Prognostic Factors Associated with Venous Thromboembolism Following Traumatic Injury: A Systematic Review and Meta-Analysis.

INTRODUCTION: Trauma patients are at increased risk of venous thromboembolism (VTE), including deep venous thrombosis (DVT) and/or pulmonary embolism (PE). We conducted a systematic review and meta-analysis summarizing the association between prognostic factors and the occurrence of VTE following traumatic injury. METHODS: We searched the EMBASE and MEDLINE databases from inception to August 2023. We identified studies reporting confounding adjusted associations between patient, injury or post-injury care factors and risk of VTE. We performed meta-analyses of odds ratios (ORs) using the random effects method and assessed individual study risk of bias using the QUIPS tool. RESULTS: We included 31 studies involving 1,981,946 patients. Studies were predominantly observational cohorts from North America. Factors with moderate or higher certainty of association with increased risk of VTE include older age, obesity, male sex, higher injury severity score, pelvic injury, lower extremity injury, spinal injury, delayed VTE prophylaxis, need for surgery and tranexamic acid use. After accounting for other important contributing prognostic variables, a delay in the delivery of appropriate pharmacologic prophylaxis for as little as 24 to 48 hours independently confers a clinically meaningful two-fold increase in incidence of VTE. CONCLUSION: These findings highlight the contribution of patient predisposition, the importance of injury pattern, and the impact of potentially modifiable post-injury care on risk of VTE after traumatic injury. These factors should be incorporated into a risk stratification framework to individualize VTE risk assessment and support clinical and academic efforts reduce thromboembolic events among trauma patients.Study TypeSystematic Review & Meta-Analysis. LEVEL OF EVIDENCE: Level II.

Prognostic factors associated with risk of stroke following blunt cerebrovascular injury: A systematic review and meta-analysis.

BACKGROUND & OBJECTIVES: Blunt cerebrovascular injury (BCVI) includes carotid and/or vertebral artery injury following trauma, and conveys an increased stroke risk. We conducted a systematic review and meta-analysis to provide a comprehensive summary of prognostic factors associated with risk of stroke following BCVI. METHODS: We searched the EMBASE and MEDLINE databases from January 1946 to June 2023. We identified studies reporting associations between patient or injury factors and risk of stroke following BCVI. We performed meta-analyses of odds ratios (ORs) using the random effects method and assessed individual study risk of bias using the QUIPS tool. We separately pooled adjusted and unadjusted analyses, highlighting the estimate with the higher certainty. RESULTS: We included 26 cohort studies, involving 20,458 patients with blunt trauma. The overall incidence of stroke following BCVI was 7.7 %. Studies were predominantly retrospective cohorts from North America and included both carotid and vertebral artery injuries. Diagnosis of BCVI was most commonly confirmed with CT angiography. We demonstrated with moderate to high certainty that factors associated with increased risk of stroke included carotid artery injury (as compared to vertebral artery injury, unadjusted odds ratio [uOR] 1.94, 95 % CI 1.62 to 2.32), Grade III Injury (as compared to grade I or II) (uOR 2.45, 95 % CI 1.88 to 3.20), Grade IV injury (uOR 3.09, 95 % CI 2.20 to 4.35), polyarterial injury (uOR 3.11 (95 % CI 2.05 to 4.72), occurrence of hypotension at the time of hospital admission (adjusted odds ratio [aOR] 1.32, 95 % CI 0.87 to 2.03) and higher total body injury severity (aOR 5.91, 95 % CI 1.90 to 18.39). CONCLUSION: Local anatomical injury pattern, overall burden of injury and flow dynamics contribute to BCVI-related stroke risk. These findings provide the foundational evidence base for risk stratification to support clinical decision making and further research.

The Kampala Trauma Score: A 20-year track record.

ABSTRACT: Quantifying the severity of traumatic injury has been foundational for the standardization of outcomes, quality improvement research, and health policy throughout the evolution of trauma care systems. Many injury severity scores are difficult to calculate and implement, especially in low- and middle-income countries (LMICs) where human resources are limited. The Kampala Trauma Score (KTS)-a simplification of the Trauma Injury Severity Score-was developed in 2000 to accommodate these settings. Since its development, numerous instances of KTS use have been documented, but extent of adoption is unknown. More importantly, does the KTS remain useful for determining injury severity in LMICs? This review aims to better understand the legacy of the KTS and assess its strengths and weaknesses. Three databases were searched to identify scientific papers concerning the KTS. Google Scholar was searched to identify grey literature. The search returned 357 papers, of which 199 met inclusion criteria. Eighty-five studies spanning 16 countries used the KTS in clinical settings. Thirty-seven studies validated the KTS, assessing its ability to predict outcomes such as mortality or need for admission. Over 80% of these studies reported the KTS equalled or exceeded more complicated scores at predicting mortality. The KTS has stood the test of time, proving itself over the last twenty years as an effective measure of injury severity across numerous contexts. We recommend the KTS as a means of strengthening trauma systems in LMICs and suggest it could benefit high-income trauma systems that do not measure injury severity.

Improving Surgical Quality for Patients With Mental Illnesses: A Narrative Review.

OBJECTIVE: The aim of this study was to identify disparities in care for surgical patients with preexisting mental health diagnoses. SUMMARY BACKGROUND DATA: Mental illness affects approximately 6.7 million Canadians. For them, stigma, comorbid disorders, and sequelae of psychiatric diagnoses can be barriers to equitable health care. The goal of this review is to define inequities in surgical care for patients with preexisting mental illness. METHODS: We searched OVID Medline, Pubmed, EMBASE, and the Cochrane review files using a combination of search terms using a PICO (population, intervention, comparison, outcome) model focusing on surgical care for patients with mental illness. RESULTS: The literature on mental illness in surgical patients focused primarily on preoperative and postoperative disparities in surgical care between patients with and without a diagnosis of mental illness. Preoperatively, patients were 7.5% to 40% less likely to be deemed surgical candidates, were less likely to receive testing, and were more likely to present at later stages of their disease or have delayed surgical care. Similar themes arose in the postoperative period: patients with mental illness were more likely to require ICU admission, were up to 3 times more likely to have a prolonged length of hospital stay, had a 14% to 270% increased likelihood of having postoperative complications, and had significantly higher health care costs. CONCLUSIONS: Surgical patients with preexisting psychiatric diagnoses have a propensity for worse perioperative outcomes compared to patients without reported mental illness. Taking a thorough psychiatric history can potentially help surgical teams address disparities in access to care as well as anticipate and prevent adverse outcomes.

Understanding the barriers and facilitators to trauma registry development in resource-constrained settings: A survey of trauma registry stewards and researchers.

BACKGROUND: The implementation of trauma registries has proven a highly effective means of injury control. However, many low and middle-income countries lack trauma registries. Those that have trauma registries vary widely in terms of both implementation and structure. We sought to identify the most common barriers that stand in the way of sustainable trauma registry implementation, and the types of strategies that have proven successful in overcoming these barriers. METHODS: We conducted a questionnaire of trauma registry stewards and researchers in LMICs. RESULTS: Twenty-two individuals responded to the questionnaire representing trauma registry experiences across thirteen LMICs. The most common barriers to trauma registry implementation identified included staffing, funding, and stakeholder engagement. Many different strategies for addressing these barriers were discussed. Those mentioned by multiple respondents included the need for a trauma registry champion, fostering strong stakeholder relationships, and improving efficiency of data collection. CONCLUSIONS: Though trauma registry implementation and structure may differ from place to place, there are many shared barriers and facilitators that can be learned from. Identifying these common experiences can help create a repository of knowledge that can better serve those looking to implement their own trauma registries in similar settings.

Time to operating room matters in modern management of pancreatic injuries: A national review on the management of adult pancreatic injury at Canadian level 1 trauma centers.

BACKGROUND: Pancreatic injuries are rare, difficult to diagnose, and complex to manage despite multiple published guidelines. This study was undertaken to evaluate the current diagnosis and management of pancreatic trauma in Canadian trauma centers. METHODS: This is a multi-institutional retrospective study from 2009 to 2014 including patients from eight level 1 trauma centers across Canada. All patients with a diagnosis of pancreatic trauma were included. Demographics, injury characteristics, vital signs on admission, and type of management were collected. Outcomes measured were mortality and pancreas-related morbidity. RESULTS: Two hundred seventy-nine patients were included. The median age was 29 years (interquartile range, 21-43 years), 72% were male, and 79% sustained blunt trauma. Pancreatic injury included the following grades: I, 26%; II, 28%; III, 33%; IV, 9%; and V, 4%. The overall mortality rate was 11%, and the pancreas-related complication rate was 25%. The majority (88%) of injuries were diagnosed within 24 hours of injury, primarily (80%) with a computed tomography scan. The remaining injuries were diagnosed with ultrasound (6%) and magnetic resonance cholangiopancreatography (MRCP) (2%) and at the time of laparotomy or autopsy (12%). One hundred seventy-five patients (63%) underwent an operative intervention, most commonly a distal pancreatectomy (44%); however, there was great variability in operative procedure chosen even when considering grade of injury. CONCLUSION: Pancreatic injuries are associated with multiple other injuries and have significant morbidity and mortality. Their management demonstrates significant practice variation within a national trauma system. LEVEL OF EVIDENCE: Therapeutic/care management, level V; Prognostic and epidemiological, level IV.

Maximizing the potential of trauma registries in low-income and middle-income countries.

Injury is a major global health issue, resulting in millions of deaths every year. For decades, trauma registries have been used in wealthier countries for injury surveillance and clinical governance, but their adoption has lagged in low-income and middle-income countries (LMICs). Paradoxically, LMICs face a disproportionately high burden of injury with few resources available to address this pandemic. Despite these resource constraints, several hospitals and regions in LMICs have managed to develop trauma registries to collect information related to the injury event, process of care, and outcome of the injured patient. While the implementation of these trauma registries is a positive step forward in addressing the injury burden in LMICs, numerous challenges still stand in the way of maximizing the potential of trauma registries to inform injury prevention, mitigation, and improve quality of trauma care. This paper outlines several of these challenges and identifies potential solutions that can be adopted to improve the functionality of trauma registries in resource-poor contexts. Increased recognition and support for trauma registry development and improvement in LMICs is critical to reducing the burden of injury in these settings.

Implementation of Neurocritical Care Is Associated With Improved Outcomes in Traumatic Brain Injury.

Background Traditionally, the delivery of dedicated neurocritical care (NCC) occurs in distinct NCC units and is associated with improved outcomes. Institution-specific logistical challenges pose barriers to the development of distinct NCC units; therefore, we developed a consultancy NCC service coupled with the implementation of invasive multimodal neuromonitoring, within a medical-surgical intensive care unit. Our objective was to evaluate the effect of a consultancy NCC program on neurologic outcomes in severe traumatic brain injury patients. METHODS: We conducted a single-center quasi-experimental uncontrolled pre- and post-NCC study in severe traumatic brain injury patients (Glasgow Coma Scale ≤8). The NCC program includes consultation with a neurointensivist and neurosurgeon and multimodal neuromonitoring. Demographic, injury severity metrics, neurophysiologic data, and therapeutic interventions were collected. Glasgow Outcome Scale (GOS) at 6 months was the primary outcome. Multivariable ordinal logistic regression was used to model the association between NCC implementation and GOS at 6 months. RESULTS: A total of 113 patients were identified: 76 pre-NCC and 37 post-NCC. Mean age was 39 years (standard deviation [SD], 2) and 87 of 113 (77%) patients were male. Median admission motor score was 3 (interquartile ratio, 1-4). Daily mean arterial pressure was higher (95 mmHg [SD, 10]) versus (88 mmHg [SD, 10], p<0.001) and daily mean core body temperature was lower (36.6°C [SD, 0.90]) versus (37.2°C [SD, 1.0], p=0.001) post-NCC compared with pre-NCC, respectively. Multivariable regression modelling revealed the NCC program was associated with a 2.5 increased odds (odds ratios, 2.5; 95% confidence interval, 1.1-5.3; p=0.022) of improved 6-month GOS. CONCLUSIONS: Implementation of a NCC program is associated with improved 6 month GOS in severe TBI patients.

A model for identifying and ranking need for trauma service in nonmetropolitan regions based on injury risk and access to services.

BACKGROUND: Timely access to definitive trauma care has been shown to improve survival rates after severe injury. Unfortunately, despite development of sophisticated trauma systems, prompt, definitive trauma care remains unavailable to over 50 million North Americans, particularly in rural areas. Measures to quantify social and geographic isolation may provide important insights for the development of health policy aimed at reducing the burden of injury and improving access to trauma care in presently under serviced populations. METHODS: Indices of social deprivation based on census data, and spatial analyses of access to trauma centers based on street network files were combined into a single index, the Population Isolation Vulnerability Amplifier (PIVA) to characterize vulnerability to trauma in socioeconomically and geographically diverse rural and urban communities across British Columbia. Regions with a sufficient core population that are more than one hour travel time from existing services were ranked based on their level of socioeconomic vulnerability. RESULTS: Ten regions throughout the province were identified as most in need of trauma services based on population, isolation and vulnerability. Likewise, 10 communities were classified as some of the least isolated areas and were simultaneously classified as least vulnerable populations in province. The model was verified using trauma services utilization data from the British Columbia Trauma Registry. These data indicate that including vulnerability in the model provided superior results to running the model based only on population and road travel time. CONCLUSIONS: Using the PIVA model we have shown that across Census Urban Areas there are wide variations in population dependence on and distances to accredited tertiary/district trauma centers throughout British Columbia. Many of the factors that influence access to definitive trauma care can be combined into a single quantifiable model that researchers in the health sector can use to predict where to place new services. The model can also be used to locate optimal locations for any basket of health services.