Predictors for Direct to Operating Room Admission in Severe Trauma

Efficacy of Group O Washed Red Blood Cell Transfusion on Vital Signs and Hematologic Stability in Trauma Patients With Different Blood Types

Objective

To comprehensively assess the impact of emergency transfusion of group O washed red blood cells on the vital signs and hematological parameters of patients with severe trauma and to analyze the differential responses among different blood types, thereby providing valuable evidence for optimizing transfusion strategies.

Methods

A retrospective analysis was conducted on the clinical data of patients with severe trauma who underwent emergency transfusion in the hospital's emergency department from April 2023 to March 2024. Changes in blood biochemical indexes and vital signs before and after transfusion were compared, and adverse transfusion reactions were monitored.

Results

A total of 65 patients were included in the study, and no adverse transfusion reactions were observed. The shock index (SI) score was 1.07 ± 0.28. Significant changes were noted in platelet count (PLT), activated partial thromboplastin time (APTT), and C-reactive protein (CRP) following transfusion (P < 0.05). Both blood pressure and SI enhanced significantly after transfusion (P < 0.05), although no significant change in heart rate (HR) was detected (P = 0.87). Patients with blood group A experienced a significant reduction in HR post-transfusion. In patients with blood groups AB or O, systolic blood pressure (SBP) significantly increased, and SI significantly decreased. Additionally, patients with blood group O revealed a significant rise in diastolic blood pressure (DBP) post-transfusion, with the differences being statistically significant (P < 0.05).

Conclusion

Timely and effective transfusion of group O washed red blood cells is crucial for stabilizing the vital signs of patients with severe trauma. This approach is not only safe but also feasible, with blood type influencing the response to transfusion. Larger, multi-center studies are warranted to further validate these findings and enhance the generalizability.

Real-time attending trauma surgeon assessment of direct-to-operating room trauma resuscitations: Results from a prospective observational study

BACKGROUND

Direct-to-operating room (DOR) resuscitation expedites interventions for trauma patients. Perceived benefit from the surgeon's perspective is not well known. This study assesses the integration of a real-time surgeon assessment tool into a DOR protocol.

METHODS

Surgeon assessment tool results from a prospective study of DOR cases were analyzed. Analysis assessed patient factors and surgeon perception for appropriateness and benefit of DOR. Multivariate analysis identified independent factors associated with perceived DOR benefit.

RESULTS

A total of 104 trauma patients underwent DOR resuscitation; 84% were perceived as appropriate triage, and 48% as beneficial. Patients with Injury Severity Score of >15 (50% vs. 28%), systolic blood pressure of <90 mm Hg (24% vs. 9%), and severe abdominal injury (28% vs. 9%) had higher perceived DOR benefits (all p < 0.05). Patients deemed to benefit from DOR underwent more emergent interventions or truncal surgery (44% vs. 92%, p < 0.01). No difference in benefit was seen based on age, sex, Glasgow Coma Scale score of <9, or injury mechanism. Forty-four percent had perceived benefit from DOR resuscitation despite requiring imaging after initial evaluation. Patients with perceived benefit had a higher rate of unplanned return to the operating room (16% vs. 2%, p < 0.05), but no differences in complication rates, Glasgow Outcome Score, or mortality. Injury Severity Score of >15 was the only independently associated variable with a perceived benefit on surgeon assessment tool (odds ratio, 3.5; p < 0.05).

CONCLUSION

The majority of DOR resuscitations were deemed as appropriately triaged, and approximately half had a perceived benefit. Benefit was associated with higher injury severity and the need for urgent interventions but was not predicted by injury mechanism or other triage variables.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

A systematic review of emergency room laparotomy in patients with severe abdominal trauma

Traumatic intra-abdominal hemorrhage contributes to mortality in patients with trauma. However, initiating an emergent laparotomy in the operating room (OR) as a standard treatment can sometimes be time-consuming. To overcome this issue, laparotomy is performed in the emergency room (ER) in some institutions. This systematic review evaluates the efficacy of performing ER laparotomy. Comprehensive searches were conducted in MEDLINE PubMed, EMBASE, and Cochrane databases, up to August 9, 2024. The risk of bias in observational studies was assessed using the ROBINS-I tool. The primary outcome was mortality following ER laparotomy, and the secondary outcome was time from admission to first laparotomy. The review included 10 studies, all of which were observational. A meta-analysis was not performed due to substantial heterogeneity and insufficient data. Mortality rates after ER laparotomy ranged from 23 to 100%. Mortality rates were 23.0-66.7% in the conventional ER group, while they were 0-30% in the OR group. In the hybrid ER group, the 28-day mortality rates were 12.7-15%, compared to 21.7-22% in the conventional group. The time from admission to the first laparotomy was 17-43 min (median) in the conventional ER group, compared to 40-111 min (median) in the OR laparotomy group. In the hybrid ER setting, the time from admission to intervention, including laparotomy, was 35-48 min (median), whereas it was 72-101 min (median) in the conventional group. A high and unclear risk of bias due to confounding was noted across the studies. ER laparotomy may provide rapid bleeding control. However, due to the limited number of studies and significant heterogeneity among the studies reviewed, the true effect size of ER laparotomy in conventional and hybrid ER settings remains unclear.

Prehospital Extended FAST Exams Improve Clinical Decision Making by Helicopter EMS Crews: A Retrospective Case Series

Point of Care Ultrasound (POCUS) has seen increasing use in the prehospital environment over the last decade, primarily with the extended focused assessment with sonography in trauma (eFAST) exam. Previous studies have shown prehospital eFAST exams are feasible in the helicopter transport environment but have yet to demonstrate effects on clinical care. This retrospective case series identified 655 patients with blunt thoraco-abdominal trauma or concern for pneumothorax due to penetrating injury transported by a single helicopter EMS (HEMS) program over a two-year period after introducing POCUS. Of those patients, 258 received prehospital ultrasound which was reported to change clinical care in seven cases (2.7%, 95%-CI [1.1-5.5]). This was primarily through preventing unnecessary needle thoracostomy and initiating blood transfusion for treatment of hemorrhagic shock in cases where the degree of shock was unclear due to inconsistent vital signs. This study highlights the improvements in clinical care that may result from the introduction of eFAST exams in the prehospital environment.

Prehospital Ultrasound: Nationwide Incidence from the NEMSIS Database

OBJECTIVE

We sought to describe prehospital ultrasound (PHUS) use and trends in PHUS utilization over time using a national database.

METHODS

Using the 2018 - 2021 National Emergency Medical Services Information System databases, we identified those EMS activations where PHUS was performed. We evaluated the association between year and number of PHUS exams performed using univariable and multivariable regression analysis. Analysis was performed on the overall group and various subgroups.

RESULTS

In total, there were 148,709,000 EMS activations by 13,899 agencies over the 4 years. Of these, 3,291 unique activations (0.002%) involved PHUS, performed by 71 EMS agencies (0.5%). The annual rate of ultrasound evaluations per 1 million EMS activations significantly increased over the study period: 5.2 in 2018, 14.8 in 2019, 18.6 in 2020, and 38.9 in 2021 (p < 0.01). The number of agencies performing PHUS each year increased over the study period from 11 in 2018 to 54 in 2021 (p < 0.05). Each year after 2018 had an increased odds of PHUS use demonstrated with logistic regression (p < 0.01). PHUS was used in each US census region, and paramedics performed most of the PHUS exams (75.5%). We identified 1,060 out-of-hospital cardiac arrest, 820 trauma, and 427 respiratory PHUS cases. These three cohorts accounted for 70.1% of all PHUS cases.

CONCLUSION

Prehospital ultrasound use in the United States increased significantly over the study period, but remains exceedingly rare. The performance of PHUS was recorded throughout the United States, with paramedics performing the majority of PHUS studies included in this database.

Outcomes After Transfer of Pediatric Trauma Patients: Does Everyone Need to Visit the Trauma Bay?

INTRODUCTION

Critically injured children and teens often present to adult trauma centers or nontrauma facilities prior to transfer to a pediatric trauma center. For pediatric patients wanting transfer to the intensive care unit (ICU), there is little data to guide which can be safely transferred directly to the unit, and which should be evaluated first in the trauma bay.

METHODS

We used our institutional trauma registry to evaluate transferred trauma patients over a three year period. We compared time to imaging, time to operating room, and overall mortality between the group evaluated first in the emergency room and those transferred directly to the ICU.

RESULTS

When adjusted for other variables, there was no increased mortality in those transferred directly to the ICU. While there was a higher nonadjusted mortality in those transferred to the ICU (13% versus 3.7%), these nonsurvivors had a lower GCS (3 versus 13), higher Pediatric Risk of Mortality scores, and a high rate of severe head trauma. There was no significant delay in ordered imaging or procedures.

CONCLUSIONS

In patients, who have been assessed at another institution prior to transfer to the pediatric ICU, transfer directly to the ICU, bypassing the emergency department, does not delay interventions and does not appear to worsen outcomes.

Helicopter Emergency Medical Services Performed Extended Focused Assessment With Sonography: Training, Workflow, and Sustainable Quality

The extended focused assessment of trauma (EFAST) examination is an invaluable tool for the initial evaluation of the trauma patient. Miniaturization of ultrasound has enabled helicopter emergency medical services (HEMS) to use point-of-care ultrasound to care for trauma patients on scene. Our study demonstrated that HEMS crews accurately performed EFAST examinations after the implementation of a novel HEMS EFAST workflow, multifaceted training, and ongoing quality assurance. The HEMS crews' overall sensitivity was 53%, and specificity was 98%. The obtained image quality was highest for the lung, cardiac, and right upper quadrant components of the EFAST. Our results suggest that with a structured multifaceted training program, user-friendly workflow, and ongoing quality assurance, HEMS crews can perform EFAST examinations safely and reliably in the field. This would allow HEMS crews to detect life-threatening, time-sensitive conditions such as a pneumothorax, pericardial effusion, and intraperitoneal hemorrhage. HEMS EFAST has the potential to triage certain trauma patients directly to the operating room or newly emerging hybrid suites, bypassing the emergency room and saving crucial time.