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Background Fatal trauma is one of the leading causes of death in Western industrialized countries. The aim of the present study was to determine the preventability of traumatic deaths, analyze the medical measures related to preventable deaths, detect management failures, and reveal specific injury patterns in order to avoid traumatic deaths in Berlin. Materials and methods In this prospective observational study all autopsied, direct trauma fatalities in Berlin in 2010 were included with systematic data acquisition, including police files, medical records, death certificates, and autopsy records. An interdisciplinary expert board judged the preventability of traumatic death according to the classification of non-preventable (NP), potentially preventable (PP), and definitively preventable (DP) fatalities. Results Of the fatalities recorded, 84.9 % ( n  = 224) were classified as NP, 9.8 % ( n  = 26) as PP, and 5.3 % ( n  = 14) as DP. The incidence of severe traumatic brain injury (sTBI) was significantly lower in PP/DP than in NP, and the incidence of fatal exsanguinations was significantly higher. Most PP and NP deaths occurred in the prehospital setting. Notably, no PP or DP was recorded for fatalities treated by a HEMS crew. Causes of DP deaths consisted of tension pneumothorax, unrecognized trauma, exsanguinations, asphyxia, and occult bleeding with a false negative computed tomography scan. Conclusions The trauma mortality in Berlin, compared to worldwide published data, is low. Nevertheless, 15.2 % ( n  = 40) of traumatic deaths were classified as preventable. Compulsory training in trauma management might further reduce trauma-related mortality. The main focus should remain on prevention programs, as the majority of the fatalities occurred as a result of non-survivable injuries.

Assessment of disease severity in patients with septic shock (SS) is crucial in determining optimal level of care. In both pre- and in-hospital settings, blood lactate measurement is broadly used in combination with the clinical evaluation of patients as the clinical picture alone is not sufficient for assessing disease severity and outcomes. From 15th April 2017 to 15th April 2019, patients with SS requiring prehospital mobile Intensive Care Unit intervention (mICU) were prospectively included in this observational study. Prehospital blood lactate clearance was estimated by the difference between prehospital (time of first contact between the patients and the mICU prior to any treatment) and in-hospital (at hospital admission) blood lactate levels divided by prehospital blood lactate. Among the 185 patients included in this study, lactate measurement was missing for six (3%) in the prehospital setting and for four (2%) at hospital admission, thus 175 (95%) were analysed for prehospital blood lactate clearance (mean age 70 ± 14 years). Pulmonary, digestive and urinary infections were probably the cause of the SS in respectively 56%, 22% and 10% of the cases. The 30-day overall mortality was 32%. Mean prehospital blood lactate clearance was significantly different between patients who died and those who survived (respectively 0.41 ± 2.50 mmol.l−1 vs 1.65 ± 2.88 mmol.l−1, p = 0.007). Cox regression analysis showed that 30-day mortality was associated with prehospital blood lactate clearance > 10% (HRa [CI95] = 0.49 [0.26–0.92], p = 0.028) and prehospital blood lactate clearance < 10% (HRa [CI95] = 2.04 [1.08–3.84], p = 0.028). A prehospital blood lactate clearance < 10% is associated with 30-day mortality increase in patients with SS handled by the prehospital mICU. Further studies will be needed to evaluate if prehospital blood lactate clearance alone or combined with clinical scores could affected the triage decision-making process for those patients.

Background Non-invasive ventilation (NIV) is widely used in emergency settings for acute respiratory failure, with NIV failure, usually defined by the need for tracheal intubation, as its primary complication. In emergency settings where patients may not be intubated or or where NIV represents the ceiling of care, a pragmatic understanding of NIV failure requires a broader definition that incorporates early clinical deterioration, including presumptive intubation criteria. This study assessed the prevalence of early clinical deterioration under NIV initiated in emergency settings (emergency department [ED] or mobile emergency medical services [EMS]) and its associated variables. Methods A prospective multicentre study was conducted in 68 French EDs and EMS in the Initiative Recherche Urgences (IRU) network. Adult patients (≥ 18 years) requiring NIV in emergency settings were included, excluding those with a known do-not-resuscitate order or low autonomy. The primary endpoint was early clinical deterioration under NIV at 1 h. Early clinical deterioration under NIV was defined as either (1) the need for tracheal intubation or; (2) the presence of presumptive criteria for intubation. Secondary endpoints were baseline factors associated with failure, the need for tracheal intubation or death within 7 days among patients surviving without tracheal intubation at 1 h, and 7-day mortality. Results A total of 198 patients were included over 5 days. Early clinical deterioration at 1 h was reported in 41% of the patients. Early clinical deterioration under NIV was associated with a Glasgow Coma Scale score < 14 (adjusted odds ratio [aOR] = 5.5, 95% confidence interval [CI] [1.8 –19.4]), heart rate > 115 beats per minute (aOR = 2.5, 95%CI [1.3–5.2]), and signs of increased work of breathing (aOR = 2.8, 95%CI [1.2–7.1]). Among the surviving patients not intubated at 1 h, 12% required intubation within 7 days in the Early Clinical Deterioration group and 3% in the No Early Clinical Deterioration group (p < 0.001). Within 7 days, 28% died in the Early Clinical Deterioration group and 10% in the No Early Clinical Deterioration group (p = 0.001). NIV failure was associated with increased 7-day mortality (aHR = 4.1, 95%CI [1.8–9.1]). Conclusions Early clinical deterioration under NIV is common in EDs, affecting nearly one out of two patients, and is associated with higher 7-day mortality. Clinical trial registration Registered 2024 january, 23th. NCT06213623. Prior to the first inclusion.

Background Despite differences in time of sepsis recognition, recent studies support that early initiation of norepinephrine in patients with septic shock (SS) improves outcome without an increase in adverse effects. This study aims to investigate the relationship between 30-day mortality in patients with SS and prehospital norepinephrine infusion in order to reach a mean blood pressure (MAP) > 65 mmHg at the end of the prehospital stage. Methods From April 06th, 2016 to December 31th, 2020, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To consider cofounders, the propensity score method was used to assess the relationship between prehospital norepinephrine administration in order to reach a MAP > 65 mmHg at the end of the prehospital stage and 30-day mortality. Results Four hundred and seventy-eight patients were retrospectively analysed, among which 309 patients (65%) were male. The mean age was 69 ± 15 years. Pulmonary, digestive, and urinary infections were suspected among 44%, 24% and 17% patients, respectively. One third of patients (n = 143) received prehospital norepinephrine administration with a median dose of 1.0 [0.5–2.0] mg h −1 , among which 84 (69%) were alive and 38 (31%) were deceased on day 30 after hospital-admission. 30-day overall mortality was 30%. Cox regression analysis after the propensity score showed a significant association between prehospital norepinephrine administration and 30-day mortality, with an adjusted hazard ratio of 0.42 [0.25–0.70], p < 10 –3 . Multivariate logistic regression of IPTW retrieved a significant decrease of 30-day mortality among the prehospital norepinephrine group: ORa = 0.75 [0.70–0.79], p < 10 –3 . Conclusion In this study, we report that prehospital norepinephrine infusion in order to reach a MAP > 65 mmHg at the end of the prehospital stage is associated with a decrease in 30-day mortality in patients with SS cared for by a MICU in the prehospital setting. Further prospective studies are needed to confirm that very early norepinephrine infusion decreases septic shock mortality.

Septic shock (SS) is characterized by low blood pressure resulting in organ failure and poor prognosis. Among SS treatments, in hospital studies reported a beneficial effect of early hemodynamic resuscitation on mortality rate. This study aims to investigate the relationship between prehospital hemodynamic optimisation and 30-day mortality in patients with SS. From April 6th, 2016 to December 31th, 2019, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (mICU) were included. Prehospital hemodynamic optimisation was defined as a arterial blood pressure of >65 mmHg, or >75 mmHg if previous hypertension history, at the end of the prehospital stage. Three hundred thirty-seven patients were retrospectively analysed. The mean age was 69 ± 15 years, and 226 patients (67%) were male. One hundred and thirty-six patients (40%) had previous hypertension history. Pulmonary, digestive and urinary infections were the suspected cause of the SS in respectively 46%, 23% and 15% of the cases. 30-day overall mortality was 30%. Prehospital hemodynamic optimisation was complete for 204 patients (61%). Cox regression analysis reports a significant association between prehospital hemodynamic optimisation and 30-day mortality (HRa = 0.52 95%CI [0.31–0.86], p = 0.01). In this study, we report that prehospital hemodynamic optimisation is associated with a decrease in 30-day mortality in patients with SS cared for by a mICU in the prehospital setting. An individualized mean arterial pressure target, based on previous hypertension history, may be considered from the prehospital stage of SS resuscitation.

Background The early identification of sepsis presenting a high risk of deterioration is a daily challenge to optimise patient pathway. This is all the most crucial in the prehospital setting to optimize triage and admission into the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the prehospital National Early Warning Score 2 (NEWS-2) and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU). Methods Septic shock (SS) patients cared for by a MICU between 2016, April 6th and 2021 December 31st were included in this retrospective cohort study. The NEWS-2 is based on 6 physiological variables (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation prior oxygen supplementation, and level of consciousness) and ranges from 0 to 20. The Inverse Probability Treatment Weighting (IPTW) propensity method was applied to assess the association with in-hospital, 30 and 90-day mortality. A NEWS-2 ≥ 7 threshold was chosen for increased clinical deterioration risk definition and usefulness in clinical practice based on previous reports. Results Data from 530 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 69 ± 15 years and presumed origin of sepsis was pulmonary (43%), digestive (25%) or urinary (17%) infection. In-hospital mortality rate was 33%, 30 and 90-day mortality were respectively 31% and 35%. A prehospital NEWS-2 ≥ 7 is associated with an increase in-hospital, 30 and 90-day mortality with respective RRa = 2.34 [1.39–3.95], 2.08 [1.33–3.25] and 2.22 [1.38–3.59]. Calibration statistic values for in-hospital mortality, 30-day and 90-day mortality were 0.54; 0.55 and 0.53 respectively. Conclusion A prehospital NEWS-2 ≥ 7 is associated with an increase in in-hospital, 30 and 90-day mortality of septic shock patients cared for by a MICU in the prehospital setting. Prospective studies are needed to confirm the usefulness of NEWS-2 to improve the prehospital triage and orientation to the adequate facility of sepsis.

Purpose Respiratory dysfunction is one of the most frequent symptoms observed during sepsis reflecting hypoxemia and/or acidosis that may be assessed by the ROX index (ratio of oxygen saturation by pulse oximetry/fraction of inspired oxygen to respiratory rate). This study aimed to describe the relationship between the prehospital ROX index and 30-day mortality rate among septic shock patients cared for in the prehospital setting by a mobile intensive care unit (MICU). Methods From May 2016 to December 2021, 530 septic shock patients cared for by a prehospital MICU were retrospectively analysed. Initial ROX index value was calculated at the first contact with MICU. A Cox regression analysis after propensity score matching was performed to assess the relationship between 30-day mortality rate and a ROX index ≤ 10. Results Pulmonary, digestive and urinary sepsis were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality reached 31%. Cox regression analysis showed a significant association between 30-day mortality and a ROX index ≤ 10: adjusted hazard ratio of 1.54 [1.08–2.31], p  < 0.05. Conclusions During the prehospital stage of septic shock patients cared for by a MICU, ROX index is significantly associated with 30-day mortality. A prehospital ROX ≤ 10 value is associated with a 1.5-fold 30-day mortality rate increase. Prospective studies are needed to confirm the ability of prehospital ROX to predict sepsis outcome since the prehospital setting.

Purpose Traumas cause great casualties, accompanied by heavy economic burdens every year. The study aimed to use ML (machine learning) survival algorithms for predicting the 8-and 24-hour survival of severe traumas. Methods A retrospective study using data from National Trauma Data Bank (NTDB) was conducted. Four ML survival algorithms including survival tree (ST), random forest for survival (RFS) and gradient boosting machine (GBM), together with a Cox proportional hazard model (Cox), were utilized to develop the survival prediction models. Following this, model performance was determined by the comparison of the C-index, integrated Brier score (IBS) and calibration curves in the test datasets. Results A total of 191,240 individuals diagnosed with severe trauma between 2015 and 2018 were identified. Glasgow Coma Scale (GCS), trauma type, age, SaO 2 , respiratory rate (RR), systolic blood pressure (SBP), EMS transport time, EMS on-scene time, pulse, and EMS response time were identified as the main predictors. For predicting the 8-hour survival with the complete cases, the C-indexes in the test sets were 0.853 (0.845, 0.861), 0.823 (0.812, 0.834), 0.871 (0.862, 0.879) and 0.857 (0.849, 0.865) for Cox, ST, RFS and GBM, respectively. Similar results were observed in the 24-hour survival prediction models. The prediction error curves based on IBS also showed a similar pattern for these models. Additionally, a free web-based calculator was developed for potential clinical use. Conclusion The RFS survival algorithms provide non-parametric alternatives to other regression models to be of clinical use for estimating the survival probability of severe trauma patients.

Background Globally, injury deaths largely occur in low- and middle-income countries. No estimates of injury-associated mortality exist in Rwanda. This study aimed to describe the patterns of injury-related deaths in Kigali, Rwanda using existing data sources. Methods We created a database of all deaths reported by the main institutions providing emergency care in Kigali—four major hospitals, two divisions of the Rwanda National Police, and the National Emergency Medical Service—during 12 months (Jan–Dec 2012) and analyzed it for demographics, diagnoses, mechanism and type of injury, causes of death, and all-cause and cause-specific mortality rates. Results There were 2682 deaths, 57 % in men, 67 % in adults >18 year, and 16 % in children <5 year. All-cause mortality rate was 236/100,000; 35 % (927) were due to probable surgical causes. Injury-related deaths occurred in 22 % (593/2682). The most common injury mechanism was road traffic crash (cause-specific mortality rate of 20/100,000). Nearly half of all injury deaths occurred in the prehospital setting (47 %, n  = 276) and 49 % of injury deaths at the university hospital occurred within 24 h of arrival. Being injured increased the odds of dying in the prehospital setting by 2.7 times ( p  < 0.0001). Conclusions Injuries account for 22 % of deaths in Kigali with road traffic crashes being the most common cause. Injury deaths occurred largely in the prehospital setting and within the first 24 h of hospital arrival suggesting the need for investment in emergency infrastructure. Accurate documentation of the cause of death would help policy-makers make data-driven resource allocation decisions.

Background Septic shock medical treatment relies on a bundle of care including antibiotic therapy and hemodynamic optimisation. Hemodynamic optimisation consists of fluid expansion and norepinephrine administration aiming to optimise cardiac output to reach a mean arterial pressure of 65mmHg. In the prehospital setting, direct cardiac output assessment is difficult because of the lack of invasive and non-invasive devices. This study aims to assess the relationship between 30-day mortality and (i) initial pulse pressure (iPP) as (ii) pulse pressure variation (dPP) during the prehospital stage among patients cared for SS by a prehospital mobile intensive care unit (MICU). Methods From May 09th, 2016 to December 02nd, 2021, septic shock patients requiring MICU intervention were retrospectively analysed. iPP was calculated as the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the first contact between the patient and the MICU team prior to any treatment and, dPP as the difference between the final PP (the difference between SBP and DBP at the end of the prehospital stage) and iPP divided by prehospital duration. To consider cofounders, the propensity score method was used to assess the relationship between (i) iPP < 40mmHg, (ii) positive dPP and 30-day mortality. Results Among the 530 patients analysed, pulmonary, digestive, and urinary infections were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality rate reached 31%. Cox regression analysis showed an association between 30-day mortality and (i) iPP < 40mmHg; aHR of 1.61 [1.03–2.51], and (ii) a positive dPP; aHR of 0.56 [0.36–0.88]. Conclusion The current study reports an association between 30-day mortality rate and iPP < 40mmHg and a positive dPP among septic shock patients cared for by a prehospital MICU. A negative dPP could be helpful to identify septic shock with higher risk of poor outcome despite prehospital hemodynamic optimization.