Trauma Patients In Emergency Department Research Articles

Evaluation of incidental findings of whole body computed tomography in multiple trauma patients in emergency department

Aim: The aim of this study was to investigate the frequency of incidental findings and the clinically significant ones in whole-body computed tomography (WBCT) scans in multiple trauma patients in the emergency department (ED). Material and Methods: This study was designed as a single-centered retrospective cohort in a tertiary emergency room. Multiple trauma patients who were screened with WBCT in the ED in 2017 were analyzed. Incidental findings (IF) were categorized into 3 groups as group 1 (emergency treatment / need further examination), group 2 (need examination depending on the symptoms of patients) and group 3 (minor findings with no need for further examination). Results: WBCT screening was performed in 206 of 3746 patients (5.4%) who were admitted to the trauma unit in ED due to multiple traumas. A total of 360 IFs were found in 138 (67%) of 206 patients. Of the patients, 13.3% were classified as group 1, 30.9% as group 2, 55.8% as group 3 and IF was detected, respectively (48, 111, 201). Cardiomegaly was the most common finding in group 1 (n = 11). In group 2, hepatomegaly (n = 18) and atherosclerosis (n = 13) were the most common ones observed. Brain calcifications (n = 42) and renal cysts (n = 17) were the most common findings in Group 3. The age distribution of patients with IF was statistically significantly higher compared to those without IF (43.54 ± 18.78, 25.16 ± 11.7, p

The Necessity of Implementing the World Health Organization Checklist for Trauma Patients in Emergency Departments throughout the Country

Injury is one of the main causes of mortality and disability in the world. Improving the trauma care process is necessary to reduce this burden in countries at all levels of the economy. One of the important components of improving the care process in each field is to reduce medical errors. Using a checklist in other medical areas has been effective in improving care and reducing medical mistakes. Field observations indicate that almost all of the emergency departments in hospitals and trauma centers in the country do not use this check list. In this short essay, efforts have been made to emphasize the necessity for coercion with the necessary training to use this checklist from the Department of Health's treatment deputy.

A fixed nitrous oxide/oxygen mixture as an analgesic for trauma patients in emergency department: study protocol for a randomized, controlled trial

BackgroundAcute pain is always the most common complaint in Emergency Department admissions and options for analgesia are limited. Nitrous oxide/oxygen possess many properties showing it may be an ideal analgesic method for the Emergency Department; it is quick-acting, well-tolerated, and does not mask signs and symptoms. The aim of this study is to evaluate the safety and analgesic effect of the fixed nitrous oxide/oxygen mixture for trauma patients in a busy emergency environment.MethodsThe randomized, double-blind, prospective, placebo-controlled study will be carried out in the Emergency Department of General Hospital of Ningxia Medical University. The target research objects are trauma patients who present to the Emergency Department and report moderate to severe intensities of acute pain. A total of 90 patients will be recruited and randomly assigned into the treatment and control group. The treatment group will receive conventional pain treatment plus nitrous oxide/oxygen mixture and the control group will receive conventional pain treatment plus oxygen. Neither patients, nor investigators, nor data collectors will know the nature of the gas mixture in each cylinder and the randomization list. Outcomes will be monitored at baseline(T0), 5 min (T1), and 15 min (T2) after the beginning of intervention and at 5 min post intervention (T3) for each group. The primary outcome is the level of pain relief after the initial administering of the intervention at T1, T2, and T3. Secondary outcomes include adverse events, physiological parameters, total time of the gas administration, satisfaction from both patients and healthcare professionals, and the acceptance of patients.DiscussionOur previous studies suggested that a fixed nitrous oxide/oxygen mixture was an efficacious analgesic for the management of burning dressing pain and breakthrough cancer pain. The results of this study will provide a more in-depth understanding of the effect of this gas. If this treatment proves successful, it could help to generate preliminary guidelines and be implemented widely in trauma patients with pain in Emergency Departments.Trial registrationChinese Clinical Trial Register, ChiCTR-INR-16007807. Registered on 21 January 2016.

Computed Tomography Assisted-Detection of Occult Elbow Fractures in adult Patients with Positive Elbow Extension Test

AbstractBackground: Elbow fractures are a common injury seen among Emergency Department trauma patients accounting for 2-3% of Emergency Department attendances. Eight to ten percent of fractures in adults occur in the elbow and forearm an effective clinical decision rule to exclude fracture in acute elbow injury would prevent unnecessary radiography, and could reduce missed injuries. Previous small studies indicate that the ability to fully extend the elbow might rule out clinically significant bony injury.Aim of the Work: The aim of this work was to detect occult adult elbow fractures using computed tomography in adult patients who presented with positive elbow extension test and had no evident fracture on X-ray study.This was to test the effectiveness of positive elbow ex-tension test as an indication to perform further radiographic evaluation of the injured elbow.Material and Methods: A prospective study was conducted in the Emergency Department (ED) of Tanta University Hospitals. All patients underwent the standard procedures of the protocol.Our study was carried out upon forty (40) patient of both sex in a duration of one (1) year from October 2016 to October 2017. They were selected from those who presented to Tanta University, Emergency Department.Results: In this study, age of about 57.5% of patients were ranged 19-39 years. While only about 5% of patients were equal or more than 60 years old.In patients with CT show elbow fracture, mean age was 38.27, while in patients had no elbow fracture mean age was 36.89. There was no statistically significant difference between patients.The most commonly occult elbow fracture detected by CT in patient with positive elbow extension test was radial head fracture (22.5% of all studied patients).About 20% of patients was diagnosed as coronoid process fracture, 5% of patients was diagnosed as olecranon process fracture and 5% of patients was diagnosed as lateral epicondyle fracture. Only about 2.5% of patients was diagnosed as medial epicondyle fracture.Conclusions: In patients with positive elbow extension test adding computed tomography to plain radiograph (that showed no evident fracture) was found to be superior to plain X-ray alone.

Communication and bed reservation: Decreasing the length of stay for emergency department trauma patients

BackgroundProlonged emergency department (ED) length of stay (LOS) is associated with poorer clinical outcomes and patient experience. At our community hospital, trauma patients were experiencing extended ED LOS incommensurate with their clinical status. Our objective was to determine if operational modifications to patient flow would reduce the LOS for trauma patients. MethodWe conducted a retrospective chart review of admitted trauma patients from January 1, 2015 to June 30, 2016 to study two interventions. First, a communication intervention [INT1], which required the ED provider to directly notify the trauma service, was studied. Second, a bed intervention [INT2], which reserved two temporary beds for trauma patients, was added. The primary outcome was the average ED LOS change across three time periods: (1) Baseline data [BASE] collected from January 1, 2015 to June 30, 2015, (2) INT1 data collected from July 1, 2015 to October 18, 2015, and (3) INT2 data collected from October 19, 2015 to June 30, 2016. Data was analyzed using descriptive statistics, two-sample t-tests, and multivariate linear regression. ResultsA total of 777 trauma patients were reviewed, with 151, 150 and 476 reviewed during BASE, INT1, and INT2 time periods, respectively. BASE LOS for trauma patients was 389 min. After INT1, LOS decreased by 74.35 min (±31.92; p < 0.0001). After INT2 was also implemented, LOS decreased by 164.56 min (±22.97; p < 0.0001) from BASE LOS. ConclusionDirect communication with the trauma service by the ED provider and reservation of two temporary beds significantly decreased the LOS for trauma patients.

41 Simultaneous trauma patients in emergency department’s: a difference in mortality?

BackgroundThe presentation of multiple simultaneous trauma patients in an Emergency Department, is likely to place significant stress and strain on trauma care resources. Currently there is limited data available to...

Acute Clinical Predictors of Symptom Recovery in Emergency Department Patients with Uncomplicated Mild Traumatic Brain Injury or Non-Traumatic Brain Injuries.

There is a subset of patients with mild traumatic brain injury (mTBI) who report persistent symptoms that impair their functioning and quality of life. Being able to predict which patients will experience prolonged symptom recovery would help clinicians target resources for clinical follow-up to those most in need, and would facilitate research to develop precision medicine treatments for mTBI. The purpose of this study was to investigate the predictors of symptom recovery in a prospective sample of emergency department trauma patients with either mTBI or non-mTBI injuries. Subjects were examined at several time points from within 72 h to 45 days post-injury. We quantified and compared the value of a variety of demographic, injury, and clinical assessment (symptom, neurocognitive) variables for predicting self-reported symptom duration in both mTBI (n = 89) and trauma control (n = 73) patients. Several injury-related and neuropsychological variables assessed acutely (< 72 h) post-injury predicted symptom duration, particularly loss of consciousness (mTBI group), acute somatic symptom burden (both groups), and acute reaction time (both groups), with reasonably good model fit when including all of these variables (area under the receiver operating characteristic curve [AUC] = 0.76). Incorporating self-reported litigation involvement modestly increased prediction further (AUC = 0.80). The results highlight the multifactorial nature of mTBI recovery, and injury recovery more generally, and the need to incorporate a variety of variables to achieve adequate prediction. Further research to improve this model and validate it in new and more diverse trauma samples will be useful to build a neurobiopsychosocial model of recovery that informs treatment development.

Assessing the Pelvic X-ray Findings of High-energy Multiple Trauma Patients in Emergency Department of Rajaee Trauma Hospital, Shiraz-October 2013 to May 2014

1. Abstract <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>1.1. Background: Because of the significance of pelvic fracture, anteroposterior pelvic X-ray (PXR) is routinely performed for all patients referring to the emergency department with multiple trauma. But routine performance of PXR may have several complications and might not be necessary in all cases. Thus, we performed PXR selectively for patients. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>1.2. Objectives: We aimed to assess the PXR findings in traumatized patients referring to emergency department of Rajaee Trauma Hospital, a level 1 triage center, by reviewing PXR findings of multiple trauma patients. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>1.3. Methods: This prospective study was conducted in Rajaee Trauma hospital of Shiraz, the level one Trauma center in south of Iran during October 2013 to May 2014. Shiraz is the center of Fars Province with the population of 2 million and 5 million for the province. Four-hundred traumatic patients were recruited for the study. PXR was performed for selected patients according to the criteria of Rajaee Trauma Hospital. Demographic data, including age, sex, type of accident, and type of hip fracture was recorded. <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>1.4. Results: Most patients (80%) were men with a mean ± SD age of 36.1(17.5) years. The most frequent pelvic fractures were left superior and inferior pubic ramus (12.8 and 12.5%) followed by right inferior pubic ramus fracture (10.5%). The most frequent causes of injury included car turnover and car to pedestrian accident. Chi-square test revealed significant difference between men and women in motor to car accident, car to pedestrian accident, and car to car accident groups (P=0.02, 0.001 and 0.004, respectively). <span style=font-size:10.0pt;font-family: times= new= roman,serif;mso-fareast-font-family:times= roman=>1.5. Conclusion: <span style=font-size:10.0pt; font-family: times= new= roman,serif=>PXR is an appropriate diagnostic tool for pelvic fractures and is most proper to be selectively performed in patients with the criteria mentioned in the current study and more attention should be paid to superior and inferior pubic ramus fractures, as it was found to be the most frequent fractures observed in the present study. 2. Keywords: Emergency; Hospital; Multiple Trauma; Patients; Pelvic X-Ray; Radiography

Diagnostic accuracy of ultrasound in upper and lower extremity long bone fractures of emergency department trauma patients

BackgroundLong bone fractures are common injuries caused by trauma. Some studies have demonstrated that ultrasound has a high sensitivity and specificity in the diagnosis of upper and lower extremity long bone fractures.ObjectiveThe aim of this study was to determine the accuracy of ultrasound compared with plain radiography in diagnosis of upper and lower extremity long bone fractures in traumatic patients.MethodsThis cross-sectional study assessed 100 patients admitted to the emergency department of Imam Khomeini Hospital, Ahvaz, Iran with trauma to the upper and lower extremities, from September 2014 through October 2015. In all patients, first ultrasound and then standard plain radiography for the upper and lower limb was performed. Data were analyzed by SPSS version 21 to determine the specificity and sensitivity.ResultsThe mean age of patients with upper and lower limb trauma were 31.43±12.32 years and 29.63±5.89 years, respectively. Radius fracture was the most frequent compared to other fractures (27%). Sensitivity, specificity, positive predicted value, and negative predicted value of ultrasound compared with plain radiography in the diagnosis of upper extremity long bones were 95.3%, 87.7%, 87.2% and 96.2%, respectively, and the highest accuracy was observed in left arm fractures (100%). Tibia and fibula fractures were the most frequent types compared to other fractures (89.2%). Sensitivity, specificity, PPV and NPV of ultrasound compared with plain radiography in the diagnosis of upper extremity long bone fractures were 98.6%, 83%, 65.4% and 87.1%, respectively, and the highest accuracy was observed in men, lower ages and femoral fractures.ConclusionThe results of this study showed that ultrasound compared with plain radiography has a high accuracy in the diagnosis of upper and lower extremity long bone fractures.

Application of ISS and CRAMS score for the assessment of the prognosis of patients with multiple trauma

Objective To compare the clinical value of injury severity score (ISS) and CRAMS (circulation, respiration, abdomen, motor, speech) score in the prognosis of patients with severe multiple trauma in emergency department. Methods A total of 93 severe multiple trauma patients with 69 male and 24 female and age ranged from 21 to78 years with mean age (43.4 ±14) years admitted in the emergency department from March 20l4 to December 20l5 were enrolled into this study. All of them were evaluated by using ISS and CRAMS score respectively and their survival during hospitalization was observed. Then, the predictive capabilities of ISS and CRAMS score for the mortality of patients were assessed by using receiver operator characteristic (ROC) curves. Results The mean ISS was (25.59±5.37) and mean CRAMS score was (6.75±1.26) in 93 patients with severe multiple trauma. Compared with the survival group (n=75), the ISS in the death group (n=18) was significantly higher (t=7.13, P 0.05). When the death was chosen as the prediction target, the optimal cut-off point for ISS was 27 and CRAMS score was 6, respectively. Conclusions CRAMS score in comparison with ISS score has the likewise predictive value for the prognosis of severe multiple trauma patients in emergency department. However, the CRAMS score is simple and easy in practice. The changes of CRAMS score demonstrate the severity of trauma timely and reliably, which is in favor of the diagnosis and treatment of hospitalized trauma patients in early stage. Key words: Injury severity score; CRAMS Score; Emergency; Multiple trauma; Prognosis assessment

PL03: Implementation of the Canadian C-Spine Rule by paramedics: a safety evaluation

Introduction: The Canadian C-Spine Rule (CCR) was validated by emergency physicians and triage nurses to determine the need for radiography in alert and stable Emergency Department trauma patients. It was modified and validated for use by paramedics in 1,949 patients. The prehospital CCR calls for evaluation of active neck rotation if patients have none of 3 high-risk criteria and at least 1 of 4 low-risk criteria. This study evaluated the impact and safety of the implementation of the CCR by paramedics. Methods: This single-centre prospective cohort implementation study took place in Ottawa, Canada. Advanced and primary care paramedics received on-line and in-person training on the CCR, allowing them to use the CCR to evaluate eligible patients and selectively transport them without immobilization. We evaluated all consecutive eligible adult patients (GCS 15, stable vital signs) at risk for neck injury. Paramedics were required to complete a standardized study data form for each eligible patient evaluated. Study staff reviewed paramedic documentation and corresponding hospital records and diagnostic imaging reports. We followed all patients without initial radiologic evaluation for 30 days for referral to our spine service, or subsequent visit with radiologic evaluation. Analyses included sensitivity, specificity, kappa coefficient, t-test, and descriptive statistics with 95% CIs. Results: The 4,034 patients enrolled between Jan. 2011 and Aug. 2015 were: mean age 43 (range 16-99), female 53.3%, motor vehicle collision 51.9%, fall 23.8%, admitted to hospital 7.0%, acute c-spine injury 0.8%, and clinically important c-spine injury (0.3%). The CCR classified patients for 11 important injuries with sensitivity 91% (95% CI 58-100%), and specificity 67% (95% CI 65-68%). Kappa agreement for interpretation of the CCR between paramedics and study investigators was 0.94 (95% CI 0.92-0.95). Paramedics were comfortable or very comfortable using the CCR in 89.8% of cases. Mean scene time was 3 min (15.6%) shorter for those not immobilized (17 min vs. 20 min; p=0.0001). A total of 2,569 (63.7%) immobilizations were safely avoided using the CCR. Conclusion: Paramedics could safely and accurately apply the CCR to low-risk trauma patients. This had a significant impact on scene times and the number of prehospital immobilizations.

Emergency Department Telemedicine Is Used for More Severely Injured Rural Trauma Patients, but Does Not Decrease Transfer: A Cohort Study.

Traumatic injury is a leading cause of death in the United States, and rural populations are at increased risk of injury and death. Rural residents have limited access to trauma care, and telemedicine has been proposed as one strategy to improve the provision of trauma care locally. The objective of this study was to describe patient-level factors associated with telemedicine consultation in North Dakota critical-access hospital (CAH) emergency departments (EDs) and to measure the association between telemedicine consultation and interhospital transfer. Observational cohort study of all adult (age≥18years) trauma patients treated in North Dakota CAH EDs with an active telemedicine subscription between 2008 and 2014. Trauma cases were identified from the North Dakota Trauma Registry, and telemedicine-enabled care was determined using a probabilistic linking algorithm with the call records of the predominant telemedicine network in North Dakota. Multivariable generalized estimating equations were used to identify factors associated with telemedicine consultation and to measure the association between telemedicine consultation and interhospital transfer, adjusting for patient, injury, and hospital factors. Of the 9,281 North Dakota trauma patients seen in CAHs, 2,837 were treated in an ED with an active telemedicine subscription. Telemedicine was consulted for 11% of all trauma patients in telemedicine-capable EDs. Factors associated with telemedicine consultation included higher Injury Severity Score, penetrating injuries, burns, hypotension, tachycardia, and ambulance transport. Adjusting for severity of illness, injury mechanism, and type of injury, telemedicine use was not associated with interhospital transfer (adjusted odds ratio=1.28, 95% confidence interval=0.94 to 1.75). Emergency department-based telemedicine consultation is requested for the most severely injured rural trauma patients, especially with those with penetrating trauma, burns, and abnormal presenting vital signs. Telemedicine consultation was not independently associated with increased probability of transfer. Future work should evaluate how telemedicine impacts the timeliness of care and specific care interventions.

How the changes in the system affect trauma care provision: The assessment of and implications for Lithuanian trauma service performance in 2007–2012

ObjectiveThe aim of this study was to identify and assess the effects of changes in the Lithuanian trauma service from 2007 to 2012. We postulate that the implications derived from this study will be of importance to trauma policy planners and makers in Lithuania and throughout other countries of Eastern and Central Europe. Materials and methodsOut of 10,390 trauma admissions to four trauma centers in 2007, 294 patients (2.8%) were randomly selected for the first arm of a representative study sample. Similarly, of 9918 trauma admissions in 2012, 250 (2.5%) were randomly chosen for comparison in the study arm. Only cases with a diagnosis falling into the ICD-10 “S” and “T” codes were included. A survey of whom regarding changes in quality of trauma care from 2007 to 2012 was carried out by emergency medical service (EMS) providers. ResultsThe Revised Trauma Score (RTS) mean value was 7.45±1.04 for the 2007 year arm; it was 7.53±0.93 for the 2012 year arm (P=0.33). Mean time from the moment of a call from the site of the traumatic event to the patient's arrival at the trauma center did not differ between the arms of the sample: 49.95min in 2007 vs. 51.6min in 2012 (P=0.81). An application of the operational procedures such as a cervical spine protection using a hard collar, oxygen therapy, infusion of intravenous fluids, and pain relief on the trauma scene was more frequent in 2012 than in 2007. Management of trauma patients in the emergency department improved regarding the availability of 24/7 computed tomography scanner facilities and an on-site radiographer. Time to CT-scanning was reduced by 38.8%, and time to decision-making was reduced by 16.5% in 2012. ConclusionsChanges in operational procedures in the Lithuanian pre-hospital care provision and management of trauma patients in emergency departments of trauma centers improved the efficiency of trauma care delivery over the 2007–2012 period.

Validation of the Shock Index, Modified Shock Index, and Age Shock Index for Predicting Mortality of Geriatric Trauma Patients in Emergency Departments.

The shock index (SI), modified shock index (MSI), and age multiplied by SI (Age SI) are used to assess the severity and predict the mortality of trauma patients, but their validity for geriatric patients is controversial. The purpose of this investigation was to assess predictive value of the SI, MSI, and Age SI for geriatric trauma patients. We used the Emergency Department-based Injury In-depth Surveillance (EDIIS), which has data from 20 EDs across Korea. Patients older than 65 years who had traumatic injuries from January 2008 to December 2013 were enrolled. We compared in-hospital and ED mortality of groups categorized as stable and unstable according to indexes. We also assessed their predictive power of each index by calculating the area under the each receiver operating characteristic (AUROC) curve. A total of 45,880 cases were included. The percentage of cases classified as unstable was greater among non-survivors than survivors for the SI (36.6% vs. 1.8%, P < 0.001), the MSI (38.6% vs. 2.2%, P < 0.001), and the Age SI (69.4% vs. 21.3%, P < 0.001). Non-survivors had higher median values than survivors on the SI (0.84 vs. 0.57, P < 0.001), MSI (0.79 vs. 1.14, P < 0.001), and Age SI (64.0 vs. 41.5, P < 0.001). The predictive power of the Age SI for in-hospital mortality was higher than SI (AUROC: 0.740 vs. 0.674, P < 0.001) or MSI (0.682, P < 0.001) in geriatric trauma patients.

Pertussis Vaccination in Adult Trauma Patients: Are We Missing an Opportunity?: Yorkgitis BK, Timoney G, Salim A, et al. Surgery. 2015;158:602-607.

Tetanus vaccine is commonly administered to trauma patients in Emergency Departments. Meanwhile, the incidence of pertussis in The United States continues to rise. There are different formulations available to deliver tetanus, including tetanus/reduced diphtheria and acellular pertussis (Tdap). In light of this available vaccination and the increase in cases of pertussis, The Center for Disease Control (CDC) has recommended that Tdap be the preferred form of delivery when the tetanus vaccination is indicated with the secondary gain of increased concurrent delivery of pertussis vaccination.

Utility of Computed Tomography in Elbow Trauma Patients with Normal X-Ray Study and Positive Elbow Extension Test

BackgroundElbow fractures are a common injury seen among emergency department trauma patients. Despite its high frequency, there is no standardized method of diagnosis using conventional x-ray imaging for trauma patients presenting with elbow pain and restricted elbow movement. ObjectiveWe aimed to assess trauma patients, using computed tomography (CT), who present with a positive elbow extension test and have no evident fracture on x-ray study. MethodsPatients presented to our emergency department with elbow trauma and were evaluated between April 2010 and March 2011. A CT scan of the injured elbow was ordered for patients with pain on elbow extension (a positive elbow extension test) and no evidence of fracture on x-ray study. All CT and x-ray images were evaluated by a designated radiologist. ResultsOne hundred and forty-eight patients presented to our emergency department with elbow trauma. Two patients were excluded from the study, one with former motion disability and another with an open fracture. In the remaining patients, there were 32 fractures in total. Forty-three of 114 patients without fracture signs had a positive elbow extension test and 4 of these patients refused CT imaging. Fractures were found in 5 (12.8%) of the 39 patients assessed with CT. CT imaging found that two of these patients had a radial head fracture, two others had an olecranon fracture, and one patient had a coronoid fracture. ConclusionsWe recommend CT as an additional evaluation imaging study for trauma patients who have a positive elbow extension test and who present with no apparent fracture on x-ray imaging.

Belief rule-based inference for predicting trauma outcome

A belief rule-based inference methodology using the evidential reasoning approach (RIMER) is employed in this study to construct a decision support tool that helps physicians predict in-hospital death and intensive care unit admission among trauma patients in emergency departments (EDs). This study contributes to the research community by developing and validating a RIMER-based decision tool for predicting trauma outcome. To compare the prediction performance of the RIMER model with those of models derived using commonly adopted methods, such as logistic regression analysis, support vector machine (SVM), and artificial neural network (ANN), several logistic regression models, SVM models, and ANN models are constructed using the same dataset. Five-fold cross-validation is employed to train and validate the prediction models constructed using four different methods. Results indicate that the RIMER model has the best prediction performance among the four models, and its performance can be improved after knowledge base training with historical data. The RIMER tool exhibits strong potential to help ED physicians to better triage trauma, optimally utilize hospital resources, and achieve better patient outcomes.

Abstract 12311: Platelet Force Measurements are Predictive of Triage Category and Blood Transfusion After Trauma

Introduction: Platelets rapidly adhere, aggregate and contract forcefully at wound sites to initiate hemostasis. This process, known as primary hemostasis, is a critical component of clot formation after trauma. However, the clinical value of monitoring primary hemostasis after trauma remains unknown. This pilot study aimed to identify the potential clinical value of monitoring primary hemostasis after trauma by measuring platelet forces. Methods: Blood was sampled from Emergency Department trauma patients at a U.S. Level I trauma center. Primary hemostasis was measured as contractile force generated by platelet micro-aggregates formed within a microfluidic device. Citrated blood was flowed through a microfluidic channel at high shear rate for 15 seconds, causing platelet aggregates to rapidly form, activate, and contract at collagen-coated micro-force sensors. The maximum platelet force generated over five minutes was recorded in nanonewtons (nN). ANOVA was used to compare platelet force for each trauma triage category: Healthy non-trauma control vs. Modified vs. Full trauma team activation. Logistic regression was used to identify the association of platelet force with the need for any blood product transfusion within 24 hours of hospitalization. Results: N=28 trauma patients and N=7 healthy control subjects were included in this pilot analysis of an ongoing cross-sectional observational study. Of the trauma subjects 7/28 (25%) met Full trauma team activation criteria, and 7/28 (25%) required a blood-product transfusion. Mean (SD) platelet force was 227(63) nN for healthy controls, 157(48) nN for Modified, and 126(35) nN for Full trauma team activations (ANOVA, p=0.004). Platelet forces were 164 (45) nN for non-transfused vs. 112(20) nN for transfused subjects (t-test, p=0.008). The platelet force unit Odds Ratio for blood product transfusion was 0.965 (95%CI= 0.936, 0.996), indicating that the odds of receiving a transfusion was decreased significantly by 3.5% for every one nN increase of platelet force. Conclusions: Directly measuring primary hemostasis using platelet forces may enhance trauma triage and predict the need for blood product transfusion after trauma.

Clot Formation Is Associated With Fibrinogen and Platelet Forces in a Cohort of Severely Injured Emergency Department Trauma Patients.

Anticoagulation, fibrinogen consumption, fibrinolytic activation, and platelet dysfunction all interact to produce different clot formation responses after trauma. However, the relative contributions of these coagulation components to overall clot formation remain poorly defined. We examined for sources of heterogeneity in clot formation responses after trauma. Blood was sampled in the emergency department from patients meeting trauma team activation criteria at an urban trauma center. Plasma prothrombin time of 18 s or longer was used to define traumatic coagulopathy. Mean kaolin-activated thrombelastography (TEG) parameters were calculated and tested for heterogeneity using analysis of means. Discriminant analysis and forward stepwise variable selection with linear regression were used to determine if prothrombin time, fibrinogen, platelet contractile force (PCF), and D-dimer concentration, representing key mechanistic components of coagulopathy, each contribute to heterogeneous TEG responses after trauma. Of 95 subjects, 16% met criteria for coagulopathy. Coagulopathic subjects were more severely injured with greater shock and received more blood products in the first 8 h compared with noncoagulopathic subjects. Mean (SD) TEG maximal amplitude (MA) was significantly decreased in the coagulopathic group (57.5 [SD, 4.7] mm vs. 62.7 [SD, 4.7], t test P < 0.001). The MA also exceeded the ANOM predicted upper decision limit for the noncoagulopathic group and the lower decision limit for the coagulopathic group at α = 0.05, suggesting significant heterogeneity from the overall cohort mean. Fibrinogen and PCF best discriminated TEG MA using discriminant analysis. Fibrinogen, PCF, and D-dimer were primary covariates for TEG MA using regression analysis. Heterogeneity in TEG-based clot formation in emergency department trauma patients was linked to changes in MA. Individual parameters representing fibrin polymerization, PCFs, and fibrinolysis were primarily associated with TEG MA after trauma and should be the focus of early hemostatic therapies.

High incidence of interpersonal violence in Northwest Ethiopia: A cross-sectional study

BackgroundInterpersonal violence has devastating consequences for the mental, physical and sexual health of the victim. It is a leading cause of injury in east Africa. Studies in Ethiopia report that the most common cause of injury was interpersonal conflict. Our objective was to study the incidence of interpersonal violence related injury and associated factors among patients visiting the emergency department of University of Gondar Hospital, Northwest Ethiopia. MethodsA cross-sectional institutional based study design was employed from November 2013–June 2014. The source population was a cohort sample of all patients presenting for treatment of a traumatic injury. Data were collected using injury surveillance guidelines developed by the World Health Organization. Bivariate and multivariate logistic regressions were performed to identify the presence and strength of association. Odds ratio with 95% confidence interval was computed to determine the level of significance. ResultsThe overall incidence of interpersonal violence related injury was 28.5% of all emergency department trauma patients. Multivariate logistic regression shows that conflict in the family prior to the event [AOR = 9.9 (95% CI: 4.433–9.536)], poor behavioral control [AOR = 2.5 (95% CI: 1.192–5.460)], alcohol use [AOR = 3.406 (95% CI: 1.813–6.398)] and paternal education [AOR = 2.441(95% CI: 1.209–4.929)] were found to be independently associated with interpersonal violence related injury. Conclusion and recommendationThe incidence of interpersonal violence related injury was high. Counseling and education on conflict resolution methods should be given for the community using mass media.