Preventable death evaluation of the appropriateness of the on-site trauma care provided by Urgences-Santé physicians

Preventable death in trauma: A systematic review on definition and classification

PURPOSE

Trauma-related preventable death (TRPD) has been used to assess the management and quality of trauma care worldwide. However, due to differences in terminology and application, the definition of TRPD lacks validity. The aim of this systematic review is to present an overview of current literature and establish a designated definition of TRPD to improve the assessment of quality of trauma care.

METHODS

A search was conducted in PubMed, Embase, the Cochrane Library and the Web of Science Core Collection. Including studies regarding TRPD, published between January 1, 1990, and April 6, 2021. Studies were assessed on the use of a definition of TRPD, injury severity scoring tool and panel review.

RESULTS

In total, 3,614 articles were identified, 68 were selected for analysis. The definition of TRPD was divided in four categories: I. Clinical definition based on panel review or expert opinion (TRPD, trauma-related potentially preventable death, trauma-related non-preventable death), II. An algorithm (injury severity score (ISS), trauma and injury severity score (TRISS), probability of survival (Ps)), III. Clinical definition completed with an algorithm, IV. Other. Almost 85% of the articles used a clinical definition in some extend; solely clinical up to an additional algorithm. A total of 27 studies used injury severity scoring tools of which the ISS and TRISS were the most frequently reported algorithms. Over 77% of the panels included trauma surgeons, 90% included other specialist; 61% emergency medicine physicians, 46% forensic pathologists and 43% nurses.

CONCLUSION

The definition of TRPD is not unambiguous in literature and should be based on a clinical definition completed with a trauma prediction algorithm such as the TRISS. TRPD panels should include a trauma surgeon, anesthesiologist, emergency physician, neurologist, and forensic pathologist.

Effects of Early Prehospital Life Support to War Injured: The Battle of Jalalabad, Afghanistan

Objective:

To study the effects of early, advanced prehospital life support on the survival rate of war casualties during the battle of Jalalabad, Afghanistan from 1989–1992.

Method:

The outcomes of simple trauma care administered from 1989–1990 were compared to the outcomes of advanced trauma care administered from 1991–1992 in the combat zone. The outcomes were measured by the number of deaths at admission to the referral surgical hospitals in Pakistan.

Results:

A total of 3,890 war casualties were treated in the combat zone by paramedics, and were evacuated through light, forward, field clinics to surgical hospitals in Pakistan. Advanced trauma care that was administered in the combat zone reduced the prehospital mortality rate from 26.1% to 13.6% (95% confidence interval for difference = 9.7–15.4%).

Conclusion:

In scenarios with protracted evacuation, early and advanced trauma care should be included in the chain of survival. Local paramedics can provide such trauma care with a minimum of resources.

Recommendations for Uniform Reporting of Data following Major Trauma — The Utstein Style: An Initiative

The document is published in collaboration with the following organisations: the European Society of Emergency Medicine (Leuven); the European Resuscitation Council (Antwerpen); the Air Medical Physician Association (Salt Lake City, US); the German Interdisciplinary Association of Critical Care Medicine; and the German Society of Anaesthesiology and Intensive Care. The document is to be published jointly in the following journals: 1) Trauma Care (ITACCS); 2) Resuscitation; 3) Prehospital and Disaster Medicine; 4) European Journal of Emergency Medicine; 5) Trauma and Emergency Medicine Journal (SA); 6) Emergency Medicine(Norway); 7) JEUR; and 8) Notfall und Rettungsmedizin (Germany).

Rural EMS en route IV insertion improves IV insertion success rates and EMS scene time

BACKGROUND

Emergency medical service (EMS) personnel are trained to insert intravenous (IV) lines at trauma scenes if the time for insertion does not prolong scene time. However, EMS providers continue to insert IV lines on scene.

METHODS

A rural EMS provider provided trauma patient EMS IV insertion data for a 1-year period. No IV lines were inserted en route during this period. During the following 1-year period, a prospective trauma patient study protocol was instituted in which all IV insertions were attempted while en route to the emergency room.

RESULTS

Three hundred six trauma patients had IV attempts on scene, and 341 trauma patients had IV insertion attempts en route. The average EMS on-scene time with IV insertions on scene was 19.8 minutes (IV insertion success, 79%) compared with 13.9 minutes (IV insertion success, 93%) on-scene time with IV insertions en route.

CONCLUSIONS

EMS IV insertion en route significantly decreases on-scene time and improves IV insertion success rates.

On-Scene Intravenous Line Insertion Adversely Impacts Prehospital Time in Rural Vehicular Trauma

Fatality rates from rural vehicular trauma are almost double those found in urban settings. Increased emergency medical services (EMS) prehospital time has been implicated as one of the causative factors for higher rural fatality rates. Advanced Trauma Life Support guidelines suggest scene time should not be extended to insert an intravenous catheter (IV). The purpose of this study was to assess the association between intravenous line placement and motor vehicle crash (MVC) scene time in rural and urban settings. An imputational methodology using the National Highway Traffic Safety Administration Crash Outcome Data Evaluation System permitted linkage of data from police motor vehicle crash and EMS records. Intergraph GeoMedia software permitted this linked data to be plotted on digital maps for segregation into rural and urban groups. MVCs were defined as rural or urban by location of the accident using the U.S. Bureau of Census Criteria. Linked data were analyzed to assess for EMS time on-scene, on-scene IV insertion, on-scene IV insertion attempts, and patient mortality. Over a 2-year period from January 2001 through December 2002, data were collected from Alabama EMS patient care reports (PCRs) and police crash reports. A total of 45,763 police crash reports were linked to EMS PCRs. Of these linked crash records, 34,341 (75%) and 11,422 (25%) were injured in rural and urban settings, respectively. Six hundred eleven (1.78%) mortalities occurred in rural settings and 103 (0.90%) in urban settings (P < 0.005). There were 6,273 (18.3%) on-scene IV insertions in the rural setting and 1,290 (11.3%) in the urban setting (P < 0.005). Mean EMS time on-scene when single IV insertion attempts occurred was 16.9 minutes in the rural setting and 14.5 minutes in the urban setting (P < 0.0001). When two attempts of on-scene IV insertion were made, mean EMS time on-scene in the rural setting (n = 891 [2.6%]) was 18.4 minutes and 15.7 minutes in the urban setting (n = 142 [1.2%; P < 0.005). Excluding dead on-scene patients, mean EMS time on-scene when mortalities occurred in rural and urban settings was 18.9 minutes and 10.8 minutes, respectively (P < 0.005). On-scene IV insertion occurred with significantly greater frequency in rural than urban settings. This incurs greater EMS time on-scene and prehospital time that may be associated with increased vehicular fatality rates in rural settings.

Military anti-shock garment: Historical relic or a device with unrealized potential?

Military anti-shock trousers represents a medical device which has engendered very divergent views, even up to today. From the time the concept was formulated in 1903 by surgeon George W Crile, there have been significant swings in opinion and evidence. The guidelines, where available, are often kept relatively general and cautious. As a spin-off to the mechanism and technology, several alternative devices have been proposed or developed over the years. This include the auto-transfusion torniquet, the non pneumatic anti-shock garment (Life Wrap) and the non inflatable antishock garment, which are discussed in this paper.

Emergency Medical Service (EMS) systems in developed and developing countries

OBJECTIVES

To compare patient- and injury-related characteristics of trauma victims and pre-hospital trauma care systems among different developed and developing countries.

METHOD

We collated de-identified patient-level data from national or local trauma registries in Australia, Austria, Canada, Greece, Germany, Iran, Mexico, New Zealand, the Netherlands, the United Kingdom and the United States. Patient and injury-related characteristics of trauma victims with injury severity score (ISS) >15 and the pre-hospital trauma care provided to these patients were compared among different countries.

RESULTS

A total of 30,339 subjects from one or several regions in 11 countries were included in this analysis. Austria (51%), Germany (41%) and Australia (30%) reported the highest proportion of air ambulance use. Monterrey, Mexico (median 10.1min) and Montreal, Canada (median 16.1min) reported the shortest and Germany (median: 30min) and Austria (median: 26min) reported the longest scene time. Use of intravenous fluid therapy among advanced EMS systems without physicians as pre-hospital care providers, varied from 30% (in the Netherlands) to 55% (in the US). The corresponding percentages in advanced EMS systems with physicians actively involved in pre-hospital trauma care, excluding Montreal in Canada, ranged from 63% (in London, in the UK) to 75% in Germany and Austria. Austria and Germany also reported the highest percentage of pre-hospital intubation (61% and 56%, respectively).

CONCLUSION

This study provides an early look at international variability in patient mix, process of care, and performance of different pre-hospital trauma care systems worldwide. International efforts should be devoted to developing a minimum standard data set for trauma patients.

Implementation of a Trauma Care System: Evolution Through Evaluation

BACKGROUND

The regionalization of trauma services has been implemented in many health care systems and communities over the past 10 to 20 years. As these trauma systems mature and evolve, changes are made to improve the care and efficiency of the system. Trauma care regionalization was introduced in Quebec in 1993. This study looked at the evolution of trauma care in Quebec over the past 13 years, from the preregionalization era to the present.

METHODS

A retrospective review scientifically evaluated a trauma system, the implementation of evidence-based changes, and the efficacy of these changes.

RESULTS

Various changes have been made in the Quebec trauma system since the introduction of regionalization. These changes have led to an incremental decrease in mortality caused by severe trauma from 51.8% in 1992 to 8.6% in 2002.

CONCLUSION

A trauma system is fluid and constantly evolving. Research and constant reevaluation are necessary for continuous evaluation of the system and improvement of its outcomes and efficiency.

Development of trauma systems and effect on outcomes after injury

The ideal system for management of trauma remains controversial, especially in respect of prehospital care and regionalisation of trauma-care delivery. To explore these issues, we compare two differing trauma systems--in the USA the focus is on the trauma centre, with a lesser emphasis on prehospital care, whereas in France there is more emphasis on prehospital care coordinated by the Service d'Aide Médicale Urgente. We describe the historical developments, current structure, and major controversies with regard to trauma-care delivery in the two countries. Comparative evidence on the effectiveness of the two systems was obtained through a structured review of databases, but very little evidence permits direct comparison of outcomes across the two systems. Crude injury mortality rates and fatality rates from motor-vehicle accidents (crashes in US usage) are higher in France than in the USA, although adjustment for potential confounders is difficult. Adjusted mortality rates suggest equivalent outcomes among patients who survive to hospital, although these data are confounded by the lack of a contemporaneous comparator population. There are differences in the American and French trauma systems that might translate into measurable differences in trauma-related mortality. However, the lack of data to allow comparison of outcomes between countries significantly impedes the identification and implementation of components of a trauma system that are effective and the discarding of those that offer little benefit.

Rapid response car as a supplement to the helicopter in a physician-based HEMS system

BACKGROUND

The purpose of this study was to describe the use of a rapid response car (RRC) as a supplement to the ambulance helicopter in a mixed urban/rural region in Norway.

METHODS

Data from all the requested missions were collected from standard flight records. Operational factors, patient characteristics, primary diagnosis, treatment and modes of transport were registered and analyzed retrospectively.

RESULTS

In 1999-2001, a total of 4777 requests were included in the study, resulting in the initiation of 3172 helicopter and 752 RRC missions. In the RRC missions, 224 patients received advanced medical treatment that would otherwise not have been provided. For 181 patients, the availability of the RRC was crucial for receiving the treatment of the helicopter emergency medical services (HEMS). The cost of equipping the base with the RRC increased the annual budget by less than one percent.

CONCLUSION

The RRC was essential for solving missions in periods of non-flying conditions. The RRC increased the availability of the advanced prehospital life support offered by the HEMS in this region. Taking the modest increase in cost into consideration, it seems reasonable that this HEMS, covering mixed urban and rural areas, is equipped with such a vehicle.

Anaesthesia in trauma

Trauma patients may need to be anaesthetized at the scene of an accident, in the emergency department or most commonly in the operating theatre. The principles of safe management of anaesthesia in each of these very different environments are discussed along with the common anaesthetic problems encountered and advice on their solution.

Trauma deaths in an Italian urban area: an audit of pre-hospital and in-hospital trauma care

In Italy, a comprehensive regional study of trauma deaths has never been performed. We examined the organization and delivery of trauma care in the city area of Milan, using panel review of trauma deaths. Two panels evaluated the appropriateness of care of all trauma victims occurred during 1 year, applying predefined criteria and judging deaths as not preventable (NP), possible preventable (PP), and definitely preventable (DP). Two hundred and fifty-five deaths were reviewed. Blunt trauma were 78.04% and motor vehicle crashes accounted for over 50%. Most victims (73.72%) died during pre-hospital settings and 91.1% died within the first 6h, principally because of central nervous system injuries in blunt and hemorrhage in penetrating trauma. Panels judged 57% of deaths NP, 32% PP, 11% DP (inter-panel K-test 0.88). Preventable deaths were higher after in-hospital admission. Main failures of treatment were lack in airway control or intravenous infusions in pre-hospital and mismanagement with missed injuries in emergency department. The high rate of avoidable deaths in Milan supports the need of trained pre-hospital personnel and of well equipped referring hospitals for trauma.

Prehospital advanced life support provided by specially trained physicians: is there a benefit in terms of life years gained?

BACKGROUND

The benefit of prehospital advanced life support (ALS) is disputed, as is the prehospital use of specially trained, hospital-based physicians. The purpose of the study was to assess the health benefit from an anesthesiologist-manned prehospital emergency medical service (EMS), and to separate the benefit of the anesthesiologist from that of rapid transport.

METHODS

The anesthesiologist-manned helicopter and rapid response car service at Rogaland Central Hospital assisted 1106 patients at the scene during the 18-month study period. Two expert panels assessed patients with a potential health benefit for life years gained (LYG) using a modified Delphi technique. The probability of survival as a result of the studied EMS was multiplied by the life expectancy of each patient. The benefit was attributed either to the anesthesiologist, the rapid transport or a combination of both.

RESULTS

The expert panels estimated a benefit of 504 LYG in 74 patients (7% of the total study population), with a median age of 54 years (range 0-88). The cause of the emergency was cardiac diseases (including cardiac arrest) in 61% of the 74 patients, trauma in 19%, and cardio-respiratory failure as a result of other conditions in 20%. The LYG were equally divided between air and ground missions, and the majority (88%) were attributed solely to ALS by the anesthesiologist.

CONCLUSION

The expert panels found LYG in every 14th patient assisted by this anesthesiologist-manned prehospital EMS. There was no difference in LYG between the helicopter and the rapid response car missions. The role of the anesthesiologist was crucial for health benefits.

Implementation of standing field treatment protocols in an urban EMS system

The objective was to describe our experience with implementation of standing field treatment protocols (SFTP) in a large, urban EMS system. A prospective, consecutive observational study examining the first 21 days of implementation of SFTPs in the City of Los Angeles, California. SFTPs were developed for 7 medical chief complaints and all major trauma patients. There were 13,586 EMS incidents, of which 4,037 (30%) received ALS treatment. SFTPs were used on 2,177 of these incidents, representing 54% of all ALS runs and 16% of all EMS incidents. The most frequently used SFTPs were for altered level of consciousness (29%), and chest pain (25%). The most common errors found were failure to document reassessment of the patient after each medication administration (45% fallout rate), and failure to document and attach a copy of the ECG to the EMS report (40%). The mean fallout rate for failure to establish or attempt IV access, administer oxygen, or provide cardiac monitoring was 7%. Out of 1,450 incidents with outcome data provided by the receiving hospitals, only 3 cases (2%) involved incorrect treatment, with an additional 2 involving the unnecessary use of lidocaine. None of these instances resulted in adverse effects or complications. SFTPs were integrated into a large EMS system with few procedural errors or adverse outcomes.

Emergency medical services assessment and treatment of children with special health care needs before and after specialized paramedic training

INTRODUCTION

This study evaluates whether a continuing education program for paramedics, focusing on Children with Special Health Care Needs, improved paramedics' assessment and management.

METHODS

Emergency Medical Services responses for children, 21 years of age or younger, with a congenital or acquired condition or a chronic physical or mental illness, were identified. The responses before and after the specialized education program were reviewed by a multidisciplinary team to evaluate assessment and management of the children. Interreviewer agreement between the nurses on the team and between the physicians on the team was assessed. We also evaluated whether there was an improvement in assessment and care by paramedics completing our education program.

RESULTS

Significant improvement was seen in appropriate assessment and overall care by paramedics who completed our specialized education program. Reviewers also noted an appropriate rating for the initial assessment category more often for responses involving paramedics who had the training. Agreement on whether assessment and treatment was appropriate for all five reviewers varied considerably, ranging from 32% to 93%. Overall there was a high percentage of agreement (>70%) between the nurses and between the physicians on most items. However, kappa statistics did not generally reflect good agreement except for most of the focused assessment items and some treatment and procedure items.

CONCLUSION

Most of the documentation on the EMS records indicated appropriate assessment and treatment during all responses for Children with Special Health Care Needs. Nevertheless, the results indicate that paramedics may improve their assessment and management of these children after specialized continuing education.

Prehospital care and survival of pediatric patients with blunt trauma

BACKGROUND

The aim of this study was to compare the outcome of severe blunt trauma in children receiving prehospital care from either physician-staffed advanced life support (ALS) units, or from basic life support (BLS) units staffed by emergency medical technicians.

METHODS

The records of 288 children with severe blunt trauma who required intensive care in the regional level 1 trauma center or who died from their injuries were analyzed retrospectively. Patients were excluded if resuscitation at the scene was not attempted, if the level of prehospital care was unspecified, or if arrival at the level 1 trauma center was delayed beyond 150 minutes. Seventy-two patients met the inclusion criteria of BLS-, and 49 the criteria of ALS-prehospital care.

RESULTS

A reduced mortality rate (22.4% v 31.9%) was seen in the ALS group, which was more apparent in a "salvageable but high-risk" subgroup, characterized by Glasgow Coma of Scale 4 through 8, Pediatric Trauma Score of 0 through 5, and Injury Severity Score (ISS) of 25 through 49. However, a statistically significant difference was only seen when trauma severity was evaluated by the ISS.

CONCLUSION

An improved outcome in children with severe blunt trauma has been demonstrated when prehospital care is provided by physician-staffed ALS units compared with BLS units.

Ineffectiveness of on-site intravenous lines: is prehospital time the culprit?

The purpose of the present study was to test the association between on-site intravenous fluid replacement and mortality in patients with severe trauma. The effect of prehospital time on this association was also evaluated. The design was that of an observational quasi-experimental study comparing 217 patients who had on-site intravenous fluid replacement (IV group) with an equal number of matched patients for whom this intervention was not performed (no-IV group). The patients were individually matched on their Prehospital Index obtained at the scene and were included in the study if they had an on-site Prehospital Index score > 3 and were transported alive to the hospital. The outcome measure of interest was mortality because of injury. The patients in the IV group had a significantly lower mean age (37 vs. 45 years; p < 0.001) and higher incidence of injuries to the head or neck (46 vs. 32%; p = 0.004), chest (34 vs. 17%; p < 0.001), and abdomen (28 vs. 12%; p < 0.001). The IV group also had a higher proportion of patients injured by motor vehicle crashes (41 vs. 27%; p = 0.003), firearms (9 vs. 2%; p = 0.001), and stabbing (20 vs. 9%; p = 0.001). The rate of extremity injuries (38 vs. 59%; p < 0.001) and falls (12 vs. 40%; p < 0.001) was lower for the IV group. In addition, the mean Injury Severity Score was significantly higher for the IV group (15 vs. 9; p < 0.001). The mortality rates for the IV and no-IV groups were 23 and 6% (p < 0.001). Logistic regression analysis showed that after adjusting for patient age, gender, Injury Severity Score, mechanism of injury, and prehospital time, the use of on-site intravenous fluid replacement was associated with a significant increase in the risk of mortality (adjusted odds ratio = 2.3; 95% confidence interval = 1.02-5.28; p = 0.04). To further evaluate the effect of prehospital time on the association between on-site IV use and mortality, the analysis was repeated separately for the following time strata: 0 to 30 minutes, 31 to 60 minutes, and >60 minutes. The adjusted odds ratios (95% confidence interval) for these strata were 1.05 (0.08-14.53; p = 0.97), 3.38 (0.84-13.62; p = 0.08), and 8.40 (1.27-54.69; p = 0.03). These results show that for prehospital times of less than 30 minutes, the use of on-site intravenous fluid replacement provides no benefit, and that for longer times, this intervention is associated with significant increases in the risk of mortality. The results of this observational study have shown that the use of on-site intravenous fluid replacement is associated with an increase in mortality risk and that this association is exacerbated by, but is not solely the result of, increased prehospital times. Our findings are consistent with the hypothesis that early intravenous fluid replacement is harmful because it disrupts the normal physiologic response to severe bleeding. Although this evidence is against the implementation of on-site intravenous fluid replacement for severely injured patients, further studies including randomized controlled trials are required to provide a definitive answer to this question.