Prehospital management of chest injuries in severely injured patients-a systematic review and clinical practice guideline update

PURPOSE

Our aim was to review and update the existing evidence-based and consensus-based recommendations for the management of chest injuries in patients with multiple and/or severe injuries in the prehospital setting. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

METHODS

MEDLINE and Embase were systematically searched to May 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, cross-sectional studies, and comparative registry studies were included if they compared interventions for the detection and management of chest injuries in severely injured patients in the prehospital setting. We considered patient-relevant clinical outcomes such as mortality and diagnostic test accuracy. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.

RESULTS

Two new studies were identified, both investigating the accuracy of in-flight ultrasound in the detection of pneumothorax. Two new recommendations were developed, one recommendation was modified. One of the two new recommendations and the modified recommendation address the use of ultrasound for detecting traumatic pneumothorax. One new good (clinical) practice point (GPP) recommends the use of an appropriate vented dressing in the management of open pneumothorax. Eleven recommendations were confirmed as unchanged because no new high-level evidence was found to support a change.

CONCLUSION

Some evidence suggests that ultrasound should be considered to identify pneumothorax in the prehospital setting. Otherwise, the recommendations from 2016 remained unchanged.

Die Neustrukturierung der Notaufnahme gemäß dem G-BA-Beschluss zu einem gestuften System von Notfallstrukturen

BACKGROUND

There is no assessment of the effects regarding the decision of the Federal Joint Committee from April 19th, 2018 which demands a central and interdisciplinary emergency room system under the control of a professionally and organizationally independent administration. The aim of this study was to solicit the current opinion of leading orthopedic surgeons regarding the above-mentioned decision.

MATERIAL AND METHODS

An online questionnaire was sent to all 731 members of the Verband Leitender Orthopäden und Unfallchirurgen (www.vlou.de) to compare the opinion of these leading physicians on their current and future emergency room system.

RESULTS

The majority of the 179 responding surgeons consider emergency room systems with primary treatment of orthopedic patients by orthopedic surgeons in certain aspects to be more appropriate suitable than systems without such primary treatment. It is also not yet clear how work-related accidents should be treated according to the specifications of the German statutory accident insurance (DGUV®). The provision of training content could become more difficult if the ER rotation of orthopedic surgeons is not any longer part of these new ER concepts.

CONCLUSION

The consequences of the decision of the Federal Joint Committee from April 19th, 2018 need to be reevaluated continuously and, if necessary, optimised accordingly, taking into account competing requirements, such as training regulations and the SGB VII.

[Position of trauma surgery in emergency medicine]

BACKGROUND

The decision of the Federal Joint Committee has resulted in the further development of in-hospital emergency medicine through the establishment of central emergency departments and staged emergency care. In addition, the additional training in clinical acute and emergency medicine was established.

AIM

The aim of this work is on the one hand to make trauma surgeons aware of these structural changes. On the other hand, we would like to evaluate an opinion and discuss the position of trauma surgery in emergency medicine.

METHODS

A web-based online survey was conducted at the Trauma Network and Trauma Registry Congress to collect participants' opinions on the position of trauma surgery in emergency medicine.

RESULTS

Of 143 congress participants, 98 (67%) responded to the survey. The majority of participants were male (n = 78, 80%), over 40 years of age (n = 62, 63%), and in a professional position with staff responsibility (n = 73, 75%). Emergency medicine (mean: 84.8; SD: 18.7) and intensive care medicine (mean: 78.3; SD: 20.4) training appears important. On the other hand, subsequent work in these areas appears less important (prehospital emergency medicine: mean: 65.1; SD: 28.0; ICU: mean: 53.7, SD: 30.3); however, activity in an emergency department is rated higher (MW: 87.0; SD: 18.7). There is high agreement that the trauma leader should be a trauma surgeon (mean 87.9; SD: 19.7).

DISCUSSION

A high volume of emergency trauma surgery patients and the care of severely injured patients in designated trauma centers show that trauma surgery expertise is mandatory in a central emergency department. Senior positions should also be sought to ensure high quality standards.

[Polytrauma care in air rescue in times of the COVID-19 pandemic: impact and development of case numbers]

Background

Changes in patient care occurred as a result of the SARS-CoV‑2 virus, and both intrahospital and prehospital care were profoundly affected. Public shutdowns during lockdown periods were intended to prevent overstretching existing resources, resulting in noticeable changes in medical care for both elective treatments and emergency medicine. This study now considered the impact of the COVID 19 pandemic on air ambulance services at a central air ambulance site in 2020 compared to the previous 2 years.

Methods

A retrospective evaluation of all missions of the rescue helicopter Christoph 9 in the first COVID-19 pandemic year 2020 in comparison to the years 2018 and 2019 was performed. The mission logs were evaluated for the analysis.

Results

There was a 20% reduction in the number of missions in 2020, with primarily internal medicine missions affected. Despite the lockdown periods and reduction in social life, the proportion of trauma deployments remained nearly the same. As expected, the proportion of occupational accidents decreased, and recreational activities resulted in accidents more frequently. Injury or illness severity showed no significant differences. In terms of internal diseases, there was a reduction in alerts for acute coronary syndrome and respiratory emergencies. The proportion of suicide-related injuries remained constant over the years.

Conclusion

During the COVID-19 study period, a decrease in the number of deployments and aborted deployments was observed. However, no significant differences in deployment and injury characteristics were observed for trauma-related deployments. These results highlight the importance of air ambulance services to ensure patient care even during pandemic periods.

[Preliminary and Final Postmortem Examination and Death Certificate in the Emergency Medical Services in Germany: Heterogeneous Process Flows and Inadequate Standards]

BACKGROUND

Inconsistent regulations and laws can lead to misunderstandings and incorrect procedures. In this study we would like to evaluate the heterogeneity of the different processes of postmortem examination and death certification in the German emergency medical services.

METHODS

An e-mail with a survey link was sent to 212 medical directors of emergency services. The questions were answered online.

RESULTS

The response rate was 47%. Regulated procedures were evident in 58% of the cases. Issue of provisional death certificate comprised 64%, postmortem examination 45%; 19.4% of emergency physicians were required to do the final post-mortem. In 41% of the cases, the application protocol was considered sufficient as a form of documentation. 45% of the participants evaluated the respective legal regulation as sufficient. Questions and concerns arose, especially when medical directors of EMS believed that the state-specific regulations were not sufficient (p<0.001).

CONCLUSION

The results show that the obligatory post-mortem examination in Germany is heterogeneous in its processing procedures. More than half of the participants rate the existing legal regulations as inadequate. As a result, it is not uncommon for queries and complaints to arise, but above all for uncertainties to arise in everyday practice. Our results suggest that uniform legislation and clearly defined processes are desirable.

A Local Survey of COVID-19: Vaccine Potential Acceptance Rate among Personnel in a Level 1 Trauma Center without Severe COVID-19 Cases

BACKGROUND

Healthcare workers (HCWs) in hospitals are at high risk during the COVID-19 pandemic. Healthcare workers' infection risk could be amplified during the ongoing pandemic due to various factors, including continuous exposure to patients and inadequate infection control training. Despite the risk healthcare workers face, vaccine hesitancy remains a global challenge. Differences in acceptance rates have ranged from less than 55% (in Russia) to nearly 90% (in China). In order to improve our knowledge of vaccine acceptance and its variation in rates, an evaluation is warranted. A survey was thus administered to healthcare workers.

METHODS

This survey aimed to address vaccination acceptance among employees in an urban level 1 trauma hospital. It was conducted through a developed and structured questionnaire that was randomly distributed online among the staff (age ≥18 years) to receive their feedback.

RESULTS

Among 285 participants (out of 995 employees), 69% were female, and 83.5% were overaged more than 30 years of age. The two largest groups were nurses (32%) and doctors (22%). The majority of respondents reported that they would "like to be vaccinated" (77.4%) and that they trusted the COVID-19 vaccine (62%). Moreover, 67.8% also reported that they felt the vaccination was effective. They reported that vaccination was a method to prevent the spread of COVID-19 (85.15%) and was a way to protect individuals with weak immune systems (78.2%). More importantly, the participants were concerned about other people (80.1%) and believed the vaccine would protect others. On the other hand, the result showed that the majority of participants (95.3%) chose to be vaccinated once everyone else was vaccinated, "I don't need to get vaccinated". Results showed that the majority of participants that chose "I don't need to get vaccinated" did so after everyone else was vaccinated. Our results show that COVID-19 vaccination intention in a level 1 trauma hospital was associated with older age males who are more confident, and also share a collective responsibility, are less complacent, and have fewer constraints.

CONCLUSION

Acceptance of the COVID-19 vaccine is relatively low among healthcare workers (HCWs). Differences in vaccine acceptance have been noted between different categories of HCWs and genders. Therefore, addressing barriers to vaccination acceptance among these HCWs is essential to avoid reluctance to receive the vaccination, but it will be challenging.

[SARS-CoV-2 IgG seroprevalence in personnel of the extraclinical fight against the COVID-19 pandemic]

BACKGROUND AND OBJECTIVES

The SARS-CoV‑2 pandemic and the different manifestations of the coronavirus disease 2019 (COVID-19) are a major challenge for health systems worldwide. Medical personnel have a special role in containing the pandemic. The aim of the study was to investigate the SARS-CoV‑2 IgG antibody prevalence in extraclinical personnel depending on their operational area in the fight against the COVID-19 pandemic.

METHODS

On May 28 and 29, 2020, serum samples were taken from 732 of 1183 employees (61.9%) of the professional fire brigade and aid organizations in the city area and tested for SARS-CoV‑2 IgG antibodies. The employees were divided into four categories according to their type of participation. category 1: decentralized PCR sampling teams, category 2: rescue service, category 3: fire protection, category 4: situation center. Some employees participated in more than one operational area.

RESULTS

SARS-CoV‑2 IgG antibodies were detected in 8 of 732 serum samples. This corresponds to a prevalence of 1.1%. A previous COVID-19 infection was known in 3 employees. In order to make a separate assessment of the other employees possible and to diagnose unknown infections, a corrected collective of 729 employees with 6 SARS-CoV‑2 antibody detection was considered separately. The prevalence in the corrected collective is 0.82%. After subdividing the collective into areas of activity, the prevalence was low (1: 0.77%, 2: 0.9%, 3: 1.00%, 4: 1.58%).

CONCLUSIONS

The seroprevalence of SARS-CoV‑2 in the study collective is low at 1.1% and 0.82%, respectively. There is an increased seroprevalence in operational areas with a lower risk of virus exposure in comparison to operational areas with a higher risk.

[COVID-19: acceptance and compliance of PPE (personal protective equipment) and rules for hygiene and reducing contacts in German emergency medical services-a nationwide survey]

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has also significantly burdened and challenged the German emergency medical services (EMS). In this regard, the personal protective equipment (PPE) and rules like wear a mask, stay 6 feet away from others, avoid crowds and poorly ventilated spaces, wash your hands often (called AHA‑L rules in Germany) play an important role in reducing the spread of COVID-19 infections.

OBJECTIVE

The aim of this study is to evaluate the acceptance and compliance of PPE and protective measures among rescue service personnel in Germany during pandemic periods.

METHOD

More than 270 medical directors of EMS were contacted. They were asked to forward a web-based online survey to the rescue stations. Participants were asked about acceptance and compliance in everyday life, in the rescue station, during missions without COVID-19, during missions with COVID-19.

RESULTS

There were n = 1295 participants. Overall acceptance and compliance of PPE and protective measures is high. The lowest acceptance and compliance is found in the questions acceptance (mean = 4.16; ±1.01) and compliance (mean = 4.26; ±0.89) in the rescue station.

CONCLUSION

We recommend targeted training regarding PPE in pandemics and the provision of appropriate premises for conflict-free compliance with AHA‑L rules.

Acceptance of COVID-19 Vaccination among Front-Line Health Care Workers: A Nationwide Survey of Emergency Medical Services Personnel from Germany

INTRODUCTION

The aim of this study was to evaluate the COVID-19 vaccination acceptance of emergency medical services (EMS) personnel as front-line health care workers (HCW) in Germany. Several studies have shown low willingness for vaccination (e.g., seasonal influenza) among HCWs and EMS personnel.

METHODS

We created a web-based survey. The questions were closed and standardized. Demographic data were collected (age, sex, federal state, profession). Experience with own COVID-19 infection, or infection in personal environment (family, friends) as well as willingness to vaccinate was queried.

RESULTS

The sample includes n = 1296 participants. A willingness to be vaccinated exists in 57%, 27.6% participants were undecided. Our results show a higher propensity to vaccinate among the following groups: male gender, higher medical education level, older age, own burden caused by the pandemic (p < 0.001).

CONCLUSIONS

Due to the low overall acceptance of vaccination by HCWs, we recommend that the groups with vaccination hesitancy, in particular, be recruited for vaccination through interventions such as continuing education and awareness campaigns.

Incidence, impact and risk factors for multidrug-resistant organisms (MDRO) in patients with major trauma: a European Multicenter Cohort Study

INTRODUCTION

The burden of MDRO in health systems is a global issue, and a growing problem. We conducted a European multicenter cohort study to assess the incidence, impact and risk factors for multidrug-resistant organisms in patients with major trauma. We conducted this study because the predictive factors and effects of MDRO in severely injured patients are not yet described. Our hypothesis is that positive detection of MDRO in severely injured patients is associated with a less favorable outcome.

METHODS

Retrospective study of four level-1 trauma centers including all patients after major trauma with an injury severity score (ISS) ≥ 9 admitted to an intensive care unit (ICU) between 2013 and 2017. Outcome was measured using the Glasgow outcome scale (GOS).

RESULTS

Of 4131 included patients, 95 (2.3%) had a positive screening for MDRO. Risk factors for MDRO were male gender (OR 1.73 [95% CI 1.04-2.89]), ISS (OR 1.01 [95% CI 1.00-1.03]), PRBC's given (OR 1.73 [95% CI 1.09-2.78]), ICU stay > 48 h (OR 4.01 [95% CI 2.06-7.81]) and mechanical ventilation (OR 1.85 [95% CI 1.01-3.38]). A positive MDRO infection correlates with worse outcome. MDRO positive cases GOS: good recovery = 0.6%, moderate disability = 2.1%, severe disability = 5.6%, vegetative state = 5.7% (p < 0.001).

CONCLUSIONS

MDRO in severely injured patients are rare but associated with a worse outcome at hospital discharge. We identified potential risk factors for MDRO in severely injured patients. Based on our results, we recommend a standardized screening procedure for major trauma patients.

Major trauma due to suicide attempt: increased workload but not mortality

INTRODUCTION

Suicide attempt is a common cause for major trauma. Due to the underlying psychiatric disease, patients` compliance or even prognosis may be reduced. Modalities of discharge after surgical acute care might differ.

METHODS

Retrospective study including trauma patients of two urban level 1 trauma centers between 2013 and 2017. Data originally collected for quality management using the German trauma registry were supplemented after review of medical charts with details on psychiatric disease and discharge modalities.

RESULTS

We included 2118 consecutive patients of which 108 (5%) attempted suicide. Most common psychiatric diagnosis were depression (38%) and schizophrenia (25.9%). Comparing patients after suicide attempt with others, suicide attempt was associated with a younger age (42.3 vs. 49.0 years), a higher injury severity (mean ISS 24.7 vs. 16.8) and consecutively, a higher expected mortality (risk-adjusted prognosis for mortality 18.0 vs. 8.1%), while observed mortality was lower than expected in both groups (16.7 vs. 6.4%). Survivors after suicide attempt had a longer stay on ICU (mean days on ICU 17 vs. 7). 56% were transferred to psychiatric facilities and only 4% could be discharged home after acute surgical care.

CONCLUSION

Incidence of suicide attempts among major trauma patients is high. Mean injury severity is higher than in unintended trauma and associated with a prolonged stay on intensive care unit even after adjustment for injury severity and age. Risk-adjusted mortality is not increased. Proportion of patients discharged home or to out-patient rehabilitation is very low. Specialized institutions who offer both, musculoskeletal rehabilitation and psychiatric care are required for rehabilitative treatment after the acute surgical care.

The influence of ABO blood group on mortality in major trauma

ABO blood group has a profound influence on hemostasis as it is a major determinant of plasma levels of von Willebrand Factor. In vitro studies suggest that blood group O is a risk factor for increased severe bleeding while blood group non-O is a risk factor for thromboembolic events. Yet, the impact of ABO blood group outcome after multiple trauma is unknown. Retrospective multicenter case-control study from three level-1 trauma centers in Germany from 2012-2015. Inclusion criteria were severe trauma with an Injury severity score ≥9 and admission to an intensive care unit. 1281 patients (69.5% male) were included. Mean Injury Severity Score (ISS) was 21.1±12.4; mean age was 50.2±22.4 years. Distribution of blood groups was: O: 37.4%; A: 44%, B: 12.7 and AB: 5.8%. Hospital mortality depending on blood group was 9.7 (A), 10.4 (B), 6.8 (AB) and 12.7 (O) %. Multivariant logistic regression for mortality revealed an Odds ratio of 0.79 (A), 0.60 (B) and 0.54 (AB) without statistical significance (P=0.35 (A), 0.17 (B), 0.33 (AB)). Thromboembolic events (blood group O vs. others) occurred in 2.8 (O) vs. 3.3 (others) %, P=0.619. In this retrospective study on 1281 multiple injured patients, no relevant influence of ABO blood group on hemorrhage, thromboembolic events and mortality could be found.