Modern Trauma Care Research Articles

The MOST (Mortality Score for TBI): A Novel Prediction Model Beyond CRASH-Basic and IMPACT-Core for Isolated Traumatic Brain Injury

BackgroundDue to significant injury heterogeneity, outcome prediction following traumatic brain injury (TBI) is challenging. This study aimed to develop a simple model for high-accuracy mortality risk prediction after TBI. Study DesignData from the American College of Surgeons (ACS) Trauma Quality Program (TQP) from 2019 to 2021 was used to develop a summary score based on age, the Glasgow Coma Scale (GCS) component subscores, and pupillary reactivity data. We then compared the predictive accuracy to that of the Corticosteroid Randomisation After Significant Head Injury Trial (CRASH)-Basic and International Mission for Prognosis and Analysis of Clinical Trial in TBI (IMPACT)-Core models. Two separate series of sensitivity analyses were conducted to further assess our model's generalizability. We evaluated predictive performance of the models with discrimination [the area under the receiver-operating characteristic curves (AUC), sensitivity, specificity] and calibration (Brier score). Discriminative ability was compared with DeLong tests. Results259,404 patients were included in the present study (mean age, 60 years; 93,495 (36%) female). The mortality score after TBI (MOST) model (AUC = 0.875) had better discrimination (DeLong test p values < 0.00001) than CRASH-Basic (AUC = 0.837) and IMPACT-Core (AUC = 0.821) models, and superior calibration (MOST = 0.02729, CRASH-Basic = 0.02962, IMPACT-Core = 0.02962) in predicting in-hospital mortality. The MOST model similarly outperformed in predicting 3-, 7-, 14-, and 30-day mortality. ConclusionThe MOST model can be rapidly calculated and outperforms two widely used models for predicting mortality in TBI patients. It utilizes a larger, contemporaneous dataset that reflects modern trauma care.

Safety and efficacy in the management of older patients with displaced intracapsular hip fractures

The management of the older person with a displaced intracapsular hip fracture is one of the most significant aspects of musculoskeletal trauma. These patients require prompt, integrated pathway delivered care. The care delivered outside of the operating theatre and that performed within, are intertwined. Traditionally, surgeons have focussed predominantly only on the operative elements. In modern trauma care for older people, this focus must broaden. We provide for the first time a comprehensive overview of all elements of care for this important patient group. This brings together pathway elements from the National Hip Fracture Database Key Performance Indicators and NICE guidance alongside a synthesis of all current research output for intracapsular hip fracture.

Applications of Deep Learning in Trauma Radiology: A Narrative Review

Diagnostic imaging is essential in modern trauma care for initial evaluation and identifying injuries requiring intervention. Deep learning (DL) has become mainstream in medical image analysis and has shown promising efficacy for classification, segmentation, and lesion detection. This narrative review provides the fundamental concepts for developing DL algorithms in trauma imaging and presents an overview of current progress in each modality. DL has been applied to detect free fluid on Focused Assessment with Sonography for Trauma (FAST), traumatic findings on chest and pelvic X-rays, and computed tomography (CT) scans, identify intracranial hemorrhage on head CT, detect vertebral fractures, and identify injuries to organs like the spleen, liver, and lungs on abdominal and chest CT. Future directions involve expanding dataset size and diversity through federated learning, enhancing model explainability and transparency to build clinician trust, and integrating multimodal data to provide more meaningful insights into traumatic injuries. Though some commercial artificial intelligence products are Food and Drug Administration-approved for clinical use in the trauma field, adoption remains limited, highlighting the need for multi-disciplinary teams to engineer practical, real-world solutions. Overall, DL shows immense potential to improve the efficiency and accuracy of trauma imaging, but thoughtful development and validation are critical to ensure these technologies positively impact patient care.

Patient perspectives of recovery following major musculoskeletal trauma: A systematic review and qualitative synthesis

Background Improved survival following major trauma has resulted in an increased number of patients with complex physical, functional and psychosocial needs requiring specialist multidisciplinary rehabilitation. A key challenge in modern trauma care is to deliver rehabilitation interventions that translate into improved outcomes. This study aimed to synthesise patient perceptions of recovery following major musculoskeletal trauma. Methods A pre-planned literature search (CINAHL, Medline, Embase, PsychInfo, and other sources) was performed 28/02/22–03/03/22 (updated 29/3/23–17/4/23 prior to submission) to capture all available qualitative or mixed methods studies describing major musculoskeletal trauma recovery from the patient perspective. Quality assessment was performed using the Joanna Briggs evaluation tool and the mixed methods appraisal tool. The qualitative data was thematically analysed. Findings Of 5648 distinct studies, 18 studies met the criteria for inclusion totalling 637 participants. Thematic analysis of the qualitative data found that recovery following major musculoskeletal trauma has physical, psychological and socio-functional dimensions. Successful recovery involves ‘crafting a new normal’ and is both a process and an outcome. Three major themes were identified: vulnerability; learning to manage; adaptation and adjustment. Patients do not experience each theme in a linear way; instead, they move through the recovery process in an individualised and cyclical manner. Conclusion This review highlights the individual experience of recovery, which requires flexible and holistic care to facilitate an occupational (or socio-functional) perspective on major musculoskeletal trauma recovery. Therefore, organisationally, an effective multi-disciplinary team model of care is essential to support survival as a long-term condition.

External fixators usage in two hospitals in Delta State south-south Nigeria

Objective: To present our experience in the use of various types of external fixators in two government owned hospitals in Delta State, Nigeria.Methods: A retrospective review of patients managed with external fixators over a period of 8 years – January 2012 to December 2019, in two government owned hospitals in Delta State, Nigeria. Relevant information including bio-data, indications for external fixation, types of external fixator applied, length of time fixators were applied, etc were collected and analysed using IBM SPSS version 22.Results: A total of 94 patients (56 males and 38 females) were included in this study giving a male: female ratio of 1.5 : 1. The mean age of patients was 33.7+ 15.9 years. Four types / designs of external fixators were used, the mono-planar AO design were the ones most commonly used (67.7%), followed by the linear rail system (LRS) type (17.2%). The most common indication for external fixator application was open fractures in 67.7% of cases, followed by bone gaps resulting from bone loss (11.1%). External fixators were used as adjunct to other treatment modalities in 59 applications (59.6%) and as the definitive treatment method in 40 applications (40.4%). The commonest solution used for pin site care was Povidone iodine in 53 patients (56.4%). The mean length of time patients were on external fixators was 124.8 days (17.8 weeks). Pin tract infection was the commonest complication encountered (26.6%). The commonest indication for removal of external fixators was the healing of the wounds in open fractures with conversion to other forms of treatment, commonly cast application (42.6%). The initial aim of applying the external fixator was achieved in 75% of cases.Conclusion: External fixators have become indispensable tools in the armamentarium of modern day Orthopaedic and trauma care. Our health facilities have also effectively keyed into this.

Managing the acutely threatened airway following head and neck trauma – Requiem for cricothyroidotomy?

• Paucity of skills to establish a surgical airway in patients presenting with head and neck trauma. • 242 patients required a surgical airway; 98% surgical tracheostomy, 2% surgical cricothyroidotomy. • The use of cricothyroidotomy in modern trauma appears to be very limited. Trauma to the head and neck results in acute facial trauma and swelling, which may occlude the airway and result in fatal hypoxia. The management is the establishment of a definitive airway. This paper reviews our experience with this clinical scenario. A retrospective study was conducted over a seven-year period from December 2012 to January 2020 at a major trauma centre in South Africa on all adult trauma patients who required a surgical airway procedure (surgical cricothyroidotomy (SC) or surgical tracheostomy (ST)). From December 2012 to January 2020, 12243 trauma patients were admitted. Of those, 242 patients required a surgical airway: 98% (238/242) underwent ST and 2% (4/242) underwent SC. A total of 3271 patients sustained trauma predominantly confined to the face and neck. The mechanism was penetrating trauma in 1077 and blunt trauma in 2194. Total of 51 patients required an emergency airway for acute head and neck trauma. There were four SC's and 47 ST's. Of the four SC, three were inserted secondary to multiple failed attempts at intubation and one was inserted directly into an open tracheal injury. All of these were performed in the resuscitation room. The 47 ST's were performed under conscious sedation in the operating theatre. There were eight failed intubations in the 51 patients with head and neck trauma, and of those three required an emergency SC and five required an emergency ST. The use of cricothyroidotomy in modern trauma care in our environment appears to be very limited.

Coagulopathy related to trauma: Is it time for a goal-directed approach?

Trauma represents a leading cause of death globally, and post-traumatic haemorrhage accounts for 40% of early mortality in spite of recent improvements in modern trauma care.1 Post-traumatic haemorrhage occurs primarily from direct injury to blood vessels, leading to exsanguination and hypovolaemic shock depending on the type and calibre of the affected vessels. However, one-third of

Pelvic fracture-related hypotension: A review of contemporary adjuncts for hemorrhage control.

Major pelvic hemorrhage remains a considerable challenge of modern trauma care associated with mortality in over a third of patients. Efforts to improve outcomes demand continued research into the optimal employment of both traditional and newer hemostatic adjuncts across the full spectrum of emergent care environments. The purpose of this review is to provide a concise description of the rationale for and effective use of currently available adjuncts for the control of pelvic hemorrhage. In addition, the challenges of defining the optimal order and algorithm for employment of these adjuncts will be outlined. Review, level IV.

Venous Chimney Procedure: A Novel Technical Solution to Prevent Iatrogenic Budd– Chiari Syndrome Following Retrohepatic Vena Cava Injury

Traumatic inferior vena cava (IVC) lesions account for approximately 25% of abdominal vascular injuries and are among the most challenging and lethal lesions sustained by trauma patients. Whether caused by blunt or penetrating mechanisms of injury, the overall mortality rate is up to 92%; as many as 50% of the patients with those injuries die before reaching medical care, and the mortality rate among patients who arrive to a trauma center, with signs of life and/or receive operative treatment, ranges between 20% and 57% (1).&#x0D; Retrohepatic Vena Cava (RHVC) injuries (RHVCI) are extremely rare and as such both the treating trauma surgeon, as well as the vascular surgeon, lacks the necessary experience to deal with such complicated injuries. The mortality rates secondary to these injuries are extremely high, even with damage control management concepts application. Improving the outcome of these injuries remains a significant challenge of modern trauma care (2, 3).&#x0D; The treatment of RHVCI confronts the treating surgeon, with major obstacles, which raises from the anatomic location of the RHVC at the posterior aspect of the liver and the abundancy of bridging veins between the RHVC and the liver. These anatomic obstacles creates a major technical challenge of gaining proximal and distal control, in proximity to the injured RHVC. This many times necessitates abdominal as well as thoracic exposure in order to gain proper control.&#x0D; The average trauma, as well as the vascular, surgeons are not familiar with handling such complex injuries. This is even truer as referred to the new generation of vascular surgeons, whose experience with open vascular surgery, mainly in such extreme situations, decreases with the increasing usage of endovascular techniques (4). &#x0D; The advancements in endovascular techniques have introduced new alternatives to traditional open repair strategies. In many cases, RHVCI treatment requires exploration of a retro-hepatic hematoma, which might be the single thing that prevents free venous rupture and as such, it should be avoided. Venous balloon occlusion is a novel endovascular strategy that may be particularly advantageous in those circumstances as a bridging maneuver, for proximal and distal control, during hybrid repair. Our case in unique since it highlights the option of total endovascular treatment, using arterial treatment concepts, to treat this extremely challenging injury. &#x0D;

Venous Chimney Procedure: A Novel Technical Solution to Prevent Iatrogenic Budd– Chiari Syndrome Following Retrohepatic Vena Cava Injury

Traumatic inferior vena cava (IVC) lesions account for approximately 25% of abdominal vascular injuries and are among the most challenging and lethal lesions sustained by trauma patients. Whether caused by blunt or penetrating mechanisms of injury, the overall mortality rate is up to 92%; as many as 50% of the patients with those injuries die before reaching medical care, and the mortality rate among patients who arrive to a trauma center, with signs of life and/or receive operative treatment, ranges between 20% and 57% (1).&#x0D; Retrohepatic Vena Cava (RHVC) injuries (RHVCI) are extremely rare and as such both the treating trauma surgeon, as well as the vascular surgeon, lacks the necessary experience to deal with such complicated injuries. The mortality rates secondary to these injuries are extremely high, even with damage control management concepts application. Improving the outcome of these injuries remains a significant challenge of modern trauma care (2, 3).&#x0D; The treatment of RHVCI confronts the treating surgeon, with major obstacles, which raises from the anatomic location of the RHVC at the posterior aspect of the liver and the abundancy of bridging veins between the RHVC and the liver. These anatomic obstacles creates a major technical challenge of gaining proximal and distal control, in proximity to the injured RHVC. This many times necessitates abdominal as well as thoracic exposure in order to gain proper control.&#x0D; The average trauma, as well as the vascular, surgeons are not familiar with handling such complex injuries. This is even truer as referred to the new generation of vascular surgeons, whose experience with open vascular surgery, mainly in such extreme situations, decreases with the increasing usage of endovascular techniques (4). &#x0D; The advancements in endovascular techniques have introduced new alternatives to traditional open repair strategies. In many cases, RHVCI treatment requires exploration of a retro-hepatic hematoma, which might be the single thing that prevents free venous rupture and as such, it should be avoided. Venous balloon occlusion is a novel endovascular strategy that may be particularly advantageous in those circumstances as a bridging maneuver, for proximal and distal control, during hybrid repair. Our case in unique since it highlights the option of total endovascular treatment, using arterial treatment concepts, to treat this extremely challenging injury. &#x0D;

Trauma Tertiary Survey: Trauma Service Medical Officers and Trauma Nurses Detect Similar Rates of Missed Injuries.

Trauma tertiary surveys (TTSs) can improve patient outcomes by identifying missed injuries following initial trauma reception and resuscitation. Most TTSs are conducted by medical officers despite the multidisciplinary team approach of modern trauma care. The study aim was to assess the accuracy of detecting missed injuries when the TTS was performed by specialist trauma nursing staff, rather than trauma service medical officers (TSMOs). A prospective, convenience sample of adult trauma patients admitted to a tertiary trauma center and attended by the trauma service between October 2015 and August 2018 was obtained. For this sample, a TTS was completed by both the TSMO and the trauma nurse (TN). The number of radiological investigations ordered and missed injuries identified were compared between the two clinicians. Additional injuries were graded using the Clavien-Dindo system. The study sample consisted of 165 patients with a dual TTS, for which at least one team member requested 35 additional radiological investigations. There was fair agreement (κ = 0.36) between the TN and the TSMO in requesting additional radiological investigations. Ten missed injuries were identified by TN-initiated review (n = 24), and 4 missed injuries were identified by TSMO-initiated review (n = 21). Injuries identified following TTSs ranged in severity grading from 0 to 3. Performance of the TN on the TTS in the identification of missed injuries is similar to that of the TSMO. Trauma nurses use an appropriate and rationalized approach to ordering additional radiological investigations and contribute a valuable addition to trauma patient care.

Use of REBOA in the universe of magical realism: a real-world review

While reading the novella “Chronicle of a Death Foretold” by the Colombian Nobel Laureate Gabriel García-Marquez, we were surprised to realize that the injuries sustained by the main character could have been successfully treated had he received modern trauma care in which REBOA may have been considered. This is a discussion of Mr. Nasar's murder to explore whether he could have been saved by deploying REBOA as a surgical adjunct to bleeding control and resuscitation. In reading García-Marquez's novel we noted the events that unfolded at the time of Santiago Nasar's murder. To contextualize the claim that Mr. Nasar could have survived, had his injuries been treated with REBOA, we explored and illustrated what could have done differently and why. On the day of his death, Mr. Nasar sustained multiple penetrating stab wounds. Although he received multiple stab wounds to his torso, the book describes seven potentially fatal injuries, resulting in hollow viscus, solid viscus, and major vascular injuries. We provided a practical description of the clinical and surgical management algorithm we would have followed in Mr. Nasar's case. This algorithm included the REBOA deployment for hemorrhage control and resuscitation. The use of REBOA as part of the surgical procedures performed could have saved Mr. Nasar's life. Based on our current knowledge about REBOA in trauma surgery, we claim that its use, coupled with appropriate surgical care for hemorrhage control, could have saved Santiago Nasar's life, and thus prevent a death foretold.

Honoring the Father of Modern Trauma Care: F. William Blaisdell, MD

Honoring the Father of Modern Trauma Care: F. William Blaisdell, MD

The Impact of the Tertiary Survey in an Established Trauma Program.

The trauma tertiary survey (TTS) was first described in 1990 and is recognized as an essential practice in trauma care. The TTS remains effective in detecting secondary injuries in the modern era. Trauma patients discharged between August 1, 2016, and December 31, 2016, were identified in our trauma registry. Collected data include TTS completion rates, detection of injuries, type of provider, and timing. TTS documentation was qualitatively evaluated. Out of 407 patients, 264 patients (65%) received a TTS. Injury detection rate was 1.1.%. Average time to TTS was 41 hours. TTS were completed by resident physicians (46%) and advanced practice providers (APPs; 46%). TTS documentation was more complete for APPs than for resident physicians. TTS remains an integral component of modern trauma care. Ongoing education on the significance of TTS and the importance of thorough documentation is essential. Provision of real-time feedback to providers is also critical for improving current practices.

A public-private collaborative model for a trauma program implementation: findings from a prospective trauma registry at 14 hospitals in Buenos Aires, Argentina.

Trauma is a leading cause of mortality and comprises an important cause of functional impairment among young people worldwide. The trauma registry (TR) is an integral component of modern comprehensive trauma care systems. Nevertheless, TRs have not been yet established in most developing countries. The objective of this study was to summarize the challenges, results, and lessons learned from a trauma program including initial results from a TR at tertiary-care public hospitals of Buenos Aires, Argentina. This is a descriptive study of the implementation of a trauma program in 14 hospitals and analysis of the initial results in the period between January 2010 and December 2018, using data from Fundación Trauma TR. Patients fitting injury definition that remained in hospital for more than 23h were included. Injured patients were divided by age groups. Data on patients' demographics, mechanism of injury and severity, complications, treatments, and in-hospital mortality were analyzed between groups. A descriptive analysis is presented. There were 29,970 trauma cases during the study period. Median age was 23years (RIC 12, 39) with a 2.4:1 male-to-female ratio. Road traffic injuries (RTI) were the leading mechanism (30.8%) of admission and head was the most frequently injured body region (33.2%). Two-thirds of RTIs were motorcycle-related. Overall in-hospital mortality was 6.1%. Intentional self-harm in adult males and burns in adult females had the highest mortality rates (17.6% and 17.9%, respectively). The implementation of a trauma program within a public-private collaborative program in a resource-limited environment is feasible. The hospital-based TR can be used as a tool for injury surveillance, monitoring of the quality of trauma care, development of a trauma system, and to guide public health policies.

Modern Trauma Care: Damage Control Surgery and Damage Control Resuscitation-Brief report

Damage control surgery strategy (DCS) rested on rapid control of bleeding, containing abdominal contamination, resuscitating patient and performing definitive surgery on stabilized injured patient.Initialy described and evolved in liver trauma surgery , the DCS implementation has resulted in improving the critically injured patient survival leading to its widespread use in intra and extra-abdominal trauma and acute abdominal emergencies. Currently, the DCS strategy has become the standard practice for severely injured patients. However, the evolution of the DCS research has led to the development of the concept of damage control resuscitation (DCR) which includes early and massive blood transfusion, fluid restriction and permissive hypotension. The DCS and DCR form conjointly the modern trauma care for critically injured patients

Outcomes and complications for portal vein or superior mesenteric vein injury: No improvement in the era of damage control resuscitation

IntroductionPortal vein (PV) and superior mesenteric vein (SMV) injuries are lethal. We hypothesised outcomes have improved with modern trauma care. MethodsWe reviewed patients presenting to our Level 1 trauma centre over ten-years with PV/SMV injuries, analysing physiology, operative management, associated injuries, and outcomes. ResultsTwenty-four patients had 7 PV and 15 SMV injuries, 2 had both; all had operative exploration. Sixty-seven percent had penetrating trauma. While many had normal vitals, profound acidosis was common. All patients had ≥2 additional abdominal injuries, liver most common (50%). Additional abdominal vascular injuries were more common in non-survivors than survivors: IVC 46% vs 22%, common hepatic artery 20% vs 0%, SMA 26% vs 11%. The mean injury severity score (ISS) was 32.4, and the mean new injury severity score (NISS) was 44.5. Mortality was 63%. Eleven patients died from exsanguination, two from SMV thrombosis, and two from sequelae of other injuries. All survivors had venorrhaphy, as did 8 non-survivors. Non-survivors were also shunted; had ligation; or bypass, shunting, and ligation. Three exsanguinated prior to repair. Two survivors had SMV related complications. One with proximal SMV injury developed severe venous congestion and multiple enterocutaneous fistulae. Another developed an arterioportal fistula, managed with embolisation and percutaneous portal vein stenting. ConclusionDespite advances (REBOA, damage control surgery and resuscitation, liberal use of ED thoracotomy), PV and SMV injuries remain lethal. Injuries to other structures are ubiquitous. Early exsanguination is the major cause of death. All survivors had successful venorrhaphy; those who required more complex repairs died. Compromised mesenteric venous flow causes morbidity and mortality.

Donald D. Trunkey, MD … The father of modern trauma care

Donald D. Trunkey, MD … The father of modern trauma care

Helicopter air ambulance services.

Helicopter air ambulances are an integral component of modern trauma care, and are able to transport patients to facilities with greater capabilities, extract injured patients from hostile terrain, and speed transport to a trauma center. HAA transport does not reduce the total time required to transport a patient, but it does reduce the time that the patient is between healthcare facilities. Factors that have been suggested to improve outcomes for trauma patients include the availability of advanced interventions, skilled personnel, speed, and trauma center access. Despite their potential benefits to the patient, HAA operations carry significant risks. HAA operations are among the most dangerous professions for both pilot and crew with a mortality rate greater than commercial fishing, loggers, and steelworkers. The US Federal Aviation Administration (FAA) has identified that the four most common causes of HAA accidents as inadvertent flight into instrument meteorological conditions, loss of control, controlled flight into terrain, and night conditions. HAA operations are safe and can improve patient care, but additional research is needed to improve our understanding of HAA operations and their effect on outcomes.

Changes in the temporal distribution of in-hospital mortality in severely injured patients-An analysis of the TraumaRegister DGU.

BackgroundThe temporal distribution of trauma mortality has been classically described as a trimodal pattern with an immediate, early and late peak. In modern health care systems this time distribution has changed.MethodsData from the TraumaRegister DGU was analysed retrospectively. Between 2002 and 2015, all registered in-hospital deaths with an Injury Severity Score (ISS) ≥ 16 were evaluated considering time of death, trauma mechanism, injured body area, age distribution, rates of sepsis and multiple organ failure. Pre-hospital and post-discharge trauma deaths were not considered.Results78 310 severely injured patients were registered, non-survivors constituted 14 816, representing an in-hospital mortality rate of 18.9%. Mean ISS of non-survivors was 36.0±16.0, 66.7% were male, mean age was 59.5±23.5. Within the first hour after admission to hospital, 10.8% of deaths occurred, after 6 hours the percentage increased to 25.5%, after 12 hours 40.0%, after 24 hours 53.2% and within the first 48 hours 61.9%. Mortality showed a constant temporal decrease. Severe head injury (defined by Abbreviated Injury Scale, AIS-Head≥3) was found in 76.4% of non-survivors. Patients with an isolated head injury showed a more distinct decrease in survival rate, which was accentuated in the first days after admission. The correlation of age and time of death showed a proportional increase with age (55-74a). The rate of sepsis and multiple organ failure among non-survivors was 11.5% and 70.1%, respectively.ConclusionIn a modern trauma care system, the mortality distribution of severely injured patients has changed its pattern, where especially the third peak is no longer detectable.