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1.
BMC Emerg Med ; 22(1): 101, 2022 Jun 07.
Artigo em Inglês | MEDLINE | ID: mdl-35672707

RESUMO

BACKGROUND: We evaluated the accuracy of the prehospital Field Triage Decision Scheme, which has recently been applied in the Korean trauma system, and the factors associated with severe injury and prognosis at a regional trauma center in Korea. METHODS: From 2016 to 2018, prehospital data of injured patients were obtained from the emergency medical services of the national fire agency and matched with trauma outcomes at our institution. Severe injury (Injury Severity Score > 15), overtriage/undertriage rate, positive predictive value, negative predictive value, and accuracy were reviewed according to the triage protocol steps. A multivariate logistic regression analysis was performed to identify influencing factors in the field triage. RESULTS: Of the 2438 patients reviewed, 853 (35.0%) were severely injured. The protocol accuracy was as follows: step 1, 72.3%; step 2, 65.0%; step 3, 66.2%; step 1 or 2, 70.2%; and step 1, 2, or 3, 66.4%. Odds ratios (OR) (95% confidence interval [CIfor systolic blood pressure < 90 mmHg (3.535 [1.920-6.509]; p < 0.001), altered mental status (17.924 [8.980-35.777]; p < 0.001), and pedestrian injuries (2.473 [1.339-4.570], p = 0.04) were significantly associated with 24-h mortality. Penetrating torso injuries (7.108 [4.108-12.300]; p < 0.001); two or more proximal long bone fractures (4.134 [2.316-7.377]); p < 0.001); crushed, degloved, and mangled extremities (8.477 [4.068-17.663]; p < 0.001); amputation proximal to the wrist or ankle (42.964 [5.764-320.278]; p < 0.001); and fall from height (2.141 [1.497-3.062]; p < 0.001) were associated with 24-h surgical intervention. CONCLUSION: The Korean field triage protocol is not yet accurate, with only some factors reflecting injury severity, making reevaluation necessary.


Assuntos
Serviços Médicos de Emergência , Ferimentos e Lesões , Ferimentos Penetrantes , Adulto , Humanos , Escala de Gravidade do Ferimento , Valor Preditivo dos Testes , Estudos Retrospectivos , Centros de Traumatologia , Triagem/métodos , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/terapia
2.
J Orthop Trauma ; 36(7): 349-354, 2022 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-35727002

RESUMO

OBJECTIVES: To document the prevalence of, and the effect on outcomes, operatively treated bilateral femur fractures treated using contemporary treatments. DESIGN: A retrospective cohort using data from the National Trauma Data Bank. PARTICIPANTS: In total, 119,213 patients in the National Trauma Data Bank between the years 2007 and 2015 who had operatively treated femoral shaft fractures. MAIN OUTCOME MEASUREMENTS: Complication rates, hospital length of stay (LOS), days in the intensive care unit (ICU LOS), days on a ventilator, and mortality rates. RESULTS: Patients with bilateral femur fractures had increased overall complications (0.74 vs. 0.50, P < 0.0001), a longer LOS (14.3 vs. 9.2, P < 0.0001), an increased ICU LOS (5.3 vs. 2.4, P < 0.0001), and more days on a ventilator (3.1 vs. 1.3, P < 0.0001), when compared with unilateral fractures. Bilateral femoral shaft fractures were independently associated with worse outcomes in all primary domains when adjusted by Injury Severity Score (P < 0.0001), apart from mortality rates. Age-adjusted bilateral injuries were independently associated with worse outcomes in all primary domains (P < 0.0001) except for the overall complication rate. A delay in fracture fixation beyond 24 hours was associated with increased mortality (P < 0.0001) and worse outcomes for all other primary measures (P < 0.0001 to P = 0.0278) for all patients. CONCLUSIONS: Bilateral femoral shaft fractures are an independent marker for increased hospital and ICU LOS, number of days on a ventilator, and increased complication rates, when compared with unilateral injuries and adjusted for age and Injury Severity Score. Timely definitive fixation, in a physiologically appropriate patient, is critical because a delay is associated with worse inpatient outcome measures and higher mortality rates. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Fraturas do Fêmur , Estudos de Coortes , Fraturas do Fêmur/complicações , Fraturas do Fêmur/epidemiologia , Fraturas do Fêmur/cirurgia , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Prevalência , Estudos Retrospectivos
3.
J Trauma Acute Care Surg ; 93(1): 130-134, 2022 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-35727592

RESUMO

BACKGROUND: This study examines the rates of pediatric auto versus pedestrian collision (APCs) and determined ages and periods of greatest risk. We hypothesized that the rate of APC in children would be higher on school days and in the timeframes correlating with travel to and from school. METHODS: Retrospective case-control study of APC on school and nonschool days for patients younger than 18 years at an urban Level II pediatric trauma center from January 2011 to November 2019. Frequency of APC by hour of the day was plotted overall, for school versus nonschool days and for age groups: 0 year to 4 years, 5 years to 9 years, 10 years to 13 years, and 14 years to 17 years. t Test was used with a p value less than 0.05, which was considered significant. RESULTS: There were 441 pediatric APC in the study period. Frequency of all APC was greater on school days (0.174 vs. 0.101; relative risk [RR], 1.72, p < 0.001), and APC with Injury Severity Score greater than 15 (0.039 vs. 0.024; p = 0.014; RR, 1.67; 95% confidence interval, 1.10-2.56). Comparing school day with nonschool day, the 0-year to 4-year group had no significant difference in APC frequency (0.021 vs. 0.014; p = 0.129), APC frequency was higher on school days in all other age groups: 5 years to 9 years (0.036 vs. 0.019; RR, 1.89; p = 0.0134), 10 years to 13 years (0.055 vs. 0.024; RR, 2.29; p < 0.001), and 14 years to 17 years (0.061 vs. 0.044; RR, 1.39; p = 0.045). The greatest increase in APC on school days was in the 10-year to 13-year age group. DISCUSSION: All school age children are at higher risk of APC on school days. The data support our hypothesis that children are at higher risk of APC during transit to and from school. The age 10-year to 13-year group had a 129% increase in APC frequency on school days. This age group should be a focus of injury prevention efforts. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.


Assuntos
Acidentes de Trânsito , Pedestres , Acidentes de Trânsito/prevenção & controle , Estudos de Casos e Controles , Criança , Pré-Escolar , Humanos , Recém-Nascido , Escala de Gravidade do Ferimento , Estudos Retrospectivos
4.
N Z Med J ; 135(1550): 86-110, 2022 Feb 25.
Artigo em Inglês | MEDLINE | ID: mdl-35728155

RESUMO

AIM: To describe the incidence and characteristics of major trauma in New Zealand. METHODS: A systematic review based on a MEDLINE search strategy was performed using the databases PubMed, EMBASE, CINAHL and Scopus. Search terms included: "Wounds and Injuries," "Fatal Injuries," "Injury Severity Score," "Major Trauma," "Severe Trauma," "Injury Scale," "Epidemiology," "Incidence," "Prevalence" and "Mortality." Studies published in English up to September 2021 reporting the incidence of major trauma in New Zealand were included. The quality of studies was assessed using the GATE LITETM tool. RESULTS: Thirty-nine studies fulfilled the inclusion criteria. The majority of studies were descriptive observational studies (n=37). The incidence of fatal trauma was highest among those injured from motor vehicle crashes (MVCs) or falls, Maori males and those sustaining head injuries. The incidence of non-fatal major trauma was highest among young Maori males. MVCs and falls were the most common mechanism of injury among trauma patients across all age groups. Length of hospital stay was greatest in patients with the highest Injury Severity Scores. CONCLUSIONS: The incidence of major trauma varies by age, sex and ethnicity. This review highlights the need for further analytical studies that can explore factors that may impact survival from major trauma.


Assuntos
Traumatismos Craniocerebrais , Ferimentos e Lesões , Acidentes de Trânsito , Traumatismos Craniocerebrais/epidemiologia , Humanos , Incidência , Escala de Gravidade do Ferimento , Masculino , Nova Zelândia/epidemiologia , Ferimentos e Lesões/epidemiologia
5.
Beijing Da Xue Xue Bao Yi Xue Ban ; 54(3): 552-556, 2022 Jun 18.
Artigo em Chinês | MEDLINE | ID: mdl-35701135

RESUMO

OBJECTIVE: To investigate the relationship between early lymphocyte responses and the prognosis in severely injured patients. METHODS: Consecutive patients with severe trauma who were treated in Peking University People's Hospital Trauma Medical Center between June 2017 and June 2020 were enrolled in this restropective chart-review study. According to the responses of lymphocyte after severe injury, the patients were divided into three groups, group 1: lymphopenia-returned to normal; group 2: persistent lymphopenia; group 3: never lymphopenic, and the outcome of 28 d were recorded. Clinical data such as gender, age, base excess, mechanism of injury, Glasgow coma scale (GCS), injury severity score (ISS) and massive blood transfusion were collected. Perform statistical analysis on the collected clinical data to understand the trend of lymphocyte changes in early trauma and the relationship with prognosis. In order to eliminate the interference of age, stratification was carried out according to whether the age was ≥ 65 years old, in different age groups, they were grouped according to whether the length of stay was ≥ 28 d, and the relationship between lymphocyte trend and length of stay was discussed. RESULTS: A total of 83 patients were included, 66 males and 17 females. The main injury mechanisms were traffic accident injuries and high-altitude fall injuries. The average ISS was (30±11) points. 65 patients had lymphopenia on the day of injury, 32 of them returned to normal on the 5th day, and the rest did not recover; the other 18 patients had normal lymphocyte levels after injury. Patients which are failure to normalize lymphopenia within the first 5 days following admission was related with the long hospitalization time and higher 28 d mortality rate. After further stratification by age, failure to normalize lymphopenia within the first 5 days following admission in the elderly group (age ≥65 years) was a risk factor for prolonged hospital stay (≥28 d), P=0.04. While in younger group, a high level of neutrophils within the first 5 d following admission was a risk factor for bad outcome. CONCLUSION: A failure to normalize lymphopenia in severely injured patients is associated with significantly higher mortality and longer hospital stay. This study reveals lymphocytes can be used as a reliable indicator for the prognostic evaluation.


Assuntos
Linfopenia , Idoso , Feminino , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Linfopenia/etiologia , Masculino , Prognóstico , Estudos Retrospectivos
6.
BMJ Open ; 12(6): e058612, 2022 Jun 09.
Artigo em Inglês | MEDLINE | ID: mdl-35680265

RESUMO

OBJECTIVES: This study analyses the clinical features and direct medical cost (DMC) of splenic injury during 2000-2013 in China. DESIGN: This was a cross-sectional study. METHODS: We used 'The No. 1 Military Medical Project' information system to conduct a retrospective study. Patients' information from 2000 to 2013 were identified. Demographic data, treatment, clinical data and DMC were collected. We performed a generalised linear method (GLM) using gamma distribution to assess the drivers of DMCs. RESULTS: We included 8083 patients with splenic injury who met the study criteria. Over the 14-year study period, 2782 (34.4%) patients were treated with non-operative management (NOM), 5301 (65.6%) with OM. From 2000 to 2013, the rate of NOM increased from 34.7% to 55.9%, while OM decreased from 65.3% to 44.1%. Mean per-patient DMC in both NOM and OM increased from 2000 to 2013. In GLM analysis, male, old age, length of stay, severe splenic injury grade, OM, intensive care unit, blood transfusion and tertiary hospitals were associated with higher DMC, while female and NOM was associated with lower DMC. CONCLUSIONS: In China, management of splenic injury was the most important factor impacting the total DMC. Proper management and public policy could curtail the burden of splenic injury.


Assuntos
Ferimentos não Penetrantes , Transfusão de Sangue , Estudos Transversais , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Estudos Retrospectivos , Baço/lesões , Resultado do Tratamento , Ferimentos não Penetrantes/complicações
7.
Injury ; 53(7): 2470-2477, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35643557

RESUMO

INTRODUCTION: The establishment of national trauma networks have resulted in significant benefits to injured patients. Older people are the majority of major trauma patients and there is need to study variations in care and performance against clinical metrics for them. We aim to describe this patient group in terms of injury, demographics, episode of care assessment and variation between component regions of the Major Trauma Network of England and Wales. METHOD: The Trauma Audit and Research Network (TARN) database was analysed from April 2017 to March 2019. Patients aged 65 years and above with injury severity score (ISS) greater than eight were selected for analysis. Patients were compared by care pathway in terms of first and second treating hospitals and by demographics, injury mechanism, severity, physiology at arrival to hospital (including Glasgow Coma Score (GCS)) and mortality, where known, at discharge. RESULTS: Fifty-three thousand three hundred and forty-seven older injured patients (median age 82.5 years and 58.2% female), were treated in 165 hospitals within the 17 regional trauma networks over the two-year study period. Aside from GCS and gender, all other patient characteristics were significantly different between networks and specifically, a large variation between the network with the highest proportion of older patients (60.4%) and that with a preponderance of younger patients (40.2%) is seen. 84% of cases were due to a fall <2 m and 36.7% of cases had a brain injury. 73.5% of cases had one or more comorbidities. DISCUSSION: We have increased the understanding of how older patients contribute to and are managed by a national trauma service. We have demonstrated variation in numbers and patient characteristics throughout regional trauma networks. We have detailed the whole patient episode, allowing us to comment on disparities in management such as senior review and access to specialist clinical care settings. Older patients dominate United Kingdom major trauma and considerable variations and shortfalls have been identified. Work is needed to focus on the whole clinical episode for these patients both to improve outcome and patient experience but to also to ensure sustainable clinical care in a resource deplete era.


Assuntos
Lesões Encefálicas , Ferimentos e Lesões , Acidentes por Quedas , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Alta do Paciente , Estudos Retrospectivos , Reino Unido , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/terapia
8.
Can J Surg ; 65(3): E326-E334, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35580882

RESUMO

BACKGROUND: Given limited resources for injury prevention, it is essential to determine which mechanisms of injury to target to provide the most benefit to the largest proportion of the population. We developed objective, evidence-based injury prevention priority scores (IPPSs) for the Canadian population across 4 prevention perspectives: mortality, injury severity, resource use and societal cost. METHODS: We performed a retrospective cohort study of all injuries in Canada from 2009/10 to 2013/14. Hospital admissions were obtained from the Discharge Abstract Database, and deaths from the Statistics Canada Canadian Vital Statistics Death Database. For each mechanism of injury, we calculated an IPPS as a balanced measure of injury frequency and 1) mortality rate, 2) median 1 - ICISS (Injury Severity Score derived from the International Statistical Classification of Diseases and Related Health Problems, 10th revision, enhanced Canadian version), 3) median cost per hospital stay or 4) median potential years of life lost (PYLL), providing a ranking of mechanisms of injury in priority order. The IPPS by definition has a mean of 50 and a standard deviation of 10. The higher the IPPS, the higher the priority for injury prevention. RESULTS: A total of 694 535 injuries were identified over the study period. The most frequent mechanism of injury was falls (391 068 [56.3%]). The overall mortality rate was 0.09 deaths/injured person, the median 1 - ICISS was 0.017, the median cost was $5217, and the median PYLL was 0. The mechanisms with the 3 highest IPPSs were falls (75), self-harm (67) and drowning (66) for mortality; falls (77), drowning (70) and suffocation (61) for severity; falls (80), suffocation (63) and fire (60) for resource use; and falls (72), assault (62), and firearms and legal interventions (59 in both cases) for societal cost. CONCLUSION: This study produced IPPSs for traumatic injuries in Canada that provide objective and quantifiable methods for identifying mechanisms of injury to target for specific prevention initiatives. Preventing falls would provide the most benefit to the largest proportion of Canadians and should be prioritized in injury-prevention policy.


Assuntos
Afogamento , Ferimentos e Lesões , Asfixia , Canadá/epidemiologia , Humanos , Escala de Gravidade do Ferimento , Estudos Retrospectivos , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/prevenção & controle
9.
PLoS One ; 17(5): e0268202, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35522686

RESUMO

BACKGROUND: Thoracic trauma is a major cause of death in trauma patients and road traffic accident (RTA)-related thoracic injuries have different characteristics than those with non-RTA related thoracic traumas, but this have been poorly described. The main objective was to investigate the epidemiology, injury pattern and outcome of patients suffering a significant RTA-related thoracic injury. Secondary objective was to investigate the influence of serious thoracic injuries on mortality, compared to other serious injuries. METHODS: We performed a multicenter observational study including patients of the Rhône RTA registry between 1997 and 2016 sustaining a moderate to lethal (Abbreviated Injury Scale, AIS≥2) injury in any body region. A subgroup (AISThorax≥2 group) included those with one or more AIS≥2 thoracic injury. Descriptive statistics were performed for the main outcome and a multivariate logistic regression was computed for our secondary outcome. RESULTS: A total of 176,346 patients were included in the registry and 6,382 (3.6%) sustained a thoracic injury. Among those, median age [IQR] was 41 [25-58] years, and 68.9% were male. The highest incidence of thoracic injuries in female patients was in the 70-79 years age group, while this was observed in the 20-29 years age group among males. Most patients were car occupants (52.3%). Chest wall injuries were the most frequent thoracic injuries (62.1%), 52.4% of which were multiple rib fractures. Trauma brain injuries (TBI) were the most frequent concomitant injuries (29.1%). The frequency of MAISThorax = 2 injuries increased with age while that of MAISThorax = 3 injuries decreased. A total of 16.2% patients died. Serious (AIS≥3) thoracic injuries (OR = 12.4, 95%CI [8.6;18.0]) were strongly associated with mortality but less than were TBI (OR = 27.9, 95%CI [21.3;36.7]). CONCLUSION: Moderate to lethal RTA-related thoracic injuries were rare. Multiple ribs fractures, pulmonary contusions, and sternal fractures were the most frequent anatomical injuries. The incidence, injury pattern and mechanisms greatly vary across age groups.


Assuntos
Lesões Encefálicas Traumáticas , Fraturas das Costelas , Traumatismos Torácicos , Escala Resumida de Ferimentos , Acidentes de Trânsito , Adulto , Lesões Encefálicas Traumáticas/complicações , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Sistema de Registros , Estudos Retrospectivos , Fraturas das Costelas/complicações , Traumatismos Torácicos/epidemiologia , Traumatismos Torácicos/etiologia , Adulto Jovem
10.
J Trauma Acute Care Surg ; 92(6): 974-983, 2022 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-35609288

RESUMO

BACKGROUND: There is variability in end-of-life care of trauma patients. Many survive resuscitation but die after limitation of care (LoC). This study investigated LoC at a level I center. METHODS: Adult trauma deaths between January 2016 and June 2020 were reviewed. Patients were stratified into "full code" versus any LoC (i.e., do not resuscitate, no escalation, or withdrawal of care) and by timing to LoC. Emergency department and "brain" deaths were excluded. Unadjusted logistic regression and Cox proportional hazards were used for analyses. Results include n (%) and odds ratios (ORs) with 95% confidence intervals (CIs), with α = 0.05. RESULTS: A total of 173 patients were included; 15 patients (8%) died full code and 158 (91%) died after LoC. Seventy-seven patients (48%) underwent incremental LoC. Age (OR, 1.05; 95% CI, 1.02-1.08; p = 0.0010) and female sex (OR, 3.71; 95% CI, 1.01-13.64; p = 0.0487) increased the odds of LoC; number of anatomic injuries (OR, 0.91; 95% CI, 0.85-0.98; p = 0.0146), chest injuries (Abbreviated Injury Scale [AIS] score chest, >3) (OR, 0.02; 95% CI, 0.01-0.26; p = 0.0021), extremity injury (AIS score, >3) (OR, 0.08; 95% CI, 0.01-0.64; p = 0.0170), and hospital complications equal to 1 (OR, 0.21; 95% CI, 0.06-0.78; p = 0.0201) or ≥2 (OR, 0.19; 95% CI, 0.04-0.87; p = 0.0319) decreased the odds of LoC. For those having LoC, final limitations were implemented in <14 days for 83% of patients; markers of injury severity (e.g., Injury Severity Score, Glasgow Coma Scale score, and AIS score) increased the odds of early LoC implementation. CONCLUSION: Most patients died after LoC was implemented in a timely fashion. Significant head injury increased the odds of LoC. The number of injuries, severe chest and extremity injuries, and increasing number of complications decreased the odds of LoC, presumably because patients died before LoCs were initiated. Understanding factors contributing to end-of-life care could help guide discussions regarding LoCs. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.


Assuntos
Traumatismos Torácicos , Escala Resumida de Ferimentos , Adulto , Feminino , Escala de Coma de Glasgow , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Traumatismos Torácicos/terapia
11.
J Trauma Acute Care Surg ; 92(6): 1005-1011, 2022 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-35609290

RESUMO

BACKGROUND: Health insurance and race impact mortality and discharge outcomes in the general trauma population. It remains unclear if disparities exist by race and/or insurance in outcomes following firearm injuries. The purpose of this study was to assess differences in mortality and discharge based on race and insurance status following firearm injuries. METHODS: The National Trauma Data Bank (2007-2016) was queried for firearm injuries by International Classification of Diseases, Ninth/Tenth Revision, Ecodes. Patients with known discharge disposition, age (18-64 years), race, and insurance were included in analysis (N = 120,005). To minimize bias due to missing data, we used multiple imputation for variables associated with outcomes following traumatic injury: Injury Severity Score, Glasgow Coma Scale score, respiratory rate, systolic blood pressure, and sex. Multivariable regression analysis was additionally adjusted for age, sex, Injury Severity Score, intent, Glasgow Coma Scale score, systolic blood pressure, heart rate, respiratory rate, year, and clustered by facility to assess differences in mortality and discharge disposition. RESULTS: The average age was 31 years, 88.6% were male, and 50% non-Hispanic Blacks. Overall mortality was 11.5%. Self-pay insurance was associated with a significant increase in mortality rates in all racial groups compared with non-Hispanic Whites with commercial insurance. Hispanic commercial, Medicaid, and self-pay patients were significantly less likely to discharge with posthospital care compared with commercially insured non-Hispanic Whites. When examining racial differences in mortality and discharge by individual insurance types, commercially insured non-Hispanic Black and other race patients were significantly less likely to die compared with similarly insured non-Hispanic White patients. Regardless of race, no significant differences in mortality were observed in Medicaid or self-pay patients compared with non-Hispanic White patients. CONCLUSION: Victims of firearm injuries with a self-pay insurance status have a significantly higher rate of mortality. Hispanic patients regardless of insurance status were significantly less likely to discharge with posthospital care compared with non-Hispanic Whites with commercial insurance. Continued efforts are needed to understand and address the relationship between insurance status, race, and outcomes following firearm violence. LEVEL OF EVIDENCE: Prognostic and epidemiologic, Level IV.


Assuntos
Armas de Fogo , Ferimentos por Arma de Fogo , Adolescente , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Cobertura do Seguro , Seguro Saúde , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Estudos Retrospectivos , Estados Unidos/epidemiologia , Ferimentos por Arma de Fogo/epidemiologia , Adulto Jovem
12.
J Trauma Acute Care Surg ; 92(6): 1054-1060, 2022 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-35609292

RESUMO

BACKGROUND: Designing clinical trials on hemorrhage control requires carefully balancing the need for high enrollment numbers with the need of focusing on the sickest patients. The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial enrolled patients within 2 hours of arrival to the emergency department for a trial of injured patients at risk for massive transfusion. We conducted a secondary analysis to determine how time-to-randomization affected patient outcomes and the balance between enrollment and mortality. METHODS: Patients from the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial were compared based on 30-minute time to randomization intervals. Outcomes included 24-hour and 30-day mortality, time to hemostasis, adverse events, and operative procedures. Additional analyses were conducted based on treatment arm allocation, mechanism of injury, and variation in start time (arrival vs. randomization). RESULTS: Randomization within 30 minutes of arrival was associated with higher injury severity (median Injury Severity Score, 29 vs. 26 overall; p < 0.01), lower systolic blood pressure (median, 91 vs. 102 mm Hg overall; p < 0.01), and increased penetrating mechanism (50% vs. 47% overall; p < 0.01). Faster time-to-randomization was associated with increased 24-hour (20% for 0- to 30 minute entry, 9% for 31-minute to 60-minute entry, 10% for 61-minute to 90-minute entry, 0% for 91-minute to 120-minute entry; p < 0.01) and 30-day mortality (p < 0.01). There were no significant associations between time-to-randomization and adverse event occurrence, operative interventions, or time to hemostasis. CONCLUSION: Increasing time to randomization in this large multicenter randomized trial was associated with increased survival. Fastest randomization (within 0-30 minutes) was associated with highest 24-hour and 30-day mortality, but only 57% of patients were enrolled within this timeframe. Only 3% of patients were enrolled within the last 30-minute window (91-120 minutes), with none of them dying within the first 24 hours. For a more optimal balance between enrollment and mortality, investigators should consider shortening the time to randomization when planning future clinical trials of hemorrhage control interventions. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level II.


Assuntos
Hemorragia , Hemostasia , Transfusão de Sangue/métodos , Hemorragia/terapia , Humanos , Escala de Gravidade do Ferimento , Plasma
13.
BMC Neurol ; 22(1): 190, 2022 May 24.
Artigo em Inglês | MEDLINE | ID: mdl-35610594

RESUMO

OBJECTIVE: Electrocardiogram (ECG) patterns can change, especially in patients with central nervous system disorders such as spontaneous subarachnoid hemorrhage. However, the association between the prognosis of traumatic brain injury (TBI) and ECG findings is unknown. Therefore, this study aimed to compare and to analyze ECG findings to predict early mortality in patients with TBI. METHODS: This retrospective observational study included patients with severe trauma and TBI who were admitted to the emergency department (ED) between January 2018 and December 2020. TBI was defined as an abbreviated injury scale score of the head of ≥3. We examined ECG findings, including PR prolongation (≥ 200 ms), QRS complex widening (≥ 120 ms), corrected QT interval prolongation (QTP, ≥ 480 ms), ST-segment elevation, and ST-segment depression (STD) at ED arrival. The primary outcome was 48-h mortality. RESULTS: Of the total patients with TBI, 1024 patients were included in this study and 48-h mortality occurred in 89 patients (8.7%). In multivariate analysis, QTP (odds ratio [OR], 2.017; confidence interval [CI], 1.203-3.382) and STD (OR, 8.428; 95% CI, 5.019-14.152) were independently associated with 48-h mortality in patients with TBI. The areas under the curve (AUCs) of the revised trauma score (RTS), injury severity score (ISS), QTP, STD, and the combination of QTP and STD were 0.790 (95% CI, 0.764-0.815), 0.632 (95% CI, 0.602-0.662), 0.605 (95% CI, 0.574-0.635), 0.723 (95% CI, 0.695-0.750), and 0.786 (95% CI, 0.759-0.811), respectively. The AUC of the combination of QTP and STD significantly differed from that of ISS, QTP, and STD, but not RTS. CONCLUSION: Based on the ECG findings, QTP and STD were associated with 48-h mortality in patients with TBI.


Assuntos
Lesões Encefálicas Traumáticas , Doenças Sexualmente Transmissíveis , Lesões Encefálicas Traumáticas/diagnóstico , Eletrocardiografia , Humanos , Escala de Gravidade do Ferimento , Estudos Retrospectivos
14.
BMJ Open ; 12(5): e061076, 2022 05 03.
Artigo em Inglês | MEDLINE | ID: mdl-35504646

RESUMO

OBJECTIVES: To identify the differences between women and men in the probability of entrapment, frequency of injury and outcomes following a motor vehicle collision. Publishing sex-disaggregated data, understanding differential patterns and exploring the reasons for these will assist with ensuring equity of outcomes especially in respect to triage, rescue and treatment of all patients. DESIGN: We examined data from the Trauma Audit and Research Network (TARN) registry to explore sex differences in entrapment, injuries and outcomes. We explored the relationship between age, sex and trapped status using multivariate logistical regression. SETTING: TARN is a UK-based trauma registry covering England and Wales. PARTICIPANTS: We examined data for 450 357 patients submitted to TARN during the study period (2012-2019), of which 70 027 met the inclusion criteria. There were 18 175 (26%) female and 51 852 (74%) male patients. PRIMARY AND SECONDARY OUTCOME MEASURES: We report difference in entrapment status, injury and outcome between female and male patients. For trapped patients, we examined the effect of sex and age on death from any cause. RESULTS: Female patients were more frequently trapped than male patients (female patients (F) 15.8%, male patients (M) 9.4%; p<0.0001). Trapped male patients more frequently suffered head (M 1318 (27.0%), F 578 (20.1%)), face, (M 46 (0.9%), F 6 (0.2%)), thoracic (M 2721 (55.8%), F 1438 (49.9%)) and limb injuries (M 1744 (35.8%), F 778 (27.0%); all p<0.0001). Female patients had more injuries to the pelvis (F 420 (14.6%), M 475 (9.7%); p<0.0001) and spine (F 359 (12.5%), M 485 (9.9%); p=0.001). Following adjustment for the interaction between age and sex, injury severity score, Glasgow Coma Scale and the Charlson Comorbidity Index, no difference in mortality was found between female and male patients. CONCLUSIONS: There are significant differences between female and male patients in the frequency at which patients are trapped and the injuries these patients sustain. This sex-disaggregated data may help vehicle manufacturers, road safety organisations and emergency services to tailor responses with the aim of equitable outcomes by targeting equal performance of safety measures and reducing excessive risk to one sex or gender.


Assuntos
Acidentes de Trânsito , Veículos Automotores , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Sistema de Registros , Reino Unido/epidemiologia
15.
J Safety Res ; 81: 21-35, 2022 06.
Artigo em Inglês | MEDLINE | ID: mdl-35589292

RESUMO

INTRODUCTION: Traffic crash reports lack detailed information about emergency medical service (EMS) responses, the injuries, and the associated treatments, limiting the ability of safety analysts to account for that information. Integrating data from other sources can enable a better understanding of characteristics of serious crashes and further explain variance in injury outcomes. In this research, an approach is proposed and implemented to link crash data to EMS run data, patient care reports, and trauma registry data. METHOD: A heuristic framework is developed to match EMS run reports to crashes through time, location, and other indicators present in both datasets. Types of matches between EMS and crashes were classified. To investigate the fidelity of the match approach, a manual review of a sample of data was conducted. A comparative bias analysis was implemented on several key variables. RESULTS: 72.2% of EMS run reports matched to a crash record and 69.3% of trauma registry records matched with a crash record. Females, individuals between 11 and 20 years old, and individuals involved in single vehicle or head on crashes were more likely to be present in linked data sets. Using the linked data sets, relationships between EMS response time and reported injury in the crash report, and between police-reported injury and injury severity score were examined. CONCLUSION: Linking data from other sources can greatly enhance the information available to address road safety issues, data quality issues, and more. Linking data has the potential to result in biases that must be investigated as they relate to the use-case for the data. PRACTICAL IMPLICATIONS: This research resulted in a transferable heuristic approach that can be used to link data sets that are commonly collected by agencies across the world. It also provides guidance on how to check the linked data for biases and errors.


Assuntos
Acidentes de Trânsito , Ferimentos e Lesões , Adolescente , Adulto , Criança , Feminino , Humanos , Armazenamento e Recuperação da Informação , Escala de Gravidade do Ferimento , Polícia , Sistema de Registros , Ferimentos e Lesões/epidemiologia , Adulto Jovem
16.
J Surg Res ; 277: 235-243, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-35504151

RESUMO

INTRODUCTION: The aging process places the elderly, a worldwide increasing age group, at an increased risk for trauma. This study aims to explore changes over time in admission rates, sociodemographical, clinical, and injury-related data in elderly patients (aged ≥65 y) admitted to the Puerto Rico Trauma Hospital (PRTH) during 2000-2019. MATERIALS AND METHODS: A time-series analysis was conducted. Admission rates were analyzed by fitting an exponential growth curve model. Trends were assessed using the Cochrane-Armitage and Cuzick tests for categorical and continuous data, respectively. RESULTS: Elderly admission rates to the PRTH have shown growth over the past 2 decades, from 6.2 cases per 100 overall admissions in 2000 to 18.2 in 2019. This trend is projected to continue with estimated 24.8 (95% CI: 21.7-27.8) cases per 100 overall admissions in 2023. Trends for mechanisms of injury such as motor vehicle accidents and pedestrians showed a significant decrease, whereas falls presented a clear positive trend, showing an increase from 25.6% in 2000-2004 to 46.2% in 2015-2019. Both Injury Severity Score ≥25 and Glasgow Coma Scale ≤8 declined significantly through time. Finally, in-hospital mortality presented a decreasing trend from 31.7% in 2000-2004 to 21.5% in 2015-2019. CONCLUSIONS: Our analysis demonstrates an increase over time in elderly admissions, especially fall-related trauma. Also, it projects this upward trend will continue. This imposes new challenges for PRTH and other healthcare services and is a gateway for the implementation of adapted clinical management.


Assuntos
Hospitalização , Ferimentos e Lesões , Idoso , Mortalidade Hospitalar , Hospitais , Humanos , Escala de Gravidade do Ferimento , Porto Rico/epidemiologia , Estudos Retrospectivos , Centros de Traumatologia , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/terapia
17.
J Surg Res ; 277: 310-318, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-35533604

RESUMO

INTRODUCTION: Damage to the thoracic cage is common in the injured patient, both when the injuries are confined to this single cavity and as part of the overall injury burden of a polytraumatized patient. In a subset of these patients, the severity of injury to the intrathoracic viscera is either underappreciated at admission or blossom over the following 48-72 h. The ability to promptly identify these patients and abrogate complications therefore requires triage of such at-risk patients to close monitoring in a critical care environment. At our institution, this triage hinges on the Pain, Inspiratory effort, Cough (PIC) score, which generates a composite unitless score from a nomogram which aggregates several variables-patient-reported Pain visual analog scale, Incentive spirometry effort, and the perceived adequacy of Cough. We thus sought to audit PIC's discriminant power in predicting intensive care unit (ICU) need. METHODS: This retrospective cohort study was performed at an urban, academic, level 1 trauma center. All isolated chest wall injuries (excluded any Abbreviated Injury Score >2 in head or abdomen) from January 2020 to June 2021 were identified in the local trauma registry. The electronic medical record was queried for standard demographics, admission PIC score, postadmission destination, ICU and hospital length of stay (LOS), and any unplanned admissions to the ICU. Chi-squared tests were used to determine differences between PIC score outcomes and the recursive partitioning method correlated admission PIC score to ICU LOS. RESULTS: Two hundred and thirty six isolated chest wall injury patients were identified, of whom 194 were included in the final analysis. The median age was 60 (interquartile range [IQR] 50-74) years, 63.1% were male, and the median (IQR) number of rib fractures was 3.0 (2.0-5.0). A cutoff PIC score of 7 or lower was associated with ICU admission (odds ratio [OR] 95% CI: 8.19 [3.39-22.55], P < 0.001 with a PPV = 41.4%, NPV = 91%), and with ICU admission for greater than 48 h [OR (95% CI): 26.86 (5.5-43.96), P < 0.001, with a PPV = 25.9%, NPV = 98.7%] but not anatomic injury severity score, hospital LOS or ICU, or the requirement for mechanical ventilation. The association between PIC score 7 or below and the presence of bilateral fractures, flail chest, or sternal fracture did not meet statistical significance. The accurate cut point of the PIC score to predict ICU admission over 48 h in our retrospective cohort was calculated as PIC ≤ 7 for P = 0.013 and PIC ≤ 6 for P = 0.001. CONCLUSIONS: Patients with isolated chest wall injuries require effective reproducible triage for ICU-level care. The PIC score appears to be a moderate discriminator of critical care need, per se, as judged by our recorded complication rate requiring critical care intervention. This vigilance may pay dividends in early detection and abrogation of respiratory failure emergencies. Furthermore, PIC score delineation for ICU need appears to be appropriate at 7 or less; this threshold can be used during admission triage to guide care.


Assuntos
Traumatismos Torácicos , Parede Torácica , Idoso , Tosse/complicações , Cuidados Críticos , Feminino , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Dor , Estudos Retrospectivos , Traumatismos Torácicos/complicações , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/terapia , Triagem/métodos
18.
Injury ; 53(6): 2081-2086, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35504763

RESUMO

OBJECTIVE: No algorithm exists to guide the orthopedic treatment of pediatric patients with pelvic fractures, as most analytic studies have been conducted in adults. The goal of this study was to identify prognostic factors of pelvic fractures, and suggest whether early total care can be safely provided. METHODS: A retrospective trauma database for pediatric pelvic fractures from 2002-2018 was gathered, and patient charts were reviewed. RESULTS: A total of 128 patients were evaluated for pelvic trauma; 99 injuries were secondary to motor vehicle accidents (MVA) (77%), and 19 were secondary to falls (15%). Patients were more likely to be male (71%), older (33% aged 15-16 years, 2% aged 0-1 years), to experience a head trauma (55%), to be treated conservatively (70%), and to survive their trauma (91%). About half of the patients (49%) experienced an additional extremity trauma. When exploring the prognostic factors, mortality was associated with thoracic trauma (72% vs. 27%, p<0.05); a lower reduction of neutrophils levels 48 hours after the initial trauma (-1.34 vs. -7.7, p<0.05); a more significant reduction upon arrival of Prothrombin Time (72% vs. 37%, p<0.01), and an increment of International Normalized Ratio (2.29 vs. 1.26, p<0.01) and Partial Thromboplastin Time (79 vs 28, p<0.01). There was also a higher demand for Fresh Frozen Plasma (24% vs. 9%, p<0.05); Upon presentation, there was a higher Injury Severity Score (49 vs. 21, p<0.001), and a lower systolic Blood Pressure (96 vs. 118, p<0.05); The deceased did not have a very prolonged stay in the hospital (3 days vs. 12 days, P<0.01); Mortality was not significantly associated with either Early Total Care or Damage Control Orthopedics. CONCLUSIONS: Prognostic factors in pediatric patients with pelvic fractures parallel those of the adult population. Pediatric patients tendentiously outlive their pelvic trauma, whether the course of action taken by their surgeons is Conservative by nature, Early Total Care or Damage Control Orthopedics.


Assuntos
Fraturas Ósseas , Ossos Pélvicos , Traumatismos Torácicos , Adulto , Criança , Feminino , Fraturas Ósseas/cirurgia , Humanos , Escala de Gravidade do Ferimento , Masculino , Ossos Pélvicos/lesões , Estudos Retrospectivos , Traumatismos Torácicos/complicações , Centros de Traumatologia
19.
Injury ; 53(6): 2114-2120, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35513939

RESUMO

PURPOSE: To assess the complications and mortality in elderly individuals with cervical spine injuries. METHODS: This retrospective observational study was conducted in a tertiary care hospital in a rural area in Japan. Data sets from the trauma registry (January 2011 to March 2018) were analyzed. Patients with cervical spine injury were divided into those aged ≥ 65 years (group Y) and > 65 years (group E). We then analyzed age, sex, 30-day mortality, hospital stay, level of cervical spine injury, presence of cervical vertebral fracture, perioperative complications (pneumonia, urinary tract infection, and severe bedsore), neurological deficit (Frankel classification), Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS). RESULTS: We evaluated a total of 398 patients; among them, 177 were included in group Y and 221 in group E. The assessed parameters were as follows: age (group Y/E; 48.7/75.9 years), men (78.0/72.3%), 30-day mortality (8.5/10.0%, p = 0.159), hospital stay (17.2/19.1 days, p = 0.36), level of cervical spine injury (C1 [5.7/4.5%], C2 [12.4/15.8%], C3 [10.2/17.2%], C4 [14.1/16.3%], C5 [26.6/22.2%], C6 [22.0/12.2%], and C7 [11.3/10.9%]), vertebral fracture (56.6/61.9%), central cord syndrome (36.2/33%), operation (18.6/13.1%), pneumonia (6.8/11.8%, p = 0.077), urinary tract infection (4.0/6.3%, p = 0.26), severe bedsore (0/1.8%, p = 0.068), Frankel classification (grade A [5.7/6.3%], grade B [6.8/7.7%], grade C [24.9/28.5%], grade D [17.5/11.8%], and grade E [34.5/33.9%]), mean AIS score in the cervical spine (3.3/3.5, p = 0.04), and mean ISS (23.2/22.2, p = 0.38). C3 injuries tended to be higher in group E. CONCLUSION: Mortality and morbidity associated with cervical spine injuries did not differ between younger and older patients. Nevertheless, vigilance is required for the detection of C3 injury in elderly individuals.


Assuntos
Lesões do Pescoço , Lesão por Pressão , Traumatismos da Medula Espinal , Fraturas da Coluna Vertebral , Traumatismos da Coluna Vertebral , Idoso , Vértebras Cervicais/lesões , Humanos , Escala de Gravidade do Ferimento , Masculino , Lesões do Pescoço/complicações , Estudos Retrospectivos , Traumatismos da Medula Espinal/complicações , Fraturas da Coluna Vertebral/cirurgia , Traumatismos da Coluna Vertebral/complicações
20.
J Trauma Acute Care Surg ; 93(1): 118-123, 2022 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-35393386

RESUMO

BACKGROUND: Although the need for high-level care persists postdischarge, severely injured trauma survivors have historically poor adherence to follow-up. We hypothesized that a dedicated Center for Trauma Survivorship (CTS) improves follow-up and facilitates postdischarge specialty care. METHODS: A retrospective study of "CTS eligible" trauma patients before (January to December 2017) and after (January to December 2019) creation of the CTS was performed. Patients with an intensive care unit stay ≥2 days or a New Injury Severity Score of ≥16 are CTS eligible. The before (PRE) cohort was followed through December 2018 and the after (CTS) cohort through December 2020. Primary outcome was follow-up within the hospital system exclusive of mental health and rehabilitative therapy appointments. Secondary outcomes include postdischarge surgical procedures and specialty-specific follow-up. RESULTS: There were no significant differences in demographics or hospital duration in the PRE (n = 177) and CTS (n = 119) cohorts. Of the CTS group, 91% presented for outpatient follow-up within the hospital system, compared with 73% in the PRE group (p < 0.001). In the PRE cohort, only 39% were seen by the trauma service compared with 62% in the CTS cohort (p < 0.001). Center for Trauma Survivorship patients also had increased follow-up with other providers (80% vs. 65%; p = 0.006). Notably, 33% of CTS patients had additional surgery compared with only 20% in the PRE group (p = 0.011). Center for Trauma Survivorship patients had more than 20% more outpatient visits (1,280 vs. 1,006 visits). CONCLUSION: Despite the follow-up period for the CTS cohort occurring during the peak of the COVID-19 pandemic, limiting availability of outpatient services, our CTS significantly improved follow-up with trauma providers, as well as with other specialties. The CTS patients also underwent significantly more secondary operations. These data demonstrate that creation of a CTS can improve the postdischarge care of severely injured trauma survivors, allowing for care coordination within the health care system, retaining patients, generating revenue, and providing needed follow-up care. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.


Assuntos
COVID-19 , Ferimentos e Lesões , Assistência ao Convalescente , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Pandemias , Alta do Paciente , Estudos Retrospectivos , Sobrevivência , Centros de Traumatologia , Ferimentos e Lesões/terapia
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