Georgios F. Giannakopoulos

The effect of tertiary surveys on missed injuries in trauma: a systematic review

BackgroundTrauma tertiary surveys (TTS) are advocated to reduce the rate of missed injuries in hospitalized trauma patients. Moreover, the missed injury rate can be a quality indicator of trauma care performance. Current variation of the definition of missed injury restricts interpretation of the effect of the TTS and limits the use of missed injury for benchmarking. Only a few studies have specifically assessed the effect of the TTS on missed injury. We aimed to systematically appraise these studies using outcomes of two common definitions of missed injury rates and long-term health outcomes.MethodsA systematic review was performed. An electronic search (without language or publication restrictions) of the Cochrane Library, Medline and Ovid was used to identify studies assessing TTS with short-term measures of missed injuries and long-term health outcomes. ‘Missed injury’ was defined as either: Type I) any injury missed at primary and secondary survey and detected by the TTS; or Type II) any injury missed at primary and secondary survey and missed by the TTS, detected during hospital stay. Two authors independently selected studies. Risk of bias for observational studies was assessed using the Newcastle-Ottawa scale.ResultsTen observational studies met our inclusion criteria. None was randomized and none reported long-term health outcomes. Their risk of bias varied considerably. Nine studies assessed Type I missed injury and found an overall rate of 4.3%. A single study reported Type II missed injury with a rate of 1.5%. Three studies reported outcome data on missed injuries for both control and intervention cohorts, with two reporting an increase in Type I missed injuries (3% vs. 7%, P<0.01), and one a decrease in Type II missed injuries (2.4% vs. 1.5%, P=0.01).ConclusionsOverall Type I and Type II missed injury rates were 4.3% and 1.5%. Routine TTS performance increased Type I and reduced Type II missed injuries. However, evidence is sub-optimal: few observational studies, non-uniform outcome definitions and moderate risk of bias. Future studies should address these issues to allow for the use of missed injury rate as a quality indicator for trauma care performance and benchmarking.

An evaluation of a Shockroom located CT scanner: a randomized study of early assessment by CT scanning in trauma patients in the bi-located trauma center North-West Netherlands (REACT trial)

BackgroundTrauma is a major source of morbidity and mortality, especially in people below the age of 50 years. For the evaluation of trauma patients CT scanning has gained wide acceptance in and provides detailed information on location and severity of injuries. However, CT scanning is frequently time consuming due to logistical (location of CT scanner elsewhere in the hospital) and technical issues. An innovative and unique infrastructural change has been made in the AMC in which the CT scanner is transported to the patient instead of the patient to the CT scanner. As a consequence, early shockroom CT scanning provides an all-inclusive multifocal diagnostic modality that can detect (potentially life-threatening) injuries in an earlier stage, so that therapy can be directed based on these findings.Methods/designThe REACT-trial is a prospective, randomized trial, comparing two Dutch level-1 trauma centers, respectively the VUmc and AMC, with the only difference being the location of the CT scanner (respectively in the Radiology Department and in the shockroom). All trauma patients that are transported to the AMC or VUmc shockroom according to the current prehospital triage system are included. Patients younger than 16 years of age and patients who die during transport are excluded. Randomization will be performed prehospitally.Study parameters are the number of days outside the hospital during the first year following the trauma (primary outcome), general health at 6 and 12 months post trauma, mortality and morbidity, and various time intervals during initial evaluation. In addition a cost-effectiveness analysis of this shockroom concept will be performed.Regarding primary outcome it is estimated that the common standard deviation of days spent outside of the hospital during the first year following trauma is a total of 12 days. To detect an overall difference of 2 days within the first year between the two strategies, 562 patients per group are needed. (alpha 0.95 and beta 0.80).DiscussionThe REACT-trial will provide evidence on the effects of a strategy involving early shockroom CT scanning compared with a standard diagnostic imaging strategy in trauma patients on both patient outcome and operations research.Trial registrationISRCTN55332315

Post-mortem imaging compared with autopsy in trauma victims – A systematic review

BACKGROUND Post-mortem imaging or virtual autopsy is a rapidly advancing field of post-mortem investigations of trauma victims. In this review we evaluate the feasibility of complementation or replacement of conventional autopsy by post-mortem imaging in trauma victims. MATERIALS AND METHODS A systematic review was performed in compliance with the PRISMA guidelines. MEDLINE, Embase and Cochrane databases were systematically searched for studies published between January 2008 and January 2014, in which post-mortem imaging was compared to conventional autopsy in trauma victims. Studies were included when two or more trauma victims were investigated. RESULTS Twenty-six studies were included, with a total number of 563 trauma victims. Post-mortem computer tomography (PMCT) was performed in 22 studies, post-mortem magnetic resonance imaging (PMMRI) in five studies and conventional radiography in two studies. PMCT and PMMRI both demonstrate moderate to high-grade injuries and cause of death accurately. PMCT is more sensitive than conventional autopsy or PMMRI in detecting skeletal injuries. For detecting minor organ and soft tissue injuries, autopsy remains superior to imaging. Aortic injuries are missed frequently by PMCT and PMMRI and form their main limitation. CONCLUSION PMCT should be considered as an essential supplement to conventional autopsy in trauma victims since it detects many additional injuries. Despite some major limitations, PMCT could be used as an alternative for conventional autopsy in situations where conventional autopsy is rejected or unavailable.

Criteria for cancelling helicopter emergency medical Services (HEMS) dispatches

Introduction In The Netherlands there is no consensus about criteria for cancelling helicopter emergency medical services (HEMS) dispatches. This study assessed the ability of the primary HEMS dispatch criteria to identify major trauma patients. The predictive power of other early prehospital parameters was evaluated to design a safe triage model for HEMS dispatch cancellations. Methods All trauma-related dispatches of HEMS during a period of 6 months were included. Data concerning prehospital information and inhospital treatment were collected. Patients were divided into two groups (major and minor trauma) according to the following criteria: injury severity score 16 or greater, emergency intervention, intensive care unit admission, or inhospital death. Logistic regression analysis was used to design a prediction model for the early identification of major trauma patients. Results In total, 420 trauma-related dispatches were evaluated, of which 155 concerned major trauma patients. HEMS was more often cancelled for minor trauma patients than for major trauma patients (57.7% vs 20.6%). Overall, HEMS dispatch criteria had a sensitivity of 87.7% and a specificity of 45.3% for identifying major trauma patients. Significant differences were found for vital sign abnormalities, anatomical components and several parameters of the mechanism of injury. A triage model designed for cancelling HEMS correctly identified major trauma patients (sensitivity 99.4%). Conclusion The accuracy of the current HEMS dispatch criteria is relatively low, resulting in high cancellation rates and low predictability for major trauma. The new HEMS cancellation triage model identified all major trauma patients with an acceptable overtriage and will probably reduce unjustified HEMS dispatches.

Long-term results and treatment modalities of conservatively treated Broberg–Morrey type 1 radial head fractures

BACKGROUND AND AIM This study assessed the long-term outcome (>6 months, with a mean of 46 months after injury) of the conservatively treated radial head fracture type 1 of the Broberg-Morrey (B-M) modification of the Mason classification. The main aim of this study is to assess the limitations in ADL activities on long term following a conservative treatment for B-M 1 radial head fractures. PATIENTS AND METHODS Out of a total patient group of 312 patients, 94 patients responded to our invitation for participation in the long-term follow-up study. These patients were included with a mean age of 42 years at time of injury and average of 46 months after injury. Most patients were treated with an upper arm cast or pressure bandage. These 94 patients were invited to fill out the validated Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire for elbow functioning as well as a demographic questionnaire. Basic patient and treatment data were collected from the hospital and trauma registration systems. RESULTS Forty-two percent of patients scored 0 (no disabilities) on the DASH questionnaire, 38% had a DASH score between 0.1 and 10.1, and 20% scored over 10.1. Correlations of the non-operative treatment modalities; immobilisation type, physiotherapy, smoking at time of injury, injury mechanism and immobilisation period with DASH outcome have not been found. CONCLUSION It appears that a B-M type 1 radial head fracture is not always accompanied with regaining full function on long term. To what extent these observed limitations influence patient behaviour and how treatment modalities influence these limitations should be the base of future prospective research.

Is a maximum Revised Trauma Score a safe triage tool for Helicopter Emergency Medical Services cancellations

Introduction The Revised Trauma Score is used worldwide in the prehospital setting and provides a snapshot of patients physiological state. Several studies have shown that the reliability of the RTS is high in trauma outcomes. In the Netherlands, Helicopter Emergency Medical Services (HEMS) are mostly used for delivery of specialized trauma teams on-scene and occasionally for patient transportation. In our trauma system, the Emergency Medical Services crew performs triage after arrival on-scene and cancels the HEMS-dispatch if deemed unnecessary. In this study we assessed the ability of a maximum on-scene Revised Trauma Score (RTS=12) to be used as a triage tool for HEMS cancellation. Methods All patients with a maximum on-scene RTS after blunt trauma (with or without receiving HEMS care) who were presented in the trauma resuscitation room of two Level-1 trauma centers during a period of 6 months, were included. Information concerning prehospital and in-hospital vital parameters, severity and localization of the injuries, and the in-hospital course were analyzed. Major trauma patients were classified using the following parameters: Injury Severity Score of at least 16, emergency intervention, Intensive Care Unit admission, and in-hospital death. Results Four-hundred and forty blunt trauma patients having a maximum RTS were included between 1 July and 31 December 2006. Eighty patients received on-scene HEMS care. Almost 16% of the total population concerned major trauma patients, of which only 25 (36%) received HEMS care. In 17 patients (3.9%), the RTS deteriorated during transportation. Major trauma patients sustained more injuries to the chest, abdomen, and lower extremities. Conclusion The RTS alone is not a reliable triage tool for HEMS cancellations in our trauma system and will lead to a considerable rate of undertriage with one in every six cancellations being incorrect. Other criteria based on patients vital signs, combined with anatomical and mechanism of injury parameters should be developed to safely minimize triage errors.

De lijkschouw bij plotselinge dood

Reijnders UJL, Das C, Giannakopoulos GF, De Bruin KH. De lijkschouw bij plotselinge dood. Onderzoek onder huisartsen naar vaardigheden en meningen over hun rol bij de lijkschouw. Huisarts Wet 2006;49(2):68-71.Doel Inventariserend onderzoek naar de mening van de huisarts over zijn rol bij de plotselinge dood van volwassenen en minderjarigen.Resultaten Van de 250 aangeschreven huisartsen deden er 217 mee aan het onderzoek (86,8%). Van de respondenten voelt 41% zich onvoldoende toegerust om naar behoren een lijkschouw te verrichten. Driekwart denkt onvoldoende vaardig te zijn in het interpreteren van letsels bij de lijkschouw. De afgelopen 5 jaar heeft 81% van de huisartsen geen enkele lijkschouw bij minderjarigen verricht. Over een wettelijk verplichte forensische lijkschouw bij onverwacht overlijden van volwassenen spreekt slechts 20% van de huisartsen zich negatief uit. Ruim 80% van de respondenten is voorstander van zo’n forensische lijkschouw bij alle overleden minderjarigen, 63% omdat ze zich als huisarts onvoldoende vaardig voelen, 59% om daarmee een belastende selectie te voorkomen, en 43% omdat ze van mening zijn dat ze zich als huisarts beter met de begeleiding van de nabestaanden kunnen bezighouden. Van de huisartsen geeft 11% aan wel eens een verklaring van natuurlijke dood te hebben afgegeven bij twijfel aan de natuurlijke aard van het overlijden. Als er sprake is van een terminale aandoening, vindt 12% van de huisartsen een schouw door een forensisch arts niet gewenst.Conclusie Ruim 40% van de huisartsen geeft aan over onvoldoende kennis en vaardigheden te beschikken ten aanzien van de lijkschouw, mishandeling en letselbeoordeling. Alleen bij een adequate meldingsprocedure zal er meer duidelijkheid en inzicht kunnen komen wat de doodsoorzaak precies is geweest en of mishandeling daar een rol in heeft gespeeld.samenvattingReijnders UJL, Das C, Giannakopoulos GF, De Bruin KH. Post-mortem following sudden death. Survey of general practitioners’ skills and opinions of their role in post-mortems. Huisarts Wet 2006;49(2):68-71.Objectives A survey regarding the opinion of general practitioners (GPs) regarding their role in relation to the new Burial Act in cases of sudden death in adults and persons under age of 18. Of the 250 GPs contacted, 217 (86.8%) participated in the study.Results Of the respondents, 41% did not feel confident in performing a post-mortem examination or felt unable to do so. As for recognition and interpretation of injuries during the post-mortem examination, 75% of the GPs did not feel sufficiently confident or equipped. Over the last five years, 81% of the GPs had not been called on to carry out a post-mortem examination on persons under the age of 18. In cases of unexpected sudden death in adults only 20% of the GPs failed to show support for the idea of a mandatory forensic post-mortem examination. More than 80% of the participants supported the idea of a forensic post-mortem examination of deceased persons under age of 18; 63% because they felt insufficiently skilled, 59% because they did not wish to make such a difficult decision, and 43% because they regarded themselves as better equipped as GPs to provide support to the relatives. Of the GPs who responded, 11% admitted to issuing a death certificate although they doubted whether the death had been natural.In case of terminal diseases, 12% of the GPs regarded a forensic post-mortem examination as undesirable.Conclusion Many GPs indicated that their knowledge of forensic matters such as post-mortem examination, violence and assessment of injuries is inadequate. Only with an adequate notification procedure will it be possible to obtain greater clarity regarding the exact cause of death of children and whether mistreatment has played a role.

Limitations in Prehospital Communication Between Trauma Helicopter, Ambulance Services, and Dispatch Centers

BACKGROUND Prehospital communication with Emergency Medical Services (EMS) is carried out in hectic situations. Proper communication among all medical personal is required to enhance collaboration, to provide the best care and enable shared situational awareness. OBJECTIVE The objective of this article was to give insight into current Dutch prehospital emergency care communication among all EMS and evaluate the usage of a new physician staffed helicopter EMS (P-HEMS) cancellation model. METHODS Trauma-related P-HEMS dispatches between November 1, 2014 and May 31, 2015 for the Lifeliner 1 were included; a random sample of 100 dispatches was generated. Tape recordings on all verbal prehospital communication between the dispatch center, EMS, and P-HEMS were transcribed and analyzed. Qualitative content analysis was performed, using open coding to code key messages. RESULTS Ninety-two tape recordings were analyzed. The most frequent reason for P-HEMS dispatch was suspicion of brain injury (24%). The cancellation model was followed in 66%, overruled in 9%, and not applicable in 25%. The main reason for not adhering to the model was hemodynamic stability. In 5% of P-HEMS dispatches, a complete ABCD (airway, breathing, circulation, disability) methodology was used for handover, in 9% a complete Situation-Background-Assessment-Recommendation technique, in 2% a complete Mechanism-Injuries-Signs-Treatment method was used. The other handovers were incomplete. CONCLUSIONS Prehospital handover between EMS on-scene and P-HEMS often entails insufficient information. The cancellation model for P-HEMS is frequently used and promotes adequate information transfer. To increase joined decision-making, more patient and situational information needs to be handed over. Standardization of prehospital trauma handovers will facilitate this and improve trauma patients outcome.

Incidence and etiology of mortality in polytrauma patients in a Dutch level I trauma center.

Background Earlier studies assessing mortality in polytrauma patients have focused on improving trauma care and reducing complications during hospital stay. The same studies have shown that the complication rate in these patients is high, often resulting in death. The aim of this study was to assess the incidence and causes of mortality in polytrauma patients in our institute. Secondarily, we assessed the donation and autopsy rates and outcome in these patients. Patients and methods All polytrauma patients (injury severity score≥16) transported to and treated in our institute during a period of 6 years were retrospectively analyzed. We included all patients who died during hospital stay. Prehospital and in-hospital data were collected on patients’ condition, diagnostics, and treatment. The chance of survival was calculated according to the TRISS methodology. Patients were categorized according to the complications during treatment and causes of death. Logistic regression analysis was used to design a prediction model for mortality in major trauma. A statistical analysis was carried out. Results Of the 1073 polytrauma patients who were treated in our institute during the study period, 205 (19.1%) died during hospital stay. The median age of the deceased patients was 58.8 years and 125 patients were men. Their mean injury severity score was 30.4. The most common mechanism of injury involved fall from height, followed by bicycle accidents. Almost 50% of the patients underwent an emergency intervention. Almost 92% of the total population died because of the effects of the accident (primary trauma). Of these, 24% died during primary assessment in the emergency department. Most patients died because of the effects of severe head injury (63.4%), followed by exsanguination (17.6%). The most common type of complications causing death during treatment was respiratory failure (6.3%), followed by multiple organ failure (1.5%). Autopsy was performed in 10.4%. Organ donation procedure was performed in 14.5%. Permission for donation was not provided in almost 20% of the population. Conclusion The mortality rate in polytrauma patients in our institute is considerable and comparable with the international literature. Most patients die because of the effects of the accident (primary trauma). Autopsy and organ donation rates are low in our institution and leave room for substantial improvements in the future.

Protocol of the DENIM study: a Delphi-procedure on the identification of trauma patients in need of care by physician-staffed Mobile Medical Teams in the Netherlands

BackgroundIn The Netherlands, standard prehospital trauma care is provided by emergency medical services and can be supplemented with advanced trauma care by Mobile Medical Teams. Due to observed over and undertriage in the dispatch of the Mobile Medical Team for major trauma patients, the accuracy of the dispatch criteria has been disputed. In order to obtain recommendations to invigorate the dispatch criteria, this study aimed at reaching consensus in expert opinion on the question; which acute trauma patient is in need of care by a Mobile Medical Team? In this paper we describe the protocol of the DENIM study (a Delphi-procedure on the identification of prehospital trauma patients in need of care by Mobile Medical Teams).MethodsA national three round digital Delphi study will be conducted to reach consensus. Literature was explored for relevant topics. After agreement on the themes of interest, the steering committee will construct questions for the first round. In total, 120 panellists with the following backgrounds; Mobile Medical Team physicians and nurses, trauma surgeons, ambulance nurses, emergency medical operators will be invited to participate. Group opinion will be fed back between each round that follows, allowing the panellists to revise their previous opinions and so, converge towards group consensus.DiscussionSuccessful prehospital treatment of trauma patients greatly depends on the autonomous decisions made by the different professionals along the chain of prehospital trauma care. Trauma patients in need of care by the Mobile Medical Team need to be identified by those professionals in order to invigorate deployment criteria and improve trauma care. The Delphi technique is used because it allows for group consensus to be reached in a systematic and anonymous fashion amongst experts in the field of trauma care. The anonymous nature of the Delphi allows all experts to state their opinion whilst eliminating the bias of dominant and/or hierarchical individuals on group opinion.