Mete Erdogan

Increased mortality in trauma patients who develop postintubation hypotension

BACKGROUND Post-intubation hypotension (PIH) is common and associated with poor outcomes in critically ill patient populations requiring emergency endotracheal intubation (ETI). The importance of PIH in the trauma population remains unclear. The objective of this study was to determine the prevalence of PIH in trauma patients and assess the association of PIH with patient outcomes. METHODS Retrospective case series of adult (≥16 years) patients who were intubated on arrival at a tertiary trauma center in Halifax, Nova Scotia, Canada between 2000 and 2015. Data were collected from the Nova Scotia Trauma Registry and patient chart, and included demographics, co-morbidities, trauma characteristics, intubation time, as well as all fluids, medications, adverse events, interventions, and vital signs during the 15 minutes before/after ETI. We evaluated the prevalence of PIH and created a logistic regression model to determine likelihood of mortality in the PIH and non-PIH groups after controlling for patient and provider characteristics. RESULTS Overall, 477 patients required ETI on assessment by the trauma service, of which 444 patients met eligibility criteria and were included in the analysis. The prevalence of PIH was 36.3% (161/444) in our study population. In-hospital mortality occurred in 29.8% (48/161) of patients in the PIH group, compared to 15.9% (45/283) of patients in the non-PIH group (p = 0.001). Development of PIH was associated with increased mortality in the emergency department (adjusted odds ratio [AOR] = 3.45, 95% CI 1.42-8.36) and in-hospital (AOR = 1.83, 95% CI 1.01-3.31). CONCLUSIONS In our study of trauma patients requiring ETI, development of PIH was common (36.3%) and associated with increased mortality. Intubation practices in critically ill trauma patients is an important patient safety issue that requires further investigation. LEVEL OF EVIDENCE Level III, Prognostic and Epidemiological.BACKGROUND Postintubation hypotension (PIH) is common and associated with poor outcomes in critically ill patient populations requiring emergency endotracheal intubation (ETI). The importance of PIH in the trauma population remains unclear. The objective of this study was to determine the prevalence of PIH in trauma patients and assess the association of PIH with patient outcomes. METHODS Retrospective case series of adult (≥16 years) patients who were intubated on arrival at a tertiary trauma center in Halifax, Nova Scotia, Canada, between 2000 and 2015. Data were collected from the Nova Scotia Trauma Registry and patient chart, and included demographics, comorbidities, trauma characteristics, intubation time, as well as all fluids, medications, adverse events, interventions, and vital signs during the 15 minutes before/after ETI. We evaluated the prevalence of PIH and created a logistic regression model to determine likelihood of mortality in the PIH and non-PIH groups after controlling for patient and provider characteristics. RESULTS Overall, 477 patients required ETI on assessment by the trauma service, of which 444 patients met eligibility criteria and were included in the analysis. The prevalence of PIH was 36.3% (161 of 444) in our study population. In-hospital mortality occurred in 29.8% (48 of 161) of patients in the PIH group, compared with 15.9% (45 of 283) of patients in the non-PIH group (p = 0.001). Development of PIH was associated with increased mortality in the emergency department (adjusted odds ratio, 3.45; 95% confidence interval, 1.42–8.36) and in-hospital (adjusted odds ratio, 1.83; 95% confidence interval, 1.01–3.31). CONCLUSION In our study of trauma patients requiring ETI, development of PIH was common (36.3%) and associated with increased mortality. Intubation practices in critically ill trauma patients is an important patient safety issue that requires further investigation. LEVEL OF EVIDENCE Prognostic and epidemiological, level III; Level IV, Therapeutic.

Paramedic Recognition of Sepsis in the Prehospital Setting: A Prospective Observational Study

Background. Patients with sepsis benefit from early diagnosis and treatment. Accurate paramedic recognition of sepsis is important to initiate care promptly for patients who arrive by Emergency Medical Services. Methods. Prospective observational study of adult patients (age ≥ 16 years) transported by paramedics to the emergency department (ED) of a Canadian tertiary hospital. Paramedic identification of sepsis was assessed using a novel prehospital sepsis screening tool developed by the study team and compared to blind, independent documentation of ED diagnoses by attending emergency physicians (EPs). Specificity, sensitivity, accuracy, positive and negative predictive value, and likelihood ratios were calculated with 95% confidence intervals. Results. Overall, 629 patients were included in the analysis. Sepsis was identified by paramedics in 170 (27.0%) patients and by EPs in 71 (11.3%) patients. Sensitivity of paramedic sepsis identification compared to EP diagnosis was 73.2% (95% CI 61.4–83.0), while specificity was 78.8% (95% CI 75.2–82.2). The accuracy of paramedic identification of sepsis was 78.2% (492/629, 52 true positive, 440 true negative). Positive and negative predictive values were 30.6% (95% CI 23.8–38.1) and 95.9% (95% CI 93.6–97.5), respectively. Conclusion. Using a novel prehospital sepsis screening tool, paramedic recognition of sepsis had greater specificity than sensitivity with reasonable accuracy.

A traumatic tale of two cities: a comparison of outcomes for adults with major trauma who present to differing trauma centres in neighbouring Canadian provinces

OBJECTIVES While the use of formal trauma teams is widely promoted, the literature is not clear that this structure provides improved outcomes over emergency physician delivered trauma care. The goal of this investigation was to examine if a trauma team model with a formalized, specialty-based trauma team, with specific activation criteria and staff composition, performs differently than an emergency physician delivered model. Our primary outcome was survival to discharge or 30 days. METHODS An observational registry-based study using aggregate data from both the New Brunswick and Nova Scotia trauma registries was performed with data from April 1, 2011 to March 31, 2013. Inclusion criteria included patients 16 years-old and older who had an Injury Severity Score greater than 12, who suffered a kinetic injury and arrived with signs of life to a level-1 trauma centre. RESULTS 266 patients from the trauma team model and 111 from the emergency physician model were compared. No difference was found in the primary outcome of proportion of survival to discharge or 30 days between the two systems (0.88, n=266 vs. 0.89, n=111; p=0.8608). CONCLUSIONS We were unable to detect any difference in survival between a trauma team and an emergency physician delivered model.

Risk factors for adverse outcomes in older adults with blunt chest trauma: A systematic review

OBJECTIVES The objective of this study was to systematically review the published literature for risk factors associated with adverse outcomes in older adults sustaining blunt chest trauma. METHODS EMBASE and MEDLINE were searched from inception until March 2017 for prognostic factors associated with adverse outcomes in older adults sustaining blunt chest trauma using a pre-specified search strategy. References were independently screened for inclusion by two reviewers. Study quality was assessed using the Quality in Prognostic Studies tool. Where appropriate, descriptive statistics were used to evaluate study characteristics and predictors of adverse outcomes. RESULTS Thirteen cohort studies representing 79,313 patients satisfied our selection criteria. Overall, 26 prognostic factors were examined across studies and were reported for morbidity (8 studies), length of stay (7 studies), mortality (6 studies), and loss of independence (1 study). No studies examined patient quality of life or emergency department recidivism. Prognostic factors associated with morbidity and mortality included age, number of rib fractures, and injury severity score. Although age and rib fractures were found to be associated with adverse outcomes in more than 3 studies, meta-analysis was not performed due to heterogeneity amongst included studies in how these variables were measured. CONCLUSIONS While blunt chest wall trauma in older adults is relatively common, the literature on prognostic factors for adverse outcomes in this patient population remains inadequate due to a paucity of high quality studies and lack of consistent reporting standards.

Development of a model to quantify the accessibility of a Canadian trauma system.

OBJECTIVES Trauma systems have been widely implemented across Canada, but access to trauma care remains a challenge for much of the population. This study aims to develop and validate a model to quantify the accessibility of definitive care within one provincial trauma system and identify populations with poor access to trauma care. METHODS A geographic information system (GIS) was used to generate models of pre-scene and post-scene intervals, respectively. Models were validated using a population-based trauma registry containing data on prehospital time intervals and injury locations for Nova Scotia (NS). Validated models were then applied to describe the population-level accessibility of trauma care for the NS population as well as a cohort of patients injured in motor vehicle collisions (MVCs). RESULTS Predicted post-scene intervals were found to be highly correlated with documented post-scene intervals (β 1.05, p<0.001). Using the model, it was found that 88.1% and 42.7% of the population had access to Level III and Level I trauma care within 60 minutes of prehospital time from their residence, respectively. Access for victims of MVCs was lower, with 84.3% and 29.7% of the cohort having access to Level III and Level I trauma care within 60 minutes of the location of injury, respectively. CONCLUSION GIS models can be used to identify populations with poor access to care and inform service planning in Canada. Although only 43% of the provincial population has access to Level I care within 60 minutes, the majority of the population of NS has access to Level III trauma care.

Resuscitation Prior to Emergency Endotracheal Intubation: Results of a National Survey

Introduction Respiratory failure is a common problem in emergency medicine (EM) and critical care medicine (CCM). However, little is known about the resuscitation of critically ill patients prior to emergency endotracheal intubation (EETI). Our aim was to describe the resuscitation practices of EM and CCM physicians prior to EETI. Methods A cross-sectional survey was developed and tested for content validity and retest reliability by members of the Canadian Critical Care Trials Group. The questionnaire was distributed to all EM and CCM physician members of three national organizations. Using three clinical scenarios (trauma, pneumonia, congestive heart failure), we assessed physician preferences for use and types of fluid and vasopressor medication in pre-EETI resuscitation of critically ill patients. Results In total, 1,758 physicians were surveyed (response rate 50.2%, 882/1,758). Overall, physicians would perform pre-EETI resuscitation using either fluids or vasopressors in 54% (1,193/2,203) of cases. Most physicians would “always/often” administer intravenous fluid pre-EETI in the three clinical scenarios (81%, 1,484/1,830). Crystalloids were the most common fluid physicians would “always/often” administer in congestive heart failure (EM 43%; CCM 44%), pneumonia (EM 97%; CCM 95%) and trauma (EM 96%; CCM 96%). Pre-EETI resuscitation using vasopressors was uncommon (4.9%). Training in CCM was associated with performing pre-EETI resuscitation (odds ratio, 2.20; 95% CI, [1.44–3.36], p<0.001). Conclusion Pre-EETI resuscitation is common among Canadian EM and CCM physicians. Most physicians use crystalloids pre-EETI as a resuscitation fluid, while few would give vasopressors. Physicians with CCM training were more likely to perform pre-EETI resuscitation.

Hemoglobin thresholds and red blood cell transfusion in adult patients with moderate or severe traumatic brain injuries: A retrospective cohort study.

Purpose: We aimed to evaluate the association between transfusion practices and clinical outcomes in patients with traumatic brain injury. Material and methods: We conducted a retrospective cohort study of adult patients with moderate or severe traumatic brain injury admitted to the intensive care unit (ICU) of a level I trauma center between 2009 and 2013. The associations between hemoglobin (Hb) level, red blood cell (RBC) transfusion and clinical outcomes were estimated using robust Poisson models and proportional hazard models with time‐dependent variables, adjusted for confounders. Results: We included 215 patients. Sixty‐six patients (30.7%) were transfused during ICU stay. The median pre‐transfusion Hb among transfused patients was 81 g/L (IQR 67–100), while median nadir Hb among non‐transfused patients was 110 g/L (IQR 93–123). Poor outcomes were significantly more frequent in patients who were transfused (mortality risk ratio [RR]: 2.15 [95% CI 1.37–3.38] and hazard ratio: 3.06 [95% CI 1.57–5.97]; neurological complications RR: 3.40 [95% CI 1.35–8.56]; trauma complications RR: 1.65 [95% CI 1.31–2.08]; ICU length of stay geometric mean ratio: 1.42 [95% CI 1.06–1.92]). Conclusions: During ICU stay, transfused patients tended to have lower Hb levels and worse outcomes than patients who did not receive RBCs, after adjustment for confounders. HIGHLIGHTSOne third of ICU patients with TBI receive a RBC transfusion.TBI patients that are transfused in the ICU have lower Hb levels over their ICU stay.RBC seems associated with unfavourable outcomes in TBI patients.

A traumatic tale of two cities: does EMS level of care and transportation model affect survival in patients with trauma at level 1 trauma centres in two neighbouring Canadian provinces?

Background Two distinct Emergency Medical Services (EMS) systems exist in Atlantic Canada. Nova Scotia operates an Advanced Emergency Medical System (AEMS) and New Brunswick operates a Basic Emergency Medical System (BEMS). We sought to determine if survival rates differed between the two systems. Methods This study examined patients with trauma who were transported directly to a level 1 trauma centre in New Brunswick or Nova Scotia between 1 April 2011 and 31 March 2013. Data were extracted from the respective provincial trauma registries; the lowest common Injury Severity Score (ISS) collected by both registries was ISS≥13. Survival to hospital and survival to discharge or 30 days were the primary endpoints. A separate analysis was performed on severely injured patients. Hypothesis testing was conducted using Fisher’s exact test and the Student’s t-test. Results 101 cases met inclusion criteria in New Brunswick and were compared with 251 cases in Nova Scotia. Overall mortality was low with 93% of patients surviving to hospital and 80% of patients surviving to discharge or 30 days. There was no difference in survival to hospital between the AEMS (232/251, 92%) and BEMS (97/101, 96%; OR 1.98, 95% CI 0.66 to 5.99; p=0.34) groups. Furthermore, when comparing patients with more severe injuries (ISS>24) there was no significant difference in survival (71/80, 89% vs 31/33, 94%; OR 1.96, 95% CI 0.40 to 9.63; p=0.50). Conclusion Overall survival to hospital was the same between advanced and basic Canadian EMS systems. As numbers included are low, individual case benefit cannot be excluded.

Organ donation by patients with and without trauma in a Canadian province: a retrospective cohort analysis

BACKGROUND People who experience trauma represent a large pool of potential organ donors. Our objective was to describe organ donation by patients with and without trauma in Nova Scotia. METHODS We performed a retrospective cohort study of all patients with trauma in the Nova Scotia Trauma Registry who were injured between Apr. 1, 2009, and Mar. 31, 2016, and died in hospital, as well as all potential organ donors captured in the Nova Scotia Legacy of Life Donor Registry over the same period. We compared characteristics of the 2 groups with respect to organ donation and identified reasons for nondonation. RESULTS Overall, 940 patients were included in the analysis, of whom 689 (73.3%) had experienced trauma. Patients with trauma accounted for 37.2% (48/129) of donors. A total of 274 (39.8%) of the patients with trauma were identified as potential organ donors, and 48 (7.0%) donated organs. Only 108 (39.4%) of the 274 were referred to the Legacy of Life Program. The conversion rate (proportion of potential donors who went on to donate an organ) was 84.2% (48/57) among patients with trauma and 83.5% (81/97) among those without trauma. Donation after circulatory death occurred in 8 patients (17%) with trauma and 13 (16%) of those without trauma. Family refusal (28/60 [47%]) and medical unsuitability (16/60 [27%]) were the most common reasons for nondonation among patients with trauma. INTERPRETATION In Nova Scotia, 40% of patients with trauma who died in hospital were potential organ donors, yet only 39% of these patients were referred for donation. More work is required to improve organ donation within the trauma population.