Emergency Trauma Surgery Research Articles

Chest Computed Tomography for the Diagnosis of COVID-19 in Emergency Trauma Surgery Patients Who Require Urgent Care During the Pandemic: Protocol for an Umbrella Review.

BackgroundMany health care facilities in low- and middle-income countries are inadequately resourced. COVID-19 has the potential to decimate surgical health care services unless health systems take stringent measures to protect health care workers from viral exposure and ensure the continuity of specialized care for patients. Among these measures, the timely diagnosis of COVID-19 is paramount to ensure the use of protective measures and isolation of patients to prevent transmission to health care personnel caring for patients with an unknown COVID-19 status or contact during the pandemic. Besides molecular and antibody tests, chest computed tomography (CT) has been assessed as a potential tool to aid in the screening or diagnosis of COVID-19 and could be valuable in the emergency care setting.ObjectiveThis paper presents the protocol for an umbrella review that aims to identify and summarize the available literature on the diagnostic accuracy of chest CT for COVID-19 in trauma surgery patients requiring urgent care. The objective is to inform future recommendations on emergency care for this category of patients.MethodsWe will conduct several searches in the L·OVE (Living Overview of Evidence) platform for COVID-19, a system that performs automated regular searches in PubMed, Embase, Cochrane Central Register of Controlled Trials, and over 30 other sources. The search results will be presented according to PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis). This review will preferentially consider systematic reviews of diagnostic test accuracy studies, as well as individual studies of such design, if not included in the systematic reviews, that assessed the sensitivity and specificity of chest CT in emergency trauma surgery patients. Critical appraisal of the included studies for risk of bias will be conducted. Data will be extracted using a standardized data extraction tool. Findings will be summarized narratively, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach will be used to grade the certainty of evidence.ResultsEthics approval is not required for this systematic review, as there will be no patient involvement. The search for this systematic review commenced in October 2020, and we expect to publish the findings in early 2021. The plan for dissemination is to publish the findings in a peer-reviewed journal and present our results at conferences that engage the most pertinent stakeholders.ConclusionsDuring the COVID-19 pandemic, protecting health care workers from infection is essential. Up-to-date information on the efficacy of diagnostic tests for detecting COVID-19 is essential. This review will serve an important role as a thorough summary to inform evidence-based recommendations on establishing effective policy and clinical guideline recommendations.Trial RegistrationPROSPERO International Prospective Register of Systematic Reviews CRD42020198267; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=198267International Registered Report Identifier (IRRID)PRR1-10.2196/25207

Association of Acute Care Surgeon Experience With Emergency Surgery Patient Outcomes and Mortality

Previous studies comparing emergency surgery outcomes with surgeon experience have been small or used administrative databases without controlling for patient physiology or operative complexity. To evaluate the association of acute care surgeon experience with patient morbidity and mortality after emergency surgical procedures. This cohort study evaluated the association of surgeon experience with emergency surgery outcomes at 5 US academic level 1 trauma centers where the same surgeons provided emergency general surgical care. A total of 772 patients who presented with a traumatic injury and required an emergency surgical procedure or who presented with or developed a condition requiring an emergency general surgical intervention were operated on by 1 of 56 acute care surgeons. Surgeon groups were divided by experience of less than 6 years (early career), 6 to 10 years (early midcareer), 11 to 30 years (late midcareer), and 30 years or more (late career) from the end of training. Surgeons with less than 3 years of experience were also compared with the entire cohort. Hierarchical logistic regression models were constructed controlling for Emergency Surgery Score, case complexity, preoperative transfusion, and trauma or emergency general surgery. Data were collected from May 2015 to July 2017 and analyzed from February to May 2020. Mortality, complications, length of stay, blood loss, and unplanned return to the operating room. Of 772 included patients, 469 (60.8%) were male, and the mean (SD) age was 50.1 (20.0) years. Of 772 operations, 618 were by surgeons with less than 10 years of experience. Early- and late-midcareer surgeons generally operated on older patients and patients with more septic shock, acute kidney failure, and higher Emergency Surgery Scores. Patient mortality, complications, postoperative transfusion, organ-space surgical site infection, and length of stay were similar between surgeon groups. Patients operated on by early-career surgeons had higher rates of unplanned return to the operating room compared with those operated on by early-midcareer surgeons (odds ratio [OR], 0.66; 95% CI, 0.40-1.09), late-midcareer surgeons (OR, 0.34; 95% CI, 0.13-0.90), and late-career surgeons (OR, 1.11; 95% CI, 0.45-2.75). Patients operated on by surgeons with less than 3 years of experience had similar mortality compared with the rest of the cohort (OR, 1.97; 95% CI, 0.85-4.57) but higher rates of complications (OR, 2.07; 95% CI, 1.05-4.07). In this study, experienced surgeons generally operated on older patients with more septic shock and kidney failure without affecting risk-adjusted mortality. Increased complications and unplanned return to the operating room may improve with experience. Early-career surgeons' outcomes may be improved if they are supported while experience is garnered.

Personal protective equipment for reducing the risk of COVID-19 infection among health care workers involved in emergency trauma surgery during the pandemic: An umbrella review.

Health care facilities in low- and middle-income countries are inadequately resourced to adhere to current COVID-19 prevention recommendations. Recommendations for surgical emergency trauma care measures need to be adequately informed by available evidence and adapt to particular settings. To inform future recommendations, we set to summarize the effects of different personal protective equipment (PPE) on the risk of COVID-19 infection in health personnel caring for trauma surgery patients. We conducted an umbrella review using Living Overview of Evidence platform for COVID-19, which performs regular automated searches in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and more than 30 other sources. Systematic reviews of experimental and observational studies assessing the efficacy of PPE were included. Indirect evidence from other health care settings was also considered. Risk of bias was assessed with the AMSTAR II tool (Assessing the Methodological Quality of Systematic Reviews, Ottawa, ON, Canada), and the Grading of Recommendations, Assessment, Development, and Evaluation approach for grading the certainty of the evidence is reported (registered in International Prospective Register of Systematic Reviews, CRD42020198267). Eighteen studies that fulfilled the selection criteria were included. There is high certainty that the use of N95 respirators and surgical masks is associated with a reduced risk of COVID-19 when compared with no mask use. In moderate- to high-risk environments, N95 respirators are associated with a further reduction in risk of COVID-19 infection compared with surgical masks. Eye protection also reduces the risk of contagion in this setting. Decontamination of masks and respirators with ultraviolet germicidal irradiation, vaporous hydrogen peroxide, or dry heat is effective and does not affect PPE performance or fit. The use of PPE drastically reduces the risk of COVID-19 compared with no mask use in health care workers. N95 and equivalent respirators provide more protection than surgical masks. Decontamination and reuse appear feasible to overcome PPE shortages and enhance the allocation of limited resources. These effects are applicable to emergency trauma care and should inform future recommendations. Review, level II.

Intraoperative vasopressor use during emergency surgery on injured meth users

BackgroundMethamphetamine is a growing drug of abuse in America. Patients with recent methamphetamine use pose potential complications to general anesthesia due to changes in hemodynamics and arrhythmias. Limited data exists...

Scoping Evidence Review on Training and Skills Assessment for Open Emergency Surgery

Scope evidence on technical performance metrics for open emergency surgery. Identify surgical performance metrics and procedures used in trauma training courses. Structured literature searches of electronic databases were conducted from January 2010 to December 2019 to identify systematic reviews of tools to measure surgical skills employed in vascular or trauma surgery evaluation and training. Faculty of Shock Trauma Anesthesiology Research Center, University of Maryland School of Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland and Implementation Science, King's College, London. The evidence from 21 systematic reviews including over 54,000 subjects enrolled into over 840 eligible studies, identified that the Objective Structured Assessment of Technical Skill was used for elective surgery not for emergency trauma and vascular control surgery procedures. The Individual Procedure Score (IPS), used to evaluate emergency trauma procedures performed before and after training, distinguished performance of residents from experts and practicing surgeons. IPS predicted surgeons who make critical errors and need remediation interventions. No metrics showed Kirkpatrick's Level 4 evidence of technical skills training benefit to emergency surgery outcomes. Expert benchmarks, errors, complication rates, task completion time, task-specific checklists, global rating scales, Objective Structured Assessment of Technical Skills, and IPS were found to identify surgeons, at all levels of seniority, who are in need of remediation of technical skills for open surgical hemorrhage control. Large-scale, multicenter studies are needed to evaluate any benefit of trauma technical skills training on patient outcomes.

Remifentanil inhibits the traumatic stress response in emergent trauma surgery

ObjectiveThe aim of this study was to explore whether remifentanil could inhibit the stress response in emergent trauma surgery more effectively than sufentanil.Patients and methodsSixty trauma patients for emergent surgery were randomly divided into remifentanil group (R group, n = 30) or sufentanil group (S group, n = 30). The patients in the R group were continuously intravenously infused with remifentanil, while those in the S group were administrated with sufentanil. The plasma contents of cortisol (COR), epinephrine (E), norepinephrine (NE), and blood glucose were measured before anesthesia induction (T1), 5 minutes after intratracheal intubation (T2) and 5 minutes (T3), 30 minutes (T4), and 1 hour (T5) after surgery, respectively. The blood pressure (BP) and the heart rate (HR) at these time points were recorded as well.ResultsThe results showed that the patients in the R group had more stable hemodynamics during the surgery and had a significantly lower HR at T2‐T5 than those in the S group. The plasma levels of norepinephrine at time points T3‐T5 and levels of cortisol at T4‐T5 in the R group were significantly lower than those in the S group (P < 0.05).ConclusionsThe results in the present study indicated that remifentanil could inhibit the stress response in emergent trauma surgery patients more effectively than sufentanil.

Profile of maxillofacial injuries in Departement of Emergency Trauma and Acute Care Surgery in Sanglah General Hospital from January 2012 to November 2018

Introduction: Maxillofacial injuries are common cause of trauma in emergency department. The goals in the treatment of maxillofacial injury are to restore premorbid occlusion. This study aimed to evaluate the characteristics and outcome of the maxillofacial injuries patient in Sanglah General Hospital Denpasar Bali.Methods Retrospective study was held in Sanglah General Hospital from January 2012 to November 2018. The samples consisted of 241 patients. Age, gender, type of the fractures and surgical management were evaluated.Results Maxillofacial injuries mostly occurred in male, aged 18-40 years old, the mandible was most frequently involved facial bone. Â Internal fixation was the golden standard of the treatment chosen (83.73%) followed by Arch bar (16.27%).Conclusion Road traffic accidents are the main reason for maxillofacial injury in Sanglah General Hospital Denpasar Bali. Precise diagnosis and proper treatment result in optimal occlusion and integrity nervous system, both internal fixation and arch bar were given good outcome.

Mortality in trauma patients admitted during, before, and after national academic emergency medicine and trauma surgery meeting dates in Japan.

Annually, many physicians attend national academic meetings. While participating in these meetings can have a positive impact on daily medical practice, attendance may result in reduced medical staffing during the meeting dates. We sought to examine whether there were differences in mortality after trauma among patients admitted to the hospital during, before, and after meeting dates. Using the Japan Trauma Data Bank, we analyzed in-hospital mortality in patients with traumatic injury admitted to the hospital from 2004 to 2015 during the dates of two national academic meetings—the Japanese Association for Acute Medicine (JAAM) and the Japanese Association for the Surgery of Trauma (JAST). We compared the data with that of patients admitted with trauma during identical weekdays in the weeks before and after the meetings, respectively. We used multiple logistic regression analysis to compare outcomes among the three groups. A total of 7,491 patients were included in our analyses, with 2,481, 2,492, and 2,518 patients in the during, before, and after meeting dates groups, respectively; their mortality rates were 7.3%, 8.0%, and 8.5%, respectively. After adjusting for covariates, no significant differences in in-hospital mortality were found among the three groups (adjusted odds ratio [95% CI] of the before meeting dates and after meeting dates groups; 1.18 [0.89–1.56] and 1.23 [0.93–1.63], respectively, with the during meeting dates group as the reference category). No significant differences in in-hospital mortality were found among trauma patients admitted during, before, and after the JAAM and JAST meeting dates.

Discussion of “Tele-mentored emergency trauma surgery: A feasibility study using live-tissue models”

•Who and how would be providing the tele-mentoring •Can Tele-mentoring be expanded to help new and rural surgeons continue to perform procedures that they may not be comfortable performing alone or that they have not done since residency. •Can this open a "semiretirement" position for experienced surgeons. Tele-mentored damage-control and emergency trauma surgery: A feasibility study using live-tissue modelsThe American Journal of SurgeryVol. 215Issue 5PreviewDamage-control and emergency surgical procedures in trauma have the potential to save lives. They may occasionally not be performed due to clinician inexperience or lack of comfort and knowledge. Full-Text PDF

Tele-mentored damage-control and emergency trauma surgery: A feasibility study using live-tissue models

BackgroundDamage-control and emergency surgical procedures in trauma have the potential to save lives. They may occasionally not be performed due to clinician inexperience or lack of comfort and knowledge. MethodsCanadian Armed Forces (CAF) non-surgeon Medical Officers (MOs) participated in a live tissue training exercise. They received tele-mentoring assistance using a secure video-conferencing application on a smartphone/tablet platform. Feasibility of tele-mentored surgery was studied by measuring their effectiveness at completing a set series of tasks in this pilot study. Additionally, their comfort and willingness to perform studied procedures was gauged using pre- and post-study surveys. ResultsWith no pre-procedural teaching, participants were able to complete surgical airway, chest tube insertion and resuscitative thoracotomy with 100% effectiveness with no noted complications. Comfort level and willingness to perform these procedures were improved with tele-mentoring. Participants felt that tele-mentored surgery would benefit their performance of resuscitative thoracotomy most. ConclusionThe use of tele-mentored surgery to assist non-surgeon clinicians in the performance of damage-control and emergency surgical procedures is feasible. More study is required to validate its effectiveness.

Quality management of a massive transfusion protocol.

Massive transfusion is a response to massive uncontrolled hemorrhage. To be effective, it must be timely and address the patient's needs for blood volume, oxygen transport, and hemostasis. A review was performed on all activations of the massive transfusion protocol (MTP) in a hospital with large emergency medicine, trauma, and vascular surgery programs. Indications, transfused amounts, and outcomes were determined for each MTP event to determine appropriateness of MTP use. Results are presented as descriptive statistics, categorical associations, and simple linear trend relationships. The MTP was activated 309 times in 2016. Of these episodes, 237 were for trauma, 29 for gastrointestinal bleeding, 16 for ruptured abdominal aortic aneurisms, and 25 for a variety of other causes. Trauma-related MTP activations had a mean injury severity score of 32. Blood use averaged 6.6 units of red blood cells (RBCs), 6.5 units of plasma, and 1.2 units of apheresis platelets. Fourteen activations ended without the administration of any blood products, and 45 (14%) did not meet the critical administration threshold of three components. Only 60 (19%) activations met the historic definition of massive with at least 10 units of RBCs administered. Mortality was 15% for the trauma-related activations. Massive transfusion protocol activations were frequent and conducted with high fidelity to the 1:1:1 unit ratio standard. Making blood components available quickly was associated with low rates of total component usage and low mortality for trauma patients and was not associated with overuse.

Low End-Tidal Carbon Dioxide at the Onset of Emergent Trauma Surgery Is Associated With Nonsurvival: A Case Series.

End-tidal carbon dioxide (EtCO2) is a valuable marker of the return of adequate circulation after cardiac arrest due to medical causes. Previously, the prognostic value of capnography in trauma has been studied among limited populations in prehospital and emergency department settings. We aimed to investigate the relationship between early intraoperative EtCO2 and nonsurvival of patients undergoing emergency surgery at a level 1 academic trauma center as a case series. If there is a threshold below which survival was extremely unlikely, it might be useful in guiding decision-making in the early termination of futile resuscitative efforts. After institutional review board approval, a data set was created to investigate the relationship between EtCO2 values at the onset of emergent trauma surgery and nonsurvival. Patients who were admitted and transferred to the operating room (OR) directly from a resuscitation bay were identified using the Ryder Center trauma registry (October 1, 2013, to June 30, 2016). Electronic records from the hospital's anesthesia information management system were queried to identify the matching anesthesia records. The maximum EtCO2 values within 5 and 10 minutes of the onset of mechanical ventilation in the OR were determined for patients undergoing general anesthesia with mechanical ventilation. Patients were divided into 2 groups: those who were discharged from the hospital alive (survivors) and those who died in the hospital before discharge (nonsurvivors). The threshold EtCO2 giving a positive predictive value of 100% for in-hospital mortality was determined from a graphical analysis of the data. Association of determined threshold and mortality was analyzed using the 2-tailed Fisher exact test. There were 1135 patients who met the inclusion criteria. Within the first 5 minutes of the onset of mechanical ventilation in the OR, if the maximum EtCO2 value was ≤20 mm Hg, hospital mortality was 100% (21/21, 95% binomial confidence interval, 83.2%-100%). A maximum EtCO2 ≤20 mm Hg within 5 minutes of the onset of mechanical ventilation in the OR may be useful in decision-making related to the termination of resuscitative efforts during emergent trauma surgery. However, a large-scale study is needed to establish the statistical reliability of this finding before potential adoption.

Anesthetic implications of recreational drug use.

As the use of recreational drugs increases, the likelihood of an anesthesiologist perioperatively encountering patients using or addicted to these drugs will also increase. Addicted patients may present for anesthetic care in a variety of circumstances in everyday elective surgeries or in acute or life-saving situations, such as emergency Cesarean delivery or trauma surgery. Therefore, it is important for anesthesiologists to know about the most common illicit drugs being used, their clinical presentation and side effects, and the anesthetic options that are beneficial or detrimental to these patients. The most frequently used illicit substances, apart from alcohol and tobacco, are cannabis, cocaine, heroin, prescription opioids, methamphetamine, and hallucinogens. When planning anesthetic care, it is important for anesthesiologists to understand the effects of these agents, including various drug interactions, to predict tolerance to some anesthetic agents, to recognize drug withdrawal signs and symptoms, and to be prepared to manage all these factors in the perioperative period. For optimal patient care through the perioperative period, it is critical to obtain information about patient drug use and other associated treatment in order to construct an appropriate anesthetic plan, including specific considerations during surgery, emergence, and in the postanesthesia care unit.

375 Improving Interdepartmental Trauma Evaluation and Resuscitation Through Mock In Situ Trauma Review and Debriefing

Effective trauma resuscitation is essential to providing patients with an optimal outcome. We implemented a curriculum to review interdepartmental, interdisciplinary mock in situ traumas from the moment EMS calls our code line all the way through the patient’s disposition. Our primary goal is to streamline and standardize the evaluation and resuscitation of our trauma patients by improving interdepartmental communication skills, identifying and reviewing each member's role, reviewing the clinical management of ATLS algorithms, and reviewing ATLS procedural skills. Design: We created a curriculum to enhance the communication and skills of all members of our trauma team. The curriculum has two components: 1. The first component is an online PowerPoint module. All members of the trauma team are required to review. 2. The second component involves monthly unannounced mock in situ trauma codes. The trauma team's response to a trauma code is reviewed through focused debriefing with a team, strategically selected for their expertise. Our debriefing process occurs immediately after the conclusion of the case. Content experts have a checklist and focus on one of six critical actions. Each of these debriefers also has an opportunity to mention one other observation for improvement within their area of expertise. Our mock in situ traumas occur in the trauma bays in our emergency department. From August 2013- February 2017, we have had 32 mock in situ traumas. In total, we had 477 participants across 7 departments (emergency medicine, trauma surgery, respiratory therapy, radiology, EMS, orthopedic surgery and anesthesia) and across 9 professions (attending, physician assistant, resident, registered nurse, patient care assistant, certified registered nurse assistant, radiology technician, emergency medicine service, respiratory therapy). We tracked and classified most of our data throughout our mock in situ traumas into three categories. In the category of Leadership, we tracked: 1.The time taken for Verbal Identification of a team leader and 2. The team member’s awareness of who is the leader. In the Category of Team work and communication, we tracked: 1. Verbal role assignment to team members by the team leader, 2. The number of “thin air” commands and the total number of recaps, and 3. The Number of people in trauma box and nursing documentation. In the category of Clinical Outcomes, we tracked: 1. Room preparedness prior to patient arrival: a. Time to first set of Vitals, b. Time to primary assessment and c.Time to secondary assessment, 2. Number of critical actions completed and number of critical actions missed, 3. Formal hand off from ED to trauma team. We recognize limitations in this study: 1. Trauma codes are only run once a month.2. We did not assess any direct correlation with patient outcomes as we do not measure patient outcomes. 3. We only had one observer who consistently collected all data for every trauma. 4. We modified our checklist as we determined what was most relevant. Our online instructional course and mock in situ trauma codes are demonstrating improvement in mock in situ trauma evaluation and resuscitation. While medical proficiency is vital, teamwork and communication are the cornerstone of effective resuscitation. Our curriculum reinforces the tools that create a culture of teamwork and communication.

Profile of the newly graduated physicians in southern Brazil and their professional insertion.

Knowledge of the profile and professional integration of new graduates enables adjustments in medical education. This study evaluated 107 graduates from a private institution in the Brazilian South region, using a self-administered electronic questionnaire. There were similar participation of young physicians of both genders and higher male concentration in general surgery. Graduates are inserted in the public and private labor market. Most do extra shifts in emergency services and trauma surgery, where there is greater need for clinical and surgical skills. These findings suggest that adequate surgical training during graduation is critical to employability. RESUMO O conhecimento do perfil e inserção profissional dos recém-formados possibilita ajustes na educação médica. Este estudo avaliou 107 egressos de instituição privada no sul do país, utilizando questionário eletrônico autoaplicável. Houve participação similar de jovens de ambos os sexos e maior concentração masculina na área de cirurgia geral. Os egressos estão inseridos no mercado de trabalho público e privado. A maioria faz plantões extras em serviços de emergência e cirurgia do trauma, onde há maior necessidade de habilidades clinicas e cirúrgica. Esses achados apontam que a formação cirúrgica adequada durante a graduação é fundamental para a empregabilidade.

Humanitarian Surgical Care Provided by a French Forward Surgical Team: Ten Years of Providing Medical Support to the Population of the Ivory Coast.

The aims of this study were as follows: first to quantify and review the types of surgical procedures performed by military surgeons assigned to a Forward Surgical Team (FST) providing medical support to the population (MSP) in the Ivory Coast (IC), and second to analyze how this MSP was achieved. Between 2002 and 2012, all of the local nationals operated on by the different FSTs deployed in the IC were included in the study. The surgical activity was analyzed and divided into surgical specialties, war wounds, nonwar emergency trauma, nontrauma emergencies, and elective surgery. Demographics, circumstances of health care management, wounded organs, and types of surgical procedures were described. Over this period, surgeons operated on 2,315 patients and performed 2,556 procedures. Elective surgery accounted for 78.7% of the surgical activity, nontrauma emergencies accounted for 12.7%, nonwar emergency trauma accounted for 8%, and war wounds accounted for 0.6%. The main surgical activities were visceral (43.8%) and orthopedic (including soft tissues) surgeries (38.5%). The FSTs contributed widely to MSP in the IC. This MSP required limited resources, standardization of the procedures and specific skills beyond the original surgical specialties of military surgeons to fulfill the needs of the local population.

Modern teaching of military surgery: why and how to prepare the orthopaedic surgeons before deployment? The French experience.

Improved survival of combat casualties in modern conflicts is especially due to early access to damage control resuscitation and surgery in forward surgical facilities. In the French Army, these small mobile units are staffed with one general surgeon and one orthopaedic surgeon who must be able to perform any kind of trauma or non trauma emergency surgery. This concept of forward surgery requires a solid foundation in general surgery which is no longer provided by the current surgical programs due to an early specialization of the residents. Obviously a specific training is needed in war trauma due to the special pathology and practice, but also in humanitarian care which is often provided in military field facilities. To meet that demand the French Military Health Service Academy created an Advanced Course for Deployment Surgery (ACDS), also called CACHIRMEX (Cours Avancé de CHIRurgie en Mission EXtérieure). Since 2007 this course is mandatory for young military surgeons before their first deployment. Orthopaedic trainees are particularly interested in learning war damage control orthopaedic tactics, general surgery life-saving procedures and humanitarian orthopaedic surgery principles in austere environments. Additional pre-deployment training was recently developed to improve the preparation of mobile surgical teams, as well as a continuing medical education for any active-duty or reserve surgeon to be deployed.

The off-hour effect on trauma patients requiring subspecialty intervention at a community hospital in Japan: a retrospective cohort study.

BackgroundBecause most community hospitals in Japan do not maintain 24-h availability of in-house anesthesiologists, surgeons, and interventional radiologists, staffing dramatically declines during off hours. It is unclear whether, in such under-resourced hospitals, trauma patients presenting during off hours and requiring subspecialty intervention have worse outcomes than those who present during business hours.MethodsThis was a retrospective cohort study at a community hospital in Japan. Participants were all injured patients requiring emergency trauma surgery or transarterial embolization who presented from January 2002 to December 2013. We investigated whether outcomes of these patients differed between business hours (8:01 AM to 6:00 PM weekdays) and off hours (6:01 PM to 8:00 AM weekdays plus all weekend hours). The primary outcome measure was mortality rate, and the secondary outcome measures were duration of emergency room (ER) stay; unexpected death (death/probability of survival > 0.5); and adverse events occurring in the ER. We adjusted for potential confounders of age, sex, Injury Severity Score (ISS), Revised Trauma Score, presentation phase (2002–2005, 2006–2009, and 2010–2013), Charlson Comorbidity Index, and injury type (blunt or penetrating) using logistic regression models.ResultsOf the 805 patients included, 379 (47.1%) presented during business hours and 426 (52.9%) during off hours. Off-hours presentation was associated with longer ER stays for patients with systolic blood pressure < 90 mmHg on admission (p = 0.021), ISS >15 (p = 0.047), and pelvic fracture requiring transarterial embolization (p < 0.001). Off-hours presentation was also associated with increased risk of adverse events in the ER (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1–2.7, p = 0.020). After adjustment for confounders, an increased risk of adverse events (OR 1.6, 95% CI 1.1–2.7, p = 0.049) persisted, but no differences were detected in mortality (p = 0.80) and unexpected death (p = 0.44) between off hours and business hours.ConclusionsAt a community hospital in Japan, presentation during off hours was associated with a longer ER stay for severely injured patients and increased risk of adverse events in the ER. However, these disadvantages did not impact mortality or unexpected outcome.

Cell salvage in emergency trauma surgery

Trauma is the leading cause of death in people under the age of 45 years. Over the past 20 years, intraoperative autologous transfusions (obtained by cell salvage, also known as intraoperative blood salvage (IBS)) have been used as an alternative to blood products from other individuals during surgery because of the risk of transfusion-related infections such as hepatitis and human immunodeficiency virus (HIV). In this review, we sought to assess the effects and cost of cell salvage in individuals undergoing abdominal or thoracic surgery. To compare the effect and cost of cell salvage with those of standard care in individuals undergoing abdominal or thoracic trauma surgery. We ran the search on 25 November 2014. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid OLDMEDLINE, EMBASE Classic + EMBASE (OvidSP), PubMed, and ISI Web of Science (SCI-Expanded & CPSI-SSH). We also screened reference lists and contacted principal investigators. Randomised controlled trials comparing cell salvage with no cell salvage (standard care) in individuals undergoing abdominal or thoracic trauma surgery. Two authors independently extracted data from the trial reports. We used the standard methodological procedures expected by The Cochrane Collaboration. Only one small study (n = 44) fulfilled the inclusion criteria. Results suggested that cell salvage did not affect mortality overall (death rates were 67% (14/21 participants) in the cell salvage group and 65% (15/23) in the control group) (odds ratio (OR) 1.07, 95% confidence interval (CI) 0.31 to 3.72). For individuals with abdominal injury, mortality was also similar in both groups (OR 0.48, 95% CI 0.11 to 2.10).Less donor blood was needed for transfusion within the first 24 hours postinjury in the cell salvage group compared with the control group (mean difference (MD) -4.70 units, 95% CI -8.09 to -1.31). Adverse events, notably postoperative sepsis, did not differ between groups (OR 0.54, 95% CI 0.11 to 2.55). Cost did not notably differ between groups (MD -177.81, 95% CI -452.85 to 97.23, measured in GBP in 2002). Evidence for the use of cell salvage in individuals undergoing abdominal or thoracic trauma surgery remains equivocal. Large, multicentre, methodologically rigorous trials are needed to assess the relative efficacy, safety and cost-effectiveness of cell salvage in different surgical procedures in the emergency context.

Identification of a Neurologic Scale That Optimizes EMS Detection of Older Adult Traumatic Brain Injury Patients Who Require Transport to a Trauma Center

Objective. We sought to identify a scale or components of a scale that optimize detection of older adult traumatic brain injury (TBI) patients who require transport to a trauma center, regardless of mechanism. Methods. We assembled a consensus panel consisting of nine experts in geriatric emergency medicine, prehospital medicine, trauma surgery, geriatric medicine, and TBI, as well as prehospital providers, to evaluate the existing scales used to identify TBI. We reviewed the relevant literature and solicited group feedback to create a list of candidate scales and criteria for evaluation. Using the nominal group technique, scales were evaluated by the expert panel through an iterative process until consensus was achieved. Results. We identified 15 scales for evaluation. The panel's criteria for rating the scales included ease of administration, prehospital familiarity with scale components, feasibility of use with older adults, time to administer, and strength of evidence for their performance in the prehospital setting. After review and discussion of aggregated ratings, the panel identified the Simplified Motor Scale, GCS-Motor Component, and AVPU (alert, voice, pain, unresponsive) as the strongest scales, but determined that none meet all EMS provider and patient needs due to poor usability and lack of supportive evidence. The panel proposed that a dichotomized decision scheme that includes domains of the top-rated scales –level of alertness (alert vs. not alert) and motor function (obeys commands vs. does not obey) –may be more effective in identifying older adult TBI patients who require transport to a trauma center in the prehospital setting. Conclusions. Existing scales to identify TBI are inadequate to detect older adult TBI patients who require transport to a trauma center. A new algorithm, derived from elements of previously established scales, has the potential to guide prehospital providers in improving the triage of older adult TBI patients, but needs further evaluation prior to use.