Epidemiology, Prehospital Characteristics and Outcomes of Severe Traumatic Brain Injury in The Netherlands: The BRAIN-PROTECT Study.

OBJECTIVE: A thorough understanding of the epidemiology, patient characteristics, trauma mechanisms, and current outcomes among patients with severe traumatic brain injury (TBI) is important as it may inform potential strategies to improve prehospital emergency care. The aim of this study is to describe the prehospital epidemiology, characteristics and outcome of (suspected) severe TBI in the Netherlands. METHODS: The BRAIN-PROTECT study is a prospective observational study on prehospital management of patients with severe TBI in the Netherlands. The study population comprised all consecutive patients with clinical suspicion of TBI and a prehospital GCS score ≤ 8, who were managed by one of the 4 Helicopter Emergency Medical Services (HEMS). Patients were followed-up in 9 trauma centers until 1 year after injury. Planned sub-analyses were performed for patients with "confirmed" and "isolated" TBI. RESULTS: Data from 2,589 patients, of whom 2,117 (81.8%) were transferred to a participating trauma center, were analyzed. The incidence rate of prehospitally suspected and confirmed severe TBI were 3.2 (95% CI: 3.1;3.4) and 2.7 (95% CI: 2.5;2.8) per 100,000 inhabitants per year, respectively. Median patient age was 46 years, 58.4% were involved in traffic crashes, of which 37.4% were bicycle related. 47.6% presented with an initial GCS of 3. The median time from HEMS dispatch to hospital arrival was 54 minutes. The overall 30-day mortality was 39.0% (95% CI: 36.8;41.2). CONCLUSION: This article summarizes the prehospital epidemiology, characteristics and outcome of severe TBI in the Netherlands, and highlights areas in which primary prevention and prehospital care can be improved.

Dutch Prospective Observational Study on Prehospital Treatment of Severe Traumatic Brain Injury: The BRAIN-PROTECT Study Protocol.

Background: Severe traumatic brain injury (TBI) is associated with a high mortality rate and those that survive commonly have permanent disability. While there is a broad consensus that appropriate prehospital treatment is crucial for a favorable neurological outcome, evidence to support currently applied treatment strategies is scarce. In particular, the relationship between prehospital treatments and patient outcomes is unclear. The BRAIN-PROTECT study therefore aims to identify prehospital treatment strategies associated with beneficial or detrimental outcomes. Here, we present the study protocol. Study Protocol: BRAIN-PROTECT is the acronym for BRAin INjury: Prehospital Registry of Outcome, Treatments and Epidemiology of Cerebral Trauma. It is a prospective observational study on the prehospital treatment of patients with suspected severe TBI in the Netherlands. Prehospital epidemiology, interventions, medication strategies, and nonmedical factors that may affect outcome are studied. Multivariable regression based modeling will be used to identify confounder-adjusted relationships between these factors and patient outcomes, including mortality at 30 days (primary outcome) or mortality and functional neurological outcome at 1 year (secondary outcomes). Patients in whom severe TBI is suspected during prehospital treatment (Glasgow Coma Scale score ≤ 8 in combination with a trauma mechanism or clinical findings suggestive of head injury) are identified by all four helicopter emergency medical services (HEMS) in the Netherlands. Patients are prospectively followed up in 9 participating trauma centers for up to one year. The manuscript reports in detail the objectives, setting, study design, patient inclusion, and data collection process. Ethical and juridical aspects, statistical considerations, as well as limitations of the study design are discussed. Discussion: Current prehospital treatment of patients with suspected severe TBI is based on marginal evidence, and optimal treatment is basically unknown. The BRAIN-PROTECT study provides an opportunity to evaluate and compare different treatment strategies with respect to patient outcomes. To our knowledge, this study project is the first large-scale prospective prehospital registry of patients with severe TBI that also collects long-term follow-up data and may provide the best available evidence at this time to give useful insights on how prehospital care can be improved.

Recognition of acute organ failure and associated fluid and oxygen resuscitation by emergency medical services of emergency department patients with a suspected infection.

INTRODUCTION: Recognition of acute organ failure is essential for recognition and resuscitation of sepsis by emergency medical services (EMS). We assessed how many EMS patients with suspected infection had clinical signs of acute organ failure (i.e. hypotension), received fluids and oxygen, and how many EMS patients without clinical signs of organ failure appeared to have organ failure in the emergency department (ED). METHODS: We interrogated an existing database in which consecutive ED patients hospitalized with suspected infection were prospectively collected. Outcomes were 1) number of patients without clinical signs of organ failure in the ambulance who developed clinical signs of organ failure or appeared to have biochemical signs of organ failure (i.e. hyperlactatemia) in the ED, and 2) number of patients who received fluids and oxygen in the ambulance. RESULTS: Of the 788 analyzed EMS patients, 529 (67.1%) had clinical signs of organ failure, of whom only 161 (30.4%) received fluids and 372 (70.3%) received oxygen. Clinical signs of organ failure were absent in 259 (32.9%) EMS patients, of which 165 patients (63.7%) developed organ failure in the ED. CONCLUSIONS: In patients with suspected infection, acute organ failure is poorly recognized and treated by EMS, partly because of delayed development of organ failure.

An observational study on survival rates of patients with out-of-hospital cardiac arrest in the Netherlands after improving the 'chain of survival'.

OBJECTIVES: To evaluate the impact of implemented procedures for out-of-hospital cardiac arrests (OHCAs) by determining patient outcome defined as the percentage return of spontaneous circulation at arrival at the emergency department, and 3-month and 1-year-survival rates. DESIGN: Observational study. SETTING: Primary emergency medical care consisting of Advanced Life Support is given by ambulance nurses and secondary care by hospitals within the mid-western part of the Netherlands covering 750 000 inhabitants. PARTICIPANTS: 433 of 500 consecutive patients with OHCA were included in the study over a 1.5 -year period. OUTCOME MEASURES: Analysis included number of patients with return of spontaneous circulation (ROSC) when handed over to the emergency department, survival at 3 months and 1 year including a comparison with global outcome rates. We further considered the influence of gender, delays, bystander Basic Life Support, use of an automated external defibrillator, initial rhythm and mechanical thorax compression in combination with Boussignac tube ventilation. RESULTS: 13% (67/500) of the initial patient population was excluded from the analysis as reanimation in these patients was aborted due to expressed wish not to be resuscitated. Resuscitation was started by bystanders, police and/or first responders in 312/433 (72%) cases. An automated external defibrillator was used in 198 of these 312 cases (63%) of which it defibrillated 108 times. Mechanical thorax compression in combination with Boussignac tube ventilation was necessary in 277/433 patients (64%). Spontaneous circulation returned in 96/277 (35%) patients of this group. In the overall studied population, ROSC percentage at arrival at the hospital was 214/433 (49%). The 3-month and 12-month-survival rates were 123/433 (28%) and 119/433 (27%), respectively. CONCLUSIONS: Optimised 'chain of survival' for patients with OHCA resulted in ROSC in 49% of the cases and a 1-year-survival rate of 27% in the studied population.