Point-of-care ultrasound (POCUS) is a valuable tool in the prehospital management of critically ill patients, particularly patients with trauma, dyspnea, or shock. This review aims to evaluate the diagnostic and therapeutic applications, limitations, and implementation challenges of POCUS in prehospital care. Key findings are that ultrasound, particularly the extended Focused Assessment with Sonography in Trauma (eFAST) protocol, offers high specificity in identifying severe hemorrhage in trauma cases, although its sensitivity varies depending on the clinical context and operator experience. In dyspnea, pulmonary ultrasound significantly enhances diagnostic accuracy, aiding early detection of heart failure and other respiratory conditions. For shock, focused echocardiography facilitates rapid diagnosis and timely therapeutic decisions, improving patient outcomes. However, the effectiveness of POCUS is highly dependent on the operator’s expertise, and challenges such as time, space, and resource limitations in prehospital settings may impact its use. Furthermore, local studies in Latin America assessing the impact of prehospital ultrasound on morbidity and mortality reduction are lacking. Based on our review, we recommend standardized training programs, increased availability of portable ultrasound devices, and prospective studies on cost-benefit analysis to optimize POCUS implementation in prehospital systems, particularly in resource-limited regions. Prehospital ultrasound has the potential to revolutionize patient care by improving diagnostic precision and reducing time to definitive treatment, but its successful implementation requires strategic integration of technology, education, and research.
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This review explores the concept of “blood failure” in traumatic injury, which arises from the interplay of oxygen debt, the endotheliopathy of trauma (EoT), and acute traumatic coagulopathy (ATC). Traumatic hemorrhage leads to the accumulation of oxygen debt, which can further exacerbate hemorrhage by triggering a cascade of events when severe. Such events include EoT, characterized by endothelial glycocalyx damage, and ATC, involving platelet dysfunction, fibrinogen depletion, and dysregulated fibrinolysis. To manage blood failure effectively, a multifaceted approach is crucial. Damage control resuscitation strategies such as use of permissive hypotension, early hemorrhage control, and aggressive transfusion of blood products including whole blood aim to minimize oxygen debt and promote its repayment while addressing endothelial damage and coagulation. Transfusions of red blood cells, plasma, and platelets, as well as the use of tranexamic acid, play key roles in hemostasis and countering ATC. Whole blood, whether fresh or cold-stored, is emerging as a promising option to address multiple needs in traumatic hemorrhage. This review underscores the intricate relationships between oxygen debt, EoT, and ATC and highlights the importance of comprehensive, integrated strategies in the management of traumatic hemorrhage to prevent blood failure. A multidisciplinary approach is essential to address these interconnected factors effectively and to improve patient outcomes.
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Objective Musculoskeletal ultrasound is increasingly used as the modality of choice in diagnosing many medical situations. The present study aimed to compare the accuracy of point-of-care ultrasonography (POCUS) and magnetic resonance imaging (MRI) to detect acute medial meniscus tears in knee. Methods The prospective study was conducted on patients with suspected medial meniscus tears in knee. in the emergency department. In the absence of a knee fracture on x-ray, POCUS on the knee was performed. All patients underwent POCUS and MRI of the knee followed by arthroscopy. POCUS findings were then compared to MRI findings to diagnose medial meniscus tears. Results A final total of 157 patients with a mean age of 25.04±7.41 years was included. Out of 157 patients, 94 (59.9%) were male. Medial meniscus tears were detected in 89 patients (56.7%) using arthroscopy as the gold standard. The sensitivity, specificity, positive and negative predictive values, and accuracy of POCUS to detect medial meniscus tears were 88.8% (95% confidence interval [CI], 80.3%–94.5%), 89.7% (95% CI, 79.9%–95.8%), 91.9% (95% CI, 84.8%–95.8%), 85.9% (95% CI, 77.2%–91.7%), and 89.2% (95% CI, 83.3%–93.6%), respectively. The diagnostic accuracy of MRI to detect medial meniscus injury was 93.0% (95% CI, 87.8%– 96.4%). Conclusion The present study demonstrated that POCUS is an accurate and reliable diagnostic tool alternative to MRI in detecting medial meniscal tears. POCUS had acceptable sensitivity, specificity, and accuracy in detecting meniscal injuries and could be performed as an effective immediate investigation to guide further modalities in patients with acute knee trauma
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Objective Fall from height (FFH) is a major public health problem that can result in severe injury, disability, and death. This study investigated how the characteristics of jumpers and fallers differ.
Methods This was a retrospective study of FFH patients enrolled in an Emergency Department-based Injury In-depth Surveillance (EDIIS) registry between 2011 and 2018. Depending on whether the injury was intentional, FFH patients who had fallen from a height of at least 1 m were divided into two groups: jumpers and fallers. Patient characteristics, organ damage, and death were compared between the two groups, and factors that significantly affected death were identified using multivariable logistic analysis.
Results Among 39,419 patients, 1,982 (5.0%) were jumpers. Of the jumpers, 977 (49.3%) were male, while 30,643 (81.9%) of fallers were male. The jumper group had the highest number of individuals in their 20s, with the number decreasing as age increased. In contrast, the number of individuals in the faller group rose until reaching their 50s, after which it declined. More thoracoabdominal, spinal, and brain injuries were found in jumpers. The in-hospital mortality of jumpers and fallers was 832 (42.0%) and 1,268 (3.4%), respectively. Intentionality was a predictor of in-hospital mortality, along with sex, age, and fall height, with an odds ratio of 7.895 (95% confidence interval, 6.746–9.240).
Conclusion Jumpers and fallers have different epidemiological characteristics, and jumpers experienced a higher degree of injury and mortality than fallers. Differentiated prevention and treatment strategies are needed for jumpers and fallers to reduce mortality in FFH patients.
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Objective Trauma is a global health problem. The causes of trauma-related deaths are diverse and may depend in part on socioeconomic and geographical factors; however, there have been few studies addressing such relationships. The aim of this study was to investigate the relationships between trauma and geographical factors in order to support policy recommendations to reduce trauma-related deaths and disability.
Methods In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched international and Korean databases to retrieve relevant literature published between 2000 and 2020.
Results Thirty-two studies showed a positive relationship between the outcomes of major trauma and geographical factors. The study investigated regional factors including economic factors such as size of urban areas, gross domestic product, and poverty rate, as well as hospital parameters, such as presence of trauma centers and number of hospital beds. There was a tendency toward higher mortality rates in rural and low-income areas, and most of the studies reported that the presence of trauma centers reduced trauma-related mortality rates.
Conclusion Our study showed that geographic factors influence trauma outcomes. The findings suggest geographical considerations be included in care plans to reduce death and disability caused by trauma.
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Objective Agriculture is a hazardous industry. However, previous studies have focused on injuries to agricultural workers without comparison with injuries to nonagricultural workers. Therefore, we compared the clinical characteristics and outcomes of injuries reported at an emergency department (ED) between agricultural workers and nonagricultural workers.
Methods We established a prospective ED-based agricultural injury surveillance system at a tertiary university hospital. Adult patients visiting the ED for an injury were divided into farmer and non-farmer groups depending on their engagement with agriculture. Using an adjusted multivariate analysis and propensity score matching (age, sex, inhabitant, and insurance type), we compared the clinical characteristics and outcomes of injuries between the farmer and non-farmer groups.
Results In total, 38,556 injured adult patients (37,746 in the non-farmer group and 810 in the farmer group) were available for the unmatched sample analysis. The 1,620 matched subjects were equally classified after one-to-one nearest-neighbor propensity score matching. A multivariate logistic regression analysis of the unmatched sample revealed higher adjusted odds ratios (ORs) for intensive care unit admission (adjusted OR, 1.752; P=0.003) and overall surgery (adjusted OR, 1.870; P<0.001) in the farmer group. In contrast, univariate logistic regression analyses of the propensity score–matched sample found a higher OR in the farmer group only for overall surgery (OR, 1.786; P<0.001).
Conclusion Injuries of agricultural workers had higher odds only of requiring surgery; differences in injury-related mortality between groups were not statistically significant in either the matched or unmatched sample analyses.
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Objective Multiple trauma is associated with a remarkable risk of in-hospital complications, which harm healthcare services and patients. This study aimed to assess the incidence of posttrauma complications, their relationship with poor outcomes, and the effect of the Injury Severity Score (ISS) on their occurrence.
Methods This retrospective cohort study was conducted at a pair of trauma centers, between January 2020 and December 2022. All hospitalized adult patients with multiple trauma were included in this study. Multivariable logistic regression was used to identify factors related to posttrauma complications.
Results Among 727 multiple trauma patients, 90 (12.4%) developed in-hospital complications. The most frequent complications were pneumonia (4.8%), atelectasis (3.7%), and superficial surgical site infection (2.5%). According to multivariable logistic regression, ISS, the length of stay in the intensive care unit (ICU), the length of stay in the hospital, and mortality were significantly associated with complications. The complication rate increased by 17% with every single-unit increase in ISS (adjusted odds ratio [OR], 1.17; 95% confidence interval [CI], 1.00–1.38). Per every 1-day increase in the ICU or hospital stay, the complication rate increased by 65% (adjusted OR, 1.65; 95% CI, 1.00–2.73) and 20% (adjusted OR, 1.20; 95% CI, 1.03–1.41), respectively. Posttrauma complications were also significantly more common in patients with mortality (adjusted OR, 163.30; 95% CI, 3.04–8,779.32). In multiple trauma patients with a higher ISS, the frequency, severity, and number of complications were significantly increased.
Conclusion In-hospital complications in multiple trauma patients are frequent and associated with poor outcomes and mortality. ISS is an important factor associated with posttrauma complications.
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Objective This study aimed to describe the relationship between sex and survival in patients experiencing unintentional trauma.
Methods This retrospective, national population–based observational, case-control study involved a cohort of Korean trauma patients who were transferred to an emergency department by a Korean emergency medical service from January 1 to December 31, 2018. Propensity score matching was used. The primary outcome was survival until hospital discharge.
Results Of 25,743 patients with severe unintentional trauma, 17,771 were male and 7,972 were female. Prior to propensity score matching, there was no significant difference in survival among male and female patients (92.6% vs. 93.1%, P=0.105). After using propensity score matching to adjust for confounders, there was still no sex difference in survival (male, 93.6% vs. female, 93.1%; P=0.270).
Conclusion Survival after severe trauma was not influenced by the sex of the patient. Further studies with patients of reproductive age and a larger study population are needed to analyze the effects of sex on survival in patients with trauma.
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Objective The global spread of the COVID-19 pandemic has affected all aspects of medicine, including orthopedic trauma surgery. This study aims to investigate whether COVID-19 patients who underwent orthopedic surgery trauma had a higher risk of postoperative mortality.
Methods ScienceDirect, the Cochrane COVID-19 Study Register, and MEDLINE were searched for original publications. This study adhered to the PPRISMA 2020 statement. The validity of the studies was evaluated using a checklist developed by the Joanna Briggs Institute. Study and participant characteristics, as well as the odds ratio, were extracted from selected publications. Data were analyzed using RevMan ver. 5.4.1.
Results After applying the inclusion and exclusion criteria, 16 articles among 717 total were deemed eligible for analysis. Lower-extremity injuries were the most common condition, and pelvic surgery was the most frequently performed intervention. There were 456 COVID-19 patients (6.12%) and 134 deaths among COVID-19 patients, revealing an increase in mortality (29.38% vs. 5.30%; odds ratio, 7.72; 95% confidence interval, 6.01–9.93; P<0.001).
Conclusion Among COVID-19 patients who received orthopedic surgery due to trauma, the postoperative death rate increased by 7.72 times.
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Objective The aim of this study was to determine the feasibility of using machine learning to establish the need for preclinical airway management for injured patients based on a standardized emergency dataset.
Methods A registry-based, retrospective analysis was conducted of adult trauma patients who were treated by physician-staffed emergency medical services in southwestern Germany between 2018 and 2020. The primary outcome was to assess the feasibility of using the random forest (RF) and Naive Bayes (NB) machine learning algorithms to predict the need for preclinical airway management. The secondary outcome was to use a principal component analysis to determine the attributes that can be used and advanced for future model development.
Results In total, 25,556 adults with multiple injuries were identified, including 1,451 patients (5.7%) who required airway management. Key attributes were auscultation, injury pattern, oxygen therapy, thoracic drainage, noninvasive ventilation, catecholamines, pelvic sling, colloid infusion, initial vital signs, preemergency status, and shock index. The area under the receiver operating characteristics curve was between 0.96 (RF; 95% confidence interval [CI], 0.96–0.97) and 0.93 (NB; 95% CI, 0.92–0.93; P<0.01). For the prediction of airway management, RF yielded a higher precision-recall area than NB (0.83 [95% CI, 0.8–0.85] vs. 0.66 [95% CI, 0.61–0.72], respectively; P<0.01).
Conclusion To predict the need for preclinical airway management in injured patients, attributes that are commonly recorded in standardized datasets can be used with machine learning. In future models, the RF algorithm could be used because it has robust prediction accuracy.
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Maxillofacial trauma occasionally presents a serious challenge for physicians, and an orofacial injury can be considered life-threatening. It is difficult to control the bleeding and prevent airway obstruction simultaneously with conventional treatment. Herein, we share two cases in which we managed massive orofacial bleeding using a King laryngeal tube, a supraglottic airway device equipped with an inflatable balloon. Both patients had uncontrolled orofacial bleeding. In one of the patients, endotracheal intubation was possible; however, bleeding continued, and vital signs became unstable. The second patient had failed endotracheal intubation due to uncontrolled bleeding. We deployed the King laryngeal tube in both patients and achieved bleeding control and airway maintenance. Both patients were discharged without complications after 3 to 4 weeks. The King laryngeal tube method can be considered a useful management option for addressing massive orofacial bleeding that is uncontrollable with conventional treatment.
Objective To examine the features of powered mobility device-related injuries and identify the predictors of injury severity in such settings.
Methods Emergency Department-based Injury In-depth Surveillance data from 2011 to 2018 were used in this retrospective study. Participants were assigned to the mild/moderate and severe groups based on their excess mortality ratio–adjusted injury severity score and their general injury-related factors and injury outcome-related factors were compared.
Results Of 407 patients, 298 (79.2%) were assigned to the mild/moderate group and 109 (26.8%) to the severe group. The severe group included a higher percentage of patients aged 70 years or older (43.0% vs. 59.6%, P=0.003), injuries incurred in the daytime (72.6% vs. 82.4%, P=0.044), injuries from traffic accidents and falls (P=0.042), head injuries (38.6% vs. 80.7%, P<0.001), torso injuries (16.8% vs. 32.1%, P=0.001), overall hospital admission (28.5% vs. 82.6%, P<0.001), intensive care unit admission (1.7% vs. 37.6%, P<0.001), death after admission (1.4% vs. 10.3%, P=0.034), and total mortality (0.7% vs. 9.2%, P<0.001). The odds ratios (ORs) for injury severity were as follows: age 70 years or older (OR, 2.124; 95% confidence interval [CI], 1.239–3.642), head injury (OR, 10.441; 95% CI, 5.465–19.950), and torso injury (OR, 4.858; 95% CI, 2.495–9.458).
Conclusion The proportions of patients aged 70 years or older, head and torso injuries, injuries from traffic accidents and falls, and injuries in the daytime were higher in the severe group. Our results highlight the need for measures to address these factors to lower the incidence of severe injuries.
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Objective Peripheral vertigo is one of the most common causes of the emergency department (ED) visits. It can impair balance and might predispose patients to injuries after discharge. The purpose of this study was to determine whether peripheral vertigo is associated with an increased risk of trauma.
Methods This matched-cohort study used the nationally representative dataset of de-identified claim information of 1 million randomly sampled individuals from a real Korean population, from 2002 to 2013. The exposure cohort included patients who visited EDs for new-onset peripheral vertigo without prior or concurrent injury. Each patient was randomly matched to five unexposed individuals (also without previous injury) by incidence density sampling. The primary outcome was a new injury within 1 year. The secondary outcomes were various injury subtypes. The time-dependent effect of the exposure was modeled using the extended Cox model. Age, sex, comorbidities, and household income level were included as covariates.
Results A total of 776 and 3,880 individuals were included as the exposure and comparison cohorts, respectively. The risks of trunk injury and upper extremity injury were significantly higher in the exposure cohort. Extended Cox models with multivariable adjustment showed significantly increased risk for up to 1 year, with the first 1-month; 1 month to 3 months; and 3 months to 1 year hazard ratios of 5.23 (95% confidence interval [CI], 2.83–9.64); 1.50 (95% CI, 1.02–2.20); and 1.37 (95% CI, 1.11–1.68), respectively.
Conclusion Patients visiting EDs for acute peripheral vertigo are at a higher risk of a new injury for up to a year.
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The United States Navy originally utilized the concept of damage control to describe the process of prioritizing the critical repairs needed to return a ship safely to shore during a maritime emergency. To pursue a completed repair would detract from the goal of saving the ship. This concept of damage control management in crisis is well suited to the care of the critically ill trauma patient, and has evolved into the standard of care. Damage control resuscitation is not one technique, but, rather, a group of strategies which address the lethal triad of coagulopathy, acidosis, and hypothermia. In this article, we describe this approach to trauma resuscitation and the supporting evidence base.
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Objective To evaluate the prognostic factors associated with the sustained return of spontaneous circulation (ROSC) and survival to hospital discharge in traumatic out-of-hospital cardiac arrest (TOHCA) patients without prehospital ROSC.
Methods We analyzed Korean nationwide data from the Out-of-Hospital Cardiac Arrest Surveillance, and included adult TOHCA patients without prehospital ROSC from January 2012 to December 2016. The primary outcome was sustained ROSC (>20 minutes). The secondary outcome was survival to discharge. Multivariate analysis was performed to investigate factors associated with the outcomes of TOHCA patients.
Results Among 142,905 cases of OHCA, 8,326 TOHCA patients were investigated. In multivariate analysis, male sex (odds ratio [OR], 1.326; 95% confidence interval [CI], 1.103–1.594; P=0.003), and an initial shockable rhythm (OR, 1.956; 95% CI, 1.113–3.439; P=0.020) were significantly associated with sustained ROSC. Compared with traffic crash, collision (OR, 1.448; 95% CI, 1.086–1.930; P=0.012) was associated with sustained ROSC. Fall (OR, 0.723; 95% CI, 0.589– 0.888; P=0.002) was inversely associated with sustained ROSC. Male sex (OR, 1.457; 95% CI, 1.026–2.069; P=0.035) and an initial shockable rhythm (OR, 4.724; 95% CI, 2.451–9.106; P<0.001) were significantly associated with survival to discharge. Metropolitan city (OR, 0.728; 95% CI, 0.541–0.980; P=0.037) was inversely associated with survival to discharge. Compared with traffic crash, collision (OR, 1.745; 95% CI, 1.125–2.708; P=0.013) was associated with survival to discharge.
Conclusion Male sex, an initial shockable rhythm, and collision could be favorable factors for sustained ROSC, whereas fall could be an unfavorable factor. Male sex, non-metropolitan city, an initial shockable rhythm, and collision could be favorable factors in survival to discharge.
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