Predicting mortality in trauma patients - A retrospective comparison of the performance of six scoring systems applied to polytrauma patients from the emergency centre of a South African central hospital

BackgroundOvertriage of trauma patients is unavoidable and requires effective use of hospital resources. A ‘pit stop’ (PS) was added to our lowest tier trauma resource (TR) triage protocol where the patient stops in the trauma bay for immediate evaluation by the emergency department (ED) physician and trauma nursing. We hypothesized this would allow for faster diagnostic testing and disposition while decreasing cost.MethodsWe performed a before/after retrospective comparison after PS implementation. Patients not meeting trauma activation (TA) criteria but requiring trauma center evaluation were assigned as a TR for an expedited PS evaluation. A board-certified ED physician and trauma/ED nurse performed an immediate assessment in the trauma bay followed by performance of diagnostic studies. Trauma surgeons were readily available in case of upgrade to TA. We compared patient demographics, Injury Severity Score, time to physician evaluation, time to CT scan, hospital length of stay, and in-hospital mortality. Comparisons were made using 95% CI for variance and SD and unpaired t-tests for two-tailed p values, with statistical difference, p<0.05.ResultsThere were 994 TAs and 474 TRs in the first 9 months after implementation. TR’s preanalysis versus postanalysis of the TR group shows similar mean door to physician evaluation times (6.9 vs. 8.6 minutes, p=0.1084). Mean door to CT time significantly decreased (67.7 vs. 50 minutes, p<0.001). 346 (73%) TR patients were discharged from ED; 2 (0.4%) were upgraded on arrival. When admitted, TR patients were older (61.4 vs. 47.2 years, p<0.0001) and more often involved in a same-level fall (59.5% vs. 20.1%, p<0.0001). Undertriage was calculated using the Cribari matrix at 3.2%.DiscussionPS implementation allowed for faster door to CT time for trauma patients not meeting activation criteria without mobilizing trauma team resources. This approach is safe, feasible, and simultaneously decreases hospital cost while improving allocation of trauma team resources.Level of evidenceLevel II, economic/decision therapeutic/care management study.

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Tranexamic Acid Treatment for Trauma Victims

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0041-1725097 ◽

2021 ◽

Author(s):

Ian Roberts ◽

Amy Brenner ◽

Haleema Shakur-Still

Keyword(s):

Tranexamic Acid ◽

Traumatic Injury ◽

Low Risk ◽

Baseline Risk ◽

Trauma Patients ◽

Wide Range ◽

Risk Patients ◽

Polytrauma Patients ◽

Time Critical ◽

Proportional Reduction

AbstractWorldwide, traumatic injury is responsible for over 5 million deaths per year, the majority due to exsanguination and head injury. The antifibrinolytic drug tranexamic acid is the only drug proven to reduce deaths after traumatic injury. Several large randomized controlled trials have provided high-quality evidence of its effectiveness and safety in trauma patients. Early tranexamic acid reduces deaths on the day of the injury in polytrauma patients and patients with isolated traumatic brain injury by around 20%. Treatment is time critical; for patients to benefit, tranexamic acid must be given as soon as possible after injury. Intramuscular administration is well tolerated and rapidly absorbed, with the potential to reduce time to treatment. Because the proportional reduction in bleeding death with tranexamic acid does not vary by baseline risk, a wide range of trauma patients stands to benefit. There are far more low-risk trauma patients than high-risk patients, with a substantial proportion of bleeding deaths in the low-risk group. As such, treatment should not be limited to patients with severe traumatic hemorrhage. We must give paramedics and physicians the confidence to treat a far wider range of trauma patients while emphasizing the importance of early treatment.

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Impact of Implementation of Sequential Trauma Education Programs (STEPs) Course on Missed Injuries in Emergency Polytrauma Patients, Ismailia, Egypt

10.21203/rs.3.rs-147008/v1 ◽

2021 ◽

Author(s):

Adel Hamed Elbaih ◽

Maged El-Setouhy ◽

Jon Mark Hirshon ◽

Hazem Mohamed El-Hariri ◽

Mohamed El-Shinawi

Keyword(s):

Low Income ◽

Life Support ◽

University Hospital ◽

Low Income Countries ◽

Advanced Trauma Life Support ◽

Trauma Patients ◽

Education Programs ◽

Missed Injuries ◽

Polytrauma Patients ◽

Trauma Education

Abstract IntroductionTrauma deaths account for 8% of all deaths in Egypt. Patients with multiple injuries are at high risk but may be saved with a good triage system and a well-trained trauma team in dedicated institutions. The incidence of missed injuries in the Emergency Department (ED) of Suez Canal University Hospital (SCUH) was found to be 9.0% after applying Advanced Trauma Life Support (ATLS) guidelines. However, this rate is still high compared with many trauma centers.AimImprove the quality of management of polytrauma patients by decreasing the incidence of missed injuries by implementing the Sequential Trauma Education Programs (STEPs) course in the ED at SCUH.MethodsThis interventional training study was conducted in the SCUH ED that adheres to CONSORT guidelines. The study was conducted during the 1-month precourse and for 6 months after the implementation of the STEPs course for ED physicians. Overall, 458 polytrauma patients were randomly selected, of which 45 were found to have missed injuries after applying the inclusion and exclusion criteria. We assessed the clinical relevance of these cases for missed injuries before and after the STEPs course.ResultsOverall, 45 patients were found to have missed injuries, of which 15 (12%) were pre-STEPs and 30 (9%) were post-STEPs course. The STEPs course significantly increased adherence to vital data recording, but the reduction of missed injuries (3.0%) was not statistically significant in relation to demographic and trauma findings. However, the decrease in missed injuries in the post-STEPs course group was an essential clinically significant finding.ConclusionSTEPs course implementation decreased the incidence of missed injuries in polytrauma patients. Thus, the STEPs course can be considered at the same level of other advanced trauma courses as a training skills program or possibly better in dealing with trauma patients. Repetition of this course by physicians should be mandatory to prevent more missed injuries. Therefore, the validation of STEPs course certification should be completed at least every 2 years to help decrease the number of missed injuries, especially in low-income countries and low-resource settings.Trial RegistrationProject manager for the Pan African Clinical Trial Registry (www.pactr.org) database has been accepted with the date of approval:18/11/2020. Current Controlled Trials number for the registry is PACTR202011853914203. Please note that the article state Retrospectively registered that my study adheres to CONSORT guidelines.

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Linea Alba Fasciotomy: A Novel Alternative in Trauma Patients with Secondary Abdominal Compartment Syndrome

The American Surgeon ◽

10.1177/000313481007600314 ◽

2010 ◽

Vol 76 (3) ◽

pp. 312-316 ◽

Cited By ~ 1

Author(s):

Juan C. Duchesne ◽

Meghan P. Howell ◽

Calvin Eriksen ◽

Georgia M. Wahl ◽

Kelly V. Rennie ◽

...

Keyword(s):

Compartment Syndrome ◽

Abdominal Compartment Syndrome ◽

Volume Index ◽

Trauma Patients ◽

Linea Alba ◽

Physiological Variables ◽

Abdominal Hypertension ◽

Polytrauma Patients ◽

Abdominal Decompression ◽

Abdominal Compartment

Polytrauma patients needing aggressive resuscitation can develop intra-abdominal hypertension (IAH) with subsequent secondary abdominal compartment syndrome (SACS). After patients fail medical therapy, decompressive laparotomy is the surgical last resort. In patients with severe pancreatitis SACS, the use of linea alba fasciotomy (LAF) is an effective intervention to lower IAH without the morbidity of laparotomy. A pilot study of LAF was designed to evaluate its benefit in patients with SACS polytrauma. We conducted an observational study of blunt injury polytrauma patients undergoing LAF. Variables measured before and after LAF included intra-abdominal pressure (IAP, mmHg), abdominal perfusion pressure (APP, mmHg), right ventricular end diastolic volume index (RVEDVI, mL/m2), and ejection fraction. Of the five trauma patients with SACS, the mean age was 36 ± 17, four (80%) male with an Injury Severity Score of 27 ± 9. Pre- and post-LAF, IAP was 20.6 ± 4.7 and 10.6 ± 2.7 ( P < 0.0001), APP 55.2 ± 5.5 and 77.6 ± 7.1 ( P < 0.0001), RVEDVI 86.4 ± 9.3 and 123.6 ± 11.9 ( P < 0.0001), and EF 27.6 ± 4.2 and 40.8 ± 5 ( P < 0.0001), respectively. One patient needed full decompression for bile ascites from unrecognized liver injury. Linea alba fasciotomy, as a first-line intervention before committing to full abdominal decompression in patients with SACS trauma, improved physiological variables without mortality Consideration for LAF as a bridge before full abdominal decompression needs further evaluation in patients with polytrauma SACS.

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Trauma Attending Physician Continuity: Does it Make a Difference?

The American Surgeon ◽

10.1177/000313481007600110 ◽

2010 ◽

Vol 76 (1) ◽

pp. 48-54

Author(s):

David G. Jacobs ◽

Jennifer L. Sarafin ◽

Karen E. Head ◽

A Britt Christmas ◽

Toan Huynh ◽

...

Keyword(s):

Length Of Stay ◽

Injury Severity ◽

Standard Of Care ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Trauma Service ◽

Retrospective Comparison ◽

Scale Scores ◽

Attending Physician

Continuity of care is important in achieving optimal outcomes in trauma patients, but the optimal length of the trauma attending (TA) rotation is unknown. We hypothesize that longer TA rotations provide greater continuity, and therefore improve outcomes. We did a retrospective comparison of trauma patient outcomes from two consecutive 6-month periods during which we transitioned from a 1-month TA rotation to a 1-week TA rotation. The Wilcoxon rank sum test, and the χ2 were used for statistical analysis. Over the 12-month study period 1924 patients were admitted to the Trauma Service. The two groups were similar with regard to age, gender, injury mechanism, Injury Severity Score and Glasgow Coma Scale scores, and Abbreviated Injury Scores for the chest, abdomen, and extremities. Although mortality, patient charges, and violations of the standard of care were similar between the two groups, overall morbidity was lower (18.6% vs 23.2%), and hospital length of stay higher (9.07 days vs 8.41 days) in the 1-week TA group compared with the 1-month TA group. A one-week TA rotation was associated with a longer hospital length of stay, but improved morbidity. Longer TA rotations do not necessarily provide improved continuity or improved outcomes.

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SOFA scoring system in assessing prognosis of critically ill surgical and trauma patients: a prospective study

International Surgery Journal ◽

10.18203/2349-2902.isj20182767 ◽

2018 ◽

Vol 5 (7) ◽

pp. 2528

Author(s):

Mohan Kumar ◽

Chandan C. S.

Keyword(s):

Prospective Study ◽

Organ Failure ◽

Critically Ill ◽

Organ Dysfunction ◽

Sofa Score ◽

Scoring System ◽

Evaluation System ◽

Scoring Systems ◽

Trauma Patients ◽

A Prospective Study

Background: Major trauma, major surgery or sepsis include the bulk of Surgical patients who become critically ill. This relates to significant injury of a single organ system or anatomical part, or multiple injuries, often of varying severity, of different body parts good scoring or predicting system essentially clears this confusion. Predicting the patients’ outcome depends on good scoring system. Scoring systems are composed of degrees of organ dysfunction, organ failure or multiple organ failures, and anatomical derangements which eventually contribute to morbidity and mortality. With the help of such evaluation system. A well-performing ICU prognostic model helps to make meaningful comparison of the hospital’s current performance with the past. But present study focuses on mainly on SOFA score. Sequential organ failure assessment score.Methods: Scoring systems in assessing prognosis of critically ill surgical and trauma patients - a prospective study was undertaken at MVJ Medical Hospital and Research Hospital, Bangalore after the approval from Ethics Committee. The study was carried out in the period of November 2016 to September 2017 and 50 patients were included in the study.Results: Studies have shown that in the SOFA scores; cardiovascular, neurological, and respiratory, renal, haematological and hepatic dysfunctions were independent risk factors for mortality.Conclusions: In this study, extensive study of SOFA score was done from day 1 to the last day. The SOFA score on day 1 was high among non-survivors and survivors which was statistically significant (9.33 v/s 6.62, p<0.001). Also, SOFA score showed significant increasing trend in the first week, especially on first 3 days, which signifies progressive organ dysfunction among non-survivors.

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Methods and Guidelines for Venous Thromboembolism Prevention in Polytrauma Patients with Pelvic and Acetabular Fractures

The Open Orthopaedics Journal ◽

10.2174/1874325001509010313 ◽

2015 ◽

Vol 9 (1) ◽

pp. 313-320 ◽

Cited By ~ 3

Author(s):

Francisco Chana-Rodríguez ◽

Rubén Pérez Mañanes ◽

José Rojo-Manaute ◽

José Antonio Calvo Haro ◽

Javier Vaquero-Martín

Keyword(s):

Venous Thromboembolism ◽

Vena Cava ◽

Acetabular Fractures ◽

Trauma Patients ◽

Inferior Vena Cava Filters ◽

Vena Cava Filters ◽

Oral Agents ◽

Venous Thromboembolism Prevention ◽

Risk Patients ◽

Polytrauma Patients

Sequential compression devices and chemical prophylaxis are the standard venous thromboembolism (VTE) prevention for trauma patients with acetabular and pelvic fractures. Current chemical pharmacological contemplates the use of heparins or fondaparinux. Other anticoagulants include coumarins and aspirin, however these oral agents can be challenging to administer and may need monitoring. When contraindications to anticoagulation in high-risk patients are present, prophylactic inferior vena cava filters can be an option to prevent pulmonary emboli. Unfortunately strong evidence about the most effective method, and the timing of their commencement, in patients with pelvic and acetabular fractures remains controversial.

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Performance of Prognostic Scoring Systems in Trauma Patients in the Intensive Care Unit of a Trauma Center

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17197226 ◽

2020 ◽

Vol 17 (19) ◽

pp. 7226

Author(s):

Shao-Chun Wu ◽

Sheng-En Chou ◽

Hang-Tsung Liu ◽

Ting-Min Hsieh ◽

Wei-Ti Su ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Organ Dysfunction ◽

Scoring Systems ◽

Predictive Performance ◽

Apache Ii ◽

Trauma Patients ◽

Saps Ii ◽

Significant Difference ◽

Prognostic Scoring Systems

Background: Prediction of mortality outcomes in trauma patients in the intensive care unit (ICU) is important for patient care and quality improvement. We aimed to measure the performance of 11 prognostic scoring systems for predicting mortality outcomes in trauma patients in the ICU. Methods: Prospectively registered data in the Trauma Registry System from 1 January 2016 to 31 December 2018 were used to extract scores from prognostic scoring systems for 1554 trauma patients in the ICU. The following systems were used: the Trauma and Injury Severity Score (TRISS); the Acute Physiology and Chronic Health Evaluation (APACHE II); the Simplified Acute Physiology Score (SAPS II); mortality prediction models (MPM II) at admission, 24, 48, and 72 h; the Multiple Organ Dysfunction Score (MODS); the Sequential Organ Failure Assessment (SOFA); the Logistic Organ Dysfunction Score (LODS); and the Three Days Recalibrated ICU Outcome Score (TRIOS). Predictive performance was determined according to the area under the receiver operator characteristic curve (AUC). Results: MPM II at 24 h had the highest AUC (0.9213), followed by MPM II at 48 h (AUC: 0.9105). MPM II at 24, 48, and 72 h (0.8956) had a significantly higher AUC than the TRISS (AUC: 0.8814), APACHE II (AUC: 0.8923), SAPS II (AUC: 0.9044), MPM II at admission (AUC: 0.9063), MODS (AUC: 0.8179), SOFA (AUC: 0.7073), LODS (AUC: 0.9013), and TRIOS (AUC: 0.8701). There was no significant difference in the predictive performance of MPM II at 24 and 48 h (p = 0.37) or at 72 h (p = 0.10). Conclusions: We compared 11 prognostic scoring systems and demonstrated that MPM II at 24 h had the best predictive performance for 1554 trauma patients in the ICU.

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Outcome Following the Rehabilitation of Hand Trauma Patients

Journal of Hand Surgery (European Volume) ◽

10.1016/s0266-7681(98)80128-9 ◽

1998 ◽

Vol 23 (4) ◽

pp. 485-489 ◽

Cited By ~ 28

Author(s):

A. M. I. WATTS ◽

M. GREENSTOCK ◽

R. P. COLE

Keyword(s):

Scoring System ◽

Daily Living ◽

Hand Function ◽

Scoring Systems ◽

Trauma Patients ◽

Hand Trauma ◽

Validity And Reliability ◽

Subjective Assessments ◽

Severity Of Injury ◽

Monitoring Progress

Objective measures of hand function have been used to assess the outcome of rehabilitation following trauma. However, subjective assessments of function have been avoided by clinicians due to the difficulty in proving their validity and reliability. We have developed a subjective hand function scoring system (HFS), based on an activities of daily living assessment, which is used in planning and monitoring progress through rehabilitation. The HFS for 64 traumatic hand injuries were assessed on admission and discharge, and a significant improvement was found. There was a positive correlation between the HFS on admission and both the severity of injury, and the length of time off work. This scoring system is not validated, but this study illustrates the use of subjective functional scoring systems in the planning, delivery and evaluation of rehabilitation.

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