Trauma


COCHRANE SYSTEMATIC REVIEW: Helicopter emergency medical services for adults with major trauma
Implications for practice: Based on the current evidence, the added benefits of HEMS compared with GEMS are unclear.
Review Overview: Due to the methodological weakness of the available literature, and the considerable heterogeneity of effects and study methodologies, we could not determine an accurate composite estimate of the benefit of HEMS. Although some of the 19 multivariate regression studies indicated improved survival associated with HEMS, others did not. This was also the case for the TRISS-based studies. All were subject to a low quality of evidence as assessed by the GRADE Working Group criteria due to their nonrandomized design. The question of which elements of HEMS may be beneficial has not been fully answered. The results from this review provide motivation for future work in this area. This includes an ongoing need for diligent reporting of research methods, which is imperative for transparency and to maximize the potential utility of results. Large, multicenter studies are warranted as these will help produce more robust estimates of treatment effects. Future work in this area should also examine the costs and safety of HEMS, since multiple contextual determinants must be considered when evaluating the effects of HEMS for adults with major trauma.
LINK to Cochrane Library: Issue 12, 2015 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009228.pub3/abstract


COCHRANE SYSTEMATIC REVIEW: Interventions for treating traumatized permanent front teeth: luxated (dislodged) teeth
Implications for practice: More research needed
Review Overview: There is no high quality evidence available on which to base an assessment of interventions ( antibiotics, splints, repositioning) to treat these injuries. Current treatment guidelines are based on studies with a greater risk of bias using study designs such as case series, animal studies and laboratory-based cellular studies. High quality studies are therefore urgently needed.
LINK to Cochrane Library: Issue 4, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006203.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Thromboprophylaxis for trauma patients
Implications for practice: Thromboprophylaxis treatment can reduce risk of DVT but not mortality or PE.
Review Overview: We did not find evidence that thromboprophylaxis reduces mortality or PE in any of the comparisons assessed. However, we found some evidence that thromboprophylaxis prevents DVT. Although the strength of the evidence was not high, taking into account existing information from other related conditions such as surgery, we recommend the use of any DVT prophylactic method for people with severe trauma.
LINK to Cochrane Library: Issue 3, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008303.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Hyperbaric oxygen therapy for the adjunctive treatment of traumatic brain injury
Implications for practice: Unclear, more large studies needed.
Review Overview: In people with traumatic brain injury, while the addition of HBOT may reduce the risk of death and improve the final GCS, there is little evidence that the survivors have a good outcome. The improvement of 2.68 points in GCS is difficult to interpret. This scale runs from three (deeply comatose and unresponsive) to 15 (fully conscious), and the clinical importance of an improvement of approximately three points will vary dramatically with the starting value (for example an improvement from 12 to 15 would represent an important clinical benefit, but an improvement from three to six would leave the patient with severe and highly dependent impairment). The routine application of HBOT to these patients cannot be justified from this review. Given the modest number of patients, methodological shortcomings of included trials and poor reporting, the results should be interpreted cautiously. An appropriately powered trial of high methodological rigour is required to define which patients, if any, can be expected to benefit most from HBOT.
LINK to Cochrane Library: Issue 12, 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004609.pub3/abstract;jsessionid=445E4FA05D9D8589420EE8DCC2A581F3.d01t03


COCHRANE SYSTEMATIC REVIEW: Helicopter emergency medical services for adults with major trauma
Implications for practice: There is low quality evidence to show that HEMS may benefit some trauma patients.
Review Overview: Trauma is a leading cause of death and disability worldwide and, since the 1970s, helicopters have been used to transport people with injuries to hospitals that specialize in trauma care. Helicopters offer several potential advantages, including faster transport to expert medical care and treatment en route to the hospital by providers who are specifically trained in trauma management. Twenty-five studies conducted internationally compared transport by helicopter emergency medical services to transport by ground emergency medical services (an ambulance), with both types of service aiming to improve either survival or disability for seriously injured patients. Some of these studies indicated some benefit of helicopter transport for survival after major trauma, but others did not. The studies were of varying sizes and different methods were used to determine if more patients survived when transported by helicopter versus ground ambulances. Some studies included helicopter teams that had specialized physicians on board whereas other helicopter crews were staffed by paramedics and nurses. Furthermore, patients transported by helicopter or ground emergency medical services had varying numbers and types of procedures en route to the trauma centre. The use of some of these procedures, such as the placement of a breathing tube, may have helped improve survival in some of the studies. Overall the quality of the included studies was low. Helicopter transport for some trauma patients may be beneficial for a variety of reasons and more research is required to determine what elements of helicopter transport help improve outcomes. The results from future research might help in better allocation of the helicopter transport resource with increased safety and decreased costs.
LINK to Cochrane Library: Issue 3, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009228.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Tranexamic acid for reducing mortality in emergency and urgent surgery
Implications for practice: Use of tranexamic acid reduces need for transfusion by approx. 30%.Unlcear generalization to EMS care.
Review Overview: Emergency or urgent surgery, which can be defined as surgery which must be done promptly to save life, limb, or functional capacity, is associated with a high risk of bleeding and death. Antifibrinolytic drugs, such as tranexamic acid, promote blood clotting by preventing blood clots from breaking down. Previous studies have shown that this drug reduces the need for blood transfusion in patients undergoing elective surgery. The authors of this review searched for randomised controlled trials assessing the effects of tranexamic acid in patients undergoing urgent or emergency surgery. The results of this review show that tranexamic acid reduces the probability that a patient will receive a blood transfusion by around 30%. The effect of tranexamic acid on other important outcomes, such as death, remains uncertain. The authors conclude that larger studies should be done to assess the effects of tranexamic acid on relevant outcomes such as death in patients undergoing all types of emergency and urgent surgery.
LINK to Cochrane Library: Issue 3, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010245.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Antifibrinolytic drugs for acute traumatic injury
Implications for practice: Early TXA is a safe way to reduce mortality in bleeding trauma victims.
Review Overview: TXA safely reduces mortality in trauma patients with bleeding without increasing the risk of adverse events. TXA should be given as early as possible and within three hours of injury, as further analysis of the CRASH-2 trial showed that treatment later than this is unlikely to be effective and may be harmful. Although there is some promising evidence for the effect of TXA in patients with TBI, substantial uncertainty remains. Two ongoing trials being conducted in patients with isolated TBI should resolve these remaining uncertainties.
LINK to Cochrane Library: Issue 5, 2015 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004896.pub4/abstract


COCHRANE SYSTEMATIC REVIEW: Interventions for treating acute elbow dislocations in adults
Implications for practice: Implications unclear
Review Overview: This review includes two trials involving a total of 80 adults with simple dislocations that had been put back into place (reduced). One trial compared early mobilization of the elbow with immobilization for three weeks in a plaster cast. The other trial compared surgical repair of the torn ligaments versus conservative treatment (cast immobilization for 2 weeks). Overall. The review concluded that there was not enough evidence form randomized controlled trials to show which methods of treatment are better for those injuries.
LINK to Cochrane Library: Issue 4, 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007908.pub2/pdf/abstract


COCHRANE SYSTEMATIC REVIEW: Dressings for superficial and partial thickness burns
Implications for practice: Unknown effectiveness due to inadequate data
Review Overview: There are many dressing materials available to treat superficial and partial thickness burns. Evidence from small trials, many with methodological limitations, suggests that these burns may be managed with hydrocolloid, silicon nylon, antimicrobial (containing silver), polyurethane film and biosynthetic dressings. There was no evidence to support the use of silver sulphadiazine.
LINK to Cochrane Library: Issue 4 2008 http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002106/frame.html


COCHRANE SYSTEMATIC REVIEW: Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury
Implications for practice: There is no evidence for one non-opioid analgesic over another when treating soft tissue injuries.
Review Overview: There is generally low- or very low-quality but consistent evidence of no clinically important difference in analgesic efficacy between NSAIDs and other oral analgesics. There is low-quality evidence of more gastrointestinal adverse effects with non-selective NSAID compared with paracetamol. There is low- or very low-quality evidence of better function and fewer adverse events with NSAIDs compared with opioid-containing analgesics; however, one study dominated this evidence using a now unavailable COX-2 selective NSAID and is of uncertain applicability. Further research is required to determine whether there is any difference in return to function or adverse effects between both non-selective and COX-2 selective NSAIDs versus paracetamol.
LINK to Cochrane Library: Issue 7, 2015 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007789.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma Implication for practice: FAST ultrasounds have little evidence to support their use in the ED.
Implications for practice: FAST ultrasounds have little evidence to support their use in the ED.
Review Overview: Many people admitted to hospital after an injury have 'blunt' (not penetrating) damage to the abdomen. Doctors treating these patients need to know whether the organs within the abdomen have been injured. Ultrasound scans are believed to help diagnose the patient's condition. In this review, the authors looked for studies that compared death rates in patients with an abdominal injury where ultrasound was used to aid diagnosis with death rates where no ultrasound was used. They also looked for evidence that ultrasound use could reduce the need to carry out other more complex and more expensive diagnostic tests. However, very few trials have been done and the authors concluded that there is insufficient evidence to justify the use of ultrasound as part of the diagnosis of patients with abdominal injury. Given this degree of uncertainty, it is probably justified to ask doctors on duty for a confirmatory CT scan in patients who have sustained an injury with a high chance of major trauma (that is, head and brain injury, cervical spine fracture, thoraco-abdominal pelvic trauma, and other injuries).
LINK to Cochrane Library: Issue 9, 2015 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004446.pub4/abstract