IMPORTANCEThe 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 PARTICIPANTSThis 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 MEASURESThe 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.

BackgroundPatients with a presumed diagnosis of acute coronary syndrome (ACS) or stroke may have had contact with several healthcare providers prior to hospital arrival. The aim of this study was to describe the various prehospital paths and the effect on time delays of patients with ACS or stroke.MethodsThis prospective observational study included patients with presumed ACS or stroke who may choose to contact four different types of health care providers. Questionnaires were completed by patients, general practitioners (GP), GP cooperatives, ambulance services and emergency departments (ED). Additional data were retrieved from hospital registries.ResultsTwo hundred two ACS patients arrived at the hospital by 15 different paths and 243 stroke patients by ten different paths. Often several healthcare providers were involved (60.8 % ACS, 95.1 % stroke). Almost half of all patients first contacted their GP (47.5 % ACS, 49.4 % stroke). Some prehospital paths were more frequently used, e.g. GP (cooperative) and ambulance in ACS, and GP or ambulance and ED in stroke. In 65 % of all events an ambulance was involved. Median time between start of symptoms and hospital arrival for ACS patients was over 6 h and for stroke patients 4 h. Of ACS patients 47.7 % waited more than 4 h before seeking medical advice compared to 31.6 % of stroke patients. Median time between seeking medical advice to arrival at hospital was shortest in paths involving the ambulance only (60 min ACS, 54 min stroke) or in combination with another healthcare provider (80 to 100 min ACS, 99 to 106 min stroke).ConclusionsPrehospital paths through which patients arrived in hospital are numerous and often complex, and various time delays occurred. Delays depend on the entry point of the health care system, and dialing the emergency number seems to be the best choice. Since reducing patient delay is difficult and noticeable differences exist between various prehospital paths, further research into reasons for these different entry choices may yield possibilities to optimize paths and reduce overall time delay.

BackgroundTiered trauma team response may contribute to efficient in-hospital trauma triage by reducing the amount of resources required and by improving health outcomes. This study evaluates current practice of trauma team activation (TTA) in Dutch emergency departments (EDs).MethodsA survey was conducted among managers of all 102 EDs in the Netherlands, using a semi-structured online questionnaire.ResultsSeventy-two questionnaires were analysed. Most EDs use a one-team system (68 %). EDs with a tiered-response receive more multi trauma patients (p < 0.01) and have more trauma team alerts per year (p < 0.05) than one-team EDs. The number of trauma team members varies from three to 16 professionals. The ED nurse usually receives the pre-notification (97 %), whereas the decision to activate a team is made by an ED nurse (46 %), ED physician (30 %), by multiple professionals (20 %) or other (4 %). Information in the pre-notification mostly used for trauma team activation are Airway-Breathing-Circulation (87 %), Glasgow Coma Score (90 %), and Revised Trauma Score (85 %) or Paediatric Trauma Score (86 %). However, this information is only available for 75 % of the patients or less. Only 56 % of the respondents were satisfied with their current in-hospital trauma triage system.ConclusionsTrauma team activation varies across Dutch EDs and there is room for improvement in the trauma triage system used, size of the teams and the professionals involved. More direct communication and more uniform criteria could be used to efficiently and safely activate a specific trauma team. Therefore, the implementation of a revised national consensus guideline is recommended.Electronic supplementary materialThe online version of this article (doi:10.1186/s13049-015-0185-0) contains supplementary material, which is available to authorized users.

Purpose Severe traumatic brain injury is a leading cause of mortality and morbidity, and these patients are frequently intubated in the prehospital setting. Cerebral perfusion and intracranial pressure are influenced by the arterial partial pressure of CO 2 and derangements might induce further brain damage. We investigated which lower and upper limits of prehospital end-tidal CO 2 levels are associated with increased mortality in patients with severe traumatic brain injury. Methods The BRAIN-PROTECT study is an observational multicenter study. Patients with severe traumatic brain injury, treated by Dutch Helicopter Emergency Medical Services between February 2012 and December 2017, were included. Follow-up continued for 1 year after inclusion. End-tidal CO 2 levels were measured during prehospital care and their association with 30-day mortality was analyzed with multivariable logistic regression. Results A total of 1776 patients were eligible for analysis. An L-shaped association between end-tidal CO 2 levels and 30-day mortality was observed ( p = 0.01), with a sharp increase in mortality with values below 35 mmHg. End-tidal CO 2 values between 35 and 45 mmHg were associated with better survival rates compared to < 35 mmHg. No association between hypercapnia and mortality was observed. The odds ratio for the association between hypocapnia (< 35 mmHg) and mortality was 1.89 (95% CI 1.53–2.34, p < 0.001) and for hypercapnia (≥ 45 mmHg) 0.83 (0.62–1.11, p = 0.212). Conclusion A safe zone of 35–45 mmHg for end-tidal CO 2 guidance seems reasonable during prehospital care. Particularly, end-tidal partial pressures of less than 35 mmHg were associated with a significantly increased mortality. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-023-07012-z.

INLEIDINGOm schade aan de hartspier te beperken en overlijden te voorkomen is het van groot belang dat de juiste behandeling van een acuut coronair syndroom (ACS) zo snel mogelijk plaatsvindt (time = muscle). Het verminderen van de (pre) hospitale vertraging leidt tot betere patiëntuitkomsten. [1][2][3] Een patiënt met ACS kan verschillende ingangen tot de acute zorgketen kiezen: de huisarts, de huisartsenpost (HAP), de meldkamer ambulancezorg (112), de spoedeisende hulp (SEH) en de Eerste Hart Hulp (EHH). 3,4 Ruim 80% van alle patiënten met verdenking op ACS neemt als eerste contact op met de eigen huisarts of de HAP. 3 De tijd van melding tot behandeling in het ziekenhuis wordt beïnvloed door de keteningang die de patiënt kiest; een directe 112-melding is het snelst. 3 Hoewel er onderzoeken zijn naar (oorzaken van) de vertraging in de zorgketen, is er weinig bekend over de motivatie van de patiënt bij het kiezen van een bepaalde keteningang. Het doel van ons onderzoek is inzicht verkrijgen in factoren die de keuze voor een keteningang bepalen. METHODE OnderzoeksopzetWe deden een retrospectief dwarsdoorsnedeonderzoek naar de motivatie van een patiënt met een ACS voor de keuze voor een bepaalde keteningang. In 2016 hebben we een vragenlijst afgenomen bij Nederlands sprekende volwassenen in de regio die binnen drie maanden na de diagnose ACS (DBC-codes 203 (instabiele angina pectoris (IAP)), 204 (ST-elevatie myocardinfarct (STEMI)) of 205 (non-STEMI)) 1) een intakegesprek hadden voor het hartrevalidatieprogramma, 2) aanwezig waren bij een informatiebijeenkomst over hartrevalidatie of 3) fysiotherapeutische hartrevalidatie kregen. Wilsonbekwame of gereanimeerde patiënten hebben we geëxcludeerd. ResultatenVan de 78 patiënten die aan de inclusiecriteria voldeden vulden 67 patiënten (86%) de vragenlijst in. Geen interesse, fysieke en mentale omstandigheden waren redenen om niet deel te nemen. Het grootste deel van de patiënten was man (73%) en de gemiddelde leeftijd was 63 jaar (sd = 11). De respondenten Inleiding Patiënten met symptomen van een acuut coronair syndroom (ACS) hebben zo snel mogelijk de juiste behandeling nodig om schade aan het hart te voorkomen of te beperken. Hoewel er veel onderzoek is gedaan naar prehospitale vertraging en de oorzaken daarvan, is er weinig bekend over de motivatie van de patiënt voor het kiezen van een keteningang. Het doel van dit onderzoek is het vinden van factoren die invloed hebben op deze keuze.Methode We deden een explorerend dwarsdoorsnedeonderzoek, waarbij we met een vragenlijst gegevens verzamelden van 67 ACS-patiënten.Resultaten Patiënten kregen toegang tot de acute zorgketen via vier verschillende ingangen: de huisarts (43%), de huisartsenpost (28%), de meldkamer ambulancezorg (112) (21%) of de spoedeisende hulp (7%). De overtuiging van patiënten dat hun huisarts het beste weet wat ze nodig hebben maakte dat ze vaker contact zochten met hun eigen huisarts. Dit deden ook de patiënten die alleen waren toen de symptomen ontstonden. Patiënten met een fast onset van de klach...