Current Issue : April - June Volume : 2014 Issue Number : 2 Articles : 5 Articles
Background: Priority grade assessment according to urgency level of the patients (triage) is considered vital in\r\nemergency medicine casualties. Little is known of the experiences of pre-hospital emergency medicine triage\r\nperformed by General Practitioners (GPs) in the community. In this study we bring such experiences from a Norwegian\r\nisland community, with special emphasis on over- and undertriage.\r\nMethods: In the island municipality of Austevoll, Western Norway, where the GPs and the ambulance services both\r\ntake part in all medical emergency cases, all these cases were recorded during a 2-year period (2005ââ?¬â??2007). We\r\ncompared the triage of the patients at the stage of the telephone reception of the incident, and the subsequent\r\nrevision of the triage at the first personal examination of the patient.\r\nResults: 236 emergency medical events were recorded, comprising 240 patients. Of these, 42% were\r\ndowngraded between the stages (i.e. initially overtriaged), 11% were upgraded (i.e. initially undertriaged) and\r\n47% remained in unchanged priority group. Of the diagnostic groups, acute abdominal cases had the highest\r\nprobability of being upgraded between stages, while the aggregated diagnostic group of syncopes, seizures,\r\nintoxications and traumas had the highest probability of being downgraded. The principal reason for upgrading\r\nwas lack of necessary information at the stage of call. In a minority of cases the upgrading was due to real\r\npatient deterioration between stages.\r\nConclusions: In pre-hospital triage of emergency patients, downgrading happens between notification of\r\nevents and actual patient examination in a substantial proportion. Upgradings of cases are considerably fewer,\r\nbut the potential serious implications of upgrading warrants individual scrutiny of such cases...
Background: Trauma remains a leading cause of morbidity and mortality in resource limited countries. There is paucity\r\nof published reports on trauma care in Tanzania, particularly the study area. This study was carried out to describe our\r\nexperiences in trauma management outlining the etiological spectrum, injury characteristics and treatment outcome of\r\ntrauma patients at our local setting and compare our results with those from other centers in the world.\r\nMethods: A descriptive prospective study of trauma patients was conducted at Bugando Medical Centre from April\r\n2010 to March 2012. Statistical data analysis was done using SPSS software version 17.0.\r\nResults: A total of 5672 trauma patients were enrolled in the study. The male to female ratio was 2.3: 1. The majority of\r\npatients were in the 2nd decade of life. Road traffic accident was the most common cause of trauma accounting for\r\n60.7% of cases. The majority of patients (76.6%) sustained blunt injuries. Musculoskeletal (68.5%) and head/neck (52.6%)\r\nwere the most frequent body region injured. Soft tissue injuries (open wounds) and fractures were the most common\r\ninjuries accounting for 82.8% and 76.8% respectively. Majority of patients (74.4%) were treated surgically with wound\r\ndebridement (94.0%) being the most frequently performed procedure. Postoperative complications were recorded in\r\n31.5% of cases.\r\nThe overall median duration of hospitalization was 26 days (range 1 day to 144 days). Mortality rate was 16.7%. Patients\r\nwho had polytrauma, burn injuries and those who had tetanus and long bone fractures stayed longer in the hospital\r\nand this was statistically significant (P < 0.001), whereas the age > 65 years, severe trauma, admission Systolic Blood\r\nPressure < 90 mmHg, presence of tetanus, severe head injury, the duration of loss of consciousness, the need for\r\nintensive care unit admission and finding of space occupying lesion on CT scan of the brain significantly influenced\r\nmortality (P < 0.001).\r\nConclusion: Trauma resulting from road traffic accidents remains a major public health problem in this part of\r\nTanzania. Urgent preventive measures targeting at reducing the occurrence of road traffic accidents is necessary to\r\nreduce the incidence of trauma in this region....
Background\r\nThe world population of inhabitants of greater than 60\r\nyears of age has doubled since 1980 and is predicted to\r\nreach 2 billion by 2050 [1]. Trauma is the sixth leading\r\ncause of death in patients over 60 years of age [2].\r\nThough this growing elderly population only comprises\r\n12% of overall trauma patients, they consume considerable\r\nmedical resources [3] and are more likely to require\r\nhospital admission [4]. An aggressive approach should\r\nbe established throughout the management of the elderly\r\ntrauma patient in order to reduce mortality and the\r\nincidence of permanent disability [5]. In the past decade,\r\nthe overall mortality rate due to trauma decreased.\r\nHowever, in the elderly population (>65 years of age),\r\nthe incidence of trauma-related mortality is still high,\r\nmostly secondary to falls [6]. Elderly patients have a\r\nhigher mortality after trauma as well as a higher complication\r\nrate, specifically for pulmonary and infectious\r\ncomplications [7,8].\r\nTrauma in the elderly clearly poses special challenges to\r\nthe physician, with physiological changes of age impacting\r\nmorbidity and mortality. Notwithstanding, little information\r\nis available regarding risk factors that aid in predicting\r\nincreased mortality in this population. More so, there\r\nare significant findings in the literature showing that severely\r\ninjured geriatric trauma patients who do survive\r\ntheir hospitalization have appreciable long-term survival\r\nand return to independent living [9-11].\r\nOur study is a retrospective review of our experience\r\nwith severely injured elderly patients. Our primary objectives\r\nwere to describe the different pattern of injury\r\namong the elderly and define and analyze predictors of\r\nin-hospital mortality. Our secondary objective was to\r\ndetermine whether pre-existing co-morbidities had an\r\nadverse effect on outcome.\r\nMethods\r\nHadassah University Hospital, Ein Kerem Campus, is a\r\ntertiary medical center and the only level I trauma center\r\nin the Jerusalem vicinity. Emergency medical services\r\n(EMS) in Israel are provided by a government funded\r\nnational organization with regional control. The catchment\r\narea incorporates Jerusalem and nearby towns and\r\nvillages and includes a population of approximately one\r\nmillion inhabitants.\r\nInclusion criteria to the study included all trauma\r\npatients = 60 years of age who presented to our Level I\r\nTrauma Center with an injury severity score (ISS) =16\r\nbetween January 2006 and December 2010. Patients\r\nwho were pronounced dead at the trauma bay or had a\r\ndo not resuscitate order were excluded from the study.\r\nData was retrieved from medical records and the\r\ntrauma registry database. The trauma registry is a prospectively\r\ncollected database that is updated daily by\r\ndedicated personnel and has institutional review board\r\n(IRB) approval.\r\nAll charts were retrospectively reviewed for demographics,\r\nISS, GCS (Glasgow Coma Scale) at presentation\r\nto the emergency department (ED), mechanism of\r\ninjury (MOI), body regions injured, pre-existing comorbidities,\r\nintensive care unit length of stay (ICU\r\nLOS), hospital LOS, surgical interventions, complications,\r\nand in-hospital mortality. Patients were divided\r\ninto 3 age groups: 60-69 years, 70-79 and =80. The\r\nmain outcome measure was in-hospital mortality. This\r\nwas defined as death which occurred at the trauma center.\r\nIn order to avoid missing late deaths which were\r\ndirectly related to the trauma, we chose to include patients\r\nwho were discharged from the hospital but died\r\nwithin 30 days of the traumatic insult regardless of \r\npatient location at time of death. Co-morbidities were\r\ndefined as presented in Table 1.\r\nStatistical analysis\r\nData are presented as mean �± standard deviation. The\r\nFisher''s exact test was used to compare proportions and\r\nthe Kruskal-Wallis test was used to compare continuous\r\nnon-parametric variables between the three groups. The\r\nchi-squared test for trends was used to compare mortality\r\nbetween the d...
Background: Severe traumatic brain injury (TBI) is a significant health concern and a major burden for society. The\r\nperiod between trauma event and hospital admission in an emergency department (ED) could be a determinant\r\nfor secondary brain injury and early survival. The aim was to investigate the relationship between prehospital factors\r\nassociated with secondary brain injury (arterial hypotension, hypoxemia, hypothermia) and the outcomes of\r\nmortality and impaired consciousness of survivors at 14 days.\r\nMethods: A multicenter, prospective cohort study was performed in dedicated trauma centres of Switzerland.\r\nAdults with severe TBI (Abbreviated Injury Scale score of head region (HAIS) >3) were included. Main outcome\r\nmeasures were death and impaired consciousness (Glasgow Coma Scale (GCS) =13) at 14 days. The associations\r\nbetween risk factors and outcome were assessed with univariate and multivariate regression models.\r\nResults: 589 patients were included, median age was 55 years (IQR 33, 70). The median GCS in ED was 4 (IQR 3-14),\r\nwith abnormal pupil reaction in 167 patients (29.2%). Median ISS was 25 (IQR 21, 34). Three hundred seven patients\r\nsustained their TBI from falls (52.1%) and 190 from a road traffic accidents (32.3%). Median time from Out-ofhospital\r\nEmergency Medical Service (OHEMS) departure on scene to arrival in ED was 50 minutes (IQR 37-72); 451\r\npatients had a direct admission (76.6%). Prehospital hypotension was observed in 24 (4.1%) patients, hypoxemia in\r\n73 (12.6%) patients and hypothermia in 146 (24.8%). Prehospital hypotension and hypothermia (apart of age and\r\ntrauma severity) was associated with mortality. Prehospital hypoxemia (apart of trauma severity) was associated with\r\nimpaired consciousness; indirect admission was a protective factor.\r\nConclusion: Mortality and impaired consciousness at 14 days do not have the same prehospital risk factors;\r\nprehospital hypotension and hypothermia is associated with mortality, and prehospital hypoxemia with impaired\r\nconsciousness....
Background: Traumatic brain injury (TBI) and hemorrhagic shock (HS) are the leading causes of death in trauma.\r\nRecent studies suggest that TBI may influence physiological responses to acute blood loss. This study was designed\r\nto assess to what extent superimposed TBI may modulate physiologic vasomotor responses in third-order blood\r\nvessels in the context of HS.\r\nMethods: We have combined two established experimental models of pressure-controlled hemorrhagic shock\r\n(HS; MAP 50 mmHg/60 min) and TBI (lateral fluid percussion (LFP)) to assess vasomotor responses and microcirculatory\r\nchanges in third-order vessels by intravital microscopy in a spinotrapezius muscle preparation. 23 male Spragueââ?¬â??\r\nDawley rats (260ââ?¬â??320 g) were randomly assigned to experimental groups: i) Sham, ii) HS, iii) TBI + HS, subjected to\r\nimpact or sham operation, and assessed.\r\nResults: HS led to a significant decrease in arteriolar diameters by 20% to baseline (p < 0.01). In TBI + HS this\r\nvasoconstriction was less pronounced (5%, non-significant). At completed and at 60 minutes of resuscitation arteriolar\r\ndiameters had recovered to pre-injury baseline values. Assessment of venular diameters revealed similar results.\r\nArteriolar and venular RBC velocity and blood flow decreased sharply to < 20% of baseline in HS and TBI + HS\r\n(p < 0.01). Immediately after and at 60 minutes of resuscitation, an overshoot in arterial RBC velocity (140% of baseline)\r\nand blood flow (134.2%) was observed in TBI + HS.\r\nConclusion: Superimposed TBI modulated arteriolar and venular responses to HS in third-order vessels in a spinotrapezius\r\nmuscle preparation. Further research is necessary to precisely define the role of TBI on the microcirculation in tissues\r\nvulnerable to HS....
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