Multiple Trauma and Emergency Room Management

Time to Surgery Following Complete Cervical Spinal Cord Injury: Evolution of Clinical Practice Patterns Over a Decade from 2010 to 2020 Across North American Trauma Centers

This study aims to quantify the change in time to surgery for treatment of complete traumatic cervical spinal cord injury (SCI) patients in American College of Surgeons accredited trauma centers across North America over the last decade (2010-2020). This multi-center retrospective observational cohort study used data from the Trauma Quality Improvement Program from 2010 to 2020. All surgically treated patients with complete traumatic cervical SCI were included. Primary outcome was time to spine surgery from treating hospital arrival in hours. Both descriptive statistics and a multi-variable Poisson regression model clustering standard of errors by each included trauma center were used to evaluate and quantify the annual change in time to surgical intervention. The study included 6855 complete traumatic cervical SCI patients managed across 484 trauma centers in North America. Median time to spine surgery was 14.6 h. A total of 4618 patients (67.3%) underwent surgical intervention within 24 h from hospital arrival. From 2010 to 2020, median time to surgery decreased by an average 0.6 h (±0.15) per year. A multi-variable adjusted model for time to surgery demonstrated a significant downward annual reduction of 5% in time to surgery between the years 2010 and 2020 (Incidence rate ratio = 0.95; 95% Confidence Interval: 0.93-0.96). This study provides compelling real-world based quantification of the change in time to surgical intervention following traumatic cervical SCI. A significant decreasing annual trend pertaining to surgical timing across trauma centers in North America over the past decade was demonstrated.

Self-Efficacy of Nurses and Physicians in the Emergency Department and Its Influence on the Outcomes of Trauma Patients

The purpose of this study was to examine the effect of self-efficacy on the implementation of the adult trauma clinical practice guidelines (ATCPGs) on improving trauma patient outcomes, including missed injuries, and ED LOS. Nurses' and physicians' self-efficacy in performing ATCPGs skills were evaluated three months prior to and three months after the intervention's implementation. Multiple strategies of ATCPGs implementation improved the length of stay (LOS) in the ED for multiple trauma patients. The quasi-experimental design has been implemented in this interventional study. Post-intervention, the self-efficacy of ED healthcare providers in performing ATCPGs skills has increased. Implementation of the ATCPGs has improved the outcomes of patients with multiple traumas. There were 66 patients in this study, and 53 (80.3%) of them were male. The ATCPGs intervention resulted in a statistically significant decrease in the amount of time spent in the ED, as shown by a comparison of the ED LOS in minutes between the two groups (t = 2.56; p = 0.013). Implementing the ATCPGs has improved multiple trauma patients' outcomes. The results will help decision-makers at hospitals to facilitate interdisciplinary ATCPGs training sessions and establish policies and procedures to introduce adult trauma sheet in the ED to improve multiple trauma patients' outcomes.

Epidemiology of work-related hand and wrist injuries in a referral center: A descriptive study

BACKGROUND

Occupational hand and wrist injuries (OHWIs) account for 25% of work-related accidents in low- and middle-income countries. In Colombia, more than 500000 occupational accidents occurred in 2021, and although the rate declined to less than 5% in 2020 and 2021, at least one in four accidents involved a hand or wrist injury.

AIM

To describe the OHWIs in workers seen at the emergency room at a second-level hospital in Colombia.

METHODS

An observational study was performed using data from workers who experienced OHWIs and attended a second-level hospital, between June, 2020 and May, 2021. The overall frequency of OHWIs, as well as their distribution by sociodemographic, clinical, and occupational variables, are described. Furthermore, association patterns between sex, anatomical area (fingers, hand, wrist), and type of job were analyzed by correspondence analysis (CA).

RESULTS

There were 2.101 workers treated for occupational accidents, 423 (20.3%) were cases of OHWIs, which mainly affected men (93.9%) with a median age of 31 years and who worked mainly in mining (75.9%). OHWIs were more common in the right upper extremity (55.3%) and comprised different types of injuries, such as contusion (42.1%), laceration (27.9%), fracture (18.7%), and crush injury (15.6%). They primarily affected the phalanges (95.2%), especially those of the first finger (25.7%). The CAs showed associations between the injured anatomical area and the worker's job that differed in men and women (explained variance > 90%).

CONCLUSION

One out of five workers who suffered occupational accidents in Cundinamarca, Columbia had an OHWI, affecting mainly males employed in mining. This occupational profile is likely to lead to prolonged rehabilitation, and permanent functional limitations. Our results might be useful for adjusting preventive measures in cluster risk groups.

Role of platelet-to-lymphocyte ratio at the time of arrival to the emergency room as a predictor of short-term mortality in trauma patients with severe trauma team activation

BACKGROUND

Platelet-to-Lymphocyte ratio (PLR) has been studied as a prognostic factor for various diseases and traumas. This study examined the utility of PLR as a tool for predicting 30-day mortality in patients experiencing severe trauma.

METHODS

This study included 139 patients who experienced trauma and fulfilled ≥1 criteria for activation of the hospital's severe trauma team. Patients were divided into non-survivor and survivor groups. Mean PLR values were compared between the groups, the optimal PLR cut-off value was determined, and mortality and survival analyses were performed. Statistical analyses were performed using SPSS ver. 26.0. The threshold of statistical significance was P<0.05.

RESULTS

There was a significant difference in mean (±standard deviation) PLR between the non-survivor (n=36) and survivor (n=103) groups (53.4±30.1 vs. 89.9±53.3, respectively; P<0.001). Receiver operating characteristic (ROC) curve analysis revealed an optimal PLR cut-off of 65.35 (sensitivity, 0.621; specificity, 0.694, respectively; area under the ROC curve, 0.742), and Kaplan-Meier survival analysis revealed a significant difference in mortality rate between the two groups.

CONCLUSIONS

PLR can be calculated quickly and easily from a routine complete blood count, which is often performed in the emergency department for individuals who experience trauma. The PLR is useful for predicting 30-day mortality in trauma patients with severe trauma team activation.

Nursing interventions and activities for patients with multiple traumas: An integrative review

PURPOSE

The purpose of this study was to identify nursing interventions and activities for patients with multiple traumas who have variations in physical mobility.

METHODS

We used integrative literature review following Whittemore and Knafl method and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses' guidelines and adopting the Oxford Center for Evidence-Based Classification Medicine - Levels of Evidence. The data collection was carried out between October and December 2019 and updated in May 2022, in the following databases: Virtual Health Library, Cochrane Library, Excerpta Medica dataBASE, Medical Literature Analysis and Retrieval System Online, PubMed®, SciVerse Scopus, The Cumulative Index to Nursing and Allied Health Literature, and Web of Science.

FINDINGS

There were 103 articles to be fully read and evaluated. From these, 34 publications were selected. Most nursing interventions and activities identified were placed in the NIC class Activity and Exercise Management in the Physiological: Basic domain, which has interventions to organize or to assist with physical activity, energy conservation, and expenditure; followed by Elimination Management (interventions to establish and maintain regular bowel and urinary elimination patterns and manage complications due to altered patterns); Immobility Management (interventions to manage restricted body movement and the sequelae); Nutrition Support (interventions to modify or maintain nutritional status); Physical Comfort Promotion (interventions to promote comfort using physical techniques); and Self-Care Facilitation (interventions to provide or assist with routine activities of daily living).

CONCLUSIONS

The interventions and nursing activities found in this research were not only related to the change in mobility in victims of multiple traumas but also aimed to prevent the consequences of immobility and to take care of already established conditions.

IMPLICATIONS FOR THE NURSING PRACTICE

This research enables the taxonomy's development and the validation of interventions for selected groups of patients. This allows the contribution to the development of the NIC-an important resource to improve nursing practice in teaching, research, and care.

["Stop the bleeding"-Acute bleeding control in injuries to the trunk and extremities]

Trauma-related blood loss is still associated with a high mortality and is a major factor in the development of a deadly triad consisting of acidosis, hypothermia and coagulopathy. Sources of bleeding occur particularly in the thoracic, abdominal and pelvic regions as well as in the extremities. For control of bleeding a timely identification of the source of bleeding and the initiation of a targeted treatment are essential. The principles are to stop the blood loss as soon as possible and to restore the lost volume to avoid the complications associated with traumatic hemorrhage. Surgical treatment in the acute situation is especially important due to its efficiency. The present article focuses on the current literature with respect to the appropriate diagnostic and treatment measures in the thoracic, abdominal and pelvic regions as well as the extremities and describes the latest scientific insights and developments. Available trauma algorithms are presented and the value of various strategies regarding surgical hemostasis for the thorax and abdomen are shown, whereby organ preservation can increasingly be achieved, particularly in the abdomen. With respect to hemostasis in severe pelvic injuries and injuries to the extremities, the regularly used surgical techniques are described and their values are differentially classified.

Permissive hypotension compared to fluid therapy for the management of traumatic haemorrhage: a rapid review

Background

Haemorrhage and subsequent hypovolemia from traumatic injury is a potentially reversible cause of cardiac arrest, as interventions can be made to increase circulatory volume and organ perfusion. Traditionally, intravenous (IV) fluid therapy is recommended for all patients who have experienced a haemorrhagic emergency. There has been some argument, however, that this may not be the most effective treatment as isotonic fluids can dilute coagulation factors and further stimulate bleeding. Permissive hypotension, also known as hypotensive resuscitation within the context of damage control resuscitation, is a method of managing haemorrhagic trauma patients by restricting IV fluid administration to allow for a reduced blood pressure. It is important to evaluate and compare current research literature on the effects of both permissive hypotension and fluid therapy on patients suffering from traumatic haemorrhage.

Methods

A rapid review was conducted by systematically searching and identifying literature to narratively compare permissive hypotension and fluid therapy. Searches were carried out across two databases to find relevant primary research containing quantitative data that provide contextual and statistical evidence to achieve the aim of this review. Papers were narratively synthesised to produce key themes for discussion.

Results

The database searches identified 125 records, 78 from PubMed and 47 from ScienceDirect. Eleven duplicates were removed, and 114 titles screened. Ninety-four records were initially excluded and nine more after abstract review. Eleven papers were critiqued using Benton and Cormack's framework, with eight articles included in the final review.

Conclusion

Permissive hypotension may have a positive impact on 30-day mortality, when compared with fluid resuscitation methods, however there is evidence to suggest that hypotensive resuscitation may be more effective for blunt force injuries. Some studies even suggest a reduction in the treatment cost when reducing fluid volumes. Penetrating injuries are usually more likely to be a compressible source of haemorrhage within which haemorrhage control can be gained much more easily. There are recommendations for the use of permissive hypotension in both compressible and non-compressible injuries. It is difficult at this time to draw definitive conclusions for the treatment of every case related to traumatic haemorrhage given the variability and unpredictability of trauma.

Effects of Targeted Intervention plus Comprehensive Nursing on the Quality of Life and Nursing Satisfaction in Multiple Traumas

Objective

To explore the effect of targeted intervention plus comprehensive nursing on quality of life and nursing satisfaction of patients with multiple traumas.

Methods

Totally 68 cases with multiple traumas admitted to Xishan People's Hospital from September 2018 to September 2019 were recruited and randomized into a control group and a study group via the random number table method, with 34 cases in each group. The control group received conventional nursing, and the study group adopted targeted intervention plus comprehensive nursing.

Results

The study group showed significantly lower life scores and Hospital Anxiety and Depression Scale (HADS) scores after the intervention, as compared to the control group. The average Newcastle Nursing Service Satisfaction Scale (NSNS) scores, various self-care ability scores, and comprehensive self-care ability scores were higher than those of the control group. Significantly lower Numerical Rating Scale (NRS) scores were observed in the study group at 7 d and 10 d of intervention than those of the control group.

Conclusion

Targeted intervention plus comprehensive nursing enhances the quality of life of patients and nursing satisfaction, which merits clinical promotion.

Comparison of Five Triage Tools for Identifying Mortality Risk and Injury Severity of Multiple Trauma Patients Admitted to the Emergency Department in the Daytime and Nighttime: A Retrospective Study

Effective triage tools are indispensable for doctors to make a prompt decision for the treatment of multiple trauma patients in emergency departments (EDs). The Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), standardized early warning score (SEWS), Modified Rapid Emergency Medicine Score (mREMS), and Revised Trauma Score (RTS) are five common triage tools proposed for trauma management. However, few studies have compared these tools in a multiple trauma cohort and investigated the influence of nighttime admission on the performance of these tools. This retrospective study was aimed at evaluating and comparing the performance of MEWS, NEWS, SEWS, mREMS, and RTS for identifying the mortality risk and trauma severity of patients with multiple trauma admitted to the ED during the daytime and nighttime. Retrospective data were collected from the medical records of patients with multiple trauma admitted in the daytime or nighttime to calculate scores for each triage tool. Logistic regression analysis was conducted on each triage tool for identifying in-hospital mortality and severe trauma (injury severity score > 15) in the daytime and nighttime. The performance of the tools was evaluated and compared by calculating area under the receiver operating characteristic curve (AUROC) of the retrospective logistic model of each tool. We collected data for 1,818 admissions, including 1,070 daytime and 748 nighttime admissions. A comparison of performance for identifying in-hospital mortality between daytime and nighttime yielded the following results (AUROC): MEWS (0.95 vs. 0.93, p = 0.384), NEWS (0.95 vs. 0.94, p = 0.708), SEWS (0.95 vs. 0.94, p = 0.683), mREMS (0.94 vs. 0.92, p = 0.286), and RTS (0.93 vs. 0.93, p = 0.87). Similarly, a comparison of performance for identifying trauma severity between daytime and nighttime yielded the following results (AUROC): MEWS (0.78 vs. 0.78, p = 0.95), NEWS (0.8 vs. 0.8, p = 0.885), SEWS (0.78 vs. 0.78, p = 0.818), mREMS (0.75 vs. 0.69, p = 0.019), and RTS (0.75 vs. 0.74, p = 0.619). All five scores are excellent triage tools (AUROC ≥ 0.9) for identifying in-hospital mortality for both daytime and nighttime admissions. However, they have only moderate effectiveness (AUROC < 0.9) at identifying severe trauma. The NEWS is the best triage tool for identifying severe trauma for both daytime and nighttime admissions. The MEWS, NEWS, SEWS, and RTS exhibited no significant differences in performance for identifying in-hospital mortality or severe trauma during the daytime or nighttime. However, the mREMS was better at identifying severe trauma during the daytime.

Structured Reporting of Whole-Body Trauma CT Scans Using Checklists: Diagnostic Accuracy of Reporting Radiologists Depending on Their Level of Experience

PURPOSE

 Evaluation of the diagnostic accuracy of a checklist-style structured reporting template in the setting of whole-body multislice computed tomography in major trauma patients depending on the level of experience of the reporting radiologist.

MATERIALS AND METHODS

 A total of 140 major trauma scans with the same protocol were included in this retrospective study. In a purely trial-intended reading, the trauma scans were analyzed by three radiologists with different levels of experience (resident, radiologist with 3 years of experience after board certification, and radiologist with 7 years of experience after board certification). The aim was to fill in the checklist 1 template within one minute to immediately diagnose management-altering findings. Checklist 2 was intended for the analysis of important trauma-related findings within 10 minutes. Reading times were documented. The final radiology report and the documented injuries in the patient's medical record were used as gold standard.

RESULTS

 The evaluation of checklist 1 showed a range of false-negative reports between 5.0 % and 11.4 % with the resident showing the highest accuracy. Checklist 2 showed overall high diagnostic inaccuracy (19.3-35.0 %). The resident's diagnostic accuracy was statistically significantly higher compared to the radiologist with 3 years of experience after board certification (p = 0.0197) and with 7 years of experience after board certification (p = 0.0046). Shorter average reporting time resulted in higher diagnostic inaccuracy. Most of the missed diagnoses were fractures of the spine and ribs.

CONCLUSION

 By using a structured reporting template in the setting of major trauma computed tomography, less experienced radiologists reach a higher diagnostic accuracy compared to experienced readers.

KEY POINTS

  · In the setting of a pure trial reading, the diagnostic inaccuracy of template-based reporting of major trauma CT examinations is high.. · Fractures in general and especially of the vertebral bodies and ribs were the most commonly missed diagnoses.. · In a study setting, less experienced radiologists seem to reach a higher diagnostic accuracy when using a structured reporting approach..

CITATION FORMAT

· Dendl LM, Pausch AM, Hoffstetter P et al. Structured Reporting of Whole-Body Trauma CT Scans Using Checklists: Diagnostic Accuracy of Reporting Radiologists Depending on Their Level of Experience. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1541-8265.

[Trauma center management]

Every year, more than 20,000 patients with polytrauma are treated in Germany. The term polytrauma refers to simultaneous injury to several body regions that are individually or collectively life-threatening for the patient. However, this assessment is made based on appropriate scoring systems. Adequate treatment of these patients requires not only medical care at the highest level, but also coordination of organizational/logistical processes. The link between preclinical and clinical care is treatment in the shock room, which should be led by a defined, experienced "trauma leader". Treatment algorithms are based on the current S3 guideline Polytrauma/Serious Injury Treatment of the AWMF and the White Paper on Serious Injury Care. Here, recommendations are defined regarding personnel, spatial, logistical and material requirements. Every shock room team should be trained regularly and have theoretical and practical knowledge on the application of shock room algorithms. This can improve the quality of treatment and thus the probability of survival of critically ill patients. In the shock room itself, the focus is on standardized and priority-oriented assessment and stabilization of the patient. Due to the varying quality of care for severely injured patients in Germany, the TraumaNetwork DGU® initiative was implemented by the German Society of Trauma Surgery to improve the treatment of polytrauma patients by defining standards and improving processes and organization in the care of severely injured patients. In Germany, there are currently 615 participating hospitals that are organized in 52 local trauma networks, some of which are cross state borders.

Influence of Oral Anticoagulation and Antiplatelet Drugs on Outcome of Elderly Severely Injured Patients

Introduction: Severely injured elderly patients have a poorer prognosis and higher mortality rates after severe trauma compared with younger patients. The aim of this study was to correlate the influence of pre-existing oral anticoagulation (OAC) and antiplatelet drugs (PAI) on the outcome of severely injured elderly patients. Methods: Using a prospective cohort study model over an 11-year period, severely injured elderly patients (≥65 years and ISS ≥ 16) were divided into two groups (no anticoagulation/platelet inhibitors: nAP and OAC/PAI). A comparison of the groups was conducted regarding injury frequency, trauma mechanism, severity of head injuries, and medication-related mortality. Results: In total, 254 out of 301 patients were analyzed (nAP: n = 145; OAC/PAI: n = 109, unknown data: n = 47). The most relevant injury was falling from low heights (<3 m), which led to a significantly higher number of severe injuries in patients with OAC/PAI. Patients with pre-existing OAC/PAI showed a significantly higher overall mortality rate compared to the group without (38.5% vs. 24.8%; p = 0.019). The severity of head injuries in OAC/PAI was also higher on average (AIS 3.7 ± 1.6 vs. 2.8 ± 1.9; p = 0.000). Conclusion: Pre-existing oral anticoagulation and/or platelet aggregation inhibitors are related to a higher mortality rate in elderly polytrauma patients. Low-energy trauma can lead to even more severe head injuries due to pre-existing medication than is already the case in elderly patients without OAC/PAI.

Strategies for the treatment of femoral fractures in severely injured patients: trends in over two decades from the TraumaRegister DGU®

Purpose

Treatment strategies for femoral fracture stabilisation are well known to have a significant impact on the patient’s outcome. Therefore, the optimal choices for both the type of initial fracture stabilisation (external fixation/EF, early total care/ETC, conservative treatment/TC) and the best time point for conversion from temporary to definitive fixation are challenging factors.

Patients

Patients aged ≥ 16 years with moderate and severe trauma documented in the TraumaRegister DGU^® between 2002 and 2018 were retrospectively analysed. Demographics, ISS, surgical treatment strategy (ETC vs. EF vs. TC), time for conversion to definitive care, complication (MOF, sepsis) and survival rates were analysed.

Results

In total, 13,091 trauma patients were included. EF patients more often sustained high-energy trauma (car: 43.1 vs. 29.5%, p < 0.001), were younger (40.6 vs. 48.1 years, p < 0.001), were more severely injured (ISS 25.4 vs. 19.1 pts., p < 0.001), and had higher sepsis (11.8 vs. 5.4%, p < 0.001) and MOF rates (33.1 vs. 16.0%, p < 0.001) compared to ETC patients. A shift from ETC to EF was observed. The time until conversion decreased for femoral fractures from 9 to 8 days within the observation period. Sepsis incidences decreased in EF (20.3 to 12.3%, p < 0.001) and ETC (9.1–4.8%, p < 0.001) patients.

Conclusions

Our results show the changes in the surgical treatment of severely injured patients with femur fractures over a period of almost two decades caused by the introduction of modern surgical strategies (e.g., Safe Definitive Surgery). It remains unclear which subgroups of trauma patients benefit most from these strategies.

Advantage of surgical intensive care unit (SICU) predominant by cardiothoracic surgeons in multiple trauma management in a primary hospital

PURPOSE

It is a challenge for the primary hospitals to manage multiple trauma patients. In this article, we explored the advantage of establishing a surgical intensive care unit (SICU) predominant by cardiothoracic surgeons in the early management of multiple trauma.

METHODS

This was a retrospective study and patients with multiple trauma in our hospital were collected and divided into two groups, based on time period and treat modes: group A (retrospective observation group) where patients were treated with the traditional treatment mode from January 2017 to December 2017 and group B (study group) where patients were treated in the SICU predominant by cardiothoracic surgeons from January 2018 to December 2018. Clinical data including demographics, injury severity score (ISS), causes of injury, time intervals from reception to entering SICU or operating room and mortality three days after injuries were collected. Data were analyzed by SPSS 20.0 software. Categorical variables were presented as number and/or frequency and continuous variables as mean ± SD.

RESULTS

Altogether 406 patients were included in this study, including 217 patients in group A and 189 patients in group B. General data between the two groups revealed no significant difference: mean age (years) (35.51 ± 12.97 vs. 33.62 ± 13.61, p = 0.631), gender distribution (mean/female, 130/87 vs. 116/73, p = 0.589) and ISS (15.92 ± 7.95 vs. 16.16 ± 6.89, p = 0.698). Fall from height were the dominant mechanism of injury, with 135 cases in group A (71.4%) and 121 cases in group B (55.8%), followed by traffic accidents. Injury mechanism showed no significant differences between two groups (p = 1.256). Introduction of the SICU significantly improved the care of trauma patients, regarding speed and mortality. Time intervals between reception and entering SICU or operating room was (108.23 ± 6.72) min and (45.67 ± 7.96) min in group A and B, respectively (p = 0.001). Mortality three days after injuries was 13.89% and 5.53% in group A and B, respectively (p = 0.005).

CONCLUSION

Establishing a SICU predominant by cardiothoracic surgeons can reduce the early mortality rates in multiple trauma patients.

Patients' experiences and wellbeing after injury: A focus group study

Background

Injury can have physical, psychological and social consequences. It is unclear which factors have an impact on patients’ wellbeing after injury. This study aimed to explore, using focus groups, patients’ experiences and wellbeing after injury and which factors, impede or facilitate patients’ wellbeing.

Methods

Trauma patients, treated in the shock room of the Elisabeth-TweeSteden Hospital, the Netherlands, participated in focus groups. Purposive sampling was used. Exclusion criteria were younger than 18 years old, severe traumatic brain injury, dementia, and insufficient knowledge of the Dutch language. The interviews were recorded, transcribed verbatim, and analyzed using coding technique open, axial, and selective coding, based on phenomenological approach.

Results

Six focus groups (3 to 7 participants) were held before data saturation was reached. In total, 134 patients were invited, 28 (21%) agreed to participate (Median age: 59.5; min. 18 –max. 84). Main reasons to decline were fear that the discussion would be too confronting or patients experienced no problems regarding the trauma or treatment. Participants experienced difficulties on physical (no recovery to pre-trauma level), psychological (fear of dying or for permanent limitations, symptoms of posttraumatic stress disorder, cognitive dysfunction), social (impact on relatives and social support) wellbeing. These are impeding factors for recovery. However, good communication, especially clarity about the injury and expectations concerning recovery and future perspectives could help patients in surrendering to care. Patients felt less helpless when they knew what to expect.

Conclusions

This is the first study that explored patients’ experiences and wellbeing after injury. Patients reported that their injury had an impact on their physical, psychological, and social wellbeing up to 12 months after injury. Professionals with the knowledge of consequences after injury could improve their anticipation on patients’ need.

Are There Any Red Flag Injuries in Severely Injured Patients in Older Age?

Introduction: Severely injured elderly patients pose a significant burden to trauma centers and, compared with younger patients, have worse prognoses and higher mortality rates after major trauma. The objective of this study was to identify the etiological mechanisms that are associated with severe trauma in elderly patients and to detect which injuries correlate with high mortality in elderly patients. Methods: Using a prospect cohort study model over an 11-year period, severely injured patients (ISS ≥ 16) were divided into two age groups (Group 1: 18–64; Group 2: 65–99 years). A comparison of the groups was conducted regarding injury frequency, trauma mechanism, distribution of affected body parts (AIS and ISS regions) and injury related mortality. Results: In total, 1008 patient were included (Group 1: n = 771; Group 2: n = 237). The most relevant injury in elderly patients was falling from low heights (<3 m) in contrast to traffic accident in young patients. Severely injured patients in the older age group showed a significantly higher overall mortality rate compared to the younger group (37.6% vs. 11.7%; p = 0.000). In both groups, the 30-day survival for patients without head injuries was significantly better compared to patients with head injuries (92.7% vs. 85.3%; p = 0.017), especially analyzing elderly patients (86.6% vs. 58.6%; p = 0.003). The relative risk of 30-day mortality in patients who suffered a head injury was also higher in the elderly group (OR: Group 1: 4.905; Group 2: 7.132). Conclusion: In contrast to younger patients, falls from low heights (<3 m) are significant risk factors for severe injuries in the geriatric collective. Additionally, elderly patients with an ISS ≥ 16 had a significantly higher mortality rate compared to severe injured younger patients. Head injuries, even minor head traumata, are associated with a significant increase in mortality. These findings will contribute to the development of more age-related therapy strategies in severely injured patients.

An improved modified early warning score that incorporates the abdomen score for identifying multiple traumatic injury severity

Background

Rapid identification of trauma severity is essential for the timely triage of multiple trauma patients. Tools such as the modified early warning score (MEWS) are used for determining injury severity. Although the conventional MEWS is a good predictor of mortality, its performance assessing injury severity is moderate. This study hypothesized that adding an injury site severity-related score (e.g., abdomen score) may enhance the capability of the MEWS for identifying severe trauma.

Method

To validate the hypothesis, we propose an improved modified early warning score called MEWS-A, which incorporates an injury site-specific severity-related abdomen score to MEWS. The utility of MEWS and MEWS-A were retrospectively evaluated and compared for identifying trauma severity in adult multiple trauma patients admitted to the emergency department.

Results

We included 1,230 eligible multiple trauma patients and divided them into minor and severe trauma groups based on the injury severity score. Results of logistic regression and receiver operating characteristic (ROC) curve analyses showed that the MEWS-A had a higher area under the ROC curve (AUC: 0.81 95% CI [0.78-0.83]) than did the MEWS (AUC: 0.77 95% CI [0.74-0.79]), indicating that the MEWS-A is superior to the MEWS in identifying severe trauma. The optimal MEWS-A cut-off score is 4, with a specificity of 0.93 and a sensitivity of 0.54. MEWS-A ≥ 4 can be used as a protocol for decision-making in the emergency department.

Conclusions

Our study suggests that while the conventional MEWS is sufficient for predicting mortality risk, adding an injury site-specific score (e.g., abdomen score) can enhance its performance in determining injury severity in multiple trauma patients.

Management of multiple traumas in emergency medicine department: A review

One of the main causes of adults' disability during their working age is multiple trauma. The process of medical care of patients who are injured seriously is still a challenging job. The primary treatment of these patients in the emergency medicine departments is the most required choice after the wilderness first aid and also would be very required before definitive care in the hospital. The main aim of emergency medicine departments is quick recognition and treatment of injuries which pose severe threat to patients' life in appropriate order of priority. The procedure of primary evaluation in emergency medicine department with the help of medical routine examination and ultrasonography is based on the concept of focused assessment with sonography in trauma (FAST) for identifying spontaneous intraperitoneal hemorrhage. Emergency patients who suffer from massive hematothorax, serious lung and heart traumas, and penetrating traumas to the chest would undergo thoracotomy and patients who have few symptoms of perforated hollow viscous will undergo emergency laparotomy. Based on the trauma severity, emergency treatment could be the way to fast recovery of the structure of injured organ and its function. The subsequent goal, in the acute phase, will concentrate on preventing and stopping bleeding and secondary injuries like painful compartment syndrome or intra-abdominal infections (IAIs). However, the main aim of emergency medicine department in taking care of severely injured patients is the management of airway, protecting circulation and breathing, identification of neurologic problems, and whole body clinical examination with the help of healthcare providers.

Clinical validation of nursing diagnosis "00085 Impaired Physical Mobility" in multiple traumas victims

OBJECTIVE

to clinically validate the nursing diagnosis "Impaired Physical Mobility", identifying its prevalence, defining characteristics, related factors, and associated conditions with the calculation of accuracy measures and generation of Decision Trees, as well as clinically and etiologically characterize the multiple traumas victims.

METHOD

methodological, cross-sectional study of clinical validation type, using diagnostic accuracy measures and generating decision tree.

RESULTS

the sample consisted of 126 patients, 73% male, with a mean age of 38.29 years. The frequency of the nursing diagnosis studied was 88.10%; the defining characteristic with the highest prevalence was "Difficulty turning" (58.73%), with a predictive power of 98.6%; the associated condition "Alteration in bone structure integrity" stood out with 72.22%. The accuracy measures also indicated their predictive power.

CONCLUSION

the components aforementioned were considered predictors of this diagnosis. This study contributed to improve the identification of clinical indicators associated with advanced methods of diagnostic validation, directing care and reducing the variability present in clinical situations.

The Correlation of Serum Chloride Level and Hospital Mortality in Multiple Trauma Patients

Introduction:

Electrolyte disorder is a prevalent complication in multiple trauma patients; nevertheless, the role of chloride has been rarely addressed in literature when evaluating serum electrolytes.

Objective:

The present study was conducted to determine the correlation between serum chloride changes and hospital mortality in multiple trauma patients.

Method:

The present cross-sectional study measured serum chloride levels in 100 multiple trauma patients upon their admission to the emergency department and 24 hours later. All these patients were followed up in terms of hospital mortality using their medical records. Exact logistic regression was used to measure the effects of independent variables on hospital mortality in the patients.

Results:

Hospital mortality was found to be 15 (15%), and the mean serum chloride level to be 106.37±4.53 mmol/l upon admission and 112.18±6.16 mmol/l 24 hours later. Although the univariate analysis suggested that serum chloride levels were independently associated with mortality 24 hours after admission (P=0.005), this correlation was insignificant in the multivariate analysis.

Conclusion:

The present study rejected the hypothesis suggesting the potential role of serum chloride levels in predicting hospital mortality in multiple trauma patients.

Bedside-measurement of serum cholinesterase activity predicts patient morbidity and length of the intensive care unit stay following major traumatic injury

Major traumatic injury (MTI), a life-threatening condition requiring prompt medical intervention, is associated with an extensive inflammatory response often resulting in multiple organ dysfunction. Early stratification of trauma severity and the corresponding inflammation may help optimize resources at the intensive care unit (ICU). The cholinergic system counters inflammation by quickly modulating the immune response. Serum cholinesterase (butyrylcholinesterase, BChE) is an enzyme that hydrolyses acetylcholine. We tested whether a change in the BChE activity correlates with the morbidity and the length of ICU stay. Blood samples from 10 healthy volunteers and 44 patients with MTI were gathered at hospital admission, followed by measurements 12, 24 and 48 hours later. Point-of-care approach was used to determine the BChE activity. Disease severity was assessed by clinical scoring performed within 24 hours following hospital admission. BChE activity, measured at hospital admission, showed a significant and sustained reduction and correlated with disease severity scores obtained 24 hours following admission. BChE activity, obtained at hospital admission, correlated with the length of ICU stay. Bedside measurement of BChE activity, as a complementary addition to established procedures, might prove useful in the primary assessment of the disease severity and might therefore optimize therapy in the ICU.

Critical incident reporting systems (CIRS) in trauma patients may identify common quality problems

BACKGROUND

Critical incident reporting systems (CIRS) are considered to be a valid instrument to identify typical errors in various clinical settings as well as in prehospital emergency medicine. Our aim was to review incidents and errors in the care of trauma patients during the period of emergency trauma room treatment before their transfer to the intensive care unit or the operation room.

METHODS

We screened six open access and German language-based CIRS-platforms on the internet.

RESULTS

We identified 78 critical incidents. They could be divided into four groups: organization related (n = 30), communication related (n = 6), equipment related (n = 28), and medical error (n = 23). Within the category, typical, common, or frequent clusters were identified, such as incomplete trauma team, malfunctioning equipment, or a lack of communication skills. In 12 cases (15.4%), patients were reported to have been harmed, mostly by medical errors. Three reported incidents (3.6%) were considered near-incidents.

CONCLUSIONS

Our results demonstrate that using CIRS is able to reveal individual or rare errors and allows for the identification of systematic errors and deficiencies in the acute care of trauma patients in the trauma room. This may guide quality control and quality improvement measures to be focused on the most common fields of demand.

[Focused sonography in orthopedic emergencies]

Focused sonography of the musculoskeletal system in the emergency room should be done for time-effective and symptom-oriented detection of suspected findings. Analogous to other point-of-care ultrasound in emergency medicine, it is by definition not a complete ultrasound examination of the respective organ (e.g., shoulder, elbow). It allows detection of important findings (luxation, effusion, fracture or rupture) with good to excellent diagnostic accuracy. Afterwards computed tomography, magnetic resonance imaging or complete sonographic examination (according to the guidelines of the working group Bewegungsorgane der Deutschen Gesellschaft für Ultraschall in der Medizin, which are identical to those of the working group Orthopädie und Unfallchirurgie) should be added as clinically required. Sonography of the musculoskeletal system in the emergency room can be performed on the lying or sitting patient, except when examining the shoulder, in which there is a difference. The interventional procedures are safe, useful and time saving.

[Optimization of criteria for activation of trauma teams : Avoidance of overtriage and undertriage]

INTRODUCTION

Severely injured patients are supposed to be admitted to hospital via the trauma room. Appropriate criteria are contained in the S3 guidelines on the treatment of patients with severe/multiple injuries (S3-GL); however, some of these criteria require scarce hospital resources while the patients then often clinically present as uninjured. There are tendencies to streamline the trauma team activation criteria (TTAC); however, additional undertriage must be avoided. A study group of the emergency, intensive care medicine and treatment of the severely injured section (NIS) is in the process of optimizing the TTAC for the German trauma system.

MATERIAL AND METHODS

In order to solve the objective the following multi-step approach is necessary: a) definition of patients who potentially benefit from TTA, b) verification of the definition in the TraumaRegister DGU® (TR-DGU), c) carrying out a prospective, multicenter study in order to determine overtriage and undertriage, thereby validating the activation criteria and d) revision of the current TTAC.

RESULTS

This article summarizes the consensus criteria of the group assumed to be capable of identifying patients who potentially benefit from TTA. These criteria are used to test if TTA was justified in a specific case; however, as the TTCA of the S3-GL are not fully incorporated into the TR-DGU dataset and because cases must also be considered which were not subject to trauma room treatment and therefore were not included in the TR-DGU, it is necessary to perform a prospective full survey of all individuals in order to be able to measure overtriage and undertriage.

CONCLUSION

Currently, the TR-DGU can only provide limited evidence on the quality of the TTAC recommended in Germany. This problem has been recognized and will be solved by conducting a prospective DGU-supported study, the results of which can be used to improve the TR-DGU dataset in order to enable further considerations on the quality of care (e. g. composition and size of the trauma team).