Implementation of tranexamic acid for bleeding trauma patients: a longitudinal and cross-sectional study.

OBJECTIVE: To describe the use of tranexamic acid (TXA) in trauma care in England and Wales since the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage (CRASH-2) trial results were published in 2010. METHODS: A national longitudinal and cross-sectional study using data collected through the Trauma Audit and Research Network (TARN), the clinical audit of major trauma care for England and Wales. All patients in the TARN database injured in England and Wales were included apart from those with an isolated traumatic brain injury, with a primary outcome of the proportion of patients given TXA and the secondary outcome of time to treatment. RESULTS: Among 228 250 patients, the proportion of trauma patients treated with TXA increased from near zero in 2010 to 10% (4593) in 2016. In 2016, most patients (82%) who received TXA did so within 3 hours of injury, however, only 30% of patients received TXA within an hour of injury. Most (80%) of the patients who had an early blood transfusion were given TXA. Patients treated with TXA by an ambulance paramedic received treatment at a median of 49 min (IQR 33-72) compared with 111 min (IQR 77-162) for patients treated in hospital. CONCLUSIONS: There is a low proportion of patients treated with TXA across the range of injury severity and the range of physiological indicators of severity of bleeding. Most patients receive treatment within the existing target of 3 hours from injury, however there remains the potential to further improve major trauma outcomes by the earlier treatment of a wider patient group.

The use of whole-body computed tomography in major trauma: variations in practice in UK trauma hospitals.

INTRODUCTION: Whole-body CT (WBCT) use in patients with trauma in England and Wales is not well documented. WBCT in trauma can reduce time to definitive care, thereby increasing survival. However, its use varies significantly worldwide. METHODS: We performed a retrospective observational study of Trauma Audit and Research Network (TARN) data from 2012 to 2014. The proportion of adult patients receiving WBCT during initial resuscitation at major trauma centres (MTCs) and trauma units/non-designated hospitals (TUs/NDHs) was compared. A model was developed that included factors associated with WBCT use, and centre effects within the model were explored to determine variation in usage beyond that expected from the model. RESULTS: Of the 115 664 study participants, 16.5% had WBCT. WBCT was performed five times more frequently in MTCs than in TUs/NDHs (31% vs 6.6%). In the multivariate model, increased injury severity, low GCS, shock, comorbidities and triage category increased the chances of having a WBCT, but there was no consistent relation with age. High falls and motor vehicle collisions also increased WBCT usage. Adjusting for casemix, there was a 13-fold intrahospital variation in the use of WBCT between MTCs and a 30-fold variation between TUs/NDHs. The amount of variability between individual hospitals that could not be accounted for by the factors shown to impact on WBCT use was 26% (95% CI 17% to 39%) for MTCs and 17% (95% CI 13% to 21%) for TUs/NDHs. CONCLUSION: There are significant variations in WBCT use between different hospitals in England and Wales, which require further investigation.

Are first rib fractures a marker for other life-threatening injuries in patients with major trauma? A cohort study of patients on the UK Trauma Audit and Research Network database.

BACKGROUND: First rib fractures are considered indicators of increased morbidity and mortality in major trauma. However, this has not been definitively proven. With an increased use of CT and the potential increase in detection of first rib fractures, re-evaluation of these injuries as a marker for life-threatening injuries is warranted. METHODS: Patients sustaining rib fractures between January 2012 and December 2013 were investigated using data from the UK Trauma Audit and Research Network. The prevalence of life-threatening injuries was compared in patients with first rib fractures and those with other rib fractures. Multivariate logistic regression was performed to determine the association between first rib fractures, injury severity, polytrauma and mortality. RESULTS: There were 1683 patients with first rib fractures and 8369 with fractures of other ribs. Life-threatening intrathoracic and extrathoracic injuries were more likely in patients with first rib fractures. The presence of first rib fractures was a significant predictor of injury severity (Injury Severity Score >15) and polytrauma, independent of mechanism of injury, age and gender with an adjusted OR of 2.64 (95% CI 2.33 to 3.00) and 2.01 (95% CI 1.80 to 2.25), respectively. Risk-adjusted mortality was the same in patients with first rib fractures and those with other rib fractures (adjusted OR 0.97, 95% CI 0.79 to 1.19). CONCLUSION: First rib fractures are a marker of life-threatening injuries in major trauma, though they do not independently increase mortality. Management of patients with first rib fractures should focus on identification and treatment of associated life-threatening injuries.

Resuscitative endovascular balloon occlusion of the aorta (REBOA): a population based gap analysis of trauma patients in England and Wales.

INTRODUCTION: Non-compressible torso haemorrhage (NCTH) carries a high mortality in trauma as many patients exsanguinate prior to definitive haemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct that has the potential to bridge patients to definitive haemostasis. However, the proportion of trauma patients in whom REBOA may be utilised is unknown. METHODS: We conducted a population based analysis of 2012-2013 Trauma Audit and Research Network (TARN) data. We identified the number of patients in whom REBOA may have been utilised, defined by an Abbreviated Injury Scale score ≥3 to abdominal solid organs, abdominal or pelvic vasculature, pelvic fracture with ring disruption or proximal traumatic lower limb amputation, together with a systolic blood pressure <90 mm Hg. Patients with non-compressible haemorrhage in the mediastinum, axilla, face or neck were excluded. RESULTS: During 2012-2013, 72 677 adult trauma patients admitted to hospitals in England and Wales were identified. 397 patients had an indication(s) and no contraindications for REBOA with evidence of haemorrhagic shock: 69% men, median age 43 years and median Injury Severity Score 32. Overall mortality was 32%. Major trauma centres (MTCs) received the highest concentration of potential REBOA patients, and would be anticipated to receive a patient in whom REBOA may be utilised every 95 days, increasing to every 46 days in the 10 MTCs with the highest attendance of this injury type. CONCLUSIONS: This TARN database analysis has identified a small group of severely injured, resource intensive patients with a highly lethal injury that is theoretically amenable to REBOA. The highest density of these patients is seen at MTCs, and as such a planned evaluation of REBOA should be further considered in these hospitals.

Epidemiology and aetiology of traumatic cardiac arrest in England and Wales - A retrospective database analysis.

BACKGROUND: Historically, reported survival from traumatic cardiac arrest (TCA) was extremely low. More recent publications have recorded survival to discharge of up to 8%. This improvement is likely to be multi-factorial; however, there are currently no published data describing the epidemiology or aetiology of TCA in England and Wales to guide future practice improvement. METHODS: Population-based analysis of 2009-2015 Trauma Audit and Research Network (TARN) data. The primary aim was to describe the 30-day survival following TCA. Patients of all ages with traumatic cardiac arrest pre-hospital or in the emergency department (ED) were included. Data are described as number (%), and median [interquartile range]. Two-group analysis with Chi-squared test was performed. RESULTS: During the study period 227,944 patients were included in the TARN database. Seven hundred and five (0.3%) suffered TCA: 74.3% were male, aged 44.3 [25.2-83.2] years, ISS 29 [21-75], and 601 (85.2%) had blunt injuries. 612 (86.8%) had a severe traumatic brain injury and or severe haemorrhage. Overall 30-day survival was 7.5% (95%CI 5.6-9.5) - 'pre-hospital only' TCA 11.5%, 'ED only' TCA 3.9%, p<0.02. No patients who were in TCA both pre-hospital and in the ED survived. CONCLUSION: This study has shown that short-term survival from TCA in this large civilian registry is 7.5%. Early and aggressive management of patients with TCA, using protocols that target the reversible causes of TCA, should be initiated. Further work to establish novel ways to manage patients with reversible causes of TCA is indicated. Resuscitation in this patient group is not futile.