Epidemiology and outcome of rib fractures:a nationwide study in the Netherlands

Purpose Rib fractures following thoracic trauma are frequently encountered injuries and associated with a significant morbidity and mortality. The aim of this study was to provide current data on the epidemiology, in-hospital outcomes and 30-day mortality of rib fractures, and to evaluate these results for different subgroups. Methods A nationwide retrospective cohort study was performed with the use of the Dutch Trauma Registry which covers 99% of the acutely admitted Dutch trauma population. All patients aged 18 years and older admitted to the hospital between January 2015 and December 2017 with one or more rib fractures were included. Incidence rates were calculated using demographic data from the Dutch Population Register. Subgroup analyses were performed for flail chest, polytrauma, primary thoracic trauma, and elderly patients. Results A total of 14,850 patients were admitted between 2015 and 2017 with one or more rib fractures, which was 6.0% of all trauma patients. Of these, 573 (3.9%) patients had a flail chest, 4438 (29.9%) were polytrauma patients, 9273 (63.4%) were patients with primary thoracic trauma, and 6663 (44.9%) were elderly patients. The incidence rate of patients with rib fractures for the entire cohort was 29 per 100.000 person-years. The overall 30-day mortality was 6.9% (n = 1208) with higher rates observed in flail chest (11.9%), polytrauma (14.8%), and elderly patients (11.7%). The median hospital length of stay was 6 days (IQR, 3-11) and 37.3% were admitted to the intensive care unit (ICU). Conclusions Rib fractures are a relevant and frequently occurring problem among the trauma population. Subgroup analyses showed that there is a substantial heterogeneity among patients with rib fractures with considerable differences regarding the epidemiology, in-hospital outcomes, and 30-day mortality

Decubitus bij traumapatiënten met een verdenking op wervelletsel : De rol van immobiliserende en medische materialen

Of all patients in a hospital environment, trauma patients may be particularly at risk for developing (devicerelated) pressure ulcers (PUs), because of their traumatic injuries, immobility, and exposure to immobilizing and medical devices. Studies on devicerelated PUs are scarce. With this study, the incidence and characteristics of PUs and the proportion of PUs that are related to devices in adult trauma patients with suspected spinal injury were described. From JanuaryDecember 2013, 254 trauma patients were visited every 2 days for skin assessment. The overall incidence of PUs was 28·3% (n = 72/254 patients). The incidence of devicerelated PUs was 20.1% (n = 51), and 13% (n = 33) developed solely devicerelated PUs. We observed 145 PUs in total of which 60·7% were related to devices (88/145). Devicerelated PUs were detected 16 different locations on the front and back of the body. These results show that the incidence of PUs and the proportion of devicerelated PUs is very high in trauma patients

Development and validation of a novel prediction model to identify patients in need of specialized trauma care during field triage : design and rationale of the GOAT study

Background: Adequate field triage of trauma patients is crucial to transport patients to the right hospital. Mistriage and subsequent interhospital transfers should be minimized to reduce avoidable mortality, life-long disabilities, and costs. Availability of a prehospital triage tool may help to identify patients in need of specialized trauma care and to determine the optimal transportation destination. Methods: The GOAT (Gradient Boosted Trauma Triage) study is a prospective, multi-site, cross-sectional diagnostic study. Patients transported by at least five ground Emergency Medical Services to any receiving hospital within the Netherlands are eligible for inclusion. The reference standards for the need of specialized trauma care are an Injury Severity Score ≥ 16 and early critical resource use, which will both be assessed by trauma registrars after the final diagnosis is made. Variable selection will be based on ease of use in practice and clinical expertise. A gradient boosting decision tree algorithm will be used to develop the prediction model. Model accuracy will be assessed in terms of discrimination (c-statistic) and calibration (intercept, slope, and plot) on individual participant's data from each participating cluster (i.e., Emergency Medical Service) through internal-external cross-validation. A reference model will be externally validated on each cluster as well. The resulting model statistics will be investigated, compared, and summarized through an individual participant's data meta-analysis. Discussion: The GOAT study protocol describes the development of a new prediction model for identifying patients in need of specialized trauma care. The aim is to attain acceptable undertriage rates and to minimize mortality rates and life-long disabilities

Hospital evacuation: Exercise versus reality

Introduction: The Dutch Major Incident Hospital (MIH) is a standby, highly prepared, 200-bed hospital strictly reserved to provide immediate, large-scale, and emergency care for victims of disasters and major incidents. It has long-standing experience training for various major incident scenarios, including functioning as a back-up facility for the Netherlands. In 1995, the MIH had experience with overtaking an evacuated hospital when that hospital was threatened by flooding. In November 2014, an exercise was performed to transfer an evacuating hospital to the MIH. The scenario again became reality when a neighbouring hospital had to evacuate in September 2015. This article evaluates the events and compares the exercise to the real events in order to further optimise future training. Methods: All three events were analysed using the Protocol for Reports from Major Accidents and Disasters, a standardised protocol to evaluate medical responses to a major incident. Results: During the 2014 exercise, 72 patients were received, compared with 143 and 70, respectively, in the real events in 1995 and 2015. Personnel from the evacuating hospitals accompanied the patients and continued working in the MIH. The patient surge differed on all three occasions. The information technology (IT) systems proved to be more prone to fail during the real event, and legal implications to have staff from another hospital work in the MIH had to be put in protocol during the deployment. The acute phase was comparable in all three events, and performance was good. However, the exercise did not last long enough to analyse the implications on multiday care, as experienced during a multiday deployment. Conclusion: Large-scale major incident exercises are a great benchmark for the medical response in the acute phase of relief. The MIH was shown to be highly prepared to admit an entire evacuating hospital or large groups of patients in such a scenario. Experiences from the past, combined with regular training that closely resembles reality, guarantee the level of preparedness. Key differences between a true deployment and an exercise are the inability to train multiple days, and in our experience, a successful operation of IT systems in test environments does not guarantee their successful use during live events. (C) 2016 Elsevier Ltd. All rights reserved

Variation in treatment of blunt splenic injury in Dutch academic trauma centers

Background: The incidence of splenectomy after trauma is institutionally dependent and varies from 18% to as much as 40%. This is important because variation in management influences splenic salvage. The aim of this study was to investigate whether differences exist between Dutch level 1 trauma centers with respect to the treatment of these injuries, and if variation in treatment was related to splenic salvage, spleen-related reinterventions, and mortality. Methods: Consecutive adult patients who were admitted between January 2009 and December 2012 to five academic level 1 trauma centers were identified. Multinomial logistic regression was used to measure the influence of hospital on treatment strategy, controlling for hemodynamic instability on admission, high grade (American Association for the Surgery of Trauma 3-5) splenic injury, and injury severity score. Binary logistic regression was used to quantify differences among hospitals in splenic salvage rate. Results: A total of 253 patients were included: 149 (59%) were observed, 57 (23%) were treated with splenic artery embolization and 47 (19%) were operated. The observation rate was comparable in all hospitals. Splenic artery embolization and surgery rates varied from 9%-32% and 8%-28%, respectively. After adjustment, the odds of operative management were significantly higher in one hospital compared with the reference hospital (adjusted odds ratio 4.98 [1.02-24.44]). The odds of splenic salvage were significantly lower in another hospital compared with the reference hospital (adjusted odds ratio 0.20 [0.03-1.32]). Conclusions: Although observation rates were comparable among the academic trauma centers, embolization and surgery rates varied. A nearly 5-fold increase in the odds of operative management was observed in one hospital, and another hospital had significantly lower odds of splenic salvage. The development of a national guideline is recommended to minimalize splenectomy after trauma. (C) 2015 Elsevier Inc. All rights reserved

Epidural Analgesia for Severe Chest Trauma: An Analysis of Current Practice on the Efficacy and Safety

Background. Adequate pain control is essential in the treatment of patients with traumatic rib fractures. Although epidural analgesia is recommended in international guidelines, the use remains debatable and is not undisputed. The aim of this study was to describe the efficacy and safety of epidural analgesia in patients with multiple traumatic rib fractures. Methods. A retrospective cohort study was performed. Patients with ≥3 rib fractures following blunt chest trauma who received epidural analgesia between January 2015 and January 2018 were included. The main outcome parameters were the success rate of epidural analgesia and the incidence of medication-related side effects and catheter-related complications. Results. A total of 76 patients were included. Epidural analgesia was successful in a total of 45 patients (59%), including 22 patients without and in 23 patients with an additional analgesic intervention. In 14 patients (18%), epidural analgesia was terminated early without intervention due to insufficient sensory blockade (n = 4), medication-related side effects (n = 4), and catheter-related complications (n = 6). In 17 patients (22%), the epidural catheter was removed after one or multiple additional interventions due to insufficient pain control. Minor epidural-related complications or side effects were encountered in 36 patients (47%). One patient had a major complication (opioid intoxication). Conclusion. Epidural analgesia was successful in 59% of patients; however, 30% needed additional analgesic interventions. As about half of the patients had epidural-related complications, it remains debatable whether epidural analgesia is a sufficient treatment modality in patients with multiple rib fractures

Feasibility of using head and neck CT imaging to assess skeletal muscle mass in head and neck cancer patients

Objectives Patients with head and neck cancer (HNC) have a higher risk of malnutrition and sarcopenia, which is associated with adverse clinical outcome. As abdominal CT-imaging is often used to detect sarcopenia, such scans are rarely available in HNC patients, possibly explaining why no studies investigate the effect of sarcopenia in this population. We correlated skeletal muscle mass assessed on head and neck CT-scans with abdominal CT-imaging. Methods Head and neck, and abdominal CT-scans of trauma (n = 51) and HNC-patients (n = 52) were retrospectively analyzed. On the head and neck CT-scans, the paravertebral and sternocleidomastoid muscles were delineated. On the abdominal CT-scans, all muscles were delineated. Cross-sectional area (CSA) of the muscles at the level of the C3 vertebra was compared to CSA at the L3 level using linear regression. A multivariate linear regression model was established. Results HNC-patients had significantly lower muscle CSA than trauma patients (37.9 vs. 45.1 cm2,

Feasibility of using head and neck CT imaging to assess skeletal muscle mass in head and neck cancer patients

Objectives Patients with head and neck cancer (HNC) have a higher risk of malnutrition and sarcopenia, which is associated with adverse clinical outcome. As abdominal CT-imaging is often used to detect sarcopenia, such scans are rarely available in HNC patients, possibly explaining why no studies investigate the effect of sarcopenia in this population. We correlated skeletal muscle mass assessed on head and neck CT-scans with abdominal CT-imaging. Methods Head and neck, and abdominal CT-scans of trauma (n = 51) and HNC-patients (n = 52) were retrospectively analyzed. On the head and neck CT-scans, the paravertebral and sternocleidomastoid muscles were delineated. On the abdominal CT-scans, all muscles were delineated. Cross-sectional area (CSA) of the muscles at the level of the C3 vertebra was compared to CSA at the L3 level using linear regression. A multivariate linear regression model was established. Results HNC-patients had significantly lower muscle CSA than trauma patients (37.9 vs. 45.1 cm2, p