Association of admission serum sodium and outcomes following out-of-hospital cardiac arrest.

BACKGROUND: The prognostic association between dysnatremia and outcomes in out-of-hospital cardiac arrest (OHCA) is not well understood. Given hypernatremia is associated with poor outcomes in critical illness and hyponatremia may exacerbate cerebral edema, we hypothesized that dysnatremia on OHCA hospital admission would be associated with worse neurological outcomes. METHODS: We studied adults (≥19 years) with non-traumatic OHCA between 2009 and 2016 who were enrolled in the British Columbia Cardiac Arrest Registry and survived to hospital admission at 2 quaternary urban hospitals. We stratified cases by admission serum sodium into hyponatremic (<135 mmol/L), normonatremic (135-145 mmol/L), and hypernatremic (>145 mmol/L) groups. We used logistic regression models, adjusted for age, sex, shockable rhythm, admission serum lactate, and witnessed arrest, to estimate the association between admission sodium and favorable neurological outcome (cerebral performance category 1-2 or modified Rankin scale 0-3). RESULTS: Of 414 included patients, 63 were hyponatremic, 330 normonatremic, and 21 hypernatremic. In each respective group, 21 (33.3%), 159 (48.2%), and 3 (14.3%) experienced good neurological outcomes. In univariable models, hyponatremia (OR 0.53, 95% CI 0.30-0.93) and hypernatremia (OR 0.19, 95% CI 0.05-0.65) were associated with lower odds of good neurological outcomes compared to the normonatremia group. After adjustment, only hypernatremia was associated with lower odds of good neurological outcomes (OR 0.22, 95% CI 0.05-0.98). CONCLUSIONS: Hypernatremia at admission was independently associated with decreased probability of good neurological outcomes at discharge post-OHCA. Future studies should focus on elucidating the pathophysiology of dysnatremia following OHCA.

Rationale, development and implementation of the ReACanROC registry for out-of-hospital cardiac arrests in France and Canada.

France and Canada prehospital systems and care delivery in out-of-hospital cardiac arrests (OHCAs) show substantial differences. This article aims to describe the rationale, design, implementation and expected research implications of the international, population-based, France-Canada registry for OHCAs, namely ReACanROC, which is built from the merging of two nation-wide, population-based, Utstein-style prospectively implemented registries for OHCAs attended to by emergency medical services. Under the supervision of an international steering committee and research network, the ReACanROC dataset will be used to run in-depth analyses on the differences in organisational, practical and geographic predictors of survival after OHCA between France and Canada. ReACanROC is the first Europe-North America registry ever created to meet this goal. To date, it covers close to 80 million people over the two countries, and includes approximately 200 000 cases over a 10-year period.

Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury.

Importance: Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI. Objective: To determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI. Design, Setting, and Participants: Multicenter, double-blinded, randomized clinical trial at 20 trauma centers and 39 emergency medical services agencies in the US and Canada from May 2015 to November 2017. Eligible participants (N = 1280) included out-of-hospital patients with TBI aged 15 years or older with Glasgow Coma Scale score of 12 or less and systolic blood pressure of 90 mm Hg or higher. Interventions: Three interventions were evaluated, with treatment initiated within 2 hours of TBI: out-of-hospital tranexamic acid (1 g) bolus and in-hospital tranexamic acid (1 g) 8-hour infusion (bolus maintenance group; n = 312), out-of-hospital tranexamic acid (2 g) bolus and in-hospital placebo 8-hour infusion (bolus only group; n = 345), and out-of-hospital placebo bolus and in-hospital placebo 8-hour infusion (placebo group; n = 309). Main Outcomes and Measures: The primary outcome was favorable neurologic function at 6 months (Glasgow Outcome Scale-Extended score >4 [moderate disability or good recovery]) in the combined tranexamic acid group vs the placebo group. Asymmetric significance thresholds were set at 0.1 for benefit and 0.025 for harm. There were 18 secondary end points, of which 5 are reported in this article: 28-day mortality, 6-month Disability Rating Scale score (range, 0 [no disability] to 30 [death]), progression of intracranial hemorrhage, incidence of seizures, and incidence of thromboembolic events. Results: Among 1063 participants, a study drug was not administered to 96 randomized participants and 1 participant was excluded, resulting in 966 participants in the analysis population (mean age, 42 years; 255 [74%] male participants; mean Glasgow Coma Scale score, 8). Of these participants, 819 (84.8%) were available for primary outcome analysis at 6-month follow-up. The primary outcome occurred in 65% of patients in the tranexamic acid groups vs 62% in the placebo group (difference, 3.5%; [90% 1-sided confidence limit for benefit, -0.9%]; P = .16; [97.5% 1-sided confidence limit for harm, 10.2%]; P = .84). There was no statistically significant difference in 28-day mortality between the tranexamic acid groups vs the placebo group (14% vs 17%; difference, -2.9% [95% CI, -7.9% to 2.1%]; P = .26), 6-month Disability Rating Scale score (6.8 vs 7.6; difference, -0.9 [95% CI, -2.5 to 0.7]; P = .29), or progression of intracranial hemorrhage (16% vs 20%; difference, -5.4% [95% CI, -12.8% to 2.1%]; P = .16). Conclusions and Relevance: Among patients with moderate to severe TBI, out-of-hospital tranexamic acid administration within 2 hours of injury compared with placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. Trial Registration: ClinicalTrials.gov Identifier: NCT01990768.

Cycling-related crash risk and the role of cannabis and alcohol: a case-crossover study.

OBJECTIVE: To examine whether alcohol and cannabis consumption increase crash risk among non-fatally injured bicyclists (N=393) seen in three Canadian emergency departments, between April 2009 and July 2011. METHOD: Employing a case-crossover design, cannabis and alcohol were identified through blood sample or by self-report. All cyclists involved in a crash and exposure status (cannabis and alcohol) were compared between case period (current crash) and two control periods: prior to the last time the victim cycled around the same time of day; and the typical use prior to bicycling. Crash risk was assessed through conditional fixed effects logistic regression models. RESULTS: Approximately 15% of cyclists reported using cannabis just prior to the crash, and 14.5% reported using alcohol. Cannabis use identified by blood testing or self-report in the case period and by self-report in the control period yielded a crash risk of 2.38 (1.04-5.43); however, when self-report was used for both the case and control periods the estimate was 0.40 (0.12-1.27). Alcohol use, as measure either in blood or self-report, was associated with an odds ratio of 4.00 (95% CI: 1.64-9.78); results were similar when alcohol was measured by self-report only. CONCLUSION: Cannabis and alcohol use each appear to increase the risk of a non-fatal injury-related crash among bicyclists, and point to the need for improved efforts to deter substance use prior to cycling, with the help of regulation, increased education, and greater public awareness. However, cannabis results should be interpreted with caution, as the observed association with crash risk was contingent on how consumption was measured.

Prehospital use of tranexamic acid for hemorrhagic shock in primary and secondary air medical evacuation.

INTRODUCTION: Major hemorrhage remains a leading cause of death in both military and civilian trauma. We report the use of tranexamic acid (TXA) as part of a trauma exanguination/massive transfusion protocol in the management of hemorrhagic shock in a civilian primary and secondary air medical evacuation (AME) helicopter EMS program. METHODS: TXA was introduced into our CCP flight paramedic program in June 2011. Indications for use include age > 16 years, major trauma (defined a priori based on mechanism of injury or findings on primary survey), and heart rate (HR) > 110 beats per minute (bpm) or systolic blood pressure (SBP) < 90 mmHg. Our protocol, which includes 24-hour online medical oversight, emphasizes rapid initiation of transport, permissive hypotension in select patients, early use of blood products (secondary AME only), and infusion of TXA while en route to a major trauma center. RESULTS: Over a 4-month period, our CCP flight crews used TXA a total of 13 times. Patients had an average HR of 111 bpm [95% CI 90.71-131.90], SBP of 91 mmHg [95% CI 64.48-118.60], and Glascow Coma Score of 7 [95% CI 4.65-9.96]. For primary AME, average response time was 33 minutes [95% CI 19.03-47.72], scene time 22 minutes [95% CI 20.23-24.27], and time to TXA administration 32 minutes [95% CI 25.76-38.99] from first patient contact. There were no reported complications with the administration of TXA in any patient. CONCLUSION: We report the successful integration of TXA into a primary and secondary AME program in the setting of major trauma with confirmed or suspected hemorrhagic shock. Further studies are needed to assess the effect of such a protocol in this patient population.

Health system use and outcomes of urgently triaged callers to a nurse-managed telephone service for provincial health information after initiation of supplemental virtual physician assessment: a descriptive study.

BACKGROUND: British Columbia's 8-1-1 telephone service connects callers with nurses for health care advice. As of Nov. 16, 2020, callers advised by a registered nurse to obtain in-person medical care can be subsequently referred to virtual physicians. We sought to determine health system use and outcomes of 8-1-1 callers urgently triaged by a nurse and subsequently assessed by a virtual physician. METHODS: We identified callers referred to a virtual physician between Nov. 16, 2020, and Apr. 30, 2021. After assessment, virtual physicians assigned callers to 1 of 5 triage dispositions (i.e., go to emergency department [ED] now, see primary care provider within 24 hours, schedule an appointment with a health care provider, try home treatment, other). We linked relevant administrative databases to ascertain subsequent health care use and outcomes. RESULTS: We identified 5937 encounters with virtual physicians involving 5886 8-1-1 callers. Virtual physicians advised 1546 callers (26.0%) to go to the ED immediately, of whom 971 (62.8%) had 1 or more ED visits within 24 hours. Virtual physicians advised 556 (9.4%) callers to seek primary care within 24 hours, of whom 132 (23.7%) had primary care billings within 24 hours. Virtual physicians advised 1773 (29.9%) callers to schedule an appointment with a health care provider, of whom 812 (45.8%) had primary care billings within 7 days. Virtual physicians advised 1834 (30.9%) callers to try a home treatment, of whom 892 (48.6%) had no health system encounters over the next 7 days. Eight (0.1%) callers died within 7 days of assessment with a virtual physician, 5 of whom were advised to go to the ED immediately. Fifty-four (2.9%) callers with a "try home treatment" disposition were admitted to hospital within 7 days of a virtual physician assessment, and no callers who were advised home treatment died. INTERPRETATION: This Canadian study evaluated health service use and outcomes arising from the addition of virtual physicians to a provincial health information telephone service. Our findings suggest that supplementation of this service with an assessment from a virtual physician safely reduces the overall proportion of callers advised to seek urgent in-person visits.

Do patient outcomes differ when the trauma team leader is a surgeon or non-surgeon? A multicentre cohort study.

PURPOSE: Trauma team leaders (TTLs) have traditionally been general surgeons; however, some trauma centres use a mixed model of care where both surgeons and non-surgeons (primarily emergency physicians) perform this role. The objective of this multicentre study was to provide a well-powered study to determine if TTL specialty is associated with mortality among major trauma patients. METHODS: Data were collected from provincial trauma registries at six level 1 trauma centres across Canada over a 10-year period. We included adult trauma patients (age ≥ 18 yrs) who triggered the highest-level trauma activation. The primary outcome was the difference in risk-adjusted in-hospital mortality for trauma patients receiving initial care from a surgeon versus a non-surgeon TTL. RESULTS: Overall, 12,961 major trauma patients were included in the analysis. Initial treatment was provided by a surgeon TTL in 57.8% (n = 7513) of cases, while 42.2% (n = 5448) of patients were treated by a non-surgeon TTL. Unadjusted mortality occurred in 11.6% of patients in the surgeon TTL group and 12.7% of patients in the non-surgeon TTL group (OR 0.87, 95% CI 0.78-0.98, p = 0.02). Risk-adjusted mortality was not significantly different between patients cared for by surgeon and non-surgeon TTLs (OR 0.92, 95% CI 0.80-1.06, p = 0.23). Furthermore, we did not observe differences in risk-adjusted mortality for any of the subgroups evaluated. CONCLUSIONS: After risk adjustment, there was no difference in mortality between trauma patients treated by surgeon or non-surgeon TTLs. Our study supports emergency physicians performing the role of TTL at level 1 trauma centres.

ABSTRAIT: OBJECTIF: Les chefs d'équipe de traumatologie (CET) sont traditionnellement des chirurgiens généralistes; cependant, certains centres de traumatologie utilisent un modèle mixte de soins où des chirurgiens et des non-chirurgiens (principalement des médecins d'urgence) qui jouent ce rôle. L'objectif de cette étude multicentrique était de fournir une étude bien menée pour déterminer si la spécialité CET est associée à la mortalité chez les patients traumatisés majeurs. MéTHODES: Les données ont été recueillies à partir des registres provinciaux de 6 niveau 1 centres de traumatologie au Canada sur une période de 10 ans. Nous avons inclus des patients adultes traumatisés (âge ≥ 18 ans) qui ont provoqué l'activation traumatique de niveau le plus haut. Le primaire résultat était la différence de mortalité hospitalière ajustée en fonction du risque pour les patients traumatisés qui ont reçu des soins primaires d'un chirurgien par rapport à un CET non chirurgien. RéSULTATS: En totale, 12 961 patients traumatisés majeurs ont été la partie de cette analyse. Le soin primaire a été assuré par un chirurgien CET dans 57,8 % (n=7 513) des cas, alors que 42,2 % (n=5 448) des patients ont été traités par un CET non chirurgien. Une mortalité non ajustée s'est produit chez 11,6 % des patients du groupe de chirurgien CET et 12,7 % des patients du groupe de non chirurgien CET (OR 0,87, IC à 95 % 0,78 à 0,98, p = 0,02). La mortalité ajustée en fonction du risque n'était pas significativement différente entre les patients pris en charge par des CET chirurgiens et non-chirurgiens (RC 0,92, IC à 95 % 0,80 à 1,06, p = 0,23). De plus, nous ne pouvons pas observer de différences de mortalité ajustée au risque pour aucun des sous-groupes évalués. CONCLUSIONS: Après avoir ajusté du risque, il n'y avait pas de différence de mortalité entre les patients traumatisés traités par des chirurgiens ou non chirurgiens CET. Notre étude soutient les médecins d'urgences jouent le rôle de CET dans les centres de traumatologie de niveau 1.

Influence of a province-wide trauma system on motor vehicle collision process of trauma care and mortality: a 10-year follow-up evaluation.

BACKGROUND: Mature trauma systems have evolved to respond to major injury-related morbidity and mortality. Studies of mature trauma systems have demonstrated improved survival, especially among seriously injured patients. From 1995 to 1998, a province-wide trauma system was implemented in the province of Nova Scotia. We measured the proportion of admissions to a tertiary level trauma centre and the proportion of in-hospital deaths among patients with major injuries as a result of a motor vehicle collisions (MVCs) before and 10 years after provincial trauma systems implementation. METHODS: We identified major trauma patients aged 16 years and older using external cause of injury codes pertaining to MVCs from population-based hospital claims and vital statistics data. Individuals who were admitted to hospital or died because of an MVC in 1993-1994 (preimplementation), were compared with those who were admitted to hospital or died in 2003-2005 (postimplementation). RESULTS: Postimplementation, there was a 9% increase in the number of seriously injured individuals with primary admission to tertiary care. This increase was statistically significant even after we adjusted for age, head injury and municipality of residence (relative risk [RR] 1.09, 95% confidence interval [CI] 1.04-1.14). The probability of dying while in hospital in the postimplementation period decreased by 29% (adjusted RR 0.57, 95% CI 0.32-1.03), although this difference was not statistically significant. CONCLUSION: Individuals seriously injured in MVCs in Nova Scotia were more likely to be admitted to tertiary care after the implementation of a province-wide trauma system. There was a trend toward decreased mortality, but further research is warranted to confirm the survival benefit and delineate other contributing factors.

Association of pre-hospital time intervals and clinical outcomes in ST-elevation myocardial infarction patients.

Study Objectives: Timely coronary reperfusion is critical for favorable outcomes after ST-elevation myocardial infarction (STEMI). A substantial proportion of the total ischemic time is patient related, occurring before first medical contact (FMC). We aimed to expand the limited current understanding of the associations between prehospital intervals and clinical outcomes. Methods: We conducted a retrospective analysis of consecutive STEMI patients who underwent primary percutaneous coronary intervention (pPCI) (January 2009-March 2016) and assessed the associations between prehospital intervals and the incidence of new heart failure, cardiogenic shock, and hospital length of stay (LOS), adjusting for important clinical variables. Results: A total of 773 patients (77% men, median age 65 years) met eligibility criteria. The median pre-911 activation interval was 29 minutes (interquartile range: 11, 89); the median 911 call to FMC interval was 12 minutes (interquartile range: 9, 15). In multivariable analysis, there was a V-shaped relationship between the pre-911 activation interval and outcomes: a lower likelihood of new heart failure (odds ratio [OR] 0.51; 95% confidence interval [CI]: 0.30, 0.87), cardiogenic shock (OR 0.40; 95% CI: 0.21, 0.75) and prolonged LOS (OR 0.24; 95% CI: 0.14, 0.42) for midrange intervals (11-88 minutes) when compared to the early (< 11-minute) interval. There was no statistically significant relationship between total pre-FMC time and FMC to device activation time. Conclusions: Among ambulance-transported STEMI patients receiving pPCI, the shortest and longest pre-911 activation time intervals were associated with poorer outcomes. However, variation in post-FMC interval alone was not associated with outcomes, suggesting that interventions to reduce pre-FMC intervals must be prioritized.

Ketamine in adult emergency medicine: controversies and recent advances.

OBJECTIVE: To review the evidence for the use of ketamine in adult emergency medicine for procedural sedation and analgesia (PSA) and rapid sequence intubation (RSI), as well as to focus on the issues of recovery agitation, combination with propofol for PSA, and the use of ketamine as an induction agent in patients with acute head injury in need of definitive airway management. DATA SOURCES: PubMed (1949-July 2011), EMBASE (1980-July 2011), Google Scholar (to July 2011), International Pharmaceutical Abstracts (1964-July 2011), and Cochrane databases were searched independently. A manual search of references was also performed. STUDY SELECTION: English-language, full reports of experimental and observational studies evaluating ketamine in adults undergoing PSA and RSI in the emergency department (ED) were included if they reported efficacy or safety outcomes. DATA EXTRACTION: Two reviewers independently assessed each article for inclusion, data extraction, and study limitations. DATA SYNTHESIS: Six studies that used ketamine for PSA were included. The majority reported adequate sedation with high patient satisfaction and lack of pain and procedural recall. There is no evidence to support the superiority of a combination of ketamine and propofol compared to propofol alone for PSA in adults. Recovery agitation is common but can be minimized with premedication with midazolam (number needed to treat 6). Two studies were identified that evaluated the role of ketamine for induction during RSI in the ED. Although ketamine is not a first-line agent for RSI, it is an alternative and may be used as an induction agent in patients requiring endotracheal intubation. CONCLUSIONS: Ketamine is an effective agent in adults undergoing PSA and RSI in the ED. The best available evidence provides sufficient confidence to consider use of this agent in the ED.

Major traumatic brain injury: time to tertiary care and the impact of a clinical guideline.

BACKGROUND: To achieve timely access to neurosurgical care for adult brain-injured patients, a Head Injury Guideline was implemented to standardize the emergency department evaluation and management of these patients. The goals of this study were to document times to neurosurgical care for patients with major traumatic brain injury presenting to a Provincial emergency room and to evaluate the impact of the Guideline on timely access to definitive care. METHODS: Data collected prospectively and stored in the Nova Scotia Trauma Registry and the Emergency Health Services Communications and Dispatch Centre database were analyzed for patients with head abbreviated injury scale score (AIS)≥3. Several time intervals from admission to a referring hospital to access to tertiary care were determined and compared for the periods before Guideline implementation, the implementation phase, and after implementation. RESULTS: The time elapsed before calling the provincial Trauma Hotline was not statistically different after Guideline implementation for polytrauma patients with head AIS score≥3 (n=388) during the preimplementation (2:34±1:30; median time in hours:minutes±standard deviation), implementation (1:57±2:33) and postimplementation (2:31±4:06) periods. Subset group analysis of patients with isolated head injuries AIS score≥3 (n=99) also showed no statistical difference in preimplementation (1:51±1:42), implementation (2:49±2:57), and postimplementation (3:10±4:58) times. Examination of overall time to tertiary care revealed prolonged transfer times and that the Guideline had no influence on either the polytrauma patient group (preimplementation, 4:20±1:41; implementation, 5:01±2:55; and postimplementation 4:46±4:22) or those with isolated head injuries (preimplementation, 3:39±1:47; implementation, 6:06±4:00; and postimplementation, 5:13±4:59). CONCLUSIONS: Times to tertiary care are lengthy and have not been reduced by Guideline implementation. System changes beyond Guideline implementation are required to provide timely access to tertiary care for patients with major head injury.

Assessing the clinical utilization of tranexamic acid by paramedics for patients with major trauma (ACUTE).

OBJECTIVES: This study aimed to characterize the clinical utilization of tranexamic acid (TXA) by paramedics in British Columbia (BC) for acute major trauma and to quantify the percentage of patients who received TXA among those who met the indications for administration. METHODS: A quality assurance review of eligible trauma patients across the province was performed using a convenience sample. Trauma patients between April 1, 2016 and March 31, 2017 with suspected or actual hemorrhage were selected if they met inclusion criteria (systolic blood pressure < 90 mm Hg ± heart rate > 120 beats per minute) and exclusion criteria (age < 16 years, injuries exclusively to the extremities). RESULTS: 35 of the 100 eligible patients assessed in this review received a dose of TXA from paramedics. All 35 of the patients received TXA within 180 min of injury regardless of their original location of injury in BC (mean: 50 min; range: 15-140 min). CONCLUSIONS: 35% of eligible patients identified in this study received TXA, which is an improvement over rates cited by previous Canadian literature. With further education opportunities for paramedics in BC and other EMS systems, there is potential to continue improving pre-hospital TXA administration rates.

RéSUMé: OBJECTIFS: Cette étude visait à caractériser l'utilisation clinique de l'acide tranexamique (TXA) par les ambulanciers paramédicaux de la Colombie-Britannique pour les traumatismes aigus majeurs et à quantifier le pourcentage de patients qui ont reçu du TXA parmi ceux qui répondaient aux indications d'administration. MéTHODES: Un examen de l'assurance qualité des patients traumatisés admissibles dans toute la province a été effectué à l'aide d'un échantillon de commodité. Les patients traumatisés entre le 1er avril 2016 et le 31 mars 2017 présentant une hémorragie suspectée ou réelle ont été sélectionnés s'ils répondaient aux critères d'inclusion (pression artérielle systolique < 90 mm Hg ± fréquence cardiaque > 120 battements par minute) et aux critères d'exclusion (âge < 16 ans, blessures exclusivement aux extrémités). RéSULTATS: 35 des 100 patients admissibles évalués dans le cadre de cet examen ont reçu une dose de TXA des ambulanciers paramédicaux. Les 35 patients ont tous reçu du TXA dans les 180 min suivant la blessure, quel que soit le lieu de leur blessure initiale en Colombie-Britannique (moyenne: 50 min; intervalle: 15 à 140 min). CONCLUSIONS: 35% des patients admissibles identifiés dans le cadre de cette étude ont reçu du TXA, ce qui représente une amélioration par rapport aux taux cités dans les publications canadiennes précédentes. Grâce aux possibilités de formation continue pour les ambulanciers en Colombie-Britannique et dans d'autres systèmes d'Aide médicale urgente (AMU), il est possible de continuer à améliorer les taux d'administration de la TXA en milieu préhospitalier.

Air versus ground transport of the major trauma patient: a natural experiment.

OBJECTIVES: 1) To compare the outcomes of adult trauma patients transported to a level I trauma center by helicopter vs. ground ambulance. 2) To determine whether using a unique "natural experiment" design to obtain the ground comparison group will reduce potential confounders. METHODS: Outcomes in adult trauma patients transported to a tertiary care trauma center by air were compared with outcomes in a group of patients who were accepted by the online medical control physician for air transport, but whose air missions were aborted for aviation reasons (weather, maintenance, out on a mission); these patients were subsequently transported by ground ambulance instead. Outcomes were also analyzed for a third ground control group composed of all other adult trauma patients transported by ground during this time period. Data were collected by retrospective database review of trauma patients transferred between July 1, 1997, and June 30, 2003. Outcomes were measured by Trauma Injury Severity Score (TRISS) analysis. Z and W scores were calculated. RESULTS: Three hundred ninety-seven missions were flown by LifeFlight during the study period vs. 57 in the clinical accept-aviation abort ground transport group. The mean ages, gender distributions, mechanisms of injury, and Injury Severity Scores (ISSs) were similar in the two groups. Per 100 patients transported, 5.61 more lives were saved in the air group vs. the clinical accept-aviation abort ground transport group (Z = 3.37). As per TRISS analysis, this is relative to the expected mortality seen with a similar group in the Major Trauma Outcomes Study (MTOS). The Z score for the clinical accept-aviation abort ground transport group was 0.4. The 1,195 patients in the third all-other ground control group had a higher mean age, lower mean ISS, and worse outcomes according to TRISS analysis (W = -2.02). CONCLUSIONS: This unique natural experiment led to better matched air vs. ground cohorts for comparison. As per TRISS analysis, air transport of the adult major trauma patient is associated with significantly improved survival as compared with ground transport.

Access to trauma systems in Canada.

BACKGROUND: Trauma is a leading cause of morbidity, potential years of life lost and health care expenditure in Canada and around the world. Trauma systems have been established across North America to provide comprehensive injury care and to lead injury control efforts. We sought to describe the current status of trauma systems in Canada and Canadians' access to acute, multidisciplinary trauma care. METHODS: A national survey was used to identify the locations and capabilities of adult trauma centers across Canada and to identify the catchment populations they serve. Geographic information science methods were used to map the locations of Level I and Level II trauma centers and to define 1-hour road travel times around each trauma center. Data from the 2006 Canadian Census were used to estimate populations within and outside 1-hour access to definitive trauma care. RESULTS: In Canada, 32 Level I and Level II trauma centers provide definitive trauma care and coordinate the efforts of their surrounding trauma systems. Most Canadians (77.5%) reside within 1-hour road travel catchments of Level I or Level II centers. However, marked geographic disparities in access persist. Of the 22.5% of Canadians who live more than an hour away from a Level I or Level II trauma centers, all are in rural and remote regions. DISCUSSION: Access to high quality acute trauma care is well established across parts of Canada but a clear urban/rural divide persists. Regional efforts to improve short- and long-term outcomes after severe trauma should focus on the optimization of access to pre-hospital care and acute trauma care in rural communities using locally relevant strategies or novel care delivery options.

Population-based analysis of the effect of a comprehensive, systematic change in an emergency medical services resource allocation plan on 24-hour mortality.

BACKGROUND: Resource allocation planning for emergency medical services (EMS) systems determines appropriate resources including what paramedic qualification and how rapidly to respond to patients for optimal outcomes. The British Columbia Emergency Health Services implemented a revised response plan in 2013. METHODS: A pre- and post-methodology was used to evaluate the effect of the resource allocation plan revision on 24-hour mortality. All adult cases with evaluable outcome data (obtained through linked provincial health administrative data) were analyzed. Multivariable logistic regression was used to adjust for variations in other significant associated factors. Interrupted time series analysis was used to estimate immediate changes in level or trend of outcome after the start of the revised resource allocation plan implementation, while simultaneously controlling for pre-existing trends. RESULTS: The derived cohort comprised 562,546 cases (April 2012-March 2015). When adjusted for age, sex, urban/metro region, season, day, hour, and dispatch determinant, the probability of dying within 24 hours of an EMS call was 7% lower in the post-resource allocation plan-revision cohort (OR = 0.936; 95% CI: 0.886-0.989; p = 0.018). A subgroup analysis of immediately life-threatening cases demonstrated similar effect (OR = 0.890; 95% CI: 0.808-0.981; p = 0.019). Using time series analysis, the descending changes in overall 24-hour mortality trend and the 24-hour mortality trend in immediately life-threatening cases, were both statistically significant (p < 0.001). CONCLUSION: Comprehensive, evidence-informed reconstruction of a provincial EMS resource allocation plan is feasible. Despite change in crew level response and resource allocation, there was significant decrease in 24-hour mortality in this pan-provincial population-based cohort.

Tranexamic acid administration in the field does not affect admission thromboelastography after traumatic brain injury.

BACKGROUND: No Food and Drug Administration-approved medication improves outcomes following traumatic brain injury (TBI). A forthcoming clinical trial that evaluated the effects of two prehospital tranexamic acid (TXA) dosing strategies compared with placebo demonstrated no differences in thromboelastography (TEG) values. We proposed to explore the impact of TXA on markers of coagulation and fibrinolysis in patients with moderate to severe TBI. METHODS: Data were extracted from a placebo-controlled clinical trial in which patients 15 years or older with TBI (Glasgow Coma Scale, 3-12) and systolic blood pressure of ≥90 mm Hg were randomized prehospital to receive placebo bolus/placebo infusion (placebo), 1 g of TXA bolus/1 g of TXA infusion (bolus maintenance), or 2 g of TXA bolus/placebo infusion (bolus only). Thromboelastography was performed, and coagulation measures including prothrombin time, activated partial thromboplastin time, international ratio, fibrinogen, D-dimer, plasmin-antiplasmin (PAP), thrombin antithrombin, tissue plasminogen activator, and plasminogen activator inhibitor 1 were quantified at admission and 6 hours later. RESULTS: Of 966 patients receiving study drug, 700 had laboratory tests drawn at admission and 6 hours later. There were no statistically significant differences in TEG values, including LY30, between groups (p > 0.05). No differences between prothrombin time, activated partial thromboplastin time, international ratio, fibrinogen, thrombin antithrombin, tissue plasminogen activator, and plasminogen activator inhibitor 1 were demonstrated across treatment groups. Concentrations of D-dimer in TXA treatment groups were less than placebo at 6 hours (p < 0.001). Concentrations of PAP in TXA treatment groups were less than placebo on admission (p < 0.001) and 6 hours (p = 0.02). No differences in D-dimer and PAP were observed between bolus maintenance and bolus only. CONCLUSION: While D-dimer and PAP levels reflect a lower degree of fibrinolysis following prehospital administration of TXA when compared with placebo in a large prehospital trial of patients with TBI, TEG obtained on admission and 6 hours later did not demonstrate any differences in fibrinolysis between the two TXA dosing regimens and placebo. LEVEL OF EVIDENCE: Diagnostic test, level III.

The epidemiology of surgically treated acute subdural and epidural hematomas in patients with head injuries: a population-based study.

BACKGROUND: The purpose of this paper is to review the population-based epidemiology of surgically treated post-traumatic epidural hematomas (EDHs) and/or subdural hematomas (SDHs) among patients who presented to the single neurosurgical centre in Nova Scotia. METHODS: We included all patients aged 16 years or older who presented to the tertiary care hospital with acute post-traumatic EDHs and/or SDHs between May 23, 1996, and May 22, 2005, and who were surgically treated. We generated an initial cohort from the provincial trauma registry and reviewed a total of 152 charts for possible inclusion; 70 (46%) patients met the study criteria. We performed a blinded, explicit chart review using a standardized data collection form, and we generated descriptive statistics. RESULTS: Of the patients who had surgery, 34 (49%) presented with SDHs, 23 (33%) presented with EDHs and 13 (19%) presented with both conditions. The median age was 45 years, and 80% of the cohort was male. The major mechanisms of injury were falls (51%), motor vehicle collisions (30%) and assault (11%). More than half (61%) of patients were transferred from referring hospitals while the remainder (39%) arrived directly without an intermediate facility. There were 18 postoperative deaths (26%). Forty-four of 70 patients (63%) had associated good outcomes at 6 months (Glasgow Outcome Scale). CONCLUSION: Acute post-traumatic EDHs and/or SDHs are relatively rare (0.83/100,000 population per annum) and are generally associated with good outcomes. Death was more likely among older, more severely injured patients and among those who required surgery for SDH rather than EDH.

Retrospective analysis of alcohol testing in trauma team activation patients at a Canadian tertiary trauma centre.

OBJECTIVES: Although alcohol screening is an essential requirement of level I trauma centre accreditation, actual rates of compliance with mandatory alcohol testing in trauma patients are seldom reported. Our objective was to determine the prevalence of blood alcohol concentration (BAC) testing in patients requiring trauma team activation (TTA) for whom blood alcohol testing was mandatory, and to elucidate patient-level, injury-level and system-level factors associated with BAC testing. DESIGN: Retrospective cohort study. SETTING: Tertiary trauma centre in Halifax, Canada. PARTICIPANTS: 2306 trauma patients who required activation of the trauma team. PRIMARY OUTCOME MEASURE: The primary outcome was the rate of BAC testing among TTA patients. Trends in BAC testing over time and across patient and injury characteristics were described. Multivariable logistic regression examined patient-level, injury-level and system-level factors associated with testing. RESULTS: Overall, 61% of TTA patients received BAC testing despite existence of a mandatory testing protocol. Rates of BAC testing rose steadily over the study period from 33% in 2000 to 85% in 2010. Testing varied considerably across patient-level, injury-level and system-level characteristics. Key factors associated with testing were male gender, younger age, lower Injury Severity Score, scene Glasgow Coma Scale score <9, direct transport to hospital and presentation between midnight and 09:00 hours, or on the weekend. CONCLUSIONS: At this tertiary trauma centre with a policy of empirical alcohol testing for TTA patients, BAC testing rates varied significantly over the 11-year study period and distinct factors were associated with alcohol testing in TTA patients.

Trauma management outcomes associated with nonsurgeon versus surgeon trauma team leaders.

STUDY OBJECTIVE: We compare the effectiveness of surgeon and nonsurgeon trauma team leaders. METHODS: This retrospective study was conducted using data from a Canadian trauma registry database. Data from April 1, 1998, to March 31, 2005, from blunt and penetrating trauma patients aged 16 years or older and with trauma team activation (and without major burns) were included. Patient age, sex, trauma team leader (surgeon or nonsurgeon), mechanism of injury, Injury Severity Score, survival to 3 hours and to discharge, length of stay in the hospital, and Trauma and Injury Severity Score (TRISS) z scores were tabulated. RESULTS: Data from 807 patients were included. Because of the limited number of penetrating trauma cases, analyses focused on blunt trauma. Surgeon and nonsurgeon trauma team leader groups did not differ on injury severity, age, or sex. No difference was noted in survival to discharge (nonsurgeon 84.8%-surgeon 81.8%=3%; 95% confidence interval [CI] -3.5% to 9.5%), survival to 3 hours (nonsurgeon 96.8%-surgeon 96%=0.8%; 95% CI -2.2% to 3.8%), length of stay (median 13 days for nonsurgeon and 12 days for surgeon groups), or difference between actual and predicted survival (TRISS z scores nonsurgeon 0.64; surgeon 0.99). No trend toward group differences on any outcome variable was observed in penetrating trauma cases. CONCLUSION: No differences were found in the outcome of trauma patients treated by nonsurgeon versus surgeon trauma team leaders. These findings support a more collaborative approach to resuscitative trauma management with involvement of nonsurgeons as trauma team leaders.

Airway management in penetrating neck trauma at a Canadian tertiary trauma centre.

OBJECTIVES: The optimal approach to airway management in penetrating neck injuries (PNIs) remains controversial. The primary objective of this study was to review the method of endotracheal intubation in PNI at a Canadian tertiary trauma centre. Secondarily, we sought to determine the incidence of PNI in our trauma population and to describe the epidemiologic elements of this population. METHODS: We conducted a review of patients with PNIs who were enrolled in the Nova Scotia Trauma Registry database. We included all penetrating injuries of the neck in patients > or = 16 years of age from April 1, 1994 to March 31 2005 with an Injury severity Score (ISS) > or = 9 or who underwent Trauma Team activation at our Tertiary Trauma Centre (regardless of ISS) and/or who were identified upon admission as a "major" trauma case. The variables of interest were patient age and sex, injury mechanism, injury location, place of intubation and method of intubation. RESULTS: There were 19 people who met inclusion criteria and they were enrolled in our study. The injury mechanisms involved knife (n = 13) or gunshot (n = 5) wounds (one patient's injuries were categorized as "other"). Three patients (15.8%) were not intubated. The remaining 16 patients were intubated during prehospital care (n = 5), in the emergency department (n = 6) or in the operating room (n = 5). Of these, 8 patients (42.1%) underwent awake intubation and 8 (42.1%) underwent rapid sequence intubation. CONCLUSION: There is clear variability of airway management in PNI. We believe that such patients represent a heterogeneous group where the attending physician must have a conservative yet varied approach to airway management based on the individual clinical scenario.