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Predictive Value of Point-of-Care, Limited Ultrasonography for Trauma Using the Focused Assessment with Sonography in Trauma Scanning Technique with a Hemoperitoneum Score in Assessing the Need for Operative Care in Torso Trauma Patients
Research Forum Abstracts
397
Predictive Value of Point-of-Care, Limited Ultrasonography for Trauma Using the Focused Assessment with Sonography in Trauma Scanning Technique with a Hemoperitoneum Score in Assessing the Need for Operative Care in Torso Trauma Patients
Melniker LA, Briggs WM, New York Methodist Hospital, Brooklyn, NY; Weill Medical College of Cornell University, New York, NY
Study Objectives: The reported sensitivity of the FAST exam for abdominal trauma ranges from 81 to 100%; depending on the outcome measure employed, i.e. free fluid, organ injury, or need for operative care. The primary objective was to assess, whether point-of-care, limited ultrasonography (PLUS) for trauma, using the FAST scanning technique with a previously described hemoperitoneum score, accurately predicted need for operative care (OR) in torso trauma patients. Secondarily, the contribution of CT results for assessing OR requirements was assessed. Methods: We analyzed the test characteristics of PLUS for trauma from the SOAP-1 trial database. Salient PLUS findings were presence of free fluid (FF) in the pericardium, pleura, or peritoneum; and the hemoperitoneum score. PLUS and CT findings were compared to OR requirements in all torso trauma patients. Results are presented as positive and negative predictive values, (PPV and NPV), and accuracy; with 95% confidence intervals. In addition, a literature search was conducted using the Ovid databases for all prospective trials conducted in the past 15 years, which contained data comparing FAST results and need for OR. Results: 75 torso trauma patients underwent PLUS; 36% had FF and 44% required OR. PPV was 1 (0.98 to 1), NPV was 0.88 (0.83 to 0.93), and accuracy was 0.92 (0.88 to 0.97). All patients with a hemoperitoneum score R3 needed OR; six penetrating trauma patients with score \3 required OR. In patients with blunt torso trauma (N=69), PLUS identified all needing OR; PPV=1 (0.98 to 1), NPV=1 (0.96 to 1), and accuracy=1 (0.98 to 1). No additional blunt intra-abdominal injury cases requiring OR were identified by CT. Five prospective trials comparing FAST and OR need were identified. In the 1550 patients assessed in these trials, the PPV and NPV of FAST for OR were 0.99 (0.98 to 1) and 0.98 (0.96 to 1), respectively. Conclusions: PLUS for trauma, using the FAST technique with this valid hemoperitoneum score, accurately predicts need for OR in blunt torso trauma. These findings are consistent with previously published predictive values of the FAST exam for OR requirements.
398
Does Intubation Prehospital Improve Outcomes for Head Injured Patients
Cameron PA, Gabbe B, Bernard S, Mulholland S, Monash University, Melbourne, Australia
Objective: To evaluate the effect of airway management on mortality in a population of major trauma patients with severe head injury. Methods: Design: Population-based retrospective cohort. Setting: The state-wide Victorian State Trauma Registry (VSTR), Victoria, Australia. Participants: Major trauma patients with a Glasgow Coma Scale score \9 on arrival at the scene, captured by the VSTR over a 3-year period (July 2001 - June 2004) (n=455). Patients were grouped into one of the following: not intubated in the pre-hospital setting, intubated without receiving sedation, intubated with sedation, and intubated using rapid sequence intubation (RSI). Main outcome measure: In-hospital mortality. Results: After adjusting for differences across the groups (ISS, maximum head injury severity and systolic BP at the scene), and age, patients intubated without drugs (OR 20.5, 95% CI: 8.6, 48.8) and those intubated using sedation only (OR 3.5, 95% CI: 1.4, 8.9) remained at elevated risk of death compared to patients not intubated at the scene. In contrast, after adjusting for the differences across the groups, patients intubated using RSI were no more likely to die (OR 1.1, 95% CI: 0.4, 2.6) than those not intubated in at the scene. Conclusions: The findings of our study suggest that intubation in the field without the use of pharmacological agents, or using sedating agents only, is associated with an increased risk of mortality. Whilst causality could not be established, the findings have implications for pre-hospital airway management protocols around the world and suggest that intubation of patients in the pre-hospital setting without drugs, or using sedation only, could be detrimental for the patient. In contrast, whilst numerous EMS systems across the world do not allow for the use of RSI, this technique was not associated with increased mortality in our cohort.
S112 Annals of Emergency Medicine
399
Comparison of the Effectiveness of Nasal Packing Devices for Emergency Department Treatment of Epistaxis
Lefkowits D, Hogle GA, Heinz S, Cutter G, Weil K, Mitchell A, HealthONE Rose Medical Center, Denver, CO; Columbine Otolaryngology, Denver, CO; HealthONE Sky Ridge Medical Center, Lone Tree, CO; Pythagoras, Birmingham, AL; Rose Biomedical Research, Denver, CO
Study Objectives: Current nasal packing devices can be difficult or painful to use and demonstrate limited effectiveness. We compared the results of treatment with a new device, the Colorado Nasal Pack (CNP), to other commonly used nasal packing. Methods: Tests were conducted on an anatomically correct nasal cavity model derived from human CT scans. Six physicians (three emergency medicine physicians, three ENTs) made three attempts to stop bleeds at three locations using four devices for a total of 36 trials per physician and 216 total tests. Non-heparinized human blood was used to more closely replicate epistaxis. 20cc samples of whole blood from volunteer human donors were drawn into syringes then immediately (within 15-20 seconds) pumped into tubes connected to holes in the model. Hole diameters were 0.5mm, average arterial diameter in the nasal cavity, and blood was pumped into the holes at a pressure of 80mmHg, mean arterial pressure of vessels in the nasal cavity. The four devices used were CNP, gauze packing, Epistat (nasal balloon), and Merocel (dessicated sponge). Data were collected on ease of insertion and removal (1-10 Likert scale) and ccs of blood used as well as time required to insert the device, stop the simulated bleed, and remove the device. Results: At 14 seconds, CNP had the shortest average time to stop bleeding and was significantly faster than all the other devices. Mean stop bleed times were 31 seconds for Epistat, 46 seconds for GP and 59 seconds for Merocel (p\0.0001). In addition, CNP stopped 95.6% of the bleeds, which was significantly better than Epistat (51.1%) and Merocel (13.3%). CNP was also better at stopping bleeds than gauze (44.4%), but the difference cannot be considered significant due to highly variable results with gauze. By location, CNP was far superior to all other methods for anterior and posterior bleeds and comparable to other methods in stopping septal bleeds. CNP stopped 95% of anterior bleeds vs. 52% for Epistat, 24% for gauze and 5% for Merocel (p\0.0001). Looking at the total ccs of blood used for the test, less blood was ‘‘lost’’ using CNP as a consequence of stopping the bleeds sooner. (CNP 1.7cc, Epistat 6.0cc, Gauze 8.3cc, Merocel 11.4cc, p\0.0001). CNP was the easiest to remove, significantly better than Merocel, Epistat and gauze. (1.8 vs. 2.4, 2.6, 4.8, p\0.0001). Overall total time (insertion, stop bleeding and removal) was significantly longer (p\0.001) for CNP (128 seconds) compared to Epistat (97 seconds) and Merocel (95) and significantly (p\0.001) shorter than gauze (171 seconds). CNP average insertion time of 90 seconds was the same as gauze but significantly slower than the others. Despite insertion time differences, CNP (3.5) was ranked easier to insert than Epistat (3.8) or gauze (6.9) but more difficult than Merocel (2.1). All mean ease of insertion scores were significantly different from one another. Insertion differences may be due to a learning curve. Conclusion: In model testing, CNP stopped 96% of the bleeds with an average time of 14 seconds, making it both quicker and more effective overall than Epistat or Merocel. CNP also more quickly stopped a far higher percentage of bleeds than gauze, but the difference cannot be considered significant due to highly variable results with gauze. A NIH-sponsored, 120 human subject emergency department trial with the device is underway and results are expected to be comparable to those demonstrated in the model tests.
400
An Optimal Solution for Enhancing Ambulance Transport Safety: A Real-Time Driver Performance Monitoring and Feedback Device
Levick N, Swanson J, Maimonides Medical Center, New York, NY; Metropolitan Emergency Medical Services, Little Rock, AR
Study Objectives: 1.To determine if emergency vehicle driver risk behavior can be modified and improved with the installation of an onboard, computer based monitoring device (‘black box’), with real time auditory feedback. 2. To enhance the safety of emergency vehicle transport. Methods: Design: This is a prospective study capturing real-time electronic field data from ‘black box’ recorders installed in ambulance vehicles over an 18 month period. Setting: A metropolitan EMS group withO250 drivers, call volume of 50,000 calls per annum. Type of participants: EMS system, ambulance vehicles and drivers. The EMS group installed the onboard computer system in 36 ambulances in March 2003. Blind data were collected for 3 months initially. The system was fully operational from June 2003. The onboard system monitors parameters every second
Volume 46, no. 3 : September 2005
397
Predictive Value of Point-of-Care, Limited Ultrasonography for Trauma Using the Focused Assessment with Sonography in Trauma Scanning Technique with a Hemoperitoneum Score in Assessing the Need for Operative Care in Torso Trauma Patients
Melniker LA, Briggs WM, New York Methodist Hospital, Brooklyn, NY; Weill Medical College of Cornell University, New York, NY
Study Objectives: The reported sensitivity of the FAST exam for abdominal trauma ranges from 81 to 100%; depending on the outcome measure employed, i.e. free fluid, organ injury, or need for operative care. The primary objective was to assess, whether point-of-care, limited ultrasonography (PLUS) for trauma, using the FAST scanning technique with a previously described hemoperitoneum score, accurately predicted need for operative care (OR) in torso trauma patients. Secondarily, the contribution of CT results for assessing OR requirements was assessed. Methods: We analyzed the test characteristics of PLUS for trauma from the SOAP-1 trial database. Salient PLUS findings were presence of free fluid (FF) in the pericardium, pleura, or peritoneum; and the hemoperitoneum score. PLUS and CT findings were compared to OR requirements in all torso trauma patients. Results are presented as positive and negative predictive values, (PPV and NPV), and accuracy; with 95% confidence intervals. In addition, a literature search was conducted using the Ovid databases for all prospective trials conducted in the past 15 years, which contained data comparing FAST results and need for OR. Results: 75 torso trauma patients underwent PLUS; 36% had FF and 44% required OR. PPV was 1 (0.98 to 1), NPV was 0.88 (0.83 to 0.93), and accuracy was 0.92 (0.88 to 0.97). All patients with a hemoperitoneum score R3 needed OR; six penetrating trauma patients with score \3 required OR. In patients with blunt torso trauma (N=69), PLUS identified all needing OR; PPV=1 (0.98 to 1), NPV=1 (0.96 to 1), and accuracy=1 (0.98 to 1). No additional blunt intra-abdominal injury cases requiring OR were identified by CT. Five prospective trials comparing FAST and OR need were identified. In the 1550 patients assessed in these trials, the PPV and NPV of FAST for OR were 0.99 (0.98 to 1) and 0.98 (0.96 to 1), respectively. Conclusions: PLUS for trauma, using the FAST technique with this valid hemoperitoneum score, accurately predicts need for OR in blunt torso trauma. These findings are consistent with previously published predictive values of the FAST exam for OR requirements.
398
Does Intubation Prehospital Improve Outcomes for Head Injured Patients
Cameron PA, Gabbe B, Bernard S, Mulholland S, Monash University, Melbourne, Australia
Objective: To evaluate the effect of airway management on mortality in a population of major trauma patients with severe head injury. Methods: Design: Population-based retrospective cohort. Setting: The state-wide Victorian State Trauma Registry (VSTR), Victoria, Australia. Participants: Major trauma patients with a Glasgow Coma Scale score \9 on arrival at the scene, captured by the VSTR over a 3-year period (July 2001 - June 2004) (n=455). Patients were grouped into one of the following: not intubated in the pre-hospital setting, intubated without receiving sedation, intubated with sedation, and intubated using rapid sequence intubation (RSI). Main outcome measure: In-hospital mortality. Results: After adjusting for differences across the groups (ISS, maximum head injury severity and systolic BP at the scene), and age, patients intubated without drugs (OR 20.5, 95% CI: 8.6, 48.8) and those intubated using sedation only (OR 3.5, 95% CI: 1.4, 8.9) remained at elevated risk of death compared to patients not intubated at the scene. In contrast, after adjusting for the differences across the groups, patients intubated using RSI were no more likely to die (OR 1.1, 95% CI: 0.4, 2.6) than those not intubated in at the scene. Conclusions: The findings of our study suggest that intubation in the field without the use of pharmacological agents, or using sedating agents only, is associated with an increased risk of mortality. Whilst causality could not be established, the findings have implications for pre-hospital airway management protocols around the world and suggest that intubation of patients in the pre-hospital setting without drugs, or using sedation only, could be detrimental for the patient. In contrast, whilst numerous EMS systems across the world do not allow for the use of RSI, this technique was not associated with increased mortality in our cohort.
S112 Annals of Emergency Medicine
399
Comparison of the Effectiveness of Nasal Packing Devices for Emergency Department Treatment of Epistaxis
Lefkowits D, Hogle GA, Heinz S, Cutter G, Weil K, Mitchell A, HealthONE Rose Medical Center, Denver, CO; Columbine Otolaryngology, Denver, CO; HealthONE Sky Ridge Medical Center, Lone Tree, CO; Pythagoras, Birmingham, AL; Rose Biomedical Research, Denver, CO
Study Objectives: Current nasal packing devices can be difficult or painful to use and demonstrate limited effectiveness. We compared the results of treatment with a new device, the Colorado Nasal Pack (CNP), to other commonly used nasal packing. Methods: Tests were conducted on an anatomically correct nasal cavity model derived from human CT scans. Six physicians (three emergency medicine physicians, three ENTs) made three attempts to stop bleeds at three locations using four devices for a total of 36 trials per physician and 216 total tests. Non-heparinized human blood was used to more closely replicate epistaxis. 20cc samples of whole blood from volunteer human donors were drawn into syringes then immediately (within 15-20 seconds) pumped into tubes connected to holes in the model. Hole diameters were 0.5mm, average arterial diameter in the nasal cavity, and blood was pumped into the holes at a pressure of 80mmHg, mean arterial pressure of vessels in the nasal cavity. The four devices used were CNP, gauze packing, Epistat (nasal balloon), and Merocel (dessicated sponge). Data were collected on ease of insertion and removal (1-10 Likert scale) and ccs of blood used as well as time required to insert the device, stop the simulated bleed, and remove the device. Results: At 14 seconds, CNP had the shortest average time to stop bleeding and was significantly faster than all the other devices. Mean stop bleed times were 31 seconds for Epistat, 46 seconds for GP and 59 seconds for Merocel (p\0.0001). In addition, CNP stopped 95.6% of the bleeds, which was significantly better than Epistat (51.1%) and Merocel (13.3%). CNP was also better at stopping bleeds than gauze (44.4%), but the difference cannot be considered significant due to highly variable results with gauze. By location, CNP was far superior to all other methods for anterior and posterior bleeds and comparable to other methods in stopping septal bleeds. CNP stopped 95% of anterior bleeds vs. 52% for Epistat, 24% for gauze and 5% for Merocel (p\0.0001). Looking at the total ccs of blood used for the test, less blood was ‘‘lost’’ using CNP as a consequence of stopping the bleeds sooner. (CNP 1.7cc, Epistat 6.0cc, Gauze 8.3cc, Merocel 11.4cc, p\0.0001). CNP was the easiest to remove, significantly better than Merocel, Epistat and gauze. (1.8 vs. 2.4, 2.6, 4.8, p\0.0001). Overall total time (insertion, stop bleeding and removal) was significantly longer (p\0.001) for CNP (128 seconds) compared to Epistat (97 seconds) and Merocel (95) and significantly (p\0.001) shorter than gauze (171 seconds). CNP average insertion time of 90 seconds was the same as gauze but significantly slower than the others. Despite insertion time differences, CNP (3.5) was ranked easier to insert than Epistat (3.8) or gauze (6.9) but more difficult than Merocel (2.1). All mean ease of insertion scores were significantly different from one another. Insertion differences may be due to a learning curve. Conclusion: In model testing, CNP stopped 96% of the bleeds with an average time of 14 seconds, making it both quicker and more effective overall than Epistat or Merocel. CNP also more quickly stopped a far higher percentage of bleeds than gauze, but the difference cannot be considered significant due to highly variable results with gauze. A NIH-sponsored, 120 human subject emergency department trial with the device is underway and results are expected to be comparable to those demonstrated in the model tests.
400
An Optimal Solution for Enhancing Ambulance Transport Safety: A Real-Time Driver Performance Monitoring and Feedback Device
Levick N, Swanson J, Maimonides Medical Center, New York, NY; Metropolitan Emergency Medical Services, Little Rock, AR
Study Objectives: 1.To determine if emergency vehicle driver risk behavior can be modified and improved with the installation of an onboard, computer based monitoring device (‘black box’), with real time auditory feedback. 2. To enhance the safety of emergency vehicle transport. Methods: Design: This is a prospective study capturing real-time electronic field data from ‘black box’ recorders installed in ambulance vehicles over an 18 month period. Setting: A metropolitan EMS group withO250 drivers, call volume of 50,000 calls per annum. Type of participants: EMS system, ambulance vehicles and drivers. The EMS group installed the onboard computer system in 36 ambulances in March 2003. Blind data were collected for 3 months initially. The system was fully operational from June 2003. The onboard system monitors parameters every second
Volume 46, no. 3 : September 2005