Clinical practice guideline recommendations to improve the mental health of adult trauma patients: protocol for a systematic review.

INTRODUCTION: Mental disorders are common in adult patients with traumatic injuries. To limit the burden of poor psychological well-being in this population, recognised authorities have issued recommendations through clinical practice guidelines (CPGs). However, the uptake of evidence-based recommendations to improve the mental health of trauma patients has been low until recently. This may be explained by the complexity of optimising mental health practices and interpretating CGPs scope and quality. Our aim is to systematically review CPG mental health recommendations in the context of trauma care and appraise their quality. METHODS AND ANALYSIS: We will identify CPG through a search strategy applied to Medline, Embase, CINAHL, PsycINFO and Web of Science databases, as well as guidelines repositories and websites of trauma associations. We will target CPGs on adult and acute trauma populations including at least one recommendation on any prevention, screening, assessment, intervention, patient and family engagement, referral or follow-up procedure related to mental health endorsed by recognised organisations in high-income countries. No language limitations will be applied, and we will limit the search to the last 15 years. Pairs of reviewers will independently screen titles, abstracts, full texts, and carry out data extraction and quality assessment of CPGs using the Appraisal of Guidelines Research and Evaluation (AGREE) II. We will synthesise the evidence on recommendations for CPGs rated as moderate or high quality using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation quality of evidence, strength of recommendation, health and social determinants and whether recommendations were made using a population-based approach. ETHICS AND DISSEMINATION: Ethics approval is not required, as we will conduct secondary analysis of published data. The results will be disseminated in a peer-reviewed journal, at international and national scientific meetings. Accessible summary will be distributed to interested parties through professional, healthcare quality and persons with lived experience associations. PROSPERO REGISTRATION NUMBER: (ID454728).

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.

Extracorporeal life support in trauma: Indications and techniques.

BACKGROUND: Clarity about indications and techniques in extracorporeal life support (ECLS) in trauma is essential for timely and effective deployment, and to ensure good stewardship of an important resource. Extracorporeal life support deployments in a tertiary trauma center were reviewed to understand the indications, strategies, and tactics of ECLS in trauma. METHODS: The provincial trauma registry was used to identify patients who received ECLS at a Level I trauma center and ECLS organization-accredited site between January 2014 and February 2021. Charts were reviewed for indications, technical factors, and outcomes following ECLS deployment. Based on this data, consensus around indications and techniques for ECLS in trauma was reached and refined by a multidisciplinary team discussion. RESULTS: A total of 25 patients underwent ECLS as part of a comprehensive trauma resuscitation strategy. Eighteen patients underwent venovenous ECLS and seven received venoarterial ECLS. Nineteen patients survived the ECLS run, of which 15 survived to discharge. Four patients developed vascular injuries secondary to cannula insertion while four patients developed circuit clots. On multidisciplinary consensus, three broad indications for ECLS and their respective techniques were described: gas exchange for lung injury, extended damage control for severe injuries associated with the lethal triad, and circulatory support for cardiogenic shock or hypothermia. CONCLUSION: The three broad indications for ECLS in trauma (gas exchange, extended damage control and circulatory support) require specific advanced planning and standardization of corresponding techniques (cannulation, circuit configuration, anticoagulation, and duration). When appropriately and effectively integrated into the trauma response, ECLS can extend the damage control paradigm to enable the management of complex multisystem injuries. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Guided blood transfusion of trauma patients with rotational thromboelastometry: a single-center cohort study.

BACKGROUND: Rotational thromboelastometry (ROTEM) is a blood test used to measure in vitro clot strength as a surrogate for a patient's ability to form clots in vivo. This provides information about induction, formation, and clot lysis, allowing goal-directed transfusion therapy for specific hemostatic needs. We sought to evaluate the effect of ROTEM-guided transfusion on blood product usage and in-hospital mortality among patients with a traumatic injury. METHODS: This was a single-center observational cohort analysis of emergency department patients in a Level 1 trauma center. We compared blood usage in trauma patients in whom ratio-based massive hemorrhage protocols were activated in the twelve months before the introduction of ROTEM (pre-ROTEM group) to the twelve months following the introduction of ROTEM (ROTEM-period group). ROTEM was implemented in this center in November 2016. The ROTEM device allowed clinicians to make real-time decisions about blood product therapy in resuscitation for trauma. RESULTS: The pre-ROTEM group contained 21 patients. Forty-three patients were included from the ROTEM-period, of whom 35 patients received ROTEM-guided resuscitation (81% compliance). The use of fibrinogen concentrate was significantly higher in the ROTEM-period group (pre-ROTEM mean 0.2 vs. ROTEM-period mean 0.8; p = 0.006). There was no significant difference in the number of units of red blood cells, platelets, cryoprecipitate, or fresh frozen plasma transfused between these groups. There was no significant difference in the mortality rate between the pre-ROTEM and ROTEM-period groups (33% vs. 19%; p = 0.22). CONCLUSIONS: The introduction of ROTEM-guided transfusion at this institution was associated with increased fibrinogen usage, but this did not impact mortality rates. There was no difference in the administration of red blood cell, fresh frozen plasma, platelet, and cryoprecipitate. Future research should focus on increased ROTEM compliance and optimizing ROTEM-guided transfusion to prevent blood product overuse among trauma patients.

The unrestricted global effort to complete the COOL trial.

BACKGROUND: Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study. METHODS: The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer. DISCUSSION: OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention. TRIAL REGISTRATION: National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).

A randomized, controlled, blinded evaluation of augmenting point-of-care ultrasound and remote telementored ultrasound in inexperienced operators.

BACKGROUND: Handheld ultrasound devices present an opportunity for prehospital sonographic assessment of trauma, even in the hands of novice operators commonly found in military, maritime, or other austere environments. However, the reliability of such point-of-care ultrasound (POCUS) examinations by novices is rightly questioned. A common strategy being examined to mitigate this reliability gap is remote mentoring by an expert. OBJECTIVES: To assess the feasibility of utilizing POCUS in the hands of novice military or civilian emergency medicine service (EMS) providers, with and without the use of telementoring. To assess the mitigating or exacerbating effect telementoring may have on operator stress. METHODS: Thirty-seven inexperienced physicians and EMTs serving as first responders in military or civilian EMS were randomized to receive or not receive telementoring during three POCUS trials: live model, Simbionix trainer, and jugular phantom. Salivary cortisol was obtained before and after the trial. Heart rate variability monitoring was performed throughout the trial. RESULTS: There were no significant differences in clinical performance between the two groups. Iatrogenic complications of jugular venous catheterization were reduced by 26% in the telementored group (P < 0.001). Salivary cortisol levels dropped by 39% (P < 0.001) in the telementored group. Heart rate variability data also suggested mitigation of stress. CONCLUSIONS: Telementoring of POCUS tasks was not found to improve performance by novices, but findings suggest that it may mitigate caregiver stress.

VA-ECMO as a salvage strategy for blunt cardiac injury in the context of multisystem trauma.

A 47-year-old man sustained multisystem injuries after being struck by a vehicle travelling at high speeds. Shortly after admission to the emergency department he suffered a ventricular tachycardia/ventricular fibrillation cardiac arrest lasting 30 min. Investigations following return of spontaneous circulation raised suspicion for an anterolateral ST-elevation myocardial infarction. Despite his major traumatic injuries the patient was transferred for percutaneous coronary intervention uncovering a complete thrombosis of the ostium of the left anterior descending artery. Immediately following coronary revascularisation, the patient developed cardiogenic shock resulting in a multidisciplinary decision to place the patient on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The management of cardiogenic shock due to acute myocardial infarction with VA-ECMO and multiple traumatic injuries were often at odds with each other, resulting in a series of challenging decisions on timing of surgery and anticoagulation. The patient was liberated from VA-ECMO after 72 hours and continues rehabilitation in hospital.

Evaluation and management of the surgical abdomen.

PURPOSE OF REVIEW: The aim of this study was to describe important features of clinical examination for the surgical abdomen, relevant investigations, and acute management of common surgical problems in the critically ill. RECENT FINDINGS: Lactate remains a relatively nonspecific marker of gut ischemia. Dual energy computed tomography (DECT) scan can improve diagnosis of bowel ischemia. Further evidence supports intravenous contrast during CT scan in critically ill patients with acute kidney injury. Outcomes for acute mesenteric ischemia have failed to improve over time; however, increasing use of endovascular approaches, including catheter-directed thrombolysis, may decrease need for laparotomy in the appropriate patient. Nonocclusive mesenteric ischemia remains a challenging diagnostic and management dilemma. Acalculous cholecystitis is managed with a percutaneous cholecystostomy and is unlikely to require interval cholecystectomy. Surgeon comfort with intervention based on point-of-care ultrasound for biliary disease is variable. Mortality for toxic megacolon is decreasing. SUMMARY: Physical examination remains an integral part of the evaluation of the surgical abdomen. Interpreting laboratory investigations in context and appropriate imaging improves diagnostic ability; intravenous contrast should not be withheld for critically ill patients with acute kidney injury. Surgical intervention should not be delayed for the patient in extremis. The intensivist and surgeon should remain in close communication to optimize care.

Large bowel obstruction secondary to schistosomiasis-related colonic stricture.

INTRODUCTION: Intestinal involvement of schistosomiasis uncommonly involves the formation of non-obstructive polypoid lesions; however, obstructing fibrotic stenoses and strictures secondary to chronic infection are extremely rare with only nine reported cases in the literature. PRESENTATION OF CASE: An 85-year-old Southeast Asian female originating from the Philippines presents with a one-day history of obstructive symptoms in the setting of chronic constipation over the past four months. Subsequent CT imaging and colonoscopy biopsy revealed a nodular cecal mural wall thickening with chronic inflammation and a single Schistosoma egg. Despite treatment with praziquantel, and medical optimization the patient did not improve. Additionally, a malignancy as the underlying cause of obstruction could not be ruled out as such, she had a right hemicolectomy. Final pathology confirmed the diagnosis of intestinal submucosal schistosomiasis causing fibrotic stenosis. CONCLUSION: Obstructing lesions including fibrotic stenoses secondary to Schistosomiasis infection can be managed safely with medical co-morbidity optimization when possible, treatment with Praziquantel and surgical resection of the involved area of colon. Given the risk of malignancy and the inability to clinically distinguish between infectious and neoplastic processes, surgical management is recommended.

Atypical Somatic Symptoms in Adults With Prolonged Recovery From Mild Traumatic Brain Injury.

Somatization may contribute to persistent symptoms after mild traumatic brain injury (mTBI). In two independently-recruited study samples, we characterized the extent to which symptoms atypical of mTBI but typical for patients suffering from somatization (e.g., gastrointestinal upset, musculoskeletal, and cardiorespiratory complaints) were present in adult patients with prolonged recovery following mTBI. The first sample was cross-sectional and consisted of mTBI patients recruited from the community who reported ongoing symptoms attributable to a previous mTBI (n = 16) along with a healthy control group (n = 15). The second sample consisted of patients with mTBI prospectively recruited from a Level 1 trauma center who had either good recovery (GOSE = 8; n = 32) or poor recovery (GOSE < 8; n = 29). In all participants, we evaluated atypical somatic symptoms using the Patient Health Questionnaire-15 and typical post-concussion symptoms with the Rivermead Post-Concussion Symptom Questionnaire. Participants with poor recovery from mTBI had significantly higher "atypical" somatic symptoms as compared to the healthy control group in Sample 1 (b = 4.308, p < 0.001) and to mTBI patients with good recovery in Sample 2 (b = 3.169, p < 0.001). As would be expected, participants with poor outcome in Sample 2 had a higher burden of typical rather than atypical symptoms [t (28) = 4.750, p < 0.001, d = 0.88]. However, participants with poor recovery still reported atypical somatic symptoms that were significantly higher (1.4 standard deviations, on average) than those with good recovery. Our results suggest that although "typical" post-concussion symptoms predominate after mTBI, a broad range of somatic symptoms also frequently accompanies mTBI, and that somatization may represent an important, modifiable factor in mTBI recovery.

A Systematic Review of the Risks and Benefits of Venous Thromboembolism Prophylaxis in Traumatic Brain Injury.

BACKGROUND: Patients suffering from traumatic brain injury (TBI) are at increased risk of venous thromboembolism (VTE). However, initiation of pharmacological venous thromboprophylaxis (VTEp) may cause further intracranial hemorrhage. We reviewed the literature to determine the postinjury time interval at which VTEp can be administered without risk of TBI evolution and hematoma expansion. METHODS: MEDLINE and EMBASE databases were searched. Inclusion criteria were studies investigating timing and safety of VTEp in TBI patients not previously on oral anticoagulation. Two investigators extracted data and graded the papers' levels of evidence. Randomized controlled trials were assessed for bias according to the Cochrane Collaboration Tool and Cohort studies were evaluated for bias using the Newcastle-Ottawa Scale. We performed univariate meta-regression analysis in an attempt to identify a relationship between VTEp timing and hemorrhagic progression and assess study heterogeneity using an I 2 statistic. RESULTS: Twenty-one studies were included in the systematic review. Eighteen total studies demonstrated that VTEp postinjury in patients with stable head computed tomography scan does not lead to TBI progression. Fourteen studies demonstrated that VTEp administration 24 to 72 hours postinjury is safe in patients with stable injury. Four studies suggested that administering VTEp within 24 hours of injury in patients with stable TBI does not lead to progressive intracranial hemorrhage. Overall, meta-regression analysis demonstrated that there was no relationship between rate of hemorrhagic progression and VTEp timing. CONCLUSIONS: Literature suggests that administering VTEp 24 to 48 hours postinjury may be safe for patients with low-hemorrhagic-risk TBIs and stable injury on repeat imaging.

Tele-mentored damage-control and emergency trauma surgery: A feasibility study using live-tissue models.

BACKGROUND: Damage-control and emergency surgical procedures in trauma have the potential to save lives. They may occasionally not be performed due to clinician inexperience or lack of comfort and knowledge. METHODS: Canadian Armed Forces (CAF) non-surgeon Medical Officers (MOs) participated in a live tissue training exercise. They received tele-mentoring assistance using a secure video-conferencing application on a smartphone/tablet platform. Feasibility of tele-mentored surgery was studied by measuring their effectiveness at completing a set series of tasks in this pilot study. Additionally, their comfort and willingness to perform studied procedures was gauged using pre- and post-study surveys. RESULTS: With no pre-procedural teaching, participants were able to complete surgical airway, chest tube insertion and resuscitative thoracotomy with 100% effectiveness with no noted complications. Comfort level and willingness to perform these procedures were improved with tele-mentoring. Participants felt that tele-mentored surgery would benefit their performance of resuscitative thoracotomy most. CONCLUSION: The use of tele-mentored surgery to assist non-surgeon clinicians in the performance of damage-control and emergency surgical procedures is feasible. More study is required to validate its effectiveness.

Process mapping as a framework for performance improvement in emergency general surgery.

BACKGROUND: Emergency general surgery conditions are often thought of as being too acute for the development of standardized approaches to quality improvement. However, process mapping, a concept that has been applied extensively in manufacturing quality improvement, is now being used in health care. The objective of this study was to create process maps for small bowel obstruction in an effort to identify potential areas for quality improvement. METHODS: We used the American College of Surgeons Emergency General Surgery Quality Improvement Program pilot database to identify patients who received nonoperative or operative management of small bowel obstruction between March 2015 and March 2016. This database, patient charts and electronic health records were used to create process maps from the time of presentation to discharge. RESULTS: Eighty-eight patients with small bowel obstruction (33 operative; 55 nonoperative) were identified. Patients who received surgery had a complication rate of 32%. The processes of care from the time of presentation to the time of follow-up were highly elaborate and variable in terms of duration; however, the sequences of care were found to be consistent. We used data visualization strategies to identify bottlenecks in care, and they showed substantial variability in terms of operating room access. CONCLUSION: Variability in the operative care of small bowel obstruction is high and represents an important improvement opportunity in general surgery. Process mapping can identify common themes, even in acute care, and suggest specific performance improvement measures.

CONTEXTE: Les conditions dans lesquelles s'effectuent les interventions chirurgicales d'urgence sont souvent jugées trop pressantes pour que l'on puisse mettre au point des approches normalisées d'amélioration de la qualité. Malgré tout, la schématisation des processus, un concept largement appliqué à l'amélioration de la qualité en milieu manufacturier, est maintenant appliquée en santé. L'objectif de cette étude était de schématiser les processus suivis dans les cas d'obstruction du grêle afin de déterminer les aspects dont la qualité pourrait être améliorée. MÉTHODES: À partir de la base de données pilote du programme d'amélioration de la qualité des chirurgies générales d'urgence de l'American College of Surgeons, nous avons recensé les patients ayant reçu un traitement chirurgical ou non chirurgical pour une obstruction du grêle entre mars 2015 et mars 2016. Nous avons aussi utilisé cette base de données, de même que les dossiers des patients et les dossiers médicaux électroniques, pour schématiser les processus suivis de l'arrivée à l'hôpital jusqu'au congé. RÉSULTATS: Nous avons recensé 88 patients atteints d'une obstruction du grêle (33 soumis à une chirurgie, et 55 à un traitement non chirurgical). Les patients opérés ont présenté un taux de complications de 32 %. Les processus thérapeutiques de l'arrivée au suivi se sont avérés très détaillés et variables en durée; par contre, la séquence de soins était uniforme. Nous avons utilisé des stratégies de visualisation des données pour repérer les goulots d'étranglement au chapitre des soins, ce qui a révélé une variabilité substantielle dans l'accès au bloc opératoire. CONCLUSION: La variabilité observée dans les soins chirurgicaux pour l'obstruction du grêle est élevée et représente une importante occasion d'amélioration en chirurgie générale. La schématisation des processus permet de dégager des thèmes communs, même dans un contexte d'urgence, et met en lumière des possibilités précises d'amélioration du rendement.

Data capture and communication during transfers to definitive care in an inclusive trauma system.

INTRODUCTION: Background trauma survivors in rural areas transferred to urban centers have higher mortality than trauma patients admitted directly to urban centers. Transfer data in trauma registries is important for injury control. Prehospital and early physiologic data may reflect processes of pre-hospital care. British Columbia currently has no standardized process for trauma patient data transfer. PATIENTS AND METHODS: We performed a retrospective data analysis for major trauma patients (ISS>15) transferred to a Level I trauma center over a 1year period (n=243). Completion rates of paramedic form and ATLS primary survey variables were extracted. Nominal and interval descriptives were calculated. Documentation rates were considered deficient at <80% and severely deficient <60%. Odds ratios were calculated for primary facility data based on ISS ≥30 vs ISS <30, with 2-sided p-values for confidence intervals RESULTS: Two hundred forty-three patients met inclusion criteria with a mean ISS of 26. Most injured patients were male (79%), the predominant mechanism was blunt (93%) and the average age at injury was 51 years old. Two hundred eighteen patients arrived by Emergency Health Services, and 140 (64%) of EHS pre-hospital forms were transferred with the patient chart. Pre-hospital airway, physiologic data, and GCS completion rates were severely deficient (43-49%). Primary facility data was adequately completed for airway management, systolic blood pressure, and heart rate in (80-83%). Completion rates were deficient for respiratory rate, GCS and temperature (60-77%). An ISS score ≥30 was significantly associated with a lower completion rate for GCS. DISCUSSION AND CONCLUSION: Overall, documentation for inter-hospital transfer of major trauma patients in BC has significant deficiencies. Physiologic and basic ATLS variables are often omitted in transferred charts. The potential for adverse events is high but performance improvement is achievable. We recommend education, training and a standardized trauma transfer protocol to improve system-wide information transfer.

No benefit to surgical fixation of flail chest injuries compared with modern comprehensive management: results of a retrospective cohort study.

BACKGROUND: Chest wall trauma is a common cause of morbidity and mortality. Recent technological advances and scientific publications have created a renewed interest in surgical fixation of flail chest. However, definitive data supporting surgical fixation are lacking, and its virtues have not been evaluated against modern, comprehensive management protocols. METHODS: Consecutive patients undergoing rib fracture fixation with rib-specific locking plates at 2 regional trauma centres between July 2010 and August 2012 were matched to historical controls with similar injury patterns and severity who were managed nonoperatively with modern, multidisciplinary protocols. We compared short- and long-term outcomes between these cohorts. RESULTS: Our patient cohorts were well matched for age, sex, injury severity scores and abbreviated injury scores. The nonoperatively managed group had significantly better outcomes than the surgical group in terms of ventilator days (3.1 v. 6.1, p = 0.012), length of stay in the intensive care unit (3.7 v. 7.4 d, p = 0.009), total hospital length of stay (16.0 v. 21.9 d, p = 0.044) and rates of pneumonia (22% v. 63%, p = 0.004). There were no significant differences in long-term outcomes, such as chest pain or dyspnea. CONCLUSION: Although considerable enthusiasm surrounds surgical fixation of flail chest injuries, our analysis does not immediately validate its universal implementation, but rather encourages the use of modern, multidisciplinary, nonoperative strategies. The role of rib fracture fixation in the modern era of chest wall trauma management should ultimately be defined by prospective, randomized trials.

CONTEXTE: Les traumatismes à la paroi thoracique sont une cause courante de morbidité et de mortalité. Dernièrement, des avancées technologiques et des articles scientifiques ont ravivé l'intérêt à l'égard du traitement chirurgical du volet costal. Les données fiables appuyant la fixation chirurgicale sont toutefois rares, et les avantages de cette technique n'ont pas été comparés à ceux de protocoles de prise en charge complets et modernes. MÉTHODES: Nous avons jumelé des patients consécutifs admis dans 2 centres régionaux de traumatologie entre juillet 2010 et août 2012 pour une fixation d'une fracture des côtes à l'aide de plaques verrouillées avec un groupe témoin rétrospectif présentant des blessures de type et de gravité semblables, toutefois pris en charge selon des protocoles multidisciplinaires modernes ne nécessitant aucune intervention chirurgicale. Nous avons ensuite comparé les issues à court et à long terme dans ces cohortes. RÉSULTATS: Les cohortes étaient bien appariées sur le plan de l'âge, du sexe et des indices de gravité des blessures. Les résultats des patients n'ayant pas subi d'intervention chirurgicale étaient significativement meilleurs que ceux de l'autre groupe en ce qui concerne le nombre de jours sous ventilation assistée (3,1 c. 6,1; p = 0,012), la durée du séjour aux soins intensifs (3,7 c. 7,4 jours; p = 0,009), la durée totale du séjour à l'hôpital (16,0 c. 21,9 jours; p = 0,044) et le taux de pneumonie (22 % c. 63 %; p = 0,004). Aucune différence significative n'a été observée en ce qui concerne les répercussions à long terme telles que les douleurs thoraciques ou la dyspnée. CONCLUSION: Si la fixation chirurgicale des blessures au volet costal suscite un grand enthousiasme, les résultats de notre analyse n'appuient pas le recours systématique à cette intervention, mais encouragent plutôt l'utilisation de stratégies modernes multidisciplinaires sans intervention chirurgicale. En conclusion, le rôle de la fixation des fractures des côtes dans la prise en charge moderne des traumatismes à la paroi thoracique devrait être défini dans le cadre d'études prospectives randomisées.

Advances in damage control resuscitation and surgery: implications on the organization of future military field forces.

Medical support to deployed field forces is increasingly becoming a shared responsibility among allied nations. National military medical planners face several key challenges, including fiscal restraints, raised expectations of standards of care in the field and a shortage of appropriately trained specialists. Even so, medical services are now in high demand, and the availability of medical support may become the limiting factor that determines how and where combat units can deploy. The influence of medical factors on operational decisions is therefore leading to an increasing requirement for multinational medical solutions. Nations must agree on the common standards that govern the care of the wounded. These standards will always need to take into account increased public expectations regarding the quality of care. The purpose of this article is to both review North Atlantic Treaty Organization (NATO) policies that govern multinational medical missions and to discuss how recent scientific advances in prehospital battlefield care, damage control resuscitation and damage control surgery may inform how countries within NATO choose to organize and deploy their field forces in the future.

De plus en plus, la responsabilité du soutien médical offert aux forces militaires déployées sur le terrain devient partagée entre les nations alliées. Les planificateurs médicaux militaires nationaux font face à plusieurs défis importants, tels que restrictions budgétaires, attentes élevées au chapitre des normes de soin sur le terrain et pénurie de spécialistes dûment formés. Malgré cela, les services médicaux sont présentement en grande demande et leur disponibilité pourrait devenir le facteur limitatif susceptible de déterminer de quelle façon et en quels lieux les unités de combat peuvent se déployer. L'impact des facteurs médicaux sur les décisions opérationnelles requiert donc de plus en plus des solutions médicales multinationales. Les nations doivent s'entendre sur des normes communes qui régissent les soins à prodiguer aux blessés. Ces normes devront toujours tenir compte des attentes accrues du public en regard de la qualité des soins. Le but de cet article est de revoir les politiques de l'Organisation du Traité de l'Atlantique Nord (OTAN) qui régissent les missions médicales multinationales et de discuter de la façon dont les progrès scientifiques récents des soins pré-hospitaliers sur les champs de bataille et les techniques de réanimation et de chirurgie de sauvetage peuvent éclairer la façon dont les pays de l'OTAN décideront d'organiser et de déployer leurs forces sur le terrain à l'avenir.

Creating a gold medal Olympic and Paralympics health care team: a satisfaction survey of the mobile medical unit/polyclinic team training for the Vancouver 2010 winter games.

BACKGROUND: The mobile medical unit/polyclinic (MMU/PC) was an essential part of the medical services to support ill or injured Olympic or Paralympics family during the 2010 Olympic and Paralympics winter games. The objective of this study was to survey the satisfaction of the clinical staff that completed the training programs prior to deployment to the MMU. METHODS: Medical personnel who participated in at least one of the four training programs, including (1) week-end sessions; (2) web-based modules; (3) just-in-time training; and (4) daily simulation exercises were invited to participate in a web-based survey and comment on their level of satisfaction with training program. RESULTS: A total of 64 (out of 94 who were invited) physicians, nurses and respiratory therapists completed the survey. All participants reported favorably that the MMU/PC training positively impacted their knowledge, skills and team functions while deployed at the MMU/PC during the 2010 Olympic Games. However, components of the training program were valued differently depending on clinical job title, years of experience, and prior experience in large scale events. Respondents with little or no experience working in large scale events (45%) rated daily simulations as the most valuable component of the training program for strengthening competencies and knowledge in clinical skills for working in large scale events. CONCLUSION: The multi-phase MMU/PC training was found to be beneficial for preparing the medical team for the 2010 Winter Games. In particular this survey demonstrates the effectiveness of simulation training programs on teamwork competencies in ad hoc groups.

Causes of death in Canadian Forces members deployed to Afghanistan and implications on tactical combat casualty care provision.

BACKGROUND: As part of its contribution to the Global War on Terror and North Atlantic Treaty Organization's International Security Assistance Force, the Canadian Forces deployed to Kandahar, Afghanistan, in 2006. We have studied the causes of deaths sustained by the Canadian Forces during the first 28 months of this mission. The purpose of this study was to identify potential areas for improving battlefield trauma care. METHODS: We analyzed autopsy reports of Canadian soldiers killed in Afghanistan between January 2006 and April 2008. Demographic characteristics, injury data, location of death within the chain of evacuation, and cause of death were determined. We also determined whether the death was potentially preventable using both explicit review and implicit review by a panel of trauma surgeons. RESULTS: During the study period, 73 Canadian Forces members died in Afghanistan. Their mean age was 29 (+/-7) years and 98% were male. The predominant mechanism of injury was explosive blast, resulting in 81% of overall deaths during the study period. Gunshot wounds and nonblast-related motor vehicle collisions were the second and third leading mechanisms of injury causing death. The mean Injury Severity Score was 57 (+/-24) for the 63 study patients analyzed. The most common cause of death was hemorrhage (38%), followed by neurologic injury (33%) and blast injuries (16%). Three deaths were deemed potentially preventable on explicit review, but implicit review only categorized two deaths as being potentially preventable. CONCLUSIONS: The majority of combat-related deaths occurred in the field (92%). Very few deaths were potentially preventable with current Tactical Combat Casualty interventions. Our panel review identified several interventions that are not currently part of Tactical Combat Casualty that may prevent future battlefield deaths.

A predeployment trauma team training course creates confidence in teamwork and clinical skills: a post-Afghanistan deployment validation study of Canadian Forces healthcare personnel.

BACKGROUND: The 10-day Intensive Trauma Team Training Course (ITTTC) was developed by the Canadian Forces (CFs) to teach teamwork and clinical trauma skills to military healthcare personnel before deploying to Afghanistan. This article attempts to validate the impact of the ITTTC by surveying participants postdeployment. METHODS: A survey consisting of Likert-type multiple-choice questions was created and sent to all previous ITTTC participants. The survey asked respondents to rate their confidence in applying teamwork skills and clinical skills learned in the ITTTC. It explored the relevancy of objectives and participants' prior familiarity with the objectives. The impact of different training modalities was also surveyed. RESULTS: The survey showed that on average 84.29% of participants were "confident" or "very confident" in applying teamwork skills to their subsequent clinical experience and 52.10% were "confident" or "very confident" in applying clinical knowledge and skills. On average 43.74% of participants were "familiar" or "very familiar" with the clinical topics before the course, indicating the importance of training these skills. Participants found that clinical shadowing was significantly less valuable in training clinical skills than either animal laboratory experience or experience in human patient simulators; 68.57% respondents thought that ITTTC was "important" or "very important" in their training. CONCLUSIONS: The ITTTC created lasting self-reported confidence in CFs healthcare personnel surveyed upon return from Afghanistan. This validates the importance of the course for the training of CFs healthcare personnel and supports the value of team training in other areas of trauma and medicine.