Initial Trauma Care Research Articles

Evaluation of Resources Necessary for Provision of Trauma Care in Botswana: An Initiative for a Local System.

Developing countries face the highest incidence of trauma, and on the other hand, they do not have resources for mitigating the scourge of these injuries. The World Health Organization through the Essential Trauma Care (ETC) project provides recommendations for improving management of the injured and building up of systems that are effective in low-middle-income countries (LMICs). This study uses ETC project recommendations and other trauma-care guidelines to evaluate the current status of the resources and organizational structures necessary for optimal trauma care in Botswana; an African country with relatively good health facilities network, subsidized public hospital care and a functioning Motor Vehicle Accident fund covering road traffic collision victims. A cross-sectional descriptive design employed convenience sampling for recruiting high-volume trauma hospitals and selecting candidates. A questionnaire, checklist, and physical verification of resources were utilized to evaluate resources, staff knowledge, and organization-of-care and hospital capabilities. Results are provided in plain descriptive language to demonstrate the findings. Necessary consumables, good infrastructure, adequate numbers of personnel and rehabilitation services were identified all meeting or exceeding ETC recommendations. Deficiencies were noted in staff knowledge of initial trauma care, district hospital capability to provide essential surgery, and the organization of trauma care. The good level of resources available in Botswana may be used to improve trauma care: To further this process, more empowering of high-volume trauma hospitals by adopting trauma-care recommendations and inclusive trauma-system approaches are desirable. The use of successful examples on enhanced surgical skills and capabilities, effective trauma-care resource management, and leadership should be encouraged.

An in-situ simulation-based educational outreach project for pediatric trauma care in a rural trauma system

BackgroundOutcome disparities between urban and rural pediatric trauma patients persist, despite regionalization of trauma systems. Rural patients are initially transported to the nearest emergency department (ED), where pediatric care is infrequent. We aim to identify educational intervention targets and increase provider experience via pediatric trauma simulation. MethodsProspective study of simulation-based pediatric trauma resuscitation was performed at three community EDs. Level one trauma center providers facilitated simulations, providing educational feedback. Provider performance comfort and skill with tasks essential to initial trauma care were assessed, comparing pre-/postsimulations. Primary outcomes were: 1) improved comfort performing skills, and 2) team performance during resuscitation. ResultsProvider comfort with the following improved (p-values <0.05): infant airway, infant IV access, blood administration, infant C-spine immobilization, chest tube placement, obtaining radiographic images, initiating transport, and Broselow tape use. The proportion of tasks needing improvement decreased: 42% to 27% (p-value=0.001). Most common deficiencies were: failure to obtain additional history (75%), beginning secondary survey (58.33%), log rolling/examining the back (66.67%), calling for transport (50%), calculating medication dosages (50%). ConclusionsSimulation-based education improves provider comfort and performance. Comparison of patient outcomes to evaluate improvement in pediatric trauma care is warranted. Level of evidence ratingIV.

Effect of team training on efficiency of trauma care in a Chinese hospital.

ObjectiveMultidisciplinary trauma teams are the standard of care in the USA, but staffing differences and lack of advanced trauma life support training hinder replication of this system in Chinese hospitals. We investigated the effect of simulation team training on initial trauma care.MethodsOver 15 months, we compared grade I trauma patients cared for by the trained team and those cared for using traditional practice on times from emergency room arrival to tests/procedures. Propensity-score analysis was performed to improve between-group comparisons.ResultsDuring the study, 144 grade I trauma patients were treated. Trained team patients showed shorter times from emergency room arrival to initiation of hemostasis (31.0 [13.5–58.5] vs. 113.5 [77–150.50] min), blood routine report (8 [5–10.25] vs. 13 [10–21] min), other blood tests (21 [14.75–25.75] vs. 31 [25–37] min), computed tomography scan (29.5 [20.25–65] vs. 58.5 [30.25–71.25] min) and tranexamic acid administration (31 [13–65] vs. 90 [65–200] min). Similar results were obtained for the propensity-score matched cohort.ConclusionSimulation team training could help reduce time to blood routine reports, scans and hemostasis. Assessment of available resources and development of targeted team training could improve care in resource-limited hospitals.

Abstract PR521

Background & Objectives: Low income countries (LICs) have limited prehospital care for trauma and emergencies. Taxis frequently serve as makeshift ambulances, filling critical emergency personnel shortages. The WHO recommends teaching laypersons as a step in the development of professional emergency medical systems. This survey evaluates Mozambique taxi driver interest and barriers in delivering basic health care. Materials & Methods: Mozambique taxi drivers were surveyed about their experiences with emergencies in Quelimane (provincial setting) and Maputo (urban setting). Quelimane population was chosen by convenience sampling. Maputo surveys targeted taxi drivers at Maputo Central Hospital (MCH), the country’s largest hospital, as well as drivers in Zona Coop, a neighborhood away from hospital centers. Results: 23 Maputo MCH drivers (23 cars, 1 chapela/bike, 1 chapa/minibus), 21 Maputo neighborhood drivers (17 cars, 3 chapelas), and 7 Quelimane (all cars) answered the survey for a total of 51. 3 participants did not finish. Etiology of emergencies included labor, hemorrhage, “sick person,” stroke, syncope, epilepsy, anemia, edema. 2 patients died in the car. Only 5 drivers were concerned about their own safety. 16 drivers requested basic health care training, 8 trauma kits, 3 an emergency number, and 7 support from physicians. FPO Conclusion: The use of non-emergency vehicles and lay providers for basic life support and transportation is important where there is a critical shortage of prehospital care. Previous studies in LICs indicate that laypersons are able to retain information and provide basic care and transport to those in need. These drivers may benefit from an organized system that would assist them to act as emergency responders that includes a standardized course development. Filling the gap for initial emergency and trauma care is an important priority as LICs scale up for greater surgical, anesthesia, and critical care capacity.

Imaging Before Transfer Is Associated with Higher Radiation Exposure in Pediatric Trauma Patients

Computed tomography (CT) scans are commonly ordered during initial trauma care. CT scans obtained at referring institutions may fall outside Advanced Trauma Life Support (ATLS) guidelines; be of poor technical quality, requiring repeat imaging; or be performed without reduced-radiation protocols. There is growing concern that early, high-dose radiation exposure in children may increase the risk for certain hematologic malignancies. In addition, excess scanning delays trauma care and …

Tertiary survey in polytrauma patients should be an ongoing process

IntroductionDue to prioritisation in the initial trauma care, non-life threatening injuries can be overlooked or temporally neglected. Polytrauma patients in particular might be at risk for delayed diagnosed injuries (DDI). Studies that solely focus on DDI in polytrauma patients are not available. Therefore the aim of this study was to analyze DDI and determine risk factors associated with DDI in polytrauma patients. MethodsIn this single centre retrospective cohort study, patients were considered polytrauma when the Injury Severity Score was ≥16 as a result of injury in at least 2 body regions. Adult polytrauma patients admitted from 2007 until 2012 were identified. Hospital charts were reviewed to identify DDI. Results1416 polytrauma patients were analyzed of which 12% had DDI. Most DDI were found during initial hospital admission after tertiary survey (63%). Extremities were the most affected regions for all types of DDI (78%) with the highest intervention rate (35%). Most prevalent DDI were fractures of the hand (54%) and foot (38%). In 2% of all patients a DDI was found after discharge, consisting mainly of injuries other than a fracture. High energy trauma mechanism (OR 1.8, 95% CI 1.2–2.7), abdominal injury (OR 1.5, 95% CI 1.1–2.1) and extremity injuries found during initial assessment (OR 2.3, 95% CI 1.6–3.3) were independent risk factors for DDI. ConclusionIn polytrauma patients, most DDI were found during hospital admission but after tertiary survey. This demonstrates that the tertiary survey should be an ongoing process and thus repeated daily in polytrauma patients. Most frequent DDI were extremity injuries, especially injuries of the hand and foot.

The Hartford Consensus on Active Shooters: Implementing the Continuum of Prehospital Trauma Response

BackgroundActive shooter incidents have led to the recognition that the traditional response paradigm of sequential response and scene entry by law enforcement, first responders, and emergency medical service (EMS) personnel produced delays in care and suboptimal victim outcomes. The Hartford Consensus Group developed recommendations to improve the response to and outcomes from active shooter events and urged that a continuum of care be implemented that incorporates not only EMS response, but also the initiation of care by law enforcement officers and potentially by lay bystanders. ObjectiveTo develop and implement tiered educational programs designed to teach police officers and lay bystanders the principles of initial trauma care and bleeding control using as a foundation the U.S. military's Tactical Combat Casualty Care course and the guidelines of the Committee on Tactical Emergency Casualty Care. DiscussionThe Tactical Casualty Care for Law Enforcement and First Responders course is a 1-day program combining didactic lecture, hands-on skills stations, and clinical scenarios designed primarily for police officers. The Bleeding Control for the Injured is a 2- to 3-h program for the potential citizen responder in the skills of hemorrhage control. In addition, we document the application of these skills by law enforcement officers and first responders in several real-life incidents involving major hemorrhage. ConclusionsDeveloping and implementing tiered educational programs for hemorrhage control will improve response by police officers and the lay public. Educating law enforcement officers in these skills has been demonstrated to improve trauma victim survival.

Where do I go? A trauma victim′s plea in an informal trauma system

Background:The three pillars of a good trauma system are the prehospital care, definitive care, and rehabilitative services. The prehospital care is a critical component of the efforts to lower trauma mortality.Objective:To study the prehospital profile of patients who died due to trauma, compute the time taken to reach our facility, find the cause of delay, and make feasible recommendations.Materials and Methods:A hospital-based study was performed at a trauma center in Puducherry from June 2009 to August 2010. Puducherry is a union territory of India in the geographical terrain of the state of Tamil Nadu. A total of 241deaths due to trauma were included. Apart from the demographic and injury characteristics, a detailed prehospital log was constructed regarding the time of incident, the referral patterns, care given in the prehospital phase, the distance travelled, and the total time taken to reach our center.Results:The majority (59%) of patients were referred, with stopovers at two consecutive referral centers (30%), needing at least two vehicles to transport to definitive care (70%), clocking unnecessary distances (67%), and delayed due to non therapeutic intervention (87%). The majority of deaths (66%) were due to head injury. Only 2.96% of referred cases reached us within the first hour. Few of the patients coming directly to us had vehicle change due to local availability and lack of knowledge of predestined definitive care facility. Overall, 94.6% of direct cases arrived within 4 h whereas 93.3% of referred cases required up to 7 h to arrive at definitive care.Conclusions:Seriously injured patients lose valuable prehospital time because there is no direction regarding destination and interfacility transfer, a lack of seamless transport, and no concept of initial trauma care. The lack of direction is compounded in geographical areas that are situated at the border of political jurisdictions.

Trauma Resuscitations and Patient Perceptions of Care and Comfort

Patients subjected to common trauma resuscitation practices can have varied emotional responses to certain aspects of their initial evaluation and care. Thirty-four patients admitted to the hospital after blunt traumatic injury were randomly selected to complete a self-reported questionnaire regarding their comfort levels with certain aspects of their initial trauma care and resuscitation. Most patients reported higher levels of comfort with procedures generally expected by the lay public and lower levels of comfort with those procedures less well known or for which they were not prepared. Analysis of survey data showed a larger percentage of discomfort with the digital rectal examination than with other aspects of trauma care. Notably, data analysis also showed a significant percentage of patients who were reluctant to disclose receiving a digital rectal examination. Additional investigation into the validity and reproducibility of these trends is warranted; however, there is legitimate evidence that there is room to improve a patient's perception of comfort during a trauma resuscitation and initial workup through improved communication and procedure disclosure.

Common errors in billing and coding for orthopaedic trauma care

Physician compensation for services rendered is an extremely complex process in the United States. Because this system is so complex, physicians often do not put forth the effort to learn how to appropriately report their services. The result is lost revenue for services provided. This review will discuss coding from the initial trauma patient evaluation through the last reconstructive procedure and common errors. Both Evaluation and Management (E&M) coding and surgical Current Procedural Terminology (CPT) codes will be explored as they pertain to initial, subsequent, and reconstructive trauma care.

Autoimmunity in transfusion babesiosis: A spectrum of clinical presentations

Transfusion-acquired babesiosis can be an asymptomatic or self-limited febrile hemolytic illness in a healthy host. A persistent, relapsing, and/or fulminant course with the development of life-threatening complications may be seen in immunocompromised or splenectomized patients. As in malaria, erythrocyte parasitemia is often associated with nonimmune hemolysis, and can be treated with erythrocytapheresis. Just as warm autoantibodies have been reported in malaria infection, the development of autoantibody-mediated immune hemolysis has been reported in babesiosis. We treated a previously healthy male with multiple injuries from a motor vehicle accident necessitating massive transfusion. Late in the hospitalization, his blood smear revealed Babesia microti, confirmed by PCR study and serology. This was eventually traced to a unit of blood from an asymptomatic blood donor that was transfused during his initial trauma care. Specific antibiotic therapy was begun, and severe hemolysis from a high parasite burden required red blood cell exchange which led to rapid abatement of the hemolysis. He had a positive DAT (IgG with a pan-reactive eluate) but no serum autoantibody. This persisted for 10 days following cessation of hemolysis, and became negative while still on antibiotics while his parasite burden became undetectable. Reports of autoimmunity associated with community acquired babesiosis often have severe hemolysis from their autoantibodies, but our case shows that autoantibodies may also follow transfusion-acquired babesiosis. The nature of the autoantigen is unknown.

Guidelines for Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage

In the United States, injury is the leading cause of death for persons aged 1--44 years, and the approximately 800,000 emergency medical services (EMS) providers have a substantial impact on the care of injured persons and on public health. At an injury scene, EMS providers determine the severity of injury, initiate medical management, and identify the most appropriate facility to which to transport the patient through a process called "field triage." Although basic emergency services generally are consistent across hospital emergency departments (EDs), certain hospitals have additional expertise, resources, and equipment for treating severely injured patients. Such facilities, called "trauma centers," are classified from Level I (centers providing the highest level of trauma care) to Level IV (centers providing initial trauma care and transfer to a higher level of trauma care if necessary) depending on the scope of resources and services available. The risk for death of a severely injured person is 25% lower if the patient receives care at a Level I trauma center. However, not all patients require the services of a Level I trauma center; patients who are injured less severely might be served better by being transported to a closer ED capable of managing milder injuries. Transferring all injured patients to Level I trauma centers might overburden the centers, have a negative impact on patient outcomes, and decrease cost effectiveness. In 1986, the American College of Surgeons developed the Field Triage Decision Scheme (Decision Scheme), which serves as the basis for triage protocols for state and local EMS systems across the United States. The Decision Scheme is an algorithm that guides EMS providers through four decision steps (physiologic, anatomic, mechanism of injury, and special considerations) to determine the most appropriate destination facility within the local trauma care system. Since its initial publication in 1986, the Decision Scheme has been revised four times. In 2005, with support from the National Highway Traffic Safety Administration, CDC began facilitating revision of the Decision Scheme by hosting a series of meetings of the National Expert Panel on Field Triage, which includes injury-care providers, public health professionals, automotive industry representatives, and officials from federal agencies. The Panel reviewed relevant literature, presented its findings, and reached consensus on necessary revisions. The revised Decision Scheme was published in 2006. This report describes the process and rationale used by the Expert Panel to revise the Decision Scheme.

Prehospital interventions: time wasted or time saved? An observational cohort study of management in initial trauma care

Objective:Preclinical actions in the primary assessment of victims of blunt trauma may prolong the time to definitive clinical care. The aim of this study was to examine the duration of...

Asistencia inicial al traumatismo pediátrico y reanimación cardiopulmonar

Accidents are a frequent cause of death in children older than 1 year. The most frequent causes of death by accident are traffic accidents, drowning, intentional injuries, burns, and falls. Cardiopulmonary resuscitation is one component of the set of actions needed to obtain initial stabilization of a child with serious trauma. In the first few minutes after the accident, cardiorespiratory arrest can occur due to airway obstruction or inadequate ventilation, massive blood loss or severe brain damage; cardiorespiratory arrest in this setting has a dismal outcome. When arrest occurs hours after trauma, it is usually caused by hypoxia, hypovolemia, hypothermia, intracranial hypertension, or electrolyte disturbances. The first response to trauma should include three objectives: to protect (scenario assessment and implementation of safety measures), to alert (activation of the emergency medical system) and to help (initial trauma care). Initial trauma care includes primary and secondary surveys. The primary survey involves several consecutive steps: A. airway and cervical spine stabilization, B. breathing, C. circulation and hemorrhage control, D. neurological dysfunction, and E. exposure. The secondary survey consists of assessment of the victim by means of anamnesis, sequential physical examination (from head to limbs) and complementary investigations. During emergency trauma care, specific procedures such as extrication and mobilization maneuvers, cervical spine control by means of bimanual immobilization, and cervical collar placement or helmet removal. If a cardiorespiratory arrest occurs during initial trauma care, resuscitation maneuvers must be immediately started with the specific adaptations indicated in children with trauma.

Clinical impact of advanced trauma life support

The Advanced Trauma Life Support (ATLS) course sponsored by the American College of Surgeons Committee On Trauma (ACSCOT) presents a standardized method of initial trauma care. This study attempted to measure any changes in morbidity and mortality in trauma patients after the introduction of ATLS training. Over a 3-year period (May 1996 to September 1997—pre-ATLS period; December 1997 to April 1999—post-ATLS period), 63 trauma patients with an Injury Severity Scale (ISS) ≥16 (n = 31, pre-ATLS and n = 32, post-ATLS) were prospectively studied in two community teaching hospitals. There was no significant difference in mortality rate between groups (48% [15 of 31] pre-ATLS vs. 30% [10 of 32] post-ATLS; P = .203, Fisher exact test). Mortality rates within the ISS range of 16 to 25 were 64% (nine of 14 pre-ATLS) versus 29% (five of 17 post-ATLS), and for the ISS 26 to 35 subgroup, 40% (four of 10 pre-ATLS) versus 25% (two of eight post-ATLS), and within the ISS 36 to 75 subgroup, 29% (two of seven pre-ATLS) versus 43% (three of seven post-ATLS). There was a significant difference in mortality during the first 60 minutes after admission: 0.0% post-ATLS versus 24.2% pre-ATLS ( P = .002, Fisher exact test (95% confidence interval ranged from 12–45% in the pre-ATLS group and 0–11% in the post-ATLS group). According to the TRISS methodology (a worldwide-accepted mathematical method to calculate chances of survival through logistical regression),ATLS improved outcome from sub-“Major Trauma Outcome Study” (MTOS) standard results (z = −2.9 to a MTOS standard result z = −0.49). Our data demonstrate that introduction of the ATLS program significantly improved trauma patient outcome in the first hour after admission, as well as improvement from sub-MTOS standard to MTOS standard levels.

Advanced Trauma Life Support Study: Trauma Resuscitation Time

The Advanced Trauma Life Support (ATLS®) course teaches procedures for administering initial trauma care. This study attempts to document changes that occurred in institutions after ATLS® training had been introduced. Prospective analysis by videotape review of trauma resuscitations in two community training hospitals was performed. The major outcome measure was the time to accomplish procedures defined in the ATLS® curriculum. There was a significant post-ATLS® improvement in frequency of the following diagnostic and therapeutic activities: obtaining arterial blood samples, hypothermia management, ultrasound examination of the abdomen and rectal examination. The median time to obtain the neurologic status decreased from 6 to 2 min (p = 0.019). The hospital trauma resuscitation time (TRT) was 49 min in both groups. ATLS® training significantly improves a number of qualitative and quantitative aspects of acute trauma resuscitation.

Pre-Hospital and Initial In-Hospital Trauma Care: Evaluation of a European Model

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General surgeons and the Advanced Trauma Life Support course: is it time to refocus?

The aim of this study was to assess Advanced Trauma Life Support (ATLS) training status of general surgeons, its perceived utility, and its relation to clinical trauma practice. A national sample of 1300 general surgeons was surveyed by mail about trauma training, ATLS status, trauma call, and confidence in clinical trauma care abilities. Response rate was 61%. Respondents most commonly (67%) felt they learned a great deal about trauma care in residency training; 13% responded similarly regarding ATLS. Course participation within 4 years of the survey was reported by 33% of respondents. Nearly 75% of those not taking the course cited primary reasons related to relevance (30%), redundancy (29%), and credentialing (15%). Inaccessibility, inconvenience, and cost were lesser factors. Of those expressing extreme confidence with trauma resuscitation, 40% had taken ATLS; 15% of those expressing a lesser degree of confidence had taken ATLS. The ATLS course represents a standard of initial trauma care education in which only one-third of surgeons report current participation. Many view ATLS as not relevant or useful, yet take trauma call. To ensure standard education and patient care, an ATLS course curriculum specifically geared to the general surgeon should be developed and made a mandatory component of residency training or a requirement for board certification and trauma call credentialing.

B-11 Initial pediatric trauma care: Air vs. ground transport

B-11 Initial pediatric trauma care: Air vs. ground transport