Do All Isolated Traumatic Subarachnoid Hemorrhages Need to Be Transferred to a Level 1 Trauma Center?

BACKGROUND: The management of isolated traumatic subarachnoid hemorrhage (itSAH) in non-trauma centers usually results in transfer to a Level 1 trauma center with neurosurgical capabilities. Due to lack of trauma center resources, we sought to evaluate if patients with itSAH need transfer to a Level I trauma center. METHODS: A retrospective review of the trauma registry was conducted from Jan 2015-Dec 2020. Patients with itSAH on initial computed tomographic imaging and a Glasgow Coma Scale score >13 were included. Patients with any other intracranial pathology, skull fractures, multi-system trauma or age less than 15 were excluded. RESULTS: 120 patients were identified with itSAH. Mean age was 63 years, and 44% were male. Mean injury severity score was 4.7 with 48% on anticoagulation/antiplatelet therapy. Radiology Reports were reviewed and only 2 scans (1.7%) showed an increase in itSAH, 98.3% reports revealed no change, improvement, or resolution. No patients deteriorated and no patients underwent neurosurgical intervention. Once admitted, 27 (23%) were treated for acute medical conditions and 39 (33%) required subspecialty medical consultations. There was no difference in increased itSAH on repeat imaging between patients on anticoagulation/antiplatelet therapy and those without. The population taking anticoagulant/antiplatelet therapy was older, more likely to have suffered a fall, have more comorbid conditions, was more likely to be treated for a non-traumatic medical condition and have a subspecialty medical consultation. DISCUSSION: Patients with itSAH do not require transfer to a Level 1 trauma center for acute neurosurgical intervention.

Can Education and Enhanced Medical Director Oversight Improve Definitive Airway Control in the Prehospital Environment?

BACKGROUND: Endotracheal intubation (ETI) is the most definitive technique for airway management. However, supraglottic airway (SGA) may be used when ETI is not feasible. The purpose of this study was to determine the effect of updated field sedation protocols, simulation teaching, robust Quality Assurance/Continuing Quality Improvement (QA/CQI) program, and enhanced emergency medical services (EMSs) medical director oversight on ETI and SGA usage at a Level 1 trauma center. METHODS: After the transition of EMS directors in May 2016, field sedation protocols were updated, a new QA/CQI was instituted, and multiple teaching and simulation sessions were conducted. A retrospective review of EMS data was conducted on all prehospital airway interventions performed by EMS personnel. Intubations occurring from July 2013 to May 2016 served as controls. Intubations from May 2016 to December 2017 served as the comparison group. Data collected included intubation type/indication, age, and successful or unsuccessful. RESULTS: There were 967 ETI and SGA performed on 84% and 15% of patients, respectively. Success rates were 75% for ETI and 82% for SGA. ETI increased from 83% in the control group to 88% in the study group, and SGA decreased from 16% in the control group to 11% in the study group (P = .029). The success rate for ETI increased by 2% in the study group (P = .539). DISCUSSION: This study showed that definitive airway control could be positively impacted by incorporating education and medical director oversight into EMS training. ETI increased and SGA decreased after implementation.