The Victorian Major Trauma Transfer Study

Aims

To comprehensively examine the inter-hospital transfer of major trauma patients—including the reason for transfer, duration, escorts, interventions and unexpected events.

Methods

This was an detailed study of the transfer of major trauma cases in the State of Victoria, Australia, between April 16, 2003 and December 31, 2004. Twenty-three hospitals and seven transfer/retrieval services participated. Defined major trauma cases that were transferred between participating hospitals for the purpose of definitive care were eligible for enrolment. The transfer phase extended from 30 min before until 30 min after the transfer. The transferring and receiving hospitals and the transfer escorts were asked to record data on a specifically designed data collection form.

Results

A total of 451 cases were enrolled (mean Injury Severity Score 22.2). Transfers originated mainly from Regional Trauma (42.8%) and Metropolitan Trauma (31.3%) Services and most (90.5%) terminated at a Major Trauma Service. Median time from injury to arrival at the receiving hospital was 8 h 30 min. Median time from arrival at referring hospital to request for transfer was 3 h 25 min.Escorts comprised ambulance and medical/nursing staff in 67.0% and 30.4% of cases, respectively. Metropolitan retrieval services were involved in only 10% of cases. Medical escorts were mainly (62.9%) from the referring hospital and the majority of these were registrars (49.4%) and hospital medical officers (HMOs, 16.9%).Overall mortality was 6.2%. Mortality rates for cases escorted by referring hospital doctors, Mobile Intensive Care Ambulance (MICA), non-MICA and any other escorts were 14.5%, 6.0%, 2.6% and 4.3%, respectively. HMO escorts had the highest mortality risk (OR 3.67, 95%CI 1.00-13.49, p < 0.001).Mortality risk was greatest for cases that required administration of vasopressor drugs (OR 11.4, 95%CI 3.78-34.36, p < 0.001), intubation prior to arrival at the referring hospital (OR 10.36, 95%CI 3.51-30.52, p < 0.001), any interventions at the referring hospital (OR 8.3, 95%CI 3.1-22.2, p < 0.001), administration of blood at the receiving hospital (OR 4.91, 95%CI 1.5-16.1, p = 0.01), and cases using escorts from the referring hospital (OR 3.8, 95%CI 1.69-8.39, p = 0.001).

Conclusion

Considerable variability in request for transfer and transfer times, transfer escorts and mortality risk exist. The single greatest issue identified that most severely injured group were escorted by the most junior doctors (HMOs) and had the highest mortality. This crucial issue must be addressed by the State Trauma System and by any redesigned retrieval service in Victoria. A detailed review of activation and responsiveness criteria and the nature of the transfer escort is indicated. The establishment of Adult Retrieval Victoria may address many of the concerns raised by this study.     

Update on trauma care in Canada. 5. Trauma and hypothermia

Trauma may be accompanied by hypothermia in all climates. Because of the associated increased death rate due to hypothermia (core body temperature less than 35 degrees C), traumatized patients must be protected from it. The body maintains heat balance by hypothalamic regulation of endogenous heat generation and heat loss. Decreased core temperature causes generalized physiologic deceleration and homeostatic disturbances in all organ systems. To prevent hypothermia in polytraumatized patients a number of methods may be used: warming crystalloid, increasing ambient temperature, the use of warming devices, irrigation of body cavities with warmed fluids, heating of inspired gases and, in severe cases when there is circulatory instability, the use of extracorporeal membrane oxygenation.     

The association of hand and wrist injuries with other injuries in multiple trauma patients. A retrospective study in a UK Major Trauma Centre

BackgroundApproximately 20,000 major trauma cases occur in England every year. However, the association with concomitant upper limb injuries is unknown. This study aims to determine the incidence, injury pattern and association of hand and wrist injuries with other body injuries and the Injury Severity Score (ISS) in multiply injured trauma patients.MethodsSingle centre retrospective study was performed at a level-one UK Major Trauma Centre (MTC). Trauma Audit and Research Network (TARN) eligible multiply injured trauma patients that were admitted to the hospital between January 2014 and December 2018 were analysed. TARN is the national trauma registry. Eligible patients were: a trauma patient of any age who was admitted for 72 h or more, or was admitted to intensive care, or died at the hospital, was transferred into the hospital for specialist care, was transferred to another hospital for specialist care or for an intensive care bed and whose isolated injuries met a set of criteria. Data extracted included: age, gender, mode of arrival, location of injuries including: hand and/or wrist and mechanism of injury. We performed a logistic regression analysis to assess the association between hand/wrist injury to ISS score of 15 points or above/below and to the presentation of other injuries.Results107 patients were analysed. Hand and wrist injuries were the second most common injury (26.2%), after thoracic injuries. Distal radial injuries were found in 5.6%, carpal/carpometacarpal in 6.5%, concurrent distal radius and carpometacarpal in 0.9%, phalangeal injuries in 4.7%, tendon injuries in 0.9% and concurrent hand and wrist injuries in 7.5% cases. There was a significant association between hand or wrist injuries and lower limb injuries (Odds Ratio (OR): 3.84; 95% confidence intervals (CI): 1.09 to 13.50; p = 0.04) and pelvic injuries (OR: 4.78; 95% CI: 1.31 to 17.44; p = 0.02). There was no statistical association between hand and wrist injuries and ISS score (OR: 0.80; 95% CI: 0.11 to 5.79; p = 0.82).ConclusionsHand and wrist injuries are prevalent in trauma patients admitted to MTCs. They should not be under-estimated but routinely screened for in multiply injured patients particularly those with a pelvic or lower limb injury.     

Management of high grade renal trauma: 20-year experience at a pediatric level I trauma center

PURPOSE: In the last 20 years the management of high grade, blunt renal trauma at our institution has evolved from primarily an operative approach to an expectant nonoperative approach. To evaluate our experience with the expectant nonoperative management of high grade, blunt renal trauma in children, we reviewed our 20-year experience regarding evaluation, management and outcomes in patients treated at our institution. MATERIALS AND METHODS: We retrospectively studied all patients sustaining renal trauma between 1983 and 2003. Medical records were reviewed for mechanism of injury, assigned grade of renal injury, patient treatment, indications for and timing of surgery, and outcome. Injuries were categorized as either low grade (I to III) or high grade (IV to V). RESULTS: We reviewed the medical records of 164 consecutive children who sustained blunt renal trauma between 1983 and 2003. A total of 38 patients were excluded for inadequate information. Of the remaining 126 children 60% had low grade and 40% had high grade renal injuries. A total of 11 patients (8.7%) required surgical or endoscopic intervention for renal causes, including 2 for congenital renal abnormalities and 1 for clot retention. Eight patients (6.3%) required surgical intervention for isolated renal trauma, of whom 2 (1.6%) required immediate surgical intervention for hemodynamic instability and 6 (4.8%) were treated with a delayed retroperitoneal approach. Only 4 patients (3.2%) required nephrectomy. All patients receiving operative intervention had high grade renal injury. CONCLUSIONS: Initial nonsurgical management of high grade blunt renal trauma in children is effective and is recommended for the hemodynamically stable child. When a child has persistent symptomatic urinary extravasation delayed retroperitoneal drainage may become necessary to reduce morbidity. Minimally invasive techniques should be considered before open operative intervention. Early operative management is rarely indicated for an isolated renal injury, except in the child who is hemodynamically unstable.     

Trauma faculty and trauma team activation: impact on trauma system function and patient outcome.

OBJECTIVE: To determine the impact of the presence of an attending trauma surgeon during trauma team activation on system function and patient outcome. METHODS: After a retrospective review of medical records and trauma registry, a comparative study between two American College of Surgeons Committee on Trauma Level I trauma centers was performed. One center (Hennepin County Medical Center) required a chief surgical resident, two junior residents, and a board-certified emergency medicine faculty to be present in the emergency department for all trauma team activations. The attending trauma surgeon was notified at the time of trauma team activation and was neither required to be present in the emergency department at time of patient arrival nor in the hospital 24 h/day. The other center (St. Paul Ramsey Medical Center) required a chief surgical resident, two junior residents, a board-certified emergency medicine faculty member, and an attending trauma surgeon to be present in the emergency department for all trauma activations and in hospital 24 hours/day. Over a 21-month period, all major trauma patients (Injury Severity Score > 15 or emergent operation within 4 hours of admission and any Injury Severity Score) that triggered trauma team activation were examined. Resuscitation time, time to incision, probability of survival, and mortality were analyzed. RESULTS: Resuscitation time was shorter at St. Paul Ramsey Medical Center when compared with Hennepin County Medical Center. Analysis by mechanism of injury demonstrates that this was true for blunt trauma (39+/-13 vs. 27+/-12 minutes, p = 0.001) and for penetrating trauma (28+/-14 vs. 24+/-17 minutes, p = 0.01). Subgroup analysis of penetrating trauma victims demonstrated that there was a significant difference in resuscitation times for gunshot wounds but not for stabs. There was no difference in how quickly operations could be initiated for blunt trauma patients. However, in penetrating cases, time to incision was significantly shorter at St. Paul Ramsey Medical Center (50+/-29 vs. 66+/-43 minutes, p = 0.01). There was no significant difference in mortality for any category of Trauma and Injury Severity Score probability of survival in blunt or penetrating trauma. Analysis of "in-house" and "out-house" time intervals demonstrated no difference in survival in any mechanism of injury, nor was there a difference in overall mortality. CONCLUSION: The presence of a trauma surgeon on the trauma team reduced resuscitation time and reduced time to incision for emergent operations, particularly in penetrating trauma. However, it had no measurable impact on mortality based on Trauma and Injury Severity Score probability of survival. Attending trauma surgeon presence on the trauma team improves in-hospital trauma system function without affecting patient outcome.     

Epidemiological data on head trauma in Europe

Objective

The primary objective of the study was to test whether there is a general downward trend in the number of head injuries in Europe.

Methods and procedures

The research design of the study was a retrospective, explorative orientating analysis. A comparison of 27 European countries is presented. They have been sourced from the World Health Organization.

Results

The mean percentage of all hospital admissions for intracranial trauma in Europe is 0.855 % (±SD 0.550; range 0.03 to 2.82 %). The highest rates of treatments due to intracranial injuries are found in the Czech Republic, Latvia and Lithuania, whereas in the new member states of the European Union, such rates have been falling since entry, and there has been an increase in countries such as Germany, Finland and Cyprus. The mean length of in-hospital stay due to intracranial trauma in Europe is 6.79 days (±SD 2.95).

Conclusions

There is no general decrease in the number of treated patients due to head injuries. There are serious regional differences and there is a need for preventive and informative action throughout Europe.     

Survival prediction of trauma patients: a study on US National Trauma Data Bank

Background

Exceptional circumstances like major incidents or natural disasters may cause a huge number of victims that might not be immediately and simultaneously saved. In these cases it is important to define priorities avoiding to waste time and resources for not savable victims. Trauma and Injury Severity Score (TRISS) methodology is the well-known and standard system usually used by practitioners to predict the survival probability of trauma patients. However, practitioners have noted that the accuracy of TRISS predictions is unacceptable especially for severely injured patients. Thus, alternative methods should be proposed.

Methods

In this work we evaluate different approaches for predicting whether a patient will survive or not according to simple and easily measurable observations. We conducted a rigorous, comparative study based on the most important prediction techniques using real clinical data of the US National Trauma Data Bank.

Results

Empirical results show that well-known Machine Learning classifiers can outperform the TRISS methodology. Based on our findings, we can say that the best approach we evaluated is Random Forest: it has the best accuracy, the best area under the curve, and k-statistic, as well as the second-best sensitivity and specificity. It has also a good calibration curve. Furthermore, its performance monotonically increases as the dataset size grows, meaning that it can be very effective to exploit incoming knowledge. Considering the whole dataset, it is always better than TRISS. Finally, we implemented a new tool to compute the survival of victims. This will help medical practitioners to obtain a better accuracy than the TRISS tools.

Conclusion

Random Forests may be a good candidate solution for improving the predictions on survival upon the standard TRISS methodology.

     

Prevalence of erectile dysfunction in Thailand. Thai Erectile Dysfunction Epidemiological Study Group

A study of the prevalence rate of erectile dysfunction (ED) in the Thai population has never been done previously, except for a small study in the hospital. The project was carried out across the whole country, including in the north, south, eastern and central plains, and there were representatives from one small and one large province and the Bangkok metropolitan area. There were 250 males in each area, giving as total of 1250 males. The interviews were carried out in urban areas, so that the questions and answers could produce good data. The interviewer was trained by one of our EDACTT members, before going to the interview locations, and the supervisor were also onsite to clarify any the questions that might occur. The questions and pretest were carried out stringently, to help in term of statistics. All the health questions were asked taking care to accommodate the interviewee's feelings, so as not to cause embarrassment. The interviews were held individually and strictly privately, so that the interviewees could speak freely The interviewees were between 40 and 70-years old, to match with MMAS. The rate of ED in this age group is increasing gradually, and the relationship between ED and hypertension, diabetics or heart disease, and lifestyle factors, including smoking habits, alcohol consumption, caffeine and risk factors is of interest.     

Changing Demographic Trends in spine trauma: The presentation and outcome of Major Spine Trauma in the elderly

IntroductionMajor trauma has seen a demographic shift in recent years and it is expected that the elderly population will comprise a greater burden on the major trauma service in the near future. However, whether a similar trend exists in those undergoing operative intervention for spinal trauma remains to be elucidated.AimsTo compare the presentation and outcomes of patients ≥65 years of age sustaining spine trauma to those <65 years at a national tertiary referral spine centre.MethodsThe local Trauma Audit Research Network (TARN) database was analysed to identify spinal patients referred to our institution, a national tertiary referral centre, between 01/2016 and 05/2019. Patients were divided into a young cohort (16–64 years old) and an elderly cohort (> 64 years old). No explicit distinction was made between major and minor spine trauma cases. Variables analysed included patient demographics, injury severity, mortality, interventions, mechanism of injury and length of hospital stay.ResultsA total of 669 patients were admitted of which 480 patients underwent operative intervention for spinal trauma. Within the elderly cohort, this represented 75.3% of cases. Among the younger population, road traffic collisions were the most common mechanism of injury (37.1%), while low falls (<2 m) (57.4%) were the most common mechanism among the older population. Patients ≥65 years old had significantly longer length of stay (21 days [1–194] v 14 days [1–183]) and suffered higher 30-day mortality rates (4.6% [0–12] v 0.97% [0–4]).ConclusionOrthopaedic spinal trauma in older people is associated with a significantly higher mortality rate as well as a longer duration of hospitalization. Even though severity of injury is similar for both young and old patients, the mechanism of injury for the older population is of typically much lower energy compared to the high energy trauma affecting younger patients.     

Major trauma with multiple injuries in Swedish children.

OBJECTIVE: To describe the demographics, mechanisms, pattern, and severity of injury, the prehospital and hospital care during the first 24 hours, and the outcome in the most severely injured children in a paediatric intensive care unit (PICU). DESIGN: Retrospective review. SETTING: Paediatric intensive care unit (PICU), Sweden. SUBJECTS: 45 children (0-16 years of age) with multiple injuries admitted to the PICU in Gothenburg from January 1990 to October 2000, inclusive. MAIN OUTCOME MEASURE: Mortality within 30 days after injury. RESULTS: About 2/100000 children with multiple injuries were admitted to the PICU from the greater Gothenburg area each year from 1990-2000 inclusive. Injuries were more common in boys (n = 29, 64%). The mean age was 7 years (SD 5). Traffic related events (n = 29, 64%) and falls (n = 11, 24%) were the leading causes of injury. Thoracic and abdominal injuries were the most common (17% and 16% respectively). Three children died. CONCLUSION: Major trauma with multiple injuries is rare in Swedish children. When they are cared for at a centre with the necessary facilities and trained personnel they have a good chance of survival.     

Trauma center closure: effects on an adjacent trauma center

The effects of the closure of a busy trauma center on an adjacent university trauma hospital were analyzed. Significant increases were found in monthly volume (P less than .01) and frequency of penetrating injuries (P less than .05) and significant decreases in patients with insurance coverage (P less than .01) and numbers requiring intensive care (P less than .01). The authors conclude that trauma center closures have significant and measurable effects which influence allocation of scarce resources within remaining hospitals and generate pressures to transfer patients to overburdened public facilities. Transfers undermine continuity of care and education and further threaten the integrity of the trauma system.