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

Inter-hospital transfer: the crux of the trauma system, a curse for trauma registries.

Hans Morten Lossius — 2010-03-16T00:00:00Z

The inter-hospital transfer of patients is crucial to a well functioning trauma system, and the transfer process may serve as a quality indicator for regional trauma care. However, the assessment of the transfer process requires high-quality data from various sources. Prospective studies and studies based on single-centre trauma registries may fail to capture an appropriate width and depth of data. Thus the creation of inclusive regional and national trauma registries that receive information from all of the services within a trauma system is a prerequisite for high quality inter-hospital transfer studies in the future.

Interfacility transfers in a non-trauma system setting: an assessment of the Greek reality

Stylianos Katsaragakis — 2010-03-16T00:00:00Z

Background: Quality assessment of any trauma system involves the evaluation of the transferring patterns. This study aims to assess interfacility transfers in the absence of a formal trauma system setting and to estimate the benefits from implementing a more organized structure. Methods: The 'Report of the Epidemiology and Management of Trauma in Greece' is a one year project of trauma patient reporting throughout the country. It provided data concerning the patterns of interfacility transfers. We compared the transferred patient group to the non transferred patient group. Information reviewed included patient and injury characteristics, need for an operation, Intensive Care Unit (ICU) admittance and mortality. Analysis employed descriptive statistics and Chi-square test. Interfacility transfers were then assessed according to each health care facility's availability of five requirements; Computed Tomography scanner, ICU, neurosurgeon, orthopedic and vascular surgeon. Results: Data on 8,524 patients were analyzed; 86.3% were treated at the same facility, whereas 13.7% were transferred. Transferred patients tended to be younger, male, and more severely injured than non transferred patients. Moreover, they were admitted to ICU more often, had a higher mortality rate but were less operated on compared to non transferred patients. The 34.3% of transfers was from facilities with none of the five requirements, whereas the 12.4% was from those with one requirement. Low level facilities, with up to three requirements transferred 43.2% of their transfer volume to units of equal resources. Conclusion: Trauma management in Greece results in a high number of transfers. Patients are frequently transferred between low level facilities. Better coordination could lead to improved outcomes and less cost.

Scenario based outdoor simulation in pre-hospital trauma care using a simple mannequin model

Per Bredmose — 2010-03-15T00:00:00Z

IntroductionWe describe a system of scenario-based training using simple mannequins under realistic circumstances for the training of pre-hospital care providers. Methods: A simple intubatable mannequin or student volunteers are used together with a training version of the equipment used on a routine basis by the pre-hospital care team (doctor + paramedic).Training is conducted outdoors at the base location all year round. The scenarios are led by scenario facilitators who are predominantly senior physicians. Their role is to brief the training team and guide the scenario, results of patient assessment and the simulated responses to interventions and treatment. Pilots, fire-fighters and medical students are utilised in scenarios to enhance realism by taking up roles as bystanders, additional ambulance staff and police. These scenario participants are briefed and introduced to the scene in a realistic manner. After completion of the scenario, the training team would usually be invited to prepare and deliver a hospital handover as they would in a real mission. A formal structured debrief then takes place. Results: This training method technique has been used for the training of all London Helicopter Emergency Medical Service (London HEMS) doctors and paramedics over the last 24 months. Informal participant feedback suggests that this is a very useful teaching method, both for improving motor skills, critical decision-making, scene management and team interaction. Although formal assessment of this technique has not yet taken place we describe how this type of training is conducted in a busy operational pre-hospital trauma service.DiscussionThe teaching and maintenance of pre-hospital care skills is essential to an effective pre-hospital trauma care system. Simple mannequin based scenario training is feasible on a day-to-day basis and has the advantages of low cost, rapid set up and turn around. The scope of scenarios is limited only by the imagination of the trainers. Significant effort is made to put the participants into "the Zone" - the psychological mindset, where they believe they are in a realistic setting and treating a real patient, so that they gain the most from each teaching session. The method can be used for learning new skills, communication and leadership as well as maintaining existing skills. Conclusion: The method described is a low technology, low cost alternative to high technology simulation which may provide a useful adjunct to delivering effective training when properly prepared and delivered. We find this useful for both induction and regular training of pre-hospital trauma care providers.

Effect of levosimendan in experimental verapamil- induced myocardial depression

Jouni Kurola — 2010-03-11T00:00:00Z

Background: Calcium antagonist overdose can cause severe deterioration of hemodynamics unresponsible to treatment with beta adrenergic inotropes. The aim of the study was to evaluate in an experimental model the effects of levosimendan during severe calcium antagonist intoxication. Methods: Twelve landrace-pigs were intoxicated with intravenous verapamil at escalating infusion rates. The infusion containing 2.5mg/ml verapamil was used aiming to a reduction of cardiac output by 40% from the baseline value. Intoxicated pigs were randomized into two groups: control (saline) and levosimendan (intravenous bolus). Inotropic effect was measured as a change in a maximum of the positive slope of the left ventricular pressure (LV dP/dt). The survival and hemodynamics of the animals were followed for 120 min after the targeted reduction of cardiac output. Results: In the control group, five out of six pigs died during the experiment. In the levosimendan group, one pig died before completion of the experiment (p=0.04). In the levosimendan group a change in LV dP/dt was positive in four out of six pigs compared to one out of six pigs in the control group (p=ns). Conclusions: In this experimental model, the use of levosimendan was associated with improved survival.

Arterial embolization in patients with grade-4 blunt renal trauma: evaluation of the glomerular filtration rates by dynamic scintigraphy with 99mTechnetium-diethylene triamine pentacetic acid

Seiji Morita — 2010-03-07T00:00:00Z

Background: High-grade blunt renal trauma has been treated by arterial embolization (AE). However, it is unknown whether AE preserves renal function, because conventional renal function tests reflect total renal function and not the function of the injured kidney alone. Dynamic scintigraphy can assess differential renal function. Methods: We performed AE in 17 patients with grade-4 blunt renal trauma and determined their serum creatinine (sCr) level and glomerular filtration rate (GFR; estimated by dynamic scintigraphy) after 3 months. In 4 patients with low GFR of the injured kidney (<20 ml·min-1·1.73 m-2), the GFR and sCr were measured again at 6 months. Data are presented as median and interquartile range (25th, 75th percentile). Results: The median GFR of the injured kidney, total GFR, and median sCr at 3 months were 29.3 (23.7, 35.3) and 96.8 (79.1, 102.6) ml·min-1·1.73 m-2 and 0.6 (0.5, 0.7) mg/dl, respectively. In the patients with low GFR (ml·min-1·1.73 m-2), the median GFR of the injured kidney, total GFR, and median sCr (mg/dl) were 16.2 (15.7, 16.3), 68.7 (61.1, 71.6), and 0.7 (0.7, 0.9), respectively, at 3 months and 34.5 (29.2, 37.0), 90.9 (79.1, 98.8), and 0.7 (0.7, 0.8), respectively, at 6 months. Conclusions: The function of the injured kidney was preserved in all patients, indicating the efficacy of AE for the treatment of grade-4 blunt renal trauma.

No impact of early intervention on late outcome after minimal, mild and moderate head injury.

Ben Heskestad — 2010-02-24T00:00:00Z

Objectives: To evaluate the effect of an educational intervention on outcome after minimal, mild and moderate head injury. Methods: Three hundred and twenty six patients underwent stratified randomization to an intervention group (n=163) or a control group (n=163). Every second patient was allocated to the intervention group. Participants in this group were offered a cognitive oriented consultation two weeks after the injury, while subjects allocated to the control group were not. Both groups were invited to follow up 3 and 12 months after injury. Results: A total of 50 (15 %) patients completed the study (intervention group n=22 (13 %), control group n=28 (17 %), not significant). There were no statistically significant differences between the intervention group and the control group. Conclusions: There was no effect on outcomes from an early educational intervention two weeks after head injury.

The epidemiology of medical emergency contacts outside hospitals in Norway - a prospective population based study

Erik Zakariassen — 2010-02-18T00:00:00Z

IntroductionThere is a lack of epidemiological knowledge on medical emergencies outside hospitals in Norway. The aim of the present study was to obtain representative data on the epidemiology of medical emergencies classified as "red responses" in Norway.MethodThree emergency medical dispatch centres (EMCCs) were chosen as catchment areas, covering 816 000 inhabitants. During a three month period in 2007 the EMCCs gathered information on every situation that was triaged as a red response, according to The Norwegian Index of Medical Emergencies (Index). Records from ground ambulances, air ambulances, and the primary care doctors were subsequently collected. International Classification of Primary Care - 2 symptom codes (ICPC-2) and The National Committee on Aeronautics (NACA) Score System were given retrospectively. Results: Total incidence of red response situations was 5 105 during the three month period. 394 patients were involved in 138 accidents, and 181 situations were without patients, resulting in a total of 5 180 patients. The patients' age ranged from 0 to 107 years, with a median age of 57, and 55% were male. 90% of the red responses were medical problems with a large variation of symptoms, the remainder being accidents. 70% of the patients were in a non-life-threatening situation. Within the accident group, males accounted for 61%, and 35% were aged between 10 and 29 years, with a median age of 37 years. Few of the 39 chapters in the Index were used, A10 "Chest pain" was the most common one (22% of all situations). ICPC-2 symptom codes showed that cardiovascular, syncope/coma, respiratory and neurological problems were most common. 50% of all patients in a sever situation (NACA score 4-7) were > 70 years of age. Conclusions: The results show that emergency medicine based on 816 000 Norwegians mainly consists of medical problems, where the majority of the patients have a non-life-threatening situation. More focus on the emergency system outside hospitals, including triage and dispatch, and how to best deal with "everyday" emergency problems is needed to secure knowledge based decisions for the future organization of the emergency system.

Risk scoring systems for adults admitted to the emergency department: a systematic review

Mikkel Brabrand — 2010-02-11T00:00:00Z

Background: Patients referred to a medical admission unit (MAU) represent a broad spectrum of disease severity. In the interest of allocating resources to those who might potentially benefit most from clinical interventions, several scoring systems have been proposed as a triaging tool.Even though most scoring systems are not meant to be used on an individual level, they can support the more inexperienced doctors and nurses in assessing the risk of deterioration of their patients.We therefore performed a systematic review on the level of evidence of literature on scoring systems developed or validated in the MAU. We hypothesized that existing scoring systems would have a low level of evidence and only few systems would have been externally validated. Methods: We conducted a systematic search using Medline, EMBASE and the Cochrane Library, according to the PRISMA guidelines, on scoring systems developed to assess medical patients at admission.The primary endpoints were in-hospital mortality or transfer to the intensive care unit. Studies derived for only a single or few diagnoses were excluded.The ability to identify patients at risk (discriminatory power) and agreement between observed and predicted outcome (calibration) along with the method of derivation and validation (application on a new cohort) were extracted. Results: We identified 1,655 articles. Thirty were selected for further review and 10 were included in this review.Eight systems used vital signs as variables and two relied mostly on blood tests.Nine systems were derived using regression analysis and eight included patients admitted to a MAU. Six systems used in-hospital mortality as their primary endpoint.Discriminatory power was specified for eight of the scoring systems and was acceptable or better in five of these. The calibration was only specified for four scoring systems. In none of the studies impact analysis or inter-observer reliability were analyzed.None of the systems reached the highest level of evidence. Conclusions: None of the 10 scoring systems presented in this article are perfect and all have their weaknesses. More research is needed before the use of scoring systems can be fully implemented to the risk assessment of acutely admitted medical patients.

Survival after prolonged resuscitation with 99 defibrillations due to Torsade De Pointes cardiac electrical storm: a case report

Anders Rostrup Nakstad — 2010-02-06T00:00:00Z

A 48-year-old previously healthy woman suffered witnessed cardiac arrest in hospital. She achieved return of spontaneous circulation and was transferred to the intensive care unit. During the following 3 hours, she suffered a cardiac electrical storm with 98 episodes of Torsade de Pointes ventricular tachycardia rapidly degenerating to ventricular fibrillation. She was converted with a total of 99 defibrillations. There was no response to the use of any recommended anti arrhythmic drugs. However, the use of bretylium surprisingly stabilized her heart rhythm and facilitated placing of a temporary pacemaker. Overdrive pacing prevented further arrhythmias and was life saving. A number of beneficial factors may have contributed to the good neurological outcome. Further investigations gave no explanation for her cardiac electrical storm.

A review of ureteral injuries after external trauma

Bruno Pereira — 2010-02-03T00:00:00Z

IntroductionUreteral trauma is rare, accounting for less than 1% of all urologic traumas. However, a missed ureteral injury can result in significant morbidity and mortality. The purpose of this article is to review the literature since 1961 with the primary objective to present the largest medical literature review, to date, regarding ureteral trauma. Several anatomic and physiologic considerations are paramount regarding ureteral injuries management.Literature reviewEighty-one articles pertaining to traumatic ureteral injuries were reviewed. Data from these studies were compiled and analyzed. The majority of the study population was young males. The proximal ureter was the most frequently injured portion. Associated injuries were present in 90.4% of patients. Admission urinalysis demonstrated hematuria in only 44.4% patients. Intravenous ureterogram (IVU) failed to diagnose ureteral injuries either upon admission or in the operating room in 42.8% of cases. Ureteroureterostomy, with or without indwelling stent, was the surgical procedure of choice for both trauma surgeons and urologists (59%). Complications occurred in 36.2% of cases. The mortality rate was 17%. Conclusion: The mechanism for ureteral injuries in adults is more commonly penetrating than blunt. The upper third of the ureter is more often injured than the middle and lower thirds. Associated injuries are frequently present. CT scan and retrograde pyelography accurately identify ureteral injuries when performed together. Ureteroureterostomy, with or without indwelling stent, is the surgical procedure of choice of both trauma surgeons and urologists alike. Delay in diagnosis is correlated with a poor prognosis.