Subgroup Of Trauma Patients Research Articles

Adapting trauma workflows for severely injured trauma patients during the COVID-19 pandemic: experience in a regional trauma centre in Singapore.

Adapting trauma workflows for severely injured trauma patients during the COVID-19 pandemic: experience in a regional trauma centre in Singapore.

Conventional and retrospective change in health-related quality of life of trauma patients: an explorative observational follow-up study

BackgroundWithin trauma care measurement of changes in health-related quality of life (HRQL) is used in understanding patterns of recovery over time. However, conventionally-measured change in HRQL may not always reflect the change in HRQL as perceived by the patient. Recall bias and response shift may contribute to disagreement between conventional and retrospective change in HRQL. This study aimed to measure conventional and retrospective change of HRQL and assess to which extent recall bias and response shift contribute to disagreement between these two in a heterogeneous sample of adult trauma patients.MethodsA sample of trauma patients (≥18 years) who attended the Emergency Department and were admitted to an Intensive Care unit or ward of one of ten Dutch hospitals received postal questionnaires 1 week (T1) and 3 months (T2) post-injury. At T1 and T2 participants completed the EQ-5D-3 L and EQ-VAS for their current health status. At T2 participants also filled out a recall and then-test regarding their health status at T1. The responses were used to assess conventional and retrospective change, recall bias and response shift. Wilcoxon signed rank tests were used to examine conventional and retrospective change on a group level. The intraclass correlation coefficient (ICC) was used to examine individual agreement between conventional and retrospective change. Uni- and multivariate linear regression analysis were used to investigate the association between background factors and recall bias and response shift.ResultsThe EQ-5D-3 L, recall and then-test were completed by 550 patients. Mean EQ-5D-3 L summary score improved from 0.48 at T1 to 0.74 at T2. Mean EQ-VAS score improved from 56 at T1 to 73 at T2. Retrospective change was significantly higher than conventional change (EQ-5D-3 L: Z = -5.2, p < 0.05; EQ-VAS Z = -2.1, p < 0.05). Pairwise comparisons showed that agreement between conventional and retrospective change was fair (EQ-5D-3 L: ICC = 0.49; EQ-VAS: ICC = 0.48). For EQ-5-3 L response shift was significantly higher than recall bias (Z = − 4.5, p < 0.05). Patients with traumatic brain injury (TBI), severe injury and/or posttraumatic stress symptoms were more susceptible to recall bias and response shift.ConclusionsWe conclude that, compared to recall bias, response shift contributed more to the disagreement between conventional and retrospective change in EQ-5D-3 L summary score and EQ-VAS. Predictable subgroups of trauma patients were more susceptible to recall bias and response shift.

The ticking clock: does actively making an enhanced care team aware of the passage of time improve pre-hospital scene time following traumatic incidents?

IntroductionPre-hospital enhanced care teams like Helicopter Emergency Medical Services (HEMS) are often dispatched to major trauma patients, including patients with traumatic brain injuries and those with major haemorrhage. For these patients, minimizing the time to definitive care is vital. The aim of this study was to determine whether increased awareness of elapsed on scene time produces a relevant time performance improvement for major trauma patients attended by HEMS, and weather introducing such a timer was feasible and acceptable to clinicians.MethodsWe performed a prospective cohort study of all single casualty traumatic incidents attended by Air Ambulance Kent Surrey Sussex (AAKSS) between 15 October 2016 and 23 May 2017 to test if introduction of a prompting scene timer within the service resulted in a reduction in pre-hospital scene times.ResultsThe majority of the patients attended were male (74%) and sustained blunt trauma (92%). Overall, median scene time was 25.5 [IQR16.3] minutes before introduction of the scene timer and 23.0 [11.0] minutes after introduction, p = 0.13). Scene times for patients with a GCS < 8 and for patients requiring prehospital anaesthesia were significantly lower after introduction of the timer (28 [IQR 14] vs 25 [1], p = 0.017 and 34 [IQR 13] vs 28 [IQR11] minutes, p = 0.007 respectively). The majority of clinicians felt the timer made them more aware of passing time (91%) but that this had not made a difference to scene time (62%) or their practice (57%).ConclusionAudible scene timers may have the potential to reduce pre-hospital scene time for certain single casualty trauma patients treated by a HEMS team, particularly for those patients needing pre-hospital anaesthesia. Regular use of on-scene timers may improve outcomes by reducing time to definitive care for certain subgroups of trauma patients.

Dense and dangerous: The tissue plasminogen activator-resistant fibrinolysis shutdown phenotype is due to abnormal fibrin polymerization

Both hyperfibrinolysis and fibrinolysis shutdown can occur after severe trauma. The subgroup of trauma patients with fibrinolysis shutdown resistant to tissue plasminogen activator (t-PA)-mediated fibrinolysis have increased mortality. Fibrin polymerization and structure may influence fibrinolysis subgroups in trauma, but fibrin architecture has not been characterized in acutely injured subjects. We hypothesized that fibrin polymerization measured in situ will correlate with fibrinolysis subgroups. Blood samples were collected from trauma patients and noninjured controls. We selected samples across a range of fibrinolysis phenotypes (shutdown, physiologic, hyperfibrinolysis) and t-PA sensitivities (sensitive, physiologic, resistant) determined by thrombelastography. Plasma clots were created in situ with fluorescent fibrinogen and imaged using confocal microscopy for analysis of clot architecture in three dimensions. For each clot, we quantified the fiber resolvability, a metric of fiber distinctness or clarity, by mapping the variance of fluorescence intensity relative to background fluorescence. We also determined clot porosity by measuring the size and distribution of the gaps between fibrin fibers in three-dimensional space. We compared these measures across fibrinolysis subgroups. Fiber resolvability was significantly lower in all trauma subgroups compared with controls (n = 35 and 5, respectively; p < 0.05). We observed markedly different patterns of fibrin architecture among trauma patients stratified by fibrinolysis subgroup. Subjects with t-PA-resistant fibrinolysis shutdown exhibited abnormal, densely packed fibrin clots nearly devoid of pores. Individuals with t-PA-hypersensitive fibrinolysis shutdown had highly irregular clots with pores as large as 2500 μm to 20,000 μm, versus 78 μm to 1250 μm in noninjured controls. Fiber resolvability was significantly lower in trauma patients than controls, and subgroups of fibrinolysis differ in the porosity of the fibrin clot structure. The dense fibrin network in the t-PA-resistant group may prevent access to plasmin, suggesting a mechanism for thrombotic morbidity after injury.

In-Hospital Outcome Based on the Mode of EMS Transportation in a High-Income Rapidly Developing Middle Eastern Country

&lt;p&gt;&lt;strong&gt;BACKGROUND:&lt;/strong&gt; Helicopter emergency medical services (HEMS) are considered as a standard component of advanced pre-hospital emergency care system. We assessed the clinical presentation and outcomes of trauma patients transported by HEMS versus ground emergency medical services (GEMS).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;METHODS:&lt;/strong&gt; A retrospective analysis of prospectively collected trauma registry data at a level I trauma center was conducted for patients transported by GEMS and HEMS between 2011 and 2013. Patients’ data were categorized and analyzed based on the mode of transportation (MOT).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;RESULTS:&lt;/strong&gt; A total of 4596 trauma patients were admitted to the hospital with a mean age of 31±15 years. Injured patients were transported to the trauma centre by GEMS (93.3%) and HEMS (6.7%). The common mechanisms of injury were motor vehicle crash (37%) and fall (25%). MVC victims were transported to the hospital by HEMS, whereas, patients with fall and pedestrian injuries (P=0.001 for all) were more likely to be transported by GEMS. Moreover, patients in the HEMS group had a higher frequency of head (p=0.001) and chest (p=0.001) injuries and required prolonged ICU and overall hospital stay (p=0.001). When compared with GEMS, HEMS group were more likely to sustain severe injuries (ISS&amp;gt;15; p=0.001) and needed frequent on-scene intubation (P=0.001). Hospital mortality was grater in HEMS patients (10% vs 4%, p=0.001) in comparison to GEMS. Multivariate analysis, after adjusting for the confounding factors demonstrated that polytrauma and lower scene GCS were the independent predictors of mortality.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;CONCLUSIONS: &lt;/strong&gt;Patients transported by HEMS are characterized by greater injury severity, traumatic brain injury and on-scene intubation. Moreover, the mortality is 2.5 fold greater in patients transported by GEMS, however, the impact of MOT on mortality disappear after adjusting for potential confounders. Institutional guidelines that focus on clinical triage criteria, key environmental factors and reducing transport time may be informed by this study. Further investigations are needed to better quantifyestimate the pre-hospital time intervals and to identify the sub-groups of trauma patients who will clearly benefit from the use of HEMS.&lt;/p&gt;

Mortality and complications in trauma patients admitted to Shariati Hospital

Background: Trauma is an inevitable part of every country’s healthcare burden. Preventive and rehabilitative aspects of the traumatic injuries are expensive. Since most of the injuries happen in lowand middle-income developing countries, a judicious allocation of the limited resources to the most cost-efficient strategies is necessary. Objectives: The present study was designed to report the causes of trauma, injured body regions, trauma severity scores, and the one-year survival rate of a randomly selected sample of trauma patients in a major referral hospital in Tehran, Iran. Materials and Methods: We chose and analyzed a random subgroup of trauma patients admitted during the one-year period from May 2012 to May 2013 to Shariati Hospital, Trauma patients who stayed at the hospital for less than 24 hours were not included. Results: In total, 73 trauma patients were registered. The mean age was 40.19 (SD 20.34) years and 67.1% of the patients were male. In general, the most common cause of injury was falls (47.9%), followed by road traffic injury (40.8%). Assault and exposure to inanimate mechanical forces each were associated with 5.6% of all injuries. Our study showed that the most commonly injured body region was the head (23.8%) followed by the elbow and forearm (19%), hip and thigh (15.9%), and multiple body regions (14.3%). The mean injury severity index (ISS) was 7.26 (SD 7.06) and the mean revised trauma score (RTS) was 7.84, calculated for 38 patients. The only cause of injury in ages of more than 65 years was falls. The most common cause of injury in ages 15–45 years was road traffic injury. During the study, 2 deaths occurred with one in the ICU and the other at home. Conclusion: Our study emphasizes the importance of the preventive strategies for falls in the old age group and road traffic injuries in young males.

An evolution of trauma care evaluation

Outcome prediction models play an invaluable role in the evaluation and improvement of modern trauma care. Trauma registries underlying these outcome prediction models need to be accurate, complete and consistent. This thesis focused on the opportunities and limitations of trauma registries and outcome prediction models for trauma patients incorporating the following objectives: 1. The validation of outcome prediction models in subgroups of trauma patients 2. The analysis of case-mix and benchmarking issues 3. The improvement of trauma registries.

Effects of routine monitoring of delirium in a surgical/trauma intensive care unit

Delirium is prevalent in surgical and trauma intensive care units (ICUs) and carries substantial morbidity. This study tested the hypothesis that daily administration of a diagnostic instrument for delirium in a surgical/trauma ICU decreases the time of institution of pharmacologic therapy and improves related outcomes. Controlled trial of two concurrent groups. The Confusion-Assessment Method for ICU was administered daily to all eligible patients admitted to our surgical/trauma ICU for 48 hours or longer. The result was communicated to one of the two preexisting ICU services (intervention service) and not the other (control service). Primary outcome was the time between diagnosis of delirium and pharmacologic treatment. Secondary outcomes included duration of delirium, mechanical ventilation, and ICU stay. Delirium occurred in 98 (35%) of 283 consecutive patients. Time between diagnosis and therapy did not differ between intervention (35 [35] hours) and control (40 [41] hours) groups. There was a difference in the number of delirium days treated in the intervention (73%) versus control (64%) groups (p = 0.035). The intervention group had significantly lower odds to neglect treating delirium when delirium was present (odds ratio, 0.67; 95% confidence interval, 0.45-1.00; p = 0.05). In the subgroup of trauma patients, the odds ratio of negligence was 0.37 (95% confidence interval, 0.14-0.99; p = 0.048), indicating lower probability for trauma patients to be untreated. There was no difference in the average duration of delirium, mechanical ventilation, and ICU stay. In our surgical/trauma ICU, daily screening for delirium did not affect the timing of pharmacologic therapy. Although the intervention resulted in a higher number of delirious ICU patients being treated, particularly trauma patients, there was no effect on related outcomes. Therapeutic study, level IV.

Management of bleeding following major trauma: is a target haemoglobin of 7 to 9 g/dl high enough?

In the latest recommendations for the management of bleeding following major trauma, Spahn and colleagues recommend a target haemoglobin of 7 to 9 g/dl to initiate blood transfusion [1]. In their rationale the authors use a subgroup of trauma patients from the Transfusion Requirements in Critical Care study; however, patients with active blood loss were excluded from this trial. Expressing a current opinion about transfusion and trauma patients, in 2006 McIntyre and Hebert wrote: 'It is important to put RBC [red blood cell] transfusions into the context of three main time frames, i.e. prehospital care, initial 24-48 h after admission to hospital and thereafter, because each frame has its own set of circumstances which may dictate the need for different timing, volume and rapidity of transfusions' [2]. To our knowledge, the only trial to evaluate a target haemoglobin in shock involved early goal-directed therapy in septic shock [3]. The early goal-directed therapy protocol included maintaining a haematocrit of 30% (haemoglobin at 10 g/dl). In the results, the early goal-directed therapy group had a significantly higher haematocrit than the control group and also received more transfusions. Raising the target haemoglobin to 10 g/dl has two interesting effects: haemodilution is reduced, harmful in the present case; and the transfusion delay is decreased. Riskin and colleagues showed that reducing the transfusion delay may decrease the mortality rate [4]. For the first time, three studies suggest that transfusion may be associated with a reduced mortality rate [5]. The real beneficial effect of blood transfusion is probably that it gives time to stop the bleeding.

Should we ban the use of colloids in patients with head injury?

Dear Editor, We read the recommendations from the ESICM task force on colloid volume therapy in critically ill patients [1]. We express our major concerns over the strong recommendation (grade 1C) not to use synthetic colloids in patients with head injury or intracranial bleeding. Indeed, this statement was based on three clinical studies only [1]. The first was retrospective, and found an association between the risk of death and the use of 6 % hetastarch 450/0.7, a highmolecular-weight hetastarch not used in Europe, in a subgroup of trauma patients with moderate or severe traumatic brain injury. The second study was a post hoc analysis of two randomised controlled trials in patients with aneurismal subarachnoid haemorrhage, and found colloids, i.e., 4 % succinylated gelatin and 6 % pentastarch, as one factor associated with unfavourable neurological outcome at 6 months. The third study was a randomised controlled study in 31 patients with severe traumatic brain injury, and reported no difference in the rate of complications between hydroxyethyl starch solution (HES) 200/0.5 and 6 % HES 130/0.4. In this latter study, 6 % HES 130/0.4 was administered over several days at doses of up to 70 ml/kg/24 h. Based on such limited and heterogeneous data, it appears highly speculative to draw conclusions about the risk of colloids in this population, and we urge that readers consider that an association between variables does not necessarily indicate a causal relation. In addition, two randomised controlled studies must be cited. The first study compared the continuous administration of 6 % HES versus crystalloid solutions over 4 days in 40 patients with acute ischaemic stroke, and found no differences in efficacy or safety between the two groups [2]. Similar findings were reported in a second study comparing 10 % HES 130/0.4 versus crystalloids in 106 patients with acute ischaemic stroke [3]. Further prospective randomised controlled trials are clearly needed to address the issue of how best to optimise fluid resuscitation in this population. This would mitigate the effects of unrecorded confounding factors that may exist in cohort studies even after statistical adjustment. In general, it is difficult to isolate the effects of fluids on neurological outcome independently of their effects on the cardiovascular system. The reasons for myocardial dysfunction are numerous after brain injury, and include pulmonary vasoconstriction centrally mediated by brain damage, associated extra-cranial lesions, and/or large doses of sedatives as part of the treatment of intracranial hypertension. In addition, stress-induced cardiomyopathy does exist in these patients [4]. In this context, fluid overloading may result in severe cardiopulmonary complications regardless of the type of fluid administered. An early goal-directed haemodynamic management to optimise cardiac output and volume status in post-subarachnoid haemorrhage vasospasm was associated with better clinical course and fewer cardiopulmonary complications compared to conventional treatment [5]. In conclusion, it would be more appropriate to recommend the routine monitoring of cardiac function in brain-injured patients rather than recommending any ban on the use of colloids after brain injury.

Helicopter transport

Traumatic injury continues to be a significant cause of morbidity and mortality in the year 2011. In addition, the healthcare expenditures and lost years of productivity represent significant economic cost to the affected individuals and their communities. Helicopters have been used to transport trauma patients for the past 40 years, but there are conflicting data on the benefits of helicopter emergency medical service (HEMS) in civilian trauma systems. Debate persists regarding the mortality benefit, cost-effectiveness, and safety of helicopter usage, largely because the studies to date vary widely in design and generalizability to trauma systems serving heterogeneous populations and geography. Strict criteria should be established to determine when HEMS transport is warranted and most likely to positively affect patient outcomes. Individual trauma systems should conduct an assessment of their resources and needs in order to most effectively incorporate helicopter transport into their triage model. Research suggests that HEMS improves mortality in certain subgroups of trauma patients, both after transport from the scene of injury and following interfacility transport. Studies examining the cost-effectiveness of HEMS had mixed results, but the majority found that it is a cost-effective tool. Safety remains an issue of contention with HEMS transport, as helicopters are associated with significant safety risk to the crew and patient. However, this risk may be justified provided there is a substantial mortality benefit to be gained. Recent studies suggest that strict criteria should be established to determine when helicopter transport is warranted and most likely to positively affect patient outcomes. Individual trauma systems should conduct an assessment of their resources and needs in order to most effectively incorporate HEMS into their triage model. This will enable regional hospitals to determine if the costs and safety risks associated with HEMS are worthwhile given the potential benefits to patient morbidity and mortality.

Is routine thromboprophylaxis justified among Indian patients sustaining major orthopedic trauma? A systematic review

Venous thromboembolism (VTE) is one of the most common preventable cause of morbidity and mortality after trauma. Though most of the western countries have their guidelines for thromboprophylaxis in these patients, India still does not have these. The increasing detection of VTE among Indian population, lack of awareness, underestimation of the risk, and fear of bleeding complications after chemical prophylaxis have made deep vein thrombosis (DVT) a serious problem, hence a standard guideline for thromboprophylaxis after trauma is essential. The present review article discusses the incidence of DVT and role of thromboprophylaxis in Indian patients who have sustained major orthopedic trauma. A thorough search of ‘PubMed’ and ‘Google Scholar’ revealed 10 studies regarding venous thromboembolism in Indian patients after major orthopedic trauma surgery (hip or proximal femur fracture and spine injury). Most of these studies have evaluated venous thromboembolism in patients of arthroplasty and trauma. The incidence, risk factors, diagnosis and management of VTE in the subgroup of trauma patients (1049 patients) were separately evaluated after segregating them from the arthroplasty patients. Except two studies, which were based on spinal injury, all other studies recommended screening/ thromboprophylaxis in posttraumatic conditions in the Indian population. Color Doppler was used as common diagnostic or screening tool in most of the studies (eight studies, 722 patients). The incidence of VTE among thromboprophylaxis-receiving group was found to be 8% (10/125), whereas it was much higher (14.49%, 40/276) in patients not receiving any form of prophylaxis. Indian patients have definite risk of venous thromboembolism after major orthopedic trauma (except spinal injury), and thromboprophylaxis either by chemical or mechanical methods seems to be justified in them.

Leukoreduction of blood transfusions does not diminish transfusion‐associated microchimerism in trauma patients

Transfusion of trauma patients can result in long-term survival of donor white blood cells (WBCs) or "transfusion-associated microchimerism" (TA-MC). The aim was to determine whether leukoreduction of blood transfusions, advocated to reduce the immunomodulatory effect of transfusion, decreases the likelihood of developing TA-MC. A subgroup of trauma patients from a randomized trial was examined, evaluating the risk of infection following leukoreduced versus nonleukoreduced blood transfusion. Patients' blood was sampled at least 1 month after hospital discharge, and TA-MC was assessed with quantitative allele-specific polymerase chain reaction detection of differences at the HLA-DR locus or a panel of insertion-deletion polymorphism loci distributed throughout the chromosomal complement. At the time of blood sampling, a scripted interview was used to ascertain symptoms suggestive of chronic graft-versus host disease (cGVHD). For 67 patients evaluated, the mean age was 43 +/- 17 years and mean Injury Severity Score was 24 +/- 12. Median time from injury to blood sampling for TA-MC was 240 (interquartile range, 116-360) days. Nine of 32 patients (28%) in the nonleukoreduced transfusion group developed TA-MC compared to 13 of 35 patients (37%) in the leukoreduced group (p = 0.43). Subjects with TA-MC were no more likely than subjects without TA-MC to have at least one symptom suggestive of cGVHD (64% vs. 76%, respectively). TA-MC seems to be a prevalent condition among injured patients at the second of two regional trauma centers evaluated, suggesting that it is a common phenomenon after transfusion in the setting of injury. Although leukoreduction removes greater than 99.9 percent of donor WBCs, it fails to prevent or even substantially reduce the likelihood of developing TA-MC. TA-MC does not appear to be strongly associated with symptoms suggestive of cGVHD several months after transfusion.

Fat embolism: the reaming controversy

Intramedullary nailing is the preferred treatment method for stabilizing femoral diaphyseal fractures. Despite its superior biomechanical advantages over other implants, its use, particularly in selected groups of patients, has been questioned because of the possible harmful systemic effects of intramedullary reaming. The increase in intramedullary canal pressure during intramedullary nailing can result in intravasation of bone marrow and fat into the venous blood system. The subsequent consequences can be fat embolism syndrome (FES), adult respiratory distress syndrome (ARDS), and multiple organ failure. The lung seems to be the primary target for fat embolization and for the mediated effects primed by inflammatory reactions. In laboratory studies, both reamed and unreamed intramedullary nailing has been shown to alter selected pulmonary variables. Although transient, this effect appears to be more prominent with reamed than unreamed techniques. Additional studies are required to determine whether a subgroup of trauma patients is adversely affected by intramedullary reaming, thus necessitating other fixation techniques.

The role of positioning in the prevention and therapy of ALI and ARDS in polytrauma patients: results of a prospective study with 100 cases

Since its introduction into intensive care medicine in the early 80s, the positive effects of kinetic therapy have been proven in different patient groups. However, polytrauma patients with severe chest injuries have not yet been studied in large numbers. According to the principles of evidence based medicine, only a small body of literature exists. With this in mind, we planned to create a greater data base in this subgroup of trauma patients to work out a baseline for an evidence based level I study.

Prehospital Hypertonic Saline/Dextran Infusion for Post-traumatic Hypotension The U.S.A. Multicenter Trial

The safety and efficacy of 7.5% sodium chloride in 6% dextran 70 (HSD) in posttraumatic hypotension was evaluated in Houston, Denver, and Milwaukee. Multicentered, blinded, prospective randomized studies were developed comparing 250 mL of HSD versus 250 mL of normal crystalloid solution administered before routine prehospital and emergency center resuscitation. During a 13-month period, 422 patients were enrolled, 211 of whom subsequently underwent operative procedures. Three hundred fifty-nine patients met criteria for efficacy analysis, 51% of whom were in the HSD group. Seventy-two per cent of all patients were victims of penetrating trauma. The mean injury severity score (19), Trauma Score plus Injury Severity Score (TRISS) probability of survival, revised trauma scores (5.9), age, ambulance times, preinfusion blood pressure, and etiology distribution were identical between groups. The total amount of fluid administered, white blood cell count, arterial blood gases, potassium, or bicarbonate also were identical between groups. The HSD group had an improved blood pressure (p = 0.024). Hematocrit, sodium chloride, and osmolality levels were significantly elevated in the Emergency Center. Although no difference in overall survival was demonstrated, the HSD group requiring surgery did have a better survival (p = 0.02), with some variance among centers. The HSD group had fewer complications that the standard treatment group (7 versus 24). A greater incidence of adult respiratory distress syndrome, renal failure, and coagulopathy occurred in the standard treatment group. No anaphylactoid nor Dextran-related coagulopathies occurred in the HSD group. Although this trial demonstrated trends supportive of HSD in hypotensive hemorrhagic shock patients requiring surgery, a larger sample size will be required to establish which subgroups of trauma patients might maximally benefit from the prehospital use of a small volume of hyperosmolar solution. This study demonstrates the safety of administering 250 mL 7.5% HDS to this group of patients.