Publications by authors named "Dennis Den Hartog"

81 Publications

Complications and range of motion of patients with an elbow dislocation treated with a hinged external fixator: a retrospective cohort study.

Eur J Trauma Emerg Surg 2022 Jun 25. Epub 2022 Jun 25.

Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.

Purpose: Elbow dislocations are at risk for persistent instability and stiffness of the joint. Treatment with a hinged external fixation provides elbow joint stability, and allows early mobilization to prevent stiffness. Mounting a hinged elbow fixator correctly, however, is technically challenging. The low incidence rate of elbow dislocations with persistent instability suggests that centralization would result in higher surgeon exposure and consequently in less complications. This study aimed to investigate the results of treatment of elbow dislocations with a hinged elbow fixator on the rate of complications, range of motion, level of pain and restrictions in activities of daily living.

Methods: A retrospective observational cohort study in a level I trauma center, in which the majority of patients was treated by a dedicated elbow surgeon, was performed. All patients of 16 years or older treated with a hinged external elbow fixator between January 1, 2006 and December 31, 2017 were included. The fixator could be used (1) for the treatment of persistent instability in acute/residual simple and complex dislocations or (2) as revision surgery to treat joint incongruency or a stiff elbow. Patient and injury characteristics, details on treatment, complications, secondary interventions, and range of motion were extracted from the patients' medical files.

Results: The results of treatment of 34 patients were analyzed with a median follow-up of 13 months. The fixator was removed after a median period of 48 days. Fixator-related complications encountered were six pintract infections, one redisclocation, one joint incongruency, one muscle hernia, and one hardware failure. The median range of motion at the end of follow-up was 140° flexion, 15° constraint in extension, 90° pronation, and 80° supination.

Conclusion: A hinged elbow fixator applied by a dedicated elbow surgeon in cases of elbow instability after elbow dislocations can result in excellent joint function. Fixator-related complications are mostly mild and only temporary.
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http://dx.doi.org/10.1007/s00068-022-02013-xDOI Listing
June 2022

Correction to: Prehospital traumatic cardiac arrest: a systematic review and meta-analysis.

Eur J Trauma Emerg Surg 2022 Aug;48(4):3373

Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.

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http://dx.doi.org/10.1007/s00068-022-01975-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9360153PMC
August 2022

Severe isolated injuries have a high impact on resource use and mortality: a Dutch nationwide observational study.

Eur J Trauma Emerg Surg 2022 Apr 21. Epub 2022 Apr 21.

Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.

Purpose: The Berlin poly-trauma definition (BPD) has proven to be a valuable way of identifying patients with at least a 20% risk of mortality, by combining anatomical injury characteristics with the presence of physiological risk factors (PRFs). Severe isolated injuries (SII) are excluded from the BPD. This study describes the characteristics, resource use and outcomes of patients with SII according to their injured body region, and compares them with those included in the BPD.

Methods: Data were extracted from the Dutch National Trauma Registry between 2015 and 2019. SII patients were defined as those with an injury with an Abbreviated Injury Scale (AIS) score ≥ 4 in one body region, with at most minor additional injuries (AIS ≤ 2). We performed an SII subgroup analysis per AIS region of injury. Multivariable linear and logistic regression models were used to calculate odds ratios (ORs) for SII subgroup patient outcomes, and resource needs.

Results: A total of 10.344 SII patients were included; 47.8% were ICU admitted, and the overall mortality was 19.5%. The adjusted risk of death was highest for external (2.5, CI 1.9-3.2) and for head SII (2.0, CI 1.7-2.2). Patients with SII to the abdomen (2.3, CI 1.9-2.8) and thorax (1.8, CI 1.6-2.0) had a significantly higher risk of ICU admission. The highest adjusted risk of disability was recorded for spine injuries (10.3, CI 8.3-12.8). The presence of ≥ 1 PRFs was associated with higher mortality rates compared to their poly-trauma counterparts, displaying rates of at least 15% for thoracic, 17% for spine, 22% for head and 49% for external SII.

Conclusion: A severe isolated injury is a high-risk entity and should be recognized and treated as such. The addition of PRFs to the isolated anatomical injury criteria contributes to the identification of patients with SII at risk of worse outcomes.
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http://dx.doi.org/10.1007/s00068-022-01972-5DOI Listing
April 2022

The impact of video laryngoscopy on the first-pass success rate of prehospital endotracheal intubation in The Netherlands: a retrospective observational study.

Eur J Trauma Emerg Surg 2022 Apr 1. Epub 2022 Apr 1.

Department of Anesthesiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.

Purpose: The first-pass success rate for endotracheal intubation (ETI) depends on provider experience and exposure. We hypothesize that video laryngoscopy (VL) improves first-pass and overall ETI success rates in low and intermediate experienced airway providers and prevents from unrecognized oesophageal intubations in prehospital settings.

Methods: In this study 3632 patients were included. In all cases, an ambulance nurse, HEMS nurse, or HEMS physician performed prehospital ETI using direct Laryngoscopy (DL) or VL.

Results: First-pass ETI success rates for ambulance nurses with DL were 45.5% (391/859) and with VL 64.8% (125/193). For HEMS nurses first-pass success rates were 57.6% (34/59) and 77.2% (125/162) respectively. For HEMS physicians these successes were 85.9% (790/920) and 86.9% (1251/1439). The overall success rate for ambulance nurses with DL was 58.4% (502/859) and 77.2% (149/193) with VL. HEMS nurses successes were 72.9% (43/59) and 87.0% (141/162), respectively. HEMS physician successes were 98.7% (908/920) and 99.0% (1425/1439), respectively. The incidence of unrecognized intubations in the oesophagus before HEMS arrival in traumatic circulatory arrest (TCA) was 30.6% with DL and 37.5% with VL. In medical cardiac arrest cases the incidence was 20% with DL and 0% with VL.

Conclusion: First-pass and overall ETI success rates for ambulance and HEMS nurses are better with VL. The used device does not affect success rates of HEMS physicians. VL resulted in less unrecognized oesophageal intubations in medical cardiac arrests. In TCA cases VL resulted in more oesophageal intubations when performed by ambulance nurses before HEMS arrival.
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http://dx.doi.org/10.1007/s00068-022-01962-7DOI Listing
April 2022

Prehospital traumatic cardiac arrest: a systematic review and meta-analysis.

Eur J Trauma Emerg Surg 2022 Aug 25;48(4):3357-3372. Epub 2022 Mar 25.

Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.

Background: Circulatory arrest after trauma is a life-threatening situation that mandates urgent action. The aims of this systematic review and meta-analysis on prehospital traumatic cardiac arrest (TCA) were to provide an updated pooled mortality rate for prehospital TCA, to investigate the impact of the time of patient inclusion and the type of prehospital trauma system on TCA mortality rates and neurological outcome, and to investigate which pre- and intra-arrest factors are prognostic for prehospital TCA mortality.

Methods: This review was conducted in accordance with the PRISMA and CHARMS guidelines. Databases were searched for primary studies published about prehospital TCA patients (1995-2020). Studies were divided into various EMS-system categories. Data were analyzed using MedCalc, Review Manager, Microsoft Excel, and Shinyapps Meta Power Calculator software.

Results: Thirty-six studies involving 51.722 patients were included. Overall mortality for TCA was 96.2% and a favorable neurological outcome was seen in 43.5% of the survivors. Mortality rates were 97.2% in studies including prehospital deaths and 92.3% in studies excluding prehospital deaths. Favorable neurological outcome rates were 35.8% in studies including prehospital deaths and 49.5% in studies excluding prehospital deaths. Mortality rates were 97.6% if no physician was available at the prehospital scene and 93.9% if a physician was available. Favorable neurological outcome rates were 57.0% if a physician was available on scene and 38.0% if no physician was available. Only non-shockable rhythm was associated with a higher mortality (RR 1.12, p = 0.06).

Conclusion: Approximately 1 in 20 patients with prehospital TCA will survive; about 40% of survivors have favorable neurological outcome.
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http://dx.doi.org/10.1007/s00068-022-01941-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9360068PMC
August 2022

Functional and clinical outcome after operative versus nonoperative treatment of a humeral shaft fracture (HUMMER): results of a multicenter prospective cohort study.

Eur J Trauma Emerg Surg 2022 Aug 9;48(4):3265-3277. Epub 2022 Feb 9.

Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.

Purpose: The best treatment of humeral shaft fractures in adults is still under debate. This study aimed to compare functional and clinical outcome of operative versus nonoperative treatment in adult patients with a humeral shaft fracture. We hypothesized that operative treatment would result in earlier functional recovery.

Methods: From October 23, 2012 to October 03, 2018, adults with a humeral shaft fracture AO type 12A or 12B were enrolled in a prospective cohort study in 29 hospitals. Patients were treated operatively or nonoperatively. Outcome measures were the Disabilities of the Arm, Shoulder, and Hand score (DASH; primary outcome), Constant-Murley score, pain (Visual Analog Score, VAS), health-related quality of life (Short Form-36 (SF-36) and EuroQoL-5D-3L (EQ-5D)), activity resumption (Numeric Rating Scale, NRS), range of motion (ROM) of the shoulder and elbow joint, radiologic healing, and complications. Patients were followed for one year. Repeated measure analysis was done with correction for age, gender, and fracture type.

Results: Of the 390 included patients, 245 underwent osteosynthesis and 145 were primarily treated nonoperatively. Patients in the operative group were younger (median 53 versus 62 years; p < 0.001) and less frequently female (54.3% versus 64.8%; p = 0.044). Superior results in favor of the operative group were noted until six months follow-up for the DASH, Constant-Murley, abduction, anteflexion, and external rotation of the shoulder, and flexion and extension of the elbow. The EQ-US, and pronation and supination showed superior results for the operative group until six weeks follow-up. Malalignment occurred only in the nonoperative group (N = 14; 9.7%). In 19 patients with implant-related complications (N = 26; 10.6%) the implant was exchanged or removed. Nonunion occurred more often in the nonoperative group (26.3% versus 10.10% in the operative group; p < 0.001).

Conclusion: Primary osteosynthesis of a humeral shaft fracture (AO type 12A and 12B) in adults is safe and superior to nonoperative treatment, and should therefore be the treatment of choice. It is associated with a more than twofold reduced risk of nonunion, earlier functional recovery and a better range of motion of the shoulder and elbow joint than nonoperative treatment. Even after including the implant-related complications, the overall rate of complications as well as secondary surgical interventions was highest in the nonoperative group.

Trial Registration: NTR3617 (registration date 18-SEP-2012).
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http://dx.doi.org/10.1007/s00068-022-01890-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9360107PMC
August 2022

The Detrimental Impact of the COVID-19 Pandemic on Major Trauma Outcomes in the Netherlands: A Comprehensive Nationwide Study.

Ann Surg 2022 02;275(2):252-258

Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.

Objective: To evaluate the impact of the COVID-19 pandemic on the outcome of major trauma patients in the Netherlands.

Summary Background Data: Major trauma patients highly rely on immediate access to specialized services, including ICUs, shortages caused by the impact of the COVID-19 pandemic may influence their outcome.

Methods: A multi-center observational cohort study, based on the Dutch National Trauma Registry was performed. Characteristics, resource usage, and outcome of major trauma patients (injury severity score ≥16) treated at all trauma-receiving hospitals during the first COVID-19 peak (March 23 through May 10) were compared with those treated from the same period in 2018 and 2019 (reference period).

Results: During the peak period, 520 major trauma patients were admitted, versus 570 on average in the pre-COVID-19 years. Significantly fewer patients were admitted to ICU facilities during the peak than during the reference period (49.6% vs 55.8%; P=0.016). Patients with less severe traumatic brain injuries in particular were less often admitted to the ICU during the peak (40.5% vs 52.5%; P=0.005). Moreover, this subgroup showed an increased mortality compared to the reference period (13.5% vs 7.7%; P=0.044). These results were confirmed using multivariable logistic regression analyses. In addition, a significant increase in observed versus predicted mortality was recorded for patients who had a priori predicted mortality of 50% to 75% (P=0.012).

Conclusions: The COVID-19 peak had an adverse effect on trauma care as major trauma patients were less often admitted to ICU and specifically those with minor through moderate brain injury had higher mortality rates.
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http://dx.doi.org/10.1097/SLA.0000000000005300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8745885PMC
February 2022

A Nationwide Retrospective Analysis of Out-of-Hospital Pediatric Cardiopulmonary Resuscitation Treated by Helicopter Emergency Medical Service in the Netherlands.

Air Med J 2021 Nov-Dec;40(6):410-414. Epub 2021 Sep 20.

Department of Anesthesiology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands.

Objective: There is generally limited but conflicting literature on the incidence, causes, and outcomes of pediatric out-of-hospital cardiac arrest. This study was performed to determine the incidence and outcome of pediatric out-of-hospital cardiac arrest reported by all helicopter emergency medical services in the Netherlands and to provide a description of causes and treatments and, in particular, a description of the specific interventions that can be performed by a physician-staffed helicopter emergency medical service.

Methods: A retrospective analysis was performed of all documented pediatric (0 < 18 years of age) out-of-hospital cardiac arrests from July 2015 to July 2017, attended by all 4 Dutch helicopter emergency medical service teams.

Results: Two hundred two out-of-hospital cardiac arrests were identified. The overall incidence in the Netherlands is 3.5 out-of-hospital cardiac arrests in children per 100,000 pediatric inhabitants. The overall survival rate for out-of-hospital cardiac arrest was 11.4%. Eleven (52%) of the survivors were in the drowning group and between 12 and 96 months of age.

Conclusion: Helicopter emergency medical services are frequently called to pediatric out-of-hospital cardiac arrests in the Netherlands. The survival rate is normal to high compared with other countries. The 12- to 96-month age group and drowning seem to have a relatively favorable outcome.
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http://dx.doi.org/10.1016/j.amj.2021.08.004DOI Listing
November 2021

The impact of upper-extremity injuries on polytrauma patients at a level 1 trauma center.

J Shoulder Elbow Surg 2022 May 20;31(5):914-922. Epub 2021 Oct 20.

Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands. Electronic address:

Background: Upper-extremity injuries often lead to long-term problems in function and quality of life in patients. However, not much is known about the effects in polytrauma patients. This study aimed to describe the upper-extremity injuries in polytrauma patients and to compare self-reported disability and quality of life in polytrauma patients with vs. without upper-extremity injuries.

Methods: We performed a retrospective cohort study of adult patients with an Injury Severity Score ≥ 16 admitted to Erasmus MC between January 1, 2007, and December 31, 2016. Patients were asked to complete the Disabilities of the Arm, Shoulder and Hand, Short Form 36, and EuroQol-5D questionnaires. Details on injuries, treatment, and clinical outcome were collected from the national trauma registry and medical files. Characteristics and self-reported outcomes of polytrauma patients with vs. without upper-extremity injuries were compared.

Results: In a cohort of 3469 trauma patients, 1246 (36.5%) had upper-extremity injuries. Of these, 278 (22.0%) had severe injuries (Abbreviated Injury Scale score ≥ 3). Upper-extremity injuries were associated with a longer hospitalization (median, 12 days vs. 8 days; P < .001), longer intensive care unit stay (median, 5 days vs. 4 days; P = .005), and lower mortality rate (14.6% vs. 23.9%, P < .001). Among the 598 patients who completed the questionnaires, no differences in the physical component summary score (47 vs. 48, P = .181) and mental component summary score (54 vs. 53, P = .315) of the Short Form 36 questionnaire, as well as the utility score (0.82 vs. 0.85, P = .101) and visual analog scale score (80 vs. 80, P = .963) of the EuroQol-5D questionnaire, were found. However, patients with upper-extremity injuries showed a minor increase in disability in the Disabilities of the Arm, Shoulder and Hand score (9.2 vs. 4.2, P = .023).

Conclusion: Upper-extremity injuries in polytrauma patients are associated with a longer hospitalization, longer intensive care unit stay, and reduced mortality rate, as well as a minor increase in long-term disability.
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http://dx.doi.org/10.1016/j.jse.2021.10.005DOI Listing
May 2022

Primary admission and secondary transfer of trauma patients to Dutch level I and level II trauma centers: predictors and outcomes.

Eur J Trauma Emerg Surg 2022 Jun 29;48(3):2459-2467. Epub 2021 Sep 29.

Trauma Research Unit, Department of Surgery, Erasmus MC University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.

Purpose: The importance and impact of determining which trauma patients need to be transferred between hospitals, especially considering prehospital triage systems, is evident. The objective of this study was to investigate the association between mortality and primary admission and secondary transfer of patients to level I and II trauma centers, and to identify predictors of primary and secondary admission to a designated level I trauma center.

Methods: Data from the Dutch Trauma Registry South West (DTR SW) was obtained. Patients ≥ 18 years who were admitted to a level I or level II trauma center were included. Patients with isolated burn injuries were excluded. In-hospital mortality was compared between patients that were primarily admitted to a level I trauma center, patients that were transferred to a level I trauma center, and patients that were primarily admitted to level II trauma centers. Logistic regression models were used to adjust for potential confounders. A subgroup analysis was done including major trauma (MT) patients (ISS > 15). Predictors determining whether patients were primarily admitted to level I or level II trauma centers or transferred to a level I trauma center were identified using logistic regression models.

Results: A total of 17,035 patients were included. Patients admitted primarily to a level I center, did not differ significantly in mortality from patients admitted primarily to level II trauma centers (Odds Ratio (OR): 0.73; 95% confidence interval (CI) 0.51-1.06) and patients transferred to level I centers (OR: 0.99; 95%CI 0.57-1.71). Subgroup analyses confirmed these findings for MT patients. Adjusted logistic regression analyses showed that age (OR: 0.96; 95%CI 0.94-0.97), GCS (OR: 0.81; 95%CI 0.77-0.86), AIS head (OR: 2.30; 95%CI 2.07-2.55), AIS neck (OR: 1.74; 95%CI 1.27-2.45) and AIS spine (OR: 3.22; 95%CI 2.87-3.61) are associated with increased odds of transfers to a level I trauma center.

Conclusions: This retrospective study showed no differences in in-hospital mortality between general trauma patients admitted primarily and secondarily to level I trauma centers. The most prominent predictors regarding transfer of trauma patients were age and neurotrauma. These findings could have practical implications regarding the triage protocols currently used.
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http://dx.doi.org/10.1007/s00068-021-01790-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9192481PMC
June 2022

Health-related quality of life and return to work 1 year after major trauma from a network perspective.

Eur J Trauma Emerg Surg 2022 Jun 12;48(3):2421-2431. Epub 2021 Sep 12.

Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.

Introduction: Major trauma often results in long-term disabilities. The aim of this study was to assess health-related quality of life, cognition, and return to work 1 year after major trauma from a trauma network perspective.

Methods: All major trauma patients in 2016 (Injury Severity Score > 15, n = 536) were selected from trauma region Southwest Netherlands. Eligible patients (n = 365) were sent questionnaires with the EQ-5D-5L and questions on cognition, level of education, comorbidities, and resumption of paid work 1 year after trauma.

Results: A 50% (n = 182) response rate was obtained. EQ-US and EQ-VAS scored a median (IQR) of 0.81 (0.62-0.89) and 70 (60-80), respectively. Limitations were prevalent in all health dimensions of the EQ-5D-5L; 90 (50%) responders reported problems with mobility, 36 (20%) responders reported problems with self-care, 108 (61%) responders reported problems during daily activities, 129 (73%) responders reported pain or discomfort, 70 (39%) responders reported problems with anxiety or depression, and 102 (61%) of the patients reported problems with cognition. Return to work rate was 68% (37% full, 31% partial). A median (IQR) EQ-US of 0.89 (0.82-1.00) and EQ-VAS of 80 (70-90) were scored for fully working responders; 0.77 (0.66-0.85, p < 0.001) and 70 (62-80, p = 0.001) for partial working respondents; and 0.49 (0.23-0.69, p < 0.001) and 55 (40-72, p < 0.001) for unemployed respondents.

Conclusion: The majority experience problems in all health domains of the EQ-5D-5L and cognition. Return to work status was associated with all health domains of the EQ-5D-5L and cognition.
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http://dx.doi.org/10.1007/s00068-021-01781-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9192406PMC
June 2022

Reply to Letter to the Editor.

J Foot Ankle Surg 2021 Sep-Oct;60(5):1095

Trauma Surgeon, Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.

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http://dx.doi.org/10.1053/j.jfas.2020.06.020DOI Listing
September 2021

Identifying trauma patients with benefit from direct transportation to Level-1 trauma centers.

BMC Emerg Med 2021 08 6;21(1):93. Epub 2021 Aug 6.

Department of Public Health, Erasmus MC University Medical Center, Na-building, room Na-2318, Wytemaweg 80, 3015, Rotterdam, CN, The Netherlands.

Background: Prehospital triage protocols typically try to select patients with Injury Severity Score (ISS) above 15 for direct transportation to a Level-1 trauma center. However, ISS does not necessarily discriminate between patients who benefit from immediate care at Level-1 trauma centers. The aim of this study was to assess which patients benefit from direct transportation to Level-1 trauma centers.

Methods: We used the American National Trauma Data Bank (NTDB), a retrospective observational cohort. All adult patients (ISS > 3) between 2015 and 2016 were included. Patients who were self-presenting or had isolated limb injury were excluded. We used logistic regression to assess the association of direct transportation to Level-1 trauma centers with in-hospital mortality adjusted for clinically relevant confounders. We used this model to define benefit as predicted probability of mortality associated with transportation to a non-Level-1 trauma center minus predicted probability associated with transportation to a Level-1 trauma center. We used a threshold of 1% as absolute benefit. Potential interaction terms with transportation to Level-1 trauma centers were included in a penalized logistic regression model to study which patients benefit.

Results: We included 388,845 trauma patients from 232 Level-1 centers and 429 Level-2/3 centers. A small beneficial effect was found for direct transportation to Level-1 trauma centers (adjusted Odds Ratio: 0.96, 95% Confidence Interval: 0.92-0.99) which disappeared when comparing Level-1 and 2 versus Level-3 trauma centers. In the risk approach, predicted benefit ranged between 0 and 1%. When allowing for interactions, 7% of the patients (n = 27,753) had more than 1% absolute benefit from direct transportation to Level-1 trauma centers. These patients had higher AIS Head and Thorax scores, lower GCS and lower SBP. A quarter of the patients with ISS > 15 were predicted to benefit from transportation to Level-1 centers (n = 26,522, 22%).

Conclusions: Benefit of transportation to a Level-1 trauma centers is quite heterogeneous across patients and the difference between Level-1 and Level-2 trauma centers is small. In particular, patients with head injury and signs of shock may benefit from care in a Level-1 trauma center. Future prehospital triage models should incorporate more complete risk profiles.
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http://dx.doi.org/10.1186/s12873-021-00487-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8344140PMC
August 2021

Proximal humerus fractures (PHFs): comparison of functional outcome 1 year after minimally invasive plate osteosynthesis (MIPO) versus open reduction internal fixation (ORIF).

Eur J Trauma Emerg Surg 2021 Jul 3. Epub 2021 Jul 3.

Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.

Purpose: Osteosynthetic treatment strategies of PHFs include MIPO or ORIF techniques. The aim of this study was to compare the 1 year outcome following either technique in type B PHFs.

Methods: This study was designed as a retrospective cohort study of patients treated at one academic Level 1 trauma center. Patients from 2009 to 2019 who required surgical treatment of a type B PHF were eligible to be included in this study. Patients with A- or C-type fractures or patients requiring arthroplasty were excluded. All patients were treated with Proximal Humerus Interlocking System (PHILOS) and stratified according the approach into Group MIPO or Group ORIF. Outcome measures include local complications that occurred during hospitalization, nonunion after 12 months, and range of motion after 1 year follow-up.

Results: This study included 149 (75.3%) patients in Group ORIF, and 49 (24.7%) in Group MIPO. The fracture morphology and concomitant injuries were comparable amongst these groups. When compared with Group MIPO, Group ORIF had a 2.6 (95% CI 0.6-11.7) higher risk of suffering from local complications. The rate of postoperative nerve lesions was comparable (OR 0.9, 95% CI 0.1-9.7) as was the rate of soft tissue complications (OR 2.0, 95% CI 0.2-17.2). The risk for nonunion was 4.5 times higher (95% 1.1-19.5) in Group ORIF when compared with Group MIPO. Group MIPO had a higher chance of flexion above 90° (OR 8.2, 95% CI 2.5-27.7).

Conclusion: This study provides indications that patients following surgical treatment of PHFs in MIPO technique might have favourable outcome. Large-scale and high-quality studies are warranted to confirm these results.
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http://dx.doi.org/10.1007/s00068-021-01733-wDOI Listing
July 2021

Ambulance deceleration causes increased intra cranial pressure in supine position: a prospective observational prove of principle study.

Scand J Trauma Resusc Emerg Med 2021 Jun 30;29(1):87. Epub 2021 Jun 30.

Department of Trauma Surgery, Dr. Molenwaterplein 40, 3015 GD, Rotterdam, The Netherlands.

Background: Ambulance drivers in the Netherlands are trained to drive as fluent as possible when transporting a head injured patient to the hospital. Acceleration and deceleration have the potential to create pressure changes in the head that may worsen outcome. Although the idea of fluid shift during braking causing intra cranial pressure (ICP) to rise is widely accepted, it lacks any scientific evidence. In this study we evaluated the effects of driving and deceleration during ambulance transportation on the intra cranial pressure in supine position and 30 upright position.

Methods: Participants were placed on the ambulance gurney in supine position. During driving and braking the optical nerve sheath diameter (ONSD) was measured with ultrasound. Because cerebro spinal fluid percolates in the optical nerve sheath when ICP rises, the diameter of this sheath will distend if ICP rises during braking of the ambulance. The same measurements were taken with the headrest in 30 upright position.

Results: Mean ONSD in 20 subjects in supine position increased from 4.80 (IQR 4.80-5.00) mm during normal transportation to 6.00 (IQR 5.75-6.40) mm (p < 0.001) during braking. ONSD's increased in all subjects in supine position. After raising the headrest of the gurney 30 mean ONSD increased from 4.80 (IQR 4.67-5.02) mm during normal transportation to 4.90 (IQR 4.80-5.02) mm (p = 0.022) during braking. In 15 subjects (75%) there was no change in ONSD at all.

Conclusions: ONSD and thereby ICP increases during deceleration of a transporting vehicle in participants in supine position. Raising the headrest of the gurney to 30 degrees reduces the effect of breaking on ICP.
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http://dx.doi.org/10.1186/s13049-021-00904-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8246666PMC
June 2021

Dutch trauma system performance: Are injured patients treated at the right place?

Injury 2021 Jul 16;52(7):1688-1696. Epub 2021 May 16.

Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, the Netherlands.

Background: The goal of trauma systems is to match patient care needs to the capabilities of the receiving centre. Severely injured patients have shown better outcomes if treated in a major trauma centre (MTC). We aimed to evaluate patient distribution in the Dutch trauma system. Furthermore, we sought to identify factors associated with the undertriage and transport of severely injured patients (Injury Severity Score (ISS) >15) to the MTC by emergency medical services (EMS).

Methods: Data on all acute trauma admissions in the Netherlands (2015-2016) were extracted from the Dutch national trauma registry. An ambulance driving time model was applied to calculate MTC transport times and transport times of ISS >15 patients to the closest MTC and non-MTC. A multivariable logistic regression analysis was performed to identify factors associated with ISS >15 patients' EMS undertriage to an MTC.

Results: Of the annual average of 78,123 acute trauma admissions, 4.9% had an ISS >15. The nonseverely injured patients were predominantly treated at non-MTCs (79.2%), and 65.4% of patients with an ISS >15 received primary MTC care. This rate varied across the eleven Dutch trauma networks (36.8%-88.4%) and was correlated with the transport times to an MTC (Pearson correlation -0.753, p=0.007). The trauma networks also differed in the rates of secondary transfers of ISS >15 patients to MTC hospitals (7.8% - 59.3%) and definitive MTC care (43.6% - 93.2%). Factors associated with EMS undertriage of ISS >15 patients to the MTC were female sex, older age, severe thoracic and abdominal injury, and longer additional EMS transport times.

Conclusions: Approximately one-third of all severely injured patients in the Netherlands are not initially treated at an MTC. Special attention needs to be directed to identifying patient groups with a high risk of undertriage. Furthermore, resources to overcome longer transport times to an MTC, including the availability of ambulance and helicopter services, may improve direct MTC care and result in a decrease in the variation of the undertriage of severely injured patients to MTCs among the Dutch trauma networks. Furthermore, attention needs to be directed to improving primary triage guidelines and instituting uniform interfacility transfer agreements.
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http://dx.doi.org/10.1016/j.injury.2021.05.015DOI Listing
July 2021

The definition of major trauma using different revisions of the abbreviated injury scale.

Scand J Trauma Resusc Emerg Med 2021 May 27;29(1):71. Epub 2021 May 27.

Department of Surgery, Trauma Research Unit, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands.

Background: A threshold Injury Severity Score (ISS) ≥ 16 is common in classifying major trauma (MT), although the Abbreviated Injury Scale (AIS) has been extensively revised over time. The aim of this study was to determine effects of different AIS revisions (1998, 2008 and 2015) on clinical outcome measures.

Methods: A retrospective observational cohort study including all primary admitted trauma patients was performed (in 2013-2014 AIS98 was used, in 2015-2016 AIS08, AIS08 mapped to AIS15). Different ISS thresholds for MT and their corresponding observed mortality and intensive care (ICU) admission rates were compared between AIS98, AIS08, and AIS15 with Chi-square tests and logistic regression models.

Results: Thirty-nine thousand three hundred seventeen patients were included. Thresholds ISS08 ≥ 11 and ISS15 ≥ 12 were similar to a threshold ISS98 ≥ 16 for in-hospital mortality (12.9, 12.9, 13.1% respectively) and ICU admission (46.7, 46.2, 46.8% respectively). AIS98 and AIS08 differed significantly for in-hospital mortality in ISS 4-8 (χ = 9.926, p = 0.007), ISS 9-11 (χ = 13.541, p = 0.001), ISS 25-40 (χ = 13.905, p = 0.001) and ISS 41-75 (χ = 7.217, p = 0.027). Mortality risks did not differ significantly between AIS08 and AIS15.

Conclusion: ISS08 ≥ 11 and ISS15 ≥ 12 perform similarly to a threshold ISS98 ≥ 16 for in-hospital mortality and ICU admission. This confirms studies evaluating mapped datasets, and is the first to present an evaluation of implementation of AIS15 on registry datasets. Defining MT using appropriate ISS thresholds is important for quality indicators, comparing datasets and adjusting for injury severity.

Level Of Evidence: Prognostic and epidemiological, level III.
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http://dx.doi.org/10.1186/s13049-021-00873-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8162011PMC
May 2021

Computer-Controlled Cooling in Operatively Treated Ankle or Hindfoot Fractures: A Retrospective Case-Control Study.

J Foot Ankle Surg 2021 Nov-Dec;60(6):1131-1136. Epub 2021 Apr 21.

Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.

Ankle and hindfoot fractures are often associated with a considerable amount of pain and need for systemic analgesics. Cooling devices have been developed to reduce swelling, pain, analgesics need, and complications. The primary aim was to examine the effect of cooling versus no cooling on pain levels in adult patients treated operatively for an ankle or hindfoot fracture. Secondary aims were to assess the effect of cooling on (1) analgesics use, (2) patient satisfaction, (3) hospital length of stay (HLOS), (4) the rate of complications, and (5) the rate of secondary interventions. In this single center, retrospective case-control study patients who used a computer-controlled cooling device before and after surgery of an ankle or hindfoot fracture between January 1, 2015 and January 1, 2017 were included. Matched patients without using cooling served as control. Patient, injury and treatment characteristics, pain scores and analgesics use during hospital admission were extracted from patient's medical files. Pain scores in the cooling group (18 patients) did not statistically differ from the non-cooling group (17 patients). After surgery, less patients in the cooling group used paracetamol (p = .041), and nonsteroidal anti-inflammatory drugs (p = .006). Patient satisfaction of both groups was eight out of ten points. The total HLOS was 14 days (P-P 9.0-17.3) in the cooling group and 9 days (P-P 5.0-16.5) in the non-cooling group. This was mostly contributable to the difference in preoperative HLOS (8 days; P-P 4.8-13.0 versus 4 days; P-P 2.0-7.0) and time to surgery (13.5 days; P-P 9.3-16.3) versus 8 days; P-P 2.5-12.0). Complications and revision surgery did not differ. Patients with ankle or hindfoot fractures seem to benefit from computer-controlled cooling, since equal pain sensation is feasible with less analgesics postoperatively, whereas rates of complications and revision surgeries were comparable in both groups. Patients were highly satisfied with cooling.
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http://dx.doi.org/10.1053/j.jfas.2021.04.014DOI Listing
November 2021

The Relationship between Hospital Volume and In-Hospital Mortality of Severely Injured Patients in Dutch Level-1 Trauma Centers.

J Clin Med 2021 Apr 15;10(8). Epub 2021 Apr 15.

Trauma Center South West Netherlands, Erasmus MC Medical Center, 3015 GD Rotterdam, The Netherlands.

Centralization of trauma centers leads to a higher hospital volume of severely injured patients (Injury Severity Score (ISS) > 15), but the effect of volume on outcome remains unclear. The aim of this study was to determine the association between hospital volume of severely injured patients and in-hospital mortality in Dutch Level-1 trauma centers. A retrospective observational cohort study was performed using the Dutch trauma registry. All severely injured adults (ISS > 15) admitted to a Level-1 trauma center between 2015 and 2018 were included. The effect of hospital volume on in-hospital mortality was analyzed with random effects logistic regression models with a random intercept for Level-1 trauma center, adjusted for important demographic and injury characteristics. A total of 11,917 severely injured patients from 13 Dutch Level-1 trauma centers was included in this study. Hospital volume varied from 120 to 410 severely injured patients per year. Observed mortality rates varied between 12% and 24% per center. After case-mix correction, no statistically significant differences between low- and high-volume centers were demonstrated (adjusted odds ratio 0.97 per 50 extra patients per year, 95% Confidence Interval 0.90-1.04, = 0.44). The variation in hospital volume of the included Level-1 trauma centers was not associated with the outcome of severely injured patients. Our results suggest that well-organized trauma centers with a similar organization of care could potentially achieve comparable outcomes.
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http://dx.doi.org/10.3390/jcm10081700DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8071237PMC
April 2021

The impact of regionalized trauma care on the distribution of severely injured patients in the Netherlands.

Eur J Trauma Emerg Surg 2022 Apr 12;48(2):1035-1043. Epub 2021 Mar 12.

Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.

Background: Twenty years ago, an inclusive trauma system was implemented in the Netherlands. The goal of this study was to evaluate the impact of structured trauma care on the concentration of severely injured patients over time.

Methods: All severely injured patients (Injury Severity Score [ISS] ≥ 16) documented in the Dutch Trauma Registry (DTR) in the calendar period 2008-2018 were included for analysis. We compared severely injured patients, with and without severe neurotrauma, directly brought to trauma centers (TC) and non-trauma centers (NTC). The proportion of patients being directly transported to a trauma center was determined, as was the total Abbreviated Injury Score (AIS), and ISS.

Results: The documented number of severely injured patients increased from 2350 in 2008 to 4694 in 2018. During this period, on average, 70% of these patients were directly admitted to a TC (range 63-74%). Patients without severe neurotrauma had a lower chance of being brought to a TC compared to those with severe neurotrauma. Patients directly presented to a TC were more severely injured, reflected by a higher total AIS and ISS, than those directly transported to a NTC.

Conclusion: Since the introduction of a well-organized trauma system in the Netherlands, trauma care has become progressively centralized, with more severely injured patients being directly presented to a TC. However, still 30% of these patients is initially brought to a NTC. Future research should focus on improving pre-hospital triage to facilitate swift transfer of the right patient to the right hospital.
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http://dx.doi.org/10.1007/s00068-021-01615-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9001217PMC
April 2022

Characteristics, management and outcome of prehospital pediatric emergencies by a Dutch HEMS.

Eur J Trauma Emerg Surg 2022 Apr 4;48(2):989-998. Epub 2021 Feb 4.

Department of Anesthesiology, Erasmus University Medical Center-Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands.

Background: In prehospital care, the Helicopter Emergency Medical Service (HEMS) can be dispatched for critically injured or ill children. However, little detail is known about dispatches for children, in terms of the incidence of prehospital interventions and overall mortality. The primary objective of this study is to provide an overview of pediatric patient characteristics and incidence of interventions.

Methods: A retrospective chart review of all patients ≤ 17 years who received medical care by Rotterdam HEMS from 2012 until 2017 was carried out.

Results: During the study period, 1905 pediatric patients were included. 59.1% of patients were male and mean age was 6.1 years with 53.2% of patients aged ≤ 3 years. 53.6% were traumatic patients and 49.7% were non-traumatic patients. 18.8% of patients were intubated. Surgical procedures were performed in 0.9%. Medication was administered in 58.1% of patients. Cardiopulmonary resuscitation (CPR) was necessary in 12.9% of patients, 19.9% were admitted to the intensive care unit and 14.0% needed mechanical ventilation. Overall mortality was 9.5%. Mortality in trauma patients was 5.5% and in non-trauma group 15.3%. 3.9% of patients died at the scene.

Conclusions: Patients attended by HEMS are at high risk of prehospital interventions like CPR or intubation. EMS has little exposure to critically ill or injured children. Hence, HEMS expertise is required to perform critical procedures. Trauma patients had higher survival rates than non-traumatic patients. This may be explained by underlying illnesses in non-traumatic patients and CPR as reason for dispatch. Further research is needed to identify options for improving prehospital care in the non trauma pediatric patients.
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http://dx.doi.org/10.1007/s00068-020-01579-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9001565PMC
April 2022

Evaluation of the Berlin polytrauma definition: A Dutch nationwide observational study.

J Trauma Acute Care Surg 2021 04;90(4):694-699

From the Dutch Network for Emergency Care (M.L.S.D., L.M.S.), Utrecht; Department of Medical Statistics (E.W.v.Z.), Leiden University Medical Center, Leiden; Department of Surgery (F.W.B.), Amsterdam University Medical Center, VU, Amsterdam; Department of Trauma Surgery (M.J.R.E.), Radboud University Medical Center, Nijmegen; Trauma Research Unit, Department of Surgery (D.d.H.), Erasmus MC, University Medical Center Rotterdam, Rotterdam; Brabant Trauma Registry (M.A.C.d.J.), Network Emergency Care Brabant, Tilburg; Department of Surgery (P.A.L.), Amsterdam University Medical Center, AMC, Amsterdam; Department of Surgery (M.P.), Maastricht University Medical Center, Maastricht; Department of Trauma Surgery (I.B.S.), Leiden University Medical Center, Leiden; Department of Trauma Surgery (R.S.), Isala Hospitals, Zwolle; Department of Trauma Surgery (K.W.W.), University Medical Center Groningen, Groningen; Department of Trauma Surgery (R.J.d.W.), Medical Spectrum Twente, Enschede; Department of Surgery Elisabeth Two Cities Hospital (S.W.A.M.v.Z.), Tilburg; and Department of Surgery (L.P.H.L.), University Medical Center Utrecht, Utrecht, the Netherlands.

Background: The Berlin polytrauma definition (BPD) was established to identify multiple injury patients with a high risk of mortality. The definition includes injuries with an Abbreviated Injury Scale score of ≥3 in ≥2 body regions (2AIS ≥3) combined with the presence of ≥1 physiological risk factors (PRFs). The PRFs are based on age, Glasgow Coma Scale, hypotension, acidosis, and coagulopathy at specific cutoff values. This study evaluates and compares the BPD with two other multiple injury definitions used to identify patients with high resource utilization and mortality risk, using data from the Dutch National Trauma Register (DNTR).

Methods: The evaluation was performed based on 2015 to 2018 DNTR data. First, patient characteristics for 2AIS ≥3, Injury Severity Score (ISS) of ≥16, and BPD patients were compared. Second, the PRFs prevalence and odds ratios of mortality for 2AIS ≥3 patients were compared with those from the Deutsche Gesellschaft für Unfallchirurgie Trauma Register. Subsequently, the association between PRF and mortality was assessed for 2AIS ≥3-DNTR patients and compared with those with an ISS of ≥16.

Results: The DNTR recorded 300,649 acute trauma admissions. A total of 15,711 patients sustained an ISS of ≥16, and 6,263 patients had suffered a 2AIS ≥3 injury. All individual PRFs were associated with a mortality of >30% in 2AIS ≥3-DNTR patients. The increase in PRFs was associated with a significant increase in mortality for both 2AIS ≥3 and ISS ≥16 patients. A total of 4,264 patients met the BPDs criteria. Overall mortality (27.2%), intensive care unit admission (71.2%), and length of stay were the highest for the BPD group.

Conclusion: This study confirms that the BPD identifies high-risk patients in a population-based registry. The addition of PRFs to the anatomical injury scores improves the identification of severely injured patients with a high risk of mortality. Compared with the ISS ≥16 and 2AIS ≥3 multiple injury definitions, the BPD showed to improve the accuracy of capturing patients with a high medical resource need and mortality rate.

Level Of Evidence: Epidemiological study, level III.
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http://dx.doi.org/10.1097/TA.0000000000003071DOI Listing
April 2021

Effect of platelet-rich plasma on fracture healing.

Injury 2021 Jun 31;52 Suppl 2:S58-S66. Epub 2020 Dec 31.

Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.

Bone has the ability to completely regenerate under normal healing conditions. Although fractures generally heal uneventfully, healing problems such as delayed union or nonunion still occur in approximately 10% of patients. Optimal healing potential involves an interplay of biomechanical and biological factors. Orthopedic implants are commonly used for providing the necessary biomechanical support. In situations where the biological factors that are needed for fracture healing are deemed inadequate, additional biological enhancement is needed. With platelets being packed with granules that contain growth factors and other proteins that have osteoinductive capacity, local application of platelet concentrates, also called platelet-rich plasma (PRP) seems an attractive biological to enhance fracture healing. This review shows an overview of the use PRP and its effect in enhancing fracture healing. PRP is extracted from the patient's own blood, supporting that its use is considered safe. Although PRP showed effective in some studies, other studies showed controversial results. Conflicts in the literature may be explained by the absence of consensus about the preparation of PRP, differences in platelet counts, low number of patients, and absence of a standard application technique. More studies addressing these issues are needed in order to determine the true effect of PRP on fracture healing.
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http://dx.doi.org/10.1016/j.injury.2020.12.005DOI Listing
June 2021

Association Between Prehospital Tranexamic Acid Administration and Outcomes of Severe Traumatic Brain Injury.

JAMA Neurol 2021 03;78(3):338-345

Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.

Importance: The development and expansion of intracranial hematoma are associated with adverse outcomes. Use of tranexamic acid might limit intracranial hematoma formation, but its association with outcomes of severe traumatic brain injury (TBI) is unclear.

Objective: To assess whether prehospital administration of tranexamic acid is associated with mortality and functional outcomes in a group of patients with severe TBI.

Design, Setting, And Participants: This multicenter cohort study is an analysis of prospectively collected observational data from the Brain Injury: Prehospital Registry of Outcome, Treatments and Epidemiology of Cerebral Trauma (BRAIN-PROTECT) study in the Netherlands. Patients treated for suspected severe TBI by the Dutch Helicopter Emergency Medical Services between February 2012 and December 2017 were included. Patients were followed up for 1 year after inclusion. Data were analyzed from January 10, 2020, to September 10, 2020.

Exposures: Administration of tranexamic acid during prehospital treatment.

Main Outcomes And Measures: The primary outcome was 30-day mortality. Secondary outcomes included mortality at 1 year, functional neurological recovery at discharge (measured by Glasgow Outcome Scale), and length of hospital stay. Data were also collected on demographic factors, preinjury medical condition, injury characteristics, operational characteristics, and prehospital vital parameters.

Results: A total of 1827 patients were analyzed, of whom 1283 (70%) were male individuals and the median (interquartile range) age was 45 (23-65) years. In the unadjusted analysis, higher 30-day mortality was observed in patients who received prehospital tranexamic acid (odds ratio [OR], 1.34; 95% CI, 1.16-1.55; P < .001), compared with patients who did not receive prehospital tranexamic acid. After adjustment for confounders, no association between prehospital administration of tranexamic acid and mortality was found across the entire cohort of patients. However, a substantial increase in the odds of 30-day mortality persisted in patients with severe isolated TBI who received prehospital tranexamic acid (OR, 4.49; 95% CI, 1.57-12.87; P = .005) and after multiple imputations (OR, 2.05; 95% CI, 1.22-3.45; P = .007).

Conclusions And Relevance: This study found that prehospital tranexamic acid administration was associated with increased mortality in patients with isolated severe TBI, suggesting the judicious use of the drug when no evidence for extracranial hemorrhage is present.
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http://dx.doi.org/10.1001/jamaneurol.2020.4596DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953275PMC
March 2021

Prehospital Management of Peripartum Neonatal Complications by Helicopter Emergency Medical Service in the South West of the Netherlands: An Observational Study.

Air Med J 2020 Nov - Dec;39(6):489-493. Epub 2020 Aug 20.

Department of Anaesthesiology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.

Objective: Emergency medical service (EMS) is responsible for prehospital care encompassing all ages, irrespective of injury cause or medical condition, which includes peripartum emergencies. When patients require care more advanced than the level provided by the national EMS protocol, an EMS physician-staffed Dutch helicopter emergency medical service (HEMS) may be dispatched. In the Netherlands in 2016, there were 21.434 planned home births guided by midwives alone without further obstetric assistance, accounting for 12.7% of all births that year. However, there are no clear data available thus far regarding neonates requiring emergency care with or without HEMS assistance. This article reviews neonates during our study period who received medical care after birth by HEMS.

Methods: A retrospective chart review was performed including neonates born on the day of the dispatch between January 2012 and December 2017 who received additional medical care from the Rotterdam HEMS.

Results: Fifty-two neonates received medical care by HEMS. The majority (73.1%) were full-term (Gestational age > 37 weeks). Home delivery was intended in 63.5%, 20% of whom experienced an uncomplicated delivery but had a poor start of life. The majority of unplanned deliveries (n = 17) were preterm (70.6%). Two were born by resuscitative hysterotomy; 1 survived in good neurologic condition, and the other died at the scene. Fifteen neonates (28.9%) required cardiopulmonary resuscitation; in 2 cases, no resuscitation was started on medical grounds, and 12 of the other 13 resuscitated neonates regained return of spontaneous circulation. In 33 (63.5%) of the neonates, respiratory interventions were required; 8 (15.4%) were intubated before transport. Death was confirmed in 5 (9.6%) neonates, all preterm.

Conclusion: During the study period, 52 neonates required medical assistance by HEMS. The 5 infants who died were all preterm. In this cohort, adequate basic life support was implemented immediately after birth either by the attending midwife, EMS, or HEMS on arrival. This suggests that prehospital first responders know the basic skills of neonatal life support.
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http://dx.doi.org/10.1016/j.amj.2020.08.002DOI Listing
November 2021

The association between level of trauma care and clinical outcome measures: A systematic review and meta-analysis.

J Trauma Acute Care Surg 2020 10;89(4):801-812

From the Trauma Research Unit, Department of Surgery (J.C.V.D., C.R.L.V.D.D., C.A.S., E.M.M.V.L., M.H.J.V., D.D.H.), and Department of Public Health (C.A.S.), Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands.

Background: With implementation of trauma systems, a level of trauma care classification was introduced. Use of such a system has been linked to significant improvements in survival and other outcomes.

Objectives: The aim of this study was assessing the association between level of trauma care and fatal and nonfatal outcome measures for general and major trauma (MT) populations.

Methods: A systematic literature search was conducted using six electronic databases up to December 18, 2019. Studies comparing mortality or nonfatal outcomes between different levels of trauma care in general and MT populations (preferably Injury Severity Score of >15) were included. Two independent reviewers performed selection of relevant studies, data extraction, and a quality assessment of included articles. With a random-effects meta-analysis, adjusted and unadjusted pooled effect sizes were calculated for level I versus non-level I trauma centers.

Results: Twenty-two studies were included. Quality of the included studies was good; however, adjustment for comorbidity (32%) and interhospital transfer (38%) was performed less frequently. Nine (60%) of the 15 studies analyzing in-hospital mortality in general trauma populations reported a survival benefit for level I trauma centers. Level I trauma centers were not associated with higher mortality than non-level I trauma centers (adjusted odd ratio, 0.97; 95% confidence interval, 0.61-1.52). Of the 11 studies reporting in-hospital mortality in MT populations, 10 (91%) reported a survival benefit for level I trauma centers. Level I trauma centers were associated with lower mortality than non-level I trauma centers (adjusted odd ratio, 0.77; 95% confidence interval, 0.69-0.87).

Conclusion: The association between level of trauma care and in-hospital mortality is evident for MT populations; however, this does not hold for general trauma populations. Level I trauma centers produce improved survival in MT populations. This association could not be proven for nonfatal outcomes in general and MT populations because of inconsistencies in the body of evidence.

Level Of Evidence: Systematic review and meta-analysis, level III.
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http://dx.doi.org/10.1097/TA.0000000000002850DOI Listing
October 2020

Epidemiology, Prehospital Characteristics and Outcomes of Severe Traumatic Brain Injury in The Netherlands: The BRAIN-PROTECT Study.

Prehosp Emerg Care 2021 Sep-Oct;25(5):644-655. Epub 2020 Nov 3.

Objective: A thorough understanding of the epidemiology, patient characteristics, trauma mechanisms, and current outcomes among patients with severe traumatic brain injury (TBI) is important as it may inform potential strategies to improve prehospital emergency care. The aim of this study is to describe the prehospital epidemiology, characteristics and outcome of (suspected) severe TBI in the Netherlands.

Methods: The BRAIN-PROTECT study is a prospective observational study on prehospital management of patients with severe TBI in the Netherlands. The study population comprised all consecutive patients with clinical suspicion of TBI and a prehospital GCS score ≤ 8, who were managed by one of the 4 Helicopter Emergency Medical Services (HEMS). Patients were followed-up in 9 trauma centers until 1 year after injury. Planned sub-analyses were performed for patients with "confirmed" and "isolated" TBI.

Results: Data from 2,589 patients, of whom 2,117 (81.8%) were transferred to a participating trauma center, were analyzed. The incidence rate of prehospitally suspected and confirmed severe TBI were 3.2 (95% CI: 3.1;3.4) and 2.7 (95% CI: 2.5;2.8) per 100,000 inhabitants per year, respectively. Median patient age was 46 years, 58.4% were involved in traffic crashes, of which 37.4% were bicycle related. 47.6% presented with an initial GCS of 3. The median time from HEMS dispatch to hospital arrival was 54 minutes. The overall 30-day mortality was 39.0% (95% CI: 36.8;41.2).

Conclusion: This article summarizes the prehospital epidemiology, characteristics and outcome of severe TBI in the Netherlands, and highlights areas in which primary prevention and prehospital care can be improved.
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http://dx.doi.org/10.1080/10903127.2020.1824049DOI Listing
September 2021

The impact of the Trauma Triage App on pre-hospital trauma triage: design and protocol of the stepped-wedge, cluster-randomized TESLA trial.

Diagn Progn Res 2020 18;4:10. Epub 2020 Jun 18.

Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.

Background: Field triage of trauma patients is crucial to get the right patient to the right hospital within a particular time frame. Minimization of undertriage, overtriage, and interhospital transfer rates could substantially reduce mortality rates, life-long disabilities, and costs. Identification of patients in need of specialized trauma care is predominantly based on the judgment of Emergency Medical Services professionals and a pre-hospital triage protocol. The Trauma Triage App is a smartphone application that includes a prediction model to aid Emergency Medical Services professionals in the identification of patients in need of specialized trauma care. The aim of this trial is to assess the impact of this new digital approach to field triage on the primary endpoint undertriage.

Methods: The Trauma triage using Supervised Learning Algorithms (TESLA) trial is a stepped-wedge cluster-randomized controlled trial with eight clusters defined as Emergency Medical Services regions. These clusters are an integral part of five inclusive trauma regions. Injured patients, evaluated on-scene by an Emergency Medical Services professional, suspected of moderate to severe injuries, will be assessed for eligibility. This unidirectional crossover trial will start with a baseline period in which the default pre-hospital triage protocol is used, after which all clusters gradually implement the Trauma Triage App as an add-on to the existing triage protocol. The primary endpoint is undertriage on patient and cluster level and is defined as the transportation of a severely injured patient (Injury Severity Score ≥ 16) to a lower-level trauma center. Secondary endpoints include overtriage, hospital resource use, and a cost-utility analysis.

Discussion: The TESLA trial will assess the impact of the Trauma Triage App in clinical practice. This novel approach to field triage will give new and previously undiscovered insights into several isolated components of the diagnostic strategy to get the right trauma patient to the right hospital. The stepped-wedge design allows for within and between cluster comparisons.

Trial Registration: Netherlands Trial Register, NTR7243. Registered 30 May 2018, https://www.trialregister.nl/trial/7038.
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http://dx.doi.org/10.1186/s41512-020-00076-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7302135PMC
June 2020

The volume-outcome relationship among severely injured patients admitted to English major trauma centres: a registry study.

Scand J Trauma Resusc Emerg Med 2020 Mar 6;28(1):18. Epub 2020 Mar 6.

Department of Public Health, Erasmus MC University Medical Centre, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands.

Background: Many countries have centralized and dedicated trauma centres with high volumes of trauma patients. However, the volume-outcome relationship in severely injured patients (Injury Severity Score (ISS) > 15) remains unclear. The aim of this study was to determine the association between hospital volume and outcomes in Major Trauma Centres (MTCs).

Methods: A retrospective observational cohort study was conducted using the Trauma Audit and Research Network (TARN) consisting of all English Major Trauma Centres (MTCs). Severely injured patients (ISS > 15) admitted to a MTC between 2013 and 2016 were included. The effect of hospital volume on outcome was analysed with random effects logistic regression models with a random intercept for centre and was tested for nonlinearity. Primary outcome was in-hospital mortality.

Results: A total of 47,157 severely injured patients from 28 MTCs were included in this study. Hospital volume varied from 69 to 781 severely injured patients per year. There were small between-centre differences in mortality after adjusting for important demographic and injury severity characteristics (adjusted 95% odds ratio range: 0.99-1.01). Hospital volume was found to be linear and not associated with in-hospital mortality (adjusted odds ratio (aOR) 1.02 per 10 patients, 95% confidence interval (CI) 0.68-1.54, p = 0.92).

Conclusions: Despite the large variation in volume of the included MTCs, no relationship between hospital volume and outcome of severely injured patients was found. These results suggest that centres with similar structure and processes of care can achieve comparable outcomes in severely injured patients despite the number of severely injured patients they treat.
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http://dx.doi.org/10.1186/s13049-020-0710-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7059707PMC
March 2020
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