[Effect of logistic and medical emergency resources on fatal outcome of severe trauma]

[Implications of prehospital estimation of trauma patients for the treatment pathway-An evaluation of the TraumaRegister DGU®]

BACKGROUND

In the prehospital acute treatment phase of severely injured patients, the stabilization of the vital parameters is paramount. The rapid and precise assessment of the injuries by the emergency physician is crucial for the initial treatment and the selection of the receiving hospital.

OBJECTIVE

The aim of this study was to determine whether the prehospital emergency medical assessment has an influence on prehospital and emergency room treatment.

MATERIAL AND METHODS

Data from the TraumaRegister DGU® between 2015 and 2019 in Germany were evaluated. The prehospital emergency medical assessment of the injury pattern and severity was recorded using the emergency physician protocol and compared with the in-hospital documented diagnoses using the abbreviated injury scale.

RESULTS

A total of 47,838 patients with an average injury severity score (ISS) of 18,7 points (SD 12.3) were included. In summary, 127,739 injured body regions were documented in the hospitals. Of these, a total of 87,921 were correctly suspected by the emergency physician Thus, 39,818 injured body regions were not properly documented. In 42,530 cases a region of the body was suspected to be injured without the suspicion being confirmed in the hospital. Traumatic brain injuries and facial injuries were mostly overdiagnosed (13.5% and 14.7%, respectively documented by an emergency physician while the diagnosis was not confirmed in-hospital). Chest injuries were underdocumented (17.3% missed by an emergency physician while the diagnosis was finally confirmed in-hospital). The total mortality of all groups was very close to the expected mortality calculated with the revised injury severity classification II(RISC II)-score (12.0% vs. 11.3%).

CONCLUSION

In the prehospital care of severely injured patients, the overall injury severity is often correctly recorded by the emergency physician and correlates well with the derived treatment, the selection of the receiving hospital as well as the clinical course and the patient outcome; however, the assessment of injuries of individual body regions seems to be challenging in the prehospital setting.

[Prehospital assessment of injury type and severity in severely injured patients by emergency physicians : An analysis of the TraumaRegister DGU®]

BACKGROUND

Prehospital assessment of injury type and severity by emergency medical services physicians impacts treatment including appropriate destination hospital selection, especially in (potentially) life-threatening cases. Injuries which are underestimated or overlooked by the emergency physician can delay adequate therapy and thus significantly influence the overall outcome. The current study used data from the TraumaRegister DGU® to evaluate the reliability of prehospital injury assessments made by emergency physicians.

MATERIAL AND METHODS

Data of 30,777 patients from the TraumaRegister DGU® between 1993 and 2009 were retrospectively evaluated. Using the abbreviated injury scale (AIS), subjective prehospital assessments of injury severity by emergency physicians were correlated with objectively identified injuries diagnosed after admission to hospital. For this evaluation, prehospital injury assessments rated moderate or severe by the emergency physician as well as injuries diagnosed in hospital with an AIS score ≥3 points were deemed relevant.

RESULTS

The 30,777 patients with an injury severity score (ISS) ≥ 9 suffered a total of 202,496 injuries and of these 26 % (51,839 out of 202,496) were considered relevant with an AIS ≥3 points. The most frequent relevant injuries were to the head (47 %) and chest (46 %). Of the 51,839 relevant injuries, the prehospital assessment by the emergency physician was accurate for 71 % and in 29 % of the cases relevant injuries were underestimated. Relevant injuries were unrecognized or underestimated in prehospital assessments for almost 1 out of every 7 cases of head trauma, almost 1 out of every 3 thoracic trauma and almost 1 out of every 2 abdominal and pelvic trauma.

CONCLUSION

The assessment of injury severity by emergency medical services physicians based on physical examination at the scene of the trauma is not very reliable. Thus, mechanisms of injury and overall presentation as well as identifiable injuries and vital parameters should be recognized by the emergency physician when considering treatment strategies and choice of appropriate destination hospital. The patient should be re-evaluated in a priority-oriented manner at the latest on arrival in the trauma room to avoid the consequences of unrecognized or underestimated injuries.

Statewide tracking of crash victims' medical system utilization and outcomes

BACKGROUND

For the study year, the state of Massachusetts had the lowest fatal motor vehicle crash rate in the nation. The state was interested in exploring new approaches to save additional lives. The study goal was to determine the potential for Massachusetts's medical system to reduce fatalities through alternative utilization of existing transport methods, treatment hospital types, and victim pathways.

METHODS

This was a 1-year retrospective statewide population-based study of all persons involved in a trafficway motor vehicle crash in which at least one person died within 30 days. Database linkage was used to track the pathway and outcome of every involved victim from the crash scene, including air medical and ground ambulance utilization, community or trauma center treatment, and interhospital transfers; air and trauma center (TC) scene triage levels were computed retrospectively. All crash and hospital locations were geomapped and confounding factors were included.

RESULTS

Air and ground scene transports to TCs were underutilized by 7:1 and 4.5:1, respectively. No request was the major reason for air underutilization. Underutilization was associated with reduced lived-to-died ratio (L/D) by pathway of up to 10:1. Statewide, air transport to Level I trauma centers had both the highest (1.0, scene) and lowest L/Ds (0.6, interfacility). A 4.5:1 difference in L/D was associated with fulfilled versus unfulfilled air requests. By emergency medical service region, L/D varied by nearly 3:1 and utilization of scene air and TC transports by 5:1 and 4:1. Victim helicopter emergency medical services transport to a TC with an Injury Severity Score > or =19 was identified as critical and was associated with L/D differences of 3.7:1. The paradox of lower L/D for scene air transports to TCs occurring simultaneously with higher overall system L/D was observed and explained. System-based L/D differences of 1.8:1 were observed associated with increases in appropriate triage. Results that explain the "golden hour" effect are shown and discussed.

CONCLUSION

Appropriate scene triage decision-making and the resulting victim pathways are associated with systemwide L/D increases of 1.8:1. On that basis, potentially 53 to 90 lives in this study (13% to 22% of the statewide total) could have been saved.

Realistic assessment of the physican-staffed emergency services in Germany

In Germany the emergency medical services, which include dispatching emergency physicians to the scene, are considered to be among the best in the world. However, the hospitals admitting these patients still report shortcomings in prehospital care. The quality of an emergency medical service depends on both formal qualification and experience in managing such emergencies. Therefore, we determined how frequently emergency medical service physicians in Germany actually encountered complex and demanding emergency situations outside the hospital and how often they had to carry out emergency interventions. We therefore evaluated data from more than 82,000 ground emergency medical service scene calls registered in the MIND ("minimaler Notarztdatensatz") data base of the state of Baden-Wuerttemberg, Germany and more than 47,000 helicopter emergency medical service scene calls from the "Luftrettungs-, Informations- und Kommunikationssystem" (LIKS) data base of the German ADAC air rescue service. The results, which were unexpectedly distinct, impressively demonstrate that in part emergency medical service staff only encountered some emergencies very rarely. In particular, patients with life-threatening conditions such as acute coronary syndrome, stroke, head trauma, as well as multiple trauma were only treated once every 0.4-14.5 months and cardiopulmonary resuscitation and intubation were only carried out once every 0.5-1.5 months. Furthermore, a time period of 6 months to more than 6 years may pass before a chest tube has to be placed. There are, of course, considerable differences between ground and helicopter emergency medical services. Particularly in areas where the frequency of such emergency cases is low, the clinical experience required to competently manage a demanding emergency situation cannot be gained or maintained just by working in the emergency medical system. As a result of the general pressure to cut costs and also of changes in hospital politics, however, only highly qualified and experienced emergency medical services may survive in Germany in the long term. In addition to formal qualifications and accompanying practice-related courses, future emergency medical service personnel should be drafted from clinical department staff that are experienced in treating severely ill and severely injured patients.

[Preclinical management of multiple trauma]

Approximately 8000 patients with multiple trauma are admitted annually to an emergency room in Germany. The prognosis of these severely injured patients is influenced in particular by concomitant craniocerebral injury, an abdominal wound, or thoracic trauma. Hypoxia and hypotension subsequent to shock induced by hemorrhagic-traumatic effects are of prime importance. Preclinical management thus includes examining the injured patient, immobilizing the spine, ensuring airway patency, stabilizing cardiovascular status suitting the approach to the injury pattern, commensurate care of partial injuries, pain therapy, as well as rapid and careful transportation to the nearest qualified trauma center. Management of patients with multiple trauma poses a particular challenge to the responding team. This article in the continuing education series deals with current algorithms for preclinical management of patients with multiple injuries with particular focus on the significant factor of time.

Invasive Techniken in der Notfallmedizin

Based on written surveys conducted during the series of workshops entitled "Invasive emergency techniques (INTECH)" the aim of this study was to characterize defined qualifications of emergency physicians and to discuss by examples whether strictly practice-oriented workshops represent a suitable means of closing the apparent gaps in training. Our data show clearly that even experienced emergency physicians indicated that they lack training in carrying out preclinical invasive emergency procedures such as chest tube, cricothyrotomy and intraosseous access. Furthermore, they are only very seldom confronted with emergency situations in which these procedures could decidedly affect the survival of a patient and which, at the same time, put them under extremely high emotional pressure. Thus, the didactic concept of continuing education workshops that are strictly practice-oriented and that focus in particular on problem areas in emergency medicine, can contribute significantly to help close the gaps in training and ensure that emergency physicians are highly qualified.

Impact of helicopter transport and hospital level on mortality of polytrauma patients

BACKGROUND

Despite numerous studies analyzing this topic, specific advantages of helicopter transport of blunt polytrauma patients as compared with ground ambulances have not yet been identified unequivocally.

METHODS

Four possible pathways in 403 polytrauma patients (Injury Severity Score [ISS] > 16) who were in reach of the helicopter emergency medical service (HEMS) Dresden were analyzed as follows: HEMS-UNI group (n = 140), transfer by HEMS into a university hospital; AMB-REG group (n = 102), transfer by ground ambulance into a regional (Level II or III) hospital; AMB-UNI group (n = 70), transfer by ground ambulance into the university hospital; and INTER group (n = 91), transfer by ground ambulance into a regional hospital, followed by transfer to the university hospital. Scores used were the ISS and the TRISS. Tests used for statistical analysis included chi2 and Fisher's tests. Statistical significance was set at p > 0.05.

RESULTS

Age, gender, and mean ISS (range, 33.3-35.6) revealed extensive homogeneity of the groups. Mortality of the AMB-REG group was almost doubled (41.2%) compared with HEMS-UNI (22.1%) patients (p = 0.002). The AMB-UNI group displayed the lowest mortality (15.7%, p = not significant). TRISS analysis (PRE-Chart) revealed identical outcome for AMB-UNI and HEMS-UNI patients. Rescue time averaged 90 +/- 29 minutes for HEMS-UNI patients, 68 +/- 25 minutes for AMB-UNI patients, and 69 +/- 26 minutes for the AMB-REG group.

CONCLUSION

Primary transfer by HEMS into a Level I trauma center reduces mortality markedly. In principle, this benefit can be attributed to superior preclinical therapy, primary admission to a Level I trauma center, or both. However, the identical probability of survival of the AMB-UNI and HEMS-UNI groups in this and comparable studies does not confirm generally better survival rates on account of a more aggressive on-site approach.

[The future of preclinical emergency medicine in Germany]

Against the background of an ever-increasing shortage of financial support, closure of smaller hospitals and shortage of personnel in the medical branch, the necessity of the Federal emergency system is being increasingly called into question. In reality the number of missions which are relatively indicated are clearly increasing nationwide: an emergency doctor is not absolutely necessary in many situations. However, for complex emergency situations in Germany, an emergency medical system must remain an integral component of the preclinical care system in addition to the well-trained rescue service personnel. Hereby it is less important to have more emergency medical doctors, but more important to have a higher emergency medical qualification, possibly by a reduction in the density of emergency service stations. By the introduction of a ranked assistance system and the inclusion of "first responders", the time period before the arrival of the highly qualified emergency medical doctor can be bridged by qualified paramedics and general practitioners. The impulse of the legislators, assimilation of the rescue service acts, restructuring of rescue service catchment areas and the introduction of integrated demand-oriented control stations with a consequent quality management system as well as the implementation of a medical leader rescue system can reduce costs and further improve the quality of the emergency medical rescue system.