Validation of the BATT score for prehospital risk stratification of traumatic haemorrhagic death: usefulness for tranexamic acid treatment criteria

Abstract Background Tranexamic acid reduces surgical blood loss and reduces deaths from bleeding in trauma patients. Tranexamic acid must be given urgently, preferably by paramedics at the scene of the injury or in the ambulance. We developed a simple score (Bleeding Audit Triage Trauma score) to predict death from bleeding. Methods We conducted an external validation of the BATT score using data from the UK Trauma Audit Research Network (TARN) from 1st January 2017 to 31st December 2018. We evaluated the impact of tranexamic acid treatment thresholds in trauma patients. Results We included 104,862 trauma patients with an injury severity score of 9 or above. Tranexamic acid was administered to 9915 (9%) patients. Of these 5185 (52%) received prehospital tranexamic acid. The BATT score had good accuracy (Brier score = 6%) and good discrimination (C-statistic 0.90; 95% CI 0.89–0.91). Calibration in the large showed no substantial difference between predicted and observed death due to bleeding (1.15% versus 1.16%, P = 0.81). Pre-hospital tranexamic acid treatment of trauma patients with a BATT score of 2 or more would avoid 210 bleeding deaths by treating 61,598 patients instead of avoiding 55 deaths by treating 9915 as currently. Conclusion The BATT score identifies trauma patient at risk of significant haemorrhage. A score of 2 or more would be an appropriate threshold for pre-hospital tranexamic acid treatment.

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Validation of the BATT score for prehospital risk stratification of traumatic haemorrhagic death: Usefulness for tranexamic acid treatment criteria.

10.21203/rs.3.rs-64755/v3 ◽

2020 ◽

Author(s):

Francois-Xavier Ageron ◽

Timothy J Coats ◽

Vincent Darioli ◽

Ian Roberts

Keyword(s):

Tranexamic Acid ◽

Acid Treatment ◽

Injury Severity ◽

External Validation ◽

Research Network ◽

Brier Score ◽

Trauma Patients ◽

Using Data ◽

The Uk ◽

The Impact

Abstract Background: Tranexamic acid reduces surgical blood loss and reduces deaths from bleeding in trauma patients. Tranexamic acid must be given urgently, preferably by paramedics at the scene of the injury or in the ambulance. We developed a simple score (Bleeding Audit Triage Trauma score) to predict death from bleeding.Methods: We conducted an external validation of the BATT score using data from the UK Trauma Audit Research Network (TARN) from 1st January 2017 to 31st December 2018. We evaluated the impact of tranexamic acid treatment thresholds in trauma patients.ResultsWe included 104,862 trauma patients with an injury severity score of 9 or above. Tranexamic acid was administered to 9,915 (9%) patients. Of these 5,185 (52%) received prehospital tranexamic acid. The BATT score had good accuracy (Brier score=6%) and good discrimination (C-statistic 0.90; 95% CI 0.89-0.91). Calibration in the large showed no substantial difference between predicted and observed death due to bleeding (1.15% versus 1.16%; P=0.81). Pre-hospital tranexamic acid treatment of trauma patients with a BATT score of 2 or more would avoid 210 bleeding deaths by treating 61,598 patients instead of avoiding 55 deaths by treating 9,915 as currently. ConclusionThe BATT score identifies trauma patient at risk of significant haemorrhage. A score of 2 or more would be an appropriate threshold for pre-hospital tranexamic acid treatment.

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Validation of the BATT score for prehospital risk stratification of traumatic haemorrhagic death: Usefulness for tranexamic acid treatment criteria.

10.21203/rs.3.rs-64755/v2 ◽

2020 ◽

Author(s):

Francois-Xavier Ageron ◽

Timothy J Coats ◽

Vincent Darioli ◽

Ian Roberts

Keyword(s):

Tranexamic Acid ◽

Acid Treatment ◽

Injury Severity ◽

External Validation ◽

Research Network ◽

Brier Score ◽

Trauma Patients ◽

Using Data ◽

The Uk ◽

The Impact

Abstract Background: Tranexamic acid reduces surgical blood loss and reduces deaths from bleeding in trauma patients. Tranexamic acid must be given urgently, preferably by paramedics at the scene of the injury or in the ambulance. We developed a simple score (Bleeding Audit Triage Trauma score) to predict death from bleeding.Methods: We conducted an external validation of the BATT score using data from the UK Trauma Audit Research Network (TARN) from 1st January 2017 to 31st December 2018. We evaluated the impact of tranexamic acid treatment thresholds in trauma patients.Results: We included 104,862 trauma patients with an injury severity score of 9 or above. Tranexamic acid was administered to 9,915 (9%) patients. Of these 5,185 (52%) received prehospital tranexamic acid. The BATT score had good accuracy (Brier score=6%) and good discrimination (C-statistic 0.90; 95% CI 0.89-0.91). Calibration in the large showed no substantial difference between predicted and observed death due to bleeding (1.15% versus 1.16%; P=0.81). Pre-hospital tranexamic acid treatment of trauma patients with a BATT score of 2 or more would avoid 210 bleeding deaths by treating 61,598 patients instead of avoiding 55 deaths by treating 9,915 as currently. Conclusion: The BATT score identifies trauma patient at risk of significant haemorrhage. A score of 2 or more would be an appropriate threshold for pre-hospital tranexamic acid treatment.

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Validation of the BATT score for prehospital risk stratification of traumatic haemorrhagic death: Usefulness for tranexamic acid treatment criteria.

10.21203/rs.3.rs-64755/v1 ◽

2020 ◽

Author(s):

Francois-Xavier Ageron ◽

Timothy J Coats ◽

Vincent Darioli ◽

Ian Roberts

Keyword(s):

Tranexamic Acid ◽

Acid Treatment ◽

Injury Severity ◽

External Validation ◽

Research Network ◽

Brier Score ◽

Trauma Patients ◽

Using Data ◽

The Uk ◽

The Impact

Abstract Background: Tranexamic acid reduces surgical blood loss and reduces deaths from bleeding in trauma patients. Tranexamic acid must be given urgently, preferably by paramedics at the scene of the injury or in the ambulance. We developed a simple score (Bleeding Audit Triage Trauma score) to predict death from bleeding.Methods: We conducted an external validation of the BATT score using data from the UK Trauma Audit Research Network (TARN) from 1st January 2017 to 31st December 2018. We evaluated the impact of tranexamic acid treatment thresholds in trauma patients.Results: We included 104,862 trauma patients with an injury severity score of 9 or above. Tranexamic acid was administered to 9,915 (9%) patients. Of these 5,185 (52%) received prehospital tranexamic acid. The BATT score had good accuracy (Brier score=6%) and good discrimination (C-statistic 0.90; 95% CI 0.89-0.91). Calibration in the large showed no substantial difference between predicted and observed death due to bleeding (1.15% versus 1.16%; P=0.81). Pre-hospital tranexamic acid treatment of trauma patients with a BATT score of 2 or more would avoid 210 bleeding deaths by treating 61,598 patients instead of avoiding 55 deaths by treating 9,915 as currently. Conclusion: The BATT score identifies trauma patient at risk of significant haemorrhage. A score of 2 or more would be an appropriate threshold for pre-hospital tranexamic acid treatment.

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1 Simultaneous trauma patients in emergency departments: a difference in mortality?

Journal of the Royal Army Medical Corps ◽

10.1136/jramc-2018-000959.1 ◽

2018 ◽

Vol 164 (3) ◽

pp. 224.1-224

Author(s):

L Morrow ◽

T Nutbeam ◽

O Bouamra

Keyword(s):

Emergency Department ◽

Patient Outcomes ◽

Major Trauma ◽

Injury Severity ◽

Research Network ◽

Trauma Patients ◽

Icu Stay ◽

Patient Category ◽

The Uk ◽

The Impact

BackgroundThe presentation of multiple simultaneous trauma patients to an Emergency Department is likely to place significant stress and strain on trauma care resources. Currently there is limited literature and no UK or multicentre data available to understand this impact. The aim of this study was to identify patient outcomes when there are simultaneous major trauma patients. We hypothesised that with increasing numbers of simultaneous trauma patients an increase in mortality may be seen.MethodsThe Trauma Audit and Research Network (TARN) database was interrogated from 2010–2015 to identify simultaneous major trauma patients. We defined simultaneous trauma as occurring when there was more than one trauma patient within an Emergency Department at any one time.Patient age, sex, Glasgow Coma Scale and Injury Severity Score (ISS) were recorded. A standardised comparison using a stratified Ws statistic was conducted to compare mortality between groups. Secondary outcomes included length of hospital and intensive care (ICU) stay.ResultsOf 2 07 094 patients, 33.7% were eligible simultaneous trauma patients. 55.7% of patients were male, median age was 61 and median ISS was 9. No increase in mortality was seen with increasing patient numbers (table 1).Abstract 1 Table 1 Ws statistic with increasing simultaneous patient numbersIsolated2 patients3 patients4 patients5 patients6+patientsTotal1 37 360 51 466 13 820 3539 671 185 Ws statistic0.05 0.38 0.72 0.53 0.39 2.70 A statistically significant increase in length of ICU stay was observed for the 6+patient category (p=0.047) but no difference was reported in hospital stay.ConclusionThe impact of simultaneous trauma patients on patient outcomes within the UK has not been previously defined. Simultaneous trauma patients do not appear to have an impact on mortality (as measured by Ws statistic).

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Relationship between the Injury Severity Score and the need for life-saving interventions in trauma patients in the UK

Emergency Medicine Journal ◽

10.1136/emermed-2019-209092 ◽

2020 ◽

pp. emermed-2019-209092

Author(s):

James Vassallo ◽

Gordon Fuller ◽

Jason E Smith

Keyword(s):

Injury Severity Score ◽

Severity Score ◽

Major Trauma ◽

Injury Severity ◽

Research Network ◽

Trauma Patients ◽

Traditional Definition ◽

Life Saving ◽

Clinically Significant ◽

The Uk

IntroductionMajor trauma is the third leading cause of avoidable mortality in the UK. Defining which patients require care in a major trauma centre is a critical component of developing, evaluating and enhancing regional major trauma systems. Traditionally, trauma patients have been classified using the Injury Severity Score (ISS), but resource-based criteria have been proposed as an alternative. The aim of this study was to investigate the relationship between ISS and the use of life-saving interventions (LSI).MethodsRetrospective cohort study using the Trauma Audit Research Network database for all adult patients (aged ≥18 years) between 2006 and 2014. Patients were categorised as needing an LSI if they received one or more interventions from a previously defined list determined by expert consensus.Results193 290 patients met study inclusion criteria: 56.9% male, median age 60.0 years (IQR 41.2–78.8) and median ISS 9 (IQR 9–16). The most common mechanism of injury was falls <2 m (52.1%), followed by road traffic collisions (22.2%). 15.1% received one or more LSIs. The probability of a receiving an LSI increased with increasing ISS, but only a low to moderate correlation was evident (0.334, p<0.001). A clinically significant number of cases (5.3% and 7.6%) received an LSI despite having an ISS ≤8 or <15, respectively.ConclusionsA clinically significant number of adult trauma patients requiring LSIs have an ISS below the traditional definition of major trauma. The traditional definition should be reconsidered and either lowered, or an alternative metric should be used.

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Clinical outcomes following major trauma for patients with a diagnosis of depression: a large UK database analysis

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2021-000819 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000819

Author(s):

Jamie Large ◽

David N Naumann ◽

Jodie Fellows ◽

Clare Connor ◽

Zubair Ahmed

Keyword(s):

Clinical Outcomes ◽

Major Trauma ◽

Injury Severity ◽

Management Strategies ◽

Research Network ◽

Trauma Patients ◽

Level Of Evidence ◽

Logistic Regression Models ◽

The Uk

BackgroundMore than a quarter of the UK population are affected by depression during their lifetime. For major trauma patients, postinjury depression can result in poorer long-term outcomes, but there is limited evidence regarding outcomes for patients with pre-existing depression. This study investigated the relationship between a diagnosis of depression prior to hospital admission and clinical outcomes after major trauma.MethodsTrauma patients at a UK major trauma center were identified during a 6.5-year period using the Trauma Audit and Research Network database. Patients with Injury Severity Score >15 who did not die in the emergency department (ED) were included. Logistic regression models were used to compare in-hospital mortality (excluding ED), requirement for surgery, and length of stay (LOS) between those with depression and those without.ResultsThere were 4602 patients included in the study and 6.45% had a diagnosis of depression. Depression was associated with a significant reduction in mortality (OR 0.54, 95% CI 0.30 to 0.91; p=0.026). However, patients with depression were more likely to have longer LOS (OR 124, 95% CI 8.5 to 1831; p<0.001) and intensive care unit LOS (OR 9.69, 95% CI 3.14 to 29.9; p<0.001). Patients with depression were also more likely to undergo surgery (OR 1.36, 95% CI 1.06 to 1.75; p=0.016).DiscussionA pre-existing diagnosis of depression has complex association with clinical outcomes after major trauma, with reduced mortality but longer LOS and higher likelihood of surgical intervention. Further prospective investigations are warranted to inform optimal management strategies for major trauma patients with pre-existing depression.Level of evidenceIII.

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National temporal variation in major trauma in England, Wales and Northern Ireland

Trauma ◽

10.1177/1460408620982264 ◽

2021 ◽

pp. 146040862098226

Author(s):

Will Kieffer ◽

Daniel Michalik ◽

Jason Bernard ◽

Omar Bouamra ◽

Benedict Rogers

Keyword(s):

Northern Ireland ◽

Temporal Variation ◽

Major Trauma ◽

Injury Severity ◽

Research Network ◽

Trauma Patients ◽

Trauma Outcomes ◽

Causes Of Mortality ◽

Injured Patients ◽

Time Of Admission

Introduction Trauma is one of the leading causes of mortality worldwide, but little is known of the temporal variation in major trauma across England, Wales and Northern Ireland. Proper workforce and infrastructure planning requires identification of the caseload burden and its temporal variation. Materials and Methods The Trauma Audit Research Network (TARN) database for admissions attending Major Trauma Centres (MTCs) between 1st April 2011 and 31st March 2018 was analysed. TARN records data on all trauma patients admitted to hospital who are alive at the time of admission to hospital. Major trauma was classified as an Injury Severity Score (ISS) >15. Results A total of 158,440 cases were analysed. Case ascertainment was over 95% for 2013 onwards. There was a statistically significant variation in caseload by year (p < 0.0001), times of admissions (p < 0.0001), caseload admitted during weekends vs weekdays, 53% vs 47% (p < 0.0001), caseload by season with most patients admitted during summer (p < 0.0001). The ISS varied by time of admission with most patients admitted between 1800 and 0559 (p < 0.0001), weekend vs weekday with more severely injured patients admitted during the weekend (p < 0.0001) and by season p < 0.0001). Discussion and Conclusion: There is a significant national temporal variation in major trauma workload. The reasons are complex and there are multiple theories and confounding factors to explain it. This is the largest dataset for hospitals submitting to TARN which can help guide workforce and resource allocation to further improve trauma outcomes.

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Funding Local Political Parties in England and Wales: Donations and Constituency Campaigns

The British Journal of Politics and International Relations ◽

10.1111/j.1467-856x.2007.00296.x ◽

2007 ◽

Vol 9 (3) ◽

pp. 365-395 ◽

Cited By ~ 25

Author(s):

Ron Johnston ◽

Charles Pattie

Keyword(s):

Political Parties ◽

England And Wales ◽

Liberal Democrats ◽

Using Data ◽

The Uk ◽

The Impact

The funding of political parties is an issue of considerable contemporary concern in the UK. Although most attention has been paid to the situation regarding national parties, the new funding regime introduced in 2001 also applies to constituency parties, and some concerns have been raised regarding the limits on spending and expenditure there. Using data released by the Electoral Commission on all donations above a specified minimum to constituency parties, this article looks at the pattern of donations over the period 2001–05. It then analyses the impact of spending on the 2005 constituency campaigns, showing that for the Conservatives and Liberal Democrats substantial donations enhanced their vote-winning performances in seats where their candidates were challengers whereas for Labour substantial donations aided its performance in marginal seats that it was defending.

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Pre-hospital CPR and early REBOA in trauma patients - Results from the ABOTrauma Registry.

10.21203/rs.2.19571/v2 ◽

2020 ◽

Author(s):

Peter Hilbert-Carius ◽

David T McGreevy ◽

Fikri M. Abu-Zidan ◽

Tal M. Hörer

Keyword(s):

Survival Rate ◽

Hospital Admission ◽

Injury Severity ◽

Balloon Occlusion ◽

Trauma Patients ◽

Probability Of Survival ◽

Traumatic Cardiac Arrest ◽

Predicted Probability ◽

Using Data

Abstract Background: Severely injured trauma patients suffering from traumatic cardiac arrest (TCA) and requiring cardiopulmonary resuscitation (CPR) rarely survive. The role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) performed early after hospital admission in patients with TCA is not well-defined. As the use of REBOA increases, there is great interest in knowing if there is a survival benefit related to the early use of REBOA after TCA. Using data from the ABOTrauma Registry, we aimed to study the role of REBOA used early after hospital admission in trauma patients who required pre-hospital CPR. Methods: Retrospective and prospective data on the use of REBOA were collected from the ABOTrauma Registry from 11 centers in seven countries globally between 2014 and 2019. In all patients with pre-hospital TCA, the predicted probability of survival, calculated with the Revised Injury Severity Classification II (RISC II), was compared with the observed survival rate. Results: Of 213 patients in the ABOTrauma Registry, 26 patients (12.2%) who had received pre-hospital CPR were identified. The median (range) Injury Severity Score (ISS) was 45.5 (25-75). Fourteen patients (54%) had been admitted to hospital with ongoing CPR. Nine patients (35%) died within the first 24 hours, while seventeen patients (65%) survived post 24 hours. The survival rate to hospital discharge was 27% (n=7). The predicted mortality using the RISC II was 0.977 (25 out of 26). The observed mortality (19 out of 26) was significantly lower than the predicted mortality (p=0.049). Patients not responding to REBOA were more likely to die. Only one (10%) out of 10 non-responders survived. Survival rate in the 16 patients responding to REBOA was 37.5% (n=6). REBOA with a median (range) duration of 45 (8-70) minutes significantly increases blood pressure from median (range) 56.5 (0-147) to 90 (0-200) mmHg. Conclusions: Mortality in patients suffering from TCA and receiving REBOA early after hospital admission is significantly lower than predicted by the RISC II. REBOA may improve survival after TCA. The use of REBOA in these patients should be further investigated.

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Barriers and facilitators to the administration of prehospital tranexamic acid: a paramedic interview study using the theoretical domains framework

Emergency Medicine Journal ◽

10.1136/emermed-2020-210622 ◽

2021 ◽

pp. emermed-2020-210622

Author(s):

Laura Goodwin ◽

Helen Nicholson ◽

Maria Robinson ◽

Adam Bedson ◽

Sarah Black ◽

...

Keyword(s):

At Risk ◽

Tranexamic Acid ◽

Domain Knowledge ◽

Theoretical Domains Framework ◽

Evidence Base ◽

Barriers And Facilitators ◽

Trauma Patients ◽

Risk Of Bleeding ◽

Behavioural Theory ◽

The Uk

BackgroundTranexamic acid (TXA) is an antifibrinolytic drug used to prevent bleeding. It was introduced as an intervention for post-traumatic haemorrhage across emergency medical services (EMS) in the UK during 2012. However, despite strong evidence of effectiveness, prehospital TXA administration rates are low. This study used the theoretical domains framework (TDF) to identify barriers and facilitators to the administration of TXA to trauma patients by EMS providers (paramedics) in the UK.MethodsInterviews were completed with 18 UK paramedics from a single EMS provider organisation. A convenience sampling approach was used, and interviews continued until thematic saturation was reached. Semistructured telephone interviews explored paramedics’ experiences of administering TXA to trauma patients, including identifying whether or not patients were at risk of bleeding. Data were analysed inductively using thematic analysis (stage 1). Themes were mapped to the theoretical domains of the TDF to identify behavioural theory-derived barriers and facilitators to the administration of TXA to trauma patients (stage 2). Belief statements were identified and assessed for importance according to prevalence, discordance and evidence base (stage 3).ResultsBarriers and facilitators to paramedics’ administration of TXA to trauma patients were represented by 11 of the 14 domains of the TDF. Important barriers included a lack of knowledge and experience with TXA (Domain: Knowledge and Skills), confusion and restrictions relating to the guidelines for TXA administration (Domain: Social/professional role and identity), a lack of resources (Domain: Environmental context and resources) and difficulty in identifying patients at risk of bleeding (Domain: Memory, attention and decision processes).ConclusionsThis study presents a behavioural theory-based approach to identifying barriers and facilitators to the prehospital administration of TXA to trauma patients in the UK. It identifies multiple influencing factors that may serve as a basis for developing an intervention to increase prehospital administration of TXA.

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