“A-OK”: Chest Radiograph during Primary Survey Facilitates Faster, More Accurate Endotracheal Tube Position in Injured Children

The Advanced Trauma Life Support algorithm recommends bedside confirmatory techniques to confirm correct endotracheal tube (ETT) depth, a critical component in the care of pediatric trauma patients. We hypothesized that bedside confirmatory techniques are inaccurate and that early chest X-ray (CXR) would overcome such inaccuracies, allowing for faster intervention of malpositioned ETTs. An “A-OK” algorithm of immediate CXR following intubation in injured children aged <16 years was implemented. Eligible patients the years before and after implementation were identified. The accuracy of bedside confirmatory techniques (use of length-based depths and auscultation of breath sounds) was assessed. Post-“A-OK” patients were compared with pre-“A-OK” controls regarding the speed of malpositioned ETTrepositioning. Twenty-eight post-“A-OK” cases and 23 pre-“A-OK” controls were identified. The groups did not differ in baseline characteristics. Bedside confirmatory techniques were accurate in only 61 per cent (length-based depth) and 58 per cent (auscultation of breath sounds) of patients. Time to ETT repositioning was significantly longer in pre-“A-OK” controls than in post-“A-OK” cases (35.2 ± 15.9 minutes vs 21.1 ± 11.8 minutes, P = 0.03). Bedside confirmatory techniques to determine ETT positioning are inaccurate in children. Inclusion of CXR in the primary survey is safe and allows for more rapid repositioning of malpositioned ETTs.

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Pediatric Trauma

10.2310/em.4403 ◽

2017 ◽

Author(s):

Kathleen Bryant ◽

Jeremiah Smith ◽

Michael Gibbs

Keyword(s):

Cervical Spine ◽

Head Trauma ◽

Abdominal Trauma ◽

Life Support ◽

Pediatric Trauma ◽

Research Network ◽

Advanced Trauma Life Support ◽

Primary Survey ◽

Persistent Symptoms ◽

National Emergency

Children have unique anatomy and physiologic responses to trauma that create different challenges for their management. It is important to follow the Advanced Trauma Life Support (ATLS) algorithm for assessing and treating a pediatric trauma patient, paying close attention to the primary survey. Once the primary survey is accomplished with adequate stabilization, the secondary survey proceeds with a focus on specific injuries. Head trauma is the leading cause of morbidity and mortality (M+M) in children. Early identification and prevention of secondary injury are important to optimize outcomes. The head and neck anatomic differences in a child cause a higher fulcrum of their cervical spine, leading to higher cervical spine injuries (CSIs). CSI is rare but carries a higher M+M due to higher spinal cord injuries. The National Emergency X-radiography Utilization Study (NEXUS) and Canadian C-spine Rule (CCR) are useful decision rules to clear cervical spines in adults but have limited strength in young children. PECARN has derived a pediatric cervical spine clearance rule, but this has yet to be prospectively validated. Similar to CSIs, thoracic injuries in children are rare but carry a higher M+M due to anatomic differences in children. A child’s chest anatomy and increased compliance cause more difficulty in injury identification. Abdominal trauma is common in children and can also be difficult to identify. Unlike adults, children can compensate for blood loss much longer while maintaining their blood pressure. Serial abdominal examinations are useful when imaging is negative and a patient has persistent symptoms. This review contains 5 highly rendered figures, 18 tables, and 92 references. Key words: abdominal trauma, Advanced Trauma Life Support (ATLS), cervical spine injury, head trauma, National Emergency X-radiography Utilization Study (NEXUS), Pediatric Emergency Care Applied Research Network (PECARN), thoracic trauma, traumatic brain injury

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Review of Different Management Modalities of Penetrating Thoracic and Abdominal Trauma

QJM ◽

10.1093/qjmed/hcaa050.026 ◽

2020 ◽

Vol 113 (Supplement_1) ◽

Author(s):

A M Almaraghy ◽

M S Farahat ◽

K R Sallam ◽

M M A Elsaigh

Keyword(s):

Life Support ◽

Operative Procedure ◽

Management Strategies ◽

Cost Savings ◽

Gunshot Wounds ◽

Comfort Level ◽

Advanced Trauma Life Support ◽

Trauma Patients ◽

Diffuse Abdominal Pain ◽

Primary Survey

Abstract Introduction The advanced trauma life support (ATLS) training program was developed to provide uniformity in the assessment and management of trauma patients. Every trauma patient is evaluated using the primary survey; a rapid reproducible physical exam designed to diagnose those conditions that are immediately life-threatening first. The primary survey consists of the sequential assessment and treatment of airway, breathing, circulation, disability and exposure/environment, represented by the mnemonic (A.B.C.D.E) Objectives To review the different management strategies of penetrating abdominal and thoracic trauma. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2018. Conclusions In summation, most patients with PAT, especially gunshot wounds, still require surgery. On initial survey, patients who are hemodynamically unstable, have diffuse abdominal pain; evisceration, or peritoneal findings must go to the operating room. Patients with an altered sensorium, head injury, inability to cooperate with serial abdominal exams, or patients who will be undergoing an operative procedure somewhere other than the abdomen may be explored as well, depending on the comfort level of the trauma surgeon. This leaves a clinical subset that can be managed non operatively. In these patients, SNOM can drastically reduce the rates of negative and nontherapeutic laparotomies and result in a cost savings and safety benefit to the patient.

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Case Report: FAST Ultrasound Interpretation in Trauma Resuscitation

POCUS Journal ◽

10.24908/pocus.v1i3.13263 ◽

2016 ◽

Vol 1 (3) ◽

pp. 13-14

Author(s):

Stuart Douglas, PGY4 ◽

Joseph Newbigging, MD ◽

David Robertson, MD

Keyword(s):

Case Report ◽

Negative Predictive Value ◽

Predictive Value ◽

Life Support ◽

Advanced Trauma Life Support ◽

Trauma Patients ◽

Ultrasound Probe ◽

Trauma Resuscitation ◽

Highly Sensitive ◽

Pouch Of Douglas

FAST Background: Focused Assessment with Sonography for Trauma (FAST) is an integral adjunct to primary survey in trauma patients (1-4) and is incorporated into Advanced Trauma Life Support (ATLS) algorithms (4). A collection of four discrete ultrasound probe examinations (pericardial sac, hepatorenal fossa (Morison’s pouch), splenorenal fossa, and pelvis/pouch of Douglas), it has been shown to be highly sensitive for detection of as little as 100cm3 of intraabdominal fluid (4,5), with a sensitivity quoted between 60-98%, specificity of 84-98%, and negative predictive value of 97-99% (3).

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Impact of Implementation of Sequential Trauma Education Programs (STEPs) Course on Missed Injuries in Emergency Polytrauma Patients, Ismailia, Egypt

10.21203/rs.3.rs-147008/v1 ◽

2021 ◽

Author(s):

Adel Hamed Elbaih ◽

Maged El-Setouhy ◽

Jon Mark Hirshon ◽

Hazem Mohamed El-Hariri ◽

Mohamed El-Shinawi

Keyword(s):

Low Income ◽

Life Support ◽

University Hospital ◽

Low Income Countries ◽

Advanced Trauma Life Support ◽

Trauma Patients ◽

Education Programs ◽

Missed Injuries ◽

Polytrauma Patients ◽

Trauma Education

Abstract IntroductionTrauma deaths account for 8% of all deaths in Egypt. Patients with multiple injuries are at high risk but may be saved with a good triage system and a well-trained trauma team in dedicated institutions. The incidence of missed injuries in the Emergency Department (ED) of Suez Canal University Hospital (SCUH) was found to be 9.0% after applying Advanced Trauma Life Support (ATLS) guidelines. However, this rate is still high compared with many trauma centers.AimImprove the quality of management of polytrauma patients by decreasing the incidence of missed injuries by implementing the Sequential Trauma Education Programs (STEPs) course in the ED at SCUH.MethodsThis interventional training study was conducted in the SCUH ED that adheres to CONSORT guidelines. The study was conducted during the 1-month precourse and for 6 months after the implementation of the STEPs course for ED physicians. Overall, 458 polytrauma patients were randomly selected, of which 45 were found to have missed injuries after applying the inclusion and exclusion criteria. We assessed the clinical relevance of these cases for missed injuries before and after the STEPs course.ResultsOverall, 45 patients were found to have missed injuries, of which 15 (12%) were pre-STEPs and 30 (9%) were post-STEPs course. The STEPs course significantly increased adherence to vital data recording, but the reduction of missed injuries (3.0%) was not statistically significant in relation to demographic and trauma findings. However, the decrease in missed injuries in the post-STEPs course group was an essential clinically significant finding.ConclusionSTEPs course implementation decreased the incidence of missed injuries in polytrauma patients. Thus, the STEPs course can be considered at the same level of other advanced trauma courses as a training skills program or possibly better in dealing with trauma patients. Repetition of this course by physicians should be mandatory to prevent more missed injuries. Therefore, the validation of STEPs course certification should be completed at least every 2 years to help decrease the number of missed injuries, especially in low-income countries and low-resource settings.Trial RegistrationProject manager for the Pan African Clinical Trial Registry (www.pactr.org) database has been accepted with the date of approval:18/11/2020. Current Controlled Trials number for the registry is PACTR202011853914203. Please note that the article state Retrospectively registered that my study adheres to CONSORT guidelines.

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Permissive Hypotension in Bleeding Trauma Patients: Helpful or Not and When?

Critical Care Nurse ◽

10.4037/ccn2013395 ◽

2013 ◽

Vol 33 (6) ◽

pp. 18-24 ◽

Cited By ~ 7

Author(s):

Stavros Gourgiotis ◽

George Gemenetzis ◽

Hemant M. Kocher ◽

Stavros Aloizos ◽

Nikolaos S. Salemis ◽

...

Keyword(s):

Clinical Trials ◽

Life Support ◽

Operative Management ◽

Advanced Trauma Life Support ◽

Trauma Patients ◽

Permissive Hypotension ◽

Randomized Controlled Clinical Trials ◽

Resuscitation Fluid ◽

Crystalloid Solutions ◽

Prehospital Trauma Life Support

Severity of hemorrhage and rate of bleeding are fundamental factors in the outcomes of trauma. Intravenous administration of fluid is the basic treatment to maintain blood pressure until bleeding is controlled. The main guideline, used almost worldwide, Advanced Trauma Life Support, established by the American College of Surgeons in 1976, calls for aggressive administration of intravenous fluids, primarily crystalloid solutions. Several other guidelines, such as Prehospital Trauma Life Support, Trauma Evaluation and Management, and Advanced Trauma Operative Management, are applied according to a patient’s current condition. However, the ideal strategy remains unclear. With permissive hypotension, also known as hypotensive resuscitation, fluid administration is less aggressive. The available models of permissive hypotension are based on hypotheses in hypovolemic physiology and restricted clinical trials in animals. Before these models can be used in patients, randomized, controlled clinical trials are necessary.

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Prehospital Care and In-hospital Mortality of Trauma Patients in Iran

Prehospital and Disaster Medicine ◽

10.1017/s1049023x14000879 ◽

2014 ◽

Vol 29 (5) ◽

pp. 473-477 ◽

Cited By ~ 9

Author(s):

Mohammad Paravar ◽

Mehrdad Hosseinpour ◽

Mahdi Mohammadzadeh ◽

Azade Sadat Mirzadeh

Keyword(s):

Hospital Mortality ◽

Trauma Center ◽

Injury Severity ◽

Life Support ◽

Prehospital Care ◽

Advanced Trauma Life Support ◽

Trauma Patients ◽

Publication Type ◽

Transport Time ◽

Severe Injuries

AbstractIntroductionThe aim of this study was to determine the effect of prehospital time and advanced trauma life support interventions for trauma patients transported to an Iranian Trauma Center.MethodsThis study was a retrospective study of trauma victims presenting to a trauma center in central Iran by Emergency Medical Services (EMS) and hospitalized more than 24 hours. Demographic and injury characteristics were obtained, including accident location, damaged organs, injury mechanism, injury severity score, prehospital times (response, scene, and transport), interventions and in-hospital outcome.ResultsTwo thousand patients were studied with an average age of 36.3 (SD = 20.8) years; 83.1% were male. One hundred twenty patients (6.1%) died during hospitalization. The mean response time, at scene time and transport time were 6.6 (SD = 3), 11.1 (SD = 5.2) and 12.8 (SD = 9.4), respectively. There was a significant association of longer transport time to worse outcome (P = .02). There was a trend for patients with transport times >10 minutes to die (OR: 0.8; 95% CI, 0.1-6.59). Advanced Life Support (ALS) interventions were applied for patients with severe injuries (Revised Trauma Score ⩽7) and ALS intervention was associated with more time on scene. There was a positive association of survival with ALS interventions applied in suburban areas (P = .001).ConclusionIn-hospital trauma mortality was more common for patients with severe injuries and long prehospital transport times. While more severely injured patients received ALS interventions and died, these interventions were associated with positive survival trends when conducted in suburban and out-of-city road locations with long transport times.HosseinpourM, ParavarM, MohammadzadehM, MirzadehAS. Prehospital care and in-hospital mortality of trauma patients in Iran. Prehosp Disaster Med. 2014;29(5):1-5.

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EXTRACORPOREAL LIFE SUPPORT (ECLS) FOR PEDIATRIC TRAUMA PATIENTS WITH RESPIRATORY FAILURE

Critical Care Medicine ◽

10.1097/00003246-199801001-00104 ◽

1998 ◽

Vol 26 (Supplement) ◽

pp. 52A ◽

Cited By ~ 1

Author(s):

Martin S. Keller ◽

Harry L. Anderson ◽

Perry W. Stafford

Keyword(s):

Respiratory Failure ◽

Life Support ◽

Extracorporeal Life Support ◽

Pediatric Trauma ◽

Trauma Patients

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Initial Management of Life-Threatening Trauma

10.2310/ps.2129 ◽

2018 ◽

Author(s):

Emily Cantrell ◽

Jay Doucet

Keyword(s):

Life Support ◽

Rapid Assessment ◽

Trauma System ◽

Injured Patient ◽

Initial Assessment ◽

Advanced Trauma Life Support ◽

Primary Survey ◽

Field Triage ◽

Life Threatening ◽

Secondary Survey

Management of the critically injured patient is optimized by a coordinated team effort in an organized trauma system that allows for rapid assessment and initiation of life-preserving therapies. This initial assessment must proceed systematically and be prioritized according to physiologic necessity for survival. Beginning in the prehospital setting, coordination, preparation, and appropriate triage of the injured are crucial to facilitating rapid resuscitation of the trauma patient. Next, active efforts to support airway, breathing, circulation, and disability are performed with simultaneous intervention to treat life-threatening injuries and restore hemodynamic stability in the primary survey. With ongoing evaluation and continued resuscitation, a secondary survey provides a head-to-toe assessment of the patient allowing for further diagnosis of injuries and triage to more definitive care. This review contains 12 figures, 8 tables and 63 references Key Words: advanced trauma life support, definitive airway, FAST/eFAST, field triage, Glasgow coma scale, primary survey, 1:1:1 resuscitation, secondary survey

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Incidental Findings in Trauma Patients during Focused Assessment with Sonography for Trauma

The American Surgeon ◽

10.1177/000313481207800349 ◽

2012 ◽

Vol 78 (3) ◽

pp. 366-372 ◽

Cited By ~ 2

Author(s):

Sophocles Lanitis ◽

Constantinos Zacharioudakis ◽

Paraskevi Zafeiriadou ◽

Vasileios Armoutides ◽

Charilaos Karaliotas ◽

...

Keyword(s):

Incidental Findings ◽

Life Support ◽

Univariate Analysis ◽

Biliary Tree ◽

Initial Assessment ◽

Advanced Trauma Life Support ◽

Trauma Patients ◽

Management Algorithm ◽

Surgical Conditions ◽

Mechanism Of Trauma

During the initial assessment of trauma patients they usually undergo a Focused Assessment with Sonography for Trauma (FAST) in which there are occasionally incidental findings of other surgical conditions. In this audit we discuss the incidence, demographics, and implications of these findings and we propose a management algorithm. Within 2 years we managed 6041 trauma patients in the emergency department based on the Advanced Trauma Life Support protocols, 95 per cent of which underwent a FAST ultrasound. Incidental findings were reported in 468 patients (7.8%), whereas in a further 11.2 per cent of these patients there was a second finding. The mean age of these patients was 57.55 years (15–105), and most of them were men (51.1%). The vast majority of the findings were related to the liver and biliary tree (52.1%) followed by the urinary track (27.1% 1 8%). In multivariate analysis only the age was a significant factor associated with incidental findings ( P < 0.001) whereas in univariate analysis both the gender [men (54.1%) vs women (45.9), P = 0.013] and the mechanism of trauma ( P < 0.001) were as important as the age ( P < 0.001). The patients who had incidental findings were 15 years older than the rest. The detection of unknown surgical conditions in FAST may lead to managerial and possible medico-legal issues rendering the development of a proper algorithm mandatory.

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Characteristics of pediatric thoracic trauma: in view of before and after the establishment of a regional trauma center

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-021-01658-4 ◽

2021 ◽

Author(s):

Pil Young Jung ◽

Jae Sik Chung ◽

Youngin Youn ◽

Chang Wan Kim ◽

Il Hwan Park ◽

...

Keyword(s):

Trauma Center ◽

Traffic Accidents ◽

Thoracic Trauma ◽

Injury Severity ◽

Pediatric Trauma ◽

Trauma Patients ◽

Efficient Treatment ◽

Before And After ◽

Level 1 ◽

Tissue Recovery

Abstract Purpose Pediatric thoracic trauma differs from those of adult in terms of the small anatomy and rapid tissue recovery. Therefore, it is important to know the characteristics of the pediatric thoracic trauma to improve treatment results. In addition, this study examined the changes in pediatric thoracic trauma features and results from the establishment of a level 1 regional trauma center. Methods Data of 168 patients’ ≤ 15 years old diagnosed with thoracic trauma between 2008 and 2019 were retrospectively analyzed. Results Pedestrian traffic accidents were the most common cause of chest injury. The average injury severity score was 17.1 ± 12.4 and the average pediatric trauma score was 5.6 ± 4.1. Lung contusion was the most common in 134 cases. There were 48 cases of closed thoracostomy. There was one thoracotomy for cardiac laceration, one case for extracorporeal membranous oxygenation, and six cases for embolization. Of all, 25 patients died, providing a mortality rate of 14.9%. In addition, independent risk factors of in-hospital mortality were hemopneumothorax and cardiac contusion. Since 2014, when the level 1 regional trauma center was established, more severely injured thoracic trauma patients came. However, the mortality was similar in the two periods. Conclusions Understanding the clinical features of pediatric thoracic trauma patients can help in efficient treatment. In addition, as the severity of pediatric thoracic trauma patients has increased due to the establishment of the regional trauma center, so pediatric trauma center should be organized in regional trauma center to improve the outcomes of pediatric thoracic trauma.

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