Sander P. G. Frankema

Beneficial effect of helicopter emergency medical services on survival of severely injured patients.

In Rotterdam, the Netherlands, a helicopter‐transported medical team (HMT), staffed with a trauma physician, provides additional therapeutic options at the scene of injury. This study evaluated the influence of the HMT on the chance of survival of severely injured trauma victims.

Routine cervical spine radiography for trauma victims: Does everybody need it?

OBJECTIVE The purpose of this study was to evaluate the indication for routine cervical spine radiography in trauma patients. METHODS Prospective analysis of radiologic and clinical findings was performed during a 5-year period. Patients suitable for a clinical decision rule were reviewed separately. RESULTS Of the 1,757 consecutive patients included in the study, 38 were diagnosed with a cervical spine injury. Of the 599 patients suitable for the clinical decision rule, 62 had midline cervical tenderness, including 2 with cervical spine injury. No additional cervical spine injuries were found during follow-up. CONCLUSION It is within good practice, and it is also cost-effective, to obtain a cervical spine radiograph only on clinical parameters in trauma patients with no apparent bodily trauma and optimal parameters. With this clinical decision rule, 30.6% of all cervical spine series were redundant, and no (occult) spinal fractures would have been undetected.

Efficiency of a Standardized Diagnostic Protocol in Trauma Management

Background: The objective of this study was to evaluate the efficiency of a radiologic trauma protocol which was implemented to ensure swift and accurate diagnosis, reduce unnecessary hospitalization and detect parameters that will efficiently predict surgical findings.Patients and Methods: 1,757 patients were included in this prospective study which was carried out over a 5-year period. All parameters, mechanisms of trauma and radiologic findings were recorded. Results: A total of 472 patients could be discharged the same day. Positive findings in all radiologic modalities ranged between 3.9% and 50% when grouped by trauma scores. Conclusions: Implementation of our protocol resulted in a reduced number of patients admitted for clinical observation. A nontrivial number of positive findings was detected in all separate RTS (Revised Trauma Score) GCS (Glasgow Coma Scale) and trauma mechanism groups, with an increase in positive findings for groups specified by deteriorating trauma scores. Due to the unreliability of physical examination, especially in nonresponsive patients, radiologic work-up remains an important tool in the assessment of trauma patients.

Predicting Survival after Trauma: a Comparison of TRISS and ASCOT in the Netherlands

AbstractBackground: Evaluating the performance of a trauma system may be attempted by comparing outcome in different trauma populations. Controlling for injury severity is a necessity for such evaluations. We compare two current models for doing so: the “Trauma and Injury Severity Score” (TRISS) and “A Severity Characterization Of Trauma” (ASCOT). Material and Methods: This study of high-energy trauma victims took place in Leiden, the Netherlands, between 1993 and 1998. Using the Hosmer-Lemeshow (HL) test and receiver operator characteristic (ROC) analysis, the TRISS and ASCOT models were compared for calibration and discrimination. Results: 1,024 patients, with an average Injury Severity Score (ISS) of 13.5, were eligible for inclusion. Blunt trauma was the predominant cause of injuries. Both models gave accurate, though pessimistic, results in predicting the actual number of fatalities (n = 71). The HL test indicated a sufficient fit for the ASCOT model (p = 0.28) and an insufficient fit (p = 0.02) for TRISS. The ROC curves were nearly identical (0.97). Including age as a linear variable, instead of using the current age groups, resulted in an improved discriminative power of the models. Conclusions: The ASCOT model proved superior over TRISS in its accuracy to estimate of survival chances. This difference was most evident for victims with an estimated survival chance of 60–90%. Future national trauma researchers should therefore collect ASCOT data. Improved ASCOT models could be developed, with age as a linear variable.

Plain radiography in patients treated with intrathecal drug delivery using an implantable pump device

AbstractObjectivesIntrathecal drug administration using an implanted pump system is well established in intractable spasticity and pain. However, despite continuous advancements in manufacturing technology, adverse events related to the pump and catheter still occur. Most of them, such as migration, damage, disconnection and occlusion, are related to the spinal catheter. The aim of this overview is to update radiologists on how plain radiography of the implanted delivery system for intrathecal drug administration should be interpreted and to increase awareness for the need of urgent and timely multidisciplinary troubleshooting.MethodsPlain radiographic images of patients treated with intrathecal drug administration using an implantable drug delivery system were analysed in a multidisciplinary setting at our (university) referral centre for complications in intrathecal drug administration.ResultsExamples of catheter-related adverse events are described and a proposal is made for stepwise interpretation of standard plain radiographic images.ConclusionsPlain radiological images are the mainstay for the diagnosis of catheter-related adverse events in intrathecal drug delivery. Radiologists play an important role in an early diagnosis. An awareness of abnormal radiological findings seems important to avoid a life-threatening withdrawal syndrome.Teaching points• Untimely cessation of intrathecal drug delivery can lead to a life-threatening withdrawal syndrome. • Initially mild symptoms can lead to an exacerbation of a withdrawal syndrome. • Most intrathecal catheter-related problems are visible on plain radiography. • Common causes of catheter problems are migration, lacerations, occlusion and disconnection. • Knowledge on implanted intrathecal catheters is crucial for interpretation of plain radiography.

Quantifying the Quality of Extra- and Intramural Trauma Care on an Individual Basis

AbstractBackground: The objective of this study was to identify the variables needed for an alternative method by which the quality of care for trauma patients can be quantified. Patients and Methods: A prospective analysis of the clinical parameters and interventions was performed for the extramural as well as the intramural scene. Based on the information available after completion of the primary survey, the interventions needed were identified by a multidisciplinary forum made up of internal and external observers. These interventions were compared with the treatment, which was actuallc performed. We evaluated the reproducibility of the decisions made by the forum by means of a variability analysis. Results: During the review period, 275 patients were evaluated. An Injury Severity Score (ISS) ≥ 18 was recorded in 41 cases. 69 ABC stabilizing interventions were identified by the forum of the injury scene, 32 of which were not performed by the personnel of the emergency medical service (EMS). 91 in-hospital ABC stabilizing interventions were indicated, 22 of which were not performed by the emergency room (ER) personnel. Twelve patients succumbed within the 1st month. Conclusions: The pilot study confirms the feasibility of using a forum to identify the interventions prescribed by protocol for each individual patient. Forum-based case-to-case evaluation will be used as a surveillance tool to evaluate the adequacy of interventions and to quantify the quality of trauma care.