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2.
Prehosp Emerg Care ; 25(4): 588-592, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32776812

RESUMO

The American College of Surgeons Committee on Trauma (ACS-COT), the American College of Emergency Physicians (ACEP), the National Association of State EMS Officials (NASEMSO), the National Association of EMS Physicians (NAEMSP) and the National Association of EMTs (NAEMT) have previously offered varied guidance on the use of ketamine in trauma patients. The following consensus statement represents the collective positions of the ACS-COT, ACEP, NASEMSO, NAEMSP and NAEMT. This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, nurses and pharmacists in their treatment of the trauma patient in both the prehospital and hospital setting.


Assuntos
Serviços Médicos de Emergência , Ketamina , Consenso , Serviço Hospitalar de Emergência , Hospitais , Humanos
3.
JAMA Netw Open ; 3(7): e209393, 2020 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-32663307

RESUMO

Importance: Trauma is the leading cause of death for US individuals younger than 45 years, and uncontrolled hemorrhage is a major cause of trauma mortality. The US military's medical advancements in the field of prehospital hemorrhage control have reduced battlefield mortality by 44%. However, despite support from many national health care organizations, no integrated approach to research has been made regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector. Objective: To create a national research agenda to help guide future work for prehospital hemorrhage control by laypersons. Evidence Review: The 2-day, in-person, National Stop the Bleed (STB) Research Consensus Conference was conducted on February 27 to 28, 2019, to identify and achieve consensus on research gaps. Participants included (1) subject matter experts, (2) professional society-designated leaders, (3) representatives from the federal government, and (4) representatives from private foundations. Before the conference, participants were provided a scoping review on layperson prehospital hemorrhage control. A 3-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items, with median rating of 8 or more on a Likert scale of 1 to 9 points, were identified and became part of the national STB research agenda. Findings: Forty-five participants attended the conference. In round 1, participants submitted 487 research questions. After deduplication and sorting, 162 questions remained across 5 a priori-defined themes. Two subsequent rounds of rating generated consensus on 113 high-priority, 27 uncertain-priority, and 22 low-priority questions. The final prioritized research agenda included the top 24 questions, including 8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy. Conclusions and Relevance: The National STB Research Consensus Conference identified and prioritized a national research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage. Investigators and funding agencies can use this agenda to guide their future work and funding priorities.


Assuntos
Serviços Médicos de Emergência , Hemorragia , Projetos de Pesquisa , Ferimentos e Lesões , Pesquisa Biomédica/métodos , Consenso , Técnica Delfos , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/organização & administração , Hemorragia/etiologia , Hemorragia/mortalidade , Hemorragia/terapia , Humanos , Inquéritos e Questionários , Ferimentos e Lesões/complicações , Ferimentos e Lesões/mortalidade
4.
Am J Health Syst Pharm ; 76(16): 1226-1230, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31369114

RESUMO

PURPOSE: A national survey performed in 2007 found that only 23% of American College of Surgeons (ACS) trauma centers involved pharmacists in trauma resuscitation. This study describes interval change in use, perceptions, and responsibilities from 2007 to 2017. METHODS: Of the 419 trauma centers identified from the ACS website, contact information was available for 335. In March 2017, a survey assessing hospital demographics, pharmacist coverage and services, and perception of pharmacist value and use was emailed to the identified trauma representatives. Data were analyzed using descriptive statistics and chi-square analysis, as appropriate. RESULTS: The response rate was 33% (110/335). Pharmacist involvement with trauma resuscitation increased significantly from 23% in 2007 to 70% (p < 0.001) and in 71% of trauma centers was provided by pharmacists practicing within the emergency department. Pharmacist involvement was greatest in the Midwest (p < 0.01), but with similar distribution with regards to ACS designation, institution type, and patient volume. Common bedside responsibilities include calculating dosages (96%), preparing medications (89%), and providing medication information (79%), while trauma program/administrative responsibilities (45%) include trauma team education, pharmacy operations, medication safety, quality improvement data collection, research, review of quality assurance cases, ACS accreditation preparation, and others. The primary reason for not considering pharmacist involvement was unfamiliarity with these roles/benefits. CONCLUSION: Pharmacists are an increasingly important component of the trauma team, as evidenced by growth over the last decade. In addition to clinical benefit at the bedside, pharmacists can support the regular activities of a trauma program in many meaningful ways.


Assuntos
Equipe de Assistência ao Paciente/organização & administração , Farmacêuticos/organização & administração , Papel Profissional , Ressuscitação , Ferimentos e Lesões/terapia , Adulto , Criança , Estudos Transversais , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Seguimentos , Humanos , Masculino , Equipe de Assistência ao Paciente/estatística & dados numéricos , Serviço de Farmácia Hospitalar/organização & administração , Serviço de Farmácia Hospitalar/estatística & dados numéricos , Inquéritos e Questionários/estatística & dados numéricos , Centros de Traumatologia/organização & administração , Centros de Traumatologia/estatística & dados numéricos , Estados Unidos
5.
J Trauma Acute Care Surg ; 87(1S Suppl 1): S40-S43, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31246905

RESUMO

BACKGROUND: National Stop the Bleed Day (NSTBD) was created to increase public awareness of the official Stop-the-Bleed initiative and the Bleeding Control Basic course. The goal was to develop and employ an effective national social media strategy that would encourage and support efforts already in place to train the public in basic bleeding control techniques. METHODS: March 31, 2018, was designated as NSTBD. Analysis focused on a 2-week window centered on NSTBD. The number of courses offered, number of instructors registered and total number of students trained overall during this period was derived from the American College of Surgeons (ACS) website bleedingcontrol.org. Courses not registered with the ACS were not included. Data on overall website activity were also included for analysis. RESULTS: Forty-three states and 18 countries participated in NSTBD. During the study period, there were 1884 courses registered on bleedingcontrol.org. Comparatively, over a 4-month period from August to November 2017, the mean number of registered courses per month was 834. There were 34,699 students trained during the two-week study period as opposed to August to November 2017, the mean number of people trained per month was 9,626. In addition, 576 new B-Con instructors were certified during this time window. Additionally, the international coordinators reported 1500 students were trained during the study period. During this time, the ACS reported a significant increase in website activity. This included 10,530 new visitors, 12,772 visitors overall and 35,342 page views recorded during the study period. CONCLUSION: The NSTBD effort was successful in generating widespread interest for the Stop-the-Bleed initiative. The use of a targeted social media campaign in this context was successful in driving people to available training opportunities while also increasing awareness of the overall effort. While only in its early stages, the NSTBD concept is a good one and should be developed further in coming years. LEVEL OF EVIDENCE: Retrospective, Level V.


Assuntos
Promoção da Saúde , Hemorragia/prevenção & controle , Mídias Sociais , Educação em Saúde , Hemorragia/etiologia , Humanos , Estudos Retrospectivos , Estados Unidos , Ferimentos e Lesões/complicações
7.
Prehosp Emerg Care ; 22(6): 659-661, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30091939

RESUMO

The American College of Surgeons Committee on Trauma (ACS-COT), American College of Emergency Physicians (ACEP), and the National Association of EMS Physicians (NAEMSP) have previously offered varied guidance on the role of backboards and spinal immobilization in out-of-hospital situations. This updated consensus statement on spinal motion restriction in the trauma patient represents the collective positions of the ACS-COT, ACEP and NAEMSP. It has further been formally endorsed by a number of national stakeholder organizations. This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, and nurses as they strive to improve the care of trauma victims within their respective domains.


Assuntos
Consenso , Restrição Física , Coluna Vertebral , Ferimentos e Lesões , Serviços Médicos de Emergência , Humanos
8.
J Trauma Acute Care Surg ; 85(1): 174-181, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29787553

RESUMO

BACKGROUND: Trauma is a time sensitive disease. Helicopter emergency medical services (HEMS) have shown benefit over ground emergency medical services (GEMS), which may be related to reduced prehospital time. The distance at which this time benefit emerges depends on many factors that can vary across regions. Our objective was to determine the threshold distance at which HEMS has shorter prehospital time than GEMS under different conditions. METHODS: Patients in the Pennsylvania trauma registry 2000 to 2013 were included. Distance between zip centroid and trauma center was calculated using straight-line distance for HEMS and driving distance from geographic information systems network analysis for GEMS. Contrast margins from linear regression identified the threshold distance at which HEMS had a significantly lower prehospital time than GEMS, indicated by nonoverlapping 95% confidence intervals. The effect of peak traffic times and adverse weather on the threshold distance was evaluated. Geographic effects across EMS regions were also evaluated. RESULTS: A total of 144,741 patients were included with 19% transported by HEMS. Overall, HEMS became faster than GEMS at 7.7 miles from the trauma center (p = 0.043). Helicopter emergency medical services became faster at 6.5 miles during peak traffic (p = 0.025) compared with 7.9 miles during off-peak traffic (p = 0.048). Adverse weather increased the distance at which HEMS was faster to 17.1 miles (p = 0.046) from 7.3 miles in clear weather (p = 0.036). Significant variation occurred across EMS regions, with threshold distances ranging from 5.4 to 35.3 miles. There was an inverse but non-significant relationship between urban population and threshold distance across EMS regions (ρ, -0.351, p = 0.28). CONCLUSION: This is the first study to demonstrate that traffic, weather, and geographic region significantly impact the threshold distance at which HEMS are faster than GEMS. Helicopter emergency medical services was faster at shorter distances during peak traffic while adverse weather increased this distance. The threshold distance varied widely across geographic region. These factors must be considered to guide appropriate HEMS triage protocols. LEVEL OF EVIDENCE: Therapeutic, level IV.


Assuntos
Ambulâncias/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania , Sistema de Registros , Estudos Retrospectivos , Fatores de Tempo , Ferimentos e Lesões/terapia , Adulto Jovem
10.
J Trauma Acute Care Surg ; 85(4): 668-673, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29462080

RESUMO

BACKGROUND: Children suffering nonaccidental trauma (NAT) are at high risk of death. It is unclear whether markers of injury severity for trauma center/system benchmarking such as Injury Severity Score (ISS) adequately characterize this. Our objective was to evaluate mortality prediction of ISS in children with NAT compared with accidental trauma (AT). METHODS: Pediatric patients younger than 16 years from the Pennsylvania state trauma registry 2000 to 2013 were included. Logistic regression predicted mortality from ISS for NAT and AT patients. Multilevel logistic regression determined the association between mortality and ISS while adjusting for age, vital signs, and injury pattern in NAT and AT patients. Similar models were performed for head Abbreviated Injury Scale (AIS). Sensitivity analysis examined impaired functional independence at discharge as an alternate outcome. RESULTS: Fifty thousand five hundred seventy-nine patients were included with 1,866 (3.7%) NAT patients. Nonaccidental trauma patients had a similar rate of mortality at an ISS of 13 as an ISS of 25 for AT patients. Nonaccidental trauma patients also have higher mortality for a given head AIS level (range, 1.2-fold to 5.9-fold higher). Injury Severity Score was a significantly greater predictor of mortality in AT patients (adjusted odds rations [AOR], 1.14; 95% confidence interval [CI], 1.13-1.15; p < 0.01) than NAT patients (AOR, 1.09; 95% CI, 1.07-1.12; p < 0.01) per 1-point ISS increase, while head injury was a significantly greater predictor of mortality in NAT patients (AOR, 3.48; 95% CI, 1.54-8.32; p < 0.01) than AT patients (AOR, 1.21; 95% CI, 0.95-1.45; p = 0.12). Nonaccidental trauma patients had a higher rate of impaired functional independence at any given ISS or head AIS level than AT patients. CONCLUSION: Nonaccidental trauma patients have higher mortality and impaired function at a given ISS/head AIS than AT patients. Conventional ISS thresholds may underestimate risk and head injury is a more important predictor of mortality in the NAT population. These findings should be considered in system performance improvement and benchmarking efforts that rely on ISS for injury characterization. LEVEL OF EVIDENCE: Epidemiologic study, level III.


Assuntos
Escala Resumida de Ferimentos , Acidentes/mortalidade , Maus-Tratos Infantis/mortalidade , Escala de Gravidade do Ferimento , Comportamento Autodestrutivo/mortalidade , Ferimentos e Lesões/mortalidade , Adolescente , Criança , Pré-Escolar , Traumatismos Craniocerebrais/mortalidade , Feminino , Previsões , Humanos , Lactente , Recém-Nascido , Masculino , Pennsylvania/epidemiologia , Sistema de Registros
12.
J Trauma Acute Care Surg ; 84(4): 549-557, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29251708

RESUMO

BACKGROUND: Helicopter emergency medical services (HEMS) have demonstrated survival benefits over ground emergency medical services (GEMS) for trauma patient transport. While HEMS speed is often-cited, factors such as provider experience and level of care may also play a role. Our objective was to identify patient groups that may benefit from HEMS even when prehospital time for helicopter utilization is longer than GEMS transport. METHODS: Adult patients transported by HEMS or GEMS from the scene of injury in the Pennsylvania State Trauma Registry were included. Propensity score matching was used to match HEMS and GEMS patients for likelihood of HEMS, keeping only pairs in which the HEMS patient had longer total prehospital time than the matched GEMS patient. Mixed-effects logistic regression evaluated the effect of transport mode on survival while controlling for demographics, admission physiology, transfusions, and procedures. Interaction testing between transport mode and existing trauma triage criteria was conducted and models stratified across significant interactions to determine which criteria identify patients with a significant survival benefit when transported by HEMS even when slower than GEMS. RESULTS: From 153,729 eligible patients, 8,307 pairs were matched. Helicopter emergency medical services total prehospital time was a median of 13 minutes (interquartile range, 6-22) longer than GEMS. Patients with abnormal respiratory rate (odds ratio [OR], 2.39; 95% confidence interval [CI], 1.26-4.55; p = 0.01), Glasgow Coma Scale score of 8 or less (OR, 1.61; 95% CI, 1.16-2.22; p < 0.01), and hemo/pneumothorax (OR, 2.25; 95% CI, 1.06-4.78; p = 0.03) had a significant survival advantage when transported by HEMS even with longer prehospital time than GEMS. Conversely, there was no association between transport mode and survival in patients without these factors (p > 0.05). CONCLUSION: Patients with abnormal respiratory rate, Glasgow Coma Scale score of 8 or less, and hemo/pneumothorax benefit from HEMS transport even when GEMS transport was faster. This may indicate that these patients benefit primarily from HEMS care, such as advanced airway and chest trauma management, rather than simply faster transport to a trauma center. LEVEL OF EVIDENCE: Therapeutic, level III.


Assuntos
Resgate Aéreo/estatística & dados numéricos , Serviços Médicos de Emergência/métodos , Traumatismo Múltiplo/terapia , Sistema de Registros , Transporte de Pacientes/métodos , Centros de Traumatologia/estatística & dados numéricos , Triagem/métodos , Adulto , Feminino , Humanos , Incidência , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/diagnóstico , Traumatismo Múltiplo/epidemiologia , Pennsylvania/epidemiologia , Pontuação de Propensão , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Tempo para o Tratamento
14.
J Am Coll Surg ; 224(6): 1084-1090, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28501449

RESUMO

BACKGROUND: With increasing active shooter and intentional mass casualty events, as well as everyday injuries resulting in severe bleeding, there have been calls for the public to learn bleeding control techniques. The aims of this project were to offer bleeding control training to surgeons attending the Clinical Congress of the American College of Surgeons (ACS), to determine if the trained surgeons believe that teaching bleeding control to the public should be a priority of the ACS, and to assess the surgeon trainees' perceptions regarding the appropriateness of the course for a public audience. STUDY DESIGN: This was an educational program with a post-course evaluation to determine if the bleeding control course is appropriate for a public audience. RESULTS: Three hundred forty-one surgeons were trained. All were trained and successfully performed a return demonstration. Regarding perceptions of the participating surgeons that teaching bleeding control to the public should be a priority of the ACS, 93.79% of the 322 surgeons responding indicated agreement with this proposition. Regarding whether or not the training was at an appropriate level of difficulty for the public, 93.13% of the 320 respondents to this item agreed that it was appropriate. CONCLUSIONS: The surgeons who were trained were very much in favor of making training the public a priority of the ACS. With additional training of surgeons and other health care professionals as trainers, and the engagement of the public, the goal of having a citizenry prepared to stop bleeding can be achieved.


Assuntos
Atitude do Pessoal de Saúde , Primeiros Socorros , Educação em Saúde , Hemorragia/prevenção & controle , Cirurgiões/educação , Humanos , Autorrelato , Sociedades Médicas , Especialidades Cirúrgicas , Estados Unidos
15.
J Trauma Acute Care Surg ; 82(6): 995-1001, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28328674

RESUMO

BACKGROUND: The Injury Severity Score (ISS) is the most commonly used injury scoring system in trauma research and benchmarking. An ISS greater than 15 conventionally defines severe injury; however, no studies evaluate whether ISS performs similarly between adults and children. Our objective was to evaluate ISS and Abbreviated Injury Scale (AIS) to predict mortality and define optimal thresholds of severe injury in pediatric trauma. METHODS: Patients from the Pennsylvania trauma registry 2000-2013 were included. Children were defined as younger than 16 years. Logistic regression predicted mortality from ISS for children and adults. The optimal ISS cutoff for mortality that maximized diagnostic characteristics was determined in children. Regression also evaluated the association between mortality and maximum AIS in each body region, controlling for age, mechanism, and nonaccidental trauma. Analysis was performed in single and multisystem injuries. Sensitivity analyses with alternative outcomes were performed. RESULTS: Included were 352,127 adults and 50,579 children. Children had similar predicted mortality at ISS of 25 as adults at ISS of 15 (5%). The optimal ISS cutoff in children was ISS greater than 25 and had a positive predictive value of 19% and negative predictive value of 99% compared to a positive predictive value of 7% and negative predictive value of 99% for ISS greater than 15 to predict mortality. In single-system-injured children, mortality was associated with head (odds ratio, 4.80; 95% confidence interval, 2.61-8.84; p < 0.01) and chest AIS (odds ratio, 3.55; 95% confidence interval, 1.81-6.97; p < 0.01), but not abdomen, face, neck, spine, or extremity AIS (p > 0.05). For multisystem injury, all body region AIS scores were associated with mortality except extremities. Sensitivity analysis demonstrated ISS greater than 23 to predict need for full trauma activation, and ISS greater than 26 to predict impaired functional independence were optimal thresholds. CONCLUSION: An ISS greater than 25 may be a more appropriate definition of severe injury in children. Pattern of injury is important, as only head and chest injury drive mortality in single-system-injured children. These findings should be considered in benchmarking and performance improvement efforts. LEVEL OF EVIDENCE: Epidemiologic study, level III.


Assuntos
Escala de Gravidade do Ferimento , Escala Resumida de Ferimentos , Adolescente , Adulto , Fatores Etários , Idoso , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Sistema de Registros , Sensibilidade e Especificidade , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidade , Adulto Jovem
17.
J Trauma Acute Care Surg ; 82(2): 270-279, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27906867

RESUMO

BACKGROUND: The Air Medical Prehospital Triage (AMPT) score was developed to identify injured patients who may benefit from scene helicopter emergency medical services (HEMS) transport. External validation using a different data set is essential to ensure reliable performance. The study objective was to validate the effectiveness of the AMPT score to identify patients with a survival benefit from HEMS using the Pennsylvania Trauma Outcomes Study registry. METHODS: Patients 16 years or older undergoing scene HEMS or ground EMS (GEMS) transport in the Pennsylvania Trauma Outcomes Study registry 2000-2013 were included. Patients with 2 or higher AMPT score points were triaged to HEMS, while those with less than 2 points were triaged to GEMS. Multilevel Poisson regression determined the association of survival with actual transport mode across AMPT score triage assignments, adjusting for demographics, mechanism, vital signs, interventions, and injury severity. Successful validation was defined as no survival benefit for actual HEMS transport in patients triaged to GEMS by the AMPT score, with a survival benefit for actual HEMS transport in patients triaged to HEMS by the AMPT score. Subgroup analyses were performed in patients treated by advanced life support providers and patients with transport times longer than 10 minutes. RESULTS: There were 222,827 patients included. For patients triaged to GEMS by the AMPT score, actual transport mode was not associated with survival (adjusted relative risk, 1.004; 95% confidence interval, 0.999-1.009; p = 0.08). For patients triaged to HEMS by the AMPT score, actual HEMS transport was associated with a 6.7% increase in the relative probability of survival (adjusted relative risk, 1.067; 95% confidence interval, 1.040-1.083, p < 0.001). Similar results were seen in all subgroups. CONCLUSIONS: This study is the first to externally validate the AMPT score, demonstrating the ability of this tool to reliably identify trauma patients most likely to benefit from HEMS transport. The AMPT score should be considered when protocols for HEMS scene transport are developed and reviewed. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III; therapeutic/care management study, level IV.


Assuntos
Resgate Aéreo , Triagem/normas , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidade , Adulto , Idoso , Serviços Médicos de Emergência , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Pennsylvania , Sistema de Registros , Taxa de Sobrevida
18.
Prehosp Emerg Care ; 20(5): 557-9, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26985786

RESUMO

Tranexamic acid (TXA) is being administered already in many prehospital air and ground systems. Insufficient evidence exists to support or refute the prehospital administration of TXA, and results are pending from several prehospital studies currently in progress. We have created this document to aid agencies and systems in best practices for TXA administration based on currently available best evidence. This document has been endorsed by the American College of Surgeons-Committee on Trauma, the American College of Emergency Physicians, and the National Association of EMS Physicians.


Assuntos
Antifibrinolíticos/uso terapêutico , Serviços Médicos de Emergência/métodos , Hemorragia/tratamento farmacológico , Ácido Tranexâmico/uso terapêutico , Ferimentos e Lesões/tratamento farmacológico , Antifibrinolíticos/efeitos adversos , Humanos , Ácido Tranexâmico/efeitos adversos
19.
J Trauma Acute Care Surg ; 81(1): 93-100, 2016 07.
Artigo em Inglês | MEDLINE | ID: mdl-26886000

RESUMO

BACKGROUND: Trauma is time sensitive, and minimizing prehospital (PH) time is appealing. However, most studies have not linked increasing PH time with worse outcomes because raw PH times are highly variable. It is unclear whether specific PH time patterns affect outcomes. Our objective was to evaluate the association of PH time interval distribution with mortality. METHODS: Patients transported by emergency medical services in the Pennsylvania trauma registry from 2000 to 2013 with a total PH time (TPT) of 20 minutes or longer were included. TPT was divided into three PH time intervals: response, scene, and transport time. The number of minutes in each PH time interval was divided by TPT to determine the relative proportion each interval contributed to TPT. A prolonged interval was defined as any one PH interval contributing equal to or greater than 50% of TPT. Patients were classified by prolonged PH interval or no prolonged PH interval (all intervals < 50% of TPT). Patients were matched for TPT, and conditional logistic regression determined the association of mortality with PH time pattern, controlling for confounders. PH interventions were explored as potential mediators, and PH triage criteria used identify patients with time-sensitive injuries. RESULTS: There were 164,471 patients included. Patients with prolonged scene time had increased odds of mortality (odds ratio, 1.21; 95% confidence interval, 1.02-1.44; p = 0.03). Prolonged response, transport, and no prolonged interval were not associated with mortality. When adjusting for mediators including extrication and PH intubation, prolonged scene time was no longer associated with mortality (odds ratio, 1.06; 95% confidence interval, 0.90-1.25; p = 0.50). Together, these factors mediated 61% of the effect between prolonged scene time and mortality. Mortality remained associated with prolonged scene time in patients with hypotension, penetrating injury, and flail chest. CONCLUSION: Prolonged scene time is associated with increased mortality. PH interventions partially mediate this association. Further study should evaluate whether these interventions drive increased mortality because they prolong scene time or by another mechanism, as reducing scene time may be a target for intervention. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.


Assuntos
Serviços Médicos de Emergência , Transporte de Pacientes/estatística & dados numéricos , Ferimentos e Lesões/mortalidade , Adolescente , Adulto , Idoso , Ambulâncias , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Sistema de Registros , Fatores de Tempo , Centros de Traumatologia , Triagem
20.
J Trauma Acute Care Surg ; 80(5): 702-10, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-26808033

RESUMO

BACKGROUND: Helicopter emergency medical services (HEMS) are frequently used to transport injured children, despite unclear evidence of benefit. The study objective was to evaluate the association of HEMS compared with ground emergency medical services (GEMS) transport with outcomes in a national sample of pediatric trauma patients. METHODS: Patients 15 years or younger undergoing scene transport by HEMS or GEMS in the National Trauma Data Bank from 2007 to 2012 were included. Propensity score matching was used to match HEMS and GEMS patients for likelihood of HEMS transport based on demographics, prehospital physiology and time, injury severity, and geographic region. Absolute standardized differences of less than 0.1 indicated adequate covariate balance between groups after matching. The primary outcome was in-hospital survival, while the secondary outcome was discharge disposition in survivors. Conditional logistic regression determined the association between HEMS versus GEMS transport with outcomes while controlling for demographics, admission physiology, injury severity, nonaccidental trauma, and in-hospital complications not accounted for in the propensity score. Subgroup analysis was performed in patients with a transport time of greater than 15 minutes to capture patients with the potential for HEMS transport. RESULTS: A total of 25,700 HEMS/GEMS pairs were matched from 166,594 patients. Groups were well matched, with all propensity score variables having absolute standardized differences of less than 0.1. In matched patients, HEMS was associated with a 72% increase in odds of survival compared with GEMS (adjusted odds ratio, 1.72; 95% confidence interval, 1.26-2.36; p < 0.01). Transport mode was not associated with discharge disposition (p = 0.47). Subgroup analysis included 17,657 HEMS/GEMS pairs. HEMS was again associated with a significant increase in odds of survival (adjusted odds ratio, 1.81; 95% confidence interval, 1.24-2.65; p < 0.01), while transport mode was not associated with discharge disposition (p = 0.58). CONCLUSION: Scene transport by HEMS was associated with improved odds of survival compared with GEMS in pediatric trauma patients. Further study is warranted to understand the underlying mechanisms and develop specific triage criteria for HEMS transport in this population. LEVEL OF EVIDENCE: Therapeutic study, level III.


Assuntos
Resgate Aéreo/estatística & dados numéricos , Serviços Médicos de Emergência/métodos , Traumatismo Múltiplo/terapia , Transporte de Pacientes/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Masculino , Traumatismo Múltiplo/mortalidade , Razão de Chances , Pontuação de Propensão , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Tempo para o Tratamento , Triagem/métodos , Estados Unidos/epidemiologia , Adulto Jovem
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