Prehospital accuracy of (H)EMS pelvic ring injury assessment and the application of non-invasive pelvic binder devices.

BACKGROUND: Pre-hospital application of a non-invasive pelvic binder device (NIPBD) is essential to increase chances of survival by limiting blood loss in patients with an unstable pelvic ring injury. However, unstable pelvic ring injuries are often not recognized during prehospital assessment. We investigated the prehospital (helicopter) emergency medical services ((H)EMS)' accuracy of the assessment of unstable pelvic ring injuries and NIPBD application rate. METHODS: We performed a retrospective cohort study on all patients with a pelvic injury transported by (H)EMS to our level one trauma centre between 2012 and 2020. Pelvic ring injuries were included and radiographically categorized using the Young & Burgess classification system. Lateral Compression (LC) type II/III -, Anterior-Posterior (AP) type II/III - and Vertical Shear (VS) injuries were considered as unstable pelvic ring injuries. (H)EMS charts and in-hospital patient records were evaluated to determine the sensitivity, specificity and diagnostic accuracy of the prehospital assessment of unstable pelvic ring injuries and prehospital NIPBD application. RESULTS: A total of 634 patients with pelvic injuries were identified, of whom 392 (61.8%) had pelvic ring injuries and 143 (22.6%) had unstable pelvic ring injuries. (H)EMS personnel suspected a pelvic injury in 30.6% of the pelvic ring injuries and in 46.9% of the unstable pelvic ring injuries. An NIPBD was applied in 108 (27.6%) of the patients with a pelvic ring injury and in 63 (44.1%) of the patients with an unstable pelvic ring injury. (H)EMS prehospital diagnostic accuracy measured in pelvic ring injuries alone was 67.1% for identifying unstable pelvic ring injuries from stable pelvic ring injuries and 68.1% for NIPBD application. CONCLUSION: The (H)EMS prehospital sensitivity of unstable pelvic ring injury assessment and NIPBD application rate is low. (H)EMS did not suspect an unstable pelvic injury nor applied an NIPBD in roughly half of all unstable pelvic ring injuries. We advise future research on decision tools to aid the routine use of an NIPBD in any patient with a relevant mechanism of injury.

Characteristics of helicopter emergency medical services (HEMS) dispatch cancellations during a six-year period in a Dutch HEMS region.

BACKGROUND: For decades, Helicopter Emergency Medical Services (HEMS) contribute greatly to prehospital patient care by performing advanced medical interventions on-scene. Unnecessary dispatches, resulting in cancellations, cause these vital resources to be temporarily unavailable and generate additional costs. A previous study showed a cancellation rate of 43.5% in our trauma region. However, little recent data about cancellation rates and reasons exist, despite revision of dispatch protocols. This study examines the current cancellation rate in our trauma region over a six-year period. Additionally, cancellation reasons are evaluated per type of dispatch and initial incident report, upon which HEMS is dispatched. METHODS: This retrospective study analyzed the data of the Dutch HEMS Lifeliner 1 (North-West region of the Netherlands, covering a population of 5 million inhabitants), analyzing all subsequent cases between April 1st 2013 and April 1st 2019. Patient characteristics, type of dispatch (primary; based on dispatcher criteria versus secondary, as judged by the first ambulance team on site), initial incident report received by the EMS dispatch center, and information regarding day- or nighttime dispatches were collected. In case of cancellation, cancel rate and reason per type of dispatch and initial incident report were assessed. RESULTS: In total, 18,638 dispatches were included. HEMS was canceled in 54.5% (95% CI 53.8-55.3%) of cases. The majority of canceled dispatches (76.1%) were canceled because respiratory, hemodynamic, and neurologic parameters were stable. Dispatches simultaneously activated with EMS (primary dispatch) were canceled in 58.3%, compared to 15.1% when HEMS assistance was requested by EMS based on their findings on-scene (secondary dispatch). A cancellation rate of 54.6% was found in trauma related dispatches (n = 12,148), compared to 52.2% in non-trauma related dispatches (n = 5378). Higher cancellation rates exceeding 60% were observed in the less common dispatch categories, e.g., anaphylaxis (66.3%), unknown incident report (66.0%), assault with a blunt object (64.1%), obstetrics (62.8%), and submersion (61.9%). CONCLUSION: HEMS cancellations are increased, compared to previous research in our region. Yet, the cancellations are acceptable as the effect on HEMS' unavailbility remains minimized. Focus should be on identifying the patient in need of HEMS care while maintaining overtriage rates low. Continuous evaluation of HEMS triage is important, and dispatch criteria should be adjusted if necessary.

The psoas compartment block for hip surgery: the past, present, and future.

A posterior lumbar plexus block or psoas compartment block (PCB) is an effective locoregional anesthetic technique for analgesia and anesthesia of the entire lower extremity including the hip. Since the first description in the early seventies, this technique has been modified based on advanced knowledge of the anatomical localization of the lumbar plexus and the improvement of technical equipment. This paper provides an overview of the history, clinical efficacy, and risk profile of the PCB focused on hip surgery. Current status and future expectations are discussed.

Psoas compartment block for lower extremity surgery: a meta-analysis.

Psoas compartment block (PCB) is a potentially useful but controversial technique for lower limb surgery. We have conducted a systematic review of the efficacy and safety of PCB for anaesthesia and postoperative analgesia for hip and knee surgery. Relevant studies were identified within PubMed, EMBASE, and the Cochrane Library. The main outcome measure for anaesthesia was anaesthetic efficacy. For postoperative analgesia, the severity of postoperative pain was compared. The data were subjected to meta-analysis using relative risks with 95% confidence intervals (95% CI) for dichotomous variables and weighted mean differences with 95% CI for continuous variables. Thirty publications were included. PCB is an effective intervention for analgesia after hip and knee surgery. It appears superior to opioids for pain relief after hip surgery. This analgesic benefit may be extended beyond 8 h by the use of a catheter technique. Compared with Winnie's 3-in-1 block, PCB is associated with more consistent block of the obturator nerve. PCB may be an alternative to postoperative neuraxial block. Although PCB combined with sciatic nerve block and sedation is an effective technique for minor knee surgery, there is currently insufficient data to recommend the use of this approach for hip and major knee surgery. PCB is a safe and effective alternative for analgesia after hip and knee surgery. More research is required to define its role in the intraoperative setting and confirm potentially beneficial effects on variables such as perioperative haemodynamics and blood loss.

Celecoxib: a new option in the treatment of arthropathies and familial adenomatous polyposis.

The discovery of the two isoenzymes of cyclooxygenase (COX) has recently lead to the development and clinical introduction of specific inhibitors of cyclooxygenase-2 (COX-2), such as celecoxib, onto the market. Celecoxib is an effective anti-inflammatory, analgesic and antipyretic agent therapeutically utilised in the management of osteoarthritis and rheumatoid arthritis. In addition, celecoxib has some novel therapeutic and pharmacological activities. Celecoxib inhibits anti-apoptotic kinase activation and is the first specific COX-2 inhibitor to be marketed for familial adenomatous polyposis, an inheritable predisposition for colorectal cancer. Celecoxib is not without gastrointestinal (GI) side effects but demonstrates markedly reduced GI ulceration in clinical trials when compared to traditional non-specific non-steroidal anti-inflammatory drugs (NSAIDs). The specific COX-2 inhibitors each have distinctive pharmacokinetic properties. Celecoxib can be given either once or twice daily. Racial differences in drug disposition, and pharmacokinetic changes in elderly patients, patients with chronic renal insufficiency and patients with mild to moderate hepatic impairment, are evident with celecoxib. Despite the specific action of these drugs, there remains the potential for significant drug interactions. Celecoxib has demonstrated interactions with fluconazole, lithium and warfarin. Increased clinical vigilance should be maintained when co-prescribing medications with celecoxib until further clinical experience is gained. Celecoxib represents a major therapeutic advance in terms of GI safety. However, long-term safety in other organ systems, safety with concomitant drug administration, and pharmacoeconomic benefits still remain to be proven.

Temporal lobe pathology in amyotrophic lateral sclerosis. Do amyotrophic lateral sclerosis and Alzheimer's disease share a common etiological factor?

An autopsy study was performed on temporal lobe samples from 20 non-demented patients with amyotrophic lateral sclerosis (ALS), 17 age-matched non-demented controls and 4 Alzheimer's disease (AD) patients. Formalin fixed, paraffin embedded sections from the hippocampus with adjacent parahippocampal gyrus and from the superior temporal gyrus were stained with conventional and immunohistochemical stains. Immunohistochemical staining for the A4 protein was enhanced by pretreatment with 0.25% pepsin before 100% formic acid. The incidence and severity of AD-like pathological changes were similar in ALS patients and non-demented controls. In both groups, pathological changes increased with age. This study does not support the hypothesis that ALS and AD share an etiopathogenetic background.