Preparation of hospitals for mass casualty incidents in Bavaria, Germany: care capacities for penetrating injuries and explosions in TerrorMASCALs

Abstract Background In a terror attack mass casualty incident (TerrorMASCAL), compared to a “normal” MASCAL, there is a dynamic course that can extend over several hours. The injury patterns are penetrating and perforating injuries. This article addresses the provision of material and personnel for the care of special injuries of severely injured persons that may occur in the context of a TerrorMASCAL. Methods To answer the research question about the preparation of hospitals for the care of severely injured persons in a TerrorMASCAL, a survey of trauma surgery departments in Bavaria (Germany) was conducted using a questionnaire, which was prepared in three defined steps based on an expert consensus. The survey is divided into a general, neurosurgical, thoracic, vascular and trauma surgery section. In the specialized sections, the questions relate to the implementation of and material and personnel requirements for special interventions that are required, particularly for injury patterns following gunshot and explosion injuries, such as trepanation, thoracotomy and balloon occlusion of the aorta. Results In the general section, it was noted that only a few clinics have an automated system to notify off-duty staff. When evaluating the data from the neurosurgical section, the following could be established with regard to the performance of trepanation: the regional trauma centers do not perform trepanation but nevertheless have the required material and personnel available. A similar result was recorded for local trauma centers. In the thoracic surgery section, it could be determined that almost all trauma centers that do not perform thoracotomy have the required material available. This group of trauma centers also stated that they have staff who can perform thoracotomy independently. The retrograde endovascular aortic occlusion procedure is possible in 88% of supraregional, 64% of regional and 10% of local trauma centers. Pelvic clamps and external fixators are available at all trauma centers. Conclusion The results of the survey show potential for optimization both in the area of framework conditions and in the care of patients. Consistent and specific training measures, for example, could improve the nationwide performance of these special interventions. Likewise, it must be discussed whether the abovementioned special procedures should be reserved for higher-level trauma centers.

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AORTA Registry 7F vs 11-12 F access

Journal of Endovascular Resuscitation and Trauma Management ◽

10.26676/jevtm.v3i1.79 ◽

2019 ◽

Vol 3 (1) ◽

Cited By ~ 1

Author(s):

Reviewer Joseph DuBose ◽

Jonathan Morrison ◽

Megan Brenner ◽

Laura Moore ◽

John B Holcomb ◽

...

Keyword(s):

Ultrasound Guidance ◽

Balloon Occlusion ◽

Aortic Occlusion ◽

Severely Injured ◽

Distal Extremity ◽

Low Profile ◽

Transfusion Requirements ◽

Thrombotic Complications ◽

Device Use ◽

Endovascular Balloon Occlusion

ABSTRACT Introduction: The introduction of low profile devices designed for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) after trauma has the potential to change practice, outcomes and complication profiles related to this procedure. Methods: The AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry was utilized to identify REBOA patients from 16 centers -comparing presentation, intervention and outcome variables for those REBOA via traditional 11-12 access platforms and trauma-specific devices requiring only 7 F access. Results:From Nov 2013-Dec 2017, 242 patients with completed data were identified, constituting 124 7F and 118 11-12F uses. Demographics of presentation were not different between the two groups, except that the 7F patients had a higher mean ISS (39.2 34.1, p = 0.028). 7F device use was associated with a lower cut-down requirement for access (22.6% vs. 37.3%, p = 0.049) and increased ultrasound guidance utilization (29.0% 23.7%, p = 0.049). 7F device afforded earlier aortic occlusion in the course of resuscitation (median 25.0 mins vs. 30 mins, p = 0.010), and had lower median PRBC (10.0 vs. 15.5 units, p = 0.006) and FFP requirements (7.5 vs. 14.0 units, p = 0.005). 7F patients were more likely to survive 24 hrs (58.1% vs. 42.4%, p = 0.015) and less likely to suffer in-hospital mortality (57.3% vs. 75.4%, p = 0.003). Finally, 7F device use was associated with a 4X lower rate of distal extremity embolism (20.0% vs. 5.6%, p = 0.014;OR 95% CI 4.25 [1.25-14.45]) compared to 11-12F counterparts. Conclusion: The introduction of trauma specific 7F REBOA devices appears to have influenced REBOA practices, with earlier utilization in severely injured hypotensive patients via less invasive means that are associated with lower transfusion requirements fewer thrombotic complications and improved survival. Additional study is required to determine optimal REBOA utilization.

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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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Feasibility of REBOA—Resuscitative Endovascular Balloon Occlusion of the Aorta—in Trauma-Related Noncompressible Torso Hemorrhage at Two Metropolitan Trauma Centers

Ochsner Journal ◽

10.31486/toj.18.0025 ◽

2018 ◽

Vol 18 (3) ◽

pp. 201-203 ◽

Cited By ~ 1

Author(s):

Glenn Ryan ◽

Kate Swift ◽

Frances Williamson ◽

Elissa Scriven ◽

Olivia Zheng ◽

...

Keyword(s):

Balloon Occlusion ◽

Trauma Centers ◽

Endovascular Balloon Occlusion

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Future of Trauma Surgery: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

Trauma: Code Red ◽

10.1201/9781351105644-20 ◽

2018 ◽

pp. 233-246

Keyword(s):

Trauma Surgery ◽

Balloon Occlusion ◽

Endovascular Balloon Occlusion

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Hate to Burst Your Balloon: Successful REBOA Use Takes More Than a Course

Journal of Endovascular Resuscitation and Trauma Management ◽

10.26676/jevtm.v4i1.106 ◽

2020 ◽

Vol 4 (1) ◽

Author(s):

Christina Mae Theodorou ◽

Edgardo S Salcedo ◽

Joseph J DuBose ◽

Joseph M Galante

Keyword(s):

Trauma Surgery ◽

Skills Training ◽

Balloon Occlusion ◽

Implementation Challenges ◽

Surgical Skills Training ◽

Trauma Activation ◽

Activation Criteria ◽

Level 1 Trauma Center ◽

Endovascular Balloon Occlusion ◽

Operating Room Staff

Background: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is emerging as a viable intervention for hemorrhagic shock. Training surgeons to place the device is only part of the process. We hypothesize that implementation challenges extend beyond surgical skills training and initial REBOA use should not be expected to mirror published success.Methods:All REBOA placements from January 2016-February 2017 at a level 1 trauma center were reviewed for opportunities for improvement (OFI). From September 2016-February 2017 all patients meeting highest trauma activation criteria were reviewed against our REBOA algorithm to identify patients meeting criteria for REBOA placement but not undergoing the procedure.Results:REBOA was introduced at our institution in September 2015, with first placement in January 2016. Trauma surgery, Emergency Department, and Operating Room staff underwent training. Nine patients had REBOA placed with six survivors. One patient underwent unsuccessful REBOA attempt and died. Four patients had complications from REBOA. Eight additional patients met indications but did not undergo REBOA. Conclusion:Successful REBOA use requires more than teaching surgeons indications and techniques. For a successful REBOA program, systems factors must be addressed. Systems processes must ensure equipment and procedures are standardized and familiar to all involved. Complications should be expected.

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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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Delays in Transfer of Elderly Less-injured Trauma Patients Can Have Deadly Consequences

The American Surgeon ◽

10.1177/000313481408001130 ◽

2014 ◽

Vol 80 (11) ◽

pp. 1132-1135 ◽

Cited By ~ 4

Author(s):

Peter E. Fischer ◽

Paul D. Colavita ◽

Gregory P. Fleming ◽

Toan T. Huynh ◽

A. Britton Christmas ◽

...

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Trauma Patients ◽

Severely Injured ◽

Severely Injured Patients ◽

Local Trauma ◽

Level 1 ◽

Poor Outcomes ◽

Injured Patients ◽

Level 1 Trauma Center

Transfer of severely injured patients to regional trauma centers is often expedited; however, transfer of less-injured, older patients may not evoke the same urgency. We examined referring hospitals’ length of stay (LOS) and compared the subsequent outcomes in less-injured transfer patients (TP) with patients presenting directly (DP) to the trauma center. We reviewed the medical records of less-injured (Injury Severity Score [ISS] 9 or less), older (age older than 60 years) patients transferred to a regional Level 1 trauma center to determine the referring facility LOS, demographics, and injury information. Outcomes of the TP were then compared with similarly injured DP using local trauma registry data. In 2011, there were 1657 transfers; the referring facility LOS averaged greater than 3 hours. In the less-injured patients (ISS 9 or less), the average referring facility LOS was 3 hours 20 minutes compared with 2 hours 24 minutes in more severely injured patients (ISS 25 or greater, P < 0.05). The mortality was significantly lower in the DP patients (5.8% TP vs 2.6% DP, P = 0.035). Delays in transfer of less-injured, older trauma patients can result in poor outcomes including increased mortality. Geographic challenges do not allow for every patient to be transported directly to a trauma center. As a result, we propose further outreach efforts to identify potential causes for delay and to promote compliance with regional referral guidelines.

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Injury patterns of mass casualty incidents involving high-speed passenger ferries presenting to accident and emergency departments in Hong Kong: a retrospective review

Injury ◽

10.1016/j.injury.2019.12.001 ◽

2020 ◽

Vol 51 (2) ◽

pp. 252-259 ◽

Cited By ~ 1

Author(s):

Rex Pui Kin Lam ◽

Ronald Tat Ming Wong ◽

Eric Ho Yin Lau ◽

Kin Wa Wong ◽

Arthur Chi Kin Cheung ◽

...

Keyword(s):

Hong Kong ◽

Retrospective Review ◽

Emergency Departments ◽

High Speed ◽

Mass Casualty ◽

Mass Casualty Incidents ◽

Injury Patterns ◽

Accident And Emergency

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Vasopressor Use during Emergency Trauma Surgery

The American Surgeon ◽

10.1177/000313481408000518 ◽

2014 ◽

Vol 80 (5) ◽

pp. 472-478 ◽

Cited By ~ 5

Author(s):

Robert M. Van Haren ◽

Chad M. Thorson ◽

Evan J. Valle ◽

Gerardo A. Guarch ◽

Jassin M. Jouria ◽

...

Keyword(s):

Cardiac Arrest ◽

Mortality Rate ◽

Odds Ratio ◽

Injury Severity ◽

Trauma Surgery ◽

Vital Signs ◽

Severely Injured ◽

Severely Injured Patients ◽

Vasopressor Use ◽

Injured Patients

Most evidence suggests early vasopressor use is associated with death after trauma, but no previous study has focused on patients requiring emergency operative intervention (OR). We test the hypothesis that vasopressors are harmful in this population. Records from 746 patients requiring OR from July 2009 to March 2013 were retrospectively reviewed and stratified based on vasopressor use (epinephrine [EPI], phenylephrine, ephedrine, norepinephrine, dobutamine, vasopressin) or no vasopressor use. Vasopressors were administered to 225 patients (30%) during OR; 59 patients (8%) received multiple vasopressors. Patients who received vasopressors were older, more severely injured, had worse vital signs, and increased mortality rate (all P < 0.001). EPI was independently associated with mortality (odds ratio, 6.88; P = 0.001). If patients who received EPI were excluded, there was no difference in mortality between those who received vasopressors alone or in combination and those that did not (5 vs 6%, P = 0.523), although multiple markers of injury severity were worse. We conclude that vasopressor use is relatively common in the most severely injured patients requiring OR and is associated with mortality. EPI is most often used for cardiac arrest, whereas other vasopressors are used for their vasoconstrictive properties. This suggests that, except for EPI, vasopressors during OR are not independently associated with mortality.

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