Attributes of leadership skill development in high-performance pre-hospital medical teams: results of an international multi-service prospective study.

BACKGROUNDS: Team leadership skills of physicians working in high-performing medical teams are directly related to outcome. It is currently unclear how these skills can best be developed. Therefore, in this multi-national cross-sectional prospective study, we explored the development of these skills in relation to physician-, organization- and training characteristics of Helicopter Emergency Medicine Service (HEMS) physicians from services in Europe, the United States of America and Australia. METHODS: Physicians were asked to complete a survey regarding their HEMS service, training, and background as well as a full Leader Behavior Description Questionnaire (LBDQ). Primary outcomes were the 12 leadership subdomain scores as described in the LBDQ. Secondary outcome measures were the association of LBDQ subdomain scores with specific physician-, organization- or training characteristics and self-reported ways to improve leadership skills in HEMS physicians. RESULTS: In total, 120 HEMS physicians completed the questionnaire. Overall, leadership LBDQ subdomain scores were high (10 out of 12 subdomains exceeded 70% of the maximum score). Whereas physician characteristics such as experience or base-specialty were unrelated to leadership qualities, both organization- and training characteristics were important determinants of leadership skill development. Attention to leadership skills during service induction, ongoing leadership training, having standards in place to ensure (regular) scenario training and holding structured mission debriefs each correlated with multiple LBDQ subdomain scores. CONCLUSIONS: Ongoing training of leadership skills should be stimulated and facilitated by organizations as it contributes to higher levels of proficiency, which may translate into a positive effect on patient outcomes. TRIAL REGISTRATION: Not applicable.

Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries.

Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.

"Falling down": a retroperitoneal catastropheC.

Hemoperitoneum due to ruptured retroperitoneal varices is an extremely rare condition and a poor prognostic sign with a catastrophic and life-threatening situation. Early recognition affords appropriate management and urgent surgical intervention in order to favor the survival rate. In this case report we accurately describe the complex clinical course of a 56-year old woman with retroperitoneal varices, who few months earlier had a chest trauma with multiple left lower rib fractures and 10 years earlier she underwent to ovarian hyperstimulation for an ovulation induction. She was taken to the emergency room for a fainting episode with signs of a clear hemodinamic shock without a present history of trauma. The intricacy of this case was mostly due to the choice of the correct management, where the damage control resuscitation turned out to have an important role.

Non-surgical Management of Blunt Splenic Trauma: A Comparative Analysis of Non-operative Management and Splenic Artery Embolization-Experience from a European Trauma Center.

PURPOSE: The objective of our study was to retrospectively compare the outcomes of non-operative management (NOM) and splenic artery embolization (SAE) in the management of hemodynamically stable patients with splenic injuries. MATERIALS AND METHODS: In a 5-year period, 109 patients were recorded; 60/109 were treated with NOM and 49/109 with SAE. For each patient, the following parameters were assessed: Glasgow coma scale, injury severity score, American Association for the Surgery of Trauma splenic injury grade, transfusion requirements, hemoglobin level, presence of a splenic vascular lesion (SVL) and amount of hemoperitoneum (Bessoud scale). Different SAE techniques (proximal, distal, combined) with different materials were employed. Clinical success was defined as spleen conservation at 30 days; failure was defined as spleen re-bleeding within 30 days, requiring splenectomy. Student's t test or Chi-square analysis and the Kaplan-Mayer curve were used to analyse each group's results and compare them with those of the other group. RESULTS: In the SAE group, AAST splenic injury grade was higher and serum hemoglobin levels were lower. The SAE group had significantly more SVL and hemoperitoneum compared to the NOM group. The clinical success rate was not significantly different between groups (NOM = 95%, SAE = 87.8%; p = 0.16). Sixty-six percent of NOM failures were related to inadequate patient selection, while 67% of SAE failures were due to technical/procedural issues. CONCLUSION: Our study observed a high splenic salvage rate with the use of SAE as an adjunct to NOM, and suggests that it may be further improved with appropriate patient selection and an improved embolization technique.

A proposed algorithm for multimodal liver trauma management from a surgical trauma audit in a western European trauma center.

Management of liver trauma is challenging and may vary widely given the heterogeneity of liver injuries' anatomical configuration, the hemodynamic status, the settings and resources available. Perhaps the use of non-operative management (NOM) may have potential drawbacks and the role of damage control surgery (DCS) and angioembolization represents a major evolving concept.1 Most severe liver trauma in polytrauma patients accounts for a significant morbidity and mortality. Major liver trauma with extensive parenchymal injury and uncontrollable bleeding is therefore a challenge for the trauma team. However a safe and effective surgical hemostasis and a carefully planned multidisciplinary approach can improve the outcome of severe liver trauma. The technique of perihepatic packing, according to DCS approach, is often required to achieve fast, early and effective control of hemorrhage in the highest grades of liver trauma and in unstable patients. A systematic and standardized technique of perihepatic packing may contribute to improve hemostatic efficacy and overall outcomes if wisely combined in a stepwise "sandwich" multimodal approach. DCS philosophy evolved alongside with damage control resuscitation (DCR) in the management of trauma patients, requiring close interaction between surgery and resuscitation. Therefore, as a result of a combined surgical and critical care clinical audit activity in our western European trauma center, a practical algorithm for multimodal sequential management of liver trauma has been developed based on a historical cohort of 253 liver trauma patients and subsequently validated on a prospective cohort of 135 patients in the period 2010-2013.

Laryngeal tube as airway rescue device from prehospital tracheostomy: a case report.

Airway management is a priority for the critically ill patient. The insertion of a cuffed tracheal tube is the best practice to obtain an airway control; however, it is associated with many practical problems in prehospital trauma care. When this common procedure is not available, it can be substituted by an extraglottic airway. We report the case of a 54-year-old victim of a multi-vehicle collision brought to the Emergency Department of a Level One Trauma Center by Emergency Medical Service. Initial evaluation revealed a Glasgow Coma Scale score of 8 and a fixed and midriatic right pupil, suggesting a severe head injury. The patient did not show any predictable sign of difficult intubation. After oxygen administration and cervical spine immobilization a rapid sequence induction was carried out and intubation failed after three attempts. Then a laryngeal tube (LT) was successfully placed and connected with a transport ventilator. The transfer to the hospital took 20 minutes with SpO(2) level of 99% and end tidal carbon dioxide not above 42 mmHg. The patient was properly ventilated by the LT during the computed tomography scan investigations. Due to the impossibility of endotracheal intubation the patient underwent surgical tracheostomy as suggested by the ear nose throat surgeon consultant. This case suggests that LT could be an important alternative device for airway management in trauma patients after a failed tracheal intubation. LT is a precious tool to achieve good ventilation and oxygenation from the field to the operatory theatre.

Subnanomole detection and quantitation of high specific activity 32P-nucleotides.

Microbore liquid chromatography utilizes conventional HPLC and ultraviolet detection principles to determine subnanomole mass quantities of biologically significant molecules. This system takes advantage of specifically designed microflow equipment to analyze ultraviolet absorbing species at the picomole range. 32P-labeled nucleotides are examples of compounds routinely used at picomole quantities that are extremely difficult to accurately quantify using standard mass measurement techniques. The procedure described in this paper has the capability of measuring nucleotides down to 10 pmol using commercially available microbore ultraviolet detection equipment. The technique can be used to accurately measure the specific activity of as little as 10 microCi of an aqueous 32P-nucleotide solution.