RESUMEN
BACKGROUND: Older patients with traumatic brain injury (TBI) have higher mortality and morbidity than their younger counterparts. Palliative care (PC) is recommended for all patients with a serious or life-limiting illness. However, its adoption for trauma patients has been variable across the nation. The goal of this study was to assess PC utilization and intensity of care in older patients with severe TBI. We hypothesized that PC is underutilized despite its positive effects. MATERIALS AND METHODS: The National Inpatient Sample database (2009-2013) was queried for patients aged ≥55 y with International Classification of Diseases, Ninth Revision codes for TBI with loss of consciousness ≥24 h. Outcome measures included PC rate, in-hospital mortality, discharge disposition, length of stay (LOS), and intensity of care represented by craniotomy and or craniectomy, ventilator use, tracheostomy, and percutaneous endoscopic gastrostomy. RESULTS: Of 5733 patients, 78% died in hospital with a median LOS of 1 d, and 85% of the survivors were discharged to facilities. The overall PC rate was 35%. Almost 40% of deaths received PC, with nearly half within 48 h of admission. PC was used in 26% who had neurosurgical procedures, compared with 35% who were nonoperatively managed (P = 0.003). PC was associated with less intensity of care in the entire population. For survivors, those with PC had significantly shorter LOS, compared with those without PC. CONCLUSIONS: Despite high mortality, only one-third of older patients with severe TBI received PC. PC was associated with decreased use of life support and lower intensity of care. Significant efforts need to be made to bridge this quality gap and improve PC in this high-risk population.
Asunto(s)
Atención de Apoyo Vital Avanzado en Trauma/estadística & datos numéricos , Lesiones Traumáticas del Encéfalo/terapia , Cuidados Paliativos/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Centros Traumatológicos/estadística & datos numéricos , Atención de Apoyo Vital Avanzado en Trauma/organización & administración , Atención de Apoyo Vital Avanzado en Trauma/tendencias , Factores de Edad , Anciano , Anciano de 80 o más Años , Lesiones Traumáticas del Encéfalo/diagnóstico , Lesiones Traumáticas del Encéfalo/mortalidad , Bases de Datos Factuales/estadística & datos numéricos , Femenino , Necesidades y Demandas de Servicios de Salud/organización & administración , Necesidades y Demandas de Servicios de Salud/estadística & datos numéricos , Necesidades y Demandas de Servicios de Salud/tendencias , Mortalidad Hospitalaria , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Cuidados Paliativos/normas , Cuidados Paliativos/tendencias , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/tendencias , Mejoramiento de la Calidad/organización & administración , Mejoramiento de la Calidad/estadística & datos numéricos , Mejoramiento de la Calidad/tendencias , Estudios Retrospectivos , Centros Traumatológicos/organización & administración , Centros Traumatológicos/tendencias , Estados UnidosRESUMEN
No disponible
Asunto(s)
Humanos , Masculino , Anciano , Atención de Apoyo Vital Avanzado en Trauma/ética , Cuidados Críticos/ética , Unidades de Cuidados Intensivos/ética , Atención de Apoyo Vital Avanzado en Trauma/métodos , Atención de Apoyo Vital Avanzado en Trauma/tendencias , Toma de DecisionesRESUMEN
No disponible
Asunto(s)
Humanos , Niño , Heridas y Lesiones/terapia , Traumatismo Múltiple/terapia , Calidad de la Atención de Salud/tendencias , Atención de Apoyo Vital Avanzado en Trauma/tendencias , Mejoramiento de la Calidad/tendencias , Grupo de Atención al Paciente/organización & administraciónRESUMEN
INTRODUCTION: In remote and mountainous areas, helicopter emergency medical systems (HEMS) are used to expedite evacuation and provide pre-hospital advanced trauma life support (ATLS) in major trauma victims. Aim of the study was to investigate feasibility of ATLS in HEMS mountain rescue missions and its influence on patient condition at hospital admission. PATIENTS: 58 major trauma victims (Injury Severity Score ≥16), evacuated by physician staffed HEMS from remote and mountainous areas in the State of Tyrol, Austria between 1.1.2011 and 31.12.2013. RESULTS: Pre-hospital time exceeded 90min in 24 (44%) cases. 31 (53%) patients suffered critical impairment of at least one vital function (systolic blood pressure <90mmHg, GCS <10, or respiratory rate <10 or >30). 4 (6.9%) of 58 patients died prior to hospital admission. Volume resuscitation was restrictive: 18 (72%) of 25 hypotensive patients received ≤500ml fluids and blood pressure was increased >90mmHg at hospital admission in only 9 (36%) of these 25 patients. 8 (50%) of 16 brain trauma patients with a blood pressure <90mmHg remained hypotensive at hospital admission. Endotracheal intubation was accomplished without major complications in 15 (79%) of 19 patients with a Glasgow Coma Scale score <10. Rope operations were necessary in 40 (69%) of 58 cases and ATLS was started before hoist evacuation in 30 (75%) of them. CONCLUSIONS: The frequent combination of prolonged pre-hospital times, with critical impairment of vital functions, supports the need for early ATLS in HEMS mountain rescue missions. Pre-hospital endotracheal intubation is possible with a high success and low complication rate also in a mountain rescue scenario. Pre-hospital volume resuscitation is restrictive and hypotension is reversed at hospital admission in only one third of patients. Prolonged pre-hospital hypotension remains an unresolved problem in half of all brain trauma patients and indicates the difficulties to increase blood pressure to a desired level in a mountain rescue scenario. Despite technical considerations, on-site ATLS is feasible for an experienced emergency physician in the majority of rope rescue operations.
Asunto(s)
Atención de Apoyo Vital Avanzado en Trauma/organización & administración , Ambulancias Aéreas , Servicios Médicos de Urgencia , Medicina de Emergencia Basada en la Evidencia/organización & administración , Montañismo/normas , Traumatismo Múltiple/terapia , Médicos , Medicina Silvestre/organización & administración , Atención de Apoyo Vital Avanzado en Trauma/tendencias , Austria , Medicina de Emergencia Basada en la Evidencia/métodos , Medicina de Emergencia Basada en la Evidencia/tendencias , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Medicina Silvestre/métodos , Medicina Silvestre/tendenciasRESUMEN
No disponible
Asunto(s)
Humanos , Niño , Atención de Apoyo Vital Avanzado en Trauma/instrumentación , Atención de Apoyo Vital Avanzado en Trauma/métodos , Atención de Apoyo Vital Avanzado en Trauma/tendencias , Heridas y Lesiones/diagnóstico , Taponamiento Cardíaco/diagnóstico , Taponamiento Cardíaco/terapia , Heridas y Lesiones/terapia , Hipovolemia/complicaciones , Hipovolemia/diagnóstico , Reanimación Cardiopulmonar/tendencias , Toracotomía/métodosRESUMEN
Aunque la mortalidad por trauma supera los 5 millones al año en todo el mundo, con innumerables incapacidades y enormes costes, faltan estándares globales y uniformes para su organización y manejo. Los cambios en el conocimiento y los cuidados del paciente con trauma grave han sido espectaculares en las últimas décadas, pero los recursos en investigación, organización y cuidados no han crecido de forma paralela. En nuestro medio, la enfermedad traumática se sitúa muy por debajo de la investigación y organización de otras enfermedades graves. En los últimos años hemos cambiado nuestros modelos en investigación en trauma, organización, cambios en la reanimación inicial, la presencia de la TC como pieza clave en el manejo inicial, etc. Estos cambios actuales y de futuro del manejo del paciente traumatizado generan una valoración y tratamiento multidisciplinares, siendo necesaria la presencia del especialista en Medicina Intensiva como parte fundamental en el equipo de atención al trauma grave y su posterior cuidado en la unidad de críticos
Despite an annual trauma mortality of 5 million people worldwide, resulting in countless physical disabilities and enormous expenses, there are no standardized guidelines on trauma organization and management. Over the last few decades there have been very notorious improvements in severe trauma care, though organizational and economical aspects such as research funding still need to be better engineered. Indeed, trauma lags behind other serious diseases in terms of research and organization. The rapid developments in trauma care have produced original models available for research projects, initial resuscitation protocols and radiological procedures such as CT for the initial management of trauma patients, among other advances. This progress underscores the need for a multidisciplinary approach to the initial management and follow-up of this complicated patient population, where intensivists play a major role in both the patient admission and subsequent care at the trauma unit
Asunto(s)
Femenino , Humanos , Masculino , Heridas y Lesiones/diagnóstico , Heridas y Lesiones/terapia , Atención de Apoyo Vital Avanzado en Trauma/tendencias , Atención de Apoyo Vital Avanzado en Trauma , Unidades de Cuidados Intensivos/organización & administración , Unidades de Cuidados Intensivos/normas , Cuidados Críticos/métodos , Cuidados Críticos/normas , Primeros Auxilios/instrumentación , Primeros Auxilios/métodos , Tratamiento de Urgencia/instrumentación , Tratamiento de Urgencia/métodos , Tratamiento de Urgencia/tendenciasRESUMEN
The pre-hospital and early in-hospital management of most severely injured patients has dramatically changed over the last 20 years. In this context, the factor time has gained more and more attention, particularly in German-speaking countries. While the management in the early 1990s aimed at comprehensive and complete therapy at the accident site, the premise today is to stabilise trauma patients at the accident site and transfer them into the hospital rapidly. In addition, the introduction of training and education programmes such as Pre-hospital Trauma Life Support (PHTLS(®)), Advanced Trauma Life Support (ATLS(®)) concept or the TEAM(®) concept has increased the quality of treatment of most severely injured trauma patients both in the preclinical field and in the emergency trauma room. Today, all emergency surgical procedures in severely injured patients are generally performed in accordance with the Damage Control Orthopaedics (DCO) principle. The advancements described in this article provide examples for the improved quality of the management of severely injured patients in the preclinical field and during the initial in-hospital treatment phase. The implementation of trauma networks, the release of the S3 polytrauma guidelines, and the DGU "Weißbuch" have contributed to a more structured management of most severely injured patients.