Reality of treatment for severely injured patients: are there age-specific differences?

BACKGROUND: Major trauma and its consequences are one of the leading causes of death worldwide across all age groups. Few studies have conducted comparative age-specific investigations. It is well known that children respond differently to major trauma than elderly patients due to physiological differences. The aim of this study was to analyze the actual reality of treatment and outcomes by using a matched triplet analysis of severely injured patients of different age groups. METHODS: Data from the TraumaRegister DGU® were analyzed. A total of 56,115 patients met the following inclusion criteria: individuals with Maximum Abbreviated Injury Scale > 2 and < 6, primary admission, from German-speaking countries, and treated from 2011-2020. Furthermore, three age groups were defined (child: 3-15 years; adult: 20-50 years; and elderly: 70-90 years). The matched triplets were defined based on the following criteria: 1. exact injury severity of the body regions according to the Abbreviated Injury Scale (head, thorax, abdomen, extremities [including pelvis], and spine) and 2. level of the receiving hospital. RESULTS: A total of 2,590 matched triplets could be defined. Traffic accidents were the main cause of severe injury in younger patients (child: 59.2%; adult: 57.9%). In contrast, low falls (from < 3 m) were the most frequent cause of accidents in the elderly group (47.2%). Elderly patients were least likely to be resuscitated at the scene. Both children and elderly patients received fewer therapeutic interventions on average than adults. More elderly patients died during the clinical course, and their outcome was worse overall, whereas the children had the lowest mortality rate. CONCLUSIONS: For the first time, a large patient population was used to demonstrate that both elderly patients and children may have received less invasive treatment compared with adults who were injured with exactly the same severity (with the outcomes of these two groups being opposite to each other). Future studies and recommendations should urgently consider the different age groups.

Outcomes improvement despite continuous visits of severely injured patients during the COVID-19 outbreak: experience at a regional trauma centre in South Korea.

BACKGROUND: Understanding the changes in characteristics of patients who visited trauma centres during the coronavirus disease 2019 (COVID-19) pandemic is important to facilitate aneffective response. This retrospective study was conducted to analyse differences in the characteristics and outcomes of patients who visited our trauma centre between pre-COVID-19 and COVID-19 eras. METHODS: Medical data of trauma patients enrolled in the Korean trauma database from 1 January 2018 to 31 August 2021 were collected. The number of trauma centre visits, patient characteristics, factors associated with in-hospital intervention, and outcomes werecompared between patients in the two time periods. Propensity score matching was performed to analyse the outcomes in patients with similar characteristics and severitybetween patients in the two time periods. RESULTS: The number of emergency department (ED) trauma service visits reduced in the COVID-19 era. Based on the mean age, the patients were older in the COVID-19 era. Abbreviated injury scale (AIS) 1, AIS3, AIS5, and injury severity score (ISS) were higher in the COVID-19 era. The proportion of motor vehicle collisions decreased, whereas falls increased during the COVID-19 era. Ambulance transportation, admission to the general ward, and time from injury to ED visit significantly increased. Patient outcomes, such as hospital length of stay (LOS), intensive care unit (ICU) LOS, and duration of mechanical ventilation improved, while injury severity worsened during the COVID-19 era. After adjusting for patient characteristics and severity, similar findings were observed. CONCLUSION: The small reduction in the number of trauma patients and visits by patients who hadhigher ISS during the COVID-19 pandemic highlights the importance of maintaining trauma service capacity and capability during the pandemic. A nationwide or nationalmulticentre study will be more meaningful to examine the impact of the COVID-19 outbreak on the changes in trauma patterns, volume, and patient outcomes.

Why do some trauma patients die while others survive? A matched-pair analysis based on data from Trauma Register DGU®.

PURPOSE: The mortality rate for severely injured patients with the injury severity score (ISS) ≥16 has decreased in Germany. There is robust evidence that mortality is influenced not only by the acute trauma itself but also by physical health, age and sex. The aim of this study was to identify other possible influences on the mortality of severely injured patients. METHODS: In a matched-pair analysis of data from Trauma Register DGU®, non-surviving patients from Germany between 2009 and 2014 with an ISS≥16 were compared with surviving matching partners. Matching was performed on the basis of age, sex, physical health, injury pattern, trauma mechanism, conscious state at the scene of the accident based on the Glasgow coma scale, and the presence of shock on arrival at the emergency room. RESULTS: We matched two homogeneous groups, each of which consisted of 657 patients (535 male, average age 37 years). There was no significant difference in the vital parameters at the scene of the accident, the length of the pre-hospital phase, the type of transport (ground or air), pre-hospital fluid management and amounts, ISS, initial care level, the length of the emergency room stay, the care received at night or from on-call personnel during the weekend, the use of abdominal sonographic imaging, the type of X-ray imaging used, and the percentage of patients who developed sepsis. We found a significant difference in the new injury severity score, the frequency of multi-organ failure, hemoglobine at admission, base excess and international normalized ratio in the emergency room, the type of accident (fall or road traffic accident), the pre-hospital intubation rate, reanimation, in-hospital fluid management, the frequency of transfusion, tomography (whole-body computed tomography), and the necessity of emergency intervention. CONCLUSION: Previously postulated factors such as the level of care and the length of the emergency room stay did not appear to have a significant influence in this study. Further studies should be conducted to analyse the identified factors with a view to optimising the treatment of severely injured patients. Our study shows that there are significant factors that can predict or influence the mortality of severely injured patients.

Diagnostic value of chest radiography in the early management of severely injured patients with mediastinal vascular injury.

INTRODUCTION: Time is of the essence in the management of severely injured patients. This is especially true in patients with mediastinal vascular injury (MVI). This rare, yet life threatening injury needs early detection and immediate decision making. According to the ATLS guidelines [American College of Surgeon Committee on Trauma in Advanced Trauma Life Support (ATLS®), 10th edn, 2018], chest radiography (CXR) is one of the first-line imaging examinations in the Trauma Resuscitation Unit (TRU), especially in patients with MVI. Yet thorough interpretation and the competence of identifying pathological findings are essential for accurate diagnosis and drawing appropriate conclusion for further management. The present study evaluates the role of CXR in detecting MVI in the early management of severely injured patients. METHOD: We addressed the question in two ways. (1) We performed a retrospective, observational, single-center study and included all primary blunt trauma patients over a period of 2 years that had been admitted to the TRU of a Level-I Trauma Center. Mediastinal/chest (M/C) ratio measurements were calculated from CXRs at three different levels of the mediastinum to identify MVI. Two groups were built: with MVI (VThx) and without MVI (control). The accuracy of the CXR findings were compared with the results of whole-body computed tomography scans (WBCT). (2) We performed another retrospective study and evaluated the usage of sonography, CXR and WBCT over 15 years (2005-2019) in level-I-III Trauma Centers in Germany as documented in the TraumaRegister DGU® (TR-DGU). RESULTS: Study I showed that in 2 years 267 patients suffered from a significant blunt thoracic trauma (AIS ≥ 3) and met the inclusion criteria. 27 (10%) of them suffered MVI (VThx). Through the initial CXR in a supine position, MVI was detected in 56-92.6% at aortic arch level and in 44.4-100% at valve level, depending on different M/C-ratios (2.0-3.0). The specificity at different thresholds of M/C ratio was 63.3-2.9% at aortic arch level and 52.9-0.4% at valve level. The ROC curve showed a statistically random process. No significant differences of the cardiac silhouette were observed between VThx and Control (mean cardiac width was 136.5 mm, p = 0.44). Study II included 251,095 patients from the TR-DGU. A continuous reduction of the usage of CXR in the TRU could be observed from 75% in 2005 to 25% in 2019. WBCT usage increased from 35% in 2005 to 80% in 2019. This development was observed in all trauma centers independently from their designated level of care. CONCLUSION: According to the TRU management guidelines (American College of Surgeon Committee on Trauma in Advanced Trauma Life Support (ATLS®), 10th edn, 2018; Reissig and Kroegel in Eur J Radiol 53:463-470, 2005) CXR in supine position is performed to detect pneumothorax, hemothorax and MVI. Our study showed that sensitivity and specificity of CXR in detecting MVI was statistically and clinically not reliable. Previous studies have already shown that CXR is inferior to sonography in detecting pneumothorax and hemothorax. Therefore, we challenge the guidelines and suggest that the use of CXR in the early management of severely injured patients should be individualized. If sonography and WBCT are available and reasonable, CXR is unnecessary and time consuming. The clinical reality reflected in the usage of CXR and WBCT over time, as documented in the TR-DGU, seems to support our statement.

Venous thromboembolism (VTE) prophylaxis in severely injured patients: an international comparative assessment.

PURPOSE: Venous thromboembolisms (VTE) are a major concern after acute survival from trauma. Variations in treatment protocols for trauma patients exist worldwide. This study analyzes the differences in the number of VTE events and the associated complications of thromboprophylaxis between two level I trauma populations utilizing varying treatment protocols. METHODS: International multicenter trauma registry-based study was performed at the University Medical Center Utrecht (UMCU) in The Netherlands (early commencement chemical prophylaxis), and Harborview Medical Center (HMC) in the United States (restrictive early chemical prophylaxis). All severely injured patients (ISS ≥ 16), aged ≥ 18 years, and admitted in 2013 were included. Primary outcomes were VTE [deep venous thrombosis (DVT) (no screening), pulmonary embolism (PE)], and hemorrhagic complications. RESULTS: In UMCU, 279 patients were included and in HMC, 974 patients. Overall, 75% of the admitted trauma patients in UMCU and 81% in HMC (p < 0.001) received thromboprophylaxis, of which 100% in and 75% at, respectively, UMCU and HMC consisted of chemical prophylaxis. From these patients, 72% at UMCU and 47% at HMC (p < 0.001) were treated within 48 h after arrival. At UMCU, 4 patients (1.4%) (PE = 3, DVT = 1) and HMC 37 patients (3.8%) (PE = 22, DVT = 16; p = 0.06) developed a VTE. At UMCU, a greater percent of patients with VTE had traumatic brain injuries (TBI). Most VTE occurred despite adequate prophylaxis being given (75% UMCU and 81% HMC). Hemorrhagic complications occurred in, respectively, 4 (1.4%) and 10 (1%) patients in UMCU and HMC (p = 0.570). After adjustment for age, ISS, HLOS, and injury type, no significant difference was demonstrated in UMCU compared to HMC for the development of VTE, OR 2.397, p = 0.102 and hemorrhagic complications, OR 0. 586, p = 0.383. CONCLUSIONS: A more early commencement protocol resulted in almost twice as much chemical prophylaxis being started within the first 48 h in comparison with a more delayed initiation of treatment. Interestingly, most episodes of VTE developed while receiving recommended prophylaxis. Early chemical thromboprophylaxis did not significantly increase the bleeding complications and it appears to be safe to start early.

Age- and Severity-Related In-Hospital Mortality Trends and Risks of Severe Traumatic Brain Injury in Japan: A Nationwide 10-Year Retrospective Study.

Traumatic brain injury (TBI) is the major cause of mortality and morbidity in severely-injured patients worldwide. This retrospective nationwide study aimed to evaluate the age- and severity-related in-hospital mortality trends and mortality risks of patients with severe TBI from 2009 to 2018 to establish effective injury prevention measures. We retrieved information from the Japan Trauma Data Bank dataset between 2009 and 2018. The inclusion criteria for this study were patients with severe TBI defined as those with an Injury Severity Score ≥ 16 and TBI. In total, 31,953 patients with severe TBI (32.6%) were included. There were significant age-related differences in characteristics, mortality trend, and mortality risk in patients with severe TBI. The in-hospital mortality trend of all patients with severe TBI significantly decreased but did not improve for patients aged ≤ 5 years and with a Glasgow Coma Scale (GCS) score between 3 and 8. Severe TBI, age ≥ 65 years, fall from height, GCS score 3-8, and urgent blood transfusion need were associated with a higher mortality risk, and mortality risk did not decrease after 2013. Physicians should consider specific strategies when treating patients with any of these risk factors to reduce severe TBI mortality.

Evaluation of new quality indicators for the TraumaRegister DGU® using the systematic QUALIFY methodology.

BACKGROUND: The TraumaRegister DGU® (TR-DGU) of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie, DGU) enables the participating hospitals to perform quality management. For that purpose, nine so-called audit filters have existed, since its foundation, which, inter alia, is listed in the Annual Report. The objective of this study effort is a revision of these quality indicators with the aim of developing pertinent new and reliable quality indicators for the management of severely injured patients. MATERIALS AND METHODS: Apart from indicators already used at national and international levels, a systematic review of the literature revealed further potential key figures for quality of the management of severely injured patients. The latter were evaluated by an interdisciplinary and interprofessional group of experts using a standardized QUALIFY process to assess their suitability as a quality indicator. RESULTS: By means of the review of the literature, 39 potential indicators could be identified. 9 and 14 indicators, respectively, were identified in existing trauma registries (TR-DGU and TARN), 17 in the ATLS® training concept, and 57 in the S3 guideline on the treatment of polytrauma/severe injuries. The exclusion of duplicates and the limitation to indicators that can be collected using the TR-DGU Version 2015 data set resulted in a total of 43 indicators to be reviewed. For each of the 43 indicators, 13 quality criteria were assessed. A consensus was achieved in 305 out of 559 individual assessments. With 13 quality criteria assessed and 43 indicators correspond this to a relative consensus value of 54.6%. None of the indicators achieved a consensus in all 13 quality criteria assessed. The following 13 indicators achieved a consensus in at least 9 quality criteria: time between hospital admission and WBCT, mortality, administration of tranexamic acid to bleeding patients, use of CCT with GCS <14, time until first emergency surgical intervention (7-item list in the TR-DGU), time until surgical intervention for penetrating trauma, application of pelvic sling belt (prehospital), capnometry (etCO2) in intubated patients, time until CCT with GCS < 15, time until surgery for hemorrhagic shock, time until craniotomy for severe TBI, prehospital airway management in unconscious patients (GCS < 9), and complete basic diagnostics available. Two indicators achieved a consensus in 11 criteria and thus represent the maximum consensus achieved within the group of experts. Four indicators only achieved a consensus in three quality criteria. 17 indicators had a mean value for the 3 relevance criteria of ≥ 3.5 and were, therefore, assessed by the group of experts as being highly relevant. CONCLUSION: Not all the key figures published for the management of severely injured patients are suitable for use as quality indicators. It remains to be seen whether the quality indicators identified by experts using the QUALIFY process will meet the requirements in practice. Prior to the implementation of the assessed quality indicators in standardized quality assurance programs, a scientific evaluation based on national data will be required.

Does the presence of an emergency physician influence pre-hospital time, pre-hospital interventions and the mortality of severely injured patients? A matched-pair analysis based on the trauma registry of the German Trauma Society (TraumaRegister DGU®).

PURPOSE: The role of emergency physicians in the pre-hospital management of severely injured patients remains controversial. In Germany and Austria, an emergency physician is present at the scene of an emergency situation or is called to such a scene in order to provide pre-hospital care to severely injured patients in approximately 95% of all cases. By contrast, in the United States and the United Kingdom, paramedics, i.e. non-physician teams, usually provide care to an injured person both at the scene of an incident and en route to an appropriate hospital. We investigated whether physician or non-physician care offers more benefits and what type of on-site care improves outcome. MATERIAL AND METHODS: In a matched-pair analysis using data from the trauma registry of the German Trauma Society, we retrospectively (2002-2011) analysed the pre-hospital management of severely injured patients (ISS ≥16) by physician and non-physician teams. Matching criteria were age, overall injury severity, the presence of relevant injuries to the head, chest, abdomen or extremities, the cause of trauma, the level of consciousness, and the presence of shock. RESULTS: Each of the two groups, i.e. patients who were attended by an emergency physician and those who received non-physician care, consisted of 1235 subjects. There was no significant difference between the two groups in pre-hospital time (61.1 [SD 28.9] minutes for the physician group and 61.9 [SD 30.9] minutes for non-physician group). Significant differences were found in the number of pre-hospital procedures such as fluid administration, analgosedation and intubation. There was a highly significant difference (p<0.001) in the number of patients who received no intervention at all applying to 348 patients (28.2%) treated by non-physician teams and to only 31 patients (2.5%) in the physician-treated group. By contrast, there was no significant difference in mortality within the first 24h and in mortality during hospitalisation. CONCLUSION: This retrospective analysis does not allow definitive conclusions to be drawn about the optimal model of pre-hospital care. It shows, however, that there was no significant difference in mortality although patients who were attended by non-physician teams received fewer pre-hospital interventions with similar scene times.

Direct transport versus inter hospital transfer of severely injured trauma patients.

INTRODUCTION: Several studies have suggested that severely injured patients should be transported directly to a trauma centre bypassing the nearest hospital. However, the evidence remains inconclusive. The purpose of this study was to examine the benefits in terms of mortality of direct transport to a trauma centre versus primary treatment in a level II or III centre followed by inter hospital transfer to a trauma centre for severely injured patients without Traumatic Brain Injury (TBI). PATIENTS AND METHODS: We used the regional trauma registry and included all patients with an Injury Severity Score (ISS) >15 and an Abbreviated Injury Score <4 for head injury. We adjusted for survival bias by including "potential transfers": patients who died at the nearest hospitals before transportation to a trauma centre. RESULTS: A total of 439 patients was included. The majority of patients (349/439, 79%) was transported directly to the level I trauma centre (direct group). The transferred group was formed by the remaining 90 patients, of whom 81 were transferred to the level I trauma centre after initial stabilisation elsewhere and 9 patients died in the emergency room before transfer to a level 1 trauma centre could occur. There were no significant differences in baseline and injury characteristics between the groups. Overall, 60 patients died in-hospital including 41 of the 349 patients (12%) in the direct group and 19 of the 90 patients (21%) in the transferred group. Nine of the 19 deaths in the transferred group were ascribed to potential transfers. After adjusting for prehospital Revised Trauma Score (RTS) and ISS, the odds ratio of death was 2.40 (95%CI: 1.07-5.40) for patients in the transfer group. When potential transfer patients were excluded from the analysis, the adjusted odds ratio of death was 1.14 (95%CI: 0.43-3.01). CONCLUSIONS: After adjusting for survivor bias by including potential transfers, the results of this study suggest a lower risk of death for patients who are directly transported to a level I trauma centre than for patients who receive primary treatment in a level II or III centre and are transferred to a trauma centre. However, this finding was only significant when adjusting for survival bias and therefore we conclude that it is still uncertain if there is a lower risk of death for patients who are transported directly to a level I trauma centre.

[Prevalence of incidental findings of the Axial skeleton on computed tomograph of severely injured patients]. / Prävalenz von Zufallsbefunden des Achsenskeletts in computertomographischen Untersuchungen polytraumatisierter Patienten.

Computed tomography has become an important component in the initial assessment of severely injured patients over the last years. The liberal use coupled with advances in imaging technology often result in incidental findings. In our present investigation, the prevalence incidence of incidental findings of the spine and skull amounted to 58% of all patients with trauma. Degenerative changes were most commonly found, followed by congenital defects and neoplasms. Within the latter, further investigation was necessary in six cases, of which two findings proved to be malignant neoplasms. The high incidence of incidental findings calls for a uniform documentation, handling and clarification of responsibility in treatment and insurance-related competence.

La tomodensitométrie est devenue un examen important dans la salle d'urgence au cours de ces dernières années. Parallèlement aux blessures causées par accidents, d'autres résultats sont apparus par hasard et sans lien direct avec l'accident. Dans ce travail, l'incidence sur le crâne et la colonne vertèbrale se chiffre à 58%. En majorité sont découverts des changements dégénératifs, suivis par des anomalies congénitales et des néoplasies. Six cas ont nécessité d'être clarifiés et deux cas se sont avérés malins. Suite à la répercution de ces découvertes fortuites, il s'est avéré nécessaire d'établir des critères uniformes afin de clarifier la nécessité d'intervention ainsi que pour des questions d'assurance.

The association between psychosocial care by physicians and patients' trust: a retrospective analysis of severely injured patients in surgical intensive care units.

AIM: Trust is an essential element in physician-patient interaction fostering in general adherence and improving patient- and physician-reported outcomes. Regarding severely injured patients, trust-building behaviour is important because of the severity of injuries and therefore potential associated physical and psychological consequences. The objective of this study was to identify significant and relevant determinants on trust of severely injured patients in their physicians in surgical intensive care units. METHODS: Ninety-one severely injured patients completed a self-administered questionnaire after being transferred from surgical intensive care unit to surgical unit. All patients were treated in four hospitals of maximal care in North Rhine-Westphalia between 2001 and 2005. To assess different aspects of trust the "trust in physician" scale of the Cologne Patient Questionnaire (CPQ) was used. "Psychosocial care by physicians" is measured through: support, devotion, information and shared-decision making provided by physicians. Patient- and trauma related control variables are also included in a logistic regression model. RESULTS: Stepwise logistic regression identified "psychosocial care provided by physicians" as a significant contributor to severely injured patients' trust (Nagelkerke's R(2): 41%). "Trust in physicians" is correlated with all four dimensions of "psychosocial care by physicians": support (0.546), devotion (0.443), information (0.396), and shared-decision making behaviour (0.342) provided by physicians in surgical intensive care units. CONCLUSIONS: This finding confirms the importance of supportive communication style in physician-patient interaction concerning reported trust of severely injured patients on surgical intensive care units. Medical education should integrate sound knowledge about psychosocial aspects of interaction to provide effective emotional and informational support to build up and maintain patient trust.

Predicting Health-related Quality of Life of Severely Injured Patients: Sociodemographic, Economic, Trauma, and Hospital Stay-related Determinants.

INTRODUCTION: Due to remarkable improvements in emergency and intensive care medicine in the recent past, the mortality rate for severely injured patients is decreasing. Outcome research therefore should no longer focus only on questions of survival, but also on aspects of the quality of life after severe trauma. This study examined the long-term effect of different sociodemographic, economic, trauma, and hospital-related factors on the health-related quality of life (SF-36) of severely injured patients. PATIENTS AND METHODS: A written questionnaire was sent to 121 trauma patients who received treatment in two hospitals in Cologne/Northrhine-Westfalia between 1996 and 2001. The inclusion criteria were more than one injury and a sum of abbreviated injury score of the two worst injuries ≥ 6. The response rate after using the total-design-method was 77.6% (n = 90). RESULTS: Severely injured patients showed significant reductions for all subscales of the SF-36, on average 4 years after discharge on average, in comparison to a German norm population. Specifically, aspects of the physical-component scale were dramatically reduced. Linear regressions controlling for time after discharge suggested that higher age, lower socioeconomic status, living together with a partner, and the severity of trauma and injury of extremities were significant predictors for a reduced quality of life, while satisfaction with the hospital stay had a positive effect. DISCUSSION: All in all, it is important to identify trauma- patients who will suffer a reduced quality of life. In so doing, it will be possible to take into account the specific circumstances of their recovery during medical treatment, care, and rehabilitation.