Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine - Most accessed articles

No impact of early intervention on late outcome after minimal, mild and moderate head injury.

Ben Heskestad — 2010-02-24T00:00:00Z

Objectives: To evaluate the effect of an educational intervention on outcome after minimal, mild and moderate head injury. Methods: Three hundred and twenty six patients underwent stratified randomization to an intervention group (n=163) or a control group (n=163). Every second patient was allocated to the intervention group. Participants in this group were offered a cognitive oriented consultation two weeks after the injury, while subjects allocated to the control group were not. Both groups were invited to follow up 3 and 12 months after injury. Results: A total of 50 (15 %) patients completed the study (intervention group n=22 (13 %), control group n=28 (17 %), not significant). There were no statistically significant differences between the intervention group and the control group. Conclusions: There was no effect on outcomes from an early educational intervention two weeks after head injury.

The epidemiology of medical emergency contacts outside hospitals in Norway - a prospective population based study

Erik Zakariassen — 2010-02-18T00:00:00Z

IntroductionThere is a lack of epidemiological knowledge on medical emergencies outside hospitals in Norway. The aim of the present study was to obtain representative data on the epidemiology of medical emergencies classified as "red responses" in Norway.MethodThree emergency medical dispatch centres (EMCCs) were chosen as catchment areas, covering 816 000 inhabitants. During a three month period in 2007 the EMCCs gathered information on every situation that was triaged as a red response, according to The Norwegian Index of Medical Emergencies (Index). Records from ground ambulances, air ambulances, and the primary care doctors were subsequently collected. International Classification of Primary Care - 2 symptom codes (ICPC-2) and The National Committee on Aeronautics (NACA) Score System were given retrospectively. Results: Total incidence of red response situations was 5 105 during the three month period. 394 patients were involved in 138 accidents, and 181 situations were without patients, resulting in a total of 5 180 patients. The patients' age ranged from 0 to 107 years, with a median age of 57, and 55% were male. 90% of the red responses were medical problems with a large variation of symptoms, the remainder being accidents. 70% of the patients were in a non-life-threatening situation. Within the accident group, males accounted for 61%, and 35% were aged between 10 and 29 years, with a median age of 37 years. Few of the 39 chapters in the Index were used, A10 "Chest pain" was the most common one (22% of all situations). ICPC-2 symptom codes showed that cardiovascular, syncope/coma, respiratory and neurological problems were most common. 50% of all patients in a sever situation (NACA score 4-7) were > 70 years of age. Conclusions: The results show that emergency medicine based on 816 000 Norwegians mainly consists of medical problems, where the majority of the patients have a non-life-threatening situation. More focus on the emergency system outside hospitals, including triage and dispatch, and how to best deal with "everyday" emergency problems is needed to secure knowledge based decisions for the future organization of the emergency system.

Survival after prolonged resuscitation with 99 defibrillations due to Torsade De Pointes cardiac electrical storm: a case report

Anders Rostrup Nakstad — 2010-02-06T00:00:00Z

A 48-year-old previously healthy woman suffered witnessed cardiac arrest in hospital. She achieved return of spontaneous circulation and was transferred to the intensive care unit. During the following 3 hours, she suffered a cardiac electrical storm with 98 episodes of Torsade de Pointes ventricular tachycardia rapidly degenerating to ventricular fibrillation. She was converted with a total of 99 defibrillations. There was no response to the use of any recommended anti arrhythmic drugs. However, the use of bretylium surprisingly stabilized her heart rhythm and facilitated placing of a temporary pacemaker. Overdrive pacing prevented further arrhythmias and was life saving. A number of beneficial factors may have contributed to the good neurological outcome. Further investigations gave no explanation for her cardiac electrical storm.

Risk scoring systems for adults admitted to the emergency department: a systematic review

Mikkel Brabrand — 2010-02-11T00:00:00Z

Background: Patients referred to a medical admission unit (MAU) represent a broad spectrum of disease severity. In the interest of allocating resources to those who might potentially benefit most from clinical interventions, several scoring systems have been proposed as a triaging tool.Even though most scoring systems are not meant to be used on an individual level, they can support the more inexperienced doctors and nurses in assessing the risk of deterioration of their patients.We therefore performed a systematic review on the level of evidence of literature on scoring systems developed or validated in the MAU. We hypothesized that existing scoring systems would have a low level of evidence and only few systems would have been externally validated. Methods: We conducted a systematic search using Medline, EMBASE and the Cochrane Library, according to the PRISMA guidelines, on scoring systems developed to assess medical patients at admission.The primary endpoints were in-hospital mortality or transfer to the intensive care unit. Studies derived for only a single or few diagnoses were excluded.The ability to identify patients at risk (discriminatory power) and agreement between observed and predicted outcome (calibration) along with the method of derivation and validation (application on a new cohort) were extracted. Results: We identified 1,655 articles. Thirty were selected for further review and 10 were included in this review.Eight systems used vital signs as variables and two relied mostly on blood tests.Nine systems were derived using regression analysis and eight included patients admitted to a MAU. Six systems used in-hospital mortality as their primary endpoint.Discriminatory power was specified for eight of the scoring systems and was acceptable or better in five of these. The calibration was only specified for four scoring systems. In none of the studies impact analysis or inter-observer reliability were analyzed.None of the systems reached the highest level of evidence. Conclusions: None of the 10 scoring systems presented in this article are perfect and all have their weaknesses. More research is needed before the use of scoring systems can be fully implemented to the risk assessment of acutely admitted medical patients.

A review of ureteral injuries after external trauma

Bruno Pereira — 2010-02-03T00:00:00Z

IntroductionUreteral trauma is rare, accounting for less than 1% of all urologic traumas. However, a missed ureteral injury can result in significant morbidity and mortality. The purpose of this article is to review the literature since 1961 with the primary objective to present the largest medical literature review, to date, regarding ureteral trauma. Several anatomic and physiologic considerations are paramount regarding ureteral injuries management.Literature reviewEighty-one articles pertaining to traumatic ureteral injuries were reviewed. Data from these studies were compiled and analyzed. The majority of the study population was young males. The proximal ureter was the most frequently injured portion. Associated injuries were present in 90.4% of patients. Admission urinalysis demonstrated hematuria in only 44.4% patients. Intravenous ureterogram (IVU) failed to diagnose ureteral injuries either upon admission or in the operating room in 42.8% of cases. Ureteroureterostomy, with or without indwelling stent, was the surgical procedure of choice for both trauma surgeons and urologists (59%). Complications occurred in 36.2% of cases. The mortality rate was 17%. Conclusion: The mechanism for ureteral injuries in adults is more commonly penetrating than blunt. The upper third of the ureter is more often injured than the middle and lower thirds. Associated injuries are frequently present. CT scan and retrograde pyelography accurately identify ureteral injuries when performed together. Ureteroureterostomy, with or without indwelling stent, is the surgical procedure of choice of both trauma surgeons and urologists alike. Delay in diagnosis is correlated with a poor prognosis.

Management of burn injuries - recent developments in resuscitation, infection control and outcomes research

David Dries — 2009-03-11T00:00:00Z

IntroductionBurn injury and its subsequent multisystem effects are commonly encountered by acute care practitioners. Resuscitation is the major component of initial burn care and must be managed to restore and preserve remote organ function. Later complications of burn injury are dominated by infection. Burn centers are often called to manage soft tissue problems outside thermal injury including soft tissue infection and Toxic Epidermal Necrolysis. Methods: A selected review of recent reports published by the American Burn Association is provided. Results: The burn-injured patient is easily and frequently over resuscitated with complications including delayed wound healing and respiratory compromise. A feedback protocol is designed to limit the occurrence of excessive resuscitation has been proposed but no new "gold standard" for resuscitation has replaced the Parkland formula. Significant additional work has been included in recent guidelines identifying specific infectious complications and criteria for these diagnoses in the burn-injured patient. While new medical therapies have been proposed for patients sustaining inhalation injury, a new standard of medical therapy has not emerged. Renal failure as a contributor to adverse outcome in burns has been reinforced by recent data generated in Scandinavia. Of special problems addressed in burn centers, soft tissue infections and Toxic Epidermal Necrolysis have been reviewed but new treatment strategies have not been identified. The value of burn centers in management of burns and other soft tissue problems is supported in several recent reports. Conclusion: Recent reports emphasize the dangers of over resuscitation in the setting of burn injury. No new medical therapy for inhalation injury exists but new standards for description of burn-related infections have been presented. The value of the burn center in care of soft tissue problems including Toxic Epidermal Necrolysis and soft tissue infections is supported in recent papers.

Hypothermia in bleeding trauma: a friend or a foe?

Tareq Kheirbek — 2009-12-23T00:00:00Z

The induction of hypothermia for cellular protection is well established in several clinical settings. Its role in trauma patients, however, is controversial. This review discusses the benefits and complications of induced hypothermia--emphasizing the current state of knowledge and potential applications in bleeding patients. Extensive pre-clinical data suggest that in advanced stages of shock, rapid cooling can protect cells during ischemia and reperfusion, decrease organ damage, and improve survival. Yet hypothermia is a double edged sword; unless carefully managed, its induction can be associated with a number of complications. Appropriate patient selection requires a thorough understanding of the pre-clinical literature. Clinicians must also appreciate the enormous influence that temperature modulation exerts on various cellular mechanisms. This manuscript aims to provide a balanced view of the published literature on this topic. While many of the advantageous molecular and physiological effects of induced hypothermia have been outlined in animal models, rigorous clinical investigations are needed to translate these promising findings into clinical practice.

Arterial embolization in patients with grade-4 blunt renal trauma: evaluation of the glomerular filtration rates by dynamic scintigraphy with 99mTechnetium-diethylene triamine pentacetic acid

Seiji Morita — 2010-03-07T00:00:00Z

Background: High-grade blunt renal trauma has been treated by arterial embolization (AE). However, it is unknown whether AE preserves renal function, because conventional renal function tests reflect total renal function and not the function of the injured kidney alone. Dynamic scintigraphy can assess differential renal function. Methods: We performed AE in 17 patients with grade-4 blunt renal trauma and determined their serum creatinine (sCr) level and glomerular filtration rate (GFR; estimated by dynamic scintigraphy) after 3 months. In 4 patients with low GFR of the injured kidney (<20 ml/min/1.73 m2), the GFR and sCr were measured again at 6 months. Data are presented as median and interquartile range (25th, 75th percentile). Results: The median GFR of the injured kidney, total GFR, and median sCr at 3 months were 29.3 (23.7, 35.3) and 96.8 (79.1, 102.6) ml/min/1.73 m2 and 0.6 (0.5, 0.7) mg/dl, respectively. In the patients with low GFR (ml/min/1.73 m2), the median GFR of the injured kidney, total GFR, and median sCr (mg/dl) were 16.2 (15.7, 16.3), 68.7 (61.1, 71.6), and 0.7 (0.7, 0.9), respectively, at 3 months and 34.5 (29.2, 37.0), 90.9 (79.1, 98.8), and 0.7 (0.7, 0.8), respectively, at 6 months. Conclusions: The function of the injured kidney was preserved in all patients, indicating the efficacy of AE for the treatment of grade-4 blunt renal trauma.

Clinician performed resuscitative ultrasonography for the initial evaluation and resuscitation of trauma

Lawrence Gillman — 2009-08-06T00:00:00Z

Background: Traumatic injury is a leading cause of morbidity and mortality in developed countries worldwide. Recent studies suggest that many deaths are preventable if injuries are recognized and treated in an expeditious manner – the so called 'golden hour' of trauma. Ultrasound revolutionized the care of the trauma patient with the introduction of the FAST (Focused Assessment with Sonography for Trauma) examination; a rapid assessment of the hemodynamically unstable patient to identify the presence of peritoneal and/or pericardial fluid. Since that time the use of ultrasound has expanded to include a rapid assessment of almost every facet of the trauma patient. As a result, ultrasound is not only viewed as a diagnostic test, but actually as an extension of the physical exam. Methods: A review of the medical literature was performed and articles pertaining to ultrasound-assisted assessment of the trauma patient were obtained. The literature selected was based on the preference and clinical expertise of authors.DiscussionIn this review we explore the benefits and pitfalls of applying resuscitative ultrasound to every aspect of the initial assessment of the critically injured trauma patient.

Effect of levosimendan in experimental verapamil- induced myocardial depression

Jouni Kurola — 2010-03-11T00:00:00Z

Background: Calcium antagonist overdose can cause severe deterioration of hemodynamics unresponsible to treatment with beta adrenergic inotropes. The aim of the study was to evaluate in an experimental model the effects of levosimendan during severe calcium antagonist intoxication. Methods: Twelve landrace-pigs were intoxicated with intravenous verapamil at escalating infusion rates. The infusion containing 2.5mg/ml verapamil was used aiming to a reduction of cardiac output by 40% from the baseline value. Intoxicated pigs were randomized into two groups: control (saline) and levosimendan (intravenous bolus). Inotropic effect was measured as a change in a maximum of the positive slope of the left ventricular pressure (LV dP/dt). The survival and hemodynamics of the animals were followed for 120 min after the targeted reduction of cardiac output. Results: In the control group, five out of six pigs died during the experiment. In the levosimendan group, one pig died before completion of the experiment (p=0.04). In the levosimendan group a change in LV dP/dt was positive in four out of six pigs compared to one out of six pigs in the control group (p=ns). Conclusions: In this experimental model, the use of levosimendan was associated with improved survival.