The right treatment at the right time in the right place: a population-based, before-and-after study of outcomes associated with implementation of an all-inclusive trauma system in a large Canadian province.

OBJECTIVE: To evaluate the implementation of an all-inclusive philosophy of trauma care in a large Canadian province. BACKGROUND: Challenges to regionalized trauma care may occur where transport distances to level I trauma centers are substantial and few level I centers exist. In 2008, we modified our predominantly regionalized model to an all-inclusive one with the hopes of increasing the role of level III trauma centers. METHODS: We conducted a population-based, before-and-after study of patient admission and transfer practices and outcomes associated with implementation of an all-inclusive provincial trauma system using multivariable Poisson and linear regression and Cox proportional hazard models. RESULTS: In total, 21,772 major trauma patients were included. Implementation of the all-inclusive model of trauma care was associated with a decline in transfers directly to level I trauma centers [risk ratio (RR) = 0.91; 95% confidence interval (CI): 0.88-0.94; P < 0.001] and an increase in transfers from level III to level I centers (RR = 1.10; 95% CI: 1.00-1.21; P = 0.04). These changes in trauma care occurred in conjunction with a 12% reduction in the hazard of mortality (hazard ratio = 0.88; 95% CI: 0.84-0.98; P = 0.003) and a decrease in mean trauma patient hospital length of stay by 1 day (95% CI: 1.02-1.11; P = 0.02) after adjustment for differences in case mix. CONCLUSIONS: In this study, introduction of an all-inclusive provincial trauma system was associated with an increased number of injured patients cared for in their local systems and improved trauma patient mortality and hospital length of stay.

Risk of Infection and Sepsis in Pediatric Patients with Traumatic Brain Injury Admitted to Hospital Following Major Trauma.

Head injury accounts for 29% of all traumatic deaths in children. Sepsis is significantly associated with an increased risk of mortality in adult traumatic brain injury patients. In the pediatric population, this relationship is not well understood. The objective of this study was to compare the proportion of pediatric traumatic brain injury (TBI) patients and trauma patients without brain injury (NTBI) who developed sepsis or any infection during their index hospital admission. We performed a retrospective study of all trauma patients <18 years of age, admitted to trauma centres in Alberta, Canada from January 1, 2003 to December 31, 2012. Patients who died within 24 hrs of trauma (n = 147) and those with burns as the primary mechanism of injury (n = 53) were excluded. Hospital admission data for the remaining 2556 patients was analyzed. 1727 TBI patients and 829 NTBI patients were included. TBI was associated with lower odds of developing sepsis (OR 0.32 95% CI 0.14-0.77 p = 0.011). TBI was not found to be independently associated with developing any infectious complication after adjusting for confounding by Injury Severity Score (OR 1.25 95% CI 0.90-1.74 p = 0.180). These relationships warrant further study.

Safety and efficacy of tranexamic acid in bleeding paediatric trauma patients: a systematic review protocol.

INTRODUCTION: Trauma is the leading cause of death among children aged 1-18. Studies indicate that better control of bleeding could potentially prevent 10-20% of trauma-related deaths. The antifibrinolytic agent tranexamic acid (TxA) has shown promise in haemorrhage control in adult trauma patients. However, information on the potential benefits of TxA in children remains sparse. This review proposes to evaluate the current uses, benefits and adverse effects of TxA in the bleeding paediatric trauma population. METHODS AND ANALYSIS: A structured search of bibliographic databases (eg, MEDLINE, EMBASE, PubMed, CINAHL, Cochrane CENTRAL) has been undertaken to retrieve randomised controlled trials and cohort studies that describe the use of TxA in paediatric trauma patients. To ensure that all relevant data were captured, the search did not contain any restrictions on language or publication time. After deduplication, citations will be screened independently by 2 authors, and selected for inclusion based on prespecified criteria. Data extraction and risk of bias assessment will be performed independently and in duplicate. Meta-analytic methods will be employed wherever appropriate. ETHICS AND DISSEMINATION: This study will not involve primary data collection, and formal ethical approval will therefore not be required. The findings of this study will be disseminated through a peer-reviewed publication and at relevant conference meetings. TRIAL REGISTRATION NUMBER: CRD42016038023.

Hantavirus cardiopulmonary syndrome: implications for transport management and care.

INTRODUCTION: A 14-year-old boy with cardiorespiratory failure was referred for air medical transport. The complexity of care during air medical transport and subsequent diagnosis of hantavirus warranted a post hoc review of the literature to establish optimal transport management criteria. METHODS: This is a case report and literature review, defining epidemiology, presentation, cause of pulmonary edema and cardiac failure, management, and outcome. RESULTS: Hantavirus cardiopulmonary syndrome is rare in children. Severe cases have manifestations similar to those seen in adults: atypical pneumonia progresses to respiratory failure with severe pulmonary edema and associated circulatory compromise. Mechanical ventilation, judicious fluid replacement, and early inotropic therapy are central to transport management. Critical care may require extracorporeal membrane oxygenation (ECMO). Mortality remains high, although it appears to be lower in children younger than 14 years. CONCLUSION: Hantavirus infection commonly progresses to a cardiopulmonary syndrome, in which mortality is high. Optimal management includes: early suspicion/recognition based on characteristic clinical course and history; provision of oxygen and comprehensive ventilatory support; judicious fluid replacement; early and intensive inotropic therapy; prompt referral to an appropriate level of care; skillful interfacility transport. Definitive care can involve ECMO.