Trauma resident exposure in Canada and operative numbers (TraumaRECON): a national multicentre retrospective review of operative and nonoperative trauma teaching.

BACKGROUND: General surgeons play an important role in the provision of trauma care in Canada and the current extent of their trauma experience during training is unknown. We sought to quantify the operative and nonoperative educational experiences among Canadian general surgery trainees. METHODS: We conducted a multicentre retrospective study of major operative exposures experienced by general surgery residents, as identified using institutional trauma registries and subsequent chart-level review, for 2008-2018. We also conducted a site survey on trauma education and structure. RESULTS: We collected data on operative exposure for general surgery residents from 7 programs and survey data from 10 programs. Operations predominantly occurred after hours (73% after 1700 or on weekends) and general surgery residents were absent from a substantial proportion (25%) of relevant trauma operations. The structure of trauma education was heterogeneous among programs, with considerable site-specific variability in the involvement of surgical specialties in trauma care. During their training, graduating general surgery residents each experienced around 4 index trauma laparotomies, 1 splenectomy, 1 thoracotomy, and 0 neck explorations for trauma. CONCLUSION: General surgery residents who train in Canada receive variable and limited exposure to operative and nonoperative trauma care. These data can be used as a baseline to inform the application of competency-based medical education in trauma care for general surgery training in Canada.

Efficacy and Safety of Anti-Xa-Guided Versus Fixed Dosing of Low Molecular Weight Heparin for Prevention of Venous Thromboembolism in Trauma Patients: A Systematic Review and Meta-Analysis.

PURPOSE: Trauma patients are at high risk of venous thromboembolism (VTE). We summarize the comparative efficacy and safety of anti-Xa-guided versus fixed dosing for low molecular weight heparin (LMWH) for the prevention of VTE in adult trauma patients. METHODS: We searched Medline and Embase from inception through June 1, 2022. We included randomized controlled trials or observational studies comparing anti-Xa-guided versus fixed dosing of LMWH for thromboprophylaxis in adult trauma patients. We incorporated primary data from 2 large observational cohorts. We pooled effect estimates using a random-effects model. We assessed risk of bias using the ROBINS-I tool for observational studies and assessed certainty of findings using GRADE methodology. RESULTS: We included 15 observational studies involving 10,348 patients. No randomized controlled trials were identified. determined that, compared to fixed LMWH dosing, anti-Xa-guided dosing may reduce deep vein thrombosis [adjusted odds ratio (aOR); 0.52, 95% CI: 0.40-0.69], pulmonary embolism (aOR: 0.48, 95% CI: 0.30-0.78) or any VTE (aOR: 0.54, 95% CI: 0.42-0.69), though all estimates are based on low certainty evidence. There was an uncertain effect on mortality (aOR: 1.06, 95% CI: 0.85-1.32) and bleeding events (aOR: 0.84, 95% CI: 0.50-1.39), limited by serious imprecision. We used several sensitivity and subgroup analyses to confirm the validity of our assumptions. CONCLUSION: Anti-Xa-guided dosing may be more effective than fixed dosing for prevention of deep vein thrombosis, pulmonary embolism, and VTE for adult trauma patients. These promising findings justify the need for a high-quality randomized study with the potential to deliver practice changing results.

Injury outcomes across Canadian trauma systems: a historical cohort study.

PURPOSE: Most North American trauma systems have designated trauma centres (TCs) including level I (ultraspecialized high-volume metropolitan centres), level II (specialized medium-volume urban centres), and/or level III (semirural or rural centres). Trauma system configuration varies across provinces and it is unclear how these differences influence patient distributions and outcomes. We aimed to compare patient case mix, case volumes, and risk-adjusted outcomes of adults with major trauma admitted to designated level I, II, and III TCs across Canadian trauma systems. METHODS: In a national historical cohort study, we extracted data from Canadian provincial trauma registries on major trauma patients treated between 2013 and 2018 in all designated level I, II, or III TCs in British Columbia, Alberta, Quebec, and Nova Scotia; level I and II TCs in New Brunswick; and four TCs in Ontario. We used multilevel generalized linear models to compare mortality and intensive care unit (ICU) admission and competitive risk models for hospital and ICU length of stay (LOS). Ontario could not be included in outcome comparisons because there were no population-based data from this province. RESULTS: The study sample comprised 50,959 patients. Patient distributions in level I and II TCs were similar across provinces but we observed significant differences in case mix and volumes for level III TCs. There was low variation in risk-adjusted mortality and LOS across provinces and TCs but interprovincial and intercentre variation in risk-adjusted ICU admission was high. CONCLUSIONS: Our results suggest that differences in the functional role of TCs according to their designation level across provinces leads to significant variations in the distribution of patients, case volumes, resource use, and clinical outcomes. These results highlight opportunities to improve Canadian trauma care and underline the need for standardized population-based injury data to support national quality improvement efforts.

RéSUMé: OBJECTIF: La plupart des systèmes de traumatologie nord-américains disposent de centres de traumatologie (CT) désignés, y compris de niveau I (centres métropolitains ultraspécialisés à volume élevé), de niveau II (centres urbains spécialisés à volume moyen) et/ou de niveau III (centres semi-ruraux ou ruraux). La configuration des systèmes de traumatologie varie d'une province à l'autre et nous ne savons pas comment ces différences influent sur la répartition de la patientèle et sur les issues. Notre objectif était de comparer le mélange de cas des patient·es, le volume de cas et les issues ajustées en fonction du risque des adultes ayant subi un traumatisme majeur admis·es dans des CT désignés de niveaux I, II et III dans l'ensemble des systèmes de traumatologie canadiens. MéTHODE: Dans une étude de cohorte historique nationale, nous avons extrait des données des registres provinciaux canadiens de traumatologie sur les patient·es ayant subi un traumatisme majeur traité·es entre 2013 et 2018 dans tous les CT désignés de niveau I, II ou III en Colombie-Britannique, en Alberta, au Québec et en Nouvelle-Écosse, les CT de niveau I et II au Nouveau-Brunswick, et dans quatre CT en Ontario. Nous avons utilisé des modèles linéaires généralisés à plusieurs niveaux pour comparer la mortalité, les admissions en unité de soins intensifs (USI) et les modèles de risque compétitif pour la durée du séjour à l'hôpital et à l'USI. L'Ontario n'a pas pu être inclus dans les comparaisons des devenirs parce qu'il n'y avait pas de données démographiques pour cette province. RéSULTATS: L'échantillon de l'étude comptait 50 959 patient·es. La répartition des patient·es dans les CT de niveaux I et II était similaire d'une province à l'autre, mais nous avons observé des différences significatives dans le mélange des cas et les volumes pour les CT de niveau III. Il y avait une faible variation de la mortalité ajustée en fonction du risque et des durées de séjour entre les provinces et les CT, mais la variation interprovinciale et intercentre des admissions à l'USI ajustées en fonction du risque était élevée. CONCLUSION: Nos résultats suggèrent que les différences dans le rôle fonctionnel des CT selon leur niveau de désignation d'une province à l'autre entraînent des variations importantes dans la répartition des patient·es, le nombre de cas, l'utilisation des ressources et les issues cliniques. Ces résultats mettent en évidence les possibilités d'amélioration des soins de traumatologie au Canada et soulignent la nécessité de disposer de données normalisées sur les blessures dans la population pour appuyer les efforts nationaux d'amélioration de la qualité.

Efficacy and Safety of Low Molecular Weight Heparin Versus Unfractionated Heparin for Prevention of Venous Thromboembolism in Trauma Patients: A Systematic Review and Meta-analysis.

PURPOSE: Trauma patients are at high risk of VTE. We summarize the efficacy and safety of LMWH versus UFH for the prevention of VTE in trauma patients. METHODS: We searched 6 databases from inception through March 12, 2021. We included randomized controlled trials (RCTs) or observational studies comparing LMWH versus UFH for thromboprophylaxis in adult trauma patients. We pooled effect estimates across RCTs and observational studies separately, using random-effects model and inverse variance weighting. We assessed risk of bias using the Cochrane tool for RCTs and the Risk of Bias in Non-Randomized Studies (ROBINS)-I tool for observational studies and assessed certainty of findings using Grading of Recommendations, Assessment, Development and Evaluations methodology. RESULTS: We included 4 RCTs (879 patients) and 8 observational studies (306,747 patients). Based on pooled RCT data, compared to UFH, LMWH reduces deep vein thrombosis (RR 0.67, 95% CI 0.50 to 0.88, moderate certainty) and VTE (RR 0.68, 95% CI 0.51 to 0.90, moderate certainty). As compared to UFH, LMWH may reduce pulmonary embolism [adjusted odds ratio from pooled observational studies 0.56 (95% CI 0.50 to 0.62)] and mortality (adjusted odds ratio from pooled observational studies 0.54, 95% CI 0.45 to 0.65), though based on low certainty evidence. There was an uncertain effect on adverse events (RR from pooled RCTs 0.80, 95% CI 0.48 to 1.33, very low certainty) and heparin induced thrombocytopenia [RR from pooled RCTs 0.26 (95% CI 0.03 to 2.38, very low certainty)]. CONCLUSIONS: Among adult trauma patients, LMWH is superior to UFH for deep vein thrombosis and VTE prevention and may additionally reduce pulmonary embolism and mortality. The impact on adverse events and heparin induced thrombocytopenia is uncertain.

Prognostic factors for development of acute respiratory distress syndrome following traumatic injury: a systematic review and meta-analysis.

BACKGROUND: Our purpose was to summarise the prognostic associations between various clinical risk factors and development of acute respiratory distress syndrome (ARDS) following traumatic injury. METHODS: We conducted this review in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and CHARMS (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies) guidelines. We searched six databases from inception through December 2020. We included English language studies describing the clinical risk factors associated with development of post-traumatic ARDS, as defined by either the American-European Consensus Conference or Berlin definition. We pooled adjusted odds ratios for prognostic factors using the random effects method. We assessed risk of bias using the QUIPS (Quality in Prognosis Studies) tool and certainty of findings using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. RESULTS: We included 39 studies involving 5 350 927 patients. We identified the amount of crystalloid resuscitation as a potentially modifiable prognostic factor associated with development of post-traumatic ARDS (adjusted OR 1.19, 95% CI 1.15-1.24 for each additional litre of crystalloid administered within the first 6 h after injury; high certainty). Non-modifiable prognostic factors with a moderate or high certainty of association with post-traumatic ARDS included increasing age, non-Hispanic White race, blunt mechanism of injury, presence of head injury, pulmonary contusion or rib fracture and increasing chest injury severity. CONCLUSIONS: We identified one important modifiable factor, the amount of crystalloid resuscitation within the first 24 h of injury, and several non-modifiable factors associated with development of post-traumatic ARDS. This information should support the judicious use of crystalloid resuscitation in trauma patients and may inform development of risk stratification tools.

Injury prevention in medical education: a Canadian medical school survey.

BACKGROUND: Injury has a major societal impact. In Canada, injury is the leading cause of death among those aged 1-44 years, the fifth-leading cause of death among those of all ages and is responsible for a burden of US$26.8 billion in 2010. It holds that most injuries are predictable and preventable, and therefore, such statistics represent a serious public health concern. Given that physicians play a vital role in the prevention and control of injuries, further information regarding the current state of injury prevention education in medical undergraduate programmes in Canada would be beneficial. We hypothesise that the results of an observational survey distribute to all Canadian medical schools will demonstrate a substantial gap in injury prevention education integration in the existing medical school curriculums. STUDY OBJECTIVE: To evaluate the current status of Injury Prevention Education in Canadian Medical Schools preclerkship and clerkship medical curriculum. METHODS: Electronic surveys evaluating the current status of injury prevention education were sent via email to each of the 16 Canadian medical schools. RESULTS: Nine Canadian medical faculties (56%, n=9) responded. Eight of the nine medical schools (88.89%, n=8) offered at least five injury prevention related topics in their respective curricula. The most common injury-related courses were Role of physicians in the prevention of injuries (100%, n=9) and epidemiology of injury (88.89%, n=8). All respondent medical faculties (100%, n=9) offered at least a single injury prevention specific topic in their curricula. Most surveyed medical faculties (88.89%, n=8) offered nine injury-specific topics. The most common injury-specific topics included falls, suicide and self-harm, alcohol, burns and scalds, and concussion (100%, n=9).

Resuscitative endovascular balloon occlusion of the aorta in Canada: a context-specific position paper from the Canadian Collaborative for Urgent Care Surgery (CANUCS).

SummaryResuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-described intervention for noncompressible torso hemorrhage. Several Canadian centres have included REBOA in their hemorrhagic shock protocols. However, REBOA has known complications and equipoise regarding its use persists. The Canadian Collaborative on Urgent Care Surgery (CANUCS) comprises surgeons who provide acute trauma care and leadership in Canada, with experience in REBOA implementation, use, education and research. Our goal is to provide evidence- and experience-based recommendations regarding institutional implementation of a REBOA program, including multidisciplinary educational programs, attention to device and care pathway logistics, and a robust quality assurance program. This will allow Canadian trauma centres to maximize patient benefits and minimize risks of this potentially life-saving technology.

The Association of Frailty With Adverse Outcomes After Multisystem Trauma: A Systematic Review and Meta-analysis.

BACKGROUND: Frailty strongly predicts adverse outcomes in a variety of clinical settings; however, frailty-related trauma outcomes have not been systematically reviewed and quantitatively synthesized. Our objective was to systematically review and meta-analyze the association between frailty and outcomes (mortality-primary; complications, health resource use, and patient experience-secondary) after multisystem trauma. METHODS: After registration (CRD42018104116), we applied a peer-reviewed search strategy to MEDLINE, EMBASE, and Comprehensive Index to Nursing and Allied Health Literature (CINAHL) from inception to May 22, 2019, to identify studies that described: (1) multisystem trauma; (2) participants ≥18 years of age; (3) explicit frailty instrument application; and (4) relevant outcomes. Excluded studies included those that: (1) lacked a comparator group; (2) reported isolated injuries; and (3) reported mixed trauma and nontrauma populations. Criteria were applied independently, in duplicate to title/abstract and full-text articles. Risk of bias was assessed using the Risk of Bias in Nonrandomized Studies-of Interventions (ROBINS-I) tool. Effect measures (adjusted for prespecified confounders) were pooled using random-effects models; otherwise, narrative synthesis was used. RESULTS: Sixteen studies were included that represented 5198 participants; 9.9% of people with frailty died compared to 4.2% of people without frailty. Frailty was associated with increased mortality (adjusted odds ratio [OR], 1.53; 95% confidence interval [CI], 1.37-1.71), complications (adjusted OR, 2.32; 95% CI, 1.72-3.15), and adverse discharge (adjusted OR, 1.78; 95% CI, 1.29-2.45). Patient function, experience, and resource use outcomes were rarely reported. CONCLUSIONS: The presence of frailty is significantly associated with mortality, complications, and adverse discharge disposition after multisystem trauma. This provides important prognostic information to inform discussions with patients and families and highlights the need for trauma system optimization to meet the complex needs of older patients.

Early identification of the need for major intervention in patients with traumatic hemorrhage: development and internal validation of a simple bleeding score.

BACKGROUND: Failure to rapidly identify bleeding in trauma patients leads to substantial morbidity and mortality. We aimed to develop and validate a simple bedside score for identifying bleeding patients requiring escalation of care beyond initial resuscitation. METHODS: We included patients with major blunt or penetrating trauma, defined as those with an Injury Severity Score greater than 12 or requiring trauma team activation, at The Ottawa Hospital from September 2014 to September 2017. We used logistic regression for derivation. The primary outcome was a composite of the need for massive transfusion, embolization or surgery for hemostasis. We prespecified clinical, laboratory and imaging predictors using findings from our prior systematic review and survey of Canadian traumatologists. We used an AIC-based stepdown procedure based on the Akaike information criterion and regression coefficients to create a 5-variable score for bedside application. We used bootstrap internal validation to assess optimism-corrected performance. RESULTS: We included 890 patients, of whom 133 required a major intervention. The main model comprised systolic blood pressure, clinical examination findings suggestive of hemorrhage, lactate level, focused assessment with sonography in trauma (FAST) and computed tomographic imaging. The C statistic was 0.95, optimism-corrected to 0.94. A simplified Canadian Bleeding (CAN-BLEED) score was devised. A score cut-off of 2 points yielded sensitivity of 97.7% (95% confidence interval [CI] 93.6 to 99.5) and specificity 73.2% (95% CI 69.9 to 76.3). An alternative version that included mechanism of injury rather than CT had lower discriminative ability (C statistic = 0.89). CONCLUSION: A simple yet promising bleeding score is proposed to identify highrisk patients in need of major intervention for traumatic bleeding and determine the appropriateness of early transfer to specialized trauma centres. Further research is needed to evaluate the performance of the score in other settings, define interrater reliability and evaluate the potential for reduction of time to intervention.

CONTEXTE: Les délais dans la détection des saignements actifs chez les patients en traumatologie entraînent une morbidité et une mortalité élevées. L'objectif était d'élaborer et de valider une échelle simple, à utiliser en contexte clinique pour repérer les patients qui présentent un saignement actif et qui nécessitent une intensification des soins après la réanimation initiale. MÉTHODES: Les critères d'inclusion étaient les suivants : admission à l'Hôpital d'Ottawa entre septembre 2014 et septembre 2017 pour un traumatisme contondant ou pénétrant, et score de gravité de la blessure supérieur à 12 ou mobilisation de l'équipe de traumatologie. Nous avons fait la dérivation par régression logistique. Le principal critère d'évaluation était la nécessité d'une transfusion massive, d'une embolisation ou d'une opération pour rétablir l'hémostase. Nous avons établi les facteurs prédictifs décelables en clinique, en laboratoire et à l'imagerie en fonction des résultats que nous avons obtenus dans le cadre d'une revue systématique et d'un sondage mené auprès de traumatologues canadiens. Nous avons utilisé une procédure avec ajustement selon le critère d'information d'Akaike (AIC) et des coefficients de régression afin de créer une échelle à 5 variables applicable en contexte clinique. Pour ce qui est de la validation interne, nous avons ajusté les valeurs dites « optimistes ¼ à l'aide de la méthode d'autoamorçage (bootstrap). RÉSULTATS: Nous avons inclus 890 patients, dont 133 nécessitaient une intervention majeure. Le modèle de base intégrait la pression artérielle systolique, les constatations cliniques indiquant une hémorragie, le taux de lactate, les résultats de l'échographie ciblée en traumatologie (FAST) et les résultats de la tomodensitométrie (TMD). La statistique C s'élevait à 0,95 (0,94 après ajustement). Nous avons conçu une échelle canadienne simplifiée d'évaluation des saignements actifs (CANBLEED). Un seuil de 2 points a généré une sensibilité de 97,7 % (intervalle de confiance [IC] à 95 % de 93,6 à 99,5) et une spécificité de 73,2 % (IC à 95 % de 69,9 à 76,3). Une deuxième version, qui tient compte du mécanisme de blessure plutôt que des résultats de la TMD, avait un pouvoir de discrimination inférieur (statistique C = 0,89). CONCLUSION: Nous proposons une échelle d'évaluation des saignements actifs simple, mais prometteuse. Celle-ci vise à repérer les patients à haut risque qui nécessitent une intervention majeure pour un saignement d'origine traumatique ainsi qu'à déterminer la pertinence d'un transfert précoce dans un centre de traumatologie. Des études complémentaires seront nécessaires afin d'évaluer l'échelle dans d'autres milieux, d'établir sa fiabilité interévaluateurs et d'évaluer le potentiel de réduction des délais d'intervention.

Exclusion criteria and adverse events in perioperative trials of tranexamic acid: a systematic review and meta-analysis.

BACKGROUND: Tranexamic acid (TXA) is an inexpensive therapy effective at minimizing perioperative blood loss and transfusion. However, it remains underutilized due to safety concerns. To date, no evidence-based guidelines exist identifying which patients should not receive TXA therapy. This study determined patient groups for whom safety information regarding TXA is lacking due to common exclusion from perioperative TXA trials. STUDY DESIGN AND METHODS: A systematic review searching the databases Medline, EMBASE, CENTRAL, and Clinicaltrials.gov was performed. Randomized controlled trials (RCTs) administering systemic TXA perioperatively to elective or emergent surgery patients were eligible. Our primary outcome was to describe exclusion criteria of RCTs, and the secondary outcome was TXA safety. A descriptive synthesis of exclusion criteria was performed, and TXA safety was assessed by meta-analysis. RESULTS: A total of 268 eligible RCTs were included. Meta-analysis showed that systemic TXA did not increase risk of adverse events compared to placebo or no intervention (relative risk, 1.05; 95% confidence interval, 0.99-1.12). Patient groups commonly excluded from perioperative TXA trials, and thus potentially lacking TXA safety data, were those with major comorbidities, a history of thromboembolism, medication use affecting coagulation, TXA allergy, and coagulopathy. Exclusion of patients with major comorbidities may not be necessary; we showed that the risk of adverse events was similar in studies that excluded patients with major comorbidities and those that did not. CONCLUSION: Sufficient evidence exists to develop perioperative guidelines for TXA use in many populations. Further studies evaluating perioperative TXA use in patients with a history of thromboembolism are warranted.

Exclusion criteria and adverse events in perioperative trials of tranexamic acid in cardiac surgery: a systematic review and meta-analysis.

PURPOSE: Tranexamic acid (TXA) reduces perioperative blood loss and transfusion requirement following cardiac surgery. Nevertheless, TXA remains underutilized because of concerns regarding development of adverse events. We conducted a systematic review to determine which patients are commonly excluded from TXA cardiac surgery clinical trials to determine if there are patient groups lacking safety data on TXA. METHODS: The databases Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were searched until September 2017. Eligible studies were randomized-controlled trials (RCTs) administering systemic TXA perioperatively to patients undergoing any cardiac surgery. Our primary outcome was the exclusion criteria for each RCT, and the secondary endpoint was TXA safety. A descriptive synthesis was performed to analyze the exclusion criteria. TXA safety was assessed with meta-analysis. PRINCIPAL FINDINGS: Seventy eligible RCTs were included. The most common reasons for excluding patients from TXA cardiac surgery trials were major hepatic, renal, or cardiac comorbidities (76% of studies). Meta-analysis showed that TXA did not increase the risk of adverse events compared with placebo or no intervention (risk ratio, 0.97; 95% confidence interval, 0.88 to 1.07), including thrombosis and seizure. CONCLUSION: We found that systemic TXA is safe to use in cardiac surgery. Certain patient groups are frequently excluded from TXA cardiac surgery trials, and may consequently have limited efficacy and safety data on TXA. Further research in these patient groups may be needed; nevertheless, for many patient populations there are sufficient data to inform evidence-based guidelines for TXA use in cardiac surgery. TRIAL REGISTRATION: PROSPERO (CRD42017060971); registered 4 April, 2017.

RéSUMé: OBJECTIF: L'acide tranexamique (ATX) réduit les pertes sanguines périopératoires et les besoins transfusionnels après une chirurgie cardiaque. L'ATX demeure toutefois sous-utilisé en raison de craintes quant à la survenue d'événements indésirables. Nous avons réalisé une revue systématique afin d'identifier les patients le plus fréquemment exclus des études cliniques sur l'utilisation d'ATX en chirurgie cardiaque pour déterminer si les données d'innocuité de l'ATX sont insuffisantes pour certains groupes de patients. MéTHODE: Des recherches ont été effectuées dans les bases de données Medline, EMBASE et dans le Cochrane Central Register of Controlled Trials pour en tirer les études publiées jusqu'en septembre 2017. Pour être éligibles, les études devaient être des études randomisées contrôlées (ERC) examinant l'administration systémique d'ATX en période périopératoire à des patients subissant une chirurgie cardiaque, quelle qu'elle soit. Le critère d'évaluation principal de notre étude s'intéressait aux critères d'exclusion de chaque ERC, et le critère d'évaluation secondaire à l'innocuité de l'ATX. Une synthèse descriptive a été réalisée afin d'analyser les critères d'exclusion. L'innocuité de l'ATX a été évaluée par une méta-analyse. CONSTATATIONS PRINCIPALES: Soixante-dix ERC éligibles ont été incluses dans notre revue. Les raisons les plus fréquentes d'exclusion de patients des études d'ATX en chirurgie cardiaque étaient des comorbidités hépatiques, rénales ou cardiaques majeures (76 % des études). La méta-analyse a démontré que l'ATX n'augmentait pas le risque d'événements indésirables par rapport au placebo ou à toute autre intervention (risque relatif, 0,97; intervalle de confiance 95 %, 0,88 à 1,07), y compris le risque de thrombose ou de convulsion. CONCLUSION: Nous avons observé que l'ATX par voie systémique peut être utilisé en toute sécurité en chirurgie cardiaque. Certains groupes de patients sont fréquemment exclus des études portant sur l'ATX en chirurgie cardiaque, et les données sur l'efficacité et l'innocuité de l'ATX dans ces populations pourraient par conséquent être limitées. Des recherches supplémentaires dans ces groupes pourraient être nécessaires; toutefois, les données pour plusieurs populations de patients sont suffisantes pour établir des directives fondées sur les données probantes concernant l'utilisation d'ATX en chirurgie cardiaque. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42017060971); enregistrée le 4 avril 2017.

Expanding the trauma code to other causes of hemorrhagic shock ­ ruptured abdominal aortic aneurysms

Summary: Expediting life-saving care for hemorrhagic shock through multi-disciplinary code protocols is a potential method to improve outcomes. Trauma codes have become standard of care at most tertiary care centres; however, it is unclear if similar protocols can improve delivery of care for other forms of hemorrhagic shock. We examined the feasibility of a code protocol for ruptured abdominal aortic aneurysms (RAAAs) by reviewing the literature and comparing patient outcomes for RAAA and trauma patients at our institution, where the latter have a wellestablished trauma code protocol. We show that, despite being similarly unstable, patients with RAAA experienced delays to care milestones compared with trauma patients, even when accounting for diagnostic delays. Combining these data with present understanding of factors implicated in RAAA survival, we propose that a "CodeAAA" protocol may fill an important gap in RAAA care and that further prospective studies examining the utility of such a code are warranted.

Blood transfusion knowledge of surgical residents: is an educational intervention effective?

BACKGROUND: Evidence-based transfusion education for surgical residents is crucial to improving practice. A pilot study was undertaken to assess the effectiveness of an education module for improving transfusion knowledge among surgical residents. METHODS: Modules were developed and delivered by experts in surgery and transfusion medicine. They were delivered to residents in their first 2 years of training (Surgical Foundations), and to General Surgery residents across all years of training. Premodule and postmodule and retention knowledge assessments were used to assess efficacy. Median assessment scores for each group were compared using a two-sample Wilcoxon rank-sum analysis. Chi-square tests were used to compare each group's correct response rates for each question across the three tests. RESULTS: Median assessment scores of residents in the Surgical Foundations program improved from a mean of 60% premodule to 80% postmodule and remained at 80% in the retention assessment (p < 0.01). Improvements were seen in the areas of transfusion dose, preoperative blood management, management of reactions, and informed consent (p < 0.01). Assessment scores of General Surgery residents also improved from 59%, to 73%, and to 82%, with significant improvement (p < 0.01) between premodule and postmodule scores. Improvements in correct response rates were seen in the areas of management of anemia and permissive hypotension in trauma (p < 0.01). CONCLUSIONS: Transfusion knowledge of surgical residents was improved by a collaborative educational initiative. This could serve as a model for other training programs to improve resident knowledge of evidence-based transfusion practices. The efficacy of such interventions in changing practice remains untested.

Conservative versus operative management in stable patients with penetrating abdominal trauma: the experience of a Canadian level 1 trauma centre.

BACKGROUND: The goal of conservative management (CM) of penetrating abdominal trauma is to avoid nontherapeutic laparotomies while identifying injuries early. Factors that may predict CM failure are not well established, and the experience of CM has not been well described in the Canadian context. METHODS: We searched a Canadian level 1 trauma centre database for all penetrating abdominal traumas treated between 2004 and 2014. Hemodynamically stable patients without peritonitis and without clear indications for immediate surgery were considered potential candidates for CM, and were included in the study. We compared those who were managed with CM with those who underwent immediate operative management (OM). Outcomes included mortality and length of stay (LOS). Further analysis was performed to identify predictors of CM failure. RESULTS: A total of 72 patients with penetrating abdominal trauma were classified as potential candidates for CM. Ten patients were managed with OM, and 62 with CM, with 9 (14.5%) ultimately failing CM and requiring laparotomy. The OM and CM groups were similar in terms of age, sex, injury severity, mechanism and number of injuries. There were no deaths in either group. The LOS in the intensive care (ICU)/trauma unit was 4.8 ± 3.2 days in the OM group and 2.9 ± 2.6 days in the CM group (p = 0.039). The only predictor for CM failure was intra-abdominal fluid on computed tomography (CT) scan (odds ratio 5.3, 95% confidence interval 1.01-28.19). CONCLUSION: In select patients with penetrating abdominal trauma, CM is safe and results in a reduced LOS in the ICU/trauma unit of 1.9 days. Fluid on CT scan is a predictor for failure.

CONTEXTE: L'objectif du traitement conservateur des traumatismes abdominaux pénétrants est d'éviter les laparotomies non thérapeutiques tout en ciblant rapidement les blessures. On n'a pas réussi à établir clairement des facteurs permettant de prédire la probabilité d'échec de ce type de traitement, ni bien décrit les paramètres d'utilisation de ce dernier dans le contexte canadien. MÉTHODES: Nous avons recensé dans la base de données d'un centre de traumatologie canadien de niveau 1 tous les cas de traumatismes abdominaux pénétrants traités entre 2004 et 2014. Les patients dont l'état hémodynamique était stable, qui ne souffraient pas de péritonite et qui ne nécessitaient pas manifestement une chirurgie immédiate ont été inclus dans l'étude en tant que candidats potentiels pour le traitement conservateur. Nous avons comparé les patients ayant reçu le traitement conservateur avec ceux ayant tout de suite été opérés. Nous avons entre autres évalué la mortalité et la durée de séjour. D'autres analyses ont été effectuées pour mettre en évidence des indicateurs de l'échec du traitement conservateur. RÉSULTATS: Au total, 72 patients affichant des traumatismes abdominaux pénétrants ont été classés comme des candidats potentiels pour le traitement conservateur. De ce nombre, 10 ont été opérés, et 62 ont reçu le traitement conservateur. Ce dernier a échoué chez 9 patients (14,5 %), qui ont dû subir une laparotomie. Les 2 groupes étaient semblables sur le plan de l'âge, du sexe, de la gravité des blessures et du mécanisme et du nombre de blessures. Aucun décès n'a été observé parmi les 2 groupes. La durée du séjour à l'unité de soins intensifs ou de traumatologie était de 4,8 ± 3,2 jours pour les patients ayant été opérés et de 2,9 ± 2,6 jours pour les patients ayant reçu le traitement conservateur (p = 0,039). Un seul indicateur de l'échec du traitement conservateur a été analysé, soit la présence de fluide intra-abdominal sur le tomodensitogramme (rapport de cotes 5,3; intervalle de confiance à 95 % 1,01-28,19). CONCLUSION: Chez un sous-groupe de patients souffrant de traumatismes abdominaux pénétrants, le traitement conservateur est sécuritaire et se traduit par une durée de séjour inférieure de 1,9 jour. La présence de fluide détectée par tomodensitographie est un indicateur de l'échec du traitement.

Road hazard: a systematic review of traffic injuries following recreational cannabis legalization.

PURPOSE: Acute cannabis use is associated with impaired driving performance and increased risk of motor vehicle crashes. Following the Canadian Cannabis Act's implementation, it is essential to understand how recreational cannabis legalization impacts traffic injuries, with a particular emphasis on Canadian emergency departments. This study aims to assess the impact of recreational cannabis legalization on traffic-related emergency department visits and hospitalizations in the broader context of North America. METHODS: A systematic review was conducted according to best practices and reported using PRISMA 2020 guidelines. The protocol was registered on July 5, 2022 (PROSPERO CRD42022342126). MEDLINE(R) ALL (OvidSP), Embase (OvidSP), CINAHL (EBSCOHost), and Scopus were searched without language or date restrictions up to October 12, 2023. Studies were included if they examined cannabis-related traffic-injury emergency department visits and hospitalizations before and after recreational cannabis legalization. The risk of bias was assessed. Meta-analysis was not possible due to heterogeneity. RESULTS: Seven studies were eligible for the analysis. All studies were conducted between 2019 and 2023 in Canada and the United States. We found mixed results regarding the impact of recreational cannabis legalization on emergency department visits for traffic injuries. Four of the studies included reported increases in traffic injuries after legalization, while the remaining three studies found no significant change. There was a moderate overall risk of bias among the studies included. CONCLUSIONS: This systematic review highlights the complexity of assessing the impact of recreational cannabis legalization on traffic injuries. Our findings show a varied impact on emergency department visits and hospitalizations across North America. This underlines the importance of Canadian emergency physicians staying informed about regional cannabis policies. Training on identifying and treating cannabis-related impairments should be incorporated into standard protocols to enhance response effectiveness and patient safety in light of evolving cannabis legislation.

RéSUMé: OBJECTIF: La consommation aiguë de cannabis est associée à une conduite avec facultés affaiblies et à un risque accru d'accidents de la route. À la suite de la mise en œuvre de la Loi canadienne sur le cannabis, il est essentiel de comprendre l'incidence de la légalisation du cannabis à des fins récréatives sur les blessures de la route, en mettant l'accent sur les services d'urgence canadiens. Cette étude vise à évaluer l'impact de la légalisation du cannabis à des fins récréatives sur les visites et les hospitalisations aux urgences liées à la circulation dans le contexte plus large de l'Amérique du Nord. MéTHODES: Une revue systématique a été menée selon les meilleures pratiques et a été rapportée en utilisant les directives PRISMA 2020. Le protocole a été enregistré le 5 juillet 2022 (PROSPERO CRD42022342126). MEDLINE(R) ALL (OvidSP), Embase (OvidSP), CINAHL (EBSCOHost) et Scopus ont été fouillés sans restriction de langue ou de date jusqu'au 12 octobre 2023. Des études ont été incluses si elles examinaient les visites aux urgences et les hospitalisations avant et après la légalisation du cannabis à des fins récréatives. Le risque de biais a été évalué. La méta-analyse n'était pas possible en raison de l'hétérogénéité. RéSULTATS: Sept études étaient admissibles à l'analyse. Toutes les études ont été menées entre 2019 et 2023 au Canada et aux États-Unis. Nous avons trouvé des résultats mitigés concernant l'impact de la légalisation du cannabis récréatif sur les visites aux urgences pour les blessures de la route. Quatre des études incluaient une augmentation des accidents de la route après la légalisation, tandis que les trois autres études n'ont révélé aucun changement significatif. Le risque global de biais était modéré parmi les études incluses. CONCLUSIONS: Cet examen systématique met en évidence la complexité de l'évaluation de l'impact de la légalisation du cannabis récréatif sur les blessures de la route. Nos résultats montrent un impact varié sur les visites aux urgences et les hospitalisations en Amérique du Nord. Cela souligne l'importance pour les médecins d'urgence canadiens de se tenir informés des politiques régionales sur le cannabis. La formation sur l'identification et le traitement des déficiences liées au cannabis devrait être intégrée aux protocoles normalisés afin d'améliorer l'efficacité de l'intervention et la sécurité des patients à la lumière de l'évolution de la législation sur le cannabis.

Rethinking cervical spine clearance in obtunded trauma patients: An updated systematic review and meta-analysis.

BACKGROUND: Cervical spine injuries (CSI) are often challenging to diagnose in obtunded adult patients with blunt trauma and the optimal imaging modality remains uncertain. This study systematically synthesized the last decade of evidence to determine the type of imaging required to clear the c-spine in obtunded patients with blunt trauma. METHODS: A systematic review with meta-analysis was conducted and reported using PRISMA 2020 guidelines. The protocol was registered on June 22, 2022 (PROSPERO CRD42022341386). MEDLINE (Ovid), EMBASE, and Cochrane Library were searched for studies published between January 1, 2012, and October 17, 2023. Studies comparing CT alone to CT combined with MRI for c-spine clearance were included. Two independent reviewers screened articles for eligibility in duplicate. Meta-analysis was conducted using a random-effect model. Risk of bias and quality assessment were performed using the ROBINS-I and QUADAS-2. The certainty of evidence was assessed using the GRADE methodology. RESULTS: 744 obtunded trauma patients from six included studies were included. Among the 584 that had a negative CT scan, the pooled missed rate of clinically significant CSI using CT scans alone was 6 % (95 % CI: 0.02 to 0.17), and the pooled missed rate of CSI requiring treatment was 7 % (95 % CI: 0.02 to 0.18). High heterogeneity was observed among included studies (I² > 84 %). The overall risk of bias was moderate, and the quality of evidence was low due to the retrospective nature of the included studies and high heterogeneity. CONCLUSIONS: Limited evidence published in the last decade found that CT scans alone may not be sufficient for detecting clinically significant CSI and injuries requiring treatment in obtunded adult patients with blunt trauma. IMPLICATIONS OF KEY FINDINGS: Clinicians should be aware of the limitations of CT scans and consider using MRI when appropriate. Future research should focus on prospective studies with standardized outcome measures and uniform reporting.

The impact of time to hemostatic intervention and delayed care for patients with traumatic hemorrhage: A systematic review.

BACKGROUND: Uncontrolled bleeding is a common cause of preventable mortality in trauma. While it is intuitive that delays to hemostasis may lead to worse outcomes, the impacts of these delays remain incompletely explored. This systematic review aimed to characterize the extant definitions of delayed hemostatic intervention and to quantify the impacts of delays on clinical outcomes. METHODS: We searched EMBASE, MEDLINE, and Web of Science from inception to August 2022. Studies defining "delayed intervention" and those comparing times to intervention among adults presenting to hospital with blunt or penetrating injuries who required major hemostatic intervention were eligible. The coprimary outcomes were mortality and the definition of delay to hemostasis used. Secondary outcomes included units of packed red blood cells received, length of stay in hospital, and length of stay in intensive care. RESULTS: We identified 2,050 studies, with 24 studies including 10,168 patients meeting the inclusion criteria. The majority of studies were retrospective observational cohort studies, and most were at high risk of bias. A variety of injury patterns and hemostatic interventions were considered, with 69.6% of studies reporting a statistically significant impact of increased time to intervention on mortality. Definitions of delayed intervention ranged from 10 minutes to 4 hours. Conflicting data were reported for impact of time on receipt of blood products, while one study found a significant impact on intensive care length of stay. No studies assessed length of stay in hospital. CONCLUSION: The extant literature is heterogeneous with respect to injuries included, methods of hemostasis employed, and durations of delay examined. While the majority of the included studies demonstrated a statistically significant relationship between time to intervention and mortality, an evidence-informed definition of delayed intervention for bleeding trauma patients at large has not been solidified. In addition, standardized research is needed to establish targets, which could reduce morbidity and mortality. LEVEL OF EVIDENCE: Systematic Review; Level IV.

A systematic review and meta-analysis of sample size methodology for traumatic hemorrhage trials.

BACKGROUND: Trauma hemorrhage remains the most common cause of preventable mortality in trauma. To guide clinical practice, RCTs provide high-quality evidence to inform clinical decision making. The clinical relevance and inferences made by RCTs are dependent on assumptions made during sample size calculation. METHODS: To describe the quality of methodology for sample size determination, we conducted a systemic review RCTs evaluating interventions that aim to improve survival in adults with trauma-related hemorrhage. Estimated and actual outcome data are compared, including components of sample size determination. RESULTS: A total of 13 RCTs were included. We noted a high rate of negative trial results (11 of 13 studies). Most studies were multi-center and conducted in North America, evaluating patients with blunt and penetrating injuries. The criteria for hemorrhagic shock varied across studies. All studies did not accurately estimate the mortality rate during sample size calculation. All but one study overestimated the mortality reduction during sample size calculation; the median absolute mortality reduction was 3%, compared with a target of 10%. Only the CRASH-2 study used a minimal clinically important different for treatment effect target. No RCTs employed prognostic enrichment. Most studies were terminated (8 of 13), mainly for futility. CONCLUSION: Taken together, this review highlights that current clinical trial methodology is limited by imprecise control group risk estimates, overly optimistic treatment effect estimates, and lack of transparent justification for such targets. These limitations result in studies at high risk for futility and potentially premature abandonment of promising therapies. Given the high morbidity and mortality of trauma-related hemorrhage, we recommend that future conduct of trauma RCTs incorporate (1) prognostic enrichment to inform baseline risk, (2) justify target treatment differences based on clinical importance and realistic estimates of feasibility, and (3) be transparent and provide justification for the assumptions made. LEVEL OF EVIDENCE: Systematic Review/Meta-Analysis; Level III.

Predictors of mortality among older major trauma patients.

BACKGROUND: Older trauma patients have a higher mortality yet are more likely to be under-triaged compared to younger patients. Studies have suggested that current trauma team activation criteria are suboptimal for older patients. OBJECTIVES: The objective was to describe trauma care delivered, patient outcomes, and to identify variables independently associated with mortality. METHODS: We performed a health records review from 2014 to 2020 of older (age ≥ 65 years) trauma patients presenting to a level one trauma centre with any of the following: injury severity score (ISS) > 12, and all trauma team activations or admission to the trauma ward. The primary outcome was 30-day all-cause mortality. Secondary outcomes included injury mechanism and trauma care delivered. Multivariable logistic regression was used to identify factors independently associated with 30-day all-cause mortality. Multiple imputation was used to deal with missing data. RESULTS: We enrolled 1,380 patients (mean age 80 years, mean ISS 18); 26.8% had multimorbidity (≥ 2 chronic conditions) and 65.9% met criteria for polypharmacy (≥ 5 medications). The most common mechanism was fall from standing height (61.1%). Thirty-day all-cause mortality occurred in 239 (17.3%) patients. A Glasgow coma scale (GCS) < 15 (odds ratio [OR] = 5.55; 95% CI 3.73-8.24), ISS > 15 (OR = 3.75, 95% CI 2.35-6.01), age ≥ 85 years (OR = 2.04, 95% CI 1.29-3.22), anticoagulation with a direct oral anticoagulant (DOAC) or warfarin (OR = 1.59, 95% CI 1.08-2.35) and multimorbidity (OR = 1.53, 95% CI 1.06-2.22) were significantly associated with increased risk 30-day mortality (C-statistic = 0.82, 95% CI 0.79-0.85). Dementia (OR = 0.61, 95% CI 0.40-0.95) and time to CT scan > 60 min (OR = 0.50, 95% CI 0.34-0.74) were associated with decreased mortality risk. CONCLUSION: We identified five factors associated with increased 30-day mortality in older trauma patients: GCS < 15, ISS > 15, age ≥ 85 years, anticoagulation, and multimorbidity. These factors should be considered when developing modified trauma team activation criteria for older adults.

ABSTRAIT: CONTEXTE: Les patients traumatisés âgés ont une mortalité plus élevée, mais sont plus susceptibles d'être sous-triés que les patients plus jeunes. Des études ont suggéré que les critères actuels d'activation des équipes de traumatologie sont sous-optimaux pour les patients âgés. OBJECTIFS: L'objectif était de décrire les soins traumatologiques dispensés, les résultats pour les patients et d'identifier les variables associées indépendamment à la mortalité. MéTHODES: De 2014 à 2020, nous avons effectué un examen des dossiers médicaux de patients de plus de 65 ans qui ont subi un traumatisme et qui se sont présentés à un centre de traumatologie de niveau 1 avec l'un ou l'autre des éléments suivants: le score de gravité de la blessure (SSI) > 12, et toutes les activations de l'équipe de traumatologie ou l'admission au service de traumatologie. Le critère de jugement principal était la mortalité toutes causes confondues de 30 jours. Les critères de jugement secondaires comprenaient le mécanisme de blessure et les soins prodigués en cas de traumatisme. La régression logistique multivariée a été utilisée pour identifier les facteurs indépendamment associés à la mortalité toutes causes confondues sur 30 jours. L'imputation multiple a été utilisée pour traiter les données manquantes. RéSULTATS: Nous avons recruté 1380 patients (âge moyen 80 ans, SSI moyenne 18); 26.8% avaient une multimorbidité (2 maladies chroniques) et 65.9% répondaient aux critères de polypharmacie (5 médicaments). Le mécanisme le plus courant était la chute de la hauteur debout (61.1%). Une mortalité toutes causes confondues sur 30 jours est survenue chez 239 (17.3%) patients. Une échelle de coma de Glasgow (GCS) < 15 (rapport de cotes [OR] = 5.55; 95% CI 3.73­8.24), ISS > 15 (OR = 3.75, 95% CI 2.35­6.01), âge 85 ans (OR = 2.04, 95% CI 1.29­3.22), anticoagulation avec un anticoagulant oral direct (DOAC) ou la warfarine (RC = 1.59, IC à 95%, de 1,08 à 2.35) et la multimorbidité (RC = 1.53, IC à 95%, de 1.06 à 2.22) étaient significativement associées à un risque accru de mortalité à 30 jours (C-statistic = 0.82, IC à 95%, de 0.79 à 0.85). Démence (RC = 0.61, IC à 95%, 0.40 à 0.95) le temps de TDM > 60 min (OR = 0.50, IC à 95%, 0.34 à 0.74) était associé à une diminution du risque de mortalité.

Do patient outcomes differ when the trauma team leader is a surgeon or non-surgeon? A multicentre cohort study.

PURPOSE: Trauma team leaders (TTLs) have traditionally been general surgeons; however, some trauma centres use a mixed model of care where both surgeons and non-surgeons (primarily emergency physicians) perform this role. The objective of this multicentre study was to provide a well-powered study to determine if TTL specialty is associated with mortality among major trauma patients. METHODS: Data were collected from provincial trauma registries at six level 1 trauma centres across Canada over a 10-year period. We included adult trauma patients (age ≥ 18 yrs) who triggered the highest-level trauma activation. The primary outcome was the difference in risk-adjusted in-hospital mortality for trauma patients receiving initial care from a surgeon versus a non-surgeon TTL. RESULTS: Overall, 12,961 major trauma patients were included in the analysis. Initial treatment was provided by a surgeon TTL in 57.8% (n = 7513) of cases, while 42.2% (n = 5448) of patients were treated by a non-surgeon TTL. Unadjusted mortality occurred in 11.6% of patients in the surgeon TTL group and 12.7% of patients in the non-surgeon TTL group (OR 0.87, 95% CI 0.78-0.98, p = 0.02). Risk-adjusted mortality was not significantly different between patients cared for by surgeon and non-surgeon TTLs (OR 0.92, 95% CI 0.80-1.06, p = 0.23). Furthermore, we did not observe differences in risk-adjusted mortality for any of the subgroups evaluated. CONCLUSIONS: After risk adjustment, there was no difference in mortality between trauma patients treated by surgeon or non-surgeon TTLs. Our study supports emergency physicians performing the role of TTL at level 1 trauma centres.

ABSTRAIT: OBJECTIF: Les chefs d'équipe de traumatologie (CET) sont traditionnellement des chirurgiens généralistes; cependant, certains centres de traumatologie utilisent un modèle mixte de soins où des chirurgiens et des non-chirurgiens (principalement des médecins d'urgence) qui jouent ce rôle. L'objectif de cette étude multicentrique était de fournir une étude bien menée pour déterminer si la spécialité CET est associée à la mortalité chez les patients traumatisés majeurs. MéTHODES: Les données ont été recueillies à partir des registres provinciaux de 6 niveau 1 centres de traumatologie au Canada sur une période de 10 ans. Nous avons inclus des patients adultes traumatisés (âge ≥ 18 ans) qui ont provoqué l'activation traumatique de niveau le plus haut. Le primaire résultat était la différence de mortalité hospitalière ajustée en fonction du risque pour les patients traumatisés qui ont reçu des soins primaires d'un chirurgien par rapport à un CET non chirurgien. RéSULTATS: En totale, 12 961 patients traumatisés majeurs ont été la partie de cette analyse. Le soin primaire a été assuré par un chirurgien CET dans 57,8 % (n=7 513) des cas, alors que 42,2 % (n=5 448) des patients ont été traités par un CET non chirurgien. Une mortalité non ajustée s'est produit chez 11,6 % des patients du groupe de chirurgien CET et 12,7 % des patients du groupe de non chirurgien CET (OR 0,87, IC à 95 % 0,78 à 0,98, p = 0,02). La mortalité ajustée en fonction du risque n'était pas significativement différente entre les patients pris en charge par des CET chirurgiens et non-chirurgiens (RC 0,92, IC à 95 % 0,80 à 1,06, p = 0,23). De plus, nous ne pouvons pas observer de différences de mortalité ajustée au risque pour aucun des sous-groupes évalués. CONCLUSIONS: Après avoir ajusté du risque, il n'y avait pas de différence de mortalité entre les patients traumatisés traités par des chirurgiens ou non chirurgiens CET. Notre étude soutient les médecins d'urgences jouent le rôle de CET dans les centres de traumatologie de niveau 1.