Establishment of a novel triage system for SARS-CoV-2 among trauma victims in trauma centers with limited facilities

ObjectivesThe triage of trauma patients with potential COVID-19 remains a major challenge given that a significant number of patients may be asymptomatic or pre-symptomatic. This study aimed to compare the specificity and sensitivity of available triage systems for COVID-19 among trauma patients. Furthermore, it aimed to develop a novel triage system for SARS-CoV-2 detection among trauma patients in centers with limited resources.MethodsAll patients referred to our center from February to May 2020 were enrolled in this prospective study. We evaluated the SARS-CoV-2 triage protocols from the WHO, the Iranian Ministry of Health and Medical Education (MOHME), and the European Centre for Disease Control and Prevention (ECDC) for their effectiveness in finding COVID-19 infected individuals among trauma patients. We then used these data to design a stepwise triage protocol to detect COVID-19 positive patients among trauma patients.ResultsAccording to our findings, the WHO protocol showed 100% specificity and 13.3% sensitivity. The MOHME protocol had 99% specificity and 23.3% sensitivity. While the ECDC protocol showed 93.3% sensitivity and 89.5% specificity, it did not prioritize patients based on traumatic injuries and unstable conditions. Our stepwise triage protocol, which prioritizes traumatic injuries, had 93.3% sensitivity and 90.3% specificity.ConclusionOur study shows that the triage protocols from the WHO, MOHME and ECDC are not best equipped to diagnose SARS-CoV-2 infected individuals among trauma patients. In our proposed stepwise triage system, patients are triaged according to their hemodynamic conditions, COVID-19 related clinical states, and COVID-19 related laboratory findings. Our triage model can lead to more accurate and resource-effective management of trauma patients with potential COVID-19 infection.Level of evidenceLevel Ⅲ.

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Mechanisms of Injury Among the Amish Population in Central Pennsylvania

The American Surgeon ◽

10.1177/00031348211050592 ◽

2021 ◽

pp. 000313482110505

Author(s):

Larissa Whitney ◽

Kelly Bonneville ◽

Madison Morgan ◽

Lindsey L. Perea

Keyword(s):

Pediatric Population ◽

Traumatic Injury ◽

Age Groups ◽

Geographic Location ◽

Future Research ◽

Common Mechanism ◽

Trauma Patients ◽

Trauma Centers ◽

Injury Patterns ◽

Level Of Evidence

Background Individuals presenting with traumatic injury in rural populations have significantly different injury patterns than those in urban environments. With an increasing Amish population, totaling over 33 000 in our catchment area, their unique way of life poses additional factors for injury. This study aims to evaluate differences in mechanism of injury, location of injury, and demographic patterns within the Amish population. We hypothesize that there will be an increased incidence of agriculture-related mechanisms of injury. Methods All Amish trauma patients presenting to our level I trauma center over 20 years (1/2000-4/2020) were retrospectively analyzed. Mechanism and geographic location of injury were collected. Demographic and clinical variables were compared between the age groups. Results There were 1740 patients included in the study with 36.4% (n = 634) ≤ 14 years. Only 10% (n = 174) were ≥ 65 years. The most common mechanism across all ages was falls. However, when separating out the pediatric population ( ≤ 14 years), 27.8% (n = 60) fell from a height on average > 8-10 feet. The most common geographic location of injury was at home in all age groups, except for the 15-24 year group, which was roadways. Discussion The Amish population poses a unique set of mechanisms of injury and thus injury patterns to rural trauma centers. We have found the most common injuries to be falls, buggy accidents, animal-related injuries, and farming accidents across all age groups. Future research and collaboration with other rural trauma centers treating large Amish populations would be beneficial to maximize injury prevention in this population. Level of Evidence Level 3a, epidemiological.

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Are there Field Triage Criteria that Can Predict Low-Yield Air Medical Transports?

Prehospital and Disaster Medicine ◽

10.1017/s1049023x19004904 ◽

2019 ◽

Vol 34 (6) ◽

pp. 596-603

Author(s):

Hiroko Miyagi ◽

David C. Evans ◽

Howard A. Werman

Keyword(s):

Trauma Center ◽

Early Discharge ◽

Hospital Death ◽

Trauma Patients ◽

Trauma Centers ◽

Predictive Values ◽

Field Triage ◽

Number Of Patients ◽

Medical Transport ◽

The Impact

AbstractIntroduction:Air medical transport of trauma patients from the scene of injury plays a critical role in the delivery of severely injured patients to trauma centers. Over-triage of patients to trauma centers reduces the system efficiency and jeopardizes safety of air medical crews.Hypothesis:The objective of this study was to determine which triage factors utilized by Emergency Medical Services (EMS) providers are strong predictors of early discharge for trauma patients transported by helicopter to a trauma center.Methods:A retrospective chart review over a two-year period was performed for trauma patients flown from the injury site into a Level I trauma center by an air medical transport program. Demographic and clinical data were collected on each patient. Prehospital factors such as Glasgow Coma Score (GCS), Revised Trauma Score (RTS), intubation status, mechanism of injury, anatomic injuries, physiologic parameters, and any combinations of these factors were investigated to determine which triage criteria accurately predicted early discharge. Hospital factors such as Injury Severity Score (ISS), length-of-stay (LOS), survival, and emergency department disposition were also collected. Early discharge was defined as a hospital stay of less than 24 hours in a patient who survives their injuries. A more stringent definition of appropriate triage was defined as a patient with in-hospital death, an ISS >15, those taken to the operating room (OR) or intensive care unit (ICU), or those receiving blood products. Those patients who failed to meet these criteria were also used to determine over-triage rates.Results:An overall early discharge rate of 35% was found among the study population. Furthermore, when the more stringent definition was applied, over-triage rates were as high as 85%. Positive predictive values indicated that patients who met at least one anatomic and physiologic criteria were appropriately transported by helicopter as 94% of these patients had stays longer than 24 hours. No other criteria or combination of criteria had a high predictive value for early discharge.Conclusions:No individual triage criteria or combination of criteria examined demonstrated the ability to uniformly predict an early discharge. Although helicopter transport and subsequent hospital care is costly and resource consuming, it appears that a significant number of patients will be discharged within 24 hours of their transport to a trauma center. Future studies must determine the impact of eliminating “low-yield” triage criteria on under-triage of scene trauma patients.

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National estimates of the use and outcomes of extracorporeal membrane oxygenation after acute trauma

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2018-000209 ◽

2019 ◽

Vol 4 (1) ◽

pp. e000209 ◽

Cited By ~ 1

Author(s):

Parker J Hu ◽

Lauren Griswold ◽

Lauren Raff ◽

Rachel Rodriguez ◽

Gerald McGwin Jr ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Statistical Significance ◽

Trauma Patients ◽

Level Of Evidence ◽

Traumatic Injuries ◽

Membrane Oxygenation ◽

Diagnostic Codes ◽

The Usa ◽

Ninth Edition ◽

National Estimates

BackgroundThe use of extracorporeal membrane oxygenation (ECMO) as salvage therapy for patients with severe acute respiratory distress syndrome is gaining greater acceptance among trauma intensivists. The objective of this study was to review ECMO usage in trauma patients in the USA.MethodsThe National Inpatient Sample (NIS) from years 2002 to 2012 was queried for patients aged 15 and older treated with ECMO who had one or more acute traumatic injuries as defined by the International Diagnostic Codes, Ninth Edition (ICD-9). The primary outcomes of interest were incidence of ECMO and overall inpatient mortality.ResultsA total of 1347 patients were identified in the NIS database who had both ECMO performed and ICD-9 codes consistent with trauma. Patients were predominantly aged 15 to 29 years (31.4%) and were male (65.5%). The incidence of ECMO for patients after traumatic injuries has increased 66-fold during the 10-year period. In-hospital mortality was 48.0% overall, with a decreasing trend during the study period that approached statistical significance (p=0.06).DiscussionAlthough ECMO use in patients in the post-trauma setting remains controversial, there is an increasing trend to use ECMO nationwide, suggesting an increasing acceptance and/or increased availability at trauma centers. Given the decrease in mortality during the study period, ECMO as a salvage method in trauma patients remains a potentially viable option. Evaluation in a prospective manner may clarify risks and benefits.Level of evidenceLevel IV, epidemiological.

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Minor change in initial PEEP setting decreases rates of ventilator-associated events in mechanically ventilated trauma patients

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000455 ◽

2020 ◽

Vol 5 (1) ◽

pp. e000455

Author(s):

Ethan Ferrel ◽

Kristina M Chapple ◽

Liviu Gabriel Calugaru ◽

Jennifer Maxwell ◽

Jessica A Johnson ◽

...

Keyword(s):

Logistic Regression ◽

Injury Severity ◽

Trauma Patients ◽

Trauma Centers ◽

Level Of Evidence ◽

Mechanically Ventilated ◽

Change In Practice ◽

Level 1 ◽

The Impact ◽

Level 1 Trauma Center

BackgroundSurveillance of ventilator-associated events (VAEs) as defined by the National Healthcare Safety Network (NHSN) is performed at many US trauma centers and considered a measure of healthcare quality. The surveillance algorithm relies in part on increases in positive end-expiratory pressure (PEEP) to identify VAEs. The purpose of this cohort study was to evaluate the effect of initiating mechanically ventilated trauma patients at marginally higher PEEP on incidence of VAEs.MethodsAnalysis of level-1 trauma center patients mechanically ventilated 2+ days from 2017 to 2018 was performed after an institutional ventilation protocol increased initial PEEP setting from 5 (2017) to 6 (2018)cm H2O. Incidence of VAEs per 1000 vent days was compared between PEEP groups. Logistic regression modelling was performed to evaluate the impact of the PEEP setting change adjusted to account for age, ventilator days, injury mechanism and injury severity.Results519 patients met study criteria (274 PEEP 5 and 245 PEEP 6). Rates of VAEs were significantly reduced among patients with initial PEEP 5 versus 6 (14.61 per 1000 vent days vs. 7.13 per 1000 vent days; p=0.039). Logistic regression demonstrated that initial PEEP 6 was associated with 62% reduction in VAEs.ConclusionsOur data suggest that an incrementally increased baseline PEEP setting was associated with a significantly decreased incidence of VAEs among trauma patients. This minor change in practice may have a major impact on a trauma center’s quality metrics.Level of evidenceIV.

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Effects of a trauma center on early mortality after trauma in a regional city in Japan: a population-based study

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2018-000291 ◽

2019 ◽

Vol 4 (1) ◽

pp. e000291 ◽

Cited By ~ 2

Author(s):

Yuji Takahashi ◽

Shuntaro Sato ◽

Kazunori Yamashita ◽

Naoya Matsumoto ◽

Yoshihiro Nozaki ◽

...

Keyword(s):

Logistic Regression ◽

Trauma Center ◽

Medical Center ◽

Early Mortality ◽

University Hospital ◽

Fiscal Year ◽

Multivariate Logistic Regression Model ◽

Trauma Patients ◽

Level Of Evidence ◽

Number Of Patients

BackgroundAlthough the effects of the trauma center(TC) were researched in several studies, there have been few studies on changes in the regional mortality due to the implementation of a TC. An emergency medical center (EMC) and TC were implemented at Nagasaki University Hospital (NUH) for the first time in the Nagasaki medical region of Japan in April 2010 and October 2011, respectively, and they have cooperated with each other in treating trauma patients. The purpose of this study was to investigate the effects on the early mortality at population level of a TC working in cooperation with an EMC.MethodsThis is a retrospective study using standardized regional data (ambulance service record) in Nagasaki medical region from April 2007 through March 2017. We included 19,045 trauma patients directly transported from the scene. The outcome measures were prognosis for one week. To examine the association between the implementation of the EMC and TC and mortality at a region, we fit adjusted logistic regression models.ResultsThe number of patients of each fiscal year increased from 1492 in 2007 to 2101 in 2016. The number of all patients transported to NUH decreased until 2009 to 70, but increased after implementation of the EMC and TC. Overall mortality of all patients in the region improved from 2.3% in 2007 to 1.0% in 2016.In multivariate logistic regression model, odds ratio of death was significantly smaller at 2013 and thereafter if the data from 2007 to 2011 was taken as reference.ConclusionsImplementation of the EMC and TC was associated with early mortality in trauma patients directly transported from the scene by ambulance. Our analysis suggested that the implementation of EMC and TC contributed to the improvement of the early mortality at a regional city with 500000 populations.Level of evidenceLevel III.

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Multicenter study of US trauma centers examining the effect of the COVID-19 pandemic on injury causes, diagnoses and procedures

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000655 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000655

Author(s):

Kristin Salottolo ◽

Rachel Caiafa ◽

Jalina Mueller ◽

Allen Tanner ◽

Matthew M Carrick ◽

...

Keyword(s):

Hospital Admissions ◽

Motor Vehicle ◽

Traumatic Injury ◽

Trauma Patients ◽

Trauma Centers ◽

Injury Patterns ◽

Level Of Evidence ◽

Study Objective ◽

Time Periods ◽

Injury Causes

BackgroundThe COVID-19 pandemic resulted in nationwide social distancing and shelter-in-place orders meant to curb transmission of the SARS-CoV-2 virus. The effect of the pandemic on injury patterns has not been well described in the USA. The study objective is to determine the effect of the COVID-19 pandemic on the distribution and determinants of traumatic injuries.MethodsThis retrospective multi-institutional cohort study included all hospital admissions for acute traumatic injury at six community level I trauma centers. Descriptive statistics were used to compare injury causes, diagnoses and procedures over two similar time periods: prepandemic (March 11–June 30, 2019) and pandemic (March 11–June 30, 2020).ResultsThere were 7308 trauma patients included: 3862 (53%) prepandemic and 3446 (47%) during the pandemic. Cause of injury significantly differed by period (p<0.001). During the pandemic, there were decreases in motor vehicle crashes (from 17.0% to 14.0%, p<0.001), worksite injuries (from 5.2% to 4.1%, p=0.02), pedestrian injuries (from 3.0% to 2.2%, p=0.02) and recreational injuries (from 3.0% to 1.7%, p<0.001), while there were significant increases in assaults (6.9% to 8.5%, p=0.01), bicycle crashes (2.8% to 4.2%, p=0.001) and off-road vehicle injuries (1.8% to 3.0%, p<0.001). There was no change by study period in falls, motorcycle injuries, crush/strikes, firearm and self-inflicted injuries, and injuries associated with home-improvement projects. Injury diagnoses differed between time periods; during the pandemic, there were more injury diagnoses to the head (23.0% to 27.3%, p<0.001) and the knee/leg (11.7% to 14.9%, p<0.001). There were also increases in medical/surgical procedures (57.5% to 61.9%, p<0.001), administration of therapeutics/blood products (31.4% to 34.2%, p=0.01) and monitoring (11.0% to 12.9%, p=0.01).DiscussionCauses of traumatic injury, diagnoses, and procedures were significantly changed by the pandemic. Trauma centers must adjust to meet the changing demands associated with altered injury patterns, as they were associated with increased use of hospital resources.Level of evidenceIII (epidemiological).

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Emergent needle thoracostomy in prehospital trauma patients: a review of procedural execution through computed tomography scans

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2021-000752 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000752

Author(s):

Michael M Neeki ◽

Christina Cheung ◽

Fanglong Dong ◽

Nam Pham ◽

Dylan Shafer ◽

...

Keyword(s):

Pleural Cavity ◽

Retrospective Chart Review ◽

Needle Insertion ◽

Trauma Patients ◽

Level Of Evidence ◽

Traumatic Injuries ◽

Life Saving ◽

Life Threatening ◽

And Performance

BackgroundTraumatic tension pneumothoraces (TPT) are among the most serious causes of death in traumatic injuries, requiring immediate treatment with a needle thoracostomy (NT). Improperly placed NT insertion into the pleural cavity may fail to treat a life-threatening TPT. This study aimed to assess the accuracy of prehospital NT placements by paramedics in adult trauma patients.MethodsA retrospective chart review was performed on 84 consecutive trauma patients who had received NT by prehospital personnel. The primary outcome was the accuracy of NT placement by prehospital personnel. Comparisons of various variables were conducted between those who survived and those who died, and proper versus improper needle insertion separately.ResultsProper NT placement into the pleural cavity was noted in 27.4% of adult trauma patients. In addition, more than 19% of the procedures performed by the prehospital providers appeared to have not been medically indicated.DiscussionLong-term strategies may be needed to improve the capabilities and performance of prehospital providers’ capabilities in this delicate life-saving procedure.Level of evidenceIV.

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Decreased adult trauma admission volumes and changing injury patterns during the COVID-19 pandemic at 85 trauma centers in a multistate healthcare system

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000642 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000642

Author(s):

Gina M Berg ◽

Ransom J Wyse ◽

Jennifer L Morse ◽

John Chipko ◽

Jeneva M Garland ◽

...

Keyword(s):

Trauma Patient ◽

Injury Severity ◽

Motor Vehicle ◽

Trauma Network ◽

Trauma Patients ◽

Trauma Centers ◽

Injury Patterns ◽

Level Of Evidence ◽

Trauma Population ◽

Absolute Decrease

BackgroundReports indicate social distancing guidelines and other effects of the COVID-19 pandemic impacted trauma patient volumes and injury patterns. This report is the first analysis of a large trauma network describing the extent of these impacts. The objective of this study was to describe the effects of the COVID-19 pandemic on patient volumes, demographics, injury characteristics, and outcomes.MethodsFor this descriptive, multicenter study from a large, multistate hospital network, data were collected from the system-wide centralized trauma registry and retrospectively reviewed to retrieve patient information including volume, demographics, and outcomes. For comparison, patient data from January through May of 2020 and January through May of 2019 were extracted.ResultsA total of 12 395 trauma patients (56% men, 79% white, mean age 59 years) from 85 trauma centers were included. The first 5 months of 2020 revealed a substantial decrease in volume, which began in February and continued into June. Further analysis revealed an absolute decrease of 32.5% in patient volume in April 2020 compared with April 2019 (4997 from 7398; p<0.0001). Motor vehicle collisions decreased 49.7% (628 from 1249). There was a statistically significant increase in injury severity score (9.0 vs. 8.3; p<0.001). As a proportion of the total trauma population, blunt injuries decreased 3.1% (87.3 from 90.5) and penetrating injuries increased 2.7% (10.0 from 7.3; p<0.001). A significant increase was found in the proportion of patients who did not survive to discharge (3.6% vs. 2.8%; p=0.010; absolute decrease: 181 from 207).DiscussionEarly phases of the COVID-19 pandemic were associated with a 32.5% decrease in trauma patient volumes and altered injury patterns at 85 trauma centers in a multistate system. This preliminary observational study describes the initial impact of the COVID-19 pandemic and warrants further investigation.Level of evidenceLevel II (therapeutic/care management).

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Large-Scale Airmedical Transport from a Peripheral Hospital to Level-1 Trauma Centers after Remote Mass-Casualty Incidents in Israel

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00007500 ◽

2009 ◽

Vol 24 (6) ◽

pp. 549-555 ◽

Cited By ~ 5

Author(s):

Ophir Lavon ◽

Dan Hershko ◽

Erez Barenboim

Keyword(s):

Large Scale ◽

Medical Personnel ◽

Mass Casualty ◽

Mass Casualty Incidents ◽

Trauma Patients ◽

Trauma Centers ◽

Preparedness Plan ◽

Peripheral Hospital ◽

Number Of Patients ◽

Level 1

AbstractIntroduction:Mass-casualty incidents (MCIs) result in the evacuation of many patients to the nearest medical facility. However, an overwhelming number of patients and the type and severity of injuries may demand rapid, mass airmedical transport to more advanced medical centers. This task may be challenging, particularly after a MCI in a neighboring country. The Israeli Air Force Rescue and Airmedical Evacuation Unit (RAEU) is the main executor of airmedical transport in Israel, including MCIs.Problem:The available data on airmedical transport from remote MCIs are limited. The objective of this study was to evaluate the airmedical transport from a rural hospital after two remote MCIs.Methods:The study was retrospective and reviewed descriptive records of airmedical transports.Results:The RAEU was involved in airmedical transports from a peripheral hospital shortly after two remote MCIs that occurred in the Sinai desert near the Egyptian-Israeli border. Nineteen (22.4%) and 25 (100%) of the treated trauma patients from each event were airmedically transported to Level-1 Trauma Centers in Israel within hours of the dispatch. The rapid dispatch and accumulation of medical personnel and equipment was remarkable. The airmedical surge capacity was broad and sufficient. Cooperation with local authorities and a tailored boarding procedure facilitated a quality outcome.Conclusions:The incorporation of a large-scale airmedical transport program with designated multidisciplinary protocols is an essential component to a remote disaster preparedness plan.

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Different strokes: differences in the characteristics and outcomes of BCVI and non-BCVI strokes in trauma patients

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000457 ◽

2020 ◽

Vol 5 (1) ◽

pp. e000457

Author(s):

Michelle K McNutt ◽

Cedar Slovacek ◽

David Rosenbaum ◽

Hari Kishan Reddy Indupuru ◽

Xu Zhang ◽

...

Keyword(s):

Traumatic Injury ◽

Cognitive Outcomes ◽

Trauma Patients ◽

Level Of Evidence ◽

Blunt Cerebrovascular Injury ◽

Traumatic Injuries ◽

Medical Comorbidities ◽

Cerebrovascular Injury ◽

Trauma Population ◽

Extremity Injuries

BackgroundAlthough strokes are rare in trauma patients, they are associated with worse functional and cognitive outcomes and decreased mobility. Blunt cerebrovascular injury (BCVI)–related strokes and mortality have decreased, likely due to refined screening and treatment algorithms in trauma literature; however, there is a paucity of research addressing non-BCVI strokes in trauma. The purpose of this study is to evaluate the incidence, etiology, and risk factors of stroke in our trauma population in order to identify preventive strategies.MethodsThis study was a retrospective review of all adult trauma patients admitted to a level 1 trauma hospital who suffered a stroke during trauma admission from 2010 to 2017. Data were collected from the prospectively maintained trauma and stroke databases. Stroke etiology was determined by a vascular neurologist.ResultsOf the 43 674 adult trauma patients admitted during the study period, 99 (0.2%) were diagnosed with a stroke during the index admission. Twenty-one (21%) strokes were due to BCVI. Seventy-eight (79%) strokes were due to non-BCVI etiologies. Patients with non-BCVI strokes were older, less severely injured, and had more medical comorbidities compared with patients with a BCVI stroke. While patients with a BCVI stroke were more likely to suffer multiple traumatic injuries from MVC (76% vs 28%, p<0.001), non-BCVI strokes had more isolated extremity injuries from fall mechanism (55% vs 10%, p<0.001). Over the study period, the age and incidence of stroke and BCVI (p<0.001) increased. However, the rate of BCVI strokes decreased while the rate of non-BCVI strokes increased.DiscussionThe incidence of stroke has increased despite aggressive screening and treatment of BCVI. This increase is primarily due to non-BCVI strokes which are associated with advanced age and medical comorbidities after low mechanism traumatic injury. Medical optimization of comorbid conditions during trauma hospitalization will become increasingly important for stroke prevention as the population ages.Level of evidence: Level III

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