A profile of deaths among trauma patients in a university hospital: the Philippine experience

Predicting the time of mortality among older adult trauma patients: Is frailty the answer?

INTRODUCTION

This study aims to evaluate the temporal trends of mortality among frail versus non-frail older adult trauma patients during index hospitalization.

METHODS

We performed a 3-year (2017-2019) analysis of ACS-TQIP. We included all older adult (age ≥65 years) trauma patients. Patients were stratified into two groups (Frail vs. Non-Frail). Outcomes were acute (<24 ​h), early (24-72 ​h), intermediate (72 hours-1 week), and late (>1 week) mortality.

RESULTS

A total of 1,022,925 older adult trauma patients were identified, of which 19.7 ​% were frail. The mean(SD) age was 77(8) years and 57.4 ​% were female. Median[IQR] ISS was 9[4-10] and both groups had comparable injury severity (p ​= ​0.362). On multivariable analysis, frailty was not associated with acute (aOR 1.034; p ​= ​0.518) and early (aOR 1.190; p ​= ​0.392) mortality, while frail patients had independently higher odds of intermediate (aOR 1.269; p ​= ​0.042) and late (aOR 1.835; p ​< ​0.001) mortality. On sub-analysis, our results remained consistent in mild, moderate, and severely injured patients.

CONCLUSION

Frailty is an independent predictor of mortality in older adult trauma patients who survive the initial 3 days of admission, regardless of injury severity.

Hemostatic efficacy evaluation of radiation-crosslinked carboxymethyl cellulose granules and kappa-carrageenan/polyethylene oxide/polyethylene glycol dressing in rat bleeding models

Carboxymethyl cellulose granules (CMC-G) and kappa-carrageenan/polyethylene oxide/polyethylene glycol dressing (KPP-D) hemostatic agents, developed through radiation-induced crosslinking and sterilization, were tested in Sprague-Dawley rats using three bleeding models: (a) deep wound with the puncture of femoral artery; (b) aortic puncture; and (c) partial nephrectomy. Dressing and granules were applied in the animals without sustained compression and monitored for a period of 7 or 14 days. Comparisons were made against the commercial chitosan-based agent, Celox (CLX). Primary outcomes observed were bleeding time, the incidence of re-bleeding, animal survival, as well as gross and microscopic changes. The KPP-D group showed the shortest bleeding time for all bleeding models (a. 2.75 ± 0.64, b. 1.63 ± 0.54, c. 2.05 ± 0.62), significantly faster than all the other treatment groups. KPP-D also registered the highest survival rate of 100% with no display of gross abnormalities. CMC-G showed comparable bleeding time with CLX products but had a better survival rate at 98% compared to 96%. The incidence of re-bleeding was greater in CLX treated groups as well as more occurrence of granular adhesions that impacted mortality outcomes. Findings indicate the efficacy of KPP-D in the treatment of severe hemorrhage due to traumatic injury and intraoperative cases, while CMC-G was more suited for external trauma. Complications arising from inflammation, granules deposition, and adhesions emphasize stringent handling and removal of granular hemostat as a critical consideration in hemostat development and testing.

Comparison of trauma care systems in Asian countries: A systematic literature review

OBJECTIVE

The study aims to compare the trauma care systems in Asian countries.

METHODS

Asian countries were categorised into three groups; 'lower middle-income country', 'upper middle-income country' and 'high-income country'. The Medline/PubMed database was searched for articles published from January 2005 to December 2014 using relevant key words. Articles were excluded if they examined a specific injury mechanism, referred to a specific age group, and/or did not have full text available. We extracted information and variables on pre-hospital and hospital care factors, and regionalised system factors and compared them across countries.

RESULTS

A total of 46 articles were identified from 13 countries, including Pakistan, India, Vietnam and Indonesia from lower middle-income countries; the Islamic Republic of Iran, Thailand, China, Malaysia from upper middle-income countries; and Saudi Arabia, the Republic of Korea, Japan, Hong Kong and Singapore from high-income countries. Trauma patients were transported via various methods. In six of the 13 countries, less than 20% of trauma patients were transported by ambulance. Pre-hospital trauma teams primarily comprised emergency medical technicians and paramedics, except in Thailand and China, where they included mainly physicians. In Iran, Pakistan and Vietnam, the proportion of patients who died before reaching hospital exceeded 50%. In only three of the 13 countries was it reported that trauma surgeons were available. In only five of the 13 countries was there a nationwide trauma registry.

CONCLUSION

Trauma care systems were poorly developed and unorganised in most of the selected 13 Asian countries, with the exception of a few highly developed countries.

Prognostic predictors of early mortality from exsanguination in adult trauma: a Malaysian trauma center experience

Background

Trauma mortality due to exsanguination is the second most common cause of death. The objective of this study is to investigate the predictors for early death from exsanguination.

Methods

A prognostic study was done to identify predictors of early mortality due to exsanguination. Data were extracted from our Trauma Surgery Registry database of Sultanah Aminah Hospital, Johor Bahru, Malaysia. All patients who were treated from May 1, 2011 to April 31, 2014 by the trauma team were included. Adult trauma patients included from the Trauma Surgery Registry were divided into two groups for analysis: early death from exsanguination and death from non-exsanguination/survivors. Univariate and multivariate analysis was performed to look for significant predictors of death from exsanguination. Variables analyzed were demography, mechanism of injury, organ injury scale, physiological parameters (systolic blood pressure (SBP), respiratory rate, heart rate, temperature), Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), New Injury Severity Score (NISS), Trauma and Injury Severity Score (TRISS) and cause of death.

Results

A total of 2208 patients with an average age of 36 (±16) years were included. Blunt trauma was the majority with 90.5%, followed by penetrating injuries (9.2%). The overall mortality is 239 out of 2208 (10.8%). Seventy-eight patients (32.6%) died due to central nervous system injury, 69 due to sepsis (28.9%) and 58 due to exsanguination (24.3%). After multivariate analysis, age (OR 1.026 (1.009 to 1.044), p=0.002), SBP (OR 0.985 (0.975 to 0.995), p=0.003) and temperature (OR 0.203 (0.076 to 0.543), p=0.001) were found to be the significant physiological parameters. Intra-abdominal injury and NISS were significant anatomic mortality predictors from exsanguination (p<0.001). Patients with intra-abdominal injury had four times higher risk of mortality from exsanguination (OR 3.948 (2.331 to 6.686), p<0.001).

Discussion

In a Malaysian trauma center, age, SBP, core body temperature, intra-abdominal injury and NISS were significant predictors of early death from exsanguination.

Level of evidence

II.

Prehospital management of gunshot patients at major trauma care centers: exploring the gaps in patient care

BACKGROUND

Prehospital management of gunshot-wounded (GW) patients influences injury-induced morbidity and mortality.

OBJECTIVES

To evaluate prehospital management to GW patients emphasizing the protocol of patient transfer to appropriate centers.

PATIENTS AND METHODS

This prospective study, included all GW patients referred to four major, level-I hospitals in Mashhad, Iran. We evaluated demographic data, triage, transport vehicles of patients, hospitalization time and the outcome.

RESULTS

There were 66 GW patients. The most affected body parts were extremities (60.6%, n = 40); 59% of cases (n = 39) were transferred to the hospitals with vehicles other than an ambulance. Furthermore, 77.3% of patients came to the hospitals directly from the site of event, and 22.7% of patients were referred from other medical centers. EMS action intervals from dispatchers to scene departure was not significantly different from established standards; however, arrival to hospital took longer than optimal standards. Additionally, time spent at emergency wards to stabilize vital signs was significantly less in patients who were transported by EMS ambulances (P = 0.01), but not with private ambulances (P = 0.47). However, ambulance pre-hospital care was not associated with a shorter hospital stay. Injury Severity was the only determinant of hospital stay duration (β = 0.36, P = 0.01) in multivariate analysis.

CONCLUSIONS

GW was more frequent in extremities and the most patients were directly transferred from the accident site. EMS (but not private) ambulance transport improved patients' emergency care and standard time intervals were achieved by EMS; however more than a half of the cases were transferred by vehicles other than an ambulance. Nevertheless, ambulance transportation (either by EMS or by private ambulance) was not associated with a shorter hospital stay. This showed that upgrade of ambulance equipment and training of private ambulance personnel may be needed.

Childhood death attributable to trauma: is there a difference between accidental and abusive fatal injuries?

BACKGROUND

Trauma is a leading cause of death among children worldwide. Detailed knowledge of the epidemiology of childhood fatal injuries is necessary for preventing injuries.

OBJECTIVE

To determine clinical differences between children who were treated in an emergency department for accidental or abusive injuries.

METHODS

A retrospective review of all deceased patients who were treated in two urban pediatric emergency departments between 1998 and 2010 was performed. Patients were categorized into two groups, accidental and abusive, for comparison.

RESULTS

A total of 1498 patients died during the study period, with 124 deaths being attributable to injury for a rate of 9.5 injury-related deaths per year. Most fatal injuries were accidental. Children with abusive fatal injuries were younger and more likely to have been seen for an injury in a clinic or emergency department within 2 months of their death. Eighty-two percent of abusive fatal injuries had documented subdural hematomas, whereas only 7.2% of accidental fatal injuries had a subdural hematoma documented. Nearly 50% of abusive fatal injuries had retinal hemorrhages reported, although no child with an accidental fatal injury had this type of injury documented.

CONCLUSION

Younger children, especially those previously seen in an emergency department or clinic for injury, are more likely to sustain an abusive fatal injury. Sentinel physical findings associated with abusive fatal injuries include subdural hematomas and retinal hemorrhages, and the presence of these findings should prompt an investigation into the circumstances of injury.

Trauma-related Therapeutic Procedures at Shohada Trauma Center in Tabriz

Background

To decrease the burden of injuries it is essential to have an overview of trauma patterns and its management at regional trauma centers.

Objectives

The aim of this study was to investigate some patterns of trauma and trauma-related therapeutic interventions at our trauma center.

Materials and Methods

In a cross-sectional study, 19530 trauma cases admitted to the emergency department and hospital wards of Shohada University Hospital during 2007-2008 were assessed.

Results

Of the 19530 trauma cases, 14960(76.7%) were males. Mean (SD) of age was 31(19.9) years. The elderly aged 65 and above, comprised 10% (1953) of the participants; while 44 were infants. Falls and traffic injuries were the most common cause of injuries among trauma patients. Most of the mortalities were men comprising 74% of the 57 deaths. Reduction of fractures and dislocations were the most common types of operations among trauma patients.

Conclusions

Young men form the target group for possible interventions to decrease the burden of trauma following falls and traffic accidents.