Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine - Latest Articles

Clinician awareness of tetanus-diphtheria vaccination in trauma patients: a questionnaire study

Young-Hoon Yoon — 2012-05-15T00:00:00Z

Background: Most trauma patients visit the hospital via the emergency department. They are at high risk for tetanus infection because many trauma patients are wounded. Tetanus immunity in the Korean population has been revealed to be decreased in age groups over 20 years old. It is important for emergency physicians to vaccinate patients with the tetanus booster in wound management. Methods: Questionnaires were sent to the directors of the emergency departments of resident training hospitals certified by the Korean Society of Emergency Medicine. Results: Two thirds of the emergency department directors surveyed reported applying tetanus prophylaxis guidelines to more than 80% of wounded patients. However, about 45% of clinicians in the emergency departments considered giving less than half of the wounded patient tetanus booster vaccinations, and there were no distinct differences in tetanus booster vaccination rates among different age groups. Most emergency physicians are familiar with tetanus prophylaxis guidelines for wound management. However, more than half of the emergency department directors reported that the major reason for not considering tetanus-diphtheria vaccination was due to assumptions that patients already had tetanus immunity. Conclusion: Attitude changes should be encouraged among emergency physicians regarding tetanus prophylaxis. As emergency physicians are frequently confronted with patients that are at a high risk for tetanus infection in emergency situations, they need to be more informed regarding tetanus immunity epidemiology and encouraged to administer tetanus booster vaccines.

Basic life support and automated external defibrillator skills among ambulance personnel: a manikin study performed in a rural low-volume ambulance setting

Anne Møller Nielsen — 2012-05-08T00:00:00Z

Background: Ambulance personnel play an essential role in the 'Chain of Survival'. The prognosis after out-of-hospital cardiac arrest was dismal on a rural Danish island and in this study we assessed the cardiopulmonary resuscitation performance of ambulance personnel on that island. Methods: The Basic Life Support (BLS) and Automated External Defibrillator (AED) skills of the ambulance personnel were tested in a simulated cardiac arrest. Points were given according to a scoring sheet. One sample t test was used to analyze the deviation from optimal care according to the 2005 guidelines. After each assessment, individual feedback was given. Results: On 3 consecutive days, we assessed the individual EMS teams responding to OHCA on the island. Overall, 70% of the maximal points were achieved. The hands-off ratio was 40%. Correct compression/ventilation ratio (30:2) was used by 80%. A mean compression depth of 40-50 mm was achieved by 55% and the mean compression depth was 42 mm (SD 7 mm). The mean compression rate was 123 per min (SD 15/min). The mean tidal volume was 746 ml (SD 221 ml). Only the mean tidal volume deviated significantly from the recommended (p = 0.01).During the rhythm analysis, 65% did not perform any visual or verbal safety check. Conclusion: The EMS providers achieved 70% of the maximal points. Tidal volumes were larger than recommended when mask ventilation was applied. Chest compression depth was optimally performed by 55% of the staff. Defibrillation safety checks were not performed in 65% of EMS providers.

Helical computerized tomography and NT-proBNP for screening of right ventricular overload on admission and at long term follow-up of acute pulmonary embolism

Mia Laiho — 2012-05-04T00:00:00Z

Background: Right ventricular dysfunction (RVD) in acute pulmonary embolism (APE) can be assessedwith helical computerized tomography (CT) and transthoracic echocardiography (TTE).Signs of RVD and elevated natriuretic peptides like NT-proBNP and cardiac troponin (TnT)are associated with increased risk of mortality. However, the prognostic role of both initialdiagnostic strategy and the use of NT-proBNP and TnT for screening for long-termprobability of RVD remains unknown.The aim of the study was to determine the role of helical CT and NT-proBNP in detection ofRVD in the acute phase. In addition, the value of NT-proBNP for ruling out RVD at longtermfollow-up was assessed. Methods: Sixty-three non-high risk APE patients were studied. RVD was assessed at admission in theemergency department by CT and TTE, and both NT-proBNP and TnT samples were taken.These, excepting CT, were repeated seven months later. Results: At admission RVD was detected by CT in 37 (59 %) patients. RVD findings in CT weresimilar in CT and TTE (p < 0.0001). NT-proBNP was elevated ([greater than or equal to] 350 ng/l) in 32 (86 %)patients with RVD but in only seven (27 %) patients without RVD (p < 0.0001). All thepatients survived until the 7-month follow-up. TTE showed persistent RVD in 6 of 63 (10 %)patients who all had RVD in CT at admission. All of them had elevated NT-proBNP levels inthe follow-up compared with 5 (9%) of patients without RVD (p < 0.0001). Conclusions: TTE does not confer further benefit when helical CT is used for screening for RVD in nonhighrisk APE. All the patients who were found to have RVD in TTE at seven months followuphad had RVD in the acute phase CT as well. Thus, patients without RVD in diagnostic CTdo not seem to require further routine follow-up to screen for RVD later. On the other hand,persistent RVD and thus need for TTE control can be ruled out by assessment of NT-proBNPat follow-up. A follow-up protocol based on these findings is suggested.

An observational study of compliance with the Scandinavian Guidelines for Management of Minimal, Mild and Moderate Head Injury

Ben Heskestad — 2012-04-17T00:00:00Z

Background: The Scandinavian guidelines for management of minimal, mild and moderate head injuries were developed to provide safe and cost effective assessment of head injured patients. In a previous study conducted one year after publication and implementation of the guidelines (2003), we showed low compliance, involving over-triage with computed tomography (CT) and hospital admissions. The aim of the present study was to investigate guideline compliance after an educational intervention. Methods: We evaluated guideline compliance in the management of head injured patients referred to the University Hospital of Stavanger, Norway. The findings from the previous study in 2003 were communicated to the hospitals physicians, and a feed-back loop training program for guideline implementation was conducted. All patients managed during the months January through June in the years 2005, 2007 and 2009 were then identified with an electronic search in the hospitals patient administrative database, and the patient files were reviewed. Patients were classified according to the Head Injury Severity Scale, and the management was classified as compliant or not with the guideline. Results: The 1 180 patients were 759 (64%) males and 421 (36%) females with a mean age of 31.5 (range 0-97) years. Over all, 738 (63%) patients were managed in accordance with the guidelines and 442 (37%) were not. Compliance was not significantly different between minimal (56%) and mild (59%) injuries, while most moderate (93%) injuries were managed in accordance with the guidelines (p < 0.05). Noncompliance was caused by overtriage in 362 cases (30%) and undertriage in 80 (7%). Guideline compliance was 54% in 2005, 71% in 2007, and 64% in 2009. Conclusions: This study shows higher guideline compliance after an educational intervention involving feed-back on performance. A substantial number of patients are exposed to over-triage, involving unnecessary radiation from CT examinations, and unnecessary costs from hospital admissions.

Basic life support skills of high school students before and after cardiopulmonary resuscitation training: a longitudinal investigation

Theresa Meissner — 2012-04-14T00:00:00Z

Background: Immediate bystander cardiopulmonary resuscitation (CPR) significantly improves survival after a sudden cardiopulmonary collapse. This study assessed the basic life support (BLS) knowledge and performance of high school students before and after CPR training. Methods: This study included 132 teenagers (mean age 14.6 ± 1.4 years). Students completed a two-hour training course that provided theoretical background on sudden cardiac death (SCD) and a hands-on CPR tutorial. They were asked to perform BLS on a manikin to simulate an SCD scenario before the training. Afterwards, participants encountered the same scenario and completed a questionnaire for self-assessment of their pre- and post-training confidence. Four months later, we assessed the knowledge retention rate of the participants with a BLS performance score. Results: Before the training, 29.5% of students performed chest compressions as compared to 99.2% post-training (P < 0.05). At the four-month follow-up, 99% of students still performed correct chest compressions. The overall improvement, assessed by the BLS performance score, was also statistically significant (median of 4 and 10 pre- and post-training, respectively, P < 0.05). After the training, 99.2% stated that they felt confident about performing CPR, as compared to 26.9% (P < 0.05) before the training. Conclusions: BLS training in high school seems highly effective considering the minimal amount of previous knowledge the students possess. We observed significant improvement and a good retention rate four months after training. Increasing the number of trained students may minimize the reluctance to conduct bystander CPR and increase the number of positive outcomes after sudden cardiopulmonary collapse.

Emergency department length of stay for patients requiring mechanical ventilation: a prospective observational study

Louise Rose — 2012-04-11T00:00:00Z

Background: Recommendations for acceptable emergency department (ED) length of stay (LOS) vary internationally with [less than or equal to] 8 h generally considered acceptable. Protracted ED LOS may place critically ill patients requiring mechanical ventilation at increased risk of adverse events as most EDs are not resourced for longitudinal delivery of critical care. Our objective was to quantify the ED LOS for mechanically ventilated patients (invasive and/or non-invasive ventilation [NIV]) and to explore patient and system level predictors of prolonged ED LOS. Additionally, we aimed to describe delivery and monitoring of ventilation in the ED. Methods: Prospective observational study of ED LOS for all patients receiving mechanical ventilation at four metropolitan EDs in Toronto, Canada over two six-month periods in 2009 and 2010. Results: We identified 618 mechanically ventilated patients which represented 0.5 % (95 % CI 0.4 %-0.5 %) of all ED visits. Of these, 484 (78.3 %) received invasive ventilation, 118 (19.1 %) received NIV; 16 received both during the ED stay. Median Kaplan-Meier estimated duration of ED stay for all patients was 6.4 h (IQR 2.8-14.6). Patients with trauma diagnoses had a shorter median (IQR) LOS, 2.5 h (1.3-5.1), compared to ventilated patients with non-trauma diagnoses, 8.5 h (3.3-14.0) (p <0.001). Patients requiring NIV had a longer ED stay (16.6 h, 8.2-27.9) compared to those receiving invasive ventilation exclusively (4.6 h, 2.2-11.1) and patients receiving both (15.4 h, 6.4-32.6) (p <0.001). Longer ED LOS was associated with ED site and lower priority triage scores. Shorter ED LOS was associated with intubation at another ED prior to transfer. Conclusions: While patients requiring mechanical ventilation represent a small proportion of overall ED visits these critically ill patients frequently experienced prolonged ED stay especially those treated with NIV, assigned lower priority triage scores at ED presentation, and non-trauma patients.

The formation and design of 'The Acute Admission Database'- a database including a prospective, observational cohort of 6279 patients triaged in the Emergency Department in a larger Danish hospital

Charlotte Barfod — 2012-04-10T00:00:00Z

Background: Management and care of the acutely ill patient have improved over the last years due to introduction of systematic assessment and accelerated treatment protocols. We have, however, sparse knowledge of the association between patient status at admission to hospital and patient outcome. A likely explanation is the difficulty in retrieving all relevant information from one database. The objective of this article was 1) to describe the formation and design of the 'Acute Admission Database', and 2) to characterize the cohort included. Methods: All adult patients triaged at the Emergency Department at Hillerod Hospital and admitted either to the observationary unit or to a general ward in-hospital were prospectively included during a period of 22 weeks. The triage system used was a Danish adaptation of the Swedish triage system, ADAPT. Data from 3 different data sources was merged using a unique identifier, the Central Personal Registry number; 1) Data from patient admission, time and date, vital signs, presenting complaint and triage category, 2) Blood sample results taken at admission, including a venous acid-base status, and 3) Outcome measures, e.g. length of stay, admission to Intensive Care Unit, and mortality within 7 and 28 days after admission. Results: In primary triage, patients were categorized as red (4.4%), orange (25.2%), yellow (38.7%) and green (31.7%). Abnormal vital signs were present at admission in 25% of the patients, most often temperature (10.5%), saturation of peripheral oxygen (9.2%), Glasgow Coma Score (6.6%) and respiratory rate (4.8%). A venous acid-base status was obtained in 43% of all patients. The majority (78%) had a pH within the normal range (7.35-7.45), 15% had acidosis (pH < 7.35) and 7% had alkalosis (pH > 7.45). Median length of stay was 2 days (range 1-123). The proportion of patients admitted to Intensive Care Unit was 1.6% (95% CI 1.2-2.0), 1.8% (95% CI 1.5-2.2) died within 7 days, and 4.2% (95% CI 3.7-4.7) died within 28 days after admission. Conclusions: Despite challenges of data registration, we succeeded in creating a database of adequate size and data quality. Future studies will focus on the association between patient status at admission and patient outcome, e.g. admission to Intensive Care Unit or in-hospital mortality.

Abnormal vital signs are strong predictors for Intensive Care Unit admission and in-hospital mortality in adults triaged in the Emergency Department - A prospective cohort study

Charlotte Barfod — 2012-04-10T00:00:00Z

Background: Assessment and treatment of the acutely ill patient have improved by introducing systematic assessment and accelerated protocols for specific patient groups. Triage systems are widely used, but few studies have investigated the ability of the triage systems in predicting outcome in the unselected acute population. The aim of this study was to quantify the association between the main component of the Hillerod Acute Process Triage (HAPT) system and the outcome measures; Admission to Intensive Care Unit (ICU) and in-hospital mortality, and to identify the vital signs, scored and categorized at admission, that are most strongly associated with the outcome measures. Methods: The HAPT system is a minor modification of the Swedish Adaptive Process Triage (ADAPT) and ranks patients into five level colour-coded triage categories. Each patient is assigned a triage category for the two main descriptors; vital signs, Tvitals, and presenting complaint, Tcomplaint. The more urgent of the two determines the final triage category, Tfinal. We retrieved 6279 unique adult patients admitted through the Emergency Department (ED) from the Acute Admission Database. We performed regression analysis to evaluate the association between the covariates and the outcome measures. Results: The covariates, Tvitals, Tcomplaint and Tfinal were all significantly associated with ICU admission and in-hospital mortality, the odds increasing with the urgency of the triage category. The vital signs best predicting in-hospital mortality were saturation of peripheral oxygen (SpO2), respiratory rate (RR), systolic blood pressure (BP) and Glasgow Coma Score (GCS). Not only the type, but also the number of abnormal vital signs, were predictive for adverse outcome. The presenting complaints associated with the highest in-hospital mortality were 'dyspnoea' (11.5 %) and 'altered level of consciousness' (10.6 %). More than half of the patients had a Tcomplaint more urgent than Tvitals, the opposite was true in just 6 % of the patients. Conclusion: The HAPT system is valid in terms of predicting in-hospital mortality and ICU admission in the adult acute population. Abnormal vital signs are strongly associated with adverse outcome, while including the presenting complaint in the triage model may result in over-triage.

High levels of soluble VEGF receptor 1 early after trauma are associated with shock, sympathoadrenal activation, glycocalyx degradation and inflammation in severely injured patients: a prospective study

Sisse Ostrowski — 2012-04-10T00:00:00Z

Background: The level of soluble vascular endothelial growth factor receptor 1 (sVEGFR1) is increased in sepsis and strongly associated with disease severity and mortality. Endothelial activation and damage contribute to both sepsis and trauma pathology. Therefore, this study measured sVEGFR1 levels in trauma patients upon hospital admission hypothesizing that sVEGFR1 would increase with higher injury severity and predict a poor outcome. Methods: Prospective observational study of 80 trauma patients admitted to a Level I Trauma Centre. Data on demography, biochemistry, Injury Severity Score (ISS), transfusions and 30-day mortality were recorded and plasma/serum (sampled a median of 68 min (IQR 48-88) post-injury) was analyzed for sVEGFR1 and biomarkers reflecting sympathoadrenal activation (adrenaline, noradrenaline), tissue injury (histone-complexed DNA fragments, hcDNA), endothelial activation and damage (von Willebrand Factor Antigen, Angiopoietin-2, soluble endothelial protein C receptor, syndecan-1, soluble thrombomodulin (sTM)), coagulation activation/inhibition and fibrinolysis (prothrombinfragment 1 + 2, protein C, activated Protein C, tissue-type plasminogen activator, plasminogen activator inhibitor-1, D-dimer) and inflammation (interleukin-6). Spearman correlations and regression analyses to identify variables associated with sVEGFR1 and its predictive value. Results: Circulating sVEGFR1 correlated with injury severity (ISS, rho = 0.46), shock (SBE, rho = -0.38; adrenaline, rho = 0.47), tissue injury (hcDNA, rho = 0.44) and inflammation (IL-6, rho = 0.54) (all p < 0.01) but by multivariate linear regression analysis only lower SBE and higher adrenaline and IL-6 were independent predictors of higher sVEGFR1. sVEGFR1 also correlated with biomarkers indicative of endothelial glycocalyx degradation (syndecan-1, rho = 0.67), endothelial cell damage (sTM, rho = 0.66) and activation (Ang-2, rho = 0.31) and hyperfibrinolysis (tPA, rho = 0.39; D-dimer, rho = 0.58) and with activated protein C (rho = 0.31) (all p < 0.01). High circulating sVEGFR1 correlated with high early and late transfusion requirements (number of packed red blood cells (RBC) at 1 h (rho = 0.27, p = 0.016), 6 h (rho = 0.27, p = 0.017) and 24 h (rho = 0.31, p = 0.004) but was not associated with mortality. Conclusions: sVEGFR1 increased with increasing injury severity, shock and inflammation early after trauma but only sympathoadrenal activation, hypoperfusion, and inflammation were independent predictors of sVEGFR1 levels. sVEGFR1 correlated strongly with other biomarkers of endothelial activation and damage and with RBC transfusion requirements. Sympathoadrenal activation, shock and inflammation may be critical drivers of endothelial activation and damage early after trauma.

The impact of CPR and AED training on healthcare professionals' self-perceived attitudes to performing resuscitation

Marie-Louise Sodersved Kallestedt — 2012-04-05T00:00:00Z

Background: Healthcare professionals have shown concern about performing mouth-to-mouth ventilation due to the risks to themselves with the procedure. However, little is known about healthcare professionals' fears and attitudes to start CPR and the impact of training.ObjectiveTo examine whether there were any changes in the attitudes among healthcare professionals to performing CPR from before to after training. Methods: Healthcare professionals from two Swedish hospitals were asked to answer a questionnaire before and after training. The questions were relating to physical and mental discomfort and attitudes to CPR. Statistical analysis used was generalized McNemar's test. Results: Overall, there was significant improvement in 10 of 11 items, reflecting various aspects of attitudes to CPR.All groups of health care professionals (physicians, nurses, assistant nurses, and "others" = physiotherapists, occupational therapists, social welfare officers, psychologists, biomedical analysts) felt more secure in CPR knowledge after education. In other aspects, such as anxiety prior to a possible cardiac arrest, only nurses and assistant nurses improved.The concern about being infected, when performing mouth to mouth ventilation, was reduced with the most marked reduction in physicians (75%; P < 0.001). Conclusion: In this hospital-based setting, we found a positive outcome of education and training in CPR concerning healthcare professionals' attitudes to perform CPR. They felt more secure in their knowledge of cardiopulmonary resuscitation. In some aspects of attitudes to resuscitation nurses and assistant nurses appeared to be the groups that were most markedly influenced. The concern of being infected by a disease was low.