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Follows A, Round A. Impact of ABO blood group on mortality in trauma patients: A systematic review. Transfus Apher Sci 2024; 63:103925. [PMID: 38653629 DOI: 10.1016/j.transci.2024.103925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND Haemorrhage is a significant cause of death in trauma patients. There is evidence that individuals with blood group O have higher rates of non-traumatic haemorrhage. It has been suggested that blood group O may be associated with higher mortality in trauma, however existing evidence is limited and conflicting. OBJECTIVE A systematic review was conducted to evaluate the impact of ABO blood group on mortality in trauma patients. METHODS MEDLINE via OVID, the Cochrane library and grey literature were searched to identify studies investigating the effect of ABO blood group on mortality of trauma patients admitted to hospital. PRISMA guidelines were followed throughout, study quality was assessed using CASP checklists and certainty of evidence was evaluated using GRADE. Meta-analysis was precluded by significant study heterogeneity. RESULTS 180 relevant records were screened and seven studies met inclusion criteria, representing 12,240 patients. Two studies found that there was a higher mortality in blood group O compared to other ABO groups. Included studies had substantial variability in methods and population. Study quality was variable with certainty of evidence rated as very low. CONCLUSIONS There is insufficient evidence to definitively establish an association between mortality and ABO group in trauma patients. In an age of increasingly individualised care, there is a need to determine the existence and cause for any association through further studies across multiple settings, trauma mechanisms and populations.
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Affiliation(s)
- Andrew Follows
- Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield, S10 2JF, United Kingdom
| | - Antonia Round
- Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield, S10 2JF, United Kingdom; University of Sheffield, Beech Hill Road, Sheffield, S10 2RX, United Kingdom.
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Valence TD, Suppan L. Time to Reconsider Analgesia in Mass Casualty Incidents. Wilderness Environ Med 2023; 34:524-527. [PMID: 37923685 DOI: 10.1016/j.wem.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/31/2023] [Accepted: 09/04/2023] [Indexed: 11/07/2023]
Abstract
The provision of analgesia in mass casualty incidents has traditionally been viewed as low-priority and reserved for later stages of care. Poor pain management is commonplace in trauma victims, and inadequate acute pain management can hinder evacuation efforts and may lead to the development of chronic pain and posttraumatic stress disorder. New, safe, and simple methods for administering quality analgesia have proven to be safe and effective in the prehospital setting and, as such, could easily be implemented into mass casualty incident protocols and allow for analgesia at earlier stages in such incidents, thereby improving patient care.
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Affiliation(s)
- Timothee de Valence
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.
| | - Laurent Suppan
- Division of Emergency Medicine, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
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Lu J, Wang X, Chen L, Sun X, Li R, Zhong W, Fu Y, Yang L, Liu W, Han W. Unmanned aerial vehicle based intelligent triage system in mass-casualty incidents using 5G and artificial intelligence. World J Emerg Med 2023; 14:273-279. [PMID: 37425090 PMCID: PMC10323497 DOI: 10.5847/wjem.j.1920-8642.2023.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/02/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Rapid on-site triage is critical after mass-casualty incidents (MCIs) and other mass injury events. Unmanned aerial vehicles (UAVs) have been used in MCIs to search and rescue wounded individuals, but they mainly depend on the UAV operator's experience. We used UAVs and artificial intelligence (AI) to provide a new technique for the triage of MCIs and more efficient solutions for emergency rescue. METHODS This was a preliminary experimental study. We developed an intelligent triage system based on two AI algorithms, namely OpenPose and YOLO. Volunteers were recruited to simulate the MCI scene and triage, combined with UAV and Fifth Generation (5G) Mobile Communication Technology real-time transmission technique, to achieve triage in the simulated MCI scene. RESULTS Seven postures were designed and recognized to achieve brief but meaningful triage in MCIs. Eight volunteers participated in the MCI simulation scenario. The results of simulation scenarios showed that the proposed method was feasible in tasks of triage for MCIs. CONCLUSION The proposed technique may provide an alternative technique for the triage of MCIs and is an innovative method in emergency rescue.
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Affiliation(s)
- Jiafa Lu
- Emergency Department of Shenzhen University General Hospital, Shenzhen 518055, China
| | - Xin Wang
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Linghao Chen
- School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen 518060, China
| | - Xuedong Sun
- Emergency Department of Shenzhen University General Hospital, Shenzhen 518055, China
| | - Rui Li
- Emergency Department of Shenzhen University General Hospital, Shenzhen 518055, China
| | - Wanjing Zhong
- Emergency Department of Shenzhen University General Hospital, Shenzhen 518055, China
| | - Yajing Fu
- Emergency Department of Shenzhen University General Hospital, Shenzhen 518055, China
| | - Le Yang
- Emergency Department of Shenzhen University General Hospital, Shenzhen 518055, China
| | - Weixiang Liu
- School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen 518060, China
| | - Wei Han
- Emergency Department of Shenzhen University General Hospital, Shenzhen 518055, China
- Tianjin University, Tianjin 300072, China
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Accuracy of prehospital triage systems for mass casualty incidents in trauma register studies - A systematic review and meta-analysis of diagnostic test accuracy studies. Injury 2022; 53:2725-2733. [PMID: 35660101 DOI: 10.1016/j.injury.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 05/06/2022] [Accepted: 05/07/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Prioritising patients in mass casualty incidents (MCI) can be extremely difficult. Therefore, triage systems are important in every emergency medical service. This study reviews the accuracy of primary triage systems for MCI in trauma register studies. METHODS We registered a protocol at PROSPERO ID: CRD42018115438. We searched MEDLINE, EMBASE, Central, Web of Science, Scopus, Clinical Trials, Google Scholar, and reference lists for eligible studies. We included studies that both examined a primary triage system for MCI in trauma registers and provided sensitivity and specificity for critically injured vs non-critically injured as results. We excluded studies that used paediatric, chemical, biological, radiological or nuclear MCIs populations or triage systems. Finally, we calculated intra-study relative sensitivity, specificity and diagnostic odds ratio for each triage system. RESULTS Triage Sieve (TS) significantly underperformed in relative diagnostic odds ratio (DOR) when compared to START and CareFlight (CF) (START vs TS: 19.85 vs 13.23 (p<0.0001)│CF vs TS: 23.72 vs 12.83 (p<0.0001)). There was no significant difference in DOR between TS and Military Sieve (MS) (p<0.710). Compared to START, MS and CF TS had significantly higher relative specificity (START vs TS: 93.6% vs 96.1% (p=0.047)│CF vs TS: 96% vs 95.3% (p=0.0006)│MS vs TS: 94% vs 88.3% (p=0.0002)) and lower relative sensitivity (START vs TS: 57.8% vs 34.8% (p<0.0001)│CF vs TS: 53.9% vs 34.7% (p<0.0001)│MS vs TS: 51.9% vs 35.2% p<0.0001)). CF had significantly better relative DOR than START (CF vs START: 23.56 vs 27.79 (p=0.043)). MS had significantly better relative sensitivity than CF and START (MS vs CF: 49.5% vs 38.7% (p<0.0001)│MS vs START: 49.4% vs 43.9% (p=0.01)). In contrast, CF had significantly better relative specificity than MS (MS vs CF: 91.3% vs 93.3% (p<0.0001)). The remaining comparisons did not yield any significant differences. CONCLUSION As the included studies were at risk of bias and had heterogenic characteristics, our results should be interpreted with caution. Nonetheless, our results point towards inferior accuracy of Triage Sieve compared to START and CareFlight, and less firmly point towards superior accuracy of Military Sieve compared to START, CareFlight and Triage Sieve.
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Stein DM, Braverman MA, Phuong J, Shipper E, Price MA, Bixby PJ, Adelson PD, Ansel BM, Cifu DX, DeVine JG, Galvagno SM, Gelb DE, Harris O, Kang CS, Kitagawa RS, McQuillan KA, Patel MB, Robertson CS, Salim A, Shutter L, Valadka AB, Bulger EM. Developing a National Trauma Research Action Plan: Results from the Neurotrauma Research Panel Delphi Survey. J Trauma Acute Care Surg 2022; 92:906-915. [PMID: 35001020 DOI: 10.1097/ta.0000000000003527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In 2016, the National Academies of Science, Engineering and Medicine called for the development of a National Trauma Research Action Plan. The Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. Given the public health burden of injuries to the central nervous system, neurotrauma was one of 11 panels formed to address this recommendation with a gap analysis and generation of high-priority research questions. METHODS We recruited interdisciplinary experts to identify gaps in the neurotrauma literature, generate research questions, and prioritize those questions using a consensus-driven Delphi survey approach. We conducted four Delphi rounds in which participants generated key research questions and then prioritized the importance of the questions on a 9-point Likert scale. Consensus was defined as 60% or greater of panelists agreeing on the priority category. We then coded research questions using an National Trauma Research Action Plan taxonomy of 118 research concepts, which were consistent across all 11 panels. RESULTS Twenty-eight neurotrauma experts generated 675 research questions. Of these, 364 (53.9%) reached consensus, and 56 were determined to be high priority (15.4%), 303 were deemed to be medium priority (83.2%), and 5 were low priority (1.4%). The research topics were stratified into three groups-severe traumatic brain injury (TBI), mild TBI (mTBI), and spinal cord injury. The number of high-priority questions for each subtopic was 46 for severe TBI (19.7%), 3 for mTBI (4.3%) and 7 for SCI (11.7%). CONCLUSION This Delphi gap analysis of neurotrauma research identified 56 high-priority research questions. There are clear areas of focus for severe TBI, mTBI, and spinal cord injury that will help guide investigators in future neurotrauma research. Funding agencies should consider these gaps when they prioritize future research. LEVEL OF EVIDENCE Diagnostic Test or Criteria, Level IV.
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Affiliation(s)
- Deborah M Stein
- From the Program in Trauma, University of Maryland School of Medicine (D.M.S.), Baltimore, Maryland; Department of Biomedical Informatics and Medical Education (J.P.), University of Washington, Seattle, Washington; Coalition for National Trauma Research (M.A.B., E.S., M.A.P., P.J.B.), San Antonio, Texas; Department of Neurosurgery, Mayo Clinic (P.D.A.), Barrow Neurological Institute at Phoenix Children's Hospital; Division of Neurosurgery, Department of Child Health (P.D.A.), University of Arizona, Phoenix, Arizona; Department of Neurological Surgery (B.M.A.), Indiana University School of Medicine, Indianapolis, Indiana; Department of Physical Medicine and Rehabilitation (D.X.C.), Virginia Commonwealth University School of Medicine, Richmond, Virginia; Department of Orthopaedics, Augusta University Health (J.G.D.), Augusta, Georgia; Department of Anesthesiology (S.M.G.), Department of Orthopaedics (D.E.G.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Neurosurgery (O.H.), Stanford University, Palo Alto, California; Department of Emergency Medicine (C.S.K.), Madigan Army Medicine Center, Tacoma, Washington; Department of Neurosurgery (R.S.K.), McGovern Medical School, Houston, Texas; R Adams Cowley Shock Trauma Center (K.A.M.), University of Maryland Medical Center, Baltimore, Maryland; Department of Surgery (M.B.P.), Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Neurosurgery (C.S.R.), Baylor College of Medicine, Houston, Texas; Department of Surgery (A.S.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Critical Care Medicine (L.S.), Neurology & Neurosurgery, University of Pittsburg, Pittsburgh, Pennsylvania; Department of Neurosurgery (A.B.V.), Virginia Commonwealth University School of Medicine, Richmond, Virginia; Department of Surgery (E.M.B.), Harborview Medical Center, University of Washington, Seattle, Washington
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Newgard CD, Braverman MA, Phuong J, Shipper ES, Price MA, Bixby PJ, Goralnick E, Daya MR, Lerner EB, Guyette FX, Rowell S, Doucet J, Jenkins P, Mann NC, Staudenmayer K, Blake DP, Bulger E. Developing a National Trauma Research Action Plan: Results from the prehospital and mass casualty research Delphi survey. J Trauma Acute Care Surg 2022; 92:398-406. [PMID: 34789701 DOI: 10.1097/ta.0000000000003469] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The National Academies of Sciences, Engineering, and Medicine 2016 trauma system report recommended a National Trauma Research Action Plan to strengthen and guide future trauma research. To address this recommendation, 11 expert panels completed a Delphi survey process to create a comprehensive research agenda, spanning the continuum of trauma care. We describe the gap analysis and high-priority research questions generated from the National Trauma Research Action Plan panel on prehospital and mass casualty trauma care. METHODS We recruited interdisciplinary national experts to identify gaps in the prehospital and mass casualty trauma evidence base and generate prioritized research questions using a consensus-driven Delphi survey approach. We included military and civilian representatives. Panelists were encouraged to use the Patient/Population, Intervention, Compare/Control, and Outcome format to generate research questions. We conducted four Delphi rounds in which participants generated key research questions and then prioritized the questions on a 9-point Likert scale to low-, medium-, and high-priority items. We defined consensus as ≥60% agreement on the priority category and coded research questions using a taxonomy of 118 research concepts in 9 categories. RESULTS Thirty-one interdisciplinary subject matter experts generated 490 research questions, of which 433 (88%) reached consensus on priority. The rankings of the 433 questions were as follows: 81 (19%) high priority, 339 (78%) medium priority, and 13 (3%) low priority. Among the 81 high-priority questions, there were 46 taxonomy concepts, including health systems of care (36 questions), interventional clinical trials and comparative effectiveness (32 questions), mortality as an outcome (30 questions), prehospital time/transport mode/level of responder (24 questions), system benchmarks (17 questions), and fluid/blood product resuscitation (17 questions). CONCLUSION This Delphi gap analysis of prehospital and mass casualty care identified 81 high-priority research questions to guide investigators and funding agencies for future trauma research.
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Affiliation(s)
- Craig D Newgard
- From the Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine (C.D.N., M.R.D.), Oregon Health and Science University, Portland, Oregon; Coalition for National Trauma Research (M.A.B., E.S.S., M.A.P., P.J.B.), San Antonio, Texas; Department of Biomedical Informatics and Medical Education (J.P.), University of Washington, Seattle, Washington; Department of Emergency Medicine (E.G.), Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts; Department of Emergency Medicine (E.B.L.), Jacobs School of Medicine and Biomedical Sciences University at Buffalo, Buffalo, New York; Department of Emergency Medicine (F.X.G.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (S.R.), University of Chicago Medicine and Biological Sciences, Chicago, Illinois; Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (J.D.), University of California San Diego Health, San Diego, California; Department of Surgery (P.J.), Indiana University School of Medicine, Indianapolis, Indiana; Department of Pediatrics (N.C.M.), University of Utah School of Medicine, Salt Lake City, Utah; Department of Surgery (K.S.), Stanford University, Palo Alto, California; Department of Surgery (D.P.B.), Inova Medical Group/Inova Fairfax Medical Campus, Falls Church, Virginia; and Department of Surgery (E.B.), Harborview Medical Center University of Washington, Seattle, Washington
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Paal P, Zafren K, Pasquier M. Higher pre-hospital anaesthesia case volumes result in lower mortality rates: implications for mass casualty care. Br J Anaesth 2021; 128:e89-e92. [PMID: 34794765 DOI: 10.1016/j.bja.2021.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 01/30/2023] Open
Abstract
Senior physicians with a higher pre-hospital anaesthesia case volume have higher first-pass tracheal intubation success rates, shorter on-site times, and lower patient mortality rates than physicians with lower case volumes. A senior physician's skill set includes the basics of management of airway and breathing (ventilating and oxygenating the patient), circulation, disability (anaesthesia), and environment (especially maintaining core temperature). Technical rescue skills may be required to care for patients requiring pre-hospital airway management especially in hazardous environments, such as road traffic accidents, chemical incidents, terror attacks or warfare, and natural disasters. Additional important tactical skills in mass casualty situations include patient triage, prioritising, allocating resources, and making transport decisions.
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Affiliation(s)
- Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
| | - Ken Zafren
- Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK, USA; Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Vassallo J, Chernbumroong S, Malik N, Xu Y, Keene D, Gkoutos G, Lyttle MD, Smith J. Comparative analysis of major incident triage tools in children: a UK population-based analysis. Emerg Med J 2021; 39:emermed-2021-211706. [PMID: 34706900 PMCID: PMC9510399 DOI: 10.1136/emermed-2021-211706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/08/2021] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Triage is a key principle in the effective management of major incidents. There is currently a paucity of evidence to guide the triage of children. The aim of this study was to perform a comparative analysis of nine adult and paediatric triage tools, including the novel 'Sheffield Paediatric Triage Tool' (SPTT), assessing their ability in identifying patients needing life-saving interventions (LSIs). METHODS A 10-year (2008-2017) retrospective database review of the Trauma Audit Research Network (TARN) Database for paediatric patients (<16 years) was performed. Primary outcome was identification of patients receiving one or more LSIs from a previously defined list. Secondary outcomes included mortality and prediction of Injury Severity Score (ISS) >15. Primary analysis was conducted on patients with complete prehospital physiological data with planned secondary analyses using first recorded data. Performance characteristics were evaluated using sensitivity, specificity, undertriage and overtriage. RESULTS 15 133 patients met TARN inclusion criteria. 4962 (32.8%) had complete prehospital physiological data and 8255 (54.5%) had complete first recorded physiological data. The majority of patients were male (69.5%), with a median age of 11.9 years. The overwhelming majority of patients (95.4%) sustained blunt trauma, yielding a median ISS of 9 and overall, 875 patients (17.6%) received at least one LSI. The SPTT demonstrated the greatest sensitivity of all triage tools at identifying need for LSI (92.2%) but was associated with the highest rate of overtriage (75.0%). Both the Paediatric Triage Tape (sensitivity 34.1%) and JumpSTART (sensitivity 45.0%) performed less well at identifying LSI. By contrast, the adult Modified Physiological Triage Tool-24 (MPTT-24) triage tool had the second highest sensitivity (80.8%) with tolerable rates of overtriage (70.2%). CONCLUSION The SPTT and MPTT-24 outperform existing paediatric triage tools at identifying those patients requiring LSIs. This may necessitate a change in recommended practice. Further work is needed to determine the optimum method of paediatric major incident triage, but consideration should be given to simplifying major incident triage by the use of one generic tool (the MPTT-24) for adults and children.
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Affiliation(s)
- James Vassallo
- Institute of Naval Medicine, Gosport, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Saisakul Chernbumroong
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Nabeela Malik
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Yuanwei Xu
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Damian Keene
- Department of Anaesthesia, University Hospitals Birmingham, Birmingham, UK
| | - George Gkoutos
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- MRC Health Data Research UK (HDR UK), Birmingham, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Children's Hospital, Bristol, UK
| | - Jason Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
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Vassallo J, Smith J. Reply to: Assessment of the mass casualty triage during the November 2015 Paris area terrorist attacks: towards a simple triage rule. Eur J Emerg Med 2021; 28:162. [PMID: 33674520 DOI: 10.1097/mej.0000000000000798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- James Vassallo
- Emergency Department, Bristol Royal Infirmary, Bristol
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham
| | - Jason Smith
- Emergency Department, Bristol Royal Infirmary, Bristol
- Emergency Department, Derriford Hospital, Plymouth, UK
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Vassallo J, Fuller G, Smith JE. Relationship between the Injury Severity Score and the need for life-saving interventions in trauma patients in the UK. Emerg Med J 2020; 37:502-507. [PMID: 32748796 DOI: 10.1136/emermed-2019-209092] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 04/12/2020] [Accepted: 05/08/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Major trauma is the third leading cause of avoidable mortality in the UK. Defining which patients require care in a major trauma centre is a critical component of developing, evaluating and enhancing regional major trauma systems. Traditionally, trauma patients have been classified using the Injury Severity Score (ISS), but resource-based criteria have been proposed as an alternative. The aim of this study was to investigate the relationship between ISS and the use of life-saving interventions (LSI). METHODS Retrospective cohort study using the Trauma Audit Research Network database for all adult patients (aged ≥18 years) between 2006 and 2014. Patients were categorised as needing an LSI if they received one or more interventions from a previously defined list determined by expert consensus. RESULTS 193 290 patients met study inclusion criteria: 56.9% male, median age 60.0 years (IQR 41.2-78.8) and median ISS 9 (IQR 9-16). The most common mechanism of injury was falls <2 m (52.1%), followed by road traffic collisions (22.2%). 15.1% received one or more LSIs. The probability of a receiving an LSI increased with increasing ISS, but only a low to moderate correlation was evident (0.334, p<0.001). A clinically significant number of cases (5.3% and 7.6%) received an LSI despite having an ISS ≤8 or <15, respectively. CONCLUSIONS A clinically significant number of adult trauma patients requiring LSIs have an ISS below the traditional definition of major trauma. The traditional definition should be reconsidered and either lowered, or an alternative metric should be used.
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Affiliation(s)
- James Vassallo
- Emergency Department, Derriford Hospital, Plymouth, UK .,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Gordon Fuller
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jason E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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Abstract
INTRODUCTION Terror attacks have increased in frequency, and tactics utilized have evolved. This creates significant challenges for first responders providing life-saving medical care in their immediate aftermath. The use of coordinated and multi-site attack modalities exacerbates these challenges. The use of triage is not well-validated in mass-casualty settings, and in the setting of intentional mass violence, new and innovative approaches are needed. METHODS Literature sourced from gray and peer-reviewed sources was used to perform a comparative analysis on the application of triage during the 2011 Oslo/Utoya Island (Norway), 2015 Paris (France), and 2015 San Bernardino (California USA) terrorist attacks. A thematic narrative identifies strengths and weaknesses of current triage systems in the setting of complex, coordinated terrorist attacks (CCTAs). DISCUSSION Triage systems were either not utilized, not available, or adapted and improvised to the tactical setting. The complexity of working with large numbers of patients, sensory deprived environments, high physiological stress, and dynamic threat profiles created significant barriers to the implementation of triage systems designed around flow charts, physiological variables, and the use of tags. Issues were identified around patient movement and "tactical triage." CONCLUSION Current triage tools are inadequate for use in insecure environments, such as the response to CCTAs. Further research and validation are required for novel approaches that simplify tactical triage and support its effective application. Simple solutions exist in tactical triage, patient movement, and tag use, and should be considered as part of an overall triage system.
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Abstract
This review provides an overview of triaging critically ill or injured patients during mass casualty incidents due to events such as disasters, pandemics, or terrorist incidents. Questions clinicians commonly have, including "what is triage?," "when to triage?," "what are the types of disaster triage?," "how to triage?," "what are the ethics of triage?," "how to govern triage?," and "what research is required on triage?," are addressed.
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13
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Investigating the effects of under-triage by existing major incident triage tools. Eur J Emerg Med 2019; 26:139-144. [DOI: 10.1097/mej.0000000000000513] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vassallo J, Smith J. Major incident triage and the evaluation of the Triage Sort as a secondary triage method. Emerg Med J 2019; 36:281-286. [PMID: 30877263 DOI: 10.1136/emermed-2018-207986] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 01/16/2019] [Accepted: 02/08/2019] [Indexed: 11/04/2022]
Abstract
INTRODUCTION A key principle in the effective management of major incidents is triage, the process of prioritising patients on the basis of their clinical acuity. In many countries including the UK, a two-stage approach to triage is practised, with primary triage at the scene followed by a more detailed assessment using a secondary triage process, the Triage Sort. To date, no studies have analysed the performance of the Triage Sort in the civilian setting. The primary aim of this study was to determine the performance of the Triage Sort at predicting the need for life-saving intervention (LSI). METHODS Using the Trauma Audit Research Network (TARN) database for all adult patients (>18 years) between 2006 and 2014, we determined which patients received one or more LSIs using a previously defined list. The first recorded hospital physiology was used to categorise patient priority using the Triage Sort, National Ambulance Resilience Unit (NARU) Sieve and the Modified Physiological Triage Tool-24 (MPTT-24). Performance characteristics were evaluated using sensitivity and specificity with statistical analysis using a McNemar's test. RESULTS 127 233patients (58.1%) had complete data and were included: 55.6% men, aged 61.4 (IQR 43.1-80.0 years), ISS 9 (IQR 9-16), with 24 791 (19.5%) receiving at least one LSI (priority 1). The Triage Sort demonstrated the lowest accuracy of all triage tools at identifying the need for LSI (sensitivity 15.7% (95% CI 15.2 to 16.2) correlating with the highest rate of under-triage (84.3% (95% CI 83.8 to 84.8), but it had the greatest specificity (98.7% (95% CI 98.6 to 98.8). CONCLUSION Within a civilian trauma registry population, the Triage Sort demonstrated the poorest performance at identifying patients in need of LSI. Its use as a secondary triage tool should be reviewed, with an urgent need for further research to determine the optimum method of secondary triage.
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Affiliation(s)
- James Vassallo
- Emergency Department, Derriford Hospital, Plymouth, UK.,Institute of Naval Medicine, Gosport, Hampshire, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK
| | - Jason Smith
- Emergency Department, Derriford Hospital, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK
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Vassallo J, Smith JE. Authors response: Marsden MER, Mossadegh S, Marsh W, et al. J R Army Med Corps Epub ahead of print. doi:10.1136/jramc-2018-001057. BMJ Mil Health 2018; 166:205. [PMID: 30455391 DOI: 10.1136/jramc-2018-001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 10/01/2018] [Indexed: 11/04/2022]
Affiliation(s)
- James Vassallo
- Institute of Naval Medicine, Hampshire, UK .,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - J E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, United Kingdom.,Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
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Vassallo J, Horne S, Smith JE. Triage and the Modified Physiological Triage Tool-24 (MPTT-24). BMJ Mil Health 2018; 166:33-36. [PMID: 29301857 DOI: 10.1136/jramc-2017-000878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 11/27/2017] [Accepted: 11/28/2017] [Indexed: 11/03/2022]
Abstract
Major incidents occur on a regular basis. So far in 2017, England has witnessed five terrorism-related major incidents, resulting in approximately 40 fatalities and 400 injured. Triage is a key principle in the effective management of a major incident and involves prioritising patients on the basis of their clinical acuity. This paper describes the limitations associated with existing methods of primary major incident triage and the process of developing a new and improved triage tool-the Modified Physiological Triage Tool-24 (MPTT-24). Whilst the MPTT-24 is likely to be the optimum physiological method for primary major incident triage, it needs to be accompanied by an appropriate secondary triage process. The existing UK military and civilian secondary triage tool, the Triage Sort, is described, which offers little advantage over primary methods for identifying patients who require life-saving intervention. Further research is required to identify the optimum method of secondary triage.
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Affiliation(s)
- James Vassallo
- Division of Emergency Medicine, University of Cape Town, South Africa .,Institute of Naval Medicine, Hampshire, UK
| | - S Horne
- Emergency Department, Derriford Hospital, Plymouth, UK
| | - J E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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Vassallo J, Smith JE, Wallis LA. Major incident triage and the implementation of a new triage tool, the MPTT-24. J ROY ARMY MED CORPS 2017; 164:103-106. [PMID: 29055894 PMCID: PMC5969370 DOI: 10.1136/jramc-2017-000819] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/31/2017] [Accepted: 09/01/2017] [Indexed: 11/12/2022]
Abstract
Introduction The Modified Physiological Triage Tool (MPTT) is a recently developed primary triage tool and in comparison with existing tools demonstrates the greatest sensitivity at predicting need for life-saving intervention (LSI) within both military and civilian populations. To improve its applicability, we proposed to increase the upper respiratory rate (RR) threshold to 24 breaths per minute (bpm) to produce the MPTT-24. Our aim was to conduct a feasibility analysis of the proposed MPTT-24, comparing its performance with the existing UK Military Sieve. Method A retrospective review of the Joint Theatre Trauma Registry (JTTR) and Trauma Audit Research Network (TARN) databases was performed for all adult (>18 years) patients presenting between 2006–2013 (JTTR) and 2014 (TARN). Patients were defined as priority one (P1) if they received one or more LSIs. Using first recorded hospital RR in isolation, sensitivity and specificity of the ≥24 bpm threshold was compared with the existing threshold (≥22 bpm) at predicting P1 status. Patients were then categorised as P1 or not-P1 by the MPTT, MPTT-24 and the UK Military Sieve. Results The MPTT and MPTT-24 outperformed existing UK methods of triage with a statistically significant (p<0.001) increase in sensitivity of between 25.5% and 29.5%. In both populations, the MPTT-24 demonstrated an absolute reduction in sensitivity with an increase in specificity when compared with the MPTT. A statistically significant difference was observed between the MPTT and MPTT-24 in the way they categorised TARN and JTTR cases as P1 (p<0.001). Conclusions When compared with the existing MPTT, the MPTT-24 allows for a more rapid triage assessment. Both continue to outperform existing methods of primary major incident triage and within the military setting, the slight increase in undertriage is offset by a reduction in overtriage. We recommend that the MPTT-24 be considered as a replacement to the existing UK Military Sieve.
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Affiliation(s)
- James Vassallo
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.,Institute of Naval Medicine, Gosport, UK
| | - J E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Birmingham, UK
| | - L A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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Vassallo J, Smith J, Bouamra O, Lecky F, Wallis LA. The civilian validation of the Modified Physiological Triage Tool (MPTT): an evidence-based approach to primary major incident triage. Emerg Med J 2017; 34:810-815. [DOI: 10.1136/emermed-2017-206647] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 07/11/2017] [Accepted: 07/22/2017] [Indexed: 11/04/2022]
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Vassallo J, Horne S, Smith JE, Wallis LA. The prospective validation of the Modified Physiological Triage Tool (MPTT): an evidence-based approach to major incident triage. J ROY ARMY MED CORPS 2017; 163:383-387. [DOI: 10.1136/jramc-2017-000771] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 05/06/2017] [Accepted: 05/21/2017] [Indexed: 11/04/2022]
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Vassallo J, Beavis J, Smith JE, Wallis LA. Major incident triage: Derivation and comparative analysis of the Modified Physiological Triage Tool (MPTT). Injury 2017; 48:992-999. [PMID: 28131484 DOI: 10.1016/j.injury.2017.01.038] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 01/10/2017] [Accepted: 01/20/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Triage is a key principle in the effective management at a major incident. There are at least three different triage systems in use worldwide and previous attempts to validate them, have revealed limited sensitivity. Within a civilian adult population, there has been no work to develop an improved system. METHODS A retrospective database review of the UK Joint Theatre Trauma Registry was performed for all adult patients (>18years) presenting to a deployed Military Treatment Facility between 2006 and 2013. Patients were defined as Priority One if they had received one or more life-saving interventions from a previously defined list. Using first recorded hospital physiological data (HR/RR/GCS), binary logistic regression models were used to derive optimum physiological ranges to predict need for life-saving intervention. This allowed for the derivation of the Modified Physiological Triage Tool-MPTT (GCS≥14, HR≥100, 12<RR≥22). A comparison of the MPTT and existing triage tools was then performed using sensitivities and specificities with 95% confidence intervals. Differences in performance were assessed for statistical significance using a McNemar test with Bonferroni correction. RESULTS Of 6095 patients, 3654 (60.0%) had complete data and were included in the study, with 1738 (47.6%) identified as priority one. Existing triage tools had a maximum sensitivity of 50.9% (Modified Military Sieve) and specificity of 98.4% (Careflight). The MPTT (sensitivity 69.9%, 95% CI 0.677-0.720, specificity 65.3%, 95% CI 0.632-0.675) showed an absolute increase in sensitivity over existing tools ranging from 19.0% (Modified Military Sieve) to 45.1% (Triage Sieve). There was a statistically significant difference between the performance (p<0.001) between the MPTT and the Modified Military Sieve. DISCUSSION & CONCLUSION The performance characteristics of the MPTT exceed existing major incident triage systems, whilst maintaining an appropriate rate of over-triage and minimising under-triage within the context of predicting the need for a life-saving intervention in a military setting. Further work is required to both prospectively validate this system and to identify its performance within a civilian environment, prior to recommending its use in the major incident setting.
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Affiliation(s)
- James Vassallo
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa; Institute of Naval Medicine, Gosport PO12 2DL, United Kingdom.
| | - John Beavis
- Faculty of Science and Technology, Bournemouth University, Bournemouth, United Kingdom.
| | - Jason E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Joint Medical Command, Birmingham, United Kingdom.
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.
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Affiliation(s)
- Ed van Beeck
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
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