Exploring the effect of factor Xa inhibitors on rotational thromboelastometry: a case series of bleeding patients.

Direct oral anticoagulants (DOACs) have become the standard for thromboembolic risk management. In cases of major bleeding, trauma, or urgent surgery, accurate monitoring of DOAC activity is desirable; however, there is often no rapid, readily available test. We therefore explored the degree to which DOAC activity correlated with two coagulation assays: rotational thromboelastometry (ROTEM) and a standard coagulation assay in bleeding patients. We conducted a retrospective review of patients who experienced bleeding while on DOAC therapy from 2015 to 2017 at a Level 1 trauma center. ROTEM (EXTEM-clotting time {CT} in seconds), activated partial thromboplastin time (aPTT) (in seconds), prothrombin time (PT) (in seconds), DOAC specific drug test (anti-Xa and Hemoclot in ng/mL), and relevant clinical parameters were recorded. Descriptive statistics (median, range) and Spearman correlation coefficients were estimated. Differences between correlations were tested using Williams' t test. Twelve cases were reviewed (13 separate bleeding episodes). Sixteen measurements of DOAC activity, EXTEM-CT, and PT were obtained. The correlations with rivaroxaban activity were 0.96 and 0.86 (p = 0.2062) for PT and EXTEM-CT, respectively. The correlations with apixaban activity were 0.63 and 0.56 (p = 0.7175) for PT and EXTEM-CT, respectively. Analyses were not conducted for dabigatran due to limited data. Although not statistically significant, PT appears to have a higher correlation with direct Xa inhibitor activity than EXTEM-CT. Further research with larger samples is necessary to clarify the differences between ROTEM and standard assays in detecting DOAC activity.

Canceled to Be Called Back: A Retrospective Cohort Study of Canceled Helicopter Emergency Medical Service Scene Calls That Are Later Transferred to a Trauma Center.

INTRODUCTION: In our trauma system, helicopter emergency medical services (HEMS) can be requested to attend a scene call for an injured patient before arrival by land paramedics. Land paramedics can cancel this response if they deem it unnecessary. The purpose of this study is to describe the frequency of canceled HEMS scene calls that were subsequently transferred to 2 trauma centers and to assess for any impact on morbidity and mortality. METHODS: Probabilistic matching was used to identify canceled HEMS scene call patients who were later transported to 2 trauma centers over a 48-month period. Registry data were used to compare canceled scene call patients with direct from scene patients. RESULTS: There were 290 requests for HEMS scene calls, of which 35.2% were canceled. Of those canceled, 24.5% were later transported to our trauma centers. Canceled scene call patients were more likely to be older and to be discharged home from the trauma center without being admitted. CONCLUSION: There is a significant amount of undertriage of patients for whom an HEMS response was canceled and later transported to a trauma center. These patients face similar morbidity and mortality as patients who are brought directly from scene to a trauma center.

Care of the Injured Patients at Nursing Stations and during Air Medical Transport.

INTRODUCTION: Nursing stations are the only access point into the health care system for some communities and have limited capabilities and resources. We describe characteristics of patients injured in Northern Ontario who present to nursing stations and require transport by air ambulance. Secondary objectives are to compare interventions performed at nursing stations with those performed by flight paramedics and to identify systemic gaps in trauma care. METHODS: A retrospective cohort study was performed of all injured patients transported by air ambulance from April 1, 2014, to March 31, 2015. RESULTS: A total of 125 injured patients were transported from nursing stations. Blunt trauma accounted for 82.5% of injuries, and alcohol intoxication was suspected in 41.6% of patients. The most frequently performed interventions were intravenous fluids and analgesia. Paramedics administered oxygen 62.4% of the time, whereas nursing stations only applied in 8.8% of cases. Flight paramedics were the only providers to intubate and administer tranexamic acid, mannitol, or vasopressors. CONCLUSION: Care for patients at nursing stations may be improved by updating the drug formulary based on gap analyses. Further research should examine the role of telemedicine support for nursing station staff and the use of point-of-care devices to screen for traumatic intracranial hemorrhage.

Comparison of Helicopter Emergency Medical Services Transport Types and Delays on Patient Outcomes at Two Level I Trauma Centers.

BACKGROUND: Helicopter emergency medical services (HEMS) have become an engrained component of trauma systems. In Ontario, transportation for trauma patients is through one of three ways: scene call, modified scene call, or interfacility transfer. We hypothesize that differences exist between these types of transports in both patient demographics and patient outcomes. This study compares the characteristics of patients transported by each of these methods to two level 1 trauma centers and assesses for any impact on morbidity or mortality. As a secondary outcome reasons for delay were identified. METHODS: A local trauma registry was used to identify and abstract data for all patients transported to two trauma centers by HEMS over a 36-month period. Further chart abstraction using the HEMS patient care reports was done to identify causes of delay during HEMS transport. RESULTS: During the study period HEMS transferred a total of 911 patients of which 139 were scene calls, 333 were modified scene calls and 439 were interfacility transfers. Scene calls had more patients with an ISS of less than 15 and had more patients discharged home from the ED. Modified scene calls had more patients with an ISS greater than 25. The most common delays that were considered modifiable included the sending physician doing a procedure, waiting to meet a land EMS crew, delays for diagnostic imaging and confirming disposition or destination. CONCLUSIONS: Differences exist between the types of transports done by HEMS for trauma patients. Many identified reasons for delay to HEMS transport are modifiable and have practical solutions. Future research should focus on solutions to identified delays to HEMS transport. Key words: helicopter emergency medical services; trauma; prehospital care; delays.

Tranexamic acid in pediatric trauma: why not?

Trauma is a leading cause of death in pediatrics. Currently, no medical treatment exists to reduce mortality in the setting of pediatric trauma; however, this evidence does exist in adults. Bleeding and coagulopathy after trauma increases mortality in both adults and children. Clinical research has demonstrated a reduction in mortality with early use of tranexamic acid in adult trauma patients in both civilian and military settings. Tranexamic acid used in the perioperative setting safely reduces transfusion requirements in children. This article compares the hematologic response to trauma between children and adults, and explores the potential use of tranexamic acid in pediatric hemorrhagic trauma.

Vision Transformer-based Decision Support for Neurosurgical Intervention in Acute Traumatic Brain Injury: Automated Surgical Intervention Support Tool.

Purpose To develop an automated triage tool to predict neurosurgical intervention for patients with traumatic brain injury (TBI). Materials and Methods A provincial trauma registry was reviewed to retrospectively identify patients with TBI from 2005 to 2022 treated at a specialized Canadian trauma center. Model training, validation, and testing were performed using head CT scans with binary reference standard patient-level labels corresponding to whether the patient received neurosurgical intervention. Performance and accuracy of the model, the Automated Surgical Intervention Support Tool for TBI (ASIST-TBI), were also assessed using a held-out consecutive test set of all patients with TBI presenting to the center between March 2021 and September 2022. Results Head CT scans from 2806 patients with TBI (mean age, 57 years ± 22 [SD]; 1955 [70%] men) were acquired between 2005 and 2021 and used for training, validation, and testing. Consecutive scans from an additional 612 patients (mean age, 61 years ± 22; 443 [72%] men) were used to assess the performance of ASIST-TBI. There was accurate prediction of neurosurgical intervention with an area under the receiver operating characteristic curve (AUC) of 0.92 (95% CI: 0.88, 0.94), accuracy of 87% (491 of 562), sensitivity of 87% (196 of 225), and specificity of 88% (295 of 337) on the test dataset. Performance on the held-out test dataset remained robust with an AUC of 0.89 (95% CI: 0.85, 0.91), accuracy of 84% (517 of 612), sensitivity of 85% (199 of 235), and specificity of 84% (318 of 377). Conclusion A novel deep learning model was developed that could accurately predict the requirement for neurosurgical intervention using acute TBI CT scans. Keywords: CT, Brain/Brain Stem, Surgery, Trauma, Prognosis, Classification, Application Domain, Traumatic Brain Injury, Triage, Machine Learning, Decision Support Supplemental material is available for this article. © RSNA, 2024 See also commentary by Haller in this issue.

The Priorities of End Users of Emergency Department Electronic Health Records: Modified Delphi Study.

BACKGROUND: The needs of the emergency department (ED) pose unique challenges to modern electronic health record (EHR) systems. A diverse case load of high-acuity, high-complexity presentations, and ambulatory patients, all requiring multiple transitions of care, creates a rich environment through which to critically examine EHRs. OBJECTIVE: This investigation aims to capture and analyze the perspective of end users of EHR about the strengths, limitations, and future priorities for EHR in the setting of the ED. METHODS: In the first phase of this investigation, a literature search was conducted to identify 5 key usage categories of ED EHRs. Using key usage categories in the first phase, a modified Delphi study was conducted with a group of 12 panelists with expertise in both emergency medicine and health informatics. Across 3 rounds of surveys, panelists generated and refined a list of strengths, limitations, and key priorities. RESULTS: The findings from this investigation highlighted the preference of panelists for features maximizing functionality of basic clinical features relative to features of disruptive innovation. CONCLUSIONS: By capturing the perspectives of end users in the ED, this investigation highlights areas for the improvement or development of future EHRs in acute care settings.

Who are the trauma team leaders across Canada? A national survey evaluating the profession in adult and pediatric level one trauma centres.

OBJECTIVES: Trauma Team Leaders (TTLs) are critical for coordinating and leading trauma resuscitations. This survey sought to characterize the demographics and professional practices of Canadian TTLs at level one trauma centres. As a secondary objective, this information will be utilized to inform the operational goals of the Trauma Association of Canada (TAC) TTL Committee. METHODS: A detailed survey, developed by the TAC board of directors and TTL committee leads, was sent to 225 TTLs across Canada's level one trauma centres. TTLs were identified via contacting trauma directors at each level one centre, in addition to public registry searches. This survey captured demographics, professional background, resuscitation practices, trauma team composition, and TTL involvement in trauma responses. RESULTS: The response rate was 41.7%. Mean respondent age was 42 (SD 7.4) and 71.0% were male. Most TTLs trained in emergency medicine (53.1%) or general surgery (25.5%); 63.8% underwent TTL training: either via a trauma surgery fellowship or TTL fellowship. All centres have a massive hemorrhage protocol implemented, and there is no large variation between the rates of use of cryoprecipitate and fibrinogen, nor the ratio of blood products transfused (2:1 vs 1:1). Most TTL respondents intend to participate in a TTL group associated with TAC (85.1%). CONCLUSION: The results of this survey will contribute to the recognition of TTLs as a crucial role in the initial phase of care of severely injured trauma patients and serves as the first publication to document professional backgrounds and practices of Canadian TTLs at level one trauma centres. All the information gathered via this survey will be used by the TAC TTL Committee, which will focus on several initiatives such as the dissemination of best practice guidelines and creation of a TTL stream at the TAC Annual Conference.

RéSUMé: OBJECTIFS: Les chefs d'équipe de traumatologie (TTL) sont essentiels pour coordonner et diriger les réanimations traumatiques. Cette enquête visait à caractériser la démographie et les pratiques professionnelles des TTL canadiens dans les centres de traumatologie de niveau 1. À titre d'objectif secondaire, cette information sera utilisée pour éclairer les objectifs opérationnels du Comité TTL de l'Association canadienne de traumatologie (ATC). MéTHODES: Un sondage détaillé, élaboré par le conseil d'administration de l'ATC et les responsables des comités de TTL, a été envoyé à 225 TTL dans les centres de traumatologie de niveau 1 du Canada. Les TTL ont été identifiés en contactant les directeurs de traumatologie de chaque centre de niveau 1, en plus des recherches dans le registre public. Cette enquête a porté sur la démographie, les antécédents professionnels, les pratiques de réanimation, la composition de l'équipe de traumatologie et la participation de la TTL aux réponses traumatologiques. RéSULTATS: Le taux de réponse était de 41,7 %. L'âge moyen des répondants était de 42 ans (ET 7,4) et 71,0 % étaient des hommes. La plupart des TTL ont suivi une formation en médecine d'urgence (53,1%) ou en chirurgie générale (25,5%); 63,8% ont suivi une formation TTL : soit via une bourse en chirurgie traumatologique ou une bourse TTL. Tous les centres ont mis en œuvre un protocole d'hémorragie massive, et il n'y a pas de grande variation entre les taux d'utilisation du cryoprécipité et du fibrinogène, ni entre le rapport des produits sanguins transfusés (2:1 vs 1:1). La plupart des répondants TTL ont l'intention de participer à un groupe TTL associé au TAC ( 85,1 %). CONCLUSION: Les résultats de ce sondage contribueront à la reconnaissance des TTL comme un rôle crucial dans la phase initiale des soins aux patients ayant subi un traumatisme grave et serviront de première publication pour documenter les antécédents et les pratiques professionnelles des TTL canadiens au niveau un centres de traumatologie. Toutes les informations recueillies dans le cadre de cette enquête seront utilisées par le Comité TAC TTL, qui se concentrera sur plusieurs initiatives telles que la diffusion de lignes directrices sur les meilleures pratiques et la création d'un flux TTL à la conférence annuelle TAC.

Non-task expert physicians benefit from correct explainable AI advice when reviewing X-rays.

Artificial intelligence (AI)-generated clinical advice is becoming more prevalent in healthcare. However, the impact of AI-generated advice on physicians' decision-making is underexplored. In this study, physicians received X-rays with correct diagnostic advice and were asked to make a diagnosis, rate the advice's quality, and judge their own confidence. We manipulated whether the advice came with or without a visual annotation on the X-rays, and whether it was labeled as coming from an AI or a human radiologist. Overall, receiving annotated advice from an AI resulted in the highest diagnostic accuracy. Physicians rated the quality of AI advice higher than human advice. We did not find a strong effect of either manipulation on participants' confidence. The magnitude of the effects varied between task experts and non-task experts, with the latter benefiting considerably from correct explainable AI advice. These findings raise important considerations for the deployment of diagnostic advice in healthcare.

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.

Bicyclist deaths and striking vehicles in the USA.

OBJECTIVES: Bicycling is a popular means of transportation that is sometimes associated with injury from collisions. The authors analysed national data for the USA to evaluate bicyclist deaths associated with motor vehicle impacts. METHODS: The authors conducted a population-based case-control analysis of road deaths reported by the National Highway Traffic Safety Administration. The authors included bicyclist deaths from 1 January 2008 to 31 December 2008 (cases), along with the non-bicyclist road deaths immediately before and after the bicyclist death in the same state (controls). Analyses also included linkages to auto appraisal websites to estimate type, size and cost of the motor vehicle involved in each death. RESULTS: A total of 711 bicyclist deaths were included, equivalent to a rate of 2 deaths per million population annually. No state had a rate statistically significantly below the national average whereas Florida was a high outlier with three times the national rate (p<0.001). The typical bicyclist who died was a man travelling in the afternoon or evening. The average estimated resale value of the involved motor vehicle was about one-third higher for bicyclist deaths than control deaths (US$10 603 vs US$8118, p<0.001). Analyses based on median estimated resale value and luxury resale value yielded similar findings. Stratified analyses based on demographics, time and posted speed limits yielded similar discrepancies. Larger motor vehicles were particularly common in bicyclist deaths compared to control deaths, especially freight trucks (11% vs 8%, p=0.008) and large automobiles (43% vs 37%, p=0.004). Conversely, motorcycles were distinctly infrequent in bicyclist deaths compared to control deaths (1% vs 14%, p<0.001). CONCLUSIONS: Large expensive motor vehicles account for a disproportionate share of bicyclist deaths. Bicyclists, motorists, policy-makers and vehicle manufacturers need to consider more imaginative solutions to help prevent future deaths.

Violence in Canadian amateur hockey: the experience of referees in Ontario.

OBJECTIVE: To determine the perceptions and roles of referees about violence and injury in hockey games. DESIGN: Questionnaire. SETTING: Web-based survey. PARTICIPANTS: We contacted referees across Canada from various leagues and all levels of play, with the majority of respondents from Ontario (92%). MAIN OUTCOME MEASURES: We gathered demographic information anonymously and posed questions on aggression and experience in hockey games. RESULTS: The majority of referees (n = 632) indicated that violence is a serious concern to both players and referees at all levels of hockey. More than 90% of referees responded that they were the recipients of aggression and anger (92.1%, 95% confidence interval, 90.0-94.2), 55% had been involved in hockey games where aggressive behavior resulted in the referee losing control of the game, and 71% said that this increased aggression leads to injury. Referees' opinions are that the coach is the most responsible for managing on-ice safety (63%). To improve hockey safety, referees suggest education and more rigorous enforcement of discipline for all participants. CONCLUSIONS: Referees are important for hockey safety and need to be appropriately supported. Referees believe that increased aggression can lead to injury and that rules need to be enforced more diligently. Referees recommend that increased education about safety is needed to guide parents, coaches, and players to make hockey safer.

Designs, facilitators, barriers, and lessons learned during the implementation of emergency department led virtual urgent care programs in Ontario, Canada.

Introduction: Virtual patient care has seen incredible growth since the beginning of the COVID-19 pandemic. To provide greater access to safe and timely urgent care, in the fall of 2020, the Ministry of Health introduced a pilot program of 14 virtual urgent care (VUC) initiatives across the province of Ontario. The objective of this paper was to describe the overall design, facilitators, barriers, and lessons learned during the implementation of seven emergency department (ED) led VUC pilot programs in Ontario, Canada. Methods: We assembled an expert panel of 13 emergency medicine physicians and researchers with experience leading and implementing local VUC programs. Each VUC program lead was asked to describe their local pilot program, share common facilitators and barriers to adoption of VUC services, and summarize lessons learned for future VUC design and development. Results: Models of care interventions varied across VUC pilot programs related to triage, staffing, technology, and physician remuneration. Common facilitators included local champions to guide program delivery, provincial funding support, and multi-modal marketing and promotions. Common barriers included behaviour change strategies to support adoption of a new service, access to high-quality information technology to support new workflow models that consider privacy, risk, and legal perspectives, and standardized data collection which underpin overall objective impact assessments. Conclusions: These pilot programs were rapidly implemented to support safe access to care and ED diversion of patients with low acuity issues during the COVID-19 pandemic. The heterogeneity of program implementation respects local autonomy yet may present challenges for sustainability efforts and future funding considerations.