Identify Trauma Patients Research Articles

External validation of the Air Medical Prehospital Triage score for identifying trauma patients likely to benefit from scene helicopter transport: Brown JB, Gestring ML, Guyette FX, et al. J Trauma Acute Care Surg. 2016;82270 - 279

External validation of the Air Medical Prehospital Triage score for identifying trauma patients likely to benefit from scene helicopter transport: Brown JB, Gestring ML, Guyette FX, et al. J Trauma Acute Care Surg. 2016;82270 - 279

Open and Endovascular Abdominal Aortic Injury Repair Outcomes in Polytrauma Patients

The management of patients with abdominal aortic injury (AAI) remains challenging. Open repair of AAI is still the standard of care although it is associated with high mortality. In past few years, endovascular surgery has evolved as a less invasive alternative to open surgery in emergency settings. The objective of this study was to compare outcomes after open repair versus endovascular repair of AAI in polytrauma patients. The National Trauma Data Bank, from 2008 to 2012, was queried to identify trauma patients undergoing open and endovascular repair of AAI using International Classification of Diseases, ninth Edition, and Clinical Modification codes. Data reviewed included demographics, type of associated injury, type of operative management, and complications. Factors independently associated with mortality were evaluated using multivariate logistic regression model. Of 325 injured patients with AAI, 91 patients underwent endovascular repair and 234 patients underwent open repair. Of these, 80.6% were male, with a mean age of 35.70years, and a mean injury severity score (ISS) was 30.59 for patients undergoing open repair and 31.56 for endovascular repair. Associated traumatic injuries included bowel injuries 57.5%, liver-pancreas injuries 36.6%, splenic injuries 14.8%, renal injuries 15.7%, and retroperitoneal injuries 19.1%. In-patient mortality for patients undergoing the open repair cohort was 63.7% and 20.9% for patients in the endovascular cohort (P<0.001). The endovascular repair cohort patients had a higher incidence of pneumonia 17.6% as compared to open repair cohort 5.1% (P<0.001). Similarly, patients in the endovascular repair cohort also had a higher abdominal compartment syndrome (4.4% vs. 0.4% in the open repair cohort, P=0.009), postoperative acute kidney injury (9.9% endovascular repair cohort vs. 6.4% in the open repair cohort, P=0.281), and acute mesenteric ischemia (1.1%). After controlling for associated injuries, acidosis, blood pressure at presentation, age, and ISS, patients in the open repair cohort had 6.58 times higher odds (confidence interval: 3.25-13.33; P<0.001) of mortality as compared to the endovascular repair cohort. Endovascular repair of abdominal aorta in polytrauma patients seems to be feasible and may improve survivorship in appropriately selected patients. More research is needed to understand to identify indications for endovascular repair versus open repair.

Effect and accuracy of emergency dispatch telephone guidance to bystanders in trauma: post-hoc analysis of a prospective observational study

BackgroundEmergency medical communication centres (EMCCs) dispatch and allocate ambulance resources, and provide first-aid guidance to on-scene bystanders. We aimed to 1) evaluate whether dispatcher guidance improved bystander first aid in trauma, and 2) to evaluate whether dispatchers and on-scene emergency medical services (EMS) crews identified the same first aid measures as indicated.MethodsFor 18 months, the crew on the first EMS crew responding to trauma calls used a standard form to assess bystander first aid. Audio recordings of the corresponding telephone calls from bystanders to the EMCC were reviewed.ResultsA total of 311 trauma calls were included. The on-scene EMS crew identified needs for the following first-aid measures: free airway in 26 patients, CPR in 6 patients, and hypothermia prevention in 179 patients. EMCC dispatchers advised these measures, respectively, in 16 (62%), 5 (83%), and 54 (30%) of these cases. Dispatcher guidance was not correlated with correctly performed bystander first aid. For potentially life saving first aid measures, all (20/20) callers who received dispatcher guidance attempted first aid, while only some few (4/22) of the callers who did not receive dispatcher guidance did not attempt first aid.DiscussionOverall, the EMCC dispatchers had low sensitivity and specificity for correctly identifying trauma patients requiring first-aid measures. Dispatcher guidance did not significantly influence whether on-scene bystander first aid was performed correctly or attempted in this study setting, with a remarkably high willingness to perform first-aid. However, the findings for potentially lifesaving measures suggests that there may be differences that this study was unable to detect.ConclusionThis study found a high rate of first-aid willingness and performance, even without dispatcher prompting, and a low precision in dispatcher advice. This underlines the need for further knowledge about how to increase EMCC dispatchers’ possibility to identify trauma patients in need of first aid. The correlation between EMCC-guidance and bystander first aid should be investigated in study settings with lower spontaneous first-aid rates.

External validation of the Air Medical Prehospital Triage score for identifying trauma patients likely to benefit from scene helicopter transport.

The Air Medical Prehospital Triage (AMPT) score was developed to identify injured patients who may benefit from scene helicopter emergency medical services (HEMS) transport. External validation using a different data set is essential to ensure reliable performance. The study objective was to validate the effectiveness of the AMPT score to identify patients with a survival benefit from HEMS using the Pennsylvania Trauma Outcomes Study registry. Patients 16 years or older undergoing scene HEMS or ground EMS (GEMS) transport in the Pennsylvania Trauma Outcomes Study registry 2000-2013 were included. Patients with 2 or higher AMPT score points were triaged to HEMS, while those with less than 2 points were triaged to GEMS. Multilevel Poisson regression determined the association of survival with actual transport mode across AMPT score triage assignments, adjusting for demographics, mechanism, vital signs, interventions, and injury severity. Successful validation was defined as no survival benefit for actual HEMS transport in patients triaged to GEMS by the AMPT score, with a survival benefit for actual HEMS transport in patients triaged to HEMS by the AMPT score. Subgroup analyses were performed in patients treated by advanced life support providers and patients with transport times longer than 10 minutes. There were 222,827 patients included. For patients triaged to GEMS by the AMPT score, actual transport mode was not associated with survival (adjusted relative risk, 1.004; 95% confidence interval, 0.999-1.009; p = 0.08). For patients triaged to HEMS by the AMPT score, actual HEMS transport was associated with a 6.7% increase in the relative probability of survival (adjusted relative risk, 1.067; 95% confidence interval, 1.040-1.083, p < 0.001). Similar results were seen in all subgroups. This study is the first to externally validate the AMPT score, demonstrating the ability of this tool to reliably identify trauma patients most likely to benefit from HEMS transport. The AMPT score should be considered when protocols for HEMS scene transport are developed and reviewed. Epidemiologic/prognostic study, level III; therapeutic/care management study, level IV.

The trauma registry compared to All Patient Refined Diagnosis Groups (APR-DRG)

BackgroundLiterature has shown there are significant differences between administrative databases and clinical registry data. Our objective was to compare the identification of trauma patients using All Patient Refined Diagnosis Related Groups (APR-DRG) as compared to the Trauma Registry and estimate the effects of those discrepancies on utilization. MethodsAdmitted pediatric patients from 1/2012–12/2013 were abstracted from the trauma registry. The patients were linked to corresponding administrative data using the Pediatric Health Information System database at a single children’s hospital. APR-DRGs referencing trauma were used to identify trauma patients. We compared variables related to utilization and diagnosis to determine the level of agreement between the two datasets. ResultsThere were 1942 trauma registry patients and 980 administrative records identified with trauma-specific APR-DRG during the study period. Forty-two percent (816/1942) of registry records had an associated trauma-specific APR-DRG; 69% of registry patients requiring ICU care had trauma APR-DRGs; 73% of registry patients with head injuries had trauma APR-DRGs. Only 21% of registry patients requiring surgical management had associated trauma APR-DRGs, and 12.5% of simple fractures had associated trauma APR-DRGs. ConclusionAPR-DRGs appeared to only capture a fraction of the entire trauma population and it tends to be the more severely ill patients. As a result, the administrative data was not able to accurately answer hospital or operating room utilization as well as specific information on diagnosis categories regarding trauma patients. APR-DRG administrative data should not be used as the only data source for evaluating the needs of a trauma program.

Extracorporeal life support is safe in trauma patients

IntroductionThe role of extracorporeal life support (ECLS) in the critically ill trauma patient is poorly defined, possibly leading to the underutilization of this lifesaving therapy in this population. This study examined survival rates and risk factors for death in trauma patients who received ECLS. MethodsData from the National Trauma Data Bank was retrospectively reviewed to identify trauma patients who received ECLS from January 2012 to December 2014. Clinical outcomes and risk factors for death were examined in these patients. ResultsEighty patients were identified and included in the final analysis. Overall survival to hospital discharge was 64%. Survivors and non-survivors were similar in regard to age, gender, weight, and injury mechanism. Non-survivors had greater median injury severity scores (ISS) (29 non-survivors vs. 24 survivors, p=0.018) and had a shorter median total hospital length of stay (8days non-survivors vs. 32days survivors, p<0.001). Analysis of specific anatomic locations of traumatic injury, including serious head/neck, thoracic, and abdominal injuries, revealed no impact on patient survival. Multivariable logistic regression analysis identified increasing age and ISS as significant risk factors for mortality; whereas treatment at facilities that performed multiple ECLS runs over the study period was associated with improved survival. ConclusionsExtracorporeal life support appears to be an effective treatment option in trauma patients with severe cardiopulmonary failure. Survival in trauma patients receiving ECLS is similar to that observed in the general ECLS population and this may represent an underutilized therapy in this population.

The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA).

Aortic occlusion (AO) for resuscitation in traumatic shock remains controversial. Resuscitative endovascular balloon occlusion of the aorta (REBOA) offers an emerging alternative. The American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry prospectively identified trauma patients requiring AO from eight ACS Level 1 centers. Presentation, intervention, and outcome variables were collected and analyzed to compare REBOA and open AO. From November 2013 to February 2015, 114 AO patients were captured (REBOA, 46; open AO, 68); 80.7% were male, and 62.3% were blunt injured. Aortic occlusion occurred in the emergency department (73.7%) or the operating room (26.3%). Hemodynamic improvement after AO was observed in 62.3% [REBOA, 67.4%; open OA, 61.8%); 36.0% achieving stability (systolic blood pressure consistently >90 mm Hg, >5 minutes); REBOA, 22 of 46 (47.8%); open OA, 19 of 68 (27.9%); p =0.014]. Resuscitative endovascular balloon occlusion of the aorta (REBOA) access was femoral cut-down (50%); US guided (10.9%) and percutaneous without imaging (28.3%). Deployment was achieved in Zones I (78.6%), II (2.4%), and III (19.0%). A second AO attempt was required in 9.6% [REBOA, 2 of 46 (4.3%); open OA, 9 of 68 (13.2%)]. Complications of REBOA were uncommon (pseudoaneurysm, 2.1%; embolism, 4.3%; limb ischemia, 0%). There was no difference in time to successful AO between REBOA and open procedures (REBOA, 6.6 ± 5.6 minutes; open OA, 7.2 ± 15.1; p = 0.842). Overall survival was 21.1% (24 of 114), with no significant difference between REBOA and open AO with regard to mortality [REBOA, 28.2% (13 of 46); open OA, 16.1% (11 of 68); p = 0.120]. Resuscitative endovascular balloon occlusion of the aorta has emerged as a viable alternative to open AO in centers that have developed this capability. Further maturation of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database is required to better elucidate optimal indications and outcomes. Therapeutic/care management study, level IV.

Pediatric Secondary Overtriage in a Statewide Trauma System

Secondary overtriage is a term that describes patients who are discharged home shortly after being transferred, an indication that transfer and hospitalization were unnecessary. The study goal was to identify factors associated with secondary triage. A statewide trauma registry was used to identify trauma patients aged less than 18 years during a 6-year period (2007-2012) who were discharged within 48 hours from arrival and did not undergo a surgical procedure. We compared those that were treated at initial facility and those transferred to a second facility using clinical indices including patterns of injury pattern using multivariate logistic regression. Of the 4441 patients who fit our inclusion criteria, 801 (18%) were transferred. Younger age groups were more likely to be transferred. Factors associated with being transferred included head, spinal, and facial injuries, and patient arrival during the nighttime work shifts. In conclusion, young patients who have signs of possible neurological or spinal injuries and those who arrive during nondaytime shifts during the workday are more likely to be transferred to another trauma center. These may reflect the comfort level and resources of the local facility.

Adult-Based Massive Transfusion Protocol Activation Criteria Do Not Work in Children.

Introduction In the adult population, assessment of blood consumption (ABC) score [penetrating mechanism, positive focused assessment sonography for trauma (FAST), systolic blood pressure < 90, and heart rate (HR) > 120] ≥2 identifies trauma patients who require massive transfusion (MT) with sensitivity and specificity of 75 and 86%. We hypothesized that the adult criteria cannot be applied to children, as the vital sign cut-offs are not age-adjusted. We aimed to determine if the use of a shock index, pediatric age-adjusted (SIPA) would improve the discriminate ability of the ABC score in children. Materials and Methods A retrospective review of children age 4 to 15 who received a packed red blood cell (PRBC) transfusion during admission for trauma between 2008 and 2014 was performed. We compared the sensitivity and specificity of ABC score ≥ 2, elevated SIPA, and age-adjusted ABC score (ABC-S) utilizing SIPA in place of HR and BP, to determine the need for MT. Results A total of 50 children were included, 31 received PRBC transfusion within 6 hours of injury, 7 children had a positive FAST, and 3 suffered penetrating trauma, all in the early transfusion group. ABC score ≥ 2 is 29% sensitive and 100% specific at predicting need for MT while ABC-S score ≥ 1 is 65% sensitive and 84% specific. Conclusions Adult-based criteria for activation of MT perform poorly in the pediatric population. The use of SIPA modestly improves the sensitivity of the ABC score in children; however, the sensitivity and specificity of this score are still worse than when used in an adult population. This suggests the need to develop a new score that takes into account the low rate of penetrating trauma and positive FAST in the pediatric population.

Development and Validation of the Air Medical Prehospital Triage Score for Helicopter Transport of Trauma Patients.

The aim of this study was to develop and internally validate a triage score that can identify trauma patients at the scene who would potentially benefit from helicopter emergency medical services (HEMS). Although survival benefits have been shown at the population level, identification of patients most likely to benefit from HEMS transport is imperative to justify the risks and cost of this intervention. Retrospective cohort study of subjects undergoing scene HEMS or ground emergency medical services (GEMS) in the National Trauma Databank (2007-2012). Data were split into training and validation sets. Subjects were grouped by triage criteria in the training set and regression used to determine which criteria had a survival benefit associated with HEMS. Points were assigned to these criteria to develop the Air Medical Prehospital Triage (AMPT) score. The score was applied in the validation set to determine whether subjects triaged to HEMS had a survival benefit when actually transported by helicopter. There were 2,086,137 subjects included. Criteria identified for inclusion in the AMPT score included GCS <14, respiratory rate <10 or >29, flail chest, hemo/pneumothorax, paralysis, and multisystem trauma. The optimal cutoff for triage to HEMS was ≥2 points. In subjects triaged to HEMS, actual transport by HEMS was associated with an increased odds of survival (AOR 1.28; 95% confidence interval [CI] 1.21-1.36, P < 0.01). In subjects triaged to GEMS, actual transport mode was not associated with survival (AOR 1.04; 95% CI 0.97-1.11, P = 0.20). The AMPT score identifies patients with improved survival following HEMS transport and should be considered in air medical triage protocols.

Prediction of Massive Transfusion in Trauma Patients with Shock Index, Modified Shock Index, and Age Shock Index

Objectives: The shock index (SI) and its derivations, the modified shock index (MSI) and the age shock index (Age SI), have been used to identify trauma patients with unstable hemodynamic status. The aim of this study was to evaluate their use in predicting the requirement for massive transfusion (MT) in trauma patients upon arrival at the hospital. Participants: A patient receiving transfusion of 10 or more units of packed red blood cells or whole blood within 24 h of arrival at the emergency department was defined as having received MT. Detailed data of 2490 patients hospitalized for trauma between 1 January 2009, and 31 December 2014, who had received blood transfusion within 24 h of arrival at the emergency department, were retrieved from the Trauma Registry System of a level I regional trauma center. These included 99 patients who received MT and 2391 patients who did not. Patients with incomplete registration data were excluded from the study. The two-sided Fisher exact test or Pearson chi-square test were used to compare categorical data. The unpaired Student t-test was used to analyze normally distributed continuous data, and the Mann-Whitney U-test was used to compare non-normally distributed data. Parameters including systolic blood pressure (SBP), heart rate (HR), hemoglobin level (Hb), base deficit (BD), SI, MSI, and Age SI that could provide cut-off points for predicting the patients’ probability of receiving MT were identified by the development of specific receiver operating characteristic (ROC) curves. High accuracy was defined as an area under the curve (AUC) of more than 0.9, moderate accuracy was defined as an AUC between 0.9 and 0.7, and low accuracy was defined as an AUC less than 0.7. Results: In addition to a significantly higher Injury Severity Score (ISS) and worse outcome, the patients requiring MT presented with a significantly higher HR and lower SBP, Hb, and BD, as well as significantly increased SI, MSI, and Age SI. Among these, only four parameters (SBP, BD, SI, and MSI) had a discriminating power of moderate accuracy (AUC > 0.7) as would be expected. A SI of 0.95 and a MSI of 1.15 were identified as the cut-off points for predicting the requirement of MT, with an AUC of 0.760 (sensitivity: 0.563 and specificity: 0.876) and 0.756 (sensitivity: 0.615 and specificity: 0.823), respectively. However, in the groups of patients with comorbidities such as hypertension, diabetes mellitus, or coronary artery disease, the discriminating power of these three indices in predicting the requirement of MT was compromised. Conclusions: This study reveals that the SI is moderately accurate in predicting the need for MT. However, this predictive power may be compromised in patients with HTN, DM or CAD. Moreover, the more complex calculations of MSI and Age SI failed to provide better discriminating power than the SI.

Muscle Oxygen Saturation Might Help Identify Trauma Patients with Severe Hemorrhage

Researchers assessed whether the addition of muscle oxygen saturation (SmO2) to vital signs improves early (before other diagnostic tests are available) identification of trauma patients with major hemorrhage. In an observational study at a Level I trauma center, the researchers analyzed mean muscle oxygen saturation (monitored with near-infrared spectrometry [NIRS]), heart rate, pulse pressure, and systolic blood pressure monitored over a 10-minute …

Massive transfusion in critical haemorrhage following trauma: Aren't we missing something?

We read with interest the recent review by Olaussen et al., presenting 36 models for prediction of critical haemorrhage following trauma. The authors present the different models, their respective variables and their performance. They also discuss the utility of the individual variables. As mentioned in the publication, early diagnosis of haemorrhagic shock is a key step in improving outcomes after severe trauma. Critical bleedings indeed require aggressive treatments and need them to be applied as early as possible. Moreover, any unilateral approach would cause harm as critical bleedings require integrative care associating a mechanical (surgical or endovascular) strategy to stop the bleeding with adequate haemostatic resuscitation. Damage control resuscitation (DCR) associates damage control surgery (DCS), massive transfusion (MT) with the optimal 1/1/1 ratio of blood products, permissive hypotension and careful attention for identification and correction of the early acute coagulopathy of trauma (EACT). Adequate and early selection of trauma patients in need for DCR is pivotal to prevent wasting time as well as unnecessary activation of the technical and human resources needed for DCR. The presented models all have been developed by retrospective identification of individual parameters independently associated with MT. Massive transfusion is commonly defined as the transfusion of more than 10 units of red blood cells (RBC) within the first 24 hours of care. This definition is problematic since it excludes trauma patients presenting to hospital with active bleeding and a need for an emergent surgical control of the bleeding. Thanks to a highly effective DCR, some of those patients do not need a large number of RBC transfusions. Moreover, severe blunt trauma patients can suffer from an EACT and are in need of a specific haemostatic resuscitation (associating treatments such as tranexamic acid, plasma, platelets or fibrinogen concentrate) and not necessarily in need of massive RBC transfusion. Defining critical haemorrhage with MT therefore does not properly consider the other crucial components of DCR (DCS and correction of EACT) which are as important as RBC transfusion. Shouldn’t we both in the clinical setting and in clinical research change our perspective, going from a massive transfusion approach to a critical haemorrhage approach? Other scoring systems have been developed with a different endpoint. The coagulopathy of severe trauma (COAST) score, developed by the same team of the present review, aims to identify trauma patients suffering from EACT. The trauma induced coagulopathy clinical score (TICCS) aims to identify trauma patients associating EACT, the need for blood products transfusion and the need for emergent surgery. There is no doubt that the presented models are all very useful in clinical practice as they bring an objective tool for prediction of critical haemorrhage. We would like to know the authors’ opinion about choosingMT as the focused outcome variable and if it is the answer to critical haemorrhage after trauma.

Toward a More Robust Prediction of Pulmonary Embolism in Trauma Patients: A Risk Assessment Model Based on 38,000 Patients.

Pulmonary embolism (PE) is a rare but sometimes fatal complication of trauma. Risk stratification models identify patients at increased risk of PE; however, they are often complex and difficult to use. This research aims to develop a model, based on a large sample of trauma patients, which can be easily and quickly used at the time of admission to predict PE. This study used trauma registry data from 38,597 trauma patients. Of these, 239 (0.619%) developed a PE. We targeted demographic and injury data, prehospital information, and data on treatments and events during hospitalization. A multivariate binary logistic regression model was developed to predict the odds of developing a PE during hospitalization. The model was developed using a 50% randomly selected development subsample and then tested for accuracy using the remaining 50% validation sample. We found 7 statistically significant predictors of PE, including (1) age [odds ratio (OR) = 1.01; 95% CI, 1.00-1.02; P = 0.05], (2) obesity (OR = 2.54; 95% CI, 1.29-4.99; P < 0.01), (3) injury from motorcycle accident (OR = 2.01; 95% CI, 1.25-3.22; P < 0.01), (4) arrival by helicopter (OR = 2.91; 95% CI, 1.16-7.27; P = 0.02), (5) emergency department admission pulse rate (OR = 1.01; 95% CI, 1.0-1.02; P = 0.06), (6) admission to intensive care unit (OR = 5.03; 95% CI, 3.12-8.12; P < 0.01), and (7) injury location, including thorax (OR = 1.57; 95% CI, 1.04-2.37; P = 0.03), abdomen (OR = 1.56; 95% CI, 1.04-2.33; P = 0.03), and lower extremity injuries (OR = 2.85; 95% CI, 3.12-8.12; P < 0.01). Our model was able to discriminate between predicted and actual PE events with a receiver operating characteristic area under the curve of 0.87. By identifying the top 25% high-risk patients, we were able to predict 80%-84% of pulmonary emboli. This knowledge allows us to focus stronger thromboprophylactic efforts on patients at highest risk. This model can be used to rapidly identify trauma patients at high risk for PE. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Additional data from clinical examination on site significantly but marginally improve predictive accuracy of the Revised Trauma Score for major complications during Helicopter Emergency Medical Service missions.

IntroductionThe Revised Trauma Score (RTS) accurately identifies trauma patients at high risk of adverse events or death. Less is known about its usefulness in the general population and non-trauma recipients of Helicopter Emergency Medical Service (HEMS). The RTS is a simple tool and omits a lot of other data obtained during clinical evaluation. The aim was to assess the role of the RTS to identify patients at risk of major complications (death, cardiopulmonary resuscitation, defibrillation, intubation) in the general population of HEMS patients. Clinical factors beyond the RTS were analyzed to identify additional prognostic factors for predicting major complications.Material and methodsA retrospective analysis of medical records of adult patients routinely collected during HEMS missions in the years 2011–2014 was performed.ResultsThe analysis included 19 554 HEMS missions. Patients were 55 ±20 years old and 68% were male. The most common indication for HEMS was diseases of the circulatory system – 41%. Major complications occurred in 2072 (10.6%) cases. In the general population of HEMS patients, the RTS accurately identified individuals at risk of major complications at a cut-off value of 10.5 and area under the curve (AUC) of 93.5%. In multivariate analysis, additional clinical data derived from clinical examination (ECG; skin, pupil and breathing examination) significantly but marginally improved the accuracy of RTS assessment: AUC 95.6% (p < 0.001 for the difference).ConclusionsThe Revised Trauma Score accurately identifies individuals at risk of major complications during HEMS missions regardless of the indication. Additional clinical data significantly but marginally improved the accuracy of RTS in the general population of HEMS patients.

Failure to clear elevated lactate predicts 24-hour mortality in trauma patients.

Lactate clearance is a standard resuscitation goal in patients in nontraumatic shock but has not been investigated adequately as a tool to identify trauma patients at risk of dying. Our objective was to determine if trauma patients with impaired lactate clearance have a higher 24-hour mortality rate than patients whose lactate concentration normalizes. A retrospective chart review identified patients who were admitted directly from the scene of injury to an urban trauma center between 2010 and 2013 and who had at least one lactate concentration measurement within 24 hours. Transfers, patients without lactate measurement, and those who were dead on arrival were excluded. Of the 26,545 screened patients, 18,304 constituted the initial lactate measurement population, and 3,887 were the lactate clearance cohorts. Initial lactate had an area under the receiver operating characteristic curve of 0.86 and 0.73 for mortality at 24 hours and in the hospital, respectively. An initial concentration of 3 mmol/L or greater had a sensitivity of 0.86 and a specificity of 0.73 for mortality at 24 hours. The mortality rate among patients with elevated lactate concentrations (n = 2,381; 5.6 [2.8] mmol/L) that did not decline to less than 2.0 mmol/L in response to resuscitative efforts (mean [SD] second measurement, 3.7 [1.9] mmol/L) was nearly seven times higher (4.1% vs. 0.6%, p < 0.001) than among those with an elevated concentration (n = 1,506, 5.3 [2.7] mmol/L) that normalized (1.4 [0.4] mmol/L). Logistic regression analysis showed that failure to clear lactate was associated with death more than any other feature (odds ratio, 7.4; 95% confidence interval, 1.5-35.5), except having an Injury Severity Score (ISS) greater than 25 (odds ratio, 8.2; 95% confidence interval, 2.7-25.2). Failure to clear lactate is a strong negative prognostic marker after injury. An initial lactate measurement combined with a second measurement for high-risk individuals might constitute a useful method of risk stratifying injured patients. Prognostic study, level III.

Trauma Patients' Family Members' Perceptions of Nurses' Caring Behaviors.

A mixed methods study was conducted to identify trauma patients' family members' perceptions of nurses' caring behaviors on a trauma step-down unit at a level I trauma center. Family members completed Caring Behaviors Inventory-Short Form 24 and a qualitative section. Quantitative data were analyzed using descriptive statistics. On a scale of 1 to 6, the mean score for individual items was 5.2 (median = 5.3). Participants considered the nurses' behaviors to be indicative of caring in each of the 4 areas measured-assurance, knowledge/skills, respectfulness, and connectedness. Four themes were identified-technical, nonverbal, personal connections, and addressing comfort.

A joint latent class analysis for adjusting survival bias with application to a trauma transfusion study.

There is no clear classification rule to rapidly identify trauma patients who are severely hemorrhaging and may need substantial blood transfusions. Massive transfusion (MT), defined as the transfusion of at least 10 units of red blood cells within 24h of hospital admission, has served as a conventional surrogate that has been used to develop early predictive algorithms and establish criteria for ordering an MT protocol from the blood bank. However, the conventional MT rule is a poor proxy, because it is likely to misclassify many severely hemorrhaging trauma patients as they could die before receiving the 10th red blood cells transfusion. In this article, we propose to use a latent class model to obtain a more accurate and complete metric in the presence of early death. Our new approach incorporates baseline patient information from the time of hospital admission, by combining respective models for survival time and usage of blood products transfused within the framework of latent class analysis. To account for statistical challenges, caused by induced dependent censoring inherent in 24-h sums of transfusions, we propose to estimate an improved standard via a pseudo-likelihood function using an expectation-maximization algorithm with the inverse weighting principle. We evaluated the performance of our new standard in simulation studies and compared with the conventional MT definition using actual patient data from the Prospective Observational Multicenter Major Trauma Transfusion study. Copyright © 2015 John Wiley & Sons, Ltd.

The effectiveness of a 'Code Red' transfusion request policy initiated by pre-hospital physicians.

Major trauma is a leading cause of mortality and serious morbidity. Recent approaches to life-threatening traumatic haemorrhage have emphasized the importance of early blood product transfusion. We have implemented a pre-hospital transfusion request policy where a pre-hospital physician can request the presence of a major transfusion pack on arrival at the destination trauma centre. This study was performed to establish whether three simple criteria (1) suspicion or evidence of active haemorrhage (2) systolic BP<90 mmHg (3) failure of blood pressure to respond to an intravenous fluid bolus) which were used to activate a pre-hospital 'Code Red' transfusion request accurately identified seriously injured patients who required transfusion on arrival at hospital. Prospective evaluation of all pre-hospital 'Code Red' requests over a 30-month period (August 2008-May 2011) was performed for patients transported to a major trauma centre. Mechanism of injury, Injury Severity Score, hospital mortality, and use of blood products were recorded. Patients were followed up to hospital discharge. 176 'Code Red' activations were made in the study period. 129 patients were transported to the Trauma Centre. Mechanism of injury was penetrating trauma in 39 (30%) cases, road traffic collision in 58 (45%), falls in 18 (14%) and 'other' in 14 (10.8%). Complete data was available for 126 patients. Of the patients reaching hospital, 20 died in the emergency department or operating theatre, 22 died following admission and 84 survived to hospital discharge. Mean Injury Severity Score (ISS) was 29.1. (range 0-66). Overall, 115 (91%) of the patients declared 'Code Red' pre-hospital received blood product transfusion after arrival in hospital. Eleven patients did not receive any blood products following hospital admission. In patients declared 'Code Red' pre-hospital, mean packed red blood cell transfusion in the first 24-h was 10.4 unit (95% CI 8.4-12.3 unit). The use of simple pre-hospital criteria allowed physicians to successfully identify trauma patients with severe injury and a requirement for blood product transfusion. This allowed blood products to be ready on the patient's arrival in a major trauma centre with the potential for earlier transfusion.

Advanced airway management is necessary in prehospital trauma patients

Treatment of airway compromise in trauma patients is a priority. Basic airway management is provided by all emergency personnel, but the requirement for on-scene advanced airway management is controversial. We attempted to establish the demand for on-scene advanced airway interventions. Trauma patients managed with standard UK paramedic airway interventions were assessed to determine whether airway compromise had been effectively treated or whether more advanced airway management was required. A prospective observational study was conducted to identify trauma patients requiring prehospital advanced airway management attended by a doctor-paramedic team. The team assessed and documented airway compromise on arrival, interventions performed before and after their arrival, and their impact on airway compromise. Four hundred and seventy-two patients required advanced airway intervention and received 925 airway interventions by ground-based paramedics. Two hundred and sixty-nine patients (57%) still had airway compromise on arrival of the enhanced care team; no oxygen had been administered to 52 patients (11%). There were 45 attempted intubations by ground paramedics with a 64% success rate and 11% unrecognized oesophageal intubation rate. Doctor-paramedic teams delivering prehospital anaesthesia achieved definitive airway management for all patients. A significant proportion of severely injured trauma patients required advanced airway interventions to effectively treat airway compromise. Standard ambulance service interventions were only effective for a proportion of patients, but might not have always been applied appropriately. Complications of advanced airway management occurred in both provider groups, but failed intubation and unrecognized oesophageal intubation were a particular problem in the paramedic intubation group.