Prehospital care of severely injured trauma patients : studies on management, assessment, and outcome

Trauma is a public health issue. According to statistics from the Swedish National Board of Health and Welfare, circumstances related to injury are the most common cause of death in the age group 15– 44 years for both genders. Prehospital care is the first link in the chain of life support. Trauma systems and regionalized trauma care have been shown to improve outcome in severely injured trauma patients, but less is known about whether gender influences the prehospital trauma care. Management in the prehospital phase of traumatic brain injury (TBI) is focused on limiting the effects of secondary insults, such as hypoxia and hypotension, and advanced prehospital airway management might potentially improve the outcome. The overall aim of this thesis was to evaluate the prehospital assessment, management and outcome in severely injured trauma patients within a regional trauma system. Paper I. A retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County. 693 primarily admitted trauma patients were included for the years 2006 and 2008. For the years 2006, 2008, and 2013, there were 114 secondarily transported trauma patients. The number of primary patient transports to the trauma center increased during these years by 20.2%, (p <0.001). Primarily transported patients had a significantly higher Injury Severity Score (ISS) in 2008 than in 2006, and the number of patients transported secondarily to the trauma center in 2006 was higher compared to 2008 and 2013 (p<0.001). Paper II. A retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County. A total of 383 trauma patients (279 males and 104 females) >15 years of age with an ISS of >15 transported to emergency care hospitals in the Stockholm area were included. Male patients had a 2.75 higher odds ratio (95% CI, 1.2–6.2) for receiving the highest prehospital priority compared to females on controlling for injury mechanism and vital signs on scene. Paper III. A retrospective observational study based on 2750 prehospital medical records of suspected TBI patients. 25.2 % of the patients were assessed according to all four core-elements in the guidelines and 78.6% of the patients underwent at least one intervention by the PECNs. Male patients were to a higher extent assessed according to guidelines and were given higher transport priority while females were more often assessed for vital parameters and received significantly more analgesics. Paper IV. A retrospective observational study based on 459 TBI patients ≥15 years admitted to the neurosurgical unit in Stockholm between the years 2008 and 2014. High energy trauma, prehospital hypotension, pupil unresponsiveness, mode of transportation and distance to the hospital were independently related to an increased rate of pre-hospital intubation (model explained p<0.001, pseudo-R2 0.482). Pre-hospital intubation did not correlate to outcome of the unconscious patients (p=0.296), or add independent information to the model of significant parameters in multivariate analysis vs. GOS (p=0.154). Transports >10 km had an intubation frequency of about 50%. With the introduction of a prehospital trauma transport directive, an increase in patients transported to the regional trauma center and a decrease in secondary transfers were detected, but a considerable number of severely injured patients were still transported to local hospitals. The results also indicated that prehospital prioritization among the severely injured and the assessment and management of parameters related to head trauma differed between genders. Pre-hospital intubation could not be related to outcome. Large multicenter prospective studies with structured protocols are of importance in order to determine potentially beneficial effects of prehospital advanced airway management

Prehospital Intubation and Outcome in Traumatic Brain Injury-Assessing Intervention Efficacy in a Modern Trauma Cohort.

BACKGROUND: Prehospital intubation in traumatic brain injury (TBI) focuses on limiting the effects of secondary insults such as hypoxia, but no indisputable evidence has been presented that it is beneficial for outcome. The aim of this study was to explore the characteristics of patients who undergo prehospital intubation and, in turn, if these parameters affect outcome. MATERIAL AND METHODS: Patients ≥15 years admitted to the Department of Neurosurgery, Stockholm, Sweden with TBI from 2008 through 2014 were included. Data were extracted from prehospital and hospital charts, including prospectively collected Glasgow Outcome Score (GOS) after 12 months. Univariate and multivariable logistic regression models were employed to examine parameters independently correlated to prehospital intubation and outcome. RESULTS: A total of 458 patients were included (n = 178 unconscious, among them, n = 61 intubated). Multivariable analyses indicated that high energy trauma, prehospital hypotension, pupil unresponsiveness, mode of transportation, and distance to the hospital were independently correlated with intubation, and among them, only pupil responsiveness was independently associated with outcome. Prehospital intubation did not add independent information in a step-up model versus GOS (p = 0.154). Prehospital reports revealed that hypoxia was not the primary cause of prehospital intubation, and that the procedure did not improve oxygen saturation during transport, while an increasing distance from the hospital increased the intubation frequency. CONCLUSION: In this modern trauma cohort, prehospital intubation was not independently associated with outcome; however, hypoxia was not a common reason for prehospital intubation. Prospective trials to assess efficacy of prehospital airway intubation will be difficult due to logistical and ethical considerations

Effect of an organizational change in a prehospital trauma care protocol and trauma transport directive in a large urban city : a before and after study

Background: Trauma systems and regionalized trauma care have been shown to improve outcome in severely injured trauma patients. The aim of this study was to evaluate the implementation of a prehospital trauma care protocol and transport directive, and to determine its effects on the number of primary admissions and secondary trauma transfers in a large Scandinavian city. Methods: We performed a retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County; patients > 15 years of age with an Injury Severity Score (ISS) > 15 transported to any emergency care hospitals in the Stockholm area were included for the years 2006 and 2008. We also included secondary transferred patients to the regional trauma center during 2006, 2008, and 2013. Results: A total of 693 primarily admitted trauma patients were included for the years 2006 and 2008. For the years 2006, 2008 and 2013, we included 114 secondarily transported trauma patients. The number of primary patient transports to the trauma center increased during the years by 20.2 %, (p <0.001); patients primarily transported to the trauma center had a significantly higher Injury Severity Score in 2008 than in 2006, and the number of patients transported secondarily to the trauma center in 2006 was higher compared to 2008 and to 2013 (p <0.001, all 3 years). Discussion: Our data indicate that implementation of a prehospital trauma care protocol may have an effect on transportation of severely injured trauma patients. A decrease in secondarily transported trauma patients to the regional trauma center was noted after 1 year and persisted at 7 years after the organizational change. Patients primarily admitted to the trauma center after the change had more severe injuries than patients transported to other emergency hospitals in the area even if 20 % of patients were not admitted primarily to a trauma center. This does not imply that the transport directives or the criteria were not followed but rather reveals the difficulties and uncertainties of field triage. Conclusions: With the introduction of a prehospital trauma transport directive in a large urban city, an increase in patients transported to the regional trauma center and a decrease in secondary transfers were detected, but a considerable number of severely injured patients were still transported to local hospitals.Peer reviewe

Nordic survey on assessment and treatment of fluid overload in intensive care

Funding Information: Acknowledgment to the physicians who helped with pretesting and supervision in the development of the survey: Maj Kjaergaard Kamper, Margrethe Duch Christensen, Lars Hein, Ulrik Skram, Dorthea Christensen, and Christian Sahl. Acknowledgment to the physicians who helped distribute the survey in their departments: Jon Henrik Laake, Christoffer Grant Sølling, Peter Toft, Elsebeth Haunstrup, Karina Baekby Houborg, Anne Højager Nielsen, Bodil Steen Rasmussen, Hansjörg Selter, Helle Scharling Pedersen, Mette Krag Vogelius, Thomas Strøm, Bjørn Mygil, Mads Kristian Holten, Michelle Chew, Per Martin Bådstøløkken, Johan Olsson, Erik Bruno, Thomas Kander, Nicklas Jonsson, Johan Mårtensson, Mattias Ringh, Anders, Paulsson, Christian Kahlbom, Marcus Castegren, Michael Haney, Karl Silvhamn, Minna Tallgren, Erika Wilkman, Sari Karlsson, Timo Porkkala, Stepani Bendel, Juha Koskenkari, Sami Mäenpää, Ari Alaspää, Tadeusz Kaminski, Johanna Kaunisto, Sanna-Maria Pohjanpaju, Björn Jäschke, Jouko Kähkönen and Antti Mäkelä, Eirik Alnes Buanes, Christian Magnus Langberg, Per Erik Ernø, Kay Rudi Karlsen, and Anne Cecilie Tvedten. Publisher Copyright: Copyright © 2022 Zeuthen, Wichmann, Schønemann-Lund, Järvisalo, Rubenson-Wahlin, Sigurðsson, Holen and Bestle.Introduction: Fluid overload in patients in the intensive care unit (ICU) is associated with higher mortality. There are few randomized controlled trials to guide physicians in treating patients with fluid overload in the ICU, and no guidelines exist. We aimed to elucidate how ICU physicians from Nordic countries define, assess, and treat fluid overload in the ICU. Materials and methods: We developed an online questionnaire with 18 questions. The questions were pre-tested and revised by specialists in intensive care medicine. Through a network of national coordinators. The survey was distributed to a wide range of Nordic ICU physicians. The distribution started on January 5th, 2022 and ended on May 6th, 2022. Results: We received a total of 1,066 responses from Denmark, Norway, Finland, Sweden, and Iceland. When assessing fluid status, respondents applied clinical parameters such as clinical examination findings, cumulative fluid balance, body weight, and urine output more frequently than cardiac/lung ultrasound, radiological appearances, and cardiac output monitoring. A large proportion of the respondents agreed that a 5% increase or more in body weight from baseline supported the diagnosis of fluid overload. The preferred de-resuscitation strategy was diuretics (91%), followed by minimization of maintenance (76%) and resuscitation fluids (71%). The majority declared that despite mild hypotension, mild hypernatremia, and ongoing vasopressor, they would not withhold treatment of fluid overload and would continue diuretics. The respondents were divided when it came to treating fluid overload with loop diuretics in patients receiving noradrenaline. Around 1% would not administer noradrenaline and diuretics simultaneously and 35% did not have a fixed upper limit for the dosage. The remaining respondents 63% reported different upper limits of noradrenaline infusion (0.05–0.50 mcg/kg/min) when administering loop diuretics. Conclusion: Self-reported practices among Nordic ICU physicians when assessing, diagnosing, and treating fluid overload reveals variability in the practice. A 5% increase in body weight was considered a minimum to support the diagnosis of fluid overload. Clinical examination findings were preferred for assessing, diagnosing and treating fluid overload, and diuretics were the preferred treatment modality.Peer reviewe

Trauma patient transport to hospital using helicopter emergency medical services or road ambulance in Sweden: a comparison of survival and prehospital time intervals

Abstract Background The benefits of helicopter emergency medical services (HEMS) transport of adults following major trauma have been examined with mixed results, with some studies reporting a survival benefit compared to regular emergency medical services (EMS). The benefit of HEMS in the context of the Swedish trauma system remains unclear. Aim To investigate differences in survival and prehospital time intervals for trauma patients in Sweden transported by HEMS compared to road ambulance EMS. Methods A total of 74,032 trauma patients treated during 2012–2022 were identified through the Swedish Trauma Registry (SweTrau). The primary outcome was 30-day mortality and Glasgow Outcome Score at discharge from hospital (to home or rehab); secondary outcomes were the proportion of severely injured patients who triggered a trauma team activation (TTA) on arrival to hospital and the proportion of severely injured patients with GCS ≤ 8 who were subject to prehospital endotracheal intubation. Results 4529 out of 74,032 patients were transported by HEMS during the study period. HEMS patients had significantly lower mortality compared to patients transported by EMS at 1.9% vs 4.3% (ISS 9–15), 5.4% vs 9.4% (ISS 16–24) and 31% vs 42% (ISS ≥ 25) (p < 0.001). Transport by HEMS was also associated with worse neurological outcome at discharge from hospital, as well as a higher rate of in-hospital TTA for severely injured patients and higher rate of prehospital intubation for severely injured patients with GCS ≤ 8. Prehospital time intervals were significantly longer for HEMS patients compared to EMS across all injury severity groups. Conclusion Trauma patients transported to hospital by HEMS had significantly lower mortality compared to those transported by EMS, despite longer prehospital time intervals and greater injury severity. However, this survival benefit may have been at the expense of a higher degree of adverse neurological outcome. Increasing the availability of HEMS to include all regions should be considered as it may be the preferrable option for transport of severely injured trauma patients in Sweden

Prehospital Intubation and Outcome in Traumatic Brain Injury—Assessing Intervention Efficacy in a Modern Trauma Cohort

BackgroundPrehospital intubation in traumatic brain injury (TBI) focuses on limiting the effects of secondary insults such as hypoxia, but no indisputable evidence has been presented that it is beneficial for outcome. The aim of this study was to explore the characteristics of patients who undergo prehospital intubation and, in turn, if these parameters affect outcome.Material and methodsPatients ≥15 years admitted to the Department of Neurosurgery, Stockholm, Sweden with TBI from 2008 through 2014 were included. Data were extracted from prehospital and hospital charts, including prospectively collected Glasgow Outcome Score (GOS) after 12 months. Univariate and multivariable logistic regression models were employed to examine parameters independently correlated to prehospital intubation and outcome.ResultsA total of 458 patients were included (n = 178 unconscious, among them, n = 61 intubated). Multivariable analyses indicated that high energy trauma, prehospital hypotension, pupil unresponsiveness, mode of transportation, and distance to the hospital were independently correlated with intubation, and among them, only pupil responsiveness was independently associated with outcome. Prehospital intubation did not add independent information in a step-up model versus GOS (p = 0.154). Prehospital reports revealed that hypoxia was not the primary cause of prehospital intubation, and that the procedure did not improve oxygen saturation during transport, while an increasing distance from the hospital increased the intubation frequency.ConclusionIn this modern trauma cohort, prehospital intubation was not independently associated with outcome; however, hypoxia was not a common reason for prehospital intubation. Prospective trials to assess efficacy of prehospital airway intubation will be difficult due to logistical and ethical considerations