Current Issue : April - June Volume : 2017 Issue Number : 2 Articles : 7 Articles
Background: This study aimed to assess whether a management algorithm using data obtained with a PiCCO system\ncan improve clinical outcomes in critically ill patients with acute respiratory distress syndrome (ARDS).\nResults: The PaO2/FiO2 ratio increased over time in both groups, with a sharper increase in the PiCCO group. There\nwas no difference in 28-day mortality (3.2 vs. 3.6%, P = 0.841). Days on mechanical ventilation (3 vs. 5 days, P = 0.002)\nand ICU length of stay (6 vs. 11 days, P = 0.004) were significantly lower in the PiCCO group than in the CVP group.\nTreatment costs were lower in the PiCCO group than in the CVP group. Multivariate logistic regression model\nshowed that the monitoring method (PiCCO vs. CVP) was independently associated with the length of ICU stay [odds\nratio (OR) 3.16, 95% confidence interval (95% CI) 1.55ââ?¬â??6.63, P = 0.001], as well as shock (OR 3.41, 95% CI 1.74ââ?¬â??6.44,\nP = 0.002), shock and ARDS (OR 3.46, 95% CI 1.79ââ?¬â??6.87, P = 0.002), and APACHE II score (OR 1.17, 95% CI 1.02ââ?¬â??1.86,\nP = 0.014).\nConclusions: This study investigated the usefulness of the PiCCO system in improving outcomes for patient with\nsevere thoracic trauma and ARDS and provided new evidence for fluid management in critical care settings....
Background: A new classification of hypovolemic shock based on the shock index (SI) was proposed in 2013. This\nclassification contains four classes of shock and shows good correlation with acidosis, blood product need and mortality.\nSince their applicability was questioned, the aim of this study was to verify the validity of the new classification in\nmultiple injured patients with traumatic brain injury.\nMethods: Between 2002 and 2013, data from 40 888 patients from the TraumaRegister DGU�® were analysed. Patients\nwere classified according to their initial SI at hospital admission (Class I: SI < 0.6, class II: SI â�¥0.6 to <1.0, class III SI â�¥1.0 to\n<1.4, class IV: SI â�¥1.4). Patients with an additional severe TBI (AIS â�¥ 3) were compared to patients without severe TBI.\nResults: 16,760 multiple injured patients with TBI (AIShead â�¥3) were compared to 24,128 patients without severe TBI.\nWith worsening of SI class, mortality rate increased from 20 to 53% in TBI patients. Worsening SI classes were\nassociated with decreased haemoglobin, platelet counts and Quickâ��s values. The number of blood units transfused\ncorrelated with worsening of SI. Massive transfusion rates increased from 3% in class I to 46% in class IV. The accuracy\nfor predicting transfusion requirements did not differ between TBI and Non TBI patients.\nDiscussion: The use of the SI based classification enables a quick assessment of patients in hypovolemic shock based\non universally available parameters. Although the pathophysiology in TBI and Non TBI patients and early treatment\nmethods such as the use of vasopressors differ, both groups showed an identical probability of recieving blood\nproducts within the respective SI class.\nConclusion: Regardless of the presence of TBI, the classification of hypovolemic shock based on the SI enables a fast\nand reliable assessment of hypovolemic shock in the emergency department. Therefore, the presented study supports\nthe SI as a feasible tool to assess patients at risk for blood product transfusions, even in the presence of severe TBI....
The aim of this study was to evaluate the medical management of traumatic brain\ninjury. We performed a retrospective and descriptive study during the period from\n1st January 2014 to 31st December 2015 (24 months), into the surgical department of\nthe University Hospital of Brazzaville. 167 cases of non-operated traumatized brain\nhave been identified. The average age was 29.84 years. The sex ratio was 8.82. Accidents\non public roads were responsible for injury in 88.2% of the cases. 46.71% of patients\nhad a moderate traumatic brain injury while 10.18% had a severe traumatic\nbrain injury. Radiological evaluation was highlighted for the brain contusion in\n52.09% of the cases. Tracheal intubation and ventilation were completed only in 6\nout of the 17 cases of severe traumatic brain injury. Prevention of post-traumatic\nseizure was performed with the use of phenobarbital or sodium valproate. Mannitol\nwas used for its osmotic properties. The outcome was favorable in 55.68% of the cases.\nThe most common complications were pulmonary infections, persistent neurological\ndisorders, urinary infection and hyponatremia. Mortality was recorded at\n13.77%. Nonsurgical management of traumatic brain injury involves an expansion of\nthe ventilatory assistance indication at all severe traumatic brain injuries, the fight\nagainst infectious complications and ionic monitoring....
Background: Because of a lack of randomized controlled trials and the methodological weakness of currently available\nobservational studies, the benefits of helicopter emergency medical services (HEMS) over ground emergency medical\nservices (GEMS) for major trauma patients remain uncertain. The aim of this retrospective nationwide cohort study was\nto compare the mortality of adults with serious traumatic injuries who were transported by HEMS and GEMS, and to\nanalyze the effects of HEMS in various subpopulations.\nMethods: Using the Japan Trauma Data Bank, we evaluated all adult patients who had an injury severity score ââ?°Â¥ 16\ntransported by HEMS or GEMS during the daytime between 2004 and 2014. We compared in-hospital mortality between\npatients transported by HEMS and GEMS using propensity score matching, inverse probability of treatment\nweighting and instrumental variable analyses to adjust for measured and unmeasured confounding factors.\nResults: Eligible patients (n = 21,286) from 192 hospitals included 4128 transported by HEMS and 17,158 transported by\nGEMS. In the propensity score-matched model, there was a significant difference in the in-hospital mortality between\nHEMS and GEMS groups (22.2 vs. 24.5%, risk difference âË?â??2.3% [95% confidence interval, âË?â??4.2 to âË?â??0.5]; number needed to\ntreat, 43 [95% confidence interval, 24 to 220]). The inverse probability of treatment weighting (20.8% vs. 23.9%;\nrisk difference, âË?â??3.9% [95% confidence interval, âË?â??5.7 to âË?â??2.1]; number needed to treat, 26 [95% confidence\ninterval, 17 to 48]) and instrumental variable analyses showed similar results (risk difference, âË?â??6.5% [95% confidence\ninterval, âË?â??9.2 to âË?â??3.8]; number needed to treat, 15 [95% confidence interval, 11 to 27]). HEMS transport was significantly\nassociated with lower in-hospital mortality after falls, compression injuries, severe chest injuries, extremity (including\npelvic) injuries, and traumatic arrest on arrival to the emergency department.\nConclusions: HEMS was associated with a significantly lower mortality than GEMS in adult patients with major traumatic\ninjuries after adjusting for measured and unmeasured confounders....
Background: Survival rates from out-of-hospital cardiac arrest (OHCA) remain low, despite remarkable efforts to\nimprove care. A number of ambulance services in the United Kingdom (UK) have developed prehospital critical care\nteams (CCTs) which attend critically ill patients, including OHCA. However, current scientific evidence describing\nCCTs attending OHCA is sparse and research to date has not demonstrated clear benefits from this model of care.\nMethods: This prospective, observational study will describe the effect of CCTs on survival from OHCA, when compared\nto advanced-life-support (ALS), the current standard of prehospital care in the UK. In addition, we will describe the\nassociation between individual critical care interventions and survival, and also the costs of CCTs for OHCA.\nTo examine the effect of CCTs on survival from OHCA, we will use routine Utstein variables data already collected in a\nnumber of UK ambulance trusts. We will use propensity score matching to adjust for imbalances between the CCT and\nALS groups. The primary outcome will be survival to hospital discharge, with the secondary outcome of survival to\nhospital admission.\nWe will record the critical care interventions delivered during CCT attendance at OHCA. We will describe frequencies and\naim to use multiple logistic regression to examine possible associations with survival.\nFinally, we will undertake a stakeholder-focused cost analysis of CCTs for OHCA. This will utilise a previously published\nEmergency Medical Services (EMS) cost analysis toolkit and will take into account the costs incurred from use of a\nhelicopter and the proportion of these costs currently covered by charities in the UK.\nDiscussion: Prehospital critical care for OHCA is not universally available in many EMS. In the UK, it is variable and largely\nfunded through public donations to charities. If this study demonstrates benefit from CCTs at an acceptable cost to the\npublic or EMS commissioners, it will provide a rationale to increase funding and service provision. If no clinical benefit is\nfound, the public and charities providing these services can consider concentrating their efforts on other areas of\nprehospital care....
Background: Hyperfibrinolysis (HF) is a major contributor to coagulopathy and mortality in trauma patients. This\nstudy investigated (i) the rate of HF during the pre-hospital management of patients with multiple injuries and (ii)\nthe effects of pre-hospital tranexamic acid (TxA) administration on the coagulation system.\nMethods: From 27 trauma patients with pre-hospital an estimated injury severity score (ISS) ââ?°Â¥16 points blood was\nobtained at the scene and on admission to the emergency department (ED). All patients received 1 g of TxA after\nthe first blood sample was taken. Rotational thrombelastometry (ROTEM) was performed for both blood samples,\nand the results were compared. HF was defined as a maximum lysis (ML) >15 % in EXTEM.\nResults: The median (min-max) ISS was 17 points (4ââ?¬â??50 points). Four patients (15 %) had HF diagnosed via ROTEM\nat the scene, and 2 patients (7.5 %) had HF diagnosed via ROTEM on admission to the ED. The median ML before\nTxA administration was 11 % (3ââ?¬â??99 %) vs. 10 % after TxA administration (4ââ?¬â??18 %; p > 0.05). TxA was administered\n37 min (10ââ?¬â??85 min) before ED arrival. The ROTEM results before and after TxA administration did not significantly\ndiffer. No adverse drug reactions were observed after TxA administration.\nDiscussion: HF can be present in severely injured patients during pre-hospital care. Antifibrinolytic therapy\nadministered at the scene is a significant time saver. Even in milder trauma fibrinogen can be decreased to critically\nlow levels. Early administration of TxA cannot reverse or entirely stop this decrease.\nConclusions: The pre-hospital use of TxA should be considered for severely injured patients to prevent the\nworsening of trauma-induced coagulopathy and unnecessarily high fibrinogen consumption....
Background: Traumatic injuries have become a substantial but neglected epidemic in low- and middle-income\ncountries (LMICs), but emergency rooms (ERs) in these countries are often staffed with healthcare providers who\nhave minimal emergency training and experience. The aim of this paper was to describe the specialized training,\navailable interventions, and the patient management strategies in the ERs in Albanian public hospitals.\nMethods: A cross-sectional descriptive study of 42 ERs in the Republic of Albania between September 5, 2014, and\nDecember 29, 2014 was performed. Assessment subcategories included the following: (1) specialized training and/\nor certifications possessed by healthcare providers, (2) interventions performed in the ER, and (3) patient\nmanagement strategies.\nResults: Across the 42 ERs surveyed, less than half (37.1ââ?¬â??42.5 %) of physicians and one third of nurses (7.1ââ?¬â??26.0 %)\nworking in the ERs received specialized trauma training. About half (47.9ââ?¬â??57.1 %) of the ER physicians and one fifth\nof the nurses (18.3ââ?¬â??22.9 %) possessed basic life support certification. This survey demonstrated some significant\ndifferences in the emergency medical care provided between primary, secondary, and tertiary hospitals across\nAlbania (the significance level was set at 0.05). Specifically, these differences involved spinal immobilization\n(p = 0.01), FAST scan (p = 0.04), splinting (p = 0.01), closed reduction of displaced fractures (p = 0.02), and nurses\nperforming cardiopulmonary resuscitation (CPR) (p = 0.01). Between 50.0 and 71.4 % of the facilities cited a\ncombined lack of training and supplies as the reason for not offering interventions such as rapid sequence\ninduction, needle thoracotomy, chest tube insertion, and thrombolysis. Mass casualty triage was utilized among 39.\n1 % primary hospitals, 41.7 % of secondary, and 28.6 % of tertiary.\nConclusions: The emergency services in Albania are currently staffed with inadequately trained personnel, who lack\nthe equipment and protocols to meet the needs of the population...
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