scholarly journals Structured and Systematic Team and Procedure Training in Severe Trauma: Going from ‘Zero to Hero’ for a Time-Critical, Low-Volume Emergency Procedure Over Three Time Periods

2021 ◽  
Vol 45 (5) ◽  
pp. 1340-1348
Author(s):  
Maryam Meshkinfamfard ◽  
Jon Kristian Narvestad ◽  
Johannes Wiik Larsen ◽  
Arezo Kanani ◽  
Jørgen Vennesland ◽  
...  
Keyword(s):  
Injury Severity ◽  
Trauma System ◽  
Severe Trauma ◽  
Emergency Procedure ◽  
Emergency Thoracotomy ◽  
Severity Scores ◽  
Time Periods ◽  
Low Volume ◽  
Time Critical ◽  
Over Time

Abstract Background Resuscitative emergency thoracotomy is a potential life-saving procedure but is rarely performed outside of busy trauma centers. Yet the intervention cannot be deferred nor centralized for critically injured patients presenting in extremis. Low-volume experience may be mitigated by structured training. The aim of this study was to describe concurrent development of training and simulation in a trauma system and associated effect on one time-critical emergency procedure on patient outcome. Methods An observational cohort study split into 3 arbitrary time-phases of trauma system development referred to as ‘early’, ‘developing’ and ‘mature’ time-periods. Core characteristics of the system is described for each phase and concurrent outcomes for all consecutive emergency thoracotomies described with focus on patient characteristics and outcome analyzed for trends in time. Results Over the study period, a total of 36 emergency thoracotomies were performed, of which 5 survived (13.9%). The “early” phase had no survivors (0/10), with 2 of 13 (15%) and 3 of 13 (23%) surviving in the development and mature phase, respectively. A decline in ‘elderly’ (>55 years) patients who had emergency thoracotomy occurred with each time period (from 50%, 31% to 7.7%, respectively). The gender distribution and the injury severity scores on admission remained unchanged, while the rate of patients with signs on life (SOL) increased over time. Conclusion The improvement over time in survival for one time-critical emergency procedure may be attributed to structured implementation of team and procedure training. The findings may be transferred to other low-volume regions for improved trauma care.

Evaluation of Microvascular Perfusion and Resuscitation after Severe Injury

2015 ◽  
Vol 81 (12) ◽  
pp. 1272-1278 ◽  
Author(s):  
Yann-Leei L. Lee ◽  
Jon D. Simmons ◽  
Mark N. Gillespie ◽  
Diego F. Alvarez ◽  
Richard P. Gonzalez ◽  
...  
Keyword(s):  
Injury Severity ◽  
Capillary Flow ◽  
Severe Trauma ◽  
Dark Field ◽  
Serum Lactate ◽  
Microvascular Perfusion ◽  
Trauma Patients ◽  
Sidestream Dark Field ◽  
Trauma Population ◽  
Severity Scores

Achieving adequate perfusion is a key goal of treatment in severe trauma; however, tissue perfusion has classically been measured by indirect means. Direct visualization of capillary flow has been applied in sepsis, but application of this technology to the trauma population has been limited. The purpose of this investigation was to compare the efficacy of standard indirect measures of perfusion to direct imaging of the sublingual microcirculatory flow during trauma resuscitation. Patients with injury severity scores >15 were serially examined using a handheld sidestream dark-field video microscope. In addition, measurements were also made from healthy volunteers. The De Backer score, a morphometric capillary density score, and total vessel density (TVD) as cumulative vessel area within the image, were calculated using Automated Vascular Analysis (AVA3.0) software. These indices were compared against clinical and laboratory parameters of organ function and systemic metabolic status as well as mortality. Twenty severely injured patients had lower TVD (X = 14.6 ± 0.22 vs 17.66 ± 0.51) and De Backer scores (X = 9.62 ± 0.16 vs 11.55 ± 0.37) compared with healthy controls. These scores best correlated with serum lactate (TVD R2 = 0.525, De Backer R2 = 0.576, P < 0.05). Mean arterial pressure, heart rate, oxygen saturation, pH, bicarbonate, base deficit, hematocrit, and coagulation parameters correlated poorly with both TVD and De Backer score. Direct measurement of sublingual microvascular perfusion is technically feasible in trauma patients, and seems to provide real-time assessment of micro-circulatory perfusion. This study suggests that in severe trauma, many indirect measurements of perfusion do not correlate with microvascular perfusion. However, visualized perfusion deficiencies do reflect a shift toward anaerobic metabolism.

scholarly journals A retrospective cohort study of 27,049 polytraumatized patients age 60 and above: identifying changes over 16 years

2021 ◽  
Author(s):  
Y. Kalbas ◽  
M. Lempert ◽  
F. Ziegenhain ◽  
J. Scherer ◽  
V. Neuhaus ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Injury Severity ◽  
Descriptive Analysis ◽  
Patient Characteristics ◽  
Severe Trauma ◽  
Diagnostic Tools ◽  
Trauma Patients ◽  
Treatment Algorithms ◽  
Injured Patients ◽  
Over Time

Abstract Purpose The number of severely injured patients exceeding the age of 60 has shown a steep increase within the last decades. These patients present with numerous co-morbidities, polypharmacy, and increased frailty requiring an adjusted treatment approach. In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017. Methods A descriptive analysis of the data from the TraumaRegister DGU® (TR-DGU) was performed. Patients admitted to a level one trauma center in Germany, Austria and Switzerland between 2002 and 2017, aged 60 years or older and with an injury severity score (ISS) over 15 were included. Patients were stratified into subgroups based on the admission: 2002–2005 (1), 2006–2009 (2), 2010–2013 (3) and 2014–2017 (4). Trauma and patient characteristics, diagnostics, treatment and outcome were compared. Results In total 27,049 patients with an average age of 73.9 years met the inclusion criteria. The majority were males (64%), and the mean ISS was 27.4. The proportion of patients 60 years or older [(23% (1) to 40% (4)] rose considerably over time. Trauma mechanisms changed over time and more specifically low falls (< 3 m) rose from 17.6% (1) to 40.1% (4). Altered injury patterns were also identified. Length-of-stay decreased from 28.9 (1) to 19.5 days (4) and the length-of-stay on ICU decreased from 17.1 (1) to 12.7 days (4). Mortality decreased from 40.5% (1) to 31.8% (4). Conclusion Length of stay and mortality decreased despite an increase in patient age. We ascribe this observation mainly to increased use of diagnostic tools, improved treatment algorithms, and the implementation of specialized trauma centers for older patients allowing interdisciplinary care.

Is Outcome after Blunt Splenic Injury in Adults Better in High-Volume Trauma Centers?

2005 ◽  
Vol 71 (11) ◽  
pp. 942-949 ◽  
Author(s):  
Brian G. Harbrecht ◽  
Mazen S. Zenati ◽  
Louis H. Alarcon ◽  
Juan B. Ochoa ◽  
Juan C. Puyana ◽  
...  
Keyword(s):  
Emergency Department ◽  
Trauma Center ◽  
Injury Severity ◽  
Trauma System ◽  
High Volume ◽  
Trauma Centers ◽  
Case Volume ◽  
Center Volume ◽  
Low Volume ◽  
Outcome Differences

An association between outcome and case volume has been demonstrated for selected complex operations. The relationship between trauma center volume and patient outcome has also been examined, but no clear consensus has been established. The American College of Surgeons (ACS) has published recommendations on optimal trauma center volume for level 1 designation. We examined whether this volume criteria was associated with outcome differences for the treatment of adult blunt splenic injuries. Using a state trauma database, ACS criteria were used to stratify trauma centers into high-volume centers (>240 patients with Injury Severity Score >15 per year) or low-volume centers, and outcome was evaluated. There were 1,829 patients treated at high-volume centers and 1,040 patients treated at low-volume centers. There was no difference in age, gender, emergency department pulse, emergency department systolic blood pressure, or overall mortality between high- and low-volume centers. Patients at low-volume centers were more likely to be treated operatively, but the overall success rate of nonoperative management between high-and low-volume centers was similar. These data suggest that ACS criteria for trauma centers level designation are not associated with differences in outcome in the treatment of adult blunt splenic injuries in this regional trauma system.

Trampoline Injuries in a Statewide Trauma System

2021 ◽  
pp. 000313482110488
Author(s):  
Megan C. Sullivan ◽  
Madison E. Morgan ◽  
Eric Bradburn ◽  
Lindsey L. Perea
Keyword(s):  
Injury Severity ◽  
Trauma System ◽  
Injury Patterns ◽  
Lower Extremity Injuries ◽  
Patient Demographics ◽  
Body Regions ◽  
Severity Scores ◽  
Icd 10 ◽  
Trauma Outcome ◽  
Extremity Injuries

Introduction It is well known that trampolines can be a particular source of danger, especially in children. We sought to examine the profile of those patients with trampoline injuries. We hypothesized there would be certain injury patterns predicative of trampoline injuries. Methods All patients submitted to Pennsylvania Trauma Outcome Study database from 2016 to 2018 were analyzed. Trampoline injury was determined by ICD-10 activity code. Injury patterns in the form of abbreviated injury scale body regions were examined. Patient demographics and clinical variables were compared between those with trampoline injury vs those without. Results There were 107 patients with a trampoline injury. All of these patients were discharged alive and had a blunt mechanism of injury. The most common injury type was injury to the extremities (n=90,[84.1%]) with 54(50.5%) upper extremity injuries and 36(33.6%) lower extremity injuries. Ten (9.35%) patients had injury to the spine and five (4.67%) had head injury. Those with trampoline injuries were significantly younger (13y vs. 48.6y) and more likely to be white or of Hispanic ethnicity. Almost half of the patients injured (49.5%) were under 10 years. Patients with trampoline injuries had significantly lower Injury Severity Scores and significantly higher shock index. Discussion The majority of patients with trampoline injuries had injury to an extremity. These results help better understand the demographic, physiologic, and anatomic patterns surrounding trampoline injuries. Current government standards recommend that no child under age six should use a full-sized trampoline; however, based of this study, we advise that this age be increased to ten.

scholarly journals Extracorporeal membrane oxygenation in trauma patients: a systematic review

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Changtian Wang ◽  
Lei Zhang ◽  
Tao Qin ◽  
Zhilong Xi ◽  
Lei Sun ◽  
...  
Keyword(s):  
Systematic Review ◽  
Extracorporeal Membrane Oxygenation ◽  
Median Time ◽  
Injury Severity ◽  
Case Reports ◽  
Severe Trauma ◽  
Trauma Patients ◽  
Membrane Oxygenation ◽  
Severity Scores ◽  
Va Ecmo

Abstract Background Extracorporeal membrane oxygenation (ECMO) has evolved considerably over the past two decades and has been gradually utilized in severe trauma. However, the indications for the use of ECMO in trauma remain uncertain and the clinical outcomes are different. We performed a systematic review to provide an overall estimate of the current performance of ECMO in the treatment of trauma patients. Materials and methods We searched PubMed and MEDLINE databases up to the end of December 2019 for studies on ECMO in trauma. The PRISMA statement was followed. Data on demographics of the patient, mechanism of injury, injury severity scores (ISS), details of ECMO strategies, and clinical outcome were extracted. Results A total of 58 articles (19 retrospective reports and 39 case reports) were deemed eligible and included. In total, 548 patients received ECMO treatment for severe trauma (adult 517; children 31; mean age of adults 34.9 ± 12.3 years). Blunt trauma (85.4%) was the primary injury mechanism, and 128 patients had traumatic brain injury (TBI). The mean ISS was 38.1 ± 15.0. A total of 71.3% of patients were initially treated with VV ECMO, and 24.5% were placed on VA ECMO. The median time on ECMO was 9.6 days, and the median time to ECMO was 5.7 days. A total of 60% of patients received initially heparin anticoagulation. Bleeding (22.9%) and thrombosis (19%) were the most common complications. Ischemia of the lower extremities occurred in 9 patients. The overall hospital mortality was 30.3%. Conclusions ECMO has been gradually utilized in a lifesaving capacity in severe trauma patients, and the feasibility and advantages of this technique are becoming widely accepted. The safety and effectiveness of ECMO in trauma require further study. Several problems with ECMO in trauma, including the role of VA-ECMO, the time to institute ECMO, and the anticoagulation strategy remain controversial and must be solved in future studies.

scholarly journals Comparison of revised Functional Capacity Index scores with Abbreviated Injury Scale 2008 scores in predicting 12-month severe trauma outcomes

2019 ◽  
Vol 26 (2) ◽  
pp. 138-146
Author(s):  
Cameron S Palmer ◽  
Peter A Cameron ◽  
Belinda J Gabbe
Keyword(s):  
Functional Capacity ◽  
Injury Severity ◽  
Severe Trauma ◽  
Population Based ◽  
Trauma Patients ◽  
Trauma Outcomes ◽  
Severity Scores ◽  
Severity Of Injury ◽  
Capacity Index ◽  
Improved Model

IntroductionAnatomical injury as measured by the AIS often accounts for only a small proportion of variability in outcomes after injury. The predictive Functional Capacity Index (FCI) appended to the 2008 AIS claims to provide a widely available method of predicting 12-month function following injury.ObjectivesTo determine the extent to which AIS-based and FCI-based scoring is able to add to a simple predictive model of 12-month function following severe injury.MethodsAdult trauma patients were drawn from the population-based Victorian State Trauma Registry. Major trauma and severely injured orthopaedic trauma patients were followed up via telephone interview including Glasgow Outcome Scale—Extended, the EQ-5D-3L and return to work status. A battery of AIS-based and FCI-based scores, and a simple count of AIS-coded injuries were added in turn to a base model using age and gender.ResultsA total of 20 813 patients survived to 12 months and had at least one functional outcome recorded, representing 85% follow-up. Predictions using the base model varied substantially across outcome measures. Irrespective of the method used to classify the severity of injury, adding injury severity to the model significantly, but only slightly improved model fit. Across the outcomes evaluated, no method of injury severity assessment consistently outperformed any other.ConclusionsAnatomical injury is a predictor of trauma outcome. However, injury severity as described by the FCI does not consistently improve discrimination, or even provide the best discrimination compared with AIS-based severity scores or a simple injury count.

scholarly journals Nonoperative management of splenic injury in closely monitored patients with reduced consciousness is safe and feasible

2019 ◽  
Vol 27 (1) ◽  
Author(s):  
Michel Teuben ◽  
Roy Spijkerman ◽  
Taco Blokhuis ◽  
Roman Pfeifer ◽  
Henrik Teuber ◽  
...  
Keyword(s):  
Mental Status ◽  
Injury Severity ◽  
Splenic Injury ◽  
Nonoperative Management ◽  
Splenic Trauma ◽  
Blunt Splenic Injury ◽  
Icu Stay ◽  
Severity Scores ◽  
Gcs Score ◽  
The Impact

Abstract Background Treatment of blunt splenic injury has changed over the past decades. Nonoperative management (NOM) is the treatment of choice. Adequate patient selection is a prerequisite for successful NOM. Impaired mental status is considered as a relative contra indication for NOM. However, the impact of altered consciousness in well-equipped trauma institutes is unclear. We hypothesized that impaired mental status does not affect outcome in patients with splenic trauma. Methods Our prospectively composed trauma database was used and adult patients with blunt splenic injury were included during a 14-year time period. Treatment guidelines remained unaltered over time. Patients were grouped based on the presence (Group GCS: < 14) or absence (Group GCS: 14–15) of impaired mental status. Outcome was compared. Results A total of 161 patients were included, of whom 82 were selected for NOM. 36% of patients had a GCS-score < 14 (N = 20). The median GCS-score in patients with reduced consciousness was 9 (range 6–12). Groups were comparable except for significantly higher injury severity scores in the impaired mental status group (19 vs. 17, p = 0.007). Length of stay (28 vs. 9 days, p < 0.001) and ICU-stay (8 vs. 0 days, p = 0.005) were longer in patients with decreased GCS-scores. Failure of NOM, total splenectomy rates, complications and mortality did not differ between both study groups. Conclusion This study shows that NOM for blunt splenic trauma is a viable treatment modality in well-equipped institutions, regardless of the patients mental status. However, the presence of neurologic impairment is associated with prolonged ICU-stay and hospitalization. We recommend, in institutions with adequate monitoring facilities, to attempt nonoperative management for blunt splenic injury, in all hemodynamically stable patients without hollow organ injuries, also in the case of reduced consciousness.

scholarly journals Endothelial glycocalyx degradation is associated with early organ impairment in polytrauma patients

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Feng Qi ◽  
Hao Zhou ◽  
Peng Gu ◽  
Zhi-He Tang ◽  
Bao-Feng Zhu ◽  
...  
Keyword(s):  
Injury Severity ◽  
Early Stage ◽  
Endothelial Glycocalyx ◽  
Control Group ◽  
Metabolic System ◽  
Metabolic Systems ◽  
Organ Systems ◽  
Severity Scores ◽  
Polytrauma Patients ◽  
Trauma Group

Abstract Background Endothelial glycocalyx (EG) abnormal degradation were widely found in critical illness. However, data of EG degradation in multiple traumas is limited. We performed a study to assess the EG degradation and the correlation between the degradation and organ functions in polytrauma patients. Methods A prospective observational study was conducted to enroll health participants (control group) and polytrauma patients (trauma group) at a University affiliated hospital between Feb 2020 and Oct 2020. Syndecan1 (SDC1) and heparin sulfate (HS) were detected in serum sample of both groups. In trauma group, injury severity scores (ISS) and sequential organ failure assessments (SOFA) were calculated. Occurrences of acute kidney injury (AKI), trauma-induced coagulopathy (TIC) within 48 h and 28-day all-cause mortality in trauma group were recorded. Serum SDC1 and HS levels were compared between two groups. Correlations between SDC1/HS and the indicators of organ systems in the trauma group were analyzed. ROC analyses were performed to assess the predictive value of SDC1 and HS for AKI, TIC within 48 h, and 28-day mortality in trauma group. Results There were 45 polytrauma patients and 15 healthy participants were collected, totally. SDC1 and HS were significantly higher in trauma group than in control group (69.39 [54.18–130.80] vs. 24.15 [13.89–32.36], 38.92 [30.47–67.96] vs. 15.55 [11.89–23.24], P <  0.001, respectively). Trauma group was divided into high degradation group and low degradation group according to SDC1 median. High degradation group had more severe ISS, SOFA scores, worse organ functions (respiratory, kidney, coagulation and metabolic system), and higher incidence of hypothermia, acidosis and shock. The area under the receiver operator characteristic curves (AUC) of SDC1 to predict AKI, TIC occurrence within 48 h and 28-day mortality were 0.838 (95%CI: 0.720–0.957), 0.700 (95%CI: 0.514–0.885) and 0.764 (95%CI: 0.543–0.984), respectively. Conclusions EG degradation was elevated significantly in polytrauma patients, and the degradation was correlated with impaired respiratory, kidney, coagulation and metabolic systems in early stage. Serum SDC1 is a valuable predictive indicator of early onset of AKI, TIC, and 28-day mortality in polytrauma patients.

scholarly journals A comparison of the demographics, injury patterns and outcome data for patients injured in motor vehicle collisions who are trapped compared to those patients who are not trapped

2021 ◽  
Vol 29 (1) ◽  
Author(s):  
Tim Nutbeam ◽  
Rob Fenwick ◽  
Jason Smith ◽  
Omar Bouamra ◽  
Lee Wallis ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Blood Loss ◽  
Injury Severity ◽  
Spinal Cord Injuries ◽  
Motor Vehicle ◽  
Tension Pneumothorax ◽  
Research Network ◽  
Motor Vehicle Collisions ◽  
Vehicle Collisions ◽  
Time Critical

Abstract Background Motor vehicle collisions (MVCs) are a common cause of major trauma and death. Following an MVC, up to 40% of patients will be trapped in their vehicle. Extrication methods are focused on the prevention of secondary spinal injury through movement minimisation and mitigation. This approach is time consuming and patients may have time-critical injuries. The purpose of this study is to describe the outcomes and injuries of those trapped following an MVC: this will help guide meaningful patient-focused interventions and future extrication strategies. Methods We undertook a retrospective database study using the Trauma Audit and Research Network database. Patients were included if they were admitted to an English hospital following an MVC from 2012 to 2018. Patients were excluded when their outcomes were not known or if they were secondary transfers. Results This analysis identified 426,135 cases of which 63,625 patients were included: 6983 trapped and 56,642 not trapped. Trapped patients had a higher mortality (8.9% vs 5.0%, p < 0.001). Spinal cord injuries were rare (0.71% of all extrications) but frequently (50.1%) associated with other severe injuries. Spinal cord injuries were more common in patients who were trapped (p < 0.001). Injury Severity Score (ISS) was higher in the trapped group 18 (IQR 10–29) vs 13 (IQR 9–22). Trapped patients had more deranged physiology with lower blood pressures, lower oxygen saturations and lower Glasgow Coma Scale, GCS (all p < 0.001). Trapped patients had more significant injuries of the head chest, abdomen and spine (all p < 0.001) and an increased rate of pelvic injures with significant blood loss, blood loss from other areas or tension pneumothorax (all p < 0.001). Conclusion Trapped patients are more likely to die than those who are not trapped. The frequency of spinal cord injuries is low, accounting for < 0.7% of all patients extricated. Patients who are trapped are more likely to have time-critical injuries requiring intervention. Extrication takes time and when considering the frequency, type and severity of injuries reported here, the benefit of movement minimisation may be outweighed by the additional time taken. Improved extrication strategies should be developed which are evidence-based and allow for the expedient management of other life-threatening injuries.

Splanchnic Hypoperfusion-Directed Therapies in Trauma: A Prospective, Randomized Trial

2005 ◽  
Vol 71 (3) ◽  
pp. 252-260 ◽  
Author(s):  
Stephen M. Cohn ◽  
Stephen M. Cohn ◽  
Orlando Kirton ◽  
Margaret Brown ◽  
S. Morad Hameed ◽  
...  
Keyword(s):  
Randomized Trial ◽  
Injury Severity ◽  
Ischemia Reperfusion ◽  
Unit Group ◽  
Severe Trauma ◽  
Prospective Randomized Trial ◽  
Gastric Tonometry ◽  
Trauma Patients ◽  
Splanchnic Perfusion ◽  
Splanchnic Hypoperfusion

Splanchnic hypoperfusion as reflected by gastric intramucosal acidosis has been recognized as an important determinant of outcome in shock. A comprehensive splanchnic hypoperfusion-ischemia reperfusion (IRP) protocol was evaluated against conventional shock management protocols in critical trauma patients. The study was a prospective randomized trial comparing three therapeutic approaches to hypoperfusion after severe trauma in 151 trauma patients admitted to the intensive care unit. Group 1 patients received hemodynamic support based on conventional indicators of hypoperfusion. In group 2, resuscitation was further guided by gastric tonometry-derived estimates of splanchnic hypoperfusion and included more invasive hemodynamic monitoring and additional administration of colloid or crystalloid solutions, or inotropic support. Group 3 patients additionally received therapies specifically aimed at optimizing splanchnic perfusion and minimizing oxidant-mediated damage from reperfusion. The three groups were similar based on age, Injury Severity Score, and Acute Physiology and Chronic Health Evaluation II Scores. There were no statistically significant differences in mortality rates, organ dysfunction, ventilator days, or length of stay between any of the interventions. Techniques of optimization of splanchnic perfusion and minimization of oxidant-mediated reperfusion injury evaluated in this study were not advantageous relative to standard resuscitation measures guided by conventional or tonometric measures of hypoperfusion in the therapy of occult and clinical shock in trauma patients.

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