Injury最新文献

Background: Canadian Armed Forces (CAF) operate in environments that challenge patient care, especially trauma. Military personnel often find themselves in remote settings without conventional healthcare facilities. Treating traumatic injuries, particularly hemorrhagic shock, often necessitates prehospital blood transfusion. This study aims to present an overview of the current CAF prehospital transfusion practices. Furthermore, the study compared current and developing protocols against expert-recommended guidelines.

Methods: A cross-sectional survey design was employed to describe and compare CAF prehospital blood transfusion practices and protocols against expert recommendations. Topics included protocols, equipment, and procedures. An online survey targeted medical leadership and providers within CAF, with data collected from August 15 to December 15, 2023. Results were summarized descriptively. This study received approval from the Unity Health Toronto Research Ethics Board (REB 23-087).

Results: Units and teams with prehospital blood transfusion capabilities were contacted, achieving a 100 % response rate. Within CAF, Canadian Special Operations Forces Command (CANSOFCOM), Mobile Surgical Resuscitation Team (MSRT), and Canadian Medical Emergency Response Team (CMERT) possess these capabilities, established between 2013 and 2018. These programs are crucial for military operations. CAF has access to standard blood components, cold Leuko-Reduced Whole Blood (LrWB), and factor concentrates from Canadian Blood Services (CBS), available for both domestic and international missions given adequate planning and favorable conditions. Key findings indicate high adherence to recommended practices, some variability in the transfusion process, and potential benefits of standardizing prehospital transfusion practices.

Conclusions: This study provided insights into CAF's implementation of prehospital transfusion practices, highlighting high adherence to national expert recommendations and the importance of structured protocols in military prehospital trauma management.

Implications of key findings: CAF's approach and adoption of prehospital transfusion protocols lay a strong foundation for managing trauma patients in remote settings and for expanding prehospital transfusion capabilities across CFHS deployed assets. Further research is needed to advance military trauma care by adapting prehospital blood transfusion to dynamic tactical landscapes and evolving technologies.

Introduction: The elderly population is growing worldwide and is more likely to die from injuries that younger patients would likely survive. Furthermore, elderly trauma patients are often subjected to triage decisions that admit them to lower-level facilities. These patients may require interhospital transfer to a major trauma center for definitive care. The aim of this study was to investigate the time interval from arrival at the primary hospital to arrival at the trauma center among elderly trauma patients (≥65 years) as compared to younger, adult patients (18-64 years). We hypothesized that elderly trauma patients would endure a longer time interval.

Methods: This was a retrospective quality assurance study based on patient data in our trauma registry at the Trauma Center of Copenhagen University Hospital, Rigshospitalet in Denmark. Data were extracted in the period between 2018 and 2023. We included all adult trauma patients (≥18 years) who underwent interhospital transfer to the trauma center. The primary outcome was minutes from arrival at the primary hospital to arrival at the trauma center. A quality standard of at least 90 % of patients arriving at the trauma center in <240 min after arrival at the primary hospital, was chosen.

Results: In total, 565 patients were included and divided into an elderly cohort (n = 184) and a younger cohort (n = 381). The elderly cohort had a significantly longer median delay (247 vs. 197 min; estimated difference 50 min, 95 % confidence interval (CI) [28, 71]; p < 0.001). The elderly cohort met the quality standard less than the younger cohort (49 % vs. 68 %). The elderly cohort had a significantly higher injury severity score (17 [IQR 13, 25] vs. 16 [IQR 9, 21]; p < 0.001), and we found a significant difference in 30-day mortality, which was supported by an adjusted odds ratio of 6.35 (95 % CI [2.84, 15.7]; p < 0.001).

Conclusions: In conclusion, elderly trauma patients experienced significantly longer median delays from arrival at the primary hospital to arrival at the trauma center compared to younger adult trauma patients. The elderly trauma patients met the quality standard for transfer time at a lower rate than the younger group.

Aim of study: This study aimed to evaluate the completeness and quality of information in written discharge instructions for patients with mild traumatic brain injury (mTBI) discharged from the emergency department (ED).

Methods: Copies of written discharge instructions provided to patients with mTBI from academic EDs in South Korea were collected in May 2023. We assessed the completeness of the content based on the National Institute for Health and Clinical Excellence guidelines, which categorize discharge instructions into four parts: general advice, emergencies, common post-concussion symptoms and signs, and advice for recovery, with one point for each item. The quality of information was evaluated using DISCERN, a validated 16-item questionnaire assessing reliability (eight questions), quality of information (seven questions), and overall quality (one question) on a 5-point Likert scale. Completeness and quality of discharge information were analyzed by ED level and annual ED visits as proxies for hospital resources.

Results: Twenty-two (44%) written discharge instructions were collected from the 55 EDs contacted, with a mean (standard deviation) content completeness score of 10.1 (2.7) out of a maximum of 30. The mean scores for each section were as follows: general advice, 0.1 (0.23) out of 2; emergencies, 6.0 (1.39) out of 10; common post-concussion symptoms and signs, 0.4 (0.9) out of 8; and advice for recovery, 3.2 (1.9) out of 10. Regarding the quality of information, the mean reliability score was 3.5 (0.3), and the mean information quality score was 1.8 (0.7), with both assessed on a scale from 1 ("very poor") to 5 ("excellent"). Significant differences were found in content completeness for emergency features and in the general scores for quality of information between different ED levels (p = 0.04 and p = 0.01, respectively). However, no significant differences were observed by the number of annual ED visits.

Conclusion: The completeness and quality of written discharge instructions for mTBI patients in South Korean EDs were low and varied across hospitals, suggesting a potential association to hospital resources.

Background: Vital signs are important factors in assessing injury severity and guiding trauma resuscitation, especially among severely injured patients. Despite this, physiological data are frequently missing from trauma registries. This study aimed to evaluate the extent of missing prehospital data in a hospital-based trauma registry and to assess the associations between prehospital physiological data completeness and indicators of injury severity.

Methods: A retrospective review was conducted on all adult trauma patients brought directly to a level 1 trauma center in Toronto, Ontario by paramedics from January 1, 2015, to December 31, 2019. The proportion of missing data was evaluated for each variable and patterns of missingness were assessed. To investigate the associations between prehospital data completeness and injury severity factors, descriptive and unadjusted logistic regression analyses were performed.

Results: A total of 3,528 patients were included. We considered prehospital data missing if any of heart rate, systolic blood pressure, respiratory rate or oxygen saturation were incomplete. Each individual variable was missing from the registry in approximately 20 % of patients, with oxygen saturation missing most frequently (n = 831; 23.6 %). Over 25 % (n = 909) of patients were missing at least one prehospital vital sign, of which 69.1 % (n = 628) were missing all four of these variables. Patients with incomplete data were more severely injured, had higher mortality, and more frequently received lifesaving interventions such as blood transfusion and intubation. Patients were most likely to have missing prehospital physiological data if they died in the trauma bay (unadjusted OR: 9.79; 95 % CI: 6.35-15.10), did not survive to discharge (unadjusted OR: 3.55; 95 % CI: 2.76-4.55), or had a prehospital GCS less than 9 (OR: 3.24; 95 % CI: 2.59-4.06).

Conclusion: In this single center trauma registry, key prehospital variables were frequently missing, particularly among more severely injured patients. Patients with missing data had higher mortality, more severe injury characteristics and received more life-saving interventions in the trauma bay, suggesting an injury severity bias in prehospital vital sign missingness. To ensure the validity of research based on trauma registry data, patterns of missingness must be carefully considered to ensure missing data is appropriately addressed.

Introduction: Thoracic injuries are prevalent in polytrauma patients, with road traffic accidents being a major cause. In India alone, over 400,000 people were injured in such accidents in 2022. Rib fractures, haemothorax, and pneumothorax are common chest injuries, often managed with tube thoracostomy. While standard procedures for chest tube placement are established, consensus on post-insertion management, particularly regarding negative pleural suction, is lacking. Research on this topic mostly pertains to planned thoracotomies rather than trauma cases. This study seeks to compare outcomes of slow negative suction versus conventional drainage in blunt or penetrating thoracic trauma.

Methods: This single-centre, open-label, randomized controlled trial in a western Indian hospital from Jan 2021 to June 2022 included adult patients with thoracic trauma requiring intercostal drainage tubes. Patients needing emergency thoracotomy, mechanical ventilation, or bilateral chest tubes were excluded. Sample size (n = 64) was calculated based on prior studies. Patients were randomly assigned to experimental (slow negative pleural suction) or control (conventional water seal drainage) groups. Both groups received standard care. Primary outcome was time to chest tube removal; secondary outcomes included hospital stay length, complications, and need for further intervention. Data were analysed using SPSS. Significance was set at p < 0.05.

Results: During the study 64 patients were randomised into experimental (n = 32) or conventional (n = 32) groups. Most of the patients were males (88 %, n = 56). Both groups had similar baseline characteristics. Experimental group patients had shorter median chest tube duration (3 [IQR 2-3.75] vs. 5 [3-8.75] days, p < 0.001) and hospital stay (5 [4-8.75] vs. 10 [6-16.75] days, p = 0.004). No discomfort was reported with slow continuous negative pleural suction. Mortality was 1 (3 %) in the experimental group vs. 2 (6 %) in the conventional group. Four patients suffered retained haemothorax, with only one occurrence in the experimental group (3 %).

Conclusion: Application of slow continuous negative pleural suction to chest tubes in patients of thoracic trauma can decrease the chest tube duration and the hospital stay. This study ought to be followed up with multicentric randomised clinical trials with larger sample sizes to better characterise the effects of slow continuous negative pleural suction.

Background: Efficient resuscitation after trauma and shorter time to definitive hemorrhage control help improve trauma outcomes. We aimed to improve the speed and efficiency of resuscitation for critically ill trauma patients in the emergency department by involving interventional radiology and a second surgeon.

Study design: In 2017 our community, non-academic level II trauma center implemented the Double 90 rule-for trauma patients with 2 confirmed systolic blood pressures <90 mm Hg-which involves a second activation including the interventional radiology team, backup trauma surgeon, and operating room charge nurse. We retrospectively reviewed our trauma registry to compare data for high-level trauma patients before (2016, "Pre-Dbl90") and 3 consecutive years after intervention (2018-2020, "Dbl90").

Results: Among 613 patients who met criteria for our highest level of trauma activation, 100 either had activation of the Double 90 rule (Dbl90 patients, n = 76) or met Double 90 rule criteria (Pre-Dbl90 patients, n = 24). The groups were similar in age, sex, injury severity score, penetrating trauma incidence, and admission vitals. Median time to computed tomography decreased throughout the study period, from 34 min in 2016 to 18 min in 2020 (P < .001). Median time to first hemorrhage control procedure decreased from 118 min (2016) to 43 min (2020), (P = .013). Mean packed red blood cell transfusion decreased from 9.1 to 4.8 units (P = .016). Mortality rates were similar between groups.

Conclusion: The Double 90 rule is effective for expediting trauma care starting in the emergency department, shortening the times to computed tomography, hemorrhage control intervention, and decreasing packed red blood cell transfusion.

Introduction: The Pain, Inspiratory effort, Cough score (PIC) has been developed and widely adopted to guide clinical prognostication for patients with chest wall injury. To date, the efficacy, accuracy, and safety of a PIC based triage system has not been validated. Therefore, this study sought to evaluate the use of a modified-PIC score to triage and down-grade trauma patients with chest wall injury at a single institution.

Methods: A retrospective study was conducted at a large, Level I Trauma Center on patients with chest wall injuries admitted between 1/1/2018-10/31/20,222. On 12/1/2020, our institution implemented a modified-PIC triage tool including the PIC score, age, and severity of chest wall injury. The Pre-PIC (1/1/2018-11/20/2020) and Post-PIC (1/1/2021-10/31/2022) groups were composed based on admission date and outcomes between the two were compared.

Results: 2,627 patients comprised the Pre-PIC group and 2,212 patients comprised Post-PIC. The groups didn't differ significantly in demographics or mechanisms of injury except for COVID status. Post-intervention, a greater proportion of patients were triaged to the intermediate care unit instead of the ICU or floor. There were no significant differences in hospital length of stay (LOS), ventilator days, unplanned ICU admission, or mortality in Pre-PIC vs Post-PIC. ICU LOS, rates of ARDS, and cardiac arrest with return of spontaneous circulation (ROSC) were significantly lower in Post-PIC. Multivariable models demonstrated significantly lower ARDS rates and ICU free days. ICU LOS trended towards significance as well.

Conclusions: This is the largest study, to date, evaluating the impact of a modified-PIC triage system on clinical outcomes. The results suggest a modified-PIC triage system may lead to decreased ICU days, ARDS rates, and rates of cardiac arrest w/ ROSC, potentially improving hospital resource allocation. Further prospective and multi-center studies are needed to validate our understanding on the impact of a chest wall scoring system on triage and outcomes.

Background: Vascular injuries are associated with high morbidity and mortality. The management is exceedingly demanding and requires involvement of senior clinician. There are known complications associated with vascular injury ranging from limb loss, stroke, and death. There are limited studies examining other injuries that are associated with vascular trauma. This study aimed to review the pattern, management and outcomes of the other injuries associated with vascular injuries.

Method: A retrospective cross-sectional study chart review of patients with vascular trauma requiring ICU admission between January 2013 and December 2021. Additional data was prospectively collected from January 2022 to December 2022. All patients admitted to trauma ICU with polytrauma including a vascular injury were reviewed, except patients who died prior the confirmation of vascular injury. The injury was either confirmed by imaging or via exploration. The non-vascular injuries were identified. The pattern, management and outcomes were documented. A pre-designed data proforma was used identifying injury type, management strategy, and outcomes.

Results: Out of 2805 patients that were admitted in trauma ICU from 2013 to 2022, 153 (5 %) patients had vascular injuries. There were 154 documented vascular injuries and 212 associated injuries. This study found that fractures are the most common injuries to be associated with vascular injury CONCLUSION: The nature of vascular injury and delay to intervention determines outcome of patients, however associated injuries also play an important role in affecting outcomes. The presence of associated injury encourages the multi-disciplinary approach to optimise outcomes.

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) serves as a bridging intervention for subsequent definitive haemorrhagic control. This study compared the clinical outcomes of REBOA and resuscitative thoracotomy (RT) in patients with bleeding below the diaphragm.

Materials and methods: This retrospective cohort study included adult trauma patients who presented to the Trauma Quality Improvement Program between 2020 and 2021 and who underwent either REBOA or RT in the emergency department (ED). Patients with severe head and chest injuries, characterised by an Abbreviated Injury Scale (AIS) score greater than 3, were excluded. The clinical data of patients treated with REBOA and those treated with RT were compared, and multivariable logistic regression (MLR) was employed to identify prognostic factors associated with mortality.

Results: A total of 346 patients were enrolled: 138 (39.9 %) received REBOA, and 208 (60.1 %) received RT at the ED. Patients in the RT group underwent ED cardiopulmonary resuscitation (CPR) more frequently (58.2 % vs. 23.2 %; p < 0.001) and had a higher mortality rate (87.0 % vs. 45.7 %; p < 0.001). Patients who died had lower Glasgow Coma Scale scores (6 [4.5] vs. 11 [4.9]; p < 0.001), underwent more ED CPR (58.6 % vs. 9.8 %; p < 0.001), and received RT more frequently (74.2 % vs. 26.5 %, p < 0.001). The MLR revealed that the major prognostic factors for mortality were systolic blood pressure (odds ratio [OR] 0.988, 95 % confidence interval [CI] 0.978-0.998; p = 0.014), ED CPR (OR 11.111, 95 % CI 4.667-26.452; p < 0.001), abdominal injuries with an AIS score ≥ 4 (OR 4.694, 95 % CI 1.921-11.467; p = 0.001) and RT (OR 5.693, 95 % CI 2.690-12.050; p < 0.001).

Conclusions: In cases of blunt trauma, prompt identification of the bleeding source is crucial. For patients with bleeding below the diaphragm, REBOA led to higher survival rates than did RT. However, it is important to consider the limitations of the database and the necessary exclusions from our analysis.

Objective: Overcrowding in an emergency department (ED) or intensive care unit (ICU) of the trauma center (TC) is an important issue for timely acute health care of a critically injured patient. Accumulated scientific evidence has indicated the negative influence of overcrowding to the process and clinical outcome of trauma care.

Method: The institutional trauma registry at an urban level I TC was retrospectively evaluated for 5 years (2018-2022). Major trauma was defined as an injury severity score (ISS) of >15. We determined simultaneous or overlapping presentations of major trauma (SOMT) in two or more patients with ISS of >15 who presented within a 4-h time window. When only two patients were included within a single time window, they were classified as SOMT-2, whereas when three or more patient clusters were identified in a single time window, they were classified as SOMT-3. The outcome measurement included process and clinical variables, such as trauma team activation (TTA) ratio, ED length of stay (LOS), time to blood product transfusion (TF), time to emergency surgery or intervention (ESI), ICU LOS, and mortality.

Result: A total of 2,815 patients were included, of which 39.6% (N = 1,116) classified as SOMT. The SOMT group had lower TTA ratio than the non-SOMT group (69.4% vs. 73.4%, P = 0.022). The TTA ratio exhibited a decreasing trend in non-SOMT, SOMT-2, and SOMT-3 groups (P = 0.006). The time to TF was significantly delayed in the SOMT group (129 vs. 91 min, P < 0.001).

Conclusion: SOMT regularly occurs and results in fewer trauma team activation and a delayed time to blood transfusion. The current intensive trauma care system should be strategically modified to improve critical trauma care and enhance disaster preparedness.