Prehospital Trauma Research Articles

Pit Crew Approach to Pre Hospital Trauma Resuscitation

<p><strong>Introduction</strong></p><p>Pre hospital trauma care is often delivered by dual crewed ambulances supported by additional resources as necessary and available. Coordinating resuscitation of a critically injured patient may require multiple simultaneous actions. Equally, a large number of practitioners can hinder patient care if not coordinated.</p><p><strong>Aims</strong></p><p>To describe a multi disciplinary, scaleabe approach to pre hospital trauma care suitable for small and large multi disciplinary teams. Methods The MCI medical team (as part of Motorsport Rescue Services) is a PHECC-registered multidisciplinary team, which provides medical cover at Motorcycle road racing events in Ireland. The MCI medical team has significant experience of major trauma and routinely performs prehospital anaesthesia for trauma patients. We have evolved a pit crew approach to trauma care with pre defined roles and interventions assigned to a five person team, three clinical members, a scribe and a team lead. The approach is both scalable and collapsible, meaning that if multiple patients are present, roles can be merged; if additional clinical input is required, roles can also be supplemented. Each team member carries equipment and medications specific to their role, allowing efficiencies at the patients side.</p><p><strong>Results</strong></p><p>The pit crew approach to pre hospital trauma care has evolved over a decade and is routinely implemented at motorcycle road races in Ireland.</p><p><strong>Conclusions</strong></p><p>The pit crew trauma approach, although applicable to a pre defined five person team in unique circumstances, may also be applicable to ad hoc clinical teams that typically form in the pre hospital arena.</p>

Resuscitation of Blunt Injured, Prehospital Arrest Trauma Patients: An Exercise in Futility

Tung, Lily MD; Leonard, Jennifer MD, PhD; Olson, Erik J. MD; Martin, Niels D. MD, FACS FCCM; Kim, Patrick K. MD, FACS; Reilly, Patrick M. MD, FACS; Seamon, Mark J. MD, FACS Author Information

Bystander Assistance for Trauma Victims in Low- and Middle-Income Countries: A Systematic Review of Prevalence and Training Interventions

Objective: Lack of organized prehospital care may contribute to the disproportionate burden of trauma-related deaths in low- and middle-income countries (LMICs). The World Health Organization (WHO) recommends bystander training in basic principles of first aid and victim transport; however, prevalence of bystander or layperson assistance to trauma victims in LMICs has not been well-described, and organized reviews of existing evidence for bystander training are lacking. This systematic review aims to 1) describe the prevalence of bystander or layperson aid or transport for trauma victims in the prehospital setting in LMICs and 2) ascertain impacts of bystander training interventions in these settings.Methods: A systematic search of OVID Medline, Cochrane Library, and relevant gray literature was conducted. We included 1) all studies detailing prevalence of bystander-administered aid or transport for trauma victims in LMICs and 2) all randomized controlled trials and observational studies evaluating bystander training interventions. We extracted study characteristics, interventions, and outcomes data. Study quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.Results: Sixty-two studies detailed prevalence of bystander transport and aid. Family members, police, and bus or taxi drivers commonly transported patients; a majority of patients, up to >94%, received aid from bystanders. Twenty-four studies examined impacts of training interventions. Only one study looked at transport interventions; the remainder addressed first aid training. Interventions varied in content, duration, and target learners. Evidence was generally of low quality, but all studies demonstrated improvements in layperson knowledge and skills. Five studies reported a mortality reduction.Conclusions: Heterogeneity in data reporting and outcomes limited formal meta-analysis. However, this review shows high rates of bystander involvement in prehospital trauma care and transport in LMICs and highlights the need for bystander training. Bystander training in these settings is feasible and may have an important impact on meaningful outcomes such as mortality. Categories of involved bystanders varied by region and training interventions should be targeted at relevant groups. “Train the trainer” models appear promising in securing community engagement and maximizing participation. Further research is needed to examine the value of bystander transport networks in trauma.

The role of emergency medical service providers in the decision-making process of prehospital trauma triage

PurposeSeverely injured patients should be treated at higher-level trauma centres, to improve chances of survival and avert life-long disabilities. Emergency medical service (EMS) providers must try to determine injury severity on-scene, using a prehospital trauma triage protocol, and decide the most appropriate type of trauma centre. The objective of this study is to investigate the role of EMS provider judgment in the prehospital triage process of trauma patients, by analysing the compliance rate to the protocol and administering a questionnaire among EMS providers.MethodsAll trauma patients transported to a trauma centre in two different regions of the Netherlands were analysed. Compliance rate was based on the number of patients meeting the triage criteria and transported to the corresponding level trauma centre. The questionnaire was administered among EMS providers. Descriptive statistics were used to analyse the data.ResultsFor adult patients, the compliance rate to the level I criteria of the triage protocol was 72% in Central Netherlands and 42% in Brabant. For paediatric patients, this was 63% and 38% in Central Netherlands and Brabant, respectively. The judgment on injury severity was mostly based on the injury-type criteria. Additionally, the distance to a level I trauma centre influenced the decision for destination facility in the Brabant region.ConclusionThe compliance rate varied between regions. Improvement of prehospital trauma triage depends on the accuracy of the protocol and compliance rate. A new protocol, including EMS provider judgment, might be the key to improvement in the prehospital trauma triage quality.

Prehospital care of spinal injuries: a historical quest for reasoning and evidence.

The practice of prehospital immobilization is coming under increasing scrutiny. Unravelling the historical sequence of prehospital immobilization might shed more light on this matter and help resolve the situation. Main purpose of this review is to provide an overview of the development and reasoning behind the implementation of prehospital spine immobilization. An extensive search throughout historical literature and recent evidence based studies was conducted. The history of treating spinal injuries dates back to prehistoric times. Descriptions of prehospital spinal immobilization are more recent and span two distinct periods. First documentation of its use comes from the early 19th century, when prehospital trauma care was introduced on the battlefields of the Napoleonic wars. The advent of radiology gradually helped to clarify the underlying pathology. In recent decades, adoption of advanced trauma life support has elevated in-hospital trauma-care to an high standard. Practice of in-hospital spine immobilization in case of suspected injury has also been implemented as standard-care in prehospital setting. Evidence for and against prehospital immobilization is equally divided in recent evidence-based studies. In addition, recent studies have shown negative side-effects of immobilisation in penetrating injuries. Although widely implementation of spinal immobilization to prevent spinal cord injury in both penetrating and blunt injury, it cannot be explained historically. Furthermore, there is no high-level scientific evidence to support or reject immobilisation in blunt injury. Since evidence in favour and against prehospital immobilization is equally divided, the present situation appears to have reached something of a deadlock. These slides can be retrieved under Electronic Supplementary Material.

Reviewing prehospital trauma deaths

Introduction: This study aimed to conduct detailed reviews of prehospital and early in-hospital trauma deaths to identify opportunities to improve the system of care.

Effects of Tactical Emergency Casualty Care Training for Law Enforcement Officers.

This study evaluated how Tactical Emergency Casualty Care (TECC) training prepared law enforcement officers (LEOs) with the tools necessary to provide immediate, on-scene medical care to successfully stabilize victims of trauma. This was a retrospective, de-identified study using a seven-item Fairfax County (Virginia USA) TECC After-Action Questionnaire and Arlington County (Virginia USA) police reports. Forty-six encounters were collected from 2015 through 2016. Eighty-four percent (n=39) of the encounters were from TECC After-Action Questionnaires and 15% (n=7) were from police reports. The main injuries included 13% (n=6) arterial bleeds, 46% (n=21) mild/moderate bleeds, 37% (n=17) large wounds, 20% (n=9) penetrating chest wounds, and 13% (n=6) open abdominal wounds. One-hundred percent of officers reported success in stabilizing victim injuries. Seventy-four percent of officers (n=26) did not encounter problems caring for a patient while 26% (n=9) encountered a problem. Ninety-seven percent (n=37/38) answered Yes, the training was sufficient, and three percent (n=1) indicated it was OK. This is the most comprehensive study of TECC use among LEOs to date that supports the importance of TECC training for all LEOs in prehospital trauma care. Results of this study showed TECC training prepared LEOs with the operational tools necessary to provide immediate, on-scene medical care to successfully stabilize victims of trauma. Continuing to train increasing numbers of LEOs in TECC is key to saving the lives of victims of trauma in the future. RothschildHR, MathiesonK. Effects of Tactical Emergency Casualty Care training for law enforcement officers. Prehosp Disaster Med. 2018;33(5):495-500.

Correlation Between the Revised Trauma Score and Injury Severity Score: Implications for Prehospital Trauma Triage

Objective: Prehospital triage of the seriously injured patient is fraught with challenges, and trauma scoring systems in current triage guidelines warrant further investigation. The primary objective of this study was to assess the correlation of the physiologically based Revised Trauma Score (RTS) and MGAP score (mechanism of injury, Glasgow Coma Scale, age, blood pressure) with the anatomically based Injury Severity Score (ISS). The secondary objectives for this study were to compare the accuracy of the MGAP score and the RTS for the prediction of in-hospital mortality for trauma patients. Methods: This study was a retrospective cohort including 10 years of patient data in a large single-center trauma registry at a primary adult resource center (Level I) for trauma patients. Participants included adults (age ≥18 years). The primary outcome measure was injury severity (measured by ISS) and a secondary analysis compared the RTS and MGAP for the prediction of patient mortality. Descriptive statistics were used to describe the cohort and correlation methods were employed. Each score’s accuracy for the prediction of mortality was calculated using the area under receiver operating characteristic (AUROC) curves. Results: In total, 43,082 trauma patient records were reviewed; 32,798 patients had complete RTS data available and 32,371 patients had complete data available for MGAP analyses. The correlation between scene RTS and ISS was poor (−.29), as was the correlation between MGAP and ISS (−.28). For the prediction of mortality, admission MGAP demonstrated the highest sensitivity and specificity for mortality (AUROC 0.96; 95% CI, 0.95–0.96). Conclusions: While elements of the RTS remain the first criterion recommended to quantify the totality of physiological injury severity, the composite RTS score derived from this system correlates poorly with actual anatomical injury severity. The MGAP scoring system demonstrated higher sensitivity and specificity for mortality but was not superior to the RTS for predicting anatomical injury severity. In the future development of national and international field triage guidelines for trauma patients, the findings from this study may be considered in order to improve the accuracy of prehospital triage. The findings in this analysis complement a growing body of evidence that suggests that MGAP may be a superior and more easily calculable prehospital scoring system for the prediction of mortality in trauma patients.

Relative Mortality Analysis Of The “Golden Hour”: A Comprehensive Acuity Stratification Approach To Address Disagreement In Current Literature

Objective: This study sought to address the disagreement in literature regarding the “golden hour” in trauma by using the Relative Mortality Analysis to overcome previous studies’ limitations in accounting for acuity when evaluating the impact of prehospital time on mortality.Methods: The previous studies that failed to support the “golden hour” suffered from limitations in their efforts to account for the confounding effects of patient acuity on the relationship between prehospital time and mortality in their trauma populations. The Relative Mortality Analysis was designed to directly address these limitations using a novel acuity stratification approach, based on patients’ probability of survival (PoS), a comprehensive triage metric calculated using Trauma and Injury Severity Score methodology. For this analysis, the population selection and analysis methods of these previous studies were compared to the Relative Mortality Analysis on how they capture the relationship between prehospital time and mortality in the University of Virginia (UVA) Trauma Center population.Results: The methods of the previous studies that failed to support the “golden hour” also failed to do so when applied to the UVA Trauma Center population. However, when applied to the same population, the Relative Mortality Analysis identified a subgroup, 9.9% (with a PoS 23%–91%), of the 5,063 patient population with significantly lower mortality when transported to the hospital within 1 hour, supporting the “golden hour.”Conclusion: These results suggest that previous studies failed to support the “golden hour” not due to a lack of patients significantly impacted by prehospital time within their trauma populations, but instead due to limitations in their efforts to account for patient acuity. As a result, these studies inappropriately rejected the “golden hour,” leading to the current disagreement in literature regarding the relationship between prehospital time and trauma patient mortality. The Relative Mortality Analysis was shown to overcome the limitations of these studies and demonstrated that the “golden hour” was significant for patients who were not low acuity (PoS >91%) or severely high acuity (PoS <23%).

The burden of trauma presenting to the government referral hospital in Freetown, Sierra Leone: An observational study.

IntroductionTrauma accounts for a significant proportion of the global burden of disease, with highest mortality rates seen in Africa. This epidemic is predicted to increase with urbanisation and an aim of the Sustainable Development Goals is to reduce deaths and trauma caused by road accidents. Data available on urban trauma in Sierra Leone is limited.MethodsWe conducted a retrospective observational study of trauma and injury related presentations to the emergency centre (EC) of Connaught Hospital, the principal adult tertiary referral centre in Freetown, Sierra Leone between January and March 2016. Patient demographics are described with mechanism of injury. Additional data on length of stay and surgical procedures were recorded for admissions to the trauma ward.ResultsDuring the 3-month period, a total of 340 patients with injury presented to the EC, accounting for 11.6% of total attendances and 68% of adult surgical admissions. The majority were male (66%) and mean age was 26 years (IQR 15–40). The proportion of trauma presentations were higher in the evening and at weekends and 41% of patients were triaged as emergency or very urgent cases. Road traffic accidents were the most frequent cause of injury (55%) followed by falls (17%) and assaults (14%). Burns were more common in children. Head and lower limbs were the most commonly injured body parts and a minority of patients underwent surgical procedures. Median length of stay for adult patients was 4.5 days (IQR 2–11) and 7 days (IQR 4–14) for children.DiscussionInjury accounts for a high burden of disease at Connaught Hospital and consumes a significant proportion of EC and hospital resources. Efforts should be directed towards strengthening the pre-hospital and emergency trauma systems with accurate, formal data collection as well as targeting injury prevention initiatives and improving road safety to reduce morbidity and mortality.

Prehospital Trauma Care among 68 European Neurotrauma Centers: Results of the CENTER-TBI Provider Profiling Questionnaires.

The first hour following traumatic brain injury (TBI) is considered crucial to prevent death and disability. It is, however, not established yet how the prehospital care should be organized to optimize recovery during the first hour. The objective of the current study was to examine variation in prehospital trauma care across Europe aiming to inform comparative effectiveness analyses on care for neurotrauma patients. A survey on prehospital trauma care was sent to 68 neurotrauma centers from 20 European countries participating in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study. The survey was developed using literature review and expert opinion and was pilot tested in 16 centers. All participants completed the questionnaire. Advanced life support was used in half of the centers (n = 35; 52%), whereas the other centers used mainly basic life support (n = 26; 38%). A mobile medical team (MMT) could be dispatched 24/7 in most centers (n = 66; 97%). Helicopters were used in approximately half of the centers to transport the MMT to the scene (n = 39; 57%) and the patient to the hospital (n = 31, 46%). Half of the centers used a stay-and-play approach at the scene (n = 37; 55%), while the others used a scoop-and-run approach or another policy. We found wide variation in prehospital trauma care across Europe. This may reflect differences in socio-economic situations, geographic differences, and a general lack of strong evidence for some aspects of prehospital care. The current variation provides the opportunity to study the effectiveness of prehospital interventions and systems of care in comparative effectiveness research.

Association between Blood Glucose and cardiac Rhythms during pre-hospital care of Trauma Patients \u2013 a retrospective Analysis

BackgroundDeranged glucose metabolism is frequently observed in trauma patients after moderate to severe traumatic injury, but little data is available about pre-hospital blood glucose and its association with various cardiac rhythms and cardiac arrest following trauma.MethodsWe retrospectively investigated adult trauma patients treated by a nationwide helicopter emergency medical service (34 bases) between 2005 and 2013. All patients with recorded initial cardiac rhythms and blood glucose levels were enrolled. Blood glucose concentrations were categorised; descriptive and regression analyses were performed.ResultsIn total, 18,879 patients were included, of whom 185 (1.0%) patients died on scene. Patients with tachycardia (≥100/min, 7.0 ± 2.4 mmol/L p < 0.0001), pulseless ventricular tachycardia (9.8 ± 1.8, mmol/L, p = 0.008) and those with ventricular fibrillation (9.0 ± 3.2 mmol/L, p < 0.0001) had significantly higher blood glucose concentrations than did patients with normal sinus rhythm between 61 and 99/min (6.7 ± 2.1 mmol/L). In patients with low (≤2.8 mmol/L, 7/79; 8.9%, p < 0.0001) and high (> 10.0 mmol/L, 70/1271; 5.5%, p < 0.0001) blood glucose concentrations cardiac arrest was more common than in normoglycaemic patients (166/9433, 1.8%). ROSC was more frequently achieved in hyperglycaemic (> 10 mmol/L; 47/69; 68.1%) than in hypoglycaemic (≤4.2 mmol/L; 13/31; 41.9%) trauma patients (p = 0.01).ConclusionsIn adult trauma patients, pre-hospital higher blood glucose levels were related to tachycardic and shockable rhythms. Cardiac arrest was more frequently observed in hypoglycaemic and hyperglycaemic pre-hospital trauma patients. The rate of ROSC rose significantly with rising blood glucose concentration. Blood glucose measurements in addition to common vital parameters (GCS, heart rate, blood pressure, breathing frequency) may help identify patients at risk for cardiopulmonary arrest and dysrhythmias.

Prehospital airway procedures performed in trauma patients by ground forces in Afghanistan.

Airway management is of critical importance in combat trauma patients. Airway compromise is the second leading cause of potentially survivable death on the battlefield and accounts for approximately 1 in 10 preventable deaths. Reports from the Iraq and Afghanistan wars indicate 4% to 7% incidence of airway interventions on casualties transported to combat hospitals. The goal of this study was to describe airway management in the prehospital combat setting and document airway devices used on the battlefield. This study is a retrospective review of casualties that required a prehospital lifesaving airway intervention during combat operations in Afghanistan. We obtained data from the Prehospital Trauma Registry that was linked to the Department of Defense Trauma Registry for outcome data for the time period between January 2013 and September 2014. Seven hundred five total trauma patients were included, 16.9% required a prehospital airway management procedure. There were 132 total airway procedures performed, including 83 (63.4%) endotracheal intubations and 26 (19.8%) nasopharyngeal airway placements. Combat medics were involved in 48 (36.4%) of airway cases and medical officers in 73 (55.3%). Most (94.2%) patients underwent airway procedures due to battle injuries caused by explosion or gunshot wounds. Casualties requiring airway management were more severely injured and less likely to survive as indicated by Injury Severity Score, responsiveness level, Glascow Coma Scale, and outcome. Percentages of airway interventions more than tripled from previous reports from the wars in Afghanistan and Iraq. These changes are significant, and further study is needed to determine the causes. Casualties requiring airway interventions sustained more severe injuries and experienced lower survival than patients who did not undergo an airway procedure, findings suggested in previous reports. Prognostic and epidemiological study, level III.

Prehospital trauma death review in the State of Victoria, Australia: a study protocol

IntroductionRegionalised trauma systems have been shown to improve outcomes for trauma patients. However, the evaluation of these trauma systems has been oriented towards in-hospital care. Therefore, the epidemiology and care...

Emergency Medicine Education and Research in Nepal: Challenges and Opportunities

Emergency medicine (EM) is a young but prestigious medical discipline worldwide.1 However, in Nepal, it is in preliminary phase.2 EM is not only restricted to urban emergency departments but also a multifaceted discipline.3 Several EM training modules are currently practiced fragmented with different curriculum and duration.4,5 Pre-hospital emergency medical services (EMS), hospitals, trauma centres, and public health are working in silos and most of them devoid of proper emergency facility.2 This brought us to the realization of an urgent need of bringing all the stakeholders together in a symposium like this.&#x0D; The symposium was arranged into four different sessions as listed below:&#x0D; &#x0D; To familiarize with the history and current state of EM from Global Emergency Medicine perspective.&#x0D; To highlight the different clinical experiences and advancements in EM in Nepal.&#x0D; To emphasize the importance and possibilities in EM education and research in Nepal.&#x0D; To discuss the roadmap to develop and establish EM as a recognized medical speciality in Nepal.&#x0D; &#x0D; The overall objectives of the symposium were to discuss the challenges faced by current Emergency Medicine providers and identify the opportunities for the future development and recognition in Nepal.&#x0D; The most important current task for Nepal’s emergency physicians of advocating for policies, programs, and funding to support further development of the specialty was realized. Rural and urban emergency service providers from academic and non-academic institutions, governmental/non-governmental organizations and international medical institutions attended the symposium. General Practice (GP) residents, medical officers, medical students, interns and paramedics were among active participants.

Accuracy of pre-hospital trauma notification calls

Study objectiveThe aim of this study is to determine the accuracy of pre-hospital trauma notifications and the effects of inaccurate information on trauma triage. MethodsThis study was conducted at a level-1 trauma center over a two-year period. Data was collected from pre-notification forms on trauma activations that arrived to the emergency department via ambulance. Trauma activations with pre-notification were compared to those without notification and pre-notification forms were assessed for accuracy and completeness. ResultsA total of 2186 trauma activations were included in the study, 1572 (71.9%) had pre-notifications, 614 (28.1%) did not and were initially under-triaged. Pre-notification forms were completed for 1505 (95.7%) patients, of which EMS provided incomplete/inaccurate information for 1204 (80%) patients and complete/accurate information for 301 (20%) patients. Missing GCS/AVPU score (1099, 91.3%), wrong age (357, 29.6%), and missing vitals (303, 25.2%) were the main problems. Missing/wrong information resulted in trauma tier over-activation in 25 (2.1%) patients and under-activation in 20 (1.7%) patients. Under-triaged patients were predominantly male (18, 90%), sustained a fall (9, 45%), transported by BLS EMS teams (12, 60%), and arrived on a weekday (13, 65%) during the time period of 11 pm–7 am (9, 45%). A total of 13 (65%) required emergent intubation, 2 (10%) required massive transfusion activation, 7 (35%) were admitted to ICU, 3 (15%) were admitted directly to the OR, and 1 (15%) died. ConclusionEMS crews frequently provide inaccurate pre-hospital information or do not provide any pre-hospital notification at all, which results in over/under triage of trauma patients.

The epidemiology of elderly falls attended by emergency medical services in Victoria, Australia

BackgroundWith an increase in the proportion of older people in the community comes an increase in the demand on emergency medical services (EMS) by elderly patients who have fallen. ObjectiveTo describe the epidemiology of elderly falls patients attended by EMS in Victoria, Australia and identify predictors of transport and repeat falls. MethodsA retrospective review included all elderly (age ≥ 65 years) falls patients attended by EMS between 2010 and 2017. Patient characteristics are described using descriptive statistics. Predictors of transport to hospital and repeat falls were identified using multivariable logistic regression analyses. ResultsBetween 2010 and 2017 EMS attended 324,060 elderly falls patients, which represents 9.7% of EMS attended workload in Victoria. The median age of patients was 83 years (IQR: 76–88) and 60.2% were female. Comorbidities and medication use were common, while private residence (64.3%) and nursing home (20.0%) were common scene locations. Overall, 78.8% of falls events resulted in transport to hospital by EMS.Predictors of transport to hospital included female gender, one or more pre-existing medical conditions or current medications and meeting the pre-hospital trauma triage criteria or hospital major trauma criteria.To investigate predictors of repeat falls, the follow-up period was restricted to 12-months post initial fall, which resulted in 30,997 patients and 42,873 (13.2%) repeat fall incidents. The median number of days between the initial fall and a second fall was 98 (IQR: 27–206). Predictors of repeat falls included living at a nursing home, one or more pre-existing medical conditions and one or more current medications. ConclusionsOlder falls patients place significant demand on EMS resources in Victoria, Australia, accounting for 9.7% of EMS attendances. Despite high demand, just 3.8% of elderly falls patients received a ‘lights and sirens’ emergency transport response to hospital. Furthermore, a large number of falls incidents recorded during the study period were repeat falls. Access to alternative pathways of care like GP referral, allied and community health services may benefit this patient group. Development and enrolment into such programs may improve patient outcomes by minimising falls risk and decrease demand on EMS and hospital resources.

Intravenous Low-Dose Ketamine Provides Greater Pain Control Compared to Fentanyl in a Civilian Prehospital Trauma System: A Propensity Matched Analysis

Objective: A few studies report comparable analgesic efficacy between low-dose ketamine and opioids such as morphine or fentanyl; however, limited research has explored the safety and effectiveness of intravenous low-dose ketamine as a primary analgesic in a civilian prehospital setting. The objective of this study is to compare pain control between low-dose ketamine and fentanyl when administered intravenously (IV) for the indication of severe pain. Methods: This was a retrospective, observational review of prehospital adult patients (≥18 years) who presented with severe pain (numeric rating scale, 7–10) and were treated solely with either low-dose ketamine IV or fentanyl IV between January 1, 2014 and December 31, 2016. Propensity matched analysis was performed adjusting for all baseline variables with p ≤ 0.10 and for baseline pain score to match ketamine and fentanyl patients on a one-to-one ratio. The primary outcome was change in pain score from baseline to after treatment and evaluated with a paired t-test. Secondary outcomes were changes in vital signs and Glasgow coma scale (GCS) from baseline to after treatment, as well as incidence of clinically significant adverse events (AEs); AEs were followed from scene arrival through emergency department discharge. Results: Propensity matched analysis produced 79 matched pairs. Ketamine IV patients, receiving a mean (SD) dose of 0.3 (0.1) mg/kg, showed a significantly larger mean decrease in pain after treatment, compared to the fentanyl IV patients (−5.5 (3.1) vs. −2.5 (2.4), p < 0.001). A significantly greater proportion of patients receiving ketamine IV achieved at least a 50% reduction in pain compared to those receiving fentanyl IV (67% vs. 19%, p < 0.001), marking 52 ketamine IV patients as responders to treatment. Vital signs demonstrated a nonsignificant decrease in blood pressure, respiratory rate, heart rate, and GCS. No clinically significant AEs were reported for patients receiving ketamine IV. Conclusion: The significant reduction in pain, significantly high proportion of ketamine responders, and the lack of clinically significant AEs characterizing patients receiving low-dose ketamine IV compared to fentanyl IV, all provide further support for its use as an effective prehospital analgesic. Level of Evidence: Level III, therapeutic.

Fluid therapy in trauma resuscitation : A review of changing practices.

Background: Haemorrhage is the leading preventable cause of post trauma death. Acute trauma resuscitation has evolved over the last decade. The ATLS guidance used since 2012 is being updated in 2018.Objectives : To search relevant representative literature over 6 years between 2012 and 2018 to gain an insight into changing concepts, practices and recent advances in acute trauma fluid resuscitation and provide a structured review of the topic.Search methods: A relevant MEDLINE search was undertaken to obtain a list of 1512 articles from which 107 were utilised to prepare this review.Selection criteria:1. Inclusion: Articles from human medicine relevant to fluid resuscitation in trauma published in English between January 2012 and January 2018. 2.Exclusion: Articles restricted to Brain, spinal trauma or cardiovascular trauma, post traumatic arrest patients, animal or human laboratory model studies and articles on septic, postoperative, obstetric patients and single case studies were excluded.Results: This review categorises the topic into various parts to explain the evolving understanding of fluid resuscitation, trauma induced coagulopathy and endotheliopathy of trauma. The strategies for acute fluid management like damage-controlled resuscitation, balanced and haemostatic resuscitation and massive transfusion protocol are explained. A detailed discussion is carried out regarding crystalloid, colloid and blood transfusion. Special consideration is given to specific age groups, combat casualties and prehospital trauma care.Conclusions: Fluid resuscitation in trauma is a complex and rapidly evolving subject. Massive transfusion protocols and principles of damage control are significant for patient outcome. Standard guidance like ATLS is relevant and important for training professionals to deliver systematic, high quality of trauma care. There is scope for local improvisation based on resources and need for more high-quality trials and frequent systematic reviews.Bangladesh Crit Care J March 2018; 6(1): 31-39

Development and validation of a pre-hospital \u201cRed Flag\u201d alert for activation of intra-hospital haemorrhage control response in blunt trauma

BackgroundHaemorrhagic shock is the leading cause of early preventable death in severe trauma. Delayed treatment is a recognized prognostic factor that can be prevented by efficient organization of care. This study aimed to develop and validate Red Flag, a binary alert identifying blunt trauma patients with high risk of severe haemorrhage (SH), to be used by the pre-hospital trauma team in order to trigger an adequate intra-hospital standardized haemorrhage control response: massive transfusion protocol and/or immediate haemostatic procedures.MethodsA multicentre retrospective study of prospectively collected data from a trauma registry (Traumabase®) was performed. SH was defined as: packed red blood cell (RBC) transfusion in the trauma room, or transfusion ≥ 4 RBC in the first 6 h, or lactate ≥ 5 mmol/L, or immediate haemostatic surgery, or interventional radiology and/or death of haemorrhagic shock. Pre-hospital characteristics were selected using a multiple logistic regression model in a derivation cohort to develop a Red Flag binary alert whose performances were confirmed in a validation cohort.ResultsAmong the 3675 patients of the derivation cohort, 672 (18%) had SH. The final prediction model included five pre-hospital variables: Shock Index ≥ 1, mean arterial blood pressure ≤ 70 mmHg, point of care haemoglobin ≤ 13 g/dl, unstable pelvis and pre-hospital intubation. The Red Flag alert was triggered by the presence of any combination of at least two criteria. Its predictive performances were sensitivity 75% (72–79%), specificity 79% (77–80%) and area under the receiver operating characteristic curve 0.83 (0.81–0.84) in the derivation cohort, and were not significantly different in the independent validation cohort of 2999 patients.ConclusionThe Red Flag alert developed and validated in this study has high performance to accurately predict or exclude SH.