Highest-level Trauma Activation Research Articles

Exposure to statin therapy decreases the incidence of venous thromboembolism after trauma.

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in trauma patients, despite chemoprophylaxis. Statins have been shown capable of acting upon the endothelium. We hypothesized that statin therapy in the pre- or in-hospital settings leads to a decreased incidence of VTE. We conducted a retrospective cohort study of injured patients who received statin therapy pre- or in-hospital. Adult, highest-level trauma activation patients admitted January 2018 - June 2022 were included. Patients on prehospital anticoagulants, history of inherited bleeding disorder, and who died within the first 24 hours were excluded. Statin users were matched to non-users by statin use indications including age, current heart and cardiovascular conditions and history, hyperlipidemia, injury severity, and body mass index. Time to in-hospital statin initiation and occurrence of VTE and other complications within 60 days were collected. Differences between groups were determined by univariate, multivariable logistic regression, and Cox proportional hazard analyses. Of 3,062 eligible patients, 79 were statin users that were matched to 79 non-users. There were no differences in admissions demographics, vital signs, injury pattern, transfusion volumes, lengths of stay, or mortality between groups. The overall VTE incidence was 10.8% (17/158). Incidence of VTE in statin users was significantly lower (3%) than non-users (19%; P = 0.003). Differences between statin users and non-users were observed for rates of DVT (0% vs 9%), PE (3% vs 15%), and sepsis (0% vs 5%). Exposure to statins was associated with an 82% decreased risk of developing VTE (hazard ratio = 0.18, 95% CI 0.04 - 0.86; P = 0.033). Statin exposure was associated with decline in VTE and lower individual rates of DVT, PE, and sepsis. Our findings indicate that statins should be evaluated further as a possible adjunctive therapy for VTE chemoprophylaxis after traumatic injury. Level III, Retrospective Cohort Study.

Use of prehospital reverse shock index times Glasgow Coma Scale to identify children who require the most immediate trauma care.

Appropriate prehospital trauma triage ensures transport of children to facilities that provide specialized trauma care. There are currently no objective and generalizable scoring tool for emergency medical services to facilitate such decisions. An abnormal reverse shock index times Glasgow Coma Scale (rSIG), which is calculated using readily available parameters, has been shown to be associated with severely injured children. This study sought to determine if rSIG could be used in the prehospital setting to identify injured children who require the highest levels of care. Patients (1-18 years old) transferred from the scene to a level 1 pediatric trauma center from 2010 to 2020 with complete prehospital and emergency department vital signs, and Glasgow Coma Scale (GCS) scores were included. Reverse shock index times GCS was calculated as previously described ((systolic blood pressure/heart rate) × GCS), and the following cutoffs were used: ≤13.1, ≤16.5, and ≤20.1 for 1- to 6-, 7- to 12-, and 13- to 18-year-old patients, respectively. Trauma activation level and clinical outcomes upon arrival to the pediatric trauma center were collected. There were 247 patients included in the analysis; 66.0% (163) had an abnormal prehospital rSIG. Patients with an abnormal rSIG had a higher rate of highest-level trauma activation compared with those with a normal rSIG (38.7% vs. 20.2%, p = 0.013). Patients with an abnormal prehospital rSIG also had higher rates of intubation (28.8% vs. 9.52%, p < 0.001), intracranial pressure monitor (9.20 vs. 1.19%, p = 0.032), need for blood (19.6% vs. 8.33%, p = 0.034), laparotomy (7.98% vs. 1.19%, p = 0.039), and intensive care unit admission (54.6% vs. 40.5%, p = 0.049). Reverse shock index times GCS may assist emergency medical service providers in early identification and triage of severely injured children. An abnormal rSIG in the emergency department is associated with higher rates of intubation, need for blood transfusion, intracranial pressure monitoring, laparotomy, and intensive care unit admission. Use of this metric may help to speed the identification, care, and treatment of any injured child. Prognostic and Epidemiological; Level IV.

Impact of Video Education to Train Trauma Staff

Background:Management of trauma patients is challenging and requires a coordinated team effort inside a crowded trauma bay. Errors can result in disastrous consequences. Trauma is the leading cause of death in the United States of people younger than the age of 45. Maintaining a cohesive team dynamic is paramount, but academic medical centers must deal with the constancy of rotating staff and learners that may be unfamiliar with resuscitation workflows. This project aims to improve the trauma resuscitation process by identifying the gaps in knowledge and process through auditing of the highest-level trauma activations.&#x0D; Methods:This is a pre- and post-intervention prospective cohort study of adherences to a standardized trauma resuscitation process through the use of an educational video at a busy level 1 academic trauma center. Process improvement resulting from the educational video will be assessed quantitatively through in-person and video review audits using a pre-defined checklist. This checklist scores the crucial elements highlighted in the educational video that must be addressed in each trauma resuscitation. The goal of this project is to illustrate improvement of the trauma resuscitation process through the comparison of trauma resuscitations audited before and after implementation of the training video.&#x0D; Results:The most commonly observed deficits have been related to the donning of correct personal protective equipment (PPE) and communication. The most common PPE left out was eye protection and hair covering. Shortcomings in communication include failure to practice 1:1 communication and the performance of adequate pre-briefs.&#x0D; Potential Impact:This study will establish a feasible method of improving the trauma resuscitation process at IU Health Methodist Hospital. Potential next steps of this study’s conclusions include improving the trauma resuscitation process at other Indianapolis trauma 1 centers outside of Methodist Hospital, and the implementation of similar video education training for additional team-based procedures.

STRAUMA: A Novel Alert System for a Combined Stroke and Trauma.

Cerebrovascular accident (CVA) can lead to traumatic injury. While timely administration of tissue plasminogen activator (tPA) can be lifesaving in CVAs, it is contraindicated with active bleeding. A STRAUMA is a combined stroke and highest-level trauma activation for patients with suspected CVA and signs of trauma. The purpose of this study is to evaluate the impact of the STRAUMA activation on time to CT and patient outcomes. A retrospective review was conducted on adult patients presenting to a Level 1 trauma and comprehensive stroke center with signs of CVA between 01/2019 and 09/2020. Patients who had a STRAUMA activation were compared to patients who had a stroke alert. Five hundred and eighty patients met the inclusion criteria. Of these, 111 had STRAUMA activations and 469 had stroke alerts. There were no differences in age, gender, or anticoagulation use. The STRAUMA group had a higher NIH stroke scale (NIHSS) (11 vs 5, P<.0001). The STRAUMA group had a longer time to CT (23.1 min vs 16.9 min, P<.0001) and a lower rate of tPA (13.5% vs 27.9%, P = .001). Time to tPA and thrombectomy were similar. The STRAUMA group had a 15% rate of traumatic injury with a median injury severity score of 9. Mortality was higher in the STRAUMA group (14.4% vs 6.0%, P = .003). Multivariable logistic regression identified NIHSS and time to CT as predictors of mortality. STRAUMA did not predict mortality. The novel STRAUMA activation allows for an evaluation of both stroke and trauma to facilitate safe and timely administration of lifesaving interventions.

Impact of Modified Geriatric Trauma Activation Criteria on patient outcomes at a level 1 trauma center

Background The American College of Surgeons Trauma Quality Improvement Program recommends a lower threshold for trauma activation on geriatric patients. We implemented the Modified Geriatric Trauma Activation Criteria (MGTAC) and assessed the clinical impact on geriatric trauma patients. Methods Geriatric trauma patients aged 65 years and over presenting between 1/1/2014 and 12/31/2020 were identified through the Trauma Registry. MGTAC were implemented on 3/1/2017, where patients aged 65 and above were rendered as Highest Level activations when presenting with no prior work-up. Those presenting from 1/1/2014 to 2/28/2017 were grouped as Standard Activation Criteria (SAC), and those presenting between 3/1/2017 and 12/31/2020 were grouped as MGTAC. Patient demographics, mechanism of injury, level of activation, operative intervention, intensive care unit (ICU) admission, length of stay, survival, and undertriage rates were reviewed. Chi square, ANOVA, and unpaired t-test were used for analysis to compare SAC and MGTAC patient outcomes. Results 2582 patients were identified: 1293 (50.1%) in SAC and 1289 (49.9%) in MGTAC. Highest Level trauma activations for SAC vs. MGTAC were 9.3% vs. 30.4%, p &lt; .01. Between SAC and MGTAC, ICU admission was 24.1% vs. 16.5%, p&lt;0.01; operative intervention was 10.3% vs. 12.9%, p = .04; undertriage rates were 6.1% vs. 3.8%, p = .01; and average length of stay was 7 days for SAC vs. 6.4 days for MGTAC, p = .54. Overall mortality was 9% for SAC and 9.5% for MGTAC, p = .66. Conclusion Implementation of MGTAC did not improve geriatric trauma patient mortality. However, it decreased ICU admission and undertriage, and increased operative intervention during the first 24 hours.

Traumatic brain injury provokes low fibrinolytic activity in severely injured patients.

Traumatic brain injury (TBI) in combination with shock has been associated with hypocoagulability. However, recent data suggest that TBI itself can promote a systemic procoagulant state via the release of brain-derived extracellular vesicles. The objective of our study was to identify if TBI was associated with differences in thrombelastography indices when controlling for other variables associated with coagulopathy following trauma. We hypothesized that TBI is independently associated with a less coagulopathic state. Prospective study includes all highest-level trauma activations at an urban Level I trauma center, from 2014 to 2020. Traumatic brain injury was defined as Abbreviated Injury Scale head score greater than 3. Blood samples were drawn at emergency department admission. Linear regression was used to assess the role of independent predictors on trauma induced coagulopathy. Models adjusted for Injury Severity Score (ISS), shock (defined as ED SBP<70, or ED SBP<90 and ED HR>108, or first hospital base deficit >10), and prehospital Glasgow Coma Scale score. Of the 1,023 patients included, 291 (28%) suffered a TBI. Traumatic brain injury patients more often were female (26% vs. 19%, p = 0.01), had blunt trauma (83% vs. 43%, p < 0.0001), shock (33% vs. 25%, p = 0.009), and higher median ISS (29 vs. 10, p < 0.0001). Fibrinolysis shutdown (25% vs. 18%) was more common in the TBI group (p < 0.0001). When controlled for the confounding effects of ISS and shock, the presence of TBI independently decreases lysis at 30 minutes (LY30) (beta estimate: -0.16 ± 0.06, p = 0.004). This effect of TBI on LY30 persisted when controlling for sex and mechanism of injury in addition to ISS and shock (beta estimate: -0.13 ± 0.06, p = 0.022). Traumatic brain injury is associated with lower LY30 independent of shock, tissue injury, sex, and mechanism of injury. These findings suggest a propensity toward a hypercoagulable state in patients with TBI, possibly due to fibrinolysis shutdown. Prognostic and Epidemiologic; Level III.

The Impact of Concurrent Multi-Service Coverage on Quality and Safety in Trauma Care

At many trauma centers in the United States, one acute care surgeon is responsible for overnight coverage of both the emergency general surgery (EGS) and trauma services. The impact of this scheduling phenomenon on the quality and safety of trauma care has not been studied. Overnight (12:00 AM to 7:00 AM) trauma admissions to an academic Level 1 trauma center from 2013-2015 were studied after the institution adopted this scheduling phenomenon. Admissions were divided into two groups based on whether the admitting surgeon covered only the trauma service, or both the trauma and EGS services ("multi-service coverage"). Four major outcomes (e.g., mortality and complications), six quality metrics (e.g., time to first OR visit and unplanned transfers to the ICU), and procedural utilization patterns were compared. A total of 1046 admissions were included. There were no differences in any major outcomes between the two exposure groups, including any National Trauma Data Bank-defined complication (OR 1.1, 95% CI 0.8-1.5, P= 0.5). Quality metrics dependent on the admitting surgeon remained unchanged, including attending presence at the highest-level trauma activations within 15 min of arrival (93% versus 86%, P= 0.07) and time to urgent operative intervention (68 min versus 82 min, P= 0.9). There were no differences in the number of laboratory and imaging studies (4.1 versus 4.1, P= 0.9) or bedside interventions (1.8 versus 2.1, P= 0.4) performed per patient by the admitting surgeon. Multivariate logistic regression did not identify multi-service coverage as an independent risk factor for adverse patient outcomes or quality metrics. Trauma admissions under a surgeon covering multiple services simultaneously had similar outcomes, quality metrics, and procedural utilization patterns compared to trauma admissions under surgeons covering only the trauma service. Despite concerns that multiple-service coverage may overburden one acute care surgeon, time-dependent quality metrics and studies done during the initial workup of trauma patients remained unchanged. These findings suggest that simultaneous trauma and EGS service coverage by one acute care surgeon does not adversely impact trauma patient care.

Shock-Induced Endothelial Dysfunction is Present in Patients With Occult Hypoperfusion After Trauma.

Shock-induced endothelial dysfunction, evidenced by elevated soluble thrombomodulin (sTM) and syndecan-1 (Syn-1), is associated with poor outcomes after trauma. The association of endothelial dysfunction and overt shock has been demonstrated; it is unknown if hypoperfusion in the setting of normal vital signs (occult hypoperfusion [OH]) is associated with endothelial dysfunction. We hypothesized that sTM and Syn-1 would be elevated in patients with OH when compared to patients with normal perfusion. A single-center study of patients requiring highest-level trauma activation (2012-2016) was performed. Trauma bay arrival plasma Syn-1 and sTM were measured by enzyme-linked immunosorbent assay. Shock was defined as systolic blood pressure (SBP) <90 mm Hg or heart rate (HR) ≥120 bpm. OH was defined as SBP ≥ 90, HR < 120, and base excess (BE) ≤-3. Normal perfusion was assigned to all others. Univariate and multivariable analyses were performed. Of 520 patients, 35% presented with OH and 26% with shock. Demographics were similar between groups. Patients with normal perfusion had the lowest Syn-1 and sTM, while patients with OH and shock had elevated levels. OH was associated with increased sTM by 0.97 ng/mL (95% CI 0.39-1.57, p = 0.001) and Syn-1 by 14.3 ng/mL (95% CI -1.5 to 30.2, p = 0.08). Furthermore, shock was associated with increased sTM by 0.64 (95% CI 0.02-1.30, p = 0.04) and with increased Syn-1 by 23.6 ng/mL (95% CI 6.2-41.1, p = 0.008). Arrival OH was associated with elevated sTM and Syn-1, indicating endothelial dysfunction. Treatments aiming to stabilize the endothelium may be beneficial for injured patients with evidence of hypoperfusion, regardless of vital signs.

It is time for TEG in pediatric trauma: unveiling meaningful alterations in children who undergo massive transfusion.

BackgroundHemorrhage is the leading cause of preventable death in pediatric trauma patients. In adults, goal-directed thrombelastography (TEG) has been shown to reduce mortality when used to guide massive transfusion (MT) resuscitation. There remains a paucity of data on the utility of TEG in directing resuscitation of pediatric trauma patients. We hypothesize that abnormalities on admission TEG will differ in pediatric trauma patients who undergo MT, compared to those who do not.MethodsPediatric patients (≤ 18 years) who were highest level trauma activations at two trauma centers from 2015 to 2018 were analyzed. We included patients who had admission TEGs and excluded those who did not. Patients were stratified into two groups: those who received MT (> 40 cc/kg total blood product within 6 h of admission) and those who did not. We defined TEG abnormalities based on each institution’s normative values and compared TEG abnormalities between the groups.ResultsOf 117 children included, 39 had MT. MT patients had higher injury severity scores (30 vs. 23, p = 0.0004), lactates levels (7.0 vs. 3.5, p < 0.001), base deficit levels ( − 12.2 vs. − 5.8, p < 0.001), and INR values (1.8 vs. 1.3, p < 0.001). MT patients had significantly shortened alpha-angles (35.9% vs. 15.4%, p = 0.023), maximum amplitude (MA) values (43.6% vs. 10.3%, p < 0.001), and significantly lower platelet counts (165 vs. 281, p < 0.001) compared to those who did not receive MT. There was no difference in the trends in R-time, LY30 (lysis or shutdown), or fibrinogen concentration between the groups. Logistic regression identified a decreased MA as a significant predictor for MT [OR 3.68 (CI 1.29–10.52)]ConclusionsPediatric trauma patients who undergo MT are more likely to have lower alpha-angles and MA values, as well as lower platelet counts. These findings support the use of TEG to identify hemorrhaging pediatric trauma patients, who may benefit from cryoprecipitate and/or platelet transfusions. TEG provides real-time information on coagulation status, which may expedite the delivery of specific blood products during trauma resuscitation.Level of evidence: Level IIIType of study: Retrospective comparative study.

Thrombelastography and transfusion patterns in severely injured pediatric trauma patients with blunt solid organ injuries.

Thrombelastography (TEG) has emerged as a useful tool to diagnose coagulopathy and guide blood product usage during trauma resuscitations. This study sought to evaluate the correlation between TEG-directed blood product administration in severely injured pediatric trauma patients with blunt solid organ injuries (BSOIs). Patients (≤18 years) with severe BSOIs who presented as highest-level trauma activations at two pediatric trauma centers were included. Thrombelastography results were evaluated to determine indications for blood product administration and rates of TEG-directed resuscitation. Tetrachoric correlations and regression modeling were used to correlate TEG-directed resuscitation with clinical outcomes. Of 64 patients who met the inclusion criteria, 32.8% (21) had elevated R times and 23.4% (15) had shortened α angles. Maximum amplitude was shortened in 29.7% (19), and percent clot lysis 30 minutes after maximum amplitude that is >3% was seen in 17.0% (9). Thrombelastography-directed resuscitation of fresh frozen plasma was followed 54.7% of the time compared with 67.2% and 81.2% for platelets and cryoprecipitate, respectively. Thrombelastography-directed resuscitation with platelets (odds ratio, 0.56; 95% confidence interval, 0.33-0.93; p = 0.03) and/or cryoprecipitate (odds ratio, 0.09; 95% confidence interval, 0.01-0.42, p = 0.003) were associated with decreased hospital length of stay and mortality, respectively. Severely injured pediatric trauma patients with BSOIs were often coagulopathic upon presentation to the emergency department. Thrombelastography-directed resuscitation with platelets and/or cryoprecipitate was followed for the majority of patients and was associated with improved outcomes. Therapeutic/Care Management, level III.

Injury Severity, Arrival Physiology, Coagulopathy, and Outcomes Among the Youngest Trauma Patients

BackgroundAlthough physiologic differences exist between younger and older children, pediatric trauma analyses are weighted toward older patients. Trauma-induced coagulopathy, determined by rapid thrombelastography (rTEG), is a predictor of outcome in trauma patients, but the significance of rTEG values among very young trauma patients remains unknown. Our objective was to identify the prehospital or physiologic factors, including rTEG values, that were associated with mortality in trauma patients younger than 5 y old. Materials and MethodsPatients younger than 5 y old that met the highest-level trauma activation criteria at an academic children's hospital from 2010-2016 were included. Data regarding demographics, pre-hospital management, laboratory values, injury severity, and outcome were queried. Univariate and multivariate analyses were performed comparing survivors and non-survivors. ResultsA total of 356 patients were included. 60% were male, and the median age was 3 y (IQR 1–4). Overall mortality was 13% (n = 45); brain injury (91%) and hemorrhage (9%) were the causes of death. Compared to survivors, rTEG values in nonsurvivors showed longer activated clotting time and slower speed of clot formation. Clot strength was also decreased in nonsurvivors. On stepwise regression modeling, rTEG values were not significant predictors of mortality. Admission base deficit, arrival temperature, and head injury severity were identified as independent predictors of mortality. ConclusionsWhile rTEG identified coagulopathy in trauma patients < 5 y old, it was not an independent predictor of mortality. Our findings suggest that trauma providers should pay close attention to admission base deficit, arrival temperature, and head injury severity when managing the youngest trauma patients.

Predictive value of the shock index (SI) compared to the age-adjusted pediatric shock index (SIPA) for identifying children that needed the highest-level trauma activation based on the presence of consensus criteria

ObjectivesIn previous studies, SIPA was shown to be better than the SI in identifying children who have an elevated ISS, required transfusion, or were at a high risk of death. No comparison has been made to the consensus-based criteria that identify patients requiring the highest-level trauma activation. The objective of this study was to determine if the SIPA was more accurate than the SI in identifying children with increased need for trauma team activation as defined by the criterion standard definition, and secondly the sensitivity and specificity of the SI and SIPA. MethodsRetrospective review of prospectively collected trauma based data. Children aged 1–17 years admitted to a pediatric level 1 trauma center between 1/1/16 and 12/31/17 and met the prehospital criteria for level 1 or 2 trauma activation were included. We evaluated the ability of SI > 0.9 at ED presentation and elevated SIPA to predict need for trauma activation based on consensus criteria. SIPA cutoffs were > 1.22 (age 4–6), >1.0 (age 7–12), and > 0.9 (age 13–17). ResultsAmong 3378 children, 1486 (44%) had an elevated SI and 590 (18%) had an elevated SIPA. There were 160 (5%) patients who met at least one consensus criterion. Broadly, sensitivity and specificity analyses reveal poor sensitivity for both SI and SIPA (59.4% versus 43.1% respectively) measures but a moderate specificity for SIPA (83.8%). Both SI and SIPA have a poor PPV (6.4% versus 11.7%) but high NPV (96.6% versus 96.7%). Overall, SIPA has higher accuracy than SI in predicting consensus criteria 82% versus 57%). ConclusionSIPA is more accurate than the SI in identifying children who meet a consensus criterion defining the need for highest-level trauma activation. The low PPV and sensitivity suggest that SIPA alone, while somewhat less likely to lead to overtriage than SI is not ideal for ruling in the need for level one resources as defined by the consensus criteria.Prognosis study, retrospective. Level of EvidenceLevel II.

Your Automated Implantable Cardioverter Defibrillator Is Not a Bulletproof Vest but It Might Save Your Life.

A 43-year-old male was brought to the emergency department as the highest level trauma activation with complaints of chest and arm pain after sustaining gunshot wounds (GSW). Initial workup was notable for superficial GSWs to the left chest and upper extremity with direct impact to the patient’s automated implantable cardioverter defibrillator. The patient underwent replacement of the device without rewiring and was discharged home without complications.

Predictors of postinjury acute respiratory distress syndrome: Lung injury persists in the era of hemostatic resuscitation.

Acute respiratory distress syndrome (ARDS) following trauma is historically associated with crystalloid and blood product exposure. Advances in resuscitation have occurred over the last decade, but their impact on ARDS is unknown. We sought to investigate predictors of postinjury ARDS in the era of hemostatic resuscitation. Data were prospectively collected from arrival to 28 days for 914 highest-level trauma activations who required intubation and survived more than 6 hours from 2005 to 2016 at a Level I trauma center. Patients with ratio of partial pressure of oxygen to fraction of inspired oxygen of 300 mmHg or less during the first 8 days were identified. Two blinded expert clinicians adjudicated all chest radiographs for bilateral infiltrates in the first 8 days. Those with left-sided heart failure detected were excluded. Multivariate logistic regression was used to define predictors of ARDS. Of the 914 intubated patients, 63% had a ratio of partial pressure of oxygen to fraction of inspired oxygen of 300 or less, and 22% developed ARDS; among the ARDS cases, 57% were diagnosed early (in the first 24 hours), and 43% later. Patients with ARDS diagnosed later were more severely injured (ISS 32 vs. 20, p = 0.001), with higher rates of blunt injury (84% vs. 72%, p = 0.008), chest injury (58% vs. 36%, p < 0.001), and traumatic brain injury (72% vs. 48%, p < 0.001) compared with the no ARDS group. In multivariate analysis, head/chest Abbreviated Injury Score scores, crystalloid from 0 to 6 hours, and platelet transfusion from 0 to 6 hours and 7 to 24 hours were independent predictors of ARDS developing after 24 hours. Blood and plasma transfusion were not independently associated with ARDS. However, platelet transfusion was a significant independent risk factor. The role of platelets warrants further investigation but may be mechanistically explained by lung injury models of pulmonary platelet sequestration with peripheral thrombocytopenia. Prognostic study, level IV.

Aggressive imaging protocol for hanging patients yields no significant findings: Over-imaging of hanging injuries

BackgroundDespite rising rates of hanging injuries, few high-quality data and no national trauma guidelines are available to standardize the evaluation of these patients. We sought to identify the yield of imaging hanging patients at our institution. MethodsThis is a retrospective study at an urban Level I Trauma Center. Charts for patients diagnosed with “Hanging, Strangulation, or Asphyxiation” (ICD-9 E93.0) from February 2008 to March 2014 were reviewed. Frequency of imaging orders and their results were recorded. Logistic regression analyses were done to determine factors associated with increased rates of imaging. Results78 patients met inclusion criteria. The average age was 34 years, 86% were male, and 65% were witnessed hangings. In total, 195 CT scans and 67 X-rays were done. Frequency of imaging in our cohort: 77% received CT of the head (CTH); 88% CT of the neck; 85% CT angiography (CTA) of the neck; 86% chest X-ray. Highest-level trauma activation occurred in 76% of patients and was associated with an increased rate of imaging, with the likelihood of CTH being increased by 31% (p < 0.01), CT of the neck without contrast by 19% (p < 0.01), CTA of the neck by 25% (p < 0.01), and chest X-ray by 25% (p < 0.01). Of the 78 patients, none had significant findings that required intervention. ConclusionsIn this study, the highest-level trauma activation was associated with increased rates of imaging, but did not alter patient care. A more selective approach in the evaluation of hanging injuries should be considered.

Evaluation of RFID Technology to Capture Surgeon Arrival Time to Meet American College of Surgeons Committee on Trauma Verification Guidelines

Background The presence of an attending surgeon at all highest-level trauma activations is a requirement for American College of Surgeons-Committee on Trauma (ACS-COT) verification for level I to III trauma centers. Programs must demonstrate compliance with this criterion at least 80% of the time. Documentation of compliance can increase administrative burden presenting an opportunity for automation. Objectives The aim of this quality improvement project was to compare surgeon arrival documentation rates obtained utilizing radio-frequency identification (RFID) technology with manual documentation. Methods This project was conducted at a single level-I trauma center. RFID badges were distributed to all trauma surgeons. Arrival times for surgeons using manual nursing documentation and RFID activation were collected from October 2017 through March 2018. Presence of appropriate documentation and attending arrival within 15 minutes of trauma activation were compared by documentation method: nursing manual documentation or RFID system. Results There were 98 code trauma activations included in the analysis over the 6-month period. Nursing documentation of trauma surgeon attendance occurred 83% of the time (n = 81), with 81% (n = 79) in compliance within 15 minutes of code trauma activation. RFID badges were activated 91% (n = 89) of the time, with 86% (n = 84) in compliance within 15 minutes. There was no statistically significant difference between the rates of nursing documentation and RFID badge activation. Conclusion RFID technology is a reliable, complementary method of documenting compliance for trauma surgeon attendance. Trauma centers searching for technological solutions to address compliance with ACS-COT guidelines and to reduce administrative burden may consider the use of RFID technology.

Evaluation of Highest Level Pediatric Trauma Activation Criteria.

Despite the presence of a tiered in-hospital trauma triage system for the past decade, trauma centers still struggle with a definitive list of highest level activation criteria. In 2002, the American College of Surgeons (ACS) mandated 6 criteria for highest level activation. However, it is unknown if pediatric trauma centers follow these criteria. The purpose of this study is to identify and categorize the highest level pediatric trauma criteria used by pediatric trauma centers in the United States. In collaboration with the ACS, we reviewed activation criteria for highest level trauma activation for all ACS-verified level I pediatric trauma centers in the United States. Criteria were sorted by 2 reviewers into categories of indicators used for activation: patient demographic, physiologic, anatomic, intervention/resource usage, mechanism, and other. A total of 51 unique criteria for highest level trauma activation were identified from 54 (96%) of 56 level I pediatric trauma centers. Each center used between 1 and 29 criteria. A total of 42.6% of pediatric trauma centers followed all 6 criteria recommended by ACS. The most commonly omitted criterion was emergency physician discretion. The most common criteria not included in the ACS recommendations, but included in the highest level activation criteria, were amputation proximal to wrist or ankle (63%), and spinal cord injury/paralysis (63%). There is wide variation in the criteria used for highest level trauma activation among pediatric trauma centers. Further research investigating individual or grouped criteria to determine the most sensitive and specific criteria are necessary for appropriate triage and resource usage.

The Positive Impact on Emergency Department Length of Stay of a Clinical Practice Guideline-Directed Process for Direct Admission from the Emergency Department Computed Tomography Scan Suite to the Intensive Care Unit of Highest Level Trauma Activation Patients

The Positive Impact on Emergency Department Length of Stay of a Clinical Practice Guideline-Directed Process for Direct Admission from the Emergency Department Computed Tomography Scan Suite to the Intensive Care Unit of Highest Level Trauma Activation Patients

Principal component analysis of coagulation assays in severely injured children

BackgroundTrauma-induced coagulopathy is common and associated with poor outcome in injured children. Our aim is to identify patterns of coagulation dysregulation after injury and associate these phenotypes with relevant clinical outcomes. MethodsWe performed principal components analysis on prospectively collected data from children with the highest-level trauma activation June 2015–June 2016. Parameters included admission international normalized ratio, platelet count and thromboelastograms. Variables were reduced to principal components; principal component scores were generated for each subject and used in logistic regression with outcomes including mortality, disability, venous thromboembolism, and blood transfusion in the first 24 hours. ResultsWe included 133 subjects with median interquartile range age =10 (5–13 years), median interquartile range Injury Severity Score =17 (9–25), 73.5% boys, 70.8% blunt trauma. principal component analysis identified 3 significant principal components accounting for 75.0% of overall variance. Principal component 1 reflected clot strength; principal component 2 reflected abnormal fibrinolysis, both hyperfibrinolysis and fibrinolysis shutdown; principal component 3 reflected global clotting factor depletion. High principal component 1 score was associated with increased mortality (odds ratio =1.63) and blood transfusion (odds ratio 1.36). Principal component 2 score was correlated with Injury Severity Score (rho 0.4) and associated with venous thromboembolism (odds ratio 1.84), functional disability (odds ratio 1.66), mortality (odds ratio 2.07) and blood transfusion (odds ratio 2.79). PC3 score was associated with increased mortality (odds ratio 1.92) and blood transfusion (odds ratio 1.25). ConclusionPrincipal component analysis detects 3 patterns of coagulation dysregulation using widely available laboratory parameters: (1) abnormalities in clot strength; (2) abnormalities in fibrinolysis, and (3) clotting factor depletion. While all were associated with mortality and transfusion, fibrinolytic dysregulation was associated with injury severity and portends particularly poor outcome including venous thromboembolism and disability.

317 Over-Imaging of Hanging Injuries

To assess whether imaging is being over utilized in patients with hanging injuries. This is a retrospective study conducted at a Level I Trauma Center in an urban setting. Charts for patients diagnosed with a clinical impression of “Hanging, Strangulation, or Asphyxiation” (ICD-9 E93.0) from February 2008 to March 2014 were extracted from the electronic medical record system and reviewed. Isolated strangulation injuries in the absence of suspension were excluded due to a fundamental difference in mechanism. Frequency of imaging orders and their results and implications were reviewed. Logistic Regressions were done to determine which factors are associated with increased rates of imaging. Statistical analysis was done using the R statistical computing software. 100 patient charts were extracted and reviewed. 22 charts were excluded, 21 for being isolated strangulations and 1 due to unclear documentation during an electronic medical record downtime. Of the remaining 78 patients, the average age was 34 years and 86% were male. Physical signs of injury were noted on 55% of patients, 65% were witnessed hangings, 58% had loss of consciousness, and 76% were incarcerated. Intubation prior to arrival occurred in 4 patients, while 7 required intubation in the emergency department. Otolaryngology consultation was requested in 76% of patients. CT of the head (CTH) without contrast was done in 77% of patients, CT of the neck without contrast in 88%, CT angiography (CTA) of the neck in 85%, and chest X-ray in 86% of patients. In total, 195 CT scans and 67 X-rays were done. Highest-level trauma activation occurred in 76% of patients and was associated with an increased rate of imaging, with the likelihood of CTH being increased by 31% (p<0.01), CT of the neck without contrast by 19% (p<0.01), CTA of the neck by 25% (p<0.01), and chest X-ray by 25% (p<0.01). Highest-level trauma activation was also associated with a 21% increase in otolaryngology consultation (p=0.05). Incarcerated patients were noted to have a 21% increase in rate of highest-level trauma activation (p=0.05). Of note, 7 patients presented with cardiac arrest in the field, of which only 1 survived. Imaging was not performed in 4 of the cardiac arrest patients. Of the 78 patients, only 4 patients were identified with abnormal findings on imaging. Of these, 2 were deemed unrelated to the hanging, 1 was found to have a sternal fracture with subcutaneous air, and 1 was found to have a questionable carotid dissection on CTA. For the questionable carotid dissection, follow-up Magnetic Resonance Angiography showed no dissection. Surgical intervention was not required in any of the 78 patients. In this retrospective study, imaging in patients with hanging injuries did not significantly alter hospital course and treatment plans. Surgical intervention was never required. Highest-level trauma activation was associated with increased rates of imaging. A more selective approach to imaging in the case of hanging injuries should be considered. Offering activation of the highest-level trauma to every patient with a mechanism of hanging is likely unnecessary and costly.