The volume-outcome relationship among severely injured patients admitted to English major trauma centres: a registry study

Abstract Introduction: The plain film chest x-ray in supine position (CXR) during the initial management of severely injured patients has almost lost its clinical relevance, since it has been challenged by extended focused assessment with sonography in trauma (eFAST) in early trauma management, due to its superiority in detecting a pneumo-/hematothorax. One of the last diagnostic fields in such setting of CXR is the mediastinal vascular injury. These injuries are rare yet life-threatening events. The most easily accessible diagnostic tool to identify these patients would be CXR as it is still one of the standard diagnostic tools in the early assessment of severely injured patients with significant thoracic trauma (Abbreviated Injury Scale, AIS ≥3). This study evaluates the role of early CXR in the Trauma Resuscitation Unit (TRU) in the last diagnostic field where eFAST cannot provide an answer: detecting mediastinal vascular injury in severely injured patients.Method: This retrospective, observational, single-centre study included all primary blunt trauma patients of a 24 months time period, that had been admitted to the TRU. Mediastinal/chest (M/C) ratio measurements were taken from CXRs at three defined levels of the mediastinum. The accuracy of the CXR findings were compared to whole-body computed tomography scans (WBCT) and therapeutic consequences were observed. Additionally a 15 years (2005–2019) time period out of the TraumaRegister DGU® was evaluated regarding usage of eFAST, CXR und WBCT in Level-1, -2, and − 3 Trauma Centres in Germany.Results: A total of 267 patients showed a significant blunt thoracic trauma (27 with mediastinal vascular injury (VThx)). The initial CXR in a supine position was unreliable for detecting mediastinal vascular injury. The sensitivity and specificity at different thresholds of maximum M/C ratio (2.0–3.0) were not clinically acceptable. The aortic contour and haemato- and pneumothorax were not reliably detected in the initial CXRs. No significant differences in the cardiac silhouette were observed between patients with or without mediastinal vascular injury (mean cardiac width, 136.5 mm, p = 0.44). No therapeutic consequences were drawn after CXR in the study period. The data from the TR-DGU (N = 251,095) showed a continuous reduction of CXR from 75% (2005) to 25% (2019), while WBCT raised from 35% to a steady level of about 80%. This development was seen in all trauma hospitals almost simultaneously.Conclusion: In present guidelines, CXR remains an integral diagnostic element during early TRU management, although several prior publications show the superior role of eFAST. Our data support that in most cases, CXR is time consuming and provides no benefit during initial management of severely injured patients and might delay the use of WBCT. The trauma centres in Germany have already significantly reduced the usage of CXR in the TRU. We therefore recommend to revise current guidelines and emphasise eFAST and rapid diagnostic through WBCT if rapidly available.

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Undertriage of the elderly major trauma patient continues in major trauma centre care: a retrospective cohort review

Emergency Medicine Journal ◽

10.1136/emermed-2019-208541 ◽

2020 ◽

pp. emermed-2019-208541

Author(s):

Antonia C Hoyle ◽

Leela C Biant ◽

Mike Young

Keyword(s):

Older Patients ◽

Major Trauma ◽

Trauma Team ◽

Trauma Centre ◽

Trauma Patients ◽

Severely Injured ◽

Severely Injured Patients ◽

Major Trauma Centre ◽

Trauma Triage ◽

Injured Patients

BackgroundMajor trauma (Injury Severity Score (ISS) ≥16) in older people is increasing, but concerns persist that major trauma is not always recognised in older patients on triage. This study compared undertriage of older and younger adult major trauma patients in the major trauma centre (MTC) setting to investigate this concern.MethodsA retrospective review of Trauma Audit and Research Network data was conducted for three MTCs in the UK for 3 months in 2014. Age, ISS, injury mechanism and injured areas were examined for all severely injured patients (ISS ≥16) and appropriate major trauma triage rates measured via the surrogate markers of trauma team activation and the presence of a consultant first attender, as per standards for major trauma care set by National Confidential Enquiry into Patient Outcomes and Deaths, Royal College of Surgeons of England and the British Orthopaedic Association. Trends in older (age ≥65) and younger (ages 18–64) adult major trauma presentation, triage and reception were reviewed.ResultsOf 153 severely injured patients, 46 were aged ≥65. Older patients were significantly less likely to receive the attention of a consultant first attender or trauma team. Similar trends were also seen on subgroup analysis by mechanism of injury or number of injured body areas. Older major trauma patients exhibit a higher mortality, despite a lower median ISS (older patient ISS=20 (IQR 16–25), younger patient ISS=25 (IQR 18–29)).ConclusionOlder major trauma patients are at greater risk of undertriage, even in the MTC environment. Existing hospital trauma triage practices should be further investigated to explain and reduce undertriage of elderly trauma patients.

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Accuracy Enhancement of Early Triage for Severely Injured Patients in Emergency Medical Dispatch through Machine Learning Based Text Analysis (Preprint)

10.2196/preprints.30210 ◽

2021 ◽

Author(s):

Kuan-Chen Chin ◽

Yu-Chia Cheng ◽

Jen-Tang Sun ◽

Chih-Yen Ou ◽

Chun-Hua Hu ◽

...

Keyword(s):

Machine Learning ◽

Predictive Value ◽

Major Trauma ◽

Learning Model ◽

Severely Injured ◽

Road Accidents ◽

Severely Injured Patients ◽

Emergency Medical ◽

Machine Learning Model ◽

Injured Patients

BACKGROUND Early recognition of severely injured patients in prehospital settings is of paramount importance for timely treatment and patient transport. The accuracy of dispatching has seldom been addressed in previous studies. OBJECTIVE In this study, we aimed to build a machine learning-based model through text mining of emergency calls for automated identification of severely injured patients in road accidents. METHODS Audio recordings of road accidents in Taipei City in 2018 were retrieved and randomly sampled. Data on transferring calls or non-Mandarin speech were excluded. All the included cases were evaluated by both humans (six dispatchers) and a machine learning model (prehospital activated major trauma (PAMT) model) to predict the major trauma cases identified by emergency medical technicians at the scene. The PAMT model was developed using frequency–inverse document frequency (TF-IDF), rule-based classification, and Bernoulli Naïve Bayes (BNB) classifier, and bootstrapping was applied to evaluate the robustness. The tests of prediction, including sensitivity (SENS), specificity (SPEC), positive predictive value (PPV), negative predictive value (NPV), and accuracy (ACC), for dispatchers and the PAMT model were performed, and the results were compared in terms of the overall performance and among different certainty levels. RESULTS The means for dispatchers vs. the PAMT model were SENS 63.1% vs. 68.0%, SPEC 85.0% vs. 78.0%, PPV 71.7% vs. 60.6%, NPV 80.3% vs. 85.8%, and ACC 76.8% vs. 75.0%, respectively. The mean ACC of dispatchers vs. the PAMT model in the cases from certainty level 0 (the lowest certainty) to 6 (the highest certainty) were 66.7% vs. 83.3%, 64.3% vs. 70.4%, 68.2% vs. 72.7%, 76.4% vs. 91.7%, 56.9% vs. 58.3%, 79.8% vs. 64.3%, and 87.1% vs. 81.3%, respectively. The overall performances of dispatchers and the PAMT model were similar, but the PAMT model had higher accuracy when the dispatchers were less certain of their judgments. CONCLUSIONS The results of our study suggest that the machine learning model is not superior to dispatchers in identifying road accident calls with severe trauma cases; however, the model can assist dispatchers when they lack confidence in the judgment of the calls.

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Timeliness of multi-detector computed tomography (MDCT) reports of the severely injured patients (SIP) in a major trauma centre

Clinical Radiology ◽

10.1016/j.crad.2017.06.088 ◽

2017 ◽

Vol 72 ◽

pp. S11

Author(s):

Nawaraj Subedi ◽

Shakir Syed ◽

Syed Ali ◽

Chooi Oh ◽

Vinay Parmar ◽

...

Keyword(s):

Computed Tomography ◽

Major Trauma ◽

Trauma Centre ◽

Severely Injured ◽

Severely Injured Patients ◽

Major Trauma Centre ◽

Injured Patients ◽

Multi Detector Computed Tomography

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The evolution of trauma care in the Netherlands over 20 years

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-019-01273-4 ◽

2019 ◽

Vol 46 (2) ◽

pp. 329-335 ◽

Cited By ~ 1

Author(s):

Falco Hietbrink ◽

Roderick M. Houwert ◽

Karlijn J. P. van Wessem ◽

Rogier K. J. Simmermacher ◽

Geertje A. M. Govaert ◽

...

Keyword(s):

The Netherlands ◽

Trauma Care ◽

Trauma System ◽

Trauma Surgeon ◽

Severely Injured ◽

Severely Injured Patients ◽

The Past ◽

Level 1 ◽

Trauma Surgeons ◽

Injured Patients

Abstract Introduction In 1999 an inclusive trauma system was initiated in the Netherlands and a nationwide trauma registry, including all admitted trauma patients to every hospital, was started. The Dutch trauma system is run by trauma surgeons who treat both the truncal (visceral) and extremity injuries (fractures). Materials and Methods In this comprehensive review based on previous published studies, data over the past 20 years from the central region of the Netherlands (Utrecht) was evaluated. Results It is demonstrated that the initiation of the trauma systems and the governance by the trauma surgeons led to a region-wide mortality reduction of 50% and a mortality reduction for the most severely injured of 75% in the level 1 trauma centre. Furthermore, major improvements were found in terms of efficiency, demonstrating the quality of the current system and its constructs such as the type of surgeon. Due to the major reduction in mortality over the past few years, the emphasis of trauma care evaluation shifts towards functional outcome of severely injured patients. For the upcoming years, centralisation of severely injured patients should also aim at the balance between skills in primary resuscitation and surgical stabilization versus longitudinal surgical involvement. Conclusion Further centralisation to a limited number of level 1 trauma centres in the Netherlands is necessary to consolidate experience and knowledge for the trauma surgeon. The future trauma surgeon, as specialist for injured patients, should be able to provide the vast majority of trauma care in this system. For the remaining part, intramural, regional and national collaboration is essential

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The impact of regionalized trauma care on the distribution of severely injured patients in the Netherlands

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-021-01615-1 ◽

2021 ◽

Author(s):

Suzan Dijkink ◽

Erik W. van Zwet ◽

Pieta Krijnen ◽

Luke P. H. Leenen ◽

Frank W. Bloemers ◽

...

Keyword(s):

The Netherlands ◽

Trauma Care ◽

Trauma System ◽

Future Research ◽

Severely Injured ◽

Trauma Centers ◽

Severely Injured Patients ◽

The Right ◽

Injured Patients ◽

The Impact

Abstract Background Twenty years ago, an inclusive trauma system was implemented in the Netherlands. The goal of this study was to evaluate the impact of structured trauma care on the concentration of severely injured patients over time. Methods All severely injured patients (Injury Severity Score [ISS] ≥ 16) documented in the Dutch Trauma Registry (DTR) in the calendar period 2008–2018 were included for analysis. We compared severely injured patients, with and without severe neurotrauma, directly brought to trauma centers (TC) and non-trauma centers (NTC). The proportion of patients being directly transported to a trauma center was determined, as was the total Abbreviated Injury Score (AIS), and ISS. Results The documented number of severely injured patients increased from 2350 in 2008 to 4694 in 2018. During this period, on average, 70% of these patients were directly admitted to a TC (range 63–74%). Patients without severe neurotrauma had a lower chance of being brought to a TC compared to those with severe neurotrauma. Patients directly presented to a TC were more severely injured, reflected by a higher total AIS and ISS, than those directly transported to a NTC. Conclusion Since the introduction of a well-organized trauma system in the Netherlands, trauma care has become progressively centralized, with more severely injured patients being directly presented to a TC. However, still 30% of these patients is initially brought to a NTC. Future research should focus on improving pre-hospital triage to facilitate swift transfer of the right patient to the right hospital.

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The (Absence of a) Role of Venous Duplex Scan in the Diagnosis of Pulmonary Embolism after Severe Trauma

The American Surgeon ◽

10.1177/000313480607200102 ◽

2006 ◽

Vol 72 (1) ◽

pp. 7-10

Author(s):

George C. Velmahos ◽

Carlos V. Brown ◽

Demetrios Demetriades

Keyword(s):

Intensive Care Unit ◽

Pulmonary Embolism ◽

Intensive Care ◽

Sensitivity And Specificity ◽

Clinical Suspicion ◽

Severely Injured ◽

Duplex Scan ◽

Severely Injured Patients ◽

High Level ◽

Injured Patients

Venous duplex scan (VDS) has been used for interim bedside diagnosis of pulmonary embolism (PE) in severely injured patients deemed to be at risk if transported out of the intensive care unit. In combination with the level of clinical suspicion for PE, VDS helps select patients for temporary treatment until definitive diagnosis is made. We evaluate the sensitivity and specificity of VDS in critically injured patients with a high level of clinical suspicion for PE. We performed a prospective observational cohort study at the surgical intensive care unit of an academic level 1 trauma center. Patients were 59 critically injured patients suspected to have PE over a 30-month period. The level of clinical suspicion for PE was classified as low or high according to preset criteria. Interventions were VDS and a PE outcome test (conventional or computed tomographic pulmonary angiography). The sensitivity and specificity of VDS to detect PE in all patients and in patients with high level of clinical suspicion was calculated against the results of the outcome test. PE was diagnosed in 21 patients (35.5%). The sensitivity and specificity of VDS was 33 per cent and 89 per cent, respectively. Among the 28 patients who had a high level of clinical suspicion for PE, the sensitivity of VDS was 23 per cent and the specificity 93 per cent. In this latter population, 1 of the 4 (25%) positive VDS was of a patient without PE and 10 of the 24 (42%) negative VDS were of patients who had PE. VDS does not accurately predict PE in severely injured patients, even in the presence of a high level of clinical suspicion.

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Early Versus Late Spine Surgery in Severely Injured Patients—Which Is the Appropriate Timing for Surgery?

Global Spine Journal ◽

10.1177/2192568221989292 ◽

2021 ◽

pp. 219256822198929

Author(s):

Arnaldo Sousa ◽

Cláudia Rodrigues ◽

Luís Barros ◽

Pedro Serrano ◽

Ricardo Rodrigues-Pinto

Keyword(s):

Mortality Rate ◽

Spinal Fractures ◽

Simplified Acute Physiology Score ◽

Neurological Injury ◽

Spine Fractures ◽

Severely Injured ◽

Intubation Time ◽

Severely Injured Patients ◽

Level Of Evidence ◽

Injured Patients

Study Design: Retrospective cohort study conducted at tertiary spinal trauma referral center. Objective: We aimed to determine if early definitive management of spine fractures in patients admitted to the Intensive Care Unit (ICU) shortens the intubation time and the length of stay (LOS), without increasing mortality. Methods: The medical records of all patients admitted to the ICU and submitted to surgical stabilization of spine fractures were reviewed over a 10-year period. Time to surgery, number of fractured vertebrae, degree of neurological injury, Simplified Acute Physiology Score (SAPS II), ASA score and associated trauma were evaluated. Surgeries performed on the first 72 hours after trauma were defined as “early surgeries.” Intubation time, LOS on ICU, overall LOS and mortality rate were compared between patients operated early and late. Results: Fifty patients were included, 21 with cervical fractures, 23 thoracic and 6 lumbar. Baseline characteristics did not differ between patients in both groups. Patients with early surgical stabilization had significantly shorter intubation time, ICU-LOS and overall LOS, with no differences in terms of mortality rate. After multivariate adjustments overall LOS was significantly shorter in patients operated earlier. Conclusions: Early spinal stabilization (<72 hours) of severely injured patients is beneficial and shortens the intubation time, ICU-LOS and overall LOS, with no differences in terms of mortality rate. Although some patients may require a delay in treatment due to necessary medical stabilization, every reasonable effort should be made to treat patients with unstable spinal fractures as early as possible. Level of Evidence of the Study: Level III.

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