Effect of under triage on early mortality after major pediatric trauma: a registry-based propensity score matching analysis

Subtotal laparoscopic cholecystectomy versus conversion to open as a bailout procedure: a cohort study

BACKGROUND

The aim of this study is to evaluate morbidity and mortality in patients taken to conversion to open procedure (CO) and subtotal laparoscopic cholecystectomy (SLC) as bailout procedures when performing difficult laparoscopic cholecystectomy.

METHOD

This observational cohort study retrospectively analyzed patients taken to SLC or CO as bailout surgery during difficult laparoscopic cholecystectomy between 2014 and 2022. Univariable and multivariable logistic regression models were used to identify prognostic factors for morbimortality.

RESULTS

A total of 675 patients were included. Of the 675 patients (mean [SD] age 63.85 ± 16.00 years; 390 [57.7%] male) included in the analysis, 452 (67%) underwent CO and 223 (33%) underwent SLC. Overall, neither procedure had an increased risk of major complications (89 [19.69%] vs 35 [15.69%] P.207). However, CO had an increased risk of bile duct injury (18 [3.98] vs 1 [0.44] P.009), bleeding (mean [SD] 165.43 ± 368.57 vs 43.25 ± 123.42 P < .001), intestinal injury (20 [4.42%] vs 0 [0.00] P.001), and wound infection (18 [3.98%] vs 2 [0.89%] P.026), while SLC had a higher risk of bile leak (15 [3.31] vs 16 [7.17] P.024). On the multivariable analysis, Charlson comorbidity index (odds ratio [OR], 1.20; CI95%, 1.01-1.42), use of anticoagulant agents (OR, 2.56; CI95%, 1.21-5.44), classification of severity of cholecystitis grade III (OR, 2.96; CI95%, 1.48-5.94), and emergency admission (OR, 6.07; CI95%, 1.33-27.74) were associated with presenting major complications.

CONCLUSIONS

SLC was less associated with complications; however, there is scant evidence on its long-term outcomes. Further research is needed on SLC to establish if it is the safest in the long-term as a bailout procedure.

Hyperkalaemia in bleeding trauma patients: A potential marker of disease severity - A retrospective cohort study

Background

Hyperkalaemia is a common electrolyte abnormality seen in critically ill patients. In haemorrhagic shock, it may contribute to cardiac arrest and has been identified as a potential marker for tissue hypoxia. However, the significance of its role in haemorrhagic shock and its contribution to mortality remains unclear. This study aimed to examine the potential underlying pathophysiology and evaluate the incidence and characteristics of patients with hyperkalaemia on hospital arrival in bleeding trauma patients before transfusions and its mortality.

Methods

A retrospective cohort study was conducted on adult patients with traumatic bleeding admitted to a European Major Trauma Centre between January 2016 and December 2021. Patients were classified according to their serum potassium levels on arrival, and relevant clinical parameters between non-hyperkalaemic and hyperkalaemic patients were compared.

Results

Among the 83 patients in this study, 8 (9.6 %) presented with hyperkalaemia on arrival. The median shock index showed a higher tendency in the hyperkalaemic group. Hyperkalaemia was found to be more common among younger patients who sustained penetrating trauma. Mortality rates were higher in the hyperkalaemic group, but the difference was not statistically significant.

Conclusion

Our results suggest that hyperkalaemia occurs frequently in bleeding trauma patients on hospital arrival pre-transfusions, indicating a more severe illness. Our findings provide insights into the pathophysiology and characteristics of hyperkalaemia in bleeding trauma patients. Further studies are required to investigate the mechanisms by which hyperkalaemia contributes to mortality in haemorrhagic shock patients.

Defining pediatric trauma center resource utilization: Multidisciplinary consensus-based criteria from the Pediatric Trauma Society

BACKGROUND

Pediatric trauma triage and transfer decisions should incorporate the likelihood that an injured child will require pediatric trauma center (PTC) resources. Resource utilization may be a better basis than mortality risk when evaluating pediatric injury severity. However, there is currently no consensus definition of PTC resource utilization that encompasses the full scope of PTC services.

METHODS

Consensus criteria were developed in collaboration with the Pediatric Trauma Society (PTS) Research Committee using a modified Delphi approach. An expert panel was recruited representing the following pediatric disciplines: prehospital care, emergency medicine, nursing, general surgery, neurosurgery, orthopedics, anesthesia, radiology, critical care, child abuse, and rehabilitation medicine. Resource utilization criteria were drafted from a comprehensive literature review, seeking to complete the following sentence: "Pediatric patients with traumatic injuries have used PTC resources if they..." Criteria were then refined and underwent three rounds of voting to achieve consensus. Consensus was defined as agreement of 75% or more panelists. Between the second and third voting rounds, broad feedback from attendees of the PTS annual meeting was obtained.

RESULTS

The Delphi panel consisted of 18 members from 15 institutions. Twenty initial draft criteria were developed based on literature review. These criteria dealt with airway interventions, vascular access, initial stabilization procedures, fluid resuscitation, blood product transfusion, abdominal trauma/solid organ injury management, intensive care monitoring, anesthesia/sedation, advanced imaging, radiologic interpretation, child abuse evaluation, and rehabilitative services. After refinement and panel voting, 14 criteria achieved the >75% consensus threshold. The final consensus criteria were reviewed and endorsed by the PTS Guidelines Committee.

CONCLUSION

This study defines multidisciplinary consensus-based criteria for PTC resource utilization. These criteria are an important step toward developing a criterion standard, resource-based, pediatric injury severity metric. Such metrics can help optimize system-level pediatric trauma triage based on likelihood of requiring PTC resources.

LEVEL OF EVIDENCE

Diagnostic Test/Criteria; Level II.

Interobserver reliability and diagnostic accuracy of prehospital triage for identifying traumatic brain injury in paediatric patients: a systematic review

PURPOSE

The consistency and accuracy of paediatric TBI triage tools can be affected by different factors, such as patients' characteristics and the level of knowledge and skill of the caregiver. This systematic review included all the available data on the level of agreement between paramedics and ED physicians about the reliability of tools to identify paediatric TBI and the diagnostic accuracy of several such tools in prehospital settings when used by paramedics.

METHODS

MEDLINE (OVID), EMBASE (OVID), Cochrane Library (OVID), and CINAHL Plus (EBSCO) databases were searched from inception to 27 October 2022. Quality, bias, and applicability were assessed using COSMIN for interobserver reliability studies and QUADAS-2 tool for diagnostic accuracy studies. Narrative synthesis was employed because data were unsuitable for meta-analysis.

RESULTS

Initial searches identified 660 papers in total. Five met the inclusion criteria. Two studies showed moderate agreement between paramedics and ED physicians for GCS assessment. The PTS overtriage rate was 10% and the undertriage rate was 62%, while the triage tape had an overtriage rate of 18% and an undertriage rate of 68%. Pre-hospital GCS had 86.67% sensitivity and 71.43% specificity [95% CI]: 0.74-0.96 for neurosurgically significant TBI.

CONCLUSION

Low level of GCS agreement and poor diagnostic accuracy may cause further harm to the patient; thus, further studies are recommended to improve the prehospital management of children with head injuries.

The most critically injured polytrauma patient mortality: should it be a measurement of trauma system performance?

PURPOSE

The risk of death after traumatic injury in developed trauma systems is at an all-time low. Among 'major trauma' patients (injury severity score, ISS > 15), the risk of dying is less than 10%. This group contains critical polytrauma patients (ISS 50-75), with high risks of death. We hypothesized that the reduction in trauma mortality was driven by reduction in moderate injury severity and that death from critical polytrauma remained persistently high.

METHODS

A 20-year retrospective analysis ending December 2021 of a Level-1 trauma center's registry was performed on all trauma patients admitted with ISS > 15. Patients' demographics, injury severity and outcomes were collected. Multivariate logistic regression analysis was performed. Mortality was examined for the entire study group and separately for the subset of critical polytrauma patients (ISS 50-75).

RESULTS

A total of 8462 severely injured (ISS > 15) trauma patients were identified during the 20-year period. Of these 238 (2.8%) were critical polytrauma patients (ISS 50-75). ISS > 15 mortality decreased from 11.3 to 9.4% over the study period (Adjusted OR 0.98, 0.97-0.99). ISS 50-75 mortality did not change significantly (46.2-60.0%), adjusted OR 0.96, 0.92-1.00).

CONCLUSION

The improvement in trauma mortality over the past 20 years has not been experienced equally. The ISS50-75 critical polytrauma mortality is a practical group to capture. It could be a group for deeper study and reporting to drive improvement.

Secondary Undertriage of Pediatric Trauma Patients Across the United States Emergency Departments

INTRODUCTION

The American College of Surgeons has developed evidence-based guidelines to triage the care of severely injured children to Level 1 and 2 trauma centers. Undertriage is the treatment of patients at facilities not equipped to treat the patient's injuries appropriately. We sought to evaluate the association between patient and hospital characteristics and secondary undertriage in children after major trauma.

METHODS

We performed a retrospective cohort study using the 2019 Nationwide Emergency Department Sample. Patients aged less than 18 y were included if they presented to a Level 3 or nontrauma center (NTC) and were diagnosed with a traumatic injury with an injury severity score >15 based on International Classification of Diseases 10 codes. Our primary outcome was secondary undertriage, defined as inpatient admission to a Level 3 or NTC. We developed generalized linear models with inverse-probability survey weighting to determine the association between patient and hospital characteristics and the primary outcome.

RESULTS

Of 6572 weighted patients, 982 (15%) were undertriaged. Undertriage was significantly associated with older age (13 versus 7, P value < 0.001), metropolitan location (86% versus 68%, P < 0.001), and major abdominal injuries (19% versus 11%, P = 0.011). After multivariable adjustment, secondary undertriage was significantly associated with patients aged 6-10 y (adjusted odds ratio [aOR]: 2.47, P = 0.002) compared to patients aged 15-17 y, penetrating injury (aOR: 1.70, P = 0.011), major chest injury (aOR: 2.10, P = 0.014), and presentation at a teaching hospital (aOR: 5.66, P < 0.001).

CONCLUSIONS

After major trauma, a significant proportion of children are secondarily undertriaged at teaching NTCs. Level 1 and 2 trauma centers must partner with lower-level trauma centers to ensure children receive equitable care.

Delays in treatment and disposition attributable to undertriage of pediatric emergency medicine patients

BACKGROUND

Triage, the initial assessment and sorting of patients in the Emergency Department (ED), determines priority of evaluation and treatment. Little is known about the impact of undertriage, the underestimation of disease severity at triage, on clinical care in pediatric ED patients. We evaluate the impact of undertriage on time to disposition and treatment decisions in pediatric ED patients.

METHODS

This was a case control study of ED visits for patients <22 years of age, with an assigned Emergency Severity Index (ESI) score of 4 or 5, and associated hospital admission, nebulized treatment, supplemental oxygen, and/or intravenous (IV) line placement, between January 1, 2018, to June 30, 2022. Controls were sampled from a pool of patient visits with an ESI score of 3, matched by intervention, disposition, and date and hour of arrival. Primary outcome measures were time to order of intervention (nebulized treatment, oxygen administration, or IV placement) and time to disposition decision. A secondary outcome measure was return visits requiring admission or emergency intervention within 14 days of the index visit. Continuous variables (time to orders) were analyzed using Wilcoxon rank sum test and dichotomous outcomes (return visits) were compared using odds ratios with 95% confidence intervals. Analysis was performed with Python v3.10.

RESULTS

The final analysis included 7245 undertriaged patients. Undertriaged patients had longer times to orders for nebulized treatments, (p < 0.001) IV placement, (p < 0.001) and admission (p < 0.001) when compared to controls. There were no significant differences in time to supplemental oxygen delivery and time to discharge compared to controls. Undertriaged patients were more likely to experience a return visit requiring admission or emergency intervention (OR 3.74, 95% CI 3.32,4.22).

CONCLUSIONS

Undertriage in the pediatric ED is associated with delays in care and disposition decisions and increases likelihood of return visits.

The experiences of Red Crescent relief workers during the COVID-19 pandemic in Iran: a qualitative phenomenological study

BACKGROUND

The daily increase of infected individuals and mortalities related to COVID-19 in Iran increased public fear and anxiety and affected the job performance of many health workers, including the Iranian Red Crescent Society, as one of the organizations responding to COVID-19.

METHODS

This study aimed to explore the experiences of Red Crescent rescuers, using a qualitative method with an interpretative phenomenological analysis (IPA), and by conducting semi-structured and in-depth interviews with Red Crescent relief workers from Mashhad in September 2020. Participants were selected by purposive sampling.

RESULTS

Rescuers in the Red Crescent Society, had gained different experiences during the COVID-19 pandemic. The experiences were categorized into four main themes. These main themes were: (1) Psychological disorders, (2) Organizational support (3) Mis-management (both structural and human factors), and (4) Opportunities.

CONCLUSION

The COVID-19 epidemic did create unique opportunities to understand the pitfalls of the Red Crescent aid services. Red Crescent rescue workers suffered from psychological symptoms, and mismanagement was also present. Psychological support and organizational improvements should be implemented.

Antimicrobial Susceptibility of E. coli Isolates from Intra-Abdominal Infections in the Asia-Pacific Region: Trends in Ciprofloxacin, Ceftriaxone, Cefepime, and Piperacillin/Tazobactam Susceptibility

Purpose

To investigate the antibiotic susceptibility of Escherichia coli isolates in patients diagnosed with intra-abdominal infections (IAIs) in the Asia-Pacific region.

Patients and Methods

This study was conducted at 50 medical hospitals across 9 countries/regions as part of the Study for Monitoring Antimicrobial Resistance Trends (SMART) surveillance program from 2014 to 2018. Nonduplicate isolates of aerobic and facultative gram-negative bacilli were collected and processed for further antimicrobial susceptibility testing.

Results

A total of 10,709 isolates were collected, with E. coli (n=4737, 44.2%) being the leading pathogen causing IAIs, followed by Klebsiella pneumoniae (n=2429, 22.7%) and Pseudomonas aeruginosa (n=931, 8.7%). Community-associated (CA) E. coli isolates generally exhibited higher susceptibility rates for most antibiotics than hospital-associated (HA) isolates. In countries/regions other than Hong Kong, South Korea, and Singapore, HA isolates displayed lower susceptibility rates for multiple classes (≥4) of antibiotics. Among the commonly used antibiotics in IAIs, the overall susceptibility rate for ciprofloxacin was low, with an average of 41.3%. Ceftriaxone susceptibility rates in all selected countries were below 80% starting in 2018, ranging from 23.3% to 75.8%. The cefepime susceptibility rates varied across regions, with consistently reduced susceptibility ranging from 45.5% to 57.8% in India, Thailand, and Vietnam. Piperacillin/tazobactam demonstrated effectiveness against E. coli isolates in almost all countries except India, with a downward trend observed in the Philippines and Taiwan. Carbapenems remained effective against more than 90% of E. coli isolates, except in India.

Conclusion

Prudent use of fluoroquinolones and ceftriaxone is advised when treating both CA and HA IAIs in the Asia-Pacific region. The low susceptibility rate of cefepime in India, Thailand, and Vietnam needs careful consideration in its administration. Moreover, the increase in nonsusceptibility to piperacillin/tazobactam in the Philippines and Taiwan poses a potential risk that should be closely monitored.

Pre-hospital and retrieval medicine in Scotland: a retrospective cohort study of the workload and outcomes of the emergency medical retrieval service in the first decade of national coverage

BACKGROUND

The Emergency Medical Retrieval Service (EMRS) has provided national pre-hospital critical care and aeromedical retrieval in Scotland since 2010. This study investigates trends in the service and patients attended over the last decade; and factors associated with clinical deterioration and pre-hospital death.

METHODS

A retrospective cohort study was conducted of all service taskings over ten years (2011-2020 inclusive). The EMRS electronic database provided data on location, sociodemographic factors, diagnoses, physiological measurements, clinical management, and pre-hospital deaths. Binary logistic regression models were used to determine change in physiology in pre-hospital care, and factors associated with pre-hospital death. Geospatial modelling, using road and air travel time models, was used to explore transfer times.

RESULTS

EMRS received 8,069 taskings over the study period, of which 2,748 retrieval and 3,633 pre-hospital critical care missions resulted in patient contact. EMRS was more commonly dispatched to socioeconomically deprived areas for pre-hospital critical care incidents (Spearman's rank correlation, r(8)=-0.75, p = 0.01). In multivariate analysis, systolic blood pressure < 90mmHg, respiratory rate < 6/min or > 30/min, and Glasgow Coma Score ≤ 14 were associated with pre-hospital mortality independent of demographic factors. Geospatial modelling suggested that aeromedical retrieval reduced the mean time to a critical care unit by 1 h 46 min compared with road/ferry transportation.

CONCLUSION

EMRS continues to develop, delivering Pre-Hospital and Retrieval Medicine across Scotland and may have a role in addressing health inequalities, including socioeconomic deprivation and geographic isolation. Age, specific distances from care, and abnormal physiology are associated with death in pre-hospital critical care.

Adherence to the transfer recommendations of the German Trauma Society in severely injured children: a retrospective study from the TraumaRegister DGU

Particularly for pediatric trauma patients, it is of utmost importance that the right patient be treated in the right place at the right time. While unnecessary interhospital transfers must be avoided, the decision against transfer should not lead to higher complication rates in trauma centers without added pediatric qualifications. We therefore identified independent predictive factors for an early transfer of severely injured patients and compared these factors with the current transfer recommendations of the German Trauma Society. Additionally, the quality of the self-assessment based on the mortality of children who were not transferred was evaluated. A national dataset from the TraumaRegister DGU® was used to retrospectively identify factors for an early interhospital transfer (< 48 h) to a superordinate trauma center. Severely injured pediatric patients (age < 16 years) admitted between 2010 and 2019 were included in this analysis. Adjusted odds ratios (OR) with 95% confidence intervals (CI) for early transfer were calculated from a multivariable model. Prognostic factors for hospital mortality in non-transferred patients were also analyzed. In total, 6069 severely injured children were included. Of these, 65.2% were admitted to a Level I trauma center, whereas 27.7% and 7.1% were admitted to Level II and III centers, respectively. After the initial evaluation in the emergency department, 25.5% and 50.1% of children primarily admitted to a Level II or III trauma center, respectively, were transferred early. Statistically significant predictors of an early transfer were: Serious traumatic brain injury (OR 1.76, 95% CI 1.28-2.43), Injury severity score (ISS) ≥ 16 points (ISS 16-24: OR 2.06, 95% CI 1.59-2.66; ISS 25-33: OR 3.0, 95% CI 2.08-4.31; ISS 34-75: OR 5.42, 95% CI 3.0-9.81, reference category: ISS 9-15), age < 10 years (age 0-1: OR 1.91, 95% CI 1.34-2.71; age 2-5: 2.04, 95% CI 1.50-2.78; age 6-9: 1.62, 95% CI 1.23-2.14; reference category: age 10-15). The most important independent factor for mortality in non-transferred patients was age < 10 years (age 0-1: 5.35, 95% CI 3.25-8.81; age 2-5: 2.46, 95% CI 1.50-4.04; age 6-9: OR 1.7, 95% CI 1.05-2.75; reference category: age 10-15). Knowing the independent predictors for an early transfer, such as a young patient's age, a high injury severity, serious traumatic brain injury (TBI), may improve the choice of the appropriate trauma center. This may guide the rapid decision for an early interhospital transfer. There is still a lack of outcome data on children with early interhospital transfers in Germany, who are the most vulnerable group.

Relationships between COVID-19 and disaster risk in Costa Rican municipalities

The COVID-19 pandemic has had far-reaching impacts on every aspect of human life since the first confirmed case in December 2019. Costa Rica reported its first case of COVID-19 in March 2020, coinciding with a notable correlation between the occurrence of disaster events at the municipal scale over the past five decades. In Costa Rica, over 90% of disasters are hydrometeorological in nature, while geological disasters have caused significant economic and human losses throughout the country's history. To analyze the relationship between COVID-19 cases and disaster events in Costa Rica, two Generalized Linear Models (GLMs) were used to statistically evaluate the influence of socio-environmental parameters such as population density, social development index, road density, and non-forested areas. The results showed that population and road density are the most critical factors in explaining the spread of COVID-19, while population density and social development index can provide insights into disaster events at the municipal level in Costa Rica. This study provides valuable information for understanding municipal vulnerability and exposure to disasters in Costa Rica and can serve as a model for other countries to assess disaster risk.

Monitoring speed variation and pedestrian crossing distraction in Enna (Sicily) during different pandemic phases

The growing phenomenon of teleworking and the recent covid-19 pandemic have caused the volumes of pedestrians who routinely cross the city to change since March 2020. This change may have resulted in further damage to the health of pedestrians due to limited activity. Some recent studies point to slight changes in walking speed and stride length compared to changes in the number of steps, these changes were consistently seen during the state of emergency, they showed that people tried to walk faster in their outdoor walking. For the safety of pedestrians, it is necessary to analyse not only the change in speed when crossing but also the potential factors influencing it. These factors include user-related variables (gender, age, weight) and variables related to potential distractors such as smartphone use or walking in groups. The results of measurements made during the pandemic period (4 different phases) in pedestrian traffic in the zebra crossing area are also presented. The research was conducted in a zebra crossing area located in a small town in Sicily (Enna) frequently used by workers, students and elderly people. The results showed that during the first and second pandemic phases (May to October 2021) there were significant changes in the way of moving and the speed of pedestrians at crossings. The same crossings were also examined in the late autumn of 2021 (third and fourth pandemic phases) and the data show further changes in pedestrian behaviour. The data collected can help to improve safety in the area of pedestrian crossings through infrastructural actions or educational programmes and campaigns, especially among vulnerable groups of pedestrians.

Impact of Post-Covid-19 on driver behaviour: A perspective towards pandemic-sustained transportation

Introduction

With the announcement of novel Coronavirus disease 2019 (Covid-19) as a pandemic by World Health Organization (WHO) in March 2020, the whole world went into a lockdown that heavily affected human economic and social life. Since December 2020, with the discovery of effective vaccines, the world is now returning to some normality, particularly for those who are vaccinated. The multimodal transportation has resumed with majority of vaccinated drivers being back on road, driving to their work, and providing transport services. However, there are still several long-term Post-Covid-19 factors, affecting driver health and psychology.

Methods

The study deployed a systematic search strategy and selected 62 research publications after rigorous evaluation of the literature. The review was based on (1) forming the inclusion and exclusion criteria, (2) selecting the appropriate keywords, and (3) searching of relevant publications and assessing the eligible articles.

Results

A broad perspective study is carried out to gauge the impact of Post-Covid-19 scenarios on the driver physical health and mindset in the context of road safety and pandemic-sustained transportation. It was found that the Post-Covid-19 factors such as wearing face-mask during driving, taking oral anti-viral drugs, and fear of contracting disease, significantly impact the driver's performance and situation awareness skills. The analysis suggested that driver's health vitals and psychological driving awareness can be precisely detected through hybrid driver state monitoring methods.

Conclusions

The paper conducts a comprehensive review of the published work and provides unique research opportunities to counteract the challenges involved in precise monitoring of driver behaviour under the effects of different Post-Covid-19 factors. The perspective suggested the possible solutions to live with the pandemic in the context of pandemic-sustained transportation.

A scoping review on acute gastrointestinal surgical complications in immunocompromised pediatric patients

Background

Gastrointestinal complications are becoming increasingly more common and pose a significant risk on the health of children with compromised immunity caused by various etiologies such as chemotherapy and posttransplantation immunosuppression. We aim to review abdominal complications in immunocompromised children and their respective management.

Main body

This is a scoping review of the literature. PubMed, MEDLINE, Google Scholar, and Scopus libraries were searched for relevant articles. Extracted data included the etiologies of immunocompromised immunity, gastrointestinal and abdominal complications in immunocompromised children, diagnosis, and treatment of these pathologies. Examples of gastrointestinal complications in immunocompromised children include, but not limited to, neutropenic enterocolitis, acute appendicitis, bowel perforation, acalculous cholecystitis, and acute pancreatitis. Our literature review showed that bacterial and fungal infections are the major causes of exacerbation and mortality. The main cause of immunosuppression in children with neutropenic enterocolitis and acute pancreatitis is chemotherapy, and management of these pathologies using intravenous fluids, antibiotic therapy, and granulocyte-stimulating factors is the current standard of care. Surgical intervention is uncommon and reserved for complicated cases. That said, in acute appendicitis and bowel perforation, laparoscopy is the mainstay treatment. However, in systemic infections, nonsurgical interventions such as transfusion and bowel rest are the gold standard. As for acalculous cholecystitis, percutaneous cholecystectomy is superior to laparotomy and other surgical interventions.

Conclusion

Timely diagnosis and management of gastrointestinal complications in the immunocompromised children is key in reducing mortality and morbidity. Both surgical and nonsurgical interventions are needed and should be further studied in order to improve outcomes.

Ukraine's Experience with Management of Combat Casualties Using NATO's Four-Tier "Changing as Needed" Healthcare System

INTRODUCTION

The full-scale war with Russia on the territory of Ukraine has revealed several problems related to care of the wounded. In this article, we summarize the mechanisms of injury and injuries sustained for the period February to April 2022, focusing on extremity injuries.

MATERIALS AND METHODS

We compared these to a period of lower-intensity warfare in 2014-2021. In both cases, we report patients treated by the National Military Medical Clinical Center (NMMCC) in Kyiv. We also sought to evaluate the care of the wounded from an organizational viewpoint, taking into account the four-level system of care also used by the North Atlantic Treaty Organization (NATO). Third, we sought to understand lessons learned that could improve the care of the wounded.

CONCLUSION

During the 2022 conflict, the percentage of patients with extremity wounds who had long bone fractures increased and the percentage of people with long bone fractures who had bone defects increased, compared with 2014-2021. This may be due to the higher blast energy from the weapons used in the current conflict. Second, we adapted the four-level NATO system of care. Level 2 (first level hospital) care was provided by civilian hospitals close to the fighting, rather than mobile military hospitals. Level 3 (specialized) and 4 (highly specialized) care were combined into one hospital (NMMCC). This is the first description of flexible use of NATO's four levels. Finally, a major lesson learned was the need to improve use of damage control surgery.

Validation of a five-level triage system in pediatric trauma and the effectiveness of triage nurse modification: A multi-center cohort analysis

INTRODUCTION

Triage is one of the most important tasks for nurses in a modern emergency department (ED) and it plays a critical role in pediatric trauma. An appropriate triage system can improve patient outcomes and decrease resource wasting. However, triage systems for pediatric trauma have not been validated worldwide. To ensure clinical reliability, nurses are allowed to override the acuity level at the end of the routine triage process. This study aimed to validate the Taiwan Triage and Acuity Scale (TTAS) for pediatric trauma and evaluate the effectiveness of triage nurse modification.

METHODS

This was a multicenter retrospective cohort study analyzing triage data of all pediatric trauma patients who visited six EDs across Taiwan from 2015 to 2019. Each patient was triaged by a well-trained nurse and assigned an acuity level. Triage nurses can modify their acuity based on their professional judgment. The primary outcome was the predictive performance of TTAS for pediatric trauma, including hospitalization, ED length of stay, emergency surgery, and costs. The secondary outcome was the accuracy of nurse modification and the contributing factors. Multivariate regression was used for data analysis. The Akaike information criterion and C-statistics were utilized to measure the prediction performance of TTAS.

RESULTS

In total, 45,364 pediatric patients were included in this study. Overall mortality, hospitalization, and emergency surgery rates were 0.17, 5.4, and 0.76%, respectively. In almost all cases (97.48%), the triage nurses agreed upon the original scale. All major outcomes showed a significant positive correlation with the upgrade of acuity levels in TTAS in pediatric trauma patients. After nurse modification, the Akaike information criterion decreased and C-statistics increased, indicating better prediction performance. The factors contributing to this modification were being under 6 years of age, heart rate, respiratory rate, and primary location of injuries.

CONCLUSION

The TTAS is a reliable triage tool for pediatric trauma patients. Modification by well-experienced triage nurses can enhance its prediction performance. Younger age, heart rate, respiratory rate, and primary location of injuries contributed to modifications of the triage nurse. Further external validation is required to determine its role in pediatric trauma worldwide.

Failure to initiate trauma team activation for patients who meet the criteria in a level 1 paediatric trauma centre: which patients are missing out?

BACKGROUND

Trauma team activation (TTA) is paramount in the early hospital management of trauma patients. This study aimed to evaluate factors which contribute to failure to activate the Trauma team for management of paediatric trauma.

METHODS

A retrospective cohort study of Emergency Department (ED) presentations at the paediatric major trauma hospital in Adelaide, South Australia was conducted over a 16-month period. Data from the hospital's trauma registry, individual case files and digital medical records were evaluated to determine factors that were associated with no TTA.

RESULTS

During the study period, 617 trauma patients who met Level 1 or Level 2 TTA criteria attended the trauma centre. For 29 (4.7%) of these patients, there was no TTA. Predictors of no TTA included sustaining abdomen and/or pelvis injuries compared to limb injuries (unadjusted odds ratio [OR] = 10.59, 95% confidence interval [CI] 1.98-56.69, P = 0.006), sustaining non-accidental injury (NAI) versus an injury with vehicle involvement (OR = 30.13, 95% CI 6.43-141.21, P < 0.001), and arriving via emergency medical retrieval service compared to private vehicle (OR = 14.23, 95% CI 3.94-51.36, P < 0.001). No patients transferred directly to Paediatric Intensive Care Unit (PICU), or High Dependency Unit (HDU) received an appropriate TTA.

CONCLUSION

Multiple factors were associated with no TTA in paediatric trauma patients. The results highlight that even in PICU and HDU admissions and transfer patients, vigilant clarification of mechanism of injury and potential for occult injuries should be undertaken to ensure appropriate TTA and improve patient outcome.

Increased unintentional drowning deaths in 2020 by age, race/ethnicity, sex, and location, United States

INTRODUCTION

During the COVID-19 pandemic, one study in Australia showed an increase in drowning deaths in certain settings, while a study in China showed a decrease in drowning deaths. The impact of the COVID-19 pandemic on drowning deaths in the United States is unknown.

OBJECTIVE

To report on unintentional drowning deaths among U.S. persons aged ≤29 years by demographic characteristics and compare 2020 fatal drowning rates with rates from 2010 to 2019.

METHODS

Data from CDC WONDER were analyzed to calculate unintentional drowning death rates among persons aged ≤29 years by age group, sex, race/ethnicity, and location of drowning. These rates were compared to drowning death rates for the previous 10 years (2010-2019).

RESULTS

In 2020, 1.26 per 100,000 persons aged ≤29 years died from unintentional drowning, a 16.79% increase from 2019. Drowning death rates decreased 1.81% per year on average (95% CI: -3.02%, -0.59%) from 2010 to 2019. The largest increases in unintentional drowning deaths from 2019 to 2020 occurred among young adults aged 20 to 24 years (44.12%), Black or African American persons (23.73%), and males (19.55%). The location with the largest increase in drowning was natural water (26.44%).

CONCLUSION

Drowning death rates among persons aged ≤29 years significantly increased from 2019 to 2020. Further research is needed to understand the impacts of the COVID-19 pandemic on drowning and identify how drowning prevention strategies can be adapted and strengthened.

PRACTICAL APPLICATIONS

Drowning remains a leading cause of injury death among persons aged ≤29 years. However, drowning is preventable. Interventions such as learning basic swimming and water safety skills, and consistent use of lifejackets on boats and among weaker swimmers in natural water, have the potential to reduce drowning deaths. Developing strategies that ensure equitable access to these interventions may prevent future drowning.

Epidemiological Characteristics, Antimicrobial Susceptibility Profile, and Surgical Outcome of Complicated Intra-Abdominal Infection at a Tertiary Hospital in Somalia

Background

Intra-abdominal infections (IAIs) are common surgical emergencies and one of the leading causes of non-trauma deaths in hospitals worldwide. Because of limited resources, most patients in low-income countries experience delayed diagnosis and treatment. To the best of our knowledge, this is the first study to evaluate the epidemiological characteristics, antimicrobial susceptibility profile, and outcome of patients with complicated IAI at a tertiary hospital in Somalia.

Methods

This study included all patients with confirmed IAIs who underwent laparotomy or percutaneous drainage, either emergency or elective, and whose cultures showed growth. Sociodemographic and clinical characteristics, culture results, antimicrobial susceptibility profile, and the type of source control were reviewed.

Results

The prevalence of CIAI was 5.3%, 144 (70%) were male, and 61 (30%) were female. The mean age was 38.6±8.5 years. Appendicitis was the most common source of infection, accounting for 32%, followed by bowel perforation in 37 (18%). Out of 15 patients with liver abscesses, ten patients had diabetes (67%). E. coli 82 (40%) was the most common isolated organism, followed by Klebsiella pneumonia (n = 44, 21.5%). The prevalence of extended-spectrum beta-lactamase-producing and multidrug-resistant pathogens was 6.8% and 5.9%, respectively. The pathogens revealed a higher antimicrobial resistance against penicillins in 62%, cephalosporins in 54%, and fluoroquinolones in 44%. E. coli showed 2.5–13% antimicrobial resistance against carbapenems, lower than Klebsiella pneumonia in about 4.5%. Tigecycline, teicoplanin, and linezolid revealed the highest sensitivity against pathogens, about 100%. Source control was achieved by laparotomy in 81%, while the 19% were managed in a percutaneous approach. The mortality rate in our study was 9.3%.

Conclusion

The prevalence of CIAI in our study was 5.3%, with an increasing number of MDR microorganisms isolated from cultures. CIAI and intra-abdominal abscess are significant sources of high morbidity and mortality with sepsis and poor clinical outcome; thus, early detection and intervention are crucial.

Advanced Automatic Crash Notification Algorithm for Children

BACKGROUND

Advanced automatic crash notification (AACN) can improve triage decision-making by using vehicle telemetry to alert first responders of a motor vehicle crash and estimate an occupant's likelihood of injury. The objective was to develop an AACN algorithm to predict the risk that a pediatric occupant is seriously injured and requires treatment at a Level I or II trauma center.

METHODS

Based on 3 injury facets (severity; time sensitivity; predictability), a list of Target Injuries associated with a child's need for Level I/II trauma center treatment was determined. Multivariable logistic regression of motor vehicle crash occupants was performed creating the pediatric-specific AACN algorithm to predict risk of sustaining a Target Injury. Algorithm inputs included: delta-v, rollover quarter-turns, belt status, multiple impacts, airbag deployment, and age. The algorithm was optimized to achieve under-triage ≤5% and over-triage ≤50%. Societal benefits were assessed by comparing correctly triaged motor vehicle crash occupants using the AACN algorithm against real-world decisions.

RESULTS

The pediatric AACN algorithm achieved 25% to 49% over-triage across crash modes, and under-triage rates of 2% for far-side, 3% for frontal and near-side, 8% for rear, and 14% for rollover crashes. Applied to real-world motor vehicle crashes, improvements of 59% in under-triage and 45% in over-triage are estimated: more appropriate triage of 32,320 pediatric occupants annually.

CONCLUSIONS

This AACN algorithm accounts for pediatric developmental stage and will aid emergency personnel in correctly triaging pediatric occupants after a motor vehicle crash. Once incorporated into the trauma triage network, it will increase triage efficiency and improve patient outcomes.

ANN-Based traffic volume prediction models in response to COVID-19 imposed measures

Many countries around the globe have imposed several response measures to suppress the rapid spread of the COVID-19 pandemic since the beginning of 2020. These measures have impacted routine daily activities, along with their impact on economy, education, social and recreational activities, and domestic and international travels. Intuitively, the different imposed policies and measures have indirect impacts on urban traffic mobility. As a result of those imposed measures and policies, urban traffic flows have changed. However, those impacts are neither measured nor quantified. Therefore, estimating the impact of these combined yet different policies and measures on urban traffic flows is a challenging task. This paper demonstrates the development of an artificial neural networks (ANN) model which correlates the impact of the imposed response measure and other factors on urban traffic flows. The results show that the adopted ANN model is capable of mapping the complex relationship between traffic flows and the response measures with a high level of accuracy and good performance. The predicted values are closed to the observed ones. They are clustered around the regression line, with a coefficient of determination ( R 2 ) of 0.9761. Furthermore, the developed model can be generalized to determine the anticipated demand levels resulted from imposing any of the response measures in the post-pandemic era. This model can be used to manage traffic during mega-events. It can be also utilized for disaster or emergency situations, where traffic flow estimates are highly required for operational and planning purposes.

Air Rescue for Pediatric Trauma in a Metropolitan Region of Brazil: Profiles, Outcomes, and Overtriage Rates

Besides ensuring a quick response and transport of trauma victims, helicopter support also involves risks to patients and professionals and has higher operational costs. Studying prehospital triage criteria and their relationship with patient overtriage and outcomes is important, particularly in newly established services and in developing countries with limited health budgets. This could help improve the use of the helicopter rescue and provide better management of the costs and risks related to it. The objective of this study was to determine the epidemiologic and severity profiles of pediatric victims of trauma attended by helicopter in a Brazilian Metropolitan Area to evaluate the outcomes and overtriage rates related to pediatric air rescue in the region. We conducted an observational and retrospective study using 49 hospital and prehospital records from victims of trauma aged <18 years old (yo) assisted by helicopter and then transferred to a tertiary University Hospital. Of the 49 patients, 39 (79.6%) individuals were male, and the mean age was 11.3 yo. Vehicular collisions accounted for 15 (30.6%) of the traumas, and traumatic brain injuries occurred in 28 (57.1%) cases. A total of 29 (59.1%) individuals had severe trauma (Injury Severity Score; ISS >15), and 34 (69.4%) required admission to the intensive care unit. Overtriage varied from 18.4 to 40.8% depending on the criteria used for its definition, being more frequent in individuals aged between 1 and 5 yo. Death occurred in 10 (20.4%) patients. On prehospital evaluation, we classified 29/32 (90.6%) patients with severe trauma according to the Pediatric Trauma Score (PTS ≤8) and 18/25 (72%) according to the Revised Trauma Score (RTS ≤11). Of these, 7/29 (24.1%) and 6/18 (33.3%), respectively, presented ISS <15 at in-hospital evaluation. None of the patients with PTS >8 and 3/7 (42.8%) of those with RTS >11 presented ISS >15. In conclusion, air rescue of pediatric trauma victims was used mainly for critically ill individuals, resulting in rates of overtriage compatible with that found in the literature. PTS showed the lowest rates of overtriage within excellent rates of undertriage.

Development of a concise injury severity prediction model for pediatric patients involved in a motor vehicle collision

OBJECTIVE

Transporting severely injured pediatric patients to a trauma center has been shown to decrease mortality. A decision support tool to assist emergency medical services (EMS) providers with trauma triage would be both as parsimonious as possible and highly accurate. The objective of this study was to determine the minimum set of predictors required to accurately predict severe injury in pediatric patients.

METHODS

Crash data and patient injuries were obtained from the NASS and CISS databases. A baseline multivariable logistic model was developed to predict severe injury in pediatric patients using the following predictors: age, sex, seat row, restraint use, ejection, entrapment, posted speed limit, any airbag deployment, principal direction of force (PDOF), change in velocity (delta-V), single vs. multiple collisions, and non-rollover vs. rollover. The outcomes of interest were injury severity score (ISS) ≥16 and the Target Injury List (TIL). Accuracy was measured by the cross-validation mean of the receiver operator curve (ROC) area under the curve (AUC). We used Bayesian Model Averaging (BMA) based on all subsets regression to determine the importance of each variable separately for each outcome. The AUC of the highest performing model for each number of variables was compared to the baseline model to assess for a statistically significant difference (p < 0.05). A reduced variable set model was derived using this information.

RESULTS

The baseline models performed well (ISS ≥ 16: AUC 0.91 [95% CI: 0.86-0.95], TIL: AUC 0.90 [95% CI: 0.86-0.94]). Using BMA, the rank of the importance of the predictors was identical for both ISS ≥ 16 and TIL. There was no statistically significant decrease in accuracy until the models were reduced to fewer than five and six variables for predicting ISS ≥ 16 and TIL, respectively. A reduced variable set model developed using the top five variables (delta-V, entrapment, ejection, restraint use, and near-side collision) to predict ISS ≥ 16 had an AUC 0.90 [95% CI: 0.84-0.96]. Among the models that did not include delta-V, the highest AUC was 0.82 [95% CI: 0.77-0.87].

CONCLUSIONS

A succinct logistic regression model can accurately predict severely injured pediatric patients, which could be used for prehospital trauma triage. However, there remains a critical need to obtain delta-V in real-time.