[Advanced Trauma Life Support. A training concept also for Europe]

[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.

Teaching Advanced Trauma Life Support (ATLS): A nationwide retrospective analysis of 8202 lessons taught in Germany

OBJECTIVE

To examine whether faculty who teach the Advanced Trauma Life Support (ATLS) course would improve with experience and, correspondingly, ratings from course evaluations would increase.

DESIGN

Retrospective analysis of student evaluations of 262 ATLS courses held between 2008 and 2012.

SETTING

All ATLS courses held between 2008 and 2012 nationwide in Germany.

PARTICIPANTS

All ATLS student course evaluations covering 8202 lessons, 81 instructors, 36 course directors, and 5 coordinators.

RESULTS

ATLS courses in Germany attained high levels of student satisfaction. Satisfaction levels increased steadily over the 5-year period studied. The entire staff influenced this finding. Teaching quality improved the most within the first 100 lessons taught. Skill stations received better evaluations than lectures, and local courses were less satisfactory than national course formats. The 2 demonstrations that open the course were the top rated events. Skill stations, including a human phantom, were highly rated; the cricothyrotomy station was top rated.

CONCLUSION

The German ATLS course evaluations indicated steady improvement over the 5-year study. The level of experience of course coordinators, directors, and instructors influenced this finding. Teaching quality improved most within the first 100 lessons taught, and then reached a steady state. Skill stations received better evaluations than lectures, and local courses were less satisfactory than national course formats.

The effect of paramedic training on pre-hospital trauma care (EPPTC-study): a study protocol for a prospective semi-qualitative observational trial

BACKGROUND

Accidents are the leading cause of death in adults prior to middle age. The care of severely injured patients is an interdisciplinary challenge. Limited evidence is available concerning pre-hospital trauma care training programs and the advantage of such programs for trauma patients. The effect on trauma care procedures or on the safety of emergency crews on the scene is limited; however, there is a high level of experience and expert opinion.

METHODS

I - Video-recorded case studies are the basis of an assessment tool and checklist being developed to verify the results of programs to train participants in the care of seriously injured patients, also known as "objective structured clinical examination" (OSCE). The timing, completeness and quality of the individual measures are assessed using appropriate scales. The evaluation of team communication and interaction will be analyzed with qualitative methods and quantified and verified by existing instruments (e.g. the Clinical Team Scale). The developed assessment tool is validated by several experts in the fields of trauma care, trauma research and medical education. II a) In a German emergency medical service, the subjective assessment of paramedics of their pre-hospital care of trauma patients is evaluated at three time points, namely before, immediately after and one year after training. b) The effect of a standardized course concept on the quality of documentation in actual field operations is determined based on three items relevant to patient safety before and after the course. c) The assessment tool will be used to assess the effect of a standardized course concept on procedures and team communication in pre-hospital trauma care using scenario-based case studies.

DISCUSSION

This study explores the effect of training on paramedics. After successful study completion, further multicenter studies are conceivable, which would evaluate emergency-physician staffed teams. The influence on the patients and prehospital measures should be assessed based on a retrospective analysis of the emergency room data.

TRIALS REGISTRATION

German Clinical Trials Register, ID DRKS00004713.

[PHTLS team course: a pilot project. Structured student education in prehospital care of severely injured patients]

BACKGROUND

The training of medical school students at the University of Heidelberg seems to be improvable regarding prehospital trauma treatment compared to an established anaesthesiology-based training for medical emergencies. This study addresses the current situation and possibilities for advancing this training.

MATERIAL AND METHODS

A baseline was set by interviews of the medical school students. Based on this the hypothesis was postulated that there is a deficit in the education of the medical school students concerning the training in prehospital trauma treatment. This was proved by questionnaires given to the students in the 7th and 8th semesters at the University of Heidelberg Medical School. The results were evaluated and a possible approach for improvement was developed.

RESULTS

A total of 111 questionnaires could be evaluated. It could be shown that the existing education was not effectual and that there is a need for a praxis-orientated 1-day course in prehospital trauma treatment.

CONCLUSION

Especially the treatment of multiply injured patients is a challenge for young medical professionals. However, there is a high motivation to learn and train in emergency medicine. The students long for a practical trauma course compared to the advanced medical CPR course provided by the Department of Anaesthesiology of the University of Heidelberg. Those algorithm-based trauma courses do exist with PHTLS® and ATLS®. Based on these courses we developed the PHTLS® TEAM course.

[Special aspects of the emergency medical care of head and neck injuries]

The overall incidence of severe head, face and neck injuries as seen from the German Trauma Registry of the National Association of German Trauma Surgeons is 81.3%. The leading causes of death among these patients are hemorrhage and severe traumatic brain injury. The aim of prehospital emergency medical care is to stabilize vital functions in order to ensure primary survival and to reduce morbidity with appropriate prehospital treatment of the individual injuries within the overall injury pattern. In this review, special aspects as well as pitfalls of the prehospital management of patients with head, face and neck injuries are demonstrated. Prehospital airway management concepts as well as concepts for stopping bleeding in the head, face and neck region are discussed in detail.

[Development of an emergency room algorithm for treatment of multiple trauma. Wolfsburg model]

Within the framework of restructuring for the certification to a regional trauma centre of the DGU (German Society for Casualty Surgery), a uniform algorithm for multiple trauma was developed in the medical centre of Wolfsburg. The Wolfsburg multiple trauma algorithm is based on ATLS (advanced trauma life support) with integration of FAST (focused assessment with sonography for trauma), as well as the white paper of the DGU and regional-specific features. Thus structural, instrumental, organizational and personnel conditions were created to improve the care of multiply traumatized patients even further. The conditions for transition to a regional trauma centre of the DGU were confirmed by a successful audit.

Pediatric Polytrauma Management

Caring for pediatric trauma patients requires an understanding of the distinct anatomy and pathophysiology of the pediatric population compared to adult trauma patients. Initial evaluation, management, and resuscitation are performed as a multidisciplinary approach including pediatric physicians, trauma surgeons, and pediatric intensive care physicians. Head injury severity is the principle determinant of outcome and mortality in polytraumatized children. Abdominal injuries rarely require surgery in contrast to adults, but need to be detected. Spine and pelvic injuries as well as injuries of the extremities require age-adapted surgical procedures. However, the degree of recovery in polytraumatized children is often remarkable, even after apparently devastating injuries. Maximal care should, therefore, be rendered under the assumption that a complete recovery will be made.

Comparison of Web-versus classroom-based basic ultrasonographic and EFAST training in 2 European hospitals

STUDY OBJECTIVE

Training physicians in new skills through classroom-based teaching has inherent cost and time constraints. We seek to evaluate whether Web-based didactics result in similar knowledge improvement and retention of basic ultrasonographic principles and the Extended Focused Assessment with Sonography for Trauma (EFAST) compared with the traditional method.

METHODS

Physicians from 2 German emergency departments were randomized into a classroom group with traditional lectures and a Web group who watched narrated lectures online. All participants completed a pre- and posttest and a second posttest 8 weeks later. Both groups underwent hands-on training after the first posttest. A control group completed the 2 initial tests without didactic intervention.

RESULTS

Fifty-five subjects participated in the study. Both the classroom and Web group showed significant improvement in pre- and posttest 1 scores (75.9% versus 93.9% and 77.8% versus 92.5%; P<.001 for both), with similar knowledge retention after 8 weeks (88.6% and 88.9%; P=.87). No statistically significant difference in mean test scores could be found between the 2 groups at each point: -1.9% (95% confidence interval [CI] -5.2% to 1.4%) for the pretest, 1.4% (95% CI -0.6% to 3.4%) for posttest 1, and -0.3% (95% CI -3.9% to 3.3%) for posttest 2. The control group showed no learning effect without intervention (83.3% versus 82.8%, ; P=.88).

CONCLUSION

Web-based learning provides the potential to teach physicians with greater flexibility than classroom instruction. Our data suggest that Web-based ultrasonography and EFAST didactics are comparable to traditional classroom lectures and result in similar knowledge retention.