A randomized, controlled, blinded evaluation of augmenting point-of-care ultrasound and remote telementored ultrasound in inexperienced operators.

BACKGROUND: Handheld ultrasound devices present an opportunity for prehospital sonographic assessment of trauma, even in the hands of novice operators commonly found in military, maritime, or other austere environments. However, the reliability of such point-of-care ultrasound (POCUS) examinations by novices is rightly questioned. A common strategy being examined to mitigate this reliability gap is remote mentoring by an expert. OBJECTIVES: To assess the feasibility of utilizing POCUS in the hands of novice military or civilian emergency medicine service (EMS) providers, with and without the use of telementoring. To assess the mitigating or exacerbating effect telementoring may have on operator stress. METHODS: Thirty-seven inexperienced physicians and EMTs serving as first responders in military or civilian EMS were randomized to receive or not receive telementoring during three POCUS trials: live model, Simbionix trainer, and jugular phantom. Salivary cortisol was obtained before and after the trial. Heart rate variability monitoring was performed throughout the trial. RESULTS: There were no significant differences in clinical performance between the two groups. Iatrogenic complications of jugular venous catheterization were reduced by 26% in the telementored group (P < 0.001). Salivary cortisol levels dropped by 39% (P < 0.001) in the telementored group. Heart rate variability data also suggested mitigation of stress. CONCLUSIONS: Telementoring of POCUS tasks was not found to improve performance by novices, but findings suggest that it may mitigate caregiver stress.

Utility of simultaneous interventional radiology and operative surgery in a dedicated suite for seriously injured patients.

PURPOSE OF REVIEW: In recent years, combined interventional radiology and operative suites have been proposed and are now becoming operational in select trauma centres. Given the infancy of this technology, this review aims to review the rationale, benefits and challenges of hybrid suites in the management of seriously injured patients. RECENT FINDINGS: No specific studies exist that investigate outcomes within hybrid trauma suites. Endovascular and interventional radiology techniques have been successfully employed in thoracic, abdominal, pelvic and extremity trauma. Although the association between delayed haemorrhage control and poorer patient outcomes is intuitive, most supporting scientific data are outdated. The hybrid suite model offers the potential to expedite haemorrhage control through synergistic operative, interventional radiology and resuscitative platforms. Maximizing the utility of these suites requires trained multidisciplinary teams, ergonomic and workplace considerations, as well as a fundamental paradigm shift of trauma care. This often translates into a more damage-control orientated philosophy. SUMMARY: Hybrid suites offer tremendous potential to expedite haemorrhage control in trauma patients. Outcome evaluations from trauma units that currently have operational hybrid suites are required to establish clearer guidelines and criteria for patient management.

The Prevent Alcohol and Risk-Related Trauma in Youth (P.A.R.T.Y) program: An interactive injury prevention initiative in South-Western Sydney.

BACKGROUND: The Prevent Alcohol and Risk Related Trauma in Youth (P.A.R.T.Y) program is an interactive injury prevention intervention, specifically designed for "at risk" youths aged 15 to 19 years. Emerging evidence has highlighted its positive impact on altering student attitudes towards risk-taking behaviour across several Australian and international settings. This study aims to describe the risk-taking behaviours of youths in South-Western and Greater Western Sydney, and assess the effectiveness of the Liverpool P.A.R.T.Y program to alter attitudes towards risk-taking. METHODS: From 2015 to 2020, schools and youth organisations across South-Western and Greater Western Sydney were invited to participate in the Liverpool Hospital P.A.R.T.Y program. Youths aged 15 to 19 years were selected to attend by their respective teachers based on eligibility criteria. Knowledge and attitudes towards risk-taking behaviours were measured using surveys across three time points (pre-program, immediately post-program, 3-to-6 months post-program). RESULTS: A total of 2544 participants from 50 schools and youth organisations attended the Liverpool Hospital P.A.R.T.Y program. There were 130 participants who did not record a response to a single question across all three time points and were omitted from analysis. Of the remaining 2414 participants, 49% were male, and 41% had access to a provisional driver's license or learner's permit. There were significant changes in knowledge and attitudes to risk-taking behaviours from pre-to immediately-post-program. A separate analysis across all three time points was conducted in response to a poor 3-to-6-month follow-up rate (25%). There was decay in improvements across all six questions, with the largest change seen in perceived likelihood of injury when engaging in physically risk-taking activities (52.2% to 36.9%, OR 0.44, 95% CI 0.33 - 0.60, p < 0.001). CONCLUSION: This study demonstrated significant changes in participant attitudes towards risk-taking behaviours and their consequences, immediately after participating in the Liverpool Hospital P.A.R.T.Y program. However, the poor response rates at later follow-up highlight the need for ongoing engagement of the South-Western and Greater Western Sydney youths, to ensure these improvements are sustained.

Intraabdominal hypertension and the abdominal compartment syndrome in burn patients.

Severe burns represent a devastating injury that induces profound systemic inflammation requiring large volumes of resuscitative fluids. The consequent massive swelling and peritoneal ascites raises intraabdominal pressures (IAP) to supraphysiologic levels commensurate with intraabdominal hypertension (IAH) and with the abdominal compartment syndrome (ACS) if consistently associated with IAP >20 mmHg and associated with new organ failure. Severe burn injuries are an example of the secondary ACS (secondary ACS), wherein there has been no primary inciting intraperitoneal injury, yet severe IAH/ACS develops, setting the stage for progressive multiorgan dysfunction. These definitions along with practice management guidelines have recently been promulgated by the World Society of the Abdominal Compartment Syndrome (WSACS) in an effort to standardize terminology and communication regarding IAH/ACS in critical care. It is currently unknown whether these syndromes are iatrogenic consequences of excessive or poorly managed fluid resuscitation or unavoidable sequelae of the primary injury. It occurs frequently with burns of >60% body surface area, especially with associated inhalational injury, delayed resuscitation, and abdominal wall injuries. IAH/ACS is often a hyperacute phenomenon that occurs within the first hours of admission and thereafter with any complication requiring aggressive fluid resuscitation. Despite a number of noninvasive management strategies, interventions such as percutaneous peritoneal drainage and, ultimately, decompressive laparotomy are often required once the ACS is established. Whether novel resuscitation strategies can avoid or minimize IAH/ACS is unproven at present and requires further study. Truly understanding postburn ACS may require further insights into the basic mechanisms of injury and resuscitation.

Ten-year evolution of a massive transfusion protocol in a level 1 trauma centre: have outcomes improved?

BACKGROUND: We aimed to evaluate the evolution and implementation of the massive transfusion protocol (MTP) in an urban level 1 trauma centre. Most data on this topic comes from trauma centres with high exposure to life-threatening haemorrhage. This study examines the effect of the introduction of an MTP in an Australian level 1 trauma centre. METHODS: A retrospective study of prospectively collected data was performed over a 14-year period. Three groups of trauma patients, who received more than 10 units of packed red blood cells (PRBC), were compared: a pre-MTP group (2002-2006), an MTP-I group (2006-2010) and an MTP-II group (2010-2016) when the protocol was updated. Key outcomes were mortality, complications and number of blood products transfused. RESULTS: A total of 168 patients were included: 54 pre-MTP patients were compared to 47 MTP-I and 67 MTP-II patients. In the MTP-II group, fewer units of PRBC and platelets were administered within the first 24 h: 17 versus 14 (P = 0.01) and 12 versus 8 (P < 0.001), respectively. Less infections were noted in the MTP-I group: 51.9% versus 31.9% (P = 0.04). No significant differences were found regarding mortality, ventilator days, intensive care unit and total hospital lengths of stay. CONCLUSION: Introduction of an MTP-II in our level 1 civilian trauma centre significantly reduced the amount of PRBC and platelets used during damage control resuscitation. Introduction of the MTP did not directly impact survival or the incidence of complications. Nevertheless, this study reflects the complexity of real-life medical care in a level 1 civilian trauma centre.

Acute resuscitation of the unstable adult trauma patient: bedside diagnosis and therapy.

Traumatic injury remains the leading cause of potentially preventable death in Canadians under age 40 years. Although only a minority of patients present with hemodynamic instability, these patients have a significant chance of dying. The causes of instability must be recognized and corrected quickly by using a systematic approach. To allow key supportive interventions to be undertaken swiftly, it is more important to identify and prioritize systemic compromise than to confirm specific diagnoses. Most potentially preventable trauma death relates to airway obstruction, hemopneumothorax, intracranial hemorrhage and intracavitary bleeding. Definitive airway control should be assured as a first priority. Hemopneumothoraces are typically addressed by chest tube insertion, although thoracic exploration will occasionally be urgently required. Hemorrhage control is much more important than fluid resuscitation and mandates the earliest possible definitive management. Unstable patients nearing physiological exhaustion require abbreviated or "damage-control" surgical tactics. This should be recognized early in the resuscitation rather than late in an operative procedure. The management of expanding intracranial hemorrhage requires optimization of oxygenation, ventilation and circulatory support while urgent CT and expert neurosurgical care are provided. Polytrauma presenting with head injury challenges the most developed of trauma systems, necessitating thoughtful prioritization of care and taking into consideration local capabilities. Bedside trauma sonography is an evolving tool that complements the physical examination during an initial survey. Future breakthroughs in trauma resuscitation may involve procoagulant medications, imaging technology, circulatory assist techniques and the use of inflammatory modulators. The greatest future challenge in trauma care, though, will be the provision of basic organized resuscitative care to the global community.

Treatment response in liver metastases following 90Y SIR-spheres: an evaluation with PET.

Selective internal radiation therapy (SIRT) with radiolabeled Yttrium-90 (90Y) microspheres is a relatively new therapeutic option for patients with primary or secondary hepatic malignancy. However, the evaluation of the therapeutic efficacy on anatomic imaging alone is suboptimal. Functional imaging with F18-2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) is increasingly utilised in therapy monitoring in malignancy and provides an accurate assessment of metabolic response. We report a case of a 75-year-old gentleman with colorectal hepatic metastases who demonstrated a dramatic metabolic response on PET scan following SIRT. This case illustrates the utility of FDG PET in the assessment of the therapeutic efficacy of 90Y microspheres in colorectal hepatic metastases.

Identifying patients at risk for high-grade intra-abdominal hypertension following trauma laparotomy.

BACKGROUND: Abdominal Compartment Syndrome (ACS) is an uncommon but deleterious complication after trauma laparotomy. Early recognition of patients at risk of developing ACS is crucial for their outcome. The aim of this study was to compare the characteristics of patients who developed high-grade intra-abdominal hypertension (IAH) (i.e., grade III or IV; intra-abdominal pressure, IAP >20 mm Hg) following an injury-related laparotomy versus those who did not (i.e., IAP ≤20 mm Hg). METHODS: A retrospective analysis of consecutive trauma patients admitted to a level 1 trauma centre in Australia between January 1, 1995 and January 31, 2010 was performed. A comparison was made between characteristics of patients who developed high-grade IAH following trauma laparotomy versus those who did not. RESULTS: A total of 567 patients (median age 31 years) were included in this study. Of these patients 10.2% (58/567) developed high-grade IAH of which 51.7% (30/58) developed ACS. Patients with high-grade IAH were older (p<0.001), had a higher Injury Severity Score (p<0.001), larger base deficit (p<0.001) and lower temperature at admission (p=0.011). In the first 24h of admission, patients with high-grade IAH received larger volumes of crystalloids (p<0.001), larger volumes of colloids (p<0.001) and more units of packed red blood cells (p<0.001). Following surgery prolonged prothrombin (p<0.001) and partial thromboplastin times (p<0.001) were seen. The patients with high-grade IAH suffered higher mortality rates (25.9% (15/58) vs. 12.2% (62/509); p=0.012). CONCLUSION: Of all patients who underwent a trauma laparotomy, 10.2% developed high-grade IAH, which increases the risk of mortality. Patients with acidosis, coagulopathy, and hypothermia were especially at risk. In these patients, the abdomen should be left open until adequate resuscitation has been achieved, allowing for definitive surgery. LEVEL OF EVIDENCE: This is a level III retrospective study.

Prehospital fluid resuscitation in hypotensive trauma patients: do we need a tailored approach?

AIM: The ideal strategy for prehospital intravenous fluid resuscitation in trauma remains unclear. Fluid resuscitation may reverse shock but aggravate bleeding by raising blood pressure and haemodilution. We examined the effect of prehospital i.v. fluid on the physiologic status and need for blood transfusion in hypotensive trauma patients after their arrival in the emergency department (ED). METHODS: Retrospective analysis of trauma patients (n=941) with field hypotension presenting to a level 1 trauma centre. Regression models were used to investigate associations between prehospital fluid volumes and shock index and blood transfusion respectively in the emergency department and mortality at 24h. RESULTS: A 1L increase of prehospital i.v. fluid was associated with a 7% decrease of shock index in the emergency department (p<0.001). Volumes of 0.5-1L and 1-2L were associated with reduced likelihood of shock as compared to volumes of 0-0.5L: OR 0.61 (p=0.03) and OR 0.54 (p=0.02), respectively. Volumes of 1-2L were also associated with an increased likelihood of receiving blood transfusion in ED: OR 3.27 (p<0.001). Patients who had received volumes of >2L have a much greater likelihood of receiving blood transfusion in ED: OR 9.92 (p<0.001). Mortality at 24h was not associated with prehospital i.v. fluids. CONCLUSION: In hypotensive trauma patients, prehospital i.v. fluids were associated with a reduction of likelihood of shock upon arrival in ED. However, volumes of >1L were associated with a markedly increased likelihood of receiving blood transfusion in ED. Therefore, decision making regarding prehospital i.v. fluid resuscitation is critical and may need to be tailored to the individual situation. Further research is needed to clarify whether a causal relationship exists between prehospital i.v. fluid volume and blood transfusion. Also, prospective trials on prehospital i.v. fluid resuscitation strategies in specific patient subgroups (e.g. traumatic brain injury and concomitant haemorrhage) are warranted.

Closure of the open abdomen.

The open abdomen is a valuable tool in the management of patients with intra-abdominal hypertension and abdominal compartment syndrome. The longer an abdomen is left open, the greater the potential morbidity, however. From the very start, specific measures should be considered to increase the likelihood of definitive closure and prevent the development of visceral adhesions, lateralization, and/or loss of skin and fascia, ileus, fistulae, and malnutrition. Early definitive closure of all abdominal wall layers is the short-term goal of management once the need for the open abdomen has resolved. Several devices and strategies improve the chances for definitive closure. If a frozen abdomen develops, split-thickness skin grafting of a granulating open abdominal wound base is an alternative. Early coverage of the exposed viscera and acceptance of a large abdominal hernia permit earlier reversal of the catabolic state and lower the risk of fistula formation. When a stoma is required, sealing and separation can become problematic. If a fistula develops, a more complex situation prevails, requiring specific techniques to isolate its output and a longer-term strategy to restore intestinal continuity. Planning the closure of an open abdomen is a process that starts on the first day that the abdomen is opened. Multiple factors need to be addressed, optimized, and controlled to achieve the best outcome.

Validation of nurse-performed FAST ultrasound.

BACKGROUND: Patients presenting to Emergency Departments (EDs) with abdominal trauma benefit from FAST (Focused Assessment with Sonography in Trauma). Not all doctor members of the trauma team are credentialed in FAST; therefore occasionally no one is available in the hospital to undertake a FAST. Hence, the aim of this study was to determine the accuracy of nurse-performed FAST as a practical alternative where suitably trained doctors are not available. METHODS: This was a prospective study of a convenience sample of patients with multisystem trauma in whom abdominal injury was clinically suspected. Senior nurses trained in FAST performed and reported FAST scans for each patient. Accuracy of nurse-performed FAST was determined by comparing results with computerised tomography (CT) scan or operation report. RESULTS: 242 indicated nurse-performed FAST scans were included in the study. Nurse-performed FAST demonstrated sensitivity of 84.4% (95% CI 72.1-92.2) and specificity of 98.4% (CI 94.9-99.6), a positive predictive value (PPV) of 94.2% (CI 83.1-98.5) and a negative predictive value (NPV) of 95.3% (91.0-97.7). Overall accuracy of nurse-performed FAST for the detection of free fluid was 95.0% (95% CI 91.3-97.3). CONCLUSION: This study demonstrates that, in a convenience sample of injured patients, nurse-performed FAST achieved similar accuracy to previously published results of doctor-performed FAST. Future studies with greater patient numbers would be valuable.

Performance and consistency of care in admitted trauma patients: our next great opportunity in trauma care?

Few studies have prospectively analysed the delivery of care in trauma patients. This study undertook a prospective analysis of performance and consistency of care at a Level 1 trauma centre. A 3-month prospective study was undertaken of all admitted trauma patients at Liverpool Hospital. Data were collected on patient demographics, mechanism of injury, injury severity score (ISS), length of hospital stay, patient outcome and cause of death. Delivery of care was evaluated using 30 performance indicators and assessment of errors. Two hundred and thirty-six consecutive major trauma patients were studied. 73.3% were male, mean age 39 years. The main mechanism of injury was road trauma in 46.2%. Mean ISS was 12 and 64 patients had an ISS > or = 16. Error-free care was delivered in 145/236 (61.4%). There were 145 errors in 91 patients (38.6%). Errors in judgement and delays in diagnosis accounted for 56/145 (38.6%) and 48/145 (33.1%), respectively. Errors occurred most commonly in the Emergency Department (ED) (48.3%), and trainees from all specialties were responsible for 67.5% of errors. There were 25 near misses detected. Three patients developed major sequelae or complications from errors. One of 13 deaths was deemed potentially preventable. This study has shown that while 61.4% of admitted trauma patients receive optimal care, errors are frequent, resulting in a spectrum of outcomes from near misses to death. The majority of errors result from the activity of unsupervised trainees and relate to errors in judgement and delays in diagnosis. Clearly, there is room for improvement of the delivery of trauma care.

Reduction of time to definitive care in trauma patients: effectiveness of a new checklist system.

This study evaluated the feasibility of establishing a new trauma transfer checklist and assessed its impact on trauma-related interhospital transfers. A standard envelope with a printed checklist (N.E.W.S.) incorporating four key concepts in the care and transfer of trauma patients was used. A prospective comparison of consecutive interhospital trauma transfers to the major trauma service between July 1999-May 2000 (pre-N.E.W.S.) and August 2000-November 2000 (post-N.E.W.S.) was made. Changes in management satisfaction were assessed by a Likert scale (1=poor to 5=excellent). Pre-N.E.W.S., 88 trauma patients were transferred and 20 trauma transfers were recorded post-N.E.W.S. The time to definitive care pre-N.E.W.S. was 443+/-322 min, and 339+/-108 min (P=0.014) post-N.E.W.S. The time in the referring hospital was also reduced from 343+/-310 min pre-N.E.W.S. to 197+/-90 min post-N.E.W.S (P=0.0002). The checklist system prompted changes in the management of the trauma patient in 20% of the cases and there was a high level of satisfaction expressed by users of the checklist (4.6+/-0.7). The N.E.W.S. checklist is effective in facilitating the interhospital transfer of trauma patients by shortening the time to definitive care.

Hemodynamically unstable pelvic fractures: recent care and new guidelines.

Consistent care of hemodynamically unstable pelvic fracture patients is a major management issue. It was uncertain whether the introduction of newly developed clinical practice guidelines would require much change in current delivery of care at our institution. Assessment of recent care was undertaken and compared with the newly developed evidence-based best practice guidelines. A multidisciplinary project team developed clinical practice guidelines for determination of early optimum management of hemodynamically unstable patients with pelvic fractures. The guidelines recommend a definitive management plan to arrest hemorrhage within 30 minutes. Intra-abdominal hemorrhage should be assessed with diagnostic peritoneal aspiration (DPA) and/or focused assessment with sonography for trauma (FAST). Early noninvasive stabilization of the pelvis followed by angiography within 90 minutes are recommended if intra-abdominal hemorrhage is not found. Recent care was assessed in a historical cohort of patients, identified in a prospectively maintained trauma registry, between June 1999 and December 2001. Investigations, interventions, and times were then compared with the new guidelines. The delivery of care to 30 patients (mortality 37%, mean ISS 37.8 +/- 20.9) was studied. Compared with the new guidelines, the abdominal assessment rate with DPA and/or FAST was 53% and early (< 90 minutes) angiography rate was 38%. A form of pelvic external stabilization was applied in 27% of cases. Noninvasive pelvic stabilization was not performed at all. The recent care of hemodynamically unstable pelvic fracture patients was not in line with newly developed guidelines. There is an opportunity to markedly improve the rates of initial assessment of the abdomen, pelvic stabilization, and early angiography.