Samuel M. Galvagno

Association Between Helicopter vs Ground Emergency Medical Services and Survival for Adults With Major Trauma

CONTEXT Helicopter emergency medical services and their possible effect on outcomes for traumatically injured patients remain a subject of debate. Because helicopter services are a limited and expensive resource, a methodologically rigorous investigation of its effectiveness compared with ground emergency medical services is warranted. OBJECTIVE To assess the association between the use of helicopter vs ground services and survival among adults with serious traumatic injuries. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study involving 223,475 patients older than 15 years, having an injury severity score higher than 15, and sustaining blunt or penetrating trauma that required transport to US level I or II trauma centers and whose data were recorded in the 2007-2009 versions of the American College of Surgeons National Trauma Data Bank. INTERVENTIONS Transport by helicopter or ground emergency services to level I or level II trauma centers. MAIN OUTCOME MEASURES Survival to hospital discharge and discharge disposition. RESULTS A total of 61,909 patients were transported by helicopter and 161,566 patients were transported by ground. Overall, 7813 patients (12.6%) transported by helicopter died compared with 17,775 patients (11%) transported by ground services. Before propensity score matching, patients transported by helicopter to level I and level II trauma centers had higher Injury Severity Scores. In the propensity score-matched multivariable regression model, for patients transported to level I trauma centers, helicopter transport was associated with an improved odds of survival compared with ground transport (odds ratio [OR], 1.16; 95% CI, 1.14-1.17; P < .001; absolute risk reduction [ARR], 1.5%). For patients transported to level II trauma centers, helicopter transport was associated with an improved odds of survival (OR, 1.15; 95% CI, 1.13-1.17; P < .001; ARR, 1.4%). A greater proportion (18.2%) of those transported to level I trauma centers by helicopter were discharged to rehabilitation compared with 12.7% transported by ground services (P < .001), and 9.3% transported by helicopter were discharged to intermediate facilities compared with 6.5% by ground services (P < .001). Fewer patients transported by helicopter left level II trauma centers against medical advice (0.5% vs 1.0%, P < .001). CONCLUSION Among patients with major trauma admitted to level I or level II trauma centers, transport by helicopter compared with ground services was associated with improved survival to hospital discharge after controlling for multiple known confounders.

The role of perioperative high inspired oxygen therapy in reducing surgical site infection: a meta-analysis.

BACKGROUND: The clinical role of hyperoxia for preventing surgical site infection remains uncertain because randomized controlled trials on this topic have reported disparate results. Our objective in this systematic review was to determine whether perioperative hyperoxia reduces surgical site infection. METHODS: An electronic search was conducted using the National Library of Medicines MEDLINE, Cochrane Collaborations CENTRAL, and EMBASE databases. Included studies consisted of randomized controlled trials in an adult population with a clearly defined comparison of high oxygen versus low oxygen or control, and with a documented assessment for perioperative infection. Pooled estimates for odds ratios (ORs) with 95% confidence intervals were obtained for our primary outcome (surgical site infection) using the Cochrane Collaborations RevMan version 5.0.25 (Cochrane Collaboration, Oxford, UK). ORs were calculated using a random effects model. RESULTS: The literature search ultimately yielded 7 trials, enrolling 2728 patients, that were included in the analysis. There were 1358 patients randomly assigned to hyperoxia and 1370 to control. The pooled infection rate in the hyperoxia group was 15.5% versus 17.5% in the control group. Hyperoxia resulted in an OR of 0.85 for surgical site infection (95% confidence interval: 0.52, 1.38) (P = 0.51). However, 2 subgroup analyses (general anesthesia and colorectal surgery trials) showed a benefit for high inspired oxygen therapy of decreasing surgical site infection. CONCLUSIONS: Perioperative high inspired oxygen therapy overall was not found to be beneficial for preventing surgical site infection based on this meta-analysis. The positive results of 2 subgroup analyses (general anesthesia and colorectal surgery trials) suggest a benefit for hyperoxia in decreasing surgical site infection. Additional studies are needed to further investigate this intervention.

Critical care considerations in the management of the trauma patient following initial resuscitation

BackgroundCare of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented.MethodsA non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012.Results and conclusionPolytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients.

Occipital Nerve Pulsed Radiofrequency Treatment: A Multi-Center Study Evaluating Predictors of Outcome

OBJECTIVE Occipital neuralgia (ON) is a challenging condition for which there is no reference standard for treatment. The purpose of this study was to provide outcome data on the largest study to date evaluating pulsed radiofrequency (PRF) for ON and to determine whether any demographic, clinical, or treatment characteristics are associated with success. DESIGN   Retrospective data analysis was conducted in 102 subjects evaluating the effect of myriad factors on treatment success. SETTING This study was conducted in academic civilian and military pain treatment centers. PATIENTS One hundred and two consecutive patients with a primary diagnosis of ON were treated with PRF of the greater and/or lesser occipital nerve. OUTCOME MEASURES A positive primary outcome was predefined as ≥50% pain relief lasting at least 3 months. The secondary outcome measure was procedural satisfaction. RESULTS Fifty-two (51%) patients experienced ≥50% pain relief and satisfaction with treatment lasting at least 3 months. Variables associated with a positive outcome included a traumatic inciting event (65.7% success rate; P=0.03), lower diagnostic block volumes (odds ratio [OR]: 0.72; 95% confidence interval [CI]: 0.62-0.82; P<0.0001), and employment of multiple rounds of PRF (OR: 2.95; 95% CI: 1.77-4.92; P<0.0001). Factors correlating with treatment failure included extension of pain anterior to the scalp apex (OR: 0.32; 95% CI: 0.14-0.73; P=0.006) and ongoing secondary gain issues (OR: 0.19; 95% CI: 0.11-0.33; P<0.0001). CONCLUSION PRF may provide intermediate-term benefit in ON to a significant proportion of refractory cases. Careful attention to selection criteria and treatment parameters may further improve treatment outcomes.

Headaches during war: Analysis of presentation, treatment, and factors associated with outcome

Background: Headache is often associated with physical trauma and psychological stress. The aim of this study is to evaluate the impact of headache on personnel deployed in war zones and to identify factors associated with return to duty (RTD). Methods: Outcome data were prospectively collected on 985 personnel medically evacuated out of Operations Iraqi and Enduring Freedom for a primary diagnosis of headache between 2004 and 2009. Electronic medical records were reviewed to examine clinical and treatment patterns and the effect that myriad factors had on RTD. Results: 33.6% of evacuees returned to duty. The most common headaches were post-concussion (34.1%) and migraine (30.0%). Headaches typically associated with trauma such as post-concussion (18.7%), occipital neuralgia (23.1%), and cervicogenic headache (29.7%) had the lowest RTD rates, whereas tension headache (49.6%) was associated with the best outcome. Other variables associated with negative outcome included presence of aura (OR 0.51, 95% CI 0.30–0.88; p = 0.02), traumatic brain injury (OR 0.50, 95% CI 0.29–0.87; p = 0.01), opioid (OR 0.41, 95% CI 0.26–0.63; p < 0.001), and beta-blocker (OR 0.26, 95% CI 0.12–0.61; p = 0.002) use, and co-existing psychopathology (p < 0.001 in univariable analysis). Conclusion: Headaches represent a significant cause of unit attrition in personnel deployed in military operations, with physical trauma and co-existing psychopathology associated with poorer outcomes.

Withholding and termination of resuscitation of adult cardiopulmonary arrest secondary to trauma: resource document to the joint NAEMSP-ACSCOT position statements.

ABSTRACT In the setting of traumatic cardiopulmonary arrest, protocols that direct emergency medical service (EMS) providers to withhold or terminate resuscitation, when clinically indicated, have the potential to decrease unnecessary use of warning lights and sirens and save valuable public health resources. Protocols to withhold resuscitation should be based on the determination that there are no obvious signs of life, the injuries are obviously incompatible with life, there is evidence of prolonged arrest, and there is a lack of organized electrocardiographic activity. Termination of resuscitation is indicated when there are no signs of life and no return of spontaneous circulation despite appropriate field EMS treatment that includes minimally interrupted cardiopulmonary resuscitation. Further research is needed to determine the appropriate duration of cardiopulmonary resuscitation before termination of resuscitation and the proper role of direct medical oversight in termination of resuscitation protocols. This article is the resource document to the position statements, jointly endorsed by the National Association of EMS Physicians and the American College of Surgeons’ Committee on Trauma, on withholding and termination of resuscitation in traumatic cardiopulmonary arrest.

Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society

INTRODUCTION Thoracic trauma is the second most prevalent nonintentional injury in the United States and is associated with significant morbidity. Analgesia for blunt thoracic trauma was first addressed by the Eastern Association for the Surgery of Trauma (EAST) with a practice management guideline published in 2005. Since that time, it was hypothesized that there have been advances in the analgesic management for blunt thoracic trauma. As a result, updated guidelines for this topic using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework recently adopted by EAST are presented. METHODS Five systematic reviews were conducted using multiple databases. The search retrieved articles regarding analgesia for blunt thoracic trauma from January1967 to August 2015. Critical outcomes of interest were analgesia, postoperative pulmonary complications, changes in pulmonary function tests, need for endotracheal intubation, and mortality. Important outcomes of interest examined included hospital and intensive care unit length of stay. RESULTS Seventy articles were identified. Of these, 28 articles were selected to construct the guidelines. The overall risk of bias for all studies was high. The majority of included studies examined epidural analgesia. Epidural analgesia was associated with lower short-term pain scores in most studies, but the quality and quantity of evidence were very low, and no firm evidence of benefit or harm was found when this modality was compared with other analgesic interventions. The quality of evidence for paravertebral block, intrapleural analgesia, multimodal analgesia, and intercostal nerve blocks was very low as assessed by GRADE. The limitations with the available literature precluded the formulation of strong recommendations by our panel. CONCLUSION We propose two evidence-based recommendations regarding analgesia for patients with blunt thoracic trauma. The overall risk of bias for all studies was high. The limitations with the available literature precluded the formulation of strong recommendations by our panel. We conditionally recommend epidural analgesia and multimodal analgesia as options for patients with blunt thoracic trauma, but the overall quality of evidence supporting these modalities is low in trauma patients. These recommendations are based on very low-quality evidence but place a high value on patient preferences for analgesia. These recommendations are in contradistinction to the previously published Practice Management Guideline published by EAST.

Continuous noninvasive respiratory volume monitoring for the identification of patients at risk for opioid-induced respiratory depression and obstructive breathing patterns.

BACKGROUND Opioid-induced respiratory depression (OIRD) and postoperative apnea (POA) can lead to complications after surgery or traumatic injury. Previously, real-time monitoring of respiratory insufficiency and identification of apneic events have been difficult. A noninvasive respiratory volume monitor (RVM) that reports minute ventilation (MV), tidal volume, and respiratory rate is now available. The RVM was used to report the effect of opioids on respiratory status as well as demonstrate apneic breathing patterns in a hospital postanesthesia care unit. METHODS RVM traces were collected from 132 patients. Predicted MV (MVPRED) for each patient was used to calculate and the “percent predicted” MV (MVMEASURED / MVPRED × 100%) before opioid administration. Patients were stratified patients into two categories: “at risk,” MV of less than 80% MVPRED, and “not at risk,” MV of 80% MVPRED or greater. After opioid dosing, patients with MV of less than 40% MVPRED were categorized as “unsafe.” POA was defined as more than five apneic or hypopneic events per hour. RESULTS Of the 132 patients, 50 received opioids. Baseline MV was 7.2 ± 0.5 L/min. The MV-based protocol classified 18 of 50 patients as at risk before opioid administration. After the first opioid dose administration, at-risk patients experienced an average MV decrease (36.7% ± 8.5% MVPRED) and 13 of 18 decreased into unsafe; the 32 not at-risk patients experienced a lesser average MV decrease (76.9% ± 6.3% MVPRED). Only 1 of 32 not at-risk patients had a decrease in MV to unsafe. The proposed protocol had a sensitivity of 93% and a specificity of 86%. Of the 132 patients, 26 displayed POA. Of the 26 patients, 12 experienced POA without receiving opioids. Of the 26 patients with POA, 14 also received opioids, and of those, 6 were classified as unsafe. CONCLUSION This investigation indicates that at risk and unsafe respiratory patterns occur frequently after procedure. RVM provides continuous noninvasive objective measurements of OIRD and POA. The RVM may prove a useful tool in opioid dosing and in recognition and management of POA and strong potential value in the rapid detection of OIRD and apnea in the contemporary combat casualty environment. LEVEL OF EVIDENCE Care management study, level V.

Increased mortality associated with EMS transport of gunshot wound victims when compared to private vehicle transport

BACKGROUND Recent studies suggest that mode of transport affects survival in penetrating trauma patients. We hypothesised that there is wide variation in transport mode for patients with gunshot wounds (GSW) and there may be a mortality difference for GSW patients transported by emergency medical services (EMS) vs. private vehicle (PV). STUDY DESIGN We studied adult (≥16 years) GSW patients in the National Trauma Data Bank (2007-2010). Level 1 and 2 trauma centres (TC) receiving ≥50 GSW patients per year were included. Proportions of patients arriving by each transport mode for each TC were examined. In-hospital mortality was compared between the two groups, PV and EMS, using multivariable regression analyses. Models were adjusted for patient demographics, injury severity, and were adjusted for clustering by facility. RESULTS 74,187 GSW patients were treated at 182 TCs. The majority (76%) were transported by EMS while 12.6% were transported by PV. By individual TC, the proportion of patients transported by each category varied widely: EMS (median 78%, interquartile range (IQR) 66-85%), PV (median 11%, IQR 7-17%), or others (median 7%, IQR 2-18%). Unadjusted mortality was significantly different between PV and EMS (2.1% vs. 9.7%, p<0.001). Multivariable analysis demonstrated that EMS transported patients had a greater than twofold odds of dying when compared to PV (OR=2.0, 95% CI 1.73-2.35). CONCLUSIONS Wide variation exists in transport mode for GSW patients across the United States. Mortality may be higher for GSW patients transported by EMS when compared to private vehicle transport. Further studies should be performed to examine this question.

A multicenter, randomized, controlled study evaluating preventive etanercept on postoperative pain after inguinal hernia repair.

BACKGROUND:Chronic postsurgical pain (CPSP) affects between 5% and 70% of surgical patients, depending on the surgery. There is no reliable treatment for CPSP, which has led to an increased emphasis on prevention. In this study, we sought to determine whether preventive etanercept can decrease the magnitude of postoperative pain and reduce the incidence of CPSP. METHODS:We performed a multicenter, randomized study in 77 patients comparing subcutaneous etanercept 50 mg administered 90 minutes before inguinal hernia surgery with saline. Patients, surgeons, anesthesiologists, the injecting physician, nursing staff, and evaluators were blinded. The primary outcome measure was a 24-hour numerical rating scale pain score. Secondary outcome measures were postanesthesia care unit pain scores, 24-hour opioid requirements, time to first analgesic, and pain scores recorded at 1 month, 3 months, 6 months, and 12 months. RESULTS:Mean 24-hour pain scores were 3.3 (95% confidence interval [CI], 3.2–4.6) in the etanercept and 3.9 (95% CI, 2.6–4.0) in the control group (P = 0.22). The mean number of analgesic pills used in the first 24 hours was 4.0 (SD, 2.8) in the treatment versus 5.8 (SD, 4.2) in the control group (P = 0.03). At 1 month, 10 patients (29%) in the treatment group reported pain versus 21 (49%) control patients (P = 0.08). The presence of pain at 1 month was significantly associated with pain at 3 months (hazard ratio, 0.74; 99% CI, 0.52–0.97; P = 0.03). CONCLUSION:Although preventive etanercept was superior to saline in reducing postoperative pain on some measures, the effect sizes were small, transient, and not statistically significant. Different dosing regimens in a larger population should be explored in future studies.