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Scandinavian Journal of Trauma,... Sep 2021Penetrating injuries to the neck pose a unique challenge to clinicians due to the proximity of multiple significant anatomical structures with little protective soft... (Review)
Review
Penetrating injuries to the neck pose a unique challenge to clinicians due to the proximity of multiple significant anatomical structures with little protective soft tissue coverage. Injuries to this area, whilst low in incidence, are potentially devastating. Respiratory, vascular, gastro-oesophageal and neurological structures may all be involved, either in isolation or combination. These injuries are particularly difficult to manage in the resource poor, often austere and/or remote, pre-hospital environment. A systematic scoping review of the literature was conducted to evaluate the current available research pertaining to managing this injury profile, prior to the patient arriving in the emergency department. The available research is discussed in sections based on the commonly used trauma management acronym 'cABCD' (catastrophic haemorrhage, Airway, Breathing, Circulation, Disability) to facilitate a systematic approach and clinical evaluation familiar to clinicians. Based on the available reviewed evidence, we have proposed a management algorithm for this cohort of patients. From this we plan to instigate a Delphi process to develop a consensus statement on the pre-hospital management of this challenging presentation.
Topics: Chest Pain; Emergency Service, Hospital; Hospitals; Humans; Neck Injuries; Wounds, Penetrating
PubMed: 34530879
DOI: 10.1186/s13049-021-00949-4 -
British Paramedic Journal Mar 2021The phenomenon of feedback is well-researched within the wider healthcare context, where it is suggested that feedback can improve patient care and patient safety by...
AIMS
The phenomenon of feedback is well-researched within the wider healthcare context, where it is suggested that feedback can improve patient care and patient safety by enhancing clinical performance and staff mental health (Ivers et al., 2012). Within a pre-hospital context, systematic reviews have been conducted for automated feedback from defibrillators and debrief after simulation, but not on the wider concept of feedback. The aim of this systematic review was to identify, describe and synthesise the published literature on the types and effects of feedback received by emergency ambulance staff.
METHODS
This study is a systematic mixed studies review including empirical primary research of qualitative, quantitative and mixed-methods methodology published in peer-reviewed journals in English. Studies were included if they explored the concept of feedback as defined in this review, i.e. the systematised provision of information to emergency ambulance staff regarding their performance within pre-hospital practice and/or patient outcomes. The search strategy consisted of three facets: ambulance staff synonyms, feedback synonyms and feedback content. Databases searched on 11 June 2020 from inception were MEDLINE, EMBASE, AMED, PsycInfo, HMIC, CINAHL and Web of Science. Study quality was appraised using the Mixed Methods Appraisal Tool (Hong et al., 2018), and data were analysed using narrative synthesis guided by Popay et al. (2006) following a parallel-results convergent synthesis design.
RESULTS
The search strategy yielded 2424 articles, excluding duplicates. Seventy-eight studies met the inclusion criteria after full-text review, of which 37 only mentioned feedback as a solution to improving specific circumstances (e.g. decision-making, burnout). The remaining 41 studies consisted of: 34 interventional pre-hospital feedback studies; four non-interventional feedback studies; and three preparatory studies. The source, content and mode of pre-hospital feedback represented in the studies varied greatly and encompassed feedback on behaviour and/or feedback on outcomes of behaviour (Michie et al., 2013). The main outcome measure of included studies was quality of care (e.g. quality of CPR, adherence to guidelines) but softer measures such as staff wellbeing, professional development and clinical decision-making were also represented.
CONCLUSION
It is anticipated that the review findings will be useful to guide the development of future pre-hospital feedback interventions, for which there is growing interest in the national and international pre-hospital setting. Further empirical research is required to explore whether the published literature reflects current pre-hospital practice.
PubMed: 34421383
DOI: 10.29045/14784726.2021.3.5.4.68 -
British Paramedic Journal Mar 2021Ambulance personnel are frequently exposed to traumatic accidents, which makes them a high risk for poor mental health. High rates of Post-Traumatic Stress Symptoms...
BACKGROUND
Ambulance personnel are frequently exposed to traumatic accidents, which makes them a high risk for poor mental health. High rates of Post-Traumatic Stress Symptoms (PTSS) have been found within ambulance personnel samples but no review has been completed to examine the factors that may be implicated in the development of these symptoms. This literature review provides an overview of the factors that predict PTSS in ambulance personnel.
METHODS
A systematic search strategy was conducted in April 2020 across the following four databases: PsycINFO, PsycARTICLES, MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL).
RESULTS
Eighteen papers were included in this review, and the predictive factors examined were grouped into four categories: coping style, personal factors, environmental factors and organisational factors.
CONCLUSIONS
An array of factors across the four categories were implicated in the development of PTSS, but these tended to be indicated in only one or two papers. Evidence was found to suggest that dysfunctional coping styles, reduced levels of some personality traits, proximity and nature of the critical incident and high levels of organisation stress can all lead to PTSS. Further research is needed to support the reliability of findings.
PubMed: 34421372
DOI: 10.29045/14784726.2021.3.5.4.18 -
British Paramedic Journal May 2021Around 10-25% of emergency calls for adults aged over 65 are attributed to falls. Regardless of whether injuries are caused, quality of life is often affected by fear of... (Review)
Review
BACKGROUND
Around 10-25% of emergency calls for adults aged over 65 are attributed to falls. Regardless of whether injuries are caused, quality of life is often affected by fear of falling, leading to reduced confidence and activity, negatively impacting mobility and risking depression and isolation. Ambulance service staff are well placed to identify falls risk factors so patients can be directed to falls prevention services. This article aims to determine how the referral by paramedics of uninjured falls patients to community falls services may reduce future falls and emergency services use.
METHODS
The CINAHL, MEDLINE and AMED electronic databases, grey literature sources and reference lists of relevant papers were systematically searched to identify primary research of an experimental design. Studies were eligible if they included elderly patients, aged over 65, who had received a paramedic response following a fall, were found to be uninjured and who were referred to local falls services rather than being transported to hospital. The study outcomes were required to include the rate of subsequent falls and emergency service use.
RESULTS
Four papers from three studies were included in the review following quality assessment. Results were not always statistically significant but showed a reduction in subsequent falls, particularly in the high-risk population, and in emergency service call-outs. A consistent positive effect was seen on the patients' well-being and independence related to activities of daily living across the studies.
CONCLUSIONS
The relationship between paramedics and local falls services has changed the pre-hospital management of these patients. Generally, access to a falls-specific care package has proved beneficial in supporting independence and reducing unnecessary transport to hospital. Further research into the uptake of this care pathway by paramedics now it is more established may be useful, as would research into barriers to adherence of the elderly to such an intervention.
PubMed: 34335100
DOI: 10.29045/14784726.2021.6.6.1.46 -
International Journal of Environmental... May 2021Systematic scleroderma is a rare chronic autoimmune disease of unknown aetiology. The aim of this study was to identify the prevalence of orofacial pathognomonic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Systematic scleroderma is a rare chronic autoimmune disease of unknown aetiology. The aim of this study was to identify the prevalence of orofacial pathognomonic conditions in patients with systemic scleroderma using only randomised prospective studies that investigated the treatment of oral and maxillofacial changes, highlighted associations between the disease and Sjogren's syndrome, and/or analysed the effect of oral hygiene.
METHODS
The literature was systematically reviewed based on Cochrane Library, EMBASE, PubMed, Scopus, and Web of Science articles published up to March 2020. The primary endpoint of this analysis was defined as an estimation of the prevalence of oral mucosal changes in different areas of the oral cavity (oral mucosa, tongue, lip, periodontal status, bones, and other regions) in patients suffering from scleroderma. Therefore, a systematic literature search (Cochrane Library, EMBASE, PubMed, Scopus, and Web of Science) was conducted and limited by the publication date (1950-03/2020) and the publication language (English). Extracted frequencies were pooled using methods for meta-analysis. In order to obtain the highest level of evidence, only prospective study reports were considered to be eligible.
RESULTS
After full-text screening, 14 (766 patients) out of 193 publications were eligible for the final analysis. Twelve studies produced reliable results in the final data sets. Calculation of the pooled effect estimate (random effects model) revealed a prevalence of 57.6% (95% CI: 40.8-72.9%) for the main area "lip". For the area "oral mucosa", a prevalence of 35.5% (95% CI: 15.7-62.0%) was calculated. The prevalence for "other regions" was only based on studies with salivary changes and was calculated to be 25.4% (95% CI: 14.2-41.3%).
CONCLUSION
The most pathognomonic conditions in the orofacial region in patients with systemic scleroderma affect the lips, oral mucosa, and salivary glands.
Topics: Humans; Lip; Prevalence; Prospective Studies; Randomized Controlled Trials as Topic; Scleroderma, Systemic; Sjogren's Syndrome
PubMed: 34069099
DOI: 10.3390/ijerph18105238 -
Scandinavian Journal of Trauma,... May 2021Trauma is a leading cause of morbidity and mortality worldwide with about 5.8 million deaths globally and the leading cause of death in those aged 45 and younger. The...
BACKGROUND
Trauma is a leading cause of morbidity and mortality worldwide with about 5.8 million deaths globally and the leading cause of death in those aged 45 and younger. The pre-hospital phase of traumatic injury is particularly important as care received during this phase has effects on survival. The need for high quality clinical trials in this area has been recognised for several years as a key priority to improve the evidence base and, ultimately, clinical care in prehospital trauma. We aimed to systematically map the existing evidence base for pre-hospital trauma trials, to identify knowledge gaps and inform decisions about the future research agenda.
METHODS
A systematic mapping review was conducted first employing a search of key databases (MEDLINE, CINAHL, EMBASE, and Cochrane Library from inception to March 23rd 2020) to identify randomised controlled trials within the pre-hospital trauma and injury setting. The evidence 'map' identified and described the characteristics of included studies and compared these studies against existing priorities for research. Narrative description of studies informed by analysis of relevant data using descriptive statistics was completed.
RESULTS
Twenty-three eligible studies, including 10,405 participants across 14 countries, were identified and included in the systematic map. No clear temporal or geographical trends in publications were identified. Studies were categorised into six broad categories based on intervention type with evaluations of fluid therapy and analgesia making up 60% of the included trials. Overall, studies were heterogenous with regard to individual interventions within categories and outcomes reported. There was poor reporting across several studies. No studies reported patient involvement in the design or conduct of the trials.
CONCLUSION
This mapping review has highlighted that evidence from trials in prehospital trauma is sparse and where trials have been completed, the reporting is generally poor and study designs sub-optimal. There is a continued need, and significant scope, for improvement in a setting where high quality evidence has great potential to make a demonstrable impact on care and outcomes.
Topics: Emergency Medical Services; Hospitals; Humans; Randomized Controlled Trials as Topic; Wounds and Injuries
PubMed: 34001219
DOI: 10.1186/s13049-021-00880-8 -
Cureus Apr 2021Trauma is the leading cause of mortality in those aged 1-19, with hemorrhage accounting for up to 40% of all trauma deaths. Manufactured tourniquets are recommended for... (Review)
Review
Trauma is the leading cause of mortality in those aged 1-19, with hemorrhage accounting for up to 40% of all trauma deaths. Manufactured tourniquets are recommended for the control of life-threatening extremity hemorrhage in adults but their use in the pediatric population requires further investigation. We performed a systematic review to evaluate the most appropriate tourniquet design for use in the pediatric population. A literature search of Embase and the Cochran databases of trials and systematic reviews on October 1, 2020 identified 454 unique references, of which 15 were included for full-text screening. Two single-arm observational studies with a high risk of bias evaluated the use of windlass tourniquets in the pediatric population (73 patients, age 2-16 years). The certainty of the evidence was very low. In both studies, conducted on uninjured extremities, the use of a manufactured windlass tourniquet, specifically the Combat Application Tourniquet (C-A-T®) Generation 7, led to the cessation of Doppler detected pulses in 71/71 (100%) of upper extremities and 69/73 (94.5%) of lower extremities. Of the four failures, one participant withdrew due to pain and three tourniquet applications failed to occlude pulses after three turns of the windlass. No controls were used for comparison. In conclusion, two observational studies demonstrated that windlass tourniquets were able to abolish distal pulses in children as young as two years of age and with a minimum limb circumference of 13 cm. These preliminary findings may be helpful for organizations in the creation of guidelines for the management of life-threatening extremity bleeding in children.
PubMed: 33996333
DOI: 10.7759/cureus.14474 -
JMIR MHealth and UHealth May 2021Continuous monitoring of patient vital signs may improve patient outcomes. Head-worn displays (HWDs) can provide hands-free access to continuous vital sign information... (Review)
Review
BACKGROUND
Continuous monitoring of patient vital signs may improve patient outcomes. Head-worn displays (HWDs) can provide hands-free access to continuous vital sign information of patients in critical and acute care contexts and thus may reduce instances of unrecognized patient deterioration.
OBJECTIVE
The purpose of the study is to conduct a systematic review of the literature to evaluate clinical, surrogate, and process outcomes when clinicians use HWDs for continuous patient vital sign monitoring.
METHODS
The review was registered with PROSPERO (CRD42019119875) and followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A literature search was conducted for articles published between January 1995 and June 2020 using the following databases: PubMed, Embase, CINAHL, PsycINFO, and Web of Science. Overall, 2 reviewers independently screened titles and abstracts and then assessed the full text of the articles. Original research articles that evaluated the clinical, surrogate, or process outcomes of head-mounted displays for continuous vital sign monitoring in critical care or acute care contexts were included.
RESULTS
Of the 214 records obtained, 15 (7%) articles met the predefined criteria and were included in this review. Of the 15 studies, 7 (47%) took place in a clinical context, whereas the remainder took place in a simulation environment. In 100% (7/7) of the studies that evaluated gaze behavior, changes were found in gaze direction with HWDs. Change detection improvements were found in 67% (2/3) of the studies evaluating changes in the participants' ability to detect changes in vital signs. Of the 10 studies assessing the ease of use of the HWD, most participants of 7 (70%) studies reported that the HWD was easy to use. In all 6 studies in which participants were asked if they would consider using the HWD in their practice, most participants responded positively, but they often suggested improvements on the HWD hardware or display design. Of the 7 studies conducted in clinical contexts, none reported any clinical outcomes.
CONCLUSIONS
Although there is limited and sometimes conflicting evidence about the benefits of HWDs from certain surrogate and process outcomes, evidence for clinical outcomes is lacking. Recommendations are to employ user-centered design when developing HWDs, perform longitudinal studies, and seek clinical outcomes.
TRIAL REGISTRATION
PROSPERO International Prospective Register of Systematic Reviews CRD42019119875; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=119875.
Topics: Critical Care; Hand; Humans; Monitoring, Physiologic; Vital Signs
PubMed: 33973863
DOI: 10.2196/27165 -
Emergency Medicine Journal : EMJ May 2021Around 25% of patients who had a stroke do not present with typical 'face, arm, speech' symptoms at onset, and are challenging for emergency medical services (EMS) to...
BACKGROUND
Around 25% of patients who had a stroke do not present with typical 'face, arm, speech' symptoms at onset, and are challenging for emergency medical services (EMS) to identify. The aim of this systematic review was to identify the characteristics of acute stroke presentations associated with inaccurate EMS identification (false negatives).
METHOD
We performed a systematic search of MEDLINE, EMBASE, CINAHL and PubMed from 1995 to August 2020 using key terms: stroke, EMS, paramedics, identification and assessment. Studies included: patients who had a stroke or patient records; ≥18 years; any stroke type; prehospital assessment undertaken by health professionals including paramedics or technicians; data reported on prehospital diagnostic accuracy and/or presenting symptoms. Data were extracted and study quality assessed by two researchers using the Quality Assessment of Diagnostic Accuracy Studies V.2 tool.
RESULTS
Of 845 studies initially identified, 21 observational studies met the inclusion criteria. Of the 6934 stroke and Transient Ischaemic Attack patients included, there were 1774 (26%) false negative patients (range from 4 (2%) to 247 (52%)). Commonly documented symptoms in false negative cases were speech problems (n=107; 13%-28%), nausea/vomiting (n=94; 8%-38%), dizziness (n=86; 23%-27%), changes in mental status (n=51; 8%-25%) and visual disturbance/impairment (n=43; 13%-28%).
CONCLUSION
Speech problems and posterior circulation symptoms were the most commonly documented symptoms among stroke presentations that were not correctly identified by EMS (false negatives). However, the addition of further symptoms to stroke screening tools requires valuation of subsequent sensitivity and specificity, training needs and possible overuse of high priority resources.
Topics: Diagnostic Errors; Emergency Medical Technicians; Emergency Service, Hospital; Humans; Ischemic Attack, Transient; Observational Studies as Topic; Retrospective Studies; Stroke
PubMed: 33608393
DOI: 10.1136/emermed-2020-209607 -
The Cochrane Database of Systematic... Feb 2021Commercial video games are a vastly popular form of recreational activity. Whilst concerns persist regarding possible negative effects of video games, they have been... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Commercial video games are a vastly popular form of recreational activity. Whilst concerns persist regarding possible negative effects of video games, they have been suggested to provide cognitive benefits to users. They are also frequently employed as control interventions in comparisons of more complex cognitive or psychological interventions. If independently effective, video games - being both engaging and relatively inexpensive - could provide a much more cost-effective add-on intervention to standard treatment when compared to costly, cognitive interventions.
OBJECTIVES
To review the effects of video games (alone or as an additional intervention) compared to standard care alone or other interventions including, but not limited to, cognitive remediation or cognitive behavioural therapy for people with schizophrenia or schizophrenia-like illnesses.
SEARCH METHODS
We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (March 2017, August 2018, August 2019).
SELECTION CRITERIA
Randomised controlled trials focusing on video games for people with schizophrenia or schizophrenia-like illnesses.
DATA COLLECTION AND ANALYSIS
Review authors extracted data independently. For binary outcomes we calculated risk ratio (RR) with its 95% confidence interval (CI) on an intention-to-treat basis. For continuous data we calculated the mean difference (MD) between groups and its CI. We employed a fixed-effect model for analyses. We assessed risk of bias for the included studies and created a 'Summary of findings' table using GRADE.
MAIN RESULTS
This review includes seven trials conducted between 2009 and 2018 (total = 468 participants, range 32 to 121). Study duration varied from six weeks to twelve weeks. All interventions in the included trials were given in addition to standard care, including prescribed medication. In trials video games tend to be the control for testing efficacy of complex, cognitive therapies; only two small trials evaluated commercial video games as the intervention. We categorised video game interventions into 'non-exergame' (played statically) and 'exergame' (the players use bodily movements to control the game). Our main outcomes of interest were clinically important changes in: general functioning, cognitive functioning, social functioning, mental state, quality of life, and physical fitness as well as clinically important adverse effects. We found no clear difference between non-exergames and cognitive remediation in general functioning scores (Strauss Carpenter Outcome Scale) (MD 0.42, 95% CI -0.62 to 1.46; participants = 86; studies = 1, very low-quality evidence) or social functioning scores (Specific Levels of Functioning Scale) (MD -3.13, 95% CI -40.17 to 33.91; participants = 53; studies = 1, very low-quality evidence). There was a clear difference favouring cognitive remediation for cognitive functioning (improved on at least one domain of MATRICS Consensus Cognitive Battery Test) (RR 0.58, 95% CI 0.34 to 0.99; participants = 42; studies = 1, low-quality evidence). For mental state, Positive and Negative Syndrome Scale (PANSS) overall scores showed no clear difference between treatment groups (MD 0.20, 95% CI -3.89 to 4.28; participants = 269; studies = 4, low-quality evidence). Quality of life ratings (Quality of Life Scale) similarly showed no clear intergroup difference (MD 0.01, 95% CI -0.40 to 0.42; participants = 87; studies = 1, very low-quality evidence). Adverse effects were not reported; we chose leaving the study early as a proxy measure. The attrition rate by end of treatment was similar between treatment groups (RR 0.96, 95% CI 0.87 to 1.06; participants = 395; studies = 5, low-quality evidence). One small trial compared exergames with standard care, but few outcomes were reported. No clear difference between interventions was seen for cognitive functioning (measured by MATRICS Consensus Cognitive Battery Test) (MD 2.90, 95% CI -1.27 to 7.07; participants = 33; studies = 1, low-quality evidence), however a benefit in favour of exergames was found for average change in physical fitness (aerobic fitness) (MD 3.82, 95% CI 1.75 to 5.89; participants = 33; studies = 1, low-quality evidence). Adverse effects were not reported; we chose leaving the study early as a proxy measure. The attrition rate by end of treatment was similar between treatment groups (RR 1.06, 95% CI 0.75 to 1.51; participants = 33; studies = 1). Another small trial compared exergames with non-exergames. Only one of our main outcomes was reported - physical fitness, which was measured by average time taken to walk 3 metres. No clear intergroup difference was identified at six-week follow-up (MD -0.50, 95% CI -1.17 to 0.17; participants = 28; studies = 1, very low-quality evidence). No trials reported adverse effects. We chose leaving the study early as a proxy outcome.
AUTHORS' CONCLUSIONS
Our results suggest that non-exergames may have a less beneficial effect on cognitive functioning than cognitive remediation, but have comparable effects for all other outcomes. These data are from a small number of trials, and the evidence is graded as of low or very low quality and is very likely to change with more data. It is difficult to currently establish if the more sophisticated cognitive approaches do any more good - or harm - than 'static' video games for people with schizophrenia. Where players use bodily movements to control the game (exergames), there is very limited evidence suggesting a possible benefit of exergames compared to standard care in terms of cognitive functioning and aerobic fitness. However, this finding must be replicated in trials with a larger sample size and that are conducted over a longer time frame. We cannot draw any firm conclusions regarding the effects of video games until more high-quality evidence is available. There are ongoing studies that may provide helpful data in the near future.
Topics: Activities of Daily Living; Adult; Bias; Cognitive Remediation; Confidence Intervals; Female; Humans; Male; Middle Aged; Patient Dropouts; Physical Fitness; Quality of Life; Randomized Controlled Trials as Topic; Schizophrenia; Schizophrenic Psychology; Social Interaction; Standard of Care; Video Games; Young Adult
PubMed: 33539561
DOI: 10.1002/14651858.CD012844.pub2