208 Disparity in Uninsured Penetrating Trauma Patients Transferred From Emergency Department to Operative Intervention

AbstractObjectiveEmergency department thoracotomy (EDT) is a rare and potentially life-saving intervention performed for trauma patients in extremis. EDT is rare at Canadian trauma centres because of our infrequent occurrence of penetrating trauma. This study was undertaken to evaluate outcomes at a Canadian level 1 trauma facility and compare survival to large published datasets. Also, we evaluated the appropriateness of an EDT performed at our centre based on published national guidelines.MethodsRetrospective medical record review of all patients undergoing an EDT during their resuscitation in the emergency department. Records were identified using our trauma registry, and all charts were manually reviewed. The primary outcome was survival to hospital discharge.ResultsOver a 20-year period, 58 EDTs were performed with 6 (10.3%) survivors. Patients undergoing an EDT secondary to penetrating trauma had the highest survival (5 of 24 patients or 20.8% survival) compared to patients undergoing an EDT for blunt trauma (1 of 34 patients or 2.9% survival). Patients undergoing an EDT who had not suffered cardiac arrest represented the group with the highest survival rate (3 of 6 patients or 50% survival). The majority of EDTs (79.3%) were indicated, and no patient undergoing an EDT survived if it was performed outside of published guidelines.ConclusionsSurvival following an EDT in our small, regional trauma centre is consistent with survival rates from larger published datasets. An EDT should continue to be performed under accepted clinical indications.

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Emergency Resuscitation of Patients Enrolled in the US Diaspirin Cross-linked Hemoglobin (DCLHb) Clinical Efficacy Trial

Prehospital and Disaster Medicine ◽

10.1017/s1049023x14001174 ◽

2014 ◽

Vol 30 (1) ◽

pp. 54-61 ◽

Cited By ~ 5

Author(s):

Edward P. Sloan ◽

Max Koenigsberg ◽

W. Brad Weir ◽

James M. Clark ◽

Robert O'Connor ◽

...

Keyword(s):

Emergency Department ◽

Blunt Trauma ◽

Surgical Intervention ◽

Penetrating Trauma ◽

Trauma Patients ◽

Efficacy Trial ◽

Estimated Blood Loss ◽

The Us ◽

The Mean ◽

Blood Loss Volume

AbstractIntroductionOptimal emergent management of traumatic hemorrhagic shock patients requires a better understanding of treatment provided in the prehospital/Emergency Medical Services (EMS) and emergency department (ED) settings.Hypothesis/ProblemDescribed in this research are the initial clinical status, airway management, fluid and blood infusions, and time course of severely-injured hemorrhagic shock patients in the EMS and ED settings from the diaspirin cross-linked hemoglobin (DCLHb) clinical trial.MethodsData were analyzed from 17 US trauma centers gathered during a randomized, controlled, single-blinded efficacy trial of a hemoglobin solution (DCLHb) as add-on therapy versus standard therapy.ResultsAmong the 98 randomized patients, the mean EMS Glasgow Coma Scale (GCS) was 10.6 (SD = 5.0), the mean EMS revised trauma score (RTS) was 6.3 (SD = 1.9), and the mean injury severity score (ISS) was 31 (SD = 17). Upon arrival to the ED, the GCS was 20% lower (7.8 (SD = 5.3) vs 9.7 (SD = 6.3)) and the RTS was 12% lower (5.3 (SD = 2.0) vs 6.0 (SD = 2.1)) than EMS values in blunt trauma patients (P< .001). By ED disposition, 80% of patients (78/98) were intubated. Rapid sequence intubation (RSI) was utilized in 77% (60/78), most often utilizing succinylcholine (65%) and midazolam (50%). The mean crystalloid volume infused was 4.2 L (SD = 3.4 L), 80% of which was infused within the ED. Emergency department blood transfusion occurred in 62% of patients, with an average transfused volume of 1.2 L (SD = 2.0 L). Blunt trauma patients received 2.1 times more total fluids (7.4 L vs 3.5 L, < .001) and 2.4 times more blood (2.4 L vs 1.0 L,P< .001). The mean time of patients taken from injury site to operating room (OR) was 113 minutes (SD = 87 minutes). Twenty-one (30%) of the 70 patients taken to the OR from the ED were sent within 60 minutes of the estimated injury time. Penetrating trauma patients were taken to the OR 52% sooner than blunt trauma patients (72 minutes vs 149 minutes,P< .001).ConclusionBoth GCS and RTS decreased prior to ED arrival in blunt trauma patients. Intubation was performed using RSI, and crystalloid infusion of three times the estimated blood loss volume (L) and blood transfusion of the estimated blood loss volume (L) were provided in the EMS and ED settings. Surgical intervention for these trauma patients most often occurred more than one hour from the time of injury. Penetrating trauma patients received surgical intervention more rapidly than those with a blunt trauma mechanism.SloanEP,KoenigsbergM,WeirWB,ClarkJM,O'ConnorR,OlingerM,CydulkaR.Emergency resuscitation of patients enrolled in the US diaspirin cross-linked hemoglobin (DCLHb) clinical efficacy trial.Prehosp Disaster Med.2015;30(1):1-8.

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Trauma Team Activation at a Level I Trauma Center in Southern California: Time of Day Matters

The American Surgeon ◽

10.1177/000313481908501014 ◽

2019 ◽

Vol 85 (10) ◽

pp. 1142-1145

Author(s):

Morgan Schellenberg ◽

Kenji Inaba ◽

Bryan E. Love ◽

Zachary Warriner ◽

Matthew J. Forestiere ◽

...

Keyword(s):

Injury Severity ◽

Motor Vehicle ◽

Penetrating Trauma ◽

Trauma Team ◽

Time Of Day ◽

Operative Intervention ◽

Trauma Patients ◽

Mechanism Of Injury ◽

Trauma Team Activation ◽

Level I

The ACS Committee on Trauma specifies prehospital criteria that trigger trauma team activation (TTA). The study aims to define the relationship between TTA and time of day, mechanism of injury, and need for operative intervention. All trauma patients presenting to LAC1USC (January 2008–July 2018) after triggering TTA were screened. Patients were excluded if time of ED arrival was undocumented. Demographics, injury data, and outcomes were analyzed. After exclusions (<1%), 54,826 patients were enrolled. The median age was 35 [IQR 23–53]. The median Injury Severity Score was 4 [1–10]. The most common mechanisms of injury were falls (n = 14,166; 31%), auto versus pedestrian collisions (n = 11,921; 26%), and motor vehicle collisions (n = 11,024; 24%). Penetrating trauma comprised 16 per cent (n = 8,686). The busiest hour for TTAs was 19:00 to 20:00, although penetrating trauma was most common between 23:00 and 01:00. Emergent surgical intervention in absolute numbers was most frequent between 20:00 and 01:00. As a proportion of the number of TTAs per hour, emergent operative intervention was most frequent between 23:00 and 06:00. In conclusion, the volume of TTAs and the triggering mechanism of injury vary significantly by time of day. The need for operative intervention is highest overnight. This information can be used to help increase hospital preparedness and allocate resources accordingly.

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Nocturnal Violence: Implications for Resident Trauma Operative Experiences

The American Surgeon ◽

10.1177/000313481207800618 ◽

2012 ◽

Vol 78 (6) ◽

pp. 657-663 ◽

Cited By ~ 3

Author(s):

Colyn J. Watkins ◽

Paul L. Feingold ◽

Barry Hashimoto ◽

Laura S. Johnson ◽

Christopher J. Dente

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Penetrating Trauma ◽

Time Of Day ◽

Operative Intervention ◽

Peak Time ◽

Trauma Patients ◽

Time Period ◽

Work Hour ◽

Level I

Trauma centers face novel challenges in resource allocation in an era of cost consciousness and work-hour restrictions. Studies have shown that time of day and day of week affect trauma admission volume; however, these studies were performed in cold climates. Data from 2000 to 2010 at a Level I trauma center were reviewed. Demographic, injury severity, and injury timing from 23,827 trauma patients were analyzed along with their emergency department disposition (operating room, intensive care unit, ward) and final outcome. Nighttime arrivals (NAs) accounted for 56.6 per cent and daytime arrivals accounted for 43.4 per cent of total admissions. The increase in NAs was most pronounced during the period from midnight to 6 AM on weekends ( P < 0.05). Also, the period from midnight to 6 AM on weekends showed a significantly increased proportion of penetrating trauma ( P < 0.01). Similarly, there was an increased rate of trauma arrivals needing emergent operative intervention in the period between midnight and 6 AM on weekends when compared with any other time period ( P < 0.01). In a southern Level I trauma center, patient volume varies nonrandomly with time. Emergent operative intervention is more likely between midnight and 6 AM, the peak time for penetrating trauma. Because resident operative experience is maximized at night and on weekends, coverage during these periods should remain a priority for residency programs.

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Comparison of occult pneumothorax and pneumothorax cases in thoracic trauma: A descriptive, cross-sectional study

Journal of Emergency Medicine Trauma and Acute Care ◽

10.5339/jemtac.2021.5 ◽

2021 ◽

Vol 2021 (1) ◽

Author(s):

Semra Aslay

Keyword(s):

Computed Tomography ◽

Emergency Department ◽

Thoracic Trauma ◽

Tension Pneumothorax ◽

Penetrating Trauma ◽

Trauma Patients ◽

Chest Computed Tomography ◽

X Ray ◽

Occult Pneumothorax ◽

Chest X Ray

Background: The emergency department usually takes a supine posteroanterior (PA) chest X-ray imaging in trauma patients. In some cases, pneumothorax is not seen in the chest X-ray because of the patient's position. These cases are called occult pneumothorax. Misdiagnosis of occult pneumothorax in the emergency department may lead to complications such as tension pneumothorax. This study aimed to update patients’ features with occult pneumothorax due to blunt or penetrating trauma. Methods: In this study, data of 615 thoracic trauma patients admitted to the emergency department between January 2008 and December 2010 were evaluated. In total, 157 patients had undergone both chest X-ray and chest computed tomography and were diagnosed with pneumothorax. Of the 157 patients, 52 were excluded due to some criteria. Data of 105 patient, including their characteristics, trauma types, accompanying traumas, etiology of the chest trauma, chest X-ray findings, and computed chest tomography results were recorded. Data obtained were compared with the results of similar studies conducted in the last 10 years. Chest computed tomography was considered the gold standard for the diagnosis of pneumothorax. Results: The mean patient age was 36.19 ± 14.74 years. Occult pneumothorax was detected in 8 of 105 patients, giving a 7.6% overall incidence of occult pneumothorax. A traffic accident was the most common cause of etiology. All occult pneumothorax cases were caused by blunt trauma, and tube thoracostomy was performed in all of them. No significant differences were found between pneumothorax and occult pneumothorax cases concerning the etiology, accompanied trauma, intervention types, and trauma reasons (p < 0.05). Conclusions: This study supports the incidence of occult pneumothorax reported in the literature. When a patient is admitted with thoracic trauma, a physician should carefully evaluate the patient through supine chest X-ray examination. Only one misdiagnosis in trauma patients can be lead to many unintentional clinical and forensic results.

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Impact of 24/7 Onsite Emergency Radiology Staff Coverage on Emergency Department Workflow

Canadian Association of Radiologists Journal ◽

10.1177/08465371211023861 ◽

2021 ◽

pp. 084653712110238

Author(s):

Francesco Macri ◽

Bonnie T. Niu ◽

Shannon Erdelyi ◽

John R. Mayo ◽

Faisal Khosa ◽

...

Keyword(s):

Emergency Department ◽

Major Trauma ◽

Patient Flow ◽

Interrupted Time Series ◽

Trauma Patients ◽

Linear Regression Models ◽

High Acuity ◽

Time Series Approach ◽

Comparison Series ◽

The Impact

Purpose: Assess the impact of 24/7/365 emergency trauma radiology (ETR) coverage on Emergency Department (ED) patient flow in an urban, quaternary-care teaching hospital. Methods: Patient ED visit and imaging information were extracted from the hospital patient care information system for 2008 to 2018. An interrupted time-series approach with a comparison group was used to study the impact of 24/7/365 ETR on average monthly ED length of stay (ED-LOS) and Emergency Physician to disposition time (EP-DISP). Linear regression models were fit with abrupt and permanent interrupts for 24/7/365 ETR, a coefficient for comparison series and a SARIMA error term; subgroup analyses were performed by patient arrival time, imaging type and chief complaint. Results: During the study period, there were 949,029 ED visits and 739,796 diagnostic tests. Following implementation of 24/7/365 coverage, we found a significant decrease in EP-DISP time for patients requiring only radiographs (-29 min;95%CI:-52,-6) and a significant increase in EP-DISP time for major trauma patients (46 min;95%CI:13,79). No significant change in patient throughput was observed during evening hours for any patient subgroup. For overnight patients, there was a reduction in EP-DISP for patients with symptoms consistent with stroke (-78 min;95%CI:-131,-24) and for high acuity patients who required imaging (-33 min;95%CI:-57,-10). Changes in ED-LOS followed a similar pattern. Conclusions: At our institution, 24/7/365 in-house ETR staff radiology coverage was associated with improved ED flow for patients requiring only radiographs and for overnight stroke and high acuity patients. Major trauma patients spent more time in the ED, perhaps reflecting the required multidisciplinary management.

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