Implementing the IMIST-AMBO tool for paramedic to trauma team handovers: a video review analysis

OBJECTIVE

Patient handover between paramedics and the trauma team is vulnerable to communication errors that may adversely affect patient care. This study assesses the feasibility of a handover tool, IMIST-AMBO (acronym of categories), implementation in the trauma bay and evaluates the degree to which it improves handover metrics.

METHODS

This is a prospective observational cohort study conducted at Canada's largest level-one trauma center. Feasibility of the tool implementation and improvement in handover metrics were assessed. Strategies for implementation included distribution of an educational video and posters, and point-of-care reminders in the trauma bay. Two reviewers independently assessed video recordings of handovers to evaluate handover metrics. Findings were compared to data obtained during a knowledge gap analysis conducted prior to the initiation of this study at the same institution.

RESULTS

Over 13 weeks (August to November 2020), 140 videos were recorded, of which 80 used the IMIST-AMBO tool (compliance of 57%). Paramedic adherence to the handover structure occurred in 70.4% of cases, with greater adherence to the IMIST (82.2%) compared to the AMBO (47.1%) section. The mean (± standard deviation) handover duration was shorter (1 min:58 s ± 0:44 s during implementation vs. 2 min:47 s ± 1:14 s pre-implementation, [p < 0.001]). Frequency of parallel conversations and informal handovers improved (61% to 30% and 65% to 13%, [p < 0.001], respectively). Interruptions during the handover decreased from 3.05 (± 1.95) to 1.5 (± 1.7), p < 0.001. The tool was received favorably among study participants.

CONCLUSION

The IMIST-AMBO tool reduced the frequency of interruptions, parallel conversations, and informal handovers during paramedic-trauma team handovers at our institution. The quality and amount of information communicated per handover improved, all with a decrease in handover duration. The IMIST-AMBO tool may be applied to other trauma centers across Canada, or more broadly on an international scale.

Effect of special operational forces surgical resuscitation teams on combat casualty survival: A narrative review

IMPORTANCE

The most common cause of preventable death on the conventional battlefield or on special operations force (SOF) missions is hemorrhage. SOF missions may take place in remote and austere locations. Many preventable deaths in combat occur within 30 min of wounding. Therefore, SOF damage control resuscitation (DCR) and damage control surgery (DCS) teams may improve combat casualty survival in the SOF environment.

OBJECTIVE

To determine the effect of SOF DCR and DCS teams on combat casualty survival. Also, to describe commonalities in team structure, logistics, and blood product usage.

DESIGN

A narrative review of the English literature used a Medline and Embase search strategy. The authors were contacted for more details as required. The risk of bias was assessed using the Cochrane Collaboration's ROBINS-I tool. Pooling of data was not done to the heterogeneity of studies.

RESULTS

Weak evidence was identified showing a clinical benefit of SOF DCR and DCS teams. Conflicting evidence from less rigorous studies was also found. The overall risk of bias using ROBINS-I was serious to critical. Several commonalities in team structure, training, and logistics were found.

CONCLUSIONS AND RELEVANCE

There is conflicting evidence regarding the effect SOF DCR and DCS teams have on combat casualty survival. There is no strong evidence that SOF DCR and DCS teams cause harm. More robust data collection is recommended to evaluate these teams.

Closed loop communication in the trauma bay: identifying opportunities for team performance improvement through a video review analysis

Objectives

Communication among trauma team members in the trauma bay is vulnerable to errors, which may impact patient outcomes. We used the previously validated trauma-non-technical skills (T-NOTECHS) tool to identify communication gaps during patient management in the trauma bay and to inform development strategies to improve team performance.

Methods

Two reviewers independently assessed non-technical skills of team members through video footage at Sunnybrook Health Sciences Centre. Team performance was measured using T-NOTECHS across five domains using a five-point Likert scale (lower score indicating worse performance): (1) leadership; (2) cooperation and resource management; (3) communication and interaction; (4) assessment and decision making; (5) situation awareness/coping with stress. Secondary outcomes assessed the number of callouts, closed loop communications and parallel conversations.

Results

The study included 55 trauma activations. Injury severity score (ISS) was used as a measure of trauma severity. A case with an ISS score ≥ 16 was considered severe. ISS was ≥ 16 in 37% of cases. Communication and interaction scored significantly lower compared to all other domains (p < 0.0001). There were significantly more callouts and completed closed loop communications in more severe cases compared to less severe cases (p = 0.017 for both). Incomplete closed loop communications and parallel conversations were identified, irrespective of case severity.

Conclusion

A lower communication score was identified using T-NOTECHS, attributed to incomplete closed loop communications and parallel conversations. Through video review of trauma team activations, opportunities for improvement in communication can be identified by the T-NOTECHS tool, as well as specifically identifying callouts and closed loop communication. This process may be useful for trauma programs as part of a quality improvement program on communication skills and team performance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43678-022-00295-z.

A Quantitative Study of Particle Dispersion due to Respiratory Support Modalities in PC-12 Aircraft: Prehospital Patient Transport

OBJECTIVE

It is unclear whether supplemental oxygen and noninvasive ventilation respiratory support devices increase the dispersion of potentially infectious bioaerosols in a pressurized air medical cabin. This study quantitatively compared particle dispersion from respiratory support modalities in an air medical cabin during flight.

METHODS

Dispersion was measured in a fixed wing air ambulance during flight with a breathing medical mannequin simulator exhaling nebulized saline from the lower respiratory tract with the following respiratory support modalities: a nasal cannula with a surgical mask, high-flow nasal oxygen (HFNO) with a surgical mask, and noninvasive bilevel positive airway pressure (BiPAP) ventilation.

RESULTS

Nasal cannula oxygen with a surgical mask was associated with the highest particle concentrations. In the absence of mask seal leaks, BiPAP was associated with 1 order of magnitude lower particle concentration compared with a nasal cannula with a surgical mask. Particle concentrations associated with HFNO with a surgical mask were lower than a nasal cannula with a surgical mask but higher than BiPAP.

CONCLUSIONS

Particle dispersion associated with the use of BiPAP and HFNO with a surgical mask is lower than nasal cannula oxygen with a surgical mask. These findings may assist air medical organizations with operational decisions where little data exist about respiratory particle dispersion.

Evaluating the Tactical Combat Casualty Care principles in civilian and military settings: systematic review, knowledge gap analysis and recommendations for future research

OBJECTIVES

The Tactical Combat Casualty Care (TCCC) guidelines detail resuscitation practices in prehospital and austere environments. We sought to review the content and quality of the current TCCC and civilian prehospital literature and characterize knowledge gaps to offer recommendations for future research.

METHODS

MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were searched for studies assessing intervention techniques and devices used in civilian and military prehospital settings that could be applied to TCCC guidelines. Screening and data extraction were performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality appraisal was conducted using appropriate tools.

RESULTS

Ninety-two percent (n=57) of studies were observational. Most randomized trials had low risk of bias, whereas observational studies had higher risk of bias. Interventions of massive hemorrhage control (n=17) were wound dressings and tourniquets, suggesting effective hemodynamic control. Airway management interventions (n=7) had high success rates with improved outcomes. Interventions of respiratory management (n=12) reported low success with needle decompression. Studies assessing circulation (n=18) had higher quality of evidence and suggested improved outcomes with component hemostatic therapy. Hypothermia prevention interventions (n=2) were generally effective. Other studies identified assessed the use of extended focused assessment with sonography in trauma (n=3) and mixed interventions (n=2).

CONCLUSIONS

The evidence was largely non-randomized with heterogeneous populations, interventions, and outcomes, precluding robust conclusions in most subjects addressed in the review. Knowledge gaps identified included the use of blood products and concentrate of clotting factors in the prehospital setting.

LEVEL OF EVIDENCE

Systematic review, level III.

Protocol for a multicentre, randomised, parallel-control, superiority trial comparing administration of clotting factor concentrates with a standard massive haemorrhage protocol in severely bleeding trauma patients: the FiiRST 2 trial (a 2020 EAST multicentre trial)

INTRODUCTION

Acute traumatic coagulopathy (ATC) in bleeding trauma patients increase in-hospital mortality. Fibrinogen concentrate (FC) and prothrombin complex concentrate (PCC) are two purified concentrates of clotting factors that have been used to treat ATC. However, there is a knowledge gap on their use compared with the standard of care, the transfusion of plasma.

METHODS AND ANALYSIS

The factors in the initial resuscitation of severe trauma 2 trial is a multicentre, randomised, parallel-control, single-blinded, phase IV superiority trial. The study aims to address efficacy and safety of the early use of FC and PCC compared with a plasma-based resuscitation. Adult trauma patients requiring massive haemorrhage protocol activation on hospital arrival will receive FC 4 g and PCC 2000 IU or plasma 4 U, based on random allocation. The primary outcome is a composite of the cumulative number of all units of red cells, plasma and platelets transfused within 24 hours following admission. Secondary outcomes include measures of efficacy and safety of the intervention. Enrolment of 350 patients will provide an initial power >80% to demonstrate superiority for the primary outcome. After enrolment of 120 patients, a preplanned adaptive interim analysis will be conducted to reassess assumptions, check for early superiority demonstration or reassess the sample size for remainder of the study.

ETHICS AND DISSEMINATION

The study has been approved by local and provincial research ethics boards and will be conducted according to the Declaration of Helsinki, Good Clinical Practice guidelines and regulatory requirements. As per the Tri-Council Policy Statement, patient consent will be deferred due to the emergency nature of the interventions. If superiority is established, results will have a major impact on clinical practice by reducing exposure to non-virally inactivated blood products, shortening the time for administration of clotting factors, correct coagulopathy more efficaciously and reduce the reliance on AB plasma.

TRIAL REGISTRATION NUMBER

NCT04534751, pre results.

Thumb carpometacarpal arthroplasty and trapeziectomy using a tenodesis screw compared to ligament reconstruction

This study aimed to compare the results of patients treated with a thumb carpometacarpal (CMC) suspension arthroplasty using an interference screw technique with patients that were treated by trapeziectomy and ligament reconstruction. A retrospective chart review was conducted of patients over 18 years old who required surgical treatment for thumb CMC joint arthritis treated by a single surgeon. Patients included in the study followed the same preoperative and postoperative protocol. Information related to functional outcomes was collected (pinch and grip strength, pain, Kapandji score, proximal migration of first metacarpal bone). One hundred and five patients were included, 77% were female, age at the time of the study was 62.7 years old; 74 (70%) patients were treated with the tenodesis screw (TS) technique and 31 (30%) with trapeziectomy and ligament reconstruction (TZLR). Patients were followed for a mean of 8.4 months. Postoperative pain was 1.2 in the TS group and 0.6 in the TZLR group; Kapandji score was 8.3 in the TS group and 9 in the TZLR group; in the TS group, the grip strength was 26.2kg and key pinch strength was 6.15kg; in the TZLR group, grip strength was 12.8kg and key pinch strength was 4.7kg. Proximal migration was 0.4cm in the TZLR group and 0.6cm in the TS group. The use of tenodesis screw and half of the flexor carpi radialis had minor advantages, such as increasing the grip and key pinch strength without differences relative the non-operated thumb, minimal migration of the first metacarpal bone compared with the other technique.

Freeze-dried plasma for major trauma - Systematic review and meta-analysis

BACKGROUND

Treatment of acute trauma coagulopathy has shifted toward rapid replacement of coagulation factors with frozen plasma (FP). There are logistic difficulties in providing FP. Freeze-dried plasma (FDP) may have logistical advantages including easier storage and rapid preparation time. This review assesses the feasibility, efficacy, and safety of FDP in trauma.

STUDY DESIGN AND METHODS

Studies were searched from Medline, Embase, Cochrane Controlled Trials Register, ClinicalTrials.gov, and Google Scholar. Observational and randomized controlled trials (RCTs) assessing FDP use in trauma were included. Trauma animal models addressing FDP use were also included. Bias was assessed using validated tools. Primary outcome was efficacy, and secondary outcomes were feasibility and safety. Meta-analyses were conducted using random-effect models. Evidence was graded using Grading of Recommendations Assessment, Development, and Evaluation profile.

RESULTS

Twelve human studies (RCT, 1; observational, 11) and 15 animal studies were included. Overall, studies demonstrated moderate risk of bias. Data from two studies (n = 119) were combined for meta-analyses for mortality and transfusion of allogeneic blood products (ABPs). For both outcomes, no difference was identified. For mortality, pooled odds ratio was 0.66 (95% confidence interval, 0.29-1.49), with I2 = 0%. Use of FDP is feasible, and no adverse events were reported. Animal data suggest similar results for coagulation and anti-inflammatory profiles for FP and FDP.

CONCLUSION

Human data assessing FDP use in trauma report no difference in mortality and transfusion of ABPs in patients receiving FDP compared with FP. Data from animal trauma studies report no difference in coagulation factor and anti-inflammatory profiles between FP and FDP. Results should be interpreted with caution because most studies were observational and have heterogeneous population (military and civilian trauma) and a moderate risk of bias. Well-designed prospective observational studies or, preferentially, RCTs are warranted to answer FDP's effect on laboratory (coagulation factor levels), transfusion (number of ABPs), and clinical outcomes (organ dysfunction, length of stay, and mortality).

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level IV.

Epidemiologic features of medical emergencies in remote First Nations in northern Ontario: a cross-sectional descriptive study using air ambulance transport data

BACKGROUND

For about 25 000 Ontarians living in remote northern First Nations communities, seeing a doctor in an emergency department requires flying in an airplane or helicopter. This study describes the demographic and epidemiologic characteristics of patients transported from these communities to access hospital-based emergency medical care.

METHODS

In this cross-sectional descriptive study, we examined primary medical data on patient transportation from Ornge, the provincial medical air ambulance service provider, for 26 remote Nishnawbe Aski Nation communities in northern Ontario from 2012 to 2016. We described these transports using univariate descriptive statistics.

RESULTS

Over the 5-year study period, 10 538 patients (mean 2107.6 per year) were transported by Ornge from the 26 communities. Transport incidence ranged from 9.2 to 9.5 per 100 on-reserve population per year. Women aged 65 years or more had the highest transport incidence (25.9 per 100). Girls aged 5-9 years had the lowest mean incidence (2.1 per 100). Gastrointestinal issues accounted for 13.3% of transfers. Neurologic issues, respiratory issues and trauma each accounted for about 11% of transfers, and cardiac issues for 9.6%. Patients with obstetric issues accounted for 7.6% of transfers per year, and toxicologic emergencies for 7.5%.

INTERPRETATION

This study provides the epidemiologic foundation to improve emergency care and emergency transport from remote First Nation communities in Ontario.

Causes of Delay During Interfacility Transports of Injured Patients Transported by Air Ambulance

Background: Many severely injured patients are initially brought to a non-trauma centers for initial assessment and stabilization. Air ambulance services are commonly used to expedite interfacility transport of injured patients to trauma centers. Little is known of the types of delays experienced during interfacility transports. The purpose of this study was to identify specific causes of modifiable delays and estimate the attributable time associated with each of these delays.Methods: This was a retrospective cohort study of injured patients undergoing interfacility transfer to a trauma center who were transported by a provincial air ambulance service between January 1, 2014 and December 31, 2016. Electronic patient care records were screened and then manually reviewed to identify causes of delay during the interfacility transport process. The attributable time for each of these delays was also estimated.Results: There were 932 injured patients emergently transported by air ambulance from a community hospital to a trauma center over the 3-year study period from which 458 unique causes of delay that were identified. The most frequent cause of delays to sending facility were refueling (38%), waiting for land emergency medical services escort (25%) and weather (12%). The most common in-hospital delays included waiting for documentation (32%), delay to intubate (15%), medically unstable patient (13%) and waiting for diagnostic imaging (12%). The most frequent delays to receiving/handover included waiting for land EMS escort (31%), trauma team not assembled (24%) and weather (17%). In-hospital delays with the longest average length of delay included chest tube insertion (53 minutes), intubation (49 minutes) and delays for diagnostic imaging (46 minutes).Conclusions: In conclusion, we identified numerous modifiable causes of delay during interfacility transport. Efforts to reduce these delays can be made at both the air ambulance and hospital levels.

Does the evidence support the importance of high transfusion ratios of plasma and platelets to red blood cells in improving outcomes in severely injured patients: a systematic review and meta-analyses

BACKGROUND

Deaths by exsanguination in trauma are preventable with hemorrhage control and resuscitation with allogeneic blood products (ABPs). The ideal transfusion ratio is unknown. We compared efficacy and safety of high transfusion ratios of FFP:RBC and PLT:RBC with low ratios in trauma.

STUDY DESIGN AND METHODS

Medline, Embase, Cochrane, and Controlled Clinical Trials Register were searched. Observational and randomized data were included. Risk of bias was assessed using validated tools. Primary outcome was 24-h and 30-day mortality. Secondary outcomes were exposure to ABPs and improvement of coagulopathy. Meta-analysis was conducted using a random-effects model. Strength and evidence quality were graded using GRADE profile RESULTS: 55 studies were included (2 randomized and 53 observational), with low and moderate risk of bias, respectively, and overall low evidence quality. The two RCTs showed no mortality difference (odds ratio [OR], 1.35; 95% confidence interval [CI], 0.40-4.59). Observational studies reported lower mortality in high FFP:RBCs ratio (OR, 0.38 [95% CI, 0.22-0.68] for 1:1 vs. <1:1; OR, 0.42 [95% CI, 0.22-0.81] for 1:1.5 vs. <1:1.5; and OR, 0.47 [95% CI, 0.31-0.71] for 1:2 vs. <1:2, respectively). Meta-analyses in observational studies showed no difference in exposure to ABPs. No data on coagulopathy for meta-analysis was identified.

CONCLUSIONS

Meta-analyses in observational studies suggest survival benefit and no difference in exposure to ABPs. No survival benefit in RCTs was identified. These conflicting results should be interpreted with caution. Studies are mostly observational, with relatively small sample sizes, nonrandom treatment allocation, and high potential for confounding. Further research is warranted.

Suicide in Canadian veterans living in Ontario: a retrospective cohort study linking routinely collected data

OBJECTIVES

To compare the risk of death by suicide in male veterans with age-matched civilians.

DESIGN

Retrospective cohort study linking provincial administrative databases between 1990 and 2013 with follow-up complete until death or December 31, 2015.

SETTING

Population-based study in Ontario, Canada.

PARTICIPANTS

Ex-serving Canadian Armed Forces and Royal Canadian Mounted Police veterans living in Ontario who registered for provincial health insurance were included. A civilian comparator group was matched 4:1 on age and sex.

MAIN OUTCOME

Death by suicide was classified using standard cause of death diagnosis codes from a provincial registry of mandatory data collected from death certificates. Fine and Gray sub-distribution hazards regression compared the risk of death by suicide between veterans and civilians. Analyses were adjusted for age, residential region, income, rurality and major physical comorbidities.

RESULTS

20 397 male veterans released to Ontario between 1990 and 2013 and 81 559 age-sex matched civilians were included. 4.2% of veterans died during the study time frame, compared with 6.5% of the civilian cohort. Death by suicide was rare in both cohorts, accounting for 4.6% and 3.6% of veteran and civilian deaths, respectively. After adjustment for confounders, veterans had an 18% lower risk of dying from causes other than suicide (HR 0.82, 95% CI 0.76 to 0.89) and a similar risk of dying by suicide (HR 1.01, 95% CI 0.71 to 1.43), compared with civilians.

CONCLUSIONS

Deaths by suicide were rare in male veterans residing in Ontario. Our findings demonstrate that veterans had a similar risk of suicide-related mortality as an age-matched civilian population. A better understanding of effective suicide prevention as well as clarifying pathways to seeking and receiving mental health supports and services are important areas for future consideration.

Risk Factors for Non-optimal Resource Utilization for Emergent Interfacility Transfers by Air Ambulance in Ontario

Background: The use of air ambulance to facilitate interfacility transfer has been associated with improved mortality; however, air ambulance is a limited resource and sometimes the optimal resource to transport a patient is unavailable. When a non-optimal resource is used there is an inherent delay and critically unwell patients may deteriorate as a result. This study aimed to identify risk factors associated with non-optimal resource utilization for adult patients undergoing emergent interfacility transport by air ambulance in Ontario, Canada. A secondary objective was to determine if non-optimal resource utilization was associated with deterioration in clinical status by measuring a delta rapid emergency medicine score (REMS). Methods: This was a retrospective cohort study of all emergent, adult interfacility transfers transported by air ambulance over a 5-year period in Ontario, Canada. Determination of optimal resource use was based on distances and historic time data for all sending-receiving facility pairs. A logistic regression model was used to explore patient, provider and institutional risk factors for non-optimal resource use. To explore the secondary objective a linear regression model was used to explore impact of non-optimal resource use on deltaREMS. Results: There were a total of 9,687 patients included in the study cohort, with 4,984 having an optimal resource use and 4,703 having non-optimal resource. The median delay in interfacility transfer caused by a non-optimal transfer strategy was 35.7 minutes. Patients who required mechanical ventilation (OR 1.13, p = 0.031) and or were transferred out of nursing stations had higher odds of non-optimal resource use (OR 2.84, p = 0.019). Paramedic level of care of advanced (OR 0.37, p = < 0.001) and critical care (OR 0.28, p = < 0.001) as well as spring season (OR 0.75, p = < 0.001) had lower odds of non-optimal resource utilization. Optimal resource utilization did not significantly affect delta REMS (beta coefficient 0.002, p = 0.64). Conclusions: Patients who required mechanical ventilation and were transferred out from a nursing station had higher odds of non-optimal resource utilization while patients that required advanced or critical care level of care and spring season had lower odds of non-optimal resource use. Additionally, non-optimal resource use for air ambulance interfacility transfers did not result in patient deterioration as measured by a delta REMS score.

Emergency Resuscitative Thoracotomy in the Combat or Operational Environment

Resuscitative thoracotomy has been extensively described in the civilian trauma literature and has a high mortality rate, due largely to the nature of the injuries leading to arrest. The survival rates are generally highest (10-30%) for penetrating truncal injuries and patients who arrive with vital signs and proceed to arrest or who have impending arrest. They are significantly lower (less than 5%) for blunt trauma victims, particularly those who arrest in the field or during transport (1% or less). In addition, the likelihood of survival with intact neurologic function is significantly lower than the overall survival rates, particularly for blunt trauma victims and for prehospital arrest.

Fibrinogen Concentrate in the Special Operations Forces Environment

Introduction

Hemorrhage is the most common cause of death among Special Operations Force (SOF) soldiers. Bringing remote damage control resuscitation into the far-forward combat environment is logistically challenging, as it requires blood products that generally require a robust cold chain. Alternatively, lyophilized products such as fibrinogen concentrate, which does not require thawing or blood group compatibility testing before use, might be advantageous in damage control resuscitation in the battlefield. In this report, we review the evidence for the use of fibrinogen concentrate in the Canadian SOF environment.

Materials and Methods

The literature on the use of fibrinogen concentrate in the trauma setting was reviewed by Canadian Forces Services Working Group, in three separate meetings. Multiple stakeholders were consulted to obtain authoritative perspectives from subject matter experts on the use of fibrinogen concentrate in the Canadian SOF environment. We also conducted a comparison review of fibrinogen content, pathogen risk, shelf life, and methods required for use for fresh frozen plasma, cryoprecipitate, and fibrinogen concentrate relevant to their application in the far-forward combat environment.

Results

Indications and a protocol for the use of fibrinogen as an adjunct to fresh whole blood were formulated based on a literature review and clinical expert opinion. Alternative strategies and other lyophilized blood products were considered before selecting fibrinogen concentrate as the lyophilized blood product of choice. Fibrinogen concentrate is an ABO-universal blood product with an excellent safety profile. Training was conducted by subject matter experts within civilian trauma centers and at military training facilities. The clinical efficacy and safety were confirmed by monitoring the use of fibrinogen concentrate in deployed combat settings.

Conclusion

Fibrinogen concentrate is a useful adjunct to remote damage control resuscitation in the SOF environment. Fibrinogen concentrate was found to be robust for transport into the SOF environment and is widely accepted among SOF operators and medics.

Uncovering Cultural Barriers to Quality Improvement Learning in a Trauma Program: An Ethnographic Study

OBJECTIVE

Quality improvement (QI) training is an essential component of postgraduate surgical education and can occur through formal and informal education programs. Informal QI education requires that faculty take advantage of learning opportunities in the hospital setting. Trauma rotations appear ideal opportunities for informal QI learning given that performance improvement is a mandatory component of care at verified trauma centers. It is unclear, however, whether QI initiatives within trauma programs are well integrated into trainee education. This study explored the QI learning environment in a level 1 academic trauma center.

STUDY DESIGN

An ethnographic study using observation and interviews methods. The theoretical lens of hidden curriculum was used to interpret the data and generate hypotheses around faculty and trainee experiences.

SETTING

University of Toronto and Sunnybrook Health Sciences Center.

PARTICIPANTS

Twenty-seven observations involving more than 50 faculty and trainees; seventeen interviews with faculty and surgical trainees.

RESULTS

All faculty and trainees endorsed QI and informal QI learning. Discrepant experiences were found regarding opportunities to learn and do QI in the clinical setting. Faculty viewed themselves as perpetually doing and teaching QI while trainees perceived little to no QI learning. Trainees identified Morbidity and Mortality rounds as the main opportunity for QI learning; however, traditional teaching style through "pimping" and a largely clinical focus acted as barriers to QI education. Furthermore, trainees chiefly viewed QI as service to the institution, rather than as a form of learning, which contributed to their disinterest in taking up informal QI lessons.

CONCLUSION

Informal QI education is highly valued and desired in academic trauma centers but enduring teaching methods, inconsistencies in the cultural learning environment and a hidden curriculum devaluing QI learning are persistent barriers to change.

A retrospective cohort study comparing non-fatal self-harm emergency department visits between Canadian veterans living in Ontario and matched civilians

This was a retrospective cohort study linking provincial administrative databases to compare rates of non-fatal self-harm between CAF and RCMP veterans living in Ontario and age-matched civilians. This study included male veterans who registered for provincial health insurance between 2002 and 2013. A civilian comparator group was matched 4:1 on age and sex. Self-harm emergency department (ED) visits were identified from provincial ED admission records until death or December 31, 2015. Multivariable Poisson regression compared the risk of self-harm. Analyses adjusted for age, geography, income, rurality, and major physical and mental comorbidities. In total, 9514 male veterans and 38,042 age- and sex-matched civilians were included. Overall, 0.55% of veterans had at least one non-fatal self-harm ED visit, compared with 0.81% of civilians. The rate of ED self-harm visits was 40% lower in the veteran population, compared to the civilian population (RR = 0.60; 95% CI = 0.41-0.87). In both groups, psychosocial and physical comorbidities, and death by suicide were more common in those who self-harmed than those who did not. A better understanding of why veterans have a lower rate of self-harm emergency department visits and how it is related to the number of completed suicides is an important area for future consideration.

Canceled to Be Called Back: A Retrospective Cohort Study of Canceled Helicopter Emergency Medical Service Scene Calls That Are Later Transferred to a Trauma Center

INTRODUCTION

In our trauma system, helicopter emergency medical services (HEMS) can be requested to attend a scene call for an injured patient before arrival by land paramedics. Land paramedics can cancel this response if they deem it unnecessary. The purpose of this study is to describe the frequency of canceled HEMS scene calls that were subsequently transferred to 2 trauma centers and to assess for any impact on morbidity and mortality.

METHODS

Probabilistic matching was used to identify canceled HEMS scene call patients who were later transported to 2 trauma centers over a 48-month period. Registry data were used to compare canceled scene call patients with direct from scene patients.

RESULTS

There were 290 requests for HEMS scene calls, of which 35.2% were canceled. Of those canceled, 24.5% were later transported to our trauma centers. Canceled scene call patients were more likely to be older and to be discharged home from the trauma center without being admitted.

CONCLUSION

There is a significant amount of undertriage of patients for whom an HEMS response was canceled and later transported to a trauma center. These patients face similar morbidity and mortality as patients who are brought directly from scene to a trauma center.

Systematic Review of Human and Animal Studies Examining the Efficacy and Safety of N-Acetylcysteine (NAC) and N-Acetylcysteine Amide (NACA) in Traumatic Brain Injury: Impact on Neurofunctional Outcome and Biomarkers of Oxidative Stress and Inflammation

Background

No new therapies for traumatic brain injury (TBI) have been officially translated into current practice. At the tissue and cellular level, both inflammatory and oxidative processes may be exacerbated post-injury and contribute to further brain damage. N-acetylcysteine (NAC) has the potential to downregulate both processes. This review focuses on the potential neuroprotective utility of NAC and N-acetylcysteine amide (NACA) post-TBI.

Methods

Medline, Embase, Cochrane Library, and ClinicalTrials.gov were searched up to July 2017. Studies that examined clinical and laboratory effects of NAC and NACA post-TBI in human and animal studies were included. Risk of bias was assessed in human and animal studies according to the design of each study (randomized or not). The primary outcome assessed was the effect of NAC/NACA treatment on functional outcome, while secondary outcomes included the impact on biomarkers of inflammation and oxidation. Due to the clinical and methodological heterogeneity observed across studies, no meta-analyses were conducted.

Results

Our analyses revealed only three human trials, including two randomized controlled trials (RCTs) and 20 animal studies conducted using standardized animal models of brain injury. The two RCTs reported improvement in the functional outcome post-NAC/NACA administration. Overall, the evidence from animal studies is more robust and demonstrated substantial improvement of cognition and psychomotor performance following NAC/NACA use. Animal studies also reported significantly more cortical sparing, reduced apoptosis, and lower levels of biomarkers of inflammation and oxidative stress. No safety concerns were reported in any of the studies included in this analysis.

Conclusion

Evidence from the animal literature demonstrates a robust association for the prophylactic application of NAC and NACA post-TBI with improved neurofunctional outcomes and downregulation of inflammatory and oxidative stress markers at the tissue level. While a growing body of scientific literature suggests putative beneficial effects of NAC/NACA treatment for TBI, the lack of well-designed and controlled clinical investigations, evaluating therapeutic outcomes, prognostic biomarkers, and safety profiles, limits definitive interpretation and recommendations for its application in humans at this time.

A pilot study of surgical telementoring for leg fasciotomy

INTRODUCTION

Acute extremity compartment syndrome requires rapid decompression. In remote locations, distance, weather and logistics may delay the evacuation of patients with extremity trauma beyond the desired timeline for compartment release. The aim of this study was to establish the feasibility of performing telementored surgery for leg compartment release and to identify methodological issues relevant for future research.

METHODS

Three anaethetists and one critical care physician were recruited as operators. They were directed to perform a two-incision leg fasciotomy on a Thiel-embalmed cadaver under the guidance of a remotely located orthopaedic surgeon. The operating physician and the surgeon (mentor) were connected through software that allows for real-time supervision and the use of a virtual pointer overlaid onto the surgical field. Two experienced orthopaedic traumatologists independently assessed the adequacy of compartment decompression and the presence of iatrogenic complications.

RESULTS

14 of 16 compartments (in four leg specimens) were felt to have been completely released. The first evaluator considered that the deep posterior compartment was incompletely released in two specimens. The second evaluator considered that the superficial posterior compartment was incompletely released in two specimens. The only complication was a large laceration of the soleus muscle that occurred during a period of blurred video signal attributed to a drop in bandwidth.

CONCLUSIONS

This study suggests that surgical telementoring may enable physicians to safely perform two-incision leg fasciotomy in remote environments. This could improve the chances of limb salvage when compartment syndrome occurs far from surgical care. We found interobserver variation in the assessment of compartment release, which should be considered in the design of future research protocols.

A recommended early goal-directed management guideline for the prevention of hypothermia-related transfusion, morbidity, and mortality in severely injured trauma patients

Hypothermia is present in up to two-thirds of patients with severe injury, although it is often disregarded during the initial resuscitation. Studies have revealed that hypothermia is associated with mortality in a large percentage of trauma cases when the patient's temperature is below 32 °C. Risk factors include the severity of injury, wet clothing, low transport unit temperature, use of anesthesia, and prolonged surgery. Fortunately, associated coagulation disorders have been shown to completely resolve with aggressive warming. Selected passive and active warming techniques can be applied in damage control resuscitation. While treatment guidelines exist for acidosis and bleeding, there is no evidence-based approach to managing hypothermia in trauma patients. We synthesized a goal-directed algorithm for warming the severely injured patient that can be directly incorporated into current Advanced Trauma Life Support guidelines. This involves the early use of warming blankets and removal of wet clothing in the prehospital phase followed by aggressive rewarming on arrival at the hospital if the patient's injuries require damage control therapy. Future research in hypothermia management should concentrate on applying this treatment algorithm and should evaluate its influence on patient outcomes. This treatment strategy may help to reduce blood loss and improve morbidity and mortality in this population of patients.

The marriage of surgical simulation and telementoring for damage-control surgical training of operational first responders: A pilot study

BACKGROUND

Hemorrhage is the leading cause of preventable posttraumatic death. Many such deaths may be potentially salvageable with remote damage-control surgical interventions. As recent innovations in information technology enable remote specialist support to point-of-care providers, advanced interventions, such as remote damage-control surgery, may be possible in remote settings.

METHODS

An anatomically realistic perfused surgical training mannequin with intrinsic fluid loss measurements (the "Cut Suit") was used to study perihepatic packing with massive liver hemorrhage. The primary outcome was loss of simulated blood (water) during six stages, namely, incision, retraction, direction, identification, packing, and postpacking. Six fully credentialed surgeons performed the same task as 12 military medical technicians who were randomized to remotely telementored (RTM) (n = 7) or unmentored (UTM) (n=5) real-time guidance by a trauma surgeon.

RESULTS

There were no significant differences in fluid loss between the surgeons and the UTM group or between the UTM and RTM groups. However, when comparing the RTM group with the surgeons, there was significantly more total fluid loss (p = 0.001) and greater loss during the identification (p = 0.002), retraction (p = 0.035), direction (p = 0.014), and packing(p = 0.022) stages. There were no significant differences in fluid loss after packing between the groups despite differences in the number of sponges used; RTM group used more sponges than the surgeons and significantly more than the UTM group (p = 0.048). However, mentoring significantly increased self-assessed nonsurgeon procedural confidence (p = 0.004).

CONCLUSION

Perihepatic packing of an exsanguinating liver hemorrhage model was readily performed by military medical technicians after a focused briefing. While real-time telementoring did not improve fluid loss, it significantly increased nonsurgeon procedural confidence, which may augment the feasibility of the concept by allowing them to undertake psychologically daunting procedures.

Blunt splenic injury and severe brain injury: a decision analysis and implications for care

BACKGROUND

The initial nonoperative management (NOM) of blunt splenic injuries in hemodynamically stable patients is common. In soldiers who experience blunt splenic injuries with concomitant severe brain injury while on deployment, however, NOM may put the injured soldier at risk for secondary brain injury from prolonged hypotension.

METHODS

We conducted a decision analysis using a Markov process to evaluate 2 strategies for managing hemodynamically stable patients with blunt splenic injuries and severe brain injury--immediate splenectomy and NOM--in the setting of a field hospital with surgical capability but no angiography capabilities. We considered the base case of a 40-year-old man with a life expectancy of 78 years who experienced blunt trauma resulting in a severe traumatic brain injury and an isolated splenic injury with an estimated failure rate of NOM of 19.6%. The primary outcome measured was life expectancy. We assumed that failure of NOM would occur in the setting of a prolonged casualty evacuation, where surgical capability was not present.

RESULTS

Immediate splenectomy was the slightly more effective strategy, resulting in a very modest increase in overall survival compared with NOM. Immediate splenectomy yielded a survival benefit of only 0.4 years over NOM.

CONCLUSION

In terms of overall survival, we would not recommend splenectomy unless the estimated failure rate of NOM exceeded 20%, which corresponds to an American Association for the Surgery of Trauma grade III splenic injury. For military patients for whom angiography may not be available at the field hospital and who require prolonged evacuation, immediate splenectomy should be considered for grade III-V injuries in the presence of severe brain injury.

The need for a robust 24/7 subspecialty "clearing house" response for telementored trauma care

Traumatic injury is increasing in importance in all settings and environments worldwide. Many preventable deaths are from conditions that are common and treatable. However, as potentially lethal injuries often induce progressive and frequently irreversible physiologic decline, the timing of interventions is critical. Invasive treatments may need to be offered by prehospital care providers who lack extensive training and practice. Telementoring allows experienced experts to guide less experienced providers remotely using information technology (IT). Early experience has shown that these techniques are practical and considered valuable. Their translation to regular practice, however, will require the immediate availability of appropriately trained remote experts willing to serve as mentors. Acute care trauma specialists are acclimatized to responding to out-of-hospital consultations and assuming overall responsibility for critical physiology and transport and may serve as the backbone of such a national/ international call response initiative.

Fresh whole blood transfusion capability for Special Operations Forces

Fresh whole blood (FWB) transfusion is an option for providing volume and oxygen carrying capacity to bleeding Special Operations soldiers who are injured in an austere environment and who are far from a regular blood bank. Retrospective data from recent conflicts in Iraq and Afghanistan show an association between the use of FWB and survival. We reviewed the literature to document the issues surrounding FWB transfusion to Special Operations soldiers in the austere environment and surveyed the literature regarding best practice guidelines for and patient outcomes after FWB transfusions. Most literature regarding FWB transfusion is retrospective or historical. There is limited prospective evidence currently to change transfusion practice in tertiary care facilities, but FWB remains an option in the austere setting.

Advances in damage control resuscitation and surgery: implications on the organization of future military field forces

Medical support to deployed field forces is increasingly becoming a shared responsibility among allied nations. National military medical planners face several key challenges, including fiscal restraints, raised expectations of standards of care in the field and a shortage of appropriately trained specialists. Even so, medical services are now in high demand, and the availability of medical support may become the limiting factor that determines how and where combat units can deploy. The influence of medical factors on operational decisions is therefore leading to an increasing requirement for multinational medical solutions. Nations must agree on the common standards that govern the care of the wounded. These standards will always need to take into account increased public expectations regarding the quality of care. The purpose of this article is to both review North Atlantic Treaty Organization (NATO) policies that govern multinational medical missions and to discuss how recent scientific advances in prehospital battlefield care, damage control resuscitation and damage control surgery may inform how countries within NATO choose to organize and deploy their field forces in the future.

Factors affecting mortality of pediatric trauma patients encountered in Kandahar, Afghanistan

BACKGROUND

The North Atlantic Treaty Organization (NATO) Role 3 Multinational Medical Unit (R3-MMU) is a tertiary care trauma facility that receives casualties, both coalition and civilian, and provides humanitarian medical assistance when able to the Kandahar province in southern Afghanistan. We examined the cohort of pediatric patients evaluated at the facility during a 16-month period to determine the characteristics and care requirements of this unique patient population.

METHODS

A database of Afghan patients younger than 18 years of age admitted to the NATO R3-MMU between January 2010 and April 2011 was developed from the Joint Theatre Trauma Registry. This patient cohort was analyzed to determine demographics, injury mechanism, injury severity, resource utilization and factors associated with mortality.

RESULTS

A total of 263 children were admitted to the NATO R3-MMU during the study period, representing 12% of all trauma admissions during this time period. The median age was 9 years (range 3 mo-17 yr) with a predominance of male patients (82%). Battle-related trauma was responsible for 62% of admissions, with explosive blast injury constituting the predominant mechanism (42%). The average injury severity score was 12.3 ± 9.3. Overall mortality was 8%. Factors associated with increased risk of death included admission acidosis, coagulopathy, hypothermia and female sex.

CONCLUSION

Children represent a significant proportion of traumatic injuries encountered in a modern war zone; many of them are critically injured. Organizations that provide health care in such environments should be prepared to care for this patient population where their mandates and facilities allow for it.

Medical mentorship in Afghanistan: How are military mentors perceived by Afghan health care providers?

BACKGROUND

Previous work has been published on the experiences of high-resource setting physicians mentoring in low-resource environments. However, not much is known about what mentees think about their First World mentors. We had the opportunity to explore this question in an Afghan Army Hospital, and we believe this is the first time this has been studied.

METHODS

We conducted a pilot cross-sectional survey of Afghan health care providers evaluating their Canadian mentors. We created a culturally appropriate 19- question survey with 5-point Likert scores that was then translated into the local Afghan language. The survey questions were based on domains of Royal College of Physicians and Surgeons of Canada's CanMEDS criteria.

RESULTS

The survey response rate was 90% (36 of 40). The respondents included 13 physicians, 21 nurses and 2 other health care professionals. Overall, most of the Afghan health care workers felt that working with mentors from high-resource settings was a positive experience (median 4.0, interquartile range [IQR] 4-4), according to CanMEDS domains. However, respondents indicated that the mentors were reliant on medical technology for diagnosis (median 5.0, IQR 4-5) and failed to consider the limited resources available in Afghanistan.

CONCLUSION

The overall impression of Afghan health care providers was that mentors are appropriate and helpful. CanMEDS can be used as a framework to evaluate mentors in low-resource conflict environments.

Needle thoracostomy for tension pneumothorax: the Israeli Defense Forces experience

BACKGROUND

Point of injury needle thoracostomy (NT) for tension pneumothorax is potentially lifesaving. Recent data raised concerns regarding the efficacy of conventional NT devices. Owing to these considerations, the Israeli Defense Forces Medical Corps (IDF-MC) recently introduced a longer, wider, more durable catheter for the performance of rapid chest decompression. The present series represents the IDF-MC experience with chest decompression by NT.

METHODS

We reviewed the IDF trauma registry from January 1997 to October 2012 to identify all cases in which NT was attempted.

RESULTS

During the study period a total of 111 patients underwent chest decompression by NT. Most casualties (54%) were wounded as a result of gunshot wounds (GSW); motor vehicle accidents (MVAs) were the second leading cause (16%). Most (79%) NTs were performed at the point of injury, while the rest were performed during evacuation by ambulance or helicopter (13% and 4%, respectively). Decreased breath sounds on the affected side were one of the most frequent clinical indications for NT, recorded in 28% of cases. Decreased breath sounds were more common in surviving than in nonsurviving patients. (37% v. 19%, p < 0.001). A chest tube was installed on the field in 35 patients (32%), all after NT.

CONCLUSION

Standard NT has a high failure rate on the battlefield. Alternative measures for chest decompression, such as the Vygon catheter, appear to be a feasible alternative to conventional NT.

Technical innovations that may facilitate real-time telementoring of damage control surgery in austere environments: a proof of concept comparative evaluation of the importance of surgical experience, telepresence, gravity and mentoring in the conduct of damage control laparotomies

Bleeding to death is the most preventable cause of posttraumatic death worldwide. Despite the fact that many of these deaths are anatomically salvageable with relatively basic surgical interventions, they remain lethal in actuality in prehospital environments when no facilities and skills exist to contemplate undertaking basic damage control surgery (DCS). With better attention to prehospital control of extremity hemorrhage, intracavitary bleeding (especially intraperitoneal) remains beyond the scope of prehospital providers. However, recent revolutions in the informatics and techniques of telementoring (TMT), DCS and highly realistic accelerated training of motivated first responders suggests that basic lifesaving DCS may have applicability to save bleeding patients in austere environments previously considered unsalvageable. Especially with informatic advances, any provider with Internet connectivity can potentially be supported by highly proficient specialists with content expertise in the index problem. This unprecedented TMT support may allow highly motivated but inexperienced personnel to provide advanced surgical interventions in extreme environments in many austere locations both on and above the planet.

Acute nontraumatic general surgical conditions on a combat deployment

BACKGROUND

Literature is lacking on acute surgical problems that may be encountered on military deployment; even less has been written on whether or not any of these surgical problems could have been avoided with more focused predeployment screening. We sought to determine the burden of illness attributable to acute nontraumatic general surgical problems while on deployment and to identify areas where more rigorous predeployment screening could be implemented to decrease surgical resource use for nontraumatic problems.

METHODS

We studied all Canadian Armed Forces (CAF) members deployed to Afghanistan between Feb. 7, 2006, and June 30, 2011, who required treatment for a nontraumatic general surgical condition.

RESULTS

During the study period 28 990 CAF personnel deployed to Afghanistan; 373 (1.28%) were repatriated because of disease and 100 (0.34%) developed an acute general surgical condition. Among those who developed an acute surgical illness, 42 were combat personnel (42%) and 58 were support personnel (58%). Urologic diagnoses (n = 34) were the most frequent acute surgical conditions, followed by acute appendicitis (n = 18) and hernias (n = 12). We identified 5 areas where intensified predeployment screening could have potentially decreased the incidence of in-theatre acute surgical illness.

CONCLUSION

Our findings suggest that there is a significant acute care surgery element encountered on combat deployment, and surgeons tasked with caring for this population should be prepared to treat these patients.

Temporal trends and differences in mortality at trauma centres across Ontario from 2005 to 2011: a retrospective cohort study

BACKGROUND

Care in a trauma centre is associated with significant reductions in mortality after severe injury. However, emerging evidence suggests that outcomes across similarly accredited trauma centres are not equivalent, even after adjusting for case-mix. The primary objective of this analysis was to evaluate secular trends in overall mortality at trauma centres. Secondarily, we explored trauma centre-specific mortality to determine the extent of variation between centres.

METHODS

Data on 26 421 adults (≥□18 yr) admitted to a trauma centre between 2005 and 2011 were derived from the Ontario Trauma Registry. We used generalized estimating equations to calculate in-hospital mortality over time and hierarchical models to estimate trauma-centre-specific mortality. To quantify variability between centres, we calculated median odds ratios. Adjusted odds of death were calculated for each trauma centre to identify those with higher than expected, average and lower than expected mortality.

RESULTS

Overall mortality at trauma centres decreased from 13.2% in 2005 to 11.2% in 2009. After adjusting for case mix, the odds of death decreased by approximately 3% a year (95% confidence interval 0%-5%). Trauma centre-specific mortality ranged from 11.4% to 13.1%. After adjusting for case mix, differences in trauma centre-specific mortality were observed (median odds ratio = 1.25), suggesting that the odds of dying could be 1.25-fold greater if the same patient was admitted to 1 randomly selected trauma centre as opposed to another. Differences were most pronounced for patients with isolated head injuries and among older patients as evidenced by higher median odds ratios and the number of outliers.

INTERPRETATION

We observed a significant improvement over time in the mortality of severely injured patients cared for at Ontario's trauma centres. However, considerable differences in trauma centre-specific mortality were observed. Differences were most pronounced among older injured patients and those with isolated traumatic brain injury. System-wide performance improvement initiatives should target these subgroups.

Tourniquet use for peripheral vascular injuries in the civilian setting

BACKGROUND

Haemorrhage in peripheral vascular injuries may cause life-threatening exsanguination. Tourniquets are used extensively by the military, with increased interest in the civilian setting to prevent deaths. This is a retrospective study of trauma patients at two large Canadian trauma centres with arterial injury after isolated extremity trauma. We hypothesized that tourniquet use may decrease mortality rate and transfusion requirements if applied early.

METHODS

The study group was all adult patients at two Level 1 Trauma Centres in two Canadian cities in Canada, who had arterial injuries from extremity trauma. The study period was from January 2001 to December 2010. We excluded patients with significant associated injuries. The intervention in this study was prehospital tourniquet use. The main outcome was in-hospital mortality. Secondary outcomes were length of stay, compartment syndrome, amputation, and blood product transfusion.

RESULTS

190 patients were included in the study, and only 4 patients had a prehospital tourniquet applied. They arrived directly from the scene of injury, had improvised tourniquets by police or bystanders, and showed a trend to be more hypotensive and acidotic. Four other patients had tourniquets applied in the trauma bay within 1h of injury. There were no differences in age, sex, injury severity or physiologic presentation between patients who had an early tourniquet applied and those who died without a tourniquet. However, six patients died without a tourniquet, and all bled to death. Of the eight patients who had early tourniquets applied, none died.

CONCLUSIONS

Tourniquets may prevent exsanguination in the civilian setting for patients suffering either blunt or penetrating trauma to the extremity. Future studies will help determine the utility of deploying tourniquets in the civilian setting, given the rarity of exsanguinating haemorrhage from isolated extremity trauma in this setting.

Effect of a fixed-ratio (1:1:1) transfusion protocol versus laboratory-results-guided transfusion in patients with severe trauma: a randomized feasibility trial

BACKGROUND

Hemorrhage coupled with coagulopathy remains the leading cause of preventable in-hospital deaths among trauma patients. Use of a transfusion protocol with a predefined ratio of 1:1:1 (1 each of red blood cells [RBC], frozen plasma [FP] and platelets) has been associated with improved survival in retrospective studies in military and civilian settings, but such a protocol has its challenges and may increase the risk of respiratory complications. We conducted a randomized controlled trial to assess the feasibility of a 1:1:1 transfusion protocol and its effect on mortality and complications among patients with severe trauma.

METHODS

We included 78 patients seen in a tertiary trauma centre between July 2009 and October 2011 who had hypotension and bleeding and were expected to need massive transfusion (≥ 10 RBC units in 24 h). We randomly assigned them to either the fixed-ratio (1:1:1) transfusion protocol (n = 40) or to a laboratory-results-guided transfusion protocol (control; n = 38). The primary outcome, feasibility, was assessed in terms of blood product ratios and plasma wastage. Safety was measured based on 28-day mortality and survival free of acute respiratory distress syndrome.

RESULTS

Overall, a transfusion ratio of 1:1:1 was achieved in 57% (21/37) of patients in the fixed-ratio group, as compared with 6% (2/32) in the control group. A ratio of 1:1 (RBC:FP) was achieved in 73% (27/37) in the fixed-ratio group and 22% (7/32) in the control group. Plasma wastage was higher with the intervention protocol (22% [86/390] of FP units v. 10% [30/289] in the control group). The 28-day mortality and number of days free of acute respiratory distress syndrome were statistically similar between the groups.

INTERPRETATION

The fixed-ratio transfusion protocol was feasible in our study, but it was associated with increased plasma wastage. Larger randomized trials are needed to evaluate the efficacy of such a protocol in trauma care.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT00945542.