Scanning the aged to minimize missed injury: An EAST multicenter study.

BACKGROUND: Despite the high incidence of blunt trauma in older adults, there is a lack of evidence-based guidance for computed tomography (CT) imaging in this population. We aimed to identify an algorithm to guide use of a Pan-Scan (Head/C-spine/Torso) or a Selective Scan (Head/C-spine ± Torso). We hypothesized that a patient's initial history and exam could be used to guide imaging. METHODS: We prospectively studied blunt trauma patients aged 65+ at 18 Level I/II trauma centers. Patients presenting >24 h after injury or who died upon arrival were excluded. We collected history and physical elements and final injury diagnoses. Injury diagnoses were categorized into CT body regions of Head/C-spine or Torso (chest, abdomen/pelvis, and T/L spine). Using machine learning and regression modeling as well as a priori clinical algorithms based, we tested various decision rules against our dataset. Our priority was to identify a simple rule which could be applied at the bedside, maximizing sensitivity (Sens) and negative predictive value (NPV) to minimize missed injuries. RESULTS: We enrolled 5,498 patients with 3,082 injuries. Nearly half (47.1%, n = 2,587) had an injury within the defined CT body regions. No rule to guide a Pan-Scan could be identified with suitable Sens/NPV for clinical use. A clinical algorithm to identify patients for Pan-Scan, using a combination of physical exam findings and specific high-risk criteria, was identified and had a Sens of 0.94 and NPV of 0.86 This rule would have identified injuries in all but 90 patients (1.6%) and would theoretically spare 11.9% (655) of blunt trauma patients a torso CT. CONCLUSIONS: Our findings advocate for Head/Cspine CT in all geriatric patients with the addition of torso CT in the setting of positive clinical findings and high-risk criteria. Prospective validation of this rule could lead to streamlined diagnostic care of this growing trauma population. LEVEL OF EVIDENCE: Level 2, Diagnostic Tests or Criteria.

Prehospital end-tidal carbon dioxide is predictive of death and massive transfusion in injured patients: An Eastern Association for Surgery of Trauma multicenter trial.

BACKGROUND: Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients. METHODS: This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as >10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused. RESULTS: A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p < 0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p < 0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%. CONCLUSION: Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock. LEVEL OF EVIDENCE: Diagnostic test, level III.

Prolonged Emergency Department Stay at Referring Facilities: A Poor Trauma Performance Improvement Tool.

BACKGROUND: Delays in the transfers of injured patients are perceived to increase morbidity and mortality and drive initiatives to limit the emergency department length of stay (LOS) at referring facilities (RF). RF LOS >4 hours is used for performance improvement (PI) with a large review burden with few improvement opportunities. METHODS: A statewide trauma registry 2013-2018 was used. Descriptive and inferential statistics including logistic regression were used to evaluate nongeriatric adult patients with ED LOS <12 hours. Paired data analyses utilizing prehospital (PH) and RF variables, vital signs (VS), Glasgow Coma Score-Motor component (GCS-M), RF LOS, mortality, trauma center hospital LOS (HLOS), and intensive care unit (ICU) LOS were performed. RESULTS: 13,721 of 56,702 transfer patients were selected. Mortality fell over time in all abbreviated injury score groups. GCS-M and systolic blood pressure (SBP) were correlated with mortality in both prehospital and RF data and highest in patients with abnormal GCS-M or SBP in both settings (38.0%, 30.1%). Examination of mortality over time in the group with abnormal VS showed SBP as the only variable with increasing mortality related to RF LOS. Average HLOS and ICU LOS were longest in patients with abnormal PH and RF SBP and GCS-M. DISCUSSION: Support for PI evaluation of RF LOS >4 hours was not identified. Increased survival over time is explained by early transfers of high mortality patients. Our data support existing efficient statewide transfers and recommend PI review of transfer patients with abnormal GCS-M and SBP in a narrower timeframe.

Evaluation of statewide utilization of helicopter emergency medical services for interfacility transfer.

BACKGROUND: Helicopter emergency medical services (HEMSs) are used with increasing frequency for the transportation of injured patients from the scene and from treatment facilities to higher levels of care. Improved outcomes have been difficult to establish, and reports of overutilization and financial harm have been published. Our study was performed to evaluate statewide utilization for interfacility transfers (IFTs). METHODS: Data from the North Carolina state trauma registry from 2013 to 2017 were evaluated and ground, and helicopter IFTs were compared. RESULTS: Overall interfacility use of HEMSs peaked at 7,861 patient transports in 2016, and the percent of all IFTs fell from 17% to 13.3% over the study period. Helicopter emergency medical services patients were more likely to be male (69.8%) and younger (48.0 vs. 56.2 years), and have higher Injury Severity Scores (14.6 vs. 9.0) and higher mortality (10.5% vs. 2.8%) than ground emergency medical services (GEMSs) patients. When adjusted for age, sex, Injury Severity Score, and transport distance, HEMSs survival was significantly higher (odds ratio, 0.353; 95% CI, 0.308-0.404; p < 0.0001). Normal prehospital vital signs (VSs) and Glasgow Coma Scale score motor component (GCS-M) were associated with low mortality rates in both groups. Abnormal prehospital VSs and GCS-M were associated with an 11.8% mortality rate in HEMSs patients and 3.1% in GEMSs patients. Normal referring facility VSs and GCS-M did not confer similar protection with a mortality rate of 10.0% in HEMSs patients and 2.8% in GEMSs. Changes in prehospital to referring facility VSs did not demonstrate a low mortality group. Abbreviated Injury Scale and changes in VSs did not identify HEMSs transport benefit groups. CONCLUSION: The proportion of HEMSs transfers fell over the study period and, while associated with a 10.5% mortality rate, had an outcome benefit compared with GEMSs. These patients could not be sorted into risk categories for transportation choice based on VSs or GCS-M derangement or by changes thereof, and opportunities for system improvement were not identified. LEVEL OF EVIDENCE: Prognostic/epidemiological study, level III; Care Management, level IV.