Trauma Team Activation Research Articles

An Analysis of Trauma Team Activations at a South African Level One Trauma Centre

ABSTRACT Introduction: South Africa has a high prevalence of trauma causing a significant healthcare and financial burden. Various scoring systems have been developed to guide trauma team activation (TTA). To date, however, there are no standardised criteria for TTA. The aim of this preliminary study was to analyse the practice of clinical judgement TTA when compared to the American College of Surgeons Committee on Trauma (ACS-COT) TTA guideline and the Loma Linda Rule for TTA. Methods: This was a retrospective analysis of trauma registry data over a one-year period from a Level 1 trauma centre in South Africa. Results: There were 9207 trauma patients that presented to the Emergency Department during the 1-year study period. The prevalence of trauma team activation by clinical judgement was 9.4%. Only 407 patients (48%) of the clinical judgement TTAs fulfilled the ACS-COT guidelines for TTA. Using the Loma Linda Rule, 456 patients (53.8%) of the clinical judgement TTAs fulfilled TTA criteria. Despite the over-triage by the clinical judgement TTA, almost two-thirds of the TTA patients were admitted to the intensive care or high care units. Conclusions: This preliminary study showed that TTA using healthcare provider clinical judgement resulted in trauma team over-activation when compared to the ACS-COT guideline and the Loma Linda Rule. Over-activation of the trauma team consumes valuable resources and potentially endangers those patients who actually need TTA and cannot receive it. Implementation of a standardised TTA tool could potentially aid in the optimisation of patient care and appropriate resource utilisation.

Forecasting the flap: predictors for pediatric lower extremity trauma reconstruction.

BackgroundPredicting the need for post-traumatic reconstruction of lower extremity injuries remains a challenge. Due to the larger volume of cases in adults than in children, the majority of the medical literature has focused on adult lower extremity reconstruction. This study evaluates predictive risk factors associated with the need for free flap reconstruction in pediatric patients following lower extremity trauma.MethodsAn IRB-approved retrospective chart analysis over a 5-year period (January 1, 2012 to December 31, 2017) was performed, including all pediatric patients (<18 years old) diagnosed with one or more lower extremity wounds. Patient demographics, trauma information, and operative information were reviewed. The statistical analysis consisted of univariate and multivariate regression models to identify predictor variables associated with free flap reconstruction.ResultsIn total, 1,821 patients were identified who fit our search criteria, of whom 41 patients (2.25%) required free flap reconstruction, 65 patients (3.57%) required local flap reconstruction, and 19 patients (1.04%) required skin graft reconstruction. We determined that older age (odds ratio [OR], 1.134; P =0.002), all-terrain vehicle accidents (OR, 6.698; P<0.001), and trauma team activation (OR, 2.443; P=0.034) were associated with the need for free flap reconstruction following lower extremity trauma in our pediatric population.ConclusionsOur study demonstrates a higher likelihood of free flap reconstruction in older pediatric patients, those involved in all-terrain vehicle accidents, and cases involving activation of the trauma team. This information can be implemented to help develop an early risk calculator that defines the need for complex lower extremity reconstruction in the pediatric population.

Impact of the COVID-19 lockdown on trauma team activations in a single major Lithuanian trauma center: A retrospective single-center study.

Background:As a result of the coronavirus disease 2019 (COVID-19) pandemic and national quarantine, different levels of social and movement restrictions, and stay-at-home requests, trauma trends have changed. The aim of the present study was to determine the impact of lockdown on patients treated by the trauma team (TT) at a single major Lithuanian trauma center during the COVID-19 pandemic.Methods:This is a retrospective, descriptive study of adult (≥18 years old) trauma patients (for whom the TT was activated). Consequently, we analyzed the national lockdown periods from 16 March to 15 May 2020 and from 16 December 2020 to 28 February 2021, compared with the corresponding period of the previous year.Results:There was a 10% reduction in TT activations during the national lockdown period. No significant differences were noted in patient demographics. In the COVID-19 cohort, patients had higher Injury Severity Score (14 [IQR 6−21] vs. 9 [IQR 3−18], P = 0.025) and longer time to computed tomography scan (33 [IQR 25−43] vs. 23 [IQR 20−31] min, P < 0.001). Moreover, in the COVID-19 cohort, three times more patients were transferred from the emergency department (ED) straight to the operating room (n = 12 [19%] vs. n = 4 [5.7%], P = 0.018, Cramer's V = 0.21).Conclusion:Patients were more severely injured, and more patients required emergent surgery during the lockdown. In addition, it took longer to transfer patients to the ED and to perform a computed tomography scan.

Volume and flow of trauma team activation patients throughout the 24-hour day over a 3-year period at an academic trauma center

Volume and flow of trauma team activation patients throughout the 24-hour day over a 3-year period at an academic trauma center

Effect of the COVID-19 pandemic at a major Danish trauma center in 2020 compared with 2018-2019: A retrospective cohort study.

BackgroundThe COVID‐19 pandemic demanded changes in societal behavior and health care worldwide. Previous studies have compared trauma patient admissions in COVID‐19‐related lockdowns to prior years. This study describes the COVID‐19 impact on trauma patient admissions during entire 2020 at a major trauma center in Denmark.MethodsWe retrospectively analyzed trauma patients received by a trauma team and admitted at Aarhus University Hospital in 2020 compared with 2018–2019. The incidence of injuries, mechanism of injury, 30‐day mortality, and Injury Severity Score (ISS) were investigated.ResultsThe incidence of minor injuries (ISS 1–15) increased by 24% in 2020 compared with 2018–2019 (incidence rate ratio 1.24 [95% CI: 1.11–1.39]). The incidence of severe injuries (ISS >15) in 2020 did not change compared with 2018–2019 (incidence rate ratio 0.97 [95% CI: 0.80–1.17]). The 30‐day mortality was similar in 2020 compared with 2018–2019. Comparing 2020 with 2018–2019, the risk ratio of traffic injuries decreased (0.90 [95% CI: 0.82–0.99]), risk ratio for fall injuries was 1.13 (95% CI: 0.97–1.30), for violence 1.13 (95% CI: 0.51–2.50), and for self‐harm 1.94 (95% CI: 0.95–3.94). During the first lockdown of 2020, trauma team activations declined from 49.5 to 42 and the risk ratio for traffic injuries was 0.74 (95% CI: 0.50–1.10) compared with the same period in 2018–2019.ConclusionThe incidence of minor injuries increased, but the incidence of severe injuries was similar in 2020 compared with 2018–2019. Societal restrictions might alter the mechanism of injuries. The first lockdown indicated an association with reduced traffic injuries.

Elevated serum lactate levels and age are associated with an increased risk for severe injury in trauma team activation due to trauma mechanism.

The identification of risk factors for severe injury is crucial in trauma triage and trauma team activation (TTA) depends on a sufficient triage. The aim of this study was to determine whether or not elevated serum lactate levels and age are risk factors for severe injury in TTA due to trauma mechanism. We conducted a retrospective cohort study in a single level one trauma center between September 2019 and May 2021 and analysed every TTA due to trauma mechanism. Primary endpoint of interest was the association of serum lactate as well as age with injury severity assessed by the injury severity score (ISS). During the study period, we included 250 patients. Mean age was 43.3years (Min.: 11, Max.: 90, SD: 18.7) and the initial lactate level was 1.7mmol/L (SD: 0.95) with a mean ISS of 8.4 (SD: 8.99). The adjusted odds ratio (OR) for age > 65 being associated with an ISS > 16 is 9.7 (p < 0.001; 95% CI 4.01-25.58) and for lactate > 2.2mmol/L being associated with an ISS > 16 is 6.29 (p < 0.001; 95% CI 2.93-13.48). A lactate level of > 4mmol/L results in a 36-fold higher risk of severe injury with an ISS > 16 (OR 36.06; 95% CI 4-324.29). This study identifies age (> 65) and lactate (> 2.2mmol/L) as independent risk factors for severe injury in a TTA due to trauma mechanism. Existing triage protocols might benefit from congruous amendments.

At risk child: a contemporary analysis of injured children in London and the South East of England: a prospective, multicentre cohort study

BackgroundInjury is a leading health burden in children yet relatively little is reported about the contemporary risks they face. Current national registry data may under-represent the true burden of injury...

Critically Ill Children in a Swiss Pediatric Emergency Department With an Interdisciplinary Approach: A Prospective Cohort Study.

Objective: Delivery of prompt and adequate care for critically ill and injured children presenting to the pediatric emergency department (PED) is paramount for optimal outcomes. Knowledge of the local epidemiology, patient profile, and presentation modes are key for organizational planning, staff education strategy, and optimal care in a PED. Our aim was to analyze the profile of critically ill and injured children admitted to a tertiary, non-academic Swiss PED, to investigate potential risk factors associated with admission to the pediatric intensive care unit (PICU), and the outcomes mortality and PICU admission.Methods: Prospective cohort study of critically ill and injured children presenting to the PED over a two-year period (2018–2019). Inclusion criteria were Australasian triage scale category (ATS) 1, trauma team activation (TTA), medical emergency response (MER) activation, additional critical care consult, and transfer to an outside hospital.Results: Of 42,579 visits during the two-year period, 347 presentations matched the inclusion criteria (0.81%). Leading presentations were central nervous system (CNS) disorders (26.2%), trauma (25.1%), and respiratory emergencies (24.2%). 288 out of 347 cases (83%) arrived during the day or evening with an even distribution over the days of the week. 128 out of 347 (37%) arrived unexpectedly as walk-ins. 233 (67.15%) were ATS category 1. 51% of the cohort was admitted to PICU. Australasian triage scale category 1 was significantly more common in this group (p = 0.0001). Infants with respiratory disease had an increased risk of PICU transfer compared to other age groups (OR 4.18 [95%CI 2.46, 7.09] p = 0.0001), and this age group presented mainly as walk-in (p = 0.0001). Pediatric intensive care unit admissions had a longer hospital stay (4 [2, 8] days vs. 2 [1, 4] days, p = 0.0001) compared to other patients. 0.045% of all PED patients had to be transferred out. Three deaths (0.86%) occurred in the PED, 10 patients died in the PICU (2.9%).Conclusions: High acuity presentations in the PED were rare, more likely to be young with CNS disorders, trauma and respiratory diseases. A significant proportion were unexpected walk-in presentations, mainly during day and evening shifts. Low exposure to high-acuity patients highlights the importance of deliberate learning and simulation for all professionals in the PED.

Trauma Computed Tomography in the Modern Era: Not Always Quick and Safe.

Computed tomography (CT) has emerged as the diagnostic modality of choice in trauma patients. Recent studies suggest its use in hemodynamically unstable patients is safe and potentially lifesaving; however, the incidence of adverse events (AE) during the trauma CT scanning process remains unknown. Over a 6-month period at a Level 1 trauma center, data on patients undergoing trauma CT (whole-body CT (WBCT) +/- additional CT studies) were prospectively collected. All patients requiring a trauma team activation (TTA) were included. Adverse events and specific time intervals were recorded from the time of TTA notification to the time of return to the resuscitation bay from the CT suite. Of the 94 consecutive patients included in the study, 47.9% experienced 1 or more AE. Median duration away from the resuscitation bay for all patients was 24minutes. Patients with AE spent a significantly longer time away from the resuscitation bay and had longer scan times. Vasopressor support and ongoing transfusion requirement at the time of CT scanning were associated with AE. Adverse events of varying clinical significance occur frequently in patients undergoing emergent trauma CT. A standard trauma CT protocol could improve the efficiency and safety of the scanning process.

Trauma Team Activation: Which Surgical Capability Is Immediately Required in Polytrauma? A Retrospective, Monocentric Analysis of Emergency Procedures Performed on 751 Severely Injured Patients.

There has been an ongoing discussion as to which interventions should be carried out by an “organ specialist” (for example, a thoracic or visceral surgeon) or by a trauma surgeon with appropriate general surgical training in polytrauma patients. However, there are only limited data about which exact emergency interventions are immediately carried out. This retrospective data analysis of one Level 1 trauma center includes adult polytrauma patients, as defined according to the Berlin definition. The primary outcome was the four most common emergency surgical interventions (ESI) performed during primary resuscitation. Out of 1116 patients, 751 (67.3%) patients (male gender, 530, 74.3%) met the inclusion criteria. The median age was 39 years (IQR: 25, 58) and the median injury severity score (ISS) was 38 (IQR: 29, 45). In total, 711 (94.7%) patients had at least one ESI. The four most common ESI were the insertion of a chest tube (48%), emergency laparotomy (26.3%), external fixation (23.5%), and the insertion of an intracranial pressure probe (ICP) (19.3%). The initial emergency treatment of polytrauma patients include a limited spectrum of potential life-saving interventions across distinct body regions. Polytrauma care would benefit from the 24/7 availability of a trauma team able to perform basic potentially life-saving surgical interventions, including chest tube insertion, emergency laparotomy, placing external fixators, and ICP insertion.

Changes in pediatric major trauma epidemiology, injury patterns, and outcome during COVID-19-associated lockdown.

The COVID-19 pandemic and its associated preventive measures such as national and regional lockdowns have dramatically changed the epidemiology of pediatric admissions to the emergency department. Nevertheless, there are scant data on the epidemiology and injury patterns of major pediatric trauma injuries during these lockdown periods. A single-center retrospective study of data obtained from a tertiary level 1 trauma hospital trauma registry. The data included demographics, injury mechanisms, injury severity and type, treatment, and resource utilization in children aged 0-18years who required trauma team activation upon arrival. The analysis compares the data from the 5-week lockdown period from March to May 2020 in Jerusalem, Israel, to its parallel periods in 2018-2019. A total of 187 trauma visits that required trauma team activation (TTA) were analyzed: 48 visits during the lockdown period vs. 139 in 2018-2019, corresponding to a 40% drop in TTA. There was a significant decrease of 34% in MVA-related injuries (p = 0.0001) but a significant increase of 14% in burns (p = 0.01) and a 16% increase in bicycle-related injuries (p = 0.001). No changes in ISS, injury patterns, admission rate, PICU utilization, or need for interventions were observed. There was a significant decrease in the number of overall pediatric trauma visits during the 2020 lockdown, mainly in MVA-associated trauma, but an increase in burns and bicycle injuries. These findings can thus inform policy makers as to the need to formulate prevention awareness programs alerting the public to indoor hazards and the dangers of activities outside the home. Furthermore, it can inform hospital policy decision-making in future lockdowns. The fact that PICU admissions and the need for operating rooms stayed unchanged suggests that it is vital to maintain trauma team capabilities even during lockdowns.

Isolated Intracranial Hemorrhage in Elderly Patients With Pre-Injury Anticoagulation: Is Full Trauma Team Activation Necessary?

Traumatic intracranial hemorrhage (ICH) is a highly morbid injury, particularly among elderly patients on preinjury anticoagulants (AC). Many trauma centers initiate full trauma team activation (FTTA) for these high-risk patients. We sought to determine if FTTA was superior compared with those who were evaluated as a trauma consultation (CON). Patients aged ≥55 on preinjury AC who presented from January 2015 to December 2019 with blunt isolated head injury (non-head AIS ≤2) and confirmed ICH were identified. CON patients and FTTA patients were matched by age and head AIS. Cox proportional hazard model was used to assess patient and injury characteristics with mortality and survivor discharge disposition. There were 45 CON patients and 45 FTTA patients. Mean age was 80 years in both groups. Fall was the most common mechanism (98% CON vs. 92% FTTA). Glasgow Coma Score (GCS) was lower in FTTA (14 vs. 15, p<0.01). CON had a significantly longer time from arrival to CT scan (1.3 vs. 0.4 hrs, p<0.01). Hospital days were similar (CON: 3.9 vs. FTTA: 3.7 days). However, CON had increased ventilator use (p=0.03). Lower admission GCS was the only factor associated with increased risk of death. Among survivors, only head AIS increased the risk of discharge to a level of care higher than that of preinjury (p=0.01). There was no difference in mortality or adverse discharge disposition between FTTA and CON, although FTTA was associated with a more rapid evaluation and diagnosis. Any alteration in GCS was strongly associated with mortality and should prompt evaluation by FTTA.

Need for Emergent Intervention within 6 Hours: A Novel Prediction Model for Hospital Trauma Triage

Objective: A tiered trauma team activation system allocates resources proportional to patients’ needs based upon injury burden. Previous trauma hospital-triage models are limited to predicting Injury Severity Score which is based on > 10% all-cause in-hospital mortality, rather than need for emergent intervention within 6 hours (NEI-6). Our aim was to develop a novel prediction model for hospital-triage that utilizes criteria available to the EMS provider to predict NEI-6 and the need for a trauma team activation. Methods: A regional trauma quality collaborative was used to identify all trauma patients ≥ 16 years from the American College of Surgeons-Committee on Trauma verified Level 1 and 2 trauma centers. Logistic regression and random forest were used to construct two predictive models for NEI-6 based on clinically relevant variables. Restricted cubic splines were used to model nonlinear predictors. The accuracy of the prediction model was assessed in terms of discrimination. Results: Using data from 12,624 patients for the training dataset (62.6% male; median age 61 years; median ISS 9) and 9,445 patients for the validation dataset (62.6% male; median age 59 years; median ISS 9), the following significant predictors were selected for the prediction models: age, gender, field GCS, vital signs, intentionality, and mechanism of injury. The final boosted tree model showed an AUC of 0.85 in the validation cohort for predicting NEI-6. Conclusions: The NEI-6 trauma triage prediction model used prehospital metrics to predict need for highest level of trauma activation. Prehospital prediction of major trauma may reduce undertriage mortality and improve resource utilization.

Geriatric Recovery and Enhancement Alliance in Trauma (GREAT) multidisciplinary quality improvement initiative: improving rates of successful resuscitation, rehabilitation and reintegration of geriatric trauma patients across the trauma spectrum of care

Geriatric Recovery and Enhancement Alliance in Trauma (GREAT) multidisciplinary quality improvement initiative: improving rates of successful resuscitation, rehabilitation and reintegration of geriatric trauma patients across the trauma spectrum of care. Sandy Widder, Kristin E. Morch, Nori L Bradley, Lauren Ternan, Ni Thuyen Lam Background: Traumatic injuries are a significant cause of morbidity and mortality in the elderly, with the risk of poor outcomes increasing with advanced age. Using a multidisciplinary geriatric trauma care approach, led by a dedicated nursing coordinator, standardized order sets were implemented to reduce in-hospital complications and screening tools applied early to identify patient specific care needs. Specifically, early trauma consult, identification of injuries, appropriate opioid ordering, polypharmacy avoidance, delirium prevention, mental health issues, and mobility needs were addressed The goal was to improve geriatric trauma awareness, decrease in-hospital complications and improve the likelihood of return to home and baseline function Implementation: Through stakeholder consultation process, it was recognized that the hospital needed a coordinated, geriatric trauma team process. The geriatric trauma navigator (GTN) role was created to lead these quality improvement initiatives. This included the development of educational strategies for frontline staff and physicians to highlight the unique challenges of trauma patient management and to introduce the GREAT study for optimized patient care. Patients 65 years of age or older with a traumatic mechanism were enrolled. GREAT patients then followed a protocol designed for tracking and implementing standardized processes, including early ED and in-patient order sets, engagement of trauma services, and the application of screening tools and specialty consultations. Screening tools (Identification of Seniors At Risk (ISAR), Confusion Assessment Method (CAM), Mini-Cog, Patient Health Questionnaire (PHQ-2), Geriatric Depression Scale (GDS-15), Alcohol Use Disorders Identification Test- Concise (AUDIT-C), Canadian Nutrition Screening Tool (CNST), Clinical Frailty Scale, ADL/IDLs) were administered to identify at-risk patients and to inform consultation with geriatrics and psychiatry, and allied health services (occupation therapy, physical therapy, nutrition services, pharmacy). The study team evaluated data on a monthly basis and met quarterly to evaluate and implement changes. Evaluation Methods: Data was prospectively collected and compared to control data from the Alberta Trauma Registry and Trauma Quality Improvement Program (American College of Surgeons). Data tabulation and statistical analysis was performed using Stat59 (STAT59 Services Ltd, Edmonton, AB, Canada). Outcome measures-provision of timely and comprehensive care: rates of trauma team activations, emergencydepartment and in-hospital length of stay-reduction of hospital complications: UTI, DVT/PE, pneumonia, pressure ulcers, ICUadmission, unexpected readmission to hospital-improvement of functionality upon discharge: in-hospital and 30 day mortality rates,return to function, disposition (home versus long term care) Process measures-time to diet and ambulation-tracking of number of days of urinary catheter in situ-compliance with GOC discussions-use of assessment screening tools-spinal clearance &lt;24 hours Results: Enrollment of patients into GREAT based on study criteria lowered the threshold for triggering a trauma team consult, improving the recognition rate of geriatric trauma. This was reflected in the decreased average ISS scores and higher rate of trauma consults. Ground level falls, which previously did not typically activate a trauma consult, are now be recognized as major trauma. With the GTN, we determined that gaps exist in the current monitoring of key performance measures. Through the GREAT data collection process, we were able to establish baseline data and target PDSA changes to address these gaps. Advice and Lessons Learned: This quality initiative was designed as a proof of concept model for early identification of the geriatric trauma patient and a collaborative team approach to optimize care processes, and in turn minimize complications. The GTN role was vital to identify patients, implement screening tools, and coordinate care. With limited resources and increasing work loads for all programs, the additional GTN role required site leadership and stakeholder support. Ideally, a protocolized geriatric trauma team activation and admission process would ensure all patients receive screening tools as part of their in-patient orders for early assessments and interventions. Further educational campaigns will need to be developed to increase awareness of the importance of geriatric trauma. Additionally, processes need to be streamlined for data gathering and monitoring of performance measures. Access to screening tools and order sets need to be user friendly, built into currently existing workflows, and evaluated for optimization.

Isolated vehicle rollover is not an independent predictor of trauma injury severity.

ObjectivesThe objective of this study was to determine if vehicle rollover in a motor vehicle crash is an independent predictor of major injury.MethodsA retrospective cohort study of all patients injured in motor vehicle crashes presenting to a major trauma center between July 2012 and June 2016 was conducted. Crashes were classified into groups: non‐rollover, isolated rollover (without other mechanisms of injury), or mixed‐mechanism rollover (with other mechanisms of injury). Associations between rollover group, other covariates (entrapment, encapsulation, ejection, death on scene, high speed, seat belt usage, airbag deployment, trauma team activation), and major injury (injury severity score >15, major surgery, intensive care unit admission, or in‐hospital death) were tested using binary logistic regression models. Vehicle rollover was categorized either as “present” or “absent” on 1 model or as either “none,” “isolated,” or “mixed mechanism” in the other.ResultsIn 2446 motor vehicle crashes, there were 423 rollovers (196 isolated, 227 mixed mechanisms). Compared with crashes without rollovers, the prevalence of patients with major injury was lower in crashes with isolated rollovers and higher in crashes with mixed‐mechanism rollovers (13.8% vs 9.5% vs 27.5%, respectively; P < 0.001). Rollover (present vs absent) was not an independent predictor of major injury (odds ratio [OR], 1.10; 95% confidence interval [CI], 0.78–1.53). Patients in crashes with mixed‐mechanism but not isolated rollovers had increased odds (OR, 2.04; 95% CI, 1.41–2.96) of major injury compared with patients from crashes without rollovers.ConclusionsPatients from crashes with isolated vehicle rollovers may not need to be transported to a trauma center as they carry a lower risk of injury.

Smartphone application alerts for early trauma team activation: Millennial technology in healthcare

BackgroundData access through smartphone applications (apps) has reframed procedure and policy in healthcare, but its impact in trauma remains unclear. Citizen is a free app that provides real-time alerts curated from 911 dispatch data. Our primary objective was to determine whether app alerts occurred earlier than recorded times for trauma team activation and emergency department arrival. MethodsTrauma registry entries were extracted from a level one urban trauma center from January 1, 2018 to June 30, 2019 and compared with app metadata from the center catchment area. We matched entries to metadata according to description, date, time, and location then compared metadata timestamps to trauma team activation and emergency department arrival times. We computed percentage of time the app reported traumatic events earlier than trauma team activation or emergency department arrival along with exact binomial 95% confidence interval; median differences between times were presented along with interquartile ranges. ResultsOf 3,684 trauma registry entries, 209 (5.7%) matched app metadata. App alerts were earlier for 96.1% and 96.2% of trauma team activation and emergency department arrival times, respectively, with events reported median 36 (24–53, IQR) minutes earlier than trauma team activation and 32 (25–42, IQR) minutes earlier than emergency department arrival. Registry entries for younger males, motor vehicle-related injuries and penetrating traumas were more likely to match alerts (P < .0001). ConclusionApps like Citizen may provide earlier notification of traumatic events and therefore earlier mobilization of trauma service resources. Earlier notification may translate into improved patient outcomes. Additional studies into the benefit of apps for trauma care are warranted.

Prehospital end-tidal carbon dioxide predicts hemorrhagic shock upon emergency department arrival.

In addition to reflecting gas exchange within the lungs, end-tidal carbon dioxide (ETCO2) also reflects cardiac output based on CO2 delivery to the pulmonary parenchyma. We hypothesized that low prehospital ETCO2 values would be predictive of hemorrhagic shock in intubated trauma patients. A retrospective observational study of adult trauma patients intubated in the prehospital setting and transported to a single Level I trauma center from 2016 to 2019. Continuous prehospital ETCO2 data were linked with patient care registries. We developed a novel analytic approach that allows for reflection of prehospital ETCO2 over the entire prehospital course of care. The primary outcome was hemorrhagic shock on emergency department (ED) presentation, defined as either initial ED systolic blood pressure of 90 mm Hg or less or initial Shock Index (SI) > 0.9, and transfusion of at least one unit of blood product during their ED stay. Prehospital ETCO2 less than 25 mm Hg was evaluated for predictive value of hemorrhagic shock. Three hundred and seven patients (82% men, 34% penetrating injury, 42% in hemorrhagic shock on ED arrival, 27% mortality) were included in the study. Patients in hemorrhagic shock had lower median ETCO2 values (26.5 mm Hg vs. 32.5 mm Hg; p < 0.001) than those not in hemorrhagic shock. Patients with prehospital ETCO2 less than 25 mm Hg were 3.0 times (adjusted odds ratio = 3.0; 95% confidence interval, 1.1-7.9) more likely to be in hemorrhagic shock upon ED arrival than patients with ETCO2 ≥ 25 mm Hg. Intubated patients with hemorrhagic shock upon ED arrival had significantly lower prehospital ETCO2 values. Incorporating ETCO2 assessment into prehospital care for trauma patients could support decisions regarding prehospital blood transfusion, and triage to higher-level trauma centers, and trauma team activation. Prognostic, level III.

Emergency department management of severely injured children in New South Wales

Presentations to EDs for major paediatric injury are considerably lower than for adults. International studies report lower levels of critical intervention, including intubation, required in injured children. A New South Wales study demonstrated an adverse event rate of 7.6% in children with major injury. Little is known about the care and interventions received by children presenting to Australian EDs with major injury. The ED care of injured children <16 years who ultimately received definitive care at a New South Wales Paediatric Trauma Centre between July 2015 and September 2016, and had an Injury Severity Score ≥9, required intensive care admission or died were included. There were 491 injured children who received treatment at 64 EDs, half (49.4%, n= 243) were treated initially in a Paediatric Trauma Centre. One third (32.8%) sustained an Injury Severity Score >12, more than half (n= 251, 51.1%) of children were classified as a triage category 1 or 2, and 38.3% received trauma team activation. Critical intervention was infrequent. Intubation was documented in 9.2% (n= 45), needle thoracostomy and activation of massive transfusion protocol in two (0.4%) and eight (1.6%) had intraosseous access established. Only a small proportion (14.7%, n= 63) had two or more observations outside the normal range. A small proportion of children arriving in the ED post-major trauma have deranged clinical observations and receive critical interventions. The limited exposure in the management of trauma in paediatric patients requires measures to ensure clinicians have adequate training, skills and confidence to manage these clinical presentations in all EDs.

Changing from a two-tiered to a one-tiered trauma team activation protocol: a before–after observational cohort study investigating the clinical impact of undertriage

BackgroundThe aim of this study was to compare the effect of the change in TTA protocol from a two-tier to one-tier, with focus on undertriage and mortality.Material and methodsA before–after observational cohort study based on data extracted from the Stavanger University Hospital Trauma registry in the transition period from two-tier to a one-tier TTA protocol over two consecutive 1-year periods (2017–2018). Comparative analysis was done between the two time-periods for descriptive characteristics and outcomes. The main outcomes of interest were undertriage and mortality.ResultsDuring the study period 1234 patients were included in the registry, of which 721 (58%) were in the two-tier and 513 (42%) in the one-tier group. About one in five patients (224/1234) were severely injured (ISS > 15).Median age was 39 in the two-tier period and 43 years in the one-tier period (p = 0.229). Median ISS was 5 for the two-tier period vs 9, in the one-tier period (p = 0.001). The undertriage of severely injured patients in the two-tier period was 18/122 (15%), compared to 31/102 (30%) of patients in the one-tier period (OR = 2.5; 95% CI 1.8–4.52). Overall mortality increased significantly between the two TTA protocols, from 2.5 to 4.7% (p = 0.033), OR 0.51 (0.28–0.96)ConclusionA protocol change from two-tiered TTA to one-tiered TTA increased the undertriage in our trauma system. A two-tiered TTA may be beneficial for better patient care.

Blood alcohol screening and outcomes in trauma team activation patients at a level 1 trauma centre in New Zealand.

A causal relationship between alcohol consumption and injury exists and the prevalence of harmful alcohol intakes in New Zealand adults is high. The present study investigates compliance to blood alcohol (BA) screening policy and the epidemiological profile and hospital-related outcomes of trauma team activation (TTA) patients with positive BA at a New Zealand level 1 trauma centre. A retrospective review of Midland Trauma Registry hospitalisation data between January 2012 and December 2019 was conducted. Eligible patients (n=2168) were ≥15 years who received TTA at Waikato Hospital. BA screening rates, demographic and event information, injury severity and hospital-related outcomes were examined. The average BA screening rate was 94.0% (95% confidence interval 92.9-95.0%) and 17.9% of screened patients were BA+ . BA+ patients were younger than BA- (34.7 and 40.5 years, P< 0.0001). More males than females (20.6 and 12.4%, P< 0.0001), Māori (30.8%) compared to non-Māori (<16.0%) and unemployed/beneficiaries (33.4%) compared to employed patients (15.5%) were BA+ . Road transport crashes accounted for the highest proportion (45.2%) but, in comparison there were higher odds of BA+ from interpersonal violence (odds ratio 4.48, P< 0.0001). No difference between BA+ and BA- was observed in survival rate, injury severity scores, length of intensive care and total hospital stay. Between 2012 and 2019, Waikato Hospital demonstrated high compliance to BA screening policy for TTA patients. Appropriate alcohol awareness initiatives that focus on road safety and interpersonal violence are required to reduce the preventable prevalence and burden of alcohol-related trauma in the Waikato region.