Major Trauma Cases Research Articles

In this October issue

The World Health Assembly (the decision-making arm of the World Health Organization) recently released this resolution, urging all countries to assess and develop their emergency care systems so as to improve care for the acutely ill and injured. Australian and New Zealand emergency care stakeholders have an important role to play. In an important editorial, we discuss the resolution in detail and what it means for the Indo-Pacific region and ACEM. [Correction added on 23 October 2019 after first online publication: the World Health Assembly Resolution number has been changed from 72.31 to 72.16.] Complaints about IT systems are common in ED. ED data are important for both primary (clinical) and secondary uses (remuneration, operational, strategic and research). Rapid turnover of patients and frequent task interruption means that emergency physicians can spend more time entering data than on patient care. We publish a paper that audits current data quality from ED systems in NSW. A linked editorial comments on the implications of these findings. Clinical research produces evidence regarding the efficacy or effectiveness of a diagnostic tool or treatment strategy, and this informs clinical decision-making. Clinicians, especially in the ED, are familiar with increasing service demands and limited resources and make daily decisions balancing risk and benefit, where providing care for one patient delays care for another. Health economics is the application of economic principles to the distribution of scarce resources for healthcare to improve patient outcomes. The latest paper in our popular Acute Geriatrics series reports on the challenge of diagnosing urinary tract infections in the elderly. Misdiagnosis is common. How valuable is dipstick testing? The AANZDEM/EURODEM study compared treatment and outcomes between patients treated for asthma in Europe and Southeast Asia/Australasia and compliance with international guidelines. A total of 584 patients were identified from a total of 112 EDs in both regions. Inhaled beta-agonists were given in 86% of cases, systemic corticosteroids in 66%, oxygen in 44% and antibiotics in 20%. Compliance with guideline-recommended therapy in both regions, particularly corticosteroid administration, is suboptimal. There is also overuse of antibiotics. Non-fatal injuries sustained from animal–vehicle collisions are a globally under-recognised road safety issue, with limited data on these crash types. An analysis of major trauma cases in Victoria between 2007 and 2016 demonstrated that 152 major trauma patients were admitted to Victorian trauma-receiving hospitals because of vehicle collisions with animals. In 2016, the World Health Organization introduced a Trauma Care checklist, which outlines steps to follow after the primary and secondary surveys and before the team leaves the patient. The checklist, whilst likely to be successful in reducing errors of omission related to hospital admission, is limited in its ability to reduce errors that occur in the initial 30 min of reception – when most of the life-saving decisions are made. An alternative option is discussed. Septic shock and severe bacterial infections benefit from antibiotics administered as soon as possible. Many hospitals have sepsis campaigns and sepsis pathways that focus on giving broad-spectrum antibiotics to patients with potential sepsis. Loosening of the definitions, clinically dichotomised cut-offs and pressure to treat might cause more harm than good. An author of a letter to the editor says that the evidence for early antibiotics is weaker than the strength of current recommendations. In the second article of our occasional series, an experienced clinician reflects on the ‘Scandinavian’ approach to barbiturate poisoning and its impact on the management of toxicological poisoning. Everything we do today is built on the pioneering work of those who came before us.

322 Major Trauma in the Older Person - Major Challenges Ahead

Abstract Background The mean and median age of major trauma continues to increase for a mean of 36 years in the 1990's to 59 and 61 years respectively in 2016 and 2017. The age planning of major trauma has important implications for healthcare planning. Methods The major trauma audit was established by the National Office of Clinical Audit (NOCA) in 2013 and focuses on the most severely injured trauma patients in our healthcare system. The methodological approach is provided by the Trauma Audit and Research Network (TARN). Since 2016 all 26 eligible hospitals have been participating in the audit and the coverage is now 86%.Data has been collected on more than 15000 trauma patients to date. Results There were 5061 recorded major trauma cases of which 2233 (44%) were over 65 years in 2017. The most common form of injury (57%) was falls less than two metres (low falls) and this began aged 45 years. 50% of injuries occurred in patient's own home. Only 11% of people were received by a trauma team and this was even lower in the older adult. Older people were very unlikely to be pre-alerted to the Emergency Department prior to arrival. 64% of the mortality from major trauma occurred in the over 65 years. 6%, 7% and 10% of patients aged 65-74, 75-84 and over 85's respectively were discharged directly to nursing home. Conclusion There is a marked change in the age profile sustaining major trauma since the late 1990's. Patients today are older with more complex medical needs, have greater lengths of stay and many do not return to independent living. The most common mechanism of injury for older people is a low fall at home. We need to prevent low galls using a multidisciplinary, multi-agency approach.

Correlating injury severity scores and major trauma volume using a state-wide in-patient administrative dataset linked to trauma registry data—A retrospective analysis from New South Wales Australia

IntroductionTrauma registries are used to analyse and report activity and benchmark quality of care at designated facilities within a trauma system. These capabilities may be enhanced with the incorporation of administrative and electronic medical record datasets, but are currently limited by the use of different injury coding systems between trauma and administrative datasets. ObjectivesUse an Abbreviated Injury Scale to International Classification of Disease (AIS-ICD) mapping tool to correlate estimated injury severity scores and major trauma volume based on administrative data collections with trauma registry data. MethodsAdult trauma cases were identified from the New South Wales Trauma Registry between 2012 and 2016 and linked probabilistically using age, facility and date of facility arrival to the Admitted Patient Data Collection (APDC). Estimated Injury Severity Scores (ISS) were derived using the AIS-ICD mapping tool applied to diagnoses contained in the APDC. ResultsA total of eligible 13,439 cases were analysed. The overall correlation between trauma registry ISS and ISS estimated from APDC using the AIS-ICD mapping tool was low to moderate (Spearman Rho 0.41 95%CI 0.40, 0.43). Based on an estimated ISS cut-off value of 8, there was high correlation between estimated trauma volume and the number of major trauma cases at each facility (Spearman Rho 0.98, 95%CI 0.95, 0.99). Trauma Revised Injury Severity Score (TRISS) was associated with only slightly higher mortality prediction performance compared to estimated ISS (AUROC 0.76 95%CI 0.75, 0.78 versus AUROC 0.74 95%CI 0.73, 0.76). ConclusionA low to moderate correlation exists between individual patient ISS scores based on AIS to ICD mapping of in-patient data collection, but a high correlation for overall major trauma volume using the AIS-ICD mapping at facility level with comparable TRISS mortality prediction.

Postponing intubation in spontaneously breathing major trauma patients upon emergency room admission does not impair outcome

BackgroundPre-hospital emergency anaesthesia and tracheal intubation are life-saving interventions in trauma patients. However, there is evidence suggesting that the risks associated with both procedures outweigh the benefits. Thus, we assessed whether induction of anaesthesia and tracheal intubation of trauma patients can be postponed in spontaneously breathing patients until emergency room (ER) admission without increasing mortality.MethodsRetrospective analysis of major trauma patients either intubated on-scene by an emergency medical service (EMS) physician (pre-hospital intubation, PHI) or within the first 10 min after admission at a level 1 trauma centre (emergency room intubation, ERI). Data was extracted from the German Trauma Registry, hospital patient data management and electronic clinical information system.ResultsFrom a total of 946 major trauma cases documented between 2010 and 2017, 294 patients matched the study inclusion criteria. Mortality rate of PHI (N = 258) vs. ERI (N = 36) patients was 26.4% vs. 16.7% (p = 0.3). After exclusion of patients with severe traumatic brain injury and/or pre-hospital cardiac arrest, mortality rate of PHI (N = 100) vs. ERI patients (N = 29) was 6% vs. 17.2%, (p = 0.07). Median on-scene time was significantly (p < 0.01) longer in PHI (30 min; IQR: 21–40) vs. ERI patients (20 min; IQR: 15–28).ConclusionsThere was no statistical difference in mortality rates of spontaneously breathing trauma patients intubated on-scene when compared with patients intubated immediately after hospital admission. Due to the retrospective study design and small case number, further studies evaluating the impact of airway management timing in sufficiently breathing trauma patients are warranted.

Animal-vehicle collisions in Victoria, Australia: An under-recognised cause of road traffic crashes.

Non-fatal injuries sustained from animal-vehicle collisions are a globally under-recognised road safety issue, with limited data on these crash types. The present study aimed to quantify the number and causes of major trauma events resulting from animal-vehicle collisions. The study was a retrospective analysis of major trauma cases occurring in Victoria, Australia, between 2007 and 2016, using data from the population-based Victorian State Trauma Registry. To identify animal-vehicle collisions, Victorian State Trauma Registry injury codes were combined with text-mining of the text description of the injury event. Over the 10 year period, there were 152 major trauma patients who were admitted to Victorian trauma-receiving hospitals due to vehicle collisions with animals. The crude population-based incidence rate for animal-vehicle collisions increased by 6.7% per year (incidence rate ratio 1.07; 95% confidence interval 1.01-1.13; P = 0.02). Development of systematic recording methods of animal-vehicle collisions will improve reporting of these crash types to assist future studies in implementing effective countermeasures.

Long-Term Follow-up of Full-Awake Hand Surgery in Major Flexor Tendon Injury of the Hand and Forearm.

Full-awake hand surgery (FAHS) has been gaining attention in recent years. However, the extent of full-awake approach for longer and more complicated major surgeries for the hand in trauma cases remains unclear. This study aimed to report the clinical nature of major flexor tendon trauma cases with subsequent repair under FAHS. Retrospective study was performed on 9 male patients with an average age of 32.22 (SD, 9.67) years who experienced surgery for major flexor tendon ruptures under FAHS. Besides involving 3 digits in fingers, hand, or forearm, extensive surgery involved 3 cases with surgical dissection similar to the one needed to repair flexor tendons of 3 digits in zone 2. The assessment that was performed at least 3 years after surgery included not only the efficacy of FAHS but also the total active range of motion, opposition function, Medsger severity scale, and Disabilities of Arm, Shoulder, and Hand score. All repairs and explorations were performed under FAHS with 2 subjects who needed conversion to general anesthesia owing to intraoperative visual analog scale score of greater than 4. Average surgery duration under FAHS was 225 (170-309) minutes. Through an average follow-up of 4.1 years, all patients showed normal Medsger scale, with 7 cases that had excellent total active range of motion and 8 cases, excellent opposition. Median Disabilities of Arm, Shoulder, and Hand score was 15 (9-28.5). Full-awake hand surgery is potential surgical approach for major flexor tendon trauma cases resulting in satisfactory long term functional outcome.

PIT18 INCREASING BURDEN OF MAJOR TRAUMA IN TAIWAN: TIME TREND OF INCIDENCE RATE AND LIFE EXPECTANCY LOSS

Major trauma has been one of leading causes of morbidity, mortality, and functional disability, resulting in substantial societal burden. The aim of this study was to estimate the trend of burden of major trauma in Taiwan during 2003-2015. We defined major trauma as those with an injury severity score (ISS) ≥ 16. All new patients with major trauma were abstracted from National Health Insurance Research Database (NHIRD) in Taiwan from January 2003 to December 2015. We explored the time trends of incidence and mortality rates stratified by age and sex, as well as life expectancy (LE) and loss of life expectancy (or, expected years of life loss, EYLL) compared with age, sex and calendar-year matched referents simulated from vital statistics of Taiwan. A total of 75,625 cases of major trauma with 30,902 fatality and an estimated loss of 917,467 life-years were found during 2003-2015. For both genders, the incidence rates of those above 65 years old were about 2-3 times higher than all the other age groups. The cumulative incidence rate (CIR0-79) of major trauma increased profoundly from 2003 to 2015. The case fatality rate was higher in men (41.8%) than female (38.5%). The LE gradually declined with advanced age in both genders, and women had a longer LE than men (21.5 ± 0.8 versus 17.9 ± 0.6 years). The EYLL were all more than 10 years in the age-groups under 65 years old. On average, men had a higher EYLL at 13±0.6 years compared with 10±0.8 years in women. There is a consistently increasing trend of cumulative incidence and mortality, especially among elderly people. With Taiwan becoming an aged population (>14%) in 2018, we should tackle this challenge effectively in the coming decades.

Ageing population has changed the nature of major thoracic injury

IntroductionAn increasing proportion of the major trauma population are older persons. The pattern of injury is different in this age group and serious chest injuries represent a significant subgroup, with...

A review of children with severe trauma admitted to pediatric intensive care in Queensland, Australia.

BackgroundThe aim of this study is to review patient characteristics, injury patterns, and outcomes of trauma cases admitted to pediatric intensive care in Children’s Health Queensland, Brisbane, Queensland, Australia.MethodsRoutinely recorded data collected prospectively from the Children’s Health Queensland Trauma Service registry from November 2008 to October 2015 were reviewed. Demographic and clinical characteristics of trauma cases in children under 16 years of age are described, and their association with age and mortality analyzed.ResultsThere were 542 cases of pediatric trauma identified and 66.4% were male. The overall mortality since January 2012 was 11.1%. The median injury severity score (ISS) was 11 (IQR = 9–22), 48.2% (n = 261) had an ISS > 12 and 41.7% (n = 226) patients had an ISS > 15. The most common injury patterns were isolated head injury (29.7%; n = 161) and multiple trauma (31.2%; n = 169). In 28.4% of cases (n = 154) surgery was required. The home was reported to be the most common place of injury (37.6%; n = 204). Children aged 0–4 years were least likely to survive their injury (15.3% mortality) compared with the 5–9 (5.6% mortality) and 10–15 (9.0% mortality) age groups. Higher mortality was associated with more severe injuries, abdomen/spine/thorax injuries, inflicted injuries, drowning and hanging.ConclusionThis description of major pediatric trauma cases admitted to pediatric intensive care in Children’s Health Queensland, Australia, will inform future pediatric major trauma service requirements as it identifies injury patterns and profiles, injury severity, management and mortality across different age groups.

Pattern of Injuries in Fall from Height Cases: An Autopsy Based Study

Introduction: Falls from height are the one of the major trauma cases presenting to emergency departments and often cause mortality and morbidity.

Evaluation of emergency department ultrasound machines for the presence of occult blood.

Bedside ultrasound in the emergency department is a common diagnostic tool, especially when evaluating trauma patients. Many trauma patients have blood on their chest and abdomen that may contact the probe during examination. The primary aim of this study was to investigate whether occult blood contamination was present on the emergency department ultrasound machine, both after daily use and after use in trauma. For a period of 31 days, the ultrasound machine at the trauma centre emergency department in Saskatoon, Saskatchewan, was tested once daily and following all Level 1 traumas. The ultrasound machine probes and keyboard were swabbed, and contamination was detected using a commercially available phenolphthalein blood testing kit. Any visible blood contamination was also noted. The machine was then cleaned following each positive test and re-tested to ensure the absence of contamination. Over the study period, the ultrasound machine tested positive for occult blood contamination on 10% of daily tests and on 43% of assessments after its use in trauma. The curvilinear probe was most frequently contaminated (daily, 6%; trauma, 26%), followed by the keyboard (daily, 3%; trauma, 26%), but both lacked visible contamination. In this single centre study, there was evidence of occult blood on the emergency department ultrasound machine after both routine use and major trauma cases, highlighting the need for a standardized cleaning and disinfection protocol.

Trauma radiology in the UK: an overview.

NHS Choices defines 'major trauma' as multiple, serious injuries that could result in disability or death. Worldwide, trauma is the leading cause of death and disability in people under 40 years of age. The National Audit Office estimates that there are at least 20 000 major trauma cases in England every year, resulting in 5400 deaths and leaving many others with serious permanent disability. Because the incidence of trauma is particularly high in younger patients, an average of 36 life years is lost for every trauma death ( Chaira and Cimbanassi, 2003 ). The landscape in major trauma imaging has evolved over the last 30 years, and this review chronicles these changes and the reasons for them, and looks at how the current guidelines have been formulated.

Comparison of outcomes in severely injured patients between a South Korean trauma center and matched patients treated in the United States

The South Korean government recently developed a master plan for establishing a national trauma system based on the implementation of regional trauma centers. We aimed to compare outcomes between severely injured patients treated at a recently established South Korean trauma center and matched patients treated in American level-1 trauma centers. Two cohorts were selected from an institutional trauma database at Ajou University Medical Center (AUMC) and the American National Trauma Data Bank. Adult patients with an Injury Severity Score of ≥9 were included. Patients were matched based on covariates that affect mortality, using 1:1 propensity score matching. We compared outcomes between the two datasets and performed survival analyses. We created 1,451 and 2,103 matched pairs for the pre-trauma center and post-trauma center periods, respectively. The in-hospital mortality rate was higher in the institutional trauma database pre-trauma center period compared with the American National Trauma Data Bank (11.6% versus 8.1%, P<.001). However, the mortality rate decreased in the institutional trauma database post-trauma center period and was similar to that in the American National Trauma Data Bank (6.9% versus 6.8%, P=.903). Being treated at Ajou University Medical Center Trauma Center was significantly associated with higher mortality during the pre-trauma center period (OR: 1.842, 95% CI: 1.336-2.540; P<.001), although no significant association was observed during the post-trauma center period (OR: 1.102, 95% CI: 0.827-1.468; P=.509). The mortality rate improved after a trauma center was established in a South Korean hospital and is similar to that from matched cases treated at American level-1 trauma centers. Thus, creating trauma centers and a regional trauma system may improve outcomes in major trauma cases.

Ten-year Trends In Major Trauma Or Death Resulting From Sport And Recreation In Victoria, Australia

Sports injuries which result in major trauma or death are associated with significant health-care burden and societal costs. Understanding changes in injury trends, and their drivers, is needed to implement policy aimed at risk reduction and injury prevention. To date, there has been no population-level reporting on trends in serious sport and recreation injuries anywhere in Australia over such an extended period, nor any studies of this length capturing comprehensive data on all sports-related major trauma internationally. PURPOSE: The aim of this study was to describe the incidence of sport and active recreation injuries resulting in major trauma or death for a 10-year period from July 2005-June 2015 in Victoria, Australia. METHODS: All sport and active recreation-related major trauma cases and deaths in Victoria, a state of Australia, were extracted from the population-level Victorian State Trauma Registry and the National Coroners Information System, over a 10-year period. Poisson regression analysis was used to examine trends in the incidence of sport and active recreation-related major trauma and death. RESULTS: There were 2,847 non-fatal major trauma cases and 614 deaths (including 96 in-hospital deaths) over the 10-year study period. The highest frequencies of major trauma cases and deaths were in cycling, motor sports and equestrian activities. The participation-adjusted major trauma and death rate was 12.2 per 100,000 participants per year. There was an 8% increase in the rate of major trauma (IRR=1.08, 95%CI, 1.06, 1.10; p<0.001), and a 7% decrease in the death rate (IRR=0.93, 95%CI: 0.90, 0.97; p<0.001). Out of all sports, there were significant increases in the rate of major trauma (including deaths) in equestrian activities, motor sports and cycling. CONCLUSIONS: The rate of major trauma due to participation in sport and recreation has increased over the past 10 years in Victoria, which was largely attributable to equestrian activities, motor sports and cycling. Study findings highlight the need to prioritize investment in the prevention of trauma in these activities.

Ten-Year Incidence of Sport and Recreation Injuries Resulting in Major Trauma or Death in Victoria, Australia, 2005-2015.

Background:Sports injuries that result in major trauma or death are associated with significant health care burden and societal costs. An understanding of changes in injury trends, and their drivers, is needed to implement policy aimed at risk reduction and injury prevention. To date, population-level reporting has not been available regarding trends in serious sport and recreation injuries anywhere in Australia over such an extended period, nor have any studies of this length captured comprehensive, long-term data on all sports-related major trauma internationally.Purpose:To describe the incidence of sport and active recreation injuries resulting in major trauma or death over a 10-year period (July 2005 to June 2015) in the state of Victoria, Australia.Study Design:Descriptive epidemiological study.Methods:All sport and active recreation–related major trauma cases and deaths in Victoria, Australia, over a 10-year period were extracted from the population-level Victorian State Trauma Registry and the National Coroners Information System. Poisson regression analysis was used to examine trends in the incidence of sport and active recreation–related major trauma and death.Results:The 10-year study period entailed 2847 nonfatal major trauma cases and 614 deaths (including 96 in-hospital deaths). The highest frequencies of major trauma cases and deaths were in cycling, motor sports, and equestrian activities. The participation-adjusted major trauma and death rate was 12.2 per 100,000 participants per year over the study period. An 8% increase was noted in the rate of nonfatal major trauma (incident rate ratio [IRR], 1.08; 95% CI, 1.06-1.10; P < .001) and a 7% decrease in the death rate (IRR, 0.93; 95% CI, 0.90-0.97; P < .001). Significant increases were found in the rates of major trauma (including deaths) in equestrian activities, motor sports, and cycling.Conclusion:The death rate from sport and active recreation decreased by more than half over the course of 10 years in Victoria, while the rate of nonfatal major trauma almost doubled. This increase is largely attributable to equestrian activities, motor sports, and cycling. Study findings highlight the need to prioritize investments in the prevention of trauma in these activities.

Pedestrian traffic injury in Victoria, Australia

IntroductionRoad traffic injuries are the fifth leading cause of years of life lost, with pedestrians comprising 39% of all road deaths (Global Burden of Disease Mortality and Causes of Death Collaborators [1]). Programs that use injury surveillance data to identify high-risk targets for intervention are known to be effective for reducing injury. This study aims to identify trends in the population incidence of pedestrian traffic injury (PTI) in Victoria, Australia. MethodA retrospective review of data from the Victorian Emergency Minimum Dataset, the Victorian Admitted Episodes Dataset, the Victorian State Trauma Registry and the National Coronial Information System was conducted of patients with a PTI who present to a public hospital emergency department, were admitted to hospital, sustained major trauma or who died of their injuries from January 1st 2009 to December 31st 2013. The primary outcome measure was population incidence of pedestrian traffic-related emergency presentations, hospital admissions, major trauma and deaths. ResultsOver the study period, 1838 cases presented to a public hospital emergency department and were discharged without admission to hospital and an additional 3241 cases were admitted to hospital. Of these, 628 cases were classified as major trauma including 90 in-hospital deaths. From January 1st 2008 to December 31st 2011, a total of 216 deaths occurred. A decrease in the population incidence of emergency presentations for PTI was observed over the study period. No significant change was observed in the population incidence of hospital admissions, major trauma cases or deaths from PTI. The demographics of PTI were observed more commonly to be young, intoxicated males and pedestrians aged over 65 years. ConclusionsAlthough the population-adjusted incidence of emergency presentations for PTI in Victoria has decreased from 2009 to 2013, no change was observed in the incidence of hospital admissions, major trauma or pedestrian fatalities. Novel programs designed to address high-risk groups should be considered to achieve further reductions in PTI and severity of injuries.

Trauma case review: A quality and safety feature of the Victorian State Trauma System.

The aim of the present study was to describe the trauma case review process and its role in a regionalised trauma system. Victoria has a population of 5.9 million people, accounting for 26% of Australia's population. Victoria has been serviced by an inclusive, organised trauma system since 2000 comprising 138 health services with trauma designations and three major trauma services. Pre- and interhospital guidelines prescribe the timely transport of patients to the appropriate level of trauma service. A review of the role and contribution of 10 years of operation of the trauma case review group (CRG) was undertaken to describe the aims, processes and governance surrounding the implementation of an individual case review for specified major trauma patients. Specified patients were those identified by the Victorian State Trauma Registry as being managed outside of established Victorian State Trauma System prehospital and interhospital guidelines. A state-wide trauma case review process was implemented across the trauma system using data-informed detection flags and screening criteria. Using data from the Victorian State Trauma Registry, detection flags were correlated with patients at risk of a poorer outcome, thereby ensuring that all patients managed outside of the requirements of established trauma triage and transfer guidelines were subject to review. The CRG provides an individual review process as a technique for assessing and monitoring major trauma patient care and compliance with trauma system triage and transfer guidelines. The process has been effective as a quality and safety strategy by improving clinician knowledge of major trauma triage and transfer guidelines and facilitating improved compliance, particularly with interhospital transfers. Strong compliance has been achieved from health services with the requirement to internally review and respond to CRG concerns regarding 'high-risk' trauma cases. Anecdotal feedback from health services regarding participation in the CRG process has been positive. The trauma case review process is an embedded feature of the Victorian State Trauma System that aims to improve compliance with major trauma guidelines by reviewing major trauma cases that have been managed outside of established triage and transfer guidelines. All trauma-designated Victorian health services, Ambulance Victoria and Victorian adult and paediatric patient retrieval services might receive trauma cases for review. The process is also an integral component of trauma system clinical governance, which enables the identification of system-level issues for escalation to the State Trauma Committee and the Victorian Department of Health and Human Services.

Road safety: serious injuries remain a major unsolved problem.

To investigate temporal trends in the incidence, mortality, disability-adjusted life-years (DALYs), and costs of health loss caused by serious road traffic injury. A retrospective review of data from the population-based Victorian State Trauma Registry and the National Coronial Information System on road traffic-related deaths (pre- and in-hospital) and major trauma (Injury Severity Score > 12) during 2007-2015.Main outcomes and measures: Temporal trends in the incidence of road traffic-related major trauma, mortality, DALYs, and costs of health loss, by road user type. There were 8066 hospitalised road traffic major trauma cases and 2588 road traffic fatalities in Victoria over the 9-year study period. There was no change in the incidence of hospitalised major trauma for motor vehicle occupants (incidence rate ratio [IRR] per year, 1.00; 95% CI, 0.99-1.01; P = 0.70), motorcyclists (IRR, 0.99; 95% CI, 0.97-1.01; P = 0.45) or pedestrians (IRR, 1.00; 95% CI, 0.97-1.02; P = 0.73), but the incidence for pedal cyclists increased 8% per year (IRR, 1.08; 95% CI; 1.05-1.10; P < 0.001). While DALYs declined for motor vehicle occupants (by 13% between 2007 and 2015), motorcyclists (32%), and pedestrians (5%), there was a 56% increase in DALYs for pedal cyclists. The estimated costs of health loss associated with road traffic injuries exceeded $14 billion during 2007-2015, although the cost per patient declined for all road user groups. As serious injury rates have not declined, current road safety targets will be difficult to meet. Greater attention to preventing serious injury is needed, as is further investment in road safety, particularly for pedal cyclists.

Venous thromboembolism in major trauma patients: a single-center retrospective cohort study of the epidemiology and utility of D-dimer for screening.

AimVenous thromboembolism (VTE) can be a life‐threatening complication after major trauma. The aim of this study was to investigate the epidemiology of VTE and to assess the usefulness of D‐dimer for screening for VTE in major trauma cases among the Japanese population.MethodsWe examined a single‐center retrospective cohort of severely injured trauma patients who had been admitted to the emergency intensive care unit at Okayama University Hospital (Okayama, Japan) from April 2013 through to March 2016. Venous thromboembolism was confirmed by computed tomography angiography and computed tomography venography, which was determined based on the attending physician monitoring daily D‐dimer levels. Independent risk factors for VTE were determined by multiple logistic regression analysis. D‐dimer levels were evaluated using area under the receiver operating characteristic curve (AUROC) to predict VTE.ResultsThe study cohort consisted of 204 trauma patients (median Injury Severity Score, 20). Of the 204 patients, 65 (32%) developed VTE. The median time from admission to VTE diagnosis was 10 days. In multiple logistic regression analysis, higher Injury Severity Score and the presence of lower extremity fractures were revealed to be a risk factor for VTE. D‐dimer levels at day 10 showed moderate accuracy, of which the AUROC was 0.785 (95% confidence interval, 0.704–0.866; P < 0.001). The cut‐off that maximized the Youden index was 12.45 μg/mL.ConclusionsAt least one of every three major trauma patients had potential development of VTE at a median of 10 days following admission to the intensive care unit. D‐dimer levels on day 10 can be a useful predictor of VTE.

Development of the major trauma case review tool

BackgroundAs many as half of all patients with major traumatic injuries do not receive the recommended care, with variance in preventable mortality reported across the globe. This variance highlights the need for a comprehensive process for monitoring and reviewing patient care, central to which is a consistent peer-review process that includes trauma system safety and human factors. There is no published, evidence-informed standardised tool that considers these factors for use in adult or paediatric trauma case peer-review. The aim of this research was to develop and validate a trauma case review tool to facilitate clinical review of paediatric trauma patient care in extracting information to facilitate monitoring, inform change and enable loop closure.MethodsDevelopment of the trauma case review tool was multi-faceted, beginning with a review of the trauma audit tool literature. Data were extracted from the literature to inform iterative tool development using a consensus approach. Inter-rater agreement was assessed for both the pilot and finalised versions of the tool.ResultsThe final trauma case review tool contained ten sections, including patient factors (such as pre-existing conditions), presenting problem, a timeline of events, factors contributing to the care delivery problem (including equipment, work environment, staff action, organizational factors), positive aspects of care and the outcome of panel discussion. After refinement, the inter-rater reliability of the human factors and outcome components of the tool improved with an average 86% agreement between raters.DiscussionThis research developed an evidence-informed tool for use in paediatric trauma case review that considers both system safety and human factors to facilitate clinical review of trauma patient care.ConclusionsThis tool can be used to identify opportunities for improvement in trauma care and guide quality assurance activities. Validation is required in the adult population.