Previous studies of heterogeneous populations (Glasgow Coma Scale (GCS) scores <9) suggest that endotracheal intubaton of trauma patients prior to hospital arrival (i.e., prehospital intubated) is associated with an increased mortality compared to those patients not intubated in the pre-hospital setting. Deeply comatose patients (GCS = 3) represent a unique population of severely traumatized patients and may benefit from intubation in the prehospital setting. The objective of this study was to compare mortality rates of severely comatose patients (scene GCS = 3) with prehospital endotracheal intubation to those intubated at the hospital.

Using the National Trauma Data Bank (V. 6.2), the following variables were analyzed retrospectively: (1) age; (2) injury type (blunt or penetrating); (3) Injury Severity Score (ISS); (4) scene GCS = 3 (scored prior to intubation/without sedation); (5) emergency department GCS score; (6) arrival emergency department intubation status; (7) first systolic blood pressure in the emergency department (>0); (8) discharge status (alive or dead); (9) Abbreviated Injury Scale Score (AIS); and (10) AIS body region.

Of the 10,948 patients analyzed, 23% (2,491/10,948) were endotracheally intubated in a prehospital setting. Mortality rate for those hospital intubated was 35% vs. 62% for those with prehospital intubation (p <0.0001); mean ISS scores 24.2 ±16.0 vs. 31.6 ±16.2, respectively (p <0.0001). Using logistic regression, controlling for first systolic blood pressure, ISS, emergency department GCS, age, and type of trauma, those with prehospital intubation were more likely to die (OR = 1.9, 95% CI = 1.7−2.2). For patients with only head AIS scores (no other body region injury, n = 1,504), logistic regression (controlling for all other variables) indicated that those with prehospital intubation were still more likely to die (OR = 2.0. 95% CI = 1.4−2.9).

Prehospital endotracheal intubation is associated with an increased mortality in completely comatose trauma patients (GCS = 3). Although the exact reasons for this remain unclear, these results support other studies and suggest the need for future research and re-appraisal of current policies for prehospital intubation in these severely traumatized patients.

In a populous city like Mumbai, which lacks an organized pre-hospital emergency medical services (EMS) system, there exists an informal network through which victims arrive at the trauma center. This baseline study describes the prehospital care and transportation that currently is available in Mumbai.

A prospective trauma database was created by interviewing 170 randomly selected patients from a total of 454 admitted over a two-month period (July–August 2005) at a Level-I, urban, trauma center.

The injured victim in Mumbai usually is rescued by a good Samaritan passer-by (43.5%) and contrary to popular belief, helped by the police (89.7%). Almost immediately after rescue, the victim begins transport to the hospital. No one waits for the EMS ambulance to arrive, as there is none. A taxi cab is the most popular substitute for the ambulance (39.3%). The trauma patient in India usually is a young man in his late-twenties, from a lower socioeconomic class. He mostly finds himself in a government hospital, as private hospitals are reluctant to provide trauma care to the seriously injured. The injured who do receive prehospital care receive inadequate and inappropriate care due to the high cost of consumables in resuscitation, and in part due to the providers' lack of training in emergency care. Those who were more likely to receive prehospital care suffered from road traffic injuries (odds ratio (OR) = 2.3) and those transported by government ambulances (OR = 10.83), as compared to railway accident victims (OR = 0 .41) and those who came by taxi (OR = 0.54).

Currently, as a result of not having an EMS system, prehospital care is a citizen responsibility using societal networks. It is easy to eliminate this system and shift the responsibility to the state. The moot point is whether the state-funded EMS system will be robust enough in a resource-poor setting in which public hospitals are poorly funded. Considering the high funding cost of EMS systems in developed countries and the insufficient evidence that prehospital field interventions by the EMS actually have improved outcomes, Mumbai must proceed with caution when implementing advanced EMS systems into its congested urban traffic. Similar cities, such as Mexico City and Jakarta, have had limited success with implementing EMS systems. Perhaps reinforcing the existing network of informal providers of taxi drivers and police and with training, funding quick transport with taxes on roads and automobile fuels and regulating the private ambulance providers, could be more cost-effective in a culture in which sharing and helping others is not just desirable, but is necessary for overall economic survival.

The ability to discriminate among a large number of patients with mild head injury to detect those most likely to have an intracranial abnormality may offer an advantage in mass-casualty situations and when clinical needs exceed diagnostic capabilities.

In patients with mild head injury (Glasgow Coma Scale score = 13−15), the likelihood of intracranial abnormality, as defined by cranial computed tomography (CT), varies according to presenting neurologic signs and symptoms.

This prospective study consisted of 152 patients with blunt head trauma and one or more of the following: initial loss of consciousness (LOC), headache, vomiting, convulsions, or amnesia. All underwent cranial CT within one hour of presentation. Positive CT findings were defined as cerebral contusion, extra-axial hematoma, intra-ventricular or subarachnoid hemorrhage, brain edema, and skull fracture. Clinical findings were tabulated and compared with CT findings.

The most common symptoms were headache (61%) followed by followed by LOC (45%), vomiting (39%), amnesia (29%), and convulsions (4%). Convulsions were the most predictive of a CT positive finding (80%); history of LOC was least predictive (29%). The presence of two or more clinical findings tended to increase the likelihood of intracranial abnormality, but the association was neither consistent nor additive.

Convulsions occurring in a patient with mild head injury are highly predictive of a positive intracranial finding on CT. Headache, amnesia, and vomiting are each likely to show positive findings in approximately 40–45% of cases. Although the least predictive of the neurologic findings studied, loss of consciousness still correlates with a positive cranial CT in 29% of cases. More than one sign or symptom increases the likelihood of concurrent brain injury.

The objective of this study was to evaluate the time saved by usage of lights and siren (L&S) during emergency medical transport and measure the total number of time-critical hospital interventions gained by this time difference.

A retrospective study was performed of all advanced life support (ALS) transports using lights and siren to this university emergency department during a three-week period. Consecutive times were measured for 112 transports and compared with measured transport times for a personal vehicle traveling the same day of the week and time of day without lights and siren. The time-critical hospital interventions are defined as procedures or treatments that could not be performed in the prehospital setting requiring a physician. The project assessed whether the patients received the hospital interventions within the average time saved using lights and siren transport.

The average difference in time with versus without L&S was -2.62 minutes (95% CI: -2.60− -2.63, paired t-test p <0.0001). The average transport time with L&S was 14.5 ±7.9 minutes (min) (1 standard deviation/minute (min), range = 1–36 min.). The average transport time without L&S was 17.1 ±8.3 min (range = 1−40 min). Of the 112 charts evaluated, five patients (4.5%) received time-critical hospital interventions. No patients received time-critical interventions within the time saved by utilizing lights and siren. Longer distances did not result in time saved with lights and siren.

Limiting lights and siren use to the patients requiring hospital interventions will decrease the risks of injury and death, while adding the benefit of time saved in these critical patients.

A rapid sequence intubation (RSI) method was introduced to a university-based emergency medical services (EMS) system. This is a report of the initial experience with the first 50 patients in a unique, two-tiered, two-advanced life support (ALS) providers system.

The data were evaluated prospectively after an extensive RSI training period, consisting of didactic information and skills performance. Fifty consecutive patient records that documented the procedure were abstracted. Data abstracted included end-tidal CO2, heart rate, blood pressure, and pulse oximetry at various time intervals. Intubation success rates and number of attempts were documented. The consistency of proper documentation also was noted on patient care records.

No differences were noted in heart rate prior to RSI and one and five minutes after the RSI procedure was begun. No differences in blood pressure at one and five minutes were noted. Statistically significant improvements were found in pulse oximetry comparing prior to RSI and one minute after (p < 0.001; 95% CI = 3.15–11.41) as well as prior to RSI and five minutes after RSI was started (p < 0.0002; 95% CI = 4.60–13.33). No differences were observed in end-tidal CO2 at one and five minutes. Overall intubation success rate was 96%, with 82% on first attempt and 92% on two or less attempts. Documentation for individual vitals was consistently <75%.

Patients had no significant worsening of vital signs during the RSI procedure and mild improvement in pulse oximetry. Intubation success rates were consistent with national averages. Proper documentation was lacking in more than one quarter of the charts. These data add to a body of literature that raises further concerns regarding prehospital RSI.

Large-scale events may overwhelm the capacity of even the most advanced emergency medical systems. When patient volume outweighs the number of available emergency medical services (EMS) providers, a mass-casualty incident may require the aid of non-medical volunteers. These individuals may be utilized to perform field disaster triage, lessening the burden on EMS personnel.

The purpose of this study was to evaluate the accuracy of triage decisions made by newly enrolled first-year medical students after receiving a brief educational intervention.

A total of 315 first-year medical students from two successive classes participated in START triage training and completed a paper-based triage exercise as part of orientation. This questionnaire consisted of 15 clinical scenarios providing brief but sufficient details for prioritization. Subjects assigned each scenario a triage category of Red, Yellow, Green, or Black, based on the START protocol and were allowed four minutes to complete the exercise. Participants from the Class of 2009 were provided with printed START reference cards, while those from the Class of 2008 were not. Two test types varying in the order of patient age values were created to determine whether patient age was a factor in triage assessment.

The mean accuracy score of triage assignment by medical student volunteers after a brief START training session was 64.3%. The overall rate of over-triage was 17.8%, compared to an under-triage rate of 12.6%. There were no significant differences in triage accuracy between subjects with and without printed materials (63.9% vs. 64.6%, p = 0.729) or those completing the age-variant test types (64.4% vs. 64.1%, p = 0.889).

First-year medical students who received brief START training achieved triage accuracy scores similar to those of emergency physicians, registered nurses, and paramedics in previous studies. Observed rates of underand over-triage suggest that a need exists for improving the accuracy of triage decisions made by medical and non-medical personnel. This study did not find that printed materials significantly improved triage accuracy, nor did it find that patient age affected the ability of participants to correctly assign triage categories. Future research might further evaluate disaster triage by non-medical volunteers.

Currently, there is little in the literature regarding the ability of rear seatbacks to act as a protective barrier from cargo in frontal crashes. However, it has been shown that unrestrained rear passengers pose a danger to front seat occupants. The association of rear seatback failures and intrusions with mortality and serious injury were examined.

The Seattle CIREN database for restrained, rear-seat passengers in front-end crashes with seatback failure or intrusion was searched. Injury patterns and crash characteristics, including the role of unrestrained cargo were examined. Next, the National Automotive Sampling System- Crashworthiness Data System (NASS-CDS) database was queried for restrained rear-seat passengers in front-end crashes with recorded seat failure or intrusion. Mortality, maximum Abbreviated Injury Scale (AIS) score and mean Injury Severity Scale (ISS) scores were compared with passengers who had no failure or intrusion. Linear regression was used to identify the differences between the groups. Logistic regression was used to estimate the mortality risk associated with seat failure.

There were four CIREN cases that met the criteria. In each case, the occupant suffered significant injury or death. All four of the seat failures were the result of unrestrained cargo striking the seatback. The CDS data revealed a statistically significantly increased mortality (OR = 18.9, 95% CI = 14.0–25.7) associated with seat failure. Both the maximum AIS and mean of the ISS scores were higher in the failure/intrusion group (p <0.0001).

Rear seatback failure/intrusion is associated with increased mortality and injury. Case reports suggest unrestrained cargo plays a significant role in these injuries.

Tehran, Iran, with a population of approximately seven million people, is at a very high risk for a devastating earthquake. This study aims to estimate the number of units of blood required at the time of such an earthquake.

To assume the damage of an earthquake in Tehran, the researchers applied the Centre for Earthquake and Environmental Studies of Tehran/Japan International Cooperation Agency (CEST/JICA) fault-activation scenarios, and accordingly estimated the injury-to-death ratio (IDR), hospital admission rate (HAR), and blood transfusion rate (BTR). The data were based on Iran's major earthquakes during last two decades. The following values were considered for the analysis: (1) IDR = 1, 2, and 3; (2) HAR = 0.25 and 0.35; and (3) BTR = 0.05, 0.07, and 0.10. The American Association of Blood Banks' formula was adapted to calculate total required numbers of Type-O red blood cell (RBC) units. Calculations relied on the following assumptions: (1) no change in Tehran's vulnerability from CEST/JICA study time; (2) no functional damage to Tehran Blood Transfusion Post; and (3) standards of blood safety are secure during the disaster responses. Surge capacity was estimated based on the Bam earthquake experience. The maximum, optimum, and minimum blood deficits were calculated accordingly.

No deficit was estimated in case of the Mosha fault activation and the optimum scenario of North Tehran fault. The maximum blood deficit was estimated from the activation of the Ray fault, requiring up to 107,293 and 95,127 units for the 0–24 hour and the 24–72 hour periods after the earthquake, respectively. The optimum deficit was estimated up to 46,824 and 16,528 units for 0–24 hour and 24–72 hour period after the earthquake, respectively.

In most Tehran earthquake scenarios, a shortage of blood was estimated to surge the capacity of all blood transfusion posts around the country within first three days, as it might ask for a 2–8 times more than what the system had produced following the Bam earthquake.

In the absence of other data, military Tactical Combat Casualty Care (TCCC) precepts are increasingly being adapted to law enforcement needs. The purpose of this study is to better describe the nature of potentially preventable law enforcement Line-of-Duty Deaths (LODDs) occurring as a result of felonious assaults.

A retrospective analysis was performed of open source data available through the US Federal Bureau of Investigation (FBI) Uniform Crime Reporting (UCR) Law Enforcement Officers Killed and Assaulted (LEOKA) program for the years 1998–2007 inclusive.

After applying exclusion criteria, 341 victim officers were included in the study. The most common cause of death was head trauma (n = 198), followed by chest trauma (n = 90). There were 123 victim officers that suffered potentially preventable deaths; the majority of these injuries involved the chest. Over the 10-year study period, only two officers (0.6%) died from isolated extremity hemorrhage.

The current emphasis of TCCC on control of exsanguinating extremity hemorrhage may not meet the needs of law enforcement personnel in an environment with expedited access to well-developed trauma systems. Further study is needed to better examine the causes of preventable deaths in law enforcement officers, as well as the most appropriate law enforcement tactical medical skill set and treatment priorities.