Prehospital Tranexamic Acid for Severe Trauma.

BACKGROUND: Whether prehospital administration of tranexamic acid increases the likelihood of survival with a favorable functional outcome among patients with major trauma and suspected trauma-induced coagulopathy who are being treated in advanced trauma systems is uncertain. METHODS: We randomly assigned adults with major trauma who were at risk for trauma-induced coagulopathy to receive tranexamic acid (administered intravenously as a bolus dose of 1 g before hospital admission, followed by a 1-g infusion over a period of 8 hours after arrival at the hospital) or matched placebo. The primary outcome was survival with a favorable functional outcome at 6 months after injury, as assessed with the use of the Glasgow Outcome Scale-Extended (GOS-E). Levels on the GOS-E range from 1 (death) to 8 ("upper good recovery" [no injury-related problems]). We defined survival with a favorable functional outcome as a GOS-E level of 5 ("lower moderate disability") or higher. Secondary outcomes included death from any cause within 28 days and within 6 months after injury. RESULTS: A total of 1310 patients were recruited by 15 emergency medical services in Australia, New Zealand, and Germany. Of these patients, 661 were assigned to receive tranexamic acid, and 646 were assigned to receive placebo; the trial-group assignment was unknown for 3 patients. Survival with a favorable functional outcome at 6 months occurred in 307 of 572 patients (53.7%) in the tranexamic acid group and in 299 of 559 (53.5%) in the placebo group (risk ratio, 1.00; 95% confidence interval [CI], 0.90 to 1.12; P = 0.95). At 28 days after injury, 113 of 653 patients (17.3%) in the tranexamic acid group and 139 of 637 (21.8%) in the placebo group had died (risk ratio, 0.79; 95% CI, 0.63 to 0.99). By 6 months, 123 of 648 patients (19.0%) in the tranexamic acid group and 144 of 629 (22.9%) in the placebo group had died (risk ratio, 0.83; 95% CI, 0.67 to 1.03). The number of serious adverse events, including vascular occlusive events, did not differ meaningfully between the groups. CONCLUSIONS: Among adults with major trauma and suspected trauma-induced coagulopathy who were being treated in advanced trauma systems, prehospital administration of tranexamic acid followed by an infusion over 8 hours did not result in a greater number of patients surviving with a favorable functional outcome at 6 months than placebo. (Funded by the Australian National Health and Medical Research Council and others; PATCH-Trauma ClinicalTrials.gov number, NCT02187120.).

Blood lactate after pre-hospital blood transfusion for major trauma by helicopter emergency medical services.

BACKGROUND AND OBJECTIVES: The appropriate use of blood components is essential for ethical use of a precious, donated product. The aim of this study was to report in-hospital red blood cell (RBC) transfusion after pre-hospital transfusion by helicopter emergency medical service paramedics. A secondary aim was to assess the potential for venous blood lactate to predict ongoing transfusion. MATERIALS AND METHODS: All patients who received RBC in air ambulance were transported to a single adult major trauma centre, had venous blood lactate measured on arrival and did not die before ability to transfuse RBC were included. The association of venous blood lactate with ongoing RBC transfusion was assessed using multi-variable logistic regression analysis and reported using adjusted odds ratios (aOR). The discriminative ability of venous blood lactate was assessed using area under receiver operating characteristics curve (AUROC). RESULTS: From 1 January 2016 to 15 May 2019, there were 165 eligible patients, and 128 patients were included. In-hospital transfusion occurred in 97 (75.8%) of patients. Blood lactate was associated with ongoing RBC transfusion (aOR: 2.00; 95% confidence interval [CI]: 1.36-2.94). Blood lactate provided acceptable discriminative ability for ongoing transfusion (AUROC: 0.78; 95% CI: 0.70-0.86). CONCLUSIONS: After excluding patients with early deaths, a quarter of those who had prehospital RBC transfusion had no further transfusion in hospital. Venous blood lactate appears to provide value in identifying such patients. Lactate levels after pre-hospital transfusion could be used as a biomarker for transfusion requirement after trauma.

Patient blood management guideline for adults with critical bleeding.

INTRODUCTION: The management of patients with critical bleeding requires a multidisciplinary approach to achieve haemostasis, optimise physiology, and guide blood component use. The 2011 Patient blood management guidelines: module 1 - critical bleeding/massive transfusion were updated and published. Systematic reviews were conducted for pre-specified research questions, and recommendations were based on meta-analyses of included studies. MAIN RECOMMENDATIONS: The critical bleeding/massive transfusion guideline includes seven recommendations and 11 good practice statements addressing: major haemorrhage protocols (MHPs) facilitating a multidisciplinary approach to haemorrhage control, correction of coagulopathy and normalisation of physiological derangement; measurement of physiological, biochemical and metabolic parameters in critical bleeding/massive transfusion; the optimal ratio of red blood cells to other blood components; the use of tranexamic acid; viscoelastic haemostatic assays; and cell salvage. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINE: The new guideline recommends MHPs be established as standard of care in all institutions managing patients with critical bleeding. In addition to routine physiological markers, the new guideline recommends temperature, biochemistry and coagulation profiles be measured early and frequently, providing parameters that define critical derangements. Ratio-based MHPs should include no fewer than four units of fresh frozen plasma and one adult unit of platelets for every eight units of red blood cells. In the setting of trauma and obstetric haemorrhage, administration of tranexamic acid within three hours of bleeding onset is recommended. The use of recombinant activated factor VII (rFVIIa) is not recommended. There was insufficient evidence to make recommendations on the use of viscoelastic haemostatic assays or cell salvage as part of MHPs.

Ultrasound for acute pyelonephritis: a systematic review and meta-analysis.

BACKGROUND: There is little consensus regarding the indications and utility of urinary tract imaging and type of imaging to perform in patients presenting with acute pyelonephritis (APN). AIMS: The aims of this systematic review were to, among patients with APN, (i) identify the proportion of patients investigated with ultrasound (US), (ii) identify the proportion of abnormal US and (iii) identify the proportion of patients with a change in management resulting from abnormal US. METHODS: A comprehensive search covered two electronic databases (Medline and EMBASE), with selection of studies performed independently by two investigators. Inclusion criteria were English language APN diagnosis and quantification of patients assessed with US or abnormal US results. Quality appraisal used the Newcastle-Ottawa instrument. RESULTS: There were 35 studies included. The proportion of patients assessed with US was reported in 16 manuscripts and ranged from 20% to 94%, with significant heterogeneity and publication bias. The proportion of abnormal US was reported in 31 manuscripts and ranged from 7% to 79%. The proportion of abnormal US leading to change in management was reported in five studies and ranged from 7% to 59%. There was marked heterogeneity among studies included in all three subgroups. CONCLUSIONS: Patients with APN are commonly investigated with US, but only a small proportion have abnormalities and appear to be associated with changes in clinical management. The use of routine US for APN is therefore questioned. The identification of clinical variables for appropriate selection of patients to investigate with US requires further research.

The GCS-Pupils (GCS-P) score to assess outcomes after traumatic brain injury: a retrospective study.

INTRODUCTION: The Glasgow Coma Scale (GCS) and pupil response to light are commonly used to assess brain injury severity and predict outcomes. The aim of this study was to investigate whether the GCS combined with pupil response (GCS-P), compared to the GCS alone, could be a better predictor of hospital mortality for patients with traumatic brain injury (TBI). METHODS: A retrospective cohort study was undertaken at an adult level one trauma centre including patients with isolated TBI of Abbreviated Injury Scale above three. The GCS and pupil response were combined to an arithmetic score (GCS score (range 3-15) minus the number of nonreacting pupils (0, 1, or 2)), or by treating each factor as separate categorical variables. The association of in-hospital mortality with GCS-P as a categorical variable was evaluated using Nagelkerke's R2 and compared using areas under the receiver operating characteristic (AUROC) curve. RESULTS: There were 392 patients included over the study period of 1 July 2014 and 30 September 2017, with an overall mortality rate of 15.2%. Mortality was highest at GCS-P of 1 (79%), with lowest mortality at a GCS-P 15 (1.6%). Nagelkerke's R2 was 0.427 for GCS alone and 0.486 for GCS-P. The AUROC for GCS-P to predict mortality was 0.87 (95%CI: 0.82-0.72), higher than for GCS alone (0.85; 95%CI: 0.80-0.90; p < .001). DISCUSSION: GCS-P provided a better predictor of mortality compared to the GCS. As both the GCS and pupillary response are routinely recorded on all patients, combination of these pieces of information into a single score can further simplify assessment of patients with TBI, with some improvement in performance.

Pharmacists in Trauma: a randomised controlled trial of emergency medicine pharmacists in trauma response teams.

BACKGROUND: Analgesia is an important component for patient well-being, but commonly delayed during trauma resuscitation. The Pharmacists in Trauma trial assessed the effects of integrating pharmacists into trauma response teams to improve analgesia delivery and medication management. METHODS: This unblinded randomised trial compared emergency medicine (EM) pharmacist involvement in trauma callouts versus standard care at an Australian level 1 trauma centre. Randomisation was performed via an online single sequence randomisation service. Eligible patients included those managed with a trauma callout during working hours of an EM pharmacist. Pharmacists were able to prescribe medications using a Partnered Pharmacist Medication Charting model. The primary outcome was the proportion of patients who had first dose analgesia within 30 min compared using the χ2 test. RESULTS: From 15 July 2021 until 31 January 2022, there were 119 patients randomised with 37 patients excluded as no analgesia was required. There were 82 patients included for analysis, 39 in the control arm and 43 in the intervention arm. The primary outcome was achieved in 25 (64.1%) patients in the control arm and 36 (83.7%) patients in the pharmacist arm (relative risk 1.31; 95% CI 1.0 to 1.71; p=0.042). Time to analgesia in the control arm was 28 (22-35) mins and 20 (15-26 mins) with pharmacist involvement; p=0.025. In the pharmacist arm, the initial dose of analgesia was prescribed by the pharmacist for 38 (88.4%) patients. There were 27 other medications prescribed by the pharmacist for the management of these patients. There were no differences in emergency and trauma centre or hospital length of stay. CONCLUSION: Addition of the EM pharmacist in trauma response teams improved time to analgesia. Involvement of an EM pharmacist in trauma reception and resuscitation may assist by optimising medication management, with members of the team more available to focus on other life-saving interventions. TRIAL REGISTRATION NUMBER: ACTRN12621000338864.

Cognitive performance in older people after mild traumatic brain injury: Trauma effects and other risk factors.

OBJECTIVE: Cognitive symptoms are common in the initial weeks after mTBI, but recovery is generally expected within three months. However, there is limited information about recovery specifically in older age cohorts. Therefore, this study investigated cognitive outcome three months after mTBI in older adults (≥ 65 years) compared to trauma and community age-matched controls and explored risk factors for outcome after traumatic injury. METHODS: Older mTBI patients (n = 40) and older adults with mild traumatic injury but without head injury (n = 66) were compared to a noninjured community control group (n = 47). Cognitive assessment included neuropsychological and computerized tests. Group differences were compared on individual tasks and overall cognitive performances using composite scores. Regression analyses identified predictors of outcome for trauma patients and moderator analyses explored possible interactions of mTBI severity with age and cognition. RESULTS: As well as lower performances in processing speed and memory, both trauma groups had significantly lower performance on composite neuropsychological (d = .557 and .670) and computerized tasks (d = .783 and .824) compared to noninjured controls. Age, education, and history of depression were direct predictors of cognitive performance after mild traumatic injury (with or without head injury). Further moderation analysis demonstrated that mTBI severity (Glasgow Coma Scale < 15) moderated the impact of older age on computerized assessment (ß = -.138). CONCLUSIONS: Three months after mild trauma (regardless of head injury), older people demonstrate lower cognition compared to noninjured peers. However, severity of mTBI (Glasgow Coma Scale < 15) can interact with older age to predict poorer cognitive outcomes.

Hospitalisations and in-hospital deaths following moderate to severe traumatic brain injury in Australia, 2015-20: a registry data analysis for the Australian Traumatic Brain Injury National Data (ATBIND) project.

OBJECTIVE: To describe the frequency of hospitalisation and in-hospital death following moderate to severe traumatic brain injury (TBI) in Australia, both overall and by patient demographic characteristics and the nature and severity of the injury. DESIGN, SETTING: Cross-sectional study; analysis of Australia New Zealand Trauma Registry data. PARTICIPANTS: People with moderate to severe TBI (Abbreviated Injury Score [head] greater than 2) who were admitted to or died in one of the twenty-three major Australian trauma services that contributed data to the ATR throughout the study period, 1 July 2015 - 30 June 2020. MAJOR OUTCOME MEASURES: Primary outcome: number of hospitalisations with moderate to severe TBI; secondary outcome: number of deaths in hospital following moderate to severe TBI. RESULTS: During 2015-20, 16 350 people were hospitalised with moderate to severe TBI (mean, 3270 per year), of whom 2437 died in hospital (14.9%; mean, 487 per year). The mean age at admission was 50.5 years (standard deviation [SD], 26.1 years), and 11 644 patients were male (71.2%); the mean age of people who died in hospital was 60.4 years (SD, 25.2 years), and 1686 deaths were of male patients (69.2%). The overall number of hospitalisations did not change during 2015-20 (per year: incidence rate ratio [IRR], 1.00; 95% confidence interval [CI], 0.99-1.02) and death (IRR, 1.00; 95% CI, 0.97-1.03). CONCLUSION: Injury prevention and trauma care interventions for people with moderate to severe TBI in Australia reduced neither the incidence of the condition nor the associated in-hospital mortality during 2015-20. More effective care strategies are required to reduce the burden of TBI, particularly among younger men.

Mild Traumatic Brain Injury and Functional Outcome in Older Adults: Pain Interference But Not Cognition Mediates the Relationship Between Traumatic Injury and Functional Difficulties.

OBJECTIVE: To examine functional status of older people 3 months after mild traumatic brain injury (mTBI) and identify whether pain interference or cognition mediates any relationship found between injury status and functional outcomes. SETTING: Patients admitted to a Melbourne-based emergency department. PARTICIPANTS: Older adults 65 years and older: 40 with mTBI, 66 with orthopedic injury without mTBI (TC), and 47 healthy controls (CC) without injury. DESIGN: Observational cohort study. MAIN MEASURES: Functional outcome was measured using the World Health Organization Disability Assessment Schedule (WHODAS 2.0) and single- and dual-task conditions of the Timed-Up-and-Go task. Pain interference and cognitive performance at 3 months post-injury were examined as mediators of the relationship between injury status (injured vs noninjured) and functional outcome. RESULTS: Patients with mTBI and/or orthopedic injury reported greater difficulties in overall functioning, including community participation, compared with noninjured older people (CC group). Both trauma groups walked slower than the CC group on the mobility task, but all groups were similar on the dual-task condition. Pain interference mediated the relationship between injury status and overall functioning [ b = 0.284; 95% CI = 0.057, 0.536), community participation ( b = 0.259; 95% CI = 0.051, 0.485), and mobility ( b = 0.116; 95% CI = 0.019, 0.247). However, cognition did not mediate the relationship between injury status and functional outcomes. CONCLUSIONS: Three months after mild traumatic injury (with and without mTBI), patients 65 years and older had greater functional difficulties compared with noninjured peers. Pain interference, but not cognition, partially explained the impact of traumatic injury on functional outcomes. This highlights the importance of reducing pain interference for older patients after injury (including mTBI) to support better functional recovery.

Implementation of Partnered Pharmacist Medication Charting in haematology and oncology inpatients.

AIM: Partnered Pharmacist Medication Charting (PPMC) in patients admitted under general medical units has been shown to reduce medication errors. The aim of this study is to evaluate the impact of the PPMC model on medication errors in patients admitted under cancer units in Victorian hospitals. METHODS: A prospective cohort study comparing cohorts before and after the introduction of PPMC was conducted. This included a 2-month pre-intervention phase and 3-month intervention phase. PPMC was implemented during the intervention phase as new model of care that enabled credentialed pharmacists to chart all admission medications, including pre-admission or new medications and cancer therapies, in collaboration with the admitting medical officer. The proportion of medication charts with at least one error was the primary outcome measure. RESULTS: Seven health services across Victoria were included in the study. The majority of health services were using paper-based prescribing systems for oncology. Of the 547 patients who received standard medical medication charting, 331 (60.5%) had at least one medication error identified compared to 18 out of 416 patients (4.3%) using the PPMC model (p < 0.001). The median (interquartile range) inpatient length of stay was 5 (2.9-10.6) days in pre-intervention and 4.9 (2.9-11) days in intervention (p = 0.88). In the intervention arm, 42 patients had cancer therapy charted by a pharmacist with no errors. CONCLUSIONS: PPMC was successfully scaled into cancer units as a collaborative medication safety strategy. The model was associated with significantly lower rates of medication errors, including cancer therapies. PPMC should be adopted more widely in cancer units in Australia.

Quality of life and psychological health after mild traumatic brain injury in older people: Three- and six-month follow up.

OBJECTIVES: Examine quality of life (QoL) and psychological health after mild traumatic brain injury (mTBI) in older people (65+ years) at 3- and 6-month follow-up and explore which injury factors predicted QoL. METHODS: mTBI patients were compared to trauma comparison (TC) and community comparison (CC) groups. QoL and psychological health were measured at both timepoints. After accounting for 3-month psychological health, injury severity, neuroimaging, and 3-month neuropsychological performance were assessed as predictors of 6-month QoL. RESULTS: Overall 3-month QoL was lower for mTBI (Cohen's d = 0.938) and TC (Cohen's d = 0.485) groups compared to CCs, but by 6 months only mTBI patients continued to report poorer overall QoL (Cohen's d = 0.577) and physical QoL (Cohen's d = 0.656). Despite group differences, QoL for most (~92%) was within normative limits. 3-month psychological health predicted QoL 6-months postinjury (ß = -.377, 95% CI -.614, -.140) but other proposed risk factors (GCS <15, neuroimaging, 3-month neuropsychological performance) did not uniquely predict QoL. CONCLUSIONS: Older adults following mTBI reported lower QoL up to 6-months postinjury compared to non-injured peers, indicating that mTBI patients were particularly susceptible to ongoing differences in QoL 6-months postinjury.

Padded Headgear in Junior and Youth Australian Football: Player Insights From a National Survey.

OBJECTIVES: To investigate beliefs and factors associated with padded headgear (HG) use in junior (<13 years) and youth (≥13 years) Australian football. DESIGN: Online survey. SETTING: Junior and youth athletes in Australia. PARTICIPANTS: Australian football players aged U8 to U18. ASSESSMENT OF VARIABLES: Survey questions regarding demographics, HG use, concussion history, beliefs about HG, and risk-taking propensity. MAIN OUTCOME MEASURES: Rates of padded HG use, and beliefs associated with HG use. RESULTS: A total of 735 players (including 190, 25.9% female) representing 206 clubs participated. Headgear was worn by 315 players (42.9%; 95% CI: 39.3-46.4). Most (59.5%) HG users wore it for games only and wore it voluntarily (59.7%), as opposed to being mandated to do so. Junior players were more likely than youth players to agree to feeling safer ( P < 0.001) and being able to play harder while wearing HG ( P < 0.001). Median responses were "disagree" on preferring to risk an injury than wear HG, and on experienced players not needing to wear HG. Beliefs did not differ between males and females. Headgear use was associated with players belonging to a club where HG was mandated for other age groups (OR 16.10; 95% CI: 7.71-33.62, P < 0.001), youth players (OR 2.79; 95% CI: 1.93-3.93, P < 0.001), and female players (OR 1.57; 95% CI: 1.07-2.30, P = 0.019). CONCLUSIONS: Club HG culture, older age and being female were prominent variables associated with voluntary HG use. Players reported believing that HG offers protection. The rate of voluntary and mandated HG use identified is at odds with current scientific evidence that does not support HG as effective concussion prevention.

Biases in the collection of blood alcohol data for adult major trauma patients in Victoria, Australia.

BACKGROUND: In-hospital alcohol testing provides an opportunity to implement prevention strategies for patients with high risk of experiencing repeated alcohol-related injuries. However, barriers to alcohol testing in emergency settings can prevent patients from being tested. In this study, we aimed to understand potential biases in current data on the completion of blood alcohol tests for major trauma patients at hospitals in Victoria, Australia. METHODS: Victorian State Trauma Registry data on all adult major trauma patients from 1 January 2018 to 31 December 2021 were used. Characteristics associated with having a blood alcohol test recorded in the registry were assessed using logistic regression models. RESULTS: This study included 14 221 major trauma patients, of which 4563 (32.1%) had a blood alcohol test recorded. Having a blood alcohol test completed was significantly associated with age, socioeconomic disadvantage level, preferred language, having pre-existing mental health or substance use conditions, smoking status, presenting during times associated with heavy community alcohol consumption, injury cause and intent, and Glasgow Coma Scale scores (p<0.05). Restricting analyses to patients from a trauma centre where blood alcohol testing was part of routine clinical care mitigated most biases. However, relative to patients injured while driving a motor vehicle/motorcycle, lower odds of testing were still observed for patients with injuries from flames/scalds/contact burns (adjusted OR (aOR)=0.33, 95% CI 0.18 to 0.61) and low falls (aOR=0.17, 95% CI 0.12 to 0.25). Higher odds of testing were associated with pre-existing mental health (aOR=1.39, 95% CI 1.02 to 1.89) or substance use conditions (aOR=2.33, 95% CI to 1.47-3.70), and living in a more disadvantaged area (most disadvantaged quintile relative to least disadvantaged quintile: aOR=2.30, 95% CI 1.52 to 3.48). CONCLUSION: Biases in the collection of blood alcohol data likely impact the surveillance of alcohol-related injuries. Routine alcohol testing after major trauma is needed to accurately inform epidemiology and the subsequent implementation of strategies for reducing alcohol-related injuries.

Initial Pain Assessment and Management in Pediatric Burn Patients Presenting to a Major Trauma Center in Saudi Arabia.

BACKGROUND: Pediatric burn injury is a traumatic experience for affected children and their families. Burn pain is frequently undertreated and may adversely affect patient experience and outcomes. The aim of this study was to investigate the current practice of initial pediatric burn pain assessment and management at a major trauma center in Riyadh, Kingdom of Saudi Arabia. METHODS: We conducted a retrospective cohort study that included children 14 years and younger who visited King Saud Medical City in the Kingdom of Saudi Arabia with a presenting complaint of burn injury from January 01, 2017 to August 30, 2018. Variables were reported using descriptive statistics as appropriate. RESULTS: The 309 patients who were analyzed were classified into 3 age groups ranging from 0 to younger than 3 years (61%), 3 to 7 years (24%), and older than 7 years (15%). They included 145 (47%) female and 164 (53%) male patients. Pain levels of 182 patients (59%) were documented using an age-appropriate tool. In 75 children (24%), pain levels were documented using an alternate tool, and the tool used was not defined for 44 children (14%). Pain assessment was not documented for 8 children. Of those with an age-appropriate tool, the median initial pain score was 4 (interquartile range [IQR], 2-4). Analgesia was recorded to have been administered to 139 patients (45%), within a median time of 50 minutes (IQR, 17-154 minutes) to first analgesia. Among patients who had appropriate assessment of pain, 92 (50.3%) received analgesia compared with 52 (41.3%) who did not have appropriate assessment (P = 0.12). Among patients who had appropriate pain assessment, time to analgesia was 42 minutes (IQR, 15-132 minutes) compared with 53 minutes (IQR, 17-189 minutes) among patients who did not have appropriate assessment (P = 0.48). DISCUSSION: Most pediatric patients presenting with burns had pain assessment, but a substantial proportion of children were not managed using recommended age-specific tools. The use of age-specific tools was not necessarily associated with delivery of analgesia. For pediatric burns, prompt delivery of analgesia should be prioritized with pain assessment using age-appropriate tools being recommended, but optional.

Detection of Acute Traumatic Coagulopathy by Viscoelastic Haemostatic Assays Compared to Standard Laboratory Tests: A Systematic Review.

Introduction: The aim of this systematic review was to investigate whether viscoelastic haemostatic assays (VHAs) offer comparative diagnostic ability of acute traumatic coagulopathy (ATC) compared to the standard laboratory coagulation tests (SLCT). ATC is a complication of major trauma characterized by dysfunctional blood clotting, leading to an increased bleeding risk. Additionally, we aimed to analyse the association of VHA with blood product use and health outcomes. Methods: The search protocol was pre-published and completed on December 2, 2020, assessing manuscripts from 2000 until the present. We searched MEDLINE, Embase, Cochrane Central, BIOSIS, Emcare, CINAHL, and additional online resources and referenced lists. Included were manuscripts that quantitatively reported the detection of ATC using VHAs and SLCTs. A meta-analysis was undertaken including observational studies that reported on patients with injuries to all body regions and results analysed using a random-effects model and reported using pooled odds ratio with 95% confidence intervals (CI). Results: There were 14 observational studies and one randomized control trial involving 2,715 participants that satisfied inclusion criteria. We observed significant heterogeneity in the definitions of ATC, study design, setting, and patient population. Among observational studies that reported on patients with injuries to all body regions, VHAs were associated with higher odds of diagnosing ATC compared to SLCT (pooled OR 2.4; 95% CI: 1.4-4.1). There was inadequate evidence to suggest VHAs were associated with reduced blood product usage or lower mortality. Conclusion: VHAs detected more patients with ATC compared to SLCTs. However, the clinical significance and applicability of this finding remains unknown as translation to management was not adequately reported.

The Australian Traumatic Brain Injury National Data (ATBIND) project: a mixed methods study protocol.

BACKGROUND: Traumatic brain injury (TBI) is the largest contributor to death and disability in people who have experienced physical trauma. There are no national data on outcomes for people with moderate to severe TBI in Australia. OBJECTIVES: To determine the incidence and key determinants of outcomes for patients with moderate to severe TBI, both for Australia and for selected population subgroups, including Aboriginal and Torres Strait Islander Australians. METHODS AND ANALYSIS: The Australian Traumatic Brain Injury National Data (ATBIND) project will analyse Australia New Zealand Trauma Registry (ATR) data and National Coronial Information Service (NCIS) deaths data. The ATR documents the demographic characteristics, injury event description and severity, processes of care, and outcomes for people with major injury, including TBI, assessed and managed at the 27 major trauma services in Australia. We will include data for people with moderate to severe TBI (Abbreviated Injury Scale [AIS] (head) score higher than 2) who had Injury Severity Scores [ISS] higher than 12 or who died in hospital. People will also be included if they died before reaching a major trauma service and the coronial report details were consistent with moderate to severe TBI. The primary research outcome will be survival to discharge. Secondary outcomes will be hospital discharge destination, hospital length of stay, ventilator-free days, and health service cost. ETHICS APPROVAL: The Alfred Ethics Committee approved ATR data extraction (project reference number 670/21). Further ethics approval has been sought from the NCIS and multiple Aboriginal health research ethics committees. The ATBIND project will conform with Indigenous data sovereignty principles. DISSEMINATION OF RESULTS: Our findings will be disseminated by project partners with the aim of informing improvements in equitable system-level care for all people in Australia with moderate to severe TBI. STUDY REGISTRATION: Not applicable.

Prevalence of alcohol and other drug use in patients presenting to hospital for fall-related injuries: a systematic review.

BACKGROUND: Alcohol and other drug (AOD) use is a key preventable risk factor for serious injuries. Prevention strategies to date have largely focused on transport injuries, despite AOD use being a significant risk factor for other injury causes, including falls. This systematic review aimed to report the prevalence of AOD use in patients presenting to hospital for fall-related injuries. METHODS: This systematic review includes studies published in English after the year 2010 that objectively measured the prevalence of AOD use in patients presenting to hospital for a fall-related injury. Screening, data extraction and risk of bias assessments were completed by two independent reviewers. Data were presented using narrative synthesis and, where appropriate, meta-analyses. RESULTS: A total of 12 707 records were screened. Full texts were retrieved for 2042 records, of which 29 were included. Four studies reported the combined prevalence of any alcohol and/or drug use, generating a pooled prevalence estimate of 37% (95% CI 25% to 49%). Twenty-two records reported on the prevalence of acute alcohol use alone and nine reported specifically on the prevalence of drugs other than alcohol, with prevalence ranging from 2% to 57% and 7% to 46%, respectively. The variation in prevalence estimates likely resulted from differences in toxicology testing methods across studies. CONCLUSIONS: AOD exposure was common in hospitalised fall-related injuries. However, research addressing prevalence across different types of falls and the use of drugs other than alcohol was limited. Future research should address these areas to improve our understanding of which populations should be targeted in AOD and injury prevention strategies . PROSPERO REGISTRATION NUMBER: CRD42020188746.

Partnered pharmacist medication charting (PPMC) in regional and rural general medical patients.

OBJECTIVE: Errors in hospital medication charts are commonly encountered and have been associated with morbidity and mortality. This study evaluates the impact of the Partnered Pharmacist Medication Charting (PPMC) model on medication errors in general medical patients admitted to rural and regional hospitals. DESIGN/METHOD: A prospective cohort study, comparing before and after the introduction of PPMC was conducted in 13 rural and regional health services. This included a 1-month pre-intervention phase and 3-month intervention phase. In the intervention phase, PPMC was implemented as a new model of care in general medical units. SETTING: Victoria, Australia. PARTICIPANTS: Patients admitted to General Medical Units. OUTCOME MEASURE: The proportion of medication charts with at least one error was the primary outcome measure. Secondary outcome measures included inpatient length of stay (LOS), risk stratification of medication errors, Medical Emergency Team (MET) calls, transfers to ICU and hospital readmission. RESULTS: Of the 669 patients who received standard medical charting during the pre-intervention period, 446 (66.7%) had at least one medication error identified compared to 64 patients (9.5%) using PPMC model (p < 0.001). There were 1361 medication charting errors identified during pre-intervention and 80 in the post-intervention. The median (interquartile range) inpatient length of stay was 4.8 (2.7-10.8) in the pre-intervention and 3.7 days (2.0-7.0) among patients that received PPMC (p < 0.001). CONCLUSION: The PPMC model was successfully scaled across rural and regional Victoria as a medication safety strategy. The model was associated with significantly lower rates of medication errors, lower severity of errors and shorter inpatient length of stay.

Involvement of emergency medicine pharmacists in stroke thrombolysis: A cohort study.

WHAT IS KNOWN AND OBJECTIVE: Thrombolysis with Alteplase (rtPA) improves functional outcome among selected patients after acute ischaemic stroke. Benefits are most pronounced with early intervention. Our aim is to assess door to needle time (DTNT) for acute stroke after a stroke call-out redesign including addition of an emergency medicine (EM) pharmacist to the team. METHODS: A retrospective cohort of stroke patients who received rtPA was compared to a prospective cohort after stroke callout re-design in an adult major referral hospital in metropolitan Melbourne, Australia. All patients who presented during EM pharmacist working hours and were thrombolysed in the ED for stroke from December 2011-June 2014 pre and July 1st 2014-August 2019 post were included. The primary outcome was DTNT. Secondary outcomes included proportion of patients with a DTNT within 60 min, time to blood pressure (SBP) reduction, intracranial and extracranial bleeding, hospital length of stay (LOS) and mortality. RESULTS AND DISCUSSION: There were 218 patients eligible, 64 patients pre and 122 patients post implementation were included. The cohorts were similar in demographics. There was a significant association of time to thrombolysis (HR 1.61; 95% CI: 1.18-2.20; p = 0.003) with the intervention. Median DTNT improved from 73 (IQR 52-111) min to 61 (IQR 47-80) min (p = 0.012). Interrupted time-series analysis did not demonstrate intervention at the single time-point of implementation of the intervention to be associated with the improvement. WHAT IS NEW AND CONCLUSION: Re-design of the stroke call-out team that included addition of an EM pharmacist was associated with improvements in DTNT. The effect of individual interventions at one point in time could not be demonstrated.

Delayed intracranial hemorrhage after trauma.

Introduction: Delayed Intracranial Hemorrhage (D-ICH), defined as finding of ICH on subsequent imaging after a normal computed tomography of the brain (CTB), is a feared complication after head trauma. The aim of this study was to determine the incidence and severity of D-ICH.Methods: This retrospective cohort study included patients that presented directly from the scene of injury to an adult major trauma center from Jan 2013 to Dec 2018.Results: There were 6536 patients who had an initial normal CTB and 23 (0.3%; 95%CI: 0.20-0.47) had D-ICH. There were 653 patients who had a repeat CTB (incidence of D-ICH 3.5%; 95%CI: 2.2-5.2). There was no significant association of D-ICH with age>65 years (OR 1.33; 95%CI: 0.54-3.29), presenting GCS <15 (OR 1.21; 95% CI: 0.52-2.80) and anti-platelet medications (OR 0.68; 95%CI: 0.26-1.74). Exposure to anti-coagulant medications was associated with lower odds of D-ICH (OR 0.23; 95%CI: 0.05-0.99). All cases of D-ICH were diffuse injury type II lesions on the Marshall classification. There were no cases that underwent neurosurgical intervention and no deaths were attributed to D-ICH.Conclusions: These results question observation of patients with head injury in hospital after a normal CTB for the sole purpose of excluding D-ICH.