Full Trauma Team Activation Research Articles

Noncompliance with American College of Surgeons Committee on Trauma recommended criteria for full trauma team activation is associated with undertriage deaths: Tignanelli CJ, Vander Kolk WE, Mikhail JN, et al. J Trauma Acute Care Surg. 2018;84(2):287-294

The appropriate triage of patients within a trauma system is critically important both to improve patient outcomes and optimize resource utilization. The American College of Surgeons (ACS) Committee on Trauma has issued recommendations for six minimum criteria (hereafter, ACS-6) that should prompt a full trauma team activation (TTA). These include Glasgow Coma Scale (GCS) <9, respiratory compromise or need for emergent intubation, systolic blood pressure <90 mmHg in the emergency department, central gunshot wound, patient transferred from other hospitals receiving blood to maintain vital signs, and emergency physician discretion. The goal of the ACS-6 is to avoid undertriage of patients requiring emergent intervention and allow for earlier mobilization of resources when caring for critically ill trauma patients.

Noncompliance with American College of Surgeons Committee on Trauma recommended criteria for full trauma team activation is associated with undertriage deaths.

The appropriate triage of acutely injured patients within a trauma system is associated with improved rates of mortality and optimal resource utilization. The American College of Surgeons Committee on Trauma (ACS-COT) put forward six minimum criteria (ACS-6) for full trauma team activation (TTA). We hypothesized that ACS-COT-verified trauma center compliance with these criteria is associated with low undertriage rates and improved overall mortality. Data from a state-wide collaborative quality initiative was used. We used data collected from 2014 through 2016 at 29 ACS verified Level I and II trauma centers. Inclusion criteria are: adult patients (≥16 years) and Injury Severity Score of 5 or less. Quantitative data existed to analyze four of the ACS-6 criteria (emergency department systolic blood pressure ≤ 90 mm Hg, respiratory compromise/intubation, central gunshot wound, and Glasgow Coma Scale score < 9). Patients were considered to be undertriaged if they had major trauma (Injury Severity Score > 15) and did not receive a full TTA. 51,792 patients were included in the study. Compliance with ACS-6 minimum criteria for full TTA varied from 51% to 82%. The presence of any ACS-6 criteria was associated with a high intervention rate and significant risk of mortality (odds ratio, 16.7; 95% confidence interval, 15.2-18.3; p < 0.001). Of the 1,004 deaths that were not a full activation, 433 (43%) were classified as undertriaged, and 301 (30%) had at least one ACS-6 criterion present. Undertriaged patients with any ACS-6 criteria were more likely to die than those who were not undertriaged (30% vs. 21%, p = 0.001). Glasgow Coma Scale score less than 9 and need for emergent intubation were the ACS-6 criteria most frequently associated with undertriage mortality. Compliance with ACS-COT minimum criteria for full TTA remains suboptimal and undertriage is associated with increased mortality. These data suggest that the most efficient quality improvement measure around triage should be ensuring compliance with the ACS-6 criteria. This study suggests that practice pattern modification to more strictly adhere to the minimum ACS-COT criteria for full TTA will save lives. Care management, level III.

Which pre-hospital triage parameters indicate a need for immediate evaluation and treatment of severely injured patients in the resuscitation area?

To find ways to reduce the rate of over-triage without drastically increasing the rate of under-triage, we applied a current guideline and identified relevant pre-hospital triage predictors that indicate the need for immediate evaluation and treatment of severely injured patients in the resuscitation area. Data for adult trauma patients admitted to our level-1 trauma centre in a one year period were collected. Outpatients were excluded. Correct triage for trauma team activation was identified for patients with an ISS or NISS≥16 or the need for ICU treatment due to trauma sequelae. In this retrospective analysis, patients were assigned to trauma team activation according to the S3 guideline of the German Trauma Society. This assignment was compared to the actual need for activation as defined above. 13 potential predictors were retained. The relevance of the predictors was assessed and 14 models of interest were considered. The performance of these potential triage models to predict the need for trauma team activation was evaluated with leave-one-out cross-validated Brier and logarithmic scores. A total of 1934 inpatients≥16years were admitted to our trauma department (mean age 48±22 years, 38% female). Sixty-nine per cent (n=1341) were allocated to the emergency department and 31% (n=593) were treated in the resuscitation room. The median ISS was 4 (IQR 7) points and the median NISS 4 (IQR 6) points. The mortality rate was 3.5% (n=67) corresponding to a standardized mortality ratio of 0.73. Under-triage occurred in 1.3% (26/1934) and over-triage in 18% (349/1934). A model with eight predictors was finally selected with under-triage rate of 3.3% (63/1934) and over-triage rate of 10.8% (204/1934). The trauma team activation criteria could be reduced to eight predictors without losing its predictive performance. Non-relevant parameters such as EMS provider judgement, endotracheal intubation, suspected paralysis, the presence of burned body surface of >20% and suspected fractures of two proximal long bones could be excluded for full trauma team activation. The fact that the emergency physicians did a better job in reducing under-triage compared to our final triage model suggests that other variables not present in the S3 guideline may be relevant for prediction.

We Do Not Need Full Activation: Gunshot Wounds Isolated to the Extremities Do Not Require Full Trauma Team Activations as Mandated by the American College of Surgeons

We Do Not Need Full Activation: Gunshot Wounds Isolated to the Extremities Do Not Require Full Trauma Team Activations as Mandated by the American College of Surgeons

Vital Signs Strongly Predict Massive Transfusion Need in Geriatric Trauma Patients

Early recognition of massive transfusion (MT) requirement in geriatric trauma patients presents a challenge, as older patients present with vital signs outside of traditional thresholds for hypotension and tachycardia. Although many systems exist to predict MT need in trauma patients, none have specifically evaluated the geriatric population. We sought to evaluate the predictive value of presenting vital signs in geriatric trauma patients for prediction of MT. We retrospectively reviewed geriatric trauma patients presenting to our Level I trauma center from 2010 to 2013 requiring full trauma team activation. The area under the receiver operating characteristic curve was calculated to assess discrimination of arrival vital signs for MT prediction. Ideal cutoffs with high sensitivity and specificity were identified. A total of 194 patients with complete data were analyzed. Of these, 16 patients received MT. There was no difference between the MT and non-MT groups in sex, age, or mechanism. Systolic blood pressure, pulse pressure, diastolic blood pressure, and shock index all were strongly predictive of MT need. Interestingly, we found that heart rate does not predict MT. MT in geriatric trauma patients can be reliably and simply predicted by arrival vital signs. Heart rate may not reflect serious hemorrhage in this population.

Intubated Trauma Patients Do Not Require Full Trauma Team Activation when Effectively Triaged

Full trauma team activation in evaluating injured patients is based on triage criteria and associated with significant costs and resources that should be focused on patients who truly need them. Overtriage leads to inefficient care, particularly when resources are finite, and it diverts care from other vital areas. Although shock and gunshot wounds to the abdomen are accepted indicators for full trauma activation, intubation as the sole criterion is controversial. We evaluated our experience to assess if intubation alone merited the highest level of trauma activation. All trauma patients from 2012 to 2013 were assessed for level of activation, injury characteristics, presence of intubation, and outcomes. Of 5,881 patients, 646 (11%) were level 1 (full) and 2,823 (48%) were level 2 (partial) activations. Level 1 patients were younger (40 ± 17 vs 45 ± 20 years), had more penetrating injuries (42% vs 9%), and had higher mortality (26% vs 8%)(p < 0.001). Intubated level 2 patients (n= 513), compared with intubated level 1 patients (n= 320), had higher systolic blood pressure (133 ± 44 vs 90 ± 58 mmHg), lower Injury Severity Score (21 ± 13 vs 25 ± 16), more falls (25% vs 3%), fewer penetrating injuries (11% vs 23%), and lower mortality (31% vs 48%)(p < 0.01). Fewer intubated level patients went directly to the operating room from the emergency department (ED)(16% vs 33%), and most who did had a craniotomy (63% vs 13%). Only 3% of intubated level 2 patients underwent laparotomy compared with 20% of intubated level 1 patients (p < 0.001). The ED lengths of stay before obtaining a head CT (47 ± 26 vs 48 ± 31 minutes) and craniotomy (109 ± 61 vs 102 ± 46 minutes) were similar. Deaths in intubated level 2 patients were primarily from fatal brain injuries. When appropriately triaged, selected intubated trauma patients do not require full trauma activation to receive timely, efficient care.

Abstract 12311: Platelet Force Measurements are Predictive of Triage Category and Blood Transfusion After Trauma

Introduction: Platelets rapidly adhere, aggregate and contract forcefully at wound sites to initiate hemostasis. This process, known as primary hemostasis, is a critical component of clot formation after trauma. However, the clinical value of monitoring primary hemostasis after trauma remains unknown. This pilot study aimed to identify the potential clinical value of monitoring primary hemostasis after trauma by measuring platelet forces. Methods: Blood was sampled from Emergency Department trauma patients at a U.S. Level I trauma center. Primary hemostasis was measured as contractile force generated by platelet micro-aggregates formed within a microfluidic device. Citrated blood was flowed through a microfluidic channel at high shear rate for 15 seconds, causing platelet aggregates to rapidly form, activate, and contract at collagen-coated micro-force sensors. The maximum platelet force generated over five minutes was recorded in nanonewtons (nN). ANOVA was used to compare platelet force for each trauma triage category: Healthy non-trauma control vs. Modified vs. Full trauma team activation. Logistic regression was used to identify the association of platelet force with the need for any blood product transfusion within 24 hours of hospitalization. Results: N=28 trauma patients and N=7 healthy control subjects were included in this pilot analysis of an ongoing cross-sectional observational study. Of the trauma subjects 7/28 (25%) met Full trauma team activation criteria, and 7/28 (25%) required a blood-product transfusion. Mean (SD) platelet force was 227(63) nN for healthy controls, 157(48) nN for Modified, and 126(35) nN for Full trauma team activations (ANOVA, p=0.004). Platelet forces were 164 (45) nN for non-transfused vs. 112(20) nN for transfused subjects (t-test, p=0.008). The platelet force unit Odds Ratio for blood product transfusion was 0.965 (95%CI= 0.936, 0.996), indicating that the odds of receiving a transfusion was decreased significantly by 3.5% for every one nN increase of platelet force. Conclusions: Directly measuring primary hemostasis using platelet forces may enhance trauma triage and predict the need for blood product transfusion after trauma.

Do prehospital criteria optimally assign injured children to the appropriate level of trauma team activation and emergency department disposition at a level I pediatric trauma center?

To examine the association of prehospital criteria with the appropriate level of trauma team activation (TTA) and emergency department (ED) disposition among injured children at a level I pediatric trauma center. Injured children younger than 15 years and transported by emergency medical services (EMS) from the scene of injury between January 1, 2008 and December 31, 2011 were identified using the institution's trauma registry. Logistic regression was used to study the main outcomes of interest, full TTA (FTTA) and ED disposition. Out of 3,213 children, 1,991 were eligible and analyzed. Only 279 children initiated the FTTA and 73.9% were admitted. Having a chest injury, abnormal heart rate or Glasgow Coma Scale less than 9 (GCSLT9) in the field was associated with higher odds of initiating the FTTA (odds ratio [OR] = 3.33, 95% confidence interval [CI] 1.54-7.20; OR = 2.59, CI 1.15-5.79 and OR = 2.67, CI 1.14-6.22, respectively). Children with the criteria above in addition to abdominal injury were more likely to be discharged to the ICU, OR or morgue compared to those without them. Children with GCSLT9, abnormal heart rate, chest and abdominal injury showed a strong association with FTTA and higher resource utilization.

Prevalence, predictors and outcome of hypofibrinogenaemia in trauma: a multicentre observational study

IntroductionExsanguination due to trauma-induced coagulopathy is a continuing challenge in emergency trauma care. Fibrinogen is a crucial factor for haemostatic competence, and may be the factor that reaches critically low levels first. Early fibrinogen substitution is advocated by a number of authors. Little evidence exists regarding the indications for fibrinogen supplementation in the acute phase. This study aims to estimate the prevalence of hypofibrinogenaemia in a multi-center trauma population, and to explore how initial fibrinogen concentration relates to outcome. Also, factors contributing to low fibrinogen levels are identified.MethodsPatients arriving in hospital less than 180 minutes post-injury requiring full trauma team activation in four different centers were included in the study. Time from injury, patient demographics, injury severity scores (ISS) and 28 days outcome status were recorded. Initial blood samples for coagulation and blood gas were analyzed. Generalized additive regression, piecewise linear regression, and multiple linear regression models were used for data analyses.ResultsOut of 1,133 patients we identified a fibrinogen concentration ≤1.5g/L in 8.2%, and <2 g/L in 19.2%. A non-linear relationship between fibrinogen concentration and mortality was detected in the generalized additive and piecewise linear regression models. In the piecewise linear regression model we identified a breakpoint for optimal fibrinogen concentration at 2.29 g/L (95% confidence interval (CI): 1.93 to 2.64). Below this value the odds of death by 28 days was reduced by a factor of 0.08 (95% CI: 0.03 to 0.20) for every unit increase in fibrinogen concentration. Low age, male gender, lengthened time from injury, low base excess and high ISS were unique contributors to low fibrinogen concentrations on arrival.ConclusionsHypofibrinogenaemia is common in trauma and strongly associated with poor outcome. Below an estimated critical fibrinogen concentration value of 2.29 g/L a dramatic increase in mortality was detected. This finding indicates that the negative impact of low fibrinogen concentrations may have been previously underestimated. A number of clinically identifiable factors are associated with hypofibrinogenaemia. They should be considered in the management of massively bleeding patients. Interventional trials with fibrinogen substitution in high-risk patients need to be undertaken.

Thromboelastometry diagnosed Acute Traumatic Coagulopathy (ATC) identifies trauma patients with poor clinical outcomes better than Disseminated Intravascular Coagulation (DIC) scoring

Acute Traumatic Coagulopathy and Disseminated Intravascular coagulation are two definitions currently used to describe the endogenous hemostatic impairment that occurs early after injury. They have separate diagnostic criteria and different putative pathophysiology. The aim of this study was to determine which system better identifies trauma patients with high morbidity and mortality. A prospective observational cohort study was performed at a level 1 trauma center. Blood was collected on arrival in the emergency department (ED) from all adult trauma patients who met the local criteria for full trauma team activation. Exclusion criteria included ED arrival >2 hours after injury or >2000mL of fluid before arrival. Blood was analysed by routine laboratory coagulation tests, rotational thromboelastometry and ELISA. Contingency analysis was performed by Fishers exact test. Four hundred and thirty patients were included in the study. Seventy-six (18%) attended with ATC, as defined by EXTEM CA5 ţ 35mm. Laboratory coagulation results for DIC scoring were available at a median of 78 (62-103) mins. Eighteen (4%, p<0.001) met criteria for DIC on arrival using the amended ISTH scoring system. Of note, 86% of patients had elevated d-dimers without any scoring abnormality of prothrombin time, fibrinogen or platelets. Overall, 115 patients required a blood transfusion within the first 12 hours. Thirty-seven (32%) of these met RoTEM criteria for ATC on admission but only fourteen (12%) had DIC (p<0.001). Similarly, 106 patients experienced a septic episode; 26% had ATC on admission but only 4% had DIC (p<0.001). Forty-seven patients died, 45% of whom had ATC on admission compared with 32% that could be diagnosed with DIC (p=0.2). Although the pathophysiology of ATC remains to be fully elucidated, this study indicates that RoTEM diagnosis is more sensitive and clinically useful than DIC scoring criteria for the early identification of trauma patients with poor outcomes.

Evaluation of TEG® and RoTEM® inter-changeability in trauma patients

BackgroundMassive haemorrhage is a leading cause of preventable deaths in trauma. Traumatic coagulopathy is frequently present early after trauma, and is associated with increased mortality. A number of recent trials suggest that viscoelastic haemostatic assays (VHA), such as thromboelastography and thromboelastometry, are useful tools in guiding transfusion. Treatment algorithms exist for the use of VHAs but are not validated in traumatic haemorrhage. In this study we examined the inter-changeability of two commonly used VHAs, TEG® and RoTEM®. MethodsA total of 184 trauma patients over the age of 18, requiring full trauma team activation, were included at three different hospitals in three different countries (Copenhagen, Denmark, San Francisco, CA, USA and Oslo, Norway). Blood samples were drawn immediately upon arrival, and TEG® and RoTEM® analyzed simultaneously. Correlations were calculated using.Spearman's rank correlation coefficient. Agreement was evaluated by Bland–Altman plots and calculation of limits of agreement. ResultsThe mean ISS in the total population was 17, and the mortality was 16.5%. Mean base excess was −2.8 (SD: 4.2). The correlation coefficient for corresponding values for the two devices was 0.24 for the R-time vs CT in all centres combined. For the K-time vs CFT the correlation was 0.48, for the α-angleTEG vs α-angleRoTEM 0.44, and for MA vs MCF 0.76. Limits of agreement exceeded the preset clinically acceptable deviation of 10% for all variables in all centres except for MA/MCF in one centre (Copenhagen). Generally, correlation coefficients were lower and agreement poorer in the one centre (Oslo) where measurements were performed bedside by clinicians. ConclusionInter-changeability between TEG® and RoTEM® is limited in the trauma setting. Agreement seems poorer when clinicians operate the devices. Development and validation of separate treatment algorithms for the two devices is required.

Elderly trauma patients have high circulating noradrenaline levels but attenuated release of adrenaline, platelets, and leukocytes in response to increasing injury severity

High patient age is a strong predictor of poor outcome in trauma patients. The present study investigated the effect of age on mortality and biomarkers of sympathoadrenal activation, tissue, endothelial, and glycocalyx damage, coagulation activation/inhibition, fibrinolysis, and inflammation in trauma patients at admission. Prospective observational study. Single level I trauma center. Eighty adult trauma patients (≥18 yrs) who met criteria for full trauma team activation and had an arterial cannula. Blood sampling a median of 68 min (interquartile range 48-88) post injury. Data on demography, biochemistry, Injury Severity Score, and 30-day mortality were recorded and plasma/serum was analyzed for biomarkers reflecting sympathoadrenal activation (adrenaline, noradrenaline), tissue/endothelial cell/glycocalyx damage (histone-complexed DNA fragments, annexin V, thrombomodulin, syndecan-1), platelet activation (soluble CD40 ligand), coagulation activation/inhibition (prothrombin fragment 1.2, thrombin/antithrombin complex, antithrombin, protein C, activated protein C, protein S, soluble endothelial protein C receptor, tissue factor pathway inhibitor, von Willebrand factor, fibrinogen, factor XIII), fibrinolysis (D-dimer, tissue-type plasminogen activator, plasminogen activator inhibitor-1), and inflammation (interleukin-6, terminal complement complex). Patients were stratified according to the median age (46 yrs) of the full cohort. Older trauma patients had markedly higher noradrenaline (p < .001) but an attenuated increase in adrenaline with increasing Injury Severity Score and lower platelets and leukocytes (both p < .05) compared to the younger patients. Older patients displayed a biomarker profile suggestive of enhanced release, activation, and consumption of the natural anticoagulants (low antithrombin, high activated protein C, protein S, and tissue factor pathway inhibitor) and hyperfibrinolysis (high tissue-type plasminogen activator) (all p < .05 vs. younger patients). Age was an independent predictor of mortality (hazard ratio 1.04 [95% confidence interval 1.01-1.07], p = .005) after adjusting for Injury Severity Score, prehospital Glasgow Coma Scale, and plasma catecholamines. In trauma patients, the association between age and mortality was confirmed. Older patients had high plasma noradrenaline but attenuated adrenaline release with higher Injury Severity Score, impaired platelet and leukocyte mobilization, enhanced consumption of anticoagulants, and hyperfibrinolysis, which may all contribute to the poor outcome in these patients.

Major trauma and urban cyclists: physiological status and injury profile

IntroductionPedal cycling in cities has the potential to deliver significant health and economic benefits for individuals and society. Safety is the main concern for potential cyclists although the statistical risk...

Functional definition and characterization of acute traumatic coagulopathy

To identify an appropriate diagnostic tool for the early diagnosis of acute traumatic coagulopathy and validate this modality through prediction of transfusion requirements in trauma hemorrhage. Prospective observational cohort study. Level 1 trauma center. Adult trauma patients who met the local criteria for full trauma team activation. Exclusion criteria included emergency department arrival >2 hrs after injury, >2000 mL of intravenous fluid before emergency department arrival, or transfer from another hospital. None. Blood was collected on arrival in the emergency department and analyzed with laboratory prothrombin time, point-of-care prothrombin time, and rotational thromboelastometry. Prothrombin time ratio was calculated and acute traumatic coagulopathy defined as laboratory prothrombin time ratio >1.2. Transfusion requirements were recorded for the first 12 hrs following admission. Three hundred patients were included in the study. Laboratory prothrombin time results were available at a median of 78 (62-103) mins. Point-of-care prothrombin time ratio had reduced agreement with laboratory prothrombin time ratio in patients with acute traumatic coagulopathy, with 29% false-negative results. In acute traumatic coagulopathy, the rotational thromboelastometry clot amplitude at 5 mins was diminished by 42%, and this persisted throughout clot maturation. Rotational thromboelastometry clotting time was not significantly prolonged. Clot amplitude at a 5-min threshold of ≤35 mm had a detection rate of 77% for acute traumatic coagulopathy with a false-positive rate of 13%. Patients with clot amplitude at 5 mins ≤35 mm were more likely to receive red cell (46% vs. 17%, p < .001) and plasma (37% vs. 11%, p < .001) transfusions. The clot amplitude at 5 mins could identify patients who would require massive transfusion (detection rate of 71%, vs. 43% for prothrombin time ratio >1.2, p < .001). In trauma hemorrhage, prothrombin time ratio is not rapidly available from the laboratory and point-of-care devices can be inaccurate. Acute traumatic coagulopathy is functionally characterized by a reduction in clot strength. With a threshold of clot amplitude at 5 mins of ≤35 mm, rotational thromboelastometry can identify acute traumatic coagulopathy at 5 mins and predict the need for massive transfusion.

Disseminated intravascular coagulation or acute coagulopathy of trauma shock early after trauma? An observational study

IntroductionIt is debated whether early trauma-induced coagulopathy (TIC) in severely injured patients reflects disseminated intravascular coagulation (DIC) with a fibrinolytic phenotype, acute coagulopathy of trauma shock (ACoTS) or yet other entities. This study investigated the prevalence of overt DIC and ACoTS in trauma patients and characterized these conditions based on their biomarker profiles.MethodsAn observational study was carried out at a single Level I Trauma Center. Eighty adult trauma patients (≥18 years) who met criteria for full trauma team activation and had an arterial cannula inserted were included. Blood was sampled a median of 68 minutes (IQR 48 to 88) post-injury. Data on demography, biochemistry, injury severity score (ISS) and mortality were recorded. Plasma/serum was analyzed for biomarkers reflecting tissue/endothelial cell/glycocalyx damage (histone-complexed DNA fragments, Annexin V, thrombomodulin, syndecan-1), coagulation activation/inhibition (prothrombinfragment 1+2, thrombin/antithrombin-complexes, antithrombin, protein C, activated protein C, endothelial protein C receptor, protein S, tissue factor pathway inhibitor, vWF), factor consumption (fibrinogen, FXIII), fibrinolysis (D-dimer, tissue-type plasminogen activator, plasminogen activator inhibitor-1) and inflammation (interleukin (IL)-6, terminal complement complex (sC5b-9)). Comparison of patients stratified according to the presence or absence of overt DIC (International Society of Thrombosis and Hemostasis (ISTH) criteria) or ACoTS (activated partial thromboplastin time (APTT) and/or international normalized ratio (INR) above normal reference).ResultsNo patients had overt DIC whereas 15% had ACoTS. ACoTS patients had higher ISS, transfusion requirements and mortality (all P < 0.01) and a biomarker profile suggestive of enhanced tissue, endothelial cell and glycocalyx damage and consumption coagulopathy with low protein C, antithrombin, fibrinogen and FXIII levels, hyperfibrinolysis and inflammation (all P < 0.05). Importantly, in non-ACoTS patients, apart from APTT/INR, higher ISS correlated with biomarkers of enhanced tissue, endothelial cell and glycocalyx damage, protein C activation, coagulation factor consumption, hyperfibrinolysis and inflammation, that is, resembling that observed in patients with ACoTS.ConclusionsACoTS and non-ACoTS may represent a continuum of coagulopathy reflecting a progressive early evolutionarily adapted hemostatic response to the trauma hit and both are parts of TIC whereas DIC does not appear to be part of this early response.

Outcome assessment of blunt trauma patients who are undertriaged

We investigated the outcomes of injured patients who were undertriaged and compared them with those meeting full trauma team activation (TTA) criteria. Blunt trauma patients (July 2002-January 2008) meeting full TTA criteria and had a partial TTA were in the undertriage group (UTG). Data was collected on demographics, injury severity, OR delays, resource utilization, and outcomes. Excluded: penetrating trauma, transfers, burns, age <18 years. Chi square, P < .05, mean +/- SD. One thousand four hundred and twenty-four patients with 318 (22.3%) in the UTG and 1,106 in the correctly triaged group (CTG). The CTG was 70.4% male (vs 67.1%; P = .26), 41.5 +/- 19.8 years old (vs 45.8 +/- 20.5; P < .01), and had an injury severity score (ISS) of 24.7 (vs 17.0; P < .0001). The CTG was more likely to require ED intubation (34.9% vs 8.2%; P < .0001), ICU admission (49.0% vs 37.1%; P < .0001), longer ICU/hospital LOS, and more ventilator days (P < .0001) with no differences in OR delays. The UTG had a lower mortality (6.0% vs 16.7%; P < .0001) and were discharged home more often (65.3% vs 52.2%; P = .02). The UTG had a lower ISS and improved outcomes compared to the CTG with no differences in OR delays. Despite inherent challenges in TTA protocols, patients who were undertriaged at our institution appear to have satisfactory outcomes.

Paediatric and adolescent horse‐related injuries: Does the mechanism of injury justify a trauma response?

To identify the frequency, variety and disposition of horse-related injury presentations to the ED and to use this information to evaluate the existing institutional trauma team activation criteria following horse-related injuries. A retrospective case analysis was performed of all horse-related injury presentations to the ED of Women's and Children's Hospital, Adelaide, Australia, in the 5 year period between January 1999 and December 2003. A total of 186 children presented with horse-related injuries during the 5 year study period. The median age of injury was 9 years (range 1-17 years), with 81% of presentations female and 60% of patients hospitalized. The mechanism of injury was divided into four groups: 148 falls (79%), 28 kicks (15%), 7 tramples (4%) and 5 bites (3%). There was one death. Seven presentations rated an Injury Severity Score >15, with full trauma team activation occurring for two of these presentations. Although horse-related injury presentations are uncommon, severe injuries do occur. Patients presenting with severe horse-related injuries do not always activate a full trauma team response based on current trauma team activation criteria. These severe injury presentations are supported by a limited trauma team response, which activates on the mechanism of injury. The effectiveness of this as a contingency system needs to be evaluated.

Trauma Team Activation and the Impact on Mortality

Trauma centers use injury mechanism, physiology, and anatomic criteria to determine the extent of trauma team activation (TTA). We examined whether physiologic variables in our three-tier TTA system stratified patients appropriately by injury severity and mortality. The trauma registry at our Level I trauma center was retrospectively reviewed for full (level 1 or L1), partial (level 2 or L2), and limited (level 3) adult TTA. Data were collected on age, injury severity score (ISS), hospital length of stay, systolic blood pressure (SBP), heart rate, respiratory rate (RR), Glasgow coma score (GCS), and intubation status. Penetrating injuries, traumatic arrests, and interfacility transfers were excluded. Data are median (25%75%). Statistical analysis included hazard ratios (HzR), Kruskal-Wallis, chi, and survival analyses. The p value overall was <0.05, and pair wise was <0.05 versus L1. There were 494 adult TTAs for blunt injury from the scene out of 1,969 admissions. Variables associated with mortality (HzR; 95% confidence interval) by univariate analysis include SBP <90 (9.4; 4.2, 21.2), RR >29 or <10 (17.8; 4.8, 66.0), intubation status (4.5; 2.3, 8.9), and GCS <8 (9.7; 4.8, 19.9). When combined in a multivariate model to evaluate multiple predictors simultaneously, SBP <90 and GCS <8 appear to be the strongest predictors of mortality (RR and intubation were not significant in the presence of SBP and GCS). The three-tier system identified patients with increased ISS and early (< or =4 weeks) mortality risk. There was a statistically significant difference in survival between L1 and L2 at 38 days, but not for >38 days (p = 0.739). TTA criteria selected patients with greater ISS and early mortality, but impact on long-term survival may not be appreciated. Full TTA criteria for blunt injury may be limited to GCS <8, SBP <90, RR >29 or <10, and intubation status.

External Validation and Modification of a Pediatric Trauma Triage Tool

Simon et al. developed a simple secondary triage tool (mPTS) based on physiologic parameters and physical findings to identify pediatric trauma patients who had a low likelihood of serious injury. Such patients could be treated in the emergency room without full trauma team activation. Our objective was to evaluate the mPTS on the trauma population at our institution, a Level I pediatric trauma center. This was a retrospective cohort study of all trauma team activations at The Hospital for Sick Children (Sick Kids) (1999-2002), excluding penetrating trauma and burns. Patients were stratified into high-risk (Injury Severity Score [ISS] >or=12) and low-risk (ISS <12) groups. The mPTS evaluates airway integrity, open wounds, neurologic status, hemodynamics, and skeletal integrity and applies a score of 1 point to each criterion. There were 628 trauma patients (382 boys, mean age of 8 +/- 3.8 years). The mPTS had a sensitivity of 92% and a positive predictive value (PPV) of 47% when applied to our population. The mPTS missed 21 patients with significant injuries, many were intra-abdominal. We modified the mPTS to include contusions to head and/or torso and a history of loss of consciousness and a 7-point score was developed. After modification the sensitivity was 99%, specificity 21%, and PPV of 46% with a 20% reduction in unnecessary trauma team activations. The original mPTS by Simon et al. was not sensitive enough when applied to our population. The Sick Kids modification to the score improved the sensitivity to 99%. The PPV of 46% indicates a safe level of overtriage is maintained. The Sick Kids mPTS remains easy to apply and would have reduced trauma team activation by 20%.

Outcomes of patients using a tiered trauma response protocol.

This study evaluated processes of care and outcome for injured patients at a Level I trauma center who had been either treated as a full trauma team activation (FULL) or managed with a modified trauma team activation (MOD). A retrospective methodology was used to evaluate all patients entered into the regional trauma system and transported from the scene to a Level I trauma center. Patients treated during a 2-year period of exclusively FULL trauma team protocols were compared with patients managed during a subsequent 2-year period after implementation of a two-tiered response. In the later era, trauma system patients were designated before hospital arrival as either FULL or MOD trauma team responses. An additional case-control analysis was conducted on a subset of MOD trauma team response patients who were undertriaged; that is, in retrospect, they met criteria for a FULL response. The outcomes in the case-control group were compared by chi2 tests and Mann-Whitney U tests. Statistical significance was assumed for p < 0.05. During the presystem period, 1,740 patients were transported as trauma system entries to Oregon Health Sciences University. During the postsystem period, 2,333 patients were transported to Oregon Health Sciences University as either MOD trauma system entries (1,272 [55%]) or as FULL trauma system entries (1,061 [45%]). Postsystem patients had longer time intervals in the emergency department compared with presystem patients. Death rates for patients who died in the emergency department or before hospital discharge were similar. Among patients who were designated as MOD trauma system entries and were subsequently categorized as meeting FULL trauma team criteria, mortality rate was low. Implementation of the tiered response protocol led to a substantial change in the operational response in the emergency department. Although processes of care were nominally prolonged, adverse consequences were not identified. We concluded from this quality improvement review that implementation of a tiered response protocol was satisfactory and improved efficiency. Further work is required to improve accuracy of the categorization of trauma system patients as either MOD or FULL trauma codes.