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Diagnostic performance of prehospital ultrasound diagnosis for traumatic pneumothorax by a UK Helicopter Emergency Medical Service

11/13/2019

 
European Journal of Emergency Medicine: November 7, 2019 - Volume Publish Ahead of Print - Issue - p 
doi: 10.1097/MEJ.0000000000000641


Objective Up to 20% of major trauma patients may sustain a pneumothorax. Traumatic pneumothoraces can be difficult to diagnose on scene. Although the use of hand-held ultrasound (HHUS) is becoming increasingly widespread, there remains uncertainty about its efficacy as a diagnostic tool in the prehospital setting. The aim of this study was to determine the diagnostic performance of prehospital chest HHUS in trauma patients.

Method Retrospective review of trauma patients who received a prehospital chest HHUS and subsequently conveyed to the Royal Sussex County Hospital (RSCH) between 1 July 2013 and 24 September 2018. Data including patient age, sex, mechanism of injury and clinical interventions were obtained. Prehospital ultrasound findings were compared with the computer tomography (CT) scan performed on arrival at the hospital.

Results Four hundred eleven patients were conveyed to RSCH, the single largest group being following road traffic collisions. The majority of HHUS (66%) were performed by doctors. Three hundred sixty-one patients (88%) subsequently had a CT scan. Of these, 98 patients (27%) were found to have pneumothoraces. For pneumothorax diagnosis, prehospital HHUS had a sensitivity of 28% [95% confidence interval (CI): 19–37%] and specificity of 98% [95% CI: 97–99%].

Conclusion In this retrospective study, sensitivity of prehospital HHUS for diagnosing a pneumothorax was lower than is often reported in in-hospital studies. This suggests that caution should be exercised in using HHUS for the exclusion of pneumothorax in the prehospital setting.

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Mortality and Prehospital Blood Pressure in Patients With Major Traumatic Brain Injury Implications for the Hypotension Threshold

1/17/2017

 

JAMA Surg. Published online December 7, 2016. 

Importance:  
Current prehospital traumatic brain injury guidelines use a systolic blood pressure threshold of less than 90 mm Hg for treating hypotension for individuals 10 years and older based on studies showing higher mortality when blood pressure drops below this level. However, the guidelines also acknowledge the weakness of the supporting evidence.

Objective:  
To evaluate whether any statistically supportable threshold between systolic pressure and mortality emerges from the data a priori, without assuming that a cut point exists.

Design, Setting, and Participants:  
Observational evaluation of a large prehospital database established as a part of the Excellence in Prehospital Injury Care Traumatic Brain Injury Study. Patients from the preimplementation cohort (January 2007 to March 2014) 10 years and older with moderate or severe traumatic brain injury (Barell Matrix Type 1 classification, International Classification of Diseases, Ninth Revision head region severity score of 3 or greater, and/or Abbreviated Injury Scale head-region severity score of 3 or greater) and a prehospital systolic pressure between 40 and 119 mm Hg were included. The generalized additive model and logistic regression were used to determine the association between systolic pressure and probability of death, adjusting for significant/important confounders.

Main Outcomes and Measures: 
The main outcome measure was in-hospital mortality.

Results:  
Among the 3844 included patients, 2565 (66.7%) were male, and the median (range) age was 35 (10-99) years. The model revealed a monotonically decreasing association between systolic pressure and adjusted probability of death across the entire range (ie, from 40 to 119 mm Hg). Each 10-point increase of systolic pressure was associated with a decrease in the adjusted odds of death of 18.8% (adjusted odds ratio, 0.812; 95% CI, 0.748-0.883). Thus, the adjusted odds of mortality increased as much for a drop from 110 to 100 mm Hg as for a drop from 90 to 80 mm Hg, and so on throughout the range.

Conclusions and Relevance:  
We found a linear association between lowest prehospital systolic blood pressure and severity-adjusted probability of mortality across an exceptionally wide range. There is no identifiable threshold or inflection point between 40 and 119 mm Hg. Thus, in patients with traumatic brain injury, the concept that 90 mm Hg represents a unique or important physiological cut point may be wrong. Furthermore, clinically meaningful hypotension may not be as low as current guidelines suggest. Randomized trials evaluating treatment levels significantly above 90 mm Hg are needed.
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Targeted Coagulation Management in Severe Trauma: The Controversies and the Evidence

10/20/2016

 
Anesthesia & Analgesia: October 2016 - Volume 123 - Issue 4 - p 910–924
doi: 10.1213/ANE.0000000000001516 


Hemorrhage in the setting of severe trauma is a leading cause of death worldwide. The pathophysiology of hemorrhage and coagulopathy in severe trauma is complex and remains poorly understood. Most clinicians currently treating trauma patients acknowledge the presence of a coagulopathy unique to trauma patients—trauma-induced coagulopathy (TIC)—independently associated with increased mortality. The complexity and incomplete understanding of TIC has resulted in significant controversy regarding optimum management. Although the majority of trauma centers utilize fixed-ratio massive transfusion protocols in severe traumatic hemorrhage, a widely accepted “ideal” transfusion ratio of blood to blood products remains elusive. The recent use of viscoelastic hemostatic assays (VHAs) to guide blood product replacement has further provoked debate as to the optimum transfusion strategy. The use of VHA to quantify the functional contributions of individual components of the coagulation system may permit targeted treatment of TIC but remains controversial and is unlikely to demonstrate a mortality benefit in light of the heterogeneity of the trauma population. Thus, VHA-guided algorithms as an alternative to fixed product ratios in trauma are not universally accepted, and a hybrid strategy starting with fixed-ratio transfusion and incorporating VHA data as they become available is favored by some institutions. We review the current evidence for the management of coagulopathy in trauma, the rationale behind the use of targeted and fixed-ratio approaches and explore future directions.
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The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

4/22/2016

 
Critical Care 2016 20:100   DOI: 10.1186/s13054-016-1265-x   ©  Rossaint et al. 2016

Background: Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.

Methods: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.
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Results: The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.

Conclusions: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

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Role of the massive transfusion protocol in the management of haemorrhagic shock

1/29/2015

 
British Journal of Anaesthesia (2014) 113 (suppl 2): ii3-ii8.

Abstract:

The concept of rapid delivery of multiple blood products to the bedside of a massively haemorrhaging patient seems to be a logical approach to the management of the massively bleeding patient. However, controversy exists in the use of fixed blood component ratios. Assessing the extent of the coagulopathy through point-of-care testing might provide patients with product administration as needed, and avoid excessive transfusion and its associated complications.
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Tension pneumothorax time for a re-think?

12/2/2014

 
Emerg Med J 2005;22:8–16

This review examines the present understanding of tension pneumothorax and produces recommendations for improving the diagnostic and treatment decision process.

Tension pneumothorax (TPT) is an uncommon disease with a malignant course leading to death if untreated. It is most commonly encountered in prehospital trauma care, emergency departments, and intensive care units (ICUs). Resuscitation and trauma courses usually illustrate a patient in extremis and assume that the clinical diagnosis is straightforward and the response to needle chest decompression is rapid and reliable. However, this might not be the case in real life. Texts differ when describing the diagnostic symptoms and signs and there are several case reports of diagnostic difficulty or missed diagnosis because of an absence of “classic” signs. Lack of chest signs along with poor correlation between the signs present and those picked up by experienced physicians have been specifically noted. There have also been multiple reports of ineffective needle decompression with adequate treatment only being achieved with tube thoracostomy.

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Trauma Care at a Multinational United Kingdom-Led Role 3 Combat Hospital: Resuscitation Outcomes From a Multidisciplinary Approach

11/10/2014

 
Mil Med. 2014 Nov;179(11):1258-62.  


Abstract:
Recent conflicts have led significant advancements in casualty care. Facilities serving combat wounded operate in challenging environments. Our purpose is to describe the multidisciplinary resuscitation algorithm utilized at a United Kingdom-led, Role 3 multinational treatment facility in Afghanistan focusing on injury severity and in-hospital mortality. Methods: Data were extracted from our prospectively collected trauma registry on military members wounded in action. Results: From November 1, 2009 to September 30, 2011, there were 3483 military trauma admissions. Common mechanisms of injury were improvised explosive devices (48%), followed by gunshot wounds (29%). Most patients (83.1%) had an Injury Severity Score (ISS) <15. For patients with complete ISS data, 8.4% had massive transfusion and 6.1% had an initial base deficit >5. Patients admitted with signs of life had a died of wounds rate of 1.8% with an average 1.2 day hospital stay. The mortality rate for patients undergoing massive transfusion was 4.8%, and for patients with a base deficit >5, mortality was 12.3%. Severely injured patients (ISS > 24) had a mortality rate of 16.5%. Conclusion: A systematic, multidisciplinary approach to trauma is associated with low in-hospital mortality. The outcomes in this study serve as a measure for future care in Role 3 facilities.
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Long-Term Outcomes of Patients Receiving a Massive Transfusion After Trauma

9/24/2014

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Shock: October 2014 - Volume 42 - Issue 4 - p 307–312

ABSTRACT: Resuscitation of patients presenting with hemorrhagic shock after major trauma has evolved to incorporate multiple strategies to maintain tissue perfusion and oxygenation while managing coagulation disorders. We aimed to study changes across time in long-term outcomes in patients with major trauma. A retrospective observational study in a single major trauma center in Australia was conducted. 

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Renaissance of base deficit for the initial assessment of trauma patients: a base deficit- based classification for hypovolemic shock developed on data from 16,305 patients derived from the TraumaRegister DGU®

6/16/2014

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Critical Care 2013, 17:R42 

Manuel Mutschler1,2*, Ulrike Nienaber3, Thomas Brockamp1, Arasch Wafaisade1, Tobias Fabian1, Thomas Paffrath1, Bertil Bouillon1, Marc Maegele1 and the TraumaRegister DGU4 

Introduction: The recognition and management of hypovolemic shock still remain an important task during initial trauma assessment. Recently, we have questioned the validity of the Advanced Trauma Life Support (ATLS) classification of hypovolemic shock by demonstrating that the suggested combination of heart rate, systolic blood pressure and Glasgow Coma Scale displays substantial deficits in reflecting clinical reality. The aim of this study was to introduce and validate a new classification of hypovolemic shock based upon base deficit (BD) at emergency department (ED) arrival.

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