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Hartung B, Schäuble A, Peldschus S, Schüssler M, Meyer HL. The Documentation of Injuries Caused by Traffic Accidents. Dtsch Arztebl Int 2024; 121:27-36. [PMID: 38055024 PMCID: PMC10916764 DOI: 10.3238/arztebl.m2023.0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Persons injured in traffic accidents may have injuries of characteristic types that are of significance for the complex reconstruction of the accident and whose medicolegally sound clinical documentation is highly important. This is of particular relevance for the approximately 55 000 persons who are severely injured in traffic accidents in Germany each year. Gaps in documentation are often disadvantageous for the injured persons. METHODS This review is based on pertinent publications retrieved by a selective literature review, with additional consideration of relevant textbooks in traffic medicine and legal medicine, as well as the guidelines of the AWMF (Association of the Scientific Medical Societies in Germany). RESULTS Injuries in traffic accidents typically differ depending on the mode of participation of the injured person in traffic. They must be examined with a view toward the sequence of events of the accident and documented in medicolegally sound fashion. In particular, because of the different mechanical forces involved, it is important to document the seat that the injured person occupied in the automobile, the nature of the collision (pedestrian vs. automobile; bicycle, e-bike, e-scooter, and motorcycle accidents), and the protective devices that were in use. CONCLUSION The precise documentation of injuries and examination findings, with critical consideration of their plausibility in relation to the sequence of events of the accident as far as it is known, is an important duty of the physician. This documentation serves as the basis for further judicial steps leading to compensation when legally appropriate.
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Affiliation(s)
- Benno Hartung
- Institute of Forensic Medicine, Essen University Hospital, Essen, Germany
| | | | - Steffen Peldschus
- Institute of Forensic Medicine, Biomechanics and Accident Analysis, LMU Munich, Munich, Germany
| | - Maximilian Schüssler
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, Essen, Germany
| | - Heinz-Lothar Meyer
- Clinic for Trauma, Hand and Reconstructive Surgery Essen University Hospital, Essen, Germany
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Benson J, Wolfson D, van den Broek-Altenburg E. Tradeoffs in Triage of Motor Vehicle Trauma by Rural 911 Emergency Medical Services Practitioners. Med Decis Making 2023; 43:311-324. [PMID: 36597349 DOI: 10.1177/0272989x221145677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE Identification and triage of severely injured patients to trauma centers is paramount to survival. Many patients are undertriaged in rural areas and do not receive proper care. The decision-making processes involved in triage are not well understood and should be assessed to improve the triage process and outcomes. METHODS Triage decision-making processes were explored through emergency medical services (EMS) practitioner focus groups and a discrete choice experiment (DCE). Attributes of trauma determined from focus groups and the literature included patient demography, injury mechanism, and trauma center distance. DCE data were analyzed using mixed logit models. RESULTS High-risk mechanism, decreased age, multiple comorbidities, and pregnancy were found to increase the preference for triage. Greater trauma center distance was found to decrease preference for triage, but practitioners were willing to trade off up to 2 h of travel time to transport a third-trimester pregnancy and 48 min of travel time to transport a 25-y-old than they would a 50-y-old with the same comorbidities, injuries, and stability. CONCLUSIONS Our findings suggest that current forms of EMS protocols may not be appropriately tailored to support the mechanisms underlying practitioner decision making. Public health professionals and researchers should consider using DCEs to better understand EMS practitioner decision making and identify structures and incentives that may improve patient outcomes and optimally guide appropriate triage decisions. HIGHLIGHTS Discrete choice experiments are an effective method to elicit prehospital practitioners' preferences around transport of the traumatized patient.Practitioner biases observed in EMS transport data are recovered in stated preference models incorporating individual preference heterogeneity.There is a discrepancy between the triage priorities recommended by protocol and those measured from prehospital practitioners' decisions-this may have implications in over- and undertriage rates and prehospital protocol design.
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Affiliation(s)
- Jamie Benson
- Department of Radiology, Larner College of Medicine at the University of Vermont, Burlington, VT, USA.,Department of Surgery, Division of Acute Care Surgery, Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Daniel Wolfson
- Department of Surgery, Division of Emergency Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT, USA.,Vermont Department of Health, Division of Emergency Preparedness, Response & Injury Prevention, Burlington, VT, USA
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Fernandez AR, Bourn SS, Hall GD, Crowe RP, Myers JB. Patient Outcomes Based on the 2011 CDC Guidelines for Field Triage of Injured Patients. J Trauma Nurs 2023; 30:5-13. [PMID: 36633338 DOI: 10.1097/JTN.0000000000000691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients drive the destination decision for millions of emergency medical services (EMS)-transported trauma patients annually, yet limited information exists regarding performance and relationship with patient outcomes as a whole. OBJECTIVE To evaluate the association of positive findings on Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients with hospitalization and mortality. METHODS This retrospective study included all 911 responses from the 2019 ESO Data Collaborative research dataset with complete Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients and linked emergency department dispositions, excluding children and cardiac arrests prior to EMS arrival. Patients were categorized by Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients step(s) met. Outcomes were hospitalization and emergency department or inhospital mortality. RESULTS There were 86,462 records included: n = 65,967 (76.3%) met no criteria, n = 16,443 (19.0%) met one step (n = 1,571 [9.6%] vitals, n = 1,030 [6.3%] anatomy of injury, n = 993 [6.0%] mechanism of injury, and n = 12,849 [78.1%] special considerations), and n = 4,052 (4.7%) met multiple. Compared with meeting no criteria, hospitalization odds increased threefold for vitals (odds ratio [OR]: 3.07, 95% confidence interval [CI]: 2.77-3.40), fourfold for anatomy of injury (OR: 3.94, 95% CI: 3.48-4.46), twofold for mechanism of injury (OR: 2.00, 95% CI: 1.74-2.29), or special considerations (OR: 2.46, 95% CI: 2.36-2.56). Hospitalization odds increased ninefold when positive in multiple steps (OR: 8.97, 95% CI: 8.37-9.62). Overall, n = 84,473 (97.7%) had mortality data available, and n = 886 (1.0%) died. When compared with meeting no criteria, mortality odds increased 10-fold when positive in vitals (OR: 9.58, 95% CI: 7.30-12.56), twofold for anatomy of injury (OR: 2.34, 95% CI: 1.28-4.29), or special considerations (OR: 2.10, 95% CI: 1.71-2.60). There was no difference when only positive for mechanism of injury (OR: 0.22, 95% CI: 0.03-1.54). Mortality odds increased 23-fold when positive in multiple steps (OR: 22.7, 95% CI: 19.7-26.8). CONCLUSIONS Patients meeting multiple Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients steps were at greater risk of hospitalization and death. When meeting only one step, anatomy of injury was associated with greater risk of hospitalization; vital sign criteria were associated with greater risk of mortality.
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Lupton JR, Davis‐O'Reilly C, Jungbauer RM, Newgard CD, Fallat ME, Brown JB, Mann NC, Jurkovich GJ, Bulger E, Gestring ML, Lerner EB, Chou R, Totten AM. Mechanism of injury and special considerations as predictive of serious injury: A systematic review. Acad Emerg Med 2022; 29:1106-1117. [PMID: 35319149 PMCID: PMC9545392 DOI: 10.1111/acem.14489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/17/2022] [Accepted: 03/19/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The Centers for Disease Control and Prevention's field triage guidelines (FTG) are routinely used by emergency medical services personnel for triaging injured patients. The most recent (2011) FTG contains physiologic, anatomic, mechanism, and special consideration steps. Our objective was to systematically review the criteria in the mechanism and special consideration steps that might be predictive of serious injury or need for a trauma center. METHODS We conducted a systematic review of the predictive utility of mechanism and special consideration criteria for predicting serious injury. A research librarian searched in Ovid Medline, EMBASE, and the Cochrane databases for studies published between January 2011 and February 2021. Eligible studies were identified using a priori inclusion and exclusion criteria. Studies were excluded if they lacked an outcome for serious injury, such as measures of resource use, injury severity scores, mortality, or composite measures using a combination of outcomes. Given the heterogeneity in populations, measures, and outcomes, results were synthesized qualitatively focusing on positive likelihood ratios (LR+) whenever these could be calculated from presented data or adjusted odds ratios (aOR). RESULTS We reviewed 2418 abstracts and 315 full-text publications and identified 42 relevant studies. The factors most predictive of serious injury across multiple studies were death in the same vehicle (LR+ 2.2-7.4), ejection (aOR 3.2-266.2), extrication (LR+ 1.1-6.6), lack of seat belt use (aOR 4.4-11.3), high speeds (aOR 2.0-2.9), concerning crash variables identified by vehicle telemetry systems (LR+ 4.7-22.2), falls from height (LR+ 2.4-5.9), and axial load or diving (aOR 2.5-17.6). Minor or inconsistent predictors of serious injury were vehicle intrusion (LR+ 0.8-7.2), cardiopulmonary or neurologic comorbidities (LR+ 0.8-3.1), older age (LR+ 0.6-6.8), or anticoagulant use (LR+ 1.1-1.8). CONCLUSIONS Select mechanism and special consideration criteria contribute positively to appropriate field triage of potentially injured patients.
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Affiliation(s)
- Joshua R. Lupton
- Department of Emergency MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Cynthia Davis‐O'Reilly
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Rebecca M. Jungbauer
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Craig D. Newgard
- Department of Emergency MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Mary E. Fallat
- Department of SurgeryUniversity of Louisville School of MedicineLouisvilleKentuckyUSA
| | - Joshua B. Brown
- Department of SurgeryUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - N. Clay Mann
- Department of PediatricsUniversity of UtahSalt Lake CityUtahUSA
| | | | - Eileen Bulger
- Department of SurgeryUniversity of WashingtonSeattleWashingtonUSA
| | - Mark L. Gestring
- Department of SurgeryUniversity of RochesterRochesterNew YorkUSA
| | - E. Brooke Lerner
- Department of Emergency MedicineUniversity at BuffaloBuffaloNew YorkUSA
| | - Roger Chou
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Annette M. Totten
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
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Newgard CD, Fischer PE, Gestring M, Michaels HN, Jurkovich GJ, Lerner EB, Fallat ME, Delbridge TR, Brown JB, Bulger EM. National guideline for the field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2021. J Trauma Acute Care Surg 2022; 93:e49-e60. [PMID: 35475939 PMCID: PMC9323557 DOI: 10.1097/ta.0000000000003627] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/09/2022] [Accepted: 03/15/2022] [Indexed: 11/26/2022]
Abstract
This work details the process of developing the updated field triage guideline, the supporting evidence, and the final version of the 2021 National Guideline for the Field Triage of Injured Patients.
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Affiliation(s)
- Craig D. Newgard
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Peter E. Fischer
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Mark Gestring
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Holly N. Michaels
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Gregory J. Jurkovich
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - E. Brooke Lerner
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Mary E. Fallat
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Theodore R. Delbridge
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Joshua B. Brown
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Eileen M. Bulger
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - the Writing Group for the 2021 National Expert Panel on Field Triage
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
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Hartka T, Glass G, Chernyavskiy P. Evaluation of mechanism of injury criteria for field triage of occupants involved in motor vehicle collisions. Traffic Inj Prev 2022; 23:S143-S148. [PMID: 35877985 PMCID: PMC9839571 DOI: 10.1080/15389588.2022.2092101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/03/2022] [Accepted: 06/16/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The mechanism of injury (MOI) criteria assist in determining which patients are at high risk of severe injury and would benefit from direct transport to a trauma center. The goal of this study was to determine whether the prognostic performance of the Centers for Disease Control's (CDC) MOI criteria for motor vehicle collisions (MVCs) has changed during the decade since the guidelines were approved. Secondary objectives were to evaluate the performance of these criteria for different age groups and evaluate potential criteria that are not currently in the guidelines. METHODS Data were obtained from NASS and Crash Investigation Sampling System (CISS) for 2000-2009 and 2010-2019. Cases missing injury severity were excluded, and all other missing data were imputed. The outcome of interest was Injury Severity Score (ISS) ≥16. The area under the receiver operator characteristic (AUROC) and 95% confidence intervals (CIs) were obtained from 1,000 bootstrapped samples using national case weights. The AUROC for the existing CDC MOI criteria were compared between the 2 decades. The performance of the criteria was also assessed for different age groups based on accuracy, sensitivity, and specificity. Potential new criteria were then evaluated when added to the current CDC MOI criteria. RESULTS There were 150,683 (weighted 73,423,189) cases identified for analysis. There was a small but statistically significant improvement in the AUROC of the MOI criteria in the later decade (2010-2019; AUROC = 0.77, 95% CI [0.76-0.78]) compared to the earlier decade (2000-2009; AUROC = 0.75, 95% CI [0.74-0.76]). The accuracy and specificity did not vary with age, but the sensitivity dropped significantly for older adults (0-18 years: 0.62, 19-54 years: 0.59, ≥55 years: 0.37, and ≥65 years: 0.36). The addition of entrapment improved the sensitivity of the existing criteria and was the only potential new criterion to maintain a sensitivity above 0.95. CONCLUSIONS The MOI criteria for MVCs in the current CDC guidelines still perform well even as vehicle design has changed. However, the sensitivity of these criteria for older adults is much lower than for younger occupants. The addition of entrapment improved sensitivity while maintaining high specificity and could be considered as a potential modification to current MOI criteria.
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Affiliation(s)
- Thomas Hartka
- Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia
| | - George Glass
- Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia
| | - Pavel Chernyavskiy
- Department of Public Health, University of Virginia, Charlottesville, Virginia
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7
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Nutbeam T, Fenwick R, Smith JE, Dayson M, Carlin B, Wilson M, Wallis L, Stassen W. A Delphi study of rescue and clinical subject matter experts on the extrication of patients following a motor vehicle collision. Scand J Trauma Resusc Emerg Med 2022; 30:41. [PMID: 35725580 PMCID: PMC9208189 DOI: 10.1186/s13049-022-01029-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 06/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Approximately 1.3 million people die each year globally as a direct result of motor vehicle collisions (MVCs). Following an MVC some patients will remain trapped in their vehicle; these patients have worse outcomes and may require extrication. Following new evidence, updated multidisciplinary guidance for extrication is needed. METHODS This Delphi study has been developed, conducted and reported to CREDES standards. A literature review identified areas of expertise and appropriate individuals were recruited to a Steering Group. The Steering Group formulated initial statements for consideration. Stakeholder organisations were invited to identify subject matter experts (SMEs) from a rescue and clinical background (total 60). SMEs participated over three rounds via an online platform. Consensus for agreement / disagreement was set at 70%. At each stage SMEs could offer feedback on, or modification to the statements considered which was reviewed and incorporated into new statements or new supporting information for the following rounds. Stakeholders agreed a set of principles based on the consensus statements on which future guidance should be based. RESULTS Sixty SMEs completed Round 1, 53 Round 2 (88%) and 49 Round 3 (82%). Consensus was reached on 91 statements (89 agree, 2 disagree) covering a broad range of domains related to: extrication terminology, extrication goals and approach, self-extrication, disentanglement, clinical care, immobilisation, patient-focused extrication, emergency services call and triage, and audit and research standards. Thirty-three statements did not reach consensus. CONCLUSION This study has demonstrated consensus across a large panel of multidisciplinary SMEs on many key areas of extrication and related practice that will provide a key foundation in the development of evidence-based guidance for this subject area.
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Affiliation(s)
- Tim Nutbeam
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK. .,Devon Air Ambulance Trust, Exeter, UK. .,Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.
| | - Rob Fenwick
- Emergency Department, Wrexham Maelor Hospital, Wrexham, UK
| | - Jason E Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Mike Dayson
- Former Fire Officer (Research), National Fire Chiefs Council, Birmingham, UK
| | - Brian Carlin
- Association for Spinal Injury Research, Rehabilitation and Reintegration, Department of Orthopaedics & Musculoskeletal Science, University College London, London, UK
| | - Mark Wilson
- Imperial Neurotrauma Centre, Imperial College, London, UK.,Kent, Surrey and Sussex Air Ambulance, Rochester, UK
| | - Lee Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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8
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Choi YU, Jang SW, Kim SH, Ko JW, Kim MJ, Shim H, Han JH, Lim JH, Kim K, Cirocchi R. Correlation between the Injury Site and Trauma Mechanism in Severely Injured Patients with Blunt Trauma. Emerg Med Int 2022; 2022:1-6. [PMID: 37020739 PMCID: PMC10070019 DOI: 10.1155/2022/8372012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background. In patients with severe injury, predicting the injury site without using advanced diagnostic modalities can help formulate a diagnosis and treatment plan based on the suspected injury site. Objectives. This study aimed to determine the correlation between the injury site and trauma mechanism in severely injured patients with blunt trauma. Methods. We retrospectively analyzed the clinical characteristics—including age, sex, date of emergency room (ER) visit, time of injury, trauma mechanism (car accident, motorcycle accident, bicycle accident, pedestrian accident, fall, slipping and rolling down, crush injury, assault, and others), final diagnosis, injury severity score, abbreviated injury scale (AIS) score, and injury site—of 1,245 patients in a tertiary trauma center. Results. There was a strong correlation between certain injury sites and specific trauma mechanisms. In particular, most trauma mechanisms were associated with injury to the head and neck, as well as the chest, with a combined frequency of >40.0%. Moreover, when using one-way analysis of variance and Bonferroni’s post hoc tests, there were significant differences in AIS scores 1, 3, 4, and 5 for each trauma mechanism. Conclusion. Generally, when patients with severe injury present to the ER, the injury site can be predicted upon initial assessment based on the trauma mechanism. Based on our study, the injury site predicted by a specific mechanism should be checked repeatedly and additionally through physical examination and imaging tools. This can reduce misdiagnosis and help with accurate diagnosis and treatment.
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Nutbeam T, Fenwick R, May B, Stassen W, Smith JE, Bowdler J, Wallis L, Shippen J. Assessing spinal movement during four extrication methods: a biomechanical study using healthy volunteers. Scand J Trauma Resusc Emerg Med 2022; 30:7. [PMID: 35033160 PMCID: PMC8760816 DOI: 10.1186/s13049-022-00996-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/07/2022] [Indexed: 11/23/2022] Open
Abstract
Background Motor vehicle collisions are a common cause of death and serious injury. Many casualties will remain in their vehicle following a collision. Trapped patients have more injuries and are more likely to die than their untrapped counterparts. Current extrication methods are time consuming and have a focus on movement minimisation and mitigation. The optimal extrication strategy and the effect this extrication method has on spinal movement is unknown. The aim of this study was to evaluate the movement at the cervical and lumbar spine for four commonly utilised extrication techniques. Methods Biomechanical data was collected using inertial Measurement Units on 6 healthy volunteers. The extrication types examined were: roof removal, b-post rip, rapid removal and self-extrication. Measurements were recorded at the cervical and lumbar spine, and in the anteroposterior (AP) and lateral (LAT) planes. Total movement (travel), maximal movement, mean, standard deviation and confidence intervals are reported for each extrication type. Results Data from a total of 230 extrications were collected for analysis. The smallest maximal and total movement (travel) were seen when the volunteer self-extricated (AP max = 2.6 mm, travel 4.9 mm). The largest maximal movement and travel were seen in rapid extrication extricated (AP max = 6.21 mm, travel 20.51 mm). The differences between self-extrication and all other methods were significant (p < 0.001), small non-significant differences existed between roof removal, b-post rip and rapid removal. Self-extrication was significantly quicker than the other extrication methods (mean 6.4 s). Conclusions In healthy volunteers, self-extrication is associated with the smallest spinal movement and the fastest time to complete extrication. Rapid, B-post rip and roof off extrication types are all associated with similar movements and time to extrication in prepared vehicles.
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Affiliation(s)
- Tim Nutbeam
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK. .,Devon Air Ambulance Trust, Exeter, UK. .,Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.
| | - Rob Fenwick
- University Hospitals Birmingham, Birmingham, UK
| | - Barbara May
- Institute for Future Transport and Cities, University of Coventry, Coventry, UK
| | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Jason E Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Jono Bowdler
- Fire and Rescue Service Trainer, Severn Park Fire and Rescue Centre, Bristol, UK
| | - Lee Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - James Shippen
- Institute for Future Transport and Cities, University of Coventry, Coventry, UK
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10
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Moriarty S, Brown N, Waller M, Chu K. Isolated vehicle rollover is not an independent predictor of trauma injury severity. J Am Coll Emerg Physicians Open 2021; 2:e12470. [PMID: 34278376 PMCID: PMC8275821 DOI: 10.1002/emp2.12470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/12/2021] [Accepted: 05/12/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES The objective of this study was to determine if vehicle rollover in a motor vehicle crash is an independent predictor of major injury. METHODS A retrospective cohort study of all patients injured in motor vehicle crashes presenting to a major trauma center between July 2012 and June 2016 was conducted. Crashes were classified into groups: non-rollover, isolated rollover (without other mechanisms of injury), or mixed-mechanism rollover (with other mechanisms of injury). Associations between rollover group, other covariates (entrapment, encapsulation, ejection, death on scene, high speed, seat belt usage, airbag deployment, trauma team activation), and major injury (injury severity score >15, major surgery, intensive care unit admission, or in-hospital death) were tested using binary logistic regression models. Vehicle rollover was categorized either as "present" or "absent" on 1 model or as either "none," "isolated," or "mixed mechanism" in the other. RESULTS In 2446 motor vehicle crashes, there were 423 rollovers (196 isolated, 227 mixed mechanisms). Compared with crashes without rollovers, the prevalence of patients with major injury was lower in crashes with isolated rollovers and higher in crashes with mixed-mechanism rollovers (13.8% vs 9.5% vs 27.5%, respectively; P < 0.001). Rollover (present vs absent) was not an independent predictor of major injury (odds ratio [OR], 1.10; 95% confidence interval [CI], 0.78-1.53). Patients in crashes with mixed-mechanism but not isolated rollovers had increased odds (OR, 2.04; 95% CI, 1.41-2.96) of major injury compared with patients from crashes without rollovers. CONCLUSIONS Patients from crashes with isolated vehicle rollovers may not need to be transported to a trauma center as they carry a lower risk of injury.
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Affiliation(s)
- Sunayana Moriarty
- Department of Emergency Medicine The Prince Charles Hospital Brisbane Australia
| | - Nathan Brown
- Emergency and Trauma Centre Royal Brisbane and Women's Hospital Brisbane Australia
- Faculty of Medicine University of Queensland Brisbane Australia
| | - Michael Waller
- School of Public Health University of Queensland Brisbane Australia
| | - Kevin Chu
- Emergency and Trauma Centre Royal Brisbane and Women's Hospital Brisbane Australia
- Faculty of Medicine University of Queensland Brisbane Australia
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11
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Nutbeam T, Fenwick R, May B, Stassen W, Smith JE, Wallis L, Dayson M, Shippen J. The role of cervical collars and verbal instructions in minimising spinal movement during self-extrication following a motor vehicle collision - a biomechanical study using healthy volunteers. Scand J Trauma Resusc Emerg Med 2021; 29:108. [PMID: 34332623 DOI: 10.1186/s13049-021-00919-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 07/14/2021] [Indexed: 11/10/2022] Open
Abstract
Background Motor vehicle collisions account for 1.3 million deaths and 50 million serious injuries worldwide each year. However, the majority of people involved in such incidents are uninjured or have injuries which do not prevent them exiting the vehicle. Self-extrication is the process by which a casualty is instructed to leave their vehicle and completes this with minimal or no assistance. Self-extrication may offer a number of patient and system-wide benefits. The efficacy of routine cervical collar application for this group is unclear and previous studies have demonstrated inconsistent results. It is unknown whether scripted instructions given to casualties on how to exit the vehicle would offer any additional utility. The aim of this study was to evaluate the effect of cervical collars and instructions on spinal movements during self-extrication from a vehicle, using novel motion tracking technology. Methods Biomechanical data on extrications were collected using Inertial Measurement Units on 10 healthy volunteers. The different extrication types examined were: i) No instructions and no cervical collar, ii) No instructions, with cervical collar, iii) With instructions and no collar, and iv) With instructions and with collar. Measurements were recorded at the cervical and lumbar spine, and in the anteroposterior (AP) and lateral (LAT) planes. Total movement, mean, standard deviation and confidence intervals are reported for each extrication type. Results Data were recorded for 392 extrications. The smallest cervical spine movements were recorded when a collar was applied and no instructions were given: mean 6.9 mm AP and 4.4 mm LAT. This also produced the smallest movements at the lumbar spine with a mean of 122 mm AP and 72.5 mm LAT. The largest overall movements were seen in the cervical spine AP when no instructions and no collar were used (28.3 mm). For cervical spine lateral movements, no collar but with instructions produced the greatest movement (18.5 mm). For the lumbar spine, the greatest movement was recorded when instructions were given and no collar was used (153.5 mm AP, 101.1 mm LAT). Conclusions Across all participants, the most frequently occurring extrication method associated with the least movement was no instructions, with a cervical collar in situ.
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12
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Stephan JC, Grossner T, Stephan-paulsen LM, Weigand MA, Schmidmaier G, Popp E. Evaluation der Aufnahmekriterien von Patienten nach Verkehrsunfall in den Schockraum. Notf Rett Med 2021; 24:134-142. [DOI: 10.1007/s10049-020-00695-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Zusammenfassung
Hintergrund
Die aktuelle S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung der Deutschen Gesellschaft für Unfallchirurgie (DGU) empfiehlt bei einem Pkw-Unfall mit einer Geschwindigkeitsveränderung von delta >30 km/h die Versorgung in einem Schockraum ohne Berücksichtigung der Verletzungen des Patienten. Ziel dieser Studie war es zu untersuchen, ob Patienten, die ausschließlich aufgrund dieses Kriteriums über einen Schockraum aufgenommen wurden, relevante Verletzungen aufwiesen, die intensivmedizinische Behandlungen oder (Not‑)Operationen benötigten.
Methode
Nach einem Pkw-Unfall wurden Patienten ohne spezifische Verletzung, bei denen ausschließlich eine Geschwindigkeitsveränderung von delta >30 km/h vorlag (Empfehlungsgrad B der S3-Leitlinie), der Studiengruppe, Patienten mit Verletzungen gem. Empfehlungsgrad A der Leitlinie der Vergleichsgruppe zugeordnet. Ein schockraumrelevantes Trauma wurde als Injury Severity Score (ISS) ≥16, operative Versorgung innerhalb 24 h, intensivmedizinische Überwachung >24 h, Versterben während des Krankenhausaufenthalts sowie DGU-Basiskollektiv (MAIS3+ oder MAIS2 mit Intensivverweildauer >24 h bzw. Versterben während des Krankenhausaufenthalts) definiert.
Ergebnisse
Der Vergleich zeigte einen hochsignifikanten Unterschied in Bezug auf den mittleren ISS (p ≤ 0,001), ein schockraumrelevantes Trauma (ISS ≥16; p ≤ 0,001), eine intensivmedizinische Versorgung >24 h (p ≤ 0,001), Operation innerhalb von 24 h nach Krankenhausaufnahme (p ≤ 0,001), Letalität (p ≤ 0,001) sowie DGU-Basiskollektiv (p ≤ 0,001). Anhand dieser Ergebnisse konnte gezeigt werden, dass innerhalb der Studiengruppe (Geschwindigkeitsveränderung von delta >30 km/h; Empfehlungsgrad B der S3-Leitlinie) lediglich ein Patient eine Traumafolge aufwies, die eine intensivmedizinische Behandlung >24 h oder eine Operation nötig machte. Studien- und Vergleichsgruppen waren in Bezug auf das mittlere Alter (p = 1,778), das männliche Geschlecht (p = 0,1728) sowie die durchschnittliche Unfallgeschwindigkeit (p = 0,4606) vergleichbar.
Diskussion
Ein alleiniges Vorliegen eines Pkw-Unfalls mit einer Geschwindigkeitsveränderung von delta >30 km/h kann nicht als adäquater Prädiktor für ein schockraumrelevantes Trauma gesehen werden. Weitere Studien könnten durch eine Leitlinienanpassung eine weiterhin sichere und hochwertige Patientenversorgung bei Reduktion von personellen und finanziellen Belastungen ermöglichen.
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13
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Nutbeam T, Fenwick R, Smith J, Bouamra O, Wallis L, Stassen W. A comparison of the demographics, injury patterns and outcome data for patients injured in motor vehicle collisions who are trapped compared to those patients who are not trapped. Scand J Trauma Resusc Emerg Med 2021; 29:17. [PMID: 33446210 PMCID: PMC7807688 DOI: 10.1186/s13049-020-00818-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/24/2020] [Indexed: 11/20/2022] Open
Abstract
Background Motor vehicle collisions (MVCs) are a common cause of major trauma and death. Following an MVC, up to 40% of patients will be trapped in their vehicle. Extrication methods are focused on the prevention of secondary spinal injury through movement minimisation and mitigation. This approach is time consuming and patients may have time-critical injuries. The purpose of this study is to describe the outcomes and injuries of those trapped following an MVC: this will help guide meaningful patient-focused interventions and future extrication strategies. Methods We undertook a retrospective database study using the Trauma Audit and Research Network database. Patients were included if they were admitted to an English hospital following an MVC from 2012 to 2018. Patients were excluded when their outcomes were not known or if they were secondary transfers. Results This analysis identified 426,135 cases of which 63,625 patients were included: 6983 trapped and 56,642 not trapped. Trapped patients had a higher mortality (8.9% vs 5.0%, p < 0.001). Spinal cord injuries were rare (0.71% of all extrications) but frequently (50.1%) associated with other severe injuries. Spinal cord injuries were more common in patients who were trapped (p < 0.001). Injury Severity Score (ISS) was higher in the trapped group 18 (IQR 10–29) vs 13 (IQR 9–22). Trapped patients had more deranged physiology with lower blood pressures, lower oxygen saturations and lower Glasgow Coma Scale, GCS (all p < 0.001). Trapped patients had more significant injuries of the head chest, abdomen and spine (all p < 0.001) and an increased rate of pelvic injures with significant blood loss, blood loss from other areas or tension pneumothorax (all p < 0.001). Conclusion Trapped patients are more likely to die than those who are not trapped. The frequency of spinal cord injuries is low, accounting for < 0.7% of all patients extricated. Patients who are trapped are more likely to have time-critical injuries requiring intervention. Extrication takes time and when considering the frequency, type and severity of injuries reported here, the benefit of movement minimisation may be outweighed by the additional time taken. Improved extrication strategies should be developed which are evidence-based and allow for the expedient management of other life-threatening injuries.
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Affiliation(s)
- Tim Nutbeam
- Emergency Department, University Hospitals Plymouth NHSTrust, Plymouth, UK. .,Devon Air Ambulance Trust, Exeter, UK.
| | - Rob Fenwick
- University Hospitals Birmingham, Birmingham, UK
| | - Jason Smith
- Emergency Department, University Hospitals Plymouth NHSTrust, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Omar Bouamra
- Trauma Audit Research Network, University of Manchester, Manchester, UK
| | - Lee Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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14
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Abstract
Most trauma systems use mechanism of injury (MOI) as an indicator for trauma center transport, often overburdening the system as a result of significant overtriage. Before 2005 our trauma center accepted all MOI. After 2005 we accepted only those patients meeting anatomic and physiologic (A&P) triage criteria. Patients entered into the trauma center database were divided into two groups: 2001 to 2005 (Group 1) and 2007 to 2010 (Group 2) and also categorized based on trauma team activation for either A&P or MOI criteria. Overtriage was defined as patient discharge from the emergency department within 6 hours of trauma activation. A total of 9899 patients were reviewed. Group 1 had 6584 patients with 3613 (55%) activated for A&P criteria and 2971 (45%) for MOI. Group 2 had 3315 patients with 3149 (95%) activated for A&P criteria and 166 (5%) for MOI. Accepting only those patients meeting A&P criteria resulted in a decrease in the overtriage rate from 66 to 9 per cent. By accepting only those patients meeting A&P criteria, we significantly reduced our overtriage rate. Patients meeting MOI criteria were transported to community hospitals and transferred to the trauma center if major injuries were identified. Trauma center transport for MOI results in significant overtriage and may not be justified.
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Affiliation(s)
- Lance E. Stuke
- Department of Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Juan C. Duchesne
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - John P. Hunt
- Department of Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Alan B. Marr
- Department of Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Peter C. Meade
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Norman E. McSwain
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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15
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Waydhas C, Bieler D, Hamsen U, Baacke M, Lefering R; The TraumaRegister DGU. ISS alone, is not sufficient to correctly assign patients post hoc to trauma team requirement. Eur J Trauma Emerg Surg. [PMID: 32556366 PMCID: PMC8825400 DOI: 10.1007/s00068-020-01410-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/28/2020] [Indexed: 01/10/2023]
Abstract
Purpose An injury severity score (ISS) ≥ 16 alone, is commonly used post hoc to define the correct activation of a trauma team. However, abnormal vital functions and the requirement of life-saving procedures may also have a role in defining trauma team requirement post hoc. The aim of this study was to describe their prevalence and mortality in severely injured patients and to estimate their potential additional value in the definition of trauma team requirement as compared to the definition based on ISS alone. Methods Retrospective analysis of a trauma registry including patients with trauma team activation from the years 2009 until 2015, who were 16 years of age or older and were brought to the trauma center directly from the scene. Patients were divided into a group with an ISS ≥ 16 vs. ISS < 16. For analysis a predefined list of abnormal vital functions and life-saving interventions was used. Results 58,723 patients were included in the study (N = 32,653 with ISS ≥ 16; N = 26,070 with ISS < 16). From the total number of patients that required life-saving procedures or presented with abnormal vital functions 29.1% were found in the ISS < 16 group. From the ISS < 16 group, 36.7% of patients required life-saving procedures or presented with abnormal vital signs. The mortality of those was 8.1%. Conclusions Defining the true requirement of trauma team activation post hoc by using ISS ≥ 16 alone does miss a considerable number of subjects who require life-saving interventions or present with abnormal vital functions. Therefore, life-saving interventions and abnormal vital functions should be included in the definitions for trauma team requirement. Further studies have to evaluate, which life-saving procedures and abnormal vital functions are most relevant.
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16
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Lerner EB, Badawy M, Cushman JT, Drendel AL, Fumo N, Jones CMC, Shah MN, Gourlay DM. Does Mechanism of Injury Predict Trauma Center Need for Children? PREHOSP EMERG CARE 2020; 25:95-102. [PMID: 32119577 DOI: 10.1080/10903127.2020.1737281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine if the Mechanism of Injury Criteria of the Field Triage Decision Scheme (FTDS) are accurate for identifying children who need the resources of a trauma center. METHODS EMS providers transporting any injured child ≤15 years, regardless of severity, to a pediatric trauma center in 3 midsized communities over 3 years were interviewed. Data collected through the interview included EMS observed physiologic condition, suspected anatomic injuries, and mechanism. Patients were then followed to determine if they needed the resources of a trauma center by reviewing their medical record after hospital discharge. Patients were considered to need a trauma center if they received an intervention included in a previously published consensus definition. Data were analyzed with descriptive statistics including positive likelihood ratios (+LR) and 95% confidence intervals (95%CI). RESULTS 9,483 provider interviews were conducted and linked to hospital outcome data. Of those, 230 (2.4%) met the consensus definition for needing a trauma center. 1,572 enrolled patients were excluded from further analysis because they met the Physiologic or Anatomic Criteria of the FTDS. Of the remaining 7,911 cases, 62 met the consensus definition for needing a trauma center (TC). Taken as a whole, the Mechanism of Injury Criteria of the FTDS identified 14 of the remaining 62 children who needed the resources of a trauma center for a 77% under-triage rate. The mechanisms sustained were 36% fall (16 needed TC), 28% motor vehicle crash (MVC) (20 needed TC), 7% struck by a vehicle (10 needed TC), <1% motorcycle crash (none needed TC), and 29% had a mechanism not included in the FTDS (16 needed TC). Of those who sustained a mechanisms not listed in the FTDS, the most common mechanisms were sport related injuries not including falls (24% of 2,283 cases with a mechanism not included) and assault (13%). Among those who fell from a height greater than 10 feet, 4 needed a TC (+LR 5.9; 95%CI 2.8-12.6). Among those in a MVC, 41 were reported to have been ejected and none needed a TC, while 31 had reported meeting the intrusion criteria and 0 needed a TC. There were 32 reported as having a death in the same vehicle, and 2 needed a TC (+LR 7.42; 95%CI: 1.90-29.0). CONCLUSION Over a quarter of the children who needed the resources of a trauma center were not identified using the Physiologic or Anatomic Criteria of the Field Triage Decision Scheme. The Mechanism of Injury Criteria did not apply to over a quarter of the mechanisms experienced by children transported by EMS for injury. Use of the Mechanism Criteria did not greatly enhance identification of children who need a trauma center. More work is needed to improve the tool used to assist EMS providers in the identification of children who need the resources of a trauma center.
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17
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Ryan JL, Pracht E, Langland-Orban B, Crandall M. Association of mechanism of injury with overtriage of injured youth patients as trauma alerts. Trauma Surg Acute Care Open 2019; 4:e000300. [PMID: 31922017 PMCID: PMC6937421 DOI: 10.1136/tsaco-2019-000300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 11/04/2019] [Accepted: 12/05/2019] [Indexed: 11/07/2022] Open
Abstract
Background Trauma alert criteria include physiologic and anatomic criteria, although field triage based on injury mechanism is common. This analysis evaluates injury mechanisms associated with pediatric trauma alert overtriage and estimates the effect of overtriage on patient care costs. Methods Florida’s Agency for Health Care Administration inpatient and financial data for 2012–2014 were used. The study population included mildly and moderately injured patients aged 5–15 years brought to a trauma center and had an International Classification of Diseases-based Injury Severity Score survival probability ≥0.90, a recorded mechanism of injury, no surgery, a hospital stay less than 24 hours, and discharged to home. Overtriaged patients were those who had a trauma alert. Logistic regression was used to analyze the odds of overtriage relative to mechanism of injury and multivariable linear regression was used to analyze cost of overtriage. Results Twenty percent of patients were overtriaged; yet these patients accounted for 37.2% of total costs. The mechanisms of injury related to firearms (OR 11.99) and motor vehicle traffic (2.25) were positively associated with overtriage as a trauma alert. Inpatient costs were 131.8% higher for overtriaged patients. Discussion Firearm injuries and motor vehicle injuries can be associated with severe injuries. However, in this sample, a proportion of patients with this mechanism suffered minimal injuries. It is possible that further identifying relevant anatomic and physiologic criteria in youth may help decrease overtriage without compromising outcomes. Level of evidence Economic, level IV.
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Affiliation(s)
- Jessica Lynn Ryan
- Health Sciences and Administration, University of West Florida, Pensacola, Florida, USA
| | - Etienne Pracht
- College of Public Health, University of South Florida, Tampa, Florida, USA
| | | | - Marie Crandall
- Surgery, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida, USA
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18
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Cassignol A, Marmin J, Cotte J, Cardinale M, Bordes J, Pauly V, Kerbaul F, Demory D, Meaudre E. Correlation between field triage criteria and the injury severity score of trauma patients in a French inclusive regional trauma system. Scand J Trauma Resusc Emerg Med 2019; 27:71. [PMID: 31382982 PMCID: PMC6683531 DOI: 10.1186/s13049-019-0652-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/26/2019] [Indexed: 11/17/2022] Open
Abstract
Background In France, the pre-hospital field triage of trauma patients is currently based on the Vittel criteria algorithm. This algorithm was originally created in 2002 before the stratification of trauma centers and, at the national level, has not been revised since. This could be responsible for the overtriage of trauma patients in Level I Trauma Centers. The principal aim of this study was to evaluate the correlation between each Vittel field triage criterion and trauma patients’ Injury Severity Score. Methods Our Level I Trauma Center receives an average of 300 trauma patients per year. Demographic and physiological data, along with the entire trauma patient management process and Vittel field triage criteria, are recorded in a local trauma registry. The Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) are calculated after a complete assessment of the trauma victim during their in-hospital management. Results were concerned with the presence of an ISS of greater than 15, which defined a major trauma patient; mortality within 30 days; and admission to the intensive care unit. This study is a registry analysis from January 2013 to September 2017. Results Of the 1373 patients in the registry, 1151 were included in the analysis with a mean age of 43 years (± 19) and a median ISS of 13 (IQR = 5–22), where 887 (77%) were male. Nine of the 24 Vittel criteria were associated with an ISS > 15. In a multivariate analysis, no criterion related to kinetic elements was significantly correlated with an ISS > 15, mortality within 30 days, or admission to intensive care. Three algorithm categories were predictive of a major trauma patient (ISS > 15): physiological variables, pre-hospital resuscitation, and physical injuries, while kinetic elements were not. Conclusions Criteria related to physiological variables, pre-hospital resuscitation, and physical injuries are the most relevant to predicting the severity of a trauma patient’s condition. A revision of the VCA could potentially have beneficial effects on the over and undertriage phenomena, which constitute ongoing medical and financial concerns.
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Affiliation(s)
- Arnaud Cassignol
- SMUR Department, Sainte-Musse Public Hospital, 83100, Toulon, cedex 9, France.
| | - Julien Marmin
- Prehospital Emergency Medical Services of Marine Fire Battalion, Marseille, France
| | - Jean Cotte
- Anesthesia and Intensive Care Department, Sainte-Anne Military Hospital, 83041, Toulon, France
| | - Mickael Cardinale
- Anesthesia and Intensive Care Department, Sainte-Anne Military Hospital, 83041, Toulon, France
| | - Julien Bordes
- Anesthesia and Intensive Care Department, Sainte-Anne Military Hospital, 83041, Toulon, France
| | - Vanessa Pauly
- Public Health and Medical Information Service, Conception Hospital, Aix-Marseille University, 13005, Marseille, France
| | - François Kerbaul
- SMUR department, Timone Hospital, Aix-Marseille University, 13005, Marseille, France.,UMR MD 2, Aix-Marseille University, Marseille, France
| | - Didier Demory
- Clinical research unit, Sainte-Musse Public Hospital, 83100, Toulon, cedex 9, France
| | - Eric Meaudre
- Anesthesia and Intensive Care Department, Sainte-Anne Military Hospital, 83041, Toulon, France
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Vassallo J, Smith J. Major incident triage and the evaluation of the Triage Sort as a secondary triage method. Emerg Med J 2019; 36:281-286. [PMID: 30877263 DOI: 10.1136/emermed-2018-207986] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 01/16/2019] [Accepted: 02/08/2019] [Indexed: 11/04/2022]
Abstract
INTRODUCTION A key principle in the effective management of major incidents is triage, the process of prioritising patients on the basis of their clinical acuity. In many countries including the UK, a two-stage approach to triage is practised, with primary triage at the scene followed by a more detailed assessment using a secondary triage process, the Triage Sort. To date, no studies have analysed the performance of the Triage Sort in the civilian setting. The primary aim of this study was to determine the performance of the Triage Sort at predicting the need for life-saving intervention (LSI). METHODS Using the Trauma Audit Research Network (TARN) database for all adult patients (>18 years) between 2006 and 2014, we determined which patients received one or more LSIs using a previously defined list. The first recorded hospital physiology was used to categorise patient priority using the Triage Sort, National Ambulance Resilience Unit (NARU) Sieve and the Modified Physiological Triage Tool-24 (MPTT-24). Performance characteristics were evaluated using sensitivity and specificity with statistical analysis using a McNemar's test. RESULTS 127 233patients (58.1%) had complete data and were included: 55.6% men, aged 61.4 (IQR 43.1-80.0 years), ISS 9 (IQR 9-16), with 24 791 (19.5%) receiving at least one LSI (priority 1). The Triage Sort demonstrated the lowest accuracy of all triage tools at identifying the need for LSI (sensitivity 15.7% (95% CI 15.2 to 16.2) correlating with the highest rate of under-triage (84.3% (95% CI 83.8 to 84.8), but it had the greatest specificity (98.7% (95% CI 98.6 to 98.8). CONCLUSION Within a civilian trauma registry population, the Triage Sort demonstrated the poorest performance at identifying patients in need of LSI. Its use as a secondary triage tool should be reviewed, with an urgent need for further research to determine the optimum method of secondary triage.
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Affiliation(s)
- James Vassallo
- Emergency Department, Derriford Hospital, Plymouth, UK.,Institute of Naval Medicine, Gosport, Hampshire, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK
| | - Jason Smith
- Emergency Department, Derriford Hospital, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK
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Waydhas C, Baake M, Becker L, Buck B, Düsing H, Heindl B, Jensen KO, Lefering R, Mand C, Paffrath T, Schweigkofler U, Sprengel K, Trentzsch H, Wohlrath B, Bieler D. A Consensus-Based Criterion Standard for the Requirement of a Trauma Team. World J Surg 2018; 42:2800-9. [PMID: 29468262 DOI: 10.1007/s00268-018-4553-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Trauma team activation (TTA) represents a considerable expenditure of trauma centre resources. It is mainly triggered by field triage criteria. The overall quality of the criteria may be evaluated based on the rate of over- and undertriage. However, there is no gold standard that defines which adult patients truly require a trauma team. The objective of this study was to develop consensus-based criteria defining the necessity for a trauma team. METHODS A consensus group was formed by trauma specialists experienced in emergency and trauma care with a specific interest in field triage and having previously participated in guideline development. A literature search was conducted to identify criteria that have already been used or suggested. The initial list of criteria was discussed in two Delphi round and two consensus conferences. The entire process of discussion and voting was highly standardized and extensively documented, resulting in a final list of criteria. RESULTS Initially 95 criteria were identified. This was subsequently reduced to 20 final criteria to appropriately indicate the requirement for attendance of a trauma team. The criteria address aspects related to injury severity, admission to an intensive care unit, death within 24 h, need for specified invasive procedures, need for surgical and/or interventional radiological procedures, and abnormal vital signs within a defined time period. CONCLUSIONS The selected criteria may be applied as a tool for research and quality control concerning TTA. However, future studies are necessary to further evaluate for possible redundancy in criteria that may allow for further reduction in criteria.
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Parreira JG, Rondini GZ, Below C, Tanaka GO, Pelluchi JN, Arantes-Perlingeiro J, Soldá SC, Assef JC. Trauma mechanism predicts the frequency and the severity of injuries in blunt trauma patients. ACTA ACUST UNITED AC 2018; 44:340-347. [PMID: 29019536 DOI: 10.1590/0100-69912017004007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/11/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE to study the correlation of trauma mechanism with frequency and severity of injuries in blunt trauma patients. METHODS retrospective analysis of trauma registry in a 15-month period was carried out. Trauma mechanism was classified into six types: occupants of four-wheeled vehicles involved in road traffic accidents (AUTO), pedestrians struck by road vehicles (PED), motorcyclists involved in road traffic accidents (MOTO), falls from height (FALL), physical assault with blunt instruments (ASSA) and falls on same level (FSL). Injuries with AIS>2 were considered severe. One-way ANOVA, Students t and Chi-square tests were used for statistical analysis, considering p<0.05 significant. RESULTS trauma mechanism was classified by group for 3639 cases, comprising 337 (9.3%) AUTO, 855 (23.5%) PED, 924 (25.4%) MOTO, 455 (12.5%) FALL, 424 (11.7%) ASSA and 644 (17.7%) FSL. There was significant difference among groups when comparing the Revised Trauma Score (RTS), the Injury Severity Score (ISS) and the Abbreviated Injury Scale (AIS) of the head, thorax, abdomen and extremities (p<0.001). Severe injuries in the head and in the extremities were more frequent in PED patients (p<0.001). Severe injuries to the chest were more frequent in AUTO (p<0.001). Abdominal injuries were less frequent in FSL (p=0.004). Complex fractures of the pelvis and spine were more frequent in FALL (p<0.001). Lethality was greater in PED, followed by FALL and AUTO (p<0.001). CONCLUSION trauma mechanism analysis predicted frequency and severity of injuries in blunt trauma patients.
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Affiliation(s)
- José Gustavo Parreira
- Irmandade da Santa Casa de Misericórdia de São Paulo, Serviço de Emergência, São Paulo, SP, Brasil.,Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, São Paulo, SP, Brasil
| | | | - Cristiano Below
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Curso de Medicina, São Paulo, SP, Brasil
| | - Giuliana Olivi Tanaka
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Curso de Medicina, São Paulo, SP, Brasil
| | - Julia Nunes Pelluchi
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Curso de Medicina, São Paulo, SP, Brasil
| | - Jacqueline Arantes-Perlingeiro
- Irmandade da Santa Casa de Misericórdia de São Paulo, Serviço de Emergência, São Paulo, SP, Brasil.,Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, São Paulo, SP, Brasil
| | - Silvia Cristine Soldá
- Irmandade da Santa Casa de Misericórdia de São Paulo, Serviço de Emergência, São Paulo, SP, Brasil.,Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, São Paulo, SP, Brasil
| | - José César Assef
- Irmandade da Santa Casa de Misericórdia de São Paulo, Serviço de Emergência, São Paulo, SP, Brasil.,Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, São Paulo, SP, Brasil
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Braken P, Amsler F, Gross T. Simple modification of trauma mechanism alarm criteria published for the TraumaNetwork DGU ® may significantly improve overtriage - a cross sectional study. Scand J Trauma Resusc Emerg Med 2018; 26:32. [PMID: 29690930 PMCID: PMC5916718 DOI: 10.1186/s13049-018-0498-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 04/10/2018] [Indexed: 11/24/2022] Open
Abstract
Background No consensus exists in the literature on the use of uniform emergency room trauma team activation criteria (ERTTAC). Today excessive over- or undertriage rates continue to be a challenge for most trauma centres. Application of ERTTAC, published for use in the German TraumaNetwork DGU®, at a Swiss trauma centre resulted in a high overtriage rate. The aim of the investigation was to analyse the ERTTAC in detail with the intention of possible improvement. Methods The investigation included consecutive adult (age > 15 years) trauma patients treated at the emergency department of a level II trauma centre from 01.01.2013–31.12.2015. All data were collected prospectively. To identify over- and undertriage, patients with an Injury Severity Score (ISS) > 15 were defined as requiring specific emergency room (ER) management. ANOVA, Student’s t-test and chi-square analysis were used for statistical analysis with mean values ± standard deviation. Results 1378 adult injured (64% male) received ER trauma team treatment (mean age 48.3 ± 21.2 years; ISS 9.7 ± 9.6) during the observation period. Of those, 326 ER patients (23.7%) were diagnosed with an ISS > 15, which proved to be an overtriage of 76.3%. 80/406 trauma patients with an ISS > 15 were not referred to the ER, resulting in an actual undertriage rate of 19.7%, mainly because the criteria list was not observed. Effectively applying ERTTAC according to the protocol in all cases would have reduced undertriage to 2.0% (8/406). The most frequent trigger for trauma team activation was injury mechanism (65%). A simulation revealed that omitting the criterion ‘passenger of car or truck’ (n = 326) would have prevented overtriage in 257 cases, as such lowering overtriage rate to 62.4% and at the same time increasing undertriage by only 8 cases to 7.1%. Conclusion Application of ERTTAC as published for TraumaNetwork DGU® resulted in a lower undertriage but higher overtriage rate than recommended by the American College of Surgeons. Omitting the criterion ‘passenger of car or truck’ markedly improved overtriage with only a minimal increase in undertriage. Trial registration NCT02165137; retrospectively registered 11. June 2014.
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Affiliation(s)
- Philipp Braken
- Kantonsspital Aarau Traumatology, Tellstrasse 25, CH-5001, Aarau, Switzerland
| | - Felix Amsler
- Amsler Consulting, Gundeldingerrain 111, CH-4059, Basel, Switzerland
| | - Thomas Gross
- Kantonsspital Aarau Traumatology, Tellstrasse 25, CH-5001, Aarau, Switzerland.
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Macke C, Sarakintsis M, Winkelmann M, Mommsen P, Omar M, Schröter C, Krettek C, Zeckey C. Influence of Entrapment on Prehospital Management and the Hospital Course in Polytrauma Patients: A Retrospective Analysis in Air Rescue. J Emerg Med 2018; 54:827-834. [PMID: 29680410 DOI: 10.1016/j.jemermed.2018.02.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 01/12/2018] [Accepted: 02/22/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Entrapment is a challenging and crucial factor in the prehospital setting. Few studies have addressed whether entrapment has an influence on on-scene treatment or on the following hospital course. OBJECTIVES Here we aimed to investigate the influence of entrapment on prehospital management and on the hospital course of polytrauma patients. METHODS We performed a retrospective analysis of consecutive patients with an Injury Severity Score ≥16 and aged 16-65 years that were admitted between 2005 and 2013 to a Level I trauma center. Two groups were built: entrapped (E) and nonentrapped patients (nE). These groups were evaluated for multiple prehospital and clinical parameters, including on-scene time, prehospital interventions, and posttraumatic complications. RESULTS There were 310 patients (n = 194 no entrapment [Group nE], n = 116 with entrapment [Group E]) enrolled. The on-scene time was significantly longer in Group E than Group nE. Moreover, this group received a significantly higher volume of colloidal solution. Regarding the Injury Severity Score and Abbreviated Injury Scale (AIS), there were no significant differences between the groups, except for the AISextremities, which was significantly increased in Group E. The overall hospital stay and the initial theater time were significantly longer in Group E than Group nE. No significant differences were present for the occurrence of systemic inflammatory response syndrome, multiple organ dysfunction syndrome, and acute respiratory distress syndrome, nor for Acute Physiology and Chronic Health Evaluation II and estimated and final mortality. CONCLUSION In polytraumatized patients, entrapment has a minor influence on the outcome and treatment in the prehospital and hospital setting when using physician-based air rescue. However, entrapped patients are prone to sustain more severe trauma to the extremities.
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Affiliation(s)
- Christian Macke
- Trauma Department, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Marika Sarakintsis
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Marcel Winkelmann
- Trauma Department, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Philipp Mommsen
- Trauma Department, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Mohamed Omar
- Trauma Department, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | | | - Christian Krettek
- Trauma Department, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Zeckey
- Trauma Department, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany; Department of General, Trauma, and Reconstructive Surgery, Ludwig-Maximilians-Universität München, Munich, Germany
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24
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Follows A, Phillips R, Vassallo J. Identifying trauma centre need in adult patients sustaining injury. Trauma 2017. [DOI: 10.1177/1460408617697818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrew Follows
- Emergency Department, Derriford Hospital, Plymouth, UK
- Peninsula College of Medicine and Dentistry, Plymouth, UK
| | - Ryan Phillips
- Emergency Department, Derriford Hospital, Plymouth, UK
- Peninsula College of Medicine and Dentistry, Plymouth, UK
| | - James Vassallo
- Emergency Department, Derriford Hospital, Plymouth, UK
- Institute of Naval Medicine, Gosport, UK
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Hare NP, Macdonald AW, Mellor JP, Younus M, Chatha H, Sammy I. Do clinical guidelines for whole body computerised tomography in trauma improve diagnostic accuracy and reduce unnecessary investigations? A systematic review and narrative synthesis. Trauma 2017. [DOI: 10.1177/1460408617700450] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Whole body computerised tomography has become a standard of care for the investigation of major trauma patients. However, its use varies widely, and current clinical guidelines are not universally accepted. We undertook a systematic review of the literature to determine whether clinical guidelines for whole body computerised tomography in trauma increase its diagnostic accuracy. Materials and methods A systematic review of Medline, Cinhal and the Cochrane database, supplemented by a manual search of relevant papers was undertaken, with narrative synthesis. Studies comparing clinical guidelines to physician gestalt for the use of whole body computerised tomography in adult trauma were included. Results A total of 887 papers were identified from the electronic databases, and 1 from manual searches. Of these, seven papers fulfilled the inclusion criteria. Two papers compared clinical guidelines with routine practice: one found increased diagnostic accuracy while the other did not. Two papers investigated the performance of established clinical guidelines and demonstrated moderate sensitivity and low specificity. Two papers compared different components of established triage tools in trauma. One paper devised a de novo clinical decision rule, and demonstrated good diagnostic accuracy with the tool. The outcome criteria used to define a ‘positive’ scan varied widely, making direct comparisons between studies impossible. Conclusions Current clinical guidelines for whole body computerised tomography in trauma may increase the sensitivity of the investigation, but the evidence to support this is limited. There is a need to standardise the definition of a ‘clinically significant’ finding on CT to allow better comparison of diagnostic studies.
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Affiliation(s)
- Nicholas P Hare
- Faculty of Medicine, Dentistry and Health, The University of Sheffield, Sheffield, UK
| | - Alistair W Macdonald
- Faculty of Medicine, Dentistry and Health, The University of Sheffield, Sheffield, UK
| | - James P Mellor
- Faculty of Medicine, Dentistry and Health, The University of Sheffield, Sheffield, UK
| | - Maaz Younus
- Faculty of Medicine, Dentistry and Health, The University of Sheffield, Sheffield, UK
| | - Hridesh Chatha
- Emergency Department, Barnsley District General Hospital, Barnsley, UK
| | - Ian Sammy
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
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Abstract
PURPOSE To evaluate the performance of a prehospital trauma diversion system in Hong Kong, China. METHODS A retrospective analysis of prospectively collected data in the trauma registry of Queen Mary Hospital, Hong Kong from 1 January 2009 to 31 December 2013 was done. All adult patients aged 18 years or above, either primarily or secondarily diverted to Queen Mary Hospital according to the trauma patient diversion protocol, were recruited. Need for trauma center level of care was based on a consensus-based criterion standard published in 2014. Performance of the protocol in terms of over- diversion and under-diversion was determined. RESULTS A total of 209 patients were included for analysis. About 30% of the patients required trauma center level of care. The most common reason was the need for vascular, neurologic, abdominal, thoracic, pelvic, spine or limb-conserving surgery within 24 h of presentation. The over-diversion rate and under- diversion rate were 69.6% and 19.7% respectively. CONCLUSION The trauma patient diversion protocol currently in use in Hong Kong is not accurate enough. Further revision and refinement is needed.
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Affiliation(s)
- Tak-Wai Lui
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
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27
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Galvagno SM, Sikorski RA, Stephens C, Grissom TE. Initial Evaluation and Triage of the Injured Patient: Mechanisms of Injury and Triggers for Operating Room Versus Emergency Department Stabilization. Curr Anesthesiol Rep 2016; 6:50-8. [DOI: 10.1007/s40140-016-0148-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Matsushima K, Chouliaras K, Koenig W, Preston C, Gorospe D, Demetriades D. Should we still use motor vehicle intrusion as a sole triage criterion for the use of trauma center resources? Injury 2016; 47:235-8. [PMID: 26542464 DOI: 10.1016/j.injury.2015.10.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 08/24/2015] [Accepted: 10/16/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Motor vehicle intrusion (MVI) is one of the field triage criteria recommended by the American College of Surgeons Committee of Trauma (ACS-COT) and Centers for Disease Control and Prevention (CDC). However, the evidence supporting its validity is scarce. The purpose of this study was to evaluate the validity of this criterion and assess its impact on overtriage or undertriage. PATIENTS AND METHODS This was a retrospective study based on the Los Angeles County Trauma and Emergency Medicine Information System (TEMIS) Trauma database. Included in the analysis were patients with MVI as the sole criterion for trauma center triage. Physiological characteristics, severity of injury, and outcomes of the MVI patients were compared between different age groups. Further, a logistic regression model was used to identify factors significantly associated with the need for trauma center resources. RESULTS During the period 2002-2012, a total of 10,554 trauma patients involved in motor vehicle crashes had documentation of MVI. A subgroup of 3998 patients (37.9%) did not meet any other criteria that require immediate transportation to a designated trauma center. Only 0.7% of these patients had hypotension and 0.1% had deterioration of the Glasgow Coma Scale on admission to the emergency room. Overall, 18.8% of patients required trauma center resources defined as intubation in the emergency room, certain surgical procedures, in-hospital death, or intensive care unit admission. Age ≥65 years, male gender, prehospital heart rate >100/min, and systolic blood pressure <110 mmHg were significantly associated with the need for trauma center resources. CONCLUSIONS The MVI itself did not appear to be a strong indicator for the use of trauma center resources and is associated with excessive overtriage. However, age >65 years, systolic blood pressure <110 mmHg, and heart rate >100/min were significant predictors for the need of trauma center resources. The MVI criterion should be refined for better utilization of trauma center resources.
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Affiliation(s)
- Kazuhide Matsushima
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA.
| | | | - William Koenig
- Emergency Medical Services Agency, Los Angeles County Department of Health Services, Santa Fe Springs, CA, USA
| | - Christy Preston
- Emergency Medical Services Agency, Los Angeles County Department of Health Services, Santa Fe Springs, CA, USA
| | - Deidre Gorospe
- Emergency Medical Services Agency, Los Angeles County Department of Health Services, Santa Fe Springs, CA, USA
| | - Demetrios Demetriades
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA
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Willenbring BD, Lerner EB, Brasel K, Cushman JT, Guse CE, Shah MN, Swor R. Evaluation of a Consensus-Based Criterion Standard Definition of Trauma Center Need for Use in Field Triage Research. PREHOSP EMERG CARE 2015; 20:1-5. [PMID: 26270033 DOI: 10.3109/10903127.2015.1056896] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Research on field triage of injured patients is limited by the lack of a widely used criterion standard for defining trauma center need. Injury Severity Score (ISS) >15 has been a commonly used outcome measure in research for determining trauma center need that has never been validated. A multidisciplinary team recently published a consensus-based criterion standard definition of trauma center need, but this measure has not yet been validated. The objective was to determine if the consensus-based criterion standard can be obtained by medical record review and compare patients identified as needing a trauma center by the consensus-based criterion standard vs. ISS >15. A subanalysis of data collected during a 2-year prospective cohort study of 4,528 adult trauma patients transported by EMS to a single trauma center was conducted. These data included ICD-9-CM codes, treatment times, and other patient care data. Presence of the consensus-based criterion standard was determined for each patient. ISS was calculated based on ICD-9-CM codes assigned for billing. The consensus-based criterion standard could be applied to 4,471 (98.7%) cases. ISS could be determined for 4,506 (99.5%) cases. Based on an ISS >15, 8.9% of cases were identified as needing a trauma center. Of those, only 48.2% met the consensus-based criterion standard. Almost all patients that did not meet the consensus-based criterion standard, but had an ISS >15 were diagnosed with chest (rib fractures (100/205 cases)/pneumothorax (57/205 cases), closed head (without surgical intervention 88/205 cases), vertebral (without spinal cord injury 45/205 cases), and/or extremity injuries (39/205 cases). There were 4,053 cases with an ISS <15. 5.0% of those with an ISS <15 met the consensus-based criterion standard with the majority requiring surgery (139/203 cases) or a blood transfusion (60/203 cases). The kappa coefficient of agreement for ISS and the consensus-based criterion standard was 0.43. We determined that the consensus-based criterion standard could be identified through a medical record review. Use of the consensus-based criterion standard for field triage research will more accurately identify injured patients who need the resources of a trauma center when compared to ISS.
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Abstract
BACKGROUND Many patients will require extrication following a motor vehicle collision (MVC). Little information exists on the time taken for extrication or the factors which affect this time. OBJECTIVE To derive a tool to predict the time taken to extricate patients from MVCs. METHODS A prospective, observational derivation study was carried out in the West Midland Fire Service's metropolitan area. An expert group identified factors that may predict extrication time-the presence and absence of these factors was prospectively recorded at eligible extrications for the study period. A step-down multiple regression method was used to identify important contributing factors. RESULTS Factors that increased extrication times by a statistically significant extent were: a physical obstruction (10 min), patients medically trapped (10 min per patient) and any patient physically trapped (7 min). Factors that shortened extrication time were rapid access (-7 min) and the car being on its roof (-12 min). All these times were calculated from an arbitrary time (which assumes zero patients) of 8 min. CONCLUSIONS This paper describes the development of a tool to predict extrication time for a trapped patient. A number of factors were identified which significantly contributed to the overall extrication time.
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Affiliation(s)
- Tim Nutbeam
- The Emergency Department, Derriford Hospital Plymouth, UK
| | - Rob Fenwick
- Emergency Department, Shrewsbury and Telford Hospitals NHS Trust, Telford, UK
| | | | - Vikki Holland
- Integrated Risk Management, West Midlands Fire Service, Birmingham, UK
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Abstract
OBJECTIVE To determine whether emergency physicians (EPs) and prehospital emergency medical services (EMS) personnel differ in their assessment of motor vehicle crash (MVC) severity and the potential for serious injury when viewing crash scene photographs. METHODS Attending and resident EPs, paramedics, and emergency medical technicians (EMTs) from a single emergency medicine system used a web-based survey platform to rate the severity of 100 crash photographs on a 10-point Likert scale (Crash Score) and the potential for serious injury on a 0-100% scale (Injury Score). Serious injury was defined as skull fracture or intracranial bleeding, spine fracture or spinal cord injury, intrathoracic or intraabdominal injury, or long bone fracture. Crash and Injury Scores were stratified into EP and paramedic/EMT (EMS) groups and the mean score was calculated for each photo. Spearman rank correlation coefficients with 95% confidence intervals (95% CI) and Bland-Altman plots were constructed to assess agreement. Secondary analyses were performed after categorizing data into quartiles based on participants' estimations of MVC severity. RESULTS A total of 54 attending and 53 resident EPs, 156 paramedics, and 34 EMTs were invited to participate in the survey. Of these, 39 (72%) attending and 46 (87%) resident EPs, 107 (69%) paramedics, and 17 (50%) EMTs completed the survey. A total of 183 (88%) surveys were completed in full. The overall Crash Score correlation coefficient between EPs and EMS was 0.98 (95% CI, 0.97-0.99). The Crash Score correlation coefficients for each quartile were 0.86 (0.57-0.97), 0.93 (0.85-0.96), 0.58 (0.16-0.85), and 0.88 (0.66-0.97), respectively. The overall Injury Score correlation coefficient between EPs and EMS was 0.98 (0.88-0.97). The Injury Score correlation coefficients for each quartile were 0.94 (0.48-0.91), 0.76 (0.50-0.92), 0.80 (0.69-1.00), and 0.94 (0.57-0.97), respectively. CONCLUSION Although overall agreement between EPs and EMS personnel was excellent, differences in estimation of crash severity and potential for injury were identified among crashes estimated to be moderate in severity.
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SHARIF-ALHOSEINI M, RAHIMI-MOVAGHAR V. Hospital-based incidence of traumatic spinal cord injury in tehran, iran. Iran J Public Health 2014; 43:331-41. [PMID: 25988093 PMCID: PMC4419171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 01/21/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND The goal of this study was to describe the hospital-based incidence of traumatic spinal cord injury in Tehran, Iran. METHODS We retrospectively reviewed the hospital records of traumatic spinal cord injury patients, admitted between March 2010 and July 2011 in 61/68 hospitals of Tehran. RESULTS Overall, 138 cases of traumatic spinal cord injury were identified. The majority of patients were male (84.8%). The mean age was 33.2 ± 14.3 years. 54.3% patients were residing in Tehran and the others were referred from other cities. The mean annual incidence of hospitalized traumatic spinal cord injury patients of Tehran was 10.5/1,000,000/year (95% confidence interval: 9-12). Fall was the leading cause of injury (45.7%), followed by road traffic crash (40.6%). The most common cause of tetraplegia (cervical traumatic spinal cord injury) was road traffic crash. The duration of hospital stay for tetraplegia and paraplegia (thoracic and lumbar traumatic spinal cord injury) was 22.7±23.7 and 12.5±7.5, respectively (P<0.001). Early surgery (surgical decompression within 24 h) was done for 19% of the patients. The median day of hospitalization for early and late surgery was 7.5 and 12, respectively (P=0.044). CONCLUSION Preventing traumatic spinal cord injury should focus on males, age group of 21-30 years, falls and road traffic crash. More studies are suggested to evaluate the incidence of non-hospitalized traumatic spinal cord injury patients.
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Affiliation(s)
- Mahdi SHARIF-ALHOSEINI
- 1. Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Vafa RAHIMI-MOVAGHAR
- 1. Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran,* Corresponding Author: E-mail:
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Nakahara S, Matsuoka T, Ueno M, Mizushima Y, Ichikawa M, Yokota J. Extremity Injuries as Predictors of Emergency Care Resource Needs among Blunt Trauma Patients in Japan. Am Surg 2014. [DOI: 10.1177/000313481408000231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study aimed to exhaustively examine associations between prehospital variables and emergency care resource needs among blunt trauma patients. The study included blunt trauma patients aged 15 years or older who were admitted to a tertiary care medical center in Osaka, Japan, from January 2005 to December 2009. The primary end point was a composite measure of overall emergency care resource needs. Predictive variables were easily detectable upper and lower extremity injuries. A multivariate logistic regression model was used to identify associations between the predictive variables and the end point; this model included other covariates known to be associated with emergency care resource needs (demographic characteristics, mechanism of injury, and physiological parameters). Of 982 blunt trauma patients, 81 died, and 573 required overall emergency care resources. Upper extremity injury (odds ratio [OR], 2.60) and lower extremity injury (OR, 4.50) were significantly associated with overall emergency care resource needs after controlling for other covariates. The results of this study suggest that easily detectable extremity injuries may be useful predictors of the emergency care resource needs of trauma patients. Further studies are needed to validate the predictive values of these injuries and to determine ways to use information about extremity injuries to improve triage decisions.
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Affiliation(s)
- Shinji Nakahara
- Department of Epidemiology, Saint Marianna University, Kawasaki, Kanagawa, Japan
| | - Tetsuya Matsuoka
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, Izumisano, Osaka, Japan; the
| | - Masato Ueno
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, Izumisano, Osaka, Japan; the
| | - Yasuaki Mizushima
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, Izumisano, Osaka, Japan; the
| | - Masao Ichikawa
- City University of Tsukuba, Tsukuba, Ibaraki, Japan; and
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Abstract
BACKGROUND Many patients will require extrication following a motor vehicle collision (MVC). Little information exists on the time taken for the various stages of extrication. OBJECTIVE To report the time taken for the various stages of extrication. METHODS A prospective, observational study carried out in the West Midland Fire Service's metropolitan area. Time points related to extrication were collected 'live' by two-way radio broadcast. Any missing data were actively gathered by fire control within 1 h of completion of extrication. This paper reports an interim analysis conducted after 1 year of data collection following a 3-month run-in and training period: data were analysed from 1 January 2011 to 31 December 2011 inclusive. RESULTS During the study period 228 incidents were identified. Seventy-nine were excluded as they met the predetermined exclusion criteria or had incomplete data collection. This left 158 extrications that were suitable for analysis. The median time for extrication was 30 min, IQR 24-38 min. CONCLUSIONS In patients requiring extrication following an MVC a median time of 8 min is typically required before initial limited patient assessment and intervention. A further 22 min is typically required before full extrication. Prehospital personnel should be aware of these times when planning their approach to a trapped patient.
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Affiliation(s)
- Tim Nutbeam
- Department of Emergency Medicine, Derriford Hospital, Plymouth, Devon, UK
| | - Rob Fenwick
- Shrewsbury and Telford Hospitals NHS Trust, UK
| | | | - Vikki Holland
- Integrated Risk Management, West Midlands Fire Service, Birmingham, UK
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Sloan R. A retrospective review of influences on clinicians to order whole body CT scans in trauma and its effectiveness in this regard. Scand J Trauma Resusc Emerg Med 2013. [PMCID: PMC3665544 DOI: 10.1186/1757-7241-21-s1-s16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Lerner EB, Roberts J, Guse CE, Shah MN, Swor R, Cushman JT, Blatt A, Jurkovich GJ, Brasel K. Does EMS perceived anatomic injury predict trauma center need? PREHOSP EMERG CARE 2013; 17:312-6. [PMID: 23627418 DOI: 10.3109/10903127.2013.785620] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Our objective was to determine the predictive value of the anatomic step of the 2011 Field Triage Decision Scheme for identifying trauma center need. METHODS Emergency medical services (EMS) providers caring for injured adults transported to regional trauma centers in three midsized communities were interviewed over two years. Patients were included, regardless of injury severity, if they were at least 18 years old and were transported by EMS with a mechanism of injury that was an assault, motor vehicle or motorcycle crash, fall, or pedestrian or bicyclist struck. The interview was conducted upon emergency department (ED) arrival and collected physiologic condition and anatomic injury data. Patients who met the physiologic criteria were excluded. Trauma center need was defined as nonorthopedic surgery within 24 hours, intensive care unit admission, or death prior to hospital discharge. Data were analyzed by calculating descriptive statistics, including positive likelihood ratios (+LRs) with 95% confidence intervals (CIs). RESULTS A total of 11,892 interviews were conducted. One was excluded because of missing outcome data and 1,274 were excluded because they met the physiologic step. EMS providers identified 1,167 cases that met the anatomic criteria, of which 307 (26%) needed the resources of a trauma center (38% sensitivity, 91% specificity, +LR 4.4; CI: 3.9-4.9). Criteria with a +LR ≥5 were flail chest (9.0; CI: 4.1-19.4), paralysis (6.8; CI: 4.2-11.2), two or more long-bone fractures (6.3; CI: 4.5-8.9), and amputation (6.1; CI: 1.5-24.4). Criteria with a +LR >2 and <5 were penetrating injury (4.8; CI: 4.2-5.6) and skull fracture (4.8; CI: 3.0-7.7). Only pelvic fracture (1.9; CI: 1.3-2.9) had a +LR less than 2. CONCLUSIONS The anatomic step of the Field Triage Guidelines as determined by EMS providers is a reasonable tool for determining trauma center need. Use of EMS perceived pelvic fracture as an indicator for trauma center need should be reevaluated. Key words: wounds and injury; triage; emergency medical services; emergency medical technicians.
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