Scene Of Injury Research Articles

The effect of interhospital transfer on pediatric burn injury mortality in a resource-limited setting.

The World Health Organization's burn mortality estimate is 180,000 annually. Ninety-five percent of all mortality caused by fire-related burns worldwide occurs in low- and middle-income countries (LMICs). Prior studies have shown that transfer status (direct transfer from an injury scene to a trauma center vs. indirect transfer from another health facility) affects patient outcomes. We evaluated the effect of interhospital transfer on burn mortality. We analyzed a burn database of pediatric patients admitted to the Kamuzu Central Hospital (KCH) burn unit in Lilongwe, Malawi. We performed a bivariate analysis based on their transfer status and mortality and a logistic regression analysis to determine the effect of transfer status on mortality after burn injury. A total of 2301 patients were analyzed, with 1095 (47.6%) being in the transfer cohort from referring hospitals. The median age was 3years (IQR 1-4). The transfer cohort had more patients presenting to the hospital more than 48h after injury. Upon multivariate logistic regression, controlling for pertinent variables, including time to presentation, burn-injured patients in the transfer cohort had increased odds of mortality (OR 2.26, 95% CI 1.22-4.19, and p=0.01) compared to patients who were not transferred. The predictive probabilities of burn mortality by TBSA showed significant differences in mortality based on transfer status at TBSA between 20% and 80%. Ensuring district hospitals and other primary health care centers in resource-limited settings are sufficiently equipped to provide initial burn resuscitation and care may decrease mortality rates associated with transferred patients.

Development and validation of prediction models for prehospital triage of military trauma patients.

The introduction of wireless sensors will enable military care providers to continuously and remotely assess/monitor vital signs. Prediction models are needed to use such data adequately and aid military care providers in their on-scene decision-making to optimise prehospital triage and improve patient outcomes. A prospective cohort comprising data from eight Emergency Medical Services and seven inclusive trauma regions was used to develop and validate prediction models that could aid military care providers in their prehospital triage decisions. Healthy (American Society of Anesthesiologists physical status classification 1 or 2) admitted adult trauma patients (aged ≥16 and ≤50 years), who suffered from a trauma mechanism that could occur to military personnel and were transported by ambulance from the scene of injury to a hospital, were included. A full model strategy was used, including prehospital predictors that are expected to be automaticly collectible by wireless sensors or to be incorporated in a personalised device that could run the models. Models were developed to predict early critical-resource use (ECRU), severe head injury (Abbreviated Injury Scale (AIS) ≥4), serious thoracic injury (AIS ≥3) and severe internal bleeding (>20% blood loss). Model performance was evaluated in terms of discrimination and calibration. Prediction models were developed with data from 4625 patients (80.0%) and validated with data from 1157 patients (20.0%). The models had good to excellent discriminative performance for the predicted outcomes in the validation cohort, with an area under the curve of 0.80 (95% CI 0.76 to 0.84) for ECRU, 0.83 (0.76 to 0.91) for severe head injury, 0.75 (0.70 to 0.80) for serious thoracic injury and 0.85 (0.78 to 0.93) for severe internal bleeding. All models showed satisfactory calibration in the validation cohort. The developed models could reliably predict outcomes in a simulated military trauma population and potentially support prehospital care providers in their triage decisions.

Trauma-induced coagulopathy across age pediatric groups: A retrospective cohort study evaluating testing and frequency.

Trauma-induced coagulopathy (TIC) is associated with negative outcomes. Pediatric TIC has been described most often in older children. Children undergo normal developmental hemostasis, but it is unknown how this process impacts the risk of TIC across childhood. To understand variations in coagulation testing and TIC across pediatric age groups. We evaluated testing patterns of coagulation studies at presentation and over the first 72 h of hospitalization by pediatric age group at a large, Level I trauma center, 2015-2020. The frequency of TIC was determined using published, age-specific reference ranges and controlling for injury severity. We performed subgroup analyses of those with isolated severe traumatic brain injury (TBI) and those who presented directly from the scene of injury. Data from 2409 pediatric patients were available; 333 patients had isolated severe TBI. Children <1 year were least likely to be tested for TIC at presentation and over the first 72 h, even among the most injured. Fibrinogen testing was uncommon, regardless of injury severity. TIC was common: 22% of patients had TIC at presentation and 35% by 72 h. Greater injury severity was associated with TIC. Children 1-4 and 5-9 years had a higher frequency of TIC at presentation and over 72 h compared to older children in the least injured cohort. We saw no difference in frequency of TIC between age groups in the subset with isolated severe TBI. Using age-specific criteria, patients most often met TIC criteria by INR/PT, followed by platelet count, and least commonly by aPTT. The presence of TIC was associated with in-hospital mortality (OR 4.10, 95% CI 2.06-8.17). Significant sampling bias exists in clinical data collection among injured children and adolescents. Contrary to previous reports and using age-specific TIC criteria, younger children are not at lower risk of TIC than older children when controlling for injury severity.

Enhancing Performance of the National Field Triage Guidelines Using Machine Learning: Development of a Prehospital Triage Model to Predict Severe Trauma.

Prehospital trauma triage is essential to get the right patient to the right hospital. However, the national field triage guidelines proposed by the American College of Surgeons have proven to be relatively insensitive when identifying severe traumas. This study aimed to build a prehospital triage model to predict severe trauma and enhance the performance of the national field triage guidelines. This was a multisite prediction study, and the data were extracted from the National Trauma Data Bank between 2017 and 2019. All patients with injury, aged 16 years of age or older, and transported by ambulance from the injury scene to any trauma center were potentially eligible. The data were divided into training, internal, and external validation sets of 672,309; 288,134; and 508,703 patients, respectively. As the national field triage guidelines recommended, age, 7 vital signs, and 8 injury patterns at the prehospital stage were included as candidate variables for model development. Outcomes were severe trauma with an Injured Severity Score ≥16 (primary) and critical resource use within 24 hours of emergency department arrival (secondary). The triage model was developed using an extreme gradient boosting model and Shapley additive explanation analysis. The model's accuracy regarding discrimination, calibration, and clinical benefit was assessed. At a fixed specificity of 0.5, the model showed a sensitivity of 0.799 (95% CI 0.797-0.801), an undertriage rate of 0.080 (95% CI 0.079-0.081), and an overtriage rate of 0.743 (95% CI 0.742-0.743) for predicting severe trauma. The model showed a sensitivity of 0.774 (95% CI 0.772-0.776), an undertriage rate of 0.158 (95% CI 0.157-0.159), and an overtriage rate of 0.609 (95% CI 0.608-0.609) when predicting critical resource use, fixed at 0.5 specificity. The triage model's areas under the curve were 0.755 (95% CI 0.753-0.757) for severe trauma prediction and 0.736 (95% CI 0.734-0.737) for critical resource use prediction. The triage model's performance was better than those of the Glasgow Coma Score, Prehospital Index, revised trauma score, and the 2011 national field triage guidelines RED criteria. The model's performance was consistent in the 2 validation sets. The prehospital triage model is promising for predicting severe trauma and achieving an undertriage rate of <10%. Moreover, machine learning enhances the performance of field triage guidelines.

Administration of Burns First Aid Treatment to Aboriginal and Torres Strait Islander children in community settings

ObjectiveThis paper investigates Burn First Aid Treatment (BFAT) provided to Aboriginal and Torres Strait Islander children in Australia at the scene of injury using data from a population-based cohort study. Study DesignThe participants were 208 Aboriginal and Torres Strait Islander children aged < 16 years who sustained a burns injury between 2015–2018, and their carers. The primary outcome measure was gold standard BFAT, (defined as at least 20 min of cool, running water within 3 h of the injury); additional measures included type of first aid, length of first aid provided, and carer's knowledge of first aid. ResultsOf the 208 caregivers, 168 provided open-ended responses that indicated first aid was applied to their child; however, only 34 received gold standard BFAT at the scene of the injury, 110 did not receive correct BFAT, and 24 were unsure what first aid was applied. ConclusionThis study highlights an important need for communities to have access to appropriate evidence-based and co-designed BFAT education and training.

PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study.

Cervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department. In this prospective observational cohort study, we screened children aged 0-17 years presenting with known or suspected blunt trauma at 18 specialised children's emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child's neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21-28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the study population to estimate the potential effect on reducing CT and x-ray use in the paediatric emergency department. This study is registered with ClinicalTrials.gov, NCT05049330. Nine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1-11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9-14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7-97·9) sensitivity, 60·4% (59·4-61·3) specificity, and 99·9% (99·8-100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays. Incorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments. The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration of the US Department of Health and Human Services in the Maternal and Child Health Bureau under the Emergency Medical Services for Children programme.

Prognostic Scores for Mortality in Invasive Mechanically Ventilated Burn Patients.

Managing burn patients is a challenge requiring a multidisciplinary team with the ability to predict complications and act early to avoid them. There are few studies characterizing the population of critically ill burn patients in need of ventilatory support. This study aimed to describe the population of burn patients in need of invasive mechanical ventilation supportand assess in-hospital mortality and the factors associated with it. A longitudinal retrospective study was conducted, including burn patients admitted to a tertiary hospital burn unit over five consecutive years, who required invasive mechanical ventilation support during their hospitalization. Demographic data, comorbidities, characteristics of the injury scene, etiology, and characteristics of the burn were collected.Length of mechanical ventilation and hospitalization as well as mortality rate were evaluated.The determination of mortality predictors and the prognostic performance of mortality prediction scores were analyzed. A one-year follow-up was performed to evaluate the survival of discharged patients. A total of 141 patients were included in this study; 68.1% patients were malewith a median age of 58 years. The mean percentage of total body surface area (TBSA) burned was 24.5%. Home incidents were the most frequent, and fire was the most common cause of burns (80.9% of patients). The mean Abbreviated Burn Severity Index Score (ABSI) was 7.83, with an area under the curve in receiver operating characteristic curve (ROC) analysis (AUC_ROC) of 0.725; the mean Belgium Outcome of Burn Injury (BOBI) score was 3.45, with AUC_ROC of 0.740 and mean R-Baux of 89.1 and AUC_ROC of 0.834. The mean duration of invasive mechanical ventilation was 16.9±19.3 days. Age (p<0.001), length of mechanical ventilation (p<0.001), length of hospitalization (p<0.001), higher degree of burn (p=0.001), TBSA (p=0.040), and the presence of buttock burn (0.006) were associated with mortality in this sample. In-hospital mortality was 29.8%. The survival group had a 12% death rate at one-year follow-up, mostly in the first three months after discharge. Age, duration of mechanical ventilation, length of hospitalization, higher degree of burn, TBSA, and the presence of buttock burn were associated with mortality in this sample. R-Baux score was the most accurate test score to predict mortality in this challenging group of patients.

Identification of severely injured children at very low risk of emergent surgery: A national trauma registry study

ObjectiveThe number of pediatric trauma patients requiring surgical interventions has been steadily decreasing allowing for a judicious approach to immediately available resources. This study aimed to derive and validate a prediction rule that reliably identifies injured children who are at very low risk for requiring emergency surgery upon emergency department (ED) arrival. MethodsA retrospective cohort study of data included in the Israeli National Trauma Registry from January 1, 2011, through December 31, 2020, was conducted. We included children aged 0–14 years who presented to EDs from the scene of injury and were hospitalized. We excluded patients transferred between facilities or with isolated burns. The primary outcome was emergency operative intervention (EOI) performed within one hour of ED arrival. We tested mechanism, GCS, heart rate, and blood pressure as candidate predictors. We then randomized patients to two cohorts, derived and internally validated a prediction rule. ResultsDuring the study period, 83,859 children met enrollment criteria. The median age was 6 years (IQR 2–10) and 56,867 (67.8 %) were male; 75,450 (90.0 %) sustained blunt trauma. One hundred sixty-nine (0.20 %) children underwent EOI. In the derivation and validation cohorts, 34,138 (81.4 %) and 34,271 (81.7 %) patients, were classified as low risk based on blunt trauma mechanism, normal GCS (15), and low-risk heart rate (according to age). Of those, 8 (0.02 %) and 13 (0.04 %) required an EOI, respectively. In the validation cohort, the prediction rule for EOI had a sensitivity of 84 % (95 % CI 75–91), a specificity of 82 % (95 % CI 81–82), and a negative predictive value of 99.96 % (95 % CI 99.94–99.98). Among children with an Injury Severity Score>15, the sensitivity was 87 % (95 % CI 77–94), the specificity of 57 % (95 % CI 54–59), and the negative predictive value was 98.97 % (95 % CI 98.13–99.44). ConclusionsA limited set of physiologic parameters, readily available at hospital admission can effectively identify injured children at very low risk for emergent surgery. For these children, immediate deployment of surgical resources may not be necessary.

Field trauma triage criteria associated with need for dedicated trauma center care: a single-center retrospective cohort study.

Direct transport from the scene of injury to a trauma centre reduces saves lives. In Ontario,paramedics use the field trauma triage standard (FTTS) to determine if a patient meets trauma bypass criteria. Recent studies have questioned the efficacy of the FTTS in identifying severely injured patients. The objective of this study was to determine the predictive performance of the FTTS on the need for trauma center care in patients who were transported to a trauma center. This was a single-center health records study of patients transported by ambulance directly to a level 1 trauma center. Hospital based trauma center need and injury severity score-based needwere defined. Bivariate associations with one or more FTTS criteria were tested using the Wilcoxon two-sample test for continuous variables, and the Chi-square or Fisher's exact test for categorical indicators. The sensitivity and specificity of each category of the FTTS were calculated. There were 1427 patients included in the study, with76% men, mean age of 40, and 76% had a blunt mechanism. The overall sensitivity and specificity of the FTTS was 90.9% and 20.8% for hospital-based needand 91.6% and 20.3 for injury severity need. The most sensitive variable for hospital-based need was physiologic criteria (53.7).Mechanism of injury was the most sensitive criteria for injury severity need(54.8). Physiological criteria had the highest association with hospital-based and injury severity need (adjusted odds ratios 7.5[95% CI 5.8-9.8] and 5.1[95% CI 3.9-6.7]). The FTTS has fair performance in identifying the need for hospital-based and injury severity need. Systolic blood pressure less than 90mmHg, Glasgow Coma Scale (motor) less than 6,and falls greater than 6m were most predictive of trauma center need. Improving prehospital trauma triage is critical to ensure timely transport to a trauma centre.

Current state of technical transfusion medicine practice for out-of-hospital blood transfusion in Canada.

Canadian out-of-hospital blood transfusion programmes (OHBTPs) are emerging, to improve outcomes of trauma patients by providing pre-hospital transfusion from the scene of injury, given prolonged transport times. Literature is lacking to guide its implementation. Thus, we sought to gather technical transfusion medicine (TM)-specific practices across Canadian OHBTPs. A survey was sent to TM representatives of Canadian OHBTPs from November 2021 to March 2022. Data regarding transport, packaging, blood components and inventory management were included and reported descriptively. Only practices involving Blood on Board programme components for emergency use were included. OHBTPs focus on helicopter emergency medical service programmes, with some supplying fixed-wing aircraft and ground ambulances. All provide 1-3 coolers with 2 units of O RhD/Kell-negative red blood cells (RBCs) per cooler, with British Columbia trialling coolers with 2 units of pre-thawed group A plasma. Inventory exchanges are scheduled and blood components are returned to TM inventory using visual inspection and internal temperature data logger readings. Coolers are validated to storage durations ranging from 72 to 124 h. All programmes audit to manage wastage, though there is no consensus on appropriate benchmarks. All programmes have a process for documenting units issued, reconciliation after transfusion and for transfusion reaction reporting; however, training programmes vary. Common considerations included storage during extreme temperature environments, O-negative RBC stewardship, recipient notification, traceability, clinical practice guidelines co-reviewed by TM and a common audit framework. OHBTPs have many similarities throughout Canada, where harmonization may assist in further developing standards, leveraging best practice and national coordination.

Epidemiology of Trauma-Related Hemorrhage and Time to Definitive Care Across North America: Making the Case for Bleeding Control Education.

Uncontrolled trauma-related hemorrhage remains the primary preventable cause of death among those with critical injury. The purpose of this investigation was to evaluate the types of trauma associated with critical injury and trauma-related hemorrhage, and to determine the time to definitive care among patients treated at major trauma centers who were predicted to require massive transfusion. A secondary analysis was performed of the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) trial data (N = 680). All patients included were predicted to require massive transfusion and admitted to one of 12 North American trauma centers. Descriptive statistics were used to characterize patients, including demographics, type and mechanism of injury, source of bleeding, and receipt of prehospital interventions. Patient time to definitive care was determined using the time from activation of emergency services to responder arrival on scene, and time from scene departure to emergency department (ED) arrival. Each interval was calculated and then summed for a total time to definitive care. Patients were primarily white (63.8%), male (80.3%), with a median age of 34 (IQR 24-51) years. Roughly one-half of patients experienced blunt (49.0%) versus penetrating (48.2%) injury. The most common types of blunt trauma were motor vehicle injuries (83.5%), followed by falls (9.3%), other (3.6%), assaults (1.8%), and incidents due to machinery (1.8%). The most common types of penetrating injuries were gunshot wounds (72.3%), stabbings (24.1%), other (2.1%), and impalements (1.5%). One-third of patients (34.5%) required some prehospital intervention, including intubation (77.4%), chest or needle decompression (18.8%), tourniquet (18.4%), and cardiopulmonary resuscitation (CPR; 5.6%). Sources of bleeding included the abdomen (44.3%), chest (20.4%), limb/extremity (18.2%), pelvis (11.4%), and other (5.7%). Patients waited for a median of six (IQR4-10) minutes for emergency responders to arrive at the scene of injury and traveled a median of 27 (IQR 19-42) minutes to an ED. Time to definitive care was a median of 57 (IQR 44-77) minutes, with a range of 12-232 minutes. Twenty-four-hour mortality was 15% (n = 100) with 81 patients dying due to exsanguination or hemorrhage. Patients who experience critical injury may experience lengthy times to receipt of definitive care and may benefit from bystander action for hemorrhage control to improve patient outcomes.

Recreational Skiing- and Snowboarding-Related Extremity Injuries: A Five-Year Tertiary Trauma Center Cohort.

Skiing and snowboarding are widely recognized winter sports with a notable risk of sports-related injuries. Comprehensive knowledge of the injuries sustained during skiing and snowboarding is imperative for preventative strategies and for understanding the injury patterns and epidemiological characteristicsfrom surgeons' standpoint, particularly orthopedic surgeons, given that all anatomical regions and systems are susceptible to harm when engaging in these activities. Our research aims to investigate the injury patterns and epidemiological characteristics of individuals seeking medical attention at Erzincan University Faculty of Medicine Orthopedics and Traumatology Clinic, Erzincan, Turkey, after experiencing recreational skiing or snowboarding injuries. During the period spanning from 2018 to 2023, a retrospective analysis was conducted on patients aged between 18 to 65 years who had sustained isolated extremity injuries while participating in recreational winter sports at the Ergan Mountain Ski Center. The causes of injuries were categorized into two types (skiing and snowboarding) based on the subjective description of the injury scene. The study employed the χ2 test for categorical variables and Student's t-test for continuous variables to conduct subgroup comparisons. The study results revealed that most patients, precisely 53.2%, sustained injuries in their lower extremities, whereas 46.8% sustained injuries in their upper extremities. The most frequently injured area of the patients presenting with skiing injury was the region around the knee (31.2%), followed by around the shoulder (21.6%) and the foot and ankle (14.9%). The anatomical region most injured among patients who sustained snowboarding injuries was the hand and wrist, accounting for 23.9% of cases. Skiing and snowboarding injuries vary anatomically. While individuals with limited experience are at a higher risk of sustaining injuries, no statistically significant disparity was observed regarding the specific body parts affected among individuals of varying skill levels. Recognizing these sports-related injuries, which are growing in young people, will encourage the use of personal protective equipment to avoid injuries, assure ski resorts'environmental safety, and reduce sports-related morbidity.

Survival Benefit of Helicopter Scene Response for Patients with an Injury Severity Score of at Least Nine: A Systematic Review and Meta-Analysis

Background and Aim Helicopter EMS (HEMS) is a well-established mode of rapid transportation for patients with need for time-sensitive interventions, especially in patients with significant traumatic injuries. Traditionally in the setting of trauma, HEMS is often considered appropriate when used for patients with “severe” injury as defined by Injury Severity Score (ISS) >15. This may be overly conservative, and patients with a lower ISS may benefit from HEMS-associated speed or care quality. Our objective was to perform a meta-analysis of trauma HEMS transports to evaluate for possible mortality benefit in injured cases defined by an ISS score >8, lower than the customary ISS cutoff of >15. Methods A broad search of the literature was performed including PubMed, EMBASE, SCOPUS, Cochrane Central Register of Controlled Trials, and Google Scholar from the years 1970 to 2022. The gray literature and reference lists of included publications were also examined. We included studies with the outcome of mortality in HEMS vs control in trauma transports from scene of injury for patients (adult or pediatric) with ISS > 8. Results Nine eligible studies were used in the final analysis: six in the primary analysis and three in sensitivity analysis due to patient overlap. All studies reported statistically significant survival benefit in HEMS compared to control group. The minimum survival odds ratio (OR) benefit observed was OR 1.15 (95% CI 1.06–1.25) and maximum was OR 2.04 (95% CI 1.18–3.57). Risk of bias tool (ROBINS-I) application yielded moderate to low risk of bias, mainly due to the observational nature of the studies included. Conclusions There was a statistically significant survival benefit in patients with ISS > 8 when HEMS was used over traditional ground ambulance transportation, although novel and more inclusive trauma triage criteria may be more appropriate in the future to guide HEMS utilization decision-making. Restricting HEMS to trauma patients with ISS >15 likely misses survival benefit that could be afforded to the subset of trauma patients with serious injury.

Prehospital Active and Passive Warming in Trauma Patients

ObjectiveHypothermia is common among trauma patients and can lead to a serious rise in morbidity and mortality. This study was performed to investigate the effect of active and passive warming measures implemented in the prehospital phase on the body temperature of trauma patients. MethodsIn a multicenter, multinational prospective observational design, the effect of active and passive warming measures on the incidence of hypothermia was investigated. Adult trauma patients who were transported by helicopter emergency medical services (HEMS) or ground emergency medical services with an HEMS physician directly from the scene of injury were included. Four HEMS/ground emergency medical services programs from Canada, the United States, and the Netherlands participated. ResultsA total of 80 patients (n = 20 per site) were included. Eleven percent had hypothermia on presentation, and the initial evaluation occurred predominantly within 60 minutes after injury. In-line fluid warmers and blankets were the most frequently used active and passive warming measures, respectively. Independent risk factors for a negative change in body temperature were transportation by ground ambulance (odds ratio = 3.20; 95% confidence interval, 1.06-11.49; P = .03) and being wet on initial presentation (odds ratio = 3.64; 95% confidence interval, 0.99-13.36; P = .05). ConclusionFor adult patients transported from the scene of injury to a trauma center, active and passive warming measures, most notably the removal of wet clothing, were associated with a favorable outcome, whereas wet patients and ground ambulance transport were associated with an unfavorable outcome with respect to temperature.

Diagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patients

BackgroundTimely and accurate identification of life- and limb-threatening injuries (LLTIs) is a fundamental objective of trauma care that directly informs triage and treatment decisions. However, the diagnostic accuracy of clinical examination to detect LLTIs is largely unknown, due to the risk of contamination from in-hospital diagnostics in existing studies. Our aim was to assess the diagnostic accuracy of initial clinical examination for detecting life- and limb-threatening injuries (LLTIs). Secondary aims were to identify factors associated with missed injury and overdiagnosis, and determine the impact of clinician uncertainty on diagnostic accuracy.MethodsRetrospective diagnostic accuracy study of consecutive adult (≥ 16 years) patients examined at the scene of injury by experienced trauma clinicians, and admitted to a Major Trauma Center between 01/01/2019 and 31/12/2020. Diagnoses of LLTIs made on contemporaneous clinical records were compared to hospital coded diagnoses. Diagnostic performance measures were calculated overall, and based on clinician uncertainty. Multivariate logistic regression analyses identified factors affecting missed injury and overdiagnosis.ResultsAmong 947 trauma patients, 821 were male (86.7%), median age was 31 years (range 16–89), 569 suffered blunt mechanisms (60.1%), and 522 (55.1%) sustained LLTIs. Overall, clinical examination had a moderate ability to detect LLTIs, which varied by body region: head (sensitivity 69.7%, positive predictive value (PPV) 59.1%), chest (sensitivity 58.7%, PPV 53.3%), abdomen (sensitivity 51.9%, PPV 30.7%), pelvis (sensitivity 23.5%, PPV 50.0%), and long bone fracture (sensitivity 69.9%, PPV 74.3%). Clinical examination poorly detected life-threatening thoracic (sensitivity 48.1%, PPV 13.0%) and abdominal (sensitivity 43.6%, PPV 20.0%) bleeding. Missed injury was more common in patients with polytrauma (OR 1.83, 95% CI 1.62–2.07) or shock (systolic blood pressure OR 0.993, 95% CI 0.988–0.998). Overdiagnosis was more common in shock (OR 0.991, 95% CI 0.986–0.995) or when clinicians were uncertain (OR 6.42, 95% CI 4.63–8.99). Uncertainty improved sensitivity but reduced PPV, impeding diagnostic precision.ConclusionsClinical examination performed by experienced trauma clinicians has only a moderate ability to detect LLTIs. Clinicians must appreciate the limitations of clinical examination, and the impact of uncertainty, when making clinical decisions in trauma. This study provides impetus for diagnostic adjuncts and decision support systems in trauma.

Interhospital Transfer Delays Care for Spinal Cord Injury Patients: A Report from the North American Clinical Trials Network for Spinal Cord Injury.

Abstract The North America Clinical Trials Network (NACTN) for Spinal Cord Injury (SCI) is a consortium of tertiary medical centers that has maintained a prospective SCI registry since 2004, and it has espoused that early surgical intervention is associated with improved outcome. It has previously been shown that initial presentation to a lower acuity center and necessity of transfer to a higher acuity center reduce rates of early surgery. The NACTN database was evaluated to examine the association between interhospital transfer (IHT), early surgery, and outcome, taking into account distance traveled and site of origin for the patient. Data from a 15-year period of the NACTN SCI Registry were analyzed (years 2005-2019). Patients were stratified into transfers directly from the scene to a Level 1 trauma center (NACTN site) versus IHT from a Level 2 or 3 trauma facility. The main outcome was surgery within 24 hours of injury (yes/no), whereas secondary outcomes were length of stay, death, discharge disposition, and 6-month American Spinal Injury Association Impairment Scale (AIS) grade conversion. For the IHT patients, distance traveled for transfer was calculated by measuring the shortest distance between origin and NACTN hospital. Analysis was performed with Brown-Mood test and chi-square tests. Of 724 patients with transfer data, 295 (40%) underwent IHT and 429 (60%) were admitted directly from the scene of injury. Patients who underwent IHT were more likely to have a less severe SCI (AIS D; p = 0.002), have a central cord injury (p = 0.004), and have a fall as their mechanism of injury (p < 0.0001) than those directly admitted to an NACTN center. Of the 634 patients who had surgery, direct admission to an NACTN site was more likely to result in surgery within 24 hours compared with IHT patients (52% vs. 38%) (p < 0.0003). Median IHT distance was 28 miles (interquartile range [IQR] = 13-62 miles). There was no significant difference in death, length of stay, discharge to a rehab facility versus home, or 6-month AIS grade conversion rates between the two groups. Patients who underwent IHT to an NACTN site were less likely to have surgery within 24 hours of injury, compared with those directly admitted to the Level 1 trauma facility. Although there was no difference in mortality rates, length of stay, or 6-month AIS conversion between groups, patients with IHT were more likely be older with a less severe level of injury (AIS D). This study suggests there are barriers to timely recognition of SCI in the field, appropriate admission to a higher level of care after recognition, and challenges related to the management of individuals with less severe SCI.

Accuracy of Prehospital Triage of Adult Patients With Traumatic Injuries Following Implementation of a Trauma Triage Intervention

Adequate prehospital triage is pivotal to enable optimal care in inclusive trauma systems and reduce avoidable mortality, lifelong disabilities, and costs. A model has been developed to improve the prehospital allocation of patients with traumatic injuries and was incorporated in an application (app) to be implemented in prehospital practice. To evaluate the association between the implementation of a trauma triage (TT) intervention with an app and prehospital mistriage among adult trauma patients. This population-based, prospective quality improvement study was conducted in 3 of the 11 Dutch trauma regions (27.3%), with full coverage of the corresponding emergency medical services (EMS) regions participating in this study. Participants included adult patients (age ≥16 years) with traumatic injuries who were transported by ambulance between February 1, 2015, and October 31, 2019, from the scene of injury to any emergency department in the participating trauma regions. Data were analyzed between July 2020 and June 2021. Implementation of the TT app and the awareness of need for adequate triage created by its implementation (ie, the TT intervention). The primary outcome was prehospital mistriage, evaluated in terms of undertriage and overtriage. Undertriage was defined as the proportion of patients with an Injury Severity Score (ISS) of 16 or greater who were initially transported to a lower-level trauma center (designated to treat patients who are mildly and moderately injured) and overtriage as the proportion of patients with an ISS of less than 16 who were initially transported to a higher-level trauma center (designated to treat patients who are severely injured). A total of 80 738 patients were included (40 427 [50.1%] before and 40 311 [49.9%] after implementation of the intervention), with a median (IQR) age of 63.2 (40.0-79.7) years and 40 132 (49.7%) male patients. Undertriage decreased from 370 of 1163 patients (31.8%) to 267 of 995 patients (26.8%), while overtriage rates did not increase (8202 of 39 264 patients [20.9%] vs 8039 of 39 316 patients [20.4%]). The implementation of the intervention was associated with a statistically significantly reduced risk for undertriage (crude risk ratio [RR], 0.95; 95% CI, 0.92 to 0.99, P = .01; adjusted RR, 0.85; 95% CI, 0.76-0.95; P = .004), but the risk for overtriage was unchanged (crude RR, 1.00; 95% CI, 0.99-1.00; P = .13; adjusted RR, 1.01; 95% CI, 0.98-1.03; P = .49). In this quality improvement study, implementation of the TT intervention was associated with improvements in rates of undertriage. Further research is needed to assess whether these findings are generalizable to other trauma systems.

Emergency care in post-conflict settings: a systematic literature review

BackgroundEmergency care systems (ECS) organize and provide access to life-saving care both during transport and at health facilities. Not enough is known about ECS in uncertain contexts such as post-conflict settings. This review aims to systematically identify and summarize the published evidence on the delivery of emergency care in post-conflict settings and to guide health sector planning.MethodsWe searched five databases (PubMed MEDLINE, Web of Science, Embase, Scopus, and Cochrane) in September 2021 to identify relevant articles on ECS in post-conflict settings. Included studies (1) described a context that is post-conflict, conflict-affected, or was impacted by war or crisis; (2) examined the delivery of an emergency care system function; (3) were available in English, Spanish, or French; and (4) were published between 1 and 2000 and 9 September 2021. Data were extracted and mapped using the essential system functions identified in the World Health Organization (WHO) ECS Framework to capture findings on essential emergency care functions at the scene of injury or illness, during transport, and through to the emergency unit and early inpatient care.ResultsWe identified studies that describe the unique burden of disease and challenges in delivering to the populations in these states, pointing to particular gaps in prehospital care delivery (both during scene response and during transport). Common barriers include poor infrastructure, lingering social distrust, scarce formal emergency care training, and lack of resources and supplies.ConclusionTo our knowledge, this is the first study to systematically identify the evidence on ECS in fragile and conflict-affected settings. Aligning ECS with existing global health priorities would ensure access to these critical life-saving interventions, yet there is concern over the lack of investments in frontline emergency care. An understanding of the state of ECS in post-conflict settings is emerging, although current evidence related to best practices and interventions is extremely limited. Careful attention should be paid to addressing the common barriers and context-relevant priorities in ECS, such as strengthening prehospital care delivery, triage, and referral systems and training the health workforce in emergency care principles.

Public guide for "first aid onsite-first responders action" in China (2023)

In order to improve the popularity of first aid knowledge among the public, First Aid Professional Committee of China Geriatric Health Care Association has formulated the Public guide for "first aid onsite-first responders action" in China (2023). This guide aims at providing with the first eyewitness action guide that are critical but weak onsite rescue link of Chinese emergency medical service system to the public. In the first scene of injury and illness emergencies, it is very important for the first eyewitness to make a prompt and correct response in the first time. Based on best practice evidence, this guide combs the core concepts of onsite first aid in order to provide guidance and help in standardizing the popularization of public first aid knowledge and skills.

Evaluating the definition of severely injured patients: a Japanese nationwide 5-year retrospective study

ObjectivesThe definition of severely injured patients lacks universal consensus based on quantitative measures. The most widely used definition of severe injury is based on the Injury Severity Score (ISS), which...