Direct transport versus inter hospital transfer of severely injured trauma patients

IntroductionSeveral studies have suggested that severely injured patients should be transported directly to a trauma centre bypassing the nearest hospital. However, the evidence remains inconclusive. The purpose of this study was to examine the benefits in terms of mortality of direct transport to a trauma centre versus primary treatment in a level II or III centre followed by inter hospital transfer to a trauma centre for severely injured patients without Traumatic Brain Injury (TBI).Patients and methodsWe used the regional trauma registry and included all patients with an Injury Severity Score (ISS) >15 and an Abbreviated Injury Score <4 for head injury. We adjusted for survival bias by including “potential transfers”: patients who died at the nearest hospitals before transportation to a trauma centre.ResultsA total of 439 patients was included. The majority of patients (349/439, 79%) was transported directly to the level I trauma centre (direct group). The transferred group was formed by the remaining 90 patients, of whom 81 were transferred to the level I trauma centre after initial stabilisation elsewhere and 9 patients died in the emergency room before transfer to a level 1 trauma centre could occur. There were no significant differences in baseline and injury characteristics between the groups. Overall, 60 patients died in-hospital including 41 of the 349 patients (12%) in the direct group and 19 of the 90 patients (21%) in the transferred group. Nine of the 19 deaths in the transferred group were ascribed to potential transfers. After adjusting for prehospital Revised Trauma Score (RTS) and ISS, the odds ratio of death was 2.40 (95%CI: 1.07–5.40) for patients in the transfer group. When potential transfer patients were excluded from the analysis, the adjusted odds ratio of death was 1.14 (95%CI: 0.43–3.01).ConclusionsAfter adjusting for survivor bias by including potential transfers, the results of this study suggest a lower risk of death for patients who are directly transported to a level I trauma centre than for patients who receive primary treatment in a level II or III centre and are transferred to a trauma centre. However, this finding was only significant when adjusting for survival bias and therefore we conclude that it is still uncertain if there is a lower risk of death for patients who are transported directly to a level I trauma centre.     

Outcomes after switching from one bisphosphonate to another in 146 patients at a single university hospital

Summary  Most patients who switched to a second bisphosphonate continued their treatment long term, although those who stopped their first drug because of adverse events were likely to discontinue the second drug for the same reason. Switching to another bisphosphonate is a reasonable treatment option for some patients with treatment failure. Introduction  Patients who experience treatment failure with a bisphosphonate because of adverse events (AEs) or other reasons might receive a second bisphosphonate. However, the frequency and benefits of switching bisphosphonates are unknown. Methods  We retrospectively evaluated 197 men and 1110 women newly treated with bisphosphonates between 1 January 2000 and 30 June 2005 at our university hospital. Results  Among the 497 patients who discontinued bisphosphonate treatment, 146 were switched to a second bisphosphonate. The cumulative probabilities of persistence of treatment after 3 years were 45% with the first bisphosphonate and 65% with the second (P = 0.017). Age ≥65 years, switching bisphosphonates because of AEs, and male gender were associated (P < 0.05) with low persistence of treatment with the second bisphosphonate. Discontinuation of the first drug because of AEs was associated with an increased rate of discontinuation of the second drug because of AEs (hazard ratio, 4.2; 95% confidence interval, 2.1–8.4). Conclusions  Patients who switched bisphosphonates had high rates of persistence of therapy. Those who stopped their first bisphosphonate because of AEs were at risk of discontinuing the second drug for the same reason. Switching to another bisphosphonate is a reasonable treatment option for some patients with treatment failure. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Intervention rates are low after direct discharge from the Edinburgh trauma triage clinic: Outcomes of 6,688 patients

AimThe Edinburgh Trauma Triage clinic (TTC) is an established form of Virtual Fracture clinic (VFC) that permits the direct discharge of simple, isolated fractures from the Emergency Department (ED). Small, short-term cohort studies of similar systems have been published, but to detect low rates of complications requires a large study sample and longer-term follow-up. This study details the outcomes of all patients with injuries suitable for a direct discharge protocol over a four-year period, reviewed at a minimum of three years after attendance.PatientsAll TTC records between February 2014 and December 2017 were collated from a prospective database. Fractures of the radial head, little finger metacarpal, fifth metatarsal, toe phalanges and mallet finger injuries were included. TTC outcome, including any deviations from a well-established direct discharge protocol, were noted. All records were re-assessed at a minimum of 36 months after TTC triage (mean 54 months) to ascertain which injuries attended the trauma clinic after initial discharge. Reasons for attendance, the source of referral and any subsequent surgical procedures were identified.ResultsThere were 6688 patients with fractures of the radial head (1861), little finger metacarpal (1621), fifth metatarsal (1916), toe phalanges (920) and mallet finger injuries (370). 298 (6%) patients were re-referred after direct discharge and attended trauma clinic at a mean time after injury of 11.9 weeks, of whom 11 (0.2%) underwent a surgical intervention. Serious adverse events, defined as those in which a patient may not have come to harm if early clinical review had been undertaken, occurred in 1 patient (0.01%).ConclusionIntervention after direct discharge of simple pre-defined injuries of the elbow, hand and foot is low. Within a TTC system, patients with these injuries can be safely discharged without routine follow-up.     

Outcomes after severe trauma at a northern Canadian regional trauma centre

Objective

To evaluate outcomes of trauma patients at a northern community trauma referral centre that does not meet several of the guidelines for a trauma centre.

Design

A retrospective study.

Setting

Sudbury General Hospital in northern Ontario.

Participants

All trauma patients admitted between 1991 and 1994 who had an Injury Severity Score (ISS) greater than 12.

Outcome measures

Actual survival to discharge was compared to survival predicted by TRISS analysis. Z, W and M scores were calculated by standard TRISS techniques.

Results

Of 526 patients with an ISS greater than 12, 416 (79%) were suitable for TRISS analysis. Of these 416 patients, 310 (74%) were men. The mean age was 39 years. Two hundred and sixty-one (63%) patients were admitted directly to the Sudbury General Hospital, whereas 155 (37%) were transferred from other hospitals. The leading causes of injury were motor vehicle–traffic accidents in 48%, motor vehicle–nontraffic in 21% and falls in 8%. Overall, there were more unexpected survivors than patients who died. The Z score for survivors was 4.95, and the W score was 5.66.

Conclusions

In the setting of a geographically isolated, medium-volume trauma centre where blunt injuries predominate, excellent trauma survival can be achieved without meeting all trauma centre guidelines for staffing and facilities. Relaxing stringent requirements for the availability of physicians may facilitate surgical recruitment and retention.     

Severe trauma of the chest wall: surgical rib stabilisation versus non-operative treatment

Background

Serial rib fractures and flail chest injury can be treated by positive-pressure ventilation. Operative techniques reduce intensive care unit (ICU) stay, overall costs, mortality and morbidity, as well as pain. The aim of this study was to evaluate the benefit of surgical rib stabilisation in comparison to non-operative treatment in patients with severe trauma of the chest wall.

Materials and methods

From 2006 to 2011, the data of 44 patients with flail chest and serial rib fractures were collected retrospectively. A surgical group and an intensive care group with only intensive care therapy were formed. Rib and sternal fractures, flail chest, injury severity, thoracic injuries, mechanical ventilation, time in the ICU, overall hospital stay and mortality were evaluated.

Results

No postoperative surgical complications had been observed. The time under mechanical ventilation in the surgical group was 10.6 ± 10.2 days, whereas in the non-surgical group, it was 13.7 ± 13.7 days. Mechanical ventilation time after surgery was 6.9 ± 6.5 days. Time in the ICU for the surgical group was 16.4 ± 13.6 days, compared to the non-surgical group with 20.1 ± 16.2 days. Postoperative time in the ICU was 11.7 ± 10.3 days. The mortality in the surgical group was 10 % and in the non-surgical group it was 17 %.

Conclusions

Operative rib stabilisation with plates is a safe therapy option for severe trauma of the chest wall. Provided that the duration of preoperative mechanical ventilation and time spent in the ICU is minimised due to early operation, our data suggest that the stabilisation of serial rib fractures and flail chest may lead to a reduced time of mechanical ventilation, time in the ICU and mortality.     

Outcomes after rib fractures in geriatric blunt trauma patients

Introduction

Rib fractures after blunt trauma contribute substantially to morbidity and mortality in the elderly.

Differences in hospital outcomes following traumatic injury for patients experiencing immediate transfer to a level I trauma facility versus resuscitation at a critical access hospital (CAH)

Background

Critical access hospitals (CAH) serve a key role in providing medical care to rural patients. The purpose of this study was to assess effectiveness of CAHs in initial care of trauma patients.

Outcomes of proximal versus distal splenic artery embolization after trauma: a systematic review and meta-analysis

The objective of this systematic review and meta-analysis was to assess the outcomes after angioembolization in blunt trauma patients with splenic injuries and to examine specifically the impact of the technique used. Studies evaluating adult trauma patients who sustained blunt splenic injuries managed by angioembolization were systematically evaluated. The following data were required for inclusion: grade of splenic injury, indication for embolization, and site of embolization (proximal [main splenic artery] or distal [selective]). In addition, major (requiring splenectomy) or minor (not requiring splenectomy) rebleeding, infarction, and infection in relation to the site of embolization (proximal vs. distal) was required. Pooled outcomes were compared between proximal and distal embolizations. To eliminate between-study heterogeneity, a sensitivity analysis was conducted on three reduced sets of studies. Fifteen of 147 evaluated studies were included for analysis. All were retrospective cohort studies and incorporated a total of 479 embolized patients. The overall failure rate of angioembolization was 10.2% (range, 0.0-33.3%). Injury severity and basic demographics did not differ among the study populations. However, the indications for angioembolization (contrast extravasation, large amount of hemoperitoneum, or high-grade splenic injury) differed between the populations but were not associated with a change in the failure rates. Rebleeding was the most common reason for failure; however, it did not differ statistically between the used techniques, and with the 95% confidence interval crossing the 5% zone of clinical indifference, this result was inconclusive. Minor complications occurred statistically and clinically more often after distal than after proximal embolization. The available literature is inconclusive regarding whether proximal or distal embolization should be used to avoid significant rebleeding and larger prospective cohort studies are required. However, both techniques have an equivalent rate of infarctions and infections requiring splenectomy. Minor complications occur more often after distal embolization. This is primarily explained by the higher rate of segmental infarctions after distal embolization.     

The initial management of severe trauma patients at hospital admission

The initial management of trauma patient is a critical period aiming at: stabilizing the vital functions; following a rigorous injury assessment; defining a therapeutic strategy. This management has to be organized to minimize loss of time that would be deleterious for the patients outcome. Thus, before patient arrival, the trauma team alert should lead to the initiation of care procedures adapted to the announced severity of the patient. Moreover, each individual should know its role in advance and the team should be managed by only one individual (the trauma leader) to avoid conflicts of decision. A rapid trauma injury assessment aims not only at guiding resuscitation (chest drainage, pelvic contention, to define the mean arterial pressure goal) but also to decide a critical intervention in case of hemodynamic instability (laparotomy, thoracotomy, arterial embolisation). This initial assessment includes a chest and a pelvic X-ray, abdominal ultrasound (extended to the lung) and transcranial Doppler (TCD). The whole body scanner with administration of intravenous contrast material is the cornerstone of the injury assessment but can be done for patients stabilized after the initial resuscitation.     

Pre-hospital CPR after traumatic arrest: Outcomes at a level 1 pediatric trauma center

BackgroundThe survival of traumatic cardiopulmonary arrest (TCA) requiring pre-hospital cardiopulmonary resuscitation (P-CPR) is abysmal across age groups. We aim to describe the mechanisms of injury and outcomes of children suffering from TCA leading to P-CPR at our institution.MethodsA retrospective review was conducted to identify children ages 0-17 years who suffered TCA leading to P-CPR at our institution between 5/2009 and 3/2020. For analysis, patients were stratified into those still undergoing CPR at arrival and those who attained pre-hospital return of spontaneous circulation (ROSC). Primary outcome was discharge alive from the hospital.ResultsP-CPR was initiated for 48 patients who had TCA; 23 had pre-hospital ROSC. Of the 25 children undergoing CPR at presentation, none survived to discharge. The median duration of CPR, from initiation to time of death declaration was 34 min [29,50]. Seventeen patients died after resuscitation attempts in the ED, while 8 died after admission to the PICU. Of the 23 patients who attained pre-hospital ROSC, 6 survived to discharge. All survivors required intensive rehabilitation services at discharge and at most recent follow-up, 5 had residual deficits requiring medical attention.ConclusionThere are poor outcomes in children with pre-hospital traumatic cardiopulmonary arrest, particularly in those without pre-hospital ROSC. These data further support the need for standardized guidelines for resuscitation in children with traumatic cardiopulmonary arrest.     

Air versus ground transport of major trauma patients to a tertiary trauma centre: a province-wide comparison using TRISS analysis

OBJECTIVE: The purpose of this study was to compare the outcomes of adult (aged > 15 yr) blunt trauma patients with an Injury Severity Score (ISS) = 12 who were transported to a single tertiary trauma centre (TTC) by helicopter emergency medical service (HEMS) versus those transported by ground ambulance. METHODS: We retrospectively analyzed all adult (aged > 15 yr) trauma patients between March 27, 1998 and March 28, 2002 with an ISS score = 12, as identified through the provincial trauma registry. We used the Trauma and Injury Severity Score (TRISS) methodology to determine a difference in outcomes between the 2 groups. RESULTS: We identified 823 patients; of these, we excluded 32 (3.9%) penetrating trauma patients. Of the blunt trauma cases (n = 791) 237 (30%) patients were transported by air and 554 were transported by ground (70%). A total of 770 (97.3%) patients were eligible for TRISS analysis. Using the TRISS methodology, the air group had a Z statistic of 2.77, yielding a W score of 6.40. This compared with the ground transport group, whose Z statistic was 1.97 and W score was 2.39. CONCLUSION: The transport of trauma patients with an ISS = 12 by a provincially dedicated rotor wing air medical service was associated with statistically significantly better outcomes than those transported by standard ground ambulance. This is the first large Canadian study to specifically compare the outcome of patients transported by ground with those transported by air.     

Emergency interhospital transport of the major trauma patient: air versus ground

A prospective cohort study was undertaken to determine the effectiveness of air transport for major trauma patients when transferred to a trauma center from a rural Emergency Department. The null hypothesis evaluated was that there was no difference in outcome for patients transported by helicopter EMS (HEMS) when compared to patients transported by conventional ground EMS. The dependent variable of outcome was studied using the TRISS method in a group of 872 consecutive trauma patients admitted after long-distance transfer. Of this group, 110 patients transported by ground and 103 patients transported by air met the inclusion criteria. The ground EMS group had a mean TS of 14.4, a mean ISS of 25.2, and a mean Ps of 0.867. TRISS predicted 15 deaths and there were 15 actual deaths. The HEMS group had a mean TS of 11.4, a mean ISS of 34.9, and a mean Ps of 0.587. There were 46 predicted deaths and 33 actual deaths. This 25.4% reduction in predicted mortality was significant (Z = 3.95; p less than 0.001). Stratification of patients into Probability of Survival (Ps) bins allowed for outcome evaluation of groups with similar levels of injury severity. The benefit of HEMS transport was seen only in the patients with a probability of survival of less than 90%. We conclude that the major trauma patients transported by HEMS had a better outcome than those transported by ground EMS. The benefit seen with HEMS was directly related to injury severity and was demonstrated only in the patients with a Ps of less than 0.90.     

Outcomes of patients with orthopaedic trauma admitted to level 1 trauma centres

BACKGROUND: Although orthopaedic trauma results in significant disability and substantial financial cost, there is a paucity of large cohort studies that collectively describe the functional outcomes of a variety of these injuries. The current study aimed to investigate the outcomes of patients admitted with a range of orthopaedic injuries to adult Level 1 trauma centres. METHODS: Patients were recruited from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), which included all patients with orthopaedic trauma admitted to the two adult Level 1 trauma centres in Victoria (Australia). Patients were categorised into three groups; isolated orthopaedic injuries, multiple orthopaedic injuries and orthopaedic and other injuries. Demographic and injury data were collected from the medical record and hospital/trauma databases, and functional outcome instruments were given at 6 months post-injury. RESULTS: Of the 1303 patients recruited for VOTOR over a 12-month period, 1181 patients were eligible for the study and a response rate of 75.6% was obtained at 6 months post-injury. Patients reported ongoing pain (moderate-severe: 37.2%), disability (79.5%) and inability to return to work (35.2%). Poorer outcomes were evident in patients with orthopaedic and other injuries than those with single or multiple orthopaedic injuries alone. CONCLUSION: A large percentage of patients have ongoing pain and disability and a reduced capacity to return to work 6 months after orthopaedic trauma. Further research into the long-term outcomes of patients with orthopaedic injuries is required to identify patient subgroups and specific injuries and procedures that result in high morbidity.     

Ilizarov bone transport after massive tibial trauma: Case report

IntroductionThis is a case report of extreme lengthening of the tibia of about 14.5 cm using bone transport technique following road traffic accident trauma to the lower limbs. The management of the subsequent massive skeletal defects was challenging to orthopedic surgeons. Based on reported cases, the highest tibial lengthening was 22 cm using bifocal transport, while the highest unifocal tibial lengthening reached 14.5 cm.Case presentationA 20-year-old male driver was brought to the emergency department after a road traffic accident. The patient had a right Gustilo IIIA segmental open tibia fracture with bone loss and other severe injuries. The tibial defect was 14.5 cm and the patient was then admitted for Ilizarov application six months after the accident. Although this case was particularly complicated, full limb length was restored.DiscussionThe management of this case was directed to correct the deformities and achieve equal length of both limbs to restore the normal function. Several new techniques have been developed recently to fill large bone defects. Limb lengthening using bone transport technique by application of Ilizarov ring fixator has been suggested as the leading option in filling massive bone gaps.ConclusionThe use of bone transport technique using Ilizarov external rings has proved to be a minimally invasive and reliable method in managing massive bone defects. Accurate application of the Ilizarov frame and proper transport of the middle segment are important factors alleviating the risk for deviation of the transported segment. However, due to the need for regular follow-ups and monitoring, it demands high compliance from the patient to achieve optimal results.