CLINICAL PRACTICESecondary insults during intrahospital transport of head-injured patients
Abstract
Secondary pathophysiological insults occurring after injury have been prospectively assessed in 50 head-injured patients who required intrahospital transfer. 35 patients were transported from the intensive care unit (ICU) and 15 from the accident and emergency department. Physiological variables were recorded every minute in the four hours before transfer (ICU group only), during the move, and for four hours afterwards. Pretransfer insults were predictive of further insults during and after transport. There was significant correlation between increased frequency of insults post-transfer (compared with pretransfer) and high injury severity score. A greater proportion of the patients transported from the emergency department had secondary injuries post-transfer. Adequate resuscitation before moving the patient, especially in patients with multiple injury, is important.
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Cited by (222)
The Effect of the Eastern Association for the Surgery of Trauma Guideline on Spinal Magnetic Resonance Imaging Use in Obtunded Adult Blunt Trauma Patients Over Time
2022, Journal of Surgical ResearchEvidence-based guidelines suggest computed tomography without magnetic resonance imaging (MRI) is sufficient to rule out clinically significant cervical spine injury in obtunded adult blunt trauma patients. This study evaluated MRI utilization over time to investigate the impact of the 2015 Eastern Association for the Surgery of Trauma guidelines suggesting cervical collar clearance with computed tomography alone in this population. We hypothesized that MRI utilization would decrease following the guidelines.
We performed a retrospective cross-sectional study of the National Trauma Data Bank from 2007 to 2018 using multivariable logistic regression of the likelihood of spinal MRI utilization. Blunt trauma patients 18 y and older with a Glasgow Coma Scale (GCS) of 8 or less, Abbreviated Injury Score head of 4 or greater, intubated for at least 72 h were included.
The sample consisted of 76,450 patients from 567 trauma centers. Controlling for age, gender, race/ethnicity, insurance status, injury mechanism, Injury Severity Score, GCS, GCS motor, hospital teaching status and trauma center level, patients seen after 2015 had a higher odds ratio (OR) of undergoing spinal MRI relative to those seen before 2015 (OR 1.77, 95% CI 1.49-2.09; P < 0.001). Each year was associated with a significantly increased OR of undergoing spinal MRI compared to the year prior (OR 1.10, 95% CI 1.05-1.15; P < 0.001).
Spinal MRI use has been increasing in obtunded adult blunt trauma patients including after the release of the Eastern Association for the Surgery of Trauma guidelines in 2015. Future work should identify whether this is driven by improper MRI utilization and, if so, strategies to promote guideline adherence.
Risk prediction using the National Early Warning Score and the Worthing Physiological Scoring System in patients who were transported to the Intensive Care Unit from the Emergency Department: A cohort study
2021, Intensive and Critical Care NursingThe aim of this study was to assess the value of the National Early Warning Score and Worthing Physiological Scoring System for predicting changes in the condition of critical cases during transfer from the emergency department to the intensive care unit.
This prospective single-centre study was conducted at a 1759-bed hospital in Beijing. We recorded the vital signs in the cases before leaving the emergency department and their changes in condition during transit.
A total of 258 critically ill cases were included. Forty-four cases (17.05%) exhibited changes in their condition during transit. Compared with cases with NEWS ≤ 5, cases with NEWS > 5 were more likely to experience changes with an OR of 5.744 (95% CI 2.888–11.426). Compared with cases with WPS ≤ 2, cases with WPS > 2 were more likely to experience changes with an OR of 7.217 (95% CI 3.575–14.569). The difference between the areas under the curve of the NEWS (0.751 ± 0.045) and the WPS (0.736 ± 0.045) was not statistically significant (P = 0.4518).
In our study, the Worthing Physiological Scoring System and National Early Warning Score both exhibited good discriminatory power, but the Worthing Physiological Scoring System is simpler to use and more suitable for use in a busy emergency department.
Better With Ultrasound: Transcranial Doppler
2020, ChestTranscranial Doppler (TCD) ultrasound is a noninvasive method of obtaining bedside neurologic information that can supplement the physical examination. In critical care, this can be of particular value in patients who are unconscious with an equivocal neurologic examination because TCD findings can help the physician in decisions related to more definitive imaging studies and potential clinical interventions. Although TCD is traditionally the domain of sonographers and radiologists, there is increasing adoption of goal-directed TCD at the bedside in the critical care environment. The value of this approach includes round-the-clock availability and a goal-directed approach allowing for repeatability, immediate interpretation, and quick clinical integration. This paper presents a systematic approach to incorporating the highest yield TCD techniques into critical care bedside practice, and includes a series of illustrative figures and narrated video presentations to demonstrate the techniques described.
Incorporation of Transcranial Doppler into the ED for the neurocritical care patient
2019, American Journal of Emergency MedicineIn the catastrophic neurologic emergency, a complete neurological exam is not always possible or feasible given the time-sensitive nature of the underlying disease process, or if emergent airway management is indicated. As the neurologic exam may be limited in some patients, the emergency physician is reliant on the assessment of brainstem structures to determine neurological function. Physicians thus routinely depend on advanced imaging modalities to further investigate for potential catastrophic diagnoses. Acquiring these tests introduces the risks of transport as well as delays in managing time-sensitive neurologic processes. A more immediate, non-invasive bedside approach complementing these modalities has evolved: Transcranial Doppler (TCD).
This narrative review will provide a description of scenarios in which TCD may be applicable. It will summarize the sonographic findings and associated underlying pathophysiology in such neurocritical care patients. An illustrated tutorial, along with pearls and pitfalls, is provided.
Although there are numerous formalized TCD protocols utilizing four views (transtemporal, submandibular, suboccipital, and transorbital), point-of-care TCD is best accomplished through the transtemporal window. The core applications include the evaluation of midline shift, vasospasm after subarachnoid hemorrhage, acute ischemic stroke, and elevated intracranial pressure. An illustrative tutorial is provided.
With the wide dissemination of bedside ultrasound within the emergency department, there is a unique opportunity for the emergency physician to utilize TCD for a variety of conditions. While barriers to training exist, emergency physician performance of limited point-of-care TCD is feasible and may provide rapid and reliable clinical information with high temporal resolution.
How do i safely transport the critically ill patient?
2019, Evidence-Based Practice of Critical CareCritical care transport is a high-risk but worthwhile activity, but the benefits of transport need to be weighed against the considerable risks of the transport process. The risk can be minimized by appropriate planning, proper equipment, and appropriate staffing, along with pretransport stabilization of the patient. Critical care transport is best undertaken by experienced specialist transport teams wherever possible. This is especially true for pediatric critical care transports. The rate of critical adverse events is 4–17.1% for interhospital critical care transports. Many of these are avoidable. Common events include a reduction in PaO2/FiO2 ratio, pneumothorax, ventilator-associated pneumonia, and atelectasis, whereas more serious events include loss of airway, prolonged hypotension, and cardiac arrest. It is difficult to draw firm conclusions regarding the attributable mortality and morbidity associated with transport of critically ill patients. Some, but not all, observational series have reported improved mortality for helicopter transfers compared with ground transportation for interhospital and prehospital transport. This may be related to the greater expertise of HEMS crews. The presence of a physician on a prehospital critical care team may be associated with improved survival, and mortality is reduced in severely injured trauma patients transferred directly to a level 1 trauma center. Prehospital tracheal intubation is a complex intervention and its value is probably related to many factors, including the skill of the provider, patient population, access to drugs to facilitate the intervention, and other aspects of the prehospital care system.
Organisation of care and initial management of severe head injury in Spain: Results of a national survey
2017, NeurocirugiaEl objetivo fundamental del estudio es conocer la organización de la asistencia al traumatismo craneoencefálico grave así como el manejo inicial de estos pacientes en los servicios de neurocirugía de España.
Se diseñó un cuestionario de 22 preguntas que fue enviado a los 59 servicios de neurocirugía identificados. El objeto del cuestionario era conocer el perfil general de los pacientes con un trauma craneoencefálico grave, las características generales de los hospitales, la atención inicial de dichos pacientes, las técnicas de monitorización empleadas y las medidas encaminadas a bajar la PIC.
De los 59 servicios de neurocirugía identificados, 29 (49,2%) respondieron a la encuesta. Existía una amplia variabilidad en el número de pacientes atendidos al año entre los distintos servicios. La dirección de la asistencia recaía a menudo (58,6%) sobre el intensivista. Muchos (69%) de los servicios no disponían de neurocirujano con especial dedicación al manejo y seguimiento de estos pacientes. La atención en la puerta de urgencias recae de forma habitual (51,7%) sobre el médico generalista de urgencias. La disponibilidad de TAC era unánime. La utilización de la telemedicina era muy variable. La monitorización de la PIC se realizaba en más del 75% de los pacientes en la mayoría (89,7%) de servicios, pero existía poca implantación de otras técnicas de monitorización. Las medidas para el control de la PIC se realizaban de forma mayoritaria siguiendo las recomendaciones de las guías de práctica clínica de la BTF.
La organización y manejo del traumatismo craneoencefálico grave en nuestro país es muy similar al de los países de nuestro entorno. Se observan, sin embargo, deficiencias tales como la escasa participación del neurocirujano en el manejo global inicial de estos pacientes, la utilización insuficiente de la telemedicina y la baja implantación de ciertas técnicas de monitorización cerebral (SjO2, ptiO2 y doppler).
The main objective of the study is to obtain knowledge about the organisation of care for severe head trauma as well as the initial management of these patients in Neurosurgical Departments in Spain.
A 22-item questionnaire was designed and sent to 59 Neurosurgical Departments. The aim of the questionnaire was to collect data regarding the general profile of the patients with a severe head injury, the general characteristics of the hospitals, the initial care of these patients, the monitoring techniques used, and the measures used to control Intracranial pressure (ICP).
Of the 59 Neurosurgical Departments identified, 29 (49.2%) completed the questionnaire. There was a wide variability in the number of patients treated per year between the different departments. The leadership of care often fell (58.6%) on the intensive care specialist. Many (69%) of the departments did not have a neurosurgeon specially dedicated to the management and monitoring of these patients. The initial care in the Emergency department usually fell (51.7%) on the general medicine practitioner. The availability of computed tomography (CT) was universal. The use of telemedicine was highly variable. ICP monitoring was performed on more than 75% of patients in most (89.7%) of departments, but there was limited use of other monitoring techniques. Most Departments followed the recommendations of the Brain Trauma Foundation (BTF) guidelines for the control of ICP.
The organisation of care and the initial management of severe head trauma in Spain is very similar to its neighbouring countries. However, there are shortcomings, such as low participation by a neurosurgeon in the initial management of these patients, insufficient use of telemedicine, and the low implementation of certain brain monitoring techniques (SjO2, PtiO2, and Doppler).