Helicopters and Injured Kids: Improved Survival with Scene Air - - PowerPoint PPT Presentation

▶
helicopters and injured kids improved survival
SMART_READER_LITE
LIVE PREVIEW

Helicopters and Injured Kids: Improved Survival with Scene Air - - PowerPoint PPT Presentation

Sep 11, 2023 240 likes •553 views

Helicopters and Injured Kids: Improved Survival with Scene Air Medical Transport in the Pediatric Trauma Population JB Brown, CM Leeper, JL Sperry, AB Peitzman, TR Billiar, BA Gaines & ML Gestring Disclosures No conflicts to disclose

slide-1
SLIDE 1

Helicopters and Injured Kids: Improved Survival with Scene Air Medical Transport in the Pediatric Trauma Population

JB Brown, CM Leeper, JL Sperry, AB Peitzman, TR Billiar, BA Gaines & ML Gestring

slide-2
SLIDE 2

Disclosures

No conflicts to disclose

slide-3
SLIDE 3

Background

  • Helicopter emergency medical services (HEMS)
  • ften transport injured children
  • Need to justify increased risk and cost compared

to ground emergency medical services (GEMS)

  • Unclear evidence of benefit to support HEMS

use in pediatric trauma patients

slide-4
SLIDE 4

Objective

Evaluate association of HEMS compared to GEMS transport with outcomes in pediatric trauma patients

slide-5
SLIDE 5

Methods: Data Source & Population

  • National Trauma Databank 2007-2012
  • Age ≤15 years
  • Transported from scene of injury by HEMS or

GEMS

  • Excluded: Burns & DOA
  • Multiple imputation for missing data
slide-6
SLIDE 6

Methods: Propensity Score Matching

  • Selection bias  HEMS patients more severely

injured

  • Propensity score to predict likelihood of

undergoing HEMS

  • Propensity score variables:
  • Age, sex, MOI, age-adjusted prehospital vital

signs, prehospital time, ISS, pediatric level I center available, geographic region

slide-7
SLIDE 7

Methods: Propensity Score Matching

  • Nearest neighbor 1:1 matching
  • Stratified matching within age groups
  • Infant/toddler (≤2 years)
  • Child (3 – 12 years)
  • Adolescent (>12 years)
  • Standardized differences to assess balance
  • |Std diff| <0.1  balance between groups
slide-8
SLIDE 8

Methods: Outcomes

  • Primary outcome
  • In-hospital survival
  • Secondary outcome
  • Discharge disposition in survivors
  • Discharge to home

vs.

  • Discharge to rehab or need for additional

services

slide-9
SLIDE 9

Methods: Analysis

  • Conditional logistic regression
  • HEMS vs GEMS
  • Adjusted for demographics, age-adjusted ED

vital signs, ICU resources, urgent OR, NAT, complications

  • Accounting for clustering within centers
slide-10
SLIDE 10

Methods: Subgroup Analysis

  • Logistic considerations for HEMS  proximity

to trauma center

  • Evaluated patients with transport time >15min
  • Capture patients with potential to undergo

HEMS transport

  • Repeated models for survival & discharge

disposition

slide-11
SLIDE 11

Study Population

NTDB 07-12 Age≤15 N=541,875 Study Population N=166,594 HEMS N=25,837 Treated Matched N=25,700 (>99%) GEMS N=140,757 Control Matched N=25,700 (18%) Non-HEMS/GEMS transport N=206,808 Transfer N=162,470 Burn injury N=5,726 DOA N=277

slide-12
SLIDE 12

Results: HEMS v GEMS Pre-Match

HEMS N=25,837 GEMS N=140,757 p value

Age (years) 10 (5, 14) 10 (4, 13) <0.01 Mechanism (% blunt) 96 94 <0.01 Prehospital hypotension (%) 37 35 <0.01 Prehospital abnormal HR (%) 21 17 <0.01 Prehospital abnormal RR (%) 34 33 <0.01 Prehospital GCS 15 (12, 15) 15 (15, 15) <0.01 Prehospital time (min) 60 (47, 79) 42 (31, 59) <0.01 ISS 9 (5, 17) 5 (4, 9) <0.01 Level I pediatric center (%) 50 37 <0.01 Geographic region (%) <0.01 Midwest 15 25

  • Northeast

11 15

  • South

45 33

  • West

29 27

slide-13
SLIDE 13

Results: HEMS v GEMS Pre-Match

HEMS N=25,837 GEMS N=140,757 p value

Age (years) 10 (5, 14) 10 (4, 13) <0.01 Mechanism (% blunt) 96 94 <0.01 Prehospital hypotension (%) 37 35 <0.01 Prehospital abnormal HR (%) 21 17 <0.01 Prehospital abnormal RR (%) 34 33 <0.01 Prehospital GCS 15 (12, 15) 15 (15, 15) <0.01 Prehospital time (min) 60 (47, 79) 42 (31, 59) <0.01 ISS 9 (5, 17) 5 (4, 9) <0.01 Level I pediatric center (%) 50 37 <0.01 Geographic region (%) <0.01 Midwest 15 25

  • Northeast

11 15

  • South

45 33

  • West

29 27

slide-14
SLIDE 14

Results: HEMS v GEMS Post-Match

0.0 0.1 0.2 0.3 0.4 0.5 Absolute Standardized Difference Prehospital bradycardia Prehospital tachypnea Prehospital Time Sex Prehospital apnea West region Prehospital hypotension Age Prehospital tachycardia Blunt mechanism Anatomic triage criteria Northeast region Midwest region South region Level I pediatric center Prehospital GCS ISS Before Matching After Matching

slide-15
SLIDE 15

Results: HEMS v GEMS Post-Match

0.0 0.1 0.2 0.3 0.4 0.5 Absolute Standardized Difference Prehospital bradycardia Prehospital tachypnea Prehospital Time Sex Prehospital apnea West region Prehospital hypotension Age Prehospital tachycardia Blunt mechanism Anatomic triage criteria Northeast region Midwest region South region Level I pediatric center Prehospital GCS ISS Before Matching After Matching

slide-16
SLIDE 16

Results: HEMS v GEMS Post-Match

HEMS N=25,700 GEMS N=25,700 Standardized Difference Age (years) 10 (5, 14) 10 (5, 14)

  • 0.002

Mechanism (% blunt) 96 95 0.027 Prehospital hypotension (%) 49 49

  • 0.006

Prehospital abnormal HR (%) 28 28

  • 0.011

Prehospital abnormal RR (%) 49 49

  • 0.007

Prehospital GCS 15 (13, 15) 15 (13, 15)

  • 0.006

Prehospital time (min) 57 (43, 75) 44 (31, 62)

  • 0.023

ISS 9 (5, 17) 9 (4, 17)

  • 0.002

ICU admission (%) 40 31 0.191* Urgent OR (%) 15 13 0.068 Mechanical ventilation (%) 18 14 0.122* Survival (%) 96 94 0.081

* Indicates residual imbalance after matching

slide-17
SLIDE 17

Results: HEMS v GEMS Post-Match

HEMS N=25,700 GEMS N=25,700 Standardized Difference Age (years) 10 (5, 14) 10 (5, 14)

  • 0.002

Mechanism (% blunt) 96 95 0.027 Prehospital hypotension (%) 49 49

  • 0.006

Prehospital abnormal HR (%) 28 28

  • 0.011

Prehospital abnormal RR (%) 49 49

  • 0.007

Prehospital GCS 15 (13, 15) 15 (13, 15)

  • 0.006

Prehospital time (min) 57 (43, 75) 44 (31, 62)

  • 0.023

ISS 9 (5, 17) 9 (4, 17)

  • 0.002

ICU admission (%) 40 31 0.191* Urgent OR (%) 15 13 0.068 Mechanical ventilation (%) 18 14 0.122* Survival (%) 96 94 0.081

* Indicates residual imbalance after matching

slide-18
SLIDE 18

Results: HEMS v GEMS Post-Match

HEMS N=25,700 GEMS N=25,700 Standardized Difference Age (years) 10 (5, 14) 10 (5, 14)

  • 0.002

Mechanism (% blunt) 96 95 0.027 Prehospital hypotension (%) 49 49

  • 0.006

Prehospital abnormal HR (%) 28 28

  • 0.011

Prehospital abnormal RR (%) 49 49

  • 0.007

Prehospital GCS 15 (13, 15) 15 (13, 15)

  • 0.006

Prehospital time (min) 57 (43, 75) 44 (31, 62)

  • 0.023

ISS 9 (5, 17) 9 (4, 17)

  • 0.002

ICU admission (%) 40 31 0.191* Urgent OR (%) 15 13 0.068 Mechanical ventilation (%) 18 14 0.122* Survival (%) 96 94 0.081

* Indicates residual imbalance after matching

slide-19
SLIDE 19

Results: HEMS v GEMS

1.72 1.10

slide-20
SLIDE 20

Results: HEMS v GEMS

1.72 1.10

slide-21
SLIDE 21

Results: HEMS v GEMS

1.72 1.10

NNT = 41 (95%CI 29 – 84)

slide-22
SLIDE 22

Results: HEMS v GEMS

1.72 1.10

slide-23
SLIDE 23

Results: HEMS v GEMS >15min

1.81 1.07

slide-24
SLIDE 24

Results: HEMS v GEMS >15min

1.81 1.07

slide-25
SLIDE 25

Results: HEMS v GEMS >15min

1.81 1.07

NNT = 38 (95%CI 27 – 89)

slide-26
SLIDE 26

Results: HEMS v GEMS >15min

1.81 1.07

slide-27
SLIDE 27

Summary

  • HEMS transport independently associated with

survival

  • Transport 41 additional patients by HEMS to

save one life

  • HEMS not associated with discharge disposition
  • Findings persist in patients with >15min

transport time

slide-28
SLIDE 28

Limitations

  • Retrospective
  • NTDB limitations
  • Unknown prehospital interventions
  • Selection bias
  • Propensity score matching
slide-29
SLIDE 29

Conclusions

  • Injured pediatric patients undergoing HEMS

scene transport have improved survival

  • Further study warranted
  • Investigate underlying mechanisms
  • Develop specific triage criteria for HEMS

transport in pediatric trauma patients

slide-30
SLIDE 30