Effects of physician-based emergency medical service dispatch in severe traumatic brain injury on prehospital run time.

INTRODUCTION: Prehospital care by physician-based helicopter emergency medical services (P-HEMS) may prolong total prehospital run time. This has raised an issue of debate about the benefits of these services in traumatic brain injury (TBI). We therefore investigated the effects of P-HEMS dispatch on prehospital run time and outcome in severe TBI. METHODS: Prehospital run times of 497 patients with severe TBI who were solely treated by a paramedic EMS (n = 125) or an EMS/P-HEMS combination (n = 372) were retrospectively analyzed. Other study parameters included the injury severity score (ISS), Glasgow Coma Scale (GCS), prehospital endotracheal intubation and predicted and observed outcome rates. RESULTS: Patients who received P-HEMS care were younger and had higher ISS values than solely EMS-treated patients (10%; P = 0.04). The overall prehospital run time was 74 ± 54 min, with similar out-of-hospital times for EMS and P-HEMS treated patients. Prehospital endotracheal intubation was more frequently performed in the P-HEMS group (88%) than in the EMS group (35%; P<0.001). The prehospital run time for intubated patients was similar for P-HEMS (66 (51-80)min) and EMS-treated patients (59 (41-88 min). Unexpectedly, mortality probability scores and observed outcome scores were less favourable for EMS-treated patients when compared to patients treated by P-HEMS. CONCLUSION: P-HEMS dispatch does not increase prehospital run times in severe TBI, while it assures prehospital intubation of TBI patients by a well-trained physician. Our data however suggest that a subgroup of the most severely injured patients received prehospital care by an EMS, while international guidelines recommend advanced life support by a physician-based EMS in these cases.

Prehospital endotracheal intubation in patients with severe traumatic brain injury: guidelines versus reality.

The international Brain Trauma Foundation guidelines recommend prehospital endotracheal intubation in all patients with traumatic brain injury (TBI) and a Glasgow Coma Scale (GCS)< or =8. Close adherence to these guidelines is associated with improved outcome, but not all severely injured TBI patients receive adequate prehospital airway support. Here we hypothesized that guideline adherence varies when skills are involved that rely on training and expertise, such as endotracheal intubation. We retrospectively studied the medical records of CT-confirmed TBI patients with a GCS< or =8 who were referred to a level 1 trauma centre in Amsterdam (n=127). Records were analyzed for demographic parameters, prehospital treatment modalities, involvement of an emergency medical service (EMS) and respiratory and metabolic parameters upon arrival at the hospital. Patients were mostly male, aged 45+/-21 years with a median injury severity score (ISS) of 26. Of all patients for whom guidelines recommend endotracheal intubation, only 56% were intubated. In 21 out of 106 severe cases an EMS was not called for, suggesting low guideline adherence. Especially those TBI patients treated by paramedics tended to develop higher levels of stress markers like glucose and lactate. We observed a low degree of adherence to intubation guidelines in a Dutch urban area. Main reasons for low adherence were the unavailability of specialized care, scoop and run strategies and absence of a specialist physician in cases where intubation was recommended. The discrepancy between guidelines and reality warrants changing practice to improve guideline compliance and optimize outcome in TBI patients.

[Helicopter-Mobile Medical Teams in The Netherlands: significant differences in deployment frequencies between different emergency room regions]. / Helikopter-Mobiele Medische Teams in Nederland: belangrijke verschillen in inzetfrequentie tussen meldkamerregio's.

OBJECTIVE: To investigate whether Helicopter-Mobile Medical Teams (H-MMTs or HEMS) are optimally deployed in all emergency dispatch centres. DESIGN: Descriptive, retrospective. METHOD: Initially, we assessed whether data from different ambulance regions could be compared effectively if they were related to the number of inhabitants per region. Data concerning the number of inhabitants, number of deaths caused by trauma, number of traffic accidents with injury, number ofemergency call-outs by ambulance services and H-MMT deployment were collected from several governmental databases for the period 2002-2005. The correlation coefficients between these data and the number of inhabitants were calculated. Subsequently, we determined the number of H-MMT deployments per 100,000 inhabitants per year per emergency dispatch centre. The number of H-MMT dispatches from the 4 H-MMT coordinating dispatch centres was compared to the number of dispatches from the 17 other emergency dispatch centres. RESULTS: There was a strong correlation between the number of deaths caused by trauma, the number of traffic accidents with injury, emergency call-outs from ambulance services, and the number of inhabitants per region (correlation coefficients: 0.90-0.98). On average there were 2664 H-MMT calls per year. The average number of H-MMT calls per emergency dispatch centre per year was 110 (range: 2-403). The number of H-MMT deployments per 100,000 inhabitants per year was 10.5 (0.9-27.8). Emergency dispatch centres coordinating H-MMTs conducted significantly more H-MMT calls with a lower cancellation rate. CONCLUSION: By relating the deployment of H-MMTs with the number of inhabitants per region, a comparison can be made of the deployment frequencies in different emergency dispatch regions. The deployment of H-MMTs proved to differ significantly between emergency dispatch centres.

The use of a mini bypass system (Cobe Synergy) without venous and cardiotomy reservoir in a mitral valve repair: a case report.

The use of mini cardiopulmonary bypass circuits is an emerging technology. The venous and cardiotomy reservoir have been excluded from the circuit. This results in a reduction of the blood contact surface area and of the priming volume. Entrainment of venous air, however, remains a drawback in the widespread acceptance of using these mini circuits. The technique described resolves this problem by automatic removal of venous air, and explains how this mini cardiopulmonary bypass circuit was utilized on a 64-year-old female presented for a mitral valve repair. In the absence of a cardiotomy reservoir, an autotransfusion cell separator was used to process shed blood and, after CPB, the residual pump blood. This mini bypass circuit, with the safety feature to remove automatically venous air, provided an additional degree of protection. In our experience, mini bypass circuits allow us safely to perform cardiopulmonary bypass during valve procedures.

Intra-observer variability in APACHE II scoring.

Although the APACHE II score is the most widely used scoring system in intensive care units worldwide, its reliability and variability have not been extensively studied. Differences in case-mix may complicate comparison and interpretation of results. We hypothesised that a degree of variability might be inherent to use of the APACHE II scoring system, and decided to assess intra-observer variability in APACHE II scoring as a potential indicator of inherent score variability. APACHE II scores were assessed twice from the charts of 11 patients by 14 physicians, with a time interval of 4 (range 3.5-4.5) months between the two assessments. Intra-observer was found to be approximately 15%. These findings are in agreement with previous observations regarding inter-observer variability in APACHE II scoring, and strongly suggest that there is an inherent score variability of about 15%.