Page 211 - Ultrasonography in Prehospital and Emergency Medicine - Rein Ketelaars
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                 patients treated by the Nijmegen HEMS were evaluated in Chapter 7. We analyzed 1631 ab- dominal ultrasound scans performed in 1583 patients. Treatment decisions were impacted in 188 of 1495 patients (12.6%). The most important categories of impacted treatment were: (1) additional information provided to the destination hospital: the request to notify the trauma team, prepare packed red blood cells, and consider follow-up diagnostic imaging; (2) mode of transportation: most often, the HEMS crew handed over the care to the ambulance paramed- ics; (3) selection of the destination hospital for definitive treatment: triage up in 13 patients and triage down in 20 patients; (4) fluid management: more aggressive in 20 patients, more restrictive in nine patients.
The sensitivity of abdominal PHUS for the diagnosis of free intraperitoneal fluid was only 31% when compared with in-hospital computed tomography (CT) scans. A plausible expla- nation is that free intraperitoneal fluid accumulates gradually after trauma. Early after an in- cident, most fluid collections would be small or even non-existent at first. As time progress- es, these collections might increase to an amount that is easily detectable. Thus, the interval between the incident and abdominal ultrasonography is a factor in the detection rate of fluid collections.3 Another explanation is that CT is much more sensitive to small quantities of free intraperitoneal fluid than ultrasonography. Therefore, health care providers should remain vigilant in the event of a negative PHUS, especially in patients who are scanned shortly after the incident. Furthermore, they should consider repeating the examination. The specificity of abdominal PHUS was 97%. The significance of the diagnostic performance of abdominal ultrasonography for hemoperitoneum is that its utility is greatest when used as a rule-in tool: whenever PHUS shows free intraperitoneal fluid, it can be concluded with a high level of certainty that it is really there. But as always, the decision-making process, apart from PHUS, must take into account a full assessment by history taking (including the mechanism of trauma), physical examination, and measurements of vital signs.
Through a prospective, observational, diagnostic study, we studied prehospital focused echo- cardiography during cardiopulmonary resuscitation (CPR) in 56 patients in whose treat- ment the Nijmegen HEMS was involved. Echocardiography was performed within the nar- row five-second interval that is allowed between two cycles of chest compressions and was repeated every ten minutes. The HEMS physicians reported whether and how treatment decisions were influenced.
This study and the impact of echocardiography on treatment decisions were presented in Chapter 8. In this population, cardiac arrest was often caused by trauma. This is proba- bly due to the criteria that are being used by the dispatch centers for HEMS deployment. Treatment decisions were impacted (either changed or supported) in 49 patients (88%). The most important impacted decisions were: (1) termination of resuscitation (n = 32 [57%]);
Summary, discussion, and future perspective 209
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