Trauma Surgery & Acute Care Open最新文献

Introduction: Forward military field hospitals often operate in battle zone environments where access to specialized personnel, such as radiologists, is limited, complicating the accuracy of diagnostic imaging. Chest radiographs are crucial for assessing thoracic injuries and other conditions, but their interpretation frequently falls to non-radiologist personnel. This study evaluates the effectiveness of an artificial intelligence (AI)-assisted model in enhancing the diagnostic accuracy of chest radiographs in such resource-limited settings.

Methods: Nine board-certified military physicians from various non-radiology specialties interpreted 159 anonymized chest radiographs, both with and without the support of AI. The AI model, INSIGHT CXR, generated automated descriptions for 80 radiographs, whereas 79 were interpreted without AI support. A linear mixed-effects model was used to assess the difference in diagnostic accuracy between the two conditions. Secondary analyses examined the effects of radiograph type and physician specialty on diagnostic performance.

Results: AI support increased mean diagnostic accuracy by 9.4% (p<0.001) from pretest to post-test, representing a 23.15% relative improvement. This improvement was consistent across both normal and abnormal findings, with no significant differences observed based on radiograph type or physician specialty. These findings suggest that AI tools can serve as effective support in field hospitals, improving diagnostic precision and decision-making in the absence of radiologists.

Conclusions: This study highlights the potential for AI-assisted radiograph interpretation to enhance diagnostic accuracy in military field hospitals. If AI tools are proven reliable, they could be integrated into the workflow of forward field hospitals, improving the quality of care for injured personnel. Immediate benefits may include faster diagnoses, increased personnel readiness, optimized performance, and cost savings, leading to better outcomes in combat operations.

Level of evidence: II. Diagnostic Test.

Objectives: Patients with traumatic intracranial hemorrhage (ICH) often undergo early stability CT scans to evaluate for progression of bleeding. The factors associated with progression after initiating venous thromboembolism (VTE) chemoprophylaxis (CP) remain poorly described. This study aimed to determine the rate of and factors associated with ICH progression following CP initiation.

Methods: This retrospective observational study included adult (≥16 years) polytrauma patients with blunt or penetrating traumatic brain injury (TBI) admitted between September 2016 and December 2021. Progression was defined as a radiographic increase in ICH following VTE CP initiation, determined by neurosurgery or radiology faculty. Postprophylaxis CT scans were obtained based on clinical deterioration. Associated factors, neurosurgical intervention rates, and outcomes were evaluated.

Results: Among 1390 included patients, ICH progression occurred in 3% (43) following CP initiation. Patients with progression were older (55 vs 45 years) and had higher injury severity scores (33 vs 27; p<0.05). Rates of pneumonia (49% vs 21%) and sepsis (19% vs 9%) were higher in the progression group (p<0.05). There was no difference between groups in time to prophylaxis initiation (40 vs 38 hours), survival (88% vs 92%), or VTE incidence (0% vs 4%; all p=NS). Factors associated with progression included midline shift (21% vs 6%), subdural hematoma (47% vs 26%), and prior progression on 6-hour stability CT (64% vs 34%; p<0.05). Multivariate analysis confirmed these findings. Among progression patients, 9% required intervention after CP, with only two requiring craniotomy.

Conclusions: ICH progression is rare (3%) after VTE CP initiation. Associated factors align with spontaneous progression, suggesting that ICH progression is independent of early VTE prophylaxis (<48 hours). These findings support the safety of early VTE CP as the standard of care for mitigating VTE risk in TBI patients with TBI.

Level of evidence: Level III, retrospective study with up to two negative criteria.

Introduction: Trauma is the leading cause of death among individuals aged 1-44 years, and it is estimated that many of these deaths could be prevented. Clinical guidance is an essential step toward the optimization of trauma care, especially within rural environments. This qualitative case series seeks to better understand how trauma clinical guidance (TCG) plays a role in rural trauma providers' patient management.

Methods: An initial exploratory qualitative case series consisting of five semi-structured interviews with rural providers recruited using snowball sampling from existing professional networks were conducted between February and April 2024. Providers were asked to provide details on how they approach clinical uncertainty and if clinical guidance plays a role in their decision making. Then, providers performed real-time reviews of clinical guidance documents, identifying areas for clinical guidance improvement. Interviews were recorded, transcribed, and data analyzed using narrative and thematic approaches, with key themes identified through peer debriefing with relevant quotes selected.

Results: Of the five providers interviewed, three provide care at a critical access hospital, one provides care at a level II trauma center, and one at a level III trauma center. Two interviewees mentioned that they do not use clinical guidance often in direct patient care, and three highlighted the use of advanced trauma life support as the foundation of their practice on which they expand their tools and training. Common requests of TCG from rural providers included: (1) visual components to guide workflow, (2) easy discoverability in a central place, (3) relevant across various resource settings, (4) a centralized 'stamp of approval,' for guidelines that have been mutually agreed on via extensive collaboration, and (5) transfer guidance.

Conclusion: The needs of rural trauma providers should be a focal point when working to improve the creation and dissemination of TCG. Collaboration when creating new TCG is essential. By intentionally designing for the rural population, we will increase the reach and impact of the guidance developed, as well as improve its accessibility and usability for all providers, regardless of resource setting. Through these efforts, we will decrease the disparate burden of trauma and unintentional injury on rural patients and their healthcare providers.

Level of evidence: Level V.

Traumatic injury is the leading cause of death for individuals aged 1-45 in the USA. Variations in patient management based on geographic locations, community resources, and provider characteristics contribute to disparities in patient outcomes. It is estimated that 20,000 Americans lives could be saved yearly if all trauma centers performed as well as the highest-performing center, which is achievable, in part, through the reduction of inappropriate practice variation. Trauma clinical guidance currently lacks standardization, is redundant, and remains difficult to access and implement at the bedside. To explore and address these issues, the Design for Implementation: The Future of Trauma Research and Clinical Guidance (DFI) Conference Series was developed. This conference series and complementary research aims to redesign the development, dissemination, and implementation of trauma clinical guidance with a focus on more effective and equitable systems. To do so, key community partners were convened to present clinical guidance best practices, including digital integration, resource stratification, and patient-centeredness. Conference attendees, which included partners from various provider groups, patients, dissemination and implementation scientists, public health experts, government agencies, and software developers, worked together to create a "minimum viable product" which specified key objectives for an ideal future state of trauma clinical guidance, as well as the "risk", "audience", and "key performance indicators". The next conference in the series will take place in February 2025, with a focus on translating the conceptualized priorities into tangible solutions. This paper serves to share the events from the 2024 conference proceedings.