.9 ± 0.2 and 1.8 ± 0.3 L, respectively). This difference was principally
Doering, G T
The focus of the study was to prioritize six emergency medical service treatment factors in terms of their impact upon patient satisfaction in the prehospital setting. The six treatment areas analyzed were: EMS response time; medical care provided on scene; explanation of care by the provider; the provider's ability to reduce patient anxiety; the provider's ability to meet the patient's non-medical needs; and the level of courtesy/politeness shown by the EMS provider toward the patient. Telephone interviews were conducted with both patients and bystanders to obtain their perception of how well the system met their needs. The study analyzed how the six issues were rated and then evaluated the impact an individual's low score in a category had on that person's overall rating of the service provided. The overall satisfaction rating is not a calculated score, but an overall score specified by the respondent. The effect each issue had on the respondent's overall rating was determined by averaging the overall ratings for a category's low scorers, averaging the overall ratings for high scorers and then measuring the difference. Results of the study indicate that the factor with the greatest negative impact on patient satisfaction came from a perceived lack of crew courtesy and politeness. Respondents who indicated a fair to poor score in this category decreased their overall score by 60.2%. Ratings in other categories yielded the following results: When respondents rated the response time as fair to poor, their average overall rating showed an 18.4% decrease. When respondents rated the quality of medical care as fair to poor, their average overall rating showed a decrease of 22.6%. When the crew's ability to explain what was happening to the patient was rated as fair to poor, the average overall score dropped 33.6%. When the EMT's and medic's ability to reduce the patient's anxiety was rated fair to poor, average overall score declined by 32.6%. Finally, when the crew
Newberry, Jennifer A; Hattaway, Leonard (Bud) F; Socheat, Phan; Raingsey, Prak P; Strehlow, Matthew C
Despite significant improvements in health outcomes nationally, many Cambodians continue to experience morbidity and mortality due to inadequate access to quality emergency medical services. Over recent decades, the Cambodian healthcare system and civil infrastructure have advanced markedly and now possess many of the components required to establish a well functioning emergency medical system. These components include enhanced access to emergency transportation through large scale road development efforts, widspread availability of emergency communication channels via the spread of cellphone and internet technology, and increased access to health services for poor patients through the implementation of health financing schemes. However, the system still lacks a number of key elements, one of which is trained prehospital care providers. Working in partnership with local providers, our team created an innovative, Cambodia-specific prehospital care provider training course to help fill this gap. Participants received training on prehospital care skills and knowledge most applicable to the Cambodian healthcare system, which was divided into four modules: Basic Prehospital Care Skills and Adult Medical Emergencies, Traumatic Emergencies, Obstetric Emergencies, and Neonatal/Pediatric Emergencies. The course was implemented in nine of Cambodia’s most populous provinces, concurrent with a number of overarching emergency medical service system improvement efforts. Overall, the course was administered to 1,083 Cambodian providers during a 27-month period, with 947 attending the entire course and passing the course completion exam. PMID:27489749
Acker, Peter; Newberry, Jennifer A; Hattaway, Leonard Bud F; Socheat, Phan; Raingsey, Prak P; Strehlow, Matthew C
Despite significant improvements in health outcomes nationally, many Cambodians continue to experience morbidity and mortality due to inadequate access to quality emergency medical services. Over recent decades, the Cambodian healthcare system and civil infrastructure have advanced markedly and now possess many of the components required to establish a well functioning emergency medical system. These components include enhanced access to emergency transportation through large scale road development efforts, widspread availability of emergency communication channels via the spread of cellphone and internet technology, and increased access to health services for poor patients through the implementation of health financing schemes. However, the system still lacks a number of key elements, one of which is trained prehospital care providers. Working in partnership with local providers, our team created an innovative, Cambodia-specific prehospital care provider training course to help fill this gap. Participants received training on prehospital care skills and knowledge most applicable to the Cambodian healthcare system, which was divided into four modules: Basic Prehospital Care Skills and Adult Medical Emergencies, Traumatic Emergencies, Obstetric Emergencies, and Neonatal/Pediatric Emergencies. The course was implemented in nine of Cambodia's most populous provinces, concurrent with a number of overarching emergency medical service system improvement efforts. Overall, the course was administered to 1,083 Cambodian providers during a 27-month period, with 947 attending the entire course and passing the course completion exam.
Adedeji, O. A.; Driscoll, P. A.
Trauma remains the leading cause of death under the age of 35 years. England and Wales lost 252,000 working years from accidental deaths, including poison, in 1992. In this country, preventable deaths from trauma are inappropriately high. In many hospitals there are not enough personnel; in the majority, there are no recognisable trauma care systems, which can reduce preventable deaths to a minimum. The appropriateness of trauma centres for this country is being assessed in Stoke-on-Trent, and a report is due out later this year. Even if the recommendation is made to establish such centres, it is unlikely that many will be set up. Consequently most hospitals will have to rely on their own resources to set up and run a trauma team. This type of trauma care system is the subject of this article. PMID:8977939
Glober, Nancy K.; Sporer, Karl A.; Guluma, Kama Z.; Serra, John P.; Barger, Joe A.; Brown, John F.; Gilbert, Gregory H.; Koenig, Kristi L.; Rudnick, Eric M.; Salvucci, Angelo A.
Introduction In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with a suspected stroke and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California. Methods We performed a literature review of the current evidence in the prehospital treatment of a patient with a suspected stroke and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the stroke protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were the use of a stroke scale, blood glucose evaluation, use of supplemental oxygen, patient positioning, 12-lead electrocardiogram (ECG) and cardiac monitoring, fluid assessment and intravenous access, and stroke regionalization. Results Protocols across EMS agencies in California varied widely. Most used some sort of stroke scale with the majority using the Cincinnati Prehospital Stroke Scale (CPSS). All recommended the evaluation of blood glucose with the level for action ranging from 60 to 80mg/dL. Cardiac monitoring was recommended in 58% and 33% recommended an ECG. More than half required the direct transport to a primary stroke center and 88% recommended hospital notification. Conclusion Protocols for a patient with a suspected stroke vary widely across the state of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols. PMID:26973735
Strehlow, Matthew C; Rao, G.V. Ramana; Newberry, Jennifer A
Background: Many low- and middle-income countries depend on emergency medical technicians (EMTs), nurses, midwives, and layperson community health workers with limited training to provide a majority of emergency medical, trauma, and obstetric care in the prehospital setting. To improve timely patient care and expand provider scope of practice, nations leverage cellular phones and call centers for real-time online medical direction. However, there exist several barriers to adequate communication that impact the provision of emergency care. We sought to identify obstacles in the cellular communication process among GVK Emergency Management and Research Institute (GVK EMRI) EMTs in Gujarat, India. Methods: A convenience sample of practicing EMTs in Gujarat, India were surveyed regarding the barriers to call initiation and completion. Results: 108 EMTs completed the survey. Overall, ninety-seven (89.8%) EMTs responded that the most common reason they did not initiate a call with the call center physician was insufficient time. Forty-six (42%) EMTs reported that they were unable to call the physician one or more times during a typical workweek (approximately 5-6 twelve-hour shifts/week) due to their hands being occupied performing direct patient care. Fifty-eight (54%) EMTs reported that they were unable to reach the call center physician, despite attempts, at least once a week. Conclusion: This study identified multiple barriers to communication, including insufficient time to call for advice and inability to reach call center physicians. Identification of simple interventions and best practices may improve communication and ensure timely and appropriate prehospital care. PMID:27551654
Stiell, I G; Wells, G A; Spaite, D W; Nichol, G; O'Brien, B; Munkley, D P; Field, B J; Lyver, M B; Luinstra, L G; Dagnone, E; Campeau, T; Ward, R; Anderson, S
The Ontario Prehospital Advanced Life Support (OPALS) Study represents the largest prehospital study yet conducted, worldwide. This study will involve more than 25,000 cardiac arrest, trauma, and critically ill patients over an 8-year period (1994-2002). The current article, Part II, describes in detail the rationale and methodology for major trauma and respiratory distress patients and for an economic evaluation of Advanced Life Support (ALS) programs in the OPALS Study. The OPALS Study, using a rigorous controlled methodology and a large sample size, should clearly indicate the benefit in trauma and respiratory distress patient survival and morbidity that results from the widespread introduction of prehospital ALS programs to communities of many different sizes. [Stiell IG, Wells GA, Spaite DW, Nichol G, O'Brien B, Munkley DP, Field BJ, Lyver MB, Luinstra LG, Dagnone E, Campeau T, Ward R, Anderson S, for the OPALS Study Group: The Ontario Prehospital Advanced Life Support (OPALS) Study Part II: Rationale and methodology for trauma and respiratory distress patients.
Wegener, Stephen T; Pollak, Andrew N; Frey, Katherine P; Hymes, Robert A; Archer, Kristin R; Jones, Clifford B; Seymour, Rachel B; OʼToole, Robert V; Castillo, Renan C; Huang, Yanjie; Scharfstein, Daniel O; MacKenzie, Ellen J
Previous research suggests that the care provided to trauma patients could be improved by including early screening and management of emotional distress and psychological comorbidity. The Trauma Collaborative Care (TCC) program, which is based on the principles of well-established models of collaborative care, was designed to address this gap in trauma center care. This article describes the TCC program and the design of a multicenter study to evaluate its effectiveness for improving patient outcomes after major, high-energy orthopaedic trauma at level 1 trauma centers. The TCC program was evaluated by comparing outcomes of patients treated at 6 intervention sites (n = 481) with 6 trauma centers where care was delivered as usual (control sites, n = 419). Compared with standard treatment alone, it is hypothesized that access to the TCC program plus standard treatment will result in lower rates of poor patient-reported function, depression, and posttraumatic stress disorder.
Rubiano, Andrés M.; Sánchez, Álvaro I.; Guyette, Francis; Puyana, Juan C.
Introduction In response to a requirement for advanced trauma care nurses to provide combat tactical medical support, the antinarcotics arm of the Colombian National Police (CNP) requested the Colombian National Prehospital Care Association to develop a Combat Tactical Medicine Course (MEDTAC course). Objective To evaluate the effectiveness of this course in imparting knowledge and skills to the students. Methods We trained 374 combat nurses using the novel MEDTAC course. We evaluated students using pre-and postcourse performance with a 45-question examination. Field simulations and live tissue exercises were evaluated by instructors using a Likert scale with possible choices of 1 to 4. Interval estimation of proportions was calculated with a 95% confidence interval (95% CI). Differences in didactic test scores were assessed using a t-test at 0.05 level of statistical significance. Results Between March 2006 and July 2007, 374 combat nursing students of the CNP were trained. The difference between examination scores before and after the didactic part of the course was statistically significant (p < 0.01). After the practical session of the course, all participants (100%) demonstrated competency on final evaluation. Conclusions The MEDTAC course is an effective option improving the knowledge and skills of combat nurses serving in the CNP. MEDTAC represents a customized approach for military trauma care training in Colombia. This course is an example of specialized training available for groups that operate in austere environments with limited resources. PMID:19947877
Jones, Courtney Marie Cora; Cushman, Jeremy T; Lerner, E Brooke; Fisher, Susan G; Seplaki, Christopher L; Veazie, Peter J; Wasserman, Erin B; Dozier, Ann; Shah, Manish N
We describe the decision-making process used by emergency medical services (EMS) providers in order to understand how 1) injured patients are evaluated in the prehospital setting; 2) field triage criteria are applied in-practice; and 3) selection of a destination hospital is determined. We conducted separate focus groups with advanced and basic life support providers from rural and urban/suburban regions. Four exploratory focus groups were conducted to identify overarching themes and five additional confirmatory focus groups were conducted to verify initial focus group findings and provide additional detail regarding trauma triage decision-making and application of field triage criteria. All focus groups were conducted by a public health researcher with formal training in qualitative research. A standardized question guide was used to facilitate discussion at all focus groups. All focus groups were audio-recorded and transcribed. Responses were coded and categorized into larger domains to describe how EMS providers approach trauma triage and apply the Field Triage Decision Scheme. We conducted 9 focus groups with 50 EMS providers. Participants highlighted that trauma triage is complex and there is often limited time to make destination decisions. Four overarching domains were identified within the context of trauma triage decision-making: 1) initial assessment; 2) importance of speed versus accuracy; 3) usability of current field triage criteria; and 4) consideration of patient and emergency care system-level factors. Field triage is a complex decision-making process which involves consideration of many patient and system-level factors. The decision model presented in this study suggests that EMS providers place significant emphasis on speed of decisions, relying on initial impressions and immediately observable information, rather than precise measurement of vital signs or systematic application of field triage criteria.
Evenson, Kelly R.; Foraker, Randi; Morris, Dexter L.; Rosamond, Wayne D.
The purpose of this study was to systematically review and summarize prehospital and in-hospital stroke evaluation and treatment delay times. We identified 123 unique peer-reviewed studies published from 1981 to 2007 of prehospital and in-hospital delay time for evaluation and treatment of patients with stroke, transient ischemic attack, or stroke-like symptoms. Based on studies of 65 different population groups, the weighted Poisson regression indicated a 6.0% annual decline (p<0.001) in hours/year for prehospital delay, defined from symptom onset to emergency department (ED) arrival. For in-hospital delay, the weighted Poisson regression models indicated no meaningful changes in delay time from ED arrival to ED evaluation (3.1%, p=0.49 based on 12 population groups). There was a 10.2% annual decline in hours/year from ED arrival to neurology evaluation or notification (p=0.23 based on 16 population groups) and a 10.7% annual decline in hours/year for delay time from ED arrival to initiation of computed tomography (p=0.11 based on 23 population groups). Only one study reported on times from arrival to computed tomography scan interpretation, two studies on arrival to drug administration, and no studies on arrival to transfer to an in-patient setting, precluding generalizations. Prehospital delay continues to contribute the largest proportion of delay time. The next decade provides opportunities to establish more effective community based interventions worldwide. It will be crucial to have effective stroke surveillance systems in place to better understand and improve both prehospital and in-hospital delays for acute stroke care. PMID:19659821
Watts, Jennifer; Cowden, John D; Cupertino, A Paula; Dowd, M Denise; Kennedy, Chris
Racial, ethnic and language-based disparities occur throughout the US health system. Pediatric prehospital emergency medical services are less likely to be used by Latinos. We identified perceptions of and barriers to prehospital pediatric emergency care (911) access among Spanish-speaking parents. A qualitative study involving six focus groups was conducted. Spanish-speaking parents participated with a bilingual moderator. Topics discussed included experiences, knowledge, beliefs, fears, barriers, and improvement strategies. All groups were audiotaped, transcribed, and reviewed for recurring themes. Forty-nine parents participated. Though parents believed 911 was available to all, many were uncertain how to use it, and what qualified as an emergency. Barriers included language discordance, fear of exposing immigration status, and fear of financial consequences. Parents strongly desired to learn more about 911 through classes, brochures, and media campaigns. Prehospital emergency care should be available to all children. Further quantitative studies may help solidify the identified barriers and uncover areas needing improvement within Emergency Medical Systems. Addressing barriers to 911 use in Spanish-speaking communities could improve the equity of health care delivery, while also decreasing the amount of non-emergency 911 use.
McGarry, Adam B; Mott, Jeffrey C; Kotwal, Russ S
Documentation of medical care provided is paramount for improving performance and ultimately reducing morbidity and mortality. However, documentation of prehospital trauma care on the battlefield has historically been suboptimal. Modernization of prehospital documentation tools have aligned data and information to be gathered with up-to-date treatment being rendered through Tactical Combat Casualty Care (TCCC) protocols and practices. Our study was conducted to evaluate TCCC Card completion, and accuracy of card completion, by military medical providers conducting precombat training through the Tactical Combat Medical Care Course. Study results do not show a deficiency in TCCC documentation training as provided by this course which should translate to adequate ability to accurately document prehospital trauma care on the battlefield. Leadership emphasis and community acceptance is required to increase compliance with prehospital documentation.
Background Injuries from skiing and snowboarding became a major challenge for emergency care providers in Switzerland. In the alpine setting, early assessment of injury and health status is essential for the initiation of adequate means of care and transport. Nevertheless, validated standardized protocols for on-slope triage are missing. This article can assist in understanding the characteristics of injured winter sportsmen and exigencies for future on-slope triage protocols. Methods Six-year review of trauma cases in a tertiary trauma centre. Consecutive inclusion of all injured skiers and snowboarders aged >15 (total sample) years with predefined, severe injury to the head, spine, chest, pelvis or abdomen (study sample) presenting at or being transferred to the study hospital. Descriptive analysis of age, gender and injury pattern. Results Amongst 729 subjects (total sample) injured from skiing or snowboarding, 401 (55%, 54% of skiers and 58% of snowboarders) suffered from isolated limb injury. Amongst the remaining 328 subjects (study sample), the majority (78%) presented with monotrauma. In the study sample, injury to the head (52%) and spine (43%) was more frequent than injury to the chest (21%), pelvis (8%), and abdomen (5%). The three most frequent injury combinations were head/spine (10% of study sample), head/thorax (9%), and spine/thorax (6%). Fisher's exact test demonstrated an association for injury combinations of head/thorax (p < 0.001), head/abdomen (p = 0.019), and thorax/abdomen (p < 0.001). Conclusion The data presented and the findings from previous investigations indicate the need for development of dedicated on-slope triage protocols. Future research must address the validity and practicality of diagnostic on-slope tests for rapid decision making by both professional and lay first responders. Thus, large-scale and detailed injury surveillance is the future research priority. PMID:21521524
Booth, A; Steel, A; Klein, J
Major trauma is a leading cause of death and disability in the UK, particularly in the young. Pre-hospital emergency medicine (PHEM) involves provision of immediate medical care to critically ill and injured patients, across all age ranges, often in environments that may be remote and are not only physically challenging but also limited in terms of time and resources. PHEM is now a GMC-recognised subspecialty of anaesthesia or emergency medicine and the first recognised training program in the UK commenced in August 2012. This article discusses subspeciality development in PHEM, the competency based framework for training in PHEM, and the provision of pre-hospital emergency anaesthesia.
Forslund, Kerstin; Kihlgren, Mona; Ostman, Ingela; Sørlie, Venke
Acute chest pain is a common reason why people call an emergency medical dispatch (EMD) centre. We examined how patients with acute chest pain experience the emergency call and their pre-hospital care. A qualitative design was used with a phenomenological-hermeneutic approach. Thirteen patients were interviewed, three women and 10 men. The patients were grateful that their lives had been saved and in general were satisfied with their pre-hospital contact. Sometimes they felt that it took too long for the emergency operators to answer and to understand the urgency. They were in a life-threatening situation and their feeling of vulnerability and dependency was great. Time seemed to stand still while they were waiting for help during their traumatic experience. The situation was fraught with pain, fear and an experience of loneliness. A sense of individualized care is important to strengthen trust and confidence between the patient and the pre-hospital personnel. Patients were aware of what number to call to reach the EMD centre, but were uncertain about when to call. More lives can be saved if people do not hesitate to call for help.
Smyth, Michael A; Brace-McDonnell, Samantha J; Perkins, Gavin D
Introduction Sepsis is a common and potentially life-threatening response to an infection. International treatment guidelines for sepsis advocate that treatment be initiated at the earliest possible opportunity. It is not yet clear if very early intervention by ambulance clinicians prior to arrival at hospital leads to improved clinical outcomes among sepsis patients. Methoda We systematically searched the electronic databases MEDLINE, EMBASE, CINAHL, the Cochrane Library and PubMed up to June 2015. In addition, subject experts were contacted. We adopted the GRADE (grading recommendations assessment, development and evaluation) methodology to conduct the review and follow PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations to report findings. Results Nine studies met the eligibility criteria – one study was a randomized controlled trial while the remaining studies were observational in nature. There was considerable variation in the methodological approaches adopted and outcome measures reported across the studies. Because of these differences, the studies did not answer a unique research question and meta-analysis was not appropriate. A narrative approach to data synthesis was adopted. Conclusion There is little robust evidence addressing the impact of prehospital interventions on outcomes in sepsis. That which is available is of low quality and indicates that prehospital interventions have limited impact on outcomes in sepsis beyond improving process outcomes and expediting the patient’s passage through the emergency care pathway. Evidence indicating that prehospital antibiotic therapy and fluid resuscitation improve patient outcomes is currently lacking. PMID:27429693
Development Program. The authors have nothing to disclose. a Division of Trauma and Acute Care Surgery , San Antonio Military Medical Center, 3551 Roger Brooke...Drive, Fort Sam Houston, San Antonio, TX 78234, USA; b Department of Surgery , Uniformed Services University of the Health Sciences, Bethesda, MD...Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 810
Advanced decision-support capabilities for prehospital trauma care may prove effec- tive at improving patient care. Such functionality would be possible...illustrate two sets of important questions: are the individual com- ponents reliable (e.g., physical integrity, power, core functionality , and end-user...challenges may be relevant to broader efforts in de- ploying automated decision-support functionality in prehospital environments. In addition, the ex
Bowley, D M; Jansen, J O; Nott, D; Sapsford, W; Streets, C G; Tai, N R M
Testing and difficult decision-making is a sine qua non of surgical practice on military operations. Better pre-hospital care protocols, reduced evacuation timelines and increased scrutiny of outcome have rightfully emphasised the requirement of surgeons to "get it right, first time and every time" when treating patients. This article addresses five contentious areas concerning severe torso trauma, with relevant literature summarised by a subject matter expert, in order to produce practical guidance that will assist the newly deployed surgeon in delivering optimal clinical outcomes.
Rudehill, Anders; Bellander, Bo-Michael; Weitzberg, Eddie; Bredbacka, Sixten; Backheden, Magnus; Gordon, Emeric
This article describes the outcome of 1,508 patients with traumatic brain injuries (TBI) treated in a single neurosurgical unit over an 8-year period. Our aim has been to compare those outcomes with our previous results and with other large patient series. Another important goal was to evaluate the effect of the introduction of a 4-year ongoing study initiated in January 1993 using a new strategy of prehospital care on postresuscitation Glasgow Coma Score (GCS) and Glasgow Outcome Score (GOS). Results from the 1,508 patients showed good recovery or moderate disability in 69%, severe disability or vegetative state in 11%, and a mortality rate of 20%. When outcome of the most severely injured patients (GCS < or = 8) was compared with those of our previous and other large international patient series, more favorable outcome figures were shown in the present study. To evaluate the impact of the improved prehospital care after half of the study period, a logistic regression analysis showed after January 1993 a significantly increased expected odds/ratio for a postresuscitation GCS 8-15 rather than a GCS 3-4 (odds/ratio: 2.2; p < 0.001). For patients with postresuscitation GCS 5-7 and 8-15, the expected odds/ratio for a GOS 4-5 instead of GOS 1 increased significantly (odds/ratio: 2.2 and 1.7, respectively; p < 0.05-0.01). For patients with GCS 3-4, an increased expected odds/ratio (2.0; p < 0.05) for a GOS 2-3 rather than a GOS 1 was seen. The principal conclusion is that outcome for the severely injured patients in the present study is more favorable than in other large series of TBI. We posit that the introduction of effective prehospital care most likely contributed to the improved postresuscitation neurological status and consequently to the better outcome observed after January 1993.
Riggle, Kevin; Joshipura, Manjul; Quansah, Robert; Reynolds, Teri; Sherr, Kenneth; Mock, Charles
Abstract Objective To understand the degree to which the trauma care guidelines released by the World Health Organization (WHO) between 2004 and 2009 have been used, and to identify priorities for the future implementation and dissemination of such guidelines. Methods We conducted a systematic review, across 19 databases, in which the titles of the three sets of guidelines – Guidelines for essential trauma care, Prehospital trauma care systems and Guidelines for trauma quality improvement programmes – were used as the search terms. Results were validated via citation analysis and expert consultation. Two authors independently reviewed each record of the guidelines’ implementation. Findings We identified 578 records that provided evidence of dissemination of WHO trauma care guidelines and 101 information sources that together described 140 implementation events. Implementation evidence could be found for 51 countries – 14 (40%) of the 35 low-income countries, 15 (32%) of the 47 lower-middle income, 15 (28%) of the 53 upper-middle-income and 7 (12%) of the 59 high-income. Of the 140 implementations, 63 (45%) could be categorized as needs assessments, 38 (27%) as endorsements by stakeholders, 20 (14%) as incorporations into policy and 19 (14%) as educational interventions. Conclusion Although WHO’s trauma care guidelines have been widely implemented, no evidence was identified of their implementation in 143 countries. More serial needs assessments for the ongoing monitoring of capacity for trauma care in health systems and more incorporation of the guidelines into both the formal education of health-care providers and health policy are needed. PMID:27516636
Le Jan, Arnaud; Dupin, Aurélie; Garrigue, Bruno; Sapir, David
Under the authority of the French Biomedicine Agency, a new care pathway integrates refractory cardiac arrest patients into a process of organ donation. It is a medical, logistical and ethical challenge for the staff of the mobile emergency services.
Tuma, Mazin A.; Acerra, John R.; El-Menyar, Ayman; Al-Thani, Hassan; Al-Hassani, Ammar; Recicar, John F.; Al Yazeedi, Wafaa; Maull, Kimball I.
Background: This study was designed to identify the incidence, injury patterns, and actual medical costs of occupational-related falls in Qatar, in order to provide a reference for establishing fall prevention guidelines and recommendations. Settings and Design: Retrospective database registry review in Level 1 Trauma Center at Tertiary Hospital in Qatar. Materials and Methods: During a 12-month period between November 1st 2007 and October 31st 2008, construction workers who fell from height were enrolled. A database was designed to characterize demographics, injury severity score (ISS), total hospital length of stay, resource utilization, and cost of care. Statistical Analysis: Data were presented as proportions, mean ± standard deviation or median and range as appropriate. In addition, case fatality rate and cost analysis were obtained from the Biostatistics and finance departments of the same hospital. Results: There were 315 fall-related injuries, of which 298 were workplace related. The majority (97%) were male immigrants with mean age of 33 ± 11 years. The most common injuries were to the spine, head, and chest. Mean ISS was 16.4 ± 10. There was total of 29 deaths (17 pre-hospital and 12 in-hospital deaths) for a case fatality rate of 8.6%. Mean cost of care (rounded figures) included pre-hospital services Emergency Medical Services (EMS), trauma resuscitation room, radiology and imaging, operating room, intensive care unit care, hospital ward care, rehabilitation services, and total cost (123, 82, 105, 130, 496, 3048,434, and 4418 thousand United States Dollars (USD), respectively). Mean cost of care per admitted patient was approximately 16,000 USD. Conclusions: Falling from height at a construction site is a common cause of trauma that poses a significant financial burden on the health care system. Injury prevention efforts are warranted along with strict regulation and enforcement of occupational laws. PMID:23724377
Corse, Teija; Firth, Chelsea; Burke, John; Schor, Kenneth; Koterski, James F; McGraw, Sabrina; Vincent-Johnson, Nancy; Gordon, Lori
Operation Canine Lifeline was a tabletop exercise developed by students and faculty of Boston University School of Medicine's Healthcare Emergency Management master's program. The tabletop exercise led to discussion on current protocols for canines working in the field, what occurs if a canine encounters a toxin in the field, and what to do in situations of national security that require working with civilian agencies. This discussion led to the creation of a set of recommendations around providing prehospital veterinary care to government working dogs. The recommendations include a government-run veterinary toxicology hotline for the sole use of the government, issuing handlers deployment kits and preprogrammed smartphones that contain information on the care practices for dogs, and an increased effort for civilian integration, through local emergency medical services, in the emergency care of government canines. (Disaster Med Public Health Preparedness. 2017;11:15-20).
Goldberg, Scott A; Rojanasarntikul, Dhanadol; Jagoda, Andrew
Traumatic brain injury (TBI) is an important cause of death and disability, particularly in younger populations. The prehospital evaluation and management of TBI is a vital link between insult and definitive care and can have dramatic implications for subsequent morbidity. Following a TBI the brain is at high risk for further ischemic injury, with prehospital interventions targeted at reducing this secondary injury while optimizing cerebral physiology. In the following chapter we discuss the prehospital assessment and management of the brain-injured patient. The initial evaluation and physical examination are discussed with a focus on interpretation of specific physical examination findings and interpretation of vital signs. We evaluate patient management strategies including indications for advanced airway management, oxygenation, ventilation, and fluid resuscitation, as well as prehospital strategies for the management of suspected or impending cerebral herniation including hyperventilation and brain-directed hyperosmolar therapy. Transport decisions including the role of triage models and trauma centers are discussed. Finally, future directions in the prehospital management of traumatic brain injury are explored.
variability and spontaneous baroreflex sequences: implications for autonomic monitoring during hemorrhage. J Trauma. 2005;58:798–805. 4. Cooke WH, Ryan KL...routine would have to overcome signif- icant technical hurdles (the power spectral analysis that is used to generate the HF/LF measure is sensitive to
Leroy, J E; Bensouda, C; Durand, E; Greffet, A; Scemama, A; Carli, P; Danchin, N; Sauval, P
More and more elderly people are hospitalised with myocardial infarction. Little is known on their pre-hospital management. In 2001 and 2002, 105 patients aged 80 years or more with suspected ST elevation infarction were managed by the mobile intensive care unit system of the SAMU de Paris-Necker. Diagnosis of infarction was confirmed in 92 (88%). Over 60% of the patients were women. Median time delay from symptom onset to call to the emergency service was 127 minutes, longer in nonagenarians (175 vs 101 minutes). Prehospital use of aspirin was 81% and 39% received an intravenous bolus of heparin. A reperfusion strategy was decided in only 30% (primary PCI: 23/26). One-month mortality was 21% and was related to older age, time when the call to the Samu was made, and absence of current smoking. Overall, the prehospital management of very elderly patients with suspected ST elevation infarction appears far from optimal.
guide- lines are posted on both the Military Health System and the PHTLS Web sites.12 At 3-year to 4-year intervals, the TCCC guidelines are also...the Prehospital Trauma Life Support Manual; PHTLS is endorsed by the American College of Surgeons Committee on Trauma and the National Association of...versions of the TCCC guidelines are posted on both the Military Health System and the PHTLS Web sites. At 3-year to 4-year intervals, the TCCC guidelines
Martins, Pedro Paulo; do Prado, Marta Lenise
The present paper is about a reflection related to the emerging of Pre-Hospital Care in Brazil ant its respective models of care during the last few decades. By drawing out a basic historical trajectory we were able to point out the successful and dead end paths of this modality of health assistance in our country. The most recent attempts of standardization at a national level of this kind of service were analyzed, especially the Health Ministry Decree no. 2048/02, which constitutes itself as a starting point, offering subsidies to institutions and to those involved in this specific field of health knowledge, in order to remake the path within another perspective.
Adhikari, Debasis Das; Mahathi, Krishna; Ghosh, Urmi; Agarwal, Indira; Chacko, Anila; Jacob, Ebor; Ebenezer, Kala
Background: Data on the prehospital interventions received by critically ill children at arrival to Paediatric Emergency Services (PES) is limited in developing countries. This study aims to describe the pre-hospital care scenario, transport and their impact on outcome in non-traumatic, acutely ill children presenting in PES with agonal breathing. Methods: Prospective observational study done on children aged below 15 years arriving in PES with agonal breathing due to non-trauma related causes. Results: Out of 75 children studied, 69% were infants. The duration of illness among 65% of them (75) was less than 3 days. Majority of them (81%) had received treatment prior to arrival. Government sector physicians (72%), half of them (51%) being pediatricians were the major treating doctors. 37% of the children had arrived to the Emergency in an ambulance. Cardiopulmonary Resuscitation (CPR) was given to 27% on arrival in PES. Other interventions included fluid boluses to correct shock (92%) and inotrope infusion (56%). Sepsis (24%) and pneumonia (24%) were the most common diagnoses. Out of 75, 57 (76%) children who were stabilized and shifted to PICU and among them 27 (47%) survived to discharge. Normal blood pressure (p=0.0410) and non-requirement of CPR (0.0047) and inotropic infusion (0.0459) in PES were associated with a higher chance of survival. Conclusion: 36% (27/75) of children who arrived to our PES with agonal breathing survived to hospital discharge. Survival was significantly better among those who did not need CPR. PMID:28217595
Mellor, Adrian; Dodds, Naomi; Joshi, Raj; Hall, John; Dhillon, Sundeep; Hollis, Sarah; Davis, Pete; Hillebrandt, David; Howard, Eva; Wilkes, Matthew; Langdana, Burjor; Lee, David; Hinson, Nigel; Williams, Thomas Harcourt; Rowles, Joe; Pynn, Harvey
To support leaders and those involved in providing medical care on expeditions in wilderness environments, the Faculty of Pre-Hospital Care (FPHC) of The Royal College of Surgeons of Edinburgh convened an expert panel of leading healthcare professionals and expedition providers. The aims of this panel were to: (1) provide guidance to ensure the best possible medical care for patients within the geographical, logistical and human factor constraints of an expedition environment. (2) Give aspiring and established expedition medics a 'benchmark' of skills they should meet. (3) Facilitate expedition organisers in selecting the most appropriate medical cover and provider for their planned activity. A system of medical planning is suggested to enable expedition leaders to identify the potential medical risks and their mitigation. It was recognised that the scope of practice for wilderness medicine covers elements of primary healthcare, pre-hospital emergency medicine and preventative medicine. Some unique competencies were also identified. Further to this, the panel recommends the use of a matrix and advisory expedition medic competencies relating to the remoteness and medical threat of the expedition. This advice is aimed at all levels of expedition medic, leader and organiser who may be responsible for delivering or managing the delivery of remote medical care for participants. The expedition medic should be someone equipped with the appropriate medical competencies, scope of practice and capabilities in the expedition environment and need not necessarily be a qualified doctor. In addition to providing guidance regarding the clinical competencies required of the expedition medic, the document provides generic guidance and signposting to the more pertinent aspects of the role of expedition medic.
Background In organised trauma systems the process of care is the key to quality. Nevertheless, the optimal process of trauma care remains unclear due to lack of or inconclusive evidence. Because monitoring and improving the performance of a trauma system is complex, this study aimed to develop consensus-based process guidelines for trauma care in the Netherlands for severely injured patients. Methods A five-round Delphi study was conducted with 141 participants that represent all professions involved in trauma care. Sensitivity analyses were carried out to evaluate whether consensus extended across all professions and to detect possible bias. Results Consensus was reached on 21 guidelines within 4 categories: timeliness, actions, competent teams and interdisciplinary process. Timeliness guidelines set specific critical limits and definitions for 10 time intervals in the time period from an emergency call until the patient leaves the trauma room. Action guidelines reflect aspects of appropriate care and strongly rely on the international Advanced Trauma Life Support principles. Competence guidelines include flow charts to assess the competence of prehospital and emergency department teams. Essential to competent teams are education and experience of all team members. The interdisciplinary process guideline focuses on cooperation, communication and feedback within and between all professions involved. Consensus was extended across all professions and no bias was detected. Conclusions In this Delphi study, a large expert panel agreed on a set of guidelines describing the optimal process of care for severely injured trauma patients in the Netherlands. In addition to time intervals and appropriate actions, these guidelines emphasise the importance of team competence and interdisciplinary processes in trauma care. The guidelines can be seen as a description of a best practice and a new field standard in the Netherlands. The next step is to implement the guidelines and
Background Although clinical applications such as emergency medicine and prehospital care could benefit from a fast-mounting electroencephalography (EEG) recording system, the lack of specifically designed equipment restricts the use of EEG in these environments. Methods This paper describes the design and testing of a six-channel emergency EEG (emEEG) system with a rapid preparation time intended for use in emergency medicine and prehospital care. The novel system comprises a quick-application cap, a device for recording and transmitting the EEG wirelessly to a computer, and custom software for displaying and streaming the data in real-time to a hospital. Bench testing was conducted, as well as healthy volunteer and patient measurements in three different environments: a hospital EEG laboratory, an intensive care unit, and an ambulance. The EEG data was evaluated by two experienced clinical neurophysiologists and compared with recordings from a commercial system. Results The bench tests demonstrated that the emEEG system's performance is comparable to that of a commercial system while the healthy volunteer and patient measurements confirmed that the system can be applied quickly and that it records quality EEG data in a variety of environments. Furthermore, the recorded data was judged to be of diagnostic quality by two experienced clinical neurophysiologists. Conclusions In the future, the emEEG system may be used to record high-quality EEG data in emergency medicine and during ambulance transportation. Its use could lead to a faster diagnostic, a more accurate treatment, and a shorter recovery time for patients with neurological brain disorders. PMID:24886096
Mehrara, Mostafa; Tavakoli, Nader; Fathi, Marzieh; Mahshidfar, Babak; Zare, Mohammad Amin; Asadi, Azita; Hosseinzadeh, Saeedeh; Safdarian, Mehdi
Introduction: Although many protocols are available in the field of the prehospital medical care (PMC), there is still a notable gap between protocol based directions and applied clinical practice. This study measures the rate of protocol adherence in PMC provided for patients with chest pain and loss of consciousness (LOC). Method: In this cross-sectional study, 10 educated research assistants audited the situation of provided PMC for non-traumatic chest pain and LOC patients, presenting to the emergency department of a tertiary level teaching hospital, compare to national recommendations in these regards. Results: 101 cases with the mean age of 56.7 ± 12.3 years (30-78) were audited (55.4% male). 61 (60.3%) patients had chest pain and 40 (39.7%) cases had LOC. Protocol adherence rates for cardiac monitoring (62.3%), O2 therapy (32.8%), nitroglycerin administration (60.7%), and aspirin administration (52.5%) in prehospital care of patients with chest pain were fair to poor. Protocol adherence rates for correct patient positioning (25%), O2 therapy (75%), cardiac monitoring (25%), pupils examination (25%), bedside glucometery (50%), and assessing for naloxone administration (55%) in prehospital care of patients with LOC were fair to poor. Conclusion: There were more than 20% protocol violation regarding prehospital care of chest pain patients regarding cardiac monitoring, O2 therapy, and nitroglycerin and aspirin administration. There were same situation regarding O2 therapy, positioning, cardiac monitoring, pupils examination, bedside glucometery, and assessing for naloxone administration of LOC patients in prehospital setting. PMID:28286847
Sampalis, J S; Lavoie, A; Williams, J I; Mulder, D S; Kalina, M
Flora's Z statistic and standardized mortality ratios (SMRs) as indicators of excess mortality were calculated for a sample of 355 patients with major trauma. A statistically significant overall excess mortality was observed in this sample (Z = 6.77, SMR = 1.81, p less than 0.05). Advanced life support provided by physicians at the scene (MD-ALS) was not associated with reduced excess mortality. A significant trend toward lower excess mortality was associated with a higher level of trauma care at the receiving hospital (p less than 0.05). Total prehospital time over 60 minutes was associated with a significant increase in excess mortality (p less than 0.001). These results support regionalization of trauma care and failed to show any benefit associated with MD-ALS.
Gigon, Fabienne; Merlani, Paolo; Ricou, Bara
Advance directives (AD) were developed to respect patient autonomy. However, very few patients have AD, even in cases when major cardiovascular surgery is to follow. To understand the reasons behind the low prevalence of AD and to help decision making when patients are incompetent, it is necessary to focus on the impact of prehospital practitioners, who may contribute to an increase in AD by discussing them with patients. The purpose of this study was to investigate self-rated communication skills and the attitudes of physicians potentially involved in the care of cardiovascular patients toward AD.Self-administered questionnaires were sent to general practitioners, cardiologists, internists, and intensivists, including the Quality of Communication Score, divided into a General Communication score (QOCgen 6 items) and an End-of-life Communication score (QOCeol 7 items), as well as questions regarding opinions and practices in terms of AD.One hundred sixty-four responses were received. QOCgen (mean (±SD)): 9.0/10 (1.0); QOCeol: 7.2/10 (1.7). General practitioners most frequently start discussions about AD (74/149 [47%]) and are more prone to designate their own specialty (30/49 [61%], P < 0.0001). Overall, only 57/159 (36%) physicians designated their own specialty; 130/158 (82%) physicians ask potential cardiovascular patients if they have AD and 61/118 (52%) physicians who care for cardiovascular patients talk about AD with some of them.The characteristics of physicians who do not talk about AD with patients were those who did not personally have AD and those who work in private practices.One hundred thirty-three (83%) physicians rated the systematic mention of patients' AD in the correspondence between physicians as good, while 114 (71%) at the patients' first registration in the private practice.Prehospital physicians rated their communication skills as good, whereas end-of-life communication was rated much lower. Only half of those surveyed speak about AD
Vavilala, Monica S.; Lujan, Silvia B.; Qiu, Qian; Petroni, Gustavo J.; Ballarini, Nicolás M.; Guadagnoli, Nahuel; Depetris, María Alejandra; Faguaga, Gabriela A.; Baggio, Gloria M.; Busso, Leonardo O.; García, Mirta E.; González Carrillo, Osvaldo R.; Medici, Paula L.; Sáenz, Silvia S.; Vanella, Elida E.; Fabio, Anthony; Bell, Michael J.
Objective There is little information on the type of early care provided to children with traumatic brain injury (TBI) in low middle income countries. We benchmarked early prehospital [PH] and emergency department [ED] pediatric TBI care in Argentina. Methods We conducted a secondary analysis of data from patients previously enrolled in a prospective seven center study of children with TBI. Eligible participants were patients 0–18 years, and had diagnosis of TBI (admission Glasgow Coma scale score [GCS] < 13 or with GCS 14–15 and abnormal head CT scan within 48 hours of admission, and head AIS > 0). Outcomes were transport type, transport time, PH and ED adherence to best practice, and discharge Pediatric Cerebral Performance Category Scale (PCPC) and Pediatric Overall Performance category Scale (POPC). Results Of the 366 children, mean age was 8.7 (5.0) years, 58% were male, 90% had isolated TBI and 45.4% were transported by private vehicle. 50 (34.7%) of the 144 children with severe TBI (39.3% of all TBI patients) were transported by private vehicle. Most (267; 73%) patients received initial TBI care at an index hospital prior to study center admission, including children with severe (81.9%) TBI. Transport times were shorter for those patients who were directly transported by ambulance to study center than for the whole cohort (1.4 vs.5.5 hours). Ambulance blood pressure data were recorded in 30.9%. ED guideline adherence rate was higher than PH guideline adherence rate (84.8% vs. 26.4%). For patients directly transferred from scene to study trauma centers, longer transport time was associated with worse discharge outcome (PCPC aOR 1.10 [1.04, 1.18] and (POPC aOR 1.10 [1.04, 1.18]). There was no relationship between PH or ED TBI guideline adherence rate and discharge POPC and PCPC. Conclusion This study benchmarks early pediatric TBI care in Argentina and shows that many critically injured children with TBI do not receive timely or best practice PH care, that
O'Dwyer, Gisele; Machado, Cristiani Vieira; Alves, Renan Paes; Salvador, Fernanda Gonçalves
Mobile prehospital care is a key component of emergency care. The aim of this study was to analyze the implementation of the State of Rio de Janeiro's Mobile Emergency Medical Service (SAMU, acronym in Portuguese). The methodology employed included document analysis, visits to six SAMU emergency call centers, and semistructured interviews conducted with 12 local and state emergency care coordinators. The study's conceptual framework was based on Giddens' theory of structuration. Intergovernmental conflicts were observed between the state and municipal governments, and between municipal governments. Despite the shortage of hospital beds, the SAMUs in periphery regions were better integrated with the emergency care network than the metropolitan SAMUs. The steering committees were not very active and weaknesses were observed relating to the limited role played by the state government in funding, management, and monitoring. It was concluded that the SAMU implementation process in the state was marked by political tensions and management and coordination weaknesses. As a result, serious drawbacks remain in the coordination of the SAMU with the other health services and the regionalization of emergency care in the state.
Holzman, T G; Griffith, A; Hunter, W G; Allen, T; Simpson, R J
Each year, civilian accidental injury results in 150,000 deaths and 400,000 permanent disabilities in the United States alone. The timely creation of and access to dynamically updated trauma patient information at the point of injury is critical to improving the state of care. Such information is often non-existent, incomplete, or inaccurate, resulting in less than adequate treatment by medics and the loss of precious time by medical personnel at the hospital or battalion aid station as they attempt to reassess and treat the patient. The Trauma Care Information Management System (TCIMS) is a prototype system for facilitating information flow and patient processing decisions in the difficult circumstances of civilian and military trauma care activities. The program is jointly supported by the United States Advanced Research Projects Agency (ARPA) and a consortium of universities, medical centers, and private companies. The authors' focus has been the human-computer interface for the system. We are attempting to make TCIMS powerful in the functions it delivers to its users in the field while also making it easy to understand and operate. To develop such a usable system, an approach known as user-centered design is being followed. Medical personnel themselves are collaborating with the authors in its needs analysis, design, and evaluation. Specifically, the prototype being demonstrated was designed through observation of actual civilian trauma care episodes, military trauma care exercises onboard a hospital ship, interviews with civilian and military trauma care providers, repeated evaluation of evolving prototypes by potential users, and study of the literature on trauma care and human factors engineering. This presentation at MedInfo '95 is still another avenue for soliciting guidance from medical information system experts and users. The outcome of this process is a system that provides the functions trauma care personnel desire in a manner that can be easily and
Bahadori, Mohammadkarim; Ghardashi, Fatemeh; Izadi, Ahmad Reza; Ravangard, Ramin; Mirhashemi, Sedigheh; Hosseini, Seyed Mojtaba
Context Pre-hospital care plays a vital role in saving trauma patients. Objectives This study aims to review studies conducted on the pre-hospital emergency status in Iran. Data Sources Data were sourced from Iranian electronic databases, including SID, IranMedex, IranDoc, Magiran, and non-Iranian electronic databases, such as Medline, Embase, Cochrane Library, Scopus, and Google Scholar. In addition, available data and statistics for the country were used. Data Selection All Persian-language articles published in Iranian scientific journals and related English-language articles published in Iranian and non-Iranian journals indexed on valid sites for September 2005 - 2014 were systematically reviewed. Data Extraction To review the selected articles, a data extraction form developed by the researchers as per the study’s objective was adopted. The articles were examined under two categories: structure and function of pre-hospital emergency. Results A total of 19 articles were selected, including six descriptive studies (42%), four descriptive-analytical studies (21%), five review articles (16%), two qualitative studies (10.5%), and two interventional (experimental) studies (10.5%). In addition, of these, 14 articles (73.5%) had been published in the English language. The focus of these selected articles were experts (31.5%), bases of emergency medical services (26%), injured (16%), data reviews (16%), and employees (10.5%). A majority of the studies (68%) investigated pre-hospital emergency functions and 32% reviewed the pre-hospital emergency structure. Conclusions The number of studies conducted on pre-hospital emergency services in Iran is limited. To promote public health, consideration of prevention areas, processes to provide pre-hospital emergency services, policymaking, foresight, systemic view, comprehensive research programs and roadmaps, and assessments of research needs in pre-hospital emergency seem necessary. PMID:27626016
Radjou, Angeline N; Mahajan, Preetam; Baliga, Dillip K
Background: The three pillars of a good trauma system are the prehospital care, definitive care, and rehabilitative services. The prehospital care is a critical component of the efforts to lower trauma mortality. Objective: To study the prehospital profile of patients who died due to trauma, compute the time taken to reach our facility, find the cause of delay, and make feasible recommendations. Materials and Methods: A hospital-based study was performed at a trauma center in Puducherry from June 2009 to August 2010. Puducherry is a union territory of India in the geographical terrain of the state of Tamil Nadu. A total of 241deaths due to trauma were included. Apart from the demographic and injury characteristics, a detailed prehospital log was constructed regarding the time of incident, the referral patterns, care given in the prehospital phase, the distance travelled, and the total time taken to reach our center. Results: The majority (59%) of patients were referred, with stopovers at two consecutive referral centers (30%), needing at least two vehicles to transport to definitive care (70%), clocking unnecessary distances (67%), and delayed due to non therapeutic intervention (87%). The majority of deaths (66%) were due to head injury. Only 2.96% of referred cases reached us within the first hour. Few of the patients coming directly to us had vehicle change due to local availability and lack of knowledge of predestined definitive care facility. Overall, 94.6% of direct cases arrived within 4 h whereas 93.3% of referred cases required up to 7 h to arrive at definitive care. Conclusions: Seriously injured patients lose valuable prehospital time because there is no direction regarding destination and interfacility transfer, a lack of seamless transport, and no concept of initial trauma care. The lack of direction is compounded in geographical areas that are situated at the border of political jurisdictions. PMID:23960371
Boschin, Matthias; Vordemvenne, Thomas
Injuries remain the leading cause of death in children and young adults. Management of multiple trauma patients has improved in recent years by quality initiatives (trauma network, S3 guideline "Polytrauma"). On this basis, strong links with preclinical management, structured treatment algorithms, training standards (ATLS®), clear diagnostic rules and an established risk- and quality management are the important factors of a modern emergency room trauma care. We describe the organizational components that lead to successful management of trauma in hospital.
Parker, Michael; Rodgers, Antony
Assessment and management of pain in pre-hospital care settings are important aspects of paramedic and clinical team roles. As emergency department waiting times and delays in paramedic-to-nurse handover increase, it becomes more and more vital that patients receive adequate pre-hospital pain relief. However, administration of analgesia can be inadequate and can result in patients experiencing oligoanalgesia, or under-treated pain. This article examines these issues along with the aetiology of trauma and the related socioeconomic background of traumatic injury. It reviews validated pain-assessment tools, outlines physiological responses to traumatic pain and discusses some of the misconceptions about the provision of effective analgesia in pre-hospital settings.
Multiple trauma management requires the application of modem trauma care theories. Optimal treatment results can be achieved by reinforcing cooperation and stipulating a treatment plan together with other disciplines. Based on modem theories in trauma care and our understanding of the theoretical points, this paper analyzes the injury assessment strategies and methods in oral and maxillofacial multiple trauma management. Moreover, this paper discusses operating time and other influencing factors as well as proposed definitive surgical timing and indications in comprehensive management of oral and maxillofacial multiple trauma patients associated with injuries in other body parts. We hope that this paper can help stomatological physicians deepen their understanding of modem trauma care theories and improve their capacity and results in the treatment of oral and maxillofacial multiple trauma.
FARINIUK, Luiz Fernando; de SOUSA, Maria Helena; WESTPHALEN, Vânia Portela Dietzel; CARNEIRO, Everdan; SILVA NETO, Ulisses X; ROSKAMP, Liliane; CAVALI, Ana Égide
Objectives The aim of this study was to evaluate cases of dental trauma treated at the specialized center of Pontifical Catholic University of Paraná, Curitiba, Brazil, during a period of 2 years. Material and Methods A total of 647 patients were evaluated and treated between 2003 and 2005. Data obtained from each patient were tabulated and analyzed as to gender, age, etiology, time elapsed after the injury, diagnosis (type of trauma), and affected teeth. Results The results revealed that male individuals aged 7 to 13 years presented the highest prevalence of injury, and falling was the main causal factor. In most cases, the time elapsed between the accident and the first care ranged from 4 to 24 h. A total of 1,747 teeth were affected, with higher incidence of concussion/subluxation and coronal fracture, followed by lateral luxation and avulsion. The permanent maxillary central incisors were the most commonly affected teeth. Conclusion The frequency and causes of dentoalveolar trauma should be investigated for identification of risk groups, treatment demands and costs in order to allow for the establishment of effective preventive measures that can reduce the treatment duration and costs for both patients and oral health services. PMID:20835567
Jacobs, L. M.; Bennett, B.
Civilian helicopters and emergency medical services in the United States have been in existence for approximately 15 years. The rapid growth of this type of health care delivery coupled with an increasing number of accidents has prompted professional and lay scrutiny of these programs. Although they have a demonstrated history of benefit to patients, the type and severity of injuries to patients who are eligible for helicopter transportation need further definition. The composition of the medical crews and the benefits that particular crew members bring to the patients require ongoing evaluation. Significant questions regarding the number of pilots in a helicopter and in a program remain to be answered. This article reviews the role of emergency medical air transport services in providing care to trauma patients, staff training and evaluation, and safety criteria and offers recommendations to minimize risks to patients and crews. PMID:2695653
Wish, John R; Long, William B; Edlich, Richard F
In March, 1970, the Maryland State Police, in cooperation with the University of Maryland, started the first statewide airborne transportation system. It was modeled after the army's success in Korea and Vietnam, where battlefield injuries were flown to front-line MASH units. The world's premier statewide medical aviation division was made possible through a cooperative effort between the Maryland State Police Aviation Division and Dr. R Adams Cowley at the University of Maryland Hospital as a public service to the citizens of the state. The Maryland Institute for Emergency Medical Services Systems (MIEMSS) has five components: (1) aircraft, (2) state troopers, (3) system communications (SYSCOM) center, (4) ambulance and fire emergency rescue, and (5) Level I adult and pediatric trauma centers and a regional burn center. The Maryland State Police Aviation Division now has 12 Aerospace Dauphin AS365N helicopters that operate out of eight fixed points throughout the state. Each helicopter has a two-person crew that consists of a pilot and a paramedic. Since 1993, the overall coordination of emergency medical services (EMS) has been under the purview of MIEMSS, an independent executive-level state agency that is governed by an appointed board and advisory council. To ensure stable funding for Maryland's world renowned emergency medical services (EMS) system, including med-evac helicopters, ambulances, fire equipment, rescue squads, and trauma units, a "surcharge" of $13.50 per year is collected with the automobile registration fee where applicable. The SYSCOM center in Baltimore coordinates the helicopter transport to the scene of the accident as well as referral to the specialty care facility: Adult Level I Trauma Center, Pediatric Level I Trauma Center, and Regional Burn Center. An on-the-scene evaluation of this exemplary emergency medical system in Maryland provides further convincing evidence of the performance of the Maryland State Police Aviation Division as
Forkey, Heather; Szilagyi, Moira
Children enter foster care with many forms of adversity and trauma beyond maltreatment that impact their short- and long-term physical, mental, and developmental health and their adaptation to their new care environment. Applying an understanding of the impact of toxic stress on the developing brain and body allows the health care provider to understand findings in this vulnerable population. Complex trauma alters immune response, neurodevelopment, and the genome, resulting in predictable and significant cognitive, behavioral, and physical consequences. Pediatric care of children in foster care must be trauma informed to meet their medical, mental health, and developmental needs.
Merrill, Alison S; Hayes, Janice S; Clukey, Lory; Curtis, Denise
Applying the theory of Nursing as Caring can help the nurse provide care that is perceived as caring by moderately to severely injured trauma patients. The Caring Behaviors Inventory was administered in a 1-to-1 interview format to hospitalized trauma patients in a level 2 trauma center. Nurses were positively perceived in their caring behaviors with some variation based on gender and ethnicity. The modified Caring Behaviors Inventory is quick to use and is reliable and valid.
Watt, Melissa H; Dennis, Alexis C; Choi, Karmel W; Ciya, Nonceba; Joska, John A; Robertson, Corne; Sikkema, Kathleen J
South African women have disproportionately high rates of both sexual trauma and HIV. To understand how sexual trauma impacts HIV care engagement, we conducted in-depth qualitative interviews with 15 HIV-infected women with sexual trauma histories, recruited from a public clinic in Cape Town. Interviews explored trauma narratives, coping behaviors and care engagement, and transcripts were analyzed using a constant comparison method. Participants reported multiple and complex traumas across their lifetimes. Sexual trauma hindered HIV care engagement, especially immediately following HIV diagnosis, and there were indications that sexual trauma may interfere with future care engagement, via traumatic stress symptoms including avoidance. Disclosure of sexual trauma was limited; no women had disclosed to an HIV provider. Routine screening for sexual trauma in HIV care settings may help to identify individuals at risk of poor care engagement. Efficacious treatments are needed to address the psychological and behavioral sequelae of trauma.
Schweigkofler, U; Hoffmann, R
Multiple trauma is still the most common cause of death in the age group below 40 years but rarely occurs in prehospital emergencies in Germany. Therefore, personal experience of emergency physicians in prehospital treatment of multiple trauma is often limited. Priority-based therapy according to standardized algorithms and advances in clinical and intensive care have reduced hospital mortality down to 13 %. Time factors, treatment and transport by Helicopter Emergency Medical Services seem to have had a significant impact on the outcome. The current German multiple trauma S3 guidelines provide algorithms for preclinical treatment. The underlying scientific evidence in this respect is, however, low.
Sand, Michael; Hessam, Schapoor; Bechara, Falk G.; Sand, Daniel; Vorstius, Christian; Bromba, Michael; Stockfleth, Eggert; Shiue, Ivy
Background: Quality of life in patients represents an important area of assessment. However, attention to health professionals should be equally important. The literature on the quality of life (QOL) of emergency physicians is scarce. This pilot study investigated QOL in emergency physicians in Germany. Materials and Methods: We conducted a cross-sectional study from January to June in 2015. We approached the German Association of Emergency Medicine Physicians and two of the largest recruitment agencies for emergency physicians in Germany and invited their members to participate. We used the WHO Q-BREF to obtain QOL scores in four domains that included physical, mental, social, and environmental health. Results: The 478 German emergency physicians included in the study held board certifications in general medicine (n = 40; 8.4%), anesthesiology (n = 243; 50.8%), surgery (n = 63; 13.2%), internal medicine (n = 81; 17.0%), or others (n = 51; 10.7%). The women surveyed tended to report a better QOL but worse general health than the men. Regarding specific domains, women scored worse in physical health, particularly energy during everyday work (relative risk ratio [RRR]: 1.98 [1.21–3.24]). Both men and women scored worse in psychological health than general health, particularly young women. Women were also more likely to view their safety (RRR: 1.87 [1.07–3.28]) and living place (RRR: 2.51 [1.10–5.73]) as being poor than their male counterparts. Conclusion: QOL in German prehospital emergency care physicians is satisfactory for the included participants; however, there were some negative effects in the psychological health domain. This is particularly obvious in young female emergency physicians. PMID:28331519
Haider, Adil H.; Weygandt, Paul Logan; Bentley, Jessica M.; Monn, Maria Francesca; Rehman, Karim Abdur; Zarzaur, Benjamin L.; Crandall, Marie L.; Cornwell, Edward E.; Cooper, Lisa A.
, prehospital factors, hospital/provider factors, and factors associated with postacute care and rehabilitation. While there are many proposed mechanisms, we believe that there are several interventions that could be particularly effective in combatting trauma disparities. These include trauma prevention programs targeting vulnerable populations, expansion of healthcare coverage, relocation of trauma centers to better provide for vulnerable populations, and restructuring clinical training to address implicit biases. While much work still remains to fully elucidate the mechanisms underlying trauma disparities, we can and should now act to begin to reduce or eliminate these disparities that still plague our healthcare system. Level of Evidence Two. PMID:23609267
Fratto, Carolyn M
For decades, evidence has shown an undeniable connection between childhood trauma and chronic adverse reactions across the lifespan (Bilchik & Nash, 2008; Perry, 2001; Perry, 2006). Childhood traumatic experiences are associated with serious and persistent, long-term physical, psychological, and substance abuse issues. In addition to adverse effects on physical health, research indicates that early childhood trauma has particularly adverse effects on adolescent self-esteem, coping skills, school performance, self-regulation, critical thinking, self-motivation, and the ability to build healthy relationships (O'Connell, Boat, & Warner, 2009). A traumatic event is a dangerous or distressing experience, outside the range of usual human experience that overwhelms the capacity to cope and frequently results in intense emotional and physical reactions, feelings of helplessness and terror, and threatens serious injury or death (The National Child Traumatic Stress Network [NCTSNET], 2014). Approximately five million children each year in the United States experience some type of traumatic experience (Perry, 2006). Nationwide community studies estimate between 25% and 61% of children and adolescents have a history of at least one exposure to a potentially traumatic event and 38.5% of American adults claim to have experienced at least one traumatic event before the age of 13 (Briggs et al., 2012; Gerson & Rappaport, 2013). According to results of a 2002-2003 survey of 900 New York City adolescents, 24% reported a history of witnessing someone being shot, 12% reported exposure to someone being killed, and 51% reported witnessing someone being beaten or mugged (O'Connell et al., 2009). Each year, 2-3 million children are victims of maltreatment, a type of trauma, including physical and/or sexual abuse (U.S. Department of Health and Human Services, 2014; Perry, 2006). Compared to the general population, youth in foster care are significantly more likely to have experienced
Lendrum, R A; Lockey, D J
The word 'trauma' describes the disease entity resulting from physical injury. Trauma is one of the leading causes of death worldwide and deaths due to injury look set to increase. As early as the 1970s, it became evident that centralisation of resources and expertise could reduce the mortality rate from serious injury and that organisation of trauma care delivery into formal systems could improve outcome further. Internationally, trauma systems have evolved in various forms, with widespread reports of mortality and functional outcome benefits when major trauma management is delivered in this way. The management of major trauma in England is currently undergoing significant change. The London Trauma System began operating in April 2010 and others throughout England became operational this year. Similar systems exist internationally and continue to be developed. Anaesthetists have been and continue to be involved with all levels of trauma care delivery, from the provision of pre-hospital trauma and retrieval teams, through to chronic pain management and rehabilitation of patients back into society. This review examines the international development of major trauma care delivery and the components of a modern trauma system.
Goldstein, Ellen; Athale, Ninad; Sciolla, Andrés F; Catz, Sheryl L
Context: Exposure to traumatic events is common in primary care patients, yet health care professionals may be hesitant to assess and address the impact of childhood trauma in their patients. Objective: To assess patient preferences for discussing traumatic experiences and posttraumatic stress disorder (PTSD) with clinicians in underserved, predominantly Latino primary care patients. Design: Cross-sectional study. Main Outcome Measure: We evaluated patients with a questionnaire assessing comfort to discuss trauma exposure and symptoms using the Adverse Childhood Experiences (ACE) Study questionnaire and the Primary Care-PTSD screen. The questionnaire also assessed patients’ confidence in their clinicians’ ability to help with trauma-related issues. Surveys were collected at an integrated medical and behavioral health care clinic. Results: Of 178 adult patients asked, 152 (83%) agreed to participate. Among participants, 37% screened positive for PTSD, 42% reported 4 or more ACEs, and 26% had elevated scores on both measures. Primary Care-PTSD and ACE scores were strongly positively correlated (r = 0.57, p < 0.001). Most patients agreed they were comfortable being asked about trauma directly or through screening questionnaires and did not oppose the inclusion of trauma-related information in their medical record. In addition, most patients perceived their clinician as comfortable asking questions about childhood trauma and able to address trauma-related problems. Conclusion: Screening is acceptable to most primary care patients regardless of trauma exposure or positive PTSD screening. Findings may aid primary care clinicians to consider screening regularly for ACEs and PTSD to better serve the health care needs of trauma-exposed patients. PMID:28333604
Liu, Nehemiah T; Holcomb, John B; Wade, Charles E; Darrah, Mark I; Salinas, Jose
This study was designed to investigate the quality of data in the pre-hospital and emergency departments when using a wearable vital signs monitor and examine the efficacy of a combined model of standard vital signs and respective data quality indices (DQIs) for predicting the need for life-saving interventions (LSIs) in trauma patients. It was hypothesised that prediction of needs for LSIs in trauma patients is associated with data quality. Also, a model utilizing vital signs and DQIs to predict the needs for LSIs would be able to outperform models using vital signs alone. Data from 104 pre-hospital trauma patients transported by helicopter were analysed, including means and standard deviations of continuous vital signs, related DQIs and Glasgow coma scale (GCS) scores for LSI and non-LSI patient groups. DQIs involved percentages of valid measurements and mean deviation ratios. Various multivariate logistic regression models for predicting LSI needs were also obtained and compared through receiver-operating characteristic (ROC) curves. Demographics of patients were not statistically different between LSI and non-LSI patient groups. In addition, ROC curves demonstrated better prediction of LSI needs in patients using heart rate and DQIs (area under the curve [AUC] of 0.86) than using heart rate alone (AUC of 0.73). Likewise, ROC curves demonstrated better prediction using heart rate, total GCS score and DQIs (AUC of 0.99) than using heart rate and total GCS score (AUC of 0.92). AUCs were statistically different (p < 0.05). This study showed that data quality could be used in addition to continuous vital signs for predicting the need for LSIs in trauma patients. Importantly, trauma systems should incorporate processes to regulate data quality of physiologic data in the pre-hospital and emergency departments. By doing so, data quality could be improved and lead to better prediction of needs for LSIs in trauma patients.
Mikkelsen, Søren; Krüger, Andreas J; Zwisler, Stine T; Brøchner, Anne C
Background Prehospital care provided by specially trained, physician-based emergency services (P-EMS) is an integrated part of the emergency medical systems in many developed countries. To what extent P-EMS increases survival and favourable outcomes is still unclear. The aim of the study was thus to investigate ambulance runs initially assigned ‘life-saving missions’ with emphasis on long-term outcome in patients treated by the Mobile Emergency Care Unit (MECU) in Odense, Denmark Methods All MECU runs are registered in a database by the attending physician, stating, among other parameters, the treatment given, outcome of the treatment and the patient's diagnosis. Over a period of 80 months from May 1 2006 to December 31 2012, all missions in which the outcome of the treatment was registered as ‘life saving’ were scrutinised. Initial outcome, level of competence of the caretaker and diagnosis of each patient were manually established in each case in a combined audit of the prehospital database, the discharge summary of the MECU and the medical records from the hospital. Outcome parameters were final outcome, the aetiology of the life-threatening condition and the level of competences necessary to treat the patient. Results Of 25 647 patients treated by the MECU, 701 (2.7%) received prehospital ‘life saving treatment’. In 596 (2.3%) patients this treatment exceeded the competences of the attending emergency medical technician or paramedic. Of these patients, 225 (0.9%) were ultimately discharged to their own home. Conclusions The present study demonstrates that anaesthesiologist administrated prehospital therapy increases the level of treatment modalities leading to an increased survival in relation to a prehospital system consisting of emergency medical technicians and paramedics alone and thus supports the concept of applying specialists in anaesthesiology in the prehospital setting especially when treating patients with cardiac arrest, patients in
Agarwal-Harding, Kiran J; von Keudell, Arvind; Zirkle, Lewis G; Meara, John G; Dyer, George S M
➤The burden of musculoskeletal trauma is high worldwide, disproportionately affecting the poor, who have the least access to quality orthopaedic trauma care.➤Orthopaedic trauma care is essential, and must be a priority in the horizontal development of global health systems.➤The education of surgeons, nonphysician clinicians, and ancillary staff in low and middle income countries is central to improving access to and quality of care.➤Volunteer surgical missions from rich countries can sustainably expand and strengthen orthopaedic trauma care only when they serve a local need and build local capacity.➤Innovative business models may help to pay for care of the poor. Examples include reducing costs through process improvements and cross-subsidizing from profitable high-volume activities.➤Resource-poor settings may foster innovations in devices or systems with universal applicability in orthopaedics.
Lin, Michelle P; Sanossian, Nerses; Liebeskind, David S
Despite significant quality improvement efforts to streamline in-hospital acute stroke care in the conventional model, there remain inherent layers of treatment delays, which could be eliminated with prehospital diagnostics and therapeutics administered in a mobile stroke unit. Early diagnosis using Telestroke and neuroimaging while in the ambulance may enable targeted routing to hospitals with specialized care, which will likely improve patient outcomes. Key clinical trials in Telestroke, mobile stroke units with prehospital neuroimaging capability, prehospital ultrasound and co-administration of various classes of neuroprotectives, antiplatelets and antithrombin agents with intravenous thrombolysis are discussed in this article. PMID:26308602
Dorsey, Shannon; Burns, Barbara J.; Southerland, Dannia G.; Cox, Julia Revillion; Wagner, H. Ryan; Farmer, Elizabeth M. Z.
Very little research has focused on rates of trauma exposure for youth in treatment foster care (TFC). Available research has utilized record review for assessing exposure, which presents limitations for the range of trauma types examined, as records are predominantly focused on abuse and neglect. The current study examines exposure rates and…
Whalen, Eileen; Hecker, Cynthia J; Butler, Steven
Harborview Medical Center in Seattle has been home to the pioneering work of University of Washington (UW) Medicine physicians and staff who have led innovations to improve trauma care for more than 40 years. As the only level I adult and pediatric trauma center and regional burn center for Washington, Alaska, Montana, and Idaho, Harborview provides cares for more than 6500 critically injured trauma and burn patients per year. Our physicians, researchers and staff are recognized as national experts and as collaborative partners with nursing in the delivery of outstanding clinical care, research, and education. Beginning with the establishment of Seattle Medic One in the late 1960s, a groundbreaking program to train firefighters as paramedics, Harborview and the work of UW Medicine has been recognized locally and globally as a leader in every component of the ideal trauma system, as defined by the American College of Surgeons: prevention, access, acute hospital care, rehabilitation, education, and research activities.
Payne, Ellen K.; Berry, David C.; Seitz, S. Robert
In Part 1 of this series [see: EJ1044392], the concepts of hemorrhaging, shock, and controlling bleeding as they relate to athletic training and prehospital emergency care along with the use of tourniquets were presented for athletic training educators (ATEs) to teach the skill in the classroom. This article, Part 2 of advanced bleeding control,…
Schafermeyer, R W
Prehospital curriculum development is a time-consuming, yet essential, component of emergency medical technician and paramedic education. Over the past several years, much has changed within the EMS system and with the approach to educating the prehospital care provider. Learning is defined as a permanent change in behavior that comes about as a result of a planned experience. This planned experience must include learning objectives that incorporate assessment of presenting signs and symptoms and demonstrate the prehospital care providers' psychomotor skills in providing prehospital care based on that assessment.
Tate, Ramsey C; Kelley, Maureen C
Minority pediatric populations have higher rates of emergency medical services use than the general pediatric population, and prior studies have documented that limited-English proficiency patients are more likely to undergo invasive procedures, require more resources, and be admitted once they arrive in the emergency department. Furthermore, limited-English proficiency patients may be particularly vulnerable because of immigration or political concerns. In this case report, we describe an infant with breath-holding spells for whom a language barrier in the prehospital setting resulted in an escalation of care to the highest level of trauma team activation. This infant underwent unnecessary, costly, and harmful interventions because of a lack of interpreter services. In a discussion of the legal, ethical, and medical implications of this case, we conclude that further investigation into prehospital strategies for overcoming language barriers is required to provide optimal prehospital care for pediatric patients.
Heimberg, Ellen; Hoffmann, Florian; Heinzel, Oliver; Kirschner, Hans-Joachim; Heinrich, Martina
Introduction. Several studies in pediatric trauma care have demonstrated substantial deficits in both prehospital and emergency department management. Methods. In February 2015 the PAEDSIM collaborative conducted a one and a half day interdisciplinary, simulation based team-training course in a simulated pediatric emergency department. 14 physicians from the medical fields of pediatric surgery, pediatric intensive care and emergency medicine, and anesthesia participated, as well as four pediatric nurses. After a theoretical introduction and familiarization with the simulator, course attendees alternately participated in six simulation scenarios and debriefings. Each scenario incorporated elements of pediatric trauma management as well as Crew Resource Management (CRM) educational objectives. Participants completed anonymous pre- and postcourse questionnaires and rated the course itself as well as their own medical qualification and knowledge of CRM. Results. Participants found the course very realistic and selected scenarios highly relevant to their daily work. They reported a feeling of improved medical and nontechnical skills as well as no uncomfortable feeling during scenarios or debriefings. Conclusion. To our knowledge this pilot-project represents the first successful implementation of a simulation-based team-training course focused on pediatric trauma care in German-speaking countries with good acceptance. PMID:28286528
... United States reported experiencing an attempted or completed rape at some time in their lives. Sexual violence, ... the CDC .* Military Sexual Trauma VA refers to sexual assault or repeated, threatening sexual harassment during military service ...
segment elevated myocardial infarction (STEMI) patients). An additional 23 prehospital patients were excluded because of missing or incomplete data...tool (J Trauma Acute Care Surgery 2014 Mar;76(3):743-9.), and is among the important findings from this project...Trauma Acute Care Surgery 2014 Mar;76(3):743-9 2) Van Haren RM, Ryan ML, Thorson CM, Namias N, Livingstone AS, Proctor KG: Bilateral near infrared
Harrop, James S; Rymarczuk, George N; Vaccaro, Alexander R; Steinmetz, Michael P; Tetreault, Lindsay A; Fehlings, Michael G
Management of spinal trauma is a complex and rapidly evolving field. To optimize patient treatment algorithms, an understanding of and appreciation for current controversies and advancing technologies in the field of spinal trauma is necessary. Therefore, members of the AOSpine Knowledge Forum Trauma initiative used a modified Delphi method to compile a list of controversial issues and emerging technologies in the field of spinal trauma, and a list of the 14 most relevant topics was generated. A total of 45 440 manuscripts covering the breadth of spine and spinal trauma were initially identified. This broad search was then refined using the 14 categories felt to be most relevant to the current field of spinal trauma. The results were further pared down using inclusion criteria to select for the most relevant topics. The 8 remaining topics were classification schemes, treatment of vertebral compression fractures, treatment of burst fractures, timing of surgery in spinal trauma, hypothermia, the importance of global sagittal balance, lumbar subarachnoid drainage, and diffusion magnetic resonance imaging. These 8 topics were felt to be the most relevant, controversial, rapidly evolving, and most deserving of inclusion in this summary. In summary, despite recent advances, the field of spinal trauma has many ongoing points of controversy. We must continue to refine our ability to care for this patient population through education, research, and development. It is anticipated that the new AOSpine fracture classification system will assist with prospective research efforts.
Fecser, Frank A.
There is increasing awareness that many children who present behavioral challenges have experienced relational trauma. These youngsters are not well served by traditional interventions in schools, treatment settings, and communities. Adults responsible for these young people often get drawn into conflict cycles and coercive interventions that only…
Trunkey, D D
Until recently the development of systems for trauma care in the United States has been inextricably linked to wars. During the Revolutionary War trauma care was based on European trauma principles particularly those espoused by the Hunter brothers. Surgical procedures were limited mostly to soft tissue injuries and amputations. The American Civil War was remarkable because of the contributions that were made to the development of systems for trauma care. The shear magnitude of casualties required extensive infrastructure to support the surgeons at the battlefield and to care for the wounded. For the first time in an armed conflict, anaesthetics were used on a routine basis. Despite these major contributions, hospital gangrene was a terrible problem and was the cause of many mortalities. World War I and World War II were noteworthy because of the contributions made by surgeons in the use of blood. One of the major lessons of World War II was the reemphasis of how frequently lessons have to be relearned regarding the treatment and care of wounds. Between the Korean Conflict and the Vietnam War the discovery was made of the tremendous fluid shifts into the cell after severe hemorrhagic shock. As a consequence, the treatment of patients with shock was altered during the Vietnam Conflict, which resulted in better outcomes and less renal failure. The first trauma centers for civilians were started in the United States in 1966. Since 1988 the number of states with mature trauma systems has expanded from two to 35. During the same period, many studies have documented the efficacy of trauma systems in reducing unnecessary mortality and disability.
Lossius, Hans Morten; Toft, Palle; Lassen, Annmarie Touborg
Objective When planning and dimensioning an emergency medical system, knowledge of the population serviced is vital. The amount of literature concerning the prehospital population is sparse. In order to add to the current body of literature regarding prehospital treatment, thus aiding future public health planning, we describe the workload of a prehospital anaesthesiologist-manned mobile emergency care unit (MECU) and the total population it services in terms of factors associated with mortality. Participants The study is a register-based study investigating all missions carried out by a MECU operating in a mixed urban/rural area in Denmark from 1 May 2006 to 31 December 2014. Information on missions was extracted from the local MECU registry and linked at the individual level to the Danish population-based databases, the National Patient Registry and the Civil Registration System. Primary and secondary outcome measures Primary outcome measures were number of missions and number of patient contacts. Secondary patient variables were mortality and association between mortality and age, sex, comorbidity, prior admission to hospital and response time. Results The MECU completed 41 513 missions (mean 13.1 missions/day) having 32 873 patient contacts, corresponding to 19.2 missions and 15.2 patient encounters per 1000 patient years. Patient variables: the median age was 57 years (range 0–108 years), 42.8% (42.3% to 43.4%) were women. For patients admitted to hospital alive, 30-day mortality was 5.7% (5.4% to 6.0%); 90-day mortality was 8.1% (7.8% to 8.5%) while 2-year mortality was 16.4% (16.0% to 16.8%). Increasing age, male sex, comorbidity and prior admission to hospital but not response time were associated with mortality. Conclusions Mortality following an incident requiring the assistance of a MECU was high in the first 2 years following the incident. MECU response time assessed as a continuous parameter was not associated with patient outcome. PMID
Mould-Millman, Nee-Kofi; Sasser, Scott M; Wallis, Lee A
Prehospital care constitutes an important link in the continuum of emergency care and confers a survival benefit to injured and ill persons. As development of acute and emergency care in sub-Saharan Africa expands, there is a strong need to improve the delivery of prehospital care to help relieve the overwhelming regional morbidity and mortality attributable to time-sensitive, life-threatening conditions. Effective research is integral to prehospital care development, as it helps quantify the need for prehospital care and tests effective solutions. Unfortunately, there is limited consensus guiding such research in the low-resource nations of sub-Saharan Africa that face unique challenges. This article aims to assimilate the current pertinent literature to demonstrate research success stories and challenges, and ultimately to build on previous efforts to establish prehospital research priorities for sub-Saharan Africa. Region-specific obstacles hindering prehospital research include the lack of epidemiologic data on emergency conditions, the underdevelopment of in-hospital emergency care, confusing prehospital terminology, poorly defined prehospital research priorities, the lack of qualified local prehospital researchers, and a poor understanding of local prehospital care systems. Solutions are offered to overcome each challenge by building on previous recommendations, by proposing new guiding principles, and by identifying areas where further consensus-building is needed. These guiding principles and suggestions are designed to steer discussions and output from future global health meetings targeted at improving prehospital research and development in sub-Saharan Africa.
Moylan, J A
This report reviews the history of the development of civilian helicopter ambulance program as a component of a total emergency medical services (EMS) system. Current literature demonstrates significant reduction in trauma mortality for those patients transported by air either from the scene of the accident or from an outlying hospital to a trauma center. The primary factor is not the speed of the transport but administration of life-saving care by the helicopter medical crew at the scene of the accident or at the outlying hospital. Regulations have been developed to assure proper patient selection, quality care, safety, and minimization of misuse of this expensive resource. Images Fig. 1. PMID:3058056
Shannon, Patricia J.; Simmelink-McCleary, Jennifer; Im, Hyojin; Becher, Emily; Crook-Lyon, Rachel E.
This article describes the development of self-care practices of social work students who were part of a larger study of students' experiences in a graduate course on the treatment of trauma. Consensual qualitative research methods were used to analyze 17 participant journals submitted at 4 times during the course. Findings indicated that…
Reid, J. G.; McGowan, J. J.; Ricci, M. A.; McFarlane, G.
Research has shown that diagnostic quality images for most teleradiology applications requires a sophisticated telemedicine system and access to a large amount of bandwidth. While the ideal standards have been set by those involved in evaluating teleradiology, these standards are impractical for many small rural health centers which deliver routine trauma care. While there is no disagreement about the ultimate need for this level of teleradiology support, the purpose of this research was to determine whether Orthopedists would be able to read plain radiographs of orthopedic trauma injuries using a desktop teleradiology system in support of rural trauma care. METHOD: Two radiology residents and two orthopedic residents viewed forty radiographs, twenty through a desktop teleradiology system and twenty in person. Diagnostic findings and certainty of diagnosis were recorded. FINDINGS: There was no statistically significant difference between modalities in orthopedic residents' ability to correctly diagnose orthopedic trauma injuries. Further, for those instances when the diagnosis was imprecise, the residents were aware of their inability to make an accurate diagnosis. CONCLUSION: Although the study was relatively limited and further research needs to be done, the use of desktop teleradiology in support of rural orthopedic trauma consultation is a promising alternative to the more expensive forms of telemedicine technology. PMID:9357657
Gerhardt, Robert T; Reeves, Patrick T; Kotwal, Russ S; Mabry, Robert L; Robinson, John B; Butler, Frank
In addition to life-saving interventions, the assessment of pain and subsequent administration of analgesia are primary benchmarks for quality emergency medical services care which should be documented and analyzed. Analyze US combat casualty data from the Department of Defense Trauma Registry (DoDTR) with a primary focus on prehospital pain assessment, analgesic administration and documentation. Retrospective cohort study of battlefield prehospital and hospital casualty data were abstracted by DoDTR from available records from 1 September 2007 through 30 June 2011. Data included demographics; injury mechanism; prehospital and initial combat hospital pain assessment documented by standard 0-to-10 numeric rating scale; analgesics administered; and survival outcome. Records were available for 8,913 casualties (median ISS of 5 [IQR 2 to 10]; 98.7% survived). Prehospital analgesic administration was documented for 1,313 cases (15%). Prehospital pain assessment was recorded for 581 cases (7%; median pain score 6 [IQR 3 to 8]), hospital pain assessment was recorded for 5,007 cases (56%; median pain score5 [CI95% 3 to 8]), and 409 cases (5%) had both prehospital and hospital pain assessments that could be paired. In this paired group, 49.1% (201/409) had alleviation of pain evidenced by a decrease in pain score (median 4,, IQR 2 to 5); 23.5% (96/409) had worsening of pain evidenced by an increase in pain score (median 3, CI95 2.8 to 3.7, IQR 1 to 5); 27.4% (112/409) had no change; and the overall difference was an average decrease in pain score of 1.1 (median 0, IQR 0 to 3, p < 0.01). Time-series analysis showed modest increases in prehospital and hospital pain assessment documentation and prehospital analgesic documentation. Our study demonstrates that prehospital pain assessment, management, and documentation remain primary targets for performance improvement on the battlefield. Results of paired prehospital to hospital pain scores and time-series analysis demonstrate
Trauma Management in South Africa A. Facilities for Prehospital Treatment B. Hospital Management C. The Johannesburg Experience IV. Special Features...Response to Heat Stroke During Islamic Pilgrimage (Hajj) V. Recommendations A. New Dimension of Experience and Knowledge for Medical Personnel, especially...Review Lactic Acidosis During Anesthesia for Grafting Procedure in Extensively Burned Patients Eight Months Experience of Acute Lung in a
hundred were incomplete and were therefore discarded. We also excluded babies (< 2 years of age); this left a total of 3,628 complete patient exemplars as...contained 4,125 complete patient records, with babies (< 2 years old) and extremely old people (> 95 years old) excluded. Among the NCTR patients, 472...blood pressure. Blood flow is allocated preferentially to those vital organs, namely the heart, lungs, and brain , least tolerant of oxygen debt. At the
Green, Bonnie L; Saunders, Pamela A; Power, Elizabeth; Dass-Brailsford, Priscilla; Schelbert, Kavitha Bhat; Giller, Esther; Wissow, Larry; Hurtado de Mendoza, Alejandra; Mete, Mihriye
Trauma exposure predicts mental disorders and health outcomes; yet there is little training of primary care providers about trauma's effects, and how to better interact with trauma survivors. This study adapted a theory-based approach to working with trauma survivors, Risking Connection, into a 6-hour CME course, Trauma-Informed Medical Care (TI-Med), to evaluate its feasibility and preliminary efficacy. We randomized four primary care sites to training or wait-list conditions; PCPs at wait-list sites were trained after reassessment. Primary care providers (PCPs) were Family Medicine residents (n = 17; 2 sites) or community physicians (n = 13; 2 sites). Outcomes reported here comprised a survey of 400 actual patients seen by the PCPs in the study. Patients, mostly minority, completed surveys before or after their provider received training. Patients rated PCPs significantly higher after training on a scale encompassing partnership issues. Breakdowns showed lower partnership scores for those with trauma or posttraumatic stress symptoms. Future studies will need to include more specific trauma-related outcomes. Nevertheless, this training is a promising initial approach to teaching trauma-informed communication skills to PCPs.
Collin-Vezina, Delphine; Coleman, Kim; Milne, Lise; Sell, Jody; Daigneault, Isabelle
The aim of this paper was to provide a description of the trauma experiences, trauma-related sequels, and resilience features of a sample of Canadian youth in residential care facilities, as well as to explore the impact of gender and of the number of different traumas experienced on trauma-related sequels and resilience features. A convenience…
Rippey, James C R; Royse, Alistair G
Point-of-care ultrasound is well suited for use in the emergency setting for assessment of the trauma patient. Currently, portable ultrasound machines with high-resolution imaging capability allow trauma patients to be imaged in the pre-hospital setting, emergency departments and operating theatres. In major trauma, ultrasound is used to diagnose life-threatening conditions and to prioritise and guide appropriate interventions. Assessment of the basic haemodynamic state is a very important part of ultrasound use in trauma, but is discussed in more detail elsewhere. Focussed assessment with sonography for Trauma (FAST) rapidly assesses for haemoperitoneum and haemopericardium, and the Extended FAST examination (EFAST) explores for haemothorax, pneumothorax and intravascular filling status. In regional trauma, ultrasound can be used to detect fractures, many vascular injuries, musculoskeletal injuries, testicular injuries and can assess foetal viability in pregnant trauma patients. Ultrasound can also be used at the bedside to guide procedures in trauma, including nerve blocks and vascular access. Importantly, these examinations are being performed by the treating physician in real time, allowing for immediate changes to management of the patient. Controversy remains in determining the best training to ensure competence in this user-dependent imaging modality.
Messing, Jonathan; Garces-King, Jasmine; Taylor, Dennis; Van Horn, Jonathan; Sarani, Babak; Christmas, A Britton
Nurse Practitioners and Physician Assistants, collectively known as advanced practitioners (APs), enhance the provision of care for the acutely injured patient. Despite their prevalence, institutions employ, train, and utilize these providers with significant variability. The Eastern Association for the Surgery of Trauma (EAST), the Society of Trauma Nurses (STN), and the American Association of Surgical Physicians Assistants (AASPA) acknowledge the value of APs and support their utilization in the management of injured and critically ill patients. This position paper offers insight into the history of, scope of practice for, and opportunities for optimal utilization of APs in trauma, critical care, and acute care surgery services.
0003; 2003. 29. McSwain NE Jr, Salomone J, Pons P, Bitner M, Callaway D, Guy J (eds). PHTLS : Prehospital Trauma life Support. 7th ed. St. Louis, MO...Mosby, Inc.; 2010. 30. McSwain NE Jr, Salomone J, Pons P, Giebner S (eds). PHTLS : Basic and Advanced Prehospital Trauma Life Support. 6th ed. St. Louis
Oral, Resmiye; Ramirez, Marizen; Coohey, Carol; Nakada, Stephanie; Walz, Amy; Kuntz, Angela; Benoit, Jenna; Peek-Asa, Corinne
Adverse childhood experiences (ACEs) are related to short- and long-term negative physical and mental health consequences among children and adults. Studies of the last three decades on ACEs and traumatic stress have emphasized their impact and the importance of preventing and addressing trauma across all service systems utilizing universal systemic approaches. Current developments on the implementation of trauma informed care (TIC) in a variety of service systems call for the surveillance of trauma, resiliency, functional capacity, and health impact of ACEs. Despite such efforts in adult medical care, early identification of childhood trauma in children still remains a significant public health need. This article reviews childhood adversity and traumatic toxic stress, presents epidemiologic data on the prevalence of ACEs and their physical and mental health impacts, and discusses intervention modalities for prevention.
Introduction Trauma provision in the UK is a topic of interest. Regional trauma networks and centres are evolving and research is blossoming, but what bearing does all this have on the care that is delivered to the individual patient? This article aims to provide an overview of key research concepts in the field of trauma care, to guide the clinician in decision making in the management of major trauma. Methods The Ovid MEDLINE®, EMBASE™ and PubMed databases were used to search for relevant articles on haemorrhage control, damage control resuscitation and its exceptions, massive transfusion protocols, prevention and correction of coagulopathy, acidosis and hypothermia, and damage-control surgery. Findings A wealth of research is available and a broad range has been reviewed to summarise significant developments in trauma care. Research has been categorised into disciplines and it is hoped that by considering each, a tailored management plan for the individual trauma patient will evolve, potentially improving patient outcome. PMID:23827287
de Abreu, Kelly Piacheski; Pelegrini, Alisia Helena Weis; Marques, Giselda Quintana; Lima, Maria Alice Dias da Silva
The Mobile Emergency Care Services handle urgent situations of various types, and demand for this service occurs according to the perception of the user regarding what is urgent. The aim of the study was to analyze the perceptions of urgency by users who demand care from a Mobile Emergency Care Service in Porto Alegre and to identify the reasons for these requests. In this explomratory-descriptive study, with qualitative approach, data were collected through semi-structured interviews conducted by telephone, during theperiod from February to April 2009. Thematic analysis was used to analyze the information. Users consider urgent life-threatening conditions, which require a quick response, and visible situations, such as bleeding, chronic diseases, and difficulties in transportation. Users themselves feel motivated to call the service due to it being rapid and free, and for transportation. The perceptions of users regarding urgency were diverse, sometimes consistent with the biomedical perspective of health providers and sometimes with their own social context.
Cook, Timothy Wayne; Cavalini, Luciana Tricai
Objectives To present the technical background and the development of a procedure that enriches the semantics of Health Level Seven version 2 (HL7v2) messages for software-intensive systems in telemedicine trauma care. Methods This study followed a multilevel model-driven approach for the development of semantically interoperable health information systems. The Pre-Hospital Trauma Life Support (PHTLS) ABCDE protocol was adopted as the use case. A prototype application embedded the semantics into an HL7v2 message as an eXtensible Markup Language (XML) file, which was validated against an XML schema that defines constraints on a common reference model. This message was exchanged with a second prototype application, developed on the Mirth middleware, which was also used to parse and validate both the original and the hybrid messages. Results Both versions of the data instance (one pure XML, one embedded in the HL7v2 message) were equally validated and the RDF-based semantics recovered by the receiving side of the prototype from the shared XML schema. Conclusions This study demonstrated the semantic enrichment of HL7v2 messages for intensive-software telemedicine systems for trauma care, by validating components of extracts generated in various computing environments. The adoption of the method proposed in this study ensures the compliance of the HL7v2 standard in Semantic Web technologies. PMID:26893947
Green, Bonnie L.; Saunders, Pamela A.; Power, Elizabeth; Dass-Brailsford, Priscilla; Schelbert, Kavitha Bhat; Giller, Esther; Wissow, Larry; Hurtado-de-Mendoza, Alejandra; Mete, Mihriye
BACKGROUND AND OBJECTIVES: Trauma exposure predicts mental disorders, medical morbidity, and healthcare costs. Yet trauma-related impacts have not received sufficient attention in primary care provider (PCP) training programs. This study adapted a theory-based approach to working with trauma survivors, Risking Connection, into a 6-hour CME course, Trauma-Informed Medical Care (TI-Med), and evaluated its efficacy. METHODS: We randomized PCPs to training or wait-list (delay) conditions; waitlist groups were trained after reassessment. The primary outcome assessing newly acquired skills was a patient-centeredness score derived from Roter Interactional Analysis System ratings of 90 taped visits between PCPs and standardized patients (SPs). PCPs were Family Medicine residents (n=17) and community physicians (n=13; 83% Family Medicine specialty), from four sites in the Washington DC metropolitan area. RESULTS: Immediately trained PCPs trended toward a larger increase in patient-centeredness than did the delayed PCPs (p < .09), with a moderate effect size (.66). The combined trained PCP groups showed a significant increase in patient-centeredness pre to post training, p < .01, Cohen’s D = .61. CONCLUSIONS: This is a promising approach to supporting relationship-based trauma-informed care among PCPs to help promote better patient health and higher compliance with medical treatment plans. PMID:25646872
Schilling, Samantha; Fortin, Kristine; Forkey, Heather
Children enter foster care with a myriad of exposures and experiences, which can threaten their physical and mental health and development. Expanding evidence and evolving guidelines have helped to shape the care of these children over the past two decades. These guidelines address initial health screening, comprehensive medical evaluations, and follow-up care. Information exchange, attention to exposures, and consideration of how the adversities, which lead to foster placement, can impact health is crucial. These children should be examined with a trauma lens, so that the child, caregiver, and community supports can be assisted to view their physical and behavioral health from the perspective of what we now understand about the impact of toxic stress. Health care providers can impact the health of foster children by screening for the negative health consequences of trauma, advocating for trauma-informed services, and providing trauma-informed anticipatory guidance to foster parents. By taking an organized and comprehensive approach, the health care provider can best attend to the needs of this vulnerable population.
Briese, G L
One of the major questions confronting prehospital care services today concerns determining the appropriate level of training for EMS personnel that will provide the most cost effective systems. Unfortunately there are no studies which assess this problem. Various communities have modified or expanded the roles of prehospital personnel beyond the traditional training of EMTs and paramedics. Continuing education and skills maintenance are ongoing problems faced by all EMS systems, which have been addressed in various ways by individual locales.
Frischknecht Christensen, Erika; Berlac, Peter Anthony; Nielsen, Henrik; Christiansen, Christian Fynbo
Aim of database The aim of the Danish quality database for prehospital emergency medical services (QEMS) is to assess, monitor, and improve the quality of prehospital emergency medical service care in the entire prehospital patient pathway. The aim of this review is to describe the design and the implementation of QEMS. Study population The study population consists of all “112 patient contacts” defined as emergency patients, where the entrance to health care is a 112 call forwarded to one of the five regional emergency medical coordination centers in Denmark since January 1, 2014. Estimated annual number of included “112 patients” is 300,000–350,000. Main variables We defined nine quality indicators and the following variables: time stamps for emergency calls received at one of the five regional emergency medical coordination centers, dispatch of prehospital unit(s), arrival of first prehospital unit, arrival of first supplemental prehospital unit, and mission completion. Finally, professional level and type of the prehospital resource dispatched to an incident and end-of-mission status (mission completed by phone, on scene, or admission to hospital) are registered. Descriptive data Descriptive data included age, region, and Danish Index for Emergency Care including urgency level. Conclusion QEMS is a new database under establishment and is expected to provide the basis for quality improvement in the prehospital setting and in the entire patient care pathway, for example, by providing prehospital data for research and other quality databases. PMID:27843347
Moffatt, Samuel Edwin
Hypovolaemic shock that results through traumatically inflicted haemorrhage can have disastrous consequences for the victim. Initially the body can compensate for lost circulating volume, but as haemorrhage continues compensatory mechanisms fail and the patient's condition worsens significantly. Hypovolaemia results in the lethal triad, a combination of hypothermia, acidosis and coagulopathy, three factors that are interlinked and serve to worsen each other. The lethal triad is a form of vicious cycle, which unless broken will result in death. This report will focus on the role of hypothermia (a third of the lethal triad) in trauma, examining literature to assess how prehospital temperature control can impact on the trauma patient. Spontaneous hypothermia following trauma has severely deleterious consequences for the trauma victim; however, both active warming of patients and clinically induced hypothermia can produce particularly positive results and improve patient outcome. Possible coagulopathic side effects of clinically induced hypothermia may be corrected with topical haemostatic agents, with the benefits of an extended golden hour given by clinically induced hypothermia far outweighing these risks. Active warming of patients, to prevent spontaneous trauma induced hypothermia, is currently the only viable method currently available to improve patient outcome. This method is easy to implement requiring simple protocols and contributes significantly to interrupting the lethal triad. However, the future of trauma care appears to lie with clinically induced therapeutic hypothermia. This new treatment provides optimism that in the future the number of deaths resulting from catastrophic haemorrhaging may be significantly lessened.
Cartaxo, Carla Kalline Alves; da Silva Nunes, Mariangela; Raposo, Oscar Felipe Falcão; Fakhouri, Ricardo; Hora, Edilene Curvelo
OBJECTIVE: To identify the scope and the characteristics of fall-related traumas in urgent care centers in Sergipe, Brazil and to verify potential associations among the following variables: gender, age, and where the event occurred. METHOD: This descriptive, cross-sectional study with a quantitative approach was conducted in the urgent care centers of two public referral hospitals in the state of Sergipe, Brazil. The data collection was conducted in November 2010, after approval was obtained from the Human Research Ethics Committee, through a structured interview with a sample of 509 fall victims. RESULTS: Most of the participants were male, between 0 and 19 years old, single, with no impairments or preexisting diseases, nor regular use of medication or alcohol. The victims were brought to the hospital by ambulance and were accompanied. Most events occurred at home, were same-level falls, and most frequently resulted from slipping and tripping during recreational activities with a subsequent fracture, contusion or sprain. Most victims were discharged from the hospital after care delivery. Statistically significant associations were found between place of fall and age and gender. CONCLUSION: There is a high incidence of seeking out care in urgent care centers due to falls, which constitutes a severe public health problem that affects both genders in different age groups. The adoption of preventive measures aimed to reduce such events is urgently required. PMID:23070338
Dhollande, Noémie; Vigani, Séverine; Angot, Nathalie; Sirabella, Julien
Nurses caring for multi-trauma patients returning from the operating theatre need to have extensive knowledge. Their role is to prevent and detect any complications, and namely respiratory and neurological complications, and act efficiently to keep the patient's condition from deteriorating.
Marsac, Meghan L; Kassam-Adams, Nancy; Hildenbrand, Aimee K; Nicholls, Elizabeth; Winston, Flaura K; Leff, Stephen S; Fein, Joel
Pediatric health care networks serve millions of children each year. Pediatric illness and injury are among the most common potentially emotionally traumatic experiences for children and their families. In addition, millions of children who present for medical care (including well visits) have been exposed to prior traumatic events, such as violence or natural disasters. Given the daily challenges of working in pediatric health care networks, medical professionals and support staff can experience trauma symptoms related to their work. The application of a trauma-informed approach to medical care has the potential to mitigate these negative consequences. Trauma-informed care minimizes the potential for medical care to become traumatic or trigger trauma reactions, addresses distress, provides emotional support for the entire family, encourages positive coping, and provides anticipatory guidance regarding the recovery process. When used in conjunction with family-centered practices, trauma-informed approaches enhance the quality of care for patients and their families and the well-being of medical professionals and support staff. Barriers to routine integration of trauma-informed approaches into pediatric medicine include a lack of available training and unclear best-practice guidelines. This article highlights the importance of implementing a trauma-informed approach and offers a framework for training pediatric health care networks in trauma-informed care practices.
Gogol, M; van den Heuvel, D; Lüttje, D; Püllen, R; Reingräber, A C; Schulz, R-J; Veer, A; Wittrich, A
For the care of the elderly, specific geriatric care facilities in hospitals and specialized rehabilitation centers have been established in the last 20 years throughout Germany. In addition, trauma surgery departments in hospitals and clinics also provide comprehensive care for trauma patients. The present requirements catalog was developed with the aim to ensure the standardization and quality assurance of these care facilities. Thus, the structural basics and, in particular, the structured cooperation between geriatrics and trauma surgery are described and defined in terms of structure, process, and outcome quality. The Bundesverband Geriatrie, the Deutsche Gesellschaft für Geriatrie, and the Deutsche Gesellschaft für Gerontologie und Geriatrie offer documentation for external and internal use and evaluation of the structures and processes for certification of geriatric trauma centers. Prerequisite for certification is to meet the technical requirements defined in the requirements catalogue or documents derived from it, and proof of a quality management system according to ISO 9001.
Sosa, Mary Ellen Burke
The pregnant woman who has experienced trauma will need to be transferred to an appropriate setting once she is stabilized. Nursing has evolved into many specialty areas with specific sets of skills developed to care for women in these areas. The trauma team and the intensive care unit team will most likely be uncomfortable with the pregnant woman. The perinatal team may be uncomfortable with the injuries or illness that brought the woman to the trauma unit. Together the combined knowledge of all teams can provide for safe care of the woman and fetus and prevent injury occurring to them. Collaborative care is part of the overall plan of care, which follows a formal plan already established by the leadership teams of the 2 units. The purpose of this article is to review collaborative care in the intensive care unit and to provide an overview of the nursing skill sets necessary to care for the pregnant trauma woman.
Mandrioli, Matteo; Inaba, Kenji; Piccinini, Alice; Biscardi, Andrea; Sartelli, Massimo; Agresta, Ferdinando; Catena, Fausto; Cirocchi, Roberto; Jovine, Elio; Tugnoli, Gregorio; Di Saverio, Salomone
The greatest advantages of laparoscopy when compared to open surgery include the faster recovery times, shorter hospital stays, decreased postoperative pain, earlier return to work and resumption of normal daily activity as well as cosmetic benefits. Laparoscopy today is considered the gold standard of care in the treatment of cholecystitis and appendicitis worldwide. Laparoscopy has even been adopted in colorectal surgery with good results. The technological improvements in this surgical field along with the development of modern techniques and the acquisition of specific laparoscopic skills have allowed for its utilization in operations with fully intracorporeal anastomoses. Further progress in laparoscopy has included single-incision laparoscopic surgery and natural orifice trans-luminal endoscopic surgery. Nevertheless, laparoscopy for emergency surgery is still considered challenging and is usually not recommended due to the lack of adequate experience in this area. The technical difficulties of operating in the presence of diffuse peritonitis or large purulent collections and diffuse adhesions are also given as reasons. However, the potential advantages of laparoscopy, both in terms of diagnosis and therapy, are clear. Major advantages may be observed in cases with diffuse peritonitis secondary to perforated peptic ulcers, for example, where laparoscopy allows the confirmation of the diagnosis, the identification of the position of the ulcer and a laparoscopic repair with effective peritoneal washout. Laparoscopy has also revolutionized the approach to complicated diverticulitis even when intestinal perforation is present. Many other emergency conditions can be effectively managed laparoscopically, including trauma in select hemodynamically-stable patients. We have therefore reviewed the most recent scientific literature on advances in laparoscopy for acute care surgery and trauma in order to demonstrate the current indications and outcomes associated with a
Mandrioli, Matteo; Inaba, Kenji; Piccinini, Alice; Biscardi, Andrea; Sartelli, Massimo; Agresta, Ferdinando; Catena, Fausto; Cirocchi, Roberto; Jovine, Elio; Tugnoli, Gregorio; Di Saverio, Salomone
The greatest advantages of laparoscopy when compared to open surgery include the faster recovery times, shorter hospital stays, decreased postoperative pain, earlier return to work and resumption of normal daily activity as well as cosmetic benefits. Laparoscopy today is considered the gold standard of care in the treatment of cholecystitis and appendicitis worldwide. Laparoscopy has even been adopted in colorectal surgery with good results. The technological improvements in this surgical field along with the development of modern techniques and the acquisition of specific laparoscopic skills have allowed for its utilization in operations with fully intracorporeal anastomoses. Further progress in laparoscopy has included single-incision laparoscopic surgery and natural orifice trans-luminal endoscopic surgery. Nevertheless, laparoscopy for emergency surgery is still considered challenging and is usually not recommended due to the lack of adequate experience in this area. The technical difficulties of operating in the presence of diffuse peritonitis or large purulent collections and diffuse adhesions are also given as reasons. However, the potential advantages of laparoscopy, both in terms of diagnosis and therapy, are clear. Major advantages may be observed in cases with diffuse peritonitis secondary to perforated peptic ulcers, for example, where laparoscopy allows the confirmation of the diagnosis, the identification of the position of the ulcer and a laparoscopic repair with effective peritoneal washout. Laparoscopy has also revolutionized the approach to complicated diverticulitis even when intestinal perforation is present. Many other emergency conditions can be effectively managed laparoscopically, including trauma in select hemodynamically-stable patients. We have therefore reviewed the most recent scientific literature on advances in laparoscopy for acute care surgery and trauma in order to demonstrate the current indications and outcomes associated with a
based resuscitation guidelines in prehospital trauma life sup- port ( PHTLS ) and advanced trauma life support (ATLS) may worsen the presenting acidosis and...eds. PHTLS Basic and Advanced Prehospital Trauma Life Support: Military Edition. 6th ed. St. Louis: Mosby; 2006. 56. Martini WZ, Pusateri AE
key prognostic decisions made by three groups of trauma care clinicians— field medical personnel and trauma centre nurses and physicians involved as the...were decided upon by the same person, the nurse survey was completed by an experienced nurse not involved in patient care, the field care providers had... Attitude and self-reported practice regarding prognostication in a national sample of internists. Arch Intern Med 1998;158:2389–95.  Mulholland SA
Cierniak, Marcin; Timler, Dariusz; Sobczak, Renata; Wieczorek, Andrzej; Sekalski, Przemyslaw; Borkowska, Natalia; Gaszynski, Tomasz
Background Intubation is still one of the best methods to secure the airway. In the case of prehospital or early hospital conditions when factors such as urgency, stress, or inaccuracy of the undertaken activities are involved, the risk of causing complications, for instance, edema or postintubation injuries, increases, especially while dealing with a difficult intubation. The risk of improper inflation of the endotracheal tube cuff also increases, which is considered in this study. Objective The aim of this study was to evaluate the prevalence of postintubation complications, such as postintubation injuries or edema, in a research sample, and to examine whether such complications occur more often, for example, while using a guidewire. In this study, we also evaluated the injuries associated with the inflation of the endotracheal tube cuff. Materials and methods This study was performed on a group of 153 patients intubated in prehospital conditions. The tests were carried out in three clinical sites that received patients from prehospital care. Postintubation injuries were revealed and photographed using videolar-yngoscope, such as the C-MAC and the McGrath series 5. The endotracheal tube cuff pressure was measured using a pressure gage manual (VBM Medizintechnik GmbH). The quantitative analyses of differences between incidence of variables were assessed using χ2 test for P<0.05. Analyses have been carried out using the Statistica software. Results In the group of 153 patients, postintubation injuries occurred in 17% of cases. The dependency between using the guidewire and the occurrence of the hematomas and loss of mucosa was statistically significant (P<0.01). In nearly half (42%) of the patients the endotracheal tube cuff pressure was excessively inflated over 30 cm H2O, and in two cases, endotracheal tube displacement was observed on account of poor cuff inflation (<20 cm H2O). Conclusion The highest percentage of overfilled cuffs were observed in the
Stiell, I G; Wells, G A; Spaite, D W; Lyver, M B; Munkley, D P; Field, B J; Dagnone, E; Maloney, J P; Jones, G R; Luinstra, L G; Jermyn, B D; Ward, R; DeMaio, V J
The Ontario Prehospital Advanced Life Support Study represents the largest prehospital study yet conducted, worldwide. This study will involve more than 25,000 cardiac arrest, trauma, and critically ill patients over an 8-year period. The study will evaluate the incremental benefit of rapid defibrillation and prehospital Advanced Cardiac Life Support measures for cardiac arrest survival and the benefit of Advanced Life Support for patients with traumatic injuries and other critically ill prehospital patients. This article describes the OPALS study with regard to the rationale and methodology for cardiac arrest patients.
Abdur-Rahman, Lukman O; van As, A B Sebastian; Rode, Heinz
Childhood trauma is one of the major health problems in the world. Although pediatric trauma is a global phenomenon in low- and middle-income countries, sub-Saharan countries are disproportionally affected. We reviewed the available literature relevant to pediatric trauma in Africa using the MEDLINE database, local libraries, and personal contacts. A critical review of all cited sources was performed with an emphasis on the progress made over the past decades as well as the ongoing challenges in the prevention and management of childhood trauma. After discussing the epidemiology and spectrum of pediatric trauma, we focus on the way forward to reduce the burden of childhood injuries and improve the management and outcome of injured children in Africa.
Seymour, Christopher W.; Alotaik, Osama; Wallace, David J.; Elhabashy, Ahmed E.; Chhatwal, Jagpreet; Rea, Thomas D; Angus, Derek C.; Nichol, Graham; Kahn, Jeremy M.
Objective Regionalization may improve critical care delivery, yet stakeholders cite concerns about its feasibility. We sought to determine the operational effects of prehospital regionalization of non-trauma, non-arrest critical illness. Design Discrete event simulation study Patients and setting All 2006 hospital discharge data from King County, Washington, linked to all adult, eligible patients transported by county EMS agencies. Methods We simulated active triage of high-risk patients to designated referral centers using a validated prehospital risk score; we studied three regionalization scenarios: (1) up triage, (2) up & down triage, (3) up & down triage after reducing intensive care unit (ICU) beds by 25%. We determined the effect on patient routing, ICU occupancy at referral and non-referral hospitals, and EMS transport times. Measurements and Main Results 119,117 patients were hospitalized at 11 non-referral centers and 76,817 patients were hospitalized at three referral centers. Among 20,835 EMS patients, 7,817 (43%) patients were eligible for up triage and 10,242 (57%) patients were eligible for down triage. At baseline mean daily ICU bed occupancy was 61% referral and 47% at non-referral hospitals. Up-triage increased referral ICU occupancy to 68%, up and down triage to 64%, and up and down triage with bed reduction to 74%. Mean daily non-referral ICU occupancy did not exceed 60%. Total EMS transport time increased by less than 3% with up and down triage. Conclusions Regionalization based on prehospital triage of the critically ill can allocate high-risk patients to referral hospitals without adversely affecting ICU occupancy or prehospital travel time. PMID:26102251
Sadek, Ahmed-Ramadan; Eynon, C Andy
The creation of neurosciences intensive care units was born out of the awareness that a group of neurological and neurosurgical patients required specialized intensive medical and nursing care. This first of two articles describes the role of neurosciences intensive care in the management of trauma and neurosurgical conditions.
Cornwell, Edward E
Trauma remains a significant and persistent public health problem, accounting for 90,000 deaths and 20 million people disabled annually. Current concepts of appropriate triage and emergency treatment of gunshot wounds are addressed from a trauma surgeon's perspective. Recent studies regarding prehospital transport policy, and acute diagnostic studies allow optimal treatment guidelines to be formulated. Specifically, rapid transport rather than prolonged on-scene treatment (including maneuvers such as formal thoracolumbar immobilization) should be given the highest priority. Also, routine arteriography (another time-consuming and invasive procedure) in the treatment of gunshot wounds to the extremity is no longer the standard of care.
an underlying traumatic injury and associated pain but also due to other stimuli potentially associated with the trauma setting, such as anxiety...Electronic evaluation of the fetal heart rate VIII. Patterns preceding fetal death, further observations. Am J Obstet Gy- necol 1963; 87:814–826 3...Haddad GG: Heart rate control in normal and aborted -SIDS in- fants. Am J Physiol 1993; 264:R638–R646 38. Peng CK, Havlin S, Stanley HE, et al: Quan
Jacobs, L. M.
Trauma and the management of injuries have changed considerably over the past century. A sound understanding of the factors that generate injuries and sophisticated systems that can be accessed immediately are now in place in most of the United States. The concept of a team approach to the management of multiple system injuries using specialists from all disciplines has resulted in the reduction of morbidity and mortality. Although many of the challenges of managing the trauma patient have been overcome, there are still a number of exciting areas that lend themselves to ongoing research. These changing perspectives allow for many exciting challenges for the trauma team. PMID:1507246
Introduction The benefits of transporting severely injured patients by helicopter remain controversial. This study aimed to analyze the impact on mortality of helicopter compared to ground transport directly from the scene to a University hospital trauma center. Methods The French Intensive Care Research for Severe Trauma cohort study enrolled 2,703 patients with severe blunt trauma requiring admission to University hospital intensive care units within 72 hours. Pre-hospital and hospital clinical data, including the mode of transport, (helicopter (HMICU) versus ground (GMICU), both with medical teams), were recorded. The analysis was restricted to patients admitted directly from the scene to a University hospital trauma center. The main endpoint was mortality until ICU discharge. Results Of the 1,958 patients analyzed, 74% were transported by GMICU, 26% by HMICU. Median injury severity score (ISS) was 26 (interquartile range (IQR) 19 to 34) for HMICU patients and 25 (IQR 18 to 34) for GMICU patients. Compared to GMICU, HMICU patients had a higher median time frame before hospital admission and were more intensively treated in the pre-hospital phase. Crude mortality until hospital discharge was the same regardless of pre-hospital mode of transport. After adjustment for initial status, the risk of death was significantly lower (odds ratio (OR): 0.68, 95% confidence interval (CI) 0.47 to 0.98, P = 0.035) for HMICU compared with GMICU. This result did not change after further adjustment for ISS and overall surgical procedures. Conclusions This study suggests a beneficial impact of helicopter transport on mortality in severe blunt trauma. Whether this association could be due to better management in the pre-hospital phase needs to be more thoroughly assessed. PMID:23131068
Castrèn, M; Mäkinen, M; Nilsson, J; Lindström, V
The aim of the study was to investigate whether interprofessional education (IPE) and interprofessional collaboration (IPC) during the educational program had an impact on prehospital emergency care nurses' (PECN) self-reported competence towards the end of the study program. A cross-sectional study using the Nurse Professional Competence (NPC) Scale was conducted. A comparison was made between PECN students from Finland who experienced IPE and IPC in the clinical setting, and PECN students from Sweden with no IPE and a low level of IPC. Forty-one students participated (Finnish n=19, Swedish n=22). The self-reported competence was higher among the Swedish students. A statistically significant difference was found in one competence area; legislation in nursing and safety planning (p<0.01). The Finnish students scored significantly higher on items related to interprofessional teamwork. Both the Swedish and Finnish students' self-reported professional competence was relatively low according to the NPC Scale. Increasing IPC and IPE in combination with offering a higher academic degree may be an option when developing the ambulance service and the study program for PECNs.
Razzak, Junaid A; Baqir, Syed M; Khan, Uzma Rahim; Heller, David; Bhatti, Junaid; Hyder, Adnan A
Background The importance of emergency medical care for the successful functioning of health systems has been increasingly recognised. This study aimed to evaluate emergency and trauma care facilities in four districts of the province of Sindh, Pakistan. Method We conducted a cross-sectional health facility survey in four districts of the province of Sindh in Pakistan using a modified version of WHO’s Guidelines for essential trauma care. 93 public health facilities (81 primary care facilities, nine secondary care hospitals, three tertiary hospitals) and 12 large private hospitals were surveyed. Interviews of healthcare providers and visual inspections of essential equipment and supplies as per guidelines were performed. A total of 141 physicians providing various levels of care were tested for their knowledge of basic emergency care using a validated instrument. Results Only 4 (44%) public secondary, 3 (25%) private secondary hospitals and all three tertiary care hospitals had designated emergency rooms. The majority of primary care health facilities had less than 60% of all essential equipments overall. Most of the secondary level public hospitals (78%) had less than 60% of essential equipments, and none had 80% or more. A fourth of private secondary care facilities and all tertiary care hospitals (n=3; 100%) had 80% or more essential equipments. The average percentage score on the physician knowledge test was 30%. None of the physicians scored above 60% correct responses. Conclusions The study findings demonstrated a gap in both essential equipment and provider knowledge necessary for effective emergency and trauma care. PMID:24157684
Shackford, S R; Mackersie, R C; Hoyt, D B; Baxt, W G; Eastman, A B; Hammill, F N; Knotts, F B; Virgilio, R W
We examined the impact of a trauma system on the survival of patients with a Trauma Score of 8 or less. We compared the observed survival with that predicted using a method that calculates the probability of survival (Ps) based on age, physiologic score, and anatomic severity of injury. Of 3394 patients triaged to trauma centers in a 12-month period, 283 (8.3%) had a Trauma Score of 8 or less. Sufficient data were available in 189 patients with blunt trauma to make the survival comparison. The Ps was 18%; the observed survival was 29%. Of 60 patients with penetrating trauma and complete data, the Ps was 8%; the observed survival was 20%. We attribute the improved survival to the integration of prehospital and hospital care and expeditious surgery.
Aléx, Jonas; Karlsson, Stig; Björnstig, Ulf; Saveman, Britt-Inger
Background The ambulance milieu does not offer good thermal comfort to patients during the cold Swedish winters. Patients’ exposure to cold temperatures combined with a cold ambulance mattress seems to be the major factor leading to an overall sensation of discomfort. There is little research on the effect of active heat delivered from underneath in ambulance care. Therefore, the aim of this study was to evaluate the effect of an electrically heated ambulance mattress-prototype on thermal comfort and patients’ temperatures in the prehospital emergency care. Methods A quantitative intervention study on ambulance care was conducted in the north of Sweden. The ambulance used for the intervention group (n=30) was equipped with an electrically heated mattress on the regular ambulance stretcher whereas for the control group (n=30) no active heat was provided on the stretcher. Outcome variables were measured as thermal comfort on the Cold Discomfort Scale (CDS), subjective comments on cold experiences, and finger, ear and air temperatures. Results Thermal comfort, measured by CDS, improved during the ambulance transport to the emergency department in the intervention group (p=0.001) but decreased in the control group (p=0.014). A significant higher proportion (57%) of the control group rated the stretcher as cold to lie down compared to the intervention group (3%, p<0.001). At arrival, finger, ear and compartment air temperature showed no statistical significant difference between groups. Mean transport time was approximately 15 minutes. Conclusions The use of active heat from underneath increases the patients’ thermal comfort and may prevent the negative consequences of cold stress. PMID:26374468
Trauma-informed care is an emerging value that is seen as fundamental to effective and contemporary mental health nursing practice. Trauma-informed care, like recovery, leaves mental health nurses struggling to translate these values into day-to-day nursing practice. Many are confused about what individual actions they can take to support these values. To date, the most clearly articulated policy to emerge from the trauma-informed care movement in Australia has been the agreement to reduce, and wherever possible, eliminate the use of seclusion and restraint. Confronted with the constant churn of admissions and readmissions of clients with challenging behaviours, and seemingly intractable mental illness, the elimination of seclusion and restraint is seen to be utopian by many mental health nurses in inpatient settings. Is trauma-informed care solely about eliminating seclusion and restraint, or are there other tangible practices nurses could utilize to effect better health outcomes for mental health clients, especially those with significant abuse histories? This article summarizes the findings from the literature from 2000-2011 in identifying those practices and clinical activities that have been implemented to effect trauma-informed care in inpatient mental health settings.
Huisman, Thierry A G M; Poretti, Andrea
Traumatic brain and spine injury (TBI/TSI) is a leading cause of death and lifelong disability in children. The biomechanical properties of the child's brain, skull, and spine, the size of the child, the age-specific activity pattern, and variance in trauma mechanisms result in a wide range of age-specific traumas and patterns of brain and spine injuries. A detailed knowledge about the various types of primary and secondary pediatric head and spine injuries is essential to better identify and understand pediatric TBI/TSI, which enhances sensitivity and specificity of diagnosis, will guide therapy, and may give important information about the prognosis. The purposes of this chapter are to: (1) discuss the unique epidemiology, mechanisms, and characteristics of TBI/TSI in children; (2) review the anatomic and functional imaging techniques that can be used to study common and rare pediatric TBI/TSI and their complications; (3) comprehensively review frequent primary and secondary brain injuries; and (4) to give a short overview of two special types of pediatric TBI/TSI: birth-related and nonaccidental injuries.
prehospital and in-hospital trauma care. The military version of the Ab- breviated Injury Scale [AIS(M)] is used to score injuries in deployed military...review. Increased accuracy might be achieved by actively collaborating in this process. Keywords: Injury Severity Score; Abbreviated Injury Scale ...the Abbreviated Injury Scale (AIS)3,4; (2) a military ad- aptation of the AIS [AIS(M)],5 which has been reported to predict mortality for casualties
Pati, Shibani; Pilia, Marcello; Grimsley, Juanita M.; Karanikas, Alexia T.; Oyeniyi, Blessing; Holcomb, John B.; Cap, Andrew P.; Rasmussen, Todd E.
ABSTRACT Trauma is a leading cause of death in both military and civilian populations worldwide. Although medical advances have improved the overall morbidity and mortality often associated with trauma, additional research and innovative advancements in therapeutic interventions are needed to optimize patient outcomes. Cell-based therapies present a novel opportunity to improve trauma and critical care at both the acute and chronic phases that often follow injury. Although this field is still in its infancy, animal and human studies suggest that stem cells may hold great promise for the treatment of brain and spinal cord injuries, organ injuries, and extremity injuries such as those caused by orthopedic trauma, burns, and critical limb ischemia. However, barriers in the translation of cell therapies that include regulatory obstacles, challenges in manufacturing and clinical trial design, and a lack of funding are critical areas in need of development. In 2015, the Department of Defense Combat Casualty Care Research Program held a joint military–civilian meeting as part of its effort to inform the research community about this field and allow for effective planning and programmatic decisions regarding research and development. The objective of this article is to provide a “state of the science” review regarding cellular therapies in trauma and critical care, and to provide a foundation from which the potential of this emerging field can be harnessed to mitigate outcomes in critically ill trauma patients. PMID:26428845
to a Level I trauma center experienced a reduction in predicted mortality rates . The medical records of 78 consecutive ground ambulance patients and...demonstrated no decrease in predicted and actual mortality rates . In this group, 16 patients were predicted to die and 18 actual deaths occurred.
Salloum, Alison; Scheeringa, Michael S.; Cohen, Judith A.; Storch, Eric A.
Young children who are exposed to traumatic events are at risk for developing posttraumatic stress disorder (PTSD). While effective psychosocial treatments for childhood PTSD exist, novel interventions that are more accessible, efficient, and cost-effective are needed to improve access to evidence-based treatment. Stepped care models currently being developed for mental health conditions are based on a service delivery model designed to address barriers to treatment. This treatment development article describes how trauma-focused cognitive-behavioral therapy (TF-CBT), a well-established evidence-based practice, was developed into a stepped care model for young children exposed to trauma. Considerations for developing the stepped care model for young children exposed to trauma, such as the type and number of steps, training of providers, entry point, inclusion of parents, treatment components, noncompliance, and a self-correcting monitoring system, are discussed. This model of stepped care for young children exposed to trauma, called Stepped Care TF-CBT, may serve as a model for developing and testing stepped care approaches to treating other types of childhood psychiatric disorders. Future research needed on Stepped Care TF-CBT is discussed. PMID:25411544
Carvalho Filho, Marcus Antonio Melo; Saintrain, Maria Vieira de Lima; Dos Anjos, Rita Edna da Silveira; Pinheiro, Solange Sousa; Cardoso, Luciana de Carvalho Pádua; Moizan, Jean André Hervé; de Aguiar, Andréa Silvia Walter
Objective To know the prevalence and etiology of oral and maxillofacial trauma in elders. Methods Analytical quantitative cross-sectional study conducted at a public trauma hospital located in Fortaleza-Ceará, Brazil. The study population comprised patients with trauma who were hospitalized from April to August 2014. Of these patients, patients with oral and maxillofacial trauma were chosen to be included in the research. A questionnaire was administered in order to obtain information on socio-demographics, systemic comorbidities, use of medication, deleterious habits (smoking and alcohol consumption), etiology of oral and maxillofacial trauma and type of pre-hospital care. Results Of the 280 elderly hospitalized with trauma, 47 had oral and maxillofacial trauma, with a prevalence of 16.8%. In this group, the age ranged from 60 to 88 years, with a mean age of 72.4 years (SD± 8.38). The elderly were mostly women (55.3%), self-declared pardos (53.2%), who presented with cardiovascular disorders (48.9%), and who received formal pre-hospital care (70.2%). Elderly who were in the 60–69 years age group, spent 6–9 years at school and drank alcohol were 2.64, 3.75, and 1.97, respectively, more likely to suffer oral and maxillofacial trauma. The main causes of trauma were physical aggression, traffic accidents, falls and domestic accidents. All of the physical aggressions resulted in oral and maxillofacial traumas, and the elderly who suffered traffic accidents were four times more likely to have oral and maxillofacial trauma. Conclusion The prevalence of 16.8% and the lack of research on oral and maxillofacial traumas in the elderly is worrisome and should be included in the oral health indicators for the elderly population to support the importance of oral health. PMID:26288229
Ho, Cheng-Maw; Lee, Chih-Hsin; Wang, Jann-Yuan; Lee, Po-Huang; Lai, Hong-Shiee; Hu, Rey-Heng; Chen, Jin-Shing
Abstract Abuse-related trauma remains a global health issue. However, there is paucity in nationwide reports. We aim to estimate the incidence of abuse-related trauma forward medical care and identify its characteristics and clinical course in Taiwan. Patients with trauma between 2005 and 2007 that occurred 3 months before or after a diagnosis of abuse were identified from a randomly sampled nationwide longitudinal health insurance database of 1 million beneficiaries. The patients’ demographic data, injury pattern, and medical resource utilization were measured, stratified by age and sex, and compared using chi-square test. Risk factors of next trauma event were identified using Cox regression analysis. Ninety-three patients (65 females) were identified (mean age, 20.6 ± 16.3 years), including 61.3% under 18 years of age. For the first trauma event, 68 patients (73.1%) visited the emergency room, 63 (67.7%) received intervention, and 14 (15.1%) needed hospital care. Seven (7.5%), all less than 11 years old, had intracranial hemorrhage and required intensive care. Thirty-three (35.5%) left with complications or sequelae, or required rehabilitation, but all survived. Of the 34 victims of sexual abuse, 32 were aged less than 18 years. Men received more mood stabilizers or antipsychotics (50.0% vs 10.7%, P = 0.030) and reeducative psychotherapy (25.0% vs 0, P = 0.044). Risk factors for a next trauma event were injury involving the extremities (hazard ratio [HR]: 5.27 [2.45–11.33]) and use of antibiotics (HR: 4.21 [1.45–12.24]) on the first trauma event. Abuse-related trauma has heterogeneous presentations among subgroups. Clinicians should be alert in providing timely diagnosis and individualized intervention. PMID:27787382
exchange during 2-to-4-week tours at the Land- stuhl Regional Medical Center in Landstuhl, Ger- many, between the leaders in civilian trauma care in the...performing surgical procedures and directing intensive care ; they also contribute to education at the center through lectures, serve as scientific...unlike any trau- ma center in the United States. The medical staff is charged with providing care for critically in- jured soldiers who have already
MILITARY MEDICINE, 180, 3:304, 2015 Prehospital Pain Medication Use by U.S. Forces in Afghanistan Col Stacy A. Shackelford, USAF MC*; Marcie Fowler...a process improvement initiative to examine the current use and safety of prehospital pain medications by U.S. Forces in Afghanistan. Prehospital pain ...casualties (39%) received pain medication during POI care and 283 (92%) received pain medication during tactical evacuation (TACEVAC). Morphine and
Multiple trauma represents the most serious type of trauma in which the result of the treatment depends on the quality of pre-hospital care according to ATLS (Advanced Trauma Life Support) as well as on the availability of emergency specialized care in traumatology centres. Resuscitation in the early post-injury phase involves prevention of the lethal triad (hypothermia, acidosis, coagulopathy) development, as early as during pre-hospital care and also during admission to a traumatology department (damage control resuscitation). Damage control resuscitation involves permissive hypotension and coagulopathy correction with red blood cells (RBCs), fresh frozen plasma and platelets administration with crystalloid solutions restriction. Management in a traumatology centre involves : 1. Determining the sequence for treating each of the injuries step by step: a) control of external and intracavitary bleeding, b) operation for craniocerebral injuries, c) external fixation of fractures. 2. Phased management of intracavitary injuries (damage control surgery) and injuries of the extremities (damage control orthopaedics). 3. Non-operative management of solid organs injuries including radiointervention procedures. 4. Post-injury intensive care after the primary operation (treatment of the lethal triad). 5. Treatment regimen extension in craniocerebral injuries (stabilisation of cerebral perfusion pressure with sufficient oxygenation). 6. Modern therapeutic strategies in mechanical ventilation (protective, non-invasive ventilation). 7. Integration of new imaging methods such as MDCT (Multidetector Computed Tomography). Ensuring complex management in polytrauma treatment requires active cooperation of numerous clinical disciplines, already in the early post-injury period.
Butler, Frank K
The US Military has achieved remarkable success in improving survival for our nation's combat wounded throughout the 14 years of conflict in Iraq and Afghanistan. For the prehospital phase of care, where most combat fatalities occur, these advances have been embodied in Tactical Combat Casualty Care (TCCC.) TCCC is a set of evidence-based, best-practice, prehospital trauma care guidelines that are customized for use on the battlefield. The TCCC Guidelines have been updated on an ongoing basis over the last 15 years through the work of the Committee on TCCC and the TCCC Working Group. The process of developing improvements in battlefield trauma care and advocating for them to be implemented throughout the US Military was lengthy, challenging, and evolutionary. This paper describes the major leadership lessons learned in the TCCC effort during the 20 years from its inception to the present.
Ghosh, Parthasarathi; Halder, Sandip Kumar; Paira, Susil Kumar; Mukherjee, Ramanuj; Kumar, Soumen Kanti; Mukherjee, Saibal Kumar
The profile and pattern of abdominal trauma is changing with progressing civilisation. We are lacking epidemiological data from most parts of the world. This study was conducted to prepare a database in our set up and look into the pattern of abdominal trauma, make an aetiological correlation of abdominal trauma with the types of injuries, identify the preventable factors causing delay in intervention and, compare the data with the other available national and international data. This prospective, observational study was done in a teaching hospital in a metropolitan city of eastern India. Records of patients with abdominal trauma were collected in predesigned forms, from admission to discharge. Data were analysed applying standard statistical techniques. Males (87.3%) predominated with the age range between 21 and 30 years, and the majority (73.5%) had blunt abdominal trauma. Compression injury (57.3%) commonly caused blunt trauma and stab injuries caused majority of penetrating trauma. The commonest organ injured both in blunt and penetrating trauma was small bowel (30.7% and 33.3% respectively). It was found that prehospital trauma care is virtually non-existent in this region. We are lacking a uniform protocol for the management of abdominal trauma across the hospitals. With the availability of better investigational modalities we are moving more towards a conservative approach to the abdominal trauma patients, especially the blunt abdominal trauma patients with solid organ injuries.
Diaz-Olavarrieta, Claudia; Garcia-Pina, Corina A.; Loredo-Abdala, Arturo; Paz, Francisco; Garcia, Sandra G.; Schilmann, Astrid
Objectives: Determine the prevalence, clinical signs and symptoms, and demographic and family characteristics of children attending a tertiary care hospital in Mexico City, Mexico, to illustrate the characteristics of abusive head trauma among this population. Methods: This is a cross-sectional descriptive study of infants and children under 5,…
Salloum, Alison; Scheeringa, Michael S.; Cohen, Judith A.; Storch, Eric A.
Background: In order to develop Stepped Care trauma-focused cognitive behavioral therapy (TF-CBT), a definition of early response/non-response is needed to guide decisions about the need for subsequent treatment. Objective: The purpose of this article is to (1) establish criterion for defining an early indicator of response/non-response to the…
Cancio LC, Barillo DJ, et al. Long range transport of war-related burn casualties. J Trauma. 2008;64(Suppl 2):S136YS144; discussion S144YS145. 33. Sherlock ...shock. J BurnCare Rehabil. 1989;10:17Y26. 96. Neff LP, Allman JM, Holmes JH. The use of theraputic plasma exchange (TPE) in the setting of refractory
Ibrahim, N.A.; Oludara, M.A.; Ajani, A.; Mustafa, I.; Balogun, R.; Idowu, O.; Osuoji, R.; Omodele, F.O.; Aderounmu, A.O.A.; Solagberu, B.A.
Introduction Significant deaths of between 21% and 38% occur from non-trauma surgical conditions in the accident and emergency room. Access to emergency surgical care is limited in many developing countries including Nigeria. We aimed to study the spectrum of non-trauma surgical emergencies, identify challenges in management and evaluate outcomes. Methods A one year prospective cohort study of all non-trauma emergencies in adults seen at the surgical emergency room of LASUTH from 1st October, 2011 to 30th September, 2012 was conducted. Data was analyzed using SPSS version 15.0. Results Of a total of 7536 patients seen, there were 7122 adults. Those with non-trauma conditions were 2065 representing 29% of adult emergencies. Age ranged between 15 and 97 years and male to female ratio was 1.7:1. Acute abdomen (30%), urological problems (18%) and malignancies (10%) were the most common. Among 985 patients requiring admission only 464 (47%) were admitted while the remaining 53% were referred to other centers. Emergency surgical intervention was carried out in 222 patients representing 48% of admitted patients. There were 12 (24%) non-trauma deaths in the emergency room. They were due to acute abdomen and malignancies in half of the cases. Conclusion Facilities for patients needing emergency care were inadequate with more than half of those requiring admission referred. Attention should be paid to the provision of emergency surgical services to the teeming number of patients seen on yearly basis in the Teaching Hospital. PMID:26566434
Rape trauma syndrome (RTS) is a posttraumatic stress disorder that can be triggered by routine procedures experienced during childbirth. An explanation of the signs and symptoms of RTS is provided, including how to avoid retraumatization during intrapartum care. A case report is presented from a provider perspective to illustrate the seriousness of this disorder and the importance of delivering respectful care. A new approach to obstetric routines is warranted to avoid further traumatizing the woman with RTS.
Maniscalco-Theberge, M E; Elliott, D C
The former Special Assistant to the Director on Biomedical Technology, Defense Advanced Research Projects Agency (DARPA), COL RM Satava, notes "Predicting the future trends in any profession jeopardizes the credibility of the author." Thus, we have attempted to outline current systems and prototype models in testing phases. Technologic advances will enable enhanced care of trauma patients. In the acute care setting, they also will affect the educational system in theory and practice.
Uthkarsh, Pallavi Sarji; Gururaj, Gopalkrishna; Reddy, Sai Sabharish; Rajanna, Mandya Siddalingaiah
Objective: To assess the availability of trauma care services in a district referral hospital of Southern India. Methods: This was a cross-sectional study being performed during 2013 in a tertiary healthcare centre in Southern Indian. A detailed assessment of trauma care services was done in a 400 bed speciality hospital which is an apex referral hospital in the public health system using a check list based on WHO guidelines for evaluation of essential trauma care services, along with in-depth interviews of hospital stake holders and key informants. Results: The hospital had physical infrastructure in terms of emergency room, inpatient wards, operation theatres, intensive care unit and blood bank facilities. The recently constructed designated building for trauma care services was not operational and existing facilities were used beyond capacity. A designated trauma team was lacking and speciality services for managing polytrauma were deficient and thus, existing personnel were performing multiple tasks. Neurosurgeons and rehabilitative nursing staff were unavailable, and a radiographer was not available on a 24/7 basis. Existing nursing personnel had not received any formal training in trauma care and standard operating protocols were not available for trauma care. Resources for acute resuscitation were partially adequate. The hospital lacked adequate resources to manage head, abdomen, chest and spine injuries, and most of the polytrauma cases were referred to nearby city hospitals. Conclusion: District hospital, the only referral hospital in public health system for trauma victims of that region, had inadequate resources to manage trauma victims, which was probably responsible for delay in trauma care, improper referrals, high cost of care and poor outcomes. PMID:27331066
Klauke, Nora; Gräff, Ingo; Fleischer, Andreas; Boehm, Olaf; Guttenthaler, Vera; Baumgarten, Georg; Meybohm, Patrick; Wittmann, Maria
Objectives Prehospital hypothermia is defined as a core temperature <36.0°C and has been shown to be an independent risk factor for early death in patients with trauma. In a retrospective study, a possible correlation between the body temperature at the time of admission to the emergency room and subsequent in-hospital transfusion requirements and the in-hospital mortality rate was explored. Setting This is a retrospective single-centre study at a primary care hospital in Germany. Participants 15 895 patients were included in this study. Patients were classified by admission temperature and transfusion rate. Excluded were ambulant patients and patients with missing data. Primary and secondary outcome measures The primary outcome values were length of stay (LOS) in days, in-hospital mortality, the transferred amount of packed red blood cells (PRBCs), and admission to an intensive care unit. Secondary influencing variables were the patient's age and the Glasgow Coma Scale. Results In 22.85% of the patients, hypothermia was documented. Hypothermic patients died earlier in the course of their hospital stay than non-hypothermic patients (p<0.001). The administration of 1–3 PRBC increased the LOS significantly (p<0.001) and transfused patients had an increased risk of death (p<0.001). Prehospital hypothermia could be an independent risk factor for mortality (adjusted OR 8.521; p=0.001) and increases the relative risk for transfusion by factor 2.0 (OR 2.007; p=0.002). Conclusions Low body temperature at hospital admission is associated with a higher risk of transfusion and death. Hence, a greater awareness of prehospital temperature management should be established. PMID:27029772
Enumah, Samuel; Scott, John W; Maine, Rebecca; Uwitonze, Eric; D'Arc Nyinawankusi, Jeanne; Riviello, Robert; Byiringiro, Jean Claude; Kabagema, Ignace; Jayaraman, Sudha
Introduction Injury is responsible for nearly five million annual deaths worldwide, and nearly 90% of these deaths occur in low- and middle-income countries (LMICs). Reliable clinical data detailing the epidemiology of injury are necessary for improved care delivery, but they are lacking in these regions.
Andersson, Sten-Ove; Dahlgren, Lars Owe; Lundberg, Lars; Sjöström, Björn
Emergency medical care for seriously injured patients in war or warlike situations is highly important when it comes to soldiers' survival and morale. The Swedish Armed Forces sends nurses, who have limited experience of caring for injured personnel in the field, on a variety of international missions. The aim of this investigation was to identify the kind of criteria nurses rely on when assessing acute trauma and what factors are affecting the emergency care of injured soldiers. A phenomenographic research approach based on interviews was used. The database for the study consists of twelve nurses who served in Bosnia in 1994-1996. The criteria nurses rely on, when assessing acute trauma in emergency care, could be described in terms of domain-specific criteria such as a physiological, an anatomical, a causal and a holistic approach as well as contextual criteria such as being able to communicate, having a sense of belonging, the military environment, the conscript medical orderly and familiarity with health-caring activity. The present study shows that the specific contextual factors affecting emergency care in the field must also be practised before the nurse faces military emergency care situations. This calls for realistic exercises and training programs, where experience from civilian emergency care is interwoven with the knowledge specific to military medical care.
Amathieu, Roland; Merouani, Medhi; Borron, Stephen W; Lapostolle, Frédéric; Smail, Nadia; Adnet, Frédéric
We report the case of a patient suspected of voluntary massive poisoning by ethylene glycol. Prehospital diagnosis was established by portable blood analyser and an early antidote with 4 MP treatment initiated in out-of-hospital setting. Use of portable blood analyser in prehospital care should be considered in case of suspected massive poisoning by ethylene glycol.
Tintinalli, J; Lisse, E; Begley, A; Campbell, C
Namibia is a sparsely populated nation in southwest Africa. A state-run health service provides care to most of the population. The geography and population distribution dictate the delivery systems for prehospital and emergency care. A state-run ambulance service provides basic patient transportation to the state-run hospitals. There is no 911 system. Two private aeromedical companies in Namibia provide the full range of ground and aeromedical treatment, diver rescue, and helicopter and fixed-wing transport services. The scope of care includes cricothyrotomies, chest tubes, and rapid-sequence intubation. Equipment is modern and virtually identical to what is used in the United States. There are no emergency physicians in Namibia. General medical officers are the backbone of the state-run health service. General medical officers assigned to cover the ED are called casualty officers. No specialized training beyond internship is required, and assignments to casualty are viewed as temporary until better positions become available. Only the largest state hospital in the capital has a dedicated, 24-hour emergency staff. The private prehospital care/transport systems are well organized and sophisticated. Formal efforts should be undertaken to develop ties with our colleagues in Namibia. Potential areas for collaboration include injury surveillance and prevention, field trauma resuscitation, and prehospital care.
Abu-Zidan, Fikri M
We have tried in a recently published systematic review (World J of Surg 2014; 38: 322-329) to study the educational value of advanced trauma life support (ATLS) courses and whether they improve survival of multiple trauma patients. This Frontier article summarizes what we have learned and reflects on future perspectives in this important area. Our recently published systematic review has shown that ATLS training is very useful from an educational point view. It significantly increased knowledge, and improved practical skills and the critical decision making process in managing multiple trauma patients. These positive changes were evident in a wide range of learners including undergraduate medical students and postgraduate residents from different subspecialties. In contrast, clear evidence that ATLS training reduces trauma death is lacking. It is obvious that it is almost impossible to perform randomized controlled trials to study the effect of ATLS courses on trauma mortality. Studying factors predicting trauma mortality is a very complex issue. Accordingly, trauma mortality does not depend solely on ATLS training but on other important factors, like presence of well-developed trauma systems including advanced pre-hospital care. We think that the way to answer whether ATLS training improves survival is to perform large prospective cohort studies of high quality data and use advanced statistical modelling. PMID:26855889
Geeraedts, L M G; Kaasjager, H A H; van Vugt, A B; Frölke, J P M
Trauma patients with haemorrhagic shock who only transiently respond or do not respond to fluid therapy and/or the administration of blood products have exsanguinating injuries. Recognising shock due to (exsanguinating) haemorrhage in trauma is about constructing a synthesis of trauma mechanism, injuries, vital signs and the therapeutic response of the patient. The aim of prehospital care of bleeding trauma patients is to deliver the patient to a facility for definitive care within the shortest amount of time by rapid transport and minimise therapy to what is necessary to maintain adequate vital signs. Rapid decisions have to be made using regional trauma triage protocols that have incorporated patient condition, transport times and the level of care than can be performed by the prehospital care providers and the receiving hospitals. The treatment of bleeding patients is aimed at two major goals: stopping the bleeding and restoration of the blood volume. Fluid resuscitation should allow for preservation of vital functions without increasing the risk for further (re)bleeding. To prevent further deterioration and subsequent exsanguinations 'permissive hypotension' may be the goal to achieve. Within the hospital, a sound trauma team activation system, including the logistic procedure as well as activation criteria, is essential for a fast and adequate response. After determination of haemorrhagic shock, all efforts have to be directed to stop the bleeding in order to prevent exsanguinations. A simultaneous effort is made to restore blood volume and correct coagulation. Reversal of coagulopathy with pharmacotherapeutic interventions may be a promising concept to limit blood loss after trauma. Abdominal ultrasound has replaced diagnostic peritoneal lavage for detection of haemoperitoneum. With the development of sliding-gantry based computer tomography diagnostic systems, rapid evaluation by CT-scanning of the trauma patient is possible during resuscitation. The concept
Enhancing the population impact of collaborative care interventions: Mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related comorbidities after acute trauma
Zatzick, Douglas; Rivara, Frederick; Jurkovich, Gregory; Russo, Joan; Trusz, Sarah Geiss; Wang, Jin; Wagner, Amy; Stephens, Kari; Dunn, Chris; Uehara, Edwina; Petrie, Megan; Engel, Charles; Davydow, Dimitri; Katon, Wayne
Objective To develop and implement a stepped collaborative care intervention targeting PTSD and related co-morbidities to enhance the population impact of early trauma-focused interventions. Method We describe the design and implementation of the Trauma Survivors Outcomes & Support Study (TSOS II). An interdisciplinary treatment development team was comprised of trauma surgical, clinical psychiatric and mental health services “change agents” who spanned the boundaries between front-line trauma center clinical care and acute care policy. Mixed method clinical epidemiologic and clinical ethnographic studies informed the development of PTSD screening and intervention procedures. Results Two-hundred and seven acutely injured trauma survivors with high early PTSD symptom levels were randomized into the study. The stepped collaborative care model integrated care management (i.e., posttraumatic concern elicitation and amelioration, motivational interviewing, and behavioral activation) with cognitive behavioral therapy and pharmacotherapy targeting PTSD. The model was feasibly implemented by front-line acute care MSW and ARNP providers. Conclusions Stepped care protocols targeting PTSD may enhance the population impact of early interventions developed for survivors of individual and mass trauma by extending the reach of collaborative care interventions to acute care medical settings and other non-specialty posttraumatic contexts. PMID:21596205
Resler, Julia; Hackworth, Jodi; Mayo, Erin; Rouse, Thomas M
Missed injuries contribute to increased morbidity in trauma patients. A retrospective chart review was conducted of pediatric trauma patients from 2010 to 2013 with a documented missed injury. A significant percentage of missed injuries were identified (3.01% during July 2012 to December 2013 vs 0.39% during January 2010 to July 2012) with the addition of acute care trained pediatric nurse practitioners to the trauma service at a pediatric trauma center. The increase is thought to be due to improvement in charting, consistent personnel performing tertiary examinations, and improved radiology reads of outside films.
Turgeon, Alexis F; Witteman, Holly O; Lauzier, François; Moore, Lynne; Lamontagne, François; Horsley, Tanya; Gagnon, Marie-Pierre; Droit, Arnaud; Weiss, Matthew; Tremblay, Sébastien; Lachaine, Jean; Le Sage, Natalie; Émond, Marcel; Berthelot, Simon; Plaisance, Ariane; Lapointe, Jean; Razek, Tarek; van de Belt, Tom H; Brand, Kevin; Bérubé, Mélanie; Clément, Julien; Grajales III, Francisco Jose; Eysenbach, Gunther; Kuziemsky, Craig; Friedman, Debbie; Lang, Eddy; Muscedere, John; Rizoli, Sandro; Roberts, Derek J; Scales, Damon C; Sinuff, Tasnim; Stelfox, Henry T; Gagnon, Isabelle; Chabot, Christian; Grenier, Richard; Légaré, France
Background Trauma is the most common cause of mortality among people between the ages of 1 and 45 years, costing Canadians 19.8 billion dollars a year (2004 data), yet half of all patients with major traumatic injuries do not receive evidence-based care, and significant regional variation in the quality of care across Canada exists. Accordingly, our goal is to lead a research project in which stakeholders themselves will adapt evidence-based trauma care knowledge tools to their own varied institutional contexts and cultures. We will do this by developing and assessing the combined impact of WikiTrauma, a free collaborative database of clinical decision support tools, and Wiki101, a training course teaching participants how to use WikiTrauma. WikiTrauma has the potential to ensure that all stakeholders (eg, patients, clinicians, and decision makers) can all contribute to, and benefit from, evidence-based clinical knowledge about trauma care that is tailored to their own needs and clinical setting. Objective Our main objective will be to study the combined effect of WikiTrauma and Wiki101 on the quality of care in four trauma centers in Quebec. Methods First, we will pilot-test the wiki with potential users to create a version ready to test in practice. A rapid, iterative prototyping process with 15 health professionals from nonparticipating centers will allow us to identify and resolve usability issues prior to finalizing the definitive version for the interrupted time series. Second, we will conduct an interrupted time series to measure the impact of our combined intervention on the quality of care in four trauma centers that will be selected—one level I, one level II, and two level III centers. Participants will be health care professionals working in the selected trauma centers. Also, five patient representatives will be recruited to participate in the creation of knowledge tools destined for their use (eg, handouts). All participants will be invited to
Nogueira, Lilia de Souza; Domingues, Cristiane de Alencar; Poggetti, Renato Sérgio; de Sousa, Regina Marcia Cardoso
Background From the perspective of nurses, trauma patients in the Intensive Care Unit (ICU) demand a high degree of nursing workload due to hemodynamic instability and the severity of trauma injuries. This study aims to identify the factors related to the high nursing workload required for trauma victims admitted to the ICU. Methods This is a prospective, cross-sectional study using descriptive and correlation analyses, conducted with 200 trauma patients admitted to an ICU in the city of São Paulo, Brazil. The nursing workload was measured using the Nursing Activities Score (NAS). The distribution of the NAS values into tertiles led to the identification of two research groups: medium/low workload and high workload. The Chi-square, Fisher's exact, Mann-Whitney and multiple logistic regression tests were utilized for the analyses. Findings The majority of patients were male (82.0%) and suffered blunt trauma (94.5%), with traffic accidents (57.5%) and falls (31.0%) being prevalent. The mean age was 40.7 years (±18.6) and the mean NAS was 71.3% (±16.9). Patient gender, the presence of pulmonary failure, the number of injured body regions and the risk of death according to the Simplified Acute Physiology Score II were factors associated with a high degree of nursing workload in the first 24 hours following admission to the ICU. Conclusion Workload demand was higher in male patients with physiological instability and multiple severe trauma injuries who developed pulmonary failure. PMID:25375369
Zhu, Thein Hlaing; Hollister, Lisa; Scheumann, Christopher; Konger, Jennifer; Opoku, Dazar
The study evaluates (1) health care provider perception of the Rural Trauma Team Development Course (RTTDC); (2) improvement in acute trauma emergency care knowledge; and (3) early transfer of trauma patients from rural emergency departments (EDs) to a verified trauma center. A 1-day, 8-hour RTTDC was given to 101 nurses and other health care providers from nine rural community hospitals from 2011 to 2013. RTTDC participants completed questionnaires to address objectives (1) and (2). ED and trauma registry data were queried to achieve objective (3) for assessing reduction in ED time (EDT), from patient arrival to decision to transfer and ED length of stay (LOS). The RTTDC was positively perceived by health care providers (96.3% of them completed the program). Significant improvement in 13 of the 19 knowledge items was observed in nurses. Education intervention was an independent predictor in reducing EDT by 28 minutes and 95% confidence interval (CI) [-57, -0.1] at 6 months post-RTTDC, and 29 minutes and 95% CI [-53, -6] at 12 months post-RTTDC. Similar results were observed with ED LOS. The RTTDC is well-perceived as an education program. It improves acute trauma emergency care knowledge in rural health care providers. It promotes early transfer of severely injured patients to a higher level of care.
Bhoi, Sanjeev; Mishra, Prakash Ranjan; Soni, Kapil Dev; Baitha, Upendra; Sinha, Tej Prakash
Introduction: There is a paucity of literature on prehospital care and epidemiology of traumatic cardiac arrest (TCA) in India. This study highlights the profile and characteristics of TCA. Methods: A retrospective cohort study was conducted to study epidemiological profile of TCA patients ≥1 year presenting to a level 1 trauma center of India. Results: One thousand sixty-one patients were recruited in the study. The median age (interquartile range) was 32 (23–45) years (male:female ratio of 5.9:1). Asystole (253), pulseless electrical activity (11), ventricular fibrillation (six), and ventricular tachycardia (five) were initial arrest rhythm. Road traffic crash (RTC) (57.16%), fall from height (18.52%), and assault (10.51%) were modes of injury. Prehospital care was provided by police (36.59%), ambulance (10.54%), relatives (45.40%), and bystanders (7.47% cases). Return of spontaneous circulation was seen in 69 patients, of which only three survived to hospital discharge. Conclusion: RTC in young males was a major cause of TCA. Asystole was the most common arrest rhythm. Police personnel were major prehospital service provider. Prehospital care needs improvement including the development of robust TCA registry. PMID:27630459
compartment syndrome mortality Hypothermia on presentation Massive transfusion mortality (damage control resuscitation). To further highlight the...theaters of combat operations was demonstrated to be associated with lower mortality from burns and abdominal compartment syndrome from 36% to 18% and...severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma 2006;60(2):371–8. 30. Papa L, Langland-Orban B
Abu-Zidan, Fikri M; Balac, Korana; Bhatia, Chetana Anand
The indications of point-of-care ultrasound (POCUS) in the management of multiple trauma patients have been expanding. Although computed tomography (CT) scan of the orbit remains the gold standard for imaging orbital trauma, ultrasound is a quick, safe, and portable tool that can be performed bedside. Here we report two patients who had severe eye injuries with major visual impairment where surgeon-performed POCUS was very useful. One had a foreign body injury while the other had blunt trauma. POCUS was done using a linear probe under sterile conditions with minimum pressure on the eyes. Ultrasound showed a foreign body at the back of the left eye globe touching the eye globe in the first patient, and was normal in the second patient. Workup using CT scan, fundsocopy, optical coherence tomography, and magnetic resonance imaging of the orbits confirmed these findings. The first patient had vitreous and sub retinal haemorrhage and a full thickness macular hole of the left eye, while the second had traumatic optic neuropathy. POCUS gave accurate information concerning severe eye injuries. Trauma surgeons and emergency physicians should be trained in performing ocular ultrasound for eye injuries. PMID:27803918
Abu-Zidan, Fikri M; Balac, Korana; Bhatia, Chetana Anand
The indications of point-of-care ultrasound (POCUS) in the management of multiple trauma patients have been expanding. Although computed tomography (CT) scan of the orbit remains the gold standard for imaging orbital trauma, ultrasound is a quick, safe, and portable tool that can be performed bedside. Here we report two patients who had severe eye injuries with major visual impairment where surgeon-performed POCUS was very useful. One had a foreign body injury while the other had blunt trauma. POCUS was done using a linear probe under sterile conditions with minimum pressure on the eyes. Ultrasound showed a foreign body at the back of the left eye globe touching the eye globe in the first patient, and was normal in the second patient. Workup using CT scan, fundsocopy, optical coherence tomography, and magnetic resonance imaging of the orbits confirmed these findings. The first patient had vitreous and sub retinal haemorrhage and a full thickness macular hole of the left eye, while the second had traumatic optic neuropathy. POCUS gave accurate information concerning severe eye injuries. Trauma surgeons and emergency physicians should be trained in performing ocular ultrasound for eye injuries.
Kumar, Parmeshwar; Jithesh, V.; Gupta, Shakti Kumar
Context: Although Intensive Care Units (ICUs) only account for 10% of the hospital beds, they consume nearly 22% of the hospital resources. Few definitive costing studies have been conducted in Indian settings that would help determine appropriate resource allocation. Aim: The aim of this study was to evaluate and compare the cost of intensive care delivery between multispecialty and neurosurgery ICUs at an apex trauma care facility in India. Materials and Methods: The study was conducted in a polytrauma and neurosurgery ICU at a 203-bedded Level IV trauma care facility in New Delhi, India, from May 1, 2012 to June 30, 2012. The study was cross-sectional, retrospective, and record-based. Traditional costing was used to arrive at the cost for both direct and indirect cost estimates. The cost centers included in the study were building cost, equipment cost, human resources, materials and supplies, clinical and nonclinical support services, engineering maintenance cost, and biomedical waste management. Statistical Analysis: Statistical analysis was performed by Fisher's two tailed t-test. Results: Total cost/bed/day for the multispecialty ICU was Rs. 14,976.9/- and for the neurosurgery ICU, it was Rs. 14,306.7/-, workforce constituting nearly half of the expenditure in both ICUs. The cost center wise and overall difference in the cost among the ICUs were statistically significant. Conclusions: Quantification of expenditure in running an ICU in a trauma center would assist health-care decision makers in better allocation of resources. Although multispecialty ICUs are more cost-effective, other factors will also play a role in defining the kind of ICU that needs to be designed. PMID:27555693
FRCAnaes 12:15 P.M. Intravenous Agents LevnM. Capn, MI) 12:45 P.M. Inhalation Agents LewoM. Coaxn, MD 1:15 P.M. Discussion 1:30 P.M. Lunch (on your own...Pathophysiologic Responses to Pain After Injury Leo H. D. J. Boo#, MD, PhD, FRCAnaes 3:30 P.M. Systemically Administered Agents T. James Gallagher, MD...Organization of Trauma Care A. Trauma Systems 1. The Orange County Experience 2. National Plans a. Trauma Care Systems Planning and Development Act b
Kirkham, Jamie J
Trauma is a term used in medicine for describing physical injury. The prospective evaluation of the care of injured patients aims to improve the management of a trauma system and acts as an ongoing audit of trauma care. One of the principal techniques used to evaluate the effectiveness of trauma care at different hospitals is through a comparative outcome analysis. In such an analysis, a national 'league table' can be compiled to determine which hospitals are better at managing trauma care. One of the problems with the conventional analysis is that key covariates for measuring physiological injury can often be missing. It is also hypothesized that this missingness is not missing at random (NMAR). We describe the methods used to assess the performance of hospitals in a trauma setting and implement the method of weights for generalized linear models to account for the missing covariate data, when we suspect the missing data mechanism is NMAR using a Monte Carlo EM algorithm. Through simulation work and application to the trauma data we demonstrate the affect the missing covariate data can have on the performance of hospitals and how the conclusions we draw from the analysis can differ. We highlight the differences in hospital performance and the ranking of hospitals.
Isobel, Sophie; Edwards, Clair
Without agreeing on an explicit approach to care, mental health nurses may resort to problem focused, task oriented practice. Defining a model of care is important but there is also a need to consider the philosophical basis of any model. The use of Trauma Informed Care as a guiding philosophy provides a robust framework from which to review nursing practice. This paper describes a nursing workforce practice development process to implement Trauma Informed Care as an inpatient model of mental health nursing care. Trauma Informed Care is an evidence-based approach to care delivery that is applicable to mental health inpatient units; while there are differing strategies for implementation, there is scope for mental health nurses to take on Trauma Informed Care as a guiding philosophy, a model of care or a practice development project within all of their roles and settings in order to ensure that it has considered, relevant and meaningful implementation. The principles of Trauma Informed Care may also offer guidance for managing workforce stress and distress associated with practice change.
Emergency Medical Treatment and Active Labor Act, an unfunded mandate for emergency hospital physician coverage, combined with falling reimbursement and escalating medico-legal risk, has resulted in declining enthusiasm for specialty coverage to emergency rooms. In a South West Florida community of 150,000, limited hand surgeons necessitated modification of acute on-call duties for hand trauma, whereby the hospital emergency room personnel performed evaluation and wound management with telephonic consultation followed by referral and definitive care in the outpatient setting by the hand surgeon. The policy for hand care, triage, management, and transfer is reviewed, as well as the first year experience with this highly efficient management methodology for urgent and emergent hand problems. In establishing a county-wide standard of care, emergency rooms and hand surgeons are coordinated to deliver excellent care by treatment protocol. PMID:18780095
Báez, Amado Alejandro; Sadosty, Annie T
The Cuban national Integrated Medical Emergeny System or "Sistema Integrado de Urgencias Medicas" (SIUM) was formed in 1997. In 1998, the SIUM began an active out-of-hospital thrombolysis program using Heberkinasa, the only streptokinase obtained through recombinant DNA techniques, produced by the Cuban Center for Genetic Engineering and Biotechnology. An active community training program has also been implemented, standardizing training for the almost 20,000 members of the national emergency medical services.
Bajwa, Sukhminder Jit Singh; Kaur, Jasbir; Singh, Amarjit; Kapoor, Vinod; Bindra, Gavinder Singh; Ghai, Gagandeep Singh
Background and Objectives: Maxillofacial trauma is commonly associated with other injuries, predominantly head injuries. The predictors of outcome in such concomitant injuries have been studied the least. The present study aims at the evaluation of types of injury, management and outcome of patients sustaining maxillofacial trauma and concomitant cranial injuries. Materials and Methods: A retrospective study was carried out in the department of anesthesiology and intensive care. A case series of 129 patients was evaluated who were admitted in ICU (Intensive Care Unit) with maxillofacial trauma and head injuries. The data was then compiled systematically and analyzed using SPSS windows and value of P < 0.05 was considered significant and P < 0.001 as highly significant. Results: Among the 129 patients, majority of them had roadside accidents (RSA > 90%) and male gender predominance with male to female ratio of 5: 1. Fracture maxilla and nasal bones were the most commonly encountered injuries (51.93%) followed by mandibular fractures (39.53%) and fracture of zygomatic bones (28.68%). Eighty five patients (65.90%) required mechanical ventilation, tracheostomy was needed in 29 (22.48%) patients and 81 (62.8%) patients were operated for head injuries as well. Majority of the victims were aged between 15 and 40 years. Conclusions: Maxillofacial trauma and cranial injuries are common among young males and so is the nature of injuries, that is, RSA. Besides facial injuries, head injuries are important determinant of outcome in such patients. Timely resuscitation and surgical interventions at specialized centers are of prime importance as far as a better prognosis is concerned in such injuries. PMID:23833486
Esposito, T J; Kuby, A M; Unfred, C; Young, H L; Gamelli, R L
A national sample of 2500 surgeons was surveyed. Thirteen variables were analyzed to ascertain perceived differences between trauma care and other surgical emergencies, as well as to identify factors contributing to a preferential reluctance to treat trauma. The response rate was 60%. Trauma was perceived as most likely to occur at inconvenient times by 67% of respondents, more often complex (44%), and more demanding of specialized knowledge (39%). Trauma was viewed as less likely to be reimbursed by 35% and most often litigious by 30%. Fewer respondents perceived differences for risk of exposure to lethal pathogens and violence (26% and 9%) and personal or professional rewards (25%). Surgeons who prefer to treat trauma view it as more often demanding of specialized knowledge and more complex than other surgical emergencies. Surgeons who prefer not to treat trauma or take trauma call perceive it as never personally or professionally rewarding, more often disruptive to personal life, emotionally taxing, litigious, and inconvenient compared with other emergencies. Perception of dissimilar reimbursement and personal health risk are less often associated factors. Perceived differences in the litigious nature of cases are not based on fact. We conclude that the individual degree of reluctance or enthusiasm for trauma care in comparison with other emergencies is influenced by perception, personality, and myth rather than by logic and facts.
Lier, H; Hinkelbein, J
Analysis of blood coagulation with thrombelastometry (ROTEM™) and thrombelastography (TEG™) and analysis of thrombocyte function by a Multiplate™ assay is possible in only a few hospitals in Germany. Recently, the grade of recommendation (GoR) for point-of-care (POC) testing in official guidelines was increased and is now classified as GoR 1C. If a POC-based option is not available alternatives must be used. Besides blood products (RBC, FFP, TC), coagulation factor concentrates are used to treat trauma-induced coagulopathy. The benefits of therapy with factor concentrates are fewer immunological and infection side effects as well as faster effects after administration of specific coagulation factors. A good outcome in patients with multiple trauma is only possible by an adequate transfusion regime and administration of coagulation factors.
Edlich, Richard F
An emergency medical system for trauma care has been conceived in our nation in an effort to improve delivery of emergency care to the accidentally injured patient. There are an estimated 20 million disabling injuries in our nation that should be cared for in trauma centers each year. This report has been written to acknowledge Dr. William Long, Jr., as well as Dr. William B. Long, III, for their unique contributions in establishing the Maryland Statewide Trauma System. Dr. William Long, Jr., played an instrumental role in working with Dr. R Adams Cowley to verify the life-saving value of the Maryland State Police helicopter system. In addition, Dr. Long, Jr., crafted a plan with Dr. R Adams Cowley that allowed Dr. Cowley the autonomy from the University of Maryland Medical School to develop a separate and distinct trauma facility, which is recognized throughout the world. It is indeed fortuitous that Dr. William B Long, III, experienced these landmark changes in trauma care in Maryland, which provided a catalyst for his future career that included extensive training in general surgery in Edinburgh as well as training in trauma surgery with Dr R Adams Cowley. These unique experiences convinced him to expand his training into cardiothoracic surgery. During these academic adventures, he became an international authority on the mathematics of trauma scores, cardiothoracic trauma resuscitation, and the components of a Level I trauma center. These empowering experiences became a catalyst for Dr. William Long, III, to undertake the scientific and clinical studies that would allow him to develop the only American College of Surgeons Committee on Trauma (ACSCOT) Verified Level I Trauma Center in the Pacific Northwest. This report describes in considerable detail Dr. William B. Long, III,'s Trauma Center at Legacy Emanuel Trauma Center (Portland, Oregon) as well as to outline his plans to further improve trauma care in the state of Oregon so that it remains a legacy for his
[New aspects of polytrauma treatment - current facts and developments: report of the first annual conference of the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS)].
Trentzsch, H; Wölfl, C; Matthes, G; Paffrath, T; Lefering, R; Flohé, S
Taking care of severely injured patients is a complex and ambitious mission. The committee on emergency medicine, intensive care and trauma management of the German Society of Trauma Surgery (Sektion NIS) has accepted this challenge. On the occasion of the release of the annual report of the TraumaRegistry DGU®, the committee held its first annual congress in order to provide members and an intrigued audience with current trends and results from the latest research in national trauma care ranging from the animal facility to the S3 guidelines. Topics of focus were new realizations based on data from the TraumaRegistry DGU® and means of quality assurance in trauma care. This article gives a report on the meeting and summarizes the major results of the presented studies and the latest deployments in this field of trauma research.
Waldrop, Ron D; Felter, Robert A
Two cases illustrating intentional withholding of information by noncitizen parents of children with major trauma are described. The difficulties and the results of not obtaining an accurate history in the initial assessment of accidental trauma victims are discussed. The core problem in these cases seems to be a fear of health care providers and a false perception that emergency medical services and emergency department personnel are extensions of law enforcement. These cases illustrate potential issues in managing the children of noncitizen immigrants.
Case study and case-based research in emergency nursing and care: Theoretical foundations and practical application in paramedic pre-hospital clinical judgment and decision-making of patients with mental illness.
Shaban, Ramon Z; Considine, Julie; Fry, Margaret; Curtis, Kate
Generating knowledge through quality research is fundamental to the advancement of professional practice in emergency nursing and care. There are multiple paradigms, designs and methods available to researchers to respond to challenges in clinical practice. Systematic reviews, randomised control trials and other forms of experimental research are deemed the gold standard of evidence, but there are comparatively few such trials in emergency care. In some instances it is not possible or appropriate to undertake experimental research. When exploring new or emerging problems where there is limited evidence available, non-experimental methods are required and appropriate. This paper provides the theoretical foundations and an exemplar of the use of case study and case-based research to explore a new and emerging problem in the context of emergency care. It examines pre-hospital clinical judgement and decision-making of mental illness by paramedics. Using an exemplar the paper explores the theoretical foundations and conceptual frameworks of case study, it explains how cases are defined and the role researcher in this form of inquiry, it details important principles and the procedures for data gathering and analysis, and it demonstrates techniques to enhance trustworthiness and credibility of the research. Moreover, it provides theoretically and practical insights into using case study in emergency care.
As the US population ages, trauma systems face new challenges in addition to the long-standing problem of access. Patients ages sixty-five and older are more likely than younger patients to fall and suffer serious injury or death as a result. This older patient population, when compared with younger cohorts, suffers higher mortality rates, has more comorbidities-diabetes, cancer, and heart conditions being the more serious among them-and takes more medications, which can complicate treatment. The University of South Florida (USF) Medical School and the HCA hospital system have partnered to create a network of five trauma centers in underserved areas of the state to increase access to trauma care for all Floridians while maintaining a special focus on geriatric trauma care. Collecting and analyzing data for improving care quality and undertaking research is a central aim of the partnership. Based on their research findings, trauma surgeons in the USF/HCA Trauma Network have identified best practices and codified them in standard operating procedures.
Chung, Joyce Y.; Frank, Lori; Subramanian, Asha; Galen, Steve; Leonhard, Sarah; Green, Bonnie L.
This study aimed to identify barriers and facilitators of mental health care for patients with trauma histories via qualitative methods with clinicians and administrators from primary care clinics for the underserved. Individual interviews were conducted, followed by a combined focus group with administrators from three jurisdictions; there were three focus groups with clinicians from each clinic system. Common themes were identified, and responses from groups were compared. Administrators and clinicians report extensive trauma histories among patients. Clinician barriers include lack of time, patient resistance, and inadequate referral options; administrators cite reimbursement issues, staff training, and lack of clarity about the term trauma. A key facilitator is doctor-patient relationship. There were differences in perceived barriers and facilitators at the institutional and clinical levels for mental health care for patients with trauma. Importantly, there is agreement about better access to and development of trauma-specific interventions. Findings will aid the development and implementation of trauma-focused interventions embedded in primary care. PMID:22551798
Chandrasekharan, Ananthnarayan; Nanavati, Aditya J; Prabhakar, Sandhya; Prabhakar, Subramaniam
law, weak legislation and law enforcement, disregard for personal safety, and driving vehicles under adverse conditions are some of the leading causes of road traffic accidents. There should be an emphasis on emergency trauma care in the pre-hospital setting. PMID:27921017
Rösch, M; Klose, T; Leidl, R; Gebhard, F; Kinzl, L; Ebinger, T
Current clinical management after multiple trauma is expensive. The aim of the present study was to quantify the actual costs of inpatient treatment after multiple trauma in a German university hospital, to compare the actual costs with the reimbursement rates, and to identify important determinants of costs. Routine documentation of hospital costs at a patient level was not available. Therefore a method for calculating the costs of resource utilization during clinical treatment of patients was developed. The concept was based on financial and utilization data provided by the hospital administration and patient-specific data. The average costs per case in the study group (mean ISS = 37) were 73.613 DM, maximal costs were up to 292.490 DM. The most costly components were intensive care, accounting for 60%, followed by procedures in the operating room (24%). A comparison with the reimbursement rates resulted in an average loss of 23.211 DM per case. Factors significantly associated with the costs of acute care hospitalization were outcome, injury severity, pattern of injury, blood volume replacement, length of mechanical ventilation, and number of operations. Whereas patient age, CNS state, mechanism of injury, pre-hospital care, and time between accident and hospital admission revealed no effect. Given the current reimbursement rates, multiple trauma care clearly belongs to those categories of care which have to be subsidized within the hospital. Any challenge to the optimal level of care resulting from this should be avoided.
Sakran, Joseph V; Greer, Sarah E; Werlin, Evan; McCunn, Maureen
Traditionally, surgical diseases including emergency and injury care have garnered less attention and support internationally when compared to other medical specialties. Over the past decade however, healthcare professionals have increasingly advocated for the need to address the global burden of non-communicable diseases. Surgical disease, including traumatic injury, is among the top causes of death and disability worldwide and the subsequent economic burden is substantial, falling disproportionately on low- and middle-income countries (LMICs). The future of global health in these regions depends on a redirection of attention to diseases managed within surgical, anesthesia and emergency specialties. Increasing awareness of these disparities, as well as increasing focus in the realms of policy and advocacy, is crucial. While the barriers to providing quality trauma and emergency care worldwide are not insurmountable, we must work together across disciplines and across boundaries in order to negotiate change and reduce the global burden of surgical disease.
Goldsmith, Rachel E; Martin, Christina Gamache; Smith, Carly Parnitzke
Substantial theoretical, empirical, and clinical work examines trauma as it relates to individual victims and perpetrators. As trauma professionals, it is necessary to acknowledge facets of institutions, cultures, and communities that contribute to trauma and subsequent outcomes. Systemic trauma-contextual features of environments and institutions that give rise to trauma, maintain it, and impact posttraumatic responses-provides a framework for considering the full range of traumatic phenomena. The current issue of the Journal of Trauma & Dissociation is composed of articles that incorporate systemic approaches to trauma. This perspective extends conceptualizations of trauma to consider the influence of environments such as schools and universities, churches and other religious institutions, the military, workplace settings, hospitals, jails, and prisons; agencies and systems such as police, foster care, immigration, federal assistance, disaster management, and the media; conflicts involving war, torture, terrorism, and refugees; dynamics of racism, sexism, discrimination, bullying, and homophobia; and issues pertaining to conceptualizations, measurement, methodology, teaching, and intervention. Although it may be challenging to expand psychological and psychiatric paradigms of trauma, a systemic trauma perspective is necessary on both scientific and ethical grounds. Furthermore, a systemic trauma perspective reflects current approaches in the fields of global health, nursing, social work, and human rights. Empirical investigations and intervention science informed by this paradigm have the potential to advance scientific inquiry, lower the incidence of a broader range of traumatic experiences, and help to alleviate personal and societal suffering.
Mellman, Thomas A; Aigbogun, Notalelomwan; Graves, Ruth Elaine; Lawson, William B; Alim, Tanya N
The occurrence of sleep paralysis (SP) absent narcolepsy appears to not be uncommon in African Americans and probably other non-European groups. Prior research has linked SP to trauma and psychiatric disorders and suggested a specific relationship to panic disorder in African Americans. The objective of our study was to evaluate relationships of SP with trauma, concurrent psychiatric symptoms and lifetime psychiatric diagnoses in an adult African American population recruited from primary care. Cross sectional study with surveys and diagnostic interviews; Patients attending primary care clinics filled out a survey that determined the 6 month prevalence and associated features of SP, a panic disorder screen, the self-rated Hamilton Depression Scale, and an inventory of trauma exposure. A subset of trauma-exposed participants (N = 142) received comprehensive diagnostic interviews that incorporated the Structured Clinical Interview for DSM-IV and the Clinician Assessed PTSD Scale. Four hundred and forty-one adults participated (mean age-40.0 SD = 13.3, 68% female, 95% African American). Fourteen percent endorsed recent SP. In approximately 1/3 of those with SP, episodes also featured panic symptoms. SP was strongly associated with trauma history, and concurrent anxiety and mood symptoms. SP was not associated with specific psychiatric disorders other than lifetime (but not current) alcohol or substance use disorders. Our findings suggest that SP is not uncommon in adult African Americans and is associated with trauma and concurrent distress but not with a specific psychiatric diagnosis.
Burghofer, K; Lackner, C K
Based on crew resource management of the airline industry the German Society for Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie, DGU) was the first scientific community in Germany to develop and implement a training course for patient safety. The S:training courses contain four course formats which focus on the prehospital life support (S:PLS), the operating room (S:OR), the trauma room (S:TR) and the intensive care unit (S:ICU). In the training the importance of the human factor for the management of acute major trauma is developed by means of presentations, training videos, practical training, discussions and realistic case scenarios associated with the special working environment of the participants. A specially developed course manual acts as a work and reference book and course booking is possible at http://www.safe-trac.de.
Brown, Joshua B; Guyette, Francis X; Neal, Matthew D; Claridge, Jeffrey A; Daley, Brian J; Harbrecht, Brian G; Miller, Richard S; Phelan, Herb A; Adams, Peter W; Early, Barbara J; Peitzman, Andrew B; Billiar, Timothy R; Sperry, Jason L
Hemorrhage and trauma induced coagulopathy remain major drivers of early preventable mortality in military and civilian trauma. Interest in the use of prehospital plasma in hemorrhaging patients as a primary resuscitation agent has grown recently. Trauma center-based damage control resuscitation using early and aggressive plasma transfusion has consistently demonstrated improved outcomes in hemorrhaging patients. Additionally, plasma has been shown to have several favorable immunomodulatory effects. Preliminary evidence with prehospital plasma transfusion has demonstrated feasibility and improved short-term outcomes. Applying state-of-the-art resuscitation strategies to the civilian prehospital arena is compelling. We describe here the rationale, design, and challenges of the Prehospital Air Medical Plasma (PAMPer) trial. The primary objective is to determine the effect of prehospital plasma transfusion during air medical transport on 30-day mortality in patients at risk for traumatic hemorrhage. This study is a multicenter cluster randomized clinical trial. The trial will enroll trauma patients with profound hypotension (SBP ≤ 70 mmHg) or hypotension (SBP 71-90 mmHg) and tachycardia (HR ≥ 108 bpm) from six level I trauma center air medical transport programs. The trial will also explore the effects of prehospital plasma transfusion on the coagulation and inflammatory response following injury. The trial will be conducted under exception for informed consent for emergency research with an investigational new drug approval from the U.S. Food and Drug Administration utilizing a multipronged community consultation process. It is one of three ongoing Department of Defense-funded trials aimed at expanding our understanding of the optimal therapeutic approaches to coagulopathy in the hemorrhaging trauma patient.
Griffin, Russell L; Davis, Gregory G; Levitan, Emily B; Maclennan, Paul A; Redden, David T; McGwin, Gerald
The distribution of time from acute traumatic injury to death has three peaks: immediate (less than or equal to one hour), early (6 to 24 hours), and late (days to weeks). It has been suggested that coordinated trauma care dampens the late peak; however, this research may be more reflective of unintentional than intentional deaths. This study examines whether a coordinated trauma system (TS) alters the temporal distribution for assault-related deaths. Data were obtained from homicides examined by the Jefferson County Coroner's/Medical Examiner's Office from 1987 to 2008. Homicides were categorized-based on year of death-as occurring in the presence of no TS, during TS implementation, in the early years of the TS, or in a mature TS. The temporal distribution of homicide mortality was compared among TS categories using a χ(2) test. A Cox Markov multistate model was used to estimate proportional changes in the temporal distribution of death adjusted for assault mechanism. With a TS, after adjusting for assault mechanism, a lower proportion of homicide victims survived through the first hour (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.54 to 1.03) and from one to six hours (HR, 0.68; 95% CI, 0.49 to 0.96). Additionally, the presence of a TS was associated with a proportional decrease in deaths after 24 hours (P = 0.0005). These results suggest that a trauma system is effective in preventing late homicide deaths; however, other means of preventing death (such as violence prevention programs) are needed to decrease the burden of immediate homicide-related deaths.
Ben-Abraham, R; Paret, G; Kluger, Y; Shemer, J; Stein, M
Combat medics play a significant role in any fighting unit. In recent years, during times of peace and low-intensity military conflicts, as well as in operations other than war, reserve combat medics have been challenged to treat major casualties in the field. Although this work requires important manual skills, the medics perform basic treatment maneuvers that are not necessarily for saving of lives. A sample survey of reserve combat medics revealed that most (70%) were engaged in medical care for trauma victims during their regular and reserve service. Many (32.5%) were involved in incidents with multiple casualties. These incidents included seriously injured victims, with 39.2% of the medics being involved with air evacuation and 44.4% with fatalities. Not all medics are exposed to major trauma, but for those who are, the numbers of patients per medic is not large. Therefore, the need to educate the medics in cognitive, and more importantly, in manual skills, is obvious. Suggestions for the means to do so are provided.
Amiri, Hassan; Gholipour, Changiz; Mokhtarpour, Mohammad; Shams Vahdati, Samad; Hashemi Aghdam, Yashar; Bakhshayeshi, Mina
The management of multiply injured trauma patients is a skill requiring broad knowledge and remarkable skills. The aim of the primary trauma care (PTC) module is to orient medical staff to the initial assessment of an injured patient. This workshop was held in the Education Development Center of Tabriz Medical University in April, September, and November 2007. The participants were given lectures, completed practices, and case scenarios about the management of traumatic patients. All participants were given a pretest and a post-test including a questionnaire and procedural skill exams. Finally, the same post-tests were performed 6-12 months later. Sixty-four individuals were interested in attending the workshop from the total of 90 invited, and 53 individuals responded to the late post-test. The mean score in the pretest, early post-test, and late post-test was 18.84, 26.72, and 22.17, respectively (P<0.001). Most of the medical staff did not have sufficient knowledge of basic PTC. We have shown that the incorporation of hands-on patient scenarios into an expanded course on the basis of PTC principles helps medical staff gain the knowledge and skills needed to perform the primary survey sequence correctly. Furthermore, extra educational planning seems to be necessary to retain these abilities as needed.
Jaycox, Lisa H; Cohen, Judith A; Mannarino, Anthony P; Walker, Douglas W; Langley, Audra K; Gegenheimer, Kate L; Scott, Molly; Schonlau, Matthias
New Orleans school children participated in an assessment and field trial of two interventions 15 months after Hurricane Katrina. Children (N = 195) reported on hurricane exposure, lifetime trauma exposure, peer and parent support, posttraumatic stress disorder (PTSD), and depressive symptoms. Teachers reported on behavior. At baseline, 60.5% screened positive for PTSD symptoms and were offered a group intervention at school or individual treatment at a mental health clinic. Uptake of the mental health care was uneven across intervention groups, with 98% beginning the school intervention, compared to 37% beginning at the clinic. Both treatments led to significant symptom reduction of PTSD symptoms, but many still had elevated PTSD symptoms at posttreatment. Implications for future postdisaster mental health work are discussed.
Piorkowska, Marta; Al-Raweshidy, Zahra; Yeong, Keefai
Peripherally Inserted Central Catheter (PICC) blockage rate was audited over a two month period on the Trauma & Orthopaedics ward at our District General Hospital. A 70% (five out of seven) PICC blockage rate was observed. High blockage rates lead to potential treatment complications, delays in delivery of treatment, increase in costs, and reduction in patient satisfaction. The factors contributing to the significant blockage rate include, long and contradictory PICC care guidelines, no information sheets in the patient notes, lack of training and awareness about care of, and flushing of, PICC lines, and lack of accountability for PICC flushing. Our project aimed to achieve a greater rate of PICC patency. We produced one succinct and comprehensive PICC care guideline, carried out staff training sessions, introduced a sticker reminding staff to flush the PICC line after use, and introduced a prescription of weekly heparin saline and PRN saline flushes (for monitoring and accountability). We used questionnaires to assess competency of hospital staff pre-teaching (doctors 6%, nurses 0%), and post-teaching (doctors 70%, nurses 38%). Blockage rate data post-intervention is pending. Education improved awareness of guidelines amongst staff and we anticipate that the proposed interventions will translate into reduced blockage rates, improving patient outcomes and reducing costs.
Landman, Adam B; Rokos, Ivan C; Burns, Kevin; Van Gelder, Carin M; Fisher, Roger M; Dunford, James V; Cone, David C; Bogucki, Sandy
Some of the most intractable challenges in prehospital medicine include response time optimization, inefficiencies at the emergency medical services (EMS)-emergency department (ED) interface, and the ability to correlate field interventions with patient outcomes. Information technology (IT) can address these and other concerns by ensuring that system and patient information is received when and where it is needed, is fully integrated with prior and subsequent patient information, and is securely archived. Some EMS agencies have begun adopting information technologies, such as wireless transmission of 12-lead electrocardiograms, but few agencies have developed a comprehensive plan for management of their prehospital information and integration with other electronic medical records. This perspective article highlights the challenges and limitations of integrating IT elements without a strategic plan, and proposes an open, interoperable, and scalable prehospital information technology (PHIT) architecture. The two core components of this PHIT architecture are 1) routers with broadband network connectivity to share data between ambulance devices and EMS system information services and 2) an electronic patient care report to organize and archive all electronic prehospital data. To successfully implement this comprehensive PHIT architecture, data and technology requirements must be based on best available evidence, and the system must adhere to health data standards as well as privacy and security regulations. Recent federal legislation prioritizing health information technology may position federal agencies to help design and fund PHIT architectures.
Ebinger, Martin; Lindenlaub, Sascha; Kunz, Alexander; Rozanski, Michal; Waldschmidt, Carolin; Weber, Joachim E.; Wendt, Matthias; Winter, Benjamin; Kellner, Philipp A.; Kaczmarek, Sabina; Endres, Matthias; Audebert, Heinrich J.
In acute ischemic stroke, time from symptom onset to intervention is a decisive prognostic factor. In order to reduce this time, prehospital thrombolysis at the emergency site would be preferable. However, apart from neurological expertise and laboratory investigations a computed tomography (CT) scan is necessary to exclude hemorrhagic stroke prior to thrombolysis. Therefore, a specialized ambulance equipped with a CT scanner and point-of-care laboratory was designed and constructed. Further, a new stroke identifying interview algorithm was developed and implemented in the Berlin emergency medical services. Since February 2011 the identification of suspected stroke in the dispatch center of the Berlin Fire Brigade prompts the deployment of this ambulance, a stroke emergency mobile (STEMO). On arrival, a neurologist, experienced in stroke care and with additional training in emergency medicine, takes a neurological examination. If stroke is suspected a CT scan excludes intracranial hemorrhage. The CT-scans are telemetrically transmitted to the neuroradiologist on-call. If coagulation status of the patient is normal and patient's medical history reveals no contraindication, prehospital thrombolysis is applied according to current guidelines (intravenous recombinant tissue plasminogen activator, iv rtPA, alteplase, Actilyse). Thereafter patients are transported to the nearest hospital with a certified stroke unit for further treatment and assessment of strokeaetiology. After a pilot-phase, weeks were randomized into blocks either with or without STEMO care. Primary end-point of this study is time from alarm to the initiation of thrombolysis. We hypothesized that alarm-to-treatment time can be reduced by at least 20 min compared to regular care. PMID:24300505
McCall-Hosenfeld, Jennifer; Winter, Michael; Heeren, Timothy; Liebschutz, Jane M.
Objective Female trauma survivors develop somatic symptoms more frequently than male survivors. We propose a model for somatic symptom development among trauma survivors, focusing on gender differences. Methods Among 597 urban primary care patients with chronic pain, we examined the association between somatic symptom severity and three interpersonal trauma types: 1) sexual trauma (ST), 2) intimate partner violence (IPV), and 3) childhood trauma history (>/=3 adverse childhood experiences (3+ACE)). We developed a structural equation model in which PTSD, depression, and substance abuse were evaluated as potential mediators of the path between trauma exposure and somatic symptom severity, and explored the role of gender in this model. Results 350 (59%) respondents were female; the mean age was 47. Women reported significantly more somatic symptoms than men, although somatic symptoms were increased among all interpersonal trauma survivors. In models in which the potential intervening variables are considered in aggregate, we did not find a signficant interaction between gender and trauma on somatic symptom severity, with the exception of 3+ACEs. A structural equation model showed that depression and substance abuse, for men, and depression, for women, were associated with somatic symptom severity. PTSD was not associated with somatic symtom severity. Paths from trauma exposures to mental health sequelae were stronger for men. Conclusions Women have more severe somatic symptoms. With the exception of 3+ACEs, the association between trauma and somatic symptoms is similarly amplified in both genders. Structural equation models showed the pathways differed by gender in function and strength of association. PMID:25149029
Münzberg, M; Harbers, T; Kneser, U; Grützner, P A; Reichert, B; Kremer, T; Wölfl, C G; Horter, J; Hirche, C
The initial treatment of severely burned patients remains a huge challenge for first responders in emergency services as well as emergency doctors who do not work in a centre for severe burn injuries. The reason for this is the low number of cases in developed countries and a lack of training concepts for the specific aspects of the initial treatment of severe burn injuries. Because of guidelines with limited evidence (S1, S2k) and a lack of structured treatment approaches, uncertainties with respect to initial treatment are still visible. Even within the professional societies and on international comparison, controversial aspects remain. In contrast, optimised and standardised procedures are available for the treatment of severely injured (trauma) patients, based on PHTLS® (Pre Hospital Trauma Life Support) for preclinical and ATLS® (Advanced Trauma Life Support) for in-hospital first aid. This article takes stock of the current structure of care and the relevant evidence for the initial treatment of severe burns. Also it discusses a possible transfer and further development of concepts for primary trauma care by all disciplines involved. Nine essential steps in the primary care of burned patients are identified and evaluated. The need for the introduction of a uniform treatment algorithm is illustrated. The treatment algorithm presented in this article addresses all first responders who are faced with initial treatment in the first 24 hours outside of burn centres. As an essential, new aspect, it offers a transfer and adaptation of concepts from trauma care to standardise the care of severely burned patients.
Opaleva-Stegantseva, V A; Ivanov, A G; Gavrilina, I A; Khar'kov, E I; Ratovskaia, V I
The impact of improvements in prehospital cardiologic service on total and prehospital mortality associated with acute coronary insufficiency (ACI) and acute myocardial infarction (AMI) and the causes of fatal outcomes is illustrated by a study based on the acute myocardial infarction register involving populations from two city districts between 20 and 69 years of age. Prehospital mortality caused by ACI and AMI is shown to decline with the progress of cardiologic care. The decline is attributed to reduced incidence of some causes of death, such as heart failure and cardiogenic shock. Sudden coronary death (85.1%) remains the principal cause of prehospital mortality.
Salloum, Alison; Scheeringa, Michael S.; Cohen, Judith A.; Storch, Eric A.
Background In order to develop Stepped Care Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), a definition of early response/non-response is needed to guide decisions about the need for subsequent treatment. Objective The purpose of this article is to (1) establish criterion for defining an early indicator of response/nonresponse to the first step within Stepped Care TF-CBT, and (2) to explore the preliminary clinical utility of the early response/non-response criterion. Method Data from two studies were used: (1) treatment outcome data from a clinical trial in which 17 young children (ages 3 to 6 years) received therapist-directed CBT for children with PTSS were examined to empirically establish the number of posttraumatic stress symptoms to define early treatment response/non-response; and (2) three case examples with young children in Stepped Care TF-CBT were used to explore the utility of the treatment response criterion. Results For defining the responder status criterion, an algorithm of either 3 or fewer PTSS on a clinician-rated measure or being below the clinical cutoff score on a parent-rated measure of childhood PTSS, and being rated as improved, much improved or free of symptoms functioned well for determining whether or not to step up to more intensive treatment. Case examples demonstrated how the criterion were used to guide subsequent treatment, and that responder status criterion after Step One may or may not be aligned with parent preference. Conclusion Although further investigation is needed, the responder status criterion for young children used after Step One of Stepped Care TF-CBT appears promising. PMID:25663796
Field, Craig A.; Caetano, Raul; Harris, T. Robert; Frankowski, Ralph; Roudsari, Bahman
Background Evidence suggests that brief interventions in the trauma care setting reduce drinking, subsequent injury and DUI arrest. However, evidence on the effectiveness of these interventions in ethnic minority groups is lacking. The current study evaluates the efficacy of brief intervention among Whites, Blacks and Hispanics in the U.S. Methods We conducted a two-group parallel randomized trial comparing Brief Motivational Intervention (BMI) and Treatment as Usual with assessment (TAU+) to evaluate treatment differences in drinking patterns by ethnicity. Patients were recruited from a Level 1 urban trauma center over a two year period. The study included 1493 trauma patients including 668 Whites, 288 Blacks, and 537 Hispanics. Hierarchical linear modeling was used to evaluate ethnic differences in drinking outcomes including volume per week, maximum amount consumed in one day, percent days abstinent and percent days heavy drinking at 6 and 12 month follow up. Analyses controlled for age, gender, employment status, marital status, prior alcohol treatment, type of injury and injury severity. Special emphasis was given to potential ethnic differences by testing the interaction between ethnicity and BMI. Results At 6 and 12 month follow up, BMI significantly reduced maximum amount consumed in one day (p<.001; p<.001, respectively) and percent days heavy drinking (p<.05; p<.05, respectively) among Hispanics. Hispanics in the BMI group also reduced average volume per week at 12 month follow up (X2=6.8, df=1, p<.01). In addition, Hispanics in TAU+ reduced maximum amount consumed at 6 and 12 month follow up (p<.001; p<.001) and volume per week at 12 month follow up (p<.001). Whites and Blacks in both BMI and TAU+ reduced volume per week and percent days heavy drinking at 12 month follow up (p<.001; p<.01, respectively) and decreased maximum amount at 6 (p<.001) and 12 month follow up (p<.001). All three ethnic groups In both BMI and TAU+ reduced volume per week at 6
Lockey, D J; Crewdson, K; Davies, G; Jenkins, B; Klein, J; Laird, C; Mahoney, P F; Nolan, J; Pountney, A; Shinde, S; Tighe, S; Russell, M Q; Price, J; Wright, C
Pre-hospital emergency anaesthesia with oral tracheal intubation is the technique of choice for trauma patients who cannot maintain their airway or achieve adequate ventilation. It should be carried out as soon as safely possible, and performed to the same standards as in-hospital emergency anaesthesia. It should only be conducted within organisations with comprehensive clinical governance arrangements. Techniques should be straightforward, reproducible, as simple as possible and supported by the use of checklists. Monitoring and equipment should meet in-hospital anaesthesia standards. Practitioners need to be competent in the provision of in-hospital emergency anaesthesia and have supervised pre-hospital experience before carrying out pre-hospital emergency anaesthesia. Training programmes allowing the safe delivery of pre-hospital emergency anaesthesia by non-physicians do not currently exist in the UK. Where pre-hospital emergency anaesthesia skills are not available, oxygenation and ventilation should be maintained with the use of second-generation supraglottic airways in patients without airway reflexes, or basic airway manoeuvres and basic airway adjuncts in patients with intact airway reflexes.
Thomasson, Joseph; Petros, Tommy; Lorenzo-Rivero, Shauna; Moore, Richard A; Stanley, J Daniel
Postoperative and posttrauma mortality in the acute care setting often occurs after a decision for de-escalation of care. It is important that the quality of consent for de-escalation of care is maintained to ensure patient autonomy. This retrospective review aims to determine the quality of the consent process for care de-escalation in patients on a trauma and general surgery service who sustained in-hospital mortality. One hundred thirty-three patients (99 trauma) were identified who died in 1 year. Of these patient deaths, 80 (60%) involved de-escalation of care. In three (3%) cases, there were no documented discussions for de-escalation consent. Of the remaining cases, documentation was considered optimal 21 per cent of the time. Only nine (11%) patients were able to participate in a discussion of their end-of-life care. The other 23 patients who were initially competent lost their ability to participate in discussions after a debilitating event. In this study, the majority of patients who died on a surgical service underwent a de-escalation of care. The documentation quality was suboptimal in most cases. Earlier and more thorough discussion of the patient's end-of-life wishes may improve the de-escalation of care consent process.
Atwoli, Lukoye; Ayuku, David; Hogan, Joseph; Koech, Julius; Vreeman, Rachel Christine; Ayaya, Samuel; Braitstein, Paula
Objective The aim of this study was to determine the impact of the domestic care environment on the prevalence of potentially traumatic events (PTEs) and posttraumatic stress disorder (PTSD) among orphaned and separated children in Uasin Gishu County, western Kenya. Methods A total of 1565 (55.5% male) orphaned and separated adolescents aged 10–18 years (mean 13.8 years, sd 2.2), were assessed for PTSD and PTEs including bullying, physical abuse and sexual abuse. In this sample, 746 lived in extended family households, 746 in Charitable Children's Institutions (CCIs), and 73 on the street. Posttraumatic stress symptom (PTSS) scores and PTSD were assessed using the Child PTSD Checklist. Results Bullying was the commonest PTE in all domestic care environments, followed by physical and sexual abuse. All PTEs were commonest among the street youth followed by CCIs. However, sexual abuse was more prevalent in households than in CCIs. Prevalence of PTSD was highest among street youth (28.8%), then households (15.0%) and CCIs (11.5%). PTSS scores were also highest among street youth, followed by CCIs and households. Bullying was associated with higher PTSS scores and PTSD odds than either sexual or physical abuse. Conclusion This study demonstrated differences in distribution of trauma and PTSD among orphaned and separated children in different domestic care environments, with street youth suffering more than those in CCIs or households. Interventions are needed to address bullying and sexual abuse, especially in extended family households. Street youth, a heretofore neglected population, are urgently in need of dedicated mental health services and support. PMID:24625395
Emergency department computed tomography dem- onstrated a bilateral ischial open pelvic fractures , vertebrae (L3, L4) compression fractures , and...perineal hematoma . Brain tomography result was normal. The patient’s admission he- moglobin was 13.7 g/dL, platelets count of 267 K, lactate of 3.74mmol/L
Chatfield-Ball, Catherine; Boyle, Peter; Autier, Philippe; van Wees, Sibylle Herzig; Sullivan, Richard
According to the Global Burden of Disease, trauma is now responsible for five million deaths each year. High-income countries have made great strides in reducing trauma-related mortality figures but low-middle-income countries have been left behind with high trauma-related fatality rates, primarily in the younger population. Much of the progress high-income countries have made in managing trauma rests on advances developed in their armed forces. This analysis looks at the recent advances in high-income military trauma systems and the potential transferability of those developments to the civilian health systems particularly in low-middle-income countries. It also evaluates some potential lifesaving trauma management techniques, proven effective in the military, and the barriers preventing these from being implemented in civilian settings.
Fernández Mondéjar, E; Alvarez, F J; González Luque, J C
The mortality of trauma patients has improved significantly in recent decades due to a combination of factors: medical care, educational campaigns and structural changes. Generalization of out-of hospital emergence medical services and the hospital care in specific centers for traumatized has undoubtedly contributed to this decline, but other factors such as periodic campaigns to prevent workplace and traffic accidents, as well as improvements in the road network have played a key role. The challenge now is to continue to decrease mortality, for which is essential an analysis of the situation to detect potential areas of improvement. The application of diagnostic or therapeutic actions with scientific evidence is associated with lower mortality, but as in other areas of medicine, the application of scientific evidence in trauma patients is barely 50%. Moreover, nearly 90% of trauma deaths occur in the crash site or in the first 72h of hospitalization, the vast majority as a result of injuries incompatible with life. In these circumstances it is clear that prevention is the most cost-effective activity. As medical practitioners, our role in prevention is mainly focused on the secondary prevention to avoid recidivism, for which it is necessary to identify risk factor (frequently alcohol, illegal drugs, psychotropic medication etc.) and implement a brief motivational intervention. This activity can reduce recidivism by nearly 50%. In Spain, the activity in this field is negligible therefore measures should be implemented for dissemination of secondary prevention in trauma.
Kaltman, Stacey; de Mendoza, Alejandra Hurtado; Serrano, Adriana; Gonzales, Felisa A.
Latinos in the United States face significant mental health disparities related to access to care, quality of care, and outcomes. Prior research suggests that Latinos prefer to receive care for common mental health problems (e.g., depression and anxiety disorders) in primary care settings, suggesting a need for evidence-based mental health services designed for delivery in these settings. This study sought to develop and preliminarily evaluate a mental health intervention for trauma-exposed Latina immigrants with depression and/or PTSD for primary care clinics that serve the uninsured. The intervention was designed to be simultaneously responsive to patients’ preferences for individual psychotherapy, to the needs of safety-net primary care clinics for efficient services, and to address the social isolation that is common to the Latina immigrant experience. Developed based on findings from the research team’s formative research, the resulting intervention incorporated individual and group sessions and combined evidence-based interventions to reduce depression and PTSD symptoms, increase group readiness, and improve perceived social support. Twenty-eight trauma-exposed low-income Latina immigrant women who screened positive for depression and/or PTSD participated in an open pilot trial of the intervention at a community primary care clinic. Results indicated that the intervention was feasible, acceptable, and safe. A randomized controlled trial of the intervention is warranted. PMID:26913774
Gopinathan, Nirmal Raj; Santhanam, Siva Swaminathan; Saibaba, Balaji; Dhillon, Mandeep Singh
Background: Vascular trauma associated with bony injuries is an orthopaedic emergency. Lack of timely intervention can lead to loss of limb or even life. Inspite of the rising incidence of high speed road traffic accidents in India, there is paucity of literature regarding the demographic pattern, clinical morbidity, management strategies and outcome of arterial injuries associated with lower limb trauma. The aim of this study is to describe the epidemiology and outcome of lower extremity musculoskeletal trauma with associated vascular injuries in a tertiary care institute in India. Materials and Methods: All individuals who presented to our tertiary care trauma center from July 2013 to December 2014 with lower extremity vascular injury associated with lower limb fractures were identified from a retrospective trauma database for this descriptive study. For the 17 months, there were 82 lower extremity vascular trauma cases admitted in our trauma center, of which 50 cases were included in the study. 32 patients with crush injuries, traumatic amputations, and those with head injury and blunt trauma to chest or abdomen were excluded from the study. Results: Out of the 50 cases of lower extremity vascular injury with associated lower limb fractures, 19 limbs were salvaged, 28 amputated, and three patients expired. Young males in the age group of 20–39 years were frequently injured. Motor vehicle accident (MVA) (82%) was found to be the most common cause followed by pedestrian injury. Popliteal artery (62%) was the most common vessel injured, followed by femoral artery (28%). The salvageability percentage was much higher (64%) in the femoral artery injury group when compared to popliteal artery injury group (25%). There were 32 open fractures, with amputation rates (60%) being higher and all three cases of death falling in this group. In addition, the limb salvageability percentage was 43.2% when the patient presented within 12 h of injury and this decreased to a mere
Beckett, Kate; Earthy, Sarah; Sleney, Jude; Barnes, Jo; Kellezi, Blerina; Barker, Marcus; Clarkson, Julie; Coffey, Frank; Elder, Georgina; Kendrick, Denise
Objective To explore views of service providers caring for injured people on: the extent to which services meet patients’ needs and their perspectives on factors contributing to any identified gaps in service provision. Design Qualitative study nested within a quantitative multicentre longitudinal study assessing longer term impact of unintentional injuries in working age adults. Sampling frame for service providers was based on patient-reported service use in the quantitative study, patient interviews and advice of previously injured lay research advisers. Service providers’ views were elicited through semistructured interviews. Data were analysed using thematic analysis. Setting Participants were recruited from a range of settings and services in acute hospital trusts in four study centres (Bristol, Leicester, Nottingham and Surrey) and surrounding areas. Participants 40 service providers from a range of disciplines. Results Service providers described two distinct models of trauma care: an ‘ideal’ model, informed by professional knowledge of the impact of injury and awareness of best models of care, and a ‘real’ model based on the realities of National Health Service (NHS) practice. Participants’ ‘ideal’ model was consistent with standards of high-quality effective trauma care and while there were examples of services meeting the ideal model, ‘real’ care could also be fragmented and inequitable with major gaps in provision. Service provider accounts provide evidence of comprehensive understanding of patients’ needs, awareness of best practice, compassion and research but reveal significant organisational and resource barriers limiting implementation of knowledge in practice. Conclusions Service providers envisage an ‘ideal’ model of trauma care which is timely, equitable, effective and holistic, but this can differ from the care currently provided. Their experiences provide many suggestions for service improvements to bridge the gap
The haemostasiological management of patients with multiple injuries requires rapid and adequate therapy decisions due to the highly dynamic surroundings. For this, diagnostic techniques which have the ability to detect and differentiate coagulation disorders that are commonly present in multiple trauma patients are necessary. Widely used routine coagulation tests (e.g., aPTT or PT) sensitively measure impairments of the intrinsic or extrinsic pathway, but without further identification or differentiation. Important influencing parameters like acidosis, hypothermia, fibrinolysis or polymerization dysfunction but especially the clot quality are not detectable. Moreover, the turn around times of these tests are about 30-60 min. However, thrombelastography measures clot strength and stability in whole blood under the present conditions of the injured patient. Impairments of clot quality can be differentiated. Because of the visualization of the clot formation, a patient's coagulation capacity can be assessed within minutes. Admittedly the use of these point-of-care devices in the operation theatre requires human and temporal resources.
Lackner, C K; Bielmeier, S; Burghofer, K
A change is emerging in the hospital landscape due to health political measures, which in consequence also influences the prehospital medical care in emergencies. The main focus of this study was to gather information about emergency medical care after traffic accidents on the basis of data from Bavarian emergency medical services. In 2006 there were 14,261 traffic accidents in Bavaria where an emergency doctor attended the scene. The patients were primarily cared for by land-based rescue services and air rescue services were only used in 19.1% of the cases. Of the patients involved in a traffic accident 47.6% were transported to a primary health care hospital. A prehospital interval of more than 60 min occurred in 20% of the missions. Of the patients 96.2% were transported to tertiary or maximum care hospital by air rescue services but emergency facilities were, however restricted to daylight hours. There was a further limitation due to the routine duty hours in hospitals as only 36.7% of accidents occurred during this time intervall. An increase of admission post trauma in maximum care clinics occurred from 2002 until 2006 while simultaneously the prehospital period was extended. In order to assure sufficient trauma care for seriously injured persons a continuous 24 h availability of emergency trauma facilities is necessary. For this purpose it is necessary to establish regional trauma networks between receiving hospitals as well as air rescue services at night time. Furthermore, a cost-efficient compensation of the structural, personnel and logistic expenses for the treatment of the severely injured has to be assured.
Heffron, Mary Claire; Gilkerson, Linda; Cosgrove, Kimberly; Heller, Sherryl Scott; Imberger, Jaci; Leviton, Audrey; Mueller, Mary; Norris-Shortle, Carole; Phillips, Caroline; Spielman, Eda; Wasserman, Kate
Erikson Institute Fussy Baby Network® (FBN) leaders from around the country have been considering the importance of building trauma-informed service programs. In this article, they discuss ways that the Facilitating Attuned Interaction (FAN) approach and the core processes used by the FAN can be helpful both when trauma is an unexpected presence…
McGonigle, John J.; Migyanka, Joann M.; Glor-Scheib, Susan J.; Cramer, Ryan; Fratangeli, Jeffrey J.; Hegde, Gajanan G.; Shang, Jennifer; Venkat, Arvind
With the rising prevalence of patients with autism spectrum disorder (ASD), there has been an increase in the acute presentation of these individuals to the general health care system. Emergency medical services and emergency department personnel commonly address the health care needs of patients with ASD at times of crisis. Unfortunately, there…
Kamath, Rajay A. D.; Bharani, Shiva; Hammannavar, Reshma; Ingle, Sumit P.; Shah, Ankit G.
Materials and Methods A 6-year retrospective analysis of 111 patients treated for maxillofacial fractures in Davangere, Karnataka from January 2004 to December 2009 was performed. Variables like age, gender, occupation, type of fracture and mechanism of injury, concomitant injury, mode of treatment, and complications were recorded and assessed. Results Men between 21 and 30 years were mostly affected (male-to-female ratio = 10:1; age range = 17.60 years; mean 31.7 ± 9.8 [standard deviation]). Most fractures were caused by road traffic accidents (RTAs; 74.7%), followed by interpersonal violence (IPV; 15.8%), falls (4.2%), industrial hazards and animal attacks (2.1% each), and self-inflicted injury (1.1%). Forty-two cases were isolated zygomaticomaxillary complex (ZMC) fractures. The total number of facial fractures documented was 316, of which 222 were purely related to the ZMC; however, 11 were confined only to the midface. Fifty-three cases had concomitant lower jaw fractures, totaling 83. Ophthalmic injuries occurred in 30.52% of cases. Ninety-two cases were treated with open reduction and internal fixation (ORIF), and three cases were managed conservatively. The complication rate observed was 25.26%. Conclusion RTA continues to be the chief etiological factor in maxillofacial injury with males being affected predominantly. IPV and falls next contribute significantly to the incidence of such injuries. Concomitant injuries, however, require prompt recognition and appropriate management. ORIF still remains the mainstay of treatment; however, fixation devices are constantly being improved upon in an attempt to reduce immobilization time thereby facilitating early return to function with minimal morbidity. Nevertheless, future advances in maxillofacial trauma diagnosis and management are likely to reduce associated morbidity. PMID:24294402
Garrido, Edward F.; Culhane, Sara E.; Raviv, Tali; Taussig, Heather N.
Previous studies find that childhood exposure to family and community violence is associated with trauma symptoms. Few studies, however, have explored whether community violence exposure (CVE) predicts trauma symptoms after controlling for the effects associated with family violence exposure (FVE). In the current study, CVE and FVE were examined in a sample of 179 youth with a recent history of maltreatment. CVE was associated with trauma symptoms after controlling for FVE, but FVE was not associated with trauma symptoms after controlling for CVE. In addition, negative coping strategies (e.g., self-harm, interpersonal aggression) partially mediated the association between CVE and trauma symptoms. These findings are discussed in terms of their implications for interventions aimed at addressing the needs of children exposed to violence. PMID:21287965
Wallace, Barbara C; Conner, Latoya C; Dass-Brailsford, Priscilla
Given the crisis of mass incarceration in the United States and the high prevalence of trauma histories among those incarcerated, it is imperative to improve service delivery to inmates in correctional facilities and to those undergoing reentry in community-based treatment settings. This article provides trauma definitions and categories, describes the sequelae of trauma, reviews research on the high prevalence of incarceration in this nation, and reviews research on the high prevalence of trauma among the incarcerated. This article also provides a menu of evidence-based and promising treatment approaches to address the overlap among trauma, mental illness, substance abuse, and behavioral problems. A synthesis of research via seven points is meant to guide practitioner and policy responses to the national challenge of meeting the needs of those undergoing reentry.
Interest in early thrombolysis has prompted a study on the feasibility and time course of prehospital thrombolysis in patients with acute myocardial infarction (AMI) in six centres in Belgium. Patients with clinically suspected AMI and with typical ECG changes presenting within 4 h after onset of pain were treated with 30 units of Anisoylated Plasminogen Streptokinase Activator Complex (APSAC, eminase) intravenously by a mobile intensive care unit (MICU). Sixty-two patients were included in the study and an AMI was confirmed in 60. The mean time (+/- 1 SD) from onset of pain to injection of APSAC was 95 +/- 47 min and the mean estimated time gain, calculated as the time difference between the arrival of the MICU at home and the arrival of the MICU at the emergency department, was 50 +/- 17 min. In the prehospital period four patients developed ventricular fibrillation and one cardiogenic shock. During hospital stay severe complications were observed in four patients. Two events were fatal, one diffuse haemorrhage and one septal rupture; two events were non fatal, one feasible and that an estimated time gain of 50 min can be obtained. Potential risks and benefits remain to be demonstrated in a large controlled clinical trial.
Sheils, Mark; Ross, Mark; Eatough, Noel; Caputo, Nicholas D
Trauma accounts for a significant portion of overall mortality globally. Hemorrhage is the second major cause of mortality in the prehospital environment. Air medical retrieval services throughout the world have been developed to help improve the outcomes of patients suffering from a broad range of medical conditions, including trauma. These services often utilize intraosseous (IO) devices as an alternative means for access of both medically ill and traumatically injured patients in austere environments. However, studies have suggested that IO access cannot reach acceptable rates for massive transfusion. We review the subject to find the answer of whether IO access should be performed by air medical teams in the prehospital setting, or would central venous (CVC) access be more appropriate? We decided to assess the literature for capacity of IO access to meet resuscitation requirements in the prehospital management of trauma. We also decided to compare the insertion and complication characteristics of IO and CVC access.
George, Linsha; Ramamoorthy, Lakshmi; Satheesh, Santhosh; Saya, Rama Prakasha; Subrahmanyam, D. K. S.
Background: Despite efforts aimed at reducing the prehospital delay and treatment delay, a considerable proportion of patients with ST elevation myocardial infarction (STEMI) present late and receive the reperfusion therapy after unacceptably long time periods. This study aimed at finding out the patients' decision delay, prehospital delay, door-to-electrocardiography (ECG), door-to-needle, and door-to-primary percutaneous coronary intervention (PCI) times and their determinants among STEMI patients. Materials and Methods: A cross-sectional study conducted among 96 patients with STEMI admitted in a tertiary care center in South India. The data were collected using interview of the patients and review of records. The distribution of the data was assessed using Kolmogorov–Smirnov test, and the comparisons of the patients' decision delay, prehospital delay, and time to start reperfusion therapy with the different variables were done using Mann–Whitney U-test or Kruskal–Wallis test based on the number of groups. Results: The mean (standard deviation) and median (range) age of the participants were 55 (11) years and 57 (51) years, respectively. The median patients' decision delay, prehospital delay, door-to-ECG, door-to-needle, and door-to-primary PCI times were 75, 290, 12, 75, 110 min, respectively. Significant factors associated (P < 0.05) with patients' decision delay were alcoholism, symptom progression, and attempt at symptom relief measures at home. Prehospital delay was significantly associated (P < 0.05) with domicile, difficulty in arranging money, prior consultation at study center, place of symptom onset, symptom interpretation, and mode of transportation. Conclusions: The prehospital delay time among the South Indian population is still unacceptably high. Public education, improving the systems of prehospital care, and measures to improve the patient flow and management in the emergency department are essentially required. The time taken to take ECG
Bartanusz, Viktor; Corneille, Michael G; Sordo, Salvador; Gildea, Marianne; Michalek, Joel E; Nair, Prakash V; Stewart, Ronald M; Jezova, Daniela
Acute trauma patients represent a specific subgroup of the critically ill population due to sudden and dramatic changes in homeostasis and consequently extreme demands on the activity of the hypothalamic-pituitary-adrenocortical (HPA) axis. Salivary cortisol is an accepted surrogate for serum free cortisol in the assessment of HPA axis function. The purpose of this study was (1) to establish the feasibility of salivary cortisol measurement in acute trauma patients in the neurosurgical-surgical intensive care unit (NSICU), and (2) to determine the diurnal pattern of salivary cortisol in the acute phase after injury. Saliva from 50 acute trauma patients was prospectively collected twice a day at 6AM and 4PM during the first week after injury in the NSICU. Mean PM cortisol concentrations were significantly higher in subjects versus controls (p<0.001). Subjects failed to develop the expected PM versus AM decrease in cortisol concentration seen in controls (p=0.005). Salivary cortisol did not vary significantly with baseline Glasgow Coma Scale (GCS), Injury Severity Score, sex, injury type, ethnicity, or age. When comparing mean AM and PM salivary cortisol by GCS severity category (GCS ⩽8 and GCS >8) the AM salivary cortisol was significantly higher in patients with GCS ⩽8 (p=0.002). The results show a loss of diurnal cortisol variation in acute trauma patient in the NSICU during the first week of hospitalization. Patients with severe brain injury had higher morning cortisol levels than those with mild/moderate brain injury.
Hussmann, Bjoern; Lendemans, Sven
The pre-hospital and early in-hospital management of most severely injured patients has dramatically changed over the last 20 years. In this context, the factor time has gained more and more attention, particularly in German-speaking countries. While the management in the early 1990s aimed at comprehensive and complete therapy at the accident site, the premise today is to stabilise trauma patients at the accident site and transfer them into the hospital rapidly. In addition, the introduction of training and education programmes such as Pre-hospital Trauma Life Support (PHTLS(®)), Advanced Trauma Life Support (ATLS(®)) concept or the TEAM(®) concept has increased the quality of treatment of most severely injured trauma patients both in the preclinical field and in the emergency trauma room. Today, all emergency surgical procedures in severely injured patients are generally performed in accordance with the Damage Control Orthopaedics (DCO) principle. The advancements described in this article provide examples for the improved quality of the management of severely injured patients in the preclinical field and during the initial in-hospital treatment phase. The implementation of trauma networks, the release of the S3 polytrauma guidelines, and the DGU "Weißbuch" have contributed to a more structured management of most severely injured patients.
Radjou, Angeline Neetha; Balliga, Dillip Kumar; Pal, Ranabir; Mahajan, Preetam
Background: There is an alarming trend of injuries leading to poor outcome of victims in India. Objective: To study the profile of patients who died due to trauma and to identify factors involved in both pre-hospital and hospital care. Materials and Methods: A hospital-based study was performed at a trauma center in Puducherry from June 2009 to May 2010. Patients who had at least one sign of life on admission and later died were included. The demographic characteristics, injury mechanism, nature and site of injury, influence of alcohol, pre-hospital time and care, distance traveled, number of referrals, time spent in study hospital, cause of death, and missed injuries revealed at post mortem were noted. Results: Of the 204 fatal cases, most were between 25-65 years of age (77%); sustained injuries over weekends (36%) and between 4 pm and midnight (41%); had at least one halt in a medical facility before reaching definitive care (56%); and died within a week (63%). Adults (25-65 y) sustained most injuries (77%) on two wheelers. In those aged over 65 years, 79 percent were pedestrians. Road traffic injuries were responsible for 82 % of deaths; 16 percent were reportedly under the influence of alcohol at the time of injury. Mean delay from the time of accident to admission was 14.9 hours and median distance traveled was 30 kilometers. Head injury was the most common (66%) cause of death. Post mortem revealed skull fractures (37%), while missed injuries were noted in 8 percent, mostly involving the cervical spine and chest wall. Conclusion: The problem of trauma care needs to be addressed urgently in this part of southern India to reduce mortality and morbidity. PMID:22416154
Schultz, Dana; Barnes-Proby, Dionne; Chandra, Anita; Jaycox, Lisa H.; Maher, Erin; Pecora, Peter
The Cognitive Behavioral Intervention for Trauma in Schools (CBITS) was developed for use by school-based mental health professionals for any student with symptoms of distress following exposure to trauma. The Supporting Students Exposed to Trauma (SSET) was adapted from CBITS for use by any school personnel with the time and interest to work with…
Hisamuddin, N A R Nik; Hamzah, M Shah; Holliman, C James
Once a very slowly developing country in a Southeast Asia region, Malaysia has undergone considerable change over the last 20 years after the government changed its focus from agriculture to developing more industry and technology. The well-known "Vision 2020," introduced by the late Prime Minister, set a target for the nation to be a developed country in the Asia region by the year 2020. As the economy and standard of living have improved, the demand from the public for a better health care system, in particular, emergency medical services (EMS), has increased. Despite the effort by the government to improve the health care system in Malaysia, EMS within the country are currently limited, best described as being in the "developing" phase. The Ministry of Health, Ministry of Education, Civil Defense, and non-governmental organizations such as Red Crescent and St. John's Ambulance, provide the current ambulance services. At the present time, there are no uniform medical control or treatment protocols, communication systems, system management, training or education, or quality assurance policies. However, the recent development of and interest in an Emergency Medicine training program has gradually led to improved EMS and prehospital care.
Bilodeau, Andrea; Gagnon, Marie-Pierre; Aubin, Karine; Lavoie, André; Lapointe, Jean; Poitras, Julien; Croteau, Sylvain; Pham-Dinh, Martin; Légaré, France
Background Wikis are knowledge translation tools that could help health professionals implement best practices in acute care. Little is known about the factors influencing professionals’ use of wikis. Objectives To identify and compare the beliefs of emergency physicians (EPs) and allied health professionals (AHPs) about using a wiki-based reminder that promotes evidence-based care for traumatic brain injuries. Methods Drawing on the theory of planned behavior, we conducted semistructured interviews to elicit EPs’ and AHPs’ beliefs about using a wiki-based reminder. Previous studies suggested a sample of 25 EPs and 25 AHPs. We purposefully selected participants from three trauma centers in Quebec, Canada, to obtain a representative sample. Using univariate analyses, we assessed whether our participants’ gender, age, and level of experience were similar to those of all eligible individuals. Participants viewed a video showing a clinician using a wiki-based reminder, and we interviewed participants about their behavioral, control, and normative beliefs—that is, what they saw as advantages, disadvantages, barriers, and facilitators to their use of a reminder, and how they felt important referents would perceive their use of a reminder. Two reviewers independently analyzed the content of the interview transcripts. We considered the 75% most frequently mentioned beliefs as salient. We retained some less frequently mentioned beliefs as well. Results Of 66 eligible EPs and 444 eligible AHPs, we invited 55 EPs and 39 AHPs to participate, and 25 EPs and 25 AHPs (15 nurses, 7 respiratory therapists, and 3 pharmacists) accepted. Participating AHPs had more experience than eligible AHPs (mean 14 vs 11 years; P = .04). We noted no other significant differences. Among EPs, the most frequently reported advantage of using a wiki-based reminder was that it refreshes the memory (n = 14); among AHPs, it was that it provides rapid access to protocols (n = 16). Only 2 EPs
adjunctive therapy in the management of severe bleeding associated with trauma. Further prospective, randomized, and placebo-controlled clinical trials...trimodal or bimodal distribution [1-4]. Of trauma deaths 50% occur at the scene of injury because of massive head injury or exsanguination [3,4...4Professor, Departement d’Anesthesie- Reanimation , Hopital de Bicetre, Le Kremlin-Bicetre, France Corresponding author: Alicia M Mohr, email@example.com
Lynch, V A
Forensic nursing is one example of an innovative expansion of the role nurses will fill in the health care delivery system of the future. Because current policies of advocacy programs mandate the inclusion of criminal justice and health care providers, it is especially timely to propose that the forensic nursing specialist be placed in the trauma treatment environs to serve as a valuable link in interagency cooperation, ensuring that human needs and medicolegal interests are served. Because most emergency personnel and prehospital care providers ordinarily have only secondary interests in forensic matters, the motivated and skilled forensic nurse can serve as an invaluable resource for the criminal justice system, the hospital, and the patient.
Miller, Joseph B.; Nicholas, Katherine S.; Varelas, Panayiotis N.; Harsh, Donna M.; Durkalski, Valerie; Silbergleit, Robert; Wang, Henry E.
Introduction Limited data describe the frequency, timing, or indications for endotracheal intubation (ETI) in patients with status epilepticus. A better understanding of the characteristics of patients with status epilepticus requiring airway interventions could inform clinical care. We sought to characterize ETI use in patients with prehospital status epilepticus. Methods This study was a secondary analysis of the Rapid Anticonvulsant Medication Prior to Arrival Trial, a multi-center, randomized trial comparing intravenous lorazepam to intramuscular midazolam for prehospital status epilepticus treatment. Subjects received ETI in the prehospital, Emergency Department (ED), or inpatient setting at the discretion of caregivers. Results Of 1023 enrollments, 218 (21 %) received ETI. 204 (93.6 %) of the ETIs were performed in the hospital and 14 (6.4 %) in the prehospital setting. Intubated patients were older (52 vs 41 years, p < 0.001), and men underwent ETI more than women (26 vs 21 %, p = 0.047). Patients with ongoing seizures on ED arrival had a higher rate of ETI (32 vs 16 %, p < 0.001), as did those who received rescue anti-seizure medication (29 vs 20 %, p = 0.004). Mortality was higher for intubated patients (7 vs 0.4 %, p < 0.001). Most ETI (n = 133, 62 %) occurred early (prior to or within 30 min after ED arrival), and late ETI was associated with higher mortality (14 vs 3 %, p = 0.002) than early ETI. Conclusions ETI is common in patients with status epilepticus, particularly among the elderly or those with refractory seizures. Any ETI and late ETI are both associated with higher mortality. PMID:25623785
Martin-Gill, Christian; Gaither, Joshua B; Bigham, Blair L; Myers, J Brent; Kupas, Douglas F; Spaite, Daniel W
Multiple national organizations have recommended and supported a national investment to increase the scientific evidence available to guide patient care delivered by Emergency Medical Services (EMS) and incorporate that evidence directly into EMS systems. Ongoing efforts seek to develop, implement, and evaluate prehospital evidence-based guidelines (EBGs) using the National Model Process created by a multidisciplinary panel of experts convened by the Federal Interagency Committee on EMS (FICEMS) and the National EMS Advisory Council (NEMSAC). Yet, these and other EBG efforts have occurred in relative isolation, with limited direct collaboration between national projects, and have experienced challenges in implementation of individual guidelines. There is a need to develop sustainable relationships among stakeholders that facilitate a common vision that facilitates EBG efforts. Herein, we summarize a National Strategy on EBGs developed by the National Association of EMS Physicians (NAEMSP) with involvement of 57 stakeholder organizations, and with the financial support of the National Highway Traffic Safety Administration (NHTSA) and the EMS for Children program. The Strategy proposes seven action items that support collaborative efforts in advancing prehospital EBGs. The first proposed action is creation of a Prehospital Guidelines Consortium (PGC) representing national medical and EMS organizations that have an interest in prehospital EBGs and their benefits to patient outcomes. Other action items include promoting research that supports creation and evaluates the impact of EBGs, promoting the development of new EBGs through improved stakeholder collaboration, and improving education on evidence-based medicine for all prehospital providers. The Strategy intends to facilitate implementation of EBGs by improving guideline dissemination and incorporation into protocols, and seeks to establish standardized evaluation methods for prehospital EBGs. Finally, the Strategy
Abhilash, Kundavaram Paul Prabhakar; Chakraborthy, Nilanchal; Pandian, Gautham Raja; Dhanawade, Vineet Subodh; Bhanu, Thomas Kurien; Priya, Krishna
Background: Trauma is an increasing cause of morbidity and mortality in India. This study was done to improve the understanding of the mode of trauma, severity of injuries, and outcome of trauma victims in our hospital. Materials and Methods: This was a retrospective observational study of all adult trauma patients more than 18-year-old presenting to our emergency department (ED). Details of the incident, injuries, and outcome were noted. Results: The ED attended to 16,169 patients during the 3-month study period with 10% (1624/16,169) being adult trauma incidents. The gender distribution was 73.6% males and 26.4% females. The mean age was 40.2 ± 16.7 years. The median duration from time of incident to time of arrival to the ED was 3 h (interquartile range [IQR]: 1.5–6.5) for priority one patients, 3 h (IQR: 1.5–7.7) for priority two patients, and 1.5 h (IQR: 1–7) for priority three patients. The average number of trauma incidents increased by 28% during the weekends. Road traffic accident (RTA) (65%) was the most common mode of injury, followed by fall on level ground (13.5%), fall from height (6.3%), work place injuries (6.3%), and others. Traumatic brain injury was seen in 17% of patients while 13.3% had polytrauma with two-wheeler accidents contributing to the majority. The ED team alone managed 23.4% of patients while the remaining 76.6% required evaluation and treatment by the trauma, surgical teams. The in-hospital mortality rate was 2.3%. Multivariate analysis showed low Glasgow coma score (odds ratio [OR]: 0.65, 95% confidence interval [CI]: 0.55–0.76, P < 0.001) and high respiratory rate (OR: 1.15, 95% CI: 1.07–1.24, P < 0.001) to be independent predictors of mortality among polytrauma victims. Conclusions: RTA and falls are the predominant causes of trauma. A simple physiological variable-based scoring system such as the revised trauma score may be used to prioritize patients with polytrauma. PMID:28217583
Mason, Virginia M; Leslie, Gail; Clark, Kathleen; Lyons, Pat; Walke, Erica; Butler, Christina; Griffin, Martha
Preparation for replacing the large proportion of staff nurses reaching retirement age in the next few decades in the United States is essential to continue delivering high-quality nursing care and improving patient outcomes. Retaining experienced critical care nurses is imperative to successfully implementing the orientation of new inexperienced critical care nurses. It is important to understand factors that affect work engagement to develop strategies that enhance nurse retention and improve the quality of patient care. Nurses' experience of moral distress has been measured in medical intensive care units but not in surgical trauma care units, where nurses are exposed to patients and families faced with sudden life-threatening, life-changing patient consequences.This pilot study is a nonexperimental, descriptive, correlational design to examine the effect of compassion satisfaction, compassion fatigue, moral distress, and level of nursing education on critical care nurses' work engagement. This is a partial replication of Lawrence's dissertation. The study also asked nurses to describe sources of moral distress and self-care strategies for coping with stress. This was used to identify qualitative themes about the nurse experiences. Jean Watson's theory of human caring serves as a framework to bring meaning and focus to the nursing-patient caring relationship.A convenience sample of 26 of 34 eligible experienced surgical intensive care unit trauma nurses responded to this survey, indicating a 77% response rate. Twenty-seven percent of the nurses scored high, and 73% scored average on compassion satisfaction. On compassion fatigue, 58% scored average on burnout and 42% scored low. On the secondary traumatic stress subscale, 38% scored average, and 62% scored low. The mean moral distress situations subscale score was 3.4, which is elevated. The mean 9-item Utrecht Work Engagement Scale total score, measuring work engagement, was 3.8, which is considered low
Stewart, Barclay T; Gyedu, Adam; Quansah, Robert; Addo, Wilfred Larbi; Afoko, Akis; Agbenorku, Pius; Amponsah-Manu, Forster; Ankomah, James; Appiah-Denkyira, Ebenezer; Baffoe, Peter; Debrah, Sam; Donkor, Peter; Dorvlo, Theodor; Japiong, Kennedy; Kushner, Adam L; Morna, Martin; Ofosu, Anthony; Oppong-Nketia, Victor; Tabiri, Stephen; Mock, Charles
Introduction Prospective clinical audit of trauma care improves outcomes for the injured in high-income countries (HICs). However, equivalent, context-appropriate audit filters for use in low- and middle-income country (LMIC) district-level hospitals have not been well established. We aimed to develop context-appropriate trauma care audit filters for district-level hospitals in Ghana, was well as other LMICs more broadly. Methods Consensus on trauma care audit filters was built between twenty panelists using a Delphi technique with four anonymous, iterative surveys designed to elicit: i) trauma care processes to be measured; ii) important features of audit filters for the district-level hospital setting; and iii) potentially useful filters. Filters were ranked on a scale from 0 – 10 (10 being very useful). Consensus was measured with average percent majority opinion (APMO) cut-off rate. Target consensus was defined a priori as: a median rank of ≥9 for each filter and an APMO cut-off rate of ≥0.8. Results Panelists agreed on trauma care processes to target (e.g. triage, phases of trauma assessment, early referral if needed) and specific features of filters for district-level hospital use (e.g. simplicity, unassuming of resource capacity). APMO cut-off rate increased successively: Round 1 - 0.58; Round 2 - 0.66; Round 3 - 0.76; and Round 4 - 0.82. After Round 4, target consensus on 22 trauma care and referral-specific filters was reached. Example filters include: triage - vital signs are recorded within 15 minutes of arrival (must include breathing assessment, heart rate, blood pressure, oxygen saturation if available); circulation - a large bore IV was placed within 15 minutes of patient arrival; referral - if referral is activated, the referring clinician and receiving facility communicate by phone or radio prior to transfer. Conclusion This study proposes trauma care audit filters appropriate for LMIC district-level hospitals. Given the successes of similar
Strait, Joshua; Bolman, Tiffany
Context: Scientific findings of adverse childhood experiences (ACEs) and their lifelong graded relationship with leading causes of death are well established. Many health care practitioners, however, have yet to implement ACEs screening in clinical practice. Furthermore, ACEs screening and trauma-informed care (TIC) are not part of standard graduate-level training. Objective: To 1) implement trauma-informed curriculum for multiple graduate health programs, 2) determine student understanding of and willingness to address ACEs, and 3) assess the relationship between students voluntarily evaluating their individual ACE Score and their attitude toward ACEs and TIC. Design: Prospective study with pre- and postcurricular surveys (12-question digital survey administered before and after the curriculum) for 967 graduate students from 9 health professions programs at 2 campuses who received curriculum focused on ACEs and TIC. Main Outcome Measures: Students’ understanding of ACEs and TIC, their awareness of personal ACEs, and their willingness to incorporate TIC in practice. Results: Among students who voluntarily completed an ACE questionnaire, there was statistical significance in familiarity with clinical and scientific findings of the ACE Study (p < 0.001) and familiarity with TIC (p < 0.02). A significant intercampus difference in the students’ familiarity with the scientific and clinical findings of the ACE Study (p < 0.05) was found. Conclusion: Students and future health care practitioners who voluntarily assess their ACE Score are significantly more likely to understand scientific and clinical findings of the ACE Study as well as TIC. PMID:27673708
van der Hal-Van Raalte, Elisheva; Van Ijzendoorn, Marinus H; Bakermans-Kranenburg, Marian J
The link between deprivation and trauma during earliest childhood and psychosocial functioning and health in later life was investigated in a group of child Holocaust survivors. In a nonconvenience sample 203 survivors, born between 1935 and 1944, completed questionnaires on Holocaust survival experience and several inventories on current health, depression, posttraumatic stress, loneliness, and attachment style. Quality of postwar care arrangements and current physical health independently predicted lack of well-being in old age. Loss of parents during the persecution, year of birth of the survivors (being born before or during the war), and memories of the Holocaust did not significantly affect present well-being. Lack of adequate care after the end of World War II is associated with lower well-being of the youngest Holocaust child survivors, even after an intervening period of 60 years. Our study validates Keilson's (1992) concept of "sequential traumatization," and points to the importance of aftertrauma care in decreasing the impact of early childhood trauma.
Agarwal, Neha; Subramanian, Arulselvi; Pandey, Ravindra Mohan; Albert, Venencia; Karjee, Sulekha; Arya, Vedanand
Fresh frozen plasma (FFP) transfusion is a crucial part of management of trauma patients. There is a paucity of literature about the audit of appropriateness of FFP use in trauma patients. To evaluate and analyze the appropriateness of FFP transfusion practices for trauma patients. Prospectively compiled blood bank records of FFP transfusion practices over a period of 4 months from Augusts'08 through Deember'08 were retrospectively analyzed for 207 patients. The number of FFP units used in all these trauma patients were evaluated a propos the cause of injury, departments, type of surgery, presence of coagulopathy, bleeding, massive transfusion, length of hospital stay and patient outcome. Trauma scores such as Glasgow coma score and injury severity score were also calculated to estimate the severity of injury. The appropriateness of FFP transfusion was assessed according to the guidelines drafted by the College of American Pathologists. FFP transfusion for patients experiencing active bleeding, micro vascular bleeding, coagulopathy and/or massive transfusion, was deemed appropriate. Patients receiving FFP were categorized and individually correlated with the outcome. The influences of other variables which affect patient outcome were excluded using stepwise multivariate logistic regression analysis. p value < 0.05 were considered to be statistically significant. A total of 207 trauma patients were included in the study, 183 (88.4 %) males and 24 (11.6 %) females. The FFP use among neurosurgery patients was 46.9 %, general surgery patients 40.6 % and orthopedics 12.6 %. Appropriate use of FFP was 49.5 % according to the CAP guidelines. Trauma patients who required FFP as a part of treatment were categorized as; Patients who had bleeding alone (n = 40), bleeding with coagulopathy (n = 16), and coagulopathy alone (n = 43), and further correlated with the outcome and were found statistically insignificant. The prevalence of appropriate use of FFP at
Beygui, Farzin; Castren, Maaret; Brunetti, Natale Daniele; Rosell-Ortiz, Fernando; Christ, Michael; Zeymer, Uwe; Huber, Kurt; Folke, Fredrik; Svensson, Leif; Bueno, Hector; Van't Hof, Arnoud; Nikolaou, Nikolaos; Nibbe, Lutz; Charpentier, Sandrine; Swahn, Eva; Tubaro, Marco; Goldstein, Patrick
Chest pain and acute dyspnoea are frequent causes of emergency medical services activation. The pre-hospital management of these conditions is heterogeneous across different regions of the world and Europe, as a consequence of the variety of emergency medical services and absence of specific practical guidelines. This position paper focuses on the practical aspects of the pre-hospital treatment on board and transfer of patients taken in charge by emergency medical services for chest pain and dyspnoea of suspected cardiac aetiology after the initial assessment and diagnostic work-up. The objective of the paper is to provide guidance, based on evidence, where available, or on experts' opinions, for all emergency medical services' health providers involved in the pre-hospital management of acute cardiovascular care.
Leon, Scott C.; Ragsdale, Brian; Miller, Steven A.; Spacarelli, Steven
Objective: The purpose of this longitudinal study was to examine the relationship between several proposed protective factors and trauma symptoms among highly vulnerable youth in the child welfare system. Methods: Participants were 142 youth identified with a sexual behavior problem and their caregivers. Two waves of data were collected for each…
Seifman, Marc A; Gomes, Keith; Nguyen, Phuong N; Bailey, Michael; Rosenfeld, Jeffrey V; Cooper, David J; Morganti-Kossmann, Maria Cristina
Melatonin is an endogenous hormone mainly produced by the pineal gland whose dysfunction leads to abnormal sleeping patterns. Changes in melatonin have been reported in acute traumatic brain injury (TBI); however, the impact of environmental conditions typical of the intensive care unit (ICU) has not been assessed. The aim of this study was to compare daily melatonin production in three patient populations treated at the ICU to differentiate the role of TBI versus ICU conditions. Forty-five patients were recruited and divided into severe TBI, trauma without TBI, medical conditions without trauma, and compared to healthy volunteers. Serum melatonin levels were measured at four daily intervals at 0400 h, 1000 h, 1600 h, and 2200 h for 7 days post-ICU admission by commercial enzyme linked immunosorbent assay. The geometric mean concentrations (95% confidence intervals) of melatonin in these groups showed no difference being 8.3 (6.3-11.0), 9.3 (7.0-12.3), and 8.9 (6.6-11.9) pg/mL, respectively, in TBI, trauma, and intensive care cohorts. All of these patient groups demonstrated decreased melatonin concentrations when compared to control patients. This study suggests that TBI as well as ICU conditions, may have a role in the dysfunction of melatonin. Monitoring and possibly substituting melatonin acutely in these settings may assist in ameliorating long-term sleep dysfunction in all of these groups, and possibly contribute to reducing secondary brain injury in severe TBI.
midwifery . In Massachusetts, the Board of Registration in Nursing is authorized to establish conditions and regulations for nursing practice in the...because as a registered nurse, she could orly practice midwifery after complying with the Prehospital Nursing 41 Board’s rules and regulations regarding...standards for the practice of Certified Nurse Practitioner and Nurse Midwifery (Md. Health Occu. Code Ann. §8-306 & §§8-601-603, 1991). Prehospital nursing
collider bias continues to plague trauma trials as well as observational studies. Collider bias is a type of selection bias that is often introduced...of treatment and outcome, plagues randomised and observational trauma research. Of the seven trials of prehospital hypertonic saline in dextran (HSD
Valles, Pola; Van den Bergh, Rafael; van den Boogaard, Wilma; Tayler-Smith, Katherine; Gayraud, Olivia; Mammozai, Bashir Ahmad; Nasim, Masood; Cheréstal, Sophia; Majuste, Alberta; Charles, James Philippe; Trelles, Miguel
Background Trauma is a leading cause of death and represents a major problem in developing countries where access to good quality emergency care is limited. Médecins Sans Frontières delivered a standard package of care in two trauma emergency departments (EDs) in different violence settings: Kunduz, Afghanistan, and Tabarre, Haiti. This study aims to assess whether this standard package resulted in similar performance in these very different contexts. Methods A cross-sectional study using routine programme data, comparing patient characteristics and outcomes in two EDs over the course of 2014. Results 31 158 patients presented to the EDs: 22 076 in Kunduz and 9082 in Tabarre. Patient characteristics, such as delay in presentation (29.6% over 24 h in Kunduz, compared to 8.4% in Tabarre), triage score, and morbidity pattern differed significantly between settings. Nevertheless, both EDs showed an excellent performance, demonstrating low proportions of mortality (0.1% for both settings) and left without being seen (1.3% for both settings), and acceptable triage performance. Physicians’ maximum working capacity was exceeded in both centres, and mainly during rush hours. Conclusions This study supports for the first time the plausibility of using the same ED package in different settings. Mapping of patient attendance is essential for planning of human resources needs. PMID:27810881
Whalen, Desmond; Harty, Chris; Ravalia, Mohamed; Renouf, Tia; Alani, Sabrina; Brown, Robert
The relevance of simulation as a teaching tool for medical professionals working in rural and remote contexts is apparent when low-frequency, high-risk situations are considered. Simulation training has been shown to enhance learning and improve patient outcomes in urban settings. However, there are few simulation scenarios designed to teach rural trauma management during complex medical transportation. In this technical report, we present a scenario using a medevac helicopter (Replica of Sikorsky S-92 designed by Virtual Marine Technology, St. John's, NL) at a rural community. This case can be used for training primary care physicians who are working in a rural or remote setting, or as an innovative addition to emergency medicine and pre-hospital care training programs. PMID:27081585
Whalen, Desmond; Harty, Chris; Ravalia, Mohamed; Renouf, Tia; Alani, Sabrina; Brown, Robert; Dubrowski, Adam
The relevance of simulation as a teaching tool for medical professionals working in rural and remote contexts is apparent when low-frequency, high-risk situations are considered. Simulation training has been shown to enhance learning and improve patient outcomes in urban settings. However, there are few simulation scenarios designed to teach rural trauma management during complex medical transportation. In this technical report, we present a scenario using a medevac helicopter (Replica of Sikorsky S-92 designed by Virtual Marine Technology, St. John's, NL) at a rural community. This case can be used for training primary care physicians who are working in a rural or remote setting, or as an innovative addition to emergency medicine and pre-hospital care training programs.
Levenson, Jill S; Willis, Gwenda M; Prescott, David S
This study explored the prevalence of childhood trauma in a sample of male sexual offenders (N = 679) using the Adverse Childhood Experience (ACE) scale. Compared with males in the general population, sex offenders had more than 3 times the odds of child sexual abuse (CSA), nearly twice the odds of physical abuse, 13 times the odds of verbal abuse, and more than 4 times the odds of emotional neglect and coming from a broken home. Less than 16% endorsed zero ACEs and nearly half endorsed four or more. Multiple maltreatments often co-occurred with other types of household dysfunction, suggesting that many sex offenders were raised within a disordered social environment. Higher ACE scores were associated with higher risk scores. By enhancing our understanding of the frequency and correlates of early adverse experiences, we can better devise trauma-informed interventions that respond to the clinical needs of sex offender clients.
Struck, Manuel Florian; Wittrock, Maike; Nowak, Andreas
The objective of this study was to analyze the prehospital use of a Glidescope video laryngoscope (GSVL) due to anticipated and unexpected difficult airway in a helicopter emergency medical service setting in which emergency physicians (EP) are experienced anesthetists. Retrospective observational study and survey of the experiences of EP were conducted for more than a 3-year period (July 2007-August 2010). In 1675 missions, 152 tracheal intubations (TI) were performed. GSVL was used in 23 cases (15%). A total of 17 patients presented with multiple traumas, including nine with cervical spine immobilization, three with burns, and three with nontraumatic diagnoses. Eight patients experienced previously failed TI with conventional laryngoscopy (five by nonhelicopter emergency medical service EP). In two patients, the EP required two attempts with GSVL to obtain a successful TI. Since the introduction of the GSVL, no other backup airway device was necessary. GSVL may be a valuable support instrument in the prehospital management of difficult airways in emergency patients.
Background Delayed admission to appropriate care has been shown increase mortality following traumatic brain injury (TBI). We investigated factors associated with delayed admission to a hospital with neurosurgical expertise in a cohort of TBI patients in the intensive care unit (ICU). Methods A retrospective analysis of all TBI patients treated in the ICUs of Helsinki University Central Hospital was carried out from 1.1.2009 to 31.12.2010. Patients were categorized into two groups: direct admission and delayed admission. Patients in the delayed admission group were initially transported to a local hospital without neurosurgical expertise before inter-transfer to the designated hospital. Multivariate logistic regression was utilized to identify pre-hospital factors associated with delayed admission. Results Of 431 included patients 65% of patients were in the direct admission groups and 35% in the delayed admission groups (median time to admission 1:07h, IQR 0:52–1:28 vs. 4:06h, IQR 2:53–5:43, p <0.001). In multivariate analysis factors increasing the likelihood of delayed admission were (OR, 95% CI): male gender (3.82, 1.60-9.13), incident at public place compared to home (0.26, 0.11-0.61), high energy trauma (0.05, 0.01-0.28), pre-hospital physician consultation (0.15, 0.06-0.39) or presence (0.08, 0.03-0.22), hypotension (0.09, 0.01-0.93), major extra cranial injury (0.17, 0.05-0.55), abnormal pupillary light reflex (0.26, 0.09-0.73) and severe alcohol intoxication (12.44, 2.14-72.38). A significant larger proportion of patients in the delayed admission group required acute craniotomy for mass lesion when admitted to the neurosurgical hospital (57%, 21%, p< 0.001). No significant difference in 6-month mortality was noted between the groups (p= 0.814). Conclusion Delayed trauma center admission following TBI is common. Factors increasing likelihood of this were: male gender, incident at public place compared to home, low energy trauma, absence of pre-hospital
Moyer, Donna L; Carpenter, Jennifer M; Landon, Margaret A; Mack, Dorothy T; Kenyon, Jennifer L; Champion, Samara A
Each year thousands of children are hospitalized for traumatic injuries associated with physical abuse. Nurses in the pediatric intensive care unit must be knowledgeable and skilled in caring for the physical, psychological, emotional, social, and developmental needs of such children and their families. This article provides direction for pediatric nurses working in the critical care setting. Specifically, it describes the nursing care of children in a pediatric intensive care unit where the mechanism of nonaccidental injury is blunt force to the head, abdomen, or musculoskeletal system, based on standards put forth by the American Association of Critical-Care Nurses.
Pal, Ranabir; Agarwal, Amit; Galwankar, Sagar; Swaroop, Mamta; Stawicki, Stanislaw P; Rajaram, Laxminarayan; Paladino, Lorenzo; Aggarwal, Praveen; Bhoi, Sanjeev; Dwivedi, Sankalp; Menon, Geetha; Misra, MC; Kalra, OP; Singh, Ajai; Radjou, Angeline Neetha; Joshi, Anuja
It is encouraging to see the much needed shift in the understanding and recognition of the concept of “burden of disease” in the context of traumatic injury. Equally important is understanding that the impact of trauma burden rivals that of nontraumatic morbidities. Subsequently, this paradigm shift reinstates the appeal for timely interventions as the standard for management of traumatic emergencies. Emergency trauma care in India has been disorganized due to inadequate sensitivity toward patients affected by trauma as well as the haphazard, nonuniform acceptance of standardization as the norm. Some of the major hospitals across various regions in the country do have trauma care units, but even those lack protocols to ensure that all trauma cases are handled by those units, largely owing to lack of structured referral system. As a first step to reform the state of trauma care in the country, a detailed overview is needed to gain insight into the prevailing reality. The objectives of this paper are to thus weave a foundation based on the statistical and qualitative burden of trauma in the country; the available infrastructure of trauma care centers equipped to deal with trauma; the need and scope of standardized protocols for intervention; and most importantly, the application of these in shaping educational initiatives in advancing emergency trauma care in the country. PMID:25024939
Background Errors in the decision-making process are probably the main threat to patient safety in the prehospital setting. The reason can be the change of focus in prehospital care from the traditional “scoop and run” practice to a more complex assessment and this new focus imposes real demands on clinical judgment. The use of Clinical Guidelines (CG) is a common strategy for cognitively supporting the prehospital providers. However, there are studies that suggest that the compliance with CG in some cases is low in the prehospital setting. One possible way to increase compliance with guidelines could be to introduce guidelines in a Computerized Decision Support System (CDSS). There is limited evidence relating to the effect of CDSS in a prehospital setting. The present study aimed to evaluate the effect of CDSS on compliance with the basic assessment process described in the prehospital CG and the effect of On Scene Time (OST). Methods In this time-series study, data from prehospital medical records were collected on a weekly basis during the study period. Medical records were rated with the guidance of a rating protocol and data on OST were collected. The difference between baseline and the intervention period was assessed by a segmented regression. Results In this study, 371 patients were included. Compliance with the assessment process described in the prehospital CG was stable during the baseline period. Following the introduction of the CDSS, compliance rose significantly. The post-intervention slope was stable. The CDSS had no significant effect on OST. Conclusions The use of CDSS in prehospital care has the ability to increase compliance with the assessment process of patients with a medical emergency. This study was unable to demonstrate any effects of OST. PMID:25106732
Stanford, Ralph; Middleton, James W; Burns, Brian; Joseph, Anthony; Flower, Oliver; Rigby, Oran; Ball, Jonathon; Dhaliwal, Shelly
Introduction Around 300 people sustain a new traumatic spinal cord injury (TSCI) in Australia each year; a relatively low incidence injury with extremely high long-term associated costs. Care standards are inconsistent nationally, lacking in consensus across important components of care such as prehospital spinal immobilisation, timing of surgery and timeliness of transfer to specialist services. This study aims to develop ‘expertly defined’ and agreed standards of care across the majority of disciplines involved for these patients. Methods and analysis A modified e-Delphi process will be used to gain consensus for best practice across specific clinical early care areas for the patient with TSCI; invited participants will include clinicians across Australia with relevant and significant expertise. A rapid literature review will identify available evidence, including any current guidelines from 2005 to 2015. Level and strength of evidence identified, including areas of contention, will be used to formulate the first round survey questions and statements. Participants will undertake 2–3 online survey rounds, responding anonymously to questionnaires regarding care practices and indicating their agreement or otherwise with practice standard statements. Relevant key stakeholders, including patients, will also be interviewed face to face. Ethics and dissemination Ethics approval for this study was obtained by the NSW Population & Health Services Research Ethics Committee on 14 January 2016 (HREC/12/CIPHS/74). Seeking comprehensive understanding of how the variation in early care pathways and treatment can be addressed to achieve optimal patient outcomes and economic costs; the overall aim is the agreement to a consistent approach to the triage, treatment, transport and definitive care of acute TSCI victims. The agreed practice standards of care will inform the development of a Clinical Pathway with practice change strategies for implementation. These standards will
Abstract This 10-year study (N=177) examines how people with HIV use spirituality to cope with life's trauma on top of HIV-related stress (e.g., facing death, stigma, poverty, limited healthcare) usual events. Spirituality, defined as a connection to a higher presence, is independent from religion (institutionalized spirituality). As a dynamic adaptive process, coping requires longitudinal studying. Qualitative content-analysis of interviews/essays yielded a coding of specific aspects and a longitudinal rating of overall spiritual coping. Most participants were rated as spiritual, using spiritual practices, about half experienced comfort, empowerment, growth/transformation, gratitude, less than one-third meaning, community, and positive reframing. Up to one-fifth perceived spiritual conflict, struggle, or anger, triggering post-traumatic stress, which sometimes converted into positive growth/transformation later. Over time, 65% used spiritual coping positively, 7% negatively, and 28% had no significant use. Spirituality was mainly beneficial for women, heterosexuals, and African Americans (p<0.05). Results suggest that spirituality is a major source of positive and occasionally negative coping (e.g., viewing HIV as sin). We discuss how clinicians can recognize and prevent when spirituality is creating distress and barriers to HIV treatment, adding a literature review on ways of effective spiritual assessment. Spirituality may be a beneficial component of coping with trauma, considering socio-cultural contexts. PMID:24601735
Peng, Lingli; Mayner, Lidia; Wang, Honghong
The correlation between patients' severity and nursing workload for multiple trauma patients within the first 24 h of admission was explored in this study. Multiple trauma adult patients (n = 229) admitted in the emergency rescue room of a public hospital in China over a 1 year period were enrolled in this study. The worst values of the Acute Physiology and Chronic Health Evaluation-II scores and the Nursing Activity Score were collected during the first 24 h after admission. The predicted number of registered nurses was calculated for the corresponding severity groups. In the results, one-way ANOVA revealed that the Nursing Activity Score in the seven severity groups differed significantly. The total Acute Physiology and Chronic Health Evaluation-II score had a positive correlation with the Nursing Activity Score. The predicted number of registered nurses required was 0.6 for the low group, 0.7 for the moderate group, 1.0 for the severe group, and 1.1 for the extremely severe group. Patients' illness severity is an important indicator of nursing workload, especially in nurse staff allocation within the emergency department.
in casualties with polytrauma and a moderate blunt TBI. Secondary insults after TBI, especially hypother- mia and hypoxemia, increased the odds of 24...combat casualty care.3 Benchmark ana - lyses can be used to document the effectiveness of the combat care provided but may also reveal gaps in care...increased mortality when hypother- mia accompanies polytrauma in the civilian sector,36–38 our data indicate that combat injured individuals with hypother
Conradi, Lisa; Agosti, Jen; Tullberg, Erika; Richardson, Lisa; Langan, Heather; Ko, Susan; Wilson, Charles
This paper will provide information on a recent Breakthrough Series Collaborative (BSC) conducted by the National Child Traumatic Stress Network on Using Trauma-Informed Child Welfare Practice to Improve Foster Care Placement Stability. Information on this particular BSC will be provided, followed by initial findings gathered from an evaluation of…
Walsh, Mary E.; Buchanan, Marla J.
A large body of research provides evidence of workplace injuries to those in the nursing profession. Research on workplace stress and burnout among medical professionals is also well known; however, the profession of acute care nursing has not been examined with regards to work-related stress. This qualitative study focused on acute care nurses'…
Korošec Jagodič, Helena; Jagodič, Klemen; Podbregar, Matej
Introduction Our aim was to determine long-term survival and quality of life of patients admitted to a surgical intensive care unit (ICU) because of sepsis or trauma. Methods This was an observational study conducted in an 11-bed, closed surgical ICU at a 860-bed teaching general hospital over a 1-year period (January 2003 to December 2003). Patients were divided into two groups according to admission diagnoses: group 1 included patients with sepsis; and group 2 included patients with trauma (polytrauma, multiple trauma, head injury, or spinal injury). Quality of life was assessed after 2 years following ICU admission using the EuroQol 5D questionnaire. Results A total of 164 patients (98 trauma patients and 66 patients with sepsis) were included in the study. Trauma patients were younger than patients with sepsis (53 ± 21 years versus 64 ± 13 years; P ≤ 0.001). There was no significant difference between groups in Acute Physiology and Chronic Health Evaluation II score or length of stay in the surgical SICU. Trauma patients stayed longer on the general ward (35 ± 44 days versus 17 ± 24 days; P < 001). Surgical ICU survival, in-hospital survival, and post-hospital and cumulative 2-year survival were lower in the sepsis group than in the trauma group (surgical ICU survival: 60% versus 74%; in-hospital survival: 42% versus 62%; post-hospital survival: 78% versus 92%; cumulative 2-year survival: 33% versus 57%; P < 0.05). There was no significant difference in quality of life in all five dimensions of the EuroQol 5D between groups: 60% of patients had signs of depression, almost 60% had problems in usual activities and 56% had pain. Conclusion Patients with sepsis treated in a surgical ICU have higher short-term and long-term mortality than do trauma patients. However, quality of life is reduced to the same level in both groups. PMID:16978417
Hummer, Victoria Latham; Dollard, Norin; Robst, John; Armstrong, Mary I.
Children in the child welfare system frequently experience trauma within the caregiving relationship. These traumatic experiences may be compounded by system trauma and place these children at high risk of emotional disorders and placement in out-of-home (OOH) mental health treatment programs. This article reviews the literature on trauma and…
War wounds usually show abundant devitalized tissue and often contain foreign material (environmental matter, shrapnels, and bullets). Thus, they are particularly prone to infection. Moreover, evacuation to a medical treatment facility and surgical debridement are often delayed due to tactical constraints. Thus, the early administration of an antibiotic on the ground in a prehospital setting seems justified to slow bacterial growth and the development of early infection. However, antibiotics are never a substitute for surgical treatment. The mix of microorganisms expected in war wounds is highly variable and determines the choice of the antibacterial agent. In a prehospital setting and in the absence of medical or paramedical personnel, the antibiotic must be administered orally (combat pill pack). In view of the antibacterial activity as well as pharmacokinetic and pharmaceutical properties, a combination of a fluoroquinolone active against Pseudomonas and a lincomycine with a high oral bioavailability at high doses seems to be a rational choice (ciprofloxacine 750 mg or alternatively levofloxacine 500 mg+clindamycine 600 mg tablets). If oral administration is excluded (unconsciousness, penetrating abdominal trauma, shock), the parenteral administration will be delayed until the patient has been taken in charge by medical or paramedical personnel. In that case, the intravenous administration of an association of an ureidopenicilline with antibacterial activity against Pseudomonas and a ß-lactamase-inhibitor at high doses could be a rational choice (piperacilline 4 g+tazobactam 0.5 g) (Tazocilline®). An antibiotic treatment beyond the time of surgery may become necessary in individual patients depending on the local features of the wound and should be prescribed by the medical officer in charge of the patient on a case-by-case basis.
Carpenter, Christopher R; Platts-Mills, Timothy F
Alternative management methods are essential to ensure high-quality and efficient emergency care for the growing number of geriatric adults worldwide. Protocols to support early condition-specific treatment of older adults with acute severe illness and injury are needed. Improved emergency department care for older adults will require providers to address the influence of other factors on the patient's health. This article describes recent and ongoing efforts to enhance the quality of emergency care for older adults using alternative management approaches spanning the spectrum from prehospital care, through the emergency department, and into evolving inpatient or outpatient processes of care.
Mattu, Amal; Lawner, Benjamin
The evolution of prehospital treatment of decompensated congestive heart failure has in some ways come full circle: rather than emphasizing a battery of new pharmacotherapies, out-of-hospital providers have a renewed focus on aggressive use of nitrates, optimization of airway support, and rapid transport. The use of furosemide and morphine has become de-emphasized, and a flurry of research activity and excitement revolves around the use of noninvasive positive-pressure ventilation. Further research will clarify the role of bronchodilators and angiotensin-converting enzyme inhibitors in the prehospital setting.
Gupta, K. J.; Clancy, M.
OBJECTIVE: To study how the cervical spine is assessed before discontinuation of cervical spine immobilisation in unconscious trauma patients in intensive care units. DESIGN: Telephone interview of consultants responsible for adult intensive care units. SETTING: All 25 intensive care units in the South and West region that admit victims of major trauma. MAIN OUTCOME MEASURES: The clinical and radiological basis on which the decision is made to stop cervical spine immobilisation in unconscious patients with trauma. RESULTS: In 19 units cervical spine immobilisation was stopped in unconscious patients on the basis of radiology alone, and six units combined radiology with clinical examination after the patient had regained consciousness. Sixteen units relied on a normal lateral radiological view of the cervical spine alone, five required a normal lateral and anteroposterior view, and four required a normal lateral, anteroposterior, and open mouth peg view. CONCLUSIONS: There are inconsistencies in the clinical and radiological approach to assessing the cervical spine in unconscious patients with trauma before the removal of immobilisation precautions. There is an overreliance on the lateral cervical spine view alone, which has been shown to be insensitive in this setting. PMID:9180066
Singh, Sheetal; Gupta, Shakti; Daga, Anoop; Siddharth, Vijaydeep; Wundavalli, LaxmiTej
Introduction: For the Commonwealth Games 2010, Jai Prakash Narayan Apex Trauma Centre (JPNATC) of India had been directed by the Director General Health Services and Ministry of Health and Family Welfare, Government of India, to set up a specialized unit for the definitive management of the injured/unwell athletes, officials, and related personnel coming for the Commonwealth Games in October 2010. The facility included a 20-bedded fully equipped ward, six ICU beds with ventilator capacity, one very very important person observation area, one perioperative management cubicle, and one fully modular and integrated operating room. Objective: The objective of this study was to calculate the cost of disaster facility at JPNATC, All India Institute of Medical Sciences, New Delhi. Methodology: Traditional (average or gross) costing methodology was used to arrive at the cost for the provisioning of these services by this facility. Results: The annual cost of providing services at disaster facility at JPNATC, New Delhi, was calculated to be INR 61,007,334.08 (US$ 983,989.258) while the per hour cost was calculated to be INR 7061.03 of the total cost toward the provisioning of services by disaster facility where 26% was the capital cost and 74% was the operating cost. Human resource caters to maximum chunk of the expenditures (47%). Conclusion: The results of this costing study will help in the future planning of resource allocation within the financial constraints (US$ 1 = INR 62 in the year 2013). PMID:27904258
Carrick, Matthew M.; Leonard, Jan; Slone, Denetta S.; Mains, Charles W.
Hemorrhagic shock is a principal cause of death among trauma patients within the first 24 hours after injury. Optimal fluid resuscitation strategies have been examined for nearly a century, more recently with several randomized controlled trials. Hypotensive resuscitation, also called permissive hypotension, is a resuscitation strategy that uses limited fluids and blood products during the early stages of treatment for hemorrhagic shock. A lower-than-normal blood pressure is maintained until operative control of the bleeding can occur. The randomized controlled trials examining restricted fluid resuscitation have demonstrated that aggressive fluid resuscitation in the prehospital and hospital setting leads to more complications than hypotensive resuscitation, with disparate findings on the survival benefit. Since the populations studied in each randomized controlled trial are slightly different, as is the timing of intervention and targeted vitals, there is still a need for a large, multicenter trial that can examine the benefit of hypotensive resuscitation in both blunt and penetrating trauma patients. PMID:27595109
Aylwin, Christopher J; Brohi, Karim; Davies, Gareth D; Walsh, Michael S
INTRODUCTION Pleural drainage with chest tube insertion for thoracic trauma is a common and often life-saving technique. Although considered a simple procedure, complication rates have been reported to be 2–25%. We conducted a prospective cohort observational study of emergency pleural drainage procedures to validate the indications for pre-hospital thoracostomy and to identify complications from both pre- and in-hospital thoracostomies. PATIENTS AND METHODS Data were collected over a 7-month period on all patients receiving either pre-hospital thoracostomy or emergency department tube thoracostomy. Outcome measures were appropriate indications, errors in tube placement and subsequent complications. RESULTS Ninety-one chest tubes were placed into 52 patients. Sixty-five thoracostomies were performed in the field without chest tube placement. Twenty-six procedures were performed following emergency department identification of thoracic injury. Of the 65 pre-hospital thoracostomies, 40 (61%) were for appropriate indications of suspected tension pneumothorax or a low output state. The overall complication rate was 14% of which 9% were classified as major and three patients required surgical intervention. Twenty-eight (31%) chest tubes were poorly positioned and 15 (17%) of these required repositioning. CONCLUSIONS Pleural drainage techniques may be complicated and have the potential to cause life-threatening injury. Pre-hospital thoracostomies have the same potential risks as in-hospital procedures and attention must be paid to insertion techniques under difficult scene conditions. In-hospital chest tube placement complication rates remain uncomfortably high, and attention must be placed on training and assessment of staff in this basic procedure. PMID:18201502
Introduction Hypothermia is associated with increased morbidity and mortality in trauma patients and poses a challenge in pre-hospital treatment. The aim of this study was to identify equipment to prevent, diagnose, and treat hypothermia in Norwegian pre-hospital services. Method In the period of April-August 2011, we conducted a survey of 42 respondents representing a total of 543 pre-hospital units, which included all the national ground ambulance services, the fixed wing and helicopter air ambulance service, and the national search and rescue service. The survey explored available insulation materials, active warming devices, and the presence of protocols describing wrapping methods, temperature monitoring, and the use of warm i.v. fluids. Results Throughout the services, hospital duvets, cotton blankets and plastic “bubble-wrap” were the most common insulation materials. Active warming devices were to a small degree available in vehicle ambulances (14%) and the fixed wing ambulance service (44%) but were more common in the helicopter services (58-70%). Suitable thermometers for diagnosing hypothermia were lacking in the vehicle ambulance services (12%). Protocols describing how to insulate patients were present for 73% of vehicle ambulances and 70% of Search and Rescue helicopters. The minority of Helicopter Emergency Medical Services (42%) and Fixed Wing (22%) units was reported to have such protocols. Conclusion The most common equipment types to treat and prevent hypothermia in Norwegian pre-hospital services are duvets, plastic “bubble wrap”, and cotton blankets. Active external heating devices and suitable thermometers are not available in most vehicle ambulance units. PMID:23938145
Ince, Elif E.; Rubin, David; Christian, Cindy W.
Objective: To determine whether a suspicion or diagnosis of child abuse during hospitalization influences parental perceptions of hospital care in families of children admitted with traumatic injuries. Method: Parents of children younger than 6 years of age admitted with traumatic injuries to a large urban children's hospital were recruited to…
Kelly, Edward; Rogers, Selwyn O
The increasing need for skilled emergency surgical providers, coupled with decreasing experience in emergency surgery among trainees, has led to significant shortages in the availability of such surgeons. In response to this crisis, surgical leaders have developed a comprehensive curriculum and a set of professional standards to guide the training of a new specialist: the acute care surgeon. This article reviews the development and goals for Fellowship training of this new specialty.
Kahn, Steven A; Iannuzzi, James C; Stassen, Nicole A; Bankey, Paul E; Gestring, Mark
Hospital quality metrics now reflect patient satisfaction and are measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Understanding these metrics and drivers will be integral in providing quality care as this process evolves. This study identifies factors associated with patient satisfaction as determined by HCAHPS survey responses in trauma and acute care surgery patients. HCAHPS survey responses from acute care surgery and trauma patients at a single institution between 3/11 and 10/12 were analyzed. Logistic regression determined which responses to individual HCAHPS questions predicted highest hospital score (a rating of 9-10/10). Demographic and clinical variables were also analyzed as predictors of satisfaction. Subgroup analysis for trauma patients was performed. In 70.3 per cent of 182 total survey responses, a 9-10/10 score was given. The strongest predictors of highest hospital ranking were respect from doctors (odds ratio [OR] = 24.5, confidence interval [CI]: 5.44-110.4), doctors listening (OR: 9.33, CI: 3.7-23.5), nurses' listening (OR = 8.65, CI: 3.62-20.64), doctors' explanations (OR = 8.21, CI: 3.5-19.2), and attempts to control pain (OR = 7.71, CI: 3.22-18.46). Clinical factors and outcomes (complications, intensive care unit/hospital length of stay, mechanism of injury, and having an operation) were nonsignificant variables. For trauma patients, Injury Severity Score was inversely related to score (OR = 0.93, CI: 0.87-0.98). Insurance, education, and disposition were also tied to satisfaction, whereas age, gender, and ethnicity were nonsignificant. In conclusion, patient perception of interactions with the healthcare team was most strongly associated with satisfaction. Complications did not negatively influence satisfaction. Insurance status might potentially identify patients at risk of dissatisfaction. Listening to patients, treating them with respect, and explaining the care plan are integral to a
Field, Craig Andrew; Baird, Janette; Saitz, Richard; Caetano, Raul; Monti, Peter M.
The purpose of this review is to provide a broad overview of the status of brief intervention in the emergency department, trauma center and inpatient hospital setting. This review is based on a symposia presented at the 2009 annual conference of the Research Society on Alcoholism (Baird et al., 2009; Field, et al., 2009; Monti et al., 2009; Saitz et al., 2009). While the general efficacy of brief alcohol interventions in these settings has been recognized, the evidence is increasingly mixed. Herein we discuss possible confounding factors; including the inconsistencies in interventions provided, differences in target population, study design and assessment procedures. Recent studies investigating potential moderators of treatment outcomes suggest that a more sophisticated approach to evaluating the effectiveness of brief interventions across varying patient populations is needed in order to further understand its effectiveness. Current dissemination efforts represent a significant advance in broadening the base of treatment for alcohol problems by providing an evidenced based intervention in health care settings and should not be curtailed. However, additional research is required to enhance treatment outcomes, refine current practice guidelines and continue to bridge the gap between science and practice. Given the current state of research, a multi-setting clinical trial is recommended to account for potential contextual differences while controlling for study design. PMID:20860610
Stimson, Christopher E; Botruff, Anita L
The electronic health record (EHR) is frequently viewed as a government-mandated charting system. As simply a replacement for the paper record, however, it was also frequently found to be inconvenient and a distraction to patient care. Broader use of the technology inherent in the EHR in the form of daily reports focused on key information that allows trauma clinical teams to efficiently monitor important information such as specific laboratory results or medications that might be missed or overlooked. In addition, other clinical personnel can monitor and assist in the care of trauma patients from remote locations such as an administrative office. Implementation of EHR reports is feasible, can be easily adopted by the clinical team, and has the potential to promote quality, safety, and efficiency. In addition, this innovation satisfies many of the requirements for meaningful use.
Agrawal, Rupesh; Wei, Ho Sue; Teoh, Stephen
Objective: To evaluate the factors influencing final vision outcome after surgical repair of open globe injuries and to correlate the Ocular trauma score. Materials and Methods: Retrospective case analysis of patients with open globe injuries at a tertiary referral eye care centre in Singapore was performed. Pre-operative factors affecting final vision outcome in patients with open globe injury and correlation of ocular trauma score in our study with international ocular trauma scoring system was performed. Results: Case records of 172 eyes with open globe injury were analyzed. Mean age was 36. 67 years. Mean follow up was 12.26 m. Males were pre-dominantly affected. Initial visual acuity was ≥20/40, 20/50 < 20/200, 20/200- CF, HM– PL and NLP in 24 (14%), 39 (22.7%), 16 (9.3%), 66 (38.4%) and 27 (15.7%) eyes respectively. Final visual acuity was ≤20/40, 20/50 < 20/200, 20/200- 1/200, HM– PL and NLP in 76 (44.2%), 28 (16.3%), 11 (6.4%), 30 (17.4%) and 27 (15.7%) eyes respectively. Ocular trauma score in our study correlates with international ocular trauma scoring system. Conclusion: The present study showed pre-operative variables such as mode of injury, pre-operative visual acuity, traumatic cataract, hyphaema, relative afferent papillary defect, vitreous lossand vitreous hemorrhage to be adversely affecting the final vision outcome. Our study showed a good synchrony with international ocular trauma score (OTS) and based on this study we were able to validate application of OTS in Singapore population. Recognizing these factors can help the surgeon in evidence based counseling. PMID:24104709
Ball, Chad G.; Das, Debanjana; Roberts, Derek J.; Vis, Christine; Kirkpatrick, Andrew W.; Kortbeek, John B.
Background Trauma centres continue to evolve with respect to clinical care and their impact on public health. Despite improvements in patient outcomes, operative volumes, and therefore maintenance of surgical skills, has become a challenging issue. We sought to determine whether injury demographics and treatments at a high- volume centre changed over time. Methods We used the Alberta Trauma Registry to analyze all severely injured (injury severity score [ISS] ≥ 12) patient admissions over a 16-year period (1995–2011). Results Of the 12 879 severely injured patients requiring admission, there was a 1.5-fold increase in the annual admission rate despite population normalization (p = 0.001). Over the 16-year interval, patients were older with a subsequent lower mortality (p = 0.001) and length of hospital stay (p = 0.007). In patients with the most severe ISS (≥ 48), there was no change in mortality (27%, p = 0.26). In 2011, falls were the most common mechanism compared with motor vehicle crashes (41% v. 23%; p < 0.001); this was a complete reversal compared with 1995 (25% v. 41%). Motorized recreational vehicle and motorcycle injuries also increased (p < 0.001). The mean number of operations performed by trauma surgeons decreased (laparotomies: 67 [17%] in 1995 v. 47 [5%] in 2011, p < 0.001). Thoracotomies and tracheostomies remained unchanged (p = 0.19). Conclusion Clinical care has improved despite an increasing overall volume of severely injured patient admissions. The number of operative interventions performed by trauma surgeons continues to decrease concurrent to a change in injury mechanisms. Despite these improvements, maintenance of technical skills among trauma surgeons has become an important issue. PMID:25427332
Holmes, D K
Most of the facial trauma in the United States is treated in trauma centers in large urban or university medical centers, with limited trauma care taking place in our military medical treatment facilities. In many cases, active duty facial trauma surgeons may lack the current experience necessary for the optimal care of facial wounds of our inquired military personnel in the early stages of the conflict. Consequently, the skills of the reservist trauma surgeons who staff our civilian trauma centers and who care for facial trauma victims daily will be critical in caring for our wounded. These "trauma-current" reservists may act as a cadre of practiced surgeons to aid those with less experience. A plan for refresher training of active duty facial trauma surgeons is presented.
Hall, Kelly E; Sharp, Claire R; Adams, Cynthia R; Beilman, Gregory
In human trauma patients, most deaths result from hemorrhage and brain injury, whereas late deaths, although rare, are the result of multiple organ failure and sepsis. A variety of experimental animal models have been developed to investigate the pathophysiology of traumatic injury and evaluate novel interventions. Similar to other experimental models, these trauma models cannot recapitulate conditions of naturally occurring trauma, and therefore therapeutic interventions based on these models are often ineffective. Pet dogs with naturally occurring traumatic injury represent a promising translational model for human trauma that could be used to assess novel therapies. The purpose of this article was to review the naturally occurring canine trauma literature to highlight the similarities between canine and human trauma. The American College of Veterinary Emergency and Critical Care Veterinary Committee on Trauma has initiated the establishment of a national network of veterinary trauma centers to enhance uniform delivery of care to canine trauma patients. In addition, the Spontaneous Trauma in Animals Team, a multidisciplinary, multicenter group of researchers has created a clinical research infrastructure for carrying out large-scale clinical trials in canine trauma patients. Moving forward, these national resources can be utilized to facilitate multicenter prospective studies of canine trauma to evaluate therapies and interventions that have shown promise in experimental animal models, thus closing the critical gap in the translation of knowledge from experimental models to humans and increasing the likelihood of success in phases 1 and 2 human clinical trials.
Kerns, Suzanne E U; Pullmann, Michael D; Negrete, Andrea; Uomoto, Jacqueline A; Berliner, Lucy; Shogren, Dae; Silverman, Ellen; Putnam, Barbara
Effective strategies that increase the extent to which child welfare professionals engage in trauma-informed case planning are needed. This study evaluated two approaches to increase trauma symptom identification and use of screening results to inform case planning. The first study evaluated the impact of training on trauma-informed screening tools for 44 child welfare professionals who screen all children upon placement into foster care. The second study evaluated a two-stage approach to training child welfare workers on case planning for children's mental health. Participants included (a) 71 newly hired child welfare professionals who received a 3-hr training and (b) 55 child welfare professionals who participated in a full-day training. Results from the first study indicate that training effectively increased knowledge and skills in administering screening tools, though there was variability in comfort with screening. In the second study, participants self-reported significant gains in their competency in identifying mental health needs (including traumatic stress) and linking children with evidence-based services. These findings provide preliminary evidence for the viability of this approach to increase the extent to which child welfare professionals are trauma informed, aware of symptoms, and able to link children and youth with effective services designed to meet their specific needs.
Maheshwari, Alok; Mehrotra, Avanti; Gupta, Anoop K; Thakur, Ranjan K
Cardiac disease is the most common cause of death in the United States, and sudden cardiac arrest frequently claims the lives of men and women during their most productive years. It is believed that much better survival rates can be achieved for victims of cardiac arrest through optimizing the "chain of survival" as described by the American Heart Association. The relative and incremental benefit of full prehospital ACLS over basic life support and defibrillation is unproven, however. This is an important issue in this era of cost containment. Some of the ongoing studies including the OPALS study may clarify the cost effectiveness and relative efficacy of rapid defibrillation and full ACLS programs for victims of prehospital cardiac arrest .
Chen, Serene I.; Wang, Yongfei; Dreyer, Rachel; Strait, Kelly M.; Spatz, Erica S.; Xu, Xiao; Smolderen, Kim G.; Desai, Nihar R.; Lorenze, Nancy P.; Lichtman, Judith H.; Spertus, John A.; D’Onofrio, Gail; Bueno, Héctor; Masoudi, Frederick A.; Krumholz, Harlan M.
This prospective study assessed whether gender differences in health insurance help explain gender differences in delay in seeking care for US patients with acute myocardial infarction (AMI). We also assessed gender differences in such prehospital delay for AMI in Spain, a country with universal insurance. We used data from 2,951 US and 496 Spanish patients aged 18–55 years with AMI. US patients were grouped by insurance status: adequately insured, underinsured, or uninsured. For each country, we assessed the association between gender and prehospital delay (symptom onset to hospital arrival). For the US cohort, we modeled the relationship between insurance groups and delay of >12 hours. US women were less likely than men to be uninsured, but more likely to be underinsured and a larger proportion of women than men experienced delays of >12 hours (38% versus 29%). We found no association between insurance status and delays of >12 hours in men or women. Only 17.3% of Spanish patients had delays of >12 hours and there were no significant gender differences. In conclusion, women were more likely than men to delay, though it was not explained by differences in insurance status. The lack of gender differences in prehospital delays in Spain suggests that these differences may vary by health care system and culture. PMID:26541907
Gurwitch, Robin H; Messer, Erica Pearl; Masse, Joshua; Olafson, Erna; Boat, Barbara W; Putnam, Frank W
Child maltreatment impacts approximately two million children each year, with physical abuse and neglect the most common form of maltreatment. These children are at risk for mental and physical health concerns and the ability to form positive social relationships is also adversely affected. Child Adult Relationship Enhancement (CARE) is a set of skills designed to improve interactions of any adult and child or adolescent. Based on parent training programs, including the strong evidence-based treatment, Parent-Child Interaction Therapy (PCIT), CARE was initially developed to fill an important gap in mental health services for children of any age who are considered at-risk for maltreatment or other problems. CARE subsequently has been extended for use by adults who interact with children and youth outside of existing mental health therapeutic services as well as to compliment other services the child or adolescent may be receiving. Developed through discussions with Parent-Child Interaction Therapy (PCIT) therapists and requests for a training similar to PCIT for the non-mental health professional, CARE is not therapy, but is comprised of a set of skills that can support other services provided to families. Since 2006, over 2000 caregivers, mental health, child welfare, educators, and other professionals have received CARE training with a focus on children who are exposed to trauma and maltreatment. This article presents implementation successes and challenges of a trauma-informed training designed to help adults connect and enhance their relationships with children considered at-risk.
McKay, S D; Johnston, J; Callaway, D W
Trauma care in the tactical environment is complex; it requires a unique blend of situational awareness, foresight, medical skill, multitasking, and physical strength. Rescue is a critical, but often over-looked, component of nearly all tactical trauma casualty management. Successful full spectrum casualty management requires proficiency in four areas: casualty access, assessment, stabilization, and extraction. When complex rescue situations arise (casualty removal from roof tops, mountain terrain, collapsed structures, wells, or a karez), casualty care often becomes further complicated. Special Operations units have historically looked to civilian technical rescue techniques and equipment to fill this ?rescue gap.? Similar to the evolution of pre-hospital military medicine from civilian guidelines (e.g. Advanced Trauma Life Support) (ATLS)) to an evidence-based, tactical-specific guideline (Tactical Combat Casualty Care (TCCC)), an evolution is required within the rescue paradigm. This shift from civilian-based technical rescue guidelines towards an Operational Rescue? capability allows tactical variables such as minimal equipment, low light/night vision goggles (NVG) considerations, enemy threats, and variable evacuation times to permeate through the individual rescue skill set. Just as with TCCC, in which the principles of casualty care remain consistent, the practices must be adapted to end-users environment, so it is with rescue.
Wesson, Hadley K H; Boikhutso, Nonkululeko; Bachani, Abdulgafoor M; Hofman, Karen J; Hyder, Adnan A
Introduction Injuries are a significant cause of mortality and morbidity, of which more than 90% occur in low- and middle-income countries (LMICs). Given the extent of this burden being confronted by LMICs, there is need to place injury prevention at the forefront of public health initiatives and to understand the costs associated with injury. The aim of this article is to describe the extent to which injury-related costing studies have been conducted in LMICs. Methods A review of literature was performed to explore costing data available for injury and/or trauma care in LMICs. Study quality was described using recommendations from the Community Guide’s quality assessment tool for economic evaluations. Results The review identified 68 studies, of which 13 were full economic evaluations. Cost of injury varied widely with mean costs ranging from US$14 to US$17 400. In terms of injury-prevention interventions, cost per disability adjusted life year averted for injury-prevention interventions ranged from US$10.90 for speed bump installation to US$17 000 for drunk driving and breath testing campaigns in Africa. The studies varied in quality, ranging from very good to unsatisfactory. Discussion There is a lack of injury-related economic evidence from LMICs. Current costing research has considerable variability in the costs and cost descriptions of injury and associated prevention interventions. The generalizability of these studies is limited. Yet the economic burden of injury is high, suggesting significant potential for cost savings through injury prevention. A standardized approach to economic evaluation of injury in LMICs is needed to further prioritize investing in injury prevention. PMID:24097794
Cho, Suck Ju; Kwon, In Ho
Objectives Although ambulance-based telemedicine has been reported to be safe and feasible, its clinical usefulness has not been well documented, and different prehospital management systems would yield different results. The authors evaluated the feasibility and usefulness of telemedicine-assisted direct medical control in the Korean emergency medical service system. Methods Twenty ambulances in the Busan area were equipped with a telemedicine system. Three-lead electrocardiogram, blood pressure, and pulse oximetry data from the patient and audiovisual input from the scene were transferred to a server. Consulting physicians used desktop computers and the internet to connect to the server. Both requesting emergency medical service (EMS) providers and consulting physicians were asked to fill out report forms and submit them for analysis. Results In the 41 cases in which telemedicine equipment was used, cellular phones were concomitantly used in 28 cases (68.35%) to compensate for the poor audio quality provided by the equipment. The EMS providers rated the video transmission quality with a 4-point average score (interquartile range [IQR] 2-5) on a 5-point scale, and they rated the biosignal transmission quality as 4 (IQR 3-5). The consulting physicians rated the video quality as 4 (IQR 2.5-4) and the biosignal quality as 4 (IQR 3-4). The physicians' ratings for usefulness for making diagnosis or treatment decisions did not differ significantly in relation to the method of communication used. Conclusions Our study did not find any significant advantage of implementing telemedicine over the use of voice calls in delivering on-line medical control. More user-friendly, smaller devices with clear advantages over voice communication would be required before telemedicine can be successfully implemented in prehospital patient care. PMID:26279957
Background Prehospital work is accomplished using guidelines and protocols, but there is evidence suggesting that compliance with guidelines is sometimes low in the prehospital setting. The reason for the poor compliance is not known. The objective of this study was to describe how guidelines and protocols are used in the prehospital context. Methods This was a single-case study with realistic evaluation as a methodological framework. The study took place in an ambulance organization in Sweden. The data collection was divided into four phases, where phase one consisted of a literature screening and selection of a theoretical framework. In phase two, semi-structured interviews with the ambulance organization's stakeholders, responsible for the development and implementation of guidelines, were performed. The third phase, observations, comprised 30 participants from both a rural and an urban ambulance station. In the last phase, two focus group interviews were performed. A template analysis style of documents, interviews and observation protocols was used. Results The development of guidelines took place using an informal consensus approach, where no party from the end users was represented. The development process resulted in guidelines with an insufficiently adapted format for the prehospital context. At local level, there was a conscious implementation strategy with lectures and manikin simulation. The physical format of the guidelines was the main obstacle to explicit use. Due to the format, the ambulance personnel feel they have to learn the content of the guidelines by heart. Explicit use of the guidelines in the assessment of patients was uncommon. Many ambulance personnel developed homemade guidelines in both electronic and paper format. The ambulance personnel in the study generally took a positive view of working with guidelines and protocols and they regarded them as indispensable in prehospital care, but an improved format was requested by both
Buehner, Michelle; Aden, Jay; Borgman, Mathew; Love, Preston; Wright, Brandi; Edwards, Mary
The purpose of this study was to define the demographics of pediatric traumatic injuries and to understand the predictive value of injury type, prehospital, and emergency department (ED) data regarding the mortality of pediatric trauma patients (<14 years of age) in South Central Texas. We report a retrospective review of pediatric trauma patients presenting to Trauma Service Area P in South Central Texas during 2004-2013. The primary outcome was mortality; secondary outcomes were ventilator days, hospital days, and intensive care unit stay. Demographics, Abbreviated Injury Score (AIS) codes, ICD-9 codes, transport times, Emergency Medical Services (EMS) vital signs en route and on arrival to the emergency department (ED), and outcomes were evaluated. A total of 8004 traumatically injured children presented to EDs in South Central Texas during the study period; 4109 of these presented via EMS. Most patients were Hispanic and male. Distribution was even across age groups. Overall mortality was 2%, and the mortality of those arriving by EMS was 3.7%. Abnormal vital signs and Glasgow Coma Score upon presentation to both EMS and the ED were strongly associated with mortality. Increased Injury Severity Score, the need for transfusion in the ED, and increased maximal AIS were also strongly associated with mortality. African American race was associated with increased mortality, although transport time and age were not. Most injuries overall were caused by motor vehicle collisions; however, burns and falls were most common in infants. The most lethal injuries were caused by firearms (mostly seen in preteens) and assaults (mostly seen in infants). This analysis of injured children in Southwest Texas offers insight into areas of needed quality improvement in the trauma system and potential areas to focus prevention efforts.
Kundal, Vijay Kumar; Debnath, Pinaki Ranjan; Sen, Amita
Aim: To assess the epidemiology, pattern, and outcome of trauma in pediatric population. Materials and Methods: A total of 1148 pediatric patients below 15 years of age presenting in the emergency department of our hospital were studied over a period of 3 years. The patients were categorized into four age groups of <1 year, 1–5 years, 6–10 years, and 11–15 years. The data were compared regarding mode of trauma, type of injury, place of injury among different age groups and both sexes. Results: The majority of the pediatric trauma cases were seen in males 69.86%, (n = 802) and females comprised only 30.13% (n = 346). Road traffic accident (RTA) was the most common mode of trauma in male children, i.e. 59.47% (n = 477) followed by fall injuries, i.e. 29.42% (n = 236). In females, fall was the most common mode of trauma, i.e. 52.31% (n = 181) followed by RTA (36.70%, n = 127). Fall injuries occurred mostly at homes. Among RTA, hit by vehicle on road while playing was most common followed by passenger accidents on two wheelers, followed by hit by vehicle while walking to school. Among fall, fall while playing at home was the most common. Out of total 1148 patients, 304 (26.48%) comprised the polytrauma cases (involvement of more than two organ systems), followed by abdominal/pelvic trauma (20.99%, n = 241), followed by head/face trauma (19.86%, n = 228). Out of total 1148 patients admitted over a period of 36 months, 64 died (5.57%). 75 (6.5%) patients had some kind of residual deformity or disability. Conclusion: The high incidence of pediatric trauma on roads and falls indicate the need for more supervision during playing and identification of specific risk factors for these injuries in our setting. This study shows that these epidemiological parameters could be a useful tool to identify burden and research priorities for specific type of injuries. A comprehensive trauma registry in our set up seems to be important for formulating policies to reduce pediatric
Wurster, Lee Ann; Coffey, Carla; Haley, Kathy; Covert, Julia
The trauma nurse leader role was developed by a group of trauma surgeons, hospital administrators, and emergency department and trauma leaders at Nationwide Children's Hospital who recognized the need for the development of a core group of nurses who provided expert trauma care. The intent was to provide an experienced group of nurses who could identify and resolve issues in the trauma room. Through increased education, exposure, mentoring, and professional development, the trauma nurse leader role has become an essential part of the specialized pediatric trauma care provided at Nationwide Children's Hospital.
Tate, Ramsey C.
Introduction Despite evidence from other healthcare settings that language barriers negatively impact patient outcomes, the literature on language barriers in emergency medical services (EMS) has not been previously summarized. The objective of this study is to systematically review existing studies of the impact of language barriers on prehospital emergency care and identify opportunities for future research. Methods A systematic review with narrative synthesis of publications with populations specific to the prehospital setting and outcome measures specific to language barriers was conducted. A four-prong search strategy of academic databases (PubMed, Academic Search Complete, and Clinical Key) through March 2015, web-based search for gray literature, search of citation lists, and review of key conference proceedings using pre-defined eligibility criteria was used. Language-related outcomes were categorized and reported as community-specific outcomes, EMS provider-specific outcomes, patient-specific outcomes, or health system-specific outcomes. Results Twenty-two studies met eligibility criteria for review. Ten publications (45%) focused on community-specific outcomes. Language barriers are perceived as a barrier by minority language speaking communities to activating EMS. Eleven publications (50%) reported outcomes specific to EMS providers, with six of these studies focused on EMS dispatch. EMS dispatchers describe less accurate and delayed dispatch of resources when confronted with language discordant callers, as well as limitations in the ability to provide medical direction to callers. There is a paucity of research on EMS treatment and transport decisions, and no studies provided patient-specific or health system-specific outcomes. Key research gaps include identifying the mechanisms by which language barriers impact care, the effect of language barriers on EMS utilization and clinically significant outcomes, and the cost implications of addressing language
[Tele-cooperation for innovative care using the example of the University Hospital Aachen. Telematics in intensive care medicine, emergency medicine, and telemedical intersectoral rehabilitation planning in geriatric trauma].
Marx, Gernot; Beckers, Rainer; Brokmann, Jörg Christian; Deisz, Robert; Pape, Hans-Christoph
The demographic challenge of the ageing society is associated with increasing comorbidity. On the other hand, there will be an ageing workforce in medicine, resulting in an imbalance between the demand and supply of medical care in the near future. In rural areas in particular, this imbalance is already present today. Based on three best practice projects carried out by our telemedical center in Aachen, including emergency medicine, intensive care medicine, and the rehabilitation planning of geriatric trauma care, some experience and the potential of the intersectoral provision of care, supported by telemedicine, are demonstrated. Telemedicine is the provision of medical services over a geographical distance by using tele-communication and data transfer. It has been proven to ensure a constant quality of health care. Telemedical support enables shared expertise independent of time and space, and allows efficient allocation of resources. A review of international experience supports this notion.
Onifer, Dana J; Butler, Frank K; Gross, Kirby R; Otten, Edward J; Patton, Robert; Russell, Robert J; Stockinger, Zsolt; Burrell, Elizabeth
The current Tactical Combat Casualty Care (TCCC) Guidelines recommend parenteral promethazine as the single agent for the treatment of opioid-induced nausea and/or vomiting and give a secondary indication of "synergistic analgesic effect." Promethazine, however, has a well-documented history of undesired side effects relating to impairment and dysregulation of the central and autonomic nervous systems, such as sedation, extrapyramidal symptoms, dystonia, impairment of psychomotor function, neuroleptic malignant syndrome, and hypotension. These may be particularly worrisome in the combat casualty. Additionally, since 16 September 2009, there has been a US Food and Drug Administration (FDA) black box warning for the injectable form of promethazine, due to "the risk of serious tissue injury when this drug is administered incorrectly." Conversely, ondansetron, which is now available in generic form, has a well-established favorable safety profile and demonstrated efficacy in undifferentiated nausea and vomiting in the emergency department and prehospital settings. It has none of the central and autonomic nervous system side effects noted with promethazine and carries no FDA black box warning. Ondansetron is available in parenteral form and an orally disintegrating tablet, providing multiple safe and effective routes of administration. Despite the fact that it is an off-label use, ondansetron is being increasingly given for acute, undifferentiated nausea and vomiting and is presently being used in the field on combat casualties by some US and Allied Forces. Considering the risks involved with promethazine use, and the efficacy and safety of ondansetron and ondansetron?s availability in a generic form, we recommend removing promethazine from the TCCC Guidelines and replacing it with ondansetron.
Eagles, Kylee; Fralich, Laura; Stevenson, J Herbert
Understanding basic ear anatomy and function allows an examiner to quickly and accurately identify at-risk structures in patients with head and ear trauma. External ear trauma (ie, hematoma or laceration) should be promptly treated with appropriate injury-specific techniques. Tympanic membrane injuries have multiple mechanisms and can often be conservatively treated. Temporal bone fractures are a common cause of ear trauma and can be life threatening. Facial nerve injuries and hearing loss can occur in ear trauma.
funding . The infrastructure/process is streamlined and efficient leading to the selection of research projects based on a solid scientific, peer review...National Trauma Institute (NTI) to build on the establishment of NTI as a national coordinating center for trauma research funding . In addition, a... research funding . 1. Requests for proposals (RFP) based on areas of scientific merit in trauma and emergency or critical care will be prepared and
Jeauneaux, Olivier; Bony, Maylis; Giroud, Olivier; Chabert, Flavien; Pagnier, Daniel; Mansuy, Charlène; Quélin, Pauline; Lemperrière, Héloïse; Grodecœur, Caroline; Armonia, Cécile
As soon as their prehospital care begins, patients with a serious head injury are given intensive care to offset the systemic failures observed and minimise secondary brain damage. In intensive care, monitoring is continuous and neuroprotection optimised. While the prognosis of the patient remains uncertain, their family are included and involved in their global care.
Integrating palliative care in the surgical and trauma intensive care unit: A report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care
Mosenthal, Anne C.; Weissman, David E.; Curtis, J. Randall; Hays, Ross M.; Lustbader, Dana R.; Mulkerin, Colleen; Puntillo, Kathleen A.; Ray, Daniel E.; Bassett, Rick; Boss, Renee D.; Brasel, Karen J.; Campbell, Margaret; Nelson, Judith E.
Objective Although successful models for palliative care delivery and quality improvement in the intensive care unit have been described, their applicability in surgical intensive care unit settings has not been fully addressed. We undertook to define specific challenges, strategies, and solutions for integration of palliative care in the surgical intensive care unit. Data Sources We searched the MEDLINE database from inception to May 2011 for all English language articles using the term “surgical palliative care” or the terms “surgical critical care,” “surgical ICU,” “surgeon,” “trauma” or “transplant,” and “palliative care” or “end-of- life care” and hand-searched our personal files for additional articles. Based on review of these articles and the experiences of our interdisciplinary expert Advisory Board, we prepared this report. Data Extraction and Synthesis We critically reviewed the existing literature on delivery of palliative care in the surgical intensive care unit setting focusing on challenges, strategies, models, and interventions to promote effective integration of palliative care for patients receiving surgical critical care and their families. Conclusions Characteristics of patients with surgical disease and practices, attitudes, and interactions of different disciplines on the surgical critical care team present distinctive issues for intensive care unit palliative care integration and improvement. Physicians, nurses, and other team members in surgery, critical care and palliative care (if available) should be engaged collaboratively to identify challenges and develop strategies. “Consultative,” “integrative,” and combined models can be used to improve intensive care unit palliative care, although optimal use of trigger criteria for palliative care consultation has not yet been demonstrated. Important components of an improvement effort include attention to efficient work systems and practical tools and to
Background Despite the use of e-FAST in management of patients with abdominal trauma, its utility in prehospital setting is not widely adopted. The goal of this study is to develop a novel portable telesonography (TS) system and evaluate the comparability of the quality of images obtained via this system among healthy volunteers who undergo e-FAST abdominal examination in a moving ambulance and at the ED. We hypothesize that: (1) real-time ultrasound images of acute trauma patients in the pre-hospital setting can be obtained and transmitted to the ED via the novel TS system; and (2) Ultrasound images transmitted to the hospital from the real-time TS system will be comparable in quality to those obtained in the ED. Methods Study participants are three healthy volunteers (one each with normal, overweight and obese BMI category). The ultrasound images will be obtained by two ultrasound-trained physicians The TS is a portable sonogram (by Sonosite) interfaced with a portable broadcast unit (by Live-U). Two UTPs will conduct e-FAST examinations on healthy volunteers in moving ambulances and transmit the images via cellular network to the hospital server, where they are stored. Upon arrival in the ED, the same UTPs will obtain another set of images from the volunteers, which are then compared to those obtained in the moving ambulances by another set of blinded UTPs (evaluators) using a validated image quality scale, the Questionnaire for User Interaction Satisfaction (QUIS). Discussion Findings from this study will provide needed data on the validity of the novel TS in transmitting live images from moving ambulances to images obtained in the ED thus providing opportunity to facilitate medical care of a patient located in a remote or austere setting. PMID:23249290
Green, Steven M
Throughout the past quarter century, there have been slow but dramatic changes in the nature and practice of trauma surgery, and this field increasingly faces potent economic, logistic, political, and workforce challenges. Patients and emergency physicians have much to lose by this budding crisis in our partner discipline. This article reviews the specific issues confronting trauma surgery, their historical context, and the potential directions available to this discipline. Implications of these issues for emergency physicians and for trauma care overall are discussed.
Garner, Alan A; Mann, Kristy P; Fearnside, Michael; Poynter, Elwyn; Gebski, Val
Background Advanced prehospital interventions for severe brain injury remains controversial. No previous randomised trial has been conducted to evaluate additional physician intervention compared with paramedic only care. Methods Participants in this prospective, randomised controlled trial were adult patients with blunt trauma with either a scene GCS score <9 (original definition), or GCS<13 and an Abbreviated Injury Scale score for the head region ≥3 (modified definition). Patients were randomised to either standard ground paramedic treatment or standard treatment plus a physician arriving by helicopter. Patients were evaluated by 30-day mortality and 6-month Glasgow Outcome Scale (GOS) scores. Due to high non-compliance rates, both intention-to-treat and as-treated analyses were preplanned. Results 375 patients met the original definition, of which 197 was allocated to physician care. Differences in the 6-month GOS scores were not significant on intention-to-treat analysis (OR 1.11, 95% CI 0.74 to 1.66, p=0.62) nor was the 30-day mortality (OR 0.91, 95% CI 0.60 to 1.38, p=0.66). As-treated analysis showed a 16% reduction in 30-day mortality in those receiving additional physician care; 60/195 (29%) versus 81/180 (45%), p<0.01, Number needed to treat =6. 338 patients met the modified definition, of which 182 were allocated to physician care. The 6-month GOS scores were not significantly different on intention-to-treat analysis (OR 1.14, 95% CI 0.73 to 1.75, p=0.56) nor was the 30-day mortality (OR 1.05, 95% CI 0.66 to 1.66, p=0.84). As-treated analyses were also not significantly different. Conclusions This trial suggests a potential mortality reduction in patients with blunt trauma with GCS<9 receiving additional physician care (original definition only). Confirmatory studies which also address non-compliance issues are needed. Trial registration number NCT00112398. PMID:25795741
Poor management communication in healthcare services affects employees' motivation, commitment, and, in the final instance, organizational performance and the quality of patient care. In any area of health management, good communication is, therefore, key to successful management. This article discusses how managers of ambulance stations should secure communication with their paramedic crews. The first part uses ethical concepts to analyze communicative disagreement in interactive dialogue between managers and paramedics. The second part outlines basic communication principles that can serve as conceptual tools for avoiding misinterpretation in prehospital manager-employee interaction.
of this study is to evaluate the resource provision of the destination hospital of Scottish trauma patients exhibiting evidence of pre-hospital shock...Methods: Patients who sustained a traumatic injury between November 2008 and October 2010 were retrospectively identified from the Scottish Ambulance... Scottish trauma patients are transported to a hospital with full transfusion capability, although the majority lack surgical sub-specialty
Hyperinvasive approach to out-of hospital cardiac arrest using mechanical chest compression device, prehospital intraarrest cooling, extracorporeal life support and early invasive assessment compared to standard of care. A randomized parallel groups comparative study proposal. “Prague OHCA study”
Background Out of hospital cardiac arrest (OHCA) has a poor outcome. Recent non-randomized studies of ECLS (extracorporeal life support) in OHCA suggested further prospective multicenter studies to define population that would benefit from ECLS. We aim to perform a prospective randomized study comparing prehospital intraarrest hypothermia combined with mechanical chest compression device, intrahospital ECLS and early invasive investigation and treatment in all patients with OHCA of presumed cardiac origin compared to a standard of care. Methods This paper describes methodology and design of the proposed trial. Patients with witnessed OHCA without ROSC (return of spontaneous circulation) after a minimum of 5 minutes of ACLS (advanced cardiac life support) by emergency medical service (EMS) team and after performance of all initial procedures (defibrillation, airway management, intravenous access establishment) will be randomized to standard vs. hyperinvasive arm. In hyperinvasive arm, mechanical compression device together with intranasal evaporative cooling will be instituted and patients will be transferred directly to cardiac center under ongoing CPR (cardiopulmonary resuscitation). After admission, ECLS inclusion/exclusion criteria will be evaluated and if achieved, veno-arterial ECLS will be started. Invasive investigation and standard post resuscitation care will follow. Patients in standard arm will be managed on scene. When ROSC achieved, they will be transferred to cardiac center and further treated as per recent guidelines. Primary outcome 6 months survival with good neurological outcome (Cerebral Performance Category 1–2). Secondary outcomes will include 30 day neurological and cardiac recovery. Discussion Authors introduce and offer a protocol of a proposed randomized study comparing a combined “hyperinvasive approach” to a standard of care in refractory OHCA. The protocol is opened for sharing by other cardiac centers with available ECLS and
Hubert, Gordian J; Müller-Barna, Peter; Audebert, Heinrich J
TeleStroke has become an increasing means to overcome shortage of stroke expertise in underserved areas. This rapidly growing field has triggered a large amount of publications in recent years. We aimed to analyze recent advances in the field of telemedicine for acute stroke, with main focus on prehospital management, Stroke Unit treatment and network implementations in developing countries. Out of 260 articles, 25 were selected for this systematic review: 9 regarding prehospital management, 14 regarding Stroke Unit treatment and 2 describing a network in developing countries. Prehospital management showed that stroke recognition can start at the dispatch emergency call, important clinical information can be electronically transmitted to hospitals before admission and even acute treatment such as thrombolysis can be initiated in the prehospital field if ambulances are equipped with CT scan and point-of-care laboratory. Articles on remote clinical examination, telemedical imaging interpretation, trial recruitment and cost-effectiveness described various aspects of Stroke Unit treatment within TeleStroke networks, underlining reliability, safety and cost savings of these systems of care. Only one network was described to have been implemented in a developing/emerging nation. TeleStroke is a growing field expanding its focus to a broader spectrum of stroke care. It still seems to be underused, particularly in developing countries.
Brown, Haywood L
Acute traumatic injury during pregnancy is a significant contributor to maternal and fetal morbidity and mortality in the United States. Motor vehicle accidents are the leading cause of injury-related maternal death, followed by violence and assault. Lack of seat belts or other restraints increases the risks of both maternal and fetal morbidity and mortality. The American College of Obstetricians and Gynecologists recommends proper seat belt use by all pregnant women and screening for domestic abuse. Maternal injury and death from physical abuse is prevalent, and in some communities, homicide is a major cause of pregnancy-associated maternal death. Blunt trauma most often occurs as a result of motor vehicle accidents, whereas penetrating trauma results from gunshots or stabbings. Blunt trauma to the abdomen increases the risk for placental abruption, and direct fetal injury is more likely with penetrating trauma. Management strategies in acute maternal trauma must focus on a thorough assessment of the mother. A coordinated team effort that includes the obstetrician is essential to ensure optimal maternal and fetal outcomes. Imaging studies should not be delayed because of concerns of fetal radiation exposure, because the risk is minimal with usual imaging procedures, especially in mid-to-late pregnancy. The obstetrician should serve in a consultative role if nonobstetric surgical care is required and must also be prepared to intervene on behalf of the mother and the fetus if trauma care is compromised by the pregnancy. Perimortem cesarean delivery should be considered early in the resuscitation of a pregnant trauma victim, especially when fetal viability is a concern. Once the mother is stabilized in the emergency setting, she should be transported for appropriate maternal and fetal observation until both mother and fetus are clear of danger. It is essential that the clinician and staff maintain thorough and accurate documentation and recording of the chronology of
Yan, Sandra C; Smith, Timothy R; Bi, Wenya Linda; Brewster, Ryan; Gormley, William B; Dunn, Ian F; Laws, Edward R
Abraham Lincoln was the 16(th) President of the United States of America. On April 14, 1865, shortly after his re-election and the conclusion of the Civil War, Lincoln was shot and killed by John Wilkes Booth. Although numerous physicians tended to the President shortly after his injury, he passed away the next morning. Today, we recognize Lincoln as one of the greatest Presidents in American history. His assassination profoundly influenced the future of the United States, especially as the country was coming back together again following the Civil War. Testaments to his lasting legacy can be seen in many places, from the stone carving of him on Mount Rushmore to his image gracing the $5 bill. What if the President had survived his injury? Would he have had a different outcome utilizing current critical care treatment? Neurotrauma care in 1865 was not yet developed, and head wounds such as the one Lincoln sustained were almost always fatal. The medical attention he received is considered by historians and physicians today to be excellent for that time. We look at the evolution of neurotrauma care during the last 150 years in the US. Particular focus is paid to the advancement of care for penetrating brain injuries in modern trauma centers.
Kornhall, Daniel K; Martens-Nielsen, Julie
Avalanche accidents are frequently lethal events with an overall mortality of 23%. Mortality increases dramatically to 50% in instances of complete burial. With modern day dense networks of ambulance services and rescue helicopters, health workers often become involved during the early stages of avalanche rescue. Historically, some of the most devastating avalanche accidents have involved military personnel. Armed forces are frequently deployed to mountain regions in order to train for mountain warfare or as part of ongoing conflicts. Furthermore, military units are frequently called to assist civilian organised rescue in avalanche rescue operations. It is therefore important that clinicians associated with units operating in mountain regions have an understanding of, the medical management of avalanche victims, and of the preceding rescue phase. The ensuing review of the available literature aims to describe the pathophysiology particular to avalanche victims and to outline a structured approach to the search, rescue and prehospital medical management.
McKinnon, K. D.
A pilot study of prehospital analgesia with 50% nitrous oxide and 50% oxygen was undertaken in patients experiencing severe pain from various sources. Under the supervision of an ambulance attendant N2O/O2 was administered through a face mask held by the patient and connected to a portable regulator/tank unit. Two types of units were evaluated -- Entonox (with premixed N2O and O2) and Nitronox (with separate cylinders of N2O and O2, the gases being mixed at the time of administration). Of the 72 patients 69 obtained worthwhile analgesia (marked or partial relief of pain) during treatment in the field or in the ambulance. There were no serious side effects, and those that did occur reflected N2O's expected action (e.g., giddiness). N2O/O2 is thus considered a safe and effective analgesic, suitable for use by ambulance personnel. Images FIG. 1 FIG. 2 PMID:7306895
Welch, Robert D.; Nicholas, Katherine; Durkalski-Mauldin, Valerie L.; Lowenstein, Daniel H.; Conwit, Robin; Mahajan, Prashant V.; Lewandowski, Christopher; Silbergleit, Robert
Summary Objective To examine the effectiveness of intramuscular (IM) midazolam versus intravenous (IV) lorazepam for the treatment of pediatric patients with status epilepticus (SE) in the prehospital care setting. Methods This multicenter clinical trial randomized patients diagnosed with SE to receive either IM midazolam or IV lorazepam administered by paramedics in the prehospital care setting. Included in this secondary analysis were only patients younger than 18 years of age. Evaluated were the associations of the treatment group (IM vs. IV) with the primary outcome, defined as seizure cessation prior to emergency department (ED) arrival, and with patient characteristics, time to important events, and adverse events. Descriptive statistics and 99% confidence intervals (CIs) were used for the analysis. Results Of 893 primary study subjects, 120 met criteria for this study (60 in each treatment group). There were no differences in important baseline characteristics or seizure etiologies between groups. The primary outcome was met in 41 (68.3%) and 43 (71.7%) of subjects in the IM and IV groups, respectively (risk difference [RD] −3.3%, 99% CI −24.9% to 18.2%). Similar results were noted for those younger than 11 years (RD −1.3%, 99% CI −25.7% to 23.1%). Time from initiating the treatment protocol was shorter for children who received IM midazolam, mainly due to the shorter time to administer the active treatment. Safety profiles were similar. Significance IM midazolam can be rapidly administered and appears to be safe and effective for the management of children with SE treated in the prehospital setting. The results must be interpreted in the context of the secondary analysis design and sample size of the study. PMID:25597369
Falasca, Tony; Caulfield, Thomas J.
Describes some classic causes of trauma and symptoms that can result when a child has been traumatized. Lists several factors that effect the degree to which a child is affected by trauma. Categories a wide range of behaviors displayed by the victims into three groups: affect, memories, and behaviors. Discusses various considerations when…
Haley, Kathy; Martin, Stacey; Kilgore, Jane; Lang, Carrie; Rozzell, Monica; Coffey, Carla; Eley, Scott; Light, Andrea; Hubartt, Jeff; Kovach, Sherri; Deppe, Sharon
Trauma nursing requires mastering a highly specialized body of knowledge. Expert nursing care is expected to be offered throughout the hospital continuum, yet identifying the necessary broad-based objectives for nurses working within this continuum has often been difficult to define. Trauma nurse leaders and educators from 7 central and southeastern Ohio trauma centers and 1 regional trauma organization convened to establish an approach to standardizing trauma nursing education from a regional perspective. Forty-two trauma nursing educational objectives were identified. The Delphi method was used to narrow the list to 3 learning objectives to serve as the framework for a regional trauma nursing education guideline. Although numerous trauma nursing educational needs were identified across the continuum of care, a lack of clearly defined standards exists. Recognizing and understanding the educational preparation and defined standards required for nurses providing optimal trauma care are vital for a positive impact on patient outcomes. This regional trauma nursing education guideline is a novel model and can be used to assist trauma care leaders in standardizing trauma education within their hospital, region, or state. The use of this model may also lead to the identification of gaps within trauma educational systems.
Jeong, Young Ha; Oh, Ji Woong
Objective The aim of this preliminary collaborative study was to assess the clinical characteristics, management, and outcome of epidural hematoma (EDH) based on the data collected and registered in the Korean Trauma Data Bank System (KTDBS). Methods Of 2,698 patients registered in the KTDBS between September 2010 and March 2014, 285 patients with EDH were analyzed. Twenty-three trauma centers participated in the study voluntarily to collect data. We subcategorized the patients into two groups with good and poor outcomes. Various clinical characteristics and the time intervals with regard to treatment course were investigated to determine the relationship between these parameters and the functional outcome. Results Of multiple parameters for this analysis, older age (p=0.0003), higher degree of brain injury (p<0.0001), cases of surgical EDH (p<0.0001), time interval from trauma to hospital before 6 hours, and the decreasing pattern of Glasgow Coma Scale (GCS) between and initial and final GCS were strongly associated with poor outcome. Use of prophylactic anticonvulsant did not affect the functional outcome. There was an interesting difference in the use of mannitol in treating EDH between the urban and rural regions (p<0.0001). Conclusion This is the first multi-center analysis of etiology of injury, pre-hospital care, treatment, and functional outcome of EDH in Korea. The degree of brain injury and the GCS difference were notable factors that were significant in determining the functional outcome of EDH. PMID:27857907
Zehtabchi, Shahriar; Nishijima, Daniel K; McKay, Mary Pat; Mann, N Clay
Trauma registries have been designed to serve a number of purposes, including quality improvement, injury prevention, clinical research, and policy development. Since their inception over 30 years ago, there are increasingly more institutions with trauma registries, many of which submit data to a national trauma registry. The goal of this review is to describe the history, logistics, and characteristics of trauma registries and their contribution to emergency medicine and trauma research. Discussed in this review are the limitations of trauma registries, such as variability in quality and type of the collected data, absence of data pertaining to long-term and functional outcomes, prehospital information, and complications as well as other methodologic obstacles limiting the utility of registry data in clinical and epidemiologic research.
Corre, Pierre; Arzul, Ludovic; Khonsari, Roman Hossein; Mercier, Jacques
The human face contains the sense organs and is responsible for essential functions: swallowing, chewing, speech, breathing and communication. It is also and most importantly the seat of a person's identity. Multiple trauma adds a life-threatening dimension to the physical and psychological impact of a facial trauma.
past which further addition of rFVIIa may have not enhanced clotting kinetics in the absence of traumatic hypothermic coagulopathy and some plasma...possible tamponade effects in the closed abdomen are not consid- ered in this model. Third, animals were anesthetized when injured, thus abrogating the...A. D., Majetschak, M. & Proctor, K. G. (2006). Prehospital HBOC-20 1 after traumatic brain injury and hemorrhagic shock in swine. J Trauma 61:46-56
Patients and their relatives are increasingly considered partners in health and social care decision-making. Numerous political drivers in the UK reflect a commitment to this partnership and to improving the experience of patients and relatives in emergency care environments. As a Lecturer/Practitioner in Emergency Care I recently experienced the London Trauma System as a relative. My dual perspective, as nurse and relative, allowed me to identify a gap in the quality of care akin to emotional intelligence. This paper aims to raise awareness of emotional intelligence (EI), highlight its importance in trauma care and contribute to the development of this concept in trauma nursing and education across the globe.
Hong, Rick; Meenan, Molly; Prince, Erin; Murphy, Ronald; Tambussi, Caitlin; Rohrbach, Rick; Baumann, Brigitte M
Introduction We wanted to compare 3 existing emergency medical services (EMS) immobilization protocols: the Prehospital Trauma Life Support (PHTLS, mechanism-based); the Domeier protocol (parallels the National Emergency X-Radiography Utilization Study [NEXUS] criteria); and the Hankins’ criteria (immobilization for patients <12 or >65 years, those with altered consciousness, focal neurologic deficit, distracting injury, or midline or paraspinal tenderness).To determine the proportion of patients who would require cervical immobilization per protocol and the number of missed cervical spine injuries, had each protocol been followed with 100% compliance. Methods This was a cross-sectional study of patients ≥18 years transported by EMS post-traumatic mechanism to an inner city emergency department. Demographic and clinical/historical data obtained by physicians were recorded prior to radiologic imaging. Medical record review ascertained cervical spine injuries. Both physicians and EMS were blinded to the objective of the study. Results Of 498 participants, 58% were male and mean age was 48 years. The following participants would have required cervical spine immobilization based on the respective protocol: PHTLS, 95.4% (95% CI: 93.1–96.9%); Domeier, 68.7% (95% CI: 64.5–72.6%); Hankins, 81.5% (95% CI: 77.9–84.7%). There were 18 cervical spine injuries: 12 vertebral fractures, 2 subluxations/dislocations and 4 spinal cord injuries. Compliance with each of the 3 protocols would have led to appropriate cervical spine immobilization of all injured patients. In practice, 2 injuries were missed when the PHTLS criteria were mis-applied. Conclusion Although physician-determined presence of cervical spine immobilization criteria cannot be generalized to the findings obtained by EMS personnel, our findings suggest that the mechanism-based PHTLS criteria may result in unnecessary cervical spine immobilization without apparent benefit to injured patients. PHTLS criteria
Wiel, Eric; Zitouni, Djamel; Assez, Nathalie; Sebilleau, Quentin; Lys, Sébastien; Duval, Audrey; Mauriaucourt, Patrick; Hubert, Hervé
Abstract Objective. Although ketamine has recently been demonstrated to provide a morphine-sparing effect, no previous study reports the effect of continuous infusion of ketamine for analgesia in out-of-hospital environments. The aim of this study was to compare the effect of a continuous infusion of ketamine (IK group) vs. a continuous infusion of saline (IS group) on morphine requirements in out-of-hospital trauma patients suffering from severe acute pain. Methods. In this prospective, multicenter, randomized, single-blind clinical study, patients suffering from isolated orthopedic injuries secondary to trauma with severe acute pain received a low-dose intravenous (IV) bolus of ketamine (0.2 mg·kg(-1)) combined with an IV bolus of morphine (0.1 mg·kg(-1)) and were randomized either in the IK group (IV continuous infusion of ketamine 0.2 mg·kg(-1)·h(-1)), or in the IS group (IV continuous infusion of saline at the same volume). The primary endpoint was morphine requirements in terms of total dose of morphine (excluding the baseline bolus) injected at the end of prehospital emergency care at hospital admission (final time, Tf). The secondary endpoint was evaluation of pain with visual analogic scale (VAS). Results. Sixty-six patients were enrolled. Total morphine dose was not significantly reduced with continuous infusion of ketamine (0.048 [0.000; 0.150] vs. 0.107 [0.052; 0.150] in IK and IS groups), with similar mean duration of care (median 35.0 min). Analgesia was as efficient without any significant difference in VAS at Tf between groups (3.1 ± 2.3 (IK group) vs. 3.7 ± 2.7 (IS group), p = 0.5). Conclusions. Continuous ketamine infusion did not reduce morphine requirements in severe acute pain trauma patients in the out-of-hospital emergency settings.
Sporer, Karl A.; Johnson, Nicholas J.
Background: Medical Priority Dispatch System (MPDS) is a type of Emergency Medical Dispatch (EMD) system used to prioritize 9-1-1 calls and optimize resource allocation. Dispatchers use a series of scripted questions to assign determinants to calls based on chief complaint and acuity. Objective: We analyzed the prehospital interventions performed on patients with MPDS determinants for breathing problems, chest pain, unknown problem (man down), seizures, fainting (unconscious) and falls for transport status and interventions. Methods: We matched all prehospital patients in complaint-based categories for breathing problems, chest pain, unknown problem (man down), seizures, fainting (unconscious) and falls from January 1, 2004, to December 31, 2006, with their prehospital record. Calls were queried for the following prehospital interventions: Basic Life Support care only, intravenous line placement only, medication given, procedures or non-transport. We defined Advanced Life Support (ALS) interventions as the administration of a medication or a procedure. Results: Of the 77,394 MPDS calls during this period, 31,318 (40%) patients met inclusion criteria. Breathing problems made up 12.2%, chest pain 6%, unknown problem 1.4%, seizures 3%, falls 9% and unconscious/fainting 9% of the total number of MPDS calls. Patients with breathing problem had a low rate of procedures (0.7%) and cardiac arrest medications (1.6%) with 38% receiving some medication. Chest pain patients had a similar distribution; procedures (0.5%), cardiac arrest medication (1.5%) and any medication (64%). Unknown problem: procedures (1%), cardiac arrest medication (1.3%), any medication (18%). Patients with Seizures had a low rate of procedures (1.1%) and cardiac arrest medications (0.6%) with 20% receiving some medication. Fall patients had a lower rate of severe illness with more medication, mostly morphine: procedures (0.2%), cardiac arrest medication (0.2%), all medications (28%). Unconscious
Dehghani, Hamideh; Tavangar, Hossein; Ghandehari, Akram
Background: Estimating pain in patients of intensive care unit (ICU) is essential, but because of their special situation, verbal scales cannot be used. Therefore, to estimate the level of pain, behavioral pain scale was developed by Payen in 2001. Objectives: The aim of this study was to investigate the validity and reliability of behavioral pain scale in patients with low level of consciousness due to head trauma hospitalized in ICU. Patients and Methods: This descriptive prospective study was performed in Yazd in 2013. In this study, fifty patients, including thirteen women and thirty seven men, were involved. To collect the data a questionnaire including demographic and Glasgow coma scale (GCS) information as well as a list of behavioral pain scale (BPS) were used. SPSS software (version 18) was used to analyze the data. Results: There was no significant difference in reliability proving of average score of BPS recorded by two day and night assessors (P > 5). Cronbach’s alpha was 85 for painful procedures and 76 for non-painful procedures. In addition, known groups’ technique (painful and non-painful procedures) was used to assess validity. The average scores were 7.75 during painful procedures and 3.28 during non-painful procedures (P = 0.001). The results stated that BPS scores during these two procedures were significantly different. Conclusions: BPS in patients with low level of consciousness due to head trauma has strong reliability and validity. Therefore, this scale can be used for patients hospitalized in ICU to assess the level of pain. PMID:25032173
Sarcevic, Aleksandra; Burd, Randall S
This paper reports on information needs of trauma teams based on an ethnographic study in an urban teaching hospital. We focus on questions posed by trauma team members during ten trauma events. We identify major categories of questions, as well as information seekers and providers. In addition to categories known from other critical care settings, we found categories unique to trauma settings. Based on these findings, we discuss implications for information technology support for trauma teams.
Jiang, Bin; Ru, Xiaojuan; Sun, Haixin; Liu, Hongmei; Sun, Dongling; Liu, Yunhai; Huang, Jiuyi; He, Li; Wang, Wenzhi
This study aimed to explore pre-hospital delay and its associated factors in first-ever stroke registered in communities from three cities in China. The rates of delay greater than or equal to 2 hours were calculated and factors associated with delays were determined by non-conditional binary logistic regression, after adjusting for different explanatory factors. Among the 403 cases of stroke with an accurate documented time of prehospital delay, the median time (interquartile range) was 4.00 (1.50–14.00) hours. Among the 544 cases of stroke with an estimated time range of prehospital delay, 24.8% of patients were transferred to the emergency department or hospital within 2 hours, only 16.9% of patients with stroke were aware that the initial symptom represented a stroke, only 18.8% used the emergency medical service and one-third of the stroke cases were not identified by ambulance doctors. In the multivariate analyses, 8 variables or sub-variables were identified. In conclusion, prehospital delay of stroke was common in communities. Thus, intervention measures in communities should focus on education about the early identification of stroke and appropriate emergency medical service (EMS) use, as well as the development of organized stroke care. PMID:27411494
Bremer, C; Cassata, L
The pregnant woman is exposed to the same risks as the non-pregnant woman for sustaining a traumatic injury, but because of the multiple physiologic changes that occur during pregnancy, the assessment and treatment of such patients must be adapted accordingly. This article discusses these normal physiologic changes, their effect on response to trauma, and the comprehensive care of the patient using the nursing process.
Ebrahimian, Abbasali; Seyedin, Hesam; Jamshidi-Orak, Roohangiz; Masoumi, Gholamreza
The physiological-social modified early warning score system is a newly developed instrument for the identification of patients at risk. The aim of this study was to investigate the feasibility of using the physiological-social modified early warning score system for the identification of patients that needed prehospital emergency care. This prospective cohort study was conducted with 2157 patients. This instrument was used as a measure to detect critical illness in patients hospitalised in internal wards. Judgment by an emergency medicine specialist was used as a measure of standard. Data were analyzed by using receiver operating characteristics curves and the area under the curve with 95% confidence interval. The mean score of the physiological-social modified early warning score system was 2.71 ± 3.55. Moreover, 97.6% patients with the score ≥ 4 needed prehospital emergency services. The area under receiver operating characteristic curve was 0.738 (95% CI = 0.708-0.767). Emergency medical staffs can use PMEWS ≥ 4 to identify those patients hospitalised in the internal ward as at risk patients. The physiological-social modified early warning score system is suggested to be used for decision-making of emergency staff about internal patients' wards in EMS situations.
The physiological-social modified early warning score system is a newly developed instrument for the identification of patients at risk. The aim of this study was to investigate the feasibility of using the physiological-social modified early warning score system for the identification of patients that needed prehospital emergency care. This prospective cohort study was conducted with 2157 patients. This instrument was used as a measure to detect critical illness in patients hospitalised in internal wards. Judgment by an emergency medicine specialist was used as a measure of standard. Data were analyzed by using receiver operating characteristics curves and the area under the curve with 95% confidence interval. The mean score of the physiological-social modified early warning score system was 2.71 ± 3.55. Moreover, 97.6% patients with the score ≥ 4 needed prehospital emergency services. The area under receiver operating characteristic curve was 0.738 (95% CI = 0.708–0.767). Emergency medical staffs can use PMEWS ≥ 4 to identify those patients hospitalised in the internal ward as at risk patients. The physiological-social modified early warning score system is suggested to be used for decision-making of emergency staff about internal patients' wards in EMS situations. PMID:25298893
Armstrong, B P; Simpson, H K; Crouch, R; Deakin, C D
Prehospital cervical spine (c-spine) immobilisation is common, despite c-spine injury being relatively rare. Unnecessary immobilisation results in a significant burden on limited prehospital and emergency department (ED) resources. This study aimed to determine whether the incidence of unnecessary c-spine immobilisation by ambulance personnel could be safely reduced through the implementation of an evidence-based algorithm. Following a training programme, complete forms on 103 patients were identified during the audit period, of which 69 (67%) patients had their c-spines cleared at scene. Of these, 60 (87%) were discharged at scene, with no clinical adverse events reported, and 9 (13%) were taken to the local ED with non-distracting minor injuries, all being discharged home the same day. 34 (33%) patients could not have their c-spines safely cleared at scene according to the algorithm. Of these, 4 (12%) patients self-discharged at scene and 30 (88%) were conveyed to an ED as per the normal procedure. C-spine clearance at scene by ambulance personnel may have positive impacts on patient care, efficient use of resources and cost to healthcare organisations.
systolic blood pressures by McManus et al.23,24 Statistical Analysis Descriptive statistics were used for tourniquet applications and resulting outcomes...whereas the mean ISSs of the prehospital and ED groups were not statistically different (P 0.6). Survival Association When Shock Was Absent Before...no controversy. J Trauma. 2004;56:214–215. 18. Husum H, Ang SC, Fosse E. War Surgery Field Manual, Penang , Malaysia: Third World Network. 1995;85:145
Ramakrishnan, V Trichur; Cattamanchi, Srihari
Resuscitation of a severely traumatised patient with the administration of crystalloids, or colloids along with blood products is a common transfusion practice in trauma patients. The determination of this review article is to update on current transfusion practices in trauma. A search of PubMed, Google Scholar, and bibliographies of published studies were conducted using a combination of key-words. Recent articles addressing the transfusion practises in trauma from 2000 to 2014 were identified and reviewed. Trauma induced consumption and dilution of clotting factors, acidosis and hypothermia in a severely injured patient commonly causes trauma-induced coagulopathy. Early infusion of blood products and early control of bleeding decreases trauma-induced coagulopathy. Hypothermia and dilutional coagulopathy are associated with infusion of large volumes of crystalloids. Hence, the predominant focus is on damage control resuscitation, which is a combination of permissive hypotension, haemorrhage control and haemostatic resuscitation. Massive transfusion protocols improve survival in severely injured patients. Early recognition that the patient will need massive blood transfusion will limit the use of crystalloids. Initially during resuscitation, fresh frozen plasma, packed red blood cells (PRBCs) and platelets should be transfused in the ratio of 1:1:1 in severely injured patients. Fresh whole blood can be an alternative in patients who need a transfusion of 1:1:1 thawed plasma, PRBCs and platelets. Close monitoring of bleeding and point of care coagulation tests are employed, to allow goal-directed plasma, PRBCs and platelets transfusions, in order to decrease the risk of transfusion-related acute lung injury. PMID:25535424
Bhatti, Khalid M.; Taqi, Kadhim M.; Al-Harthy, Ahmed Z. S.; Hamid, Rana S.; Al-Balushi, Zainab N.; Sankhla, Dilip K.; Al-Qadhi, Hani A.
Objectives: Trauma is the greatest cause of morbidity and mortality in paediatric/adolescent populations worldwide. This study aimed to describe trauma mechanisms, patterns and outcomes among children with blunt torso trauma admitted to the Sultan Qaboos University Hospital (SQUH) in Muscat, Oman. Methods: This retrospective single-centre study involved all children ≤12 years old with blunt torso trauma admitted for paediatric surgical care at SQUH between January 2009 and December 2013. Medical records were analysed to collect demographic and clinical data. Results: A total of 70 children were admitted with blunt torso trauma during the study period, including 39 (55.7%) male patients. The mean age was 5.19 ± 2.66 years. Of the cohort, 35 children (50.0%) received their injuries after having been hit by cars as pedestrians, while 19 (27.1%) were injured by falls, 12 (17.1%) during car accidents as passengers and four (5.7%) by falling heavy objects. According to computed tomography scans, thoracic injuries were most common (65.7%), followed by abdominal injuries (42.9%). The most commonly involved solid organs were the liver (15.7%) and spleen (11.4%). The majority of the patients were managed conservatively (92.9%) with a good outcome (74.3%). The mortality rate was 7.1%. Most deaths were due to multisystem involvement. Conclusion: Among children with blunt torso trauma admitted to SQUH, the main mechanism of injury was motor vehicle accidents. As a result, parental education and enforcement of infant car seat/child seat belt laws are recommended. Conservative management was the most successful approach. PMID:27226913
Current patient movement items (PMI) supporting the military's Critical Care Air Transport Team (CCATT) mission as well as the Crew Health Care System for space (CHeCS) have significant limitations: size, weight, battery duration, and dated clinical technology. The LTM is a small, 20 lb., system integrating diagnostic and therapeutic clinical capabilities along with onboard data management, communication services and automated care algorithms to meet new Aeromedical Evacuation requirements. The Lightweight Trauma Module is an Impact Instrumentation, Inc. project with strong Industry, DoD, NASA, and Academia partnerships aimed at developing the next generation of smart and rugged critical care tools for hazardous environments ranging from the battlefield to space exploration. The LTM is a combination ventilator/critical care monitor/therapeutic system with integrated automatic control systems. Additional capabilities are provided with small external modules.
finding indicates a need for improved procedures, training, and tools for EMS documentation. Documentation is in itself a quality criterion for appropriate care and is crucial to trauma research. PMID:21453536
Wurster, Lee Ann; Groner, Jonathan I; Hoffman, Jeffrey
Although many hospitals across the country have implemented an electronic medical record (EMR) for inpatient care, very few have successfully implemented an EMR for trauma resuscitations. Although there is evidence that the EMR improves patient safety, increases access to all care providers, increases workflow efficiency, and minimizes time spent on documenting thereby improving nursing care, the fast paced, complex nature of trauma resuscitations makes it difficult to implement such a system for trauma documentation. With the support of multiple disciplines with a variety of clinical knowledge, this article describes the design process that has led us to successful development and implementation of an EMR for documentation of trauma resuscitations.
Carrillo, Eli; Hern, H Gene; Barger, Joseph
Anaphylaxis in the pediatric population is both serious and potentially lethal. The incidence of allergic and anaphylactic reactions has been increasing and the need for life saving intervention with epinephrine must remain an important part of Emergency Medical Services (EMS) provider training. Our aim was to characterize dosing and timing of epinephrine, diphenhydramine, and albuterol in the pediatric patient with anaphylaxis. In this retrospective chart review, we studied prehospital medication administration in pediatric patients ages 1 month up to 14 years old classified as having a severe allergic reaction or anaphylaxis. We compared rates of epinephrine, diphenhydramine, and albuterol given to patients with allergic conditions including anaphylaxis. In addition, we calculated the rate of epinephrine administration in cases of anaphylaxis and determined what percentage of time the epinephrine was given by EMS or prior to their arrival. Of the pediatric patient contacts, 205 were treated for allergic complaints. Of those with allergic complaints, 98 of 205 (48%; 95% CI 41%, 55%) had symptoms consistent with anaphylaxis and indications for epinephrine. Of these 98, 53 (54%, 95% CI 44%, 64%) were given epinephrine by EMS or prior to EMS arrival. Among the patients in anaphylaxis not given epinephrine prior to EMS arrival, 6 (12%; 95% CI 3%, 21%) received epinephrine from EMS, 10 (20%; 95% CI 9%, 30%) received diphenhydramine only, 9 (18%, 95% CI 7%-28%) received only albuterol and 17 (33%, 95% CI 20%-46%) received both albuterol and diphenhydramine. 9 patients in anaphylaxis received no treatment prior to arriving to the emergency department (18%, 95% CI 7%-28%). In pediatric patients who met criteria for anaphylaxis and the use of epinephrine, only 54% received epinephrine and the overwhelming majority received it prior to EMS arrival. EMS personnel may not be treating anaphylaxis appropriately with epinephrine.
Injury is still the number 1 killer of children ages 1 to 18 years in the United States (http://www.cdc.gov/nchs/fastats/children.htm). Children who sustain injuries with resulting disabilities incur significant costs not only for their health care but also for productivity lost to the economy. The families of children who survive childhood injury with disability face years of emotional and financial hardship, along with a significant societal burden. The entire process of managing childhood injury is enormously complex and varies by region. Only the comprehensive cooperation of a broadly diverse trauma team will have a significant effect on improving the care of injured children.
Saranteas, Theodosios; Mavrogenis, Andreas F; Mandila, Christina; Poularas, John; Panou, Fotios
In the perioperative period, the emergency department or the intensive care unit accurate assessment of variable chest pain requires meticulous knowledge, diagnostic skills, and suitable usage of various diagnostic modalities. In addition, in polytrauma patients, cardiac injury including aortic dissection, pulmonary embolism, acute myocardial infarction, and pericardial effusion should be immediately revealed and treated. In these patients, arrhythmias, mainly tachycardia, cardiac murmurs, or hypotension must alert physicians to suspect cardiovascular trauma, which would potentially be life threatening. Ultrasound of the heart using transthoracic and transesophageal echocardiography are valuable diagnostic tools that can be used interchangeably in conjunction with other modalities such as the electrocardiogram and computed tomography for the diagnosis of cardiovascular abnormalities in trauma patients. Although ultrasound of the heart is often underused in the setting of trauma, it does have the advantages of being easily accessible, noninvasive, and rapid bedside assessment tool. This review article aims to analyze the potential cardiac injuries in trauma patients, and to provide an elaborate description of the role of echocardiography for their accurate diagnosis.
Wongwaisayawan, Sirote; Suwannanon, Ruedeekorn; Prachanukool, Thidathit; Sricharoen, Pungkava; Saksobhavivat, Nitima; Kaewlai, Rathachai
Ultrasound plays a pivotal role in the evaluation of acute trauma patients through the use of multi-site scanning encompassing abdominal, cardiothoracic, vascular and skeletal scans. In a high-speed polytrauma setting, because exsanguinations are the primary cause of trauma morbidity and mortality, ultrasound is used for quick and accurate detection of hemorrhages in the pericardial, pleural, and peritoneal cavities during the primary Advanced Trauma Life Support (ATLS) survey. Volume status can be assessed non-invasively with ultrasound of the inferior vena cava (IVC), which is a useful tool in the initial phase and follow-up evaluations. Pneumothorax can also be quickly detected with ultrasound. During the secondary survey and in patients sustaining low-speed or localized trauma, ultrasound can be used to help detect abdominal organ injuries. This is particularly helpful in patients in whom hemoperitoneum is not identified on an initial scan because findings of organ injuries will expedite the next test, often computed tomography (CT). Moreover, ultrasound can assist in detection of fractures easily obscured on radiography, such as rib and sternal fractures.
Furuta, Marie; Spain, Debbie; Bick, Debra; Ng, Edmond S W; Sin, Jacqueline
Introduction Maternal mental health has been largely neglected in the literature. Women, however, may be vulnerable to developing post-traumatic stress symptoms or post-traumatic stress disorder (PTSD), following traumatic birth. In turn, this may affect their capacity for child rearing and ability to form a secure bond with their baby and impact on the wider family. Trauma-focused psychological therapies (TFPT) are widely regarded as effective and acceptable interventions for PTSD in general and clinical populations. Relatively little is known about the effectiveness of TFPT for women postpartum who have post-traumatic stress symptoms. Methods and analysis We will conduct a review to assess the effectiveness of TFPT, compared with usual postpartum care, as a treatment for post-traumatic stress symptoms or PTSD for women following traumatic birth. Using a priori search criteria, we will search for randomised controlled trials (RCT) in four databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO and OpenGrey. We will use search terms that relate to the population, TFPT and comparators. Screening of search results and data extraction will be undertaken by two reviewers, independently. Risk of bias will be assessed in RCTs which meet the review criteria. Data will be analysed using the following methods, as appropriate: narrative synthesis; meta-analysis; subgroup analysis and meta-regression. Dissemination and ethics As this work comprises a synthesis of existing studies, ethical approvals are not required. Results will be disseminated at conferences and in publications. PMID:27884855
Di Saverio, S; Sibilio, A; Coniglio, C; Bianchi, E; Biscardi, A; Villani, S; Gordini, G; Tugnoli, G
Management of liver trauma is challenging and may vary widely given the heterogeneity of liver injuries' anatomical configuration, the hemodynamic status, the settings and resources available. Perhaps the use of non-operative management (NOM) may have potential drawbacks and the role of damage control surgery (DCS) and angioembolization represents a major evolving concept.1 Most severe liver trauma in polytrauma patients accounts for a significant morbidity and mortality. Major liver trauma with extensive parenchymal injury and uncontrollable bleeding is therefore a challenge for the trauma team. However a safe and effective surgical hemostasis and a carefully planned multidisciplinary approach can improve the outcome of severe liver trauma. The technique of perihepatic packing, according to DCS approach, is often required to achieve fast, early and effective control of hemorrhage in the highest grades of liver trauma and in unstable patients. A systematic and standardized technique of perihepatic packing may contribute to improve hemostatic efficacy and overall outcomes if wisely combined in a stepwise "sandwich" multimodal approach. DCS philosophy evolved alongside with damage control resuscitation (DCR) in the management of trauma patients, requiring close interaction between surgery and resuscitation. Therefore, as a result of a combined surgical and critical care clinical audit activity in our western European trauma center, a practical algorithm for multimodal sequential management of liver trauma has been developed based on a historical cohort of 253 liver trauma patients and subsequently validated on a prospective cohort of 135 patients in the period 2010-2013.
Hussain, L. M.; Redmond, A. D.
OBJECTIVE--To determine what proportion of pre-hospital deaths from accidental injury--deaths at the scene of the accident and those that occur before the person has reached hospital--are preventable. DESIGN--Retrospective study of all deaths from accidental injury that occurred between 1 January 1987 and 31 December 1990 and were reported to the coroner. SETTING--North Staffordshire. MAIN OUTCOME MEASURES--Injury severity score, probability of survival (probit analysis), and airway obstruction. RESULTS--There were 152 pre-hospital deaths from accidental injury (110 males and 42 females). In the same period there were 257 deaths in hospital from accidental injury (136 males and 121 females). The average age at death was 41.9 years for those who died before reaching hospital, and their average injury severity score was 29.3. In contrast, those who died in hospital were older and equally likely to be males or females. Important neurological injury occurred in 113 pre-hospital deaths, and evidence of airway obstruction in 59. Eighty six pre-hospital deaths were due to road traffic accidents, and 37 of these were occupants in cars. On the basis of the injury severity score and age, death was found to have been inevitable or highly likely in 92 cases. In the remaining 60 cases death had not been inevitable and airway obstruction was present in up to 51 patients with injuries that they might have survived. CONCLUSION--Death was potentially preventable in at least 39% of those who died from accidental injury before they reached hospital. Training in first aid should be available more widely, and particularly to motorists as many pre-hospital deaths that could be prevented are due to road accidents. PMID:8173428
Bassett, Aaron K; Auten, Jonathan D; Zieber, Tara J; Lunceford, Nicole L
Balanced component therapy (BCT) remains the mainstay in trauma resuscitation of the critically battle injured. In austere medical environments, access to packed red blood cells, apheresis platelets, and fresh frozen plasma is often limited. Transfusion of warm, fresh whole blood (FWB) has been used to augment limited access to full BCT in these settings. The main limitation of FWB is that it is not readily available for transfusion on casualty arrival. This small case series evaluates the impact early, mechanism-of-injury (MOI)-based, preactivation of the walking blood bank has on time to transfusion. We report an average time of 18 minutes to FWB transfusion from patient arrival. Early activation of the walking blood bank based on prehospital MOI may further reduce the time to FWB transfusion.
Greeson, Johanna K. P.; Briggs, Ernestine C.; Kisiel, Cassandra L.; Layne, Christopher M.; Ake, George S., III; Ko, Susan J.; Gerrity, Ellen T.; Steinberg, Alan M.; Howard, Michael L.; Pynoos, Robert S.; Fairbank, John A.
Many children in the child welfare system (CWS) have histories of recurrent interpersonal trauma perpetrated by caregivers early in life often referred to as "complex trauma". Children in the CWS also experience a diverse range of reactions across multiple areas of functioning that are associated with such exposure. Nevertheless, few CWSs…
Burke, Thomas F; Hines, Rosemary; Ahn, Roy; Walters, Michelle; Young, David; Anderson, Rachel Eleanor; Tom, Sabrina M; Clark, Rachel; Obita, Walter; Nelson, Brett D
Objective Injuries, trauma and non-communicable diseases are responsible for a rising proportion of death and disability in low-income and middle-income countries. Delivering effective emergency and urgent healthcare for these and other conditions in resource-limited settings is challenging. In this study, we sought to examine and characterise emergency and urgent care capacity in a resource-limited setting. Methods We conducted an assessment within all 30 primary and secondary hospitals and within a stratified random sampling of 30 dispensaries and health centres in western Kenya. The key informants were the most senior facility healthcare provider and manager available. Emergency physician researchers utilised a semistructured assessment tool, and data were analysed using descriptive statistics and thematic coding. Results No lower level facilities and 30% of higher level facilities reported having a defined, organised approach to trauma. 43% of higher level facilities had access to an anaesthetist. The majority of lower level facilities had suture and wound care supplies and gloves but typically lacked other basic trauma supplies. For cardiac care, 50% of higher level facilities had morphine, but a minority had functioning ECG, sublingual nitroglycerine or a defibrillator. Only 20% of lower level facilities had glucometers, and only 33% of higher level facilities could care for diabetic emergencies. No facilities had sepsis clinical guidelines. Conclusions Large gaps in essential emergency care capabilities were identified at all facility levels in western Kenya. There are great opportunities for a universally deployed basic emergency care package, an advanced emergency care package and facility designation scheme, and a reliable prehospital care transportation and communications system in resource-limited settings. PMID:25260371
Plischke, M; Wolf, K H; Lison, T; Pretschner, D P
In the German emergency medical service system (EMSS) medical treatment can be improved in most of mass casualty incidents (MCI). Currently, the incident commander who is responsible for classification of the victims (depending on their urgency and condition, the so called triage) and ordered transportation uses paper-based documentation. Triage tags are used to identify and classify patients and gather treatment information. This can cause problems in medical treatment and in transportation of injured victims. Object-oriented modelling, simulation, and visualisation of processes can show deficits in treatment and data processing and thereby help to optimise medical workflow and logistics. If documentation by paramedics and emergency physicians is done electronically, all patient records could be send to a telemedical centre for central data administration. A telemedical supported triage tag helps identifying victims and managing detailed identification protocols. The paper-based documentation in emergency would become obsolete, if hospitals can query all protocols, diagnoses, and findings from the telemedical centre. Safety and security aspects can be guaranteed. The complete medical treatment workflow can be supported by telemedicine. Therefore, in case of MCI, telemedicine can optimise medical treatment and exonerate the paramedics from unnecessary documentation.
Lalezarzadeh, Fariborz; Wisniewski, Paul; Huynh, Katie; Loza, Maria; Gnanadev, Dev
Hypotension is a trauma activation criterion validated by multiple studies. However, field systolic blood pressures (SBP) are still met with skepticism. How significant is the role of prehospital (PH) and emergency department (ED) SBP in the patient's overall condition? A review of the trauma registry over a 5-year period was conducted. PH SBPs were stratified into four categories: severe (SBP 80 mmHg or less), moderate (81-100 mmHg), mild hypotension (101-120 mmHg), and normotension (greater than 120 mmHg). These four groups were further subcategorized into the patients who were hypotensive, SBP 90 mmHg or less in the ED, versus those that were not (SBP greater than 90 mmHg). Data for 6964 patients were analyzed. Patients with PH SBP of 80 mmHg or less compared with patients who had PH SBP of greater than 80 mmHg had higher mortality (OR, 9; 95% CI, 6.45-12.84). Patients with both PH SBP 80 mmHg or less and ED SBP 90 mmHg or less had the highest risk of mortality (50%) and highest need for emergent operative intervention (54%). PH and ED hypotension is a strong predictor of in-hospital mortality and need for emergent surgical intervention in trauma patients. Field or ED blood pressures should serve as a significant marker of the patient's condition.
Major trauma remains a significant cause of mortality and morbidity in young people and adolescents throughout the western world. Both the physical and psychological consequences of trauma are well documented and it is shown that peri-traumatic factors play a large part in the emotional recovery of children involved in trauma. Indeed, parental anxiety levels may play one of the biggest roles. There are no publically available guidelines on pre-hospital accompaniment, and where research has been done on parental presence it often focuses primarily on the parents or staff, rather than the child themselves. Whilst acknowledging the impact on parents and staff, the importance of the emotional wellbeing of the child should be reinforced, to reduce the likelihood of developing symptoms in keeping with post-traumatic stress disorder. This non-systematic literature review, aims to examine the impact of parental accompaniment to hospital, following paediatric trauma, and to help pre-hospital clinicians decide whether accompaniment would be of benefit to their patient population. The lack of published data does not enable a formal recommendation of parental accompaniment in the helicopter to be mandated, though it should be the preference in land based conveyance. Future research is needed into the emotional recovery of children after trauma, as well as the experiences of patient, parent and staff during conveyance. PMID:24887082
Budassi, S A
For any patient with obvious or suspected chest trauma, one must first assure an adequate airway and adequate ventilation. One should never hesitate to administer oxygen to a victim with a chest injury. The nurse should be concerned with adequate circulation--this may mean the administration of intravenous fluids, specifically volume expanders, via large-bore cannulae. Any obvious open chest wound should be sealed, and any fractures should be splinted. These patients should be rapidly transported to the nearest Emergency Department capable of handling this type of injury. The majority of patients who arrive in the Emergency Department following blunt or penetrating trauma should be considered to be in critical condition until proven otherwise. On presentation, it is essential to recognize those signs, symptoms, and laboratory values that identify the patient's condition as life-threatening. Simple recognition of these signs and symptoms and early appropriate intervention may alter an otherwise fatal outcome.
AWARD NUMBER: W81XWH-13-2-0080 TITLE: Study of Tranexamic Acid During Air Medical Prehospital Transport Trial (STAAMP trial) PRINCIPAL INVESTIGATOR...TITLE AND SUBTITLE 5a. CONTRACT NUMBER Study of Tranexamic Acid During Air Medical Prehospital Transport Trial (STAAMP trial) 5b. GRANT NUMBER W81XWH...IRB approval regarding changes to the protocol language. 15. SUBJECT TERMS Prehospital; Tranexamic acid 16. SECURITY CLASSIFICATION OF: 17. LIMITATION
Bhandarkar, Prashant; Munivenkatappa, Ashok; Roy, Nobhojit; Kumar, Vineet; Samudrala, Veda Dhruthy; Kamble, Jyoti; Agrawal, Amit
Background: Injury-induced alteration in initial physiological responses such as hypertension and heart rate (HR) has a significant effect on mortality. Research on such associations from our country-India is limited. The present study investigates the injury-induced early blood pressure (BP) and HR changes and their association with mortality. Materials and Methods: The data were selected from Towards Improved Trauma Care Outcomes collected from October 1, 2013, to July 24, 2014. Patients above 18 years of age with documented systolic BP (SBP) and HR were selected. BP was categorized into hypotension (SBP <90 mmHg), hypertension (SBP >140 mmHg), and normal (SBP 90–140 mmHg). HR was categorized into bradycardia (HR <60 beats/min [bpm]), tachycardia (HR >100 bpm), and normal (HR 60–100 bpm). These categories were compared with mortality. Results: A total of 10,200 patients were considered for the study. Mortality rate was 24%. Mortality among females was more than males. Patients with normal BP and HR had 20% of mortality. Mortality in patients with abnormal BP and HR findings was 36%. Mortality was higher among hypotension-bradycardia patients (80%) followed by hypertension-bradycardia patients (58%) and tachycardia hypotension patients (48%). Elderly patients were at higher risk of deaths with an overall mortality of 35% compared to 23% of adults. Conclusion: The study reports that initial combination of hypotension-bradycardia had higher mortality rate. Specific precautions in prehospital care should be given to trauma patients with these findings. Further prospective study in detail should be considered for exploring this abnormality.
motion of inversion and eversion, (c) midtarsal motion of forefoot adduction and abduction and, (d) toe motion of flexion and extension (Hoppenfield...Edema/Swelling 17 General previous history- 12 (trauma, surgery /hardware) *Point tenderness 16 What s worked so far 2 Redness/ecchymosis/hematoma 9...Mentioned Mechanism of injury1 21 15 Ability to bear weight/ambulate2 19 13 Edema/swelling2 17 12 *Point tenderness2 16 11 Previous trauma, surgery
Leech, Caroline; Porter, Keith
Objective Prehospital emergency amputation is a rare procedure, which may be necessary to free a time-critical patient from entrapment. This study aimed to evaluate four techniques of cadaveric lower limb prehospital emergency amputation. Method A guillotine amputation of the distal femur was undertaken in fresh frozen self-donated cadavers. A prehospital doctor conducted a surgical amputation with Gigli saw or hacksaw for bone cuts and firefighters carried out the procedure using the reciprocating saw and Holmatro device. The primary outcome measures were time to full amputation and the number of attempts required. The secondary outcomes were observed quality of skin cut, soft tissue cut and CT assessment of the proximal bone. Observers also noted the potential risks to the rescuer or patient during the procedure. Results All techniques completed amputation within 91 s. The reciprocating saw was the quickest technique (22 s) but there was significant blood spattering and continuation of the cut to the surface under the leg. The Holmatro device took less than a minute. The quality of the proximal femur was acceptable with all methods, but 5 cm more proximal soft tissue damage was made by the Holmatro device. Conclusions Emergency prehospital guillotine amputation of the distal femur can effectively be performed using scalpel and paramedic shears with bone cuts by the Gigli saw or fire service hacksaw. The reciprocating saw could be used to cut bone if no other equipment was available but carried some risks. The Holmatro cutting device is a viable option for a life-threatening entrapment where only firefighters can safely access the patient, but would not be a recommended primary technique for medical staff. PMID:27280425
Stubbs, James R; Zielinski, Martin D; Berns, Kathleen S; Badjie, Karafa S; Tauscher, Craig D; Hammel, Scott A; Zietlow, Scott P; Jenkins, Donald
Almost 50% of trauma-related fatalities within the first 24 hours of injury are related to hemorrhage. Improved survival in severely injured patients has been demonstrated when massive transfusion protocols are rapidly invoked as part of a therapeutic approach known as damage control resuscitation (DCR). DCR incorporates the early use of plasma to prevent or correct trauma-induced coagulopathy. DCR often requires the transfusion of plasma before determination of the recipient's ABO group. Historically, group AB plasma has been considered the "universal donor" plasma product. At our facility, the number of AB plasma products produced on an annual basis was found to be inadequate to support the trauma service's DCR program. A joint decision was made by the transfusion medicine and trauma services to provide group A thawed plasma (TP) for in-hospital and prehospital DCR protocols. A description of the implementation of group A TP into the DCR program is provided as well as outcome data pertaining to the use of TP in trauma patients.
Drury, T; Zacharias, S
A level 1 trauma center is challenged to provide optimal trauma care to patients in the region it serves. One approach is to increase the knowledge and clinical skills of all trauma care providers, especially those who work outside urban areas. This article describes one trauma center's experience of integrating rural nursing education into an existing medical trauma outreach program. The educational strategies, example of course content, and organizational aspects of the program are described, along with marketing strategies used to promote the program.
Ross, Jessica; Ashby, Nichola
Major trauma services in the UK underwent reform in April 2012, following reports that trauma care in England was 'unacceptable' and in need of desperate change, and urgent recommendations were made to improve coordination, costs, and information about trauma care to avoid unnecessary deaths. Following the reconfiguration of services, NHS England highlighted the need for nurse key-workers, or coordinators, to support patients through the major trauma pathway and into rehabilitation. This article examines the literature on the coordinator role to understand its function in UK and international major trauma networks.
White, J M; Nowak, R M; Martin, G B; Best, R; Carden, D L; Tomlanovich, M C
Approximately 25% of patients in prehospital cardiac arrest present in bradyasystolic rhythms, and their long-term prognosis is very poor. Our study was undertaken to determine the utility of immediate emergency department (ED) external cardiac pacing in this situation. Twenty patients presenting with bradyasystolic prehospital cardiac arrest were entered in the study. All received the usual advanced cardiac life support therapy, but also were externally paced immediately using an automated external defibrillator and pacemaker (AEDP). Only two of 20 patients showed evidence of electrical capture, and none developed pulses with pacing. Four of the 20 patients developed a sinus rhythm and blood pressure during resuscitation. Three survived to leave the ED, but none survived to leave the hospital. An increase in the rate of bradycardia and pulseless idioventricular rhythms that was independent of electrical capture or pharmacologic therapy was noted occasionally. Although survival was not enhanced using the AEDP, the device was reliable, easy to use, and free of complications. External cardiac pacing warrants further investigation in the prehospital setting.
DeRoss, Anthony L; Vane, Dennis W
Trauma is the leading case of death for children in the United States. Effective initial resuscitation of pediatric trauma patients can reduce mortality. Guidelines have been developed to facilitate patient care in a systematic and productive manner. Advances have been made in both diagnostic and therapeutic methods. The evaluation and treatment of trauma patients will continue to engage pediatric surgeons as efforts in trauma prevention become more successful.
Martin, Kathleen D; Molitor-Kirsch, Shirley; Elgart, Heidi; Ruffolo, Daria C; Sicoutris, Corinna; Meredith, Denise
The need for advanced practice nurses (APN) has expanded over the past several decades as a result of the changing healthcare environment. Increased patient acuity and decreased resident work hours have lead to a need for additional clinical expertise at the bedside. APNs are becoming an integral part of the acute care delivery team in many trauma programs and intensive care units. To date little has been published regarding the role of the APN in Trauma Centers. This article outlines the wide variety of responsibilities and services provided by a select group of nurse practitioners who work in trauma centers throughout the United States.
Carr, Brendan G.; Branas, Charles C.; Metlay, Joshua P.; Sullivan, Ashley F.; Camargo, Carlos A.
Objective Rapid access to emergency services is essential for emergency care sensitive conditions such as acute myocardial infarction, stroke, sepsis, and major trauma. We sought to determine US population access to an emergency department (ED). Methods The National Emergency Department Inventories (NEDI) – USA was used to identify the location, annual visit volume, and teaching status of all EDs in the US. EDs were categorized as 1) any ED, 2) by patient volume, and 3) by teaching status. Driving distances, driving speeds, and prehospital times were estimated using validated models and adjusted for population density. Access was determined by summing the population that could reach an ED within the specified time intervals. Results Overall, 71% of the US population has access to an ED within 30 minutes, and 98% has access within 60 minutes. Access to teaching hospitals was more limited, with 16% having access within 30 minutes and 44% within 60 minutes. Rural states had lower access to all types of EDs. Conclusions Although the majority of the US population has access to an ED, there are regional disparities in ED access, especially by rurality. Future efforts should measure the relationship between access to emergency services and outcomes for emergency care sensitive conditions. The development of a regionalized emergency care delivery system should be explored. PMID:19201059
Vardon, Fanny; Mrozek, Ségolène; Geeraerts, Thomas; Fourcade, Olivier
Hypothermia, along with acidosis and coagulopathy, is part of the lethal triad that worsen the prognosis of severe trauma patients. While accidental hypothermia is easy to identify by a simple measurement, it is no less pernicious if it is not detected or treated in the initial phase of patient care. It is a multifactorial process and is a factor of mortality in severe trauma cases. The consequences of hypothermia are many: it modifies myocardial contractions and may induce arrhythmias; it contributes to trauma-induced coagulopathy; from an immunological point of view, it diminishes inflammatory response and increases the chance of pneumonia in the patient; it inhibits the elimination of anaesthetic drugs and can complicate the calculation of dosing requirements; and it leads to an over-estimation of coagulation factor activities. This review will detail the pathophysiological consequences of hypothermia, as well as the most recent principle recommendations in dealing with it.
angina pectoris and utility of fractal and complexity measures. Am J Cardiol. 1998;81:27–31. 35. Mandelbrot BB. Fractals, Form and Chance. San Francisco...associated with myocardial ischemia, manifested by angina .34 Thus, decreases in RRI complexity as measured by entropy appear to be associated with
818 October 2008 23. Makikallio TH, Ristimae T, Airaksinen KE, Peng CK, Goldberger AL, Huikuri HV. Heart rate dynamics in patients with stable angina ... pectoris and utility of fractal and complexity measures. Am J Cardiol. 1998;81:27–31. 24. Peng CK, Havlin S, Stanley HE, Goldberger AL. Quantification
Neeki, Michael M.; MacNeil, Colin; Toy, Jake; Dong, Fanglong; Vara, Richard; Powell, Joe; Pennington, Troy; Kwong, Eugene
Introduction Mobilization of trauma resources has the potential to cause ripple effects throughout hospital operations. One major factor affecting efficient utilization of trauma resources is a discrepancy between the prehospital estimated time of arrival (ETA) as communicated by emergency medical services (EMS) personnel and their actual time of arrival (TOA). The current study aimed to assess the accuracy of the perceived prehospital estimated arrival time by EMS personnel in comparison to their actual arrival time at a Level II trauma center in San Bernardino County, California. Methods This retrospective study included traumas classified as alerts or activations that were transported to Arrowhead Regional Medical Center in 2013. We obtained estimated arrival time and actual arrival time for each transport from the Surgery Department Trauma Registry. The difference between the median of ETA and actual TOA by EMS crews to the trauma center was calculated for these transports. Additional variables assessed included time of day and month during which the transport took place. Results A total of 2,454 patients classified as traumas were identified in the Surgery Department Trauma Registry. After exclusion of trauma consults, walk-ins, handoffs between agencies, downgraded traumas, traumas missing information, and traumas transported by agencies other than American Medical Response, Ontario Fire, Rialto Fire or San Bernardino County Fire, we included a final sample size of 555 alert and activation classified traumas in the final analysis. When combining all transports by the included EMS agencies, the median of the ETA was 10 minutes and the median of the actual TOA was 22 minutes (median of difference=9 minutes, p<0.0001). Furthermore, when comparing the difference between trauma alerts and activations, trauma activations demonstrated an equal or larger difference in the median of the estimated and actual time of arrival (p<0.0001). We also found month and time of
Kosmos, C A
This case study reinforces key principles in caring for multiply injured trauma victims. The Primary Survey is a tool developed to allow those caring for trauma patients to prioritize injuries. Those injuries identified in the Primary Survey will be the most life threatening.
Taddeo, Joseph; Devine, Maj Melissa; McAlister, LCol Vivian C.
Background The injury pattern from improvised explosive device (IED) trauma is different if the target is in a vehicle (mounted) or on foot (dismounted). Combat and civilian first response protocols require the placement of a cervical collar on all victims of a blast injury. Methods We searched the Joint Theatre Trauma Registry (JTTR) and the Role 3 Hospital, Kandahar Airfield (KAF) database from Mar. 1, 2008, to May 31, 2011. We collected data on cervical fracture; head injury; traumatic amputation; initial blood pressure, pulse, injury severity score (ISS), Glasgow Coma Scale (GCS) score and base excess; and patient demographic information. Results The concordance rate between JTTR and KAF databases was 98%. Of the 15 693 admissions in JTTR, 326 patients with dismounted IED injuries were located. The rate of cervical collar prehospital placement was 7.6%. Cervical fractures were found in 19 (5.8%) dismounted IED victims, but only 4 (1.2%) were considered radiographically unstable. None of these 19 patients had prehospital placement of a collar. Patients with cervical spine fractures were more severely injured than those without (ISS 18.2 v. 13.4; GCS 10.1 v. 12.5). Patients with head injuries had significantly higher risk of cervical spine injury than those with no head injury recorded (13.6% v. 3.9%). No differences in frequency of cervical spine injury were found between patients who had associated traumatic amputations and those who did not (5.4% v. 6.0%). Conclusion Dismounted IED is a mechanism of injury associated with a low risk for cervical spine trauma. A selective protocol for cervical collar placement on victims of dismounted IED blasts is possible and may be more amenable to combat situations. PMID:26100769
Gonzalez, Enrique; Peña, Raul; Vargas-Rosales, Cesar; Avila, Alfonso; de Cerio, David Perez-Diaz
This survey aims to encourage the multidisciplinary communities to join forces for innovation in the mobile health monitoring area. Specifically, multidisciplinary innovations in medical emergency scenarios can have a significant impact on the effectiveness and quality of the procedures and practices in the delivery of medical care. Wireless body sensor networks (WBSNs) are a promising technology capable of improving the existing practices in condition assessment and care delivery for a patient in a medical emergency. This technology can also facilitate the early interventions of a specialist physician during the pre-hospital period. WBSNs make possible these early interventions by establishing remote communication links with video/audio support and by providing medical information such as vital signs, electrocardiograms, etc. in real time. This survey focuses on relevant issues needed to understand how to setup a WBSN for medical emergencies. These issues are: monitoring vital signs and video transmission, energy efficient protocols, scheduling, optimization and energy consumption on a WBSN.
Gonzalez, Enrique; Peña, Raul; Vargas-Rosales, Cesar; Avila, Alfonso; Perez-Diaz de Cerio, David
This survey aims to encourage the multidisciplinary communities to join forces for innovation in the mobile health monitoring area. Specifically, multidisciplinary innovations in medical emergency scenarios can have a significant impact on the effectiveness and quality of the procedures and practices in the delivery of medical care. Wireless body sensor networks (WBSNs) are a promising technology capable of improving the existing practices in condition assessment and care delivery for a patient in a medical emergency. This technology can also facilitate the early interventions of a specialist physician during the pre-hospital period. WBSNs make possible these early interventions by establishing remote communication links with video/audio support and by providing medical information such as vital signs, electrocardiograms, etc. in real time. This survey focuses on relevant issues needed to understand how to setup a WBSN for medical emergencies. These issues are: monitoring vital signs and video transmission, energy efficient protocols, scheduling, optimization and energy consumption on a WBSN. PMID:26007741
El-Menyar, A; Asim, M; Zarour, A; Abdelrahman, H; Peralta, R; Parchani, A; Al-Thani, H
A structured research programme is one of the main pillars of a trauma care system. Despite the high rate of injury-related mortalities, especially road traffic accidents, in Qatar, little consideration has been given to research in trauma. This review aimed to analyse research publications on the subject of trauma published from Qatar and to discuss the progress of clinical research in Qatar and the Gulf Cooperation Council countries with special emphasis on trauma research. A literature search using PubMed and Google Scholar search engines located 757 English-language articles within the fields of internal medicine, surgery and trauma originating from Qatar between the years 1993 and 2013. A steep increase in the number of trauma publications since 2010 could be linked to the setting up of a trauma research centre in Qatar in 2011. We believe that establishing a research unit has made a major impact on research productivity, which ultimately benefits health care.
Cone, David C; Irvine, Katrina A; Middleton, Paul M
This paper describes the methodology of a large emergency medical services (EMS) data linkage research project currently under way in the statewide EMS system of New South Wales, Australia. The paper is intended to provide the reader with an understanding of how linkage techniques can be used to facilitate EMS research. This project, the Australian Prehospital Outcomes Study of Longitudinal Epidemiology (APOStLE) Project, links data from six statewide sources (computer-assisted dispatch, EMS patient health care reports, emergency department data, inpatient data, and two death registries) to enable researchers to examine the patient's entire journey through the health care system, from the emergency 0-0-0 call to the emergency department and inpatient setting, through to discharge or death, for approximately 2.6 million patients transported by the Ambulance Service of New South Wales to emergency departments between June 2006 and July 2009. Manual, deterministic, and probabilistic data linkages are described, and potential applications of linked data in EMS research are outlined.
Vertkin, A L; Morozov, S N; Fedorov, A I
We studied effect of time on the outcome of acute coronary syndrome and elevated ST segment at the prehospital stage. Logistic regression analysis revealed two time-dependent predictors: "symptom-needle" time and total call service time. In patients undergoing prehospital thrombolysis, these indices (88 and 85 min respectively) reliably predicted the probability of fatal outcome. Their values of 71 and 77 min respectively predicted the risk of unfavourable outcome. The total call service time may serve as an indicator of the quality of work of an ambulance crew at the prehospital stage of management of acute coronary syndrome with elevated ST segment.
Cameron, P; Dziukas, L; Hadj, A; Clark, P; Hooper, S
This study was undertaken to evaluate the frequency, distribution, cause, pattern, and outcome of patients suffering from major trauma in the State of Victoria over a 1-year period. No previous study in Australia has attempted a comprehensive regional analysis of major trauma. All major trauma admissions resulting from blunt, penetrating, and burns injury were identified, and data collected from emergency departments and intensive care log books at 25 major metropolitan and rural hospitals from the January 3, 1992 to February 28, 1993 by onsite data collectors. The total number of patients admitted into the study was 2,944. There were 1,076 major trauma cases with an Injury Severity Score greater than 15 in a population of 4.2 million people. The type of injury was predominantly blunt (87.5%), with only a small percentage of penetrating injuries (6.4%) and burns (6%). Major trauma in pediatric cases is less common (132 cases). The most common causes of injury were road transport (56%) and falls (22%). The overall outcome of the group was favorable when compared with the Major Trauma Outcome Study group (Z = 1.4, M = 0.93, W = 0.52). There was an unexpectedly low number of patients suffering from major trauma. Outcome using Trauma and Injury Severity Score methodology was favorable when compared with North America.
Trauma patients with fever Total IED 70 56 126 GSW 20 16 36 Rocket 18 7 25 Other 17 9 26 Fall 8 2 10 MVC 6 8 14 Shrapnel 4 1 5 Helicopter crash 3 1 4 Crush...1 9 10 Total 147 101 248 GSW, Gunshot wound; MVC , motor vehicle collision. RESEARCH/Minnick et al e104 JOURNAL OF EMERGENCY NURSING VOLUME 39 • ISSUE
Polito, Carmen C.; Isakov, Alex; Yancey, Arthur H.; Wilson, Duncan K.; Anderson, Blake A.; Bloom, Ingrid; Martin, Greg S.; Sevransky, Jonathan E.
Objective To derive and validate a predictive model and novel Emergency Medical Services (EMS) screening tool for severe sepsis (SS). Design Retrospective cohort study. Setting A single EMS system and an urban, public hospital. Patients Sequential adult, non-trauma, non-arrest, at-risk, EMS-transported patients between January 1, 2011 and December 31, 2012. At-risk patients were defined as having all 3 of the following criteria present in the EMS setting: heart rate >90bpm, 2) respiratory rate >20bpm, and 3) systolic blood pressure <110mmHg. Interventions None. Measurements and Main Results Among 66,439 EMS encounters, 555 met criteria for analysis. Fourteen percent (n=75) of patients had SS, of which 19% (n=14) were identified by EMS clinical judgment. In-hospital mortality for patients with SS was 31% (n=23). Six EMS characteristics were found to be predictors of SS: older age, transport from nursing home, Emergency Medical Dispatch (EMD) 9-1-1 chief complaint category of “Sick Person”, hot tactile temperature assessment, low systolic blood pressure, and low oxygen saturation. The final predictive model showed good discrimination in derivation and validation subgroups (AUC 0.843 and 0.820, respectively). Sensitivity of the final model was 91% in the derivation group and 78% in the validation group. At a pre-defined threshold of 2 or more points, prehospital severe sepsis (PRESS) score sensitivity was 86%. Conclusions The PRESS score is a novel EMS screening tool for SS that demonstrates a sensitivity of 86% and specificity of 47%. Additional validation is needed before this tool can be recommended for widespread clinical use. PMID:26070235
Mavrogenis, Andreas F; Panagopoulos, George N; Kokkalis, Zinon T; Koulouvaris, Panayiotis; Megaloikonomos, Panayiotis D; Igoumenou, Vasilios; Mantas, George; Moulakakis, Konstantinos G; Sfyroeras, George S; Lazaris, Andreas; Soucacos, Panayotis N
Vascular injury in orthopedic trauma is challenging. The risk to life and limb can be high, and clinical signs initially can be subtle. Recognition and management should be a critical skill for every orthopedic surgeon. There are 5 types of vascular injury: intimal injury (flaps, disruptions, or subintimal/intramural hematomas), complete wall defects with pseudoaneurysms or hemorrhage, complete transections with hemorrhage or occlusion, arteriovenous fistulas, and spasm. Intimal defects and subintimal hematomas with possible secondary occlusion are most commonly associated with blunt trauma, whereas wall defects, complete transections, and arteriovenous fistulas usually occur with penetrating trauma. Spasm can occur after either blunt or penetrating trauma to an extremity and is more common in young patients. Clinical presentation of vascular injury may not be straightforward. Physical examination can be misleading or initially unimpressive; a normal pulse examination may be present in 5% to 15% of patients with vascular injury. Detection and treatment of vascular injuries should take place within the context of the overall resuscitation of the patient according to the established principles of the Advanced Trauma Life Support (ATLS) protocols. Advances in the field, made mostly during times of war, have made limb salvage the rule rather than the exception. Teamwork, familiarity with the often subtle signs of vascular injuries, a high index of suspicion, effective communication, appropriate use of imaging modalities, sound knowledge of relevant technique, and sequence of surgical repairs are among the essential factors that will lead to a successful outcome. This article provides a comprehensive literature review on a subject that generates significant controversy and confusion among clinicians involved in the care of trauma patients. [Orthopedics. 2016; 39(4):249-259.].
Desai, Pratik; Suk, Michael
Trauma sustained during pregnancy can trigger uncertainty and anxiety for patient and orthopedic surgeon alike. In particular, orthopedic-related injuries raise concerns about preoperative, intraoperative, and postoperative care. In this article, we review common concerns about radiation exposure, leukemia, pain management, anticoagulation, and anesthesia. One finding is that radiation risk is minimal when obtaining x-rays for operative planning, provided that the cumulative dose is within 5 rad. We also address safety concerns about patient positioning and staff radiation exposure. In addition, we found that most anesthetics used in pregnancy are category C (ie, safe). Perioperative opioid use for pain management is recommended with little risk. Regarding anticoagulation, low-molecular-weight heparin and fondaparinux are the safest choices. Last, pregnancy is not a contraindication to operative management of pelvic and acetabular fractures.
Taylor, Louise H; Shewan, Jane; Baldwin, Trevor; Grünewald, Richard A; Reuber, Markus
Objectives Suspected seizures are a common reason for emergency calls to ambulance services. Prehospital management of these patients is an important element of good quality care. The aim of this study, conducted in a regional ambulance service in the UK, was to quantify the number of emergency telephone calls for suspected seizures in adults, the associated costs, and to describe the patients’ characteristics, their prehospital management and their immediate outcomes. Design Quantitative cross-sectional study using routinely collected data and a detailed review of the clinical records of a consecutive series of adult patients (≥16 years). Setting A regional ambulance service within the National Health Service in England. Participants Cross-sectional data from all 605 481 adult emergency incidents managed by the ambulance service from 1 April 2012 to 31 March 2013. We selected a consecutive series of 178 individual incidents from May 2012 for more detailed analysis (132 after exclusions and removal of non-seizure cases). Results Suspected seizures made up 3.3% of all emergency incidents. True medical emergencies were uncommon but 3.3% had partially occluded airways, 6.8% had ongoing seizure activity and 59.1% had clinical problems in addition to the seizure (29.1% involving injury). Emergency vehicles were dispatched for 97.2% of suspected seizures, the seizure had terminated on arrival in 93.2% of incidents, 75% of these patients were transported to hospital. The estimated emergency management cost per annum of suspected seizures in the English ambulance services is £45.2 million (€64.0 million, $68.6 million). Conclusions Many patients with suspected seizures could potentially be treated more effectively and at lower cost by modifying ambulance call handling protocols. The development of innovative care pathways could give call handlers and paramedics alternatives to hospital transportation. Increased adoption of care plans could reduce 999 calls and
Stewart, Kenneth; Garwe, Tabitha; Bhandari, Naresh; Danford, Brandon; Albrecht, Roxie
Objective A review of the literature yielded little information regarding factors associated with the decision to use ground (GEMS) or helicopter (HEMS) emergency medical services for trauma patients transferred inter-facility. Furthermore, studies evaluating the impact of inter-facility transport mode on mortality have reported mixed findings. Since HEMS transport is generally reserved for more severely injured patients, this introduces indication bias, which may explain the mixed findings. Our objective was to identify factors at referring non-tertiary trauma centers (NTC) influencing transport mode decision. Methods This was a case-control study of trauma patients transferred from a Level III or IV NTC to a tertiary trauma center (TTC) within 24-hours reported to the Oklahoma State Trauma Registry between 2005 and 2012. Multivariable logistic regression was used to determine clinical and non-clinical factors associated with the decision to use HEMS. Results A total of 7380 patients met the study eligibility. Of these, 2803(38%) were transported inter-facility by HEMS. Penetrating injury, prehospital EMS transport, severe torso injury, hypovolemic shock, and TBI were significant predictors (p<0.05) of HEMS use regardless of distance to a TTC. Association between HEMS use and male gender, Level IV NTC, and local ground EMS resources varied by distance from the TTC. Many HEMS transported patients had minor injuries and normal vital signs. Conclusions Our results suggest that while distance remains the most influential factor associated with HEMS use, significant differences exist in clinical and non-clinical factors between patients transported by HEMS versus GEMS. To ensure comparability of study groups, studies evaluating outcome differences between HEMS and GEMS should take factors determining transport mode into account. The findings will be used to develop propensity scores to balance baseline risk between GEMS and HEMS patients for use in subsequent studies
Gruen, Russell L.; Jurkovich, Gregory J.; McIntyre, Lisa K.; Foy, Hugh M.; Maier, Ronald V.
Objective: To identify patterns of errors contributing to inpatient trauma deaths. Methods: All inpatient trauma deaths at a high-volume level I trauma center from 1996 to 2004 inclusive were audited. Data were collected with daily trauma registry chart abstraction, weekly morbidity and mortality reports, hospital quality assurance reports, and annual trauma registry analyses of risk of death using TRISS and HARM methodology. Deaths that met criteria for low to medium probability of mortality or those with quality of care concerns were analyzed for errors and then subjected to 3-stage peer review at weekly departmental, monthly hospital, and annual regional forums. Patterns of errors were constructed from the compiled longitudinal data. Results: In 9 years, there were 44,401 trauma patient admissions and 2594 deaths (5.8%), of which 601 met low to medium mortality risks. Sixty-four patients (0.14% admissions, 2.47% deaths) had recognized errors in care that contributed to their death. Important error patterns included: failure to successfully intubate, secure or protect an airway (16%), delayed operative or angiographic control of acute abdominal/pelvic hemorrhage (16%), delayed intervention for ongoing intrathoracic hemorrhage (9%), inadequate DVT or gastrointestinal prophylaxis (9%), lengthy initial operative procedures rather than damage control surgery in unstable patients (8%), over-resuscitation with fluids (5%), and complications of feeding tubes (5%). Resulting data-directed institutional and regional trauma system policy changes have demonstrably reduced the incidence of associated error-related deaths. Conclusions: Preventable deaths will occur even in mature trauma systems. This review has identified error patterns that are likely common in all trauma systems, and for which policy interventions can be effectively targeted. PMID:16926563
Govett, G S; Amedee, R G
Otolaryngologists are commonly called upon to emergently evaluate blunt trauma to the facial skeleton. These injuries are occasionally associated with serious trauma to the orbital contents. This manuscript reviews these orbital injuries by considering the pertinent eye anatomy and the extensive examination usually performed by an ophthalmologist. Anterior and posterior segment injuries along with specific trauma to the optic nerve will also be discussed.
National Child Traumatic Stress Network, 2008
This paper offers facts which can help educators deal with children undergoing trauma. These include: (1) One out of every 4 children attending school has been exposed to a traumatic event that can affect learning and/or behavior; (2) Trauma can impact school performance; (3) Trauma can impair learning; (4) Traumatized children may experience…
Military Sexual Trauma What is military sexual trauma (MST)? Military sexual trauma, or MST, is the term used by VA to refer to experiences of sexual assault ... that a Veteran experienced during his or her military service. The definition used by the VA comes ...
Chambers, Jamie C.
The effects of trauma can roll on unchecked like a spirit of death. In its path are strewn its once vibrant victims. Human bonds are rent asunder by the disgrace of trauma. These are the youngsters who have been verbally bashed, physically battered, sexually assaulted, and spiritually exploited. Other traumas of childhood neglect include: (1)…
Burkhardt, Markus; Kristen, Alexander; Culemann, Ulf; Koehler, Daniel; Histing, Tina; Holstein, Joerg H; Pizanis, Antonius; Pohlemann, Tim
Until today the mortality of complex pelvic trauma remains unacceptably high. On the one hand this could be attributed to a biological limit of the survivable trauma load, on the other hand side an ongoing inadequate treatment might be conceivable too. For the management of multiple trauma patients with life-threatening pelvic fractures, there is ongoing international debate on the adequate therapeutic strategy, e.g. arterial embolization or pelvic packing, as well as aggressive or restrained volume therapy. Whereas traditional pelvis-specific trauma algorithms still recommend massive fluid resuscitation, there is upcoming evidence that a restrained volume therapy in the preclinical setting may improve trauma outcomes. Less intravenous fluid administration may also reduce haemodilution and concomitant trauma-associated coagulopathy. After linking the data of the TraumaRegister DGU(®) and the German Pelvic Injury Register, for the first time, the initial fluid management for complex pelvic traumas as well as for different Tile/OTA types of pelvic ring fractures could be addressed. Unfortunately, the results could not answer the question of the adequate fluid resuscitation but confirmed the actuality of massive fluid resuscitation in the prehospital and emergency room setting. Low-volume resuscitation seems not yet accepted in practice in managing multiple trauma patients with pelvic fractures at least in Germany. Nevertheless, prevention of exsanguination and of complications like multiple organ dysfunction syndrome still poses a major challenge in the management of complex pelvic ring injuries. Even nowadays, fluid management for trauma, not only for pelvic fractures, remains a controversial area and further research is mandatory.
Evaluation of the Relation between Deliberate Self-Harm Behavior and Childhood Trauma Experiences in Patients Admitted to a Secondary-Care Psychiatric Outpatient Clinic for Adolescents and Young Adults
SAÇARÇELİK, Gülhazar; TÜRKCAN, Ahmet; GÜVELİ, Hülya; YEŞİLBAŞ, Dilek
Introduction The aim of this study was to determine the prevalence and the features of deliberate self-harm (DSH) behavior in patients admitted to the psychiatric outpatient clinic for adolescents and young adults and also to detect the association between the act of DSH and childhood traumas. Method In this study, we included all patients who were admitted to the secondary-care psychiatric outpatient clinic for adolescents and young adults in Bakırkoy Research and Training Hospital Psychiatry, Neurology and Neurosurgery throughout a month. A sociodemographic data form, the Childhood Trauma Questionnaire (CTQ-28), Childhood Abuse and Neglect Question List and the Deliberate Self-Harm and Intent Screening Form were applied to three hundred participants. Result The prevalence of DSH was 50.0% among the participants (56.8% for females and 28.8% for males). Childhood abuse was detected in 57.0% of all participants (60.4% of females and 46.6% of males). Among patients with act of DSH, the rate of childhood abuse was 71.3%, while it was 42.7% in the subjects without act of DSH. Conclusion DSH is a common behavior among adolescent psychiatric patients. It is more common in females than in males. The prevalence of experience of childhood abuse and neglect is remarkably high and is associated with self-harm behavior.
Thurairajah, Kabilan; Broadhead, Matthew L.; Balogh, Zsolt J.
Trauma may cause irreversible tissue damage and loss of function despite current best practice. Healing is dependent both on the nature of the injury and the intrinsic biological capacity of those tissues for healing. Preclinical research has highlighted stem cell therapy as a potential avenue for improving outcomes for injuries with poor healing capacity. Additionally, trauma activates the immune system and alters stem cell behaviour. This paper reviews the current literature on stem cells and its relevance to trauma care. Emphasis is placed on understanding how stem cells respond to trauma and pertinent mechanisms that can be utilised to promote tissue healing. Research involving notable difficulties in trauma care such as fracture non-union, cartilage damage and trauma induced inflammation is discussed further. PMID:28272352
Ciesla, David J; Moore, Ernest E; Cothren, C Clay; Johnson, Jeffery L; Burch, Jon M
Summary The general surgeon’s growing disinterest in trauma is fueled by lack of surgical opportunity and high burden of non operative responsibilities. The majority of care provided by the trauma surgeon supports other procedure oriented specialties. This is a major deterrent surgeon participation in trauma care and must be addressed in the evolution of the Acute Care Surgeon. Background The role of the trauma surgeon is perceived to be mostly supportive of other procedure oriented specialties. We designed this study to characterize the operative and nonoperative responsibilities of the contemporary trauma surgeon. Methods Trauma patients admitted to an urban academic Level I Trauma Center were studied using trauma registry data for 2004. Results The large majority of patients admitted to trauma service have mild single system injuries to one or two anatomic regions. Most (57%) did not have injuries to the neck, chest, or abdomen. Head and extremity injuries were present in 45% and 46% of patients respectively. Operations were performed by orthopedists in 28%, trauma surgeons in 11% and neurosurgeons in 6% of patiets respectively. Conclusions The contemporary trauma surgeon has little operative opportunity and provides a disproportionate amount of nonoperative care in supportive of consultant specialists. This is a major deterrent to general surgeon interest in trauma care and must be addressed as the Acute Care Surgeon evolves. PMID:17161084
Hansen, Matthew; O'Brien, Kerth; Dickinson, Caitlin; Meckler, Garth; Engle, Phil; Lambert, William; Jui, Jonathan
Objective Prehospital emergency medical services (EMS) providers report anxiety as the second most common contributor to paediatric patient safety events. The objective of this study was to understand how EMS providers perceive the effect of stress and anxiety on paediatric out-of-hospital patient safety. Setting This was a nationwide study of EMS providers from 44 of 50 (88%) US states. Participants A total of 753 eligible EMS professionals, including emergency medical technicians, emergency department physicians and nurses (general and paediatric), and respiratory therapists who participate in out-of-hospital transports. Primary and secondary outcome measures Outcomes included responses to: (1) clinical situations where heightened stress or anxiety was likely to contribute to safety events, (2) aspects of these clinical situations that cause stress or anxiety and (3) how stress or anxiety may lead to paediatric safety events. Results EMS providers reported that the clinical situations where stress and anxiety were more likely to contribute to paediatric patient safety events were trauma, respiratory distress and cardiac issues. Key themes were: (1) provider sympathy or identification with children, (2) difficulty seeing an innocent child hurt and the inherent value of children and (3) insufficient exposure to paediatric emergencies. Conclusions Caring for paediatric emergencies creates unique stresses on providers that may affect patient safety. Many of the factors reported to cause provider stress and anxiety are inherent attributes of children and therefore not modifiable. Tools that support care during stressful conditions such as cognitive aids may help to mitigate anxiety in the prehospital care of children. Further research is needed to identify opportunities for and attributes of interventions. PMID:28246139
Mort, Alasdair J; Rushworth, Gordon F
To gather preferences for novel pre-hospital physiologic monitoring technologies from emergency rescue services. Qualitative semi-structured interviews and focus groups were conducted with three groups from UK Search and Rescue (SAR); (1) Extractors (e.g. SAR teams), (2) Transporters (personnel primarily responsible for casualty transport), and (3) Treaters (e.g. Emergency Department doctors). Three themes were defined; SAR casualty management, novel physiologic monitor potential, and physiologic monitor physical properties. Some SAR groups already employed physiologic monitoring but there was no consensus on which monitor(s) to carry or what to monitor and how frequently. Existing monitors also tended to be bulky and heavy and could be unreliable in an unstable environment or if the casualty was cold. Those performing monitoring tended to have only basic first-aid training, and their workload was often high particularly if there was more than one casualty. The potential benefits of employing a novel monitor were strategic and clinical; an opportunity for transmitting data off-scene in order to facilitate monitoring or generate advice (i.e. telemedicine) was also voiced. A range of more intuitive, physical properties was also raised (e.g. small/compact, lightweight). SAR-specific technology should be simple to operate by those with less medical training, which means that clinical data interpretation and presentation should be carefully considered. It would be beneficial if novel monitors carried out a majority of the interpretation, allowing rescuers to proceed with their priority task of removing the casualty to safety.
Livingstone AS, Schulman CI, Namias N, Proctor KG: Is hydroxyethyl starch safe in penetrating trauma patients? An analysis with propensity score...with hydroxyethyl starch J Trauma Acute Care Surg 2014 Dec;77(6):859-864. 9) Allen CJ, Tashiro J, Valle EJ, Thorson CM, Shariatmadar S, Schulman CI... starch solutions safe in trauma patients? Presented at 2014 MHSRS (Military Health Science Research Symposium), Fort Lauderdale, FL, Aug 2014 14
Gillman, Lawrence M.; Widder, Sandy; Clément, Julien; Engels, Paul T.; Paton-Gay, John Damian; Brindley, Peter G.
Summary The Standardized Trauma and Resuscitation Team Training (S.T.A.R.T.T.) course focuses on training multidisciplinary trauma teams: surgeons/physicians, registered nurses (RNs), respiratory therapists (RTs) and, most recently, prehospital personnel. The S.T.A.R.T.T. curriculum highlights crisis management (CRM) skills: communication, teamwork, leadership, situational awareness and resource utilization. This commentary outlines the modifications made to the course curriculum in order to satisfy the learning needs of a bilingual audience. The results suggest that bilingual multidisciplinary CRM courses are feasible, are associated with high participant satisfaction and have no clear detriments. PMID:26820320
Kumar, Atin; Panda, Ananya; Gamanagatti, Shivanand
Blunt pancreatic trauma is an uncommon injury but has high morbidity and mortality. In modern era of trauma care, pancreatic trauma remains a persistent challenge to radiologists and surgeons alike. Early detection of pancreatic trauma is essential to prevent subsequent complications. However early pancreatic injury is often subtle on computed tomography (CT) and can be missed unless specifically looked for. Signs of pancreatic injury on CT include laceration, transection, bulky pancreas, heterogeneous enhancement, peripancreatic fluid and signs of pancreatitis. Pan-creatic ductal injury is a vital decision-making parameter as ductal injury is an indication for laparotomy. While lacerations involving more than half of pancreatic parenchyma are suggestive of ductal injury on CT, ductal injuries can be directly assessed on magnetic resonance imaging (MRI) or encoscopic retrograde cholangio-pancreatography. Pancreatic trauma also shows temporal evolution with increase in extent of injury with time. Hence early CT scans may underestimate the extent of injures and sequential imaging with CT or MRI is important in pancreatic trauma. Sequential imaging is also needed for successful non-operative management of pancreatic injury. Accurate early detection on initial CT and adopting a multimodality and sequential imaging strategy can improve outcome in pancreatic trauma. PMID:26981225
Rollins, Rochelle; Gribble, Anna; Barrett, Sharon E; Powell, Clydette
Evidence-based practice standards are not yet well defined for assisting potential victims of human trafficking. Nonetheless, health care professionals are learning to be first responders in identifying, treating, and referring potential victims. As more public and private sector resources are used to train health care professionals about human trafficking, more evaluation and research are needed to develop an effective standard of care. Adopting a public health lens and using the "National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care" can guide critical decision making and actions. Through collaboration between researchers and policymakers, lessons learned in health care settings can inform future evidence-based standards of care so that all patients receive the services that they need.
Bernhard, M; Matthes, G; Kanz, K G; Waydhas, C; Fischbacher, M; Fischer, M; Böttiger, B W
Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate <6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S(p)O(2)<90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)<9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)<90 mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate >29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation and oxygenation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices and a fiber-optic endoscope need to be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the
Since the 1970s, the management of blunt splenic trauma has evolved from almost exclusive surgical management to selective use of nonsurgical management in hemodynamically stable patients. Understanding of the spleen's immunologic importance in protection against overwhelming postsplenectomy infection led to development first of surgical techniques for splenic salvage and later to protocols for nonsurgical management of adults with blunt splenic injury. The evolution of nonsurgical management has resulted in new patterns of postsplenic trauma complications.This article describes a pancreatic pseudocyst, one of several described delayed complications of nonsurgical management of blunt splenic trauma. Along with missed splenic injury and delayed rupture, the development of a splenic pseudocyst represents challenges for any multidisciplinary team involved in trauma care. Detection and management of these complications is discussed, as is postsplenectomy vaccination and return to activity.
Chico-Fernández, M; Terceros-Almanza, L L; Mudarra-Reche, C C
The management of critical trauma disease (CTD) has always trends the trends in military war experiences. These conflicts have historically revolutionized clinical concepts, clinical practice guidelines and medical devices, and have marked future lines of research and aspects of training and learning in severe trauma care. Moreover, in the civil setting, the development of intensive care, technological advances and the testing of our healthcare systems in the management of multiple victims, hasve also led to a need for innovation in our trauma care systems.
Nwomeh, Benedict C; Lowell, Wendi; Kable, Renae; Haley, Kathy; Ameh, Emmanuel A
Background A trauma registry is an integral component of modern comprehensive trauma care systems. Trauma registries have not been established in most developing countries, and where they exist are often rudimentary and incomplete. This review describes the role of trauma registries in the care of the injured, and discusses how lessons from developed countries can be applied toward their design and implementation in developing countries. Methods A detailed review of English-language articles on trauma registry was performed using MEDLINE and CINAHL. In addition, relevant articles from non-indexed journals were identified with Google Scholar. Results The history and development of trauma registries and their role in modern trauma care are discussed. Drawing from past and current experience, guidelines for the design and implementation of trauma registries are given, with emphasis on technical and logistic factors peculiar to developing countries. Conclusion Improvement in trauma care depends on the establishment of functioning trauma care systems, of which a trauma registry is a crucial component. Hospitals and governments in developing countries should be encouraged to establish trauma registries using proven cost-effective strategies. PMID:17076896
McNamara, K J; Schulman, C; Jepsen, D; Cuffley, J E
A mission of the Navy Nurse Corps is to deploy medical support for military forces on short notice. Navy nurses must possess a working knowledge of trauma management, but meeting this clinical experience is a challenge. Peacetime military hospitals do not routinely care for severely injured patients. This article describes how the Navy established a partnership with a Level 1 Trauma Center, the role and expectations for both Navy and civilian nurses, and an evaluation of the experience.
Gwinnutt, C L; Driscoll, P A; Whittaker, J
Trauma is an inevitable consequence of the lives we lead. There are many approaches to dealing with it but an ideal system, universally applicable, probably does not exist because of the national variations in social, economic, cultural and geographical characteristics. Many countries are beginning to recognise that the 'systems' they have in place for dealing with the burden of trauma are seriously deficient and that this situation cannot be allowed to continue into the new millennium. However, it is highly unlikely that in the near future. governments will suddenly find substantial extra finance for trauma care or the implementation of new systems. Throughout many countries, the individual components of trauma care systems are in place but, for whatever reasons, there is a lack of integration, which results in suboptimal care. The system we all should be aiming for is one of closer communication and greater cooperation. By taking into account community and national needs, available resources, and adapting what is currently in place it should then be possible to create 'a set of things working together as parts of a trauma mechanism'.
Carello, Janice; Butler, Lisa D.
This article presents the starting case for applying the elements of trauma-informed care (TIC) to education and outlines the authors' initial efforts to develop guidelines for what they call trauma-informed educational practice. To this end, the article starts with a literature review related to the potential for vicarious traumatization and…
Chinitz, Susan; Stettler, Erin M.; Giammanco, Denise; Silverman, Marian; Briggs, Rahil D.; Loeb, Joanne
Infants most vulnerable to trauma are often the least able to access interventions. Universal child-serving systems, such as primary pediatrics, early care and education, and the child welfare system, can offer a port of entry for millions of children annually for trauma-related supports and services. However, practitioners in these systems have…
van Vugt, A B
Introduction of the principles of advanced trauma life support (ATLS) in the management of accident victims has been in progress in the Netherlands since 1995. The main ATLS principles are that the aid giver treats the most dangerous disorder first and does no further damage. After assessment and, if necessary, treatment of the airways, the respiration, the circulation and any craniocerebral injury, an exploratory examination is carried out. Physicians receive theoretical and practical instructions in this form of management during an intensive two-day course, counselled by a coordinating organization in the USA. Most of those attending are interns in general surgery, traumatology and orthopaedics, gatekeeper doctors of emergency rooms and army medical officers. The standardized way of thinking improves the communication and understanding between the various disciplines involved in trauma care, in part because there exist comparable programmes for ambulance care and emergency care. Other measures improving the quality of trauma care are regionalization of the trauma care, medical helicopter teams and evaluation of the effects of ATLS as an operating procedure.
Wang, Hao; Umejiego, Johnbosco; Robinson, Richard D.; Schrader, Chet D.; Leuck, JoAnna; Barra, Michael; Buca, Stefan; Shedd, Andrew; Bui, Andrew; Zenarosa, Nestor R.
Background There is no existing adequate blood transfusion needs determination tool that Emergency Medical Services (EMS) personnel can use for prehospital blood transfusion initiation. In this study, a simple and pragmatic prehospital blood transfusion needs scoring system was derived and validated. Methods Local trauma registry data were reviewed retrospectively from 2004 through 2013. Patients were randomly assigned to derivation and validation cohorts. Multivariate logistic regression was used to identify the independent approachable risks associated with early blood transfusion needs in the derivation cohort in which a scoring system was derived. Sensitivity, specificity, and area under the receiver operational characteristic (AUC) were calculated and compared using both the derivation and validation data. Results A total of 24,303 patients were included with 12,151 patients in the derivation and 12,152 patients in the validation cohorts. Age, penetrating injury, heart rate, systolic blood pressure, and Glasgow coma scale (GCS) were risks predictive of early blood transfusion needs. An early blood transfusion needs score was derived. A score > 5 indicated risk of early blood transfusion need with a sensitivity of 83% and a specificity of 80%. A sensitivity of 82% and a specificity of 80% were also found in the validation study and their AUC showed no statistically significant difference (AUC of the derivation = 0.87 versus AUC of the validation = 0.86, P > 0.05). Conclusions An early blood transfusion scoring system was derived and internally validated to predict severe trauma patients requiring blood transfusion during prehospital or initial emergency department resuscitation. PMID:27429680
instituted as standards of care within the theater trauma system, including deep venous thrombosis ( DVT ) prophylaxis, hypothermia prevention , and...for massive transfusion / damage control resuscitation, burn care, hypothermia prevention and management, wound and amputation management have been...advances in numerous components of battlefield injury care. PREVENTION Since the implementation of the military trauma system, the effect of new
Tallo, Fernando Sabia; de Campos Vieira Abib, Simone; Baitello, André Luciano; Lopes, Renato Delascio
OBJECTIVE: To describe the profile of physicians working at the Prehospital Emergency Medical System (SAMU) in Brazil and to evaluate their quality of life. METHODS: Both a semi-structured questionnaire with 57 questions and the SF-36 questionnaire were sent to research departments within SAMU in the Brazilian state capitals, the Federal District and inland towns in Brazil. RESULTS: Of a total of 902 physicians, including 644 (71.4%) males, 533 (59.1%) were between 30 and 45 years of age and 562 (62.4%) worked in a state capital. Regarding education level, 45.1% had graduated less than five years before and only 43% were specialists recognized by the Brazilian Medical Association. Regarding training, 95% did not report any specific training for their work at SAMU. The main weaknesses identified were psychiatric care and surgical emergencies in 57.2 and 42.9% of cases, respectively; traumatic pediatric emergencies, 48.9%; and medical emergencies, 42.9%. As for procedure-related skills, the physicians reported difficulties in pediatric advanced support (62.4%), airway surgical access (45.6%), pericardiocentesis (64.4%) and thoracentesis (29.9%). Difficulties in using an artificial ventilator (43.3%) and in transcutaneous pacing (42.2%) were also reported. Higher percentages of young physicians, aged 25-30 years (26.7 vs 19.0%; p<0.01), worked exclusively in prehospital care (18.0 vs 7.7%; p<0.001), with workloads >48 h per week (12.8 vs 8.6%; p<0.001), and were non-specialists with the shortest length of service (<1 year) at SAMU (30.1 vs 18.2%; p<0.001) who were hired without having to pass public service exams* (i.e., for a temporary job) (61.8 vs 46.2%; p<0.001). Regarding quality of life, the pain domain yielded the worst result among physicians at SAMU. CONCLUSIONS: The doctors in this sample were young and within a few years of graduation, and they had no specific training in prehospital emergencies. Deficiencies were mostly found in pediatrics and psychiatry
Ferri, Marica; De Luca, Assunta; Rossi, Paolo Giorgi; Lori, Giuliano; Guasticchi, Gabriella
Background Early interventions proved to be able to improve prognosis in acute stroke patients. Prompt identification of symptoms, organised timely and efficient transportation towards appropriate facilities, become essential part of effective treatment. The implementation of an evidence based pre-hospital stroke care pathway may be a method for achieving the organizational standards required to grant appropriate care. We performed a systematic search for studies evaluating the effect of pre-hospital and emergency interventions for suspected stroke patients and we found that there seems to be only a few studies on the emergency field and none about implementation of clinical pathways. We will test the hypothesis that the adoption of emergency clinical pathway improves early diagnosis and referral in suspected stroke patients. We designed a cluster randomised controlled trial (C-RCT), the most powerful study design to assess the impact of complex interventions. The study was registered in the Current Controlled Trials Register: ISRCTN41456865 – Implementation of pre-hospital emergency pathway for stroke – a cluster randomised trial. Methods/design Two-arm cluster-randomised trial (C-RCT). 16 emergency services and 14 emergency rooms were randomised either to arm 1 (comprising a training module and administration of the guideline), or to arm 2 (no intervention, current practice). Arm 1 participants (152 physicians, 280 nurses, 50 drivers) attended an interactive two sessions course with continuous medical education CME credits on the contents of the clinical pathway. We estimated that around 750 patients will be met by the services in the 6 months of observation. This duration allows recruiting a sample of patients sufficient to observe a 30% improvement in the proportion of appropriate diagnoses. Data collection will be performed using current information systems. Process outcomes will be measured at the cluster level six months after the intervention. We will
Zinman, Leonard N; Vanni, Alex J
Genitourinary trauma usually occurs in the setting of multisystem trauma, accounting for approximately 10% of all emergency department admissions. Timely evaluation and management of the trauma patient have the potential to minimize urologic morbidity and mortality. New imaging modalities and a growing emphasis on nonoperative expectant management of both upper and lower urinary tract injuries have changed the field of urologic trauma. Concomitant injury to both the upper and the lower urinary tract is rare, but careful evaluation is critical to identify these devastating injuries.
Borgohain, B; Khonglah, T
A trauma system is a chain of arrangements and preparedness to provide quality response to injured from the site of injury to the appropriate hospital for the full range of care. Israel has a unique trauma system developed from the experience gained in peace and in war. The system is designed to fit the state's current health system, which is different from the European and American systems. An effective trauma system may potentially manage mass casualty incidence better. The aim of this paper is to discuss learning points to develop a trauma system based on the Israeli trauma model. After participating in a course on developing a trauma system organized by a top Israeli trauma center, a literature search on the topic on the Internet was done using relevant key words like trauma system and disaster management in Israel using the Google search engine in the pubmed, open access journals and websites of trauma organizations. Israel has a unique trauma system of organizing and managing an emergency event, characterized by a central national organization responsible for management, coordination and ongoing quality control. Because of its unique geopolitical situation, the armed forces has a significant role in the system. Investing adequate resources on continuous education, manpower training, motivation, team-work and creation of public volunteers through advocacy is important for capacity building to develop a trauma system. Wisdom, motivation and pragmatism of the Israeli model may be useful to streamline work in skeletal trauma services of developing countries having fewer resources to bring consistency and acceptable standards in trauma care. PMID:23634336
Bates, P; Parker, P; McFadyen, I; Pallister, I
Trauma care has evolved rapidly over the past decade. The benefits of operative fracture management in major trauma patients are well recognised. Concerns over early total care arose when applied broadly. The burden of additional surgical trauma could constitute a second hit, fuelling the inflammatory response and precipitating a decline into acute respiratory distress syndrome, sepsis and multiple organ dysfunction syndrome. Temporary external fixation aimed to deliver the benefits of fracture stabilisation without the risk of major surgery. This damage control orthopaedics approach was advocated for those in extremis and a poorly defined borderline group. An increasing understanding of the physiological response to major trauma means there is now a need to refine our treatment options. A number of large scale retrospective reviews indicate that early definitive fracture fixation is beneficial in the majority of major trauma patients. It is recommended that patients are selected appropriately on the basis of their response to resuscitation. The hope is that this approach (dubbed ‘safe definitive fracture surgery’ or ‘early appropriate care’) will herald an era when care is individualised for each patient and their circumstances. The novel Damage Control in Orthopaedic Trauma Surgery course at The Royal College of Surgeons of England aims to equip senior surgeons with the insights and mindset necessary to contribute to this key decision making process as well as also the technical skills to provide damage control interventions when needed, relying on the improved techniques of damage control resuscitation and advances in the understanding of early appropriate care. PMID:27023640
for prehospital care. The appropriate guidelines for military tourniquet use are outlined in the Pre Hospital Trauma Life Support ( PHTLS ) Manual: Mil...ation of the US Army one-handed tourniquet. Mil Med 2005; 170:776–781. 8. PHTLS : Basic and advanced prehospital trauma life support; mil- itary edition
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Kieffer, WKM; Michalik, DV; Gallagher, K; McFadyen, I; Bernard, J; Rogers, BA
Introduction Trauma is a significant cause of morbidity and mortality in the UK. Since the inception of the trauma networks, little is known of the temporal pattern of trauma admissions. Methods Trauma Audit and Research Network data for 1 April 2011 to 31 March 2013 were collated from two large major trauma centres (MTCs) in the South East of England: Brighton and Sussex University Hospitals NHS Trust (BSUH) and St George's University Hospitals NHS Foundation Trust (SGU). The number of admissions and the injury severity score by time of admission, by weekdays versus weekend and by month/season were analysed. Results There were 1,223 admissions at BSUH and 1,241 at SGU. There was significant variation by time of admission; there were more admissions in the afternoons (BSUH p<0.001) and evenings (SGU p<0.001). There were proportionally more admissions at the weekends than on weekdays (BSUH p<0.001, SGU p=0.028). There was significant seasonal variation in admissions at BSUH (p<0.001) with more admissions in summer and autumn. No significant seasonal variation was observed at SGU (p=0.543). Conclusions The temporal patterns observed were different for each MTC with important implications for resource planning of trauma care. This study identified differing needs for different MTCs and resource planning should be individualised to the network. PMID:26741676
Dueck, Andrew; Poenaru, Dan; Pichora, David R.
Objectives To estimate the costs of Canadian pediatric trauma and identify cost predictors. Design A chart review. Setting A regional trauma centre. Study material The charts of all 221 children who suffered traumatic injuries with an Injury Severity Score (ISS) of 4 or more seen over 6 years at a regional trauma centre. Main outcome measures Patient data, injury data, all hospital-based costs, excluding nursing, food and medication costs. Results Mean (and standard deviation) patient age was 12.8 (5) years. Sixty percent were boys. Motor vehicle accidents (MVAs) accounted for 71% of the injuries, followed by falls (11%). The mean (and SD) total cost of care was Can$7582 (Can$12 370), and the cost of media was Can$2666. Total cost correlated directly with age (r = 0.29, p < 0.001) and Injury Severity Score (ISS) (r = 0.34, p < 0.001) and inversely with the Pediatric Trauma Score (PTS) (r = −0.20, p = 0.003). The presence of extremity injuries correlated significantly with total cost (r = 0.22, p = 0.001) and PTS (r = −0.25, p < 0.001) but not with the ISS. Logistic regression analysis identified runk injury, ISS and PTS as the main determinants of survival. Conclusions The cost of pediatric trauma in Canada can be predicted from admission data and trauma scores. The cost of extremity injuries is significant and can be predicted by the PTS but not the ISS. PMID:11308233
Dayton, Lauren; Buttress, Amelia; Agosti, Jen; Aceves, Javier; Kieschnick, Meredith; Popejoy, Agatha; Robbins, Robyn; Farinholt, Kate
This article explores barriers and strategies to achieving family-driven integrated child health care. Family involvement in health system design and reform has become a guiding principle in national and local efforts to improve children's mental health services. In practice, primary care clinicians, staff, and families continue to describe common barriers to integrating family voice. Drawing from the collective knowledge of the Pediatric Integrated Care Collaborative (PICC) and the National Alliance on Mental Illness (NAMI), we present strategies to overcome these barriers to successfully recruit, sustain, and expand family influence on health systems. Family advocates and clinical leaders from two clinic sites in Albuquerque, New Mexico and Santa Rosa, California share challenges and strategies for building family involvement in system design.
Opaleva-Stegantseva, V A; Rybkin, I A; Protopopova, A N; Litvintseva, G A; Ratovskaia, V I
The data on the dynamics of prehospital mortality in acute coronary failure (ACF) and myocardial infarction (MI) depending on the improvement in medical service in the prehospital stage of treatment are presented. The research showed that prehospital mortality in ACF and MI accounts for 75% of the total mortality. Among deaths registered in the prehospital stage 73.7% were sudden. As the result of improvements in prehospital medical service due to the training of physicians of the emergency medical service, the organization of cardiologic emergency aid teams, clinico-pathologic conferences held at the emergency medical service stations, etc. extrahospital mortality dropped from 45.6% (1963) to 26.2% (1975) with simultaneous drop in total mortality from 61.9% (1963) to 37.4% (1975).
Terry, Shawn M
Truma surgery today is facing a number of significant challenges that offer a stimulus for growth and evolution of tl practice. To successfully face these challenges, reexamination of the discipline, the current practice models for its providers, and the definition/scope of the specialty will be necessary. Further development and application of the cute care surgery model may represent the future direction for trauma care practitioners.
Holman, E Alison; Silver, Roxane Cohen
The September 11, 2001 terrorist attacks (9/11) presented a unique opportunity to assess the physical health impact of collective stress in the United States. This study prospectively examined rates of physical ailments and predictors of health care utilization in a U.S. nationally representative sample over three years following the attacks. A sample of adults (N = 2592) completed a survey before 9/11/01 that assessed MD-diagnosed physical and mental health ailments. Follow-up surveys were administered at one (N = 1923), two (N = 1576), and three (N = 1950) years post-9/11 to assess MD-diagnosed physical health ailments (e.g., cardiovascular, endocrine) and health care utilization. Reports of physical ailments increased 18% over three years following 9/11. 9/11-related exposure, lifetime and post-9/11 stress, MD-diagnosed depression/anxiety, smoking status, age, and female gender predicted increased incidence of post-9/11 ailments, after controlling for pre-9/11 health. After adjusting for covariates (demographics, somatization, smoking status, pre-9/11 mental and physical health, lifetime and post-9/11 stress, and degree of 9/11-related exposure), increases in MD-diagnosed cardiovascular, endocrine, gastrointestinal, and hematology-oncology ailments predicted greater utilization of health care services over two years. After the collective stress of 9/11, rates of physical ailments increased and predicted greater health care utilization in a U.S. national sample.
Bowen, Elizabeth A; Murshid, Nadine Shaanta
Trauma-informed care is a service provision model used across a range of practice settings. Drawing on an extensive body of research on trauma (broadly defined as experiences that produce enduring emotional pain and distress) and health outcomes, we have argued that the principles of trauma-informed care can be extended to social policy. Citing a variety of health-related policy examples, we have described how policy can better reflect 6 core principles of trauma-informed care: safety, trustworthiness and transparency, collaboration, empowerment, choice, and intersectionality. This framework conveys a politicized understanding of trauma, reflecting the reality that trauma and its effects are not equally distributed, and offers a pathway for public health professionals to disrupt trauma-driven health disparities through policy action.
Ahmadi-Noorbakhsh, Siavash; Azizi, Saeed; Dalir-Naghadeh, Bahram; Maham, Masoud
Oxygen is an essential part of the most important metabolic pathways in aerobic organisms. Oxygen delivery is merely dependent on blood, rendering blood loss a devastating event. Traumatic pre-hospital liver bleeding is a major cause of early trauma deaths in human and animals, with no established therapeutic method yet. Increasing intra-abdominal pressure (IAP) has been shown to reduce liver bleeding by half. Although reduction of blood loss could be in favor of blood oxygen delivery, however, the complex interaction between increased IAP and respiratory mechanics during severe hemorrhagic shock remained unclear. We used a novel model of liver trauma in 16 rabbits and randomly assigned them to either normotensive abdomen group or increased IAP by fluid infusion (HA) groups (n=8 each). Liver size and the amount of liver injury were evaluated. Various blood oxygenation parameters were recorded. Both groups were identical in terms of the liver size and injury. The HA group had significantly lower shock index. Arterial oxygen capacity and oxygen content were higher in the HA group. No significant statistical difference was seen between groups in terms of abdominal perfusion pressure; alveolar pressure of oxygen; dissolved oxygen in blood plasma; alveolar to arterial oxygen tension gradient; arterial to alveolar oxygen pressure ratio; the ratio between partial pressure of arterial oxygen and fraction of inspired oxygen; and respiratory index. In conclusion, the novel therapeutic method of increasing IAP by fluid infusion in a rabbit model of liver hemorrhage preserved blood oxygenation better than the classic therapeutic method.
Lozano, Luis Manuel Barrera; Perel, Pablo; Ker, Katharine; Cirocchi, Roberto; Farinella, Eriberto; Morales, Carlos Hernando
This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of thromboprophylaxis in trauma patients on mortality and incidence of DVT and PE. To compare the effects of different thromboprophylaxis interventions and their relative effects according to the type of trauma. PMID:25267908
Terr, Lenore C
This review begins with the question "What is childhood trauma?" Diagnosis is discussed next, and then the article focuses on treatment, using 3 basic principles-abreaction, context, and correction. Treatment modalities and complications are discussed, with case vignettes presented throughout to illustrate. Suggestions are provided for the psychiatrist to manage countertransference as trauma therapy proceeds.
... up after Facial trauma: A prospective study. Otolaryngol Head Neck Surg 1997: 117:72-75 Kim MK, Buchman ... trauma in children: An urban hospitals experience. Otolaryngoly–Head Neck Surgery 2000: 123: 439-43 Patient Health Home ...
Clements, J Randolph; Schopf, Robert
Forefoot traumas, particularly involving the metatarsals, are commonly occurring injuries. There have been several advances in management of these injuries. These advances include updates in operative technique, internal fixation options, plating constructs, and external fixation. In addition, the advances of soft tissue management have improved outcomes. This article outlines these injuries and provides an update on techniques, principles, and understanding of managing forefoot trauma.
In much of contemporary culture, "trauma" signifies not so much terrible experience as a particular context for understanding and responding to a terrible experience. In therapy, in the media, and in international interventions, the traumatized are seen not simply as people who suffer and so are deserving of concern and aid; they are seen also as people who suffer for us, who are given special dispensation. They are treated with awe if they tell a certain kind of trauma story, and are ignored or vilified if they tell another. Trauma has become not simply a story of pain and its treatment, but a host of sub-stories involving the commodification of altruism, the justification of violence and revenge, the entry point into "true experience," and the place where voyeurism and witnessing intersect. Trauma is today the stuff not only of suffering but of fantasy. Historically, trauma theory and treatment have shown a tension, exemplified in the writings of Freud and Janet, between those who view trauma as formative and those who view it as exceptional. The latter view, that trauma confers exceptional status deserving of special privilege, has gained ground in recent years and has helped to shape the way charitable dollars are distributed, how the traumatized are presented in the media, how governments justify and carry out international responses to trauma, and how therapists attend to their traumatized patients. This response to trauma reflects an underlying, unarticulated belief system derived from narcissism; indeed, trauma has increasingly become the venue, in society and in treatment, where narcissism is permitted to prevail.
Perea-Milla, Emilio; Olalla, Julián; Sánchez-Cantalejo, Emilio; Martos, Francisco; Matute-Cruz, Petra; Carmona-López, Guadalupe; Fornieles, Yolanda; Cayuela, Aurelio; García-Alegría, Javier
Background Mortality from invasive meningococcal disease (IMD) has remained stable over the last thirty years and it is unclear whether pre-hospital antibiotherapy actually produces a decrease in this mortality. Our aim was to examine whether pre-hospital oral antibiotherapy reduces mortality from IMD, adjusting for indication bias. Methods A retrospective analysis was made of clinical reports of all patients (n = 848) diagnosed with IMD from 1995 to 2000 in Andalusia and the Canary Islands, Spain, and of the relationship between the use of pre-hospital oral antibiotherapy and mortality. Indication bias was controlled for by the propensity score technique, and a multivariate analysis was performed to determine the probability of each patient receiving antibiotics, according to the symptoms identified before admission. Data on in-hospital death, use of antibiotics and demographic variables were collected. A logistic regression analysis was then carried out, using death as the dependent variable, and pre-hospital antibiotic use, age, time from onset of symptoms to parenteral antibiotics and the propensity score as independent variables. Results Data were recorded on 848 patients, 49 (5.72%) of whom died. Of the total number of patients, 226 had received oral antibiotics before admission, mainly betalactams during the previous 48 hours. After adjusting the association between the use of antibiotics and death for age, time between onset of symptoms and in-hospital antibiotic treatment, pre-hospital oral antibiotherapy remained a significant protective factor (Odds Ratio for death 0.37, 95% confidence interval 0.15–0.93). Conclusion Pre-hospital oral antibiotherapy appears to reduce IMD mortality. PMID:19344518
Sebastian, Raynard J.; Miller, Kenneth; Langdorf, Mark I.; Johnson, David
Purpose: To determine the degree of adherence to a cervical spine (c-spine) clearance protocol by pre-hospital Emergency Medical Services (EMS) personnel by both self-assessment and receiving hospital assessment, to describe deviations from the protocol, and to determine if the rate of compliance by paramedic self-assessment differed from receiving hospital assessment. Methods: A retrospective sample of pre-hospital (consecutive series) and receiving hospital (convenience sample) assessments of the compliance with and appropriateness of c-spine immobilization. The c-spine clearance protocol was implemented for Orange County EMS just prior to the April–November 1999 data collection period. Results: We collected 396 pre-hospital and 162 receiving hospital data forms. From the pre-hospital data sheet, the percentage deviation from the protocol was 4.0% (16/396). Only one out of 16 cases that did not comply with the protocol was due to over immobilization (0.2%). The remaining 15 cases were under immobilized, according to protocol. Nine of the under immobilized cases (66%) that should have been placed in c-spine precautions met physical assessment criteria in the protocol, while the other five cases met mechanism of injury criteria. The rate of deviations from protocol did not differ over time. The receiving hospital identified 8.0% (13/162; 6/l6 over immobilized, 7/16 under immobilized) of patients with deviations from the protocol; none was determined to have actual c-spine injury. Conclusion: The implementation of a pre-hospital c-spine clearance protocol in Orange County was associated with a moderate overall adherence rate (96% from the pre-hospital perspective, and 9250 from the hospital perspective. p = .08 for the two evaluation methods). Most patients who deviated from protocol were under immobilized. but no c-spine injuries were missed. The rate of over immobilization was better than previously reported, implying a saving of resources. PMID:20852696
CARE PROVIDERS William Anthony Novak APPROVED Carol Ledbetter, PhD, RN-C, CS, FNP Date Eugene Levine, PhD Date Patricia McMullen, CRNP, CNS, MS, JD...Services University (MSN) May, 1999 Major: FNP Bethesda, Maryland (1997-1999) California State University Major: Nursing Sacramento, California (1992-1994...and worked in an orthopedic clinic. One PA and one FNP reported working in both an emergency department and primary/family clinic. A Novak Thesis 39
Goodacre, S W; Gray, A; McGowan, A
OBJECTIVE: To assess whether length of time on-scene in patients with major injury was associated with severity of injury or with abnormal on-scene physiology. METHODS: A retrospective analysis of a convenience sample of patients in whom prehospital on-scene times were entered onto the regional major trauma database. On-scene times of patients were analysed to assess whether ultimate injury severity score or on scene physiology measurements affected times. This was undertaken by examining subgroups of patients with similar injury severity or physiological measurements by Wilcoxon-Mann-Whitney testing and comparing 95% confidence intervals of the mean on-scene times. RESULTS: The mean on-scene time for 111 non-entrapped patients was 26 minutes (95% confidence interval 23.5 to 28.6). Patients with injury severity score of > 15, with a Glasgow coma scale of < 13, and with an abnormal pulse spent significantly less time on-scene than less severely injured or physiologically deranged patients. CONCLUSIONS: Paramedics have the ability to recognise patients with severe injury and reduce on-scene times. On-scene times were consistently long throughout all subgroups of major trauma patients. PMID:9315926
Billington, Michael; Kandalaft, Osama R.; Aisiku, Imoigele P.
Seizures are a common presentation in the prehospital and emergency department setting and status epilepticus represents an emergency neurologic condition. The classification and various types of seizures are numerous. The objectives of this narrative literature review focuses on adult patients with a presentation of status epilepticus in the prehospital and emergency department setting. In summary, benzodiazepines remain the primary first line therapeutic agent in the management of status epilepticus, however, there are new agents that may be appropriate for the management of status epilepticus as second- and third-line pharmacological agents. PMID:27563928
A short-cut review was carried out to determined whether the addition of prehospital focused abdominal ultrasound to triage protocols might reduce time to necessary surgery and reduce overall mortality. Thirty-five papers were found using the reported searches, of which three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of those best papers are shown in table 2. It is concluded that although the feasibility of prehospital ultrasound in mass casualty incidents has been demonstrated, there is, as yet, no clear evidence of benefit as part of a triage protocol.
Fitzpatrick, David; O'Meara, Patrick; Cunningham, Andrew
This short report describes the case of a young adult male who had smoked a synthetic cannabinoid legal high product called 'Exodus Damnation'. The patient's presentation was atypical from that described in the literature, with hypotension and hypoxaemia. Of note was the rapid recovery after pre-hospital intervention with high-flow oxygen therapy and intravenous fluids. The patient refused on-going care, despite repeated advice to attend the Emergency Department. The distinct lack of specialist support and referral to drug treatment for this patient population, with whom ambulance services are coming into contact with increasing frequency, is reported. For those patients with the capacity to refuse on-going care, ambulance services may be in an opportune position to actively promote referral to support services for these vulnerable individuals.
Abantanga, Francis; Goosen, Jacques; Joshipura, Manjul; Juillard, Catherine
Abstract Part of the solution to the growing problem of child injury is to strengthen the care that injured children receive. This paper will point out the potential health gains to be made by doing this and will then review recent advances in the care of injured children in individual institutions and countries. It will discuss how these individual efforts have been aided by increased international attention to trauma care. Although there are no major, well-funded global programmes to improve trauma care, recent guidance documents developed by WHO and a broad network of collaborators have stimulated increased global attention to improving planning and resources for trauma care. This has in turn led to increased attention to strengthening trauma care capabilities in countries, including needs assessments and implementation of WHO recommendations in national policy. Most of these global efforts, however, have not yet specifically addressed children. Given the special needs of the injured child and the high burden of injury-related death and disability among children, clearly greater emphasis on childhood trauma care is needed. Trauma care needs assessments being conducted in a growing number of countries need to focus more on capabilities for care of injured children. Trauma care policy development needs to better encompass childhood trauma care. More broadly, the growing network of individuals and groups collaborating to strengthen trauma care globally needs to engage a broader range of stakeholders who will focus on and champion the improvement of care for injured children. PMID:19551257
Ewing, Michael; Funk, Geoffrey A; Warren, Ann Marie; Rapier, Nakia; Reynolds, Megan; Bennett, Monica; Mastropieri, Cyndi; Foreman, Michael L
Trauma centers manage an active Trauma Registry from which research, quality improvement, and epidemiologic information are extracted to ensure optimal care of the trauma patient. We evaluated coding procedures using the Relational Trauma Scoring System(™) to determine the relative accuracy of the Relational Trauma Scoring System for coding diagnoses in comparison to the standard retrospective chart-based format. Charts from 150 patients admitted to a level I trauma service were abstracted using standard methods. These charts were then randomized and abstracted by trauma nurse clinicians with coding software aide. For charts scored pre-training, percent correct for the trauma nurse clinicians ranged from 52 to 64 percent, while the registrars scored 51 percent correct. After training, percentage correct for the trauma nurse clinicians increased to a range of 80-86 percent. Our research has demonstrated implementable changes that can significantly increase the accuracy of data from trauma centers.
Hörer, Tal M.; Hebron, Dan; Swaid, Forat; Korin, Alexander; Galili, Offer; Alfici, Ricardo; Kessel, Boris
PurposeTo describe the usage of aortic balloon occlusion (ABO), based on a multidisciplinary approach in severe trauma patients, emphasizing the role of the interventional radiologist in primary trauma care.MethodsWe briefly discuss the relevant literature, the technical aspects of ABO in trauma, and a multidisciplinary approach to the bleeding trauma patient. We describe three severely injured trauma patients for whom ABO was part of initial trauma management.ResultsThree severely injured multi-trauma patients were treated by ABO as a bridge to surgery and embolization. The procedures were performed by an interventional radiologist in the early stages of trauma management.ConclusionsThe interventional radiologist and the multidisciplinary team approach can be activated already on severe trauma patient arrival. ABO usage and other endovascular methods are becoming more widely spread, and can be used early in trauma management, without delay, thus justifying the early activation of this multidisciplinary approach.
Ahmadi, Alireza; Bazargan-Hejazi, Shahrzad; Heidari Zadie, Zahra; Euasobhon, Pramote; Ketumarn, Penkae; Karbasfrushan, Ali; Amini-Saman, Javad; Mohammadi, Reza
Abstract: Background: Pain in trauma has a role similar to the double-edged sword. On the one hand, pain is a good indicator to determine the severity and type of injury. On the other hand, pain can induce sever complications and it may lead to further deterioration of the patient. Therefore, knowing how to manage pain in trauma patients is an important part of systemic approach in trauma. The aim of this manuscript is to provide information about pain management in trauma in the Emergency Room settings. Methods: In this review we searched among electronic and manual documents covering a 15-yr period between 2000 and 2016. Our electronic search included Pub Med, Google scholar, Web of Science, and Cochrane databases. We looked for articles in English and in peer-reviewed journals using the following keywords: acute pain management, trauma, emergency room and injury. Results: More than 3200 documents were identified. After screening based on the study inclusion criteria, 560 studies that had direct linkage to the study aim were considered for evaluation based World Health Organization (WHO) pain ladder chart. Conclusions: To provide adequate pain management in trauma patients require: adequate assessment of age-specific pharmacologic pain management; identification of adequate analgesic to relieve moderate to severe pain; cognizance of serious adverse effects of pain medications and weighting medications against their benefits, and regularly reassessing patients and reevaluating their pain management regimen. Patient-centered trauma care will also require having knowledge of barriers to pain management and discussing them with the patient and his/her family to identify solutions. PMID:27414816
Cushing, M; Shaz, B H
Massive transfusion is an essential part of resuscitation efforts in acute trauma patients. The goal is to quickly correct trauma-induced coagulopathy and replace red blood cell (RBC) mass with the minimal number as well as the appropriate choice of blood components to minimize the possible adverse effects of transfusions. Early trauma induced coagulopathy (ETIC) is present in about 20% of patients upon hospital admission and predicts for decreased survival. The mechanism of ETIC is still being elucidated; however, most theories of ETIC's pathophysiology justify the early use of plasma. Most massive transfusion protocol (MTP) ratios deliver blood products in a ratio of 1:1:1 for RBCs:plasma:platelets, which is supported by the majority of the literature demonstrating improved patient survival with higher ratios (>1 plasma and platelet for every 2 RBCs transfused). Indeed, formula-driven MTPs allow trauma services to react quickly to ETIC and provide coagulation factors and platelets in these ratios without having to wait for the results of coagulation assays while the patient's coagulopathy worsens. New MTPs are being created which are adjusted according to an individual's coagulation laboratory values based on point-of-care laboratory tests, such as thromboelastography. When creating an MTP, product wastage due to inappropriate activation and improper product storage should be considered and closely monitored. Another area of discussion regarding transfusion in trauma includes the potential association of prolonged storage of RBCs and adverse outcomes, which has yet to be confirmed. Significant progress has been made in the transfusion management of trauma patients, but further studies are required to optimize patient care and outcomes.
Jin, Hai-Qiang; Wang, Jin-Chao; Sun, Yong-An; Lyu, Pu; Cui, Wei; Liu, Yuan-Yuan; Zhen, Zhi-Gang; Huang, Yi-Ning
Background: Differentiating intracerebral hemorrhage (ICH) from cerebral infarction as early as possible is vital for the timely initiation of different treatments. This study developed an applicable model for the ambulance system to differentiate stroke subtypes. Methods: From 26,163 patients initially screened over 4 years, this study comprised 1989 consecutive patients with potential first-ever acute stroke with sudden onset of the focal neurological deficit, conscious or not, and given ambulance transport for admission to two county hospitals in Yutian County of Hebei Province. All the patients underwent cranial computed tomography (CT) or magnetic resonance imaging to confirm the final diagnosis based on stroke criteria. Correlation with stroke subtype clinical features was calculated and Bayes’ discriminant model was applied to discriminate stroke subtypes. Results: Among the 1989 patients, 797, 689, 109, and 394 received diagnoses of cerebral infarction, ICH, subarachnoid hemorrhage, and other forms of nonstroke, respectively. A history of atrial fibrillation, vomiting, and diabetes mellitus were associated with cerebral infarction, while vomiting, systolic blood pressure ≥180 mmHg, and age <65 years were more typical of ICH. For noncomatose stroke patients, Bayes’ discriminant model for stroke subtype yielded a combination of multiple items that provided 72.3% agreement in the test model and 79.3% in the validation model; for comatose patients, corresponding agreement rates were 75.4% and 73.5%. Conclusions: The model herein presented, with multiple parameters, can predict stroke subtypes with acceptable sensitivity and specificity before CT scanning, either in alert or comatose patients. This may facilitate prehospital management for patients with stroke. PMID:27098788
In England, trauma is the leading cause of death across all age groups, with over 16,000 deaths per year. Major trauma implies the presence of multiple, serious injuries that could result in death or serious disability. Successive reports have documented the fa