- Email: [email protected]
Rural Area
Research Forum Abstracts standard, sensitivity for the 12 risk factors ranged from 0 to 50% and specificity ranged from 67 to 100%. For attendings, sensitivity ranged from 0 to 38% and specificity ranged from 57 to 92%. Using any (versus none) of the 12 risk factors as the indicator, residents sensitivity was 38% (95% confidence interval [CI] 23-55%), specificity 78% (95% CI 40-97%), likelihood ratio positive (LR+) 1.7 (95% CI 0.48-6.3), and LR- 0.79 (95% CI .52-1.2). For attending, using any risk factor as the indicator, sensitivity was 46% (95% CI 30-63%), specificity 56% (95% CI 2186%),LR+ 1.04 (95% CI .46-2.3), and LR- 0.97 (95% CI .50-1.9). Conclusion: Emergency physicians were not able to detect psychological risk by observation only detecting 1/3 of psychological risk factors in patients. As with trauma screening for alcohol abuse, PTSD risk identification in the ED may lead to reductions in psychological disorders. Training is needed for emergency physicians to reliably identify PTSD risk to reduce a preventable aspect of the chronic health burden of injuries.
269
Validation of the National Trauma Triage Protocol in a Suburban/Rural Area
Henry MC, Huang E, McCormack JE, Thode HC, Jr./Stony Brook University, Stony Brook, NY; Stony Brook Medicine, Stony Brook, NY
Study Objectives: Trauma triage protocols are used to guide out-of-hospital personnel in their decision to transport to the hospital or other facility which would be the most appropriate to meet the needs of the patient. The most recent recommended protocol is the National Trauma Triage Protocol (NTTP) developed by the CDC in 2011. In this study we use historical data to determine the efficacy of the NTTP. Methods: Trauma triage out-of-hospital care reports (TPCRs) were used by out-of-hospital personnel for all trauma emergency calls from 2003 to 2007 in Suffolk County, NY. Suffolk County has a population of 1.5 million, and is located on Long Island; it is surrounded by water on three sides and by Nassau County on its western border. Emergency response is essentially a closed system, where 90 independent ambulance corps provides service to the entire county and transports patients to hospitals within the county. Data were collected from each ambulance transport on the TPCR which included trauma triage criteria. These data were matched with the county trauma registry, with which all county hospitals participate. The NTTP protocol involves combining criteria into one of 4 blocks and applying the blocks in a stepwise fashion in order to determine the need to transport a patient to a trauma center. The blocks, in order of application are physiological criteria (NTTP1), anatomic criteria (NTTP2), mechanism of injury criteria (NTTP3), and special considerations (NTTP4). This protocol was used to determine the receiver operating characteristics of using the NTTP for outcome measures which included injury severity score > 15 (ISS), admission, ICU admission, hospital length of stay > 2 days (LOS3), need for major surgery (MOR), and died in ED or were DOA, in adult patients who were transported to a hospital by ambulance. Results: There were 17,120 adult trauma patients transported to hospitals within the county. Of these, 2.6% had NTTP1 criteria, 1.0% had NTTP2 criteria, 10.0% had NTTP3 criteria, and 27.8% had NTTP 4 criteria. Mortality was 0.4%, 1.7% had M-OR, 3.5% were admitted, 1.3% were admitted to an ICU, 3.2% had LOS3, 1.8% had ISS. Sensitivity of the NTTP was highest for mortality (97%), ICU admission (79%), and ISS (79%). Sensitivity for admission, LOS3, and M-OR were all 68%. Specificity of the NTTP was 62-63% for all outcomes. Conclusion: The NTTP criteria are sensitive for determining patient outcomes but have only moderate specificity. In a sample of more than 17,000 patients over 6,000 (>35%) would have been over-triaged using the NTTP.
270
Efficacy of Resuscitative Endovascular Balloon Occlusion of the Aorta for Treatment in Severe Penetrating Trauma Patients
Norii T, Crandall C, Terasaka Y/University of New Mexico, Albuquerque, NM; Kenwakai Ohtemachi Hospital, Kitakyushu, Japan
Study Objective: Trauma and acute hemorrhagic shock are leading causes of death worldwide. Although multiple clinical and animal studies show a potential survival benefit from the use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for critical uncontrolled hemorrhagic shock, clinical evidence of REBOA
S96 Annals of Emergency Medicine
treatment efficacy are limited and derive from case series or small sample size studies. We compared the mortality in patients with severe penetrating injury who received REBOA to those who did not, adjusting for the likelihood of treatment. Methods: We analyzed observational prospective data from the Japan Trauma Data Bank (JTDB) to compare the mortality between patients who received a REBOA to those who did not. We used propensity score matching to adjust for potential treatment bias. The JTDB, established in 2003 by the Japanese Association for the Surgery of Trauma and the Japanese Association for Acute Medicine, consists of data from 196 major emergency departments/hospitals in Japan. We restricted our analysis to patients 13 years and older who received care at a facility where at least 1 REBOA had been placed. Our outcome measure was survival to discharge. We calculated the likelihood of REBOA placement (propensity score, PS) using unconditional logistic regression. We used available pretreatment variables included age, sex, and vital signs. Comparisons of the baseline REBOA treated and untreated groups used Chi square tests for categorical data and Wilcoxon Rank Sum tests for continuous data. We used the PS to match patients who received a REBOA to up to 10 patients who did not receive a REBOA using a greedy matching algorithm. We then used conditional logistic regression to calculate the odds of survival in patients who received a REBOA to those who did not. Results: Of the 94,664 patients in the JTDB (2004-2011), 3,288 experienced penetrating trauma (3%); of these patients, 30 (1%) had a REBOA placed and 18 (60%) survived to discharge. Most penetrating trauma patients were male (71%) as were REBOA patients (70%). Penetrating trauma patients had a median Injury Severity Score (ISS) of 9 (interquartile range (IQR) 4 to 16) and a median age of 49 years (IQR 34 to 63 years). Compared to the non-REBOA group, patients who received a REBOA were of similar age (median age: 48.5 years, IQR 40 to 65 years, P¼.628) but were more seriously injured (median ISS: 17.5, IQR: 10 to 25, P<.0001). The overall mortality for patients who did not have a REBOA placed was 11.8% but was 40% in the REBOA group (P<.0001). After matching REBOA patients to up to 10 controls with similar propensity scores for treatment (0.1% PS), the crude conditional odds ratio [OR] of survival by REBOA treatment was 1.67; 95% confidence interval [CI]: 0.59, 4.75). After adjustment for ISS and revised trauma score (RTS), survival improved but remained non-significant (OR 2.13, CI; 0.26, 17.6). Conclusion: Contrary to our previous study in blunt trauma patients, REBOA treatment may be effective in patients with severe penetrating injury. A larger sample size is needed to achieve enough statistical power.
271
Traumatic Cardiac Arrests in Asystole Managed by French Out-of-Hospital Emergency Medical Service: A Nationwide Survey
Tazarourte K, Escutnaire J, Tourtier JP, Savary D, Hubert H, Gueugniaud P-Y REAC Group/Claude Bernard University Lyon 1, Lyon, France; Lille 2 University, Lille, France; Medical Unit of Paris Firemen, Paris, France; SAMU 74, Annecy, France
Study Objective: The prognostic of traumatic cardiac arrest (TCA) patients is considered to be extremely pejorative and the resuscitation attempt to be futile when the victim presents an asystole at EMS arrival. The aim of this study is to describe, in the out-of-hospital medical system in France, the TCA in asystole and to compare this population with non-traumatic cardiac arrests which initial pace is also asystole at emergency medical service (EMS) arrival. Material and Method: French multicentric (221 EMS), prospective, comparative study based on the data gathered in the RéAC registry framework between July 1, 2011 and December 10, 2013. Results: Among 15982 registered CA with asystole as initial rhythm, 13892 were medical CA and 2090 TCA. TCA occurred in younger patients (48 21 versus 66,9 21; P<.04). They also happen in a more masculine population than in nontraumatic CA (76,6% versus 62,8%; P<10-4). The other variables concerning care and prognostic are set out in Table. Discussion: Out-of-hospital resuscitation maneuvers was significantly less attempted in TCA victims and yet 8% of them are admitted to hospital with a spontaneous circulation. At Day 30, 2% of them survived and half of them had a Cerebral Performance Category score. Conclusion: We observe a survival odd significantly inferior in TCA victims than in non-traumatic CA population. However, the survival rates of TCA patients in asystole suggest that out-of-hospital resuscitation is not futile. Some complementary studies are requested to identify the factors of good functional prognostic.
Volume 64, no. 4s : October 2014
269
Validation of the National Trauma Triage Protocol in a Suburban/Rural Area
Henry MC, Huang E, McCormack JE, Thode HC, Jr./Stony Brook University, Stony Brook, NY; Stony Brook Medicine, Stony Brook, NY
Study Objectives: Trauma triage protocols are used to guide out-of-hospital personnel in their decision to transport to the hospital or other facility which would be the most appropriate to meet the needs of the patient. The most recent recommended protocol is the National Trauma Triage Protocol (NTTP) developed by the CDC in 2011. In this study we use historical data to determine the efficacy of the NTTP. Methods: Trauma triage out-of-hospital care reports (TPCRs) were used by out-of-hospital personnel for all trauma emergency calls from 2003 to 2007 in Suffolk County, NY. Suffolk County has a population of 1.5 million, and is located on Long Island; it is surrounded by water on three sides and by Nassau County on its western border. Emergency response is essentially a closed system, where 90 independent ambulance corps provides service to the entire county and transports patients to hospitals within the county. Data were collected from each ambulance transport on the TPCR which included trauma triage criteria. These data were matched with the county trauma registry, with which all county hospitals participate. The NTTP protocol involves combining criteria into one of 4 blocks and applying the blocks in a stepwise fashion in order to determine the need to transport a patient to a trauma center. The blocks, in order of application are physiological criteria (NTTP1), anatomic criteria (NTTP2), mechanism of injury criteria (NTTP3), and special considerations (NTTP4). This protocol was used to determine the receiver operating characteristics of using the NTTP for outcome measures which included injury severity score > 15 (ISS), admission, ICU admission, hospital length of stay > 2 days (LOS3), need for major surgery (MOR), and died in ED or were DOA, in adult patients who were transported to a hospital by ambulance. Results: There were 17,120 adult trauma patients transported to hospitals within the county. Of these, 2.6% had NTTP1 criteria, 1.0% had NTTP2 criteria, 10.0% had NTTP3 criteria, and 27.8% had NTTP 4 criteria. Mortality was 0.4%, 1.7% had M-OR, 3.5% were admitted, 1.3% were admitted to an ICU, 3.2% had LOS3, 1.8% had ISS. Sensitivity of the NTTP was highest for mortality (97%), ICU admission (79%), and ISS (79%). Sensitivity for admission, LOS3, and M-OR were all 68%. Specificity of the NTTP was 62-63% for all outcomes. Conclusion: The NTTP criteria are sensitive for determining patient outcomes but have only moderate specificity. In a sample of more than 17,000 patients over 6,000 (>35%) would have been over-triaged using the NTTP.
270
Efficacy of Resuscitative Endovascular Balloon Occlusion of the Aorta for Treatment in Severe Penetrating Trauma Patients
Norii T, Crandall C, Terasaka Y/University of New Mexico, Albuquerque, NM; Kenwakai Ohtemachi Hospital, Kitakyushu, Japan
Study Objective: Trauma and acute hemorrhagic shock are leading causes of death worldwide. Although multiple clinical and animal studies show a potential survival benefit from the use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for critical uncontrolled hemorrhagic shock, clinical evidence of REBOA
S96 Annals of Emergency Medicine
treatment efficacy are limited and derive from case series or small sample size studies. We compared the mortality in patients with severe penetrating injury who received REBOA to those who did not, adjusting for the likelihood of treatment. Methods: We analyzed observational prospective data from the Japan Trauma Data Bank (JTDB) to compare the mortality between patients who received a REBOA to those who did not. We used propensity score matching to adjust for potential treatment bias. The JTDB, established in 2003 by the Japanese Association for the Surgery of Trauma and the Japanese Association for Acute Medicine, consists of data from 196 major emergency departments/hospitals in Japan. We restricted our analysis to patients 13 years and older who received care at a facility where at least 1 REBOA had been placed. Our outcome measure was survival to discharge. We calculated the likelihood of REBOA placement (propensity score, PS) using unconditional logistic regression. We used available pretreatment variables included age, sex, and vital signs. Comparisons of the baseline REBOA treated and untreated groups used Chi square tests for categorical data and Wilcoxon Rank Sum tests for continuous data. We used the PS to match patients who received a REBOA to up to 10 patients who did not receive a REBOA using a greedy matching algorithm. We then used conditional logistic regression to calculate the odds of survival in patients who received a REBOA to those who did not. Results: Of the 94,664 patients in the JTDB (2004-2011), 3,288 experienced penetrating trauma (3%); of these patients, 30 (1%) had a REBOA placed and 18 (60%) survived to discharge. Most penetrating trauma patients were male (71%) as were REBOA patients (70%). Penetrating trauma patients had a median Injury Severity Score (ISS) of 9 (interquartile range (IQR) 4 to 16) and a median age of 49 years (IQR 34 to 63 years). Compared to the non-REBOA group, patients who received a REBOA were of similar age (median age: 48.5 years, IQR 40 to 65 years, P¼.628) but were more seriously injured (median ISS: 17.5, IQR: 10 to 25, P<.0001). The overall mortality for patients who did not have a REBOA placed was 11.8% but was 40% in the REBOA group (P<.0001). After matching REBOA patients to up to 10 controls with similar propensity scores for treatment (0.1% PS), the crude conditional odds ratio [OR] of survival by REBOA treatment was 1.67; 95% confidence interval [CI]: 0.59, 4.75). After adjustment for ISS and revised trauma score (RTS), survival improved but remained non-significant (OR 2.13, CI; 0.26, 17.6). Conclusion: Contrary to our previous study in blunt trauma patients, REBOA treatment may be effective in patients with severe penetrating injury. A larger sample size is needed to achieve enough statistical power.
271
Traumatic Cardiac Arrests in Asystole Managed by French Out-of-Hospital Emergency Medical Service: A Nationwide Survey
Tazarourte K, Escutnaire J, Tourtier JP, Savary D, Hubert H, Gueugniaud P-Y REAC Group/Claude Bernard University Lyon 1, Lyon, France; Lille 2 University, Lille, France; Medical Unit of Paris Firemen, Paris, France; SAMU 74, Annecy, France
Study Objective: The prognostic of traumatic cardiac arrest (TCA) patients is considered to be extremely pejorative and the resuscitation attempt to be futile when the victim presents an asystole at EMS arrival. The aim of this study is to describe, in the out-of-hospital medical system in France, the TCA in asystole and to compare this population with non-traumatic cardiac arrests which initial pace is also asystole at emergency medical service (EMS) arrival. Material and Method: French multicentric (221 EMS), prospective, comparative study based on the data gathered in the RéAC registry framework between July 1, 2011 and December 10, 2013. Results: Among 15982 registered CA with asystole as initial rhythm, 13892 were medical CA and 2090 TCA. TCA occurred in younger patients (48 21 versus 66,9 21; P<.04). They also happen in a more masculine population than in nontraumatic CA (76,6% versus 62,8%; P<10-4). The other variables concerning care and prognostic are set out in Table. Discussion: Out-of-hospital resuscitation maneuvers was significantly less attempted in TCA victims and yet 8% of them are admitted to hospital with a spontaneous circulation. At Day 30, 2% of them survived and half of them had a Cerebral Performance Category score. Conclusion: We observe a survival odd significantly inferior in TCA victims than in non-traumatic CA population. However, the survival rates of TCA patients in asystole suggest that out-of-hospital resuscitation is not futile. Some complementary studies are requested to identify the factors of good functional prognostic.
Volume 64, no. 4s : October 2014