Scene Of Injury Research Articles

Prehospital rapid sequence induction following trauma in the era of regional networks for major trauma.

Rapid sequence induction (RSI) provides prompt airway control during emergency evacuation of trauma patients. Physicians may be tasked to travel with paramedic ambulance crews to the scene of injury when RSI is more likely to be required. This study investigates whether there are any differences in the practice of prehospital RSI during emergency retrievals for trauma since the establishment of the regional Major Trauma Network (MTN) in March 2012. A retrospective observational study examined prehospital records for all trauma patients from September 2010 to January 2015 at a Major Trauma Centre in Birmingham, UK. Prehospital physician availability increased from 12 to 24 h after March 2012, and tasking became centralized. Data included demographics, mechanism of injury, crew personnel, and details of RSI. The periods before and after the establishment of the regional MTN were compared. There were 5244 patients: 1432 (27.3%) before and 3812 (72.7%) after March 2012. Of the patients, 67.2% were male. The most common injuries were road traffic collisions (45.0%). Physicians were more likely to be present after (2345 missions, 61.5%) than before (529 missions, 36.9%) March 2012 (P<0.01). RSI was performed 434 (8.3%) times and was more likely during the latter than the former period [359 (9.4%) vs. 75 (5.2%), P<0.01]. Successful tracheal intubation was achieved in 99% of occasions. The establishment of regional MTNs enables centrally tasked, 24-h physician availability for emergency trauma patients. There has been an increase in physician presence on emergency missions and increased frequency of RSI for at-risk trauma patients at times when there may previously have been an unmet requirement.

Clinical Evaluation of a Microwave-Based Device for Detection of Traumatic Intracranial Hemorrhage.

Traumatic brain injury (TBI) is the leading cause of death and disability among young persons. A key to improve outcome for patients with TBI is to reduce the time from injury to definitive care by achieving high triage accuracy. Microwave technology (MWT) allows for a portable device to be used in the pre-hospital setting for detection of intracranial hematomas at the scene of injury, thereby enhancing early triage and allowing for more adequate early care. MWT has previously been evaluated for medical applications including the ability to differentiate between hemorrhagic and ischemic stroke. The purpose of this study was to test whether MWT in conjunction with a diagnostic mathematical algorithm could be used as a medical screening tool to differentiate patients with traumatic intracranial hematomas, chronic subdural hematomas (cSDH), from a healthy control (HC) group. Twenty patients with cSDH and 20 HC were measured with a MWT device. The accuracy of the diagnostic algorithm was assessed using a leave-one-out analysis. At 100% sensitivity, the specificity was 75%—i.e., all hematomas were detected at the cost of 25% false positives (patients who would be overtriaged). Considering the need for methods to identify patients with intracranial hematomas in the pre-hospital setting, MWT shows promise as a tool to improve triage accuracy. Further studies are under way to evaluate MWT in patients with other intracranial hemorrhages.

Out-of-hospital and Inter-hospital Under-triage to Designated Tertiary Trauma Centers among Injured Older Adults: A 10-year Statewide Geospatial-Adjusted Analysis

Objective: While out-of-hospital under-triage of seriously injured older adults to tertiary trauma centers has long been acknowledged, no study has adjusted for place of injury or evaluated the extent of inter-facility under-triage. We sought to determine distance and confounder adjusted odds of treatment at a tertiary trauma center (TTC) for older adult trauma patients compared to younger trauma patients, for patients transported from the scene of injury and those transferred from a non-tertiary trauma (NTTC) center. Methods: This was a retrospective cohort study utilizing data from a statewide trauma registry reported over a 10-year period (2005–14). The outcome of interest was treatment at an American College of Surgeons or state-designated Level I/II trauma center (TTC). The predictor variable of interest was age group (> = 55 years vs. < 55 years). Covariates of interest included patient demographics, clinical characteristics and various distance measures calculated based on the patient's injury location. Results: 84 930 patients met study criteria. Of these 42% (35659) were 55 years and older with an average age of 74 years (SD, 11.6). Older adult patients were on average, injured slightly farther away from a TTC (median distance, 34 vs. 29 miles, p < 0.001). Among patients initially presenting to NTTCs, older adults were significantly more likely to be transferred to another NTTC (53% vs. 34%). After adjusting for confounders and distance measures, older adults were less likely to be treated at TTCs overall (OR = 0.54, 95% CI: 0.52–0.56), whether transported by EMS from the scene of injury (OR = 0.47, 95% CI: 0.44–0.50) or via inter-facility transfer (OR = 0.63, 95%CI: 0.59–0.68). Conclusions: Injured older adults face significant under-triage to TTCs whether by EMS from the scene of injury or via transfer from NTTCs. Adjusting for proximity of injury to a TTC does not alter these findings.

Damage Control Resuscitation Across the Phases of Major Injury Care

Trauma damage control has undergone a recent paradigm shift, broadening its focus from surgery to resuscitation. This review details central components of damage control resuscitation (DCR) across the phases of major injury care and the evidence behind its adoption. Permissive hypotension, minimization of crystalloid fluids, and early balanced blood product resuscitation have each been associated with improved outcomes in hemorrhaging patients. These tactics compliment current strategies of achieving hemorrhage control, including damage control surgery. DCR is now integrated into care from the injury scene, through the resuscitation bay, the operating room, and into the intensive care unit. Its use limits the physiologic derangement experienced by the injured patient and minimizes preventable death from hemorrhage. It has become the accepted standard of modern trauma care and is shaping contemporary trauma systems and education. Future evidence-based advancements in trauma care will be scrutinized against this standard.

A safe haven for the injured? Urban trauma care at the intersection of healthcare, law enforcement, and race

Patients with traumatic injuries often interact with police before and during hospitalization, particularly when their injuries are due to violence. People of color are at highest risk for violent injuries and have the poorest outcomes after injury. The purpose of this study was to describe how injured, Black patients perceived their interactions with police and what these perceptions reveal about police involvement within trauma care systems. We combined data from two qualitative studies to achieve this aim. The first was ethnographic fieldwork that followed Black trauma patients in the hospital through the physical and emotional aftermath of their injuries. The second was a qualitative, descriptive study of how patients experienced trauma resuscitation in the emergency department (ED). Both studies were conducted between 2012 and 2015 at the Trauma Center at Penn, an academic medical center in Philadelphia, Pennsylvania, United States. The present study includes data from 24 adult, Black participants undergoing treatment for injury. We reanalyzed all interview data related to law enforcement encounters from the scene of injury through inpatient hospitalization and coded data using a constant comparative technique from grounded theory. Participants described law enforcement encounters at the scene of injury and during transport to the hospital, in the ED, and over the course of inpatient care. Injured participants valued police officers' involvement when they perceived that officers provided safety at the scene, speed of transport to the hospital, or support and information after injury. Injured participants also found police questioning to be stressful and, at times, disrespectful or conflicting with clinical care. Communities, trauma centers, and professional societies have the opportunity to enact policies that standardize law enforcement access in trauma centers and balance patients’ health, privacy, and legal rights with public safety needs.

Assessment of mechanism, type and severity of injury in multiple trauma patients: A cross sectional study of a trauma center in Iran

PurposeTo accurately assess the mechanism, type and severity of injury in Iranian multiple trauma patients of a trauma center. MethodsPatients with multiple traumas referring to the emergency department of Hasheminejad University Hospital in Mashhad, Iran, entered this cross sectional study from March 2013 to December 2013. All the patients with injury severity score (ISS) > 9 were included in this study. Data analysis was performed by SPSS software (Version 11.5) and P values less than 0.05 were considered as significant differences. ResultsAmong the 6306 hospitalized trauma patients during this period, 148 had ISS>9. The male female ratio was 80%. The mean age of the patients was (33.5 ± 19.3) years. And 71% of the patients were younger than 44 years old. There were 19 (13%) deaths from which 68.5% were older than 44 years old. The mean transfer time from the injury scene to hospital was (55 ± 26) minutes. The most frequent mechanisms of injury were motorcycle crashes and falling from height, which together included 66.2% of all the injuries. A total of 84% of hospital deaths occurred after the first 24 h of hospitalization. Head and neck were the most common body injured areas with a prevalence of 111 cases (75%). ConclusionMotorcycle crashes have high frequency in Iran. Since most victims are young males, injury prevention strategies should be considered to reduce the burden of injuries.

Early neurological deterioration in older adults with traumatic brain injury

IntroductionTraumatic brain injuries (TBIs) and resulting fatalities among older adults increased considerably in recent years. Neurological deterioration often goes unrecognized at the injury scene and patients arrive at emergency departments with near-normal Glasgow Coma Scale (GCS) scores. This study examined the proportion of older adults experiencing early neurological deterioration (prehospital to emergency department), associated factors, and association of the magnitude of neurological deterioration with TBI severity. MethodsThis secondary analysis of National Trauma Data Bank Research Datasets included patients who were age ⩾65, sustained a TBI, and transported from the injury scene to an emergency department. Data analysis included chi-square analysis, t-tests, and logistic regression. Long-term anticoagulant/antiplatelet therapy was not associated with deterioration. ResultsOf the sample of 91,886 patients, 13,913 (15.1%) experienced early neurological deterioration. Adjusting for covariates, age, gender, head AISmax injury severity, and probability of death were associated with early deterioration. Patients with severe and critical head injuries had the highest odds of early neurological deterioration (OR=1.41 [CI=1.22–1.63] and OR=1.98 [CI=1.63–2.40], p<0.001). Discussion/conclusionsPrehospital providers, nurses, physicians, and other providers have opportunities to optimize outcomes from older adult TBI through early recognition of neurological deterioration, rapid transport to facilities for definitive treatment, and targeted rehabilitation.

PP150 Rapid Analgesia For Prehospital Hip Disruption: A Feasibility Study

INTRODUCTION:Adequate pain relief at the scene of injury and during transport to hospital is a major challenge in all acute traumas, especially for those with hip fractures, whose injuries are difficult to immobilize and long-term outcomes may be adversely affected by administration of opiate analgesics. Fascia Iliaca Compartment Block (FICB) is a procedure routinely undertaken by clinicians in emergency departments for hip fracture patients, but use by paramedics at the scene of emergency calls, is not yet evaluated (1).METHODS:We undertook a randomized controlled feasibility trial using novel audited scratchcard randomization to allocate eligible patients to FICB or usual care. Paramedics are recruited and trained to assess patients for hip fracture and carry out FICB. We will follow up patients to assess accuracy of paramedic diagnosis, acceptability to patients and paramedics, compliance of paramedics and also measures of pain, side effects, time in hospital and quality of life in order to plan a full trial if appropriate. The primary outcome measure is health related quality of life, measured using Short Form (SF)-12 at 1 and 6 months. Interviews and focus groups will be used to understand acceptability of FICB to patients and paramedics. This study was funded by Health and Care Research Wales (1003).RESULTS:We have developed: •paramedic pathway to assess patients for hip fracture and FICB•paramedic training package, delivered by Consultant Anaesthetist•randomization scratchcards.To date we have recruited nineteen paramedics; ten are fully trained and recruiting patients, the remainder are being trained. Fifty-four patients have been randomized and thirty-five have consented to follow-up. Thirteen 1-month and five 6-month follow-up questionnaires have been received.CONCLUSIONS:This study will enable us to recommend whether to undertake a definitive multi-centre randomized controlled trial of FICB by paramedics for hip fracture to determine if the procedure is effective for patients and worthwhile for the National Health Service.

Resuscitative endovascular balloon occlusion of the aorta: promise, practice, and progress?

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive damage control procedure for life-threatening abdominal or pelvic haemorrhage. The purpose of this review is to summarize the current understanding and experience with REBOA, outline potential future applications of this technology, and highlight priority areas for further research. REBOA is a feasible method of achieving temporary aortic occlusion and can be performed rapidly, with a high degree of success, in the emergency setting (including at the scene of injury) by appropriately trained clinicians. The procedure supports central perfusion, controls noncompressible haemorrhage, and may improve survival in certain profoundly shocked patient groups; but is also associated with significant risks, including ischaemic tissue damage and procedural complications. Evolutions of this strategy are being explored, with promising proof-of-concept studies in the fields of partial aortic occlusion and the combination of REBOA with extracorporeal support. Noncompressible torso haemorrhage is the leading cause of preventable trauma deaths. The majority of these deaths occur soon after injury, often before any opportunity for definitive haemorrhage control. For a meaningful reduction in trauma mortality, novel methods of rapid haemorrhage control are required.

UNSTABLE SPINAL FRACTURES IN SNOWDONIA MOUNTAIN CASUALTIES

Objectives & BackgroundFor decades, spinal immobilisation has been a cornerstone of pre-hospital trauma care, driven by fears that unstable spinal fractures without spinal cord injury (SCI) initially may convert to...

A novel methodology to characterize interfacility transfer strategies in a trauma transfer network

More than half of severely injured patients are initially transported from the scene of injury to nontrauma centers (NTCs), with many requiring subsequent transfer to trauma center (TC) care. Definitive care in the setting of severe injury is time sensitive. However, transferring severely injured patients from an NTC is a complex process often fraught with delays. Selection of the receiving TC and the mode of interfacility transport both strongly influence total transfer time and are highly amenable to quality improvement initiatives. We analyzed transfer strategies, defined as the pairing of a destination and mode of transport (land vs. rotary wing vs. fixed wing), for severely injured adult patients. Existing transfer strategies at each NTC were derived from trauma registry data. Geographic Information Systems network analysis was used to identify the strategy that minimized transfer times the most as well as alternate strategies (+15 or +30 minutes) for each NTC. Transfer network efficiency was characterized based on optimality and stability. We identified 7,702 severely injured adult patients transferred from 146 NTCs to 9 TCs. Nontrauma centers transferred severely injured patients to a median of 3 (interquartile range, 1-4) different TCs and utilized a median of 4 (interquartile range, 2-6) different transfer strategies. After allowing for the use of alternate transfer strategies, 73.1% of severely injured patients were transported using optimal/alternate strategies, and only 40.4% of NTCs transferred more than 90% of patients using an optimal/alternate transfer strategy. Three quarters (75.5%) of transfers occurred between NTCs and their most common receiving TC. More than a quarter of patients with severe traumatic injuries undergoing interfacility transport to a TC in Ontario are consistently transported using a nonoptimal combination of destination and mode of transport. Our novel analytic approach can be easily adapted to different system configurations and provides actionable data that can be provided to NTCs and other stakeholders. Therapeutic study, level IV.

Cumulative effective radiation dose received by blunt trauma patients arriving to a military level I trauma center from point of injury and interhospital transfers

BackgroundTrauma patients sustaining blunt injuries are exposed to multiple radiologic studies. Evidence indicates that the risk of cancer from exposure to ionizing radiation rises in direct proportion to the cumulative effective dose (CED) received. The purpose of this study is to quantify the amount of ionizing radiation accumulated when arriving directly from point of injury to San Antonio Military Medical Center (SAMMC), a level I trauma center, compared with those transferred from other facilities. MethodsA retrospective record review was conducted from 1st January 2010 through 31st December 2012. The SAMMC trauma registry, electronic medical records, and the digital radiology imaging system were searched for possible candidates. The medical records were then analyzed for sex, age, mechanism of injury, received directly from point of injury (direct group), transfer from another medical facility (transfer group), computed tomographic scans received, dose-length product, CED of radiation, and injury severity score. A diagnostic imaging physicist then calculated the estimated CED each subject received based on the dose-length product of each computed tomographic scan. ResultsA total of 300 patients were analyzed, with 150 patients in the direct group and 150 patients in the transfer group. Both groups were similar in age and sex. Patients in the transfer group received a significantly greater CED of radiation compared with the direct group (mean, 37.6 mSv vs 28 mSv; P=.001). The radiation received in the direct group correlates with a lifetime attributable risk (LAR) of 1 in 357 compared with the transfer group with an increase in LAR to 1 in 266. ConclusionPatients transferred to our facility received a 34% increase in ionizing radiation compared with patients brought directly from the injury scene. This increased dose of ionizing radiation contributes to the LAR of cancer and needs to be considered before repeating imaging studies.Level of Evidence: III.

Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients.

Hemorrhage is a leading cause of death in traumatically injured patients. Currently, the importance of earlier administration of packed red blood cells (pRBC) to improve outcomes is limited. We evaluated the association of earlier pRBC administration and mortality when compared with later transfusion initiation. This single-center retrospective cohort study of trauma patients transported by a single helicopter service from the scene of injury to an urban academic trauma center included patients receiving at least one unit of pRBC within 24 hours of hospital arrival. The final cohort included patients transported to the trauma center between March 11, 2010, and October 30, 2013. The helicopter service carries two units of pRBC for protocol-driven prehospital transfusion. Logistic regression was used to model odds of death, and 95% confidence intervals were calculated. The 94 patients meeting inclusion criteria had a mean (SD) age of 43 (19) years; 87 (93%) of 94 were white, 66 (70%) of 94 were male, and 88(94%) of 94 sustained blunt force injuries. Median Injury Severity Score was 29 (range, 2-75), and 31 (33%) of 94 died within 30 days. Most patients [82/94 (87%)] received their first pRBC transfusion during transport or within one hour of arrival at the emergency department (ED). For the 82 patients receiving a first pRBC transfusion within one hour of ED arrival, each 10-minute increase in time to transfusion increased the odds of death [OR, 1.27 (95% CI, 1.01-1.62; p = 0.044)], controlling for TRISS. At 30 days, 29/82 (35%) patients who received a pRBC transfusion within one hour of ED arrival, and 2 (16%) of 12 patients who received delayed transfusion were deceased (difference, 19%; 95% CI, -5% to 42%). In this study, delays in time to pRBC administration of as short as 10 minutes were associated with increased odds of death for patients receiving ultra-early pRBC transfusion. Expedient prehospital and ED transfusion capabilities may improve outcomes after trauma. Therapeutic/care management study, level III.

Indications for embolization in a French level 1 trauma center

Abdominal trauma accounts for nearly 20% of all traumatic injuries. It often involves young patients sustaining multiple injuries, with a high associated mortality rate. Management should begin at the scene of injury and relies on a structured chain of care in order to transport the trauma patient to the appropriate hospital center. Management is multi-disciplinary, involving intensive care specialists, surgeons and radiologists. Imaging to precisely define injury is best performed with whole body dual phase computed tomography, which can also identify the source of bleeding. Non-operative management has developed considerably over the years: this includes selective embolization in case of active bleeding or vascular anomalies in stable or stabilized patients after resuscitation. Embolization has become one of the corner stones of abdominal trauma management and interventional radiologists must play an active role on the trauma team. This overview details the different embolization procedures according to the involved organ and embolic agent used.

Using the Reverse Shock Index at the Injury Scene and in the Emergency Department to Identify High-Risk Patients: A Cross-Sectional Retrospective Study

Background: The ratio of systolic blood pressure (SBP) to heart rate (HR), called the reverse shock index (RSI), is used to evaluate the hemodynamic stability of trauma patients. A SBP lower than the HR (RSI < 1) indicates the probability of hemodynamic shock. The objective of this study was to evaluate whether the RSI as evaluated by emergency medical services (EMS) personnel at the injury scene (EMS RSI) and the physician in the emergency department (ED RSI) could be used as an additional variable to identify patients who are at high risk of more severe injury. Methods: Data obtained from all 16,548 patients added to the trauma registry system at a Level I trauma center between January 2009 and December 2013 were retrospectively reviewed. Only patients transferred by EMS were included in this study. A total of 3715 trauma patients were enrolled and subsequently divided into four groups: group I patients had an EMS RSI ≥1 and an ED RSI ≥1 (n = 3485); group II an EMS RSI ≥ 1 and an ED RSI < 1 (n = 85); group III an EMS RSI < 1 and an ED RSI ≥ 1 (n = 98); and group IV an EMS RSI < 1 and a ED RSI < 1 (n = 47). A Pearson’s χ2 test, Fisher’s exact test, or independent Student’s t-test was conducted to compare trauma patients in groups II, III, and IV with those in group I. Results: Group II and IV patients had a higher injury severity score, a higher incidence of commonly associated injuries, and underwent more procedures (including intubation, chest tube insertion, and blood transfusion in the ED) than patients in group I. Group II and IV patients were also more likely to receive a severe injury to the thoracoabdominal area. These patients also had worse outcomes regarding the length of stay in hospital and intensive care unit (ICU), the proportion of patients admitted to ICU, and in-hospital mortality. Group II patients had a higher adjusted odds ratio for mortality (5.8-times greater) than group I patients. Conclusions: Using an RSI < 1 as a threshold to evaluate the hemodynamic condition of the patients at the injury scene and upon arrival to the ED provides valid information regarding deteriorating outcomes for certain subgroups of patients in the ED setting. Particular attention and additional resources should be provided to patients with an EMS RSI ≥ 1 that deteriorates to an RSI < 1 upon arrival to the ED since a higher odds of mortality was found in these patients.

Alcohol consumption decreases lactate clearance in acutely injured patients

IntroductionAlcohol, a common risk factor for injury, has direct toxic effects on the liver. The use of lactate clearance has been well described as an indicator of the adequacy of resuscitation in injured patients. We investigated whether acutely injured patients with positive blood alcohol content (+BAC) had less lactate clearance than sober patients. MethodsWe conducted a retrospective cohort study of acutely injured patients treated at an urban Level 1 trauma centre between January 2010 and December 2012. Blood alcohol and venous lactate levels were measured on all patients at the time of arrival. Study subjects were patients transported directly from the scene of injury, who had an elevated lactate concentration on arrival (≥3.0mmol/L) and at least one subsequent lactate measurement within 24h after admission. Lactate clearance ([Lactate1−Lactate2]/Lactate1) was calculated for all patients. Chi-squared tests were used to compare values from sober and intoxicated subjects. Lactate clearance was plotted against alcohol levels and stratified by age and Injury Severity Score (ISS). ResultsSerial lactate concentration measurements were obtained in 3910 patients; 1674 of them had +BAC. Patients with +BAC were younger (mean age: 36.6 [SD 14.7] vs 41.0 [SD 19.9] years [p=0.0001]), were more often male (83.4% vs 75.9% [p=0.0001]), had more minor injuries (ISS<9) (33.8% vs 27.1% [p=0.0001]), had a lower in-hospital mortality rate (1.4% vs 3.9% [p=0.0001]), but also had lower average lactate clearance (37.8% vs 47.6% [p=0.0001]). The lactate clearance of the sober patients (47.6 [SD 33.5]) was twice that of those with +BAC >400 (23.5 [SD 6.5]). Lactate clearance decreased with increasing BAC irrespective of age and ISS. ConclusionsIn a large group of acutely injured patients, a dose-dependent decrease in lactate clearance was seen in those with elevated BAC. This relationship will cause a falsely elevated lactate reading or prolong lactate clearance and should be taken into account when evaluating patients with +BAC.

Inadequate sociomedical evaluation of possible abusive head trauma in Yokohama.

There have been no previous studies on the adequacy of combined evaluation of possible abusive head trauma cases by frontline medical personnel, hospital-based child protection teams, and child protective services in local districts of Japan. We conducted a questionnaire survey of hospitalized patients under 24 months old with a diagnosis of intracranial hemorrhage (ICH) from January 2011 to December 2013. Eleven large-scale general hospitals in Yokohama, Japan were surveyed, which provide centralized inpatient care to moderately-severely ill children. A total of 51 ICH patients were listed from eight hospitals. Median patient age was 7 months, and 84% were younger than 12 months. The most common diagnosis on computed tomography was subdural hematoma (n = 26; 51%). Of a total of 51 cases, 31 (61%) occurred inside the home; the injury scene was unknown in six cases (12%). We reviewed these 37 cases from the viewpoint of evaluation with concern for suspected child abuse. Three out of 37 patients (8%) were not examined for inflicted skin lesions, and skeletal surveys and funduscopy were not conducted in 14 (38%) and 15 (41%), respectively. Thirteen out of 37 cases (35%) were not reported to hospital-based child protection teams and 22 (59%) were not reported to regional child protective services. The sociomedical evaluation of possible child abuse appears to be systematically inadequate in Yokohama.

Needle thoracostomy: Clinical effectiveness is improved using a longer angiocatheter.

Decompression of tension physiology may be lifesaving, but significant doubts remain regarding ideal needle thoracostomy (NT) catheter length in the treatment of tension physiology. We aimed to demonstrate increased clinical effectiveness of longer NT angiocatheter (8 cm) compared with current Advanced Trauma Life Support recommendations of 5-cm NT length. This is a retrospective review of all adult trauma patients from 2003 to 2013 (age > 15 years) transported to a Level I trauma center. Patients underwent NT at the second intercostal space midclavicular line, either at the scene of injury, during transport (prehospital), or during initial hospital trauma resuscitation. Before March 2011, both prehospital and hospital trauma team NT equipment routinely had a 5-cm angiocatheter available. After March 2011, prehospital providers were provided an 8-cm angiocatheter. Effectiveness was defined as documented clinical improvement in respiratory, cardiovascular, or general clinical condition. There were 91 NTs performed on 70 patients (21 bilateral placements) either in the field (prehospital, n = 41) or as part of resuscitation in the hospital (hospital, n = 29). Effectiveness of NT was 48% until March 2011 (n = 24). NT effectiveness was significantly higher in the prehospital setting than in the hospital (68.3% success rate vs. 20.7%, p < 0.01). Patients who underwent NT using 8 cm compared with 5 cm were significantly more effective (83% vs. 41%, respectively, p = 0.01). No complications of NT were identified in either group. Eight-centimeter angiocatheters are more effective at chest decompression compared with currently recommended 5 cm at the second intercostal space midclavicular line. Therapeutic study, level IV.

Patient safety in spinal surgery: from scene of injury to discharge

Abstract In 1999 the Institute of Medicine (IOM) report To Err is Human. Building a Safer Health System, was a landmark publication that identified adverse events associated with surgery. The IOM report was effectively a wakeup call for a safer healthcare system for patients. Fourteen years later, much has been achieved, but patient safety still remains an important issue. The IOM report categorized incidents as nonsurgical and surgical, although nothing was specifically directed at spinal surgery. Some of the broad topics of concern that may relate to the spine were medication errors , infection , and technical problems of surgery. Almost 50% of adverse events identified in the IOM report were surgical in origin. Technical errors constituted the most frequent adverse events within surgery- however, the IOM did not specify what these were. According to other studies, we can deduce some of the most frequent technical issues in spine surgery; these include: wrong-level surgery, incomplete decompression, dural tears, battered root syndrome, and development of instability. We review the spinal patient pathway of the trauma patient, including pre-hospital and peri-operative care, and focus on strategies and campaigns to improve patient safety such as the WHO surgical safety checklist.

Failure to clear elevated lactate predicts 24-hour mortality in trauma patients.

Lactate clearance is a standard resuscitation goal in patients in nontraumatic shock but has not been investigated adequately as a tool to identify trauma patients at risk of dying. Our objective was to determine if trauma patients with impaired lactate clearance have a higher 24-hour mortality rate than patients whose lactate concentration normalizes. A retrospective chart review identified patients who were admitted directly from the scene of injury to an urban trauma center between 2010 and 2013 and who had at least one lactate concentration measurement within 24 hours. Transfers, patients without lactate measurement, and those who were dead on arrival were excluded. Of the 26,545 screened patients, 18,304 constituted the initial lactate measurement population, and 3,887 were the lactate clearance cohorts. Initial lactate had an area under the receiver operating characteristic curve of 0.86 and 0.73 for mortality at 24 hours and in the hospital, respectively. An initial concentration of 3 mmol/L or greater had a sensitivity of 0.86 and a specificity of 0.73 for mortality at 24 hours. The mortality rate among patients with elevated lactate concentrations (n = 2,381; 5.6 [2.8] mmol/L) that did not decline to less than 2.0 mmol/L in response to resuscitative efforts (mean [SD] second measurement, 3.7 [1.9] mmol/L) was nearly seven times higher (4.1% vs. 0.6%, p < 0.001) than among those with an elevated concentration (n = 1,506, 5.3 [2.7] mmol/L) that normalized (1.4 [0.4] mmol/L). Logistic regression analysis showed that failure to clear lactate was associated with death more than any other feature (odds ratio, 7.4; 95% confidence interval, 1.5-35.5), except having an Injury Severity Score (ISS) greater than 25 (odds ratio, 8.2; 95% confidence interval, 2.7-25.2). Failure to clear lactate is a strong negative prognostic marker after injury. An initial lactate measurement combined with a second measurement for high-risk individuals might constitute a useful method of risk stratifying injured patients. Prognostic study, level III.