Clinical Outcomes Of Trauma Patients Research Articles

The characteristics and clinical outcomes of trauma patients transferred by a physician-staffed helicopter emergency medical service in Korea: a retrospective study

The characteristics and clinical outcomes of trauma patients transferred by a physician-staffed helicopter emergency medical service in Korea: a retrospective study

Serum Selenium-Binding Protein 1 (SELENBP1) in Burn Injury: A Potential Biomarker of Disease Severity and Clinical Course.

Oxidative stress, systemic inflammation, and metabolic derangements are hallmarks of burn pathophysiology. Severely burned patients are highly susceptible to infectious complications. Selenium-binding protein 1 (SELENBP1) modulates intracellular redox homeostasis, and elevated serum concentrations have been associated with adverse clinical outcomes in trauma patients. We hypothesized that serum SELENBP1 at hospital admission and during hospitalization may constitute a meaningful biomarker of disease severity and the clinical course in burn injury, with pulmonary infection as primary endpoint. To this end, we conducted a prospective cohort study that included 90 adult patients admitted to the Burn Center of the University Hospital Zurich, Switzerland. Patients were treated according to the local standard of care, with high-dose selenium supplementation during the first week. Serum SELENBP1 was determined at nine time-points up to six months postburn and the data were correlated to clinical parameters. SELENBP1 was initially elevated and rapidly declined within the first day. Baseline SELENBP1 levels correlated positively with the Abbreviated Burn Severity Index (ABSI) (R = 0.408; p < 0.0001). In multiple logistic regression, a higher ABSI was significantly associated with increased pulmonary infection risk (OR, 14.4; 95% CI, 3.2-88.8; p = 0.001). Similarly, baseline SELENBP1 levels constituted a novel but less accurate predictor of pulmonary infection risk (OR, 2.5; 95% CI, 0.7-8.9; p = 0.164). Further studies are needed to explore the additional value of serum SELENBP1 when stratifying patients with respect to the clinical course following major burns and, potentially, for monitoring therapeutic measures aimed at reducing tissue damage and oxidative stress.

Evaluation of the Potential for Improvement of Clinical Outcomes in Trauma Patients with Massive Hemorrhage by Maintaining a High Plasma-to-Red Blood Cell Ratio during the First Hour of Hospitalization.

Several reports indicate that early plasma transfusion may promote survival and reduce the incidence of traumatic coagulopathy in situations of massive bleeding. Consequently, it is recommended to maintain a plasma and RBC transfusion ratio between 1 : 1 and 1 : 2 at the start of admission. This retrospective study examined the effect of an early high plasma : RBC ratio on mortality rates by adopting a massive transfusion protocol (MTP) that forced an early and rapid issue of plasma products. Patients who received massive transfusions at a single trauma center between January 2014 and May 2020 were included in the study. A new protocol was established in January 2020, wherein a fixed amount of plasma was issued following MTP activation. Patients who underwent massive transfusions before and after the adoption of the new protocol were compared. In total, 1059 patients met the inclusion criteria. Fifty-one patients who underwent MTP were propensity score-matched with the patients who received a nonprotocolized massive transfusion. The MTP group had a higher plasma : RBC ratio at 1 h (0.8 vs. 0.2) and 4 h of hospitalization (1.1 vs. 0.6), with no significant between-group difference in the plasma : RBC ratio at 24 h of hospitalization. The MTP group had a lower 24 h mortality rate than the control group. There was no significant difference in the 30-day mortality. Using MTP to achieve a high plasma : RBC ratio in the early period of hospitalization appeared to affect 24-hour mortality; however, 30-day mortality did not change.

Massive Transfusion Protocol Adherence: Relationship to Trauma Patient Outcomes.

Ongoing evaluation of massive transfusion protocol adherence is critical to ensure better trauma patient outcomes. This quality improvement initiative aimed to determine provider adherence to a recently revised massive transfusion protocol and its relationship to clinical outcomes among trauma patients requiring massive transfusion. A retrospective, descriptive, correlational design was used to determine the association between provider adherence to a recently revised massive transfusion protocol and clinical outcomes in trauma patients with hemorrhage treated at a Level I trauma center from November 2018 to October 2020. Patient characteristics, provider massive transfusion protocol adherence, and patient outcomes were assessed. Patient characteristics and massive transfusion protocol adherence associations with 24-hr survival and survival to discharge were determined using bivariate statistical methods. A total of 95 trauma patients with massive transfusion protocol activation were evaluated. Of the 95, 71 (75%) survived the initial 24 hr following massive transfusion protocol activation and 65 (68%) survived to discharge. Based on protocol applicable items, the median massive transfusion protocol overall adherence rate per patient was 75% (IQR = 57.1-85.7) for the 65 survivors and 25% (IQR = 12.5-50.0) for the 21 nonsurvivors to discharge whose death occurred at least 1 hr after massive transfusion protocol activation (p < .001). Findings indicate the importance of ongoing evaluations of adherence to massive transfusion protocols in hospital trauma settings to target areas for improvement.

Social Determinants of Health in Trauma.

Social determinants (SD) refer to a variety of environmental factors that can influence certain clinical outcomes. SD that affect clinical outcomes in trauma patients are largely understudied. We hypothesized that patients with an "at risk" (AR) classification for any SD will have a greater frequency of negative outcomes when compared to their "not at risk" (NAR) counterparts. A retrospective review was performed (1/2021-2/2022) of all trauma patients that met the inclusion criteria. 2225 patients were included. SD included (based on collection rates) for analysis were: tobacco use, stress, and intimate partner violence. Tobacco usage was the only SD that was significantly associated with a higher 30-day mortality. This study demonstrated a paucity of data in the medical record regarding SD. In an effort to provide more inclusive care and address health disparities in our patient population, there is a need for more complete data collection upon admission/duration of hospital stay.

Modifying effects of alcohol use and age on the predictive performance of prehospital shock index for functional and survival outcomes in severe trauma patients

This study investigated whether the prehospital shock index (SI) could predict clinical outcomes in trauma patients, with or without pre-injury alcohol consumption, and whether this predictive capacity varied by age. We conducted a retrospective study on severe trauma patients transported to a level-1 trauma center by emergency medical services from 2015 to 2021. Our primary exposure was abnormal SI, defined as an SI ≥0.9, with in-hospital mortality and poor functional outcomes as study outcomes of interest. Multivariable logistic regression analysis estimated the effect of SI on clinical outcomes. Our findings indicated a significant association between abnormal SI and poor functional outcomes in all trauma patients (adjusted odds ratio: 2.15; 95%confidence interval: 1.41–3.28), notably pronounced in the older age group (adjusted odds ratio: 3.56; 95% confidence interval: 1.55–8.30). However, no association was found with in-hospital mortality. Importantly, among severe trauma patients who did not consume alcohol, abnormal SI was significantly associated with poor functional outcomes, irrespective of age, and with increased in-hospital mortality exclusively in the older age group. Thus, abnormal SI significantly predicted clinical outcomes in non-alcohol-consuming severe trauma patients, with the predictive power for in-hospital mortality being specifically significant in older, non-alcohol-consuming patients.

Impact of Early Tracheostomy on Clinical Outcomes in Trauma Patients Admitted to the Intensive Care Unit: A Retrospective Causal Analysis

To assess the indications, timing, and clinical outcomes that result from the early tracheostomy (ET) administration, by causal inference models. A retrospective observational study. Multiinstitutional intensive care unit in the United States PARTICIPANTS: The study comprised 626 trauma patients. An ET versus late tracheostomy (LT). Trauma patients with tracheostomy were identified from 2 public databases named Medical Information Mart for the Intensive Care-IV and eICU Collaborative Research Database. Tracheostomy was defined as early (≤7 days) or late (>7 days) from intensive care unit admission. A marginal structural Cox model (MSCM) with inverse probability weighting was employed. For comparison, the authors also used time-dependent propensity-score matching (PSM) to account for differences in the probability of receiving an ET or LT. A total of 626 eligible patients were enrolled in the study, of whom 321 (51%) received a ET. The MSCM and time-dependent PSM indicated that the ET group was associated with reduced ventilation-associated pneumonia (VAP) and a shorter mechanical ventilation (MV) duration than the LT group. Yet, mortality did not show any difference between the two groups. The authors' study observed that ET was not associated with reduced mortality in trauma patients, but it was associated with reduced VAP risk and MV duration. The results warrant further validation in randomized controlled trials.

Immunopathology of terminal complement activation and complement C5 blockade creating a pro-survival and organ-protective phenotype in trauma.

Traumatic haemorrhage (TH) is the leading cause of potentially preventable deaths that occur during the prehospital phase of care. No effective pharmacological therapeutics are available for critical TH patients yet. Here, we identify terminal complement activation (TCA) as a therapeutic target in combat casualties and evaluate the efficacy of a TCA inhibitor (nomacopan) on organ damage and survival in vivo. Complement activation products and cytokines were analysed in plasma from 54 combat casualties. The correlations between activated complement pathway(s) and the clinical outcomes in trauma patients were assessed. Nomacopan was administered to rats subjected to lethal TH (blast injury and haemorrhagic shock). Effects of nomacopan on TH were determined using survival rate, organ damage, physiological parameters, and laboratory profiles. Early TCA was associated with systemic inflammatory responses and clinical outcomes in this trauma cohort. Lethal TH in the untreated rats induced early TCA that correlated with the severity of tissue damage and mortality. The addition of nomacopan to a damage-control resuscitation (DCR) protocol significantly inhibited TCA, decreased local and systemic inflammatory responses, improved haemodynamics and metabolism, attenuated tissue and organ damage, and increased survival. Previous findings of our and other groups revealed that early TCA represents a rational therapeutic target for trauma patients. Nomacopan as a pro-survival and organ-protective drug, could emerge as a promising adjunct to DCR that may significantly reduce the morbidity and mortality in severe TH patients while awaiting transport to critical care facilities.

Use of venovenous extracorporeal membrane oxygenation in trauma patients with severe adult respiratory distress syndrome: A retrospective study.

The use of extracorporeal membrane oxygenation (ECMO) has increased, although its survival benefit in trauma patients with severe adult respiratory distress syndrome (ARDS) remains controversial. We investigated the effect of veno-venous (VV)-ECMO on the clinical outcomes of trauma patients with severe ARDS. This was a retrospective study at a single center comprising trauma patients admitted between January 2013 and December 2017, diagnosed with severe ARDS using the Berlin definition (PaO2/FiO2 ratio ⩽100), in the 7 days following trauma. Patients were managed with VV-ECMO or conventional mechanical ventilation (CMV). The primary outcome was in-hospital mortality (mortality at 60 days); secondary outcomes comprised 28-day mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, ICU-free days, duration of mechanical ventilation (MV), and MV-free days. Propensity score matching was performed to adjust for the baseline differences. Sixteen patients (22.5%) were managed with VV-ECMO and 55 were managed with CMV. After matching, the in-hospital mortality rate (43.8% vs 53.1%; p = 0.760), 28-day mortality rate (37.5% vs 31.3%; p = 0.750), median hospital LOS (39.5 vs 36.5 days; p = 0.533), ICU-free days (0 vs 0 days; p = 0.241), and MV-free days (0 vs 0 days; p = 0.272) did not significantly differ between the VV-ECMO and CMV groups. In-hospital mortality (mortality at 60 days) did not differ significantly between the VV-ECMO and CMV groups. Although the safety of ECMO in trauma patients requires further investigation, VV-ECMO may be considered as a rescue therapy.

A randomized, controlled study to evaluate the effect of parenteral glutamine on the reduction of infection related morbidity in burn patients in ICU

Background: Burn patients are characterized by alterations within the immune system, increased exposure to infectious complications, sepsis, and potentially organ failure and death. Glutamine supplementation to parenteral nutrition has been proven to be related to improved clinical outcomes in trauma patients. We studied the effect of glutamine supplementation on infection and clinical outcomes among burn patients.&#x0D; Methodology: Sixty burn patients were randomly divided into two equal groups. Group I received 0.5 gm/kg/day glutamine infusion as a part of parenteral nutrition for seven days after ICU admission. Group II received an intravenous placebo by continuous infusion (24 h/day). The primary outcome was the presence of infection assessed by the wound culture over a 15-days period. The secondary outcomes were: blood culture, WBCs count, serum C-reactive protein (CRP) and procalcitonin, sequential organ failure assessment (SOFA) score, and length of stay within the intensive care unit.&#x0D; Results: The results showed that the incidence of positive wound culture was considerably reduced within the glutamine group, e.g., 6 (10%) patients) vs. control 19 (33%) patients; P &lt; 0.001). The incidence of positive blood culture was significantly reduced within the study group (1 case) vs. control (9 cases; P = 0.006). In addition, the WBC, serum CRP and procalcitonin were better; and the SOFA score and the ICU-stay were reduced within the glutamine group vs. the control group.&#x0D; Conclusion: The present results prove that IV glutamine supplementation in adult burn patients can reduce the impact of infectious morbidity and improve the clinical outcome.&#x0D; Ethical committee approval: 19/5/2019 ANETS 4&#x0D; Trial registration: www.clinicaltrials.gov No. NCT05140772&#x0D; Abbreviations: ICU - intensive care unit; SOFA - Sequential Organ Failure Assessment; CRP - C-reactive protein; GFR- glomerular filtration rate; TBSA - total body surface area; BMI – Body mass index&#x0D; Key words: Glutamine; Infection; Burn; ICU; Mortality&#x0D; Citation: Eskandr AM, Attalla HA, Massoud ME, Alaa-Eldin A. Aiad AEA. A randomized, controlled study to evaluate the effect of parenteral glutamine on the reduction of infection related morbidity in burn patients in ICU. Anaesth. pain intensive care 2022;26(2):318-325; DOI: 10.35975/apic.v26i3.1898&#x0D; Received: December 24. 2021, Reviewed: January 18, 2022, Accepted: January 29, 2022&#x0D;

The Association Between Early Versus Late Physical Therapy Initiation and Outcomes of Trauma Patients With and Without Traumatic Brain Injuries.

There is a lack of literature regarding the most effective timing to initiate physical therapy (PT) among traumatically injured patients. We aim to evaluate the association between early PT/mobilization versus delayed or late PT/mobilization and clinical outcomes of trauma patients. A retrospective cohort analysis of an urban level-I trauma center from 2014 to 2019 was performed. Univariate analyses and multivariable logistic regression were performed with significance defined as P < 0.05. A total of 11,937 patients were analyzed. Among patients without a traumatic brain injury (TBI), late PT initiation times were associated with 60% lower odds of being discharged home without services (P < 0.05), significantly increased hospital and ICU length of stay (H-LOS, ICU-LOS) (P < 0.05), and significantly higher odds of complications (VTE, pneumonia, pressure ulcers, ARDS) (P < 0.001). Among patients with a TBI, late PT initiation time had 76% lower odds of being discharged home without services (P < 0.05) and significantly longer H-LOS and ICU-LOS (P < 0.05) however did not experience significantly higher odds of complications (P > 0.05). Among traumatically injured patients, early PT is associated with decreased odds of complications, shorter H-LOS and ICU-LOS, and a favorable discharge disposition to home without services. Adoption of early PT initiation/mobilization protocols and establishment of prophylactic measures against complications associated with delayed PT is critical to maximize quality of care and trauma patient outcomes. Multi-center prospective studies are needed to ascertain the impact of PT initiation times in greater detail and to minimize trauma patient morbidity.

“Low initial pre-hospital end-tidal carbon dioxide predicts inferior clinical outcomes in trauma patients”

IntroductionCurrent guidelines continue to lead to under- and over-triage of injured patients in the pre-hospital setting. End-tidal carbon dioxide (ETCO2) has been correlated with mortality and hemorrhagic shock in trauma patients. This study examines the correlation between ETCO2 and in-hospital outcomes among non-intubated patients in the pre-hospital setting. MethodsWe retrospectively studied a cohort of non-intubated adult trauma patients with initial pre-hospital side-stream capnography-obtained ETCO2 presenting via ground transport from a single North Carolina EMS agency to a level one trauma center from January 2018 to December 2018. Using the Liu method, the optimal threshold for low ETCO2 was ≤ 28.5 mmHg. ResultsInitial pre-hospital ETCO2 was recorded for 324 (22.0%) of 1473 patients with EMS data. Patients with low ETCO2 (N = 98, 30.3% of cohort) were older (median 58y vs 45y), but mechanisms of injury and scene vital signs were similar (p>0.05) between low and normal/high ETCO2 cohorts. Median injury severity score (ISS) did not differ significantly between the low and normal/high ETCO2 groups (5 vs 8, p=0.48). Compared to normal/high ETCO2, low ETCO2 correlated with increased unadjusted odds of mortality (OR 5.06), in-hospital complications (OR 2.06), and blood transfusion requirement (OR 3.05), p<0.05. Low ETCO2 was associated with 7.25 odds of mortality (95% CI 2.19,23.97, p=0.001) and 3.94 odds of blood transfusion (95% CI 1.32-11.78) after adjusting for age, ISS, and scene GCS. All but one of the massive transfusion patients (N = 8/9) had a low pre-hospital ETCO2. ConclusionsLow initial pre-hospital ETCO2 associates with poor clinical outcomes despite similar ISS and mechanisms of injury. ETCO2 is a potentially useful pre-hospital point-of-care tool to aid triage of trauma patients as it may identify hemorrhaging patients and predict mortality.

Single-Center Clinical Analysis of Traumatic Thoracic Aortic Injuries: A Retrospective Observational Study

Purpose This study investigated the clinical outcomes of trauma patients with blunt thoracic aortic injuries at a single institution. Methods During the study period, 9,501 patients with traumatic aortic injuries presented to Trauma Center of Gil Medical Center. Among them, 1,594 patients had severe trauma, with an Injury Severity Score (ISS) of >15. Demographics, physiological data, injury mechanism, hemodynamic parameters associated with the thoracic injury according to chest computed tomography (CT) findings, the timing of the intervention, and clinical outcomes were reviewed. Results Twenty-eight patients had blunt aortic injuries (75% male, mean age, 45.9±16.3 years). The majority (82.1%, n=23/28) of these patients were involved in traffic accidents. The median ISS was 35.0 (interquartile range 21.0–41.0). The injuries were found in the ascending aorta (n=1, 3.6%) aortic arch (n=8, 28.6%) aortic isthmus (n=18, 64.3%), and descending aorta (n=1, 3.6%). The severity of aortic injuries on chest CT was categorized as intramural hematoma (n=1, 3.6%), dissection (n=3, 10.7%), transection (n=9, 32.2%), pseudoaneurysm (n=12, 42.8%), and rupture (n=3, 10.7%). Endovascular repair was performed in 71.4% of patients (45% within 24 hours), and two patients received surgical management. The mortality rate was 25% (n=7). Conclusions Traumatic thoracic aortic injuries are life-threatening. In our experience, however, if there is no rupture and extravasation from an aortic injury, resuscitation and stabilization of vital signs are more important than an intervention for an aortic injury in patients with multiple traumas. Further study is required to optimize the timing of the intervention and explore management strategies for blunt thoracic aortic injuries in severe trauma patients needing resuscitation. Keywords: Aorta, thoracic; Aneurysm, false; Traumatic; Multiple trauma

Outcomes and management approaches of resuscitative endovascular balloon occlusion of the aorta based on the income of countries

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) could provide a survival benefit to severely injured patients as it may improve their initial ability to survive the hemorrhagic shock. Although the evidence supporting the use of REBOA is not conclusive, its use has expanded worldwide. We aim to compare the management approaches and clinical outcomes of trauma patients treated with REBOA according to the countries’ income based on the World Bank Country and Lending Groups.MethodsWe used data from the AORTA (USA) and the ABOTrauma (multinational) registries. Patients were stratified into two groups: (1) high-income countries (HICs) and (2) low-to-middle income countries (LMICs). Propensity score matching extracted 1:1 matched pairs of subjects who were from an LMIC or a HIC based on age, gender, the presence of pupillary response on admission, impeding hypotension (SBP ≤ 80), trauma mechanism, ISS, the necessity of CPR on arrival, the location of REBOA insertion (emergency room or operating room) and the amount of PRBCs transfused in the first 24 h. Logistic regression (LR) was used to examine the association of LMICs and mortality.ResultsA total of 817 trauma patients from 14 countries were included. Blind percutaneous approach and surgical cutdown were the preferred means of femoral cannulation in HICs and LIMCs, respectively. Patients from LMICs had a significantly higher occurrence of MODS and respiratory failure. LR showed no differences in mortality for LMICs when compared to HICs; neither in the non-matched cohort (OR = 0.63; 95% CI: 0.36‑1.09; p = 0.1) nor in the matched cohort (OR = 1.45; 95% CI: 0.63‑3,33; p = 0.3).ConclusionThere is considerable variation in the management practices of REBOA and the outcomes associated with this intervention between HICs and LMICs. Although we found significant differences in multiorgan and respiratory failure rates, there were no differences in the risk-adjusted odds of mortality between the groups analyzed. Trauma surgeons practicing REBOA around the world should joint efforts to standardize the practice of this endovascular technology worldwide.

Delta neutrophil index for predicting mortality in trauma patients who underwent emergent abdominal surgery: A case controlled study.

Delta neutrophil index (DNI) can be used as a biomarker for infection to predict patient outcomes. We aimed to investigate the relationship between DNI and clinical outcomes in trauma patients who underwent abdominal surgery. We retrospectively analyzed injured patients who underwent emergent abdominal surgery in the regional trauma center of Wonju Severance Christian Hospital between March 2016 and May 2018. Patient characteristics, operation type, preoperative and postoperative laboratory findings, and clinical outcomes were evaluated. Logistic regression analysis was performed for risk factors associated with mortality. Overall, 169 patients (mean age, 53.8 years; 66.3% male) were enrolled in this study, of which 19 (11.2%) died. The median injury severity score (ISS) was 12. The non-survivors had a significantly higher ISS [25(9-50) vs. 10(1-50), p<0.001] and serum lactate level (9.00±4.10 vs. 3.04±2.23, p<0.001) and more frequent shock (63.2% vs 23.3%, p<0.001) and solid organ injury (52.6% vs. 25.3%, p = 0.013) than the survivors. There were significant differences in postoperative DNI between the two groups (p<0.009 immediate post-operation, p = 0.001 on postoperative day 1 [POD1], and p = 0.013 on POD2). Logistic regression analysis showed that the independent factors associated with mortality were postoperative lactate level (odds ratio [OR] 1.926, 95% confidence interval [CI] 1.101-3.089, p = 0.007), postoperative sequential organ failure assessment score (OR 1.593, 95% CI 1.160-2.187, p = 0.004), and DNI on POD1 (OR 1.118, 95% CI 1.028-1.215, p = 0.009). The receiver operating characteristics curve demonstrated that the area under the curve of DNI on POD1 was 0.887 (cut-off level: 7.1%, sensitivity 85.7%, and specificity 84.4%). Postoperative DNI may be a useful biomarker to predict mortality in trauma patients who underwent emergent abdominal surgery.

200 Thromboelastography For Prediction of Neurological Deterioration or Hemorrhagic Transformation in Patients With Acute Ischemic Stroke at Emergency Department

Thromboelastography (TEG) provides a rapid assessment of a patient’s comprehensive information on hemostatic processes in emergency settings. It has been reported to be a useful tool for clinical outcomes in trauma patients; however, there are limited data about ischemic stroke, particularly in predicting adverse events in patients with acute stroke. We investigated the significance of TEG on admission for prediction of adverse events in patients with acute ischemic stroke. TEG was performed prospectively in 772 patients with suspecting acute stroke who met stroke calling criteria at emergency department consecutively between March and December 2018. Excluding 114 patients, 628 patients were evaluated and 205 patients with acute ischemic stroke were finally included. Adverse events included hemorrhagic transformation (defined as any blood on follow-up brain imaging study) or neurological deterioration, defined as an increase of ≥2 National Institutes of Health Stroke Scale (NIHSS) within 72 h of stroke onset. Of the 205 ischemic stroke patients (mean age 67.3 ± 12.8 years, 66.3% male), adverse events were identified in 43 (21.0%) patients (Clinical bleeding 28, neurological deterioration 24 and both event in 9 patients). In patients of acute ischemic stroke, R of less than 5 in thromboelastography was independently associated with adverse events. Further studies are needed to evaluate R as a predictor of adverse events in stroke management.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The influence of tracheostomy timing on outcomes in trauma patients: A meta-analysis

ObjectiveThis study aims to assess the influence of tracheostomy timing on outcomes among trauma patients, including mortality, medical resource utility and incidence of pneumonia. MethodA systematic review of the literature was conducted by internet search. Data were extracted from selected studies and analyzed using Stata to compare outcomes in trauma patients with early tracheostomy (ET) or late tracheostomy (LT)/prolonged intubation (PI). Result20 studies met our inclusion criteria with 3305 patients in ET group and 4446 patients in LT/PI group. Pooled data revealed that mortality was not lower in trauma patients with ET compared to those with LT/IP. However, ET was found to be associated with a significantly reduced length of ICU and hospital stay, shorter MV duration and lower risk of pneumonia. ConclusionEvidence of this meta-analysis supports the dimorphism in some clinical outcomes of trauma patients with different tracheostomy timing. Additional well-designed randomized controlled trials (RCTs) are needed to confirm it in future.

Gene Expression of Proresolving Lipid Mediator Pathways Is Associated With Clinical Outcomes in Trauma Patients.

Specialized proresolving lipid mediators have emerged as powerful modulators of inflammation and activators of resolution. Animal models show significant benefits of specialized proresolving lipid mediators on survival and wound healing after major burn trauma. To date, no studies have investigated specialized proresolving lipid mediators and their relation to other lipid mediator pathways in humans after trauma. Here we determine if patients with poor outcomes after trauma have dysregulated lipid mediator pathways. We studied blood leukocyte expression of 18 genes critical to the synthesis, signaling, and metabolism of specialized proresolving lipid mediators and proinflammatory lipid mediators, and we correlated these expression patterns with clinical outcomes in trauma patients from the Inflammation and the Host Response to Injury study. Seven U.S. medical trauma centers. Ninety-six patients enrolled in the Inflammation and Host Response to Injury study, after blunt trauma and unambiguously classified as having uncomplicated or complicated recoveries. Twenty-eight healthy volunteers were enrolled as controls. None. Within each patient, the 18 genes of interest were used to calculate scores for distinct families of lipid mediators, including resolvins, lipoxins, prostaglandins, and leukotrienes, as well as leukotriene to resolvin score ratios. Scores were built using a simple weighting scheme, taking into consideration both dependent and independent activities of enzymes and receptors responsible for lipid mediator biosynthesis and function. Individually, ALOX12, PTGS2, PTGES, PTGDS, ALOX5AP, LTA4H, FPR2, PTGER2, LTB4R, HPGD, PTGR1, and CYP4F3 were expressed differentially over 28 days posttrauma between patients with uncomplicated and complicated recoveries (p < 0.05). When all genes were combined into scores, patients with uncomplicated recoveries had differential and higher resolvin scores (p < 0.001) and lower leukotriene scores (p < 0.001). A final combined ratio was calculated for each patient, and posttrauma leukotriene score to resolvin score ratios were significantly lower in patients with uncomplicated clinical courses (p < 0.001). proresolving lipid mediator lipidomics and/or protein expression, and identifying associated therapeutic targets, may influence the clinical management of trauma patients.

Clinical Outcomes of Trauma Patients after Implementation of a Standardised Diversion Protocol for Trauma Patients in Two Regional Hospitals in Hong Kong

Introduction Despite recent advance in prehospital trauma diversion, patients are triaged to the nearest medical facility before transferred to designated trauma centre. A new standardised diversion protocol for trauma patients was implemented on 1st April 2011 to facilitate trauma care. Severely-injured patients were transferred to designated trauma centre directly from emergency department of the regional hospital after initial resuscitation. Objective This study was undertaken to examine clinical outcomes of trauma patients after implementation of the new standardised diversion protocol for trauma patients in the emergency department. Method This was a before-and-after interventional study on trauma patients presenting to the emergency department in critical or emergency conditions during the study period from 1st April 2011 to 31st March 2012. Patients presented in the two-year period before implementation of the trauma protocol were used as historical control. Medical records of eligible cases were reviewed. Main outcome measures were 30-day mortality, length of hospital stay and time to definitive care. Mortality data was compared with oversea standard by TRISS methodology. Results There were 153 eligible patients in the study group and 355 in the historical control group. After new arrangement of trauma diversion, W-statistics improves from -1.26 to 0.09. Z-statistics was -2.03 before and 0.09 after implementation. M-statistics were 0.91 before and 0.88 after the new protocol. Mean time to definitive care was shortened by 33.4 minutes in the subgroup who were transferred to trauma centre after trauma team activation (p=0.005). Conclusion A trend of improved outcomes and shorter time to definitive care are observed after implementation of the new trauma diversion protocol. (Hong Kong j.emerg.med. 2015;22:201-209)

Benchmarking statewide trauma mortality using Agency for Healthcare Research and Quality's patient safety indicators

BackgroundImproving clinical outcomes of trauma patients is a challenging problem at a statewide level, particularly if data from the state's registry are not publicly available. Promotion of optimal care throughout the state is not possible unless clinical benchmarks are available for comparison. Using publicly available administrative data from the State Department of Health and the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs), we sought to create a statewide method for benchmarking trauma mortality and at the same time also identifying a pattern of unique complications that have an independent influence on mortality. MethodsData for this study were obtained from State of Florida Agency for Health Care Administration. Adult trauma patients were identified as having International Classification of Disease ninth edition codes defined by the state. Multivariate logistic regression was used to create a predictive inpatient expected mortality model. The expected value of PSIs was created using the multivariate model and their beta coefficients provided by the AHRQ. Case-mix adjusted mortality results were reported as observed to expected (O/E) ratios to examine mortality, PSIs, failure to prevent complications, and failure to rescue from death. ResultsThere were 50,596 trauma patients evaluated during the study period. The overall fit of the expected mortality model was very strong at a c-statistic of 0.93. Twelve of 25 trauma centers had O/E ratios <1 or better than expected. Nine statewide PSIs had failure to prevent O/E ratios higher than expected. Five statewide PSIs had failure to rescue O/E ratios higher than expected. The PSI that had the strongest influence on trauma mortality for the state was PSI no. 9 or perioperative hemorrhage or hematoma. Mortality could be further substratified by PSI complications at the hospital level. ConclusionsAHRQ PSIs can have an integral role in an adjusted benchmarking method that screens at risk trauma centers in the state for higher than expected mortality. Stratifying mortality based on failure to prevent PSIs may identify areas of needed improvement at a statewide level.