Are geriatric transfer patients with traumatic brain injury at risk for worse outcomes compared to non-geriatric? Propensity-matched study.

OBJECTIVE: To compare outcomes between geriatric and non-geriatric patients with traumatic brain injury (TBI) transferred to trauma center and effects of anticoagulants/antiplatelets (AC/AP) and reversal therapy. METHODS: A retrospective review of 1,118 patients with TBI transferred from acute care facilities to level 1 trauma center compared in groups: geriatric versus non-geriatric, geriatric with AC/AP therapy versus without, and geriatric AC/AP with AC/AP reversal therapy versus without. RESULTS: Patients with TBI constituted 54.4% of trauma transfers. Mean transfer time was 3.9 h. Propensity matched by Injury Severity Score and Abbreviated Injury Score (AIS) head geriatric compared to non-geriatric patients had more AC/AP use (53.9% vs 8.8%), repeat head computed tomography (93.7% vs 86.1%), intensive care unit (ICU) admissions (57.4% vs 45.7%) and mortality (9.8% vs 3.2%), all p < 0.004. Patients on AC/AP versus without had more ICU admissions (69.1% vs 51.8%, p < 0.001). Patients with AC/AP reversals compared to without reversals had more AIS head 5 (32.0% vs 13.1%), brain surgeries (17.8% vs 3.5%) and ICU admissions (84.8% vs 57.1%), all p < 0.001. CONCLUSION: TBI constituted half of trauma transfers and 10% required surgery. Based on higher ICU admissions, mortality, and prevalence of AC/AP therapy requiring reversal, geriatric patients with TBI on anticoagulants/antiplatelets should be considered for direct trauma center admission.

Computed tomography pulmonary angiography (CTPA) for the detection of pulmonary embolism (PE) among trauma patients: a systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: Computed tomography pulmonary angiography (CTPA) is a standard imaging technique employed for the detection of pulmonary embolism (PE). This systematic review and meta-analysis aims to examine the prevalence of PE among the trauma patients undergoing CTPA. METHODS: A comprehensive search across PubMed, Scopus, Google Scholar, and Web of Science yielded 13 studies encompassing 5,570 individuals conducted following Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline. Studies that used CTPA for the detection of PE among the trauma patients were selected. This resulted in an evaluation of prevalence, trauma types, clinical manifestations, radiological findings, and mortality rates of PE among traumatic patients undergoing CTPA. RESULTS: The overall prevalence of PE among trauma patients undergoing CTPA was 18% (95% CI = 13-24%). After pooling the existing data, femur fractures were determined to be the most prevalent trauma type (12%). The most prevalent clinical manifestations of PE among trauma patients included shortness of breath, chest pain, and altered vital signs. Radiological findings encompassed various pulmonary abnormalities, such as opacity, ground-glass opacities, and pleural effusions. Mortality rates of PE among the trauma patients ranged from 0% to 29.4% across the included studies. CONCLUSION: This study provides comprehensive insights into the prevalence, clinical manifestations, radiological findings and mortality of PE among trauma patients undergoing CTPA. According to our findings, lower threshold for CTPA is recommended in patients with lower extremity or spine fractures.

Researching how music affects the autonomic nervous system and influences wound healing processes in trauma patients.

An area of increasing interest continues to be the interaction between music therapy and its impacts on the autonomic nervous system (ANS) and wound repair in patients who have experienced trauma. This study intended to quantify the effect of music therapy on ANS regulation and wound healing. A cross-sectional observational study from March to December 2023 was undertaken involving 500 trauma patients. A control group received standard care, and an experimental group received daily 30-min music therapy sessions. Heart rate variability (HRV), cortisol levels, wound healing rates and patient-reported outcomes regarding pain, tension and well-being were among the critical parameters assessed. After 1 month, the experimental group exhibited a statistically significant rise in HRV (p < 0.05), suggesting increased parasympathetic activity. The experimental group exhibited a significant decrease in cortisol levels in comparison to the control group, with notable reduction observed after 1 month (p < 0.05). At 9 months, the experimental group exhibited significantly faster wound healing than the control group, with 85% wound recovery as opposed to 75% in control group. There was notable decrease in pain and stress scores at all time intervals in the music therapy group, with the greatest reduction occurring at the 9-month mark (p < 0.05). A significant positive correlation (p < 0.05) was identified between the number of completed music therapy sessions and patient outcomes, with individuals attending more than 20 sessions experiencing 33.6% positive outcomes. In trauma patients, music therapy substantially enhanced ANS regulation and accelerated wound healing. As evidenced by the elevated HRV and decreased cortisol levels, the therapy induced a physiologically tranquil state that is conducive to recovery. The considerable enhancements in the rates of wound healing, in conjunction with the substantial decreases in pain and tension levels, highlighted the therapeutic capacity of music therapy as intervention in trauma care. Additionally, the observed dose-response relationship indicated that customised music therapy regimens are crucial for achieving the best possible results for patients.

Observed differences in nutrition management at two time points spanning a decade in critically ill trauma patients with and without head injury.

BACKGROUND: Nutritional needs of trauma patients admitted to the intensive care unit may differ from general critically ill patients, but most current evidence is based on large clinical trials recruiting mixed populations. OBJECTIVE: The aim of the study was to investigate nutrition practices at two time points that span a decade in trauma patients with and without head injury. METHODS: This observational study recruited adult trauma patients receiving mechanical ventilation and artificial nutrition from a single-centre intensive care unit between February 2005 to December 2006 (cohort 1), and December 2018 to September 2020 (cohort 2). Patients were categorised into head injury and non-head injury subgroups. Data regarding energy and protein prescription and delivery were collected. Data are presented as median [interquartile range]. Wilcoxon rank-sum test assessed the differences between cohorts and subgroups, with a P value ≤ 0.05. The protocol was registered with the Australian and New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001816246). RESULTS: Cohort 1 included 109 patients, and 112 patients were included in cohort 2 (age: 46 ± 19 vs 50 ± 19 y; 80 vs 79% M). Overall, nutrition practice did not differ between head-injured and non-head-injured subgroups (all P > 0.05). Energy prescription and delivery decreased from time point one to time point two, regardless of subgroup (Prescription: 9824 [8820-10 581] vs 8318 [7694-9071] kJ; Delivery: 6138 [5130-7188] vs 4715 [3059-5996] kJ; all P < 0.05). Protein prescription did not change from time point one to time point two. Although protein delivery remained constant from time point one to time point two in the head injury group, protein delivery reduced in the non-head injury subgroup (70 [56-82] vs 45 [26-64] g/d, P < 0.05). CONCLUSION: In this single-centre study, energy prescription and delivery in critically ill trauma patients reduced from time point one to time point two. Protein prescription did not change, but protein delivery reduced from time point one to time point two in non-head injury patients. Reasons for these differing trajectories require exploration. STUDY REGISTRATION: Trial registered at www.anzctr.org.au. TRIAL ID: ACTRN12618001816246.

Are the non-weight bearing guidelines for the after treatment of calcaneal fractures still decisive? A Dutch survey among orthopaedic and trauma surgeons.

PURPOSE: The current rehabilitation for patients with surgically treated displaced intra-articular calcaneal fractures (DIACFs) consists of non-weightbearing for 8-12 weeks. The purpose of the present survey was to investigate the current pre-, peri- and post-operative practices among Dutch foot and ankle surgeons. Moreover, it aims to analyze whether surgeons comply to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) guidelines and which decision criteria were used in the determination of the start of weightbearing. METHODS: A survey was distributed among Dutch trauma and orthopaedic surgeons to determine the most common practices in postoperative weightbearing in patients with DIACFs. RESULTS: 75 surgeons responded to the survey. 33% of the respondents adhered to the AO guidelines. 4% of the respondents strictly followed non-weightbearing guidelines, while 96% interpret the AO guidelines or their local protocol freely, in any frequency. When respondents tended to deviate from the AO guidelines or local protocol, a good patients' compliance to therapy was expected. 83% of the respondents started weightbearing on the fracture, based on reported patient complaints. 87% of the respondents did not see any relation between early weightbearing and the occurrence of complications, including loosening of osteosynthesis materials. CONCLUSION: This study demonstrates that there is limited consensus on the rehabilitation for DIACFs. Moreover, it shows that most surgeons are inclined to interpret the current (AO) guideline or their own local protocol freely. New guidelines, supported with well-founded literature, could help surgeons in a more appropriate daily practice in weightbearing for the rehabilitation of calcaneal fractures.

Effectiveness of permissive weight bearing in surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities: a prospective comparative multicenter cohort study.

PURPOSE: The aim of the present study was to investigate the effectiveness of a novel approach involving permissive weight bearing (PWB) in surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities. METHODS: Prospective comparative multicenter cohort study in one level 1 trauma center and five level 2 trauma centers. Surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities were included. Permissive weight bearing (PWB) in comparison to restricted weight bearing (RWB) was assessed over a 26-week post-surgery follow-up period. Patients' self-perceived outcome levels regarding activities of daily living (ADL), quality of life (QoL), pain and weight bearing compliance were used. RESULTS: This study included 106 trauma patients (N = 53 in both the PWB and RWB groups). Significantly better ADL and QoL were found in the PWB group compared to the RWB group at 2-, 6-, 12- and 26-weeks post-surgery. There were no significant differences in postoperative complication rates between the PWB and RWB groups. CONCLUSION: PWB is effective and is associated with a significantly reduced time to full weight bearing, and a significantly better outcome regarding ADL and QoL compared to patients who followed RWB regimen. Moreover, no significant differences in complication rates were found between the PWB and RWB groups. LEVEL OF EVIDENCE: Level II. REGISTRATION: This study is registered in the Dutch Trial Register (NTR6077). Date of registration: 01-09-2016.

Elevation of neutrophil-derived factors in patients after multiple trauma.

Trauma represents one of the leading causes of death worldwide. Traumatic injuries elicit a dynamic inflammatory response with systemic release of inflammatory cytokines. Disbalance of this response can lead to systemic inflammatory response syndrome or compensatory anti-inflammatory response syndrome. As neutrophils play a major role in innate immune defence and are crucial in the injury-induced immunological response, we aimed to investigate systemic neutrophil-derived immunomodulators in trauma patients. Therefore, serum levels of neutrophil elastase (NE), myeloperoxidase (MPO) and citrullinated histone H3 (CitH3) were quantified in patients with injury severity scores above 15. Additionally, leukocyte, platelet, fibrinogen and CRP levels were assessed. Lastly, we analysed the association of neutrophil-derived factors with clinical severity scoring systems. Although the release of MPO, NE and CitH3 was not predictive of mortality, we found a remarkable increase in MPO and NE in trauma patients as compared with healthy controls. We also found significantly increased levels of MPO and NE on Days 1 and 5 after initial trauma in critically injured patients. Taken together, our data suggest a role for neutrophil activation in trauma. Targeting exacerbated neutrophil activation might represent a new therapeutic option for critically injured patients.

Effective use of the hybrid emergency Department system in the treatment of non-traumatic critical care diseases.

BACKGROUND: The hybrid emergency room (ER) system can provide resuscitation, computed tomography imaging, endovascular treatment, and emergency surgery, without transferring the patient. However, although several reports have demonstrated the effectiveness of the hybrid ER for trauma conditions, only a few case reports have demonstrated its usefulness for non-traumatic critical diseases. In this observational cohort study, we aimed to identify endogenous diseases that may benefit from treatment in the hybrid ER. METHODS: We retrospectively reviewed the clinical characteristics of patients with non-traumatic conditions treated in a hybrid ER between August 2017 and July 2022 at our institution. Patients who underwent surgery, endoscopy, or interventional radiology (IR) in the hybrid ER were selected and pathophysiologically divided into a bleeding and non-bleeding group. The rate of shock or cardiac arrest, blood transfusion, and death within 24 h of admission or in-hospital death were compared among the groups using Fisher's exact test. Multivariable logistic regression analysis was performed to confirm the relationships among in-hospital mortality, transfusion, and hemorrhagic conditions in patients who underwent endoscopy and IR. RESULTS: Among the 726 patients with non-traumatic conditions treated in a hybrid ER system, 50 (6.9%) experienced cardiac arrest at or before admission to the hybrid ER, 301 (41.5%) were in shock, 126 (17.4%) received blood transfusions, 42 (5.8%) died within 24 h of admission to the hybrid ER, and 141 (19.4%) died in the hospital. Emergency surgery was performed in 39 patients (7 in the bleeding group and 32 in the non-bleeding group). Significantly more blood transfusions were administered in the bleeding group (71.4% vs. 18.8%, P = 0.01); there were no significant differences in the rate of shock or cardiac arrest, death within 24 h, or in-hospital death between groups. Endoscopy was performed in 122 patients (80 in the bleeding group and 42 in the non-bleeding group). The bleeding group had a significantly higher rate of shock or cardiac arrest (87.5% vs. 66.7%, P = 0.008) and rate of blood transfusion (62.5% vs. 4.8%, P < 0.0001); there was no significant difference in death within 24 h and in-hospital death between groups. IR was performed in 100 patients (68 in the bleeding group and 32 in the non-bleeding group). Significantly more blood transfusions were administered in the hemorrhage group (67.7% vs. 12.5%, P < 0.0001); there was no difference in the rate of shock or cardiac arrest, death within 24 h, or in-hospital death between groups. Multivariable analysis in patients who underwent endoscopy showed a trend toward more in-hospital deaths in non-hemorrhagic conditions than in hemorrhagic conditions (odds ratio = 3.8, 95% confidence interval: 0.88-17, P = 0.073); however, no significant relationship with in-hospital death was observed for any of the adjusted variables. CONCLUSION: Among endogenous diseases treated in the hybrid ER, there is a possible association between in-hospital mortality and hemorrhagic conditions. Future studies are needed to focus on diseases to demonstrate the effectiveness of the hybrid ER.

Expecting the unexpected: incidental findings at a level 1 trauma center.

INTRODUCTION: Incidental findings on comprehensive imaging in the adult trauma population occur at rates as high as 54.8%. We sought to determine the incidence of potentially malignant or pre-malignant incidental findings in a high-volume level 1 trauma center and to evaluate follow-up recommendations. METHODS: This was a retrospective review of all patients with incidental findings on imaging who were admitted to the trauma service at our level 1 trauma center between January 1st, 2014, and October 1st, 2019. A multi-disciplinary team characterized findings as potentially malignant or pre-malignant. RESULTS: The study included 495 patients who had incidental findings, 410 of whom had potentially malignant or pre-malignant findings on imaging, resulting in a cumulative incidence of 6.6%. The mean age was 65 and 217 (52.9%) patients were male. The majority of "incidentalomas" were discovered on CT imaging (n=665, 98.1%); over half were solid (n=349, 51.5%), while 27.4% were cystic (n=186) in nature. The lungs (n=199, 29.4%), kidneys (n=154, 22.8%), liver (n=74, 10.9%), thyroid gland (n=58, 8.6%), and adrenal glands (n=53, 7.8%) harbored the most incidentalomas. Less than half of patients with incidental findings received specific follow-up recommendations on the radiologist's report (n=150, 39%). Sixty-one percent of patients (n=250) had their incidentalomas detailed in the discharge paperwork. CONCLUSION: The results of our study suggest that potentially malignant or pre-malignant incidental findings are common among trauma patients. Specific follow-up recommendations were not presented in 61% of the radiology reports, highlighting the need to standardize medical record capture of an incidentaloma to ensure adequate and appropriate follow-up.

Assessment of adequacy and appropriateness of pain management practice among trauma patients at the Ethiopian Aabet Hospital: A prospective observational study.

INTRODUCTION: Pain is unpleasant sensory and emotional experiences associated with actual and/or potential tissue damage. It is the most common and prevalent reason for emergency departments (ED) visits with prevalence over 70% in the world. AIM OF THE STUDY: The study aimed to assess the adequacy and appropriateness of pain management at Aabet Hospital, Addis Ababa, Ethiopia. METHODS: A hospital-based prospective cross-sectional study was conducted at Aabet hospital from December 1, 2020 to March 30, 2021. Adult trauma patients having pain (at least score 1 on Numeric Rating Scale) with Glasgow Coma Scale score > 13 were eligible to participate in the study. The pain intensity was evaluated at the time of admission (o minute) and then at 60, 120, 180, and 240 minutes. The time of the first analgesics was registered. The adequacy and the appropriateness of the pain management were calculated through pain management index (PMI). RESULTS: Two hundred thirty-two (232) participants were included in this study of which 126 (54.3%) were admitted due to road traffic accident followed by fall 44(19%). Only 21 (9.1%) study participants received the first analgesic treatment within 30 minutes while 27(11.6%) participants had no treatment at all within 240 minutes. The mean pain intensity score at admission was 5.55 ± 2.32 and reduced to 4.09 ± 2.69. Nearly half 110 (47.4%) of the study participants were treated inadequately (PMI (-) score). There was a weak and negative correlation between PMI and time to analgesia (r = - .159, p = 0.0001). The type of analgesia used, the time to analgesia, and the degree of pain may predict 65% of the variance in PMI score (R2 = 0.65, P = .001). CONCLUSION: From the results of this study, it can be concluded that acute pain in trauma patients was under and inappropriately treated.

A recalibrated prediction model can identify level-1 trauma patients at risk of nosocomial pneumonia.

INTRODUCTION: Nosocomial pneumonia has poor prognosis in hospitalized trauma patients. Croce et al. published a model to predict post-traumatic ventilator-associated pneumonia, which achieved high discrimination and reasonable sensitivity. We aimed to externally validate Croce's model to predict nosocomial pneumonia in patients admitted to a Dutch level-1 trauma center. MATERIALS AND METHODS: This retrospective study included all trauma patients (≥ 16y) admitted for > 24 h to our level-1 trauma center in 2017. Exclusion criteria were pneumonia or antibiotic treatment upon hospital admission, treatment elsewhere > 24 h, or death < 48 h. Croce's model used eight clinical variables-on trauma severity and treatment, available in the emergency department-to predict nosocomial pneumonia risk. The model's predictive performance was assessed through discrimination and calibration before and after re-estimating the model's coefficients. In sensitivity analysis, the model was updated using Ridge regression. RESULTS: 809 Patients were included (median age 51y, 67% male, 97% blunt trauma), of whom 86 (11%) developed nosocomial pneumonia. Pneumonia patients were older, more severely injured, and underwent more emergent interventions. Croce's model showed good discrimination (AUC 0.83, 95% CI 0.79-0.87), yet predicted probabilities were too low (mean predicted risk 6.4%), and calibration was suboptimal (calibration slope 0.63). After full model recalibration, discrimination (AUC 0.84, 95% CI 0.80-0.88) and calibration improved. Adding age to the model increased the AUC to 0.87 (95% CI 0.84-0.91). Prediction parameters were similar after the models were updated using Ridge regression. CONCLUSION: The externally validated and intercept-recalibrated models show good discrimination and have the potential to predict nosocomial pneumonia. At this time, clinicians could apply these models to identify high-risk patients, increase patient monitoring, and initiate preventative measures. Recalibration of Croce's model improved the predictive performance (discrimination and calibration). The recalibrated model provides a further basis for nosocomial pneumonia prediction in level-1 trauma patients. Several models are accessible via an online tool. LEVEL OF EVIDENCE: Level III, Prognostic/Epidemiological Study.

The Association Between Early Versus Late Physical Therapy Initiation and Outcomes of Trauma Patients With and Without Traumatic Brain Injuries.

BACKGROUND: There is a lack of literature regarding the most effective timing to initiate physical therapy (PT) among traumatically injured patients. We aim to evaluate the association between early PT/mobilization versus delayed or late PT/mobilization and clinical outcomes of trauma patients. METHODS: A retrospective cohort analysis of an urban level-I trauma center from 2014 to 2019 was performed. Univariate analyses and multivariable logistic regression were performed with significance defined as P < 0.05. RESULTS: A total of 11,937 patients were analyzed. Among patients without a traumatic brain injury (TBI), late PT initiation times were associated with 60% lower odds of being discharged home without services (P < 0.05), significantly increased hospital and ICU length of stay (H-LOS, ICU-LOS) (P < 0.05), and significantly higher odds of complications (VTE, pneumonia, pressure ulcers, ARDS) (P < 0.001). Among patients with a TBI, late PT initiation time had 76% lower odds of being discharged home without services (P < 0.05) and significantly longer H-LOS and ICU-LOS (P < 0.05) however did not experience significantly higher odds of complications (P > 0.05). CONCLUSIONS: Among traumatically injured patients, early PT is associated with decreased odds of complications, shorter H-LOS and ICU-LOS, and a favorable discharge disposition to home without services. Adoption of early PT initiation/mobilization protocols and establishment of prophylactic measures against complications associated with delayed PT is critical to maximize quality of care and trauma patient outcomes. Multi-center prospective studies are needed to ascertain the impact of PT initiation times in greater detail and to minimize trauma patient morbidity.

Defining Risk and Risk Factors for Unplanned ICU Admission of Trauma Patients.

BACKGROUND: Unplanned ICU admissions (up-ICUad) are associated with poor outcomes. It is difficult to identify who is at risk for up-ICUad in trauma patients. This study aimed to identify injury patterns and comorbidities associated with up-ICUad and develop a predictive tool for who is at risk. METHODS: A retrospective study compared trauma patients admitted to the floor who experienced an up-ICUad to similar patients without an up-ICUad. Univariate analysis and multivariate logistic regression identified independent risk factors associated with up-ICUad. Based on those factors, a Risk Score (RS) was created and compared between the two groups. RESULTS: 2.15% of the 7206 patients experienced an up-ICUad. The up-ICUad group was older, experienced longer length of stay, and had higher mortality. Age, congestive heart failure, COPD, peptic ulcer disease, mild liver disease, CKD, and significant injuries to the thorax, spine, and lower extremities were independently associated with up-ICUad. A RS equation was created and was used for each patient. CONCLUSIONS: Trauma patients are at increased risk for up-ICUad based on specific factors. These factors can be used to calculate a RS to determine who is at greatest risk for an up-ICUad which may be helpful for preventing up-ICUad.

Dynamic Bayesian network for predicting physiological changes, organ dysfunctions and mortality risk in critical trauma patients.

BACKGROUND: Critical trauma patients are particularly prone to increased mortality risk; hence, an accurate prediction of their conditions enables early identification of patients' mortality status. Thus, we aimed to develop and validate a real-time prediction model for physiological changes, organ dysfunctions and mortality risk in critical trauma patients. METHODS: We used Dynamic Bayesian Networks (DBNs) to model complicated relationships of physiological variables across time slices, accessing data of trauma patients from the Medical Information Mart for Intensive Care database (MIMIC-III) (n = 2915) and validated with patients' data from ICU admissions at the Changhai Hospital (ICU-CH) (n = 1909). The DBN model's evaluation included the predictive ability of physiological changes, organ dysfunctions and mortality risk. RESULTS: Our DBN model included two static variables (age and sex) and 18 dynamic physiological variables. The differences in ratios between the real values and the 24- and 48-h predicted values of most physiological variables were within 5% in the two datasets. The accuracy of our DBN model for predicting renal, hepatic, cardiovascular and hematologic dysfunctions was more than 0.8.The calculated area under the curve (AUC) from receiver operating characteristic curves and 95% confidence interval for predicting the 24- and 48-h mortality risk were 0.977 (0.967-0.988) and 0.958 (0.945-0.971) in the MIMIC-III and 0.967 (0.947-0.987) and 0.946 (0.925-0.967) in ICU-CH. CONCLUSIONS: A DBN is a promising method for predicting medical temporal data such as trauma patients' mortality risk, demonstrated by high AUC scores and validation by a real-life ICU scenario; thus, our DBN prediction model can be used as a real-time tool to predict physiological changes, organ dysfunctions and mortality risk during ICU admissions.

Predictive value of qSOFA score for death in emergency department resuscitation room among adult trauma patients:a retrospective study.

BACKGROUND: To explore the predictive value of the quick Sequential Organ Failure Assessment (qSOFA) score for death in the emergency department (ED) resuscitation room among adult trauma patients. METHODS: During the period November 1, 2016 to November 30, 2019, data was retrospectively collected of adult trauma patients triaged to the ED resuscitation room in the First Affiliated Hospital of Soochow University. Death occurring in the ED resuscitation room was the study endpoint. Univariate and multivariate analyses were performed to explore the association between qSOFA score and death. Receiver operating characteristic (ROC) curve analysis was also performed for death. RESULTS: A total of 1739 trauma victims were admitted, including 1695 survivors and 44 non-survivors. The death proportion raised with qSOFA score: 0.60% for qSOFA = 0, 3.28% for qSOFA = 1, 12.06% for qSOFA = 2, and 15.38% for qSOFA = 3, p < 0.001. Subgroup of qSOFA = 0 was used as a reference. In univariate analysis, crude OR for death with qSOFA = 1 was 5.65 [95% CI 2.25 to 14.24, p < 0.001], qSOFA = 2 was 22.85 [95% CI 8.84 to 59.04, p < 0.001], and qSOFA = 3 was 30.30 [95% CI 5.50 to 167.05, p < 0.001]. In multivariate analysis, with an adjusted OR (aOR) of 2.87 (95% CI 0.84 to 9.87, p = 0.094) for qSOFA = 1, aOR 6.80 (95% CI 1.79 to 25.90, p = 0.005) for qSOFA = 2, and aOR 24.42 (95% CI 3.67 to 162.27, p = 0.001) for qSOFA = 3. The Area Under the Curve (AUC) for predicting death in the ED resuscitation room among trauma patients was 0.78 [95% CI, 0.72-0.85]. CONCLUSIONS: The qSOFA score can assess the severity of emergency trauma patients and has good predictive value for death in the ED resuscitation room.

Impact of a New Helicopter Base on Transport Time and Survival in a Rural Adult Trauma Population.

BACKGROUND: Significant disparities in access to prompt helicopter transport exist among rural trauma populations. We evaluated the impact of an additional helicopter base on transport time and mortality in a rural adult trauma population. MATERIALS AND METHODS: We performed a retrospective cohort study of adult patients with trauma transported by helicopter from scene to a level one trauma center between 2014 and 2018. A new rural helicopter base added to the trauma center's catchment area in 2016 served as the transition time for an interrupted time series analysis. Patients injured in this base's county and adjoining counties were analyzed. Baseline characteristics were compared with a Student's t-test and Pearson's chi-squared test. Cox and linear regression models evaluated the new base's effect on mortality and transport time, respectively. RESULTS: A total of 332 patients were analyzed: 120 (36.1%) transported before the addition of the new helicopter base and 212 (63.9%) transported after. Patients transported after the addition of the base had higher injury severity score (13.7 versus 10.1, P < 0.001) and were more likely to receive blood en route (19.3% versus 6.7%, P = 0.005). After the addition of the base, there was a decreased hazard ratio for mortality (hazard ratio 0.26, 95% confidence interval: 0.11-0.65, P = 0.004) with no significant change in transport time (-36.7 min, P = 0.071) for the area. CONCLUSIONS: Local helicopter transport units may confer improved survival for the injured patient. This study demonstrates the important role of helicopter transport within a regional trauma system and the impact that expanded access to rapid air transport can have on mortality.

Prevalence of serious injuries in low risk trauma patients.

OBJECTIVES: Computed tomography (CT) utilization is widespread in contemporary Emergency Departments (EDs). CT overuse leads to radiation exposure, contrast toxicity, overdiagnosis, and incidental findings. This study explores the prevalence of clinically significant injuries in patients identified as low-risk trauma patients (LRTPs) using newly created criteria that account for the patient's age, trauma mechanism, assessability (which relies on level of consciousness, intoxication, and neurologic deficits), vital signs and other evidence of hypoperfusion, bleeding risk, and past medical history. METHODS: This was a 6-month retrospective chart review of all LRTPs presenting to a level 1 trauma center in Queens, New York. Data abstraction was performed independently by two abstractors and discrepancies adjudicated by the senior author. Patients were identified using the hospital trauma registry and two reports, created by the researchers, identifying selected chief complaints and discharge diagnoses. RESULTS: 750 patients were identified of which 352 (46.93%) received one or more CT scans. There were a total of 790 CT scans ordered, of which 731 (92.53%) were negative for acute injury. There were 13 clinically significant injuries of which only one (0.13%) required immediate intervention. There were no mortalities in this LRTP group. CONCLUSION: The prevalence of clinically significant injuries in this population is very low and injuries requiring immediate intervention are even lower. CT utilization in LRTPs should be guided by an explicit consideration of benefit and harm for each patient.

Thoracic computerised tomography scans in one hundred eighteen orthopaedic patients during the COVID-19 pandemic: identification of chest lesions; added values; help in managing patients; burden on the computerised tomography scan department.

PURPOSE: Based on the recent literature, chest computed tomography (CT) examination could aid for management of patients during COVID-19 pandemic. However, the role of chest CT in management of COVID-19 patients is not exactly the same for medical or surgical specialties. In orthopaedic or trauma emergency, abdomen, pelvis, cervical, dorsal, and lumbar spine CT are performed to investigate patients; the result is a thoracic CT scan incorporating usually the thorax; however, information about lung parenchyma can be obtained on this thorax CT, and manifestations of COVID-19 can be diagnosed. The objective of our study was to evaluate this role in orthopedic patients to familiarize orthopaedists with the value and limits of thoracic CT in orthopaedic surgery. MATERIALS AND METHODS: Among the 1397 chest CT scans performed during the pandemic period from 1 March 2020 to 10 May 2020, in two centres with orthopaedic surgery, we selected all the 118 thoracic or chest CT performed for patients who presented to the Emergency Department of the hospital with a diagnosis of trauma for orthopaedic surgical treatment. Thirty-nine of these 118 patients were tested with PCR for the diagnosis of COVID-19 infection. Depending on clinical status (symptomatic or non-symptomatic), the information useful for the orthopaedist surgeon and obtained from the Chest CT scan according to the result of the PCR (gold standard) was graded from 0 (no or low value) to 3 (high value). The potential risks of chest CT as exposure to radiation, and specific pathway were analyzed and discussed. A group of patients treated during a previous similar period (1 March 2018 to 15 April 2018) was used as control for evaluation of the increase of CT scanning during the COVID-19 pandemic. RESULTS: Among the 118 patients with chest CT, there were 16 patients with positive COVID-19 chest CT findings, and 102 patients with negative chest CT scan. With PCR results as reference, the sensitivity, specificity, positive predictive value of chest CT in indicating COVID-19 infection were 81%, 93%, and 86%, respectively (p = 0.001). A useful information for the orthopaedic surgeon (graded as 1 for 71 cases, as 2 for 5 cases, and as 3 for 11 cases) was obtained from 118 chest CT scans for 87 (74%) patients, while the CT was no value in 30 (25%) cases, and negative value in one (1%) case. Roughly 20% of the total number of CT scanner performed over the pandemic period was dedicated to COVID-19, but only 2% were for orthopaedic or trauma patients. However, this was ten times higher than during the previous control period of comparison. CONCLUSION: Although extremely valuable for surgery management, these results should not be overstated. The CT findings studied are not specific for COVID-19, and the positive predictive value of CT will be low unless disease prevalence is high, which was the case during this period.

Impact of Referring Hospital Imaging on Mortality at a Level I Trauma Center.

BACKGROUND: Computed tomography (CT) has become a standard adjunct in the evaluation of patients with trauma. However, utility of imaging at the referring hospital remains controversial. We study the effect of CT scans at referring hospitals on in-hospital mortality at a receiving trauma center. MATERIALS AND METHODS: A retrospective cohort study was performed with adult patients with severe trauma transferred to a level I trauma center from regional nontrauma hospitals between 2012 and 2017. Baseline characteristics were compared with Student's t-test and Pearson's chi-squared testing. The primary endpoint was in-hospital mortality. Cox regression, controlling for transfer time, was used to evaluate the effect of imaging on mortality. RESULTS: Three thousand four hundred and fifteen adult patients with trauma were included: 1135 (33.2%) received a pretransfer CT scan, whereas 2280 (66.8%) did not. Patients who received a pretransfer CT scan were more likely to be older, female, white, have a higher Charlson Comorbidity Index, less severely injured, have a blunt mechanism, and be transferred by ground. There was no difference in distance (58.3 miles versus 57.0 miles, P = 0.34), but transfer times were significantly increased for those who received pretransfer scans (288 versus 213 min, P < 0.005). The adjusted model controlling for multiple variables has a hazard ratio of 0.533 (95% confidence interval 0.42-0.68, P < 0.005). CONCLUSIONS: There is a survival advantage for patients who receive pretransfer CT scans despite having significantly longer transport times. We suggest that this decreased mortality associated with pretransfer imaging may reflect improving trends in referring physician transfer decisions.

Pre-referral stabilization and compliance with WHO guidelines for trauma care among adult patients referred to an urban emergency department of a tertiary referral hospital in Tanzania.

BACKGROUND: The outcomes of trauma are considered to be time dependent. Efficient and timely pre-referral stabilization of trauma patients has been shown to impact survival. Tanzania has no formal pre-hospital or trauma system. World Health Organisation has provided a set of standards for initial stabilization of trauma patients according to the level of the hospitals. We aimed to describe pre-referral stabilization provided to adult trauma patient referred to the national referral hospital and compliance with World Health Organisation guidelines. METHODS: This prospective observational cross-sectional study was conducted at the Emergency Medicine Department of Muhimbili National Hospital (EMD-MNH), between July 2017 and December 2017. Eligible patients were adults with head injury and extremity injury ≥18 years who were referred from a peripheral hospital and had a referral note. Research assistant enrolled patients using structured case report form clinical information, and initial stabilization received at the referring hospital. Primary outcome was the proportion of patients who had initial stabilization performed according to World Health Organisation recommendation. RESULTS: We enrolled 368 (29% of eligible patients), the median age was 34 years (Interquartile range 26-44 years), and 281 (76%) were male. Overall 69% of referred patients arrived at the EMD more than 24 h after injury. Of those enrolled, 50 (13.6%) patients had received at least one stabilization intervention prior to transfer to MNH. Among 206 patients with extremity injuries, splinting was inadequate or missing in all cases; No patients with head injury received cervical spine protection. Among patients referred from a health center, 26.9% received an initial stabilization, while stabilization procedures were administered to 13.2% of those from district hospitals, and 10% of those from regional hospitals. CONCLUSIONS: In this urban public emergency department in Tanzania, majority of trauma patients were referred from lower health facilities after 24-h of injury. Most did not receive initial trauma stabilization as recommended by the World Health Organisation guidelines. Future studies should identify barriers to pre-referral stabilization of adult trauma patients.