Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine - Latest Articles

Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities

Johan Herlitz — 2010-09-06T00:00:00Z

Background: The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably.In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count.This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase.MethodA literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases. Results: In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women).With regard to detection of stroke AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably.In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke. Conclusion: Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.

Teamwork skills, shared mental models, and performance in simulated trauma teams: an independent group design

Heidi Kristina Westli — 2010-08-31T00:00:00Z

Background: Non-technical skills are seen as an important contributor to reducing adverse events and improving medical management in healthcare teams. Previous research on the effectiveness of teams has suggested that shared mental models facilitate coordination and team performance. The purpose of the study was to investigate whether demonstrated teamwork skills and behaviour indicating shared mental models would be associated with observed improved medical management in trauma team simulations. Methods: Revised versions of the 'Anesthetists' Non-Technical Skills Behavioural marker system' and 'Anti-Air Teamwork Observation Measure' were field tested in moment-to-moment observation of 27 trauma team simulations in Norwegian hospitals. Independent subject matter experts rated medical management in the teams. An independent group design was used to explore differences in teamwork skills between higher-performing and lower-performing teams. Results: Specific teamwork skills and behavioural markers were associated with indicators of good team performance. Higher and lower-performing teams differed in information exchange, supporting behaviour and communication, with higher performing teams showing more effective information exchange and communication, and less supporting behaviours. Behavioural markers of shared mental models predicted effective medical management better than teamwork skills. Conclusions: The present study replicates and extends previous research by providing new empirical evidence of the significance of specific teamwork skills and a shared mental model for the effective medical management of trauma teams. In addition, the study underlines the generic nature of teamwork skills by demonstrating their transferability from different clinical simulations like the anaesthesia environment to trauma care, as well as the potential usefulness of behavioural frequency analysis in future research on non-technical skills.

Patterns in deer-related traffic injuries over a decade: the Mayo clinic experience

Dustin Smoot — 2010-08-17T00:00:00Z

Background: Our American College of Surgeons Level 1 Trauma Center serves a rural population. As a result, there is a unique set of accidents that are not present in an urban environment such as deer related motor vehicle crashes (dMVC). We characterized injury patterns between motorcycle/all-terrain vehicles (MCC) and automobile (MVC) crashes related to dMVC (deer motor vehicle crash) with the hypotheses that MCC will present with higher Injury Severity Score (ISS) and that it would be related to whether the driver struck the deer or swerved. Methods: The records of 157 consecutive patients evaluated at our institution for injury related to dMVC from January 1st, 1997 to December 31st, 2006 were reviewed from our prospectively collected trauma database. Demographic, clinical, and crash specific parameters were abstracted. Injury severity was analyzed by the Abbreviated Injury Scale score for each body region as well as the overall Injury Severity Score (ISS). Results: Motorcycle crashes presented with a higher median ISS than MVCs (14 vs 5, p < 0.001). Median Abbreviated Injury Score (AIS) of the spine for MCC riders was higher (3 vs 0, p < 0.001) if they swerved rather than collided. Seventy-seven percent of riders were not wearing a helmet which did not result in a statistically significant increase in median ISS (16 vs 10), head AIS (2 vs 0) or spine AIS (0 vs 0).Within the MVC group, there was no difference between swerving and hitting the deer in any AIS group. Forty-seven percent of drivers were not wearing seat belts which resulted in similar median ISS (6 vs 5) and AIS of all body regions. Conclusions: Motorcycle operators suffered higher ISS. There were no significant differences in median ISS if a driver involved in a deer-related motor vehicle crash swerved rather than collided, was helmeted, or restrained.

Pitfalls with the "chest compression-only" approach: The challenge of detecting an unusual cause.

Bjorn Ole Reid — 2010-08-13T00:00:00Z

Chest compression-only (CC-only) is now incorporated in the Norwegian protocol for dispatch guided CPR (cardiopulmonary resuscitation) in cardiac arrest of presumed cardiac aetiology.We present a case that is unique and instructive as well as unusual. It reminds us of the challenges that face bystanders, dispatch centres and ambulance services when faced with possible cardiac arrest.This case report describes a 50 year old man in a rural community. He had suffered a heart attack 8 months previously, and was found unconscious with respiratory arrest in his garden one morning. Due to the proximity to the ambulance station, the paramedics were on the scene within three minutes. A chain-saw was lying beside him, but no external injuries were seen. The patient had no radial pulse, central cyanosis and respiratory gasps approximately every 30 seconds. Ventilation with bag and mask was given, and soon a femoral pulse could be palpated. Blood sugar was elevated and ECG (electrocardiogram) was normal. GCS (Glasgow Coma Scale) was 3. Upon arrival of the physician staffed air ambulance, further examination revealed bilateral miosis of the pupils and continuing bradypnoea. Naloxone was given with an immediate effect and the patient woke up. The patient denied intake of narcotics, but additional information from the dispatch centre revealed that he was hepatitis C positive.After a few hours, the patient admitted to have obtained a fentanyl transdermal patch from an acquaintance, having chewed it before falling unconscious.This case report shows the importance as well as the challenges of identifying a non-cardiac cause of possible cardiac arrest, and the value of providing causal therapy.

Time needed to achieve completeness and accuracy in bedside lung ultrasound reporting in Intensive Care Unit

Lorenzo Tutino — 2010-08-12T00:00:00Z

Background: The use of lung ultrasound (LUS) in ICU is increasing but ultrasonographic patterns of lung are often difficult to quantify by different operators. The aim of this study was to evaluate the accuracy and quality of LUS reporting after the introduction of a standardized electronic recording sheet. Methods: Intensivists were trained for LUS following a teaching programme. From April 2008, an electronic sheet was designed and introduced in ICU database in order to uniform LUS examination reporting. A mark from 0 to 24 has been given for each exam by two senior intensivists not involved in the survey. The mark assigned was based on completeness of a precise reporting scheme, concerning the main finding of LUS. A cut off of 15 was considered sufficiency. Results: The study comprehended 12 months of observations and a total of 637 LUS. Initially, although some improvement in the reports completeness, still the accuracy and precision of examination reporting was below 15. The time required to reach a sufficient quality was 7 months. A linear trend in physicians progress was observed. Conclusions: The uniformity in teaching programme and examinations reporting system permits to improve the level of completeness and accuracy of LUS reporting, helping physicians in following lung pathology evolution.

Hospital employees' theoretical knowledge on what to do in an in-hospital cardiac arrest

Marie-Louise Sodersved Kallestedt — 2010-08-09T00:00:00Z

Background: Guidelines recommend that all health care professionals should be able to perform cardiopulmonary resuscitation (CPR), including the use of an automated external defibrillator. Theoretical knowledge of CPR is then necessary.The aim of this study was to investigate how much theoretical knowledge in CPR would increase among all categories of health care professionals lacking training in CPR, in an intervention hospital, after a systematic standardised training. Their results were compared with the staff at a control hospital with an ongoing annual CPR training programme. Methods: Health care professionals at two hospitals, with a total of 3144 employees, answered a multiple-choice questionnaire before and after training in CPR. Bootstrapped chi-square tests and Fisher's exact test were used for the statistical analyses. Results: In the intervention hospital, physicians had the highest knowledge pre-test, but other health care professionals including nurses and assistant nurses reached a relatively high level post-test. Improvement was inversely related to the level of previous knowledge and was thus most marked among other health care professionals and least marked among physicians.The staff at the control hospital had a significantly higher level of knowledge pre-test than the intervention hospital, whereas the opposite was found post-test. Conclusions: Overall theoretical knowledge increased after systematic standardised training in CPR. The increase was more pronounced for those without previous training and for those staff categories with the least medical education.

Focused nurse-defibrillation training: a simple and cost-effective strategy to improve survival from in-hospital cardiac arrest

John Stewart — 2010-07-29T00:00:00Z

Time to first defibrillation is widely accepted to correlate closely with survival and recovery of neurological function after cardiac arrest due to ventricular fibrillation or ventricular tachycardia. Focused training of a cadre of nurses to defibrillate on their own initiative may significantly decrease time to first defibrillation in cases of in-hospital cardiac arrest outside of critical care units. Such a program may be the best single strategy to improve in-hospital survival, simply and at reasonable cost.

Vascular relaxation of canine visceral arteries after ischemia by means of supraceliac aortic cross-clamping followed by reperfusion

Jose Ciscato — 2010-07-19T00:00:00Z

Background: The supraceliac aortic cross-clamping can be an option to save patients with hipovolemic shock due to abdominal trauma. However, this maneuver is associated with ischemia/reperfusion (I/R) injury strongly related to oxidative stress and reduction of nitric oxide bioavailability. Moreover, several studies demonstrated impairment in relaxation after I/R, but the time course of I/R necessary to induce vascular dysfunction is still controversial. We investigated whether 60 minutes of ischemia followed by 30 minutes of reperfusion do not change the relaxation of visceral arteries nor the plasma and renal levels of malondialdehyde (MDA) and nitrite plus nitrate (NOx). Methods: Male mongrel dogs (n = 27) were randomly allocated in one of the three groups: sham (no clamping, n = 9), ischemia (supraceliac aortic cross-clamping for 60 minutes, n = 9), and I/R (60 minutes of ischemia followed by reperfusion for 30 minutes, n = 9). Relaxation of visceral arteries (celiac trunk, renal and superior mesenteric arteries) was studied in organ chambers. MDA and NOx concentrations were determined using a commercially available kit and an ozone-based chemiluminescence assay, respectively. Results: Both acetylcholine and calcium ionophore caused relaxation in endothelium-intact rings and no statistical differences were observed among the three groups. Sodium nitroprusside promoted relaxation in endothelium-denuded rings, and there were no inter-group statistical differences. Both plasma and renal concentrations of MDA and NOx showed no significant difference among the groups. Conclusion: Supraceliac aortic cross-clamping for 60 minutes alone and followed by 30 minutes of reperfusion did not impair relaxation of canine visceral arteries nor evoke biochemical alterations in plasma or renal tissue.

A heuristic approach and heretic view on the technical issues and pitfalls in the management of penetrating abdominal injuries

Tugba Yilmaz — 2010-07-14T00:00:00Z

There is a general decline in penetrating abdominal trauma throughout the western world. As a result of that, there is a significant loss of expertise in dealing with this type of injury particularly when the patient presents to theatre with physiological instability. A significant percentage of these patients will not be operated by a trauma surgeon but, by the "occasional trauma surgeon", who is usually trained as a general surgeon. Most general surgeons have a general knowledge of operating penetrating trauma, knowledge originating from their training years and possibly enhanced by reading operative surgery textbooks. Unfortunately, the details included in most of these books are not extensive enough to provide them with enough armamentaria to tackle the difficult case. In this scenario, their operative dexterity and knowledge cannot be compared to that of their trauma surgeon colleagues, something that is taken for granted in the trauma textbooks. Techniques that are considered basic and easy by the trauma surgeons can be unfamiliar and difficult to general surgeons.Knowing the danger points and pitfalls that will be encountered in penetrating trauma to the abdomen, will help the occasional trauma surgeons to avoid intraoperative errors and improve patient care. This manuscript provides a heuristic approach from surgeons working in a high volume penetrating trauma centers in South African. Some of the statements could be considered heretic by the "accepted" trauma literature. We believe that this heuristic ("rule of thumb" approach, that originating from "try and error" experience) can help surgical trainees or less experienced in penetrating trauma surgeons to improve their surgical decision making and technique, resulting in better patient outcome.

Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation

Lawrence Gillman — 2010-07-13T00:00:00Z

Background: Ultrasound guidance during central line insertion has significantly reduced complications associated with this procedure and has led to it being incorporated as standard of care in many institutions. However, inadvertent arterial penetration and dilation remains a problem despite ultrasound guidance and can result in significant morbidity and even mortality. Dynamic ultrasound confirmation of guidewire position within the vein prior to dilation may help to prevent and even eliminate this feared complication. Methods: A prospectively collected database of central line insertions for one author utilizing this novel technique was retrospectively reviewed for all incidents of arterial dilation over a period from September 2008 to January 2010. Results: During the study period 53 central lines were inserted with no incidents of arterial dilation. Conclusions: Ultrasound confirmation of guidewire position has the potential to reduce or eliminate the morbidity and mortality of arterial dilation during central line placement.