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ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 2  |  Page : 115-119

Prospective observational study to assess the circulatory status of the patients presenting to resuscitation room in emergency department


Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission08-Jan-2020
Date of Decision02-Feb-2020
Date of Acceptance02-Mar-2020
Date of Web Publication17-Apr-2020

Correspondence Address:
Miss. Ivy George Edacheril
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_7_20

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  Abstract 

Background: Circulation forms an integral part of a patient presenting to the emergency department (ED). Appropriate management of critically ill patients being brought to the ED is of paramount importance, and inappropriate resuscitation during prehospital transfer could be fatal. Methodology: This prospective study included all priority 1 and trauma patients arriving to the resuscitation room of our ED between August 2018 and October 2018. Details of prehospital management of the circulatory status in the different types of prehospital transport and methods used were noted. A comparison was done between ambulances and private vehicles and receiving prehospital care with the help of univariate analysis. Results: During the study, we recruited 209 patients which comprised trauma (64.1%) and 67 nontrauma (35.9%) priority 1 patients. There was a male predominance (76.7%). Patients were transported by 108 ambulances (9.6%), private ambulances (26.9%), and private vehicles (car, auto, and other vehicles) (60.3%). Of the 142 trauma patients, 66.1% received hemorrhage control as a part of prehospital management. Of the 39.4% trauma patients transported through an ambulance, hypotension was observed in 3.6%, upon their arrival to the ED. Dead and left against medical advice was seen in 0.5% and 1.9%, respectively, whereas 48.8% were discharged stable from the ED. Conclusion: Ambulances bought in patients with adequate hemorrhage control than other vehicles. With an unstable prehospital management in place, a significant sample of patients arrived at ED with a compromised circulatory status. Our study clearly highlights the glaring deficiency in circulatory status at arrival to ED.

Keywords: Ambulance, circulatory status, emergency department outcome, fluid resuscitation, hemorrhage control, patient, severity at presentation


How to cite this article:
Divya B, Edacheril IG, Jacob M, Abhilash KP. Prospective observational study to assess the circulatory status of the patients presenting to resuscitation room in emergency department. Curr Med Issues 2020;18:115-9

How to cite this URL:
Divya B, Edacheril IG, Jacob M, Abhilash KP. Prospective observational study to assess the circulatory status of the patients presenting to resuscitation room in emergency department. Curr Med Issues [serial online] 2020 [cited 2020 May 30];18:115-9. Available from: http://www.cmijournal.org/text.asp?2020/18/2/115/282787




  Introduction Top


Circulatory management is a critical issue in prehospital transport phase of multiple trauma patients. However, the quality of this important care did not receive enough attention. The components of managing circulatory status include hemorrhage control, fluid resuscitation, inotropes, and blood products. In India, prehospital care is in its nascent stage, and much work is needed to be done on stabilizing a patient with a compromised status. Newer techniques and methods to achieve hemodynamic stability are the need of the hour. Modern methods of hemostasis should be implemented to decrease the mortality rate among trauma victims before their admission to the emergency department (ED).[1] The public often plays a vital role in the golden hour of trauma. Hence, it is important to educate them on methods of effective hemorrhage control on a hemorrhaging victim until medical personnel arrives.[2]

Based on available data, in 1997, the National Association of Emergency Medical Services (EMS) physicians issued a position paper on the use of the military antishock trousers (MAST) and pneumatic antishock garments (PASG) in modern EMS. Many services provide MAST for use in possible pelvic and lower extremity fractures.[3] Blood loss in trauma is an ever-present, seen trouble, and can be rectified with timely intervention. With hemodynamic instability at hand, initiation of fluid resuscitation in a prehospital setting as an attempt to restore blood loss proves to be beneficial for the victim.[4] Pelvic binders have been used increasingly in recent years. In developed countries, the application of pelvic binder has become a part of emergency care of all trauma patients with suspected pelvic fractures, in both the prehospital environment and ED. In India, there is a profound deficit in managing patients with compromised circulatory status in a prehospital setting.[5]

Inotropes and vasopressors play an essential role in the supportive care of hypotensive patients. Considering the time gap between shifting a patient from a scene to the nearest hospital, most patients with hemodynamic instability may not receive inotropes. Short-term use of inotropic agents is recommended for the alleviation of symptoms, restoration of peripheral organ perfusion, and reduction of abnormal filling pressures in patients with low output symptoms. In India, the absence of a well-trained and well-equipped prehospital care system and an integrated approach to tackle trauma management has weighed in on the outcome of a trauma patient.[6] Many trauma centers focus on stabilizing the circulatory status of a hypotensive patient before definitive management than following the conventional airway, breathing, and circulation (ABC).[7] With an effective EMS in place, the developed countries run quite successfully in providing prehospital management to victims who contact their services with the help of advanced technology and skilled medical personnel. In India, the underdeveloped prehospital care is yet to move to great lengths.[8] The trauma system in place in our country which includes the prehospital care has not been instrumental in providing primary management to patients.[9] Hence, we have undertaken this study to understand the circulatory status at arrival to the ED.


  Methodology Top


Study design

After procuring the institutional review board (IRB) approval, this prospective observational study was conducted during the period of August 2018–October 2018.

Study setting

Our study is conducted in the adult ED of a tertiary hospital in South India. Our ED is one of the largest in the country with 6 priority I beds and 50 beds in total with an average of 250 admissions per day.

Participants

The study cohort included priority 1 and all trauma patients admitted in ED. A convenient sample of patients was recruited from Monday to Friday between 8 a.m. and 8 p.m. The patients were recruited after obtaining their informed consent.

Sample size calculation

Based on a pilot study done in the ED, the sample size collection was done using the formula n = 4pq/d[2] with an expected proportion of 8%, and an absolute precision of three, we calculated the sample size to be 327. However, during our 3-month study period, we recruited 209 patients.

Variables

As our study was focused on assessing the circulatory status of priority I and trauma patients presenting to the ED, we selected variables representing the above domain. These included patient's sex, number of trauma and nontrauma victims, their mode of transportation to the ED, vital signs at presentation, and interventions done to promote the circulatory status on ED arrival.

Definitions

  • Priority 1: Patients who arrive to the ED with ABC compromise
  • Hemodynamic instability: This term refers to the condition where the patient present with hypotension (systolic blood pressure <90 mmHg)
  • Inadequate circulatory: This term refers to patients who arrive to the ED with hypotension and tissue hypoperfusion.


Outcome variables

The outcome variables include the percentage of patients presenting with tachycardia and hypotension to the ED, the percentage of patients admitted in the intensive care units and wards, discharged stable from hospital and death in hospital. The severity and outcome of patients brought by ambulances were compared to those who were brought by private vehicles (auto and car).

Statistical analysis

Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software version 17.0 (SPSS Inc., Released 2008, Chicago, IL, USA). Analysis of data was done by descriptive analytic statistics (categorical variables as frequencies and percentages) and univariate analysis.

Ethical consideration

This study was approved by the IRB (IRB Min. No. 11514 dated 03.09.2018) and patient confidentiality was maintained using unique identifiers, and by password-protected data entry software with restricted users.


  Results Top


Our study comprised 209 patients with a male dominance of 76.7%. Trauma patients comprised 64.1%, whereas nontrauma patients were 35.9% [Figure 1]. Patients were transported by 108 ambulances (9.6%), private ambulances (26.9%), and private vehicles (car, auto, and other vehicles) (60.3%). Thirty-seven of the 56 trauma patients transported via an ambulance did not receive adequate hemorrhage control. Fluid resuscitation as a part of the prehospital treatment was not initiated in 70.4% of trauma patients [Figure 2]. A significant percentage of patients (46.4%) were referred from other hospitals [Table 1]. Among 39.4% of trauma patients transported through an ambulance, 3.6% presented with hypotension on arrival to the ED [Table 2]. On comparing vital signs between trauma and nontrauma patients, a significant number of trauma patients (78.2%) arrived with tachypnea, and 50 (35.2%) patients presented with tachycardia on arrival to the ED [Table 2]. Tachypnea was observed in 71% of patients bought in by ambulances.
Figure 1: STROBE statement.

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Figure 2: Prehospital treatment in trauma and nontrauma patients.

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Table 1: Baseline characteristics

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Table 2: Comparison of vital signs between trauma and nontrauma patients

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Despite ambulances being capable of medical intervention, patients were transferred with a compromised circulatory status on their arrival to the ED as seen in [Table 3].
Table 3: Comparison of prehospital care and vital signs between ambulances and other vehicles

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Almost half of the patients (48.8%) who encountered hemodynamic instability on arrival to the ED were discharged with proper medical management, whereas 1.9% left against medical advice [Table 4].
Table 4: Patient outcome from the emergency department

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  Discussion Top


Prehospital care is the backbone of EMS. The golden hour of trauma summons trained and skilled medical personnel for timely intervention to improve the outcome of a trauma victim. In developed countries, there is an effective trauma management in place which is instrumental in providing primary management to trauma patients followed by their transportation to definitive care. Ambulances are furnished with advanced technology and skilled paramedics who play a vital role in identifying emergencies and their management.[8] India, however, lacks an effective system of prehospital management that caters to the needs of a patient in a compromised situation. This deficit extends to communication, dispatch, and trained personnel to perform medical interventions.[10] Wesson and Kwong, in their study on trauma care in India, reported that an underdeveloped prehospital care led to poorly managed ambulance services, untimely patient transfer, and medical personnel who lacked trauma-specific training.[10]



Bleeding patients need to be tended at the earliest. Increased blood loss can lead to hypotension. There are many ways to prevent a hemorrhaging victim from slipping into hypotension. Compression bandages, direct pressure, tourniquets, PASG, MAST, pelvic binders initiation of restricted fluid resuscitation, and inotropic support proves to be vital in a prehospital setting to improve the outcome of a trauma victim.[1],[4] A study conducted in the Netherlands on hemorrhage control suggests that the application of HemCon ChitoGauze bought forth positive outcomes to 69.6% of trauma patients, resulting in their hemodynamic stability on arrival to the ED.[2] Hemorrhage control failed in 10.6% of those patients.[2] In our study, although 66% of trauma patients received hemorrhage control, 3.6% were hypotensive on arrival to the ED. In India, ambulances are undersupplied with basic hemorrhage control devices thereby, lowering the quality of prehospital care. The usage of pelvic binders to curb hypotension has been more frequent in the recent years. Modern binders are light, easily portable, and simple to apply; moreover, they can be used in conscious patients thus reducing pain and movement during transport.[6] Although inotropic support is essential in patients with prolonged hypotension, primary intervention suggests two large-bore catheters with intravenous fluid being rushed in to maintain the patient's circulatory status.[7] A study conducted by Geeraedts et al. on prehospital fluid resuscitation in hypotensive trauma patients concludes that the administration of intravenous fluid in a prehospital setting has bought forth positive outcome in trauma patients. On arrival to ED, a stable circulatory status can be obtained when intravenous fluid resuscitation is commenced en route to definitive care.[5] Ferrada et al. hypothesized that patients in hypovolemic shock would have comparable outcomes with the initiation of bleeding treatment (transfusion) before intubation (compressions, airway, and breathing), compared to those patients treated with the traditional ABC sequence.[8]

In developed countries, ambulances are equipped with state-of-the art technology and highly trained paramedics to perform medical interventions, followed by their transport to definitive care, whereas in India, though some ambulances are equipped with life-–saving interventional devices, they are often manned by unskilled medical personnel, thereby aiding to the further deterioration of the patient's condition.[9],[10] The bystanders are always first on scene; hence, they play a major role in the golden hour of trauma. It is vital to educate the public about the importance of primary assistance to a trauma victim until medical personnel arrives.[3] In a country such as India, where trauma is at a higher frequency, much work is needed to be done to mitigate the current status of prehospital care.


  Conclusion Top


Although ambulances bought in patients with better hemorrhage control than other vehicles, there is a dire need to improve the quality of care provided to reach the standards of the developed world. With a nascent prehospital management system in place in our country, a significant proportion of patients arrived at ED with a compromised circulatory status. Our study clearly highlights the glaring deficiency in circulatory status at arrival to ED.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require IRB/Ethics Committee review, and the corresponding protocol/approval number is IRB Min. No. 11514 dated September 03, 2018. We also certify that we have not plagiarized the contents in this submission and have done a Plagiarism Check.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Holcomb JB. Methods for improved hemorrhage control. Crit Care 2004;8 Suppl 2:S57-60.  Back to cited text no. 1
    
2.
Te Grotenhuis R, van Grunsven PM, Heutz WM, Tan EC. Prehospital use of hemostatic dressings in emergency medical services in the Netherlands: A prospective study of 66 cases. Injury 2016;47:1007-11.  Back to cited text no. 2
    
3.
Hegvik JR, Spilman SK, Olson SD, Gilchrist CA, Sidwell RA. Effective hospital-wide education in hemorrhage control. J Am Coll Surg 2017;224:796-90.  Back to cited text no. 3
    
4.
Hauswalt M, Willamson MR, Baty GM, Kerr NL, Edgar-Mied VL. Use of improvised pneumatic anti-shock garments and non-pneumatic anti-shock garments to increase pelvic blood flow. Int J Emerg Med 2010;3:173-5.  Back to cited text no. 4
    
5.
Geeraedts LM Jr., Pothof LA, Caldwell E, de Lange-de Klerk ES, D'Amours SK. Prehospital fluid resuscitation in hypotensive trauma patients: Do we need a tailored approach? Inj 2015;46:4-9.  Back to cited text no. 5
    
6.
Hsu SD, Chen CJ, Chou YC, Wang SH, Chan DC. Effect of early pelvic binder use in the emergency department suspected pelvic trauma: A retrospective cohort study. Res Cardiol 2015;2:23-29.  Back to cited text no. 6
    
7.
Macit K, Mustafa O, Mahmut Y, Suleyman K, Karavelioglu Y, Ozkan M. Review and update of inotropes and vasopressors: Evidence- based use in cardiovascular disease Curr. Res Cardio 2015;2:23-9.  Back to cited text no. 7
    
8.
Ferrada P, Callcut RA, Skarupa DJ, Duane TM, Garcia A, Inaba K, et al. Circulation first-the time has come to question the sequencing of care in the ABCs of trauma – An American Association for the Surgery of Trauma multicenter trial. World J Emerg Surg 2018;13:8.  Back to cited text no. 8
    
9.
Moore L. Measuring quality and effectiveness of prehospital EMS. Prehosp Emerg Care 1999;3:325-31.  Back to cited text no. 9
    
10.
Wesson HK, Kwong M. Trauma care in India: A review of the literature. Surgery 2017;162:S85-106.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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