The use of prophylactic inferior vena cava filters in trauma patients: a systematic review.

INTRODUCTION: Pulmonary embolisms (PE) are an often preventable cause of late morbidity and mortality after trauma. Although there is evidence for the use of therapeutic inferior vena cava (IVC) filters (defined as IVC filters implanted in those with proven deep venous thrombosis [DVT] in order to prevent PE), there is not as much evidence to support the use of prophylactic IVC filters. Thus, we undertook a systematic review of the literature to assess the following in prophylactic IVC filters: efficacy in PE reduction, prevalence of filter-related complications and the indications for use. MATERIALS AND METHODS: After screening 249 studies, 24 studies met inclusion criteria for qualitative synthesis. RESULTS: Overall, the literature is supportive of the use of prophylactic IVC filters in high-risk poly-trauma patients who may have contraindications to DVT prophylaxis. Filter-associated complications are uncommon and, when they do occur, tend to be of limited clinical significance. Limited data, mostly in the form of case series, supports a reduction in PE and PE-related mortality. There has been increasing use of retrievable filters as well as the ability to safely retrieve them at longer intervals. CONCLUSION: Despite the addition of a few matched-control studies, the literature is still plagued by a lack of high quality data, and therefore the true efficacy of prophylactic IVC filters for prevention of PE in trauma patients remains unclear. Further studies are required to determine the true role of prophylactic IVC filters in trauma patient.

Shaken baby syndrome and a triple-dose strategy for its prevention.

OBJECTIVES: Inflicted traumatic brain injury associated with Shaken Baby Syndrome (SBS) is a leading cause of injury mortality and morbidity in infants. A triple-dose SBS prevention program was implemented with the aim to reduce the incidence of SBS. The objectives of this study were to describe the epidemiology of SBS, the triple-dose prevention program, and its evaluation. METHODS: Descriptive and spatial epidemiologic profiles of SBS cases treated at Children's Hospital, London Health Sciences Centre, from 1991 to 2010 were created. Dose 1 (in-hospital education): pre-post impact evaluation of registered nurse training, with a questionnaire developed to assess parents' satisfaction with the program. Dose 2 (public health home visits): process evaluation of additional education given to new parents. Dose 3 (media campaign): a questionnaire developed to rate the importance of factors on a 7-point Likert scale. These factors were used to create weights for statistical modeling and mapping within a geographic information system to target prevention ads. RESULTS: Forty-three percent of severe infant injuries were intentional. A total of 54 SBS cases were identified. The mean age was 6.7 months (standard deviation, 10.9 months), with 61% of infant males. The mean Injury Severity Score was 26.3 (standard deviation, 5.5) with a 19% mortality rate. Registered nurses learned new information on crying patterns and SBS, with a 47% increase in knowledge posttraining (p < 0.001). Over 10,000 parents were educated in-hospital, a 93% education compliance rate. Nearly all parents (93%) rated the program as useful, citing "what to do when the crying becomes frustrating" as the most important message. Only 6% of families needed to be educated during home visits. Locations of families with a new baby, high population density, and percentage of lone parents were found to be the most important factors for selecting media sites. The spatial analysis revealed six areas needed to be targeted for ad locations. CONCLUSIONS: SBS is a devastating intentional injury that often results in poor outcomes for the child. Implementing a triple-dose prevention program that provides education on crying patterns, coping strategies, and the dangers of shaking is key to SBS prevention. The program increased knowledge. Parents rated the program as useful. The media campaign allowed us to extend the primary prevention beyond new parents to help create a cultural change in the way crying, the primary trigger for SBS, is viewed. Targeting our intervention increased the likelihood that our message was reaching the population in greatest need.

Drug use and screening in pediatric trauma.

BACKGROUND: There is a paucity of research on substance use in the pediatric trauma population. This study aims to describe trends in substance use and screening in the Canadian pediatric trauma population. MATERIALS AND METHODS: A retrospective review of the London Health Sciences Centre trauma database from April 1999 to January 2009 identified patients less than 18 years old admitted after major trauma [injury severity score (ISS) > 12]. Data extracted included age, gender, ISS, blood alcohol concentration (BAC), and results of toxicology screens. RESULTS: BAC data were available for 799 patients and toxicology screens for 761 patients. BAC testing was completed in 30% (21% positive). Toxicology screens were completed in 7% (44% positive). Increasing age was associated with screening for alcohol (odds ratio = 1.4; 95% confidence interval 1.3-1.5). Screening for drug use had a bimodal distribution, with no children aged 4-10 years screened. Those screened for drugs and alcohol had a significantly higher ISS than those not tested (BAC 28 versus 23, P < 0.001, toxin screening 29 versus 24, P = 0.003). The most common ingestions were alcohol, benzodiazepines, cannabinoids, and opiates. CONCLUSIONS: Screening for drugs and alcohol is sporadic in the pediatric trauma population. Further study utilizing a universal approach to drug and alcohol screening is needed to further delineate the true prevalence of substance use in this population.

Access to trauma systems in Canada.

BACKGROUND: Trauma is a leading cause of morbidity, potential years of life lost and health care expenditure in Canada and around the world. Trauma systems have been established across North America to provide comprehensive injury care and to lead injury control efforts. We sought to describe the current status of trauma systems in Canada and Canadians' access to acute, multidisciplinary trauma care. METHODS: A national survey was used to identify the locations and capabilities of adult trauma centers across Canada and to identify the catchment populations they serve. Geographic information science methods were used to map the locations of Level I and Level II trauma centers and to define 1-hour road travel times around each trauma center. Data from the 2006 Canadian Census were used to estimate populations within and outside 1-hour access to definitive trauma care. RESULTS: In Canada, 32 Level I and Level II trauma centers provide definitive trauma care and coordinate the efforts of their surrounding trauma systems. Most Canadians (77.5%) reside within 1-hour road travel catchments of Level I or Level II centers. However, marked geographic disparities in access persist. Of the 22.5% of Canadians who live more than an hour away from a Level I or Level II trauma centers, all are in rural and remote regions. DISCUSSION: Access to high quality acute trauma care is well established across parts of Canada but a clear urban/rural divide persists. Regional efforts to improve short- and long-term outcomes after severe trauma should focus on the optimization of access to pre-hospital care and acute trauma care in rural communities using locally relevant strategies or novel care delivery options.

Evaluation of an adolescent hospital-based injury prevention program.

BACKGROUND: IMPACT (Impaired Minds Produce Actions Causing Trauma) is an adolescent, hospital-based program aimed to prevent injuries and their consequences caused by alcohol or drug impairment and other high-risk behaviors. The overall objective of this evaluation was to determine the effect of the program on students' knowledge and behavior regarding drinking and driving, over time. METHODS: A randomized control trial between students randomly selected to attend IMPACT and those not selected served as a control group. Students completed a questionnaire before the program and at three posttime periods (1 week, 1 month, and 6 months). Panel data models were used to analyze the effects of the experiment on students' knowledge of alcohol and crash issues and negative driving behaviors (no seat belt, driving while using a cell phone, involved in conversation, eating, annoyed with other drivers, and drowsy). Descriptive statistics and logistic regression models were used to analyze the effect of IMPACT on students' influence on friends and family about road safety. RESULTS: This study consisted of 269 students (129 IMPACT; 140 control) with an overall response rate of 84% (range, 99% presurvey to 71% at 6 months). The IMPACT group had a 57%, 38%, and 43% increase in the number of correct answers on alcohol and crash issues during the three time periods, respectively (p < 0.05). Students in the IMPACT group would try to influence friends and family to improve their road safety twice as often as 1-week postprogram (odds ratio 1.94, confidence interval 1.07, 3.53). The models did not suggest that the program had an effect on negative driving behaviors. Men and students who drove more frequently had worse driving behavior. CONCLUSIONS: Our evaluation demonstrates that the IMPACT program had a statistically significant, positive effect on students' knowledge of alcohol and crash issues that was sustained over time. IMPACT had an initial effect on students' behaviors in terms of peer influence toward improving road safety (i.e., buckling up, not drinking, and driving) 1 week after the program, but this effect diminished after 1 month. Other negative driving behaviors had low prevalence at baseline and were not further influenced by the program.

Neural correlates of trauma script-imagery in posttraumatic stress disorder with and without comorbid major depression: a functional MRI investigation.

The goal of this study was to compare neural activation patterns in patients with PTSD with and without current comorbid major depression. Traumatized subjects with PTSD (n=11), PTSD+major depression (MDD, n=15), and subjects (n=16) who met criterion A for PTSD but never developed the disorder were studied using the script-driven symptom-provocation paradigm adapted to functional magnetic resonance imaging (fMRI) at a 4-Tesla field strength. Both the PTSD+MDD and PTSD-MDD groups revealed decreased brain activation in the anterior cingulate gyrus (BA 24) and the right ventrolateral prefrontal cortex (BA 47). After covariation for differences in PTSD severity between these groups, the left insula (BA 13) remained more significantly activated in the PTSD-MDD group than in the PTSD+MDD group. In contrast, the PTSD+MDD group showed greater activation than the PTSD-MDD group in the bilateral anterior cingulate gyrus (BA 24) and posterior cingulate cortices (BA 23, 31). These results suggest different patterns of brain activation related to comorbid major depression occurring in the context of PTSD.

The fastest route between two points is not always a straight line: An analysis of air and land transfer of nonpenetrating trauma patients.

BACKGROUND: The distance beyond which helicopter transport is faster than ground for interfacility transfer of trauma patients has not been established. Our objective was to determine whether such a threshold exists. METHODS: A retrospective cohort study was conducted involving 243 patients transported by land and 139 patients by air from 13 sites during a 3-year period. Time intervals between critical events were compared for the two modes of transport at each site. RESULTS: The time interval between the decision to transfer and the actual departure time was shorter for patients transferred by land from all sites studied (mean 41.3 versus 89.7 minutes, p < 0.001). The travel time was shorter by helicopter from all sites (mean 58.4 versus 78.9 minutes, p < 0.001). The time between the decision to transfer and the arrival at the trauma center was similar at most sites but faster by land overall (mean 120.3 versus 150.0 minutes, p = 0.014). No threshold was detected beyond which helicopter transport was superior. CONCLUSIONS: Several factors other than the distance to be traveled determine the time required for interfacility transfer of trauma patients. A fixed distance threshold beyond which helicopter transport should be used does not exist. The decision as to which mode of transport to use for emergent trauma patient transfers should be based upon multiple factors including the distance traveled and ambulance availability, and must be individualized for each site that transfers patients.

Human immunodeficiency virus, hepatitis B, and hepatitis C seroprevalence in a Canadian trauma population.

BACKGROUND: The current seroprevalence of human immunodeficiency virus (HIV), hepatitis B, and hepatitis C in the Canadian trauma population is unknown. Establishing the seroprevalence of these diseases is vital for education, postexposure prophylaxis, and counseling, and to establish potential screening guidelines. The purpose of this study was to determine the seroprevalence of HIV, hepatitis B, and hepatitis C in the trauma population of London, Ontario, Canada. METHODS: All adult (aged > or = 18 years) trauma patients treated by the trauma team at London Health Sciences Centre were prospectively studied from January to December 2003. The study was conducted as a linked, confidential serosurvey with delayed full disclosure. Serum was analyzed for HIV, hepatitis C antibody, and Hepatitis B surface antigen. RESULTS: A total of 287 (76%) of 377 consecutive trauma patients had blood testing completed. Of the 287 patients tested, 1 (0.3%) was positive for hepatitis B, 8 (2.8%) were positive for hepatitis C, and no patients tested positive for HIV. Hepatitis C-positive patients were predominantly men (63%) with a mean age of 46 years and a mean Injury Severity Score of 19; 63% were injured in a motor vehicle crash, and 88% were discharged alive. There were no statistically significant differences in the demographic and injury profiles from the hepatitis C-negative patients (p > 0.2 for all). CONCLUSION: This is the first study to determine the rates of HIV, hepatitis B, and hepatitis C in the Canadian trauma population. Our trauma population demonstrated a threefold higher hepatitis C seroprevalence rate compared with the general population. Hepatitis C poses the highest risk to the trauma team of the three bloodborne diseases studied. With no vaccine or postexposure prophylaxis currently available for hepatitis C, this study highlights the importance of prevention and the strict use of universal precautions in the setting of trauma.

Pediatric trauma in southwestern Ontario: linking data with injury prevention initiatives.

BACKGROUND: Our objective was to provide an epidemiologic description of pediatric trauma in SW Ontario using multiple data sets. Injury prevention (IP) initiatives were linked with predominant injury mechanisms to determine whether IP programs were supported by data. METHODS: Descriptive analysis was undertaken for five pediatric age groups (<1 year, 1-4 years, 5-9 years, 10-14 years, 15-19 years) using the Ontario Trauma Registry's Death Data Set, Comprehensive Data Set (Lead Trauma Hospitals [LTH] patients), and Minimal Data Set (hospital admissions), 1999-2000, for all pediatric patients residing in SW Ontario. National Ambulatory Care Reporting System (NACRS) data from the Children's Hospital of Western Ontario/London Health Sciences Centre were used to capture the Emergency Room (ER) injury data. Information on IP initiatives for children and youth was gathered through an Internet search, supplemented by a survey. RESULTS: Injury in SW Ontario resulted in 13,197 ER visits, 1,616 hospital admissions, 70 severe trauma (ISS > 12) cases treated at a LTH and 47 deaths to children and youth. More males than females were injured, with the sex differential more pronounced as age increased. Falls were the leading mechanism for ER visits (37%) and hospital admissions (26%). Recreational injuries represented approximately 30% of injuries to the 10-14 yr age group. As ISS increased, MVCs emerged as an important mechanism, representing 71% of LTH cases and 53% of pediatric injury deaths in SW Ontario. There were 61 pediatric IP programs identified in SW Ontario. Eighty-four percent of programs (51/61) were supported by data, and were related to one of the predominant injury mechanisms. CONCLUSIONS: Injury is a serious problem for children in SW Ontario. Data can be used to identify modifiable risk factors to develop and implement new IP initiatives with the goal of reducing childhood injury and death. There is a need to integrate and link IP programs in SW Ontario for full coverage of all injury mechanisms.

Effect of airbag deployment on head injuries in severe passenger motor vehicle crashes in Ontario, Canada.

BACKGROUND: The purpose of this study was to identify and analyze factors contributing to both airbag deployment and resulting head injuries (HIs) and to quantify the effect of airbag deployment on head injuries, in terms of odds of head injury and severity, in severe motor vehicle collisions (MVCs). METHODS: Data were derived from severely injured (Injury Severity Score [ISS] > 12) drivers treated at Ontario's lead trauma hospitals (n = 1,272), and included all MVC driver deaths in the province (n = 665) from 1997-98. We conducted an epidemiologic description and a case-control study to compare drivers with and without HIs. Statistical analysis included Pearson's chi2, Wilcoxon rank-sum, and multiple logistic regression tests. RESULTS: Seventy-one percent of drivers were men, peaking in the 25- to 34-year age group. The most common impact involved multiple vehicles (62%) approaching each other. Overall, 59% of crashes had a frontal location of impact. HIs were significantly associated with a lower age (median, 36 vs. 43 years), seat belt use (53% vs. 59%), and airbag deployment (7% vs. 10%), with higher ISS (median, 34 vs. 22), ejection (20% vs. 10%), and mortality rate (44% vs. 35%). Airbag deployment was associated with higher age and seat belt use, and lower ISS, ejection, and deaths. Importantly, there were fewer HIs with the deployment of an airbag (64% vs. 73%) and a lower severity of HI. When logistic regression was used to control for the effects of possible confounders, airbag deployment was not statistically associated with one's odds of HI (odds ratio, 0.827; 95% confidence interval, 0.560-1.220), but ISS, age, and ejection were. CONCLUSION: Airbag deployment did not significantly lower a driver's odds of head injury in a severe MVC, but it did significantly lower the severity of head injury. This is a significant finding, given that 72% of our study population sustained a head injury and the importance of lowering the severity of these head injuries in terms of patients' ultimate outcome. The most important factor associated with head injuries was ejection, which nearly doubled a driver's odds of head injury (odds ratio, 1.759; 95% confidence interval, 1.201-2.577). This reinforces the supplementary protective effect of an airbag and that "buckling up" and keeping occupants in the vehicle is of primary importance in the prevention of head injuries.

Surgical case costing: trauma is underfunded according to resource intensity weights.

OBJECTIVE: To determine whether rate-based funding using resource intensity weights (RIWs) adequately represents trauma case costs. DESIGN: A prospective time-in-motion resource utilization pilot study to assure the effectiveness of the computerized hospital Transition-One data acquisition system, followed by a retrospective observational case costing study. Patient costs with no identifing data were used, and all costs were tabulated as mean cost per group. SETTING: London Health Sciences Centre, London, Ont., a tertiary care "lead" trauma hospital. PATIENTS: A modified random selection of 4 control case mix groups (CMGs) of surgical patients for the fiscal year 1996-97. The trauma group was selected as a representative resource-intensive CMG. Each patient was assigned to a CMG by Health Records according to the most responsible diagnosis. OUTCOMES MEASURES: Total case costs were tabulated for each patient then combined for a mean case cost per CMG. The RIW assignments for each patient were combined to create a mean RIW per CMG and mean length of stay per CMG. RESULTS: There was no statistically significant difference between the control surgical CMGs and the trauma CMG for mean RIW-adjusted length of stay per CMG, but there was a significant difference (p < 0.0001) between the control CMGs and the trauma CMG for RIW-adjusted mean case cost per CMG. CONCLUSIONS: RIWs underrepresent trauma case costs by a factor of 3.5, which could result in underfinding and potential fiscal difficulties for leading trauma hospitals as has occurred in the United States.