Trauma Surgery & Acute Care Open最新文献

This essay won the American Association for the Surgery of Trauma Diversity, Equity, and Inclusion essay contest for 2024. I am submitting this as requested by Dr Elliott Haut and Kaitlyn Sanders.

Background: Blood transfusions have become a vital intervention in trauma care. There are limited data on the safety and effectiveness of submassive transfusion (SMT), that is defined as receiving less than 10 units packed red blood cells (PRBCs) in the first 24 hours. This study aimed to evaluate the efficacy and safety of fresh frozen plasma (FFP) and platelet transfusions in patients undergoing SMT.

Methods: This is a retrospective cohort, reviewing the Trauma Quality Improvement Program database spanning 3 years (2016 to 2018). Adult patients aged 18 years and older who had received at least 1 unit of PRBC within 24 hours were included in the study. We used a multivariate regression model to analyze the cut-off units of combined resuscitation (CR) (which included PRBCs along with at least one unit of FFP and/or platelets) that leads to survival improvement. Patients were then stratified into two groups: those who received PRBC alone and those who received CR. Propensity score matching was performed in a 1:1 ratio.

Results: The study included 85 234 patients. Based on the multivariate regression model, transfusion of more than 3 units of PRBC with at least 1 unit of FFP and/or platelets demonstrated improved mortality compared with PRBC alone. Among 66 319 patients requiring SMT and >3 units of PRBCs, 25 978 received PRBC alone, and 40 341 received CR. After propensity matching, 4215 patients were included in each group. Patients administered CR had a lower rate of complications (15% vs 26%), acute respiratory distress syndrome (3% vs 5%) and acute kidney injury (8% vs 11%). Rates of sepsis and venous thromboembolism were similar between the two groups. Multivariate regression analysis indicated that patients receiving 4 to 7 units of PRBC alone had significantly higher ORs for mortality than those receiving CR.

Conclusion: Trauma patients requiring more than 3 units of PRBCs who received CR with FFP and platelets experienced improved survival and reduced complications.

Level of evidence: Level III retrospective study.

Background: Tiered trauma team activation (TTA) allows systems to optimally allocate resources to an injured patient. Target undertriage and overtriage rates of <5% and <35% are difficult for centers to achieve, and performance variability exists. The objective of this study was to optimize and externally validate a previously developed hospital trauma triage prediction model to predict the need for emergent intervention in 6 hours (NEI-6), an indicator of need for a full TTA.

Methods: The model was previously developed and internally validated using data from 31 US trauma centers. Data were collected prospectively at five sites using a mobile application which hosted the NEI-6 model. A weighted multiple logistic regression model was used to retrain and optimize the model using the original data set and a portion of data from one of the prospective sites. The remaining data from the five sites were designated for external validation. The area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) were used to assess the validation cohort. Subanalyses were performed for age, race, and mechanism of injury.

Results: 14 421 patients were included in the training data set and 2476 patients in the external validation data set across five sites. On validation, the model had an overall undertriage rate of 9.1% and overtriage rate of 53.7%, with an AUROC of 0.80 and an AUPRC of 0.63. Blunt injury had an undertriage rate of 8.8%, whereas penetrating injury had 31.2%. For those aged ≥65, the undertriage rate was 8.4%, and for Black or African American patients the undertriage rate was 7.7%.

Conclusion: The optimized and externally validated NEI-6 model approaches the recommended undertriage and overtriage rates while significantly reducing variability of TTA across centers for blunt trauma patients. The model performs well for populations that traditionally have high rates of undertriage.

Level of evidence: 2.

Introduction: Venous thromboembolism (VTE) prophylaxis implementation strategies are well-studied in some hospitalized medical and surgical patients. Although VTE is associated with substantial mortality and morbidity in trauma patients, implementation strategies for the prevention of VTE in trauma appear to be based on limited evidence. Therefore, we conducted a systematic review and meta-analysis of published literature on active implementation strategies for VTE prophylaxis administration in hospitalized trauma patients and the impact on VTE events.

Methods: A systematic review and meta-analysis was performed in adult hospitalized trauma patients to assess if active VTE prevention implementation strategies change the proportion of patients who received VTE prophylaxis, VTE events, and adverse effects such as bleeding or heparin-induced thrombocytopenia as well as hospital length of stay and the cost of care. An academic medical librarian searched Medline, Scopus, and Web of Science until December 2022.

Results: Four studies with a total of 1723 patients in the active implementation strategy group (strategies included education, reminders, human and computer alerts, audit and feedback, preprinted orders, and/or root cause analysis) and 1324 in the no active implementation strategy group (guideline creation and dissemination) were included in the analysis. A higher proportion of patients received VTE prophylaxis with an active implementation strategy (OR=2.94, 95% CI (1.68 to 5.15), p<0.01). No significant difference was found in VTE events. Quality was deemed to be low due to bias and inconsistency of studies.

Conclusions: Active implementation strategies appeared to improve the proportion of major trauma patients who received VTE prophylaxis. Further implementation studies are needed in trauma to determine effective, sustainable strategies for VTE prevention and to assess secondary outcomes such as bleeding and costs.

Level of evidence: Systematic review/meta-analysis, level III.

Prospero registration number: CRD42023390538.

Background: With the increasing prevalence of electric scooters, a concomitant increase in the number of specific injuries, emergency department (ED) admissions and hospital admissions have been reported.

Objectives: Analyze patient flow changes in the ED with a focus on e-scooter-related injuries through a case series and a comparison with the contemporary literature.

Data sources: A systematic literature review was performed on Medline/PubMed and Embase using terms related to the topic.Data collected from two-wheeled vehicle trauma patients at our Italian ED from May 1 to October 31, 2021, were analyzed for the case series.

Study eligibility criteria: Studies were included if they evaluated populations with an e-scooter-related injury referred to the ED with precise localization and nature of the injury reported.

Participants and interventions: Data collected from the literature studies and from our case series included overall ED patient numbers, patient demographics, injury mechanism, location of the injury, discharge diagnosis, and performance of surgery.

Study appraisal and synthesis methods: All studies were checked in order to establish the coherence with the purposes of this review. Data from the contemporary literature and from this case series were compared.

Results: During a 6-month period, 280 patients had e-scooter injuries, resulting in 292 traumas, including 123 fractures, primarily in the elbow. Surgical intervention was necessary for 28 patients. The review included nine papers, highlighting that injuries to the upper and lower extremities and head were frequent in e-scooter-related incidents. The upper extremities were the most common fracture location.

Limitations: The study is a retrospective, single-center study without a comparison group, focusing exclusively on orthopedic injuries.

Conclusions or implications of key findings: The prevalence of electric scooters, which offer an affordable and eco-friendly mode of transport, is steadily increasing. It is important to focus on injury risk mitigation through effective public health policies, thereby lowering costs to society.