Validation of the Conventional Trauma and Injury Severity Score and a Newly Developed Survival Predictive Model in Pediatric Patients with Blunt Trauma: A Nationwide Observation Study.

To date, there is no clinically useful prediction model that is suitable for Japanese pediatric trauma patients. Herein, this study aimed to developed a model for predicting the survival of Japanese pediatric patients with blunt trauma and compare its validity with that of the conventional TRISS model. Patients registered in the Japan Trauma Data Bank were grouped into a derivation cohort (2009-2013) and validation cohort (2014-2018). Logistic regression analysis was performed using the derivation dataset to establish prediction models using age, injury severity, and physiology. The validity of the modified model was evaluated by the area under the receiver operating characteristic curve (AUC). Among 11 predictor models, Model 1 and Model 11 had the best performance (AUC = 0.980). The AUC of all models was lower in patients with survival probability Ps < 0.5 than in patients with Ps ≥ 0.5. The AUC of all models was lower in neonates/infants than in other age categories. Model 11 also had the best performance (AUC = 0.762 and 0.909, respectively) in patients with Ps < 0.5 and neonates/infants. The predictive ability of the newly modified models was not superior to that of the current TRISS model. Our results may be useful to develop a highly accurate prediction model based on the new predictive variables and cutoff values associated with the survival mortality of injured Japanese pediatric patients who are younger and more severely injured by using a nationwide dataset with fewer missing data and added valuables, which can be used to evaluate the age-related physiological and anatomical severity of injured patients.

Evaluating the definition of severely injured patients: a Japanese nationwide 5-year retrospective study.

OBJECTIVES: The definition of severely injured patients lacks universal consensus based on quantitative measures. The most widely used definition of severe injury is based on the Injury Severity Score (ISS), which is calculated using the Abbreviated Injury Scale in Japan. This study aimed to compare the prevalence, in-hospital mortality and OR for mortality in patients with ISS ≥16, ISS ≥18 and ISS ≥26 by age groups. DESIGN: Retrospective cohort study. SETTING: Japan Trauma Data Bank, which is a nationwide trauma registry with data from 280 hospitals. PARTICIPANTS: We used data of 117 199 injured patients from a national database. We included injured patients who were transferred from the scene of injury by ambulance and/or physician. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence, in-hospital mortality and OR for mortality with respect to age and injury level (ISS group). RESULTS: In all age categories, the in-hospital mortality of patient groups with an ISS ≥16, ISS ≥18 and ISS ≥26 was 13.3%, 17.4% and 23.5%, respectively. The in-hospital mortality for patients aged >75 years was the highest (20% greater than that of the other age groups). Moreover, in-hospital mortality for age group 5-14 years was the lowest (4.0-10.9%). In all the age groups, the OR for mortality for patients with ISS ≥16, ISS ≥18 and ISS ≥26 was 12.8, 11.0 and 8.4, respectively. CONCLUSIONS: Our results revealed the lack of an acceptable definition, with a high in-hospital mortality and high OR for mortality for all age groups.

The association between age and vital signs documentation of trauma patients in prehospital settings: analysis of a nationwide database in Japan.

BACKGROUND: Emergency medical service (EMS) providers are the first medical professionals to make contact with patients in an emergency. However, the frequency of care by EMS providers for severely injured children is limited. Vital signs are important factors in assessing critically ill or injured patients in the prehospital setting. However, it has been reported that documentation of pediatric vital signs is sometimes omitted, and little is known regarding the performance rate of vital sign documentation by EMS providers in Japan. Using a nationwide data base in Japan, this study aimed to evaluate the relationship between patients' age and the documentation of vital signs in prehospital settings. METHODS: This study was a secondary data analysis of the Japan Trauma Data Bank. The inclusion criterion was patients with severe trauma, as defined by an Injury Severity Score ≥ 16. Our primary outcome was the rate of recording all four basic vital signs, namely blood pressure, heart rate, respiratory rate, and level of consciousness in the prehospital setting among different age groups. We also compared the prehospital vital sign completion rate, that is, the rate at which all four vital signs were recorded in a prehospital setting based on age groups. Multivariate analysis was performed to evaluate factors associated with the prehospital vital sign completion rate. RESULTS: We analyzed 75,777 severely injured patients. Adults accounted for 94% (71400) of these severely injured patients, whereas only 6% of patients were children. The rate of prehospital recording of vital signs was lower in children ≤5 years than in adult patients for all four vital signs. When the adult group was used as a reference, the adjusted odds ratios of vital sign completion rate in infants (0 years), younger children (1-5 years), older children (6-11 years), and teenagers (12-17 years) were 0.09, 0.30, 0.78, and 0.87, respectively. CONCLUSIONS: Analysis of the nationwide trauma registry showed that younger children tended to have a lower rate of vital sign documentation in prehospital settings.

Ten-year in-hospital mortality trends among Japanese injured patients by age, injury severity, injury mechanism, and injury region: A nationwide observational study.

The Injury Severity Score (ISS) is widely used in trauma research worldwide. An ISS cutoff value of ≥16 is frequently used as the definition of severe injury in Japan. The mortality of patients with ISS ≥16 has decreased in recent years, owing to the developing the trauma care system. This study aimed to analyze the prevalence, in-hospital mortality, and odds ratio (OR) for mortality in Japanese injured patients by age, injury mechanism, injury region, and injury severity over 10 years. This study used the Japan Trauma Data Bank (JTDB) dataset, which included 315,614 patients registered between 2009 and 2018. 209,290 injured patients were utilized. This study evaluated 10-year trends of the prevalence and in-hospital mortality and risk factors associated with in-hospital mortality. The overall in-hospital mortality was 10.5%. During the 10-year study period in Japan, the mortality trend among all injured patient groups with ISS 0-15, 16-25, and ≥26 showed significant decreases (p <0.001). Moreover, the mortality risk of patients with ISS ≥26 was significantly higher than that of patients with ISS 0-15 and 16-25 (p <0.001, OR = 0.05 and p<0.001, OR = 0.22). If we define injured patients who are expected to have a mortality rate of 20% or more as severely injured, it may be necessary to change the injury severity definition according to reduction of trauma mortality as ISS cutoff values to ≥26 instead of ≥16. From 2009 to 2018, the in-hospital mortality trend among all injured patient groups with ISS 0-15, 16-25, and ≥26 showed significant decreases in Japan. Differences were noted in mortality trends and risks according to anatomical injury severity.

ABCD approach at the #7119 center, telephone triage system in Tokyo, Japan; a retrospective cohort study.

BACKGROUND: The algorithm and protocol of the #7119 telephone triage in Tokyo, Japan, had been originally established and consists of three steps. In this study, we investigated the outcome of patients treated with physiological abnormality (ABCD approach: A, airway; B, breathing; C, circulation, and D, dysfunction of central nervous system) in step 2 during the #7119 telephone triage and clarified the meaning of evaluation of this approach. METHODS: We retrospectively reviewed data from the Tokyo Fire Department from January 2016 to December 2017. Almost all the patients triaged using the ABCD approach were transferred to the hospital by ambulance and assigned severity by a physician. We divided patients into groups with combinations of 15 patterns including A, B, C, D, AB, AC, AD, BC, BD, CD, ABC, ABD, ACD, BCD, and ABCD. We compared the proportion of severe cases in each group using a Fisher's exact test, followed by residual analysis. RESULTS: We analyzed 13,793 cases triaged using the ABCD approach. In this analysis, 31% of total cases were assessed as severe cases. Groupwise analysis showed that the proportion of severe cases was significantly higher in the AD, BC, CD, ABD, and ABCD groups, while it was significantly less in the C and AB groups than in the total cases. CONCLUSION: At the #7119 telephone triage, we can pick up the severe cases by the ABCD approach. This may contribute to the prompt transportation of severe patients to hospitals by dispatching ambulance cars using the #7119 telephone triage methods.

A simulation study of high-flow versus normal-flow three-way stopcock for rapid fluid administration in emergency situations: A randomised crossover design.

BACKGROUND: Initial fluid resuscitation is presumed to be important for treating shock in the resuscitation phase. However, little is known how quickly and easily a physician could perform a rapid infusion with a syringe. OBJECTIVES: We hypothesised that using a high-flow three-way stopcock (HTS) makes initial fluid resuscitation faster and easier than using a normal-flow three-way stopcock (NTS). METHODS: This was a simulation study with a prospective, nonblinded randomised crossover design. Twenty physicians were randomly assigned into two groups. Each participant used six peripheral intravenous infusion circuits, three with the HTS and the others with the NTS, and three cannulae, 22, 20, and 18 gauge (G). The first group started with the HTS first, while the other started with the NTS first. They were asked to inject the fluid as quick as possible. We compared the time until the participants finished rapid infusions of 500 ml of 0.9% saline and the practitioner's effort. RESULTS: In infusion circuits attached with the 22G cannula, the mean difference using the HTS and the NTS (95% confidence interval [CI]) was 16.30 ml/min (7.65-24.94) (p < 0.01). In those attached with the 20G cannula, the mean difference (95% CI) was 23.47 (12.43-34.51) (p < 0.01). In those attached with the 18G cannula, the mean difference (95% CI) was 42.53 (28.68-56.38) (p < 0.01). CONCLUSIONS: This study revealed that the push-and-pull technique using the HTS was faster, easier, and less tiresome than using the NTS, with a statistically significant difference. In the resuscitation phase, initial and faster infusion is important. If only a single physician or other staff member such as a nurse is attending or does not have accessibility to any other devices in such an environment where medical resources are scarce, performing the push-and-pull technique using the HTS could help a physician to perform fluid resuscitation faster. By setting up the HTS instead of the NTS from the beginning, we would be able to begin fluid resuscitation immediately while preparing other devices.

Simplified Clinical Decision Rule Using Clinically Important Events for Risk Prediction in Pediatric Head Injury: A Retrospective Cohort Study.

Computed tomography (CT) scans are useful for confirming head injury diagnoses. However, there is no standard clinical decision rule (CDR) for determining the need for CT scanning in pediatric patients with head injuries. We developed a CDR and conducted a retrospective cohort study to evaluate its diagnostic accuracy in identifying children with clinically important traumatic brain injury (ciTBI). We selected predictors based on three existing CDRs: CATCH, CHALICE, and PECARN. Of the 2569 eligible patients, 645 (439 (68%) boys, median age: five years) were included in this study. In total, 59 (9%) patients showed ciTBI, and 129 (20%) were admitted to hospital. The novel CDR comprised six predictors of abnormal CT findings. It had a sensitivity of 79.5% (95% confidence interval (CI): 65.5-89.0%) and a specificity of 50.9% (95% CI: 48.9-52.3%). The area under the receiver-operating characteristic curve (0.72, 95% CI: 0.67-0.77) was non-inferior to those of CATCH, CHALICE, and PECARN (0.71, 95% CI: 0.66-0.77; 0.67, 95% CI: 0.61-0.74; and 0.69, 95% CI: 0.64-0.73, respectively; p = 0.57). The novel CDR was statistically noninferior in diagnostic accuracy compared to the three existing CDRs. Further development and validation studies are needed before clinical application.

Revision of the Protocol of the Telephone Triage System in Tokyo, Japan.

INTRODUCTION: The Emergency Telephone Consultation Center in Tokyo (#7119) was the first telephone triage system in Japan and has operated since 2007. This study examined the revision of the #7119 protocol by referring the linked data to each code of the triage protocol. METHODS: We selected candidates based on the medical codes targeted by the revision, linking data from the nurses' decisions in triage and the patients' condition severity when the ambulance arrived at the hospital, gathering data from June 1, 2016, to December 31, 2017. Then, several emergency physicians evaluated the cases and decided whether the code should be moved to the more or less urgent category or if new protocols and codes would be established. RESULTS: In this revision, 371 codes were moved to the less urgent category, 35 codes were moved to the more urgent category, and 128 codes were newly established. In all, 59 red codes (transfer to the ambulance dispatcher) were reduced, while 254 orange codes (attendance at hospital within 1 hour) and yellow codes (within 6 hours) were moved to less urgent, and 12 yellow and green codes (within 24 hours) were moved to more urgent. CONCLUSION: We adjusted the triage codes for the revision by linking the call data with the case data. This revision should decrease the inappropriate use of ambulances and reduce the primary care workload. To achieve a more accurate revision, we need to refine the process of evaluating the validity of patients' acuity over the telephone during triage.

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.

Correlation between Hospital Volume of Severely Injured Patients and In-Hospital Mortality of Severely Injured Pediatric Patients in Japan: A Nationwide 5-Year Retrospective Study.

Appropriate trauma care systems, suitable for children are needed; thus, this retrospective nationwide study evaluated the correlation between the annual total hospital volume of severely injured patients and in-hospital mortality of severely injured pediatric patients (SIPP) and compared clinical parameters and outcomes per hospital between low- and high-volume hospitals. During the five-year study period, we enrolled 53,088 severely injured patients (Injury Severity Score, ≥16); 2889 (5.4%) were pediatric patients aged <18 years. Significant Spearman correlation analysis was observed between numbers of total patients and SIPP per hospital (p < 0.001), and the number of SIPP per hospital who underwent interhospital transportation and/or urgent treatment was correlated with the total number of severely injured patients per hospital. Actual in-hospital mortality, per hospital, of SIPP patients was significantly correlated with the total number patients per hospital (p < 0.001,). The total number of SIPP, requiring urgent treatment, was higher in the high-volume than in the low-volume hospital group. No significant differences in actual in-hospital morality (p = 0.246, 2.13 (0-8.33) vs. 0 (0-100)) and standardized mortality ratio (SMR) values (p = 0.244, 0.31 (0-0.79) vs. 0 (0-4.87)) were observed between the two groups; however, the 13 high-volume hospitals had an SMR of <1.0. Centralizing severely injured patients, regardless of age, to a higher volume hospital might contribute to survival benefits of SIPP.

Daytime admission is associated with higher 1-month survival for pediatric out-of-hospital cardiac arrest: Analysis of a nationwide multicenter observational study in Japan.

OBJECTIVE: Hospital characteristics, such as hospital type and admission time, have been reported to be associated with survival in adult out-of-hospital cardiac arrest (OHCA) patients. However, findings regarding the effects of hospital types on pediatric OHCA patients have been limited. The aim of this study was to analyze the relationship between the hospital characteristics and the outcomes of pediatric OHCA patients. METHODS: This study was a retrospective secondary analysis of the Japanese Association for Acute Medicine-out-of-hospital cardiac arrest registry. The period of this study was from 1 June 2014 to 31 December 2015. We enrolled all pediatric patients (those 0-17 years of age) experiencing OHCA in this study. We enrolled all types of OHCA. The primary outcome of this study was 1-month survival after the onset of cardiac arrest. RESULTS: We analyzed 310 pediatric patients (those 0-17 years of age) with OHCA. In survivors, the rate of witnessed arrest and daytime admission was significantly higher than nonsurvivors (56% vs. 28%, p < 0.001: 49% vs. 31%; p = 0.03, respectively). The multiple logistic regression model showed that daytime admission was related to 1-month survival (odds ratio, OR: 95% confidence interval, CI, 3.64: 1.23-10.80) (p = 0.02). OHCA of presumed cardiac etiology and witnessed OHCA were associated with higher 1-month survival. (OR: 95% CI, 3.92: 1.23-12.47, and 6.25: 1.98-19.74, respectively). Further analyses based on the time of admission showed that there were no significant differences in the proportions of patients with witnessed arrest and who received bystander cardiopulmonary resuscitation and emergency medical service response time by admission time. CONCLUSION: Pediatric OHCA patients who were admitted during the day had a higher 1-month survival rate after cardiac arrest than patients who were admitted at night.

JAAM Nationwide Survey on the response to the first wave of COVID-19 in Japan. Part I: How to set up a treatment system in each hospital.

AIM: To clarify how the medical institutions overcame the first wave of coronavirus disease 2019 (COVID-19) in Japan and to discuss its impact on the medical labor force. METHODS: We analyzed questionnaire data from the end of May 2020 from 180 hospitals (102,578 beds) certified by the Japanese Association for Acute Medicine. RESULTS: Acute (emergency) medicine physicians treated severe COVID-19 patients in more than half of hospitals. Emergency medical teams consisted of acute medicine physicians and other specialists. Frontline acute care physicians were concerned about their risk of infection in 80% of hospitals, and experienced stress due to a lack of personal protective equipment. Twenty-six of the 143 hospitals that had a mental health check/consultation system in place indicated that there was a doctor who experienced mental health problems. Of the 37 hospitals without a system, only one hospital was aware of the presence of a doctor complaining of mental health problems. CONCLUSION: Acute care physicians and physicians in other departments experienced high levels of stress as they fought to arrange COVID-19 treatment teams and inpatient COVID-19 wards for infected patients. Medical materials and equipment may be sufficient for a second or third wave; however, active support is needed for the physical and mental care of medical staff. Mental health problems may be missed in facilities without mental check and consultation system.

Prehospital medical equipment for care of pediatric injury patients in Japanese ambulances: a nationwide survey.

AIM: We evaluated the status of the allocation of medical emergency equipment suitable for pediatric patients of all ages. METHODS: In 2019, we surveyed the emergency medical officers from 728 fire defense headquarters around Japan. The questionnaire was designed to evaluate the kind and size of equipment available to ambulance crews for prehospital emergency care of injured pediatric patients. A complete pediatric equipment set was defined as a set containing equipment suitable for children aged 0-14 years. RESULTS: Overall, 599 (82%) fire defense headquarters responded to our survey. Of these, 596 (99.5%) declared that pediatric equipment was available to ambulance crews. The allocation rates of complete pediatric sets were considerably low: blood pressure cuff, 5%; nasopharyngeal airway, 1%; oropharyngeal airway, 7%; laryngoscope, 6%; supraglottic airway device, 13%; endotracheal tube, 0.2%; and bag-valve-mask, 23%. Moreover, none of these fire defense headquarters had complete pediatric equipment sets for all 14 devices assessed in this study. CONCLUSIONS: Although most Japanese ambulances can provide prehospital emergency care to pediatric patients, this survey revealed the dispersion and deficiencies in the availability of complete pediatric equipment sets.

Validation of age-specific survival prediction in pediatric patients with blunt trauma using trauma and injury severity score methodology: a ten-year Nationwide observational study.

BACKGROUND: In-hospital mortality in trauma patients has decreased recently owing to improved trauma injury prevention systems. However, no study has evaluated the validity of the Trauma and Injury Severity Score (TRISS) in pediatric patients by a detailed classification of patients' age and injury severity in Japan. This retrospective nationwide study evaluated the validity of TRISS in predicting survival in Japanese pediatric patients with blunt trauma by age and injury severity. METHODS: Data were obtained from the Japan Trauma Data Bank during 2009-2018. The outcomes were as follows: (1) patients' characteristics and mortality by age groups (neonates/infants aged 0 years, preschool children aged 1-5 years, schoolchildren aged 6-11 years, and adolescents aged 12-18 years), (2) validity of survival probability (Ps) assessed using the TRISS methodology by the four age groups and six Ps-interval groups (0.00-0.25, 0.26-0.50, 0.51-0.75, 0.76-0.90, 0.91-0.95, and 0.96-1.00), and (3) the observed/expected survivor ratio by age- and Ps-interval groups. The validity of TRISS was evaluated by the predictive ability of the TRISS method using the receiver operating characteristic (ROC) curves that present the sensitivity, specificity, positive predictive value, negative predictive value, accuracy, area under the receiver operator characteristic curve (AUC) of TRISS. RESULTS: In all the age categories considered, the AUC for TRISS demonstrated high performance (0.935, 0.981, 0.979, and 0.977). The AUC for TRISS was 0.865, 0.585, 0.614, 0.585, 0.591, and 0.600 in Ps-interval groups (0.96-1.00), (0.91-0.95), (0.76. - 0.90), (0.51-0.75), (0.26-0.50), and (0.00-0.25), respectively. In all the age categories considered, the observed survivors among patients with Ps interval (0.00-0.25) were 1.5 times or more than the expected survivors calculated using the TRISS method. CONCLUSIONS: The TRISS methodology appears to predict survival accurately in Japanese pediatric patients with blunt trauma; however, there were several problems in adopting the TRISS methodology for younger blunt trauma patients with higher injury severity. In the next step, it may be necessary to develop a simple, high-quality prediction model that is more suitable for pediatric trauma patients than the current TRISS model.

JAAM nationwide survey on the response to the first wave of COVID-19 in Japan. Part II: how did medical institutions overcome the first wave and how should they prepare for the future?

Aim: To investigate and clarify the surge capacity of staff/equipment/space, and patient outcome in the first wave of coronavirus disease (COVID-19) in Japan. Methods: We analyzed questionnaire data from the end of May 2020 from 180 hospitals (total of 102,578 beds) with acute medical centers. Results: A total of 4,938 hospitalized patients with COVID-19 were confirmed. Of 1,100 severe COVID-19 inpatients, 112 remained hospitalized and 138 died. There were 4,852 patients presumed to be severe COVID-19 patients who were confirmed later to be not infected. Twenty-seven hospitals (15% of 180 hospitals) converted their intensive care unit (ICU) to a unit for COVID-19 patients only, and 107 (59%) had to manage both severe COVID-19 patients and others in the same ICU. Restriction of ICU admission occurred in one of the former 27 hospitals and 21 of the latter 107 hospitals. Shortage of N95 masks was the most serious concern regarding personal protective equipment. As for issues that raised ICU bed occupancy, difficulty undertaking or progressing rehabilitation for severe patients (42%), and the improved patients (28%), long-lasting severely ill patients (36%), and unclear isolation criteria (34%) were mentioned. Many acute medicine physicians assisted regional governmental agencies, functioning as advisors and volunteer coordinators. Conclusion: The mortality rate of COVID-19 in this study was 4.1% of all hospitalized patients and 12.5% (one in eight) severe patients. The hospitals with dedicated COVID-19 ICUs accepted more patients with severe COVID-19 and had lower ICU admission restrictions, which could be helpful as a strategy in the next pandemic.

Transcatheter arterial embolisation is efficient and safe for paediatric blunt torso trauma: a case-control study.

BACKGROUND: It remains unclear whether transcatheter arterial embolisation (TAE) is as safe and effective for paediatric patients with blunt torso trauma as it is for adults in Japan, owing to few trauma cases and sporadic case reports. The study aimed to compare the efficacy and safety of TAE performed in paediatric (age ≤ 15 years) and adult patients with blunt torso trauma. METHODS: This was a single-centre, retrospective chart review study that included blunt torso trauma patients who underwent TAE in the trauma centre from 2012 to 2017. The comparative study was carried out between a 'paediatric patient group' and an 'adult patient group'. The outcome measures for TAE were the success of haemorrhage control and complications and standardised mortality ratio (SMR). RESULTS: A total of 504 patients with blunt torso trauma were transported to the trauma centre, out of which 23% (N = 114) with blunt torso trauma underwent TAE, including 15 paediatric and 99 adult patients. There was no significant difference between the use of TAE in paediatric and adult patients with blunt torso trauma (29% vs 22%, P = .221). The paediatric patients' median age was 11 years (interquartile ranges 7-14). The predicted mortality rate and SMR for paediatric patients were lower than those for adult patients (18.3% vs 25.9%, P = .026, and 0.37 vs 0.54). The rate of effective haemorrhage control without repeated TAE or additional surgical intervention was 93% in paediatric patients, which was similar to that in adult patients (88%). There were no complications in paediatric patients at our centre. There were no significant differences in the proportion of paediatric patients who underwent surgery before TAE or urgent blood transfusion (33% vs 26%, P = .566, or 67% vs 85%, P = .084). CONCLUSIONS: It is possible to provide an equal level of care related to TAE for paediatric and adult patients as it relates to TAE for blunt torso trauma with haemorrhage in the trauma centre. Alternative haemorrhage control procedures should be established as soon as possible whenever the patients reach a haemodynamically unstable state.

In-Hospital Mortality Risk of Transcatheter Arterial Embolization for Patients with Severe Blunt Trauma: A Nationwide Observational Study.

This study investigated the risk factors for in-hospital mortality of severe blunt trauma patients who underwent transcatheter arterial embolization (TAE). We analysed data from the Japan Trauma Data Bank from 2009 to 2018. Patients with severe blunt trauma and an Injury Severity Score (ISS) ≥ 16 who underwent TAE were enrolled. The primary analysis evaluated patient characteristics and outcomes, and variables with significant differences were included in the secondary multivariate logistic regression analysis. In total, 5800 patients (6.4%) with ISS ≥ 16 underwent TAE. There were significant differences in the proportion of male patients, transportation method, injury mechanism, injury region, Revised Trauma Score, survival probability values, and those who underwent urgent blood transfusion and additional urgent surgery. In multivariable regression analyses, higher age, urgent blood transfusion, and initial urgent surgery were significantly associated with higher in-hospital mortality risk [p < 0.001, odds ratio (OR), 95% confidence interval (CI): 1.01 (1.00-1.01); p < 0.001, 3.50 (2.55-4.79); and p = 0.001, 1.36 (1.13-1.63), respectively]. Inter-hospital transfer was significantly associated with lower in-hospital mortality risk (p < 0.001, OR = 0.56, 95% CI = 0.44-0.71). Treatment protocols for urgent intervention before and after TAE and a safe, rapid inter-hospital transport system are needed to improve mortality risks for severe blunt trauma patients.

Ten-Year in-Hospital Mortality Trends among Paediatric Injured Patients in Japan: A Nationwide Observational Study.

Injury is a major cause of worldwide child mortality. This retrospective nationwide study aimed to evaluate the characteristics of paediatric injured patients in Japan and their in-hospital mortality trends from 2009 to 2018. Injured patients aged <17 years were enrolled. Data were extracted from the Japan Trauma Data Bank. In the Cochran-Armitage test, in-hospital mortality significantly decreased during the study period (p < 0.001), except among patients <1 year old, and yearly reductions were observed among those with an Injury Severity Score ≥16 and survival rate ≥50% (p < 0.001). In regression analyses, patients who underwent urgent blood transfusion within 24 h after hospital admission (odds ratio (OR) = 3.24, 95% confidence interval (CI) = 2.38-4.41) had a higher in-hospital mortality risk. Higher survival probability as per the Trauma and Injury Severity Score was associated with lower in-hospital mortality (OR = 0.92, 95% CI = 0.91-0.92), a risk which decreased from 2009 to 2018 (OR = 6.16, 95% CI = 2.94-12.88). Based on our results, there is a need for improved injury surveillance systems for establishment of injury prevention strategies along with evaluation of the quality of injury care and outcome measures.

Validation of the Pediatric Physiological and Anatomical Triage Score in Injured Pediatric Patients.

INTRODUCTION: Triaging plays an important role in providing suitable care to a large number of casualties in a disaster setting. A Pediatric Physiological and Anatomical Triage Score (PPATS) was developed as a new secondary triage method. This study aimed to validate the accuracy of the PPATS in identifying injured pediatric patients who are admitted at a high frequency and require immediate treatment in a disaster setting. The PPATS method was also compared with the current triage methods, such as the Triage Revised Trauma Score (TRTS). METHODS: A retrospective review of pediatric patients aged ≤15 years, registered in the Japan Trauma Data Bank (JTDB) from 2012 through 2016, was conducted and PPATS was performed. The PPATS method graded patients from zero to 22, and was calculated based on vital signs, anatomical abnormalities, and the need for life-saving interventions. It categorized patients based on their priority, and the intensive care unit (ICU)-indicated patients were assigned a PPATS ≥six. The accuracy of PPATS and TRTS in predicting the outcome of ICU-indicated patients was compared. RESULTS: Of 2,005 pediatric patients, 1,002 (50%) were admitted to the ICU. The median age of the patients was nine years (interquartile range [IQR]: 6-13 years). The sensitivity and specificity of PPATS were 78.6% and 43.7%, respectively. The area under the receiver-operating characteristic (ROC) curve (AUC) was larger for PPATS (0.61; 95% confidence interval [CI], 0.59-0.63) than for TRTS (0.57; 95% CI, 0.56-0.59; P <.01). Regression analysis showed a significant correlation between PPATS and the Injury Severity Score (ISS; r2 = 0.353; P <.001), predicted survival rate (r2 = 0.396; P <.001), and duration of hospital stay (r2 = 0.252; P <.001). CONCLUSION: The accuracy of PPATS for injured pediatric patients was superior to that of current secondary triage methods. The PPATS method is useful not only for identifying high-priority patients, but also for determining the priority ranking for medical treatments and evacuation.

Effects of establishing a trauma center on the mortality rate among injured pediatric patients in Japan.

INTRODUCTION: It remains unclear whether trauma centers are effective for the treatment of injured pediatric patients. The aim of this study was to evaluate children's mortality before and after the establishment a trauma center by using standard mortality ratios (SMR) and a modified observed-expected chart. METHODS: This was a single center, retrospective chart review study that included injured pediatric patients (age <16 years) who were transported to our trauma center by the emergency medical services from 2012 to 2016 in Japan. RESULTS: Our study included 143 subjects: 45 (31%) were preschoolers aged < 6 years, and 43 (30%) had an injury severity score (ISS) ≥ 16. After the trauma centers established, the number of patients increased (70% increase per month), as did the number of the patients with an ISS of 41-75. The percentage of indirect transportations was significantly higher in the trauma center than in the non-trauma center (49% vs. 28%; p < 0.05). The SMR was significantly lower in the trauma-center than in the non-trauma center (0.461 vs. 0.589; p < 0.05). The mean value of the modified observed-expected chart was significantly higher in the trauma-center than in the non-trauma center (4.6 vs. 2.3; p < 0.05). For the patients who were directly transferred to our center, the transfer distance was greater in the trauma-center than in the non-trauma center (6.8 vs. 6.2 km; p < 0.05). The time interval from hospital admission to initiation of computed tomography (15.5 vs. 33 minutes; p < 0.05) and to definitive care (44 vs. 64.5 minutes; p < 0.05) decreased in the after group compared to the non-trauma center. CONCLUSIONS: The results of our study revealed that the centralization of pediatric injured pediatric patients in trauma centers improved the mortality rate in this population in Japan.