Analysis of preventable trauma deaths and inappropriate trauma care in a rural state

Functional outcome and associations with prehospital time and urban-remote disparities in trauma: A Norwegian national population-based study

BACKGROUND

There is a lack of knowledge regarding the functional outcomes of patients after trauma. Remote areas in Norway has been associated with an increased risk of trauma-related mortality. However, it is unknown how this might influence trauma-related morbidity. The aim of this study was to assess the functional outcomes of patients in the Norwegian trauma population and the relationship between prehospital time and urban-remote disparities on functional outcome.

METHODS

This registry-based study included 34,611 patients from the Norwegian Trauma Registry from 2015 - 2020. Differences in study population characteristics and functional outcomes as measured on the Glasgow Outcome Scale (GOS) at discharge were analysed. Three multinomial regression models were performed to assess the association between total prehospital time and urban-remote disparities and morbidity reported as GOS categories.

RESULTS

Ninety-four per cent of trauma patients had no disability or moderate disability at discharge. Among patients with severe disability or vegetative state, 81 % had NISS > 15. Patients with fall-related injuries had the highest proportion of severe disability or vegetative state. Among children and adults, every minute increase in total prehospital time was associated with higher odds of moderate disability. Urban areas were associated with higher odds of moderate disability in all age groups, whereas remote areas were associated with higher odds of severe disability or vegetative state in elderly patients. NISS was associated with a worse functional outcome.

CONCLUSIONS

The majority of trauma patients admitted to a trauma hospital in Norway were discharged with minimal change in functional outcome. Patients with severe injuries (NISS > 15) and patients with injuries from falls experienced the greatest decline in function. Every minute increase in total prehospital time was linked to an increased likelihood of moderate disability in children and adults. Furthermore, incurring injuries in urban areas was found to be associated with higher odds of moderate disability in all age groups, while remote areas were found to be associated with higher odds of severe disability or vegetative state in elderly patients.

Progressive Reduction in Preventable Mortality in a State Trauma System Using Continuous Preventable Mortality Review to Drive Provider Education: Results of Analyzing 1,979 Trauma Deaths from 2015 to 2022

BACKGROUND

The state legislature codified and funded the Arkansas Trauma System (ATS) in 2009. Quarterly preventable mortality reviews (PMRs) by the ATS began in 2015 and were used to guide state-wide targeted education to reduce preventable or potentially preventable (P/PP) deaths. We present the results of this PMR-education initiative from 2015 to 2022.

STUDY DESIGN

The ATS uses a statistical sampling model of the Arkansas Trauma Registry to select ~40% of the deaths for quarterly review, reflecting the overall the Arkansas Trauma Registry mortality population. A multispecialty PMR committee reviews the medical records from prehospital care to death, and hospital and regional advisory council reviews for each death. The PMR committee assigns opportunities for improvement (OFIs), cause(s) of death, and the likelihood of preventability for each case. Education to improve trauma care includes annual state-wide trauma meetings, novel classes targeted at level III/IV trauma center hospital providers, trauma evidence-based guidelines, and PMR "pearls."

RESULTS

We reviewed 1,979 deaths with 211 (10.6%) deaths judged to be P/PP deaths. There was a progressive decrease in P/PP deaths and OFIs for P/PP deaths. Five OFI types targeted by education accounted for 72% of the 24 possible OFI types in the P/PP cases, and 94% of the "contributory OFIs." Reductions in "delay in treatment" resulted in the most rapid decrease in P/PP deaths.

CONCLUSIONS

Using ongoing PMR studies to target provider education led to a reduction in P/PP deaths and OFIs for P/PP deaths. Focusing on education designed to improve preventable mortality can result in a substantial decrease in P/PP deaths by 43% (14% to 8%) for trauma systems.

Prehospital and emergency department airway management of severe penetrating trauma in Sweden during the past decade

BACKGROUND

Prehospital tracheal intubation (TI) is associated with increased mortality in patients with penetrating trauma, and the utility of prehospital advanced airway management is debated. The increased incidence of deadly violence in Sweden warrants a comprehensive evaluation of current airway management for patients with penetrating trauma in the Swedish prehospital environment and on arrival in the emergency department (ED).

METHODS

This was an observational, multicenter study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 included in the Swedish national trauma register (SweTrau) between 2011 and 2019. We investigated the frequency and characteristics of prehospital and ED TI, including 30-day mortality and patient characteristics associated with TI.

RESULT

Of 816 included patients, 118 (14.5%) were intubated prehospitally, and 248 (30.4%) were intubated in the ED. Patients who were intubated prehospitally had a higher ISS, 33 (interquartile range [IQR] 25, 75), than those intubated in the ED, 25 (IQR 18, 34). Prehospital TI was associated with a higher associated mortality, OR 4.26 (CI 2.57, 7.27, p < 0.001) than TI in the ED, even when adjusted for ISS (OR 2.88 [CI 1.64, 5.14, p < 0.001]). Hemodynamic collapse (≤ 40 mmHg) and low GCS score (≤ 8) were the characteristics most associated with prehospital TI. Traumatic cardiac arrests (TCAs) occurred in 154 (18.9%) patients, of whom 77 (50%) were intubated prehospitally and 56 (36.4%) were intubated in the ED. A subgroup analysis excluding TCA showed that patients with prehospital TI did not have a higher mortality rate than those with ED TI, OR 2.07 (CI 0.93, 4.51, p = 0.068), with OR 1.39 (0.56, 3.26, p = 0.5) when adjusted for ISS.

CONCLUSION

Prehospital TI was associated with a higher mortality rate than those with ED TI, which was specifically related to TCA; intubation did not affect mortality in patients without cardiac arrest. Mortality was high when airway management was needed, regardless of cardiac arrest, thereby emphasizing the challenges posed when anesthesia is needed. Several interventions, including whole blood transfusions, the implementation of second-tier EMS units and measures to shorten scene times, have been initiated in Sweden to counteract these challenges.

Airway Management of Suspected Traumatic Brain Injury Patients in the Emergency Room

The patients of trauma offers a special challenge because of the associated head injury, maxillofacial, neck and spine injuries, which puts the airway at imminent risk. The response time for the emergency team to initiate the airway management determines the outcome of the individual undergoing treatment. A judious implementatin of triage and ATLS guidelines are helpful in the allocation of resources in airway management of trauma patients. One must not get distracted with the severity of other organ systems because cerebral tissue permits a low threshold to the hypoxic insults. Adequate preparedness and a team effort result in better airway management and improved outcomes in trauma patients with variable hemodynamic response to resuscitation. All possible efforts must be made to secure a definitive airway (if required) and should be verified clinically as well as with the available adjuncts. The success of a trauma team depends on the familiarity to the airways devices and their discrete application in various situations.

Pre-hospital emergency anaesthesia in trauma patients: An observational study from a state-wide Australian pre-hospital and retrieval service

OBJECTIVE

To assess the performance of an Australian pre-hospital and retrieval medicine (PHRM) service against the National Institute for Health and Care Excellence (NICE) standard which recommends that pre-hospital emergency anaesthesia (PHEA) in trauma patients should be conducted within 45-min of first contact with emergency services.

METHODS

Retrospective observational study of all adult trauma patients in which PHEA was conducted by the PHRM service covering a 5-year period from January 2015 to December 2019.

RESULTS

Over the 5-year study period, 1509 (22%) of the PHRM service workload comprised primary retrievals from scene. Most 1346 (89%) of these cases had a primary diagnosis of trauma. Of these we have complete data for 328 of the 337 cases requiring a PHEA and 121 (37%) patients received this within the recommended 45-min time frame. The service attended in rapid response vehicles (n = 160, 49%), rotary wing (n = 151, 46%) and fixed wing (n = 17, 5%) transport modalities. For a service covering 983 482 km² , the median distance travelled to patients was 35 (16-71) km and the median time to PHEA was 54 (38-80) min.

CONCLUSIONS

In a cohort of 337 patients treated by a dedicated PHRM service in South Australia, the median time to PHEA was 54 (38-80) min with only 37% of patients receiving PHEA within 45 min from the activation of the team. Despite differing patient demographics, the percentage of patients receiving PHEA within the recommended time frame was greater than a similar cohort from the UK. However, both data sets still fall short of recommended targets.

Preventable death in trauma: A systematic review on definition and classification

PURPOSE

Trauma-related preventable death (TRPD) has been used to assess the management and quality of trauma care worldwide. However, due to differences in terminology and application, the definition of TRPD lacks validity. The aim of this systematic review is to present an overview of current literature and establish a designated definition of TRPD to improve the assessment of quality of trauma care.

METHODS

A search was conducted in PubMed, Embase, the Cochrane Library and the Web of Science Core Collection. Including studies regarding TRPD, published between January 1, 1990, and April 6, 2021. Studies were assessed on the use of a definition of TRPD, injury severity scoring tool and panel review.

RESULTS

In total, 3,614 articles were identified, 68 were selected for analysis. The definition of TRPD was divided in four categories: I. Clinical definition based on panel review or expert opinion (TRPD, trauma-related potentially preventable death, trauma-related non-preventable death), II. An algorithm (injury severity score (ISS), trauma and injury severity score (TRISS), probability of survival (Ps)), III. Clinical definition completed with an algorithm, IV. Other. Almost 85% of the articles used a clinical definition in some extend; solely clinical up to an additional algorithm. A total of 27 studies used injury severity scoring tools of which the ISS and TRISS were the most frequently reported algorithms. Over 77% of the panels included trauma surgeons, 90% included other specialist; 61% emergency medicine physicians, 46% forensic pathologists and 43% nurses.

CONCLUSION

The definition of TRPD is not unambiguous in literature and should be based on a clinical definition completed with a trauma prediction algorithm such as the TRISS. TRPD panels should include a trauma surgeon, anesthesiologist, emergency physician, neurologist, and forensic pathologist.

Effectiveness and safety of whole blood compared to balanced blood components in resuscitation of hemorrhaging trauma patients - A systematic review

INTRODUCTION

Hemorrhage is a leading cause of death among trauma patients, and is the most common cause of preventable death after trauma. Since the advent of blood component fractioning, most patients receive blood components rather than whole blood (WB). WB contains all of the individual blood components and has the advantages of simplifying resuscitation logistics, providing physiological ratios of components, reducing preservative volumes and allowing transfusion of younger red blood cells (RBC). Successful experience with fresh whole blood (FWB) by the US military is well documented. In the civilian setting, transfusion of cold-stored low titer type O whole blood (LTOWB) was shown to be safe. Reports of WB are limited by small numbers and low transfusion volumes.

STUDY DESIGN

We conducted a systematic review of the available published studies, comparing efficacy and safety of resuscitation with WB to resuscitation with blood components, in hemorrhaging trauma patients, using MEDLINE, EMBASE and ISI Web of Science. The main outcomes of interest were 24 hour and 30-day survival, blood product utilization and adverse events. Two reviewers independently abstracted the studies and assessed for bias. Sub-group analyses were pre-planned on the FWB and LTOWB groups separately.

RESULTS

Out of 126 references identified through our search strategy, five studies met the inclusion criteria. Only one study of FWB showed a significant benefit on 24 hour and 30-day survival. Other studies of both FWB and LTOWB showed no statistically significant difference in survival. There is an apparent benefit in blood product utilization with the use of WB across most studies. There were no reports of transfusion related reactions, however there was an increase in the organ failure rates in the FWB groups.

CONCLUSIONS

WB was not associated with a significant survival benefit or reduced blood product utilization. Nonetheless, it seems that the use of LTOWB is safe and might carry a significant logistic benefit. The quality of the existing data is poor and further high quality studies are required.

Current status of trauma surgery at a Japanese prefectural academic institute: improved organization in a regional prefecture

PURPOSES

Balancing scheduled surgery and trauma surgery is difficult with a limited number of surgeons. To address the issues and systematize education, we analyzed the current situation and the effectiveness of having a trauma team in the ER of a regional hospital.

METHODS

This retrospective study analyzed the demographics, traumatic variables, procedures, postoperative morbidities, and outcomes of 110 patients who underwent trauma surgery between 2012 and 2019. The trauma team was established in 2016 and our university hospital Emergency Room (ER) opened in 2012.

RESULTS

Blunt trauma accounted for 82% of the trauma injuries and 39% of trauma victims were transported from local centers to our institute. The most frequently injured organs were in the digestive tract and about half of the interventions were for hemostatic surgery alone. Concomitant treatments for multiple organ injuries were performed in 31% of the patients. The rates of postoperative severe complications (over Clavien-Dindo IIIb) and mortality were 10% and 13%, respectively. Fourteen (12.7%) of 24 patients who underwent damage-control surgery died, with multiple organ injury being the predominant cause of death.

CONCLUSION

Systematic education or training of medical students and general surgeons, as well as the co-operation of the team at the regional academic institute, are necessary to overcome the limited human resources and save trauma patients.

Early administration of fibrinogen concentrate in patients with polytrauma with thromboelastometry suggestive of hypofibrinogenemia: A randomized feasibility trial

OBJECTIVE

To evaluate the clinical effects of early administration of fibrinogen concentrate in patients with severe trauma and hypofibrinogenemia.

METHODS

We conducted an open randomized feasibility trial between December 2015 and January 2017 in patients with severe trauma admitted to the emergency department of a large trauma center. Patients presented with hypotension, tachycardia, and FIBTEM findings suggestive of hypofibrinogenemia. The intervention group received fibrinogen concentrate (50 mg/kg), and the control group did not receive early fibrinogen replacement. The primary outcome was feasibility assessed as the proportion of patients receiving the allocated treatment within 60 min after randomization. The secondary outcomes were transfusion requirements and other exploratory outcomes. Randomization was performed using sequentially numbered and sealed opaque envelopes. ClinicalTrials.gov: NCT02864875.

RESULTS

Thirty-two patients were randomized (16 in each group). All patients received the allocated treatment within 60 min after randomization (100%, 95% confidence interval, 86.7%-100%). The median length of intensive care unit stay was shorter in the intervention group (8 days, interquartile range [IQR] 5.75-10.0 vs. 11 days, IQR 8.5-16.0; p=0.02). There was no difference between the groups in other clinical outcomes. No adverse effects related to treatment were recorded in either group.

CONCLUSION

Early fibrinogen replacement with fibrinogen concentrate was feasible. Larger trials are required to properly evaluate clinical outcomes.

Introduction of a mobile device based tertiary survey application reduces missed injuries: A multi-center prospective study

BACKGROUND

Missed injuries during the initial assessment are a major cause of morbidity after trauma. The tertiary survey is a head-to-toe exam designed to identify any injuries missed after initial resuscitation. We designed a novel mobile device application (Physician Assist Trauma Software [PATS]) to standardize performance and documentation of the tertiary survey. This study was undertaken to assess the feasibility of introducing PATS into routine clinical practice, as well as its capacity to reduce missed injuries.

METHODS

Prior to implementation of PATS, the missed injury rates at a higher-volume and a medium-volume level I trauma center were assessed. The PATS program was implemented simultaneously at both centers. Missed injuries were tracked during the study period. Compliance and tertiary survey completion rates were evaluated as a marker of feasibility.

RESULTS

At the higher-volume trauma center, the missed injury rated decreased from 1% to 0% with the introduction of the PATS program (p = 0.04). At the medium-volume trauma center, the missed injury rate decreased from 9% to 1% (p < 0.001). Compliance and documentation increased from 68% to 100%, and from no formal documentation to 60% compliance at the higher- and medium-volume centers respectively.

CONCLUSIONS

The implementation of a mobile tertiary survey application significantly reduced missed injuries at both a higher- and medium-volume trauma center. The use of this application resulted in a significant improvement in compliance with documentation of the tertiary survey.

Changes in the temporal distribution of in-hospital mortality in severely injured patients-An analysis of the TraumaRegister DGU

Background

The temporal distribution of trauma mortality has been classically described as a trimodal pattern with an immediate, early and late peak. In modern health care systems this time distribution has changed.

Methods

Data from the TraumaRegister DGU was analysed retrospectively. Between 2002 and 2015, all registered in-hospital deaths with an Injury Severity Score (ISS) ≥ 16 were evaluated considering time of death, trauma mechanism, injured body area, age distribution, rates of sepsis and multiple organ failure. Pre-hospital and post-discharge trauma deaths were not considered.

Results

78 310 severely injured patients were registered, non-survivors constituted 14 816, representing an in-hospital mortality rate of 18.9%. Mean ISS of non-survivors was 36.0±16.0, 66.7% were male, mean age was 59.5±23.5. Within the first hour after admission to hospital, 10.8% of deaths occurred, after 6 hours the percentage increased to 25.5%, after 12 hours 40.0%, after 24 hours 53.2% and within the first 48 hours 61.9%. Mortality showed a constant temporal decrease. Severe head injury (defined by Abbreviated Injury Scale, AIS-Head≥3) was found in 76.4% of non-survivors. Patients with an isolated head injury showed a more distinct decrease in survival rate, which was accentuated in the first days after admission. The correlation of age and time of death showed a proportional increase with age (55-74a). The rate of sepsis and multiple organ failure among non-survivors was 11.5% and 70.1%, respectively.

Conclusion

In a modern trauma care system, the mortality distribution of severely injured patients has changed its pattern, where especially the third peak is no longer detectable.

Preventable deaths in a French regional trauma system: A six-year analysis of severe trauma mortality

BACKGROUND

Analyzing mortality in a mature trauma system is useful to improve quality of care of severe trauma patients. Standardization of error reporting can be done using the classification of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). The aim of our study was to describe preventable deaths in our trauma system and to classify errors according to the JCAHO taxonomy.

METHODS

We performed a six-year retrospective study using the registry of the Northern French Alps trauma network (TRENAU). Consecutive patients who died in the prehospital field or within their stay at hospital were included. An adjudication committee analyzed deaths to identify preventable or potentially preventable deaths from 2009 to 2014. All errors were classified using the JCAHO taxonomy.

RESULTS

Within the study period, 503 deaths were reported among 7484 consecutive severe trauma patients (overall mortality equal to 6.7%). Seventy-two (14%) deaths were judged as potentially preventable and 36 (7%) deaths as preventable. Using the JACHO taxonomy, 170 errors were reported. These errors were detected both in the prehospital setting and in the hospital phase. Most were related to clinical performance of physicians and consisted of rule-based or knowledge based failures. Prevention or mitigation of errors required an improvement of communication among caregivers.

CONCLUSIONS

Standardization of error reporting is the first step to improve the efficiency of trauma systems. Preventable deaths are frequently related to clinical performance in the early phase of trauma management. Universal strategies are necessary to prevent or mitigate these errors.

Injury Related Deaths in Singapore

Background

Injury is the commonest cause of morbidity and mortality amongst the younger age groups. Management of injuries has been identified as one of the major health issues facing our community. The study objective was to define the epidemiology of injury related deaths in Singapore.

Methods

A nationwide review of all deaths arising as a result of injury in 1995 was conducted.

Results

There were 913 cases with an injury mortality rate of 27 per 100,000 population. Ninety-seven percent (97%) were due to blunt injury. Falls from heights from deliberate self-harm was the commonest mechanism, followed by motor vehicle collisions (MVC). Fifty-two percent (52%) of MVC deaths were motorcyclists or pillion riders. Sixty-six percent (66%) of all deaths occurred in the prehospital phase. Central nervous system injury was the main cause of hospital deaths.

Conclusion

Results from this study will help our community focus on the appropriate preventive strategies to reduce mortality and the cost of injuries to our society.

American vs. European Trauma Centers: A Comparison of Preventable Deaths

INTRODUCTION

The aim is comparing the quality of care at a typical American trauma center (USC) vs. an equivalent European referral center in Spain (SRC), through the analysis of preventable and potentially preventable deaths.

METHODS

Comparative study that evaluated trauma patients older than 16 years old who died during their hospitalization. We cross-referenced these deaths and extracted all deaths that were classified as potentially preventable or preventable. All errors identified were then classified using the JC taxonomy.

RESULTS

The rate of preventable and potentially preventable mortality was 7.7% and 13.8% in the USC and SRC respectively. According to the JC taxonomy, the main error type was clinical in both centers, due to errors in intervention (treatment). Errors occurred mostly in the emergency department and were caused by physicians. In the USC, 73% of errors were therapeutic as compared to 59% in the SRC (P=.06). The SRC had a 41% of diagnosis errors vs just 18% in the USC (P = .001). In both centers, the main cause of error was human. At the USC, the most frequent human cause was 'knowledge-based' (44%). In contrast, at the SRC center the most common errors were 'rule-based' (58%) (P<.001).

CONCLUSIONS

The use of a common language of errors among centers is key in establishing benchmarking standards. Comparing the quality of care of an American trauma center and a Spanish referral center, we have detected remarkably similar avoidable errors. More diagnostic and 'ruled-based' errors have been found in the Spanish center.

Validation of a noninvasive monitor to continuously trend individual responses to hypovolemia

BACKGROUND

Humans are able to compensate for significant blood loss with little change in traditional vital signs, limiting early detection and intervention. We hypothesized that the Compensatory Reserve Index (CRI), a new hemodynamic parameter that trends changes in intravascular volume relative to the individual patient's response to hypovolemia, would accurately trend each subject's progression from normovolemia to decompensation (systolic blood pressure < 80) and back to normovolemia in humans.

METHODS

Men and women, ages 19 years to 36 years, underwent stepwise (~333 mL aliquot) removal and replacement of 20% blood volume (men, 15 mL/kg; women, 13 mL/kg) via a large bore intravenous (i.v.) line. During each experiment, subjects were monitored with four CipherOx CRI Tablets. Withdrawn blood was reinfused at the end of each experiment.

RESULTS

Forty-two subjects (24 men; 18 women) were enrolled in the study, of which 32 completed the protocol. Seven subjects became symptomatic and collapsed (systolic blood pressure < 80), six never achieving maximum blood loss; each was rescued with a saline infusion followed by reinfusion of their stored blood. The mean CRI at baseline for all 42 subjects was 0.9 ± 0.04. The mean CRI for the 32 subjects while asymptomatic at maximum blood loss was 0.611 ± 0.028. For the asymptomatic subjects, the average blood loss volume was 1018 mL ± 286 mL. In comparison, the mean CRI at maximum blood loss for the seven subjects who collapsed was 0.15 ± 0.007 and their average blood loss volume was 860 ± 183 mL. Mean CRI after reinfusion of blood was 0.89 ± 0.02. In addition symptomatic subjects demonstrated three times larger average decrease in CRI per liter of blood removed, 0.85 versus 0.28 for asymptomatic subjects.

CONCLUSION

CRI trends change in intravascular volume relative to an individual's response to hypovolemia and is sensitive to the differing risks associated with individuals' differing tolerance to volume loss.

LEVEL OF EVIDENCE

Prognostic study, level II.

Telemedicine Use Decreases Rural Emergency Department Length of Stay for Transferred North Dakota Trauma Patients

BACKGROUND

Telemedicine has been proposed as one strategy to improve local trauma care and decrease disparities between rural and urban trauma outcomes.

OBJECTIVES

This study was conducted to describe the effect of telemedicine on management and clinical outcomes for trauma patients in North Dakota.

METHODS

Cohort study of adult (age ≥18 years) trauma patients treated in North Dakota Critical Access Hospital (CAH) Emergency Departments (EDs) from 2008 to 2014. Records were linked to a telemedicine network's call records, indicating whether telemedicine was available and/or used at the institution at the time of the care. Multivariable generalized estimating equations were developed to identify associations between telemedicine consultation and availability and outcomes such as transfer, timeliness of care, trauma imaging, and mortality.

RESULTS

Of the 7,500 North Dakota trauma patients seen in CAH, telemedicine was consulted for 11% of patients in telemedicine-capable EDs and 4% of total trauma patients. Telemedicine utilization was independently associated with decreased initial ED length of stay (LOS) (30 min, 95% confidence interval [CI] 14-45 min) for transferred patients. Telemedicine availability was associated with an increase in the probability of interhospital transfer (adjusted odds ratio [aOR] 1.2, 95% CI 1.1-1.4). Telemedicine availability was associated with increased total ED LOS (15 min, 95% CI 10-21 min), and computed tomography scans (aOR 1.6, 95% CI 1.3-1.9).

CONCLUSIONS

ED-based telemedicine consultation is requested for the most severely injured rural trauma patients. Telemedicine consultation was associated with more rapid interhospital transfer, and telemedicine availability is associated with increased radiography use and transfer. Future work should evaluate how telemedicine could target patients likely to benefit from telemedicine consultation.

Prehospital deaths from trauma: Are injuries survivable and do bystanders help?

BACKGROUND AND OBJECTIVES

Deaths from trauma occurring in the prehospital phase of care are typically excluded from analysis in trauma registries. A direct historical comparison with Hussain and Redmond's study on preventable prehospital trauma deaths has shown that, two decades on, the number of potentially preventable deaths remains high. Using updated methodology, we aimed to determine the current nature, injury severity and survivability of traumatic prehospital deaths and to ascertain the presence of bystanders and their role following the point of injury including the frequency of first-aid delivery.

METHODS

We examined the Coroners' inquest files for deaths from trauma, occurring in the prehospital phase, over a three-year period in the Cheshire and Manchester (City), subsequently referred to as Manchester, Coronial jurisdictions. Injuries were scored using the Abbreviated-Injury-Scale (AIS-2008), Injury Severity Score (ISS) calculated and probability of survival estimated using the Trauma Audit and Research Network's outcome prediction model.

RESULTS

One hundred and seventy-eight deaths were included in the study (one hundred and thirty-four Cheshire, forty-four Manchester). The World Health Organisation's recommendations consider those with a probability of survival between 25-50% as potentially preventable and those above 50% as preventable. The median ISS was 29 (Cheshire) and 27.5 (Manchester) with sixty-two (46%) and twenty-six (59%) respectively having a probability of survival in the potentially preventable and preventable ranges. Bystander presence during or immediately after the point of injury was 45% (Cheshire) and 39% (Manchester). Bystander intervention of any kind was 25% and 30% respectively. Excluding those found dead and those with a probability of survival less than 25%, bystanders were present immediately after the point of injury or "within minutes" in thirty-three of thirty-five (94%) Cheshire and ten of twelve (83%) Manchester. First aid of any form was attempted in fourteen of thirty-five (40%) and nine of twelve (75%) respectively.

CONCLUSIONS

A high number of prehospital deaths from trauma occur with injuries that are potentially survivable, yet first aid intervention is infrequent. Following injury there is a potential window of opportunity for the provision of bystander assistance, particularly in the context of head injury, for simple first-aid manoeuvres to save lives.

What factor within the Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC) criteria is most strongly correlated with trauma induced DIC? A retrospective study using thromboelastometry in a single center in Japan

Purpose

The diagnostic criteria for disseminated intravascular coagulation (DIC) established by the Japanese Association for Acute Medicine (JAAM) is able to diagnose DIC accurately and promptly. The aim of this retrospective study is to evaluate the degree of association between each parameter of JAAM DIC criteria and the diagnosis of trauma induced DIC (T-DIC) utilizing thromboelastometry (ROTEM).

Methods

Trauma patients transported to our hospital with ROTEM performed in the emergency department between January 2013 and December 2015 were enrolled in this study. We evaluated (1) the characteristics of T-DIC, (2) the relationships between T-DIC and each parameter of the JAAM DIC criteria and (3) the diagnostic accuracies of each parameter for T-DIC by statistical measurement.

Results

All 72 patients (21 T-DIC and 51 control) were included in primary analysis. T-DIC was significantly related to younger age, more severe trauma scores, more cases of massive transfusions, and remarkable coagulation abnormality detected by standard coagulation tests. In the cases of T-DIC, ROTEM showed longer clotting time, lower acceleration, lower clot firmness, and inhibited fibrinolysis in EXTEM/INTEM. Within the JAAM DIC score, PT-INR ≥1.2 was the most accurate factor for T-DIC diagnosis; sensitivity 60.0%, specificity 100.0%, and accuracy 88.7%. PT-INR ≥1.2 was statistically correlated with the JAAM DIC score (p < 0.001, r = 0.709). The univariate analysis based on 1.2 of PT-INR indicated statistical differences in most categories of ROTEM, which is similar to analysis performed for the presence and absence of T-DIC.

Conclusions

Among JAAM DIC criteria, the PT-INR ≥1.2 was the most accurate factor for both the diagnosis of T-DIC and the evaluation of its severity.

Potentially preventable prehospital deaths from motor vehicle collisions

BACKGROUND

In 2011, about 30,000 people died in motor vehicle collisions (MVCs) in the United States. We sought to evaluate the causes of prehospital deaths related to MVCs and to assess whether these deaths were potentially preventable.

METHODS

Miami-Dade Medical Examiner records for 2011 were reviewed for all prehospital deaths of occupants of 4-wheeled motor vehicle collisions. Injuries were categorized by affected organ and anatomic location of the body. Cases were reviewed by a panel of 2 trauma surgeons to determine cause of death and whether the death was potentially preventable. Time to death and hospital arrival times were determined using the Fatality Analysis Reporting System (FARS) data from 2002 to 2012, which allowed comparison of our local data to national prevalence estimates.

RESULTS

Local data revealed that 39% of the 98 deaths reviewed were potentially preventable (PPD). Significantly more patients with PPD had neurotrauma as a cause of death compared to those with a nonpreventable death (NPD) (44.7% vs. 25.0%, P =.049). NPDs were significantly more likely to have combined neurotrauma and hemorrhage as cause of death compared to PPDs (45.0% vs. 10.5%, P <.001). NPDs were significantly more likely to have injuries to the chest, pelvis, or spine. NPDs also had significantly more injuries to the following organ systems: lung, cardiac, and vascular chest (all P <.05). In the nationally representative FARS data from 2002 to 2012, 30% of deaths occurred on scene and another 32% occurred within 1 h of injury. When comparing the 2011 FARS data for Miami-Dade to the remainder of the United States in that year, percentage of deaths when reported on scene (25 vs. 23%, respectively) and within 1 h of injury (35 vs. 32%, respectively) were similar.

CONCLUSIONS

Nationally, FARS data demonstrated that two thirds of all MVC deaths occurred within 1 h of injury. Over a third of prehospital MVC deaths were potentially preventable in our local sample. By examining injury patterns in PPDs, targeted intervention may be initiated.

Scandinavian SSAI clinical practice guideline on pre-hospital airway management

Background

The Scandinavian society of anaesthesiology and intensive care medicine task force on pre‐hospital airway management was asked to formulate recommendations following standards for trustworthy clinical practice guidelines.

Methods

The literature was systematically reviewed and the grading of recommendations assessment, development and evaluation (GRADE) system was applied to move from evidence to recommendations.

Results

We recommend that all emergency medical service (EMS) providers consider to: apply basic airway manoeuvres and airway adjuncts (good practice recommendation); turn unconscious non‐trauma patients into the recovery position when advanced airway management is unavailable (good practice recommendation); turn unconscious trauma patients to the lateral trauma position while maintaining spinal alignment when advanced airway management is unavailable [strong recommendation, low quality of evidence (QoE)]. We suggest that intermediately trained providers use a supraglottic airway device (SAD) or basic airway manoeuvres on patients in cardiac arrest (weak recommendation, low QoE). We recommend that advanced trained providers consider using an SAD in selected indications or as a rescue device after failed endotracheal intubation (ETI) (good practice recommendation). We recommend that ETI should only be performed by advanced trained providers (strong recommendation, low QoE). We suggest that videolaryngoscopy is considered for ETI when direct laryngoscopy fails or is expected to be difficult (weak recommendation, low QoE). We suggest that advanced trained providers apply cricothyroidotomy in ‘cannot intubate, cannot ventilate’ situations (weak recommendation, low QoE).

Conclusion

This guideline for pre‐hospital airway management includes a combination of techniques applied in a stepwise fashion appropriate to patient clinical status and provider training.

Monitoring the injured patient

Monitoring of the injured patient is important. It includes clinical assessment, following the ABCDE approach, and the use of instruments found from the prehospital to critical care setting.

Correctly used, these provide important information about the patient's current physiological state and response to treatment plus diagnostic and prognostic implications that are useful to the clinician involved in the care of injured patients.

A Call for Consensus on Methodology and Terminology to Improve Comparability in the Study of Preventable Prehospital Trauma Deaths: A Systematic Literature Review

OBJECTIVES

The study of preventable deaths is essential to trauma research for measuring service quality and highlighting avenues for improving care and as a performance indicator. However, variations in the terminology and methodology of studies on preventable prehospital trauma death limit the comparability and wider application of data. The objective of this study was to describe the heterogeneity in terminology and methodology.

METHODS

We performed a systematic literature review and report this using the PRISMA guidelines. Searches were conducted using PubMed (including Medline), Ovid, and Embase databases. Studies, with a full text available in English published between 1990 and 2015, meeting the following inclusion criteria were included: analysis of 1) deaths from trauma, 2) occurring in the prehospital phase of care, and 3) application of criteria to ascertain whether deaths were preventable. One author screened database results for relevance by title and abstract. The full text of identified papers was reviewed for inclusion. The reference list of included papers was screened for studies not identified by the database search. Data were extracted on predefined core elements relating to preventability reporting and definitions using a standardized form.

RESULTS

Twenty-seven studies meeting the inclusion criteria were identified: 12 studies used two categories to assess the preventability of death while 15 used three categories. Fifteen variations in the terminology of these categories and combination with death descriptors were found. Eleven different approaches were used in defining what constituted a preventable death. Twenty-one included survivability of injuries as a criterion. Methods used to determine survivability differed and eight variations in parameters for categorization of deaths were used. Nineteen used panel review in determining preventability with six implementing panel blinding. Panel composition varied greatly by expertise of personnel. Separation of prehospital deaths differed with 10 separating those dead at scene (DAS) and dead on arrival, three excluding those DAS, three excluding deaths prior to EMS arrival, and 11 not separating prehospital deaths.

CONCLUSIONS

The heterogeneity in methodology, terminology, and definitions of "preventable" between studies render data incomparable. To facilitate common understanding, comparability, and analysis, a commonly agreed ontology by the prehospital research community is required.

Preventable deaths and potentially preventable deaths. What are our errors?

BACKGROUND

A variety of systems have been applied to identify and address errors in the management of multiple trauma patients. This lack of standardisation represents a serious problem.

OBJECTIVES

Detect preventable and potentially preventable deaths, and classify all the errors with universal language.

METHODS

We studied all trauma patients over 16 admitted to the critical care unit or who died before. In multidisciplinary sessions we decided which deaths were preventable, potentially preventable and non preventable. Guided by ATLS protocols, we detected errors in their management that were classified using the taxonomy of Joint Commission.

RESULTS

We registered 1236 trauma patients (ISS 20.77). Of the 115 trauma deaths, 19 were preventable or potentially preventable deaths. We recorded 130 errors in all deaths, 46 of them in preventable or potentially preventable deaths. Using our own classification, the main errors were delay in starting correct treatment or performance of CT in hemodynamically unstable patients. Using the taxonomy of Joint Commission, the main type error was clinical, during the intervention: the delay in initiating correct treatment. Mistakes were made in the emergency department by medical specialists. The incidence of therapeutic and diagnostic errors was similar. The main cause of error was human failure, specifically 'rule-based' errors

CONCLUSIONS

Measuring and recording the results is the first step on the way to improving the quality of care for trauma patients. A common language like the taxonomy of Joint Commission will help standardise patient safety data, thus improving the recording of incidents and their analysis and treatment.

Ultrasonographic assessment of inferior vena cava/abdominal aorta diameter index: a new approach of assessing hypovolemic shock class 1

Background

We designed this study to expand the usage of ultrasound to detect early occurrence of hypovolemia. We explore the potential use of inferior vena cava (IVC) and abdominal aorta (AA) diameter index (IVC:AA) measured ultrasonographically to detect class 1 hypovolemic shock with blood loss less than 15%.ᅟ

Methods

The aim of this study was to determine the changes in the diameter of inferior vena cava and abdominal aorta in blood donors by using ultrasound, pre and post blood donation. The result of the study would be further explorated to determine the inferior vena cava (IVC) abdominal aorta (Aorta) diameter index (IVC:Aorta). This was a prospective study done in the blood bank of a university hospital. Researcher was trained by a senior radiologist to assess inferior vena cava and abdominal aorta diameter. Fifty-two healthy blood donors were included in the study. Inclusion criteria were same with the blood bank criteria to donate blood. Demographic data and vital signs were taken before the ultrasound measurement done for inferior vena cava and abdominal aorta diameter. Once the volunteers donated their blood of approximately 450 mls; the measurements were repeated using the same methods.

Results

There were differences in IVC, abdominal aorta and inferior vena cava:aorta diameters index pre and post donation. With mathematical analysis, we suggested the number of IVC:Aorta index as 1.14±2SD with SD 0.18 as a cut off value for class 1 hypovolemic shock.

Conclusion

The IVC:Aorta diameter index can be used as a parameter for detecting early phase (Class 1) of hypovolemic shock.

Prehospital rapid sequence induction following trauma in the era of regional networks for major trauma

OBJECTIVE

Rapid sequence induction (RSI) provides prompt airway control during emergency evacuation of trauma patients. Physicians may be tasked to travel with paramedic ambulance crews to the scene of injury when RSI is more likely to be required. This study investigates whether there are any differences in the practice of prehospital RSI during emergency retrievals for trauma since the establishment of the regional Major Trauma Network (MTN) in March 2012.

METHODS

A retrospective observational study examined prehospital records for all trauma patients from September 2010 to January 2015 at a Major Trauma Centre in Birmingham, UK. Prehospital physician availability increased from 12 to 24 h after March 2012, and tasking became centralized. Data included demographics, mechanism of injury, crew personnel, and details of RSI. The periods before and after the establishment of the regional MTN were compared.

RESULTS

There were 5244 patients: 1432 (27.3%) before and 3812 (72.7%) after March 2012. Of the patients, 67.2% were male. The most common injuries were road traffic collisions (45.0%). Physicians were more likely to be present after (2345 missions, 61.5%) than before (529 missions, 36.9%) March 2012 (P<0.01). RSI was performed 434 (8.3%) times and was more likely during the latter than the former period [359 (9.4%) vs. 75 (5.2%), P<0.01]. Successful tracheal intubation was achieved in 99% of occasions.

CONCLUSION

The establishment of regional MTNs enables centrally tasked, 24-h physician availability for emergency trauma patients. There has been an increase in physician presence on emergency missions and increased frequency of RSI for at-risk trauma patients at times when there may previously have been an unmet requirement.

Urban/Rural disparities in Oregon pediatric traumatic brain injury

Background

Traumatic brain injury (TBI) greatly contributes to morbidity and mortality in the pediatric population. We examined potential urban/rural disparities in mortality amongst Oregon pediatric patients with TBI treated in trauma hospitals.

Methods

We conducted a retrospective study of children ages 0–19 using the Oregon Trauma Registry for years 2009–2012. Geographic location of injury was classified using the National Center for Health Statistics Urban/Rural Classification Scheme. Incidence rates were calculated using Census data for denominators. Associations between urban/rural injury location and mortality were assessed using multivariable logistic regression, controlling for potential confounders. Generalized estimating equations were used to help account for clustering of data within hospitals.

Results

Of 2794 pediatric patients with TBI, 46.6 % were injured in large metropolitan locations, 24.8 % in medium/small metropolitan locations, and 28.6 % in non-metropolitan (rural) locations. Children with rural locations of injury had a greater annualized TBI incidence rate, at 107/100,000 children per year, than those from large metropolitan areas (71/100,000 per year). Compared to children injured in urban locations, those in rural locations had more than twice the crude odds of mortality (odds ratio [OR], 2.5; 95 % CI, 1.6–4.0). This association remained significant (OR, 1.8; 95 % CI, 1.04–3.3) while adjusting for age, gender, race, insurance status, injury severity, and type of TBI (blunt vs. penetrating).

Conclusion

We observed higher rates of TBI and greater proportions of severe injury in rural compared to urban areas in Oregon. Rural children treated in the trauma system for TBI were more likely to die than urban children after controlling for demographic and injury factors associated with urban/rural residence. Further research is needed to examine treatment disparities by urban/rural location. Future work should also identify interventions that can reduce risk of TBI and TBI-related mortality among children, particularly those who live in rural areas.

Electronic supplementary material

The online version of this article (doi:10.1186/s40621-015-0063-2) contains supplementary material, which is available to authorized users.

Advanced airway management for pre-hospital trauma patients

The need for timely and appropriate airway management for trauma patients is widely recognised. There are a small number of severely injured patients who cannot be adequately supported with basic airway manoeuvres, and require early advanced airway management. The way in which this care is provided remains highly controversial. Whilst it is clear that effective airway management remains a priority for all patients and poorly performed pre-hospital anaesthesia may be detrimental to patient outcome, debate remains over exactly which patients will benefit from early advanced airway interventions, and how it should be provided. The evidence base is small and inconsistent, with significant heterogeneity in the reported data, making it impossible to draw meaningful conclusions. Current practice is not standardised, and care is delivered by providers of different abilities using a range of equipment and techniques. Standards of care provided during in-hospital practice relating to these issues of provider competence, equipment, and monitoring should be directly translated into delivery of care outside the hospital, but this is not always the case. The aim of this review is to evaluate the current evidence surrounding pre-hospital advanced airway management.

Thoracotomy for blunt chest trauma: is chest tube output a useful criterion?

Aim

The aim of this study was to determine whether the traditional criteria of chest tube output are useful indicators for urgent thoracotomy in patients with blunt chest trauma.

Methods

Data were collected retrospectively from our trauma registry of 542 blunt chest trauma patients (Chest Abbreviated Injury Scale score of 3 or greater) over a 10-year period (2000-2010). The 1-h chest tube output was calculated from chest tube output and time after admission, and the results were compared between patients who underwent thoracotomy for hemorrhage and those who did not.

Results

Data were available for 24 patients who underwent thoracotomy for hemorrhage and 93 patients who did not undergo thoracotomy. The 1-h chest tube output between the groups was significantly different (708.0 ± 258.3 mL versus 108.9 ± 222.9 mL). Receiver operating characteristic curve analysis of the predictive value of 1-h chest tube output for thoracotomy was conducted. The area under the receiver operating characteristic curve was 0.98, and the cutoff 1-h chest tube output value for predicting thoracotomy was 404 mL (sensitivity, 87.5%; specificity, 96.8%).

Conclusions

The 1-h chest tube output of patients who underwent thoracotomy was lower than the thresholds traditionally reported as indications for urgent thoracotomy. High chest tube output as a traditional indicator for thoracotomy may not apply to patients with blunt chest trauma.

How we provide thawed plasma for trauma patients

Almost 50% of trauma-related fatalities within the first 24 hours of injury are related to hemorrhage. Improved survival in severely injured patients has been demonstrated when massive transfusion protocols are rapidly invoked as part of a therapeutic approach known as damage control resuscitation (DCR). DCR incorporates the early use of plasma to prevent or correct trauma-induced coagulopathy. DCR often requires the transfusion of plasma before determination of the recipient's ABO group. Historically, group AB plasma has been considered the "universal donor" plasma product. At our facility, the number of AB plasma products produced on an annual basis was found to be inadequate to support the trauma service's DCR program. A joint decision was made by the transfusion medicine and trauma services to provide group A thawed plasma (TP) for in-hospital and prehospital DCR protocols. A description of the implementation of group A TP into the DCR program is provided as well as outcome data pertaining to the use of TP in trauma patients.

Indications and results of emergency surgical airways performed by a physician-staffed helicopter emergency service

BACKGROUND

Airway management is essential in critically ill or injured patients. In a "can't intubate, can't oxygenate" scenario, an emergency surgical airway (ESA), similar to a cricothyroidotomy, is the final step in airway management. This procedure is infrequently performed in the prehospital or clinical setting. The incidence of ESA may differ between physician- and non-physician-staffed emergency medical services (EMS). We examined the indications and results of ESA procedures among our physician-staffed EMS compared with non-physician-staffed services.

METHODS

Data for all forms of airway management were obtained from our EMS providers and analyzed and compared with data from non-physician-staffed EMS found in the literature.

RESULTS

Among 1871 patients requiring a secured airway, the incidence of a surgical airway was 1.6% (n=30). Fourteen patients received a primary ESA. In 16 patients, a secondary ESA was required after failed endotracheal intubation. The total prehospital ESA tracheal access success rate was 96.7%.

CONCLUSION

The incidence of ESA in our patient population was low compared with those reported in the literature from non-physician-staffed EMS. Advanced intubation skills might be a contributing factor, thus reducing the number of ESAs required.

Fitness for purpose study of the Field Assessment Conditioning Tool (FACT): a research protocol

INTRODUCTION

As part of a programme of research aiming to improve the outcomes of traumatically injured children, a multisource healthcare advocacy tool has been developed to allow trauma team members and hospital governance administrators to reflect and to act on complex trauma team-hospital systems interactions. We have termed this tool a Field Assessment Conditioning Tool (FACT). The FACT draws on quantitative data including clinical care points in addition to self-reflective qualitative data. The FACT is designed to provide feedback on this assessment data both horizontally across fellow potential team members and vertically to the hospital/organisation governance structure, enabling process gap identification and allowing an agenda of improvements to be realised. The aim of the study described in this paper is to explore the perceived fitness for purpose of the FACT to provide an opportunity for healthcare advocacy by healthcare professionals caring for traumatically injured children.

METHODS AND ANALYSIS

The FACT will be implemented and studied in three district hospitals, each around a major trauma centre in the UK, USA and New Zealand. Using a qualitative approach with standardised semi-structured interviews and thematic analysis we will explore the following question: Is the FACT fit for purpose in terms of providing a framework to evaluate, reflect and act on the individual hospital's own performance (trauma team-hospital interactions) in terms of readiness to receive traumatically injured children?

ETHICS AND DISSEMINATION

Ethics opinion was sought for each research host organisation participating and deemed not required. The results will be disseminated to participating sites, networks and published in high-impact journals.

An update on the coagulopathy of trauma

Trauma remains the leading cause of death with bleeding as the primary cause of preventable mortality during the first 24 h following trauma. When death occurs, it happens quickly, typically within the first 6 h after injury. One of four patients to arrive in the emergency department after trauma is already in the state of acute traumatic coagulopathy and shock. The principal drivers of acute traumatic coagulopathy have been characterized by tissue hypoperfusion, inflammation, and the acute activation of the neurohumoral system. Hypoperfusion leads to an activation of protein C with cleavage of activated factors V and VIII and the inhibition of plasminogen activator inhibitor 1 with subsequent hyperfibrinolysis. Endothelial damage and activation result in Weibel-Palade body degradation and glycocalyx shedding associated with autoheparinization. In contrast, there is an iatrogenic coagulopathy that occurs secondary to uncritical volume therapy leading to acidosis, hypothermia, and hemodilution. This coagulopathy then may be an integral part of the "vicious cycle" when combined with acidosis and hypothermia. The present article summarizes an update on the principal mechanisms and triggers of the coagulopathy of trauma including traumatic brain injury.

Preventable mortality in geriatric hip fracture inpatients

There is a high rate of mortality in elderly patients who sustain a fracture of the hip. We aimed to determine the rate of preventable mortality and errors during the management of these patients. A 12 month prospective study was performed on patients aged > 65 years who had sustained a fracture of the hip. This was conducted at a Level 1 Trauma Centre with no orthogeriatric service. A multidisciplinary review of the medical records by four specialists was performed to analyse errors of management and elements of preventable mortality. During 2011, there were 437 patients aged > 65 years admitted with a fracture of the hip (85 years (66 to 99)) and 20 died while in hospital (86.3 years (67 to 96)). A total of 152 errors were identified in the 80 individual reviews of the 20 deaths. A total of 99 errors (65%) were thought to have at least a moderate effect on death; 45 reviews considering death (57%) were thought to have potentially been preventable. Agreement between the panel of reviewers on the preventability of death was fair. A larger-scale assessment of preventable mortality in elderly patients who sustain a fracture of the hip is required. Multidisciplinary review panels could be considered as part of the quality assurance process in the management of these patients.

Cite this article: Bone Joint J 2014;96-B:1178–84.

Infrastructure and clinical practice for the detection and management of trauma-associated haemorrhage and coagulopathy

PURPOSE

Early detection and management of post-traumatic haemorrhage and coagulopathy have been associated with improved outcomes, but local infrastructures, logistics and clinical strategies may differ.

METHODS

To assess local differences in infrastructure, logistics and clinical management of trauma-associated haemorrhage and coagulopathy, we have conducted a web-based survey amongst the delegates to the 15th European Congress of Trauma and Emergency Surgery (ECTES) and the 2nd World Trauma (WT) Congress held in Frankfurt, Germany, 25-27 May 2014.

RESULTS

446/1,540 delegates completed the questionnaire yielding a response rate of 29%. The majority specified to work as consultants/senior physicians (47.3%) in general (36.1%) or trauma/orthopaedic surgery (44.5%) of level I (70%) or level II (19%) trauma centres. Clinical assessment (>80%) and standard coagulation assays (74.6%) are the most frequently used strategies for early detection and monitoring of bleeding trauma patients with coagulopathy. Only 30% of the respondents declared to use extended coagulation assays to better characterise the bleeding and coagulopathy prompted by more individualised treatment concepts. Most trauma centres (69%) have implemented local protocols based on international and national guidelines using conventional blood products, e.g. packed red blood cell concentrates (93.3%), fresh frozen plasma concentrates (93.3%) and platelet concentrates (83%), and antifibrinolytics (100%). 89% considered the continuous intake of anticoagulants including "new oral anticoagulants" and platelet inhibitors as an increasing threat to bleeding trauma patients.

CONCLUSIONS

This study confirms differences in infrastructure, logistics and clinical practice for the detection and management of trauma-haemorrhage and trauma-associated coagulopathy amongst international centres. Ongoing work will focus on geographical differences.

International normalized ratio as a predictor of mortality in trauma patients in India

BACKGROUND

Hemorrhage is the second leading cause of death in trauma patients preceded only by traumatic brain injury. But hemorrhagic shock is the most common cause of preventable death within 6 hours of admission. Traumatic coagulopathy is a hypocoagulable state that occurs in the most severely injured. International normalized ratio (INR) and its relationship with trauma mortality have not been studied specifically. This study aimed to establish a predictive value of INR for trauma-related mortality.

METHODS

A total of 99 trauma patients aged 18-70 years were included in the study. Their INR was determined and patient progression was followed up till death/discharge. According to previous retrospective studies, the cutoff value for INR in our study was kept at 1.5.

RESULTS

The total mortality rate of the patients was 16.16% (16/99). The mean INR was 1.45 with a SD of 1.35. INR was deranged in a total of 14 patients (14.14%). Of these patients, 11 died (78.57%) and 3 survived. INR was deranged in 11 (68.75%) of the 16 patients who died, but 5 deaths (31.25%) had normal INR values. The sensitivity of INR was 69% (95%CI 41%-88%) and the specificity 96% (95%CI 90%-99%). The diagnostic accuracy of INR was 92% (95%CI 85%-96%). Positive predictive value and negative predictive value were 79% (95%CI 49%-95%) and 94% (95%CI 87%-98%), respectively.

CONCLUSION

Our results showed that INR is a good predictor of mortality in trauma patients.

Pre-hospital anaesthesia: the same but different

Advanced airway management is one of the most controversial areas of pre-hospital trauma care and is carried out by different providers using different techniques in different Emergency Medical Services systems. Pre-hospital anaesthesia is the standard of care for trauma patients arriving in the emergency department with airway compromise. A small proportion of severely injured patients who cannot be managed with basic airway management require pre-hospital anaesthesia to avoid death or hypoxic brain injury. The evidence base for advanced airway management is inconsistent, contradictory and rarely reports all key data. There is evidence that poorly performed advanced airway management is harmful and that less-experienced providers have higher intubation failure rates and complication rates. International guidelines carry many common messages about the system requirements for the practice of advanced airway management. Pre-hospital rapid sequence induction (RSI) should be practiced to the same standard as emergency department RSI. Many in-hospital standards such as monitoring, equipment, and provider competence can be achieved. Pre-hospital and emergency in-hospital RSI has been modified from standard RSI techniques to improve patient safety, physiological disturbance, and practicality. Examples include the use of opioids and long-acting neuromuscular blocking agents, ventilation before intubation, and the early release of cricoid pressure to improve laryngoscopic view. Pre-hospital RSI is indicated in a small proportion of trauma patients. Where pre-hospital anaesthesia cannot be carried out to a high standard by competent providers, excellent quality basic airway management should be the mainstay of management.

Pitfalls to avoid in the medical management of mass casualty incidents following terrorist bombings: the hospital perspective

BACKGROUND

The unique patterns of injury following explosions together with the involvement of numerous physicians, most of whom are not experienced in trauma, may create problems in the medical management of mass casualty incidents.

METHODS

Four hundred patient files admitted in 19 mass casualty events following bombing incidents were reviewed and possible areas which could impact survival were defined.

RESULTS

Forty-nine (9.3 %) patients had an Injury Severity Score ≥16. Of 205 patients in whom triage decisions were available, 5 of 25 severely injured patients were undertriaged by the triage officers at the door of the hospital. Following primary evaluation inside the emergency department critical injuries in two patients were missed due to distracting, less serious injuries. Of 68 (16.1 %) patients who were operated, 28 were in need of either immediate, urgent or high-priority operations. Except for neurosurgical cases which needed to be transferred to other hospitals, there was no delay in surgery. One patient underwent negative laparotomy. There were 15 in-hospital deaths, 6 of which were deemed as either anticipated or unanticipated mortality with possibility for improvement.

CONCLUSION

Medical management should be evaluated following MCIs as this may illustrate possible problems which many need to be addressed in contingency planning.

Year in review 2012: Critical Care--Out-of-hospital cardiac arrest and trauma

In 2012 Critical Care published many articles pertaining to the resuscitation of out-of-hospital cardiac arrest and trauma. In this review, we summarize several of these articles, including those regarding advances in resuscitation techniques and methods. We examine articles pertaining to prehospital endotracheal intubation, the use of specialized devices for cardiopulmonary resuscitation and policies regarding transport destinations for both cardiac arrest and trauma patients. Articles on the predictors of outcome in both pediatric and adult populations are evaluated, including articles on the effects of obesity on survival from hemorrhage and pediatric outcomes from traumatic cardiac arrest. The effects of the type and volume of resuscitation fluids for both adult and pediatric patients are discussed, as are the factors contributing to hypothermia in trauma patients.

Opportunities for improvement in the management of patients who die from haemorrhage after trauma

BACKGROUND

Bleeding is the leading cause of preventable death after injury. This retrospective study aimed to characterize opportunities for performance improvement (OPIs) identified in patients who died from bleeding and were considered by the quality improvement system of a major trauma centre.

METHODS

All trauma deaths in 2006-2010 were discussed at the trauma morbidity and mortality meeting. Deaths from haemorrhage were identified and subjected to qualitative and quantitative evaluation. OPIs were identified and remedial action was taken.

RESULTS

During the study interval there were 7511 trauma team activations; 423 patients died. Haemorrhage was the second most common cause of death, in 112 patients, and made a substantial contribution to death in a further 15. For 84 of these 127 patients, a total of 150 OPIs were identified. Most arose in the emergency department, but involved personnel from many departments. Problems with decision-making were more common than errors in technical skill. OPIs frequently involved the decision between surgery, radiology and further investigation. Delayed and inappropriate surgery occurred even when investigation and diagnosis were appropriate. The mortality rate among patients presenting in shock fell significantly over the study interval (P < 0·026).

CONCLUSION

Problems with judgement are more common than those of skill. Death from traumatic haemorrhage is associated with identifiable, remediable failures in care. The implementation of a systematic trauma quality improvement system was associated with a fall in the mortality rate among patients presenting in shock.

The acute coagulopathy of trauma: mechanisms and tools for risk stratification

Trauma remains the leading cause of death, with bleeding as the primary cause of preventable mortality. When death occurs, it happens quickly, typically within the first 6 h after injury. The principal drivers of the acute coagulopathy of trauma have been characterized, but another group of patients with early evidence of coagulopathy both physiologically and mechanistically distinct from this systemic acquired coagulopathy has been identified. This distinct phenotype is present in 25% to 30% of patients with major trauma without being exposed to the traditional triggers and is associated with higher morbidity and a 4-fold increase in mortality. Despite improvements in the resuscitation of exsanguinating patients, one of the remaining keys is to expeditiously and reproducibly identify the patients most likely to require transfusion including massive transfusion with damage control resuscitation principles. Several predictive scoring systems/algorithms for transfusion including massive transfusion in both civilian and military trauma populations have been introduced. The models developed usually suggest combinations of physiologic, hemodynamic, laboratory, injury severity, and demographic triggers identified on the initial evaluation. Many use a combination of dichotomous variables that are readily accessible after the patient's arrival to the trauma bay, but others rely on time-consuming mathematical calculations and may thus have limited real-time application. Weighted and more sophisticated systems including higher numbers of variables perform superiorly. A common limitation to all models is their retrospective nature, and prospective validations are needed. Point-of-care viscoelastic testing may be an alternative to early recognize trauma-induced coagulopathy with the risk of ongoing hemorrhage and transfusion.