Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury: A Propensity Score-Matched Analysis.

OBJECTIVE: We examined early (≤24 h) versus delayed (>24 h) thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI), taking the aortic injury severity into consideration. BACKGROUND: Current trauma surgery guidelines recommend delayed TEVAR following BTAI. However, this recommendation was based on small studies, and specifics regarding recommendation strategies based on aortic injury grades are lacking. METHODS: Patients undergoing TEVAR for BTAI in the American College of Surgeons Trauma Quality Improvement Program between 2016 and 2019 were included and then stratified into 2 groups (early: ≤24 h vs. delayed: >24 h). In-hospital outcomes were compared after creating 1:1 propensity score-matched cohorts, matching for demographics, comorbidities, concomitant injuries, additional procedures, and aortic injury severity based on the acute aortic syndrome (AAS) classification. RESULTS: Overall, 1339 patients were included, of whom 1054(79%) underwent early TEVAR. Compared with the delayed group, the early group had significantly less severe head injuries (early vs delayed; 25% vs 32%; P =0.014), fewer early interventions for AAS grade 1 occurred, and AAS grade 3 aortic injuries often were intervened upon within 24 hours (grade 1: 28% vs 47%; grade 3: 49% vs 23%; P <0.001). After matching, the final sample included 548 matched patients. Compared with the delayed group, the early group had a significantly higher in-hospital mortality (8.8% vs 4.4%, relative risk: 2.2, 95% CI: 1.1-4.4; P =0.028), alongside a shorter length of hospital stay (5.0 vs 10 days; P =0.028), a shorter intensive care unit length of stay (4.0 vs 11 days; P <0.001) and fewer days on the ventilator (4.0 vs 6.5 days; P =0.036). Furthermore, regardless of the higher risk of acute kidney injury in the delayed group (3.3% vs 7.7%, relative risk: 0.43, 95% CI: 0.20-0.92; P =0.029), no other differences in in-hospital complications were observed between the early and delayed group. CONCLUSION: In this propensity score-matched analysis, delayed TEVAR was associated with lower mortality risk, even after adjusting for aortic injury grade.

Sex Related Outcomes Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury.

OBJECTIVE: Current literature suggests that thoracic endovascular aortic repair (TEVAR) in older patients with aortic aneurysms results in higher peri-operative mortality and lower long term survival in females compared with males. However, sex related outcomes in younger patients with blunt thoracic aortic injury (BTAI) undergoing TEVAR remain unknown. This study examined the association between sex and outcomes after TEVAR for BTAI. METHODS: A retrospective cohort study was performed of all patients who underwent TEVAR for BTAI in the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) between 2016 and 2019. The primary outcome was in hospital death. Secondary outcomes were peri-operative complications. Multivariable logistic regression was used to adjust for demographics, comorbidities, injury severity score, and aortic injury grade. RESULTS: Two thousand and twenty-two patients were included; 26% were female. Compared with males, females were older (46 [IQR 30, 62] vs. 39 [IQR 28, 56] years; p < .001), more often obese (41% vs. 33%; p = .005), had lower rates of alcohol use disorder (4.1% vs. 8.9%; p < .001) and a higher prevalence of hypertension (29% vs. 22%; p = .001). The injury severity was comparable between females and males (Injury Severity Score ≥ 25; 84% vs. 80%; p = .11) and there was no difference in aortic injury grades when comparing females with males (grade 1, 33% vs. 33%; grade 2, 24% vs. 25%; grade 3, 43% vs. 40%; grade 4, 0.8% vs. 1.3%; p = .53). Multivariable logistic regression demonstrated no difference for in hospital mortality between females and males (OR 1.02; 95% CI 0.67 - 1.53, p = .93). Compared with males, females were at lower risk of acute kidney injury (AKI) (OR 0.33; 95% CI 0.17 - 0.64; p = .001) and ventilator associated pneumonia (VAP) (OR 0.50; 95% CI 0.28 - 0.91; p = .023). CONCLUSION: This study did not demonstrate a sex related in hospital mortality difference following TEVAR for BTAI. However, female sex was associated with a lower risk of AKI and VAP. Future studies should evaluate sex differences and long term outcomes following TEVAR in patients with BTAI.

Prehospital Intubation of Patients with Severe Traumatic Brain Injury: A Dutch Nationwide Trauma Registry Analysis.

OBJECTIVE: Patients with severe traumatic brain injury (TBI) are commonly intubated during prehospital treatment despite a lack of evidence that this is beneficial. Accumulating evidence even suggests that prehospital intubation may be hazardous, in particular when performed by inexperienced EMS clinicians. To expand the limited knowledge base, we studied the relationship between prehospital intubation and hospital mortality in patients with severe TBI in a large Dutch trauma database. We specifically hypothesized that the relationship differs depending on whether a physician-based emergency medical service (EMS) was involved in the treatment, as opposed to intubation by paramedics. METHODS: A retrospective analysis was performed using the Dutch Nationwide Trauma Registry that includes all trauma patients in the Netherlands who are admitted to any hospital with an emergency department. All patients treated for severe TBI (Head Abbreviated Injury Scale score ≥4) between January 2015 and December 2019 were selected. Multivariable logistic regression was used to assess the relationship between prehospital intubation and mortality while adjusting for potential confounders. An interaction term between prehospital intubation and the involvement of physician-based EMS was added to the model. Complete case analysis as well as multiple imputation were performed. RESULTS: 8946 patients (62% male, median age 63 years) were analyzed. The hospital mortality was 26.4%. Overall, a relationship between prehospital intubation and higher mortality was observed (complete case: OR 1.86, 95% CI 1.35-2.57, p < 0.001; multiple imputation: OR 1.92, 95% CI 1.56-2.36, p < 0.001). Adding the interaction revealed that the relationship of prehospital intubation may depend on whether physician-based EMS is involved in the treatment (complete case: p = 0.044; multiple imputation: p = 0.062). Physician-based EMS involvement attenuated but did not completely remove the detrimental association between prehospital intubation and mortality. CONCLUSION: The data do not support the common practice of prehospital intubation. The effect of prehospital intubation on mortality might depend on EMS clinician experience, and it seems prudent to involve prehospital personnel well proficient in prehospital intubation whenever intubation is potentially required. The decision to perform prehospital intubation should not merely be based on the largely unsupported dogma that it is generally needed in severe TBI, but should rather individually weigh potential benefits and harms.

Pre-hospital transfusion of red blood cells. Part 1: A scoping review of current practice and transfusion triggers.

OBJECTIVES: The primary aim of this scoping review is to describe the current use of pre-hospital transfusion of red blood cells (PHTRBC) and to evaluate criteria used to initiate PHTRBC. The effects on patients' outcomes will be reviewed in Part 2. BACKGROUND: Haemorrhage is a preventable cause of death in trauma patients, and transfusion of red blood cells is increasingly used by Emergency Medical Services (EMS) for damage control resuscitation. However, there are no guidelines and little consensus on when to initiate PHTRBC. METHODS: PubMed and Web of Science were searched through January 2019; 71 articles were included. RESULTS: Transfusion triggers vary widely and involve vital signs, clinical signs of poor tissue perfusion, point of care measurements and pre-hospital ultrasound imaging. In particular, hypotension (most often defined as systolic blood pressure ≤ 90 mmHg), tachycardia (most often defined as heart rate ≥ 120/min), clinical signs of poor perfusion (eg, prolonged capillary refill time or changes in mental status) and injury type (ie, penetrating wounds) are common pre-hospital transfusion triggers. CONCLUSIONS: PHTRBC is increasingly used by Emergency Medical Services, but guidelines on when to initiate transfusion are lacking. We identified the most commonly used transfusion criteria, and these findings may provide the basis for consensus-based pre-hospital transfusion protocols.

Pre-hospital transfusion of red blood cells. Part 2: A systematic review of treatment effects on outcomes.

The primary aim of this systematic review is to describe the effects of prehospital transfusion of red blood cells (PHTRBC) on patient outcomes. Damage control resuscitation attempts to prevent death through haemorrhage in trauma patients. In this context, transfusion of red blood cells is increasingly used by emergency medical services (EMS). However, evidence on the effects on outcomes is scarce. PubMed and Web of Science were searched through January 2019; 55 articles were included. No randomised controlled studies were identified. While several observational studies suggest an increased survival after PHTRBC, consistent evidence for beneficial effects of PHTRBC on survival was not found. PHTRBC appears to improve haemodynamic parameters, but there is no evidence that shock on arrival to hospital is averted, nor of an association with trauma induced coagulopathy or with length of stay in hospitals or intensive care units. In conclusion, PHTRBC is increasingly used by EMS, but there is no strong evidence for effects of PHTRBC on mortality. Further research with study designs that allow causal inferences is required for more conclusive evidence. The combination of PHTRBC with plasma, as well as the use of individualised transfusion criteria, may potentially show more benefits and should be thoroughly investigated in the future. The review was registered at Prospero (CRD42018084658).

Effect of Physician-Staffed Emergency Medical Services (P-EMS) on the Outcome of Patients with Severe Traumatic Brain Injury: A Review of the Literature.

Introduction: Traumatic injury is the fourth leading cause of death in western countries and the leading cause of death in younger age. However, it is still unclear which groups of patients benefit most from advanced prehospital trauma care. A minimal amount is known about the effect of prehospital physician-based care on patients with specifically traumatic brain injury (TBI). The aim of this review is to assess the effect of physician-staffed Emergency Medical Services (EMS) on the outcome of patients with severe TBI. Methods: Literature searches have been performed in the bibliographic databases of PubMed, EMBASE and The Cochrane Library. Data concerning (physician-staffed) prehospital care for patients with severe TBI were only included if the control group was based on non-physician-staffed EMS. Primarily the mortality rate and secondarily the neurological outcome were examined. Additionally, data concerning hypotension, hypoxia, length of stay (hospital and intensive care unit) and the number of required early neurosurgical interventions were taken into account. Results: The overall mortality was decreased in three of the fourteen included studies after the implementation of a physician in the prehospital setting. One study found also a decrease in mortality only for patients with a Glasgow Coma Scale of 6-8. Strikingly, two other studies reported higher mortality, one for all the included patients and one for patients with GCS 10-12 only. Neurological outcome was improved in five studies after prehospital deployment of a physician. One study reported that more patients had a poor neurological outcome in the P-EMS group. Results of the remaining outcome measures differed widely. Conclusion: The included literature did not show a clear beneficial effect of P-EMS in the prehospital management of patients with severe TBI. The available evidence showed contradictory results, suggesting more research should be performed in this field with focus on decreasing heterogeneity in the compared groups.

Preoperative chest radiographs in hip fracture patients: is there any additional value?

PURPOSE: Preoperative screening in hip fracture patients is vital to minimize perioperative complications. Preoperative chest radiographs (POCR) are performed in many hip fracture patients. Earlier research showed that few POCR abnormalities influence perioperative policy. However, no studies in nonelective patient with a specific surgical conditions have been performed. With many hip fractures per year worldwide, a significant cost reduction could be made by performing selective POCR without compromising the quality of care. This study assessed the need for POCR in hip fracture patients. METHOD: Retrospective analysis of low-energy trauma patients was performed aged 18 years and older in the VU University Medical Center for a hip fracture in a 5-year period. All preoperative diagnostics were analyzed. All adjourned operations were evaluated. RESULTS: A total of 642 patients were included, 70% female, matching current epidemiologic figures. The POCR showed abnormalities in 22.6%. In 0.6% the POCR lead to an adjournment of the operation (2.8% of abnormal POCR's). These patients suffered from pneumonia. The POCR in these cases acted as a confirmation of the clinical diagnosis. CONCLUSION: Many factors involving the treatment of hip fracture patients are of importance in minimizing the risk of complications and mortality during and after admission. In 0.6% of all performed POCR's an abnormality leads to the adjournment of the operation. In all four cases the POCR matched the clinical findings. Because the additional value of the POCR in hip fracture patients was limited, we think that its selective use in clinical abnormalities is safe and will reduce unnecessary costs.

Complications after laparotomy for trauma: a retrospective analysis in a level I trauma centre.

PURPOSE: Laparotomy is a potential life-saving procedure after traumatic abdominal injury. There is limited literature about morbidity and mortality rates after trauma laparotomy. The primary aim of this study is to describe the complications which may occur due to laparotomy for trauma. METHODS: Retrospective evaluated single-centre study with data registry up to 1 year after initial laparotomy for trauma was performed in a level 1 trauma centre in The Netherlands. Between January 2000 and January 2011, a total of 2390 severely injured trauma patients (ISS ≥ 16) were transported to the VUMC. Patient demographics; mechanism of injury; injury patterns defined by Abbreviated Injury Scale (AIS), Injury Severity Score (ISS) and Revised Trauma Score (RTS); surgical interventions and findings; and morbidity and mortality were documented. RESULTS: A total of 92 trauma patients who underwent a trauma laparotomy met the inclusion criteria. Of these patients, 71 % were male. Median age was 37 years. Median ISS was 27. Mechanisms of injury comprised of car accidents (20 %), fall from height (17 %), motorcycle accidents (12 %), pedestrian/cyclist hit by a vehicle (9 %) and other in three patients (5 %). Penetrating injuries accounted for 37 % of the injuries, consisting of stab wounds (21 %) and gunshot wounds (16 %). Complications classified by the Clavien-Dindo Classification of Surgical Complications showed grade I complications in 21 patients (23 %), grade II in 36 patients (39 %), grade III in 21 patients (23 %), grade IV in 2 patients (2 %) and grade V in 16 patients (17 %). CONCLUSION: Laparotomy for trauma has a high complication rate resulting in significant morbidity and mortality. Most events occur in the early postoperative period. Further prospective research needs to be conducted in order to identify possibilities to improve care in the future.

Traumatic Cardiac Arrest-A Narrative Review.

A paradigm shift in traumatic cardiac arrest (TCA) perception switched the traditional belief of futility of TCA resuscitation to a more optimistic perspective, at least in selected cases. The goal of TCA resuscitation is to rapidly and aggressively treat the common potentially reversible causes of TCA. Advances in diagnostics and therapy in TCA are ongoing; however, they are not always translating into improved outcomes. Further research is needed to improve outcome in this often young and previously healthy patient population.

Merging of two level-1 trauma centers in Amsterdam: premerger demand in integrated acute trauma care.

PURPOSE: Availability of adequate and appropriate trauma care is essential. A merger of two Dutch academic level-1 trauma centers is upcoming. However, in the literature, volume effects after a merger are inconclusive. This study aimed to examine the premerger demand for level-1 trauma care on integrated acute trauma care and evaluate the expected demand on the system. METHODS: A retrospective observational study was conducted between 1-1-2018 and 1-1-2019 in two level-1 trauma centers in the Amsterdam region using data derived from the local trauma registries and electronic patient records. All trauma patients presented at both centers' Emergency Departments (ED) were included. Patient- and injury characteristics and data concerning all prehospital and in-hospital-delivered trauma care were collected and compared. Pragmatically, the demand for trauma care in the post-merger setting was considered a sum of care demand for both centers. RESULTS: In total, 8277 trauma patients were presented at both EDs, 4996 (60.4%) at location A and 3281 (39.6%) at location B. Overall, 462 patients were considered severely injured patients (Injury Severity Score ≥ 16). In total, 702 emergency surgeries (< 24 h) were performed, and 442 patients were admitted to the ICU. The sum care demand of both centers resulted in a 167.4% increase in trauma patients and a 151.1% increase in severely injured patients. Moreover, on 96 occasions annually, two or more patients within the same hour would require advanced trauma resuscitation by a specialized team or emergency surgery. CONCLUSION: A merger of two Dutch level-1 trauma centers would, in this scenario, result in a more than 150% increase in the post-merger setting's demand for integrated acute trauma care.

Readmission after thoracic endovascular aortic repair following blunt thoracic aortic injury.

PURPOSE: Thoracic endovascular aortic repair (TEVAR) is increasingly utilized to treat blunt thoracic aortic injury (BTAI), but post-discharge outcomes remain underexplored. We examined 90-day readmission in patients treated with TEVAR following BTAI. METHODS: Adult patients discharged alive after TEVAR for BTAI in the Nationwide Readmissions Database between 2016 and 2019 were included. Outcomes examined were 90-day non-elective readmission, primary readmission reasons, and 90-day mortality. As a complementary analysis, 90-day outcomes following TEVAR for BTAI were compared with those following TEVAR for acute type B aortic dissection (TBAD). RESULTS: We identified 2085 patients who underwent TEVAR for BTAI. The median age was 43 years (IQR, 29-58), 65% of all patients had an ISS ≥ 25, and 13% were readmitted within 90 days. The main primary causes for readmission were sepsis (8.8%), wound complications (6.7%), and neurological complications (6.5%). Two patients developed graft thrombosis as primary readmission reasons. Compared with acute TBAD patients, BTAI patients had a significantly lower rate of readmission within 90 days (BTAI vs. TBAD; 13% vs. 29%; p < .001). CONCLUSION: We found a significant proportion of readmission in patients treated with TEVAR for BTAI. However, the 90-day readmission rate after TEVAR for BTAI was significantly lower compared with acute TBAD, and the common cause for readmission was not related to residual aortic disease or vascular devices. This represents an important distinction from other patient populations treated with TEVAR for acute vascular conditions. Elucidating differences between trauma-related TEVAR readmissions and non-traumatic indications better informs both the clinician and patients of expected post-discharge course. Level of evidence/study type: IV, Therapeutic/care management.

Adjunctive hyperbaric oxygen therapy in the management of severe lower limb soft tissue injuries: a systematic review.

PURPOSE: Traumatic crush injuries of the lower limb often accompany severe complications. The incorporation of hyperbaric oxygen therapy to standard trauma care may have the potential to diminish injury-related complications and improve outcome in such cases. This systematic review aims to evaluate the effectiveness of hyperbaric oxygen therapy in the management of severe lower limb soft tissue injuries. METHODS: The electronic databases Medline, Embase and Cochrane Library were searched to identify studies involving patients with crush-associated sever lower limb soft tissue injuries who received hyperbaric oxygen therapy in conjunction with standard trauma care. Relevant data on type of injury, hyperbaric oxygen therapy protocol and outcome related to wound healing were extracted. RESULTS: In total seven studies met the inclusion criteria, involving 229 patients. The studies included two randomized clinical trials, one retrospective cohort study, three case series and one case report. The randomized placebo-controlled clinical trial showed a significant increase in wound healing and decrease in the need for additional surgical interventions in the patient group receiving hyperbaric oxygen therapy when compared to those undergoing sham therapy. The randomized non-placebo-controlled clinical trial revealed that early hyperbaric oxygen therapy reduces tissue necrosis and the likelihood of long-term complications. The retrospective cohort study indicated that hyperbaric oxygen therapy effectively reduces infection rates and the need for additional surgical interventions. The case series and case report presented beneficial results with regard to wound healing when hyperbaric oxygen therapy was added to the treatment regimen. CONCLUSION: Hyperbaric oxygen therapy is generally considered a safe therapeutic intervention and seems to have a beneficial effect on wound healing in severe lower limb soft tissue injuries when implemented as an addition to standard trauma care.

Effect of Daytime versus Nighttime on Prehospital Care and Outcomes after Severe Traumatic Brain Injury.

Background/Objectives: Severe traumatic brain injury (TBI) is a frequent cause of morbidity and mortality worldwide. In the Netherlands, suspected TBI is a criterion for the dispatch of the physician-staffed helicopter emergency medical services (HEMS) which are operational 24 h per day. It is unknown if patient outcome is influenced by the time of day during which the incident occurs. Therefore, we investigated the association between the time of day of the prehospital treatment of severe TBI and 30-day mortality. Methods: A retrospective analysis of prospectively collected data from the BRAIN-PROTECT study was performed. Patients with severe TBI treated by one of the four Dutch helicopter emergency medical services were included and followed up to one year. The association between prehospital treatment during day- versus nighttime, according to the universal daylight period, and 30-day mortality was analyzed with multivariable logistic regression. A planned subgroup analysis was performed in patients with TBI with or without any other injury. Results: A total of 1794 patients were included in the analysis, of which 1142 (63.7%) were categorized as daytime and 652 (36.3%) as nighttime. Univariable analysis showed a lower 30-day mortality in patients with severe TBI treated during nighttime (OR 0.74, 95% CI 0.60-0.91, p = 0.004); this association was no longer present in the multivariable model (OR 0.82, 95% CI 0.59-1.16, p = 0.262). In a subgroup analysis, no association was found between mortality rates and the time of prehospital treatment in patients with combined injuries (TBI and any other injury). Patients with isolated TBI had a lower mortality rate when treated during nighttime than when treated during daytime (OR 0.51, 95% CI 0.34-0.76, p = 0.001). Within the whole cohort, daytime versus nighttime treatments were not associated with differences in functional outcome defined by the Glasgow Outcome Scale. Conclusions: In the overall study population, no difference was found in 30-day mortality between patients with severe TBI treated during day or night in the multivariable model. Patients with isolated severe TBI had lower mortality rates at 30 days when treated at nighttime.

The effect of a clock's presence on trauma resuscitation times in a Dutch level-1 trauma center: a pre-post cohort analysis.

PURPOSE: Interventions performed within the first hour after trauma increase survival rates. Literature showed that measuring times can optimize the trauma resuscitation process as time awareness potentially reduces acute care time. This study examined the effect of a digital clock placement on trauma resuscitation times in an academic level-1 trauma center. METHODS: A prospective observational pre-post cohort analysis was conducted for six months before and after implementing a visible clock in the trauma resuscitation room, indicating the time passed since starting the in-hospital resuscitation process. Trauma patients (age ≥ 16) presented during weekdays between 9.00 AM and 9.00 PM were included. Time until diagnostics (X-Ray, FAST, or CT scan), time until therapeutic intervention, and total resuscitation time were measured manually with a stopwatch by a researcher in the trauma resuscitation room. Patient characteristics and information regarding trauma- and injury type were collected. Times before and after clock implementation were compared. RESULTS: In total, 100 patients were included, 50 patients in each cohort. The median total resuscitation time (including CT scan) was 40.3 min (IQR 23.3) in the cohort without a clock compared to 44.3 (IQR 26.1) minutes in the cohort with a clock. The mean time until the first diagnostic and until the CT scan was 8.3 min (SD 3.1) and 25.5 min (SD 7.1) without a clock compared to 8.6 min (SD 6.5) and 26.6 min (SD 11.5) with a clock. Severely injured patients (Injury Severity Score (ISS) ≥ 16) showed a median resuscitation time in the cohort without a clock (n = 9) of 54.6 min (IQR 50.5) compared to 46.0 min (IQR 21.6) in the cohort with a clock (n = 8). CONCLUSION: This study found no significant reduction in trauma resuscitation time after clock placement. Nonetheless, the data represent a heterogeneous population, not excluding specific patient categories for whom literature has shown that a short time is essential, such as severely injured patients, might benefit from the presence of a trauma clock. Future research is recommended into resuscitation times of specific patient categories and practices to investigate time awareness.

The Pedicled Fibula Flap for Lower Limb Reconstruction.

The pedicled fibula flap is a reliable technique to treat large defects in the tibia. Despite increasing evidence of its efficacy and good long-term outcomes, a knowledge gap exists in its indications and technique. This instructional article presents a comprehensive overview of the indications, pre-operative planning, step-by-step surgery, and subsequent post-operative management. How to cite this article: Noorlander-Borgdorff MP, Giannakópoulos GF, Winters HAH, et al. The Pedicled Fibula Flap for Lower Limb Reconstruction. Strategies Trauma Limb Reconstr 2023;18(3):186-193.

Criteria for cancelling helicopter emergency medical services (HEMS) dispatches.

INTRODUCTION: In The Netherlands there is no consensus about criteria for cancelling helicopter emergency medical services (HEMS) dispatches. This study assessed the ability of the primary HEMS dispatch criteria to identify major trauma patients. The predictive power of other early prehospital parameters was evaluated to design a safe triage model for HEMS dispatch cancellations. METHODS: All trauma-related dispatches of HEMS during a period of 6 months were included. Data concerning prehospital information and inhospital treatment were collected. Patients were divided into two groups (major and minor trauma) according to the following criteria: injury severity score 16 or greater, emergency intervention, intensive care unit admission, or inhospital death. Logistic regression analysis was used to design a prediction model for the early identification of major trauma patients. RESULTS: In total, 420 trauma-related dispatches were evaluated, of which 155 concerned major trauma patients. HEMS was more often cancelled for minor trauma patients than for major trauma patients (57.7% vs 20.6%). Overall, HEMS dispatch criteria had a sensitivity of 87.7% and a specificity of 45.3% for identifying major trauma patients. Significant differences were found for vital sign abnormalities, anatomical components and several parameters of the mechanism of injury. A triage model designed for cancelling HEMS correctly identified major trauma patients (sensitivity 99.4%). CONCLUSION: The accuracy of the current HEMS dispatch criteria is relatively low, resulting in high cancellation rates and low predictability for major trauma. The new HEMS cancellation triage model identified all major trauma patients with an acceptable overtriage and will probably reduce unjustified HEMS dispatches.

In-House Attending Trauma Surgeon Does Not Reduce Mortality in Patients Presented to a Level 1 Trauma Center.

BACKGROUND: Trauma is the leading cause of death in the Western world. Trauma systems have been paramount in opposing this problem. Commonly, Level 1 Trauma Centers are staffed by in-house (IH) attending trauma surgeons available 24/7, whereas other institutions function on an on-call (OC) basis with defined response times. There is on-going debate about the value of an IH attending trauma surgeon compared to OC trauma surgeons regarding clinical outcome. METHODS: This study was performed at a tertiary care facility complying with all requirements to be a designated Level 1 Trauma Center as defined by the American College of Surgeons Committee on Trauma (ACSCOT). Inclusion occurred from January 1, 2012 through December 31, 2013. Patients were assigned an identifier for IH trauma surgeon attendance versus OC attendance. The primary outcome variable studied was overall mortality in relation to IH or OC attending trauma surgeons. Additionally, time to operating theater, hospital length-of-stay (HLOS), and intensive care unit (ICU) admittance were investigated. RESULTS: A total of 1,287 unique trauma cases in 1,285 patients were presented to the trauma team. Of all cases, 712 (55.3%) occurred between 1700h and 0800h. These 712 cases were treated by an IH attending in 66.3% (n = 472) and an OC attending in 33.7% (n = 240). In the group of patients treated by an IH attending trauma surgeon, the overall mortality rate was 5.5% (n = 26); in the group treated by an OC attending, the overall mortality rate was 4.6% (n = 11; P = .599). Cause of death was traumatic brain injury (TBI) in 57.6%. No significant difference was found in the time between initial presentation at the trauma room and arrival in the operating theater. CONCLUSION: In terms of trauma-related mortality during non-office hours, no benefit was demonstrated through IH trauma surgeons compared to OC trauma surgeons.

Operational experience of the Dutch helicopter emergency medical services (HEMS) during the initial phase of the COVID-19 pandemic: jeopardy on the prehospital care system?

PURPOSE: The SARS-CoV-2 virus has disrupted global and local medical supply chains. To combat the spread of the virus and prevent an uncontrolled outbreak with limited resources, national lockdown protocols have taken effect in the Netherlands since March 13th, 2020. The aim of this study was to describe the incidence, type and characteristics of HEMS and HEMS-ambulance 'Lifeliner 1' dispatches during the initial phase of the COVID-19 pandemic compared to the same period one year prior. METHODS: A retrospective review of all HEMS and HEMS-ambulance 'Lifeliner 1' dispatches was performed from the start of Dutch nationwide lockdown orders from March 13th until May 13th, 2020 and the corresponding period one year prior. Dispatch-, operational-, patient-, injury-, and on-site treatment characteristics were extracted for analysis. In addition, the rate of COVID-19 positively tested HEMS personnel and the time physicians were unable to take call was described. RESULTS: During the initial phase of the COVID-19 pandemic, the HEMS and HEMS-ambulance was requested in 528 cases. One year prior, a total of 620 requests were received. The HEMS (helicopter and ambulance) was cancelled after deployment in 56.4% of the COVID-19 cohort and 50.7% of the historical cohort (P = 0.05). Incident location type did not differ between the two cohorts, specifically, there was no significant difference in the number of injuries that occurred at home in pandemic versus non-pandemic circumstances. Besides a decrease in the number of falls, the distribution of mechanisms of injury remained similar during the COVID-19 study period. There was no difference in self-inflicted injuries observed. Prehospital interventions remained similar during the COVID-19 pandemic compared to one year prior. Specifically, prehospital intubation did not differ between the two cohorts. The rate of COVID-19 positively tested HEMS personnel was 23.1%. Physicians who tested positive were unable to take call for a mean of 25 days (range 8-53). CONCLUSION: A decrease in the number of deployments and increase in the number of cancelled missions was observed during the COVID-19 study period. No major differences in operational- and injury characteristics were found for HEMS and HEMS-ambulance dispatches between the initial phase of the COVID-19 pandemic in the Netherlands and the same period one year prior. These findings highlight the importance of continued operability of the HEMS, even during pandemic circumstances. LEVEL OF EVIDENCE: III, retrospective comparative study.

Distribution of radiation exposure in patients with partially stable and unstable pelvic ring fractures: first-time use of highly accurate assessment by Monte Carlo calculations.

PURPOSE: Radiological examinations including X-ray and CT play a critical role in the assessment and treatment of trauma patients. The ionizing radiation used is known to be carcinogenic. However, little is known about the total radiation exposure in trauma patients. The objective of this study was to accurately estimate radiation exposure of patients with severe pelvic ring fractures. METHODS: In this retrospective dynamic cohort study, adult patients with partially stable and unstable pelvic ring fractures were included. For each patient, data concerning demography and injury characteristics were collected. Subsequently, the total effective radiation dose due to all trauma-related X-rays and CT scans during initial assessment, treatment and follow-up was calculated using Monte Carlo software. RESULTS: A total of 114 patients were included. The median total effective dose was 49.7 millisievert (mSv). 57 patients (50.0%) received more than 50 mSv and 13 patients (11.4%) received more than 100 mSv. 62.4% of the total effective dose was received within the 24 h after admission. The median total effective dose for survivors (n = 95) was 52.0 mSv. Polytrauma patients received a significantly higher total effective dose than non-polytrauma patients. CONCLUSIONS: This study showed that a substantial number of patients with partially stable and unstable pelvic ring fractures have an increased cancer risk due to trauma-related medical imaging. Physicians should be aware of the amount of radiation their patients are exposed to, and minimize imaging related increase of cancer risks during initial assessment, treatment and follow-up.

The effect of socioeconomic status on severe traumatic injury: a statistical analysis.

PURPOSE: The amount of studies performed regarding a link between socioeconomic status (SES) and fatal outcome after traumatic injury is limited. Most research is focused on work-related injuries without taking other important characteristics into account. The aim of this study is to examine the association between SES and outcome after traumatic injury. METHODS: The study involved polytrauma patients [Injury Severity Score (ISS) ≥ 16] admitted to the Amsterdam University Medical Center (location VUmc) and Northwest Clinics Alkmaar (level 1 trauma centers). The SES of every patient was based on their postal code and represented with a "status score". Univariate and multivariable analyses were performed to estimate the association between SES and mortality, length of stay at the hospital and length of stay at the Intensive Care Unit (ICU). Z-statistics were used to determine the difference between the expected and actual survival, based on Trauma Revised Injury Severity Score (TRISS) and PSNL15 (probability of survival based on the Dutch population). RESULTS: A total of 967 patients were included in this study. The lowest SES group was significantly associated with more penetrating injuries and a younger age (45 years versus 55 years). Additionally, severely injured patients with lower SES were noted to have a prolonged stay at the ICU. Furthermore, differences were found in the expected and observed survival, especially for the lower SES groups. CONCLUSION: Polytrauma patients with lower SES have more often penetrating injuries, are younger and have a longer stay at the ICU. No association was found between SES and length of hospital stay and neither between SES and mortality.