Patterns of Early Mortality after Trauma in a Neighborhood Urban Trauma Center: Can We Improve Outcomes?

Even with specialized trauma systems, a significant number of deaths occur within the early postinjury period. Our goal was to examine deaths within this period for cause and determine if care could improve outcomes. A retrospective chart review was performed on all patients who were dead on arrival or died within 4 hours of arrival between January 1, 2005, and December 31, 2011. Survival probabilities and Injury Severity Score (ISS) were calculated. Chart review and trauma review processes were used to determine cases with opportunities for care improvement. Two hundred eighty-nine patients were dead on arrival (DOA), and 176 patients died within 4 hours of arrival. The most common mechanism of injury was gunshot wounds (68.4%). The most common causes of death were uncontrolled hemorrhage (68.2%) and neurologic trauma (23.4%). Average ISS was 32. Twenty-nine patients had survival probability percentages over 50. Ten of 176 (5.7%) deaths were found to have opportunities for care improvement. In three cases (1.7%), errors contributed to death. The majority of trauma patients DOA or dying within 4 hours of hospital arrival have nonsurvivable injuries. Regular trauma review processes are invaluable in determining opportunities for care improvement. Autopsy information increases the reliability of the review process.

Download Full-text

Hematologic Effects of Ethanol Consumption in Trauma Patients

Annals of Pharmacotherapy ◽

10.1177/106002809302700716 ◽

1993 ◽

Vol 27 (7-8) ◽

pp. 889-891 ◽

Cited By ~ 3

Author(s):

Brian L. Erstad ◽

Diana K. Harlander ◽

John A. Daller

Keyword(s):

Length Of Stay ◽

Outcome Measures ◽

Chart Review ◽

Injury Severity ◽

Medical Center ◽

Retrospective Chart Review ◽

Trauma Patients ◽

Blood Products ◽

Coagulation Abnormalities ◽

Transfusion Requirements

OBJECTIVE: To determine the effects of ethanol (EtOH) ingestion by trauma patients on the hematologic system as evidenced by coagulation abnormalities and transfusion requirements. DESIGN: Retrospective chart review. The injury severity score (ISS) was determined for each patient. Patients were grouped according to presence of EtOH (+EtOH) and absence of EtOH (-EtOH) with further subdivision based on an ISS ≤8 or ≥9. SETTING: University medical center. PATIENTS: All adult trauma patients admitted during a one-month period. MAIN OUTCOME MEASURES: The volume of resuscitation fluids (including blood products) administered, laboratory parameters indicative of bleeding, and length of stay. RESULTS: Of 104 evaluable patients, 38 had measurable EtOH concentrations, 46 had undetectable EtOH concentrations, and the remaining 20 patients had not been tested. Although isolated, statistically significant differences were found among groups for some of the outcome measures, there were no clinically important differences. CONCLUSIONS: EtOH ingestion prior to injury did not appear to cause significant alterations in the hematologic system of trauma patients, but a larger study is needed to confirm these findings.

Download Full-text

Assessing the need for resuscitative endovascular balloon occlusion of the aorta (REBOA) for management of non-compressible hemorrhage at a Canadian urban trauma centre

10.21203/rs.3.rs-198760/v1 ◽

2021 ◽

Author(s):

Elizabeth Purssell ◽

Sean Patrick ◽

Joseph Haegert ◽

Vesna Ivkov ◽

John Taylor

Keyword(s):

Injury Severity ◽

Retrospective Chart Review ◽

Balloon Occlusion ◽

Trauma Centre ◽

Trauma Patients ◽

Potential Candidate ◽

Study Objective ◽

Resuscitative Thoracotomy ◽

Less Invasive ◽

Endovascular Balloon Occlusion

Abstract Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less invasive alternative to resuscitative thoracotomy (RT) for life threatening, infra-diaphragmatic, non-compressible hemorrhage from trauma. Existing evidence surrounding the efficacy of REBOA is conflicting; nevertheless, expert consensus suggests that REBOA should be considered in select trauma patients. There has been a paucity of studies that evaluate the potential utility of REBOA in the Canadian setting. The study objective was to evaluate the percentage of trauma patients presenting to a Level 1 Canadian trauma centre that would have met criteria for REBOA. Methods We conducted a retrospective chart review of patients recorded in the British Columbia Trauma Registry who warranted a trauma team activation (TTA) at our institution. We identified REBOA candidates using pre-defined criteria based on published guidelines. Each TTA case was screened by a reviewer, and then each Potential Candidate was reviewed by a panel of trauma physicians for determination of final candidacy. Results Fourteen patients were classified as Likely REBOA Candidates (2.2% of TTAs, median age 46.1 years, 64.3% female). These patients had a median Injury Severity Score of 31.5 (IQR 26.8). The main sources of hemorrhage in these patients were from abdominal injuries (71.4%) and pelvic fractures (42.9%). Conclusion The percentage of patients who met criteria for REBOA is similar to that of RTs performed at our Canadian institution. While REBOA would be performed infrequently, it is a less-invasive alternative to RT, which could be a potentially life-saving procedure in a small group of the most severely injured trauma patients.

Download Full-text

Trauma Intensive Care Unit ‘Bouncebacks': Identifying Risk Factors for Unexpected Return Admission to the Intensive Care Unit

The American Surgeon ◽

10.1177/000313481408000827 ◽

2014 ◽

Vol 80 (8) ◽

pp. 778-782 ◽

Cited By ~ 2

Author(s):

A. Britton Christmas ◽

Elizabeth Freeman ◽

Angela Chisolm ◽

Peter E. Fischer ◽

Gaurav Sachdev ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Brain Injuries ◽

Injury Severity ◽

Hospital Costs ◽

Retrospective Chart Review ◽

Trauma Patients ◽

Respiratory Compromise ◽

Patient Demographics ◽

Hygiene Practices

Return transfer (RT) to the intensive care unit (ICU) negatively impacts patient outcomes, length of stay (LOS), and hospital costs. This study assesses the most common events necessitating RT in trauma patients. We performed a retrospective chart review of ICU RT from 2004 to 2008. Patient demographics, injuries and injury severity, reason for transfer, LOS, interventions, and outcomes data were collected. Overall, 158 patients required readmission to the ICU. Respiratory insufficiency/ failure (48%) was the most common reason for RT followed by cardiac (16%) and neurological (13%) events. The most commonly associated injuries were traumatic brain injuries (TBIs) (32%), rib fractures (30%), and pulmonary contusions (20%). Initial ICU LOS was 6.6 ± 8 days (range, 1 to 44 days) with 4.4 ± 7.8 ventilator days. Mean floor time before ICU RT was 5.7 ± 6.3 days (range, 0 to 33 days). Forty-nine patients (31%) required intubation and mechanical ventilation on RT. ICU RT incurred an additional ICU LOS of 8 ± 8.5 days (range, 1 to 40 days) and 5.2 ± 7.5 ventilator days. Mortality after a single RT was 10 per cent (n = 16). RT to the ICU most often occurs as a result of respiratory compromise, and patients with TBI are particularly vulnerable. Trauma pulmonary hygiene practices should be evaluated to determine strategies that could decrease RT.

Download Full-text

P142: The anticoagulated trauma patient: a Canadian experience in the era of direct oral anticoagulants

CJEM ◽

10.1017/cem.2016.316 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S125-S125 ◽

Cited By ~ 1

Author(s):

B. Wood ◽

A. Ackery ◽

S. Rizoli ◽

B. Nascimento ◽

M. Sholzberg ◽

...

Keyword(s):

Trauma Patient ◽

Injury Severity ◽

Hematological Parameters ◽

Oral Anticoagulants ◽

Demographic Data ◽

Direct Oral Anticoagulants ◽

Significant Proportion ◽

Common Mechanism ◽

Trauma Patients ◽

Trauma Population

Introduction: The anticoagulated trauma patient is a particularly vulnerable population. Our current practice is guided by experience with patients taking vitamin K dependent antagonists (VKA, like warfarin). It is currently unknown how the increasing use of direct oral anticoagulants (DOACs) will change our trauma population. We collected data about this new subset of patients to compare their clinical characteristics to patients on pre-injury VKA therapy. Methods: Retrospective review of anticoagulated trauma patients presenting to Toronto’s two adult trauma centres, Saint Michael’s Hospital and Sunnybrook Health Sciences Centre, from June 2014-June 2015 was undertaken. Patients were recruited through the institutions’ trauma registries and were eligible if they suffered a traumatic injury and taking an oral anticoagulant pre-injury. Clinical and demographic data were extracted by a trained reviewer and analysed with descriptive statistics. Results: Our study recruited 85 patients, 33% were taking DOACs and 67% VKAs. Trauma patients on DOACs & VKAs respectively had similar baseline characteristics such as age (75.9 vs 77.4), initial injury severity score (ISS (16.9 vs 20.6)) and concomitant antiplatelet use (7.1% vs 5.4%). Both groups’ most common mechanism for injury was falls and the most common indication for anticoagulation was atrial fibrillation. Patients on DOACs tended to have lower average INR (1.25 vs 2.3) and serum creatinine (94.9 vs 127.4). Conclusion: Patients on DOACs pre-injury now account for a significant proportion of orally anticoagulated trauma patients. Patients on DOACs tended to have less derangement of basic hematological parameters complicating diagnosis and management of coagulopathy.

Download Full-text

Influence of a Stay-At-Home Order on Trauma Volume and Injury Patterns at a Level I Trauma Center in Ohio

The American Surgeon ◽

10.1177/00031348211047488 ◽

2021 ◽

pp. 000313482110474

Author(s):

Gregory S. Huang ◽

Elisha A. Chance ◽

C. Michael Dunham

Keyword(s):

Trauma Center ◽

Drug Testing ◽

Injury Severity ◽

Census Data ◽

Retrospective Chart Review ◽

Trauma Patients ◽

Injury Patterns ◽

Trauma Service ◽

Level I ◽

At Home

Background Changes in injury patterns during the COVID pandemic have been reported in other states. The objective was to explore changes to trauma service volume and admission characteristics at a trauma center in northeast Ohio during a stay-at-home order (SAHO) and compare the 2020 data to historic trauma census data. Methods Retrospective chart review of adult trauma patients admitted to a level I trauma center in northeast Ohio. Trauma admissions from January 21 to July 21, 2020 (COVID period) were compared to date-matched cohorts of trauma admissions from 2018 to 2019 (historic period). The COVID period was further categorized as pre-SAHO, active-SAHO, and post-SAHO. Results The SAHO was associated with a reduction in trauma center admissions that increased after the SAHO ( P = .0033). Only outdoor recreational vehicle (ORV) injuries ( P = .0221) and self-inflicted hanging ( P = .0028) mechanisms were increased during the COVID period and had substantial effect sizes. Glasgow Coma Scores were lower during the COVID period ( P = .0286) with a negligible effect size. Violence-related injuries, injury severity, mortality, and admission characteristics including alcohol and drug testing and positivity were similar in the COVID and historic periods. Discussion The SAHO resulted in a temporary decrease in trauma center admissions. Although ORV and hanging mechanisms were increased, other mechanisms such as alcohol and toxicology proportions, injury severity, length of stay, and mortality were unchanged.

Download Full-text

Percutaneous versus Open Tracheostomy in the Pediatric Trauma Population

The American Surgeon ◽

10.1177/000313481007600307 ◽

2010 ◽

Vol 76 (3) ◽

pp. 276-278 ◽

Cited By ~ 3

Author(s):

Ashish Raju ◽

D'Andrea K. Joseph ◽

Cheickna Diarra ◽

Steven E. Ross

Keyword(s):

Injury Severity ◽

Percutaneous Tracheostomy ◽

Pediatric Trauma ◽

Retrospective Chart Review ◽

Feeding Tube ◽

Tube Placement ◽

Trauma Patients ◽

Complication Rates ◽

Trauma Population ◽

Significant Difference

The purpose of this study was to determine the safety and efficacy of percutaneous versus open tracheostomy in the pediatric trauma population. A retrospective chart review was conducted of all tracheostomies performed on trauma patients younger than 18 years for an 8-year period. There was no difference in the incidence of brain, chest, or facial injury between the open and percutaneous tracheostomy groups. However, the open group had a significantly lower age (14.2 vs. 15.5 years; P < 0.01) and higher injury severity score (26 vs. 21; P = 0.015). Mean time from injury to tracheostomy was 9.1 days (range, 0 to 16 days) and was not different between the two methods. The majority of open tracheostomies were performed in the operating room and, of percutaneous tracheostomies, at the bedside. Concomitant feeding tube placement did not affect complication rates. There was not a significant difference between complication rates between the two methods of tracheostomy (percutaneous one of 29; open three of 20). Percutaneous tracheostomy can be safely performed in the injured older child.

Download Full-text

Using Arterial Pressure Index to Predict Arterial Injuries in Penetrating Trauma to the Upper Extremities

The American Surgeon ◽

10.1177/00031348211011142 ◽

2021 ◽

pp. 000313482110111

Author(s):

Lily Tung ◽

Mark J. Seamon ◽

Elizabeth Dauer ◽

Olamide Alabi ◽

Jaime Benarroch‐Gampel ◽

...

Keyword(s):

Arterial Pressure ◽

Injury Severity ◽

Penetrating Trauma ◽

Gunshot Wounds ◽

Trauma Patients ◽

Vascular Injuries ◽

Predictive Values ◽

Lower Extremity Injuries ◽

Pressure Index ◽

Arterial Injuries

Background Upper extremity (UE) vascular injuries account for 18.4% of all traumatic vascular injuries. Arterial pressure index (API) use in lower extremity injuries to determine the need for further investigations is well established. However, due to collateral circulation in UEs, it is unclear if the same algorithm can be applied. The purpose of this study was to determine if APIs can be used to determine the need for computed tomography angiogram (CTA) in penetrating UE trauma. Methods All adult trauma patients with penetrating UE trauma and APIs from 2006 to 2016 were identified at 3 urban US level 1 trauma centers. Sensitivity, specificity, and positive and negative predictive values of APIs <.9 in detecting UE arterial injuries were calculated. Results During the 11-year study period, 218 patients met our inclusion criteria. Gunshot wounds comprised 76.6% and stab wounds 17.9%. Median injury severity score and API were 9 and 1, respectively. Seventy-two of our patients underwent evaluation with CTA. Of the injuries, the most common were thrombus or occlusion (46.7%), transection (23.1%), and dissection (15.4%), radiographically. Ultimately, 32 patients underwent surgical.

Download Full-text

Incidence, Demographics, and Outcomes of Penetrating Trauma in Sweden During the Past Decade

Frontiers in Neurology ◽

10.3389/fneur.2021.730405 ◽

2021 ◽

Vol 12 ◽

Author(s):

Mattias Günther ◽

Martin Dahlberg ◽

Amir Rostami ◽

Ali Azadali ◽

Ulf P. Arborelius ◽

...

Keyword(s):

Head Trauma ◽

Interpersonal Violence ◽

Injury Severity ◽

Penetrating Trauma ◽

Gunshot Wounds ◽

Trauma Patients ◽

National Council ◽

Contributing Factors ◽

Penetrating Injuries ◽

Head Neck

Trauma injury is the sixth leading cause of death worldwide, and interpersonal violence is one of the major contributors in particular regarding injuries to the head and neck. The incidence, demographics, and outcomes of penetrating trauma reaching hospitals in Sweden are not known. We report the largest, nationwide epidemiological study of penetrating injuries in Sweden, using the Swedish Trauma Registry (SweTrau). A multi-center retrospective descriptive study of 4,776 patients was conducted with penetrating injuries in Sweden, between 2012 and 2018. Due to the increase in coverage of the SweTrau registry during the same period, we chose to analyze the average number of cases for the time intervals 2013–2015 and 2016–2018 and compare those trends to the reports of the Swedish National Council for Crime Prevention (Brå) as well. A total of 663 patients had Injury Severity Score (ISS) ≥ 15 at admission and were included in the study. Three hundred and sixty-eight (55.5%) were stab wounds (SW), 245 (37.0%) gunshot wounds (GSW), and 50 (7.5%) other traumas. A majority of the cases involved injuries to the head, neck, and face. SW increased from 145 during 2013–2015 to 184 during the second period of 2016–2018. The increase was greater for GSW from 92 to 141 during the same respective periods. This trend of increase over time was also seen in head, neck, and face injuries. The 30-day mortality was unaffected (48–47%) in GSW and trended toward lower in SW (24–21%) when comparing 2013–2015 with 2016–2018. Patients with head trauma had 45% mortality compared to 18% for non-head trauma patients. Head trauma also resulted in worse outcomes, only 13% had Glasgow outcome score (GOS) 5 compared to 27% in non-head trauma. The increasing number of cases of both SW and GSW corresponded well with reports from Brå although further studies also are needed to address deaths outside of hospitals and not registered at the SweTrau. The majority of cases had injuries to the head, neck, and face and were associated with higher mortality and poor outcomes. Further studies are needed to understand the contributing factors to these worse outcomes in Sweden and whether more targeted trauma care of these patients can improve outcomes.

Download Full-text

Major trauma patients are not who you might think they are: a linked data study

Australasian Journal of Paramedicine ◽

10.33151/ajp.16.704 ◽

2019 ◽

Vol 16 ◽

Author(s):

Elizabeth Brown ◽

Hideo Tohira ◽

Paul Bailey ◽

Daniel Fatovich ◽

Judith Finn

Keyword(s):

Major Trauma ◽

Injury Severity ◽

Motor Vehicle ◽

High Energy ◽

Categorical Variables ◽

Common Mechanism ◽

Trauma Patients ◽

Continuous Variables ◽

Mechanism Of Injury ◽

Young Males

IntroductionMajor trauma patients are often perceived as being young males injured by high energy transfer mechanisms. The aim of this study was to describe the demographics of major trauma patients who were transported to hospital by ambulance.MethodsThis is a retrospective cohort study of adult major trauma (injury severity score >15) patients transported to hospital by St John Western Australia emergency ambulance in metropolitan Perth, between 1 January 2013 and 31 December 2016. To describe the cohort, median and interquartile range (IQR) were used for continuous variables and counts and percentages for categorical variables. Differences between mechanism of injury groups were assessed using the Kruskal-Wallis test. Trauma deaths were defined as early (declared deceased within 24 hours) or late (declared deceased within 30 days). ResultsA total of 1625 patients were included. The median age was 51 years (IQR 30-75) and 1158 (71%) were male. Falls from standing were the most common mechanism of injury (n=460, 28%) followed by motor vehicle crashes (n=259, 16%). Falls from standing were responsible for the majority of early (n=45/175, 26%) and late deaths (n=69/158, 44%). A large number of early deaths also resulted from motorbike crashes (n=32/175, 18%) with a median age of 34 years (IQR 21-46, p<0.001). ConclusionMajor trauma is not only a disease of the young. More than half of the cohort was more than 51 years of age and the most common cause was a fall from standing. Pre-hospital care must evolve to address the needs of a changing trauma patient demographic.

Download Full-text

The Trauma Pan Scan: What Else Do you Find?

The American Surgeon ◽

10.1177/000313481408000917 ◽

2014 ◽

Vol 80 (9) ◽

pp. 855-859 ◽

Cited By ~ 7

Author(s):

Katherine A. Baugh ◽

Leonard J. Weireter ◽

Jay N. Collins

Keyword(s):

Incidental Findings ◽

Injury Severity ◽

Renal Cysts ◽

Retrospective Chart Review ◽

Ct Scans ◽

Trauma Patients ◽

Patient Demographics ◽

Head Neck ◽

Discharge Summaries

The objective of this study was to investigate the prevalence of incidental findings in pan-computed tomography (CT) scans of trauma patients and the communication of significant findings requiring follow-up to the patient. A retrospective chart review of adult trauma patients was performed during the period of January 1, 2011, to August 31, 2011. During that period, 990 patient charts were examined and 555 charts were selected based on the inclusion criteria of a pan-CT scan including the head, neck, abdomen/pelvis, and chest. Patient demographics such as age, gender, mechanism of injury, and Injury Severity Score were collected. Nontraumatic incidental findings were analyzed to establish the prevalence of incidental findings among trauma patients. Discharge summaries were also examined for follow-up instructions to determine the effectiveness of communication of the significant findings. Between the 555 pan-CT scans (1759 total scans), 1706 incidental findings were identified with an incidence of 3.1 incidental findings per patient and with the highest concentration of findings occurring in the abdomen/pelvis. The majority of findings were benign including simple renal cysts with a prevalence of 7.7 per cent. However, 282 significant findings were identified that were concerning for possible malignancy or those requiring further evaluation, the most common of which were lung nodules, which accounted for 21.6 per cent of significant findings. However, only 32.6 per cent of significant findings were documented as reported to the patient. With the use of pan scans on trauma patients, many incidental findings have been identified to the benefit of the patient. The majority of these are clinically insignificant; however, only 32.6 per cent of potentially significant findings were communicated to the patient. The advantage of early detection comes from proper communication and this study demonstrates that there could be improvement in conveying findings to the patient.

Download Full-text