Pre-hospital CPR and early REBOA in trauma patients-results from the ABOTrauma Registry

Publisher Copyright: © 2020 The Author(s).Background: Severely injured trauma patients suffering from traumatic cardiac arrest (TCA) and requiring cardiopulmonary resuscitation (CPR) rarely survive. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) performed early after hospital admission in patients with TCA is not well-defined. As the use of REBOA increases, there is great interest in knowing if there is a survival benefit related to the early use of REBOA after TCA. Using data from the ABOTrauma Registry, we aimed to study the role of REBOA used early after hospital admission in trauma patients who required pre-hospital CPR. Methods: Retrospective and prospective data on the use of REBOA were collected from the ABOTrauma Registry from 11 centers in seven countries globally between 2014 and 2019. In all patients with pre-hospital TCA, the predicted probability of survival, calculated with the Revised Injury Severity Classification II (RISC II), was compared with the observed survival rate. Results: Of 213 patients in the ABOTrauma Registry, 26 patients (12.2%) who had received pre-hospital CPR were identified. The median (range) Injury Severity Score (ISS) was 45.5 (25-75). Fourteen patients (54%) had been admitted to the hospital with ongoing CPR. Nine patients (35%) died within the first 24 h, while seventeen patients (65%) survived post 24 h. The survival rate to hospital discharge was 27% (n = 7). The predicted mortality using the RISC II was 0.977 (25 out of 26). The observed mortality (19 out of 26) was significantly lower than the predicted mortality (p = 0.049). Patients not responding to REBOA were more likely to die. Only one (10%) out of 10 non-responders survived. The survival rate in the 16 patients responding to REBOA was 37.5% (n = 6). REBOA with a median (range) duration of 45 (8-70) minutes significantly increases blood pressure from the median (range) 56.5 (0-147) to 90 (0-200) mmHg. Conclusions: Mortality in patients suffering from TCA and receiving REBOA early after hospital admission is significantly lower than predicted by the RISC II. REBOA may improve survival after TCA. The use of REBOA in these patients should be further investigated.Peer reviewe

The Coagulation system in the German S3 guideline on treatment of polytrauma and severely injured patients 2016. Update on the latest concepts for sufficient hemostasis

Traumatic brain injury and massive bleeding are the most frequent causes of death in severely injured patients. Uncontrolled hemorrhage is still a major cause of preventable death after trauma. The current German S3 trauma guideline on the treatment of polytrauma and severely injured patients emphasize the importance of early bleeding control in various areas. Besides uncontrolled hemorrhage, subsequent trauma-induced coagulopathy (TIC) is a second frequent problem after trauma; therefore, the current guideline addresses TIC in a separate and dedicated chapter. The key factors in management of TIC are early detection and aggressive therapy. Apart from standard coagulation tests and parameters indicating shock, viscoelastic tests are of increasing interest in the diagnostics of TIC. Trauma centers are urged to establish massive transfusion and coagulation protocols, which are individually adapted to the structure of the hospital. For treatment an optimization of the preconditions of coagulation, such as normothermia, normovolemia, normocalcemia and prevention of acidosis must be considered, even if sometimes hard to establish. Besides damage control resuscitation, two therapeutic approaches are possible: a ratio-driven and a coagulation factor-based regimen for treatment of TIC. Independent of the preferred concept, the early use of tranexamic acid should be taken into consideration for bleeding trauma patients. The present article summarizes the coagulation chapter of the current German guideline and gives a brief overview of current publications on this topic

Thrombozytenfunktionsstörung bei Traumapatienten, ein unterschätztes Problem? Ergebnisse einer monozentrischen Untersuchung

BackgroundPlasmatic coagulation disorders in trauma patients are common and their management is subject to current guidelines. Less evidence exists for platelet function. Although it is known that several trauma-associated factors have a negative influence on platelet function, routine monitoring has not yet become established.MethodsA retrospective single center study was carried out at aGerman level 1 trauma center from 2010 to 2016. In all patients fulfilling the requirements for the German Trauma Society (DGU) Traumaregister (R) who were admitted directly from the scene of the incident, platelet function was analyzed using the Platelet Function Analyzer (PFA 100 (R)) with adenosine diphosphate (ADP) and epinephrine as activation factors. After exclusion of patients with intake of long-term anticoagulant and antiaggregant medication, possible influencing factors of areduced platelet function were identified.ResultsThe results from 310 patients (44.0 +/- 14.7 years, 76% male, Injury Severity Score, ISS 28.4 +/- 14.2 points) were available. Adelayed platelet activation was found in 25.5% using ADP and 31% using epinephrine. Laboratory parameters indicated agreater blood loss. Prolonged closure times were associated with an increased transfusion rate of packed red blood cell concentrates and ahigher mortality rate. Logistic regression revealed hemoglobin (Hb) and fibrinogen levels at admission to be independent predictors for adecreased platelet activation in the assay with ADP (p<0.001, Cohen's f=0.61) and with epinephrine (p<0.001, f=0.42).ConclusionApproximately one quarter to one third of primarily admitted trauma patients without long-term anticoagulation medication showed adelayed platelet activation in the PFA-100 test. By considering all trauma patients an even higher rate can be expected. The Hb and fibrinogen levels at admission can be helpful to estimate platelet disorders. The development of platelet assays to guide the resuscitation of individual patients seems to be absolutely necessary. The contribution of platelet disorders to trauma-induced coagulopathy is not sufficiently understood. Regarding the importance assigned to platelet transfusion or administration of desmopressin, these aspects should be the subject of further research

Anaesthesia Procedures and invasive Vascular Access in the severely injured Patients at Trauma Room Admission in Germany An Online Survey

The continuous monitoring of vital parameters and subsequent therapy belong to the core duties of anaesthetists during acute trauma resuscitation in the trauma room. Important procedures may include placement of arterial lines and central venous catheters (CVCs). Knowledge of indication, performance and localization of invasive catheterisation of trauma care in Germany is scarce. After approval of the German Society of Anaesthesiology and Intensive Care Medicine we conducted an online survey about arterial and central venous catheterisation of severely injured patients with consideration of common practice used by anaesthetists in German trauma rooms. Data are presented in a descriptive manner. Of 843 hospitals invited for the survey, 72 (8.5%) had complete and valid data and were thus included in the analysis. Of these, 47% were supra-regional (level 1) trauma centres, 38% regional trauma centres and 15% local trauma centres. The annual mean injury severity score (ISS) of admitted patients to these hospitals was 21 +/- 10. In the trauma room, the responding hospitals place CVCs (49%) and arterial lines (59%) only in haemodynamically unstable patients, whereas 24% (CVC) and 39% (arterial line) do when pathological laboratory tests were confirmed. Standard operating procedures (SOPs) merely exist for placement of either arterial lines (25%) or CVCs (22%) in multiple trauma resuscitation. The decision to perform CVC or arterial line placement is usually (79%) at the discretion of the attending anaesthetist. The preferred anatomical access site for CVCs is the right internal jugular vein (46%) and for arterial lines the radial artery (without side preference) (57%), respectively. Of the responding hospitals, 49% prefer landmark-guided CVC-puncture (91% of arterial lines) instead of 43% using sonographic guidance (9% of arterial lines). Intravascular electrocardiography monitoring for CVC tip detection is used by 36%. In Germany, medical indication and schedule of invasive vascular catheterisation of severely injured patients in the trauma room is rarely regulated by SOPs and often performed at the discretion of the attending trauma team. Sonographic assistance during vascular puncture and electrocardiography for CVC tip detection is not as common as in non-emergency anaesthesia. Further studies are required to explore the real necessity and safety of invasive vascular catheterisation in multiple trauma patients in order to improve trauma care

Use of the helicopter ventilator for ground transport from the helipad to the destination in the hospital Secondary analysis of the HOVER survey of ventilated HEMS patients

Background. In helicopter emergency medical service (HEMS), ventilated patients are frequently transported. Any disconnection of the patient from the ventilator may be associated with complications. Recently, an online survey (HOVER, Handover of ventilated Helicopter Emergency Medical Service [HEMS] patients in the emergency room) was published suggesting that only half of the patients are transferred from the landing site to the destination in the hospital using the helicopter ventilator (rather than using another ventilator supplied by the hospital). The goal of this study was to discover factors of the ventilator management during this transport using the data from this survey for secondary analysis. Methods. Emergency medical physicians and HEMS-TCs (HEMS technical crew members) of 145 HEMS bases were invited to participate in an anonymous online survey HOVER. Results. The probability to use of the helicopter ventilator was higher in special intensive care transport course trained HEMS teams (p = 0.01), HEMS bases with higher rates of interhospital transports (rather than primary missions) (p < 0.001), larger helicopter sizes (p < 0.001) and the existence of a roll-in stretcher in the helicopter (p < 0.001). The types of ventilators used (p = 0.91) and the mountings of the ventilator inside the helicopter (p = 0.08) did not influence the use of the helicopter ventilator. Conclusion. The use of helicopter ventilators seems to be associated with training and particular designation of participating HEMS bases. Further studies are required to explore if the ventilator management during transfer from the landing site to the emergency room may contribute to outcome

Transport of ventilated emergency patients from the air rescue service to the hospital destination (HOVER study). Results of an online survey

BackgroundIn Germany more than 110,000 helicopter emergency medical service (HEMS) missions are carried out annually. Aconsiderable number of patients are ventilated during the flight. So far, structured surveys with respect to the ground transport from the helipad to the hospital facility and handover of ventilated patients in the emergency room (ER) are not available in the German-speaking HEMS system. The handover of ventilated HEMS patients in the ER (HOVERI study) explored the use of the helicopter ventilator and medical equipment during the transport from the hospital landing site to the ER.MethodAfter approval by the HEMS operators, emergency medical doctors and HEMS technical crew members (HEMS-TC) of 145 German-speaking HEMS bases were invited to participate in an anonymous online survey (period: 1 February 2018-1 March 2018). Each participant was only allowed to submit the survey once.ResultsData of 569 participants were completely analyzed, with responses from 429 emergency physicians and 140 HEMS-TC (75% from Germany, 13% Switzerland, 11% Austria, 1% Italy and Luxembourg). The most frequent type of aircraft used was the Eurocopter (EC)/Airbus helicopter(H) 135 (60.5%) followed by the EC/H 145 (33%). The majority of the respondents (53%) principally used the helicopter ventilator machine for patient transport from the helipad to the ER, 38% used it depending on the circumstances and 7% never used it. Of the participants 52% always took the emergency backpack for patient transport to the ER, 43% depending on the situation and 5% never took it along. The availability of oxygen or aventilator at the helipad was considered to be helpful (59% and 45%, respectively), obligatory (25% and 14%, respectively) but was also considered unnecessary by some participants (16% and 40%, respectively). The collection of the HEMS team by ahospital team at the helipad was rated as helpful (64%) or mandatory (19%), 12% considered it to be unimportant and 5% even disturbing. For most respondents (58.5%) the responsibility for the patient ended after astructured handover on reaching the internal hospital target area (e.g. the ER).ConclusionThe management of the handover of ventilated emergency patients in German-speaking HEMS is heterogeneously structured. Only approximately 50% of the participants frequently carried the helicopter ventilator and emergency equipment during patient transport to the ER. Depending on the situation, more than 90% of the respondents used the helicopter ventilator and emergency backpack during the transport. The collection of the HEMS team by ahospital team at the helipad was appreciated by the majority of participants. The use of the helicopter ventilator for patient transport to the ER needs to be explored in future studies.The study was registered at the Research Registry (www.researchregistry.com) under the following number: researchregistry292

Care for Severely Injured Persons Update of the 2016 S3 Guideline for the Treatment of Polytrauma and the Severely Injure

In 2011 the first interdisciplinary S3 guideline for the management of patients with serious injuries/trauma was published. After intensive revision and in consensus with 20 different medical societies, the updated version of the guideline was published online in September 2016. It is divided into three sections: prehospital care, emergency room management and the first operative phase. Many recommendations and explanations were updated, mostly in the prehospital care and emergency room management sections. These two sections are of special interest for anesthesiologists in field emergency physician roles or as team members or team leaders in the emergency room. The present work summarizes the changes to the current guideline and gives a brief overview of this very important work

Recommendations of the 2016 S3 guideline on polytrauma/severe injuries for prehospital care. A practice-oriented presentation

In 2011 the first interdisciplinary S3 guideline for the management of patients with serious injuries/trauma was published. After intensive revision and in consensus with 20 different medical societies, the updated version of the guideline was published in 2016. Divided into the three different sections prehospital care, emergency room management, and first operative phase, many recommendations and explanations were updated, mostly in the prehospital care and emergency room management sections. The prehospital care section is of special interest for all members of emergency medical services (e.g., emergency physician, paramedics, emergency technicians). The present work summarizes changes and innovations in prehospital care of the current guideline in a practice-oriented manner using the ABCDE scheme

Vascular access in the initial management of adult emergency patients in the resuscitation room

The initial in-hospital acute care of critically ill and severely injured emer-gency patients in the resuscitation room includes vascular access. Due to time -sensitive circumstances and critical con-ditions of emergency patients, invasive vascular access may be challenging. Current evidence and research on emer - gency vascular access is scarce and mainly focused on perioperative man-agement and intensive care settings. This article provides an expert-validated structured review and practice recom-mendations for resuscitation room vas-cular access in critically ill and severely injured patients