National guideline for the field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2021

Combination of reverse shock index and simplified motor score as a strong discriminator of trauma outcomes

BACKGROUND

The reverse shock index multiplied by simplified motor score (rSI-sMS) is a novel and rapid measure for assessing injury severity in patients with trauma in prehospital settings; however, its discriminant ability requires further validation.

METHODS

A retrospective cohort study was conducted from trauma database of Taipei Tzu Chi Hospital to compare the accuracy of the rSI-sMS with that of the shock index, modified shock index, reverse shock index multiplied by the Glasgow Coma Scale (rSI-GCS), and the reverse shock index multiplied by GCS motor subscale (rSI-GCSM) for discriminating in-hospital mortality, intensive care unit (ICU) admissions, prolonged ICU stays ≥14 days, and prolonged hospital stays ≥30 days in patients with trauma.

RESULTS

A total of 11,760 patients from the trauma database were included. rSI-sMS had significantly better accuracy in discriminating in-hospital mortality, ICU admissions, prolonged ICU stays (≥14 days), and prolonged hospital stays (≥30 days) than the shock index, modified shock index, and rSI-GCSM, whereas its accuracy was similar to that of the rSI-GCS. Furthermore, rSI-sMS had better accuracy for discriminating clinical outcomes in patients with an injury severity score (ISS) ≥16, motor vehicle collisions, falls, no chronic disease, and cardiovascular disease as well as in geriatric and nongeriatric patients. In patients with mixed and isolated brain injuries, rSI-sMS accurately discriminated the four clinical outcomes, similar to rSI-GCS. The optimal cutoff value of rSI-sMS had a discriminant ability of 85.0, 78.6, 75.2, and 81.0% for in-hospital mortality, ICU admissions, ICU stay ≥14 days, and hospital stays of ≥30 days, respectively.

CONCLUSIONS

Compared with the shock index, modified shock index, and rSI-GCSM, rSI-sMS is a more accurate field triage scoring system for discriminating in-hospital mortality, ICU admissions, prolonged ICU stay, and prolonged hospital stays in patients with trauma.

Secondary Undertriage in a Rural Trauma System: A Retrospective Study of Twice-Transferred Patients

INTRODUCTION

Undertriage is a metric of trauma system efficiency. In rural areas, field undertriage is a necessity due to long distances to other trauma centers. We investigated multiple transferred trauma patients from 2017 to 2020 to better understand secondary trauma triaging in a rural trauma system.

METHODS

This was a retrospective cohort study. One hundred trauma patients were transferred multiple times before arrival to our level I trauma center between 2017 and 2020. Data were collected from our institution's trauma registry and medical records. Results were compared to a previous study from 1996 to 1999.

RESULTS

Eighty-seven eligible patients, 70 (80.5%) adults and 17 (19.5%) pediatric patients, were included. In comparison to 1996-1999, fewer trauma patients were twice transferred controlled for total trauma volume (3.0% versus 0.66%, P < 0.05). Patients were older (37.5 versus 47.1 years, P < 0.05) and less likely to be male compared to the original study (78.0 versus 62.1%, P < 0.05). Nearly 90% of adults first presented to state-verified level 4 trauma centers. Of those, 90.3% were transferred to a higher-level facility (Level 1: 14, Level 2: 14, and Level 3: 28).

CONCLUSIONS

Over the past 2 decades, the rate of secondary undertriage as measured by twice transferred trauma patients has declined significantly in our state. Further studies are warranted to understand the impact of multiple transfers on patient outcomes.

Global, regional, and national burdens of traumatic brain injury from 1990 to 2021

Background

Of all the injuries on a global scale, traumatic brain injury (TBI) has the most serious consequences for the individual. Depending on its severity, it can be classified as minor, moderate, or severe, but even minor TBI can sometimes still cause severe functional deficits. This study seeks to assess the latest burden of TBI and analyze their differences in terms of country, age, sex, and cause.

Methods

Based on the Global Burden of Diseases database, the incidence, years lived with disability (YLDs), and causes of total head injuries, minor TBI, and moderate/severe TBI from 1990 to 2021 were analyzed separately by sex, age group, and region.

Results

In 2021, there were 20,837,465 [95% uncertainty interval (UI): 18,128,306-23,839,393] new cases of TBI worldwide, with an age-standardized incidence of 259 cases per 100,000 population (95% UI: 226-296). From 1990 to 2021, there was a decline in global age-standardized incidence (estimated annual percentage change: -0.11, 95% UI: -0.18% to -0.04%). In 2021, countries with higher rates will be mainly in Central and Eastern Europe and the Middle East. In 2021, the global incidence of TBI in all age groups was higher in men than in women. Falls are the leading cause for most age groups in most areas.

Discussion

TBI still accounts for a significant portion of the global injury burden in 2021, but differences do exist between countries. This study introduced the possibility of TBI with different degrees and the trend of injury causes in different age groups and regions from 1990 to 2021, providing a basis for further research on injury causes in different regions and formulating corresponding policies and protection measures in the future.

Prehospital and Emergency Department Vital Sign Abnormalities Among Injured Children

OBJECTIVES

Vital signs are a critical component in the assessment of the injured child. We compared vital sign abnormalities among injured children in the prehospital setting to those in the emergency department (ED) and evaluated the predictive value of each for the presence of major trauma.

METHODS

We performed a multi-agency and multicenter retrospective study of injured children within a county-based emergency medical services (EMS) system between 2010 and 2021, including injured children (<18 years) transported to the hospital. We compared prehospital vital signs for heart rate (HR), respiratory rate (RR), and systolic blood pressure (SBP) in the prehospital and ED setting. Using the Standard Triage Assessment Tool to define major trauma, we constructed multivariable models to evaluate the association of prehospital and ED vital sign abnormalities for major trauma.

RESULTS

We included 21,298 encounters (median age 13 years, IQR 6-16), with major trauma was present in 3,606 (16.9%). In the prehospital setting, abnormal vital signs were reported in 25.7% for HR, 14.6% for RR, and 24.3% for SBP. ED measurements recorded a higher proportion of abnormal HR (28.2%) and RR (21.3%), and slightly lower proportion with abnormal SBP (21.8%). Cohen's Kappa was fair for HR (0.27) and SBP (0.20), but slight for RR (0.09). Prehospital vital signs most strongly associated with major trauma included tachypnea (odds ratio [OR] 2.7, 95% confidence interval (CI 2.4-3.1) and bradypnea (OR 1.7, 95% CI 1.4-1.9). ED vital signs most strongly associated with major trauma included hypotension (OR 2.4, 95% CI 2.1-2.7) and tachypnea (OR 1.8, 95% CI 1.6-2.0). Prehospital and ED vital signs demonstrated similar performance in predicting major trauma (area under the receiver operator characteristic curve (AUROC 0.63); 95% CI 0.61-0.64 for prehospital; 0.63; 95% CI, 0.61-0.64 for ED). When combining prehospital and ED vital signs into a single model, predictive power increased (AUROC 0.66, 95% CI 0.65-0.67).

CONCLUSIONS

We identified poor correlation between prehospital and ED vital signs. In both settings, vital sign abnormalities were associated with major trauma. The combined use of prehospital and ED vital signs improved predictive value for major trauma, suggesting potential for future integration into trauma triage tools.

Age-Related Disparities in the Predictive Performance of the Shock Index for Massive Transfusion in Trauma Patients: A Retrospective Cohort Study

Background: In trauma, the shock index (SI) is commonly used to assess the presence of significant blood loss. Prior studies have shown that the SI has a fair predictive ability for clinical outcomes such as massive transfusion (MT) or mortality in adult trauma patients. We hypothesized that the relatively lower predictive power of the SI in older adult patients compared to that of younger adult patients results in the overall fair predictive ability of the SI for clinical outcomes in adult trauma patients. Methods: This retrospective observational study analyzed adult trauma patients who presented to a single regional trauma center between 2019 and 2023, categorizing them into younger (18-64 years) and older (≥65 years) cohorts. The association between SI and MT was evaluated using simple logistic regression, while the modifying effect of age on this association was evaluated through an interaction model. The predictive performance was compared between the groups using the area under the receiver operating characteristic curve (AUC). Age-stratified AUC trends were visualized using cubic spline analysis. Results: A total of 2404 trauma patients met the inclusion criteria, including 1531 younger adults and 873 older adults. The SI was identified as an independent predictor of MT, with a stronger association in younger adults. The AUC for predicting MT was significantly higher in younger adults compared to older adults (0.801 vs. 0.666; p < 0.001), with optimal SI cut-off values of 1.18 and 0.88, respectively. Age-stratified analysis showed the highest AUC in the 41-50 age group (AUC 0.880; 95% CI, 0.836-0.916) and the lowest in the 71-80 age group (AUC 0.624; 95% CI, 0.573-0.674). Conclusions: The predictive performance of the SI for MT was influenced by age, demonstrating a lower predictive ability in older adult patients compared to younger adults.

Improving paediatric undertriage in a regional trauma network - A registry cohort study

BACKGROUND

Trauma remains a leading cause of death in children worldwide. Management in dedicated paediatric trauma centres is beneficial, making accurate prehospital triage crucial. We assessed undertriage in a regional trauma system after implementing a revised paediatric triage rule.

METHODS

This retrospective, multicentre registry study included all injured children <15 years admitted to hospitals in the Northern French Alps with suspected major trauma and/or an Abbreviated Injury Scale ≥3. Triage performance was assessed before and after implementation of a revised paediatric triage rule. Multivariate logistic regression identified predictors of undertriage defined as a child with major trauma (need for trauma intervention) not directly transported to the paediatric trauma centre.

RESULTS

All 1524 injured children from January 2009 to December 2020 were included. Of these, 725/1524 (47.6%) presented with major trauma; 593/1524 (38.9%) were referred to a non-paediatric trauma centre, and 220/1524 (15%) were considered undertriaged. Over the years, undertriage decreased from 15% to 9%, after the implementation of a revised triage rule. After adjustment, revised paediatric triage rules decreased undertriage, OR = 0.5; 95% CI: 0.3-0.9; P < 0.02. The multivariate regression model identified the following risk factors of undertriage: children >10 years, two-wheel vehicle road traffic accident, girls after a fall, for boys after a winter ski accident, and infants with severe limb and pelvic injuries.

CONCLUSION

The implementation of regional revised triage rule contributed to a reduction in the paediatric undertriage rate to 9%; several clinical factors were associated with undertriage.

Impact of trauma center designation level on survival in trauma during pregnancy: Observational study across US trauma centers

BACKGROUND

Trauma is the leading non obstetric cause of death in pregnant women. Pregnancy above 20 weeks falls under special considerations group in the Center for Disease Control and Prevention (CDC) field triage criteria. Trauma centers' designation level in the United States is based on available resources for care.

AIM

In this study, we examine the association between trauma center designation level and survival of pregnant patients presenting to the Emergency Department (ED) after a traumatic injury.

METHODS

This retrospective observational study included all pregnant women of reproductive age (16 years and above) who experienced any form of trauma and were registered in the National Trauma Data Bank 2020 dataset. Descriptive analysis was carried out. All variables were stratified by the trauma designation levels. Firth logistic regression was conducted to examine the association between trauma designation levels and survival to hospital discharge after controlling for all potential confounding factors.

RESULTS

A total of 1612 patients were included in this study. The average age was 27.2 (±6.9 years). Most patients were taken to level I (58.3 %) and II (33.9 %) centers. Overall survival of patients after pregnancy trauma was 97.2 %. After adjusting for confounders, patients taken to level II and III trauma centers had similar survival to hospital discharge compared with those taken to level I centers [OR = 2.561, 95 % CI: 0.644-10.182 and OR = 4.886, 95 % CI: 0.584-40.862 respectively].

CONCLUSION

In this study, trauma center designation level did not impact survival of pregnant patients sustaining injuries. This provides further evidence that the CDC's field triage guidelines, including their specific considerations for pregnant patients are accurate and that the current practice seems to be effective.

Reverse shock index multiplied by simplified motor score as an indicator of clinical outcomes in patients with abdominal trauma in the emergency department: a retrospective cohort study

BACKGROUND

This study aimed to determine the diagnostic value of the product of the reverse Shock Index (rSI) and the simplified Motor Score (sMS) (rSIsMS) as a predictor of clinical outcomes in patients with abdominal trauma.

METHODS

Patients who presented with abdominal trauma to the emergency department of a tertiary care hospital between 2023 and 2024 were included in the study. Using the patients' data, we calculated the Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Revised Trauma Score (RTS), and Trauma and Injury Severity Score (TRISS). Additionally, the rSIsMS and the product of the rSI and Glasgow Coma Scale (GCS) (rSIG) were calculated.

RESULTS

A total of 270 patients were included in the study. The diagnostic validity of the TRISS, rSIsMS, and rSIG, which had the highest area under the curve (AUC) values for mortality outcomes, was examined; the AUC values were 0.928, 0.908, and 0.886, respectively. The AUC values of the TRISS and rSIsMS concerning intensive care unit (ICU) needs were 0.844 and 0.852, respectively. With regard to surgical intervention needs, the AUC values of the TRISS and rSIsMS were 0.774 and 0.881, respectively. The diagnostic validity of the rSIsMS for surgical intervention needs was significantly higher than that of the TRISS (p<0.001, DeLong test). Concerning massive transfusion protocol (MTP) requirements, the AUC values of the TRISS and rSIsMS were 0.799 and 0.930, respectively. The diagnostic validity of the rSIsMS for MTP requirements was significantly higher than that of the TRISS (p<0.001, DeLong test).

CONCLUSION

The rSIsMS is superior to other trauma scores in predicting MTP and surgical intervention needs in patients with abdominal trauma, and it performs similarly to other trauma scores in predicting mortality and ICU needs. The ease of calculation and its ability to be obtained at the bedside may further enhance the clinical utility of the rSIsMS in the emergency department.

Management of traumatic spinal cord injury in the Nordic countries: a multidisciplinary survey

BACKGROUND

Management of traumatic spinal cord injury is complex and depends on a multidisciplinary approach involving pre-hospital services, spinal surgery, intensive care unit treatment and specialized rehabilitation. International clinical practice guidelines for the handling of these patients offer specific recommendations regarding transportation, radiological investigations, timing of surgery, intensive care management and rehabilitation. We performed a comprehensive multicenter survey to assess the agreement between the Nordic countries on the different aspects of traumatic spinal cord injury management.

METHODS

Sequential, cross-sectional, structured survey comprising the key clinical domains (pre-hospital services, spinal surgery, intensive care management and rehabilitation) in all tertiary spine trauma centers in Sweden, Denmark, Norway, Iceland and Finland. Data are presented descriptively.

RESULTS

A total of 109 respondents from 22 Nordic centers were invited to take the survey, with a response rate of 90% (98/109). Overall, clinical practices were comparable within the domains. Prehospital services had similar practices for airway management, clinical spine clearance and patient transport. Preoperative magnetic resonance imaging was available to 33/35 of the spine surgeons (94%) on a 24/7 basis. This examination was considered mandatory prior to surgery by 66% (23/35) of the surgeons. Surgery was defined as early if performed within 24 h of the injury by all surveyed surgeons. Augmented blood pressure regimens were widely applied in the intensive care units, with mean arterial pressure targets varying between > 80 and > 90 mmHg. Postoperative thromboprophylaxis was administered within 48 h by all centers and rehabilitation policies were similar overall. Notable variations in practice were the occasional steroid administration and the use of lumbar drains in 54% (14/26) of intensive care units.

CONCLUSION

Although there is some variability in the current management of traumatic spinal cord injury in the Nordic countries at the center- and country-level, practices in most key clinical domains are similar and follow established international guidelines.

Recent Advances in Prehospital and In-Hospital Management of Patients with Severe Trauma

Background: Trauma is a major global public health concern. Many countries are working to reduce preventable deaths; however, the mortality rate remains higher than their goal, indicating a need for continuous development in trauma care, including further improvements across the system. This article explores recent developments and updated guidelines for both prehospital emergency care and in-hospital trauma management, emphasizing evidence-based and patient-centered approaches. Current concepts: In the prehospital phase, the primary focus is on early and aggressive hemorrhage control using techniques such as tourniquet application, wound packing, and permissive hypotension as standard practices. Advancements in this field, including intraosseous vascular access and tranexamic acid administration, have improved patient outcomes. The emphasis on structured assessments, particularly "circulation, airway, breathing" (CAB) assessments, underscores the importance of managing life-threatening hemorrhages. During the in-hospital phase, the primary focus is on controlling bleeding. Protocols emphasize the judicious administration of fluids to prevent over-resuscitation and mitigate the risk of exacerbating coagulopathy. Efficient transfusion strategies are implemented to address hypovolemia, while ensuring balanced ratios of blood products. Furthermore, the implementation of advanced interfacility transfer systems and communication tools such as "Situation, Background, Assessment, Recommendation" (SBAR) plays a pivotal role in optimizing patient care and reducing delays in definitive treatment. Discussion and Conclusions: This review highlights the importance of implementing advanced strategies to align with international standards and further decrease the rate of preventable trauma-related deaths. Strengthening education and optimizing resource allocation for both prehospital and hospital-based trauma care are essential steps toward achieving these objectives.

Prehospital Trauma Compendium: Management of Injured Pregnant Patients- A Position Statement and Resource Document of NAEMSP

The assessment and management of critically injured pregnant trauma patients represents a high-risk, low-frequency event. One in every 12 pregnant patients experience physical trauma during their pregnancy, but only 0.1% experience major trauma with an injury severity score (ISS) greater than fifteen. It is crucial that emergency medical services (EMS) clinicians understand the anatomic and pathophysiologic changes that impact morbidity and mortality for pregnant trauma patients so they can effectively provide life-saving interventions and resuscitation for this patient population.

The triage performance of emergency medical dispatch prioritisation compared to prehospital on-scene triage in the Western Cape Province of South Africa

INTRODUCTION

The emergency medical service (EMS) response is dependent on the emergency medical dispatch (EMD) and the operations response team to ensure that the patient receives the required EMS resources and treatment in the appropriate time. EMS resources must be dispatched to calls of appropriate patient acuity. Overtriage and undertriage impact the appropriate response and optimization of EMS resources and, most importantly, patient outcomes. This study examines overtriage and undertriage rates in ambulance dispatch operations in the Western Cape Government (WCG), South Africa.

AIM

Determine undertriage and overtriage rates of EMD priority allocation compared to on-scene ambulance triage.

METHODS

This was a retrospective descriptive study conducted with data received separately for dispatching emergency calls through computer-aided dispatch records and triage information from electronic patient care records. The data were derived from 1st October 2018 to 30th September 2019 and included primary response calls only. Using the South African Triage Scale, overtriage and undertriage of the priority rating of the incident at dispatch were calculated using the Cribari matrix for each incident type.

RESULTS

A total of 242,576 primary emergency responses were analysed. Overall, the overtriage rate was 62.28% (95% CI: 61.94%-62.63%), and the undertriage rate was 15.29% (95% CI: 15.10%-15.47%). The sensitivity was 53.71% (95% CI: 53.29%-54.13%), and the specificity was 74.31% (95% CI: 74.11%-74.51%). The incident types with the highest overtriage rates were obstetric (89%) and gynaecological (86%) complaints and allergic reactions (79%); while the incident types with the highest undertriage rates were respiratory complaints (31%), diabetes (30%), and chest pain (29%).

CONCLUSION

This study revealed substantial overtriage and undertriage across all incident types. The results of this study provide a good reference point for future comparisons of triage rates in the Western Cape. It can be used to inform the development of policies, processes, guidelines, triage and training in dispatching systems, which may contribute to the optimization of prehospital resource management and patient care.

Role of trauma center level in the outcome of severely injured geriatric patients

BACKGROUND

According to the nationally imposed standard of care in the Netherlands, severely injured patients should be brought to a Level-1 trauma center for primary treatment. If not, they are considered to be undertriaged. This study aimed to determine the incidence of undertriage among severely injured geriatric patients and to evaluate the relation between hospital-undertriage and patient outcomes in elderly.

METHODS

This retrospective cohort study used anonymized data from the regional trauma registry of 1,431 patients aged ≥70 years with an Injury Severity Score ≥16 that were admitted to hospitals within the Trauma Region West-Netherlands between 2015 and 2022. Poor patient outcome was defined as in-hospital mortality or as a Glasgow Outcome Scale (GOS) score ≤3 at hospital discharge. The association between hospital level and poor outcomes was analyzed using multivariable logistic regression analysis with adjustment for confounders after multiple imputation of missing values.

RESULTS

Seventeen percent of the severely injured geriatric patients were primarily transported to a Level-2/3 hospital. Female patients, older patients, and patients that had suffered a low-energy fall were most likely to be undertriaged. The adjusted odds ratio's for in-hospital mortality and GOS score ≤3 in Level-1 versus Level-2/3 hospitals were 1.26 (95 % confidence interval, 0.83-1.93; p = 0.28) and 0.81 (95 % confidence interval, 0.57-1.15; p = 0.24), respectively.

CONCLUSION

Undertriaged severely injured geriatric patients did not have a higher risk for poor outcomes. Level-2/3 hospitals seem to present a safe alternative for the treatment of these patients.

Prehospital Reverse Shock Index Times Glasgow Coma Scale as a Predictor for Trauma Intervention in Paediatric Trauma Patients

BACKGROUND

Previous studies have identified the reverse shock index x Glasgow Coma Scale (rSIG) as a tool for predicting the need for trauma intervention in pediatric patients. This study sought to investigate the utility of prehospital rSIG as a triage tool to predict the need for trauma-center level of care in a large pediatric cohort.

METHODS

Data from the American College of Surgeons National Trauma Data Bank (NTDB) (2018-2020) were used. Patients aged 1-18 with valid values for prehospital systolic blood pressure (EMS SBP), prehospital heart rate (EMS HR), and EMS total GCS, were included. Prehospital rSIG was calculated as (EMS SBP/EMS HR) x EMS total GCS. Abnormal values for rSIG were defined as: ≤13.1, ≤16.5, and ≤20.1 for patients aged 1-6, 7-12, and 13-18, respectively. Injury severity was determined by Injury Severity Score (ISS). ISS 1-8 represented minor injury, 9-15 moderate injury, and 16 severe injury. Rates of hemorrhage control surgery, embolization, transfusion at 4 hours, mechanical ventilation, ICU stay 3 days, and mortality was compared between patients with abnormal vs. normal prehospital rSIG.

RESULTS

120,941 patients were included in the analysis; 60269 (49.8 %) had an abnormal prehospital rSIG. Patients with abnormal prehospital rSIG had significantly higher rates of 1 trauma intervention (23.3 % vs 8.3 %, p < 0.0001) and mortality (2.7 % vs 0.1 %, p < 0.0001). When stratified by injury severity, rates of 1 trauma intervention were significantly higher for patients with abnormal prehospital rSIG in minor (2.8 % vs. 1.5 %, p < 0.0001), moderate (18.9 % vs 10.5 %, p < 0.0001), and severe injury (69.8 % vs 43.1 %).

CONCLUSION

Prehospital rSIG appears to be an independent predictor of both trauma intervention and mortality, regardless of injury severity, in the pediatric trauma population. Use of prehospital rSIG may prove useful in triage situations, particularly mass casualty incidents, to determine need for trauma-center care.

ROTEM's utility in guiding resuscitation of traumatic lower extremity fracture patients

INTRODUCTION

Rotational thromboelastometry (ROTEM) is a method for real-time detection of clotting derangements allowing for targeted blood product resuscitation. We sought to determine if coagulopathy profiles differed based on fracture location (comparing pelvic versus tibia and femur fractures), if ROTEM profiles correlated between both total hospital and intensive care unit length of stay (LOS), and if ROTEM profiles correlated with patients undergoing an immediate definitive fixation versus an early damage control approach to care.

MATERIALS AND METHODS

A retrospective cohort study was performed using data from a level 1 trauma registry database. ICD codes were used to isolate operative lower extremity fractures that had a ROTEM on admission. Two cohorts were created: (1) stratification by fracture location including pelvis, femur, and tibia (n = 498) and (2) stratification by fixation method including external fixation versus early definitive fixation (n = 154). The fracture location cohort assessed length of stay parameters while the fixation cohort assessed fixation approaches with ROTEM profiles.

RESULTS

The majority of fracture location patients with ROTEM APTEM and ROTEM EXTEM profiles were physiologically coagulable with all three fracture locations. Most patients with ROTEM INTEM profiles showed hypocoagulable derangements with femur (75.2%), tibia (68.1%), and pelvic fractures (68.8%). Fractures classified as ROTEM APTEM hypocoagulable indicated a longer hospital LOS (r = 0.282) and ICU LOS (r = 0.510). No correlation was found between coagulopathy profiles and fixation approaches.

CONCLUSIONS

ROTEM studies on fracture types showed little consensus on ROTEM profiles correlating to a specific fracture location. ROTEM profiles collected showed limited predictive ability of a patient's hospital and ICU LOS. Early definitive fixation versus external fixation did not correlate between specific ROTEM profiles. Overall, there did not appear to be utility in routine use of ROTEM in fracture patients and this should be limited to those with severe multisystem injuries.

How many minutes matter: Association between time saved with air medical transport and survival in trauma patients

BACKGROUND

Air medical transport (AMT) offers a survival advantage to trauma patients for several reasons, including time-savings over ground transport. Triage guidelines suggest AMT use when there are significant time-savings, but how much time needs to be saved to confer a benefit is unclear. Our objective was to define the time-savings threshold for which AMT has a survival benefit over ground transport.

METHODS

Retrospective cohort of adult trauma patients transported ≤40 miles by ground or air in the Pennsylvania Trauma Outcomes Study 2000 to 2017. Geographic information system network analysis generated the counterfactual transport mode times, and we calculated a time-savings of AMT for each patient. We used restricted cubic splines to allow for non-linear effects of time-saved within multilevel logistic regression to identify a threshold of AMT time-savings associated with survival. Subgroups of patients meeting physiologic or anatomic criteria from the National Field Triage Guidelines (NFTG) and those with a positive Air Medical Prehospital Triage (AMPT) Score were analyzed.

RESULTS

There were 280,271 patients included. The NFTG subgroup had survival advantage starting at 13 minutes of AMT time-saved (adjusted odds ratio, 1.14; 95% confidence interval, 1.01-1.30). The AMPT subgroup had survival advantage starting at 23 minutes with the greatest magnitude of improvement (adjusted odds ratio, 1.22; 95% confidence interval, 1.01-1.48). Among patients that did not meet either NFTG criteria or the AMPT score, no amount of time-saved by AMT was associated with survival (p > 0.05). Sensitivity analysis accounting for injury severity in scene time showed the survival benefit starting at 17 minutes of AMT time-saved for the NFTG subgroup and remained 23 minutes in the AMPT subgroup.

CONCLUSION

Among patients meeting physiologic or anatomic NFTG criteria, a ≥ 13- to 17-minute AMT time-savings threshold was associated with improved survival. There is heterogeneity among this threshold among different patient groups that may be due to other benefits of AMT, such as advanced capabilities. These findings can inform AMT triage guidelines.

LEVEL OF EVIDENCE

Therapeutic; Level IV.

Creation of a novel national dataset through linkage of EMS transport destination and verified ED capability

OBJECTIVES

Emergency department (ED) capabilities, such as trauma center or stroke center designation, are key to understanding the effects of emergency medical services (EMS) transport destination decisions on patient outcomes. In current EMS datasets, ED capabilities are self-reported by the EMS clinician or agency. The reliability and validity of the EMS-reported ED capabilities is unknown. Our objective was to link EMS transport destinations with verified ED capability data to develop a novel national dataset to better understand prehospital routing practices.

METHODS

We linked two cross-sectional databases: the 2021 ESO Data Collaborative and the 2021 National Emergency Department Inventory (NEDI)-USA. The ESO Data Collaborative contains de-identified prehospital patient care records from nearly 2,000 participating EMS agencies across the U.S. The NEDI-USA is a survey of all non-federal, non-specialty U.S. EDs open 24/7/365 (including freestanding EDs), with verified stroke, trauma, and burn capability data. From EMS records, we obtained all unique destinations designated as "hospital" as of 2021. After verifying addresses were NEDI-eligible EDs (i.e., providing emergency services 24/7/365), we performed a 3-step linkage process to NEDI-USA: 1) name/address exact matches; 2) probabilistic matching on name/address based on bigrams, accepting adequate (>85%) match scores after review; and 3) hand-matching using Google Maps. We calculated descriptive statistics to describe the linkage process.

RESULTS

Of the 9,420 unique "hospital" destinations in the EMS dataset, 2,714 (29%) were non-hospital facilities (e.g., nursing home) or were non-NEDI-eligible (e.g., specialty hospital such as a psychiatric facility). We linked 98% (n = 6,605/6,706) of NEDI-eligible EMS hospital transport destinations to EDs in NEDI-USA. Excluding duplicate addresses for a single hospital (e.g., ED address versus main entrance address), the linked addresses represented 3,877 unique EDs in 49 states, which included 68% (n = 3,821/5,580) of the EDs included in the 2021 NEDI-USA database.

CONCLUSIONS

We successfully linked 98% of EMS ED transport destinations to verified ED capability information. This novel linked dataset now includes rich destination capability information associated with each EMS transport that can be leveraged for describing and improving routing practices for specific patient conditions, such as patients with stroke-like symptoms to stroke centers or major traumas to verified trauma centers.

An Activation Failure: Factors Associated With Undertriage of Pediatric Major Trauma Victims

INTRODUCTION

Undertriage of children contributes to poorer clinical outcomes. The objective of this study was to determine factors associated with undertriage of pediatric major trauma victims.

METHODS

We performed a retrospective cross-sectional study of children (aged < 16 ys) using the 2021 American College of Surgeons National Trauma Data Bank. We identified children who met the definition of major trauma defined by the Standard Triage Assessment Tool. We performed multivariable logistic regression to determine factors associated with undertriage, defined as encounters which met criteria, but did not receive highest-level activation.

RESULTS

Of 97,812 included children, 5.3% met major trauma criteria. Undertriage occurred in 34.4% of encounters with major trauma. Factors associated with undertriage included fall and striking mechanisms, missing blood pressure, private vehicle arrival, and incoming interfacility transfers. Hypotension, decreased level of consciousness, prehospital and in-hospital intubation, tachycardia, hypothermia, penetrating mechanism, presentation to a pediatric level 2 or adult level 1 trauma center relative to pediatric level 1 center, and arrival by flight were associated with lower odds of undertriage.

CONCLUSIONS

Many children with major trauma were undertriaged, particularly those presenting with lower-risk histories, such as private vehicle arrivals and fall mechanisms. Future work should seek to develop risk-stratification systems that can better identify children with major trauma, with an emphasis on those with blunt traumatic mechanisms.

Substantial heterogeneity in trauma triage tool characteristic operationalization for identification of major trauma: a hybrid systematic review

PURPOSE

Trauma Triage Tools (TTTs) support pre-hospital staff to identify major trauma patients based on prehospital characteristics and bring them to appropriate trauma centres. However, while triaging trauma has been examined extensively, there appears to be little consensus on how variables within TTTs are applied. We therefore aimed to examine the prehospital characteristics and their operationalization applied in the international literature in TTTs.

METHODS

We applied a hybrid systematic review approach. Searches were conducted in multiple databases. We initially searched for systematic reviews that analyse prehospital characteristics applied in TTTs, then supplemented this with an updated search of original TTT papers from November 2019.

RESULTS

We identified 92 papers which identified 52 adult general population TTTs. Results indicate considerable heterogeneity in prehospital characteristics included in TTTs internationally. There was similarity in the higher-level categories included in the tools: tools often included measurements of a patient's physiological characteristics, injury characteristics, mechanism of injury and any modifiers for high-risk groups. However, the prehospital characteristics that made up those groups, how they were applied and interpreted were found to vary considerably.

CONCLUSION

While there is agreement in the higher-level categories used in TTTs, the thresholds adopted in specific variables vary widely, which may reflect statistical rather than clinical considerations. This may contribute to considerable variation in standards of major trauma triaging internationally. An agreed taxonomy of operationalization of prehospital characteristics used in TTTs is required to prevent sub-optimal clinical decision-making in major trauma triaging.

REGISTRATION

PROSPERO CRD42023393094.

Inter-facility transfers to an urban level 1 trauma center and rates of secondary overtriage

PURPOSE

Many patients originally transported to non-trauma centers (NTC) require transfer to a trauma center (TC) for treatment. The aim was to analyze injury characteristics and outcomes of transfer patients and investigate the secondary overtriage (SOT).

METHODS

Study included 2,056 transfers to an urban level 1 TC between 01/2016 and 06/2020. Analyzed variables included: demographics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), transfer reason and timing, computed tomography (CT) scans, surgery rate, intensive care unit (ICU) admissions, hospital lengths of stay (HLOS), mortality and SOT. SOT was defined as discharge within 48 h without surgery or ICU admission.

RESULTS

Transfers constituted 32.1% of TC admissions. Mean age was 66.7 and 60.7% were geriatric (≥ 65 years). Mean ISS was 11.6 and GCS was 14.3. The average time between NTC and TC admission was 4.2 h. Main reason for transfer was a head injury (57.9%), followed by a spine injury (19.2%). CT scans were repeated at the TC in 76.1% of patients. Surgical interventions were necessary in 18.5% of patients, with lowest rate in head (13.8%) and spine (15.4%) injuries. 45.9% of patients required ICU admissions. Overall mortality was 7.2%. SOT was 30.5%, being the highest in patients with spine (43.0%) and head (29.4%) injuries. Short HLOS affected SOT rates the most.

CONCLUSIONS

Transfers constituted a third of all TC admissions. The main reasons for transfer were head and spine injuries. SOT accounted for one third of transfers and occurred primarily in patients with spine and head injuries.

Medical validity and layperson interpretation of emergency visit recommendations by the GPT model: A cross-sectional study

Aim

In Japan, emergency ambulance dispatches involve minor cases requiring outpatient services, emphasizing the need for improved public guidance regarding emergency care. This study evaluated both the medical plausibility of the GPT model in aiding laypersons to determine the need for emergency medical care and the laypersons' interpretations of its outputs.

Methods

This cross-sectional study was conducted from December 10, 2023, to March 7, 2024. We input clinical scenarios into the GPT model and evaluated the need for emergency visits based on the outputs. A total of 314 scenarios were labeled with red tags (emergency, immediate emergency department [ED] visit) and 152 with green tags (less urgent). Seven medical specialists assessed the outputs' validity, and 157 laypersons interpreted them via a web-based questionnaire.

Results

Experts reported that the GPT model accurately identified important information in 95.9% (301/314) of red-tagged scenarios and recommended immediate ED visits in 96.5% (303/314). However, only 43.0% (135/314) of laypersons interpreted those outputs as indicating urgent hospital visits. The model identified important information in 99.3% (151/152) of green-tagged scenarios and advised against immediate visits in 88.8% (135/152). However, only 32.2% (49/152) of laypersons considered them routine follow-ups.

Conclusions

Expert evaluations revealed that the GPT model could be highly accurate in advising on emergency visits. However, laypersons frequently misinterpreted its recommendations, highlighting a substantial gap in understanding AI-generated medical advice.

Injury severity bias in missing prehospital vital signs: Prevalence and implications for trauma registries

BACKGROUND

Vital signs are important factors in assessing injury severity and guiding trauma resuscitation, especially among severely injured patients. Despite this, physiological data are frequently missing from trauma registries. This study aimed to evaluate the extent of missing prehospital data in a hospital-based trauma registry and to assess the associations between prehospital physiological data completeness and indicators of injury severity.

METHODS

A retrospective review was conducted on all adult trauma patients brought directly to a level 1 trauma center in Toronto, Ontario by paramedics from January 1, 2015, to December 31, 2019. The proportion of missing data was evaluated for each variable and patterns of missingness were assessed. To investigate the associations between prehospital data completeness and injury severity factors, descriptive and unadjusted logistic regression analyses were performed.

RESULTS

A total of 3,528 patients were included. We considered prehospital data missing if any of heart rate, systolic blood pressure, respiratory rate or oxygen saturation were incomplete. Each individual variable was missing from the registry in approximately 20 % of patients, with oxygen saturation missing most frequently (n = 831; 23.6 %). Over 25 % (n = 909) of patients were missing at least one prehospital vital sign, of which 69.1 % (n = 628) were missing all four of these variables. Patients with incomplete data were more severely injured, had higher mortality, and more frequently received lifesaving interventions such as blood transfusion and intubation. Patients were most likely to have missing prehospital physiological data if they died in the trauma bay (unadjusted OR: 9.79; 95 % CI: 6.35-15.10), did not survive to discharge (unadjusted OR: 3.55; 95 % CI: 2.76-4.55), or had a prehospital GCS less than 9 (OR: 3.24; 95 % CI: 2.59-4.06).

CONCLUSION

In this single center trauma registry, key prehospital variables were frequently missing, particularly among more severely injured patients. Patients with missing data had higher mortality, more severe injury characteristics and received more life-saving interventions in the trauma bay, suggesting an injury severity bias in prehospital vital sign missingness. To ensure the validity of research based on trauma registry data, patterns of missingness must be carefully considered to ensure missing data is appropriately addressed.

Identifying opportunities for community EMS fall prevention

BACKGROUND

Falls are a leading cause of morbidity and mortality among older adults in the United States. Current fall prevention interventions rely on provider referral or enrollment during inpatient admissions and require engagement and independence of the patient. Community emergency medical services (CEMS) are a unique opportunity to rapidly identify older adults at risk for falls and provide proactive fall prevention interventions in the home. We describe the demographics and treatment characteristics of the older adult population most likely to benefit from these interventions.

MATERIALS AND METHODS

We linked 2019 Healthcare Cost and Utilization Project Massachusetts State Emergency Department (ED) and State Inpatient Databases with American Hospital Association survey data to query ED encounters and inpatient admissions for adults age ≥55 with ED encounters for fall-related injury between July 1, 2019 and December 31, 2019. Univariable descriptive statistics assessed participant characteristics and bivariable tests of significance compared diagnoses, disposition, and hospital characteristics between older adults with and without an EMS encounter in the six months prior to the presenting fall.

RESULTS

Of 66,027 older adults who presented with a fall to a Massachusetts ED in July-December 2019, 7,942 (11%) had a prior encounter with EMS in the preceding six months, most of which included an injury diagnosis (99%). Compared to older adults without previous EMS encounters, those with previous EMS encounters were more often in poorer health (17% vs. 10% with multiple or complex comorbidities, p < 0.001) and of lower socioeconomic status (12% vs. 8% in lowest neighborhood income quartile, p < 0.001; 10% vs. 6% enrolled in Medicaid, p < 0.001) compared to those without a prior EMS encounter.

CONCLUSIONS

A significant proportion of older adults presenting to the ED with fall related injury have encounters with EMS in the preceding months. These participants are predisposed to poorer health and economic outcomes worsened by their fall and thus demonstrate a population that would benefit from CEMS fall prevention programs.

System-Level Variability in Trauma Center Utilization for Seriously Injured Older Adults

INTRODUCTION

Many seriously injured older adults are not transported to trauma centers (TCs), a phenomenon known as undertriage. System-level factors that contribute to undertriage are poorly understood. One important system-level factor is the regional supply of TCs. We hypothesized that regions with greater supply of TCs would have higher rates of transport to a TC for seriously injured older adults.

METHODS

In this retrospective cross-sectional study using Medicare data from 2014 to 2015, we measured the proportion of seriously injured (injury severity score > 15) older adults (age ≥ 65 y) who were transported to a level I or level II TC within trauma service areas (TSAs), which consist of United States counties aggregated into contiguous geographic regions based on the most frequent hospital destinations for emergency conditions. Patients residing in rural regions were excluded. The primary outcome was transported to a level I or level II TC. The exposure was the supply of TCs within TSAs, grouped into terciles based on the number of TCs per capita. We performed a multivariable hierarchical logistic regression for the odds of TC transport with a random intercept for TSA and fixed effects for TC supply, patient demographics, and injury characteristics.

RESULTS

Our study included 68,128 seriously injured older adults residing in 309 TSAs. The tercile of TSAs with the lowest supply of TCs had 1.13 TCs per 1,000,000 population, and 38.8% of seriously injured older adults were transported to a TC. In contrast, the tercile with the highest supply of TCs had 4.15 TCs per 1,000,000 population, and 68.5% were transported to a TC. On multivariable hierarchical logistic regression, TSAs with the highest supply of TCs had four times higher odds of transport to a TC compared to TSAs with the lowest supply of TCs (odds ratio 4.23; 95% confidence interval: 3.32-5.38; P < 0.001).

CONCLUSIONS

Older adults with serious injuries are more likely to be transported to a TC in TSAs with greater supply of TCs. Ensuring an appropriate supply of TCs within TSA regions may help to reduce rates of undertriage for seriously injured older adults.

Incidence, severity and changes of abnormal vital signs in trauma patients: A national population-based analysis

BACKGROUND

Physiological criteria are used to assess the potential severity of injury in the early phase of a trauma patient's care trajectory. Few studies have described the extent of abnormality in vital signs and different combinations of these at a national level. Aim of the study was to identify physiologic abnormalities in trauma patients and describe different combinations of abnormalities and changes between the pre-hospital and emergency department (ED) settings.

METHOD

Norwegian Trauma Registry (NTR) data between 01.01.15 - 31.12.18, where evaluated on the prevalence and characteristics of abnormal physiologic variables. Primary outcome were rates of hypoventilation (respiratory rate [RR] < 10 breaths per min), hyperventilation (RR > 29 breaths per min), hypotension (systolic blood pressure [SBP] < 90 mmHg), and reduced level of consciousness (Glasgow Coma Scale [GCS] < 13).

RESULTS

A total of 24,482 patients were included. Documented values for RR, SBP and GCS were 77.6%, 78.5% and 81.9% in the pre-hospital phase, and the corresponding percentages in the ED were 95.5%, 99.2% and 98.6%, respectively. In the pre-hospital phase, 3,615 (14.8%) patients had at least one abnormal vital sign, whereas the corresponding numbers in the ED, were 3,616 (14.8%) patients. The most frequent combination was low GCS and hyperventilation. A worsened RTS-score from pre-hospital phase to the ED was observed for RR, SBP and GCS in 3.9%, 1.2% and 1.9% of incidents, respectively. Overall 30-day mortality was 3.1% (n=752). Of these, 60.8% had abnormal vital signs, with decreased GCS as the most prevalent (61.3%).

CONCLUSION

Most trauma patients had normal vital signs. According to the RTS-score, there were few deteriorations in RR, SBP and GCS between pre-hospital phase and the ED. The most frequent abnormality was low GCS, with a higher proportion in those who died within 30 days.

Adherence to national trauma triage criteria in Norway: a cross-sectional study

BACKGROUND

Norwegian hospitals employed individual trauma triage criteria until 2015 when nationwide criteria were implemented. There is a lack of empirical evidence regarding adherence to Norwegian national criteria for activation of the trauma team (NTrC) and the decision-making processes regarding trauma team activation (TTA) within Norwegian trauma hospitals. The objectives of this study were to investigate institutional adherence to the NTrC and to investigate similarities and differences in the decision-making process leading to TTA in Norwegian trauma hospitals.

METHODS

A digital semi-structured questionnaire regarding adherence to criteria, TTA decision-making and criteria documentation was distributed to all Norwegian trauma hospitals (n = 38) in the spring of 2022. Contact details of trauma coordinators and registrars were provided by the Norwegian Trauma Registry secretariat. Follow-up telephone interviews were conducted at the investigator's discretion in cases of non-respondents or need to clarify answers.

RESULTS

Thirty-eight trauma hospitals were invited to answer the survey, where 35 hospitals responded (92%), making 35 the denominator of the results. Thirty-four (97.1%) hospitals stated that they followed NTrC. Thirty-three (94.3%) of the responding hospitals provided documentation of their criteria in use, of which twenty-eight (80%) of responding hospitals adhered to the NTrC. Three (8.6%) hospitals employed a tiered TTA approach with different sized teams. In addition four hospitals (11.4%) used specialized teams to meet the needs of defined patient groups (e.g. geriatric patients, traumatic brain injury). Twenty-one (60%) of the responding hospitals had written guidelines on who could perform TTA and in 18 hospitals (51.4%) TTA could be performed by pre-hospital personnel. Twenty-three (65.7%) of the hospitals documented which criteria that were used for TTA.

CONCLUSION

There is good adherence to the national criteria for activation of the trauma team among Norwegian trauma hospitals after implementation of national guidelines. Individual hospitals argue the use of certain local criteria and trauma team activation decision-making processes to increase their precision in specific patient populations and demographics. Further steps should be done to reduce the variation in TTA decision-making processes among hospitals and improve documentation quality.

Traumatic pediatric cervical spine injury-a proposed clearance algorithm incorporating a 24-h time delay

PURPOSE

Pediatric cervical spine injury (pCSI) is rare. Physiological differences necessitate alternate management from adults. Yet, no standardized pediatric protocols exist. Previous investigations applying adult-validated clinical decision rules (CDRs)-NEXUS Criteria (NX) and Canadian C-spine Rules (CCR)-to children are mixed. We hypothesized a combined NX + CCR approach applied at a delayed 24-h time point would enhance screening efficacy in select patients.

METHODS

We conducted a retrospective review of a prospectively-collected database over 15 months at a pediatric-capable Level-1 trauma center. Age and mechanism determined initial inclusion. NX and CCR criteria were collected and retroactively applied on arrival (T0) and 24 h later (T1). Statistical analyses were performed in SPSS.

RESULTS

A total of 306 patients met inclusion. Current practices compel computed tomography (CT) overuse for craniocervical evaluations: 298 (97.4%) underwent ≥ 1 CT. Of cervical spines imaged (n = 175), 161 (92.0%) underwent CT while 74 (42.3%) underwent magnetic resonance imaging with 14 (18.9%) completed after 72 h. Of collars placed on arrival (n = 181), 136 (75.1%) were cleared before discharge with 86 (63.2%) CTs denoting preferred clearance modality; CT utilization was unchanged when stratified by age < 5 years (p = 0.819). Notably, we found more patients met NX + CCR criteria at T1 versus T0 (p = 0.008) without missed pCSI resulting in imaging overutilization in 15 (8.6%) patients.

CONCLUSION

We showed incorporating a 24-h time delay before a second CDR reapplication may enhance screening efficacy in pCSI. Our new algorithm combines these findings with other literature-based recommendations and may represent a standardizable option for evaluating pCSI in the acute trauma setting.

Characteristics of a revised quick sequential organ failure assessment score (RqSOFA) to predict in-hospital mortality of patients visiting the emergency department via ambulance: an observational cohort study

The National Early Warning Score (NEWS), Quick Sequential Organ Failure Assessment (qSOFA), and modified qSOFA (MqSOFA) are scoring systems that rely on vital signs. However, NEWS is time-consuming, qSOFA has low sensitivity, and MqSOFA includes a difficult calculation. To address these issues, we developed the Revised qSOFA score (RqSOFA) that consists of percutaneous oxygen saturation, oxygen usage, Simple Shock Index, and the parameters of qSOFA. The predictability of RqSOFA was examined for in-hospital mortality among patients who were transported by ambulance. This observational cohort study included all patients transported via ambulance to an Emergency Department between 2019 and 2021. Patients who had prehospital cardiopulmonary arrest, were pregnant, were younger than 15 years old, arrived from another hospital, and had missing data were excluded. The Area Under the Receiver Operating Characteristic curve (AUROC) of RqSOFA, as well as its sensitivity and specificity at the optimal cut-off point, were determined and compared to those of qSOFA, NEWS and MqSOFA. Among 1849 included patients, 53 died in the hospital. The AUROC for RqSOFA was 0.867 and the optimal cut-off point was 2. The sensitivity and specificity were 0.849 and 0.802, respectively. The AUROC of RqSOFA was larger than qSOFA but had no significance with NEWS and MqSOFA. RqSOFA exhibited the same sensitivity and better specificity compared to NEWS. There were no differences in sensitivity and specificity between RqSOFA and MqSOFA. In conclusion, RqSOFA exhibited superior predictability for in-hospital mortality to qSOFA and NEWS, while offering similar predictability to MqSOFA despite relying only on simple measurements.

'Endless variation on a theme': a document analysis of international and UK major trauma triage tools

Introduction

Triage tools are used within trauma networks to identify which injured patients should be bypassed and pre-alerted to major trauma centres. Despite the importance of treating the 'right patient in the right place at the right time', there has been no consensus on triage tool structure or content. This study aimed to identify, collate, review, summarise and recognise patterns across established major trauma triage tools.

Methods

UK and international triage tools used between 2012 and 2021 were identified through literature review and correspondence with trauma networks. A conceptual content analysis was then undertaken using an inductive codebook, comprising concepts of triage tool structure, intended population, inclusion criteria and included variables and thresholds. Thematic analysis was also performed to identify higher-level patterns within the data, with emerging patterns becoming categories for analysis. A narrative synthesis of findings was then undertaken.

Results

In total, 53 major trauma tools were identified, comprising 19 UK tools and 35 published international tools. Most triage tools (n = 42/53, 80%) were developed by expert opinion, were paper based and shared a common structure of multiple domains, with constituent triage predictors assessed in parallel. A minority of tools were statistically derived prediction models, operationalised either as simple scores (n = 10, 19%) or as an electronic application (n = 1, 1%). Overall, 173 distinct triage variables were used, with the median number of constituent triage variables per triage tool being 19 (range 3-31). Four distinct patterns of triage tools were identified during thematic analysis, which differed in terms of format, number of triage variables, thresholds, scope for clinical judgement and relative diagnostic accuracy.

Conclusion

Many diverse major trauma triage tools were identified, with no consensus in format, structure or content. Quantification of constituent variables and identification of distinct categories of triage tools may guide the design of future triage tools.

2024 Systematic Review of Evidence-Based Guidelines for Prehospital Care

OBJECTIVES

Evidence-based guidelines (EBGs) are widely recognized as valuable tools to aggregate and translate scientific knowledge into clinical care. High-quality EBGs can also serve as important components of dissemination and implementation efforts focused on educating emergency medical services (EMS) clinicians about current evidence-based prehospital clinical care practices and operations. We aimed to perform the third biennial systematic review of prehospital EBGs to identify and assess the quality of prehospital EBGs published since 2021.

METHODS

We systematically searched Ovid Medline and EMBASE from January 1, 2021, to June 6, 2023, for publications relevant to prehospital care, based on an organized review of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised using the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Tool.

RESULTS

We identified 33 new guidelines addressing clinical and operational topics of EMS medicine. The most addressed EMS core content areas were time-life critical conditions (n = 17, 51.5%), special clinical considerations (n = 15, 45%), and injury (n = 12, 36%). Seven (21%) guidelines included all elements of the National Academy of Medicine (NAM) criteria for high-quality guidelines, including the full reporting of a systematic review of the evidence. Guideline appraisals by the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool demonstrated modest compliance to reporting recommendations and similar overall quality compared to previously identified guidelines (mean overall domain score 67%, SD 12%), with Domain 5 ("Applicability") scoring the lowest of the six AGREE II domains (mean score of 53%, SD 13%).

CONCLUSIONS

This updated systematic review identified and appraised recent guidelines addressing prehospital care and identifies important targets for education of EMS personnel. Continued opportunities exist for prehospital guideline developers to include comprehensive evidence-based reporting into guideline development to facilitate widespread implementation of high-quality EBGs in EMS systems and incorporate the best available scientific evidence into initial education and continued competency activities.

Prehospital Delta Shock Index Predicts Mortality and Need for Life Saving Interventions in Trauma Patients

OBJECTIVES

The delta shock index (ΔSI), defined as the change in shock index (SI) over time, is associated with hospital morbidity and mortality, but prehospital studies about ΔSI are limited. We investigate the association of prehospital ΔSI with mortality and resource utilization, hypothesizing that increases in SI among field trauma patients are associated with increased mortality and blood product transfusion.

METHODS

We performed a multicenter, retrospective, observational study from the Linking Investigators in Trauma and Emergency Services (LITES) network. We obtained data from January 2017 to June 2021. We fit logistic regression models to evaluate the association between an increase ΔSI > 0.1 and 28-day mortality and blood product transfusion within 4 h of emergency department (ED) arrival. We used negative binomial models to evaluate the association between ΔSI > 0.1 and days in hospital, intensive care unit (ICU), and on ventilator (up to 28 days).

RESULTS

We identified 33,219 prehospital patients. We excluded burn patients and those without documented prehospital or ED heart rate or blood pressure, resulting in 30,511 cases for analysis. In adjusted analysis for the primary outcome of 28-day mortality, patients who had a ΔSI > 0.1 based on initial vital signs were 31% more likely to die (adjusted odds ratio (AOR) of 1.31, 95% CI 1.21-1.41) compared to those patients who had a ΔSI ≤0.1. These patients also spent 16% more days in hospital (adjusted incident rate ratio (AIRR) 1.16, 95% CI 1.14-1.19), 34% more days in ICU (AIRR 1.34, 95% CI 1.28-1.41), and 61% more days on ventilator (ARR 1.61, 95% CI 1.47-1.75). Additionally, patients with a ΔSI > 0.1 had higher odds of receiving blood products (AOR 2.00, 95% CI 1.88-2.12) within 4 h of ED arrival. Models fit excluding hypotensive patients performed similarly.

CONCLUSIONS

An increase of greater than 0.1 in the ΔSI was associated with increased 28-day mortality; increased days in hospital, in ICU, and on ventilator; and increased need for blood product transfusion within 4 h of ED arrival. This association held true for initially normotensive patients. Validation and implementation are needed to incorporate ΔSI into prehospital and ED triage.

CETARS/CAR Practice Guideline on Imaging the Pregnant Trauma Patient

Imaging of pregnant patients who sustained trauma often causes fear and confusion among patients, their families, and health care professionals regarding the potential for detrimental effects from radiation exposure to the fetus. Unnecessary delays or potentially harmful avoidance of the justified imaging studies may result from this understandable anxiety. This guideline was developed by the Canadian Emergency, Trauma and Acute Care Radiology Society (CETARS) and the Canadian Association of Radiologists (CAR) Working Group on Imaging the Pregnant Trauma Patient, informed by a literature review as well as multidisciplinary expert panel opinions and discussions. The working group included academic subspecialty radiologists, a trauma team leader, an emergency physician, and an obstetriciangynaecologist/maternal fetal medicine specialist, who were brought together to provide updated, evidence-based recommendations for the imaging of pregnant trauma patients, including patient safety aspects (eg, radiation and contrast concerns) and counselling, initial imaging in maternal trauma, specific considerations for the use of fluoroscopy, angiography, and magnetic resonance imaging. The guideline strives to achieve clarity and prevent added anxiety in an already stressful situation of injury to a pregnant patient, who should not be imaged differently.

Ready to launch: a cross-sectional study of field trauma triage and air-ambulance policies across Canada

PURPOSE

This study aimed to understand current prehospital trauma air-ambulance policies and triage guidelines across Canada. The research question centered on understanding the guidelines used by provinces and territories and identifying potential regional variations in air-ambulance triage.

METHODS

We conducted a cross-sectional survey from November 2022 to May 2023, involving trauma leaders from Canada's 13 provinces and territories. Participants were identified via the Trauma Association of Canada and professional networks. The survey, developed with expert input and pilot tested for clarity, focused on prehospital trauma-triage guidelines, level of adoption of Center for Disease Control and Prevention (CDC) triage guidelines, and auto-launch air-ambulance policies. Data were collected using an 18-item electronic survey. Potential response bias was considered, and confidentiality was maintained. A cross-sectional qualitative analysis was used to evaluate the guidelines' adoption and variations, with responses compared across regions.

RESULTS

The analysis revealed a nationwide adoption (11 of 11 respondents) of the CDC guidelines, indicating a standardized approach to patient transportation. Notably, many provinces and territories (5 of 11) endorse auto-launch protocols for air ambulances in specific scenarios. These policies offer advantages in geographically vast regions weighed against the cost of over-triage and inefficient resource allocation. Each province and territory tailors its approach based on factors such as geographic areas served, and available resources.

CONCLUSION

This study provides a snapshot of the current state of prehospital trauma-triage guidelines in Canada. With some differences in nomenclature, Canadian provinces and territories widely apply the CDC guidelines to serve their populations. There is some regional variation on how transport is initiated within their borders. The findings underscore the delicate balance required for optimizing air-ambulance policies, considering factors such as timely access, resource allocation, and the local application of guidelines.

Implementation of an Education Module to Improve Emergency Medical Service Provider Accuracy and Confidence in Trauma Triage

INTRODUCTION

Prehospital triage is critical to ensure timely activation of trauma center resources. Undertriage (UT) results in higher morbidity and mortality. To minimize this risk, the American College of Surgeons Committee on Trauma recommends trauma centers aim for a UT rate below 5%. Our center has a 3-tiered triage system aimed at optimizing resource allocation. We hypothesized that a trauma triage criteria educational module (TCEM) would 1) improve emergency medical services (EMSs) provider confidence and accuracy in triage and 2) improve our UT rate.

METHODS

From July to November 2022, the TCEM was presented to 8 local EMS agencies who transport patients to our Level 1 trauma center. Preclass and postclass surveys assessed EMS provider triage confidence using a Likert scale 1-5. Validated trauma scenario questions were used to measure triage accuracy. The UT rate was compared between January-May 2022 (pre-TCEM) to January-May 2023 (post-TCEM) using trauma registry data. Data were analyzed using paired Wilcoxon signed rank and t-tests.

RESULTS

72 prehospital providers participated in TCEM, most were Caucasian (65.3%), non-Hispanic (84.7%), males (77.8%) with emergency medical technician-basic certifications (90.3%). There was a significant increase in triage confidence from pre-TCEM to post-TCEM (2 versus 5; P < 0.001) and accuracy (23.2% versus 88.9%; P < 0.001). Regression analysis did not indicate a significant difference in confidence or accuracy based on years of experience, paid or volunteer provider status, or transport volume per week. The UT rate remained stable after TCEM initiation (2.3% versus 2.0%; P < 0.669).

CONCLUSIONS

This novel community based educational program demonstrated improvements in EMS provider confidence and accuracy regarding prehospital trauma triage. Outreach programs like these are often well received by EMS, and implementation is highly reproducible at other centers.

Burden of Non-Protocolized Patient Transport Outside of Response Area on a Rural Emergency Medical Services System

OBJECTIVES

Transport destination decisions by prehospital personnel depend on a combination of protocols, judgment, patient acuity, and patient preference. Non-protocolized transport outside the service area may result in unnecessary time out of service and inappropriate resource utilization. Scant research exists regarding clinician rationale for destination decisions.

METHODS

We retrospectively reviewed one year of scene transports by a single rural, hospital-based emergency medical services (EMS) system. We collected dispatch, patient demographic, primary impression, and transport data from prehospital records and matched them to emergency department (ED) data. We characterized rationale for transport decisions and compared rates of hospital admission and specialist consultation in the ED as surrogates for decision appropriateness.

RESULTS

We reviewed 2,223 patient transports, 281 of which were transported out of the service area. The most common reasons for out-of-area transport were patient preference NOT related to prior medical care (40%) and clinician judgment (24%). Admit rates were highest for per protocol (85%) and patient preference related to prior medical care (67%) groups and lowest for no explanation (41%) and clinician judgment (47%) groups. Rates of in person specialist consultation in the ED were highest in per protocol (69%) and clinician judgment (47%) groups and lowest in no explanation (23%) and patient preference NOT related to prior medical care (30%) groups. Clinician judgment was less predictive of admission and specialist consultation for non-trauma and pediatric patients than for all patients. Median time out of service was more than twice as long for out-of-area transports (140 min) compared to patients transported to the nearest facility (62 min). For out-of-area transports discharged from the ED without specialty consultation (n = 104), ambulances traveled an additional 52 miles/patient compared to theoretical transport to nearest facility.

CONCLUSIONS

Unit out of service time more than doubled for non-protocolized transports outside of the service area and rationale for destination decisions variably predicted admission and specialist consultation rates. Patient preference NOT related to prior medical care and, in pediatric and non-trauma populations, clinician judgment, were less predictive of admission and specialist consultation. Transport guidelines should balance rationale for transport destination and patient characteristics with resource preservation, especially in low-resource systems.

Effectiveness of a two-tiered trauma team activation system at a level I trauma center

PURPOSE

Many trauma patients who are transported to our level I trauma center have minor injuries that do not require full trauma team activation (FTTA). Thus, we implemented a two-tiered TTA system categorizing patients into red and yellow code alerts, indicating FTTA and Limited TTA (LTTA) requirements, respectively. This study aimed to assess the effectiveness of this triage tool by evaluating its diagnostic parameters (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), undertriage and overtriage) and comparing injury severity between the two groups.

METHODS

A retrospective cohort study of patients admitted to a Level I trauma center. Characteristics compared between the red and yellow code groups included demographics, injury severity, treatments, and hospital length of stay (LOS). Calculating the diagnostic parameters was based on Injury Severity Score (ISS) and the need for life-saving surgery or procedures.

RESULTS

Significant differences in injury severity indicators were observed between the two groups. Patients in the red code group had a higher ISS and New Injury Severity Score (NISS), a lower Glasgow Coma Score (GCS), Revised Trauma Score (RTS), and probability of survival. They had a longer hospital LOS, a higher Intensive Care Unit (ICU) admission rate and required more emergency operations. The Sensitivity of the triage tool was 85.2%, specificity was 55.6%, PPV was 74.2%, NPV was 71.5%, undertriage was 14.7%, and overtriage was 25.7%.

CONCLUSION

The two-tiered TTA system effectively distinguish between patients with major trauma who need FTTA and patients with minor trauma who can be managed by LTTA.

Enhancing Performance of the National Field Triage Guidelines Using Machine Learning: Development of a Prehospital Triage Model to Predict Severe Trauma

BACKGROUND

Prehospital trauma triage is essential to get the right patient to the right hospital. However, the national field triage guidelines proposed by the American College of Surgeons have proven to be relatively insensitive when identifying severe traumas.

OBJECTIVE

This study aimed to build a prehospital triage model to predict severe trauma and enhance the performance of the national field triage guidelines.

METHODS

This was a multisite prediction study, and the data were extracted from the National Trauma Data Bank between 2017 and 2019. All patients with injury, aged 16 years of age or older, and transported by ambulance from the injury scene to any trauma center were potentially eligible. The data were divided into training, internal, and external validation sets of 672,309; 288,134; and 508,703 patients, respectively. As the national field triage guidelines recommended, age, 7 vital signs, and 8 injury patterns at the prehospital stage were included as candidate variables for model development. Outcomes were severe trauma with an Injured Severity Score ≥16 (primary) and critical resource use within 24 hours of emergency department arrival (secondary). The triage model was developed using an extreme gradient boosting model and Shapley additive explanation analysis. The model's accuracy regarding discrimination, calibration, and clinical benefit was assessed.

RESULTS

At a fixed specificity of 0.5, the model showed a sensitivity of 0.799 (95% CI 0.797-0.801), an undertriage rate of 0.080 (95% CI 0.079-0.081), and an overtriage rate of 0.743 (95% CI 0.742-0.743) for predicting severe trauma. The model showed a sensitivity of 0.774 (95% CI 0.772-0.776), an undertriage rate of 0.158 (95% CI 0.157-0.159), and an overtriage rate of 0.609 (95% CI 0.608-0.609) when predicting critical resource use, fixed at 0.5 specificity. The triage model's areas under the curve were 0.755 (95% CI 0.753-0.757) for severe trauma prediction and 0.736 (95% CI 0.734-0.737) for critical resource use prediction. The triage model's performance was better than those of the Glasgow Coma Score, Prehospital Index, revised trauma score, and the 2011 national field triage guidelines RED criteria. The model's performance was consistent in the 2 validation sets.

CONCLUSIONS

The prehospital triage model is promising for predicting severe trauma and achieving an undertriage rate of <10%. Moreover, machine learning enhances the performance of field triage guidelines.

Survival of the fastest? A descriptive analysis of severely injured trauma patients primarily admitted or secondarily transferred to major trauma centers in a Danish inclusive trauma system

BACKGROUND

Trauma systems are crucial for enhancing survival and quality of life for trauma patients. Understanding trauma triage and patient outcomes is essential for optimizing resource allocation and trauma care.

AIMS

The aim was to explore prehospital trauma triage in Region Zealand, Denmark. Specifically, characteristics for patients who were either primarily admitted or secondarily transferred to major trauma centers were described.

METHODS

A retrospective descriptive study of severely injured trauma patients was conducted from January 2017 to December 2021.

RESULTS

The study comprised 744 patients including 55.6% primary and 44.4% secondary patients. Overall, men accounted for 70.2% of patients, and 66.1% were aged 18-65 years. The secondary patients included more women-34.2% versus 26.3% and a higher proportion of Injury Severity Score of ≥ 15-59.6% versus 47.8%, compared to primary patients. 30-day survival was higher for secondary patients-92.7% versus 87%. Medical dispatchers assessed urgency as Emergency level A for 98.1% of primary patients and 86.3% for secondary patients. Physician-staffed prehospital units attended primary patients first more frequently-17.1% versus 3.5%. Response times were similar, but time at scene was longer for primary patients whereas time from injury to arrival at a major trauma center was longer for secondary patients.

CONCLUSIONS

Secondary trauma patients had higher Injury Severity Scores and better survival rates. They were considered less urgent by medical dispatchers and less frequently assessed by physician-staffed units. Prospective quality data are needed for further investigation of optimal triage and continuous quality improvement in trauma care.

Trauma Centre admission criteria for elderly patients

<b>Introduction:</b> Injuries are among the three most common causes of sudden death in Poland, and patients particularly at risk of fatal outcomes of trauma are elderly. Geriatric age is associated with pathological changes that determine a worse response to trauma. In order to improve treatment outcomes of elderly trauma patients, it is essential for them to have access to specialized healthcare units i.e. Trauma Centers (TC). In Poland, admission criteria for TC are determined in the Regulation of the Ministry of Health published in 2010. Those criteria do not include age. According to recent research, such admission criteria lead to undertriage i.e., underestimation of injuries of elderly trauma patients and referred to a healthcare unit of lower reference level.<b>Aim:</b> Analyze the current national admission criteria of elderly trauma patients admitted to TCs.<b>Materials and methods:</b> TC admission criteria were subject to analysis in referral to available scientific publications in the field of medical segregation of elderly trauma patients, available in PubMed, Medline-EBSCO.<b>Results:</b> TC admission criteria in current form are fulfilled only by elderly patients with minimal survival chance. As a result, majority of elderly trauma patients are referred to healthcare units of lower reference level. Those patients are deprived of professional trauma care in TC. Such discrepancies in medical segregation often stem from lack of anatomical changes or shifts in physiological parameters typically observed in trauma patients.<b>Conclusions:</b> It is essential to develop national research to find the optimal system of triage for elderly trauma patient and an adequate tool for appropriate admitted them to TC.

Predicting severe outcomes in pediatric trauma patients: Shock index pediatric age-adjusted vs. age-adjusted tachycardia

INTRODUCTION

When an injured patient arrives in the Emergency Department (ED), timely and appropriate care is crucial. Shock Index Pediatric Age-Adjusted (SIPA) has been shown to accurately identify pediatric patients in need of emergency interventions. However, no study has evaluated SIPA against age-adjusted tachycardia (AT). This study aims to compare SIPA with AT in predicting outcomes such as mortality, severe injury, and the need for emergent intervention in pediatric trauma patients.

MATERIAL AND METHODS

This is a retrospective cross-sectional analysis of patient data abstracted from the Trauma Quality Improvement Program Participant Use Files (TQIP PUFs) for years 2013-2020. Patients aged 4-16 with blunt mechanism of injury and injury severity score (ISS) > 15 were included. 36,517 children met this criteria. Sensitivity, specificity, overtriage, and undertriage rates were calculated to compare the effectiveness of AT and elevated SIPA as predictors of severe injuries and need for emergent intervention. Emergent interventions included craniotomy, endotracheal intubation, thoracotomy, laparotomy, or chest tube placement within 24 h of arrival.

RESULTS

AT classified 59% of patients as "high risk," while elevated SIPA identified 26%. Compared to AT patients, a greater proportion of patients with elevated SIPA required a blood transfusion within 24 h (22% vs. 12%, respectively; p < 0.001). In-hospital mortality was higher for the elevated SIPA group than AT (10% vs. 5%, respectively; p < 0.001) as well as the need for emergent operative interventions (43% vs. 32% respectively; p < 0.001). Grade 3 or higher liver/spleen lacerations requiring blood transfusion were also more common among elevated SIPA patients than AT patients (8% vs. 4%, respectively; p < 0.001). AT demonstrated greater sensitivity but lower specificity compared to SIPA across all outcomes. AT showed improved overtriage and undertriage rates compared to SIPA, but this is attributed to identifying a large proportion of the sample as "high risk."

CONCLUSIONS

AT outperforms SIPA in sensitivity for mortality, injury severity and emergent interventions in pediatric trauma patients while the specificity of SIPA is high across these outcomes.

Limitations of Blood Pressure Measurements in Pediatric Trauma Patients During Field Triage

INTRODUCTION

Recent revisions of national field triage guidelines recommend the addition of age-specific systolic blood pressure (SBP) measurement for identifying the most severely injured children requiring transport to a trauma center. The purpose of this study was to determine the frequency in which blood pressures are documented by Emergency Medical Service (EMS) providers and the role this measurement has had, among other factors, in triage decisions.

METHODS

This is an exploratory descriptive study with a retrospective review from the trauma registry database of all pediatric trauma admissions that arrived by EMS at a level II pediatric trauma center from January 1, 2019 to December 31, 2022.

RESULTS

Two hundred ninety-eight patient records of patients aged 0 to 14 were included. EMS providers documented blood pressure in 70.1% of the total sample. A significant difference in the frequency of this documentation was seen between ages zero to nine and = > 10 years (χ2(1,298) = 28.98 p <0.001). No children ages zero to nine years had SBP of < 70 mmHg + (2x age in years) documented by EMS. There were two children aged = > 10 who had a documented SBP < 90 and 12 children with documented EMS heart rate > SBP.

CONCLUSION

Many children transported by EMS in this hospital's catchment area did have a field blood pressure measurement documented, but the frequency was significantly less in younger-aged children. The blood pressure measurements of children determined to have severe injuries in the sample did not meet the inclusion criteria for high risk of serious injury by the newly established national guidelines. This suggests other prehospital criteria, such as mechanism of injury or visual cues, prompted EMS to transport these pediatric trauma patients to a regional trauma center for specialized care.

Reverse shock index multiplied by the motor component of the Glasgow Coma Scale predicts mortality and need for intervention in pediatric trauma patients

BACKGROUND

Timely identification of high-risk pediatric trauma patients and appropriate resource mobilization may lead to improved outcomes. We hypothesized that reverse shock index times the motor component of the Glasgow Coma Scale (GCS) (rSIM) would perform equivalently to reverse shock index times the total GCS (rSIG) in the prediction of mortality and the need for intervention following pediatric trauma.

METHODS

The 2017-2020 National Trauma Data Bank data sets were used. We included all patients 16 years or younger who had a documented prehospital and trauma bay systolic blood pressure, heart rate, and total GCS. We excluded all patients who arrived at the trauma center without vital signs and interfacility transport patients. Receiver operating characteristic curves were used to model the performance of each metric as a classifier with respect to our primary and secondary outcomes, and the area under the receiver operating characteristic curve (AUROC) was used for comparison. Our primary outcome was mortality before hospital discharge. Secondary outcomes included blood product administration or hemorrhage control intervention (surgery or angiography) <4 hours following hospital arrival and intensive care unit admission.

RESULTS

After application of exclusion criteria, 77,996 patients were included in our analysis. Reverse shock index times GCS-motor and rSIG performed equivalently as predictors of mortality in the 1- to 2- ( p = 0.05) and 3- to 5-year-old categories ( p = 0.28), but rSIM was statistically outperformed by rSIG in the 6- to 12- (AUROC, 0.96 vs. 0.95; p = 0.04) and 13- to 16-year-old age categories (AUROC, 0.96 vs. 0.95; p < 0.01). Reverse shock index times GCS-motor and rSIG also performed similarly with respect to prediction of secondary outcomes.

CONCLUSION

Reverse shock index times GCS-total and rSIM are both outstanding predictors of mortality following pediatric trauma. Statistically significant differences in favor of rSIG were noted in some age groups. Because of the simplicity of calculation, rSIM may be a useful tool for pediatric trauma triage.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level III.

Comparison of adult versus elderly patients with abdominal trauma: A retrospective database analysis

BACKGROUND

The growing geriatric population has specific medical characteristics that should be taken into account especially in trauma setting. There is little evidence on management of abdominal trauma in the elderly and this article compares the management and outcomes of younger and older patients in order to highlight fields of improvement.

METHOD

We conducted a retrospective database analysis from two European university hospitals selecting patients admitted for abdominal injury and extracted the following data: epidemiological data, mechanisms of the trauma, vital signs, blood tests, injuries, applied treatments, trauma scores and outcomes. We compared to different age group (16-64 and 65+ years old) using uni- and multivariable analysis.

RESULTS

1181 patients were included for statistical analysis. The main mechanisms of injury in both group were traffic accidents and in the elderly group, falls were more frequent. Both had similar Abbreviated Injury Score except for the thoracic injuries, which was higher in the elderly group. We reported a death rate of 13% in the elderly group and 7% in the younger group. However, multivariable analysis did not report age as an independent predictor of mortality. The management including surgery, blood transfusion and need for intensive care were similar in both groups.

CONCLUSION

Although elderly patients suffering abdominal trauma have an almost two fold higher mortality, their management is quite similar leading to an important point of improvement in regards to triage and lower threshold for more aggressive management and surveillance. Age itself does not seem to be a reliable predictor of mortality. Introducing a frailty score when taking care of elderly trauma patients could improve the outcomes.

Clinical trauma severity of indoor and outdoor injurious falls requiring emergency medical service response

BACKGROUND

Injurious falls represent a significant public health burden. Research and policies have primarily focused on falls occurring indoors despite evidence that outdoor falls account for 47-58% of all falls requiring some medical attention. This study described the clinical trauma severity of indoor versus outdoor injurious falls requiring Emergency Medical Services (EMS) response.

METHODS

Using the 2019 National Emergency Medical Services Information System (NEMSIS) dataset, we identified the location of patients injured from falls that required EMS response. We classified injury severity using (1) the Revised Trauma Score for Triage (T-RTS): ≤ 11 indicated the need for transport to a Trauma Center; (2) Glasgow Coma Scale (GCS): ≤ 8 and 9-12 indicated severe and moderate neurologic injury; and (3) patient clinical acuity by EMS: Dead, Critical, Emergent, Low.

RESULTS

Of 1,854,909 encounters for patients with injurious falls, the vast majority occurred indoors (n = 1,596,860) compared to outdoors (n = 152,994). For patients who fell indoors vs outdoors on streets or sidewalks, the proportions were comparable for moderate or severe GCS scores (3.0% vs 3.9%), T-RTS scores indicating need for transport to a Trauma Center (5.2% vs 5.9%) and EMS acuity rated as Emergent or Critical (27.7% vs 27.1%). Injurious falls were more severe among male patients compared to females and males injured by falling on streets or sidewalks had higher percentages for moderate or severe GCS scores (5.2% vs 1.9%) and T-RTS scores indicating the need for transport to a Trauma Center (7.3% vs 3.9%) compared to falling indoors. Young and middle-aged patients who fell on streets or sidewalks had higher proportions for a T-RTS score indicating the need for Trauma Center care compared to those in this subgroup who fell indoors. Yet older patients injured by falling indoors were more likely to have a T-RTS score indicating the need for transport to a Trauma Center than older patients who fell on streets or sidewalks.

CONCLUSIONS

There was a similar proportion of patients with severe injurious falls that occurred indoors and outdoors on streets or sidewalks. These findings suggest the need to determine outdoor environmental risks for outdoor falls to support location-specific interventions.

Geriatric trauma triage: optimizing systems for older adults-a publication of the American Association for the Surgery of Trauma Geriatric Trauma Committee

Background

Geriatric trauma patients are an increasing population of the United States (US), sustaining a high incidence of falls, and suffer greater morbidity and mortality to their younger counterparts. Significant variation and challenges exist to optimize outcomes for this cohort, while being mindful of available resources. This manuscript provides concise summary of locoregional and national practices, including relevant updates in the triage of geriatric trauma in an effort to synthesize the results and provide guidance for further investigation.

Methods

We conducted a review of geriatric triage in the United States (US) at multiple stages in the care of the older patient, evaluating existing literature and guidelines. Opportunities for improvement or standardization were identified.

Results

Opportunities for improved geriatric trauma triage exist in the pre-hospital setting, in the trauma bay, and continue after admission. They may include physiologic criteria, biochemical markers, radiologic criteria and even age. Recent Trauma Quality Improvement Program (TQIP) Best Practices Guidelines for Geriatric Trauma Management published in 2024 support these findings.

Conclusion

Trauma systems must adjust to provide optimal care for older adults. Further investigation is required to provide pertinent guidance.

Are geriatric transfer patients with traumatic brain injury at risk for worse outcomes compared to non-geriatric? Propensity-matched study

OBJECTIVE

To compare outcomes between geriatric and non-geriatric patients with traumatic brain injury (TBI) transferred to trauma center and effects of anticoagulants/antiplatelets (AC/AP) and reversal therapy.

METHODS

A retrospective review of 1,118 patients with TBI transferred from acute care facilities to level 1 trauma center compared in groups: geriatric versus non-geriatric, geriatric with AC/AP therapy versus without, and geriatric AC/AP with AC/AP reversal therapy versus without.

RESULTS

Patients with TBI constituted 54.4% of trauma transfers. Mean transfer time was 3.9 h. Propensity matched by Injury Severity Score and Abbreviated Injury Score (AIS) head geriatric compared to non-geriatric patients had more AC/AP use (53.9% vs 8.8%), repeat head computed tomography (93.7% vs 86.1%), intensive care unit (ICU) admissions (57.4% vs 45.7%) and mortality (9.8% vs 3.2%), all p < 0.004. Patients on AC/AP versus without had more ICU admissions (69.1% vs 51.8%, p < 0.001). Patients with AC/AP reversals compared to without reversals had more AIS head 5 (32.0% vs 13.1%), brain surgeries (17.8% vs 3.5%) and ICU admissions (84.8% vs 57.1%), all p < 0.001.

CONCLUSION

TBI constituted half of trauma transfers and 10% required surgery. Based on higher ICU admissions, mortality, and prevalence of AC/AP therapy requiring reversal, geriatric patients with TBI on anticoagulants/antiplatelets should be considered for direct trauma center admission.

Aeromedical Transport for Critically Ill Patients

Aeromedical transport (AMT) is an integral part of healthcare systems worldwide. In this article, the personnel and equipment required, associated safety considerations, and evidence supporting the use of AMT is reviewed, with an emphasis on helicopter emergency medical services (HEMS). Indications for HEMS as guideded by the Air Medical Prehospital Triage Score are presented. Lastly, physiologic considerations, which are important to both AMT crews and receiving clinicians, are reviewed.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.