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.

Changes in pediatric major trauma epidemiology, injury patterns, and outcome during COVID-19–associated lockdown

Introduction The COVID-19 pandemic and its associated preventive measures such as national and regional lockdowns have dramatically changed the epidemiology of pediatric admissions to the emergency department. Nevertheless, there are scant data on the epidemiology and injury patterns of major pediatric trauma injuries during these lockdown periods. Methods A single-center retrospective study of data obtained from a tertiary level 1 trauma hospital trauma registry. The data included demographics, injury mechanisms, injury severity and type, treatment, and resource utilization in children aged 0–18 years who required trauma team activation upon arrival. The analysis compares the data from the 5-week lockdown period from March to May 2020 in Jerusalem, Israel, to its parallel periods in 2018–2019. Results A total of 187 trauma visits that required trauma team activation (TTA) were analyzed: 48 visits during the lockdown period vs. 139 in 2018–2019, corresponding to a 40% drop in TTA. There was a significant decrease of 34% in MVA-related injuries ( p = 0.0001) but a significant increase of 14% in burns ( p = 0.01) and a 16% increase in bicycle-related injuries ( p = 0.001). No changes in ISS, injury patterns, admission rate, PICU utilization, or need for interventions were observed. Conclusion There was a significant decrease in the number of overall pediatric trauma visits during the 2020 lockdown, mainly in MVA-associated trauma, but an increase in burns and bicycle injuries. These findings can thus inform policy makers as to the need to formulate prevention awareness programs alerting the public to indoor hazards and the dangers of activities outside the home. Furthermore, it can inform hospital policy decision-making in future lockdowns. The fact that PICU admissions and the need for operating rooms stayed unchanged suggests that it is vital to maintain trauma team capabilities even during lockdowns.

Evaluation of a standardized instrument for post hoc analysis of trauma-team-activation-criteria in 75,613 injured patients an analysis of the TraumaRegister DGU®

Introduction To improve the quality of criteria for trauma-team-activation it is necessary to identify patients who benefited from the treatment by a trauma team. Therefore, we evaluated a post hoc criteria catalogue for trauma-team-activation which was developed in a consensus process by an expert group and published recently. The objective was to examine whether the catalogue can identify patients that died after admission to the hospital and therefore can benefit from a specialized trauma team mostly. Materials and methods The catalogue was applied to the data of 75,613 patients from the TraumaRegister DGU® between the 01/2007 and 12/2016 with a maximum abbreviated injury score (AIS) severity ≥ 2. The endpoint was hospital mortality, which was defined as death before discharge from acute care. Results The TraumaRegister DGU® dataset contains 18 of the 20 proposed criteria within the catalogue which identified 99.6% of the patients who were admitted to the trauma room following an accident and who died during their hospital stay. Moreover, our analysis showed that at least one criterion was fulfilled in 59,785 cases (79.1%). The average ISS in this group was 21.2 points (SD 9.9). None of the examined criteria applied to 15,828 cases (average ISS 8.6; SD 5). The number of consensus-based criteria correlated with the severity of injury and mortality. Of all deceased patients (8,451), only 31 (0.37%) could not be identified on the basis of the 18 examined criteria. Where only one criterion was fulfilled, mortality was 1.7%; with 2 or more criteria, mortality was at least 4.6%. Discussion The consensus-based criteria identified nearly all patients who died as a result of their injuries. If only one criterion was fulfilled, mortality was relatively low. However, it increased to almost 5% if two criteria were fulfilled. Further studies are necessary to analyse and examine the relative weighting of the various criteria. Summary Our instrument is capable to identify severely injured patients with increased in-hospital mortality and injury severity. However, a minimum of two criteria needs to be fulfilled. Based on these findings, we conclude that the criteria list is useful for post hoc analysis of the quality of field triage in patients with severe injury.

A Review of “Prehospital Hypotension as a Valid Indicator of Trauma Team Activation” (2000)

Prehospital hypotension has been utilized for decades as a surrogate marker of injury severity. Several studies have discussed the correlation between injury and hypotension both in the field as well as in the emergency department. Increases have been noted in injury severity score and mortality. Resource utilization is higher in this patient population. This study revisits our original work from 2000 and reviews the current literature regarding hypotension and injury severity. We also examine the role of prehospital hypotension as an indicator of trauma team activation and resource allocation. This review serves as a part of a Literary Festschrift in honor of Dr J David Richardson’s role as the Editor-in-Chief of The American Surgeon.

Undertriage Despite Use of Geriatric-Specific Trauma Team Activation Guidelines

Background Elderly trauma patients are at risk for undertriage, resulting in substantial morbidity and mortality. The objective of this study was to determine whether implementation of geriatric-specific trauma team activation (TTA) protocols appropriately identified severely-injured elderly patients. Methods This single-center retrospective study evaluated all severely injured (injury severity score [ISS] >15), geriatric (≥65 years) patients admitted to our Level 1 tertiary-care hospital between January 2014 and September 2017. Undertriage was defined as the lack of TTA despite presence of severe injuries. The primary outcome was all-cause in-hospital mortality; secondary outcomes were mortality within 48 hours of admission and urgent hemorrhage control. A multivariable logistic regression analysis was performed to identify predictors of appropriate triage in this study. Results Out of 1039 severely injured geriatric patients, 628 (61%) did not undergo TTA. Undertriaged patients were significantly older and had more comorbidities. In-hospital mortality was 5% and 31% in the undertriaged and appropriately triaged groups, respectively ( P < .0001). One percent of undertriaged patients needed urgent hemorrhage control, compared to 6% of the appropriately triaged group ( P < .0001). One percent of undertriaged patients died within 48 hours compared to 19% in the appropriately triaged group ( P < .0001). Predictors of appropriate triage include GCS, heart rate, systolic blood pressure, lactic acid, ISS, shock, and absence of dementia, stroke, or alcoholism. Discussion Geriatric-specific TTA guidelines continue to undertriage elderly trauma patients when using ISS as a metric to measure undertriage. However, undertriaged patients have much lower morbidity and mortality, suggesting the geriatric-specific TTA guidelines identify those patients at highest risk for poor outcomes.