30-Day In-hospital Trauma Mortality in Four Urban University Hospitals Using an Indian Trauma Registry

Achieving Surgical, Obstetric, Trauma, and Anesthesia (SOTA) care for all in South Asia

South Asia is a demographically crucial, economically aspiring, and socio-culturally diverse region in the world. The region contributes to a large burden of surgically-treatable disease conditions. A large number of people in South Asia cannot access safe and affordable surgical, obstetric, trauma, and anesthesia (SOTA) care when in need. Yet, attention to the region in Global Surgery and Global Health is limited. Here, we assess the status of SOTA care in South Asia. We summarize the evidence on SOTA care indicators and planning. Region-wide, as well as country-specific challenges are highlighted. We also discuss potential directions-initiatives and innovations-toward addressing these challenges. Local partnerships, sustained research and advocacy efforts, and politics can be aligned with evidence-based policymaking and health planning to achieve equitable SOTA care access in the South Asian region under the South Asian Association for Regional Cooperation (SAARC).

Traumatic Brain Injury in Select Low- and Middle-Income Countries: A Narrative Review of the Literature

Low- and middle-income countries (LMICs) experience the majority of traumatic brain injuries (TBIs), yet few studies have examined the epidemiology and management strategies of TBI in LMICs. The objective of this narrative review is to discuss the epidemiology of TBI within LMICs, describe the adherence to Brain Trauma Foundation (BTF) guidelines for the management of severe TBI in LMICs, and document TBI management strategies currently used in LMICs. Articles from January 1, 2009 to September 30, 2021 that included patients with TBI greater than 18 years of age in low-, low middle-, and high middle-income countries were queried in PubMed. Search results demonstrated that TBI in LMICs mostly impacts young males involved in road traffic accidents. Within LMICs there are a myriad of approaches to managing TBI with few randomized controlled trials performed within LMICs to evaluate those interventions. More studies are needed in LMICs to establish the effectiveness and appropriateness of BTF guidelines for managing TBI and to help identify methods for managing TBI that are appropriate in low-resource settings. The problem of limited pre- and post-hospital care is a bigger challenge that needs to be considered while addressing management of TBI in LMICs.

Pediatric trauma mortality in India and the United States: A comparison and risk-adjusted analysis

BACKGROUND

There is a paucity of research comparing pediatric risk-adjusted trauma mortality between high-income and low- and middle-income countries. This limits identification of populations and injury patterns for targeted interventions. We aim to compare independent predictors of pediatric trauma mortality between India and the United States (US).

METHODS

A retrospective cohort study was conducted for pediatric patients (age <18 years) in India's Towards Improved Trauma Care Outcomes (TITCO) project database and the US National Trauma Data Bank (NTDB) from 2013 to 2015. Demographic, injury, physiologic, anatomic and outcome data were analyzed. Multivariable regressions were used to determine independent predictors of mortality.

RESULTS

126,678 pediatric trauma patients were included (India 3,373; US 123,305). Pediatric patients in India were on average significantly younger, with a higher median injury severity score (ISS), had lower systolic blood pressure, and suffered a higher case fatality rate (13.0% vs. 1.0%). When controlling for demographic, mechanism, physiologic, and anatomic injury characteristics, sustaining an injury in India was the strongest predictor of mortality (OR 22.70, 95% CI 18.70-27.56). On subgroup analysis, the highest relative odds of mortality in India was seen in children with lower injury and physiologic severity.

CONCLUSIONS

Risk-adjusted pediatric trauma-related mortality is significantly higher in India compared to the US. The comparative odds of mortality are highest among children with lower injury and physiologic severity. This suggests that low-cost targeted interventions focused on standard timely trauma care, protocols, training and early imaging could improve pediatric injury mortality in India.

TYPE OF STUDY

Retrospective Prognosis Study LEVEL OF EVIDENCE: II.

In-Hospital Mortality Following Traumatic Injury in South Africa

Trauma is a leading cause of death worldwide and in South Africa. We aimed to quantify the in-hospital trauma mortality rate in Pietermaritzburg, South Africa.

Background

The in-hospital trauma mortality rate in South Africa remains unknown, and it is unclear whether deficits in hospital care are contributing to the high level of trauma-related mortality.

Methods

All patients hospitalized because of trauma at the Department of Surgery at Grey's Hospital, Pietermaritzburg Metropolitan Trauma Service, were prospectively entered in an electronic database starting in 2013 and the data were retrospectively analyzed. The trauma service adheres to Advanced Trauma Life Support and the doctors have attended basic and advanced courses in trauma care. The primary outcome was in-hospital mortality.

Results

Of 9795 trauma admissions, 412 (4.2%) patients died during hospital care between January 2013 and January 2019. Forty-six percent died after road traffic accidents, 19% after gunshot wounds, 13% after stab wounds, and 10% after assaults. Sixteen percent were classified as avoidable deaths due to inappropriate care and resource limitations. Fifty percent died because of traumatic brain injury and 80% of them were unavoidable.

Conclusions

In conclusion, the in-hospital trauma mortality rate at a South African trauma center using systematic trauma care is lower than that reported from other trauma centers in the world during the past 20 years. Nevertheless, 16% of death cases were assessed as avoidable if there had been better access to intensive care, dialysis, advanced respiratory care, blood for transfusion, and improvements in surgery and medical care.

Patterns of Head and Neck Injuries in Urban India: A Multicenter Study

Objective

The pattern of head and neck injuries has been well studied in high-income countries, but the data are limited in low- and middle-income countries, which are disproportionately affected by trauma. We examined a prospective multicenter database to describe patterns and outcomes of head and neck injuries in urban India.

Study Design

Retrospective review of trauma registry.

Setting

Four tertiary public hospitals in Mumbai, Delhi, Kolkata.

Methods

We identified patients with isolated head and neck injuries using International Classification of Diseases, 10th Revision (ICD-10) codes and excluded those with traumatic brain and/or ophthalmic injuries and injuries in other body regions.

Results

Our cohort included 171 patients. Most were males (80.7%) and adults aged 18 to 55 years (60.2%). Falls (36.8%) and road traffic accidents (36.3%) were the 2 predominant mechanisms of injury. Overall, 35.7% required intensive care unit (ICU) admission, and 11.7% died. More than 20% of patients were diagnosed with “unspecified injury of neck.” Those with the diagnosis had a higher ICU admission rate (51.4% vs 31.3%, P = .025) and mortality rate (27.0% vs 7.5%, P = .001) than those without the diagnosis.

Conclusion

Isolated head and neck injuries are not highly prevalent among Indian trauma patients admitted to urban tertiary hospitals but are associated with high mortality. Over a fifth of patients were diagnosed with “unspecified injury of neck,” which is associated with more severe clinical outcomes. Exactly what this diagnosis entails and encompasses remains unclear.

The State of Global Trauma and Acute Care Surgery/Surgical Critical Care

Trauma is a leading cause of morbidity and mortality globally, with a significant burden attributable to the low- and middle-income countries (LMICs), where more than 90% of injury-related deaths occur. Road injuries contribute largely to the economic burden from trauma and are prevalent among adolescents and young adults. Trauma systems vary widely across the world in their capacity of providing basic and critical care to injured patients, with delays in treatment being present at multiple levels at LMICs. Strengthening existing systems by providing cost-effective and efficient solutions can help mitigate the injury burden in LMICs.

Mortality and Risk Factors in Isolated Traumatic Brain Injury Patients: A Prospective Cohort Study

INTRODUCTION

Outcomes in patients with isolated traumatic brain injury (iTBI) have not been evaluated comprehensively in low-income and middle-income countries. We aimed to study the in-hospital iTBI mortality and its associated risk factors in a prospective multicenter Indian trauma registry.

METHODS

Patients with iTBI (head and neck Abbreviated Injury Score ≥2 and other region Abbreviated Injury Score ≤2) were included. Study variables comprised age, gender, mechanism of injury, systolic blood pressure (SBP) at arrival, Glasgow Coma Scale (GCS) score - classified as mild (13-15), moderate (9-12), and severe (3-8), transfer status, and time to presentation at any participating hospital. A multivariable logistic regression was performed to assess the impact of these factors on 24-h and 30-d mortality following iTBI.

RESULTS

Among 5042 included patients, 24-h and 30-d in-hospital mortalities were 5.9% and 22.4%. On a regression analysis, 30-d mortality was associated with age ≥45 y (odds ratio [OR] = 2.1 [1.6-2.7]), railway injury mechanisms (OR = 2.1 [1.3-3.5]), SBP <90 mmHg (OR = 2.6 [1.6-4.1]), and moderate (OR = 3.8 [3.0-5.0]) to severe (OR = 21.1 [16.8-26.7]) iTBI based on GCS scores. 24-h mortality showed similar trends. Patients transferred to the participating hospitals from other centers had higher odds of 30-d mortality (OR = 1.4 [1.2-1.8]) compared to those arriving directly. Those who received neurosurgical intervention had lower odds of 24-h mortality (0.3 [0.2-0.4]).

CONCLUSIONS

Age ≥45 y, GCS score ≤12, and SBP <90 mmHg at arrival increased the risk of in-hospital mortality from iTBI.

Perceived usefulness of trauma audit filters in urban India: a mixed-methods multicentre Delphi study comparing filters from the WHO and low and middle-income countries

OBJECTIVE

To compare experts' perceived usefulness of audit filters from Ghana, Cameroon, WHO and those locally developed; generate context-appropriate audit filters for trauma care in selected hospitals in urban India; and explore characteristics of audit filters that correlate to perceived usefulness.

DESIGN

A mixed-methods approach using a multicentre online Delphi technique.

SETTING

Two large tertiary hospitals in urban India.

METHODS

Filters were rated on a scale from 1 to 10 in terms of perceived usefulness, with the option to add new filters and comments. The filters were categorised into three groups depending on their origin: low and middle-income countries (LMIC), WHO and New (locally developed), and their scores compared. Significance was determined using Kruskal-Wallis test followed by Wilcoxon rank-sum test. We performed a content analysis of the comments.

RESULTS

26 predefined and 15 new filter suggestions were evaluated. The filters had high usefulness scores (mean overall score 9.01 of 10), with the LMIC filters having significantly higher scores compared with those from WHO and those newly added. Three themes were identified in the content analysis relating to medical relevance, feasibility and specificity.

CONCLUSIONS

Audit filters from other LMICs were deemed highly useful in the urban India context. This may indicate that the transferability of defined trauma audit filters between similar contexts is high and that these can provide a starting point when implemented as part of trauma quality improvement programmes in low-resource settings.

Management of pancreatic trauma in urban India: A multicenter study

Background

Pancreatic trauma occurs in 0.2–2% of patients with blunt trauma and 1–12% of patients with penetrating trauma. The mortality and morbidity rates range from 9 to 34% and 30–60% respectively. We aimed to review the management of pancreatic trauma in a multicenter database from India.

Methods

We analyzed all patients who suffered a pancreatic injury and who were included in the multicenter prospective observational study ‘Towards Improved Trauma Care Outcomes (TITCO)’.

Results

Of the 16047 trauma cases, 1134 (7.1%) patients suffered abdominal trauma. Of all those with abdominal trauma, 55 patients (4.9%) had injury to the pancreas. 28 patients (50.9%) with pancreatic trauma were managed conservatively. 27 patients (49.1%) underwent surgical exploration in the form of laparotomies. 11 procedures were undertaken for pancreas. A total of 45 (82%) patients had associated injuries along with pancreatic injury. Thorax (19) (including injuries to lung, pleura and ribs), liver (17), bowel (14) and spleen (13) were the most common associated injuries.

Conclusion

Conservative management was as common as operative management in patients with pancreatic injuries. Most (80%) grade III/IV underwent operative treatment. Many patients (82%) had associated injuries.

Level of evidence

III.

•

Our study is a multicentric study from India to review management of pancreatic trauma.

•

Most of the pancreatic injuries are associated with other intrabdominal injuries.

Comparing trauma mortality of injured patients in India and the USA: a risk-adjusted analysis

Objectives

Comparisons of risk-adjusted trauma mortality between high-income countries and low and middle-income countries (LMICs) can be used to identify specific patient populations and injury patterns for targeted interventions. Due to a paucity of granular patient and injury data from LMICs, there is a lack of such comparisons. This study aims to identify independent predictors of trauma mortality and significant differences between India and the USA.

Methods

A retrospective cohort study of two trauma databases was conducted. Demographic, injury, physiologic, anatomic and outcome data were analyzed from India’s Towards Improved Trauma Care Outcomes project database and the US National Trauma Data Bank from 2013 to 2015. Multivariate logistic regression analyses were performed to determine significant independent predictors of mortality.

Results

687 407 adult trauma patients were included (India 11 796; USA 675 611). Patients from India were significantly younger with greater male preponderance, a higher proportion presented with physiologic abnormalities and suffered higher mortality rates (23.2% vs. 2.8%). When controlling for age, sex, physiologic abnormalities, and injury severity, sustaining an injury in India was the strongest predictor of mortality (OR 13.85, 95% CI 13.05 to 14.69). On subgroup analyses, the greatest mortality difference was seen in patients with lower Injury Severity Scores.

Conclusion

After adjusting for demographic, physiologic abnormalities, and injury severity, trauma-related mortality was found to be significantly higher in India. When compared with trauma patients in the USA, the odds of mortality are most notably different among patients with lower Injury Severity Scores. While troubling, this suggests that relatively simple, low-cost interventions focused on standard timely trauma care, early imaging, and protocolized treatment pathways could result in substantial improvements for injury mortality in India, and potentially other LMICs.

Level of evidence

Level 3, retrospective cohort study.

Outcomes of Renal Trauma in Indian Urban Tertiary Healthcare Centres: A Multicentre Cohort Study

BACKGROUND

Renal trauma is present in 0.5-5% of patients admitted for trauma. Advancements in radiologic imaging and minimal-invasive techniques have led to decreased need for surgical intervention. We used a large trauma cohort to characterise renal trauma patients, their management and outcomes.

METHODS

We analysed "Towards Improved Trauma Care Outcomes in India" cohort from four urban tertiary public hospitals in India between 1st September 2013 and 31st December 2015. The data of patients with renal trauma were extracted using International Classification of Diseases 10 codes and analysed for demographic and clinical details.

RESULTS

A total of 16,047 trauma patients were included in this cohort. Abdominal trauma comprised 1119 (7%) cases, of which 144 (13%) had renal trauma. Renal trauma was present in 1% of all the patients admitted for trauma. The mean age was 28 years (SD-14.7). A total of 119 (83%) patients were male. Majority (93%) were due to blunt injuries. Road traffic injuries were the most common mechanism (53%) followed by falls (29%). Most renal injuries (89%) were associated with other organ injuries. Seven of the 144 (5%) patients required nephrectomy. Three patients had grade V trauma; all underwent nephrectomy. The 30-day in-hospital mortality, in patients with renal trauma, was 17% (24/144).

CONCLUSION

Most renal trauma patients were managed nonoperatively. 89% of patients with renal trauma had concomitant injuries. The renal trauma profile from this large cohort may be generalisable to urban contexts in India and other low- and middle-income countries.

Does ATLS Training Work? 10-Year Follow-Up of ATLS India Program

BACKGROUND

Studies evaluating the efficacy of ATLS in low- and middle-income countries are limited. We followed up ATLS providers certified by the ATLS India program over a decade (2009 to 2019), aiming to measure the benefits in knowledge, skills, attitude and their attrition over time.

METHODS

The survey instrument was developed taking a cue from published literature on ATLS and improvised using the Delphi method. Randomly selected ATLS providers were sent the survey instrument via email as a Google form, along with a statement of purpose. Results are presented descriptively.

RESULTS

ATLS India trained 7,847 providers over the study period. 2500 providers were selected for the survery using computer-generated random number table. One thousand and thirty doctors (41.2%) responded. Improvement in knowledge (n = 1,013 [98.3%]), psychomotor skills (n = 986 [95.7%]), organizational skills (n = 998 [96.9%]), overall trauma management (n = 1,013 [98.7%]) and self-confidence (n = 939 [91%]) were reported. Majority (904 [87.8%]) started ATLS promulgation at workplace in personal capacity. These benefits lasted beyond 2 years in majority (>60%) of respondents. More than 40% reported cognitive (n = 492 [47.8%]), psychomotor (n = 433 [42%]), and organizational benefits (n = 499 [48.4%]) lasting beyond 3 years. Improvement in self-confidence, ATLS promulgation at the workplace, and retention of organizational skills were more pronounced in ATLS faculties than providers. All other benefits were found to be comparable in both sub-groups. Lack of trained staff (n = 660 [64.1%]) and attitude issues (n = 495 [48.1%]) were the major impediments in implementing ATLS at the workplace. More than a third of respondents (n = 373 [36.2%]) could enumerate one or more incidents where ATLS principles were life- or limb- saving.

CONCLUSIONS

Cognitive, psychomotor, organizational, and affective impact of ATLS is overwhelmingly positive in the Indian scenario. Until formal trauma systems are established, ATLS remains the best hope for critically injured patients in resource-contrained settings.

Participants' perception of the AIIMS Trauma Assessment and Management (ATAM) course for management of polytrauma: A multi-institutional experience from India

BACKGROUND

In India, the mortality due to polytrauma after road traffic injuries is high and there is a need to train medical and paramedical personnel. The AIIMS Trauma Assessment and Management (ATAM) course was developed at the Apex Trauma Centre of All India Institute of Medical Sciences, New Delhi to sensitize medical personnel with initial assessment and management of polytrauma victims. The aim of this study was to evaluate the impact on knowledge and skills and also evaluate the feedback and the perception of the participants of the ATAM course.

METHODS

The course was conducted for doctors, nurses and other paramedical/allied professionals in five tertiary level centres associated to medical colleges from geographically diverse locations (Anand, Bengaluru, Delhi, Lucknow and Thrissur). Cognitive knowledge was assessed using pre-training and post-training multiple choice question (MCQ) tests. The participants also self-rated their level of knowledge, skill, confidence and capability (Numerical rating scale of 1-10). Post-training feedback was obtained from the participants using a five-point Likert scale response.

RESULTS

26 ATAM courses were conducted by 68 course instructors and attended by 780 participants. These participants include 40.4% doctors, 44.2% nurses, 4.7% paramedical technicians, 4.2% medical students and 6.4% paramedical and allied health professionals. There was significant improvement (p < 0.0001) in the cognitive knowledge, skill, confidence and capability of the participants. 85%-86% of the participants strongly agreed or agreed that the course content was effective and 85% of participants perceived that the course was excellent or very good.

CONCLUSION

The ATAM course had a positive impact on the knowledge, skills, confidence and capability of health caregivers attending the course. The ATAM course is an effective, practical and favourable option that is tailored to the polytrauma training needs of India. We recommend widespread dissemination of this course.

An Analysis of 30-Day in-Hospital Trauma Mortality in Four Urban University Hospitals Using the Australia India Trauma Registry

Background

India has one-sixth (16%) of the world’s population but more than one-fifth (21%) of the world’s injury mortality. A trauma registry established by the Australia India Trauma Systems Collaboration (AITSC) Project was utilized to study 30-day in-hospital trauma mortality at high-volume Indian hospitals.

Methods

The AITSC Project collected data prospectively between April 2016 and March 2018 at four Indian university hospitals in New Delhi, Mumbai, and Ahmedabad. Patients admitted with an injury mechanism of road or rail-related injury, fall, assault, or burns were included. The associations between demographic, physiological on-admission vitals, and process-of-care parameters with early (0–24 h), delayed (1–7 days), and late (8–30 days) in-hospital trauma mortality were analyzed.

Results

Of 9354 patients in the AITSC registry, 8606 were subjected to analysis. The 30-day mortality was 12.4% among all trauma victims. Early (24-h) mortality was 1.9%, delayed (1–7 days) mortality was 7.3%, and late (8–30 days) mortality was 3.2%. Abnormal physiological parameters such as a low SBP, SpO2, and GCS and high HR and RR were observed among non-survivors. Early initiation of trauma assessment and monitoring on arrival was an important process of care indicator for predicting 30-day survival.

Conclusions

One in ten admitted trauma patients (12.4%) died in urban trauma centers in India. More than half of the trauma deaths were delayed, beyond 24 h but within one week following injury. On-admission physiological vital signs remain a valid predictor of early 24-h trauma mortality.

Management of liver trauma in urban university hospitals in India: an observational multicentre cohort study

BACKGROUND

Low- and middle-income countries (LMICs) contribute to 90% of injuries occurring in the world. The liver is one of the commonest organs injured in abdominal trauma. This study aims to highlight the demographic and management profile of liver injury patients, presenting to four urban Indian university hospitals in India.

METHODS

This is a retrospective registry-based study. Data of patients with liver injury either isolated or concomitant with other injuries was used using the ICD-10 code S36.1 for liver injury. The severity of injury was graded based on the World Society of Emergency Surgery (WSES) grading for liver injuries.

RESULTS

A total of 368 liver injury patients were analysed. Eighty-nine percent were males, with road traffic injuries being the commonest mechanism. As per WSES liver injury grade, there were 127 (34.5%) grade I, 96 (26.1%) grade II, 70 (19.0%) grade III and 66 (17.9%) grade IV injuries. The overall mortality was 16.6%. Two hundred sixty-two patients (71.2%) were managed non-operatively (NOM), and 106 (38.8%) were operated. 90.1% of those managed non-operatively survived.

CONCLUSION

In this multicentre cohort of liver injury patients from urban university hospitals in India, the commonest profile of patient was a young male, with a blunt injury to the abdomen due to a road traffic accident. Success rate of non-operative management of liver injury is comparable to other countries.

WITHDRAWN: Participants' perception of the AIIMS Trauma Assessment and Management (ATAM) course for management of polytrauma due to road traffic injuries: A multi-institutional experience from India

OBJECTIVE

In India, the mortality due to polytrauma after road traffic injuries is high and there is a need to train medical and paramedical personnel. The AIIMS Trauma Assessment and Management (ATAM) course was developed at the Apex Trauma Centre of All India Institute of Medical Sciences, New Delhi to sensitize medical personnel with initial assessment and management of polytrauma victims. The aim of this study was to evaluate the impact on knowledge and skills and also evaluate the feedback and the perception of the participants of the ATAM course.

METHODS

The course was conducted for doctors, nurses and other paramedical/allied professionals in five tertiary level centres associated to medical colleges from geographically diverse locations (Anand, Bengaluru, Delhi, Lucknow and Thrissur). Cognitive knowledge was assessed using pre-training and post-training multiple choice question (MCQ) tests. The participants also self-rated their level of knowledge, skill, confidence and capability (Numerical rating scale of 1-10). Post-training feedback was obtained from the participants using a five-point Likert scale response.

RESULTS

26 ATAM courses were conducted by 68 course instructors and attended by 780 participants. These participants include 40.4% doctors, 44.2% nurses, 4.7% paramedical technicians, 4.2% medical students and 6.4% paramedical and allied health professionals. There was significant improvement (p < 0.0001) in the cognitive knowledge, skill, confidence and capability of the participants. 85%-86% of the participants strongly agreed or agreed that the course content was effective and 85% of participants perceived that the course was excellent or very good.

CONCLUSION

The ATAM course had a positive impact on the knowledge, skills, confidence and capability of health caregivers attending the course. The ATAM course is an effective, practical and favourable option that is tailored to the polytrauma training needs of India. We recommend widespread dissemination of this course.

Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review

Background

About 5.8 million people die each year as a result of injuries, and nearly 90% of these deaths occur in low and middle-income countries (LMIC). Trauma scoring is a cornerstone of trauma quality improvement (QI) efforts, and is key to organizing and evaluating trauma services. The objective of this review was to assess the appropriateness, feasibility, and QI applicability of traditional trauma scoring systems in LMIC settings.

Materials and methods

This systematic review searched PubMed, Scopus, CINAHL, and trauma-focused journals for articles describing the use of a standardized trauma scoring system to characterize holistic health status. Studies conducted in high-income countries (HIC) or describing scores for isolated anatomic locations were excluded. Data reporting a score’s capacity to discriminate mortality, feasibility of implementation, or use for QI were extracted and synthesized.

Results

Of the 896 articles screened, 336 were included. Over half of studies (56%) reported Glasgow Coma Scale, followed by Injury Severity Score (ISS; 51%), Abbreviated Injury Scale (AIS; 24%), Revised Trauma Score (RTS; 19%), Trauma and Injury Severity Score (TRISS; 14%), and Kampala Trauma Score (7%). While ISS was overwhelmingly predictive of mortality, 12 articles reported limited feasibility of ISS and/or AIS. RTS consistently underestimated injury severity. Over a third of articles (37%) reporting TRISS assessmentsobserved mortality that was greater than that predicted by TRISS. Several articles cited limited human resources as the key challenge to feasibility.

Conclusions

The findings of this review reveal that implementing systems designed for HICs may not be relevant to the burden and resources available in LMICs. Adaptations or alternative scoring systems may be more effective.

PROSPERO registration number

CRD42017064600.

Both the multiplicative and single-worst-injury International Classification of Diseases Injury Severity Score underperform in urban Indian hospitals

Introduction

Trauma accounts for 9% of all deaths worldwide, killing almost five million people annually. As India accounts for more than one million of these deaths, research on local trauma care is of great importance. A key aspect of such research is outcome comparisons between contexts. One tool to adjust these comparisons for trauma severity is the International Classification of Diseases Injury Severity Score. The aim was to assess two versions of this score in India.

Methods

The data used were from the project Towards Improved Trauma Care Outcomes in India. Published survival risk ratios were used to calculate multiplicative-International Classification of Diseases Injury Severity Score and single-worst-injury-International Classification of Diseases Injury Severity Score for the 200 most recent non-surviving patients and the surviving patients during the same period. Score performance was measured in discrimination and calibration.

Results

The 30-day prediction single-worst-injury-International Classification of Diseases Injury Severity Score discriminated best with an area under the receiver operating characteristics curve of 0.668 (95% CI 0.645–0.690) and a calibration slope of 0.830 (95% CI 0.708–0.940).

Conclusions

The single-worst-injury-International Classification of Diseases Injury Severity Score applied on 30-day mortality was the only score to calibrate on a satisfactory level. None of the scores had an acceptable discrimination. In interpreting these findings, we see that none of the tested scores can currently be implemented in the studied hospitals.

Going to the nearest hospital vs. designated trauma centre for road traffic crashes: estimating the time difference in Delhi, India

Background: Time to hospital after a road traffic crash (RTC) plays a vital role in determining the outcome for crash victims. In Delhi, there are seven designated trauma centres where crash victims are typically taken, which may not be nearest hospital. We compare the transport time access (crash to hospital) depending on whether the victim is transported to a designated trauma centre or the nearest hospital. Data and methods: For each RTC geocoded manually from police records, the nearest hospital and the designated trauma centre is identified using Google Maps places nearby Search API and guidelines. Travel time matrix is generated between RTC's and identified hospitals using Google maps distance matrix API. Index accounting inter-district differences is developed. Results and conclusions: The network of designated trauma centres in New Delhi is located such that they can be accessed within 45 min of most crashes while nearest hospital within 30 min. As a result, the vast majority of crash victims are likely to receive timely care if they are rapidly transferred to either of these caregivers. However, for the most severely injured and time-sensitive cases, bypassing nearest hospital for trauma care, could substantially improve survival outcomes.

Epidemiology of Trauma Patients from the Mosul Offensive, 2016-2017: Results from a Dedicated Trauma Center in Erbil, Iraqi Kurdistan

INTRODUCTION

Most epidemiological studies from conflicts are restricted to either combatants or civilians. It is largely unknown how the epidemiology differs between the two groups. In 2016, an Iraqi-led coalition began retaking Mosul from the terrorist group Islamic State of Iraq and Syria. One key institution that received trauma patients from Mosul was Emergency Management Center (EMC) in Erbil, 90 km away. The aim of this study was to describe the epidemiology, morbidity, and mortality of civilians and combatants admitted during the ongoing conflict.

METHOD

This retrospective cohort study utilized routinely collected data on patients with conflict-related injuries who were admitted to EMC between October 16, 2016, and July 10, 2017. Data processing and analysis was carried out using JMP 13. Categorical variables were compared using Fisher's exact test.

RESULTS

The analysis included 1725 patients, out of which 46% were civilian. Ordnance accounted for most injuries (68%), followed by firearms (18%) and improvised explosive devices (IEDs) (14%). The proportion of IED-related injuries among combatants were almost three times that of civilians. The proportions of abdominal injuries, need for surgery, laparotomies, and amputations were significantly higher among civilians than among combatants. The mortality rate was 0.5%.

DISCUSSION

The fact that civilians had greater surgical needs than combatants may be explained by several factors including a lack of ballistic protection. The extremely low mortality rate indicates significant gaps in prehospital care and transport. Our results may provide useful information to guide medical preparedness and response during future conflicts. CLINICALTRIALS.

GOV ID

NCT03358758.

Pattern and Distribution of Shock Index and Age Shock Index Score Among Trauma Patients in Towards Improved Trauma Care Outcomes (TITCO) Dataset

OBJECTIVE

To compare the shock index (SI - which is the ratio of heart rate to systolic blood pressure) and Age SI (Age in years multiplied by SI) with survival outcome of the patients across multicenter trauma registry in India.

METHODS

Study is based on Towards Improved Trauma Care Outcomes (TITCO) project. Records with valid details of age, heart rate, systolic blood pressure, Injury Severity Scale (ISS) and Glasgow Coma Scale (GCS) score was considered. SI was categorized into four groups; Group I (SI<0.6) as no shock, group II (SI ≥0.6 to <1.0) as mild shock, group III (SI ≥1.0 to <1.4) as moderate shock and group IV (SI ≥1.4) as severe shock. Age SI was categorized decade wise into six groups. Mortality was dependent variable. GCS and ISS were considered as secondary variables.

RESULTS

10843 participants from TITCO registry satisfying inclusion-exclusion criteria were considered for study. Mean SI score in group I to IV was increasing with 0.53 to 1.72 respectively. Age SI was seen to be increasing across its six groups. Gender wise no difference was found among SI group. For severe ISS and critical ISS, mortality in SI group IV was 50% and 56 % respectively. Mortality was increasing across mild to severe GCS among all SI groups.

CONCLUSION

The categorized SI and Age SI had shown increase in death percentages from mild to severe severity of injuries. Similar to GCS and ISS, SI and Age SI should also be calculated and categorized in all health care and further plan for management aspects.

Bystander Assistance for Trauma Victims in Low- and Middle-Income Countries: A Systematic Review of Prevalence and Training Interventions

OBJECTIVE

Lack of organized prehospital care may contribute to the disproportionate burden of trauma-related deaths in low- and middle-income countries (LMICs). The World Health Organization (WHO) recommends bystander training in basic principles of first aid and victim transport; however, prevalence of bystander or layperson assistance to trauma victims in LMICs has not been well-described, and organized reviews of existing evidence for bystander training are lacking. This systematic review aims to 1) describe the prevalence of bystander or layperson aid or transport for trauma victims in the prehospital setting in LMICs and 2) ascertain impacts of bystander training interventions in these settings.

METHODS

A systematic search of OVID Medline, Cochrane Library, and relevant gray literature was conducted. We included 1) all studies detailing prevalence of bystander-administered aid or transport for trauma victims in LMICs and 2) all randomized controlled trials and observational studies evaluating bystander training interventions. We extracted study characteristics, interventions, and outcomes data. Study quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

RESULTS

Sixty-two studies detailed prevalence of bystander transport and aid. Family members, police, and bus or taxi drivers commonly transported patients; a majority of patients, up to >94%, received aid from bystanders. Twenty-four studies examined impacts of training interventions. Only one study looked at transport interventions; the remainder addressed first aid training. Interventions varied in content, duration, and target learners. Evidence was generally of low quality, but all studies demonstrated improvements in layperson knowledge and skills. Five studies reported a mortality reduction.

CONCLUSIONS

Heterogeneity in data reporting and outcomes limited formal meta-analysis. However, this review shows high rates of bystander involvement in prehospital trauma care and transport in LMICs and highlights the need for bystander training. Bystander training in these settings is feasible and may have an important impact on meaningful outcomes such as mortality. Categories of involved bystanders varied by region and training interventions should be targeted at relevant groups. "Train the trainer" models appear promising in securing community engagement and maximizing participation. Further research is needed to examine the value of bystander transport networks in trauma.

Prevalence of a definitive airway in patients with severe traumatic brain injury received at four urban public university hospitals in India: a cohort study

AIM

To estimate the proportion of patients arriving with a Glasgow Coma Scale (GCS) less than 9 who had a definitive airway placed prior to arrival.

METHODS

We conducted a retrospective analysis of the data from a multicentre, prospective observational research project entitled Towards Improved Trauma Care Outcomes in India. Adults aged ≥18 years with an isolated traumatic brain injury (TBI) who were transferred from another hospital to the emergency department of the participating hospital with a GCS less than 9 were included. Our outcome was a definitive airway, defined as either intubation or surgical airway, placed prior to arrival at a participating centre.

RESULTS

The total number of patients eligible for this study was 1499. The median age was 40 years and 84% were male. Road traffic injuries and falls comprised 88% of the causes of isolated TBI. The number of patients with GCS<9 who had a definitive airway placed before reaching the participating centres was 229. Thus, the proportion was 0.15 (95% CI 0.13 to 0.17). The proportions of patients with a definitive airway who arrived after 24 hours (19%) were approximately double the proportion of patients who arrived within 6 hours (10%) after injury to the definitive care centre.

CONCLUSION

The rates of definitive airway placement are poor in adults with an isolated TBI who have been transferred from another health facility to tertiary care centres in India.

Mortality following surgery for trauma in an Indian trauma cohort

Background

India accounts for 20 per cent of worldwide trauma mortality. Little is known about the quality of trauma surgery in an Indian setting. The aim of this study was to estimate the overall perioperative mortality rate, and to assess the association between type of acute surgical intervention and perioperative mortality among adult patients treated for trauma in an urban Indian setting.

Methods

Data were obtained from injured adult patients enrolled in four urban Indian hospitals during 2013–2015. Those who had surgery within 24 h of arrival at hospital were included in the analysis. Patients with missing data were excluded. The perioperative mortality rate was measured at 48 h and 30 days after arrival at hospital. Generalized linear mixed models were used for risk adjustment of procedure-specific mortality.

Results

Among 2986 patients who underwent trauma surgery, the overall 48-h mortality rate was 6·0 per cent, and the 30-day mortality rate was 23·1 per cent. The highest adjusted odds ratios (ORs) for 48-h mortality were found for patients who underwent surgery on the peripheral vasculature (OR 4·71, 95 per cent c.i. 1·18 to 16·59; P = 0·030) and the digestive system and spleen (OR 3·77, 1·33 to 9·01; P = 0·010) compared with those who had nervous system surgery.

Conclusion

In this study of surgery in an Indian trauma cohort, there was an excess of late perioperative deaths. Mortality differed significantly according to the type of surgery being undertaken.

Distribution of Laboratory Parameters in Trauma Population

Background:

Biochemical laboratory investigations help plan optimum management and communication in short- as well as long-term outcome to trauma victims.

Objective:

To assess the status of real-time values of biochemical laboratory investigations of different trauma patients and their association with overall mortality.

Materials and Methods:

Data based on prospective, observational registry of “Towards Improved Trauma Care Outcomes” (TITCO) from four Indian city hospitals. Hemoglobin, hematocrit, random blood sugar, blood urea nitrogen (BUN), and serum creatinine of patients on admission were recorded. Logistic regression was applied with all biochemical investigation as independent variable and overall mortality as dependent variable.

Results:

Among 17047 trauma patients, 3456 with available laboratory result details were considered for this study. Overall mortality was 20% (range 14%–21%). For the higher laboratory results, value mortality was 21%–70%, with highest death (70%) for higher hemoglobin patients, followed by hematocrit (44%) and then creatinine (43%). Odds of high hemoglobin compared to normal were 15.20; odds of higher and lower of normal creatinine were 3.80 and 1.65 and for BUN were 2.17 and 1.92, respectively. Gender-wise significant difference was in overall female mortality (29%)% compared males (18%). Similar differences were replicated with results of each laboratory tests.

Conclusion:

The study ascertained the composite additional explanatory values of laboratory parameters in predicting outcome among injured patients in our population from Indian settings.

International Classification of Diseases-Based Audit of the Injury Database to Understand the Injury Distribution in Patients Who have Sustained a Head Injury (International Classification of Diseases Codes: S00-S09)

Background:

Traumatic brain injury (TBI) is the leading cause of mortality, morbidity, and disability globally. Methods for a reliable prediction of outcomes on the admission of TBI cases are of great clinical relevance to stakeholders.

Objectives:

This study used the International Classification of Diseases-10 codes (S00-S09) for analysis of injury distribution of TBI patients and attempted to find the prognostic predictors of Glasgow coma scale (GCS) in the outcome from readily accessible parameters.

Methods:

The data were reanalyzed from the Towards Improved Trauma Care Outcomes (TITCO) project from India. TITCO is the prospective, observational, multicenter trauma registry, contained data of trauma patients admitted to four public university hospitals in Mumbai, Delhi, and Kolkata collected from October 2013 to September 2015.

Results:

Among 8525 cases under study, low GCS scores before admission, which was dependent on the demographic variables and related risk factors occurring at the time of injury, were important in the prognostic predictors of mortality. However, survival probability during hospitalization remained uniformly uncertain for the elderly. Death as outcome of injury was dependent on the average intensity of injury, GCS on admission, critical injury severity score, and intubation within 1 h of admission and between 1 and 24 h of admission. These factors emerged as the independent predictors of fatality. The time of the day of injury did not yield any significant association with low GCS or demise in our study.

Conclusions:

GCS <8, i.e., severe at the time of admission, was an unfavorable predictor of in-hospital mortality.

Learning from 2523 trauma deaths in India- opportunities to prevent in-hospital deaths

BACKGROUND

A systematic analysis of trauma deaths is a step towards trauma quality improvement in Indian hospitals. This study estimates the magnitude of preventable trauma deaths in five Indian hospitals, and uses a peer-review process to identify opportunities for improvement (OFI) in trauma care delivery.

METHODS

All trauma deaths that occurred within 30 days of hospitalization in five urban university hospitals in India were retrospectively abstracted for demography, mechanism of injury, transfer status, injury description by clinical, investigation and operative findings. Using mixed methods, they were quantitatively stratified by the standardized Injury Severity Score (ISS) into mild (1-8), moderate (9-15), severe (16-25), profound (26-75) ISS categories, and by time to death within 24 h, 7, or 30 days. Using peer-review and Delphi methods, we defined optimal trauma care within the Indian context and evaluated each death for preventability, using the following categories: Preventable (P), Potentially preventable (PP), Non-preventable (NP) and Non-preventable but care could have been improved (NPI).

RESULTS

During the 18 month study period, there were 11,671 trauma admissions and 2523 deaths within 30 days (21.6%). The overall proportion of preventable deaths was 58%, among 2057 eligible deaths. In patients with a mild ISS score, 71% of deaths were preventable. In the moderate category, 56% were preventable, and 60% in the severe group and 44% in the profound group were preventable. Traumatic brain injury and burns accounted for the majority of non-preventable deaths. The important areas for improvement in the preventable deaths subset, inadequacies in airway management (14.3%) and resuscitation with hemorrhage control (16.3%). System-related issues included lack of protocols, lack of adherence to protocols, pre-hospital delays and delays in imaging.

CONCLUSION

Fifty-eight percent of all trauma deaths were classified as preventable. Two-thirds of the deaths with injury severity scores of less than 16 were preventable. This large subgroup of Indian urban trauma patients could possibly be saved by urgent attention and corrective action. Low-cost interventions such as airway management, fluid resuscitation, hemorrhage control and surgical decision-making protocols, were identified as OFI. Establishment of clinical protocols and timely processes of trauma care delivery are the next steps towards improving care.

On-admission blood pressure and pulse rate in trauma patients and their correlation with mortality: Cushing's phenomenon revisited

BACKGROUND

Injury-induced alteration in initial physiological responses such as hypertension and heart rate (HR) has a significant effect on mortality. Research on such associations from our country-India is limited. The present study investigates the injury-induced early blood pressure (BP) and HR changes and their association with mortality.

MATERIALS AND METHODS

The data were selected from Towards Improved Trauma Care Outcomes collected from October 1, 2013, to July 24, 2014. Patients above 18 years of age with documented systolic BP (SBP) and HR were selected. BP was categorized into hypotension (SBP <90 mmHg), hypertension (SBP >140 mmHg), and normal (SBP 90-140 mmHg). HR was categorized into bradycardia (HR <60 beats/min [bpm]), tachycardia (HR >100 bpm), and normal (HR 60-100 bpm). These categories were compared with mortality.

RESULTS

A total of 10,200 patients were considered for the study. Mortality rate was 24%. Mortality among females was more than males. Patients with normal BP and HR had 20% of mortality. Mortality in patients with abnormal BP and HR findings was 36%. Mortality was higher among hypotension-bradycardia patients (80%) followed by hypertension-bradycardia patients (58%) and tachycardia hypotension patients (48%). Elderly patients were at higher risk of deaths with an overall mortality of 35% compared to 23% of adults.

CONCLUSION

The study reports that initial combination of hypotension-bradycardia had higher mortality rate. Specific precautions in prehospital care should be given to trauma patients with these findings. Further prospective study in detail should be considered for exploring this abnormality.

Injury epidemiology in Iran: a systematic review

Background:

Injuries are the second greatest cause of mortality in Iran. Information about the epidemiological pattern of injuries is effective in decision-making. In this regard, the aim of the current study is to elaborate on the epidemiology of injuries in Iran through a systematic review.

Methods:

Required data were collected searching the following key words and their Persian equivalents; trauma, injury, accident, epidemiology, prevalence, pattern, etiology, risk factors and Iran. The following databases were searched: Google Scholar, PubMed, Scopus, MagIran, Iranian scientific information database (SID) and Iran Medex. Some of the relevant journals and web sites were searched manually. The lists of references from the selected articles were also investigated. We have also searched the gray literature and consulted some experts.

Results:

Out of 2747 retrieved articles, 25 articles were finally included in the review. A total of 3234481 cases have been investigated. Mean (SD) age among these cases was 30 (17.4) years. The males comprised 75.7% of all the patients. Only 31.1% of patients were transferred to hospital by ambulance. The most common mechanism of injuries was road traffic accidents (50.1%) followed by falls (22.3%). In road traffic accidents, motorcyclists have accounted for the majority of victims (45%). Roads were the most common accident scene for the injuries (57.5%). The most common injuries were to the head and neck. (47.3%). The mean (SD) Injury Severity Score (ISS) was 8.1(8.6%). The overall case-fatality proportion was 3.8% and 75% of all the mortalities related to road traffic accidents.

Conclusions:

The main priorities in reducing the burden of injuries include: the young, male target group, improving pre-hospital and ambulance services, preventing road traffic accidents, improving road safety and the safety of motorcyclists (compulsory helmet use, safer vehicles, dedicated motorcycle lanes).

Validation of international trauma scoring systems in urban trauma centres in India

INTRODUCTION

In the Lower-Middle Income Country setting, we validate trauma severity scoring systems, namely Injury Severity Score (ISS), New Injury Severity Scale (NISS) score, the Kampala Trauma Score (KTS), Revised Trauma Score (RTS) score and the TRauma Injury Severity Score (TRISS) using Indian trauma patients.

PATIENTS AND METHODS

From 1 September 2013 to 28 February 2015, we conducted a prospective multi-centre observational cohort study of trauma patients in four Indian university hospitals, in three megacities, Kolkata, Mumbai and Delhi. All adult patients presenting to the casualty department with a history of injury and who were admitted to inpatient care were included. The primary outcome was in-hospital mortality within 30-days of admission. The sensitivity and specificity of each score to predict inpatient mortality within 30days was assessed by the areas under the receiver operating characteristic curve (AUC). Model fit for the performance of individual scoring systems was accomplished by using the Akaike Information criterion (AIC).

RESULTS

In a registry of 8791 adult trauma patients, we had a cohort of 7197 patients eligible for the study. 4091 (56.8%)patients had all five scores available and was the sample for a complete case analysis. Over a 30-day period, the scores (AUC) was TRISS (0.82), RTS (0.81), KTS (0.74), NISS (0.65) and ISS (0.62). RTS was the most parsimonious model with the lowest AIC score. Considering overall mortality, both physiologic scores (RTS, KTS) had better discrimination and goodness-of-fit than ISS or NISS. The ability of all Injury scores to predict early mortality (24h) was better than late mortality (30day).

CONCLUSION

On-admission physiological scores outperformed the more expensive anatomy-based ISS and NISS. The retrospective nature of ISS and TRISS score calculations and incomplete imaging in LMICs precludes its use in the casualty department of LMICs. They will remain useful for outcome comparison across trauma centres. Physiological scores like the RTS and KTS will be the practical score to use in casualty departments in the urban Indian setting, to predict early trauma mortality and improve triage.

Implementation and analysis of initial trauma registry in Iquitos, Peru

Background: In Peru, 11% of deaths are due to trauma. Iquitos is a large underserved Peruvian city isolated from central resources by its geography. Our objective was to implement a locally driven trauma registry to sustainably improve trauma healthcare in this region.

Methods: All trauma patients presenting to the main regional referral hospital were included in the trauma registry. A pilot study retrospectively analyzed data from the first two months after implementation.

Results: From March to April 2013, 572 trauma patients were entered into the database. Average age was 26.9 years. Ten percent of patients presented more than 24 hours after injury. Most common mechanisms of injury were falls (25.5%), motor vehicle collisions (23.3%), and blunt assault (10.5%). Interim analysis revealed that 99% of patients were entered into the database. However, documentation of vital signs was poor: 42% of patients had temperature, 26% had oxygen saturation documented. After reporting to registry staff, a significant increase in temperature (42 to 97%, P < 0.001) and oxygen saturation (26 to 92%, P < 0.001) documentation was observed.

Conclusion: A trauma registry is possible to implement in a resource-poor setting. Future efforts will focus on analysis of data to enhance prevention and treatment of injuries in Iquitos.