Direct to operating room trauma resuscitation decreases mortality among severely injured children

Penetrating cardiac injuries: What you need to know

ABSTRACT

Despite significant advances in trauma surgery in recent years, patients sustaining penetrating cardiac injuries still have an overall survival rate of 19%. A substantial number of deaths occur at the scene, while approximately 40% of those reaching trauma centers survive. To increase survival, the key factor is timely intervention for bleeding control, pericardial tamponade release, and definitive repair. Asymptomatic patients sustaining precordial wounds or mediastinal gunshot wounds should be assessed with chest ultrasound to rule out cardiac injuries. Shock on admission is an immediate indication of surgery repair. Patients admitted in posttraumatic cardiac arrest may benefit from resuscitative thoracotomy. The surgical team must be assured that appropriate personnel, equipment, instruments, and blood are immediately available in the operating room. A left anterolateral thoracotomy, which can be extended to a clamshell incision, and sternotomy are the most common surgical incisions. Identification of cardiac anatomical landmarks during surgery is vital to avoid complications. There are several technical options for bleeding control, and the surgeon must be trained to use them to obtain optimal results. Ultimately, prioritizing surgical intervention and using effective resuscitation strategies are essential for improving survival rates and outcomes.

Real-time attending trauma surgeon assessment of direct-to-operating room trauma resuscitations: Results from a prospective observational study

BACKGROUND

Direct-to-operating room (DOR) resuscitation expedites interventions for trauma patients. Perceived benefit from the surgeon's perspective is not well known. This study assesses the integration of a real-time surgeon assessment tool into a DOR protocol.

METHODS

Surgeon assessment tool results from a prospective study of DOR cases were analyzed. Analysis assessed patient factors and surgeon perception for appropriateness and benefit of DOR. Multivariate analysis identified independent factors associated with perceived DOR benefit.

RESULTS

A total of 104 trauma patients underwent DOR resuscitation; 84% were perceived as appropriate triage, and 48% as beneficial. Patients with Injury Severity Score of >15 (50% vs. 28%), systolic blood pressure of <90 mm Hg (24% vs. 9%), and severe abdominal injury (28% vs. 9%) had higher perceived DOR benefits (all p < 0.05). Patients deemed to benefit from DOR underwent more emergent interventions or truncal surgery (44% vs. 92%, p < 0.01). No difference in benefit was seen based on age, sex, Glasgow Coma Scale score of <9, or injury mechanism. Forty-four percent had perceived benefit from DOR resuscitation despite requiring imaging after initial evaluation. Patients with perceived benefit had a higher rate of unplanned return to the operating room (16% vs. 2%, p < 0.05), but no differences in complication rates, Glasgow Outcome Score, or mortality. Injury Severity Score of >15 was the only independently associated variable with a perceived benefit on surgeon assessment tool (odds ratio, 3.5; p < 0.05).

CONCLUSION

The majority of DOR resuscitations were deemed as appropriately triaged, and approximately half had a perceived benefit. Benefit was associated with higher injury severity and the need for urgent interventions but was not predicted by injury mechanism or other triage variables.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

A systematic review of emergency room laparotomy in patients with severe abdominal trauma

Traumatic intra-abdominal hemorrhage contributes to mortality in patients with trauma. However, initiating an emergent laparotomy in the operating room (OR) as a standard treatment can sometimes be time-consuming. To overcome this issue, laparotomy is performed in the emergency room (ER) in some institutions. This systematic review evaluates the efficacy of performing ER laparotomy. Comprehensive searches were conducted in MEDLINE PubMed, EMBASE, and Cochrane databases, up to August 9, 2024. The risk of bias in observational studies was assessed using the ROBINS-I tool. The primary outcome was mortality following ER laparotomy, and the secondary outcome was time from admission to first laparotomy. The review included 10 studies, all of which were observational. A meta-analysis was not performed due to substantial heterogeneity and insufficient data. Mortality rates after ER laparotomy ranged from 23 to 100%. Mortality rates were 23.0-66.7% in the conventional ER group, while they were 0-30% in the OR group. In the hybrid ER group, the 28-day mortality rates were 12.7-15%, compared to 21.7-22% in the conventional group. The time from admission to the first laparotomy was 17-43 min (median) in the conventional ER group, compared to 40-111 min (median) in the OR laparotomy group. In the hybrid ER setting, the time from admission to intervention, including laparotomy, was 35-48 min (median), whereas it was 72-101 min (median) in the conventional group. A high and unclear risk of bias due to confounding was noted across the studies. ER laparotomy may provide rapid bleeding control. However, due to the limited number of studies and significant heterogeneity among the studies reviewed, the true effect size of ER laparotomy in conventional and hybrid ER settings remains unclear.

Prognosis and assessment of the predictive value of severity scores in paediatric abdominal trauma: A French national cohort study

BACKGROUND

Paediatric closed abdominal trauma is common, however, its severity and influence on survival are difficult to determine. No prognostic score integrating abdominal involvement exists to date in paediatrics.

OBJECTIVES

To evaluate the severity and short-term and medium-term prognosis of closed abdominal trauma in children, and the performance of severity scores in predicting mortality.

DESIGN

Retrospective, cohort, observational study.

SETTING AND PARTICIPANTS

Patients aged 0 to 18 years presenting at the trauma room of a French paediatric Level I Trauma Centre over the period 2015 to 2019 with an isolated closed abdominal trauma or as part of a polytrauma.

MAIN OUTCOMES

Primary outcome was the six months mortality. Secondary outcomes were related complications and therapeutic interventions, and performance for predicting mortality of the scores listed. Paediatric Trauma Score (PTS), Revised Trauma Score (RTS), Shock Index Paediatric Age-adjusted (SIPA) score, Reverse shock index multiplied by Glasgow Coma Scale score (rSIG), Base Deficit, International Normalised Ratio, and Glasgow Coma Scale (BIG), Injury Severity Score (ISS) and Trauma Score and the Injury Severity (TRISS) score.

DATA COLLECTION

Data collected include clinical, biological and CT scan data at admission, first 24 h management and prognosis. The PTS, RTS, SIPA, rSIG, BIG and ISS scores were calculated and mortality was predicted according to BIG score and TRISS methodology.

RESULTS

Of 1145 patients, 149 met the inclusion criteria and 12 (8.1%) died. Of the 12 deceased patients, 11 (91.7%) presented with severe head injury, 11 (91.7%) had blood products transfusion and 7 received tranexamic acid. ROC curves analysis concluded that PTS, RTS, rSIG and BIG scores accurately predict mortality in paediatric closed abdominal trauma with AUCs at least 0.92. The BIG score offered the best predictive performance for predicting mortality at a threshold of 24.8 [sensitivity 90%, specificity 92%, negative-predictive value (NPV) 99%, area under the curve (AUC) 0.93].

CONCLUSION

PEVALPED is the first French study to evaluate the prognosis of paediatric closed abdominal trauma. The use of PTS, rSIG and BIG scores are relevant from the acute phase and the pathophysiological interest and accuracy of the BIG score make it a powerful tool for predicting mortality of closed abdominal trauma in children.

Challenging Dogma by Skipping the Emergency Department Thoracotomy: A Propensity Score Matched Analysis of the Trauma Quality Improvement Database

INTRODUCTION

Survival following emergency department thoracotomy (EDT) for patients in extremis is poor. Whether intervention in the operating room instead of EDT in select patients could lead to improved outcomes is unknown. We hypothesized that patients who underwent intervention in the operating room would have improved outcomes compared to those who underwent EDT.

METHODS

We conducted a retrospective review of the Trauma Quality Improvement Program database from 2017 to 2021. All adult patients who underwent EDT, operating room thoracotomy (ORT), or sternotomy as the first form of surgical intervention within 1 h of arrival were included. Of patients without prehospital cardiac arrest, propensity score matching was utilized to create three comparable groups. The primary outcome was survival. Secondary outcomes included time to procedure.

RESULTS

There were 1865 EDT patients, 835 ORT patients, and 456 sternotomy patients who met the inclusion criteria. There were 349 EDT, 344 ORT, and 408 sternotomy patients in the matched analysis. On Cox multivariate regression, there was an increased risk of mortality with EDT versus sternotomy (HR 4.64, P < 0.0001), EDT versus ORT (HR 1.65, P < 0.0001), and ORT versus sternotomy (HR 2.81, P < 0.0001). Time to procedure was shorter with EDT versus sternotomy (22 min versus 34 min, P < 0.0001) and versus ORT (22 min versus 37 min, P < 0.0001).

CONCLUSIONS

There was an association between sternotomy and ORT versus EDT and improved mortality. In select patients, operative approaches rather than the traditional EDT could be considered.

Emergency department laparotomy for patients with severe abdominal trauma: a retrospective study at a single regional trauma center in Korea

Purpose

Severe abdominal injuries often require immediate clinical assessment and surgical intervention to prevent life-threatening complications. In Jeju Regional Trauma Center, we have instituted a protocol for emergency department (ED) laparotomy at the trauma bay. We investigated the mortality and time taken from admission to ED laparotomy.

Methods

We reviewed the data recorded in our center's trauma database between January 2020 and December 2022 and identified patients who underwent laparotomy because of abdominal trauma. Laparotomies that were performed at the trauma bay or the ED were classified as ED laparotomy, whereas those performed in the operating room (OR) were referred to as OR laparotomy. In cases that required expeditious hemostasis, ED laparotomy was performed appropriately.

Results

From January 2020 to December 2022, 105 trauma patients admitted to our hospital underwent emergency laparotomy. Of these patients, six (5.7%) underwent ED laparotomy. ED laparotomy was associated with a mortality rate of 66.7% (four of six patients), which was significantly higher than that of OR laparotomy (17.1%, 18 of 99 patients, P=0.006). All the patients who received ED laparotomy also underwent damage control laparotomy. The time between admission to the first laparotomy was significantly shorter in the ED laparotomy group (28.5 minutes; interquartile range [IQR], 14-59 minutes) when compared with the OR laparotomy group (104 minutes; IQR, 88-151 minutes; P<0.001). The two patients who survived after ED laparotomy had massive mesenteric bleeding, which was successfully ligated. The other four patients, who had liver laceration, kidney rupture, spleen injury, and pancreas avulsion, succumbed to the injuries.

Conclusions

Although ED laparotomy was associated with a higher mortality rate, the time between admission and ED laparotomy was markedly shorter than for OR laparotomy. Notably, major mesenteric hemorrhages were effectively controlled through ED laparotomy.

Efficacy of direct-to-operating room trauma resuscitation: a systematic review

BACKGROUND

Hemorrhage control is a time-critical task, and recent studies have demonstrated that a shorter time to definitive care is positively associated with patient survival and functional outcomes. The concept of direct transport to the operating room was proposed in the 1960s to reduce treatment time. Some trauma centers have developed protocols for direct-to-operating room resuscitation (DOR) programs. Moreover, few studies have reported the clinical outcomes of DOR in patients with trauma; however, their clinical effect in improving the efficiency and quality of care remains unclear. In this systematic review, we aimed to consolidate all published studies reporting the effect of DOR on severe trauma and evaluate its utility.

METHODS

The PubMed, EMBASE, and Cochrane databases were searched from inception to April 2023, to identify all articles published in English that reported the effect of direct-to-operating room trauma resuscitation for severe trauma. The articles were reviewed as references of interest.

RESULTS

We reviewed six studies reporting the clinical effect of operating room trauma resuscitation. A total of 3232 patients were identified. Five studies compared the actual mortality with the predicted mortality using the trauma score and injury severity score, while one study compared mortality using propensity matching. Four studies reported that the actual survival rate for overall injuries was better than the predicted survival rate, whereas two studies reported no difference. Some studies performed subgroup analyses. Two studies showed that the survival rate for penetrating injuries was better than the predicted survival rate, and one showed that the survival rate for blunt injuries was better than the predicted survival rate. Five studies reported the time to surgical intervention, which was within 30 min. Two studies time-compared surgical intervention, which was shorter in patients who underwent DOR.

CONCLUSION

Implementing DOR is likely to have a beneficial effect on mortality and can facilitate rapid intervention in patients with severe shock. Future studies, possibly clinical trials, are needed to ensure a proper comparison of the efficiency.

Predictors of long-term survival in 5,680 patients admitted to a UK major trauma centre with thoracic injuries

INTRODUCTION

The long-term outcomes of chest trauma are largely unknown. We sought to determine the predictors of in-hospital and long-term survival in patients admitted to a major trauma centre (MTC) with chest injuries and to evaluate spatial patterns of injury in our network area.

METHODS

Retrospective analysis of data collected on the National Trauma Audit Research Network (TARN) database using multivariate analysis and Cox regression analysis. Spatial analysis was performed using ArcGis 10.7.1.

RESULTS

Some 5,680 patients were admitted with chest trauma between December 1999 and December 2019. Median patient age was 45 years and the median Injury Severity Score (ISS) was 20. The proportion of patients who had an operation was 39.8%. Age, blood transfusion, head injury, shock, emergency thoracotomy and heart disease were predictors of hospital mortality (p < 0.05). However, having an operation on concomitant injuries was protective. ISS and Glasgow Coma Score were discriminators of in-hospital mortality (C-indices 0.76 and 0.80, respectively). The 10-year survival values for patients who survived to discharge from hospital and who were aged <40, 50, 60, 70, 80 and >80 years were 99%, 93%, 95%, 87%, 75% and 43%, respectively. Preadmission lung disease and alcohol/drug misuse were poor predictors of long-term survival (p < 0.05). Hotspot analysis revealed the areas with the highest incidents were all close to the MTC.

CONCLUSIONS

The MTC is geographically central to areas with high numbers of trauma incidents. Although emergency thoracotomy was a predictor of poor in-hospital outcomes, having surgery for concomitant injuries improved outcomes. Patients surviving to discharge have good long-term survivals.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

BACKGROUND

Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.

RESULTS

This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.

CONCLUSION

A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

A Case Series of Trauma Resuscitation in the Intensive Care Unit Bypassing the Emergency Room During the Conversion to a COVID-19 Only Hospital

When a patient with severe trauma is admitted to the emergency room (ER), they are evaluated before transfer to either the intensive care unit (ICU) or operating room. To minimize the time until a definitive treatment can be provided, direct operating room resuscitation can be performed. In this hospital the ER was closed during the hospital’s transition to a coronavirus disease 2019-dedicated hospital, and direct ICU resuscitation for patients with trauma was performed for a short period. To perform effective trauma resuscitation, all ICU beds were reorganized to achieve a modified, experienced nurse: patient ratio (1:2-3) and 2 beds were assigned for trauma ICU resuscitation alone. The equipment for initial resuscitation was installed and ICU nurses received training. Consultations with the hospital administration, nursing, and pharmaceutical departments were completed in advance to avoid formal problems. Conversion of the ICU for direct resuscitation procedures was performed in 4 patients.

Outcomes After Transfer of Pediatric Trauma Patients: Does Everyone Need to Visit the Trauma Bay?

INTRODUCTION

Critically injured children and teens often present to adult trauma centers or nontrauma facilities prior to transfer to a pediatric trauma center. For pediatric patients wanting transfer to the intensive care unit (ICU), there is little data to guide which can be safely transferred directly to the unit, and which should be evaluated first in the trauma bay.

METHODS

We used our institutional trauma registry to evaluate transferred trauma patients over a three year period. We compared time to imaging, time to operating room, and overall mortality between the group evaluated first in the emergency room and those transferred directly to the ICU.

RESULTS

When adjusted for other variables, there was no increased mortality in those transferred directly to the ICU. While there was a higher nonadjusted mortality in those transferred to the ICU (13% versus 3.7%), these nonsurvivors had a lower GCS (3 versus 13), higher Pediatric Risk of Mortality scores, and a high rate of severe head trauma. There was no significant delay in ordered imaging or procedures.

CONCLUSIONS

In patients, who have been assessed at another institution prior to transfer to the pediatric ICU, transfer directly to the ICU, bypassing the emergency department, does not delay interventions and does not appear to worsen outcomes.

Talk and Die: A Descriptive Analysis of Penetrating Trauma Patients

INTRODUCTION

"Talk and die" traditionally described occult presentations of fatal intracranial injuries, but we broaden its definition to victims of penetrating trauma.

METHODS

We conducted a descriptive analysis of patients with penetrating torso trauma who presented with a Glasgow Coma Scale verbal score ≥3 and died within 48 h of arrival from 2008 to 2018.

RESULTS

Sixty patients were identified. Eighteen (30.0%) required resuscitative thoracotomy with 7 (11.7%) dying in the trauma bay. Fifty-three (86.9%) patients went to the operating room, and 35 (66.0%) required multicavitary exploration. The most common injuries were hollow viscous (58.5%), intra-abdominal vascular (49.0%), liver (28.3%), pulmonary (26.4%), intrathoracic vascular (18.9%), and cardiac (15.75) injuries. Twenty-three (43.4%) patients survived their initial operation, but died in the first 48 h postoperatively.

CONCLUSIONS

Patients who "talk and die" most frequently have intra-abdominal vascular injures and require multicavitary exploration.

The role of prehospital ultrasound in reducing time to definitive care in abdominal trauma patients with moderate to severe liver and spleen injuries

BACKGROUND

The role of prehospital focused assessment sonography for trauma (FAST) is still under debate and no definitive recommendations are available in actual guidelines, moreover, the availability of ultrasound machines in emergency medical services (EMS) is still inhomogeneous. On the other hand, time to definitive care is strictly related to survival in bleeding trauma patients. This study aimed at investigating if a positive prehospital FAST in abdominal trauma patients could have a role in reducing door-to-CT scan or door-to-operating room (OR) time.

METHODS

This retrospective observational study included all the patients affected by an abdominal trauma with an abdominal abbreviated injury score ≥ 2 and a spleen or liver injury admitted to Maggiore Hospital Carlo Alberto Pizzardi, a level 1 trauma centre between 2014 and 2019. Prehospital and emergency department (ED) clinical and laboratory variables were collected, as well as in-hospital times during the diagnostic and therapeutic pathways of these patients.

RESULTS

199 patients were included in the final analysis. Of these, 44 had a prehospital FAST performed and in 27 of them, peritoneal free fluid was detected in the prehospital setting, while 128 out of 199 patients had a positive ED-FAST. Sensitivity was 62.9% (95% CI: 42.4%-80.6%) and specificity 100% (95% CI: 80.5% - 100%). Patients with a positive prehospital FAST reported a significantly lower door-to-CT or door-to-OR median time (46 vs 69 min, p < 0.001). Prehospital hypotension and Glasgow coma scale, first arterial blood lactate, ISS, age, positive prehospital and ED FAST were inserted in a stepwise selection for a multivariable Cox proportional regression hazards model. Only ISS and prehospital FAST resulted significantly associated with a reduction in the door-to-CT scan or door-to-operating theatre time in the multivariable model.

CONCLUSION

Prehospital FAST information of intraperitoneal free fluid could significantly hasten door-to-CT scan or door-to-operating theatre time in abdominal trauma patients if established hospital response protocols are available.

LEVEL OF EVIDENCE

III, (Therapeutic / Care Management).

Choosing wisely: A prospective study of direct to operating room trauma resuscitation including real-time trauma surgeon after-action review

INTRODUCTION

Although several centers have direct to operating room (DOR) resuscitation programs, there are no published prospective studies on optimal patient selection, interventions, outcomes, or real-time surgeon assessments.

METHODS

Direct to operating room cases for 1 year were prospectively enrolled. Demographics, injury types/severity, triage criteria, interventions, and outcomes including Glasgow Outcome Scale score were collected. Detailed time-to-event and sequence data on initial lifesaving interventions (LSIs) or emergent surgeries were analyzed. A structured real-time attending surgeon assessment tool for each case was collected. Direct to operating room activation criteria were grouped into categories: mechanism, physiology, injury pattern, or emergency medical services (EMS) suspicion.

RESULTS

There were 104 DOR cases: male, 84%; penetrating, 80%; and severely injured (Injury Severity Score, >15), 39%. The majority (65%) required at least one LSI (median of 7 minutes from arrival), and 41% underwent immediate emergent surgery (median, 26 minutes). Blunt patients were more severely injured and more likely to undergo LSI (86% vs. 59%) but less likely to require emergent surgery (19% vs. 47%, all p < 0.05). Analysis of DOR criteria categories showed unique patterns in each group for interventions and outcomes, with EMS suspicion associated with the lowest need for DOR. Surgeon assessment tool results found that DOR was indicated in 84% and improved care in 63%, with a small subset identified (9%) where DOR had a negative impact.

CONCLUSION

Direct to operating room resuscitation facilitated timely emergent interventions in penetrating truncal trauma and a select subset of critically ill blunt patients. Unique intervention/outcome profiles were identified by activation criteria groups, with little utility among activations for EMS suspicion. Real-time surgeon assessment tool identified high- and low-yield DOR groups.

LEVEL OF EVIDENCE

Prospective observational study, level III.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Time to surgery: Is it truly crucial in initially stable patients with penetrating injury?

BACKGROUND

Treatment recommendations for patients with penetrating abdominal injury are well established. Trauma victims with clear indications for surgery, should undergo immediate operative intervention without any delay or additional imaging. However, the optimal time for surgery remains unclear. There are some significant advantages in preoperative abdominal CT, including gathering essential information regarding a few difficult to reach anatomical areas, avoiding unnecessary explorations associated with increased morbidity and assessing the existence of extra-abdominal injuries that may have non-expectable impact on initial therapeutic plan. The aim of this study was to determine the impact of "time-to-surgery" on final medical outcomes in patients with penetrating abdominal trauma with normal blood pressure on admission.

METHODS

A retrospective cohort study using the Israeli National Trauma Registry was conducted from 2000- 2018. This study included trauma patients with penetrating injuries and a systolic blood pressure of 90mmHg or above on admission. All patients included in the study were divided into three groups according to the time that lapsed from their admission to surgery: half an hour, an hour, and two hours. We assessed the outcome for each patient, including length of hospital stay, need for intensive care and mortality. Statistical analysis was performed using the Chi-square test, ANOVA test. A p-value of less than 0.05 was considered statistically significant.

RESULTS

The study included 1,136 penetrating trauma patients. Among these, 78.0% (886) had sustained low-energy penetrating injury (SWPI) and 22.0% (250) had sustained high-energy penetrating injury (FAPI). Males accounted for 93.5% (1,062) of the patients. Mean age was 30.4. About 29% (327) of all the patients underwent surgery within 30 minutes from admission, 42% (475) within 30-60 min, and 29% (334) patients were operated within one to two hours. Patients who underwent surgery within 30 minutes, had worse ISS and GCS scores and were, therefore, more likely to have worse clinical outcomes. No other differences in outcomes were found in patients who were operated upon within 2 hours.

CONCLUSIONS

Time to surgery within two hours from admission has no impact on final outcomes in trauma patients with penetrating injury and normal blood pressure on admission.

Predictors for Direct to Operating Room Admission in Severe Trauma

BACKGROUND

Protocols for expediting critical trauma patients directly from the helipad to the operating room tend to vary by center, rely heavily on physician gestalt, and lack supporting evidence. We evaluated a population of severely injured trauma patients with the aim of determining objective factors associated with the need for immediate surgical intervention.

METHODS

All highest-activation trauma patients transported by air ambulance between 1/1/16 and 12/31/17 were enrolled retrospectively. Transfer, pediatric, isolated burn, and isolated head trauma patients were excluded. Patients who underwent emergency general surgery within 30 min of arrival without the aid of cross-sectional imaging were compared to the remainder of the cohort.

RESULTS

Of the 863 patients who were enrolled, 85 (10%) spent less than 30 min in the emergency department (ED) before undergoing an emergency operation. The remaining 778 patients (90%) formed the comparison group. The ED ≤ 30 min group had a higher percentage of penetrating injuries, lower blood pressure, and was more likely to have a positive FAST exam. The "Direct to Operating Room" (DTOR) score is a predictive scoring system devised to identify patients most likely to benefit from bypassing the ED. The odds ratio of emergency operation within 30 min of hospital arrival increased by 2.71 (95% confidence interval 2.23-3.29; P < 0.001) for every 1-point increase in DTOR score.

CONCLUSIONS

Trauma patients with profound hypotension or acidosis and positive FAST were more likely to require surgery within 30 min of hospital presentation. Use of a scoring system may allow early identification of these patients in the prehospital setting by nonphysician providers.

Direct to operating room trauma resuscitation: Optimizing patient selection and time-critical outcomes when minutes count

BACKGROUND

Although several trauma centers have developed direct to operating room (DOR) trauma resuscitation programs, there is little published data on optimal patient selection, practices, and outcomes. We sought to analyze triage criteria and interventions associated with optimal DOR outcomes and resource utilization.

METHODS

Retrospective review of all adult DOR resuscitations for a 6-year period was performed. Triage criteria were analyzed individually and grouped into categories: mechanism, physiology, anatomy/injury, or other. The best univariate and multivariate predictors of requiring lifesaving interventions (LSIs) or emergent surgery (ES) were analyzed. Actual and predicted mortality were compared for all patients and for predefined time-sensitive subgroups.

RESULTS

There were 628 DOR patients (5% of all admissions) identified; the majority were male (79%), penetrating mechanism (70%), severely injured (40% ISS >15), and 17% died. Half of patients required LSI and 23% required ES, with significantly greater need for ES and lower need for LSI after penetrating versus blunt injury (p < 0.01). Although injury mechanism criteria triggered most DOR cases and best predicted need for ES, the physiology and anatomy/injury criteria were associated with greater need for LSI and mortality. Observed mortality was significantly lower than predicted mortality with DOR for several key subgroups. Triage schemes for both ES and LSI could be simplified to four to six independent predictors by regression analysis.

CONCLUSION

The DOR program identified severely injured trauma patients at increased risk for requiring LSI and/or ES. Different triage variable categories drive the need for ES versus LSI and could be simplified or optimized based on local needs or preferences. Direct to operating room was associated with better than expected survival among specific time-sensitive subgroups.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level IV.

The need for a rapid transfer to a hybrid operating theatre: Do we lose benefit with poor efficiency?

PURPOSE

Recent studies on hybrid operating rooms (ORs) have mainly reported their applications in orthopaedic surgery and interventional radiology (IR); there are few studies assessing severely injured patients who underwent IR or surgery in hybrid ORs for haemostasis. Therefore, this study aimed to evaluate our early experience with the use of hybrid OR to control haemorrhage in severe trauma patients.

METHODS

Medical charts of patients who underwent an emergency surgery or IR for haemostasis were analysed retrospectively between January and December 2015.

RESULTS

Of the 95 patients directly transported to the general or hybrid OR, 69 (73%) were transported to the non-hybrid OR and underwent emergency surgeries, whereas 26 (27%) were transported to the hybrid OR and underwent emergency IR or surgery on-site. Patients transported to the hybrid OR had a higher median Injury Severity Score (median: 29, interquartile range[IQR]: 21-36.5 vs median: 21, IQR: 16-27) and lower median initial systolic blood pressure (median: 96, IQR: 82.75-128.75 vs median: 114, IQR: 95-151.5) than those transported to the non-hybrid OR. The median time from the emergency room (ER) arrival to the start of the emergency procedure in the hybrid OR group was similar with that in the non-hybrid OR group (median: 80, IQR: 62.75-91.5 vs median: 75, IQR: 56.5-99). Seven patients underwent IR and surgery concurrently in the hybrid OR because of a haemodynamically unstable pelvic fracture, severe liver injury, and severe brain haemorrhage. The median time from the ER arrival to the start of the haemostatic procedure or operation was 64(43-97) minutes.

CONCLUSIONS

Although the hybrid OR may be used for haemostasis in severely injured patients, the long median time from ER arrival to the start of a haemostatic procedure in hybrid OR indicates the need for a new workflow to reduce this time and to facilitate hybrid OR use.

Life-saving interventions in pediatric trauma: A National Trauma Data Bank experience

BACKGROUND

Emergent procedures are infrequent in pediatric trauma. We sought to determine the frequency and efficacy of life-saving interventions (LSI) performed for pediatric trauma patients within the first hour of care at a trauma center.

METHODS

The National Trauma Data Bank (2010-2014) was queried for patients 19 years or younger who underwent LSIs within 1 hour of arrival to the emergency department. Life-saving interventions included emergency department thoracotomy (EDT) and emergent airway procedures (EAP). Multivariable logistic regression was used to evaluate the influence of patient and hospital characteristics on mortality.

RESULTS

Of 725,284 recorded traumatic encounters, only 1,488 (0.2%) pediatric patients underwent at least one of the defined LSI during the 5-year study period (EDT, 1,323; EAP, 187). Most patients (85.6%) were 15 years or older. Mortality was high but varied by procedure type (EDT, 64.3%; EAP, 28.3%). Mortality for patients younger than 1 year undergoing EDT was 100%, decreasing to 62.6% in patients aged 15 years to 19 years. For EAP, mortality ranged from 66.7% for infants to 27.2% in 15-year-old to 19-year-old patients. Lower Glasgow Coma Scale score, higher Injury Severity Score, presence of shock, and a blunt mechanism of injury were independently associated with mortality in the EDT cohort. On average, trauma centers in this study performed approximately one LSI per year, with only 13.8% of cases occurring at a verified pediatric trauma center.

CONCLUSION

Life-saving interventions in the pediatric trauma population are uncommon and outcomes variable. Novel solutions to keep proficient at such interventions should be sought, especially for younger children. Guidelines to improve identification of appropriate candidates for LSI are critical given their rare occurrence.

LEVEL OF EVIDENCE

Retrospective cohort study, III.

[Reduction of treatment time for children in the trauma room care : Impact of implementation of an interdisciplinary trauma room concept (iTRAPS)]

INTRODUCTION

In addition to infrastructural and conceptual planning, smooth interdisciplinary cooperation is crucial for trauma room care of severely injured children based on time-saving management and a clear set of priorities. The time to computed tomography (CT) is a well-accepted marker for the efficacy of trauma management. Up to now there are no guidelines in the literature for an adapted approach in pediatric trauma room care.

METHODS

A step-by-step algorithm for pediatric trauma room care (Interdisciplinary Trauma Room Algorithm in Pediatric Surgery, iTRAP^S) was developed within the framework of an interdisciplinary team: pediatric surgeons, pediatric anaethesiologists, pediatric intensivists and pediatric radiologists. In two groups of patients from January 2014 to April 2015 (group 1) and from July 2015 to January 2017 (group 2) process quality was monitored by the time required for trauma room treatment until the CT scan was performed and used as a surrogate marker. Inclusion criteria were patients aged 0-16 years, who were evaluated in a level 1 pediatric trauma room with an injury severity score (ISS) ≥8 and the necessity for a CT scan.

RESULTS

Before (group 1) and after (group 2) implementation of iTRAP^S 16 patients were included in each group. There were no significant differences between the age and the ISS in the two groups of patients. The required time for trauma room treatment was significantly reduced from an average of 33.6 min before to 15.2 min after implementation of iTRAP^S (p < 0.01).

DISCUSSION

The required time for the trauma care room treatment could be significantly reduced by more than half after the implementation of iTRAP^S. The reasons were the interdisciplinary organization of the trauma room leadership, reorganization of patient transfer and improved briefing by emergency doctors.

CONCLUSION

Besides a well-organized trauma team, it is essential that the trauma room workflow is adapted to the specific structure of the hospital. Despite the limitations of the study the data demonstrate that the trauma room workflow enables an efficient management. By the interdisciplinary reorganization of the pediatric trauma room treatment with improved structures and standardized processes, patient care was more effective with a significant reduction in the time required for trauma room treatment. The suggested iTRAP^S concept could be used as a framework to establish individualized workflows for pediatric trauma room treatment in other hospitals. This algorithm should be supplemented by standardized operating procedures (SOPs) for the differentiated radiological diagnostic procedures in areas of traumatic brain injury (TBI), thoracic and abdominal trauma in children.