The value of pre-hospital trauma life support courses for medical personnel-a questionnaire study.

Background: The aim of the study was to determine the impact that PHTLS® course participation had on self-confidence of emergency personnel, regarding the pre-hospital treatment of patients who had suffered severe trauma. Furthermore, the goal was to determine the impact of specific medical profession, work experience and prior course participation had on the benefits of PHTLS® training. Methods: A structured questionnaire study was performed. Healthcare providers from local emergency services involved in pre-hospital care in the metropolitan area of Zurich (Switzerland, Europe) who completed a PHTLS® course were included. Altered self-confidence, communication, and routines in the treatment of severe trauma patients were examined. The impact of prior course participation, work experience and profession on course benefits were evaluated. Results: The response rate was 76%. A total of 6 transport paramedics (TPs), 66 emergency paramedics (EPs) and 15 emergency doctors (EDs) were included. Emergency paramedics had significantly more work experience compared with EDs (respectively 7.1 ± 5.7 yrs. vs. 4.5 ± 2.1 yrs., p = 0.004). 86% of the participants reported increased self-confidence in the pre-hospital management of severe trauma upon PHTLS® training completion. Moreover, according to 84% of respondents, extramural treatment of trauma changed upon course completion. PHTLS® course participants had improved communication in 93% of cases. This was significantly more frequent in EPs than TPs (p = 0.03). Multivariable analysis revealed emergency paramedics benefit the most from PHTLS® course participation. Conclusion: The current study shows that PHTLS® training is associated with improved self-confidence and enhanced communication, with regards to treatment of severe trauma patients in a pre-hospital setting, among medical emergency personnel. Additionally, emergency paramedics who took the PHTLS® course improved in overall self-confidence. These findings imply that all medical personal involved in the pre-hospital care of trauma patients, in a metropolitan area in Europe, do benefit from PHTLS® training. This was independent of the profession, previous working experience or prior alternative course participation.

Honey bee venom re-challenge during specific immunotherapy: prolonged cardio-pulmonary resuscitation allowed survival in a case of near fatal anaphylaxis.

BACKGROUND: Specific immunotherapy for patients with honey bee hypersensitivity is commonly applied. Re-challenge with venom is performed to prove protection in individual cases. CASE PRESENATION: We report a case of near fatal anaphylaxis with asystole for 24 min in a 35-years-old patient with mastocytosis after honey bee sting challenge, despite 5-years of specific immunotherapy. Successful cardio-pulmonary resuscitation was applied for 32 min. CONCLUSION: This intervention demonstrates, that in anaphylaxis with cardio-vascular arrest, prolonged cardio-pulmonary resuscitation for up to 40 min may be appropriate to overcome the half-life of massively released histamine. Failure of specific immunotherapy was possibly due to sensitization to the allergen Api m10, potentially underrepresented in commercial honey bee venom extracts. Molecular analyses may provide additional clues to the potentially unsuccessful outcome of venom specific immunotherapy, especially in high-risk patients such as mastocytosis.

Improved pre-hospital care efficiency due to the implementation of pre-hospital trauma life support (PHTLS®) algorithms.

PURPOSE: Pre-hospital trauma life support (PHTLS®) includes a standardized algorithm for pre-hospital care. Implementation of PHTLS® led to improved outcome in less developed medical trauma systems. We aimed to determine the impact of PHTLS® on quality of pre-hospital care in a European metropolitan area. We hypothesized that the introduction of PHTLS® was associated with improved efficiency of pre-hospital care for severely injured patients and less emergency physician deployment. METHODS: We included adult polytrauma (ISS > 15) patients that were admitted to our level one trauma center during a 7-year time period. Patients were grouped based on the presence or absence of a PHTLS®-trained paramedic in the pre-hospital trauma team. Group I (no-PHTLS group) included all casualties treated by no-PHTLS®-trained personnel. Group II (PHTLS group) was composed of casualties managed by a PHTLS® qualified team. We compared outcome between groups. RESULTS: During the study period, 187,839 rescue operations were executed and 280 patients were included. No differences were seen in patient characteristics, trauma severity or geographical distances between groups. Transfer times were significantly reduced in PHTLS® teams than non-qualified teams (9.3 vs. 10.5 min, P = 0.006). Furthermore, the in-field operation times were significantly reduced in PHTLS® qualified teams (36.2 vs. 42.6 min, P = 0.003). Emergency physician involvement did not differ between groups. CONCLUSION: This is the first study to show that the implementation of PHTLS® algorithms in a European metropolitan area is associated with improved efficiency of pre-hospital care for the severely injured. We therefore recommend considering the introduction of PHTLS® in metropolitan areas in the first world.

Impact of city police layperson education and equipment with automatic external defibrillators on patient outcome after out of hospital cardiac arrest.

INTRODUCTION: Out of hospital cardiac arrest (OHCA) occurs frequently and the outcome is often dismal. Early defibrillation saves lives and brain function in OHCA. The Zurich city police (STAPO) forces were instructed and equipped to provide basic life support (BLS) and to use an AED in 2009. METHODS: Retrospective observational study comparing period 1 (P1) 2004-2009 before equipping and training of the STAPO and period 2 (P2) 2010-2015 after the implementation. Patients suffering from OHCA of cardiac or presumed cardiac origin in the city of Zurich undergoing CPR by EMS in P1 (n=709) and P2 (n=684) were included. Intervention periods and outcome were compared between the periods. Outcome variables were adjusted for patient age and gender, witnessed status, and defibrillation by the EMS, STAPO, layperson or no defibrillation. RESULTS: In P2, CPR was started by the STAPO in a median of 8 (IQR 6-9) minutes after the arrest and thus significantly earlier (median 3min) than by the EMS (p<0.001). STAPO performed the first defibrillation in a median of 9 (IQR 8-10) minutes and thus significantly earlier (median 6min) than the EMS (p<0.001). Outcome improved significantly in P2: proportion of patients with return of spontaneous circulation (ROSC, P2 35.8%, P1 24.0%, OR 1.8, 95% CI 1.4-2.2, p<0.001), hospital admission (P2 32.2%, P1 21.4%, OR 1.7, 95% CI 1.4-2.2, p<0.001) and survival to hospital discharge (P2 13.6%, P1 6.9%, OR 2.1 95% CI 1.5-3.0, p<0.001). If the patient was firstly defibrillated by the STAPO, ROSC (STAPO 74.4%, adj. OR 2.6, 95% CI 1.3-5.4, p=0.010) and hospital admission (STAPO 72.1%, adj. OR 2.8, 95% CI 1.4-5.6, p=0.005) was higher compared to patients firstly defibrillated by the EMS. Survival to hospital discharge (STAPO 30.2%, adj. OR 1.4, 95% CI 0.7-2.9, p=0.38) was unchanged. CONCLUSION: Dispatching BLS trained and AED equipped police forces results in earlier and more successful resuscitation of OHCA victims, leading to higher proportions of patients with ROSC, hospital admission and survival to hospital discharge.

Blood component ratios in massively transfused, blunt trauma patients--a time-dependent covariate analysis.

BACKGROUND: This study evaluated critical thresholds for fresh frozen plasma (FFP) and platelet (PLT) to packed red blood cell (PRBC) ratios and determined the impact of high FFP:PRBC and PLT:PRBC ratios on outcomes in patients requiring massive transfusion (MT). METHODS: Retrospective review of a cohort of massively transfused blunt trauma patients admitted to a Level I trauma center. MT was defined as transfusion of ≥10 units of PRBC within 24 hours of admission. Critical thresholds for FFP:PRBC and PLT:PRBC ratios associated with mortality were identified using Cox regression with time-dependent variables. Impacts of high blood component ratios on 12-hour and 24-hour survival were evaluated. RESULTS: During the 10-year study period, a total of 229 blunt trauma patients required a MT. At 12 hours and 24 hours after admission, a FFP:PRBC ratio threshold of 1:1.5 was found to have the strongest association with mortality. At 12 hours, 58 patients (25.4%) received a low (<1:1.5) and 171 patients (74.6%) a high (≥1:1.5) FFP:PRBC ratio. Patients in the low ratio group had a significantly higher mortality compared with those in the high ratio group (51.7% vs. 9.4%; adjusted hazard ratio [95% confidence interval] = 1.18 [1.04-1.34]; adjusted p = 0.008). A similar statistically significant difference was found at 24 hours after admission. For PLTs, a PLT:PRBC ratio of 1:3 was identified as the best cut-off associated with both 12-hour and 24-hour survival. At 12 hours, 79 patients (34.5%) received a low (<1:3) and 150 patients (65.5%) a high (≥1:3) PLT:PRBC ratio. After adjusting for differences between the ratio groups, no statistically significant survival advantage associated with a high PLT:PRBC ratio was found (40.5% vs. 9.3%; adjusted hazard ratio [95% confidence interval] = 1.11 [0.99-1.26]; adjusted p = 0.082). CONCLUSION: For massively transfused blunt trauma patients, a plasma to PRBC ratio of ≥1:1.5 was associated with improved survival at 12 hours and 24 hours after hospital admission. However, for PLTs, no statistically significant survival benefit with increasing ratio was observed. The results of this analysis highlight the need for prospective studies to evaluate the clinical significance of high blood component ratios on outcome.

Whole-body CT in polytrauma patients: effect of arm positioning on thoracic and abdominal image quality.

The purpose of this study is to assess the influence of different arm positioning techniques on thoracic and abdominal image quality and radiation dose of whole-body trauma CT (wbCT). One hundred and fifty polytrauma patients (104 male, mean age 47 ± 19) underwent wbCT with arms elevated above the head (group A, n=50), alongside the abdomen (group B, n=50), and on a pillow ventrally to the chest with both arms flexed (group C, n=50). Two blinded, independent observers measured image noise and rated image quality (scores 1-3) of the liver, aorta, spleen, spine, and lower lungs. Radiation dose parameters were noted, and the abdomens' anterior-posterior diameter and scan lengths were measured. Interreader agreements for image noise (r=0.86; p<0.001) and subjective image quality (k=0.71-0.84) were good. Noise was lower (p<0.05), image quality of the liver, aorta, spleen, and spine was higher, and radiation dose lower in group A than in groups B and C (p<0.001, each). Image quality of the spleen, liver, and aorta were higher in group C than in group B (p<0.05, each). No significant differences in scan length (p=0.61) were found among groups. Abdominal anterior-posterior diameter correlated significantly with noise (r=0.82; p<0.01) and dose (r=0.47; p<0.001). Estimated effective radiation doses were significantly (p<0.001) higher in groups B (21.2 mSv) and C (21.9 mSv) as compared to A (16.1 mSv). In wbCT for polytrauma patients, positioning of the arms above the head results in better image quality and lower radiation dose. Placing the flexed arms on a large pillow ventrally to the chest significantly improves image quality as compared to positioning alongside the abdomen.

The role of rotation thromboelastometry in early prediction of massive transfusion.

INTRODUCTION: Early prediction of massive transfusion (MT) is critical in the management of severely injured trauma patients. Variables available early after injury including physiologic, laboratory, and rotation thromboelastometric (ROTEM) parameters were evaluated as predictors for the need of MT. METHODS: After Institutional Review Board approval, we retrospectively reviewed a cohort of severely injured trauma patients (Injury Severity Score ≥ 16) admitted to a Level I trauma center with available ROTEM measurements on hospital admission during a 1-year study period. Patients with isolated head injury (Abbreviated Injury Scale head ≥ 3 and Abbreviated Injury Scale chest, abdomen, and extremity < 3) and patients with a penetrating mechanism of injury were excluded. Patients who received a MT (≥ 10 units packed red blood cell within 24 hours of admission) were compared with patients who did not. Variables independently associated with MT were identified using stepwise logistic regression. RESULTS: A total of 53 patients met inclusion criteria. Of these, 18 patients (34.0%) received a MT and 35 patients (66.0%) did not. Massively transfused patients had significantly lower baseline hemoglobin values (7.9 g/dL ± 0.4 g/dL vs. 11.4 g/dL ± 0.4 g/dL; p < 0.001) and a trend toward higher lactate (4.8 mmol/L ± 0.8 mmol/L vs. 3.0 mmol/L ± 0.3 mmol/L; p = 0.056) and base deficit values (5.9 mmol/L ± 1.1 mmol/L vs. 3.6 mmol/L ± 0.6 mmol/L; p = 0.052). Mean international normalized ratio (1.46 ± 0.07 vs. 1.22 ± 0.05; p = 0.001) and partial thromboplastin times (42.4 seconds ± 5.0 seconds vs. 29.7 seconds ± 1.8 seconds; p < 0.001) were significantly higher in MT patients. Patients receiving a MT had significantly altered ROTEM values on admission compared with non-MT patients. An increase in the clot formation time (471.3 seconds ± 169.9 seconds vs. 178.1 seconds ± 19.9 seconds; p = 0.001), a shortening of the maximum clot firmness (37.5 mm ± 2.9 mm vs. 50.7 mm ± 1.4 mm; p < 0.001), and a shortening of the clot amplitude at all time points (10/20/30 minutes) were observed in massively transfused trauma patients. Variables independently associated with MT included a hemoglobin level ≤ 10 g/dL and an abnormal maximum clot firmness value (area under the receiver operator characteristic curve: 0.831 [95% confidence interval: 0.719-0.942; p < 0.001]). CONCLUSION: Hemoglobin ≤ 10 g/dL and an abnormal maximum cloth firmness measured by rotation thromboelastometry on admission reliably predict the need for MT. Prospective validation of the effectiveness of thromboelastometry to guide the transfusion practice after trauma is warranted.