Enhanced trauma care for the severely injured: A helicopter view of early interventions and diagnostics

The main objective of this dissertation was to enhance the understanding and management of patients with severe injuries. Several related topics were explored to improve trauma care. Part I focused on predictive factors for the outcome after severe traumatic injury, while Part II addressed diagnostics and interventions in prehospital and inhospital settings. PART I Chapter 2 discusses the definition of severely injured patients, critical for decision-making in trauma care. Current definitions often rely on anatomical injury scoring systems like the Injury Severity Score (ISS), which may not fully predict outcomes. A holistic approach, integrating injury mechanism, anatomical injuries, and physiological effects, is suggested for better outcome prediction and tailored interventions. Chapter 3 examines the impact of socioeconomic status (SES) on trauma outcomes, analyzing 967 patients with an ISS ≥16 from two Dutch level 1 trauma centers. SES, determined via postal code, was not associated with mortality or hospital length of stay. However, patients with lower SES had longer ICU stays and were more likely to have penetrating injuries. In Chapter 4, a retrospective study investigated prehospital time and trauma outcomes using data from a Dutch trauma registry. Among 342 polytrauma patients, no significant difference was found in mortality based on prehospital time (p=0.156). Mortality was 25.7%, with a median prehospital time of approximately 45 minutes for both survivors and non-survivors. PART II Chapter 5 retrospectively assessed survival rates in traumatic cardiac arrest (TCA) treated by Dutch Helicopter Emergency Services (P-HEMS). Among 915 patients, return of spontaneous circulation (ROSC) was achieved in 28.5%, and 3.9% survived. Survival was higher in patients under 70 years (5.2%) and those with a shockable rhythm (p<0.001). Chapter 6 evaluated the impact of prehospital ultrasound in trauma care through a literature review. Among 2,889 patients in nine studies, prehospital ultrasound significantly influenced management in up to 48.9% of cases. High sensitivity and specificity were observed for pneumothorax, free abdominal fluid, and hemoperitoneum. Standardized protocols and training are recommended for further improvement. Chapter 7 compared the effects of P-HEMS versus non-physician Emergency Medical Services (EMS) on patients with severe traumatic brain injury (TBI). Fourteen studies revealed mixed results on mortality and neurological outcomes. Mortality decreased in three studies, especially for patients with a Glasgow Coma Scale (GCS) score of 6–8, but increased in two. Neurological outcomes were improved in five studies, though findings varied widely. Chapter 8 analyzed laboratory test use in trauma management, including 1,287 patients from a level 1 trauma center. Abnormal values in D-dimer, pO2, glucose, creatinine, and alcohol were common in unstable patients or those requiring emergency intervention. Regularly obtained tests like MCV, INR, amylase, fibrinogen, and thrombocytes were abnormal in only a small number of cases, suggesting a need to reconsider routine testing in stable trauma patients.