Current Issue : January - March Volume : 2018 Issue Number : 1 Articles : 7 Articles
Abstract\nBackground: The objective of this study was to determine the attitude of patients, healthcare professionals,\nand noninjured lay persons towards adding a video with discharge instructions to patient care for patients\nwith mild traumatic brain injury (MTBI). A survey was conducted at the emergency department (ED).\nParticipants consisted of MTBI patients (n = 50), healthcare professionals (n = 50), and noninjured lay persons\n(n = 50). The participants viewed a video with discharge instructions on MTBI and filled out a questionnaire\nthat measured their attitude towards the use of a video as part of discharge instructions.\nFindings: Nearly all healthcare professionals (94%) and 70% of the noninjured lay persons considered the\nvideo to be a valuable addition to oral discharge instructions. For 84% of patients, verbal information from\nthe doctor is of importance. And, 50% of patients would like to receive additional video discharge\ninstructions.\nConclusions: The majority of noninjured lay persons and healthcare professionals and half of the MTBI\npatients consider a video with discharge instructions to be a valuable addition to patient care. Video\ndischarge instructions are a relative low-cost measure that could enhance patient care at the ED, provided\nthat this does not compromise the personal contact between patient and healthcare professional....
Background: Seizure is a common complication for severe traumatic brain injury (TBI). Valproic acid (VPA) is a firstline\nantiepileptic drug, though its metabolism is affected by genetic polymorphisms and varies between individuals.\nThe aim of this study was to investigate such association and to explore its influence on the occurrence of early\npost-traumatic seizure.\nMethods: A prospective case control study was conducted from 2012 to 2016 recruiting adult patients with severe\nTBI. Electroencephalograph (EEG) monitoring was performed approximately 4 h for each patient from day 1 to day\n7 after injury. If seizures were detected, EEG monitoring was extended until 12 h after seizures being controlled.\nGenetic polymorphisms in UGT1A6, UGT2B7, CYP2C9, and CYP2C19 were analyzed in association with daily VPA\nplasma concentrations, adjusted dosages, and occurrence of seizures.\nResults: Among the 395 recruited patients, eighty-three (21%) had early post-traumatic seizure, of which 30 (36.14%)\nwere non-convulsive. Most seizures were first detected on day 1 (34.94%) and day 2 (46.99%) after injury. Patients with\nseizure had longer ICU length of stay and relatively lower VPA plasma concentrations. Patients with UGT1A6_19T > G/\n541A > G/552A > C double heterozygosities or CYP2C9 extensive metabolizers (EMs) initially had lower adjusted VPA\nplasma concentrations (power >0.99) and accordingly require higher VPA dosages during later time of treatment (power\n>0.99). The odds ratio indicated a higher risk of early post-traumatic seizure occurrence in male patients (OR 1.96, 95% CI\n1.01-3.81, p = 0.043), age over 65 (OR 2.13, 95% CI 1.01-4.48), and with UGT1A6_19T > G/541A > G/552A > C double\nheterozygosities (OR 2.38, 95% CI 1.11-5.10, p = 0.02), though the power of the difference was between 0.54 to 0.61.\nDiscussion: Due to limited facility, the actual frequency of non-convulsive seizures is suspected to be higher than\nidentified. There has been discrepancy regarding to genetic polymorphisms and VPA metab olism between this study\nand some previous reports. This could be related to confounders such as sample size, race, and patient age. Another\nlimitation is that the case numbers of certain genotypes are limited in this study.\nConclusions: Continuous EEG monitoring is necessary to detect both convulsive and non-convulsive early post-traumatic\nseizures in severe TBI patients. UGT1A6/CYP2C9 polymorphisms have influence on VPA metabolism. UGT1A6_19T > G/\n541A > G/552A > C double heterozygositie is associated with occurrence of early post-traumatic seizures in addition to\npatients� age and gender. Further investigations with larger sample size are required to confirm the difference....
Minor head injury (MHT) is one of the most common causes of all trauma\nadmissions and it is still controversial to manage adequately. Although the incidence\nof clinically significant traumatic brain injury is low in this group, the\nconsequences of missing clinically important problem are potentially life\nthreatening. Early diagnosis of intracranial hematoma by computed tomography\nscan (CT) followed by early surgery is very important in the treatment\nof such patients. Thus, there has been a tendency to use high levels of diagnostic\nimaging in these conditions. There are many decision rules for the use\nof computed tomography (CT) for patients with minor head injury. This survey\nis to determine the awareness and utilization rates of these head CT rules\namong our emergency physicians (EP). Questionnaire was randomly sent to\nEPs from different ministry of health hospitals in Makkah. Our participants\nwere asked about their awareness of such rules and their applications in their\ncareers. Data were collected and analyzed by SPSS V16.0. The awareness and\nutilization rate of clinical decision rules among 91 ER physicians who responded\nwere 54.4% and 42.2% respectively. The barriers to utilize such rules\nwere the working environment and increased chances of getting lawsuits,\nwhich were 55.4% and 61.7% respectively. 91.1% of those physicians would\nlike to receive guidance on how to apply such rules in their daily practices.\nThere is a misunderstanding of the definition of minor head injury, despite\nthe high number of head traumas, which led to request more CT scan. This\nwill be a burden on the healthcare system and will lead to more radiation exposure.\nMore educations regarding head CT rules will result in better utilizing\nof our resources and reduction in radiation risks....
Background: The effective treatment of airway compromise in trauma and non-trauma patients is important.\nHypoxia and hypotension are predictors of negative patient outcomes and increased mortality, and may be\nimportant quality indicators of care provided by emergency medical services. Excluding cardiac arrests, critical\ntrauma and non-trauma patients remain the two major groups to which helicopter emergency medical services\n(HEMS) are dispatched. Several studies describe the impact of pre-hospital hypoxia or hypotension on trauma\npatients, but few studies compare this in trauma and non-trauma patients. The primary aim was to describe the\nincidence of pre-hospital hypoxia and hypotension in the two groups receiving pre-hospital tracheal intubation\n(TI) by physician-staffed HEMS.\nMethods: Data were collected prospectively over a 12-month period, using a uniform Utstein-style airway\ntemplate. Twenty-one physician-staffed HEMS in Europe and Australia participated. We compared peripheral\noxygen saturation and systolic blood pressure before and after definitive airway management. Data were\nanalysed using Cochranââ?¬â??Mantelââ?¬â??Haenszel methods and mixed-effects models.\nResults: Eight hundred forty three trauma patients and 422 non-trauma patients receiving pre-hospital TI\nwere included. Non-trauma patients had significantly lower predicted mean pre-intervention SpO2 compared\nto trauma patients. Post-intervention and admission SpO2 for the two groups were comparable. However, 3% in\nboth groups were still hypoxic at admission. For hypotension, the differences between the groups were less\nprominent. However, 9% of trauma and 10% of non-trauma patients were still hypotensive at admission. There\nwas no difference in short-term survival between trauma (97%) and non-trauma patients (95%). Decreased level\nof consciousness was the most frequent indication for TI, and was associated with increased survival to hospital\n(cOR 2.8; 95% CI: 1.4ââ?¬â??5.4). Conclusions: Our results showed that non-trauma patients had a higher incidence of hypoxia before TI than\ntrauma patients, but few were hypoxic at admission. The difference for hypotension was less prominent, but\none in ten patients were still hypotensive at admission. Further investigations are needed to identify reversible\ncauses that may be corrected to improve haemodynamics in the pre-hospital setting. We found high survival\nrates to hospital in both groups, suggesting that physician-staffed HEMS provide high-quality emergency airway\nmanagement in trauma and non-trauma patients....
Background: Major trauma is often life threatening and the leading cause of death in the United Kingdom (UK) for\nadults aged less than 45 years old. This study aimed to identify pre-hospital factors associated with patient\noutcomes for major trauma within one Regional Trauma Network.\nMethod: Secondary analysis of pre-hospital audit data and patient outcome data from the Trauma Audit Research\nNetwork (TARN) was undertaken. The primary outcome used in analysis was ââ?¬Ë?Status at Dischargeââ?¬â?¢ (alive/deceased).\nIndependent variables considered included ââ?¬Ë?Casualty Characteristicsââ?¬â?¢ such as mechanism of injury (MOI), age, and\nphysiological measurements, as well as ââ?¬Ë?Response Characteristicsââ?¬â?¢ such as response timings and skill mix. Binary\nLogistic Regression analysis using the ââ?¬Ë?forward stepwiseââ?¬â?¢ method was undertaken for physiological measures taken\nat the scene.\nResults: The study analysed 1033 major trauma records (mean age of 38.5 years, SD 21.5, 95% CI 37ââ?¬â??40). Adults\ncomprised 82.6% of the sample (n = 853), whilst 12.9% of the sample were children (n = 133). Men comprised 68.\n5% of the sample (n = 708) in comparison to 28.8% women (n = 298).\nGlasgow Coma Score (GCS) (p < 0.000), Respiration Rate (p < 0.001) and Age (p < 0.000), were all significant when\nassociated with the outcome ââ?¬Ë?Status at Dischargeââ?¬â?¢ (alive/deceased).\nIsolated bivariate associations provided tentative support for response characteristics such as existing dispatching\npractices and the value of rapid crew arrival. However, these measurements appear to be of limited utility in\npredictive modelling of outcomes.\nDiscussion: The complexity of physiological indices potentially complicate their predictive utility e.g. whilst a Systolic\nBlood Pressure (SBP) of < 90 mmHg serves as a trigger for bypass to a Major Trauma Centre, the utility of this\nobservation is nullified in cases of Traumatic Brain Injury.\nAnalysis suggested that as people age, outcomes from major trauma significantly worsened. This finding is consistent\nwith existing research highlighting the relationship between trauma in elderly patients and poorer outcomes.\nConclusion: Findings lend further validity to GCS, Respiration Rate and Age as predictive triggers for transport to a\nMajor Trauma Centre. Analysis of interactions between response times, skill mix and triage demand further exploration\nbut tentatively support the ââ?¬Ë?Golden Hourââ?¬â?¢ concept and suggest a potential ââ?¬Ë?load and go and play on the wayââ?¬â?¢ approach....
Background: To reduce the possibility of secondary deterioration of spinal injuries, it is desirable to maintain the\nspinal immobilisation that is applied in the prehospital setting throughout computed tomography (CT) scanning. A\nprevious study found that metallic components within the inflation valve of the vacuum mattresses caused CT artefacts.\nThe aim of our study was to investigate the effect of vacuum mattresses with plastic valves on CT artefacts, the radiation\ndose, and noise compared to a trauma transfer board and the spine boards currently used in our trauma system.\nMethods: We scanned an anthropomorphic whole body phantom with different immobilisation devices on a 128-slice\nCT scanner using the standard polytrauma CT-protocol at our institution. The phantom was scanned without any\nimmobilisation device and with three different vacuum mattresses, two spine boards, and one trauma transfer board.\nTwo radiologists independently assessed the artefacts. Agreement between the two radiologists was measured using\nthe kappa coefficient. The radiation dose and noise were assessed.\nResults: One spine board produced major artefacts due to its metal components. One of the vacuum mattresses\nresulted in artefacts that impaired clinical judgement. Otherwise, the artefacts predominantly did not impede clinical\njudgement and were mainly subtle. One of the vacuum mattresses resulted in no artefacts that affected clinical judgement.\nThe overall inter-rater agreement was substantial (0.86, kappa 0.77). We did not observe any artefacts due to plastic valves.\nThe mean CT radiation dose was slightly higher for two of the devices in the head series than that for the trauma transfer\nboard, used as the standard in our system. Only marginal differences were noted for the other devices and series. Small\ndifferences in image noise were found between the devices.\nConclusions: Our results indicate that it is feasible to maintain some vacuum mattresses with plastic valves on trauma\npatients during CT scanning. The tested mattresses did not result in a considerably increased radiation dose or artefacts\nthat hampered clinical judgement. One of the tested vacuum mattresses produced no artefacts that hampered clinical\njudgement whatsoever....
Background: In order to enhance patient safety during resuscitation of critically ill patients, we need to optimize team\ncommunication and enhance team situational awareness but little is known about resuscitation team communication\npatterns. The objective of this study is to understand how teams communicate during resuscitation; specifically to\nassess for a shared mental model (organized understanding of a team�s relationships) and information needs.\nMethods: We triangulated 3 methods to evaluate resuscitation team communication at a tertiary care academic\ntrauma center: (1) interviews; (2) simulated resuscitation observations; (3) live resuscitation observations. We interviewed\n18 resuscitation team members about shared mental models, roles and goals of team members and procedural\nexpectations. We observed 30 simulated resuscitation video recordings and documented the timing, source and\ndestination of communication and the information category. We observed 12 live resuscitations in the emergency\ndepartment and recorded baseline characteristics of the type of resuscitations, nature of teams present and type and\ncontent of information exchanges. The data were analyzed using a qualitative communication analysis method.\nResults: We found that resuscitation team members described a shared mental model. Respondents understood the\nroles and goals of each team member in order to provide rapid, efficient and life-saving care with an overall need for\nsituational awareness. The information flow described in the interviews was reflected during the simulated and live\nresuscitations with the most responsible physician and charting nurse being central to team communication. We\nconsolidated communicated information into six categories: (1) time; (2) patient status; (3) patient history; (4)\ninterventions; (5) assistance and consultations; 6) team members present.\nConclusions: Resuscitation team members expressed a shared mental model and prioritized situational awareness. Our\nfindings support a need for cognitive aids to enhance team communication during resuscitations...
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