An analysis of overtriage and undertriage by advanced life support transport in a mature trauma system.

BACKGROUND: While issues regarding triage of severely injured trauma patients are well publicized, little information exists concerning the difference between triage rates for patients transported by advanced life support (ALS) and basic life support (BLS). We sought to analyze statewide trends in undertriage (UT) and overtriage (OT) to address this question, hypothesizing that there would be a difference between the UT and OT rates for ALS compared with BLS over a 13-year period. METHODS: All patients submitted to Pennsylvania Trauma Outcomes Study database from 2003 to 2015 were analyzed. Undertriage was defined as not calling a trauma alert for patients with an Injury Severity Score (ISS) of 16 or greater. Overtriage was defined as calling a trauma alert for patients with an ISS of 9 or less. A logistic regression was used to assess mortality between triage groups in ALS and BLS. A multinomial logistic regression assessed the adjusted impact of ALS versus BLS transport on UT and OT versus normal triage while controlling for age, sex, Glasgow Coma Scale, systolic blood pressure (SBP), pulse, Shock Index and injury year. RESULTS: A total of 462,830 patients met inclusion criteria, of which 115,825 had an ISS of 16 or greater and 257,855 had an ISS of 9 or less. Both ALS and BLS had significantly increased mortality when patients were undertriaged compared with the reference group. Multivariate analysis in the form of a multinomial logistic regression revealed that patients transported by ALS had a decreased adjusted rate of undertriage (relative risk ratio, 0.92; 95% confidence interval, 0.87-0.97; p = 0.003) and an increased adjusted rate of OT (relative risk ratio, 1.59; 95% confidence interval, 1.54-1.64; p < 0.001) compared with patients transported by BLS. CONCLUSION: Compared with their BLS counterparts, while UT is significantly lower, OT is substantially higher in ALS-further increasing the high levels of resource (over)utilization in trauma patients. Undertriage in both ALS and BLS are associated with increased mortality rates. Additional education, especially in the BLS provider, on identifying the major trauma victim may be warranted based on the results of this study. LEVEL OF EVIDENCE: Epidemiological, Level III.

Older Patients With Severe Traumatic Brain Injury: National Variability in Palliative Care.

BACKGROUND: Older patients with traumatic brain injury (TBI) have higher mortality and morbidity than their younger counterparts. Palliative care (PC) is recommended for all patients with a serious or life-limiting illness. However, its adoption for trauma patients has been variable across the nation. The goal of this study was to assess PC utilization and intensity of care in older patients with severe TBI. We hypothesized that PC is underutilized despite its positive effects. MATERIALS AND METHODS: The National Inpatient Sample database (2009-2013) was queried for patients aged ≥55 y with International Classification of Diseases, Ninth Revision codes for TBI with loss of consciousness ≥24 h. Outcome measures included PC rate, in-hospital mortality, discharge disposition, length of stay (LOS), and intensity of care represented by craniotomy and or craniectomy, ventilator use, tracheostomy, and percutaneous endoscopic gastrostomy. RESULTS: Of 5733 patients, 78% died in hospital with a median LOS of 1 d, and 85% of the survivors were discharged to facilities. The overall PC rate was 35%. Almost 40% of deaths received PC, with nearly half within 48 h of admission. PC was used in 26% who had neurosurgical procedures, compared with 35% who were nonoperatively managed (P = 0.003). PC was associated with less intensity of care in the entire population. For survivors, those with PC had significantly shorter LOS, compared with those without PC. CONCLUSIONS: Despite high mortality, only one-third of older patients with severe TBI received PC. PC was associated with decreased use of life support and lower intensity of care. Significant efforts need to be made to bridge this quality gap and improve PC in this high-risk population.

Are Primary Trauma Care (PTC) courses beneficial in low- and middle-income countries - A systematic review.

BACKGROUND: Injuries remain an important public health concern, resulting in considerable annual morbidity and mortality. In low- and middle-income countries (LMICs), the lack of appropriate infrastructure, equipment and skilled personnel compound the burden of injury, leading to higher mortality rates. As Advanced Trauma Life Support (ATLS) courses remain uneconomical and inappropriate in LMICs, the Primary Trauma Care (PTC) course was introduced to provide an alternative that is both sustainable and appropriate to local resources. METHODS: A systematic review was performed in May 2019, utilising MEDLINE, EMBASE, Cochrane Library and Google Scholar. All studies reporting patient related outcomes (mortality and morbidity rates) and course participant related outcomes (knowledge, confidence and skills) in LMICs were included. PRISMA guidelines were adhered to throughout. RESULTS: Nine observational studies were identified (Level 3 evidence). Six studies reported improved knowledge in injury management post-PTC course (p < 0.05). Two studies reported improvements in confidence (p < 0.05) and one on skill attainment (p < 0.0001). One study reported a reduction in mortality rates post-PTC course (p < 0.01). CONCLUSION: Departmental, institutional and personal improvements may occur in clinical practice as a result of formal PTC training of trauma team members in LMICs. Further high-quality research is needed to evaluate this course's effects on observed change in clinical practice and patient outcomes. This may require long-term observational and epidemiological studies to assess improvements in morbidity and mortality. PROSPERO Registration Number: CRD42019133986.

Association Between Prearrival Notification Time and Advanced Trauma Life Support Protocol Adherence.

BACKGROUND: Prearrival notification of injured patients facilitates preparation of personnel, equipment, and other resources needed for trauma evaluation and treatment. Our purpose was to determine the impact of prearrival notification time on adherence to Advanced Trauma Life Support (ATLS) protocols. MATERIALS AND METHODS: Pediatric trauma activations of admitted patients were analyzed by video review to determine activities performed before and after patient arrival. Using an expert model based on ATLS, fitness scores were calculated that represented model adherence, ranging from "0" (noncompliant) to "100" (completely compliant). Multivariate regression was used to determine the association between fitness values of the evaluation phases and the length of prearrival notification time and injury profiles. RESULTS: Ninety-four patients met study criteria. The average overall fitness was 89.0 ± 7.3, with similar fitness values being observed for the primary and secondary surveys (91.5 ± 13.4 and 88.6 ± 7.7, respectively). Prearrival notification time ranged from 67.3 min before to 4.8 min after patient arrival. Longer prearrival notification time was associated with improved completion of prearrival tasks, overall resuscitation performance, and secondary survey performance. The positive association of overall and secondary survey fitness with notification time was no longer observed when notification time was <5 min and <10 min, respectively. Notification time was correlated with a higher percentage of required team members when the patient arrived (Pearson correlation coefficient 0.46, P < 0.001). CONCLUSIONS: Prearrival notification time has a significant impact on adherence to ATLS protocol. Strategies for improving notification time or improving performance when adequate notification cannot be achieved are needed.

Indication for resuscitative thoracotomy in thoracic injuries-Adherence to the ATLS guidelines. A forensic autopsy based evaluation.

BACKGROUND: The appropriate indications for Resuscitative Thoracotomy (RT) are still debated in the literature and various guidelines have been proposed. This study aimed to evaluate whether Advanced Trauma Life Support (ATLS) guidelines for RT were applied correctly and to evaluate the proportion of deceased patients with potentially reversible thoracic lesions (PRTL). METHODS: The database at the Department of Forensic Medicine at Copenhagen University was queried for autopsy cases with thoracic lesions indicated by the SNOMED autopsy coding system. Patients were included if thoracic lesions were caused by a traumatic event with trauma team activation. Patient cases were blinded for any surgical intervention and evaluated independently by two reviewers for indications or contraindications for RT as determined by the ATLS guidelines. Second, autopsy reports were evaluated for the presence of PRTL. RESULTS: Sixty-seven patients met the inclusion criteria. Two were excluded due to insufficient data. The overall agreement with guidelines was 86% and 77% for blunt and penetrating trauma, respectively. For patients submitted to RT the overall agreement with guidelines was 63% being 45% and 74% for blunt and penetrating trauma, respectively. For patients who did not undergo RT the agreement with guidelines was 100%. In all cases where RT was performed in agreement between guidelines and the clinical decision the autopsy reports showed PRTL in 16 (84%) patients. In cases of non-agreement PRTL were found in 9 (82%) patients. CONCLUSIONS: Agreement with ATLS guidelines for RT was 63% for intervention and 100% for non-intervention in deceased patients with thoracic trauma. Agreement was higher for penetrating trauma than for blunt trauma. The adherence to guidelines did not improve the ability to predict autopsy findings of PRTL. Although the study has methodical limitations it represents a novel approach to the evaluation of the clinical use of RT guidelines.

ATLS adherence in the transfer of rural trauma patients to a level I facility.

BACKGROUND: Injury sustained in rural areas has been shown to carry higher mortality rates than trauma in urban settings. This disparity is partially attributed to increased distance from definitive care and underscores the importance of proper primary trauma management prior to transfer to a trauma facility. The purpose of this study was to assess Advanced Trauma Life Support (ATLS) guideline adherence in the management of adult trauma patients transferred from rural hospitals to a level I facility. METHODS: We performed a retrospective analysis of all adult major trauma patients transferred ≥50km from an outlying hospital to a level I trauma centre from 2007 through 2009. Transfer practices were evaluated using ATLS guidelines. RESULTS: 646 patients were analyzed. Mean age was 40.5years and 94% sustained blunt injuries with a median Injury Severity Score (ISS) of 22. Median transport distance was 253km. Among all patients, there were notable deficiencies (<80% adherence) in 8 of 11 ATLS recommended interventions, including patient rewarming (8% adherence), chest tube insertion (53%), adequate IV access (53%), and motor/sensory exam (72%). Patients with higher ISS scores, and those transferred by air were more likely to receive ATLS recommended interventions. CONCLUSIONS: Key aspects of ATLS resuscitation guidelines are frequently missed during transfer of trauma patients from the periphery to level I trauma centres. Comprehensive quality improvement initiatives, including targeted education, telemedicine and trauma team training programmes could improve quality of care.

[The concept of small volume resuscitation for preclinical trauma management. Experiences in the Air Rescue Service]. / Das Konzept der "small volume resuscitation" im Rahmen des präklinischen Traumamanagements. Erfahrungen im Luftrettungsdienst

BACKGROUND: Prompt hemorrhage control and adequate fluid resuscitation are the key components of early trauma care. However, the optimal resuscitation strategy remains controversial. In this context the small volume resuscitation (SVR) concept with hypertonic-hyperoncotic solutions is a new strategy. PATIENTS AND METHODS: This was a retrospective study in the Helicopter Emergency Medical Service over a 5-year period. Included were all major trauma victims if they were candidates for SVR (initially 4 ml HyperHaes/kg body weight, followed by conventional fluid resuscitation with crystalloids and colloids). Demographic data, type and cause of injury and injury severity score (ISS) were recorded and the amount of fluid volume and the hemodynamic profile were analyzed. Negative side-effects as well as sodium chloride serum levels on hospital admission were recorded. RESULTS: A total of 342 trauma victims (male 70.2%, mean age 39.0 ± 18.8 years, ISS 31.6 ± 16.9, ISS>16, 81.6%) underwent prehospital SVR. A blunt trauma mechanism was predominant (96.8%) and the leading cause of injury was motor vehicle accidents (61.5%) and motorcycle accidents (22.3%). Multiple trauma and polytrauma were noted in 87.4% of the cases. Predominant was traumatic brain injury (73.1%) as well as chest injury (73.1%) followed by limb injury (69.9%) and abdominal/pelvic trauma (45.0%). Within the whole study group in addition to 250 ml HyperHaes, mean volumes of 1214 ± 679 ml lactated Ringers and 1288 ± 954 ml hydroxethylstarch were infused during the prehospital treatment phase. There were no statistically significant differences in the amount of crystalloids and colloids infused regarding the subgroups multisystem trauma (ISS>16), severe traumatic brain injury (GCS<9) and entrapment trauma compared to the total study group. In patients with an initial systolic blood pressure (SBP) >80 mmHg significantly less colloids (1035 ± 659 ml vs. 1288 ± 954 ml, p<0.006) were infused, whereas in patients with an initial SBP ≤ 80 mmHg significantly more colloids were infused (1609 ± 1159 ml vs. 1288 ± 954 ml, p<0.002). There was a statistically significant increase in systolic as well as diastolic blood pressure at all times of blood pressure measurement during prehospital treatment after bolus infusion of HyperHaes within the whole study group. The same applies to the subgroups multisystem trauma, severe traumatic brain injury and entrapment trauma. Minor negative side-effects were observed in 4 cases (1.2%). The mean serum sodium chloride profile on hospital admission was 146.9 ± 5.0 mmol/l, the base excess (BE) was -5.7 ± 5.3 mmol/l) and the pH was 7.3 ± 0.1. CONCLUSION: The concept of small volume resuscitation provides early and effective hemodynamic control. Clinical side-effects associated with bolus infusion of hypertonic-hyperoncotic solutions are rare.