Giuseppe Nardi

A population-based study on pneumothorax in severely traumatized patients.

BACKGROUND Pneumothorax (PNX) is a recognized cause of preventable deaths in trauma patients. Our objective was to determine the incidence of traumatic PNX, the characteristics of its victims, and the treatment they receive. METHODS The study consisted of data set of a population-based study on major trauma. RESULTS The incidence of PNX was 81 per 1 million population per year, mostly caused by transport accidents. PNX victims generally had multiple injuries, and they showed on-scene clinical parameters worse than victims of other chest injuries of comparable severity. Fifty-three percent of PNXs were drained during the prehospital and early (< 2 hours) hospital course. There was no uniformity of treatment among different types of rescue facilities, some of them never performing decompression despite clinical need. The z statistic for mortality was -0.63. CONCLUSION PNX can be expected in one in five major trauma victims found alive. PNX is associated with a peculiar on-scene instability. Early decompression is often required. The effects of wider access to prehospital decompression and the reasons for its uneven availability in our setting need elucidation. Nevertheless, the present mortality follows the international standards.

Road traffic accidents with vehicular entrapment: incidence of major injuries and need for advanced life support.

Road traffic accidents (RTAs) with entrapment are perceived as a challenge to emergency systems because of the severity of the ensuing traumas and the inherent complexity of the rescue procedures. To clarify these two aspects this prospective cohort study enrolling 244 entrapped trauma patients was conducted by a Regional Medical Helicopter Service. Forty-six victims (18.9%) were found dead, 101 (51%) of the 198 patients who reached the hospital alive had an injury severity score (ISS) > or = 16. The use of seat belts was associated with lower trauma severity. Out of the 101 severely traumatized patients (ISS > or = 16), 46 (42.6%) were intubated at road side, 12 required decompression of a tension pneumothorax on the scene and in 15 cases a pneumothorax was drained during the early intrahospital phase. Thirty-six (34.7%) patients had the first systolic blood pressure (SBP) < or = 90 mmHg and were then aggressively infused: in 75% of these cases, the SBP on arrival at the emergency department increased. The first SBP was significantly correlated with mortality. There was no correlation of extrication time, total rescue time and mortality. Fourteen patients (13.9%) died during hospitalization. These data demonstrate that a high percentage of entrapped patients require advanced life support (ALS), including on scene intubation and chest decompression. Aggressive field resuscitation and immediate transport to a level 1 trauma centre is associated with a mortality lower than that predicted by TRISS in spite of the prolonged prehospital time.

Epidemiology of major injury in the population of Friuli Venezia Giulia—Italy

OBJECTIVE To provide reliable and comparable information on major injury (MIJ) (Injury Severity Score (ISS) > 15) by establishing a comprehensive and Utstein-style compliant registry of all occurrences in a defined geographical area. METHODS Prospective, population-based, 12-month study targeting the 1,200,000 inhabitants of the Italian region Friuli Venezia Giulia (FVG). Deliberate self-harm was excluded. RESULTS The total number of MIJ cases was 627, the resulting incidence 522 per million per year. Trauma was mostly blunt (98.4%). Young (15-44 years) adults (54.8%) and males (78.6%) were most affected. Leading mechanisms of injury were traffic accidents (81%) and falls (9.1%). Most events occurred in rural (80.9%) areas despite one third of the regional population living in major urban centres. Summer and weekends carried the highest frequency. The mean ISS ( n = 455 ) was 30.0, median 25. On-scene vital parameters were often subnormal, e.g. 53.9%, GCS < 14. The Emergency Medical System was nearly always activated (98.4%). The time intervals were within standards although in part susceptible of improvement. The percentage of direct triage to the definitive hospital was 79.8%. Overall mortality was 45.6% or 238 per million per year. Most fatalities were found already dead (171/300) and no trimodal distribution was verified. Only 1.5% of the patients found alive died outside hospital. Mean GOS was 4.4 +/- 1 (S.D.), median 5. CONCLUSION A considerable amount of information on MIJ in FVG has been gathered, of both local and general interest because it can help to assess the local trauma system and also, given the relative scarcity of prospective, population-based information on MIJ, contribute to scientific research.

HEMS vs. Ground-BLS care in traumatic cardiac arrest.

Objective. To assess whether a top-level type of prehospital care, made of helicopter, physician, andadvanced life support (ALS) procedures, improves the outcome of blunt trauma victims found in cardiac arrest (CA) as compared with a simpler type, composed of ground ambulance, nurse, andexpanded basic life support (BLS). Methods. This was a cohort study from the data set of a prospective, population-based, 12-month study targeting the 1,200,000 inhabitants of the Italian region Friuli Venezia Giulia. Results. Fifty-six victims received the higher level of care (helicopter emergency medical services [HEMS] group) and73 received the lower one (ground-BLS group). The two groups were homogeneous for mechanism of injury, gender, andtime interval before cardiopulmonary resuscitation (CPR). Age was lower in the ground-BLS group. The percentage of patients in which CPR was attempted was significantly higher in the HEMS group (43% vs. 20%; CI 0.061 to 0.379). On-scene return of spontaneous circulation (ROSC) was also more likely in the HEMS group (37.5% of attempted CPRs vs. 6.6%; CI 0.027 to 0.591). None of the patients evacuated from the scene without ROSC ever attained it in hospital. This policy was virtually exclusive to the ground-BLS group. Survival to hospital discharge was 3.5% (severely disabled) in the HEMS group and0% in the ground-BLS group (CI −0.008 to 0.078). Conclusion. A top-level type of prehospital care had significantly more chances to resuscitate blunt trauma victims found in CA as compared with a simpler level. No significant benefit on long-term outcome was found, but more cases might be needed in future studies because of the inevitably low number of survivors.

The European Trauma Course (ETC) and the team approach: past, present and future.

The European Trauma Course (ETC) was officially launched during the international conference of the European Resuscitation Council (ERC) in 2008. The ETC was developed on behalf of ESTES (European Society of Trauma and Emergency Surgery), EuSEM (European Society of Emergency Medicine), the ESA (European Society of Anaesthesiology) and the ERC. The objective of the ETC is to provide an internationally recognised and certified life support course, and to teach healthcare professionals the key principles of the initial care of severely injured patients. Its core elements, that differentiates it from other trauma courses, are a strong focus on team training and a novel modular design that is adaptable to the differing regional European requirements. This article describes the lessons learnt during the European Trauma Course development and provides an outline of the planned future development.

Systematic review of the literature and evidence-based recommendations for antibiotic prophylaxis in trauma: results from an Italian consensus of experts.

Background Antibiotic prophylaxis is frequently administered in severe trauma. However, the risk of selecting resistant bacteria, a major issue especially in critical care environments, has not been sufficiently investigated. The aim of the present study was to provide guidelines for antibiotic prophylaxis for four different trauma-related clinical conditions, taking into account the risks of antibiotic-resistant bacteria selection, thus innovating previous guidelines in the field. Methods The MEDLINE database was searched for studies comparing antibiotic prophylaxis to controls (placebo or no antibiotic administration) in four clinical traumatic conditions that were selected on the basis of the traumatic event frequency and/or infection severity. The selected studies focused on the prevention of early ventilator associated pneumonia (VAP) in comatose patients with traumatic brain injury, of meningitis in severe basilar skull fractures, of wound infections in long-bone open fractures. Since no placebo-controlled study was available for deep surgical site-infections prevention in abdominal trauma with enteric contamination, we compared 24-hour and 5-day antibiotic prophylaxis policies. A separate specific research focused on the question of antibiotic-resistant bacteria selection caused by antibiotic prophylaxis, an issue not adequately investigated by the selected studies. Randomised trials, reviews, meta-analyses, observational studies were included. Data extraction was carried out by one author according to a predefined protocol, using an electronic form. The strength of evidence was stratified and recommendations were given according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Results Uncertain evidence deserving further studies was found for two-dose antibiotic prophylaxis for early VAP prevention in comatose patients. In the other cases the risk of resistant-bacteria selection caused by antibiotic administration for 48 hours or more, outweighed potential benefits. Conclusions When accounting for antibiotic-resistant bacteria selection we found no evidence in favour of antibiotic prophylaxis lasting two or more days in the studied clinical conditions.

Trauma Intensive Care: Early and Late Challenges

The development of a trauma program, with a clinical service, trauma protocols, and a well-organized trauma team could be expected to improve the process of care and thereby outcomes after injury. An integrated model of trauma care allows better continuity of care, minimizes communication errors, and establishes the overall responsibilities for the whole process through the identification of a trauma team leader. Evidence supports the assertion that a fully implemented trauma system reduces mortality rate for severely injured patients [1]. Continuous quality improvement and performance monitoring are cornerstones in achieving the principal targets of the trauma program: reduction of preventable death after injury.

Trauma Management: From the Field to the Emergency Department

The goal of pre-hospital trauma care is to reduce mortality and morbidity by preventing the development of hypovolaemia, hypoxia, hypercapnia and acidosis, and to ensure, at the same time, the quickest access to a Centre of definitive care and to early surgery when needed.