Prehospital Tourniquet Use Should be a Trauma Team Activation Criterion.

Purpose Prehospital tourniquet application is not a standard trauma team activation (TTA) criterion recommended by the ACS COT. Tourniquet use has seen a resurgence recently with associated risks and benefits of more liberal usage. Our institution added tourniquet application as TTA criterion in January 2019. This study aimed to evaluate the effect this would have on patient care and overtriage. Methods A prospective analysis was conducted for all TTA associated with tourniquets placed during 2019. An overtriage analysis was conducted utilizing a modified Cribari method as described in Resources for the Optimal Care of the Injured Patient, comparing patients that met standard TTA criteria (TTA-S), to those who met criteria due to tourniquet placement (TTA-T). Results During the study, there were 46 TTA with tourniquets. Mean prehospital tourniquet time was 80 minutes. Median ISS was 10, 8 (17%) had an ISS >15. Urgent operative intervention was needed in 74%, with 23% and 21% requiring orthopedic and vascular procedures, respectively. Tourniquets were correctly placed in 80% and clinically appropriate in 57%. Of these subjects, 25 (54%) were TTA-S and 21 TTA-T. Overtriage analysis was performed. Overtriage for TTA-T was 33.3%. Overtriage among TTA-S was 4%. Conclusion Patients with prehospital tourniquets are frequently severely injured. The immediate presence of a trauma surgeon can have significant impacts in these cases. This is particularly important in a rural environment with long tourniquet times. Prehospital tourniquet application as a TTA criteria does not result in excessive overtriage.

Structural and Process Data on Radiological Imaging in the Treatment of Severely Injured Patients – Results of a Survey of Level I and II Trauma Centers in Germany

Purpose Systematic data collection regarding the integration of radiology as well as structural and process characteristics of radiological diagnostics of severely injured patients in Germany using a structured questionnaire. Materials and Methods Personal contact with all certified Level I and Level II Trauma Centers in Germany. Data on infrastructure, composition of the trauma room team, equipment, and data on the organization/performance of primary major trauma diagnostics were collected. Results With a participation rate of 46.9 % (n = 151) of all German trauma centers (N = 322), a solid database is available. There were highly significant differences in the structural characteristics incl. CT equipment between the level I and II centers: In 63.8 % of the level II centers, the CT unit was located more than 50 m away from the trauma room (34.2 % in the level I centers). A radiologist was part of the trauma room team in 59.5 % of level II centers (level I 88.1 %). Additionally, highly significant differences were found comparing 24-h provision of other radiologic examinations and interventions, such as MRI (level II 44.9 %, level I 92.8 %) and angiography (level II 69.2 %, level I 97.1 %). Conclusion Heterogeneous structural and process characteristics of the diagnosis of severely injured patients in Germany were revealed, with highly significant differences between level I and level II centers. Key Points: Citation Format

Which injured patients with moderate fibrinogen deficit need fibrinogen supplementation?

Background In severely injured patients, fibrinogen supplementation is recommended when fibrinogenemia is < 1.5 g L−1, but some teams have suggested to use higher thresholds (fibrinogenemia < 2.0 g L−1 or FIBTEM clot amplitude at 5 min (A5) values < 11 mm). The goal of this study was to specify in patients with a moderate fibrinogen deficit (MFD) whether some admission characteristics would be associated with fibrinogen administration at 24 h. Methods Prospective analysis of retrospectively collected data from a trauma registry (01/2011–12/2019). MFD-C was defined by a fibrinogenemia 1.51–1.99 g L−1 or the corresponding FIBTEM-A5 values (MFD-A5) that were determined from linear regression and ROC curve analysis. Administration of fibrinogen were described according to the following admission parameters: shock index (SI) > 1, hemoglobin level < 110 g L−1 (HemoCue®), and base deficit > 5 mEq L−1. Data are expressed as count (%), median [IQR]. Results 1076 patients were included in the study and 266 (27%) had MFD-C, among them, 122/266 (46%) received fibrinogen. Patients with MFD-C who received fibrinogen were more severely injured (ISS: 27 [19–36] vs. 24 [17–29]) and had more impaired vital signs (base deficit: 5.4 [3.6–7.8] vs. 3.8 [2.0–6.0]). Linear regression analysis found a positive correlation between fibrinogen level and FIBTEM-A5 (r: 0.805). For a fibrinogen level < 1.5 g L−1 and < 2.0 g L−1, FIBTEM-A5 thresholds were 6 mm (sensitivity 85%, specificity 83%, AUC: 0.934) and 9 mm (sensitivity 84%, specificity 69%, AUC: 0.874), respectively. MFD-A5 values (185 (27%) patients) were defined as a FIBTEM-A5 between 7 and 9 mm. More than 50% of MFD-C patients presenting a SI > 1, a hemoglobin level < 110 g L−1, or a base deficit > 5.0 mEq L−1 received fibrinogen. The relative risk [95% CI] for fibrinogen administration (SI > 1) were 1.39 [1.06–1.82] for MFD-C, and 2.17 [1.48–3.19] for MFD-A5. Results were not modified after adjustment on the ISS. Conclusions We have shown in this study an association between shock parameters and fibrinogen administration. Further studies are needed to determine how these parameters may be used to guide fibrinogen administration in trauma patients with MFD.

Influence of anaemia in severely injured patients on mortality, transfusion and length of stay: An analysis of the TraumaRegister DGU®

Purpose Anaemia is one of the leading causes of death among severely injured patients. Anaemia is known to increase the risk of death and prolong the length of hospital stay in various surgical groups. The main objective of this study is to analyse the anaemia rate on admission to the emergency department and the impact of anaemia on in-hospital mortality. Methods Data from the TraumaRegister DGU® (TR-DGU) between 2015 and 2019 was analysed. Inclusion criteria were age >= 16 years and worst Abbreviated Injury Scale (AIS) score ≥ 3. Patients were divided into three anaemia subgroups: no or mild anaemia (NA), moderate anaemia (MA) and severe anaemia (SA). Pre-hospital data, patient characteristics, treatment in the ER, outcomes, and differences between trauma centres were analysed. Results Of 67,595 patients analysed, 94.9% (n=64,153) exhibited no or mild anaemia (Hb ≥ 9 g/dl), 3.7% (n=2,478) displayed moderate anaemia (Hb 7–8 g/dl) and 1.4% (n=964) presented with severe anaemia (Hb < 7 g/dl). Haemoglobin (Hb) values ranged from 3 g/dl to 18 g/dl with a mean Hb value of 12.7 g/dl. In surviving patients, anaemia was associated with prolonged length of stay (LOS). Multivariate logistic regression analyses revealed moderate (p<0.001 OR 1.88 (1.66-2.13)) and severe anaemia (p<0.001 OR 4.21 (3.46-5.12)) to be an independent predictor for mortality. Further significant predictors are ISS score per point (OR 1.0), age 70-79 (OR 4.8), age >80 (OR 12.0), severe pre-existing conditions (ASA 3/4) (OR 2.26), severe head injury (AIS 5/6) (OR 4.8), penetrating trauma (OR 1.8), unconsciousness (OR 4.8), shock (OR 2.2) and prehospital intubation (OR 1.6). Conclusion The majority of severely injured patients are admitted without anaemia to the ER. Injury-associated moderate and severe anaemia is an independent predictor of mortality in severely injured patients.

Location of Injury and Other Factors Associated With Increased Survival Among Severely Injured Geriatric Trauma Patients

Background Patients with a Trauma Injury Severity Score (TRISS) < .5 are termed “unexpected survivors.” There is scarce information published on this subset of geriatric patients whose survival is an anomaly. Methods This is a retrospective case-control study examining all geriatric patients (age ≥65) not expected to survive (TRISS<.5) in the Pennsylvania Trauma Outcome Study (PTOS) database from 2013 to 2017. Primary outcome was survival to discharge. We selected 10 clinically important variables for logistic regression analysis as possible factors that may improve survival. Results 1336 patients were included, 395 (29.6%) were unexpected survivors. Factors that improved survival odds are the following: Place of injury: street/highway (AOR:0.51; 95% CI: .36-.73, P < .001) and residential institution (AOR:0.46; 95% CI: .21-.98, P = .043); and presence of Benzodiazepines (AOR:0.49; 95% CI: .31-.77, P = .002) or ethanol (AOR:0.57; 95% CI: .34-.97, P = .040). Factors that decreased survival odds are the following: Hypotension (AOR: 8.59; 95% CI: 4.33-17.01, P < .001) and hypothermia (AOR: 1.58; 95% CI: 1.10-2.28, P = .014). Gender, race/ethnicity, blood transfusion in first 24 hours, shift of presentation to Emergency Department, place of injury (farm, industrial, recreational, or public building), use of Tetrahydrocannabinol, amphetamines or opioids, and level of trauma activation did not impact survival. Discussion Location of injury (street/highway and residential institution) and ethanol or benzodiazepine use led to a significant increased survival in severely injured geriatric patients. Hypotension and hypothermia led to decreased survival. Future studies should determine possible reasons these factors lead to survival (and identify additional factors) to focus efforts in these areas to improve outcomes in geriatric trauma.

Combined disruption of the thoracic spine and costal arch fracture: An indicator of a severe chest trauma

Background Blunt high-energy trauma increase the risk of associated thoracic and accompanying abdominal organ injuries in chest trauma. A higher overall injury severity has been shown for sternovertebral injuries caused by a flexion-compression mechanism. Literature for a hyperextension-distraction mechanism equivalent to a costal arch fracture combined with a thoracic spinal fracture is sparse. Therefore, we want to show the clinical significance of this entity. Methods A retrospective analysis of our level-one trauma center collective of severely injured patients was performed. Patients from 2013 to 2019 that involved an Injury Severity Score (ISS) ≥16 were screened for the combined thoracovertebral injury entity and analyzed concerning its accident mechanism, the injury spectrum, and the clinical course. Results The thoracovertebral injury entity is rare. Three male patients (50–65 years old) with ISS of 57, 41, and 20 could be observed from over 1000 severely injured. All patients suffered from high-energy trauma and from tearing of the thoracic vertebrae regions 7–9. The costal arch was torn in the anterior area. All cases showed a posterolateral serial rib fracture, a traumatic intercostal pulmonary hernia, and an avulsion of the diaphragm. Two patients sustained further life-threatening injuries, such as severely bleeding avulsion to the azygos vein and a rupture of the spleen. The physicians performed exploratory thoracotomy, closure of the pulmonary hernia, re-fixation of the diaphragm and angle-stable plate osteosynthesis of the fractured ribs, including the costal arch. The spine was fixed dorsally using a screw-rod system. The patients were discharged home with independent mobility and without neurological damage. Conclusions This thoracovertebral injury entity is associated with high overall injury severity and life-threatening thoracoabdominal injuries. Injuries to the costal arch can act as an indicator of severe trauma. They should be detected thorough clinical examination and assessment of the trauma CT in the soft tissue window.