Pooled preventable death rates in trauma patients: Meta analysis and systematic review since 1990

Prospective validation of a hospital triage predictive model to decrease undertriage: an EAST multicenter study

Background

Tiered trauma team activation (TTA) allows systems to optimally allocate resources to an injured patient. Target undertriage and overtriage rates of <5% and <35% are difficult for centers to achieve, and performance variability exists. The objective of this study was to optimize and externally validate a previously developed hospital trauma triage prediction model to predict the need for emergent intervention in 6 hours (NEI-6), an indicator of need for a full TTA.

Methods

The model was previously developed and internally validated using data from 31 US trauma centers. Data were collected prospectively at five sites using a mobile application which hosted the NEI-6 model. A weighted multiple logistic regression model was used to retrain and optimize the model using the original data set and a portion of data from one of the prospective sites. The remaining data from the five sites were designated for external validation. The area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) were used to assess the validation cohort. Subanalyses were performed for age, race, and mechanism of injury.

Results

14 421 patients were included in the training data set and 2476 patients in the external validation data set across five sites. On validation, the model had an overall undertriage rate of 9.1% and overtriage rate of 53.7%, with an AUROC of 0.80 and an AUPRC of 0.63. Blunt injury had an undertriage rate of 8.8%, whereas penetrating injury had 31.2%. For those aged ≥65, the undertriage rate was 8.4%, and for Black or African American patients the undertriage rate was 7.7%.

Conclusion

The optimized and externally validated NEI-6 model approaches the recommended undertriage and overtriage rates while significantly reducing variability of TTA across centers for blunt trauma patients. The model performs well for populations that traditionally have high rates of undertriage.

Level of evidence

2.

Investigating major trauma in Māori youth at Te Whatu Ora Counties Manukau

BACKGROUND

The Ninth Perioperative Mortality Review Committee (POMRC) report found the likelihood of death was over three times higher in Māori youth compared to non-Māori (age: 15-18 years) in the 30-days following major trauma. The aim of our study is to investigate variations in care provided to Māori youth presenting to Te Whatu Ora Counties Manukau (TWO-CM) with major trauma, to inform policies and improve care.

METHODS

This was a retrospective, observational study of 15-18-year-olds admitted to Middlemore Hospital from January 2018 to December 2021 following major trauma (Injury Severity Score (ISS) >12 or with (ISS) <12 who died). Data were obtained from the New Zealand Trauma Registry (NZTR). Six key performance indicators were studied against hospital guidelines/international consensus: Deaths, Cause-of-death, trauma call, RedBlanket activations, time-to-computed tomography (CT), and time-to-operating theatre (OT).

RESULTS

Of 77 patients, five deaths occurred, four non-Māori, and one Māori (P = 0.645). Five trauma calls were not activated (P = 0.642). There was no statistically significant difference for both median time to CT (P = 0.917) and time to CT for patients with GCS >13 (P = 0.778) between Māori and non-Māori. Five patients did not meet guidelines for time-to-OT (three non-Māori and two Māori) (P = 0.377).

CONCLUSION

No statistically significant variations in care were present for Māori youth presenting with major trauma, these findings did not match the national trend.

Societal Burden of Trauma and Disparities in Trauma Care

Trauma imposes a significant societal burden, with injury being a leading cause of mortality worldwide. While numerical data reveal that trauma accounts for millions of deaths annually, its true impact goes beyond these figures. The toll extends to non-fatal injuries, resulting in long-term physical and mental health consequences. Moreover, injury-related health care costs and lost productivity place substantial strain on a nation's economy. Disparities in trauma care further exacerbate this burden, affecting access to timely and appropriate care across various patient populations. These disparities manifest across the entire continuum of trauma care, from prehospital to in-hospital and post-acute phases. Addressing these disparities and improving access to quality trauma care are crucial steps toward alleviating the societal burden of trauma and enhancing equitable patient outcomes.

Re-triage moderates association between state trauma funding and lower mortality of trauma patients

BACKGROUND

Severely injured patients who are re-triaged (emergently transferred from an emergency department to a high-level trauma center) experience lower in-hospital mortality. Patients in states with trauma funding also experience lower in-hospital mortality. This study examines the interaction of re-triage, state trauma funding, and in-hospital mortality.

STUDY DESIGN

Severely injured patients (Injury Severity Score (ISS) >15) were identified from 2016 to 2017 Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases in five states (FL, MA, MD, NY, WI). Data were merged with the American Hospital Association Annual Survey and state trauma funding data. Patients were linked across hospital encounters to determine if they were appropriately field triaged, field under-triaged, optimally re-triaged, or sub-optimally re-triaged. A hierarchical logistic regression modeling in-hospital mortality was used to quantify the effect of re-triage on the association between state trauma funding and in-hospital mortality, while adjusting for patient and hospital characteristics.

RESULTS

A total of 241,756 severely injured patients were identified. Median age was 52 years (IQR: 28, 73) and median ISS was 17 (IQR: 16, 25). Two states (MA, NY) allocated no funding, while three states (WI, FL, MD) allocated $0.09-$1.80 per capita. Patients in states with trauma funding were more broadly distributed across trauma center levels, with a higher proportion of patients brought to Level III, IV, or non-trauma centers, compared to patients in states without trauma funding (54.0% vs. 41.1%, p < 0.001). Patients in states with trauma funding were more often re-triaged, compared to patients in states without trauma funding (3.7% vs. 1.8%, p < 0.001). Patients who were optimally re-triaged in states with trauma funding experienced 0.67 lower adjusted odds of in-hospital mortality (95% CI: 0.50-0.89), compared to patients in states without trauma funding. We found that re-triage significantly moderated the association between state trauma funding and lower in-hospital mortality (p = 0.018).

CONCLUSION

Severely injured patients in states with trauma funding are more often re-triaged and experience lower odds of mortality. Re-triage of severely injured patients may potentiate the mortality benefit of increased state trauma funding.

Association of Prehospital Transfusion With Mortality in Pediatric Trauma

Importance

Optimal hemostatic resuscitation in pediatric trauma is not well defined.

Objective

To assess the association of prehospital blood transfusion (PHT) with outcomes in injured children.

Design, Setting, and Participants

This retrospective cohort study of the Pennsylvania Trauma Systems Foundation database included children aged 0 to 17 years old who received a PHT or emergency department blood transfusion (EDT) from January 2009 and December 2019. Interfacility transfers and isolated burn mechanism were excluded. Analysis took place between November 2022 and January 2023.

Exposure

Receipt of a blood product transfusion in the prehospital setting compared with the emergency department.

Main Outcomes and Measures

The primary outcome was 24-hour mortality. A 3:1 propensity score match was developed balancing for age, injury mechanism, shock index, and prehospital Glasgow Comma Scale score. A mixed-effects logistic regression was performed in the matched cohort further accounting for patient sex, Injury Severity Score, insurance status, and potential center-level heterogeneity. Secondary outcomes included in-hospital mortality and complications.

Results

Of 559 children included, 70 (13%) received prehospital transfusions. In the unmatched cohort, the PHT and EDT groups had comparable age (median [IQR], 47 [9-16] vs 14 [9-17] years), sex (46 [66%] vs 337 [69%] were male), and insurance status (42 [60%] vs 245 [50%]). The PHT group had higher rates of shock (39 [55%] vs 204 [42%]) and blunt trauma mechanism (57 [81%] vs 277 [57%]) and lower median (IQR) Injury Severity Score (14 [5-29] vs 25 [16-36]). Propensity matching resulted in a weighted cohort of 207 children, including 68 of 70 recipients of PHT, and produced well-balanced groups. Both 24-hour (11 [16%] vs 38 [27%]) and in-hospital mortality (14 [21%] vs 44 [32%]) were lower in the PHT cohort compared with the EDT cohort, respectively; there was no difference in in-hospital complications. Mixed-effects logistic regression in the postmatched group adjusting for the confounders listed above found PHT was associated with a significant reduction in 24-hour (adjusted odds ratio, 0.46; 95% CI, 0.23-0.91) and in-hospital mortality (adjusted odds ratio, 0.51; 95% CI, 0.27-0.97) compared with EDT. The number needed to transfuse in the prehospital setting to save 1 child's life was 5 (95% CI, 3-10).

Conclusions and Relevance

In this study, prehospital transfusion was associated with lower rates of mortality compared with transfusion on arrival to the emergency department, suggesting bleeding pediatric patients may benefit from early hemostatic resuscitation. Further prospective studies are warranted. Although the logistics of prehospital blood product programs are complex, strategies to shift hemostatic resuscitation toward the immediate postinjury period should be pursued.

Low Titer Group O Whole Blood In Injured Children Requiring Massive Transfusion

OBJECTIVE

The aim of this study was to assess the survival impact of low-titer group O whole blood (LTOWB) in injured pediatric patients who require massive transfusion.

SUMMARY BACKGROUND DATA

Limited data are available regarding the effectiveness of LTOWB in pediatric trauma.

METHODS

A prospective observational study of children requiring massive transfusion after injury at UPMC Children's Hospital of Pittsburgh, an urban academic pediatric Level 1 trauma center. Injured children ages 1 to 17 years who received a total of >40 mL/kg of LTOWB and/or conventional components over the 24 hours after admission were included. Patient characteristics, blood product utilization and clinical outcomes were analyzed using Kaplan-Meier survival curves, log rank tests and Cox proportional hazards regression analyses. The primary outcome was 28-day survival.

RESULTS

Of patients analyzed, 27 of 80 (33%) received LTOWB as part of their hemostatic resuscitation. The LTOWB group was comparable to the component therapy group on baseline demographic and physiologic parameters except older age, higher body weight, and lower red blood cell and plasma transfusion volumes. After adjusting for age, total blood product volume transfused in 24 hours, admission base deficit, international normalized ratio (INR), and injury severity score (ISS), children who received LTOWB as part of their resuscitation had significantly improved survival at both 72 hours and 28 days post-trauma [adjusted odds ratio (AOR) 0.23, P = 0.009 and AOR 0.41, P = 0.02, respectively]; 6-hour survival was not statistically significant (AOR = 0.51, P = 0.30). Survivors at 28 days in the LTOWB group had reduced hospital LOS, ICU LOS, and ventilator days compared to the CT group.

CONCLUSION

Administration of LTOWB during the hemostatic resuscitation of injured children requiring massive transfusion was independently associated with improved 72-hour and 28-day survival.

Activation and On-Scene Intervals for Severe Trauma EMS Interventions: An Analysis of the NEMSIS Database

Objective: Time to care is a determinant of trauma patient outcomes, and timely delivery of trauma care to severely injured patients is critical in reducing mortality. Numerous studies have analyzed access to care using prehospital intervals from a Carr et al. meta-analysis of studies from 1975 to 2005. Carr et al.'s research sought to determine national mean activation and on-scene intervals for trauma patients using contemporary emergency medical services (EMS) records. Since the Carr et al. meta-analysis was published, the National Highway Traffic Safety Administration (NHTSA) created and refined the National Emergency Medical Services Information System (NEMSIS) database. We sought to perform a modern analysis of prehospital intervals to establish current standards and temporal patterns.Methods: We utilized NEMSIS to analyze EMS data of trauma patients from 2016 to 2019. The dataset comprises more than 94 million EMS records, which we filtered to select for severe trauma and stratified by type of transport and rurality to calculate mean activation and on-scene intervals. Furthermore, we explored the impact of basic life support (BLS) and advanced life support (ALS) of ground units on activation and on-scene time intervals.Results: Mean activation and on-scene intervals for ground transport were statistically different when stratified by rurality. Urban, suburban, and rural ground activation intervals were 2.60 ± 3.94, 2.88 ± 3.89, and 3.33 ± 4.58 minutes, respectively. On-scene intervals were 15.50 ± 10.46, 17.56 ± 11.27, and 18.07 ± 16.13 minutes, respectively. Mean helicopter transport activation time was 13.75 ± 7.44 minutes and on-scene time was 19.42 ± 16.09 minutes. This analysis provides an empirically defined mean for activation and on-scene times for trauma patients based on transport type and rurality. Results from this analysis proved to be significantly longer than the previous analysis, except for helicopter transport on-scene time. Shorter mean intervals were seen in ALS compared to BLS for activation intervals, however ALS on-scene intervals were marginally longer than BLS.Conclusions: With the increasing sophistication of geospatial technologies employed to analyze access to care, these intervals are the most accurate and up-to-date and should be included in access to care models.

Resuscitative practices and the use of low-titer group O whole blood in pediatric trauma

ABSTRACT

Increasing rates of penetrating trauma in the United States makes rapid identification of hemorrhagic shock, coagulopathy, and early initiation of balanced resuscitation in injured children of critical importance. Hemorrhagic shock begins early after injury and can be challenging to identify in children, as hypotension is a late sign that a child is on the verge of circulatory collapse and should be aggressively resuscitated. Recent data support shifting away from crystalloid and toward early resuscitation with blood products because of worse coagulopathy and clinical outcomes in injured patients resuscitated with crystalloid. Multicenter studies have found improved survival in injured children who receive balanced resuscitation with higher fresh frozen plasma: red blood cell ratios. Whole blood is an efficient way to achieve balanced resuscitation in critically injured children with limited intravenous access and decreased exposure to multiple donors. Administration of cold-stored, low-titer O-negative whole blood (LTOWB) appears to be safe in adults and children and may be associated with improved survival in children with life-threatening hemorrhage. Many pediatric centers use RhD-negative LTOWB for all female children because of the risk of hemolytic disease of the fetus and newborn (0-6%); however. there is a scarcity of LTOWB compared with the demand. Low risks of hemolytic disease of the fetus and newborn affecting a future pregnancy must be weighed against high mortality rates in delayed blood product administration in children in hemorrhagic shock. Survey studies involving key stakeholder's opinions on pediatric blood transfusion practices are underway. Existing pediatric-specific literature on trauma resuscitation is often limited and underpowered; multicenter prospective studies are urgently needed to define optimal resuscitation products and practices in injured children in an era of increasing penetrating trauma.

Developing a National Trauma Research Action Plan: Results from the postadmission critical care research gap Delphi survey

INTRODUCTION

The 2016 National Academies of Science, Engineering and Medicine report included a proposal to establish a National Trauma Research Action Plan. In response, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care from prehospital care to rehabilitation as part of an overall strategy to achieve zero preventable deaths and disability after injury. The Postadmission Critical Care Research panel was 1 of 11 panels constituted to develop this research agenda.

METHODS

We recruited interdisciplinary experts in surgical critical care and recruited them to identify current gaps in clinical critical care research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. The first of four survey rounds asked participants to generate key research questions. On subsequent rounds, we asked survey participants to rank the priority of each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category.

RESULTS

Twenty-five subject matter experts generated 595 questions. By Round 3, 249 questions reached ≥60% consensus. Of these, 22 questions were high, 185 were medium, and 42 were low priority. The clinical states of hypovolemic shock and delirium were most represented in the high-priority questions. Traumatic brain injury was the only specific injury pattern with a high-priority question.

CONCLUSION

The National Trauma Research Action Plan critical care research panel identified 22 high-priority research questions, which, if answered, would reduce preventable death and disability after injury.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level IV.

Femoral fractures are an indicator of increased severity of injury for road traffic collision victims: an autopsy-based case-control study on 4895 fatalities

INTRODUCTION

The course of road traffic collision (RTC) victims with femoral fractures (FFx) from injury to death was reviewed. We sought to correlate the presence of femoral fractures with the overall severity of injury from RTCs using objective indices and to identify statistically significant associations with injuries in other organs.

PATIENTS AND METHODS

A case-control study based on forensic material from 4895 consecutive RTC-induced fatalities, between 1996 and 2005. Injuries were coded according to the Abbreviated Injury Scale-1990 Revision (AIS-90), and the Injury Severity Score (ISS) was calculated. Victims were divided according to the presence of femoral fractures in all possible anatomic locations or not. Univariate comparisons and logistic regression analysis for probabilities of association as odds ratios (OR) were performed.

RESULTS

The FFx group comprised 788 (16.1%) victims. The remaining 4107 victims constituted the controls. The FFx group demonstrated higher ISS (median 48 vs 36, p < 0.001) and shorter post-injury survival times (median 60 vs 85 min, p < 0.001). Presence of bilateral fractures (15.5%) potentiated this effect (median ISS 50 vs 43, p = 0.006; median survival time 40 vs 65, p = 0.0025; compared to unilateral fractures). Statistically significant associations of FFx were identified with AIS2-5 thoracic trauma (OR 1.43), AIS2-5 abdominal visceral injuries (OR 1.89), AIS1-3 skeletal injuries of the upper (OR 2.7) and lower limbs (OR 3.99) and AIS2-5 of the pelvis (OR 2.75) (p < 0.001). In the FFx group, 218 (27.7%) victims survived past the emergency department and 116 (53.2%) underwent at least one surgical procedure. Complications occurred in 45.4% of hospitalized victims, the most common being pneumonia (34.8%).

CONCLUSION

This study has documented that femoral fractures are associated with increased severity of injury, shorter survival times and higher incidence of associated thoracic, abdominal and skeletal extremity injuries, compared to controls. These findings should be considered for an evidence-based upgrading of trauma care.

It is time to look in the mirror: Individual surgeon outcomes after emergent trauma laparotomy

BACKGROUND

Multiple quality indicators are used by trauma programs to decrease variation and improve outcomes. However, little if any provider level outcomes related to surgical procedures are reviewed. Emergent trauma laparotomy (ETL) is arguably the signature case that trauma surgeons perform on a regular basis, but few data exist to facilitate benchmarking of individual surgeon outcomes. As part of our comprehensive performance improvement program, we examined outcomes by surgeon for those who routinely perform ETL.

METHODS

A retrospective cohort study of patients undergoing ETL directly from the trauma bay by trauma faculty from December 2019 to February 2021 was conducted. Patients were excluded from mortality analysis if they required resuscitative thoracotomy for arrest before ETL. Surgeons were compared by rates of damage control and mortality at multiple time points.

RESULTS

There were 242 ETL (7-32 ETLs per surgeon) performed by 14 faculties. Resuscitative thoracotomy was performed in 7.0% (n = 17) before ETL. Six patients without resuscitative thoracotomy died intraoperatively and damage-control laparotomy was performed on 31.9% (n = 72 of 226 patients). Mortality was 4.0% (n = 9) at 24 hours and 7.1% (n = 16) overall. Median Injury Severity Score (p = 0.21), new injury severity score (p = 0.21), and time in emergency department were similar overall among surgeons (p = 0.15), while operative time varied significantly (40-469 minutes; p = 0.005). There were significant differences between rates of individual surgeon's mortality (range [hospital mortality], 0-25%) and damage-control laparotomy (range, 14-63%) in ETL.

CONCLUSION

Significant differences exist in outcomes by surgeon after ETL. Benchmarking surgeon level performance is a necessary natural progression of quality assurance programs for individual trauma centers. Additional data from multiple centers will be vital to allow for development of more granular quality metrics to foster introspective case review and quality improvement.

LEVEL OF EVIDENCE

Therapeutic/care management, level III.

Transfusion Ratios and Deficits in Injured Children With Life-Threatening Bleeding

OBJECTIVES

To assess the impact of plasma and platelet ratios and deficits in injured children with life-threatening bleeding.

DESIGN

Secondary analysis of the MAssive Transfusion epidemiology and outcomes In Children study dataset, a prospective observational study of children with life-threatening bleeding events.

SETTING

Twenty-four childrens hospitals in the United States, Canada, and Italy.

PATIENTS

Injured children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under activation of massive transfusion protocol.

INTERVENTION/EXPOSURE

Weight-adjusted blood product volumes received during the bleeding event were recorded. Plasma:RBC ratio (plasma/RBC weight-adjusted volume in mL/kg) and platelet:RBC ratio (platelet/RBC weight-adjusted volume in mL/kg) were analyzed. Plasma deficit was calculated as RBC mL/kg - plasma mL/kg; platelet deficit was calculated as RBC mL/kg - platelet mL/kg.

MEASUREMENTS AND MAIN RESULTS

Of 191 patients analyzed, median (interquartile range) age was 10 years (5-15 yr), 61% were male, 61% blunt mechanism, and median (interquartile range) Injury Severity Score was 29 (24-38). After adjusting for Pediatric Risk of Mortality score, cardiac arrest, use of vasoactive medications, and blunt mechanism, a high plasma:RBC ratio (> 1:2) was associated with improved 6-hour survival compared with a low plasma:RBC ratio (odds ratio [95% CI] = 0.12 [0.03-0.52]; p = 0.004). Platelet:RBC ratio was not associated with survival. After adjusting for age, Pediatric Risk of Mortality score, cardiac arrest, and mechanism of injury, 6-hour and 24-hour mortality were increased in children with greater plasma deficits (10% and 20% increased odds of mortality for every 10 mL/kg plasma deficit at 6 hr [p = 0.04] and 24 hr [p = 0.01], respectively); 24-hour mortality was increased in children with greater platelet deficits (10% increased odds of 24-hr mortality for every 10 mL/kg platelet deficit [p = 0.02)]).

CONCLUSIONS

In injured children, balanced resuscitation may improve early survival according to this hypothesis generating study. Multicenter clinical trials are needed to assess whether clinicians should target ratios and deficits as optimal pediatric hemostatic resuscitation practice.

Assessing Trauma Center Accessibility for Healthcare Equity Using an Anti-Covering Approach

Motor vehicle accidents are one of the most prevalent causes of traumatic injury in patients needing transport to a trauma center. Arrival at a trauma center within an hour of the accident increases a patient's chances of survival and recovery. However, not all vehicle accidents in Tennessee are accessible to a trauma center within an hour by ground transportation. This study uses the anti-covering location problem (ACLP) to assess the current placement of trauma centers and explore optimal placements based on the population distribution and spatial pattern of motor vehicle accidents in 2015 through 2019 in Tennessee. The ACLP models seek to offer a method of exploring feasible scenarios for locating trauma centers that intend to provide accessibility to patients in underserved areas who suffer trauma as a result of vehicle accidents. The proposed ACLP approach also seeks to adjust the locations of trauma centers to reduce areas with excessive service coverage while improving coverage for less accessible areas of demand. In this study, three models are prescribed for finding optimal locations for trauma centers: (a) TraCt: ACLP model with a geometric approach and weighted models of population, fatalities, and spatial fatality clusters of vehicle accidents; (b) TraCt-ESC: an extended ACLP model mitigating excessive service supply among trauma center candidates, while expanding services to less served areas for more beneficiaries using fewer facilities; and (c) TraCt-ESCr: another extended ACLP model exploring the optimal location of additional trauma centers.

Preventable death in trauma: A systematic review on definition and classification

PURPOSE

Trauma-related preventable death (TRPD) has been used to assess the management and quality of trauma care worldwide. However, due to differences in terminology and application, the definition of TRPD lacks validity. The aim of this systematic review is to present an overview of current literature and establish a designated definition of TRPD to improve the assessment of quality of trauma care.

METHODS

A search was conducted in PubMed, Embase, the Cochrane Library and the Web of Science Core Collection. Including studies regarding TRPD, published between January 1, 1990, and April 6, 2021. Studies were assessed on the use of a definition of TRPD, injury severity scoring tool and panel review.

RESULTS

In total, 3,614 articles were identified, 68 were selected for analysis. The definition of TRPD was divided in four categories: I. Clinical definition based on panel review or expert opinion (TRPD, trauma-related potentially preventable death, trauma-related non-preventable death), II. An algorithm (injury severity score (ISS), trauma and injury severity score (TRISS), probability of survival (Ps)), III. Clinical definition completed with an algorithm, IV. Other. Almost 85% of the articles used a clinical definition in some extend; solely clinical up to an additional algorithm. A total of 27 studies used injury severity scoring tools of which the ISS and TRISS were the most frequently reported algorithms. Over 77% of the panels included trauma surgeons, 90% included other specialist; 61% emergency medicine physicians, 46% forensic pathologists and 43% nurses.

CONCLUSION

The definition of TRPD is not unambiguous in literature and should be based on a clinical definition completed with a trauma prediction algorithm such as the TRISS. TRPD panels should include a trauma surgeon, anesthesiologist, emergency physician, neurologist, and forensic pathologist.

Pre-hospital transfusion of post-traumatic hemorrhage: Medical and regulatory aspects

Data of good methodological quality have recently become available to support prehospital use of transfusion in the severe trauma setting. Consistent with recent guidelines for the implementation of damage control resuscitation in the hospital in this setting and in the wake of numerous cohort study data from wartime medicine, they are now guided by recent guidelines for the use of freeze-dried plasma. The main difficulties to overcome in order to implement a practice are of a regulatory and logistic nature.

A new definition for massive transfusion in the modern era of whole blood resuscitation

BACKGROUND

Multiple thresholds are defined to identify patients at risk of death from hemorrhage, including massive transfusion (MT), critical administration threshold (CAT), and resuscitation intensity (RI). All fail to account for the use of whole blood (WB). We hypothesized that a definition including WB transfusion would better predict early mortality following trauma.

METHODS

This is a retrospective review of all trauma patients with activation of the MT protocol from December 2018 to February 2020. Combinations of WB, RBCs, and fresh frozen plasma (FFP) units transfused during the initial hour of resuscitation were compared using receiver operating characteristic and area under the receiver curve (AUC) for 3- and 6-h mortality. WB massive transfusion (WB MT) score was defined as the sum of each unit RBC plus three times each unit of WB transfused within the first hour of resuscitation.

RESULTS

There were 235 patients eligible for analysis with 60 resuscitated using ≥1 unit of WB. Overall, 27 and 29 patients died in the first 3 and 6 h, respectively. WB MT ≥7 had the greatest 3-h and 6-h mortality AUC values (0.78 and 0.79, respectively) when compared to MT, CAT, RI4+, and other attempted definitions using units of WB, RBC, and FFP. Compared to WB MT-, WB MT+ patients died at significantly higher rates at 3 h (28.9% vs. 3.1%, p < .001), 24 h (35.5% vs. 5.7%, p < .001), and 28 days (42.1% vs. 11.9%, p < .001).

CONCLUSION

WB MT is the first measure of massive resuscitation to incorporate WB and better identifies early mortality than other definitions.

Preventable Trauma Deaths and Corrective Actions to Prevent Them: A 10-Year Comparative Study at the Komfo Anokye Teaching Hospital, Kumasi, Ghana

OBJECTIVE

To determine the rate of preventable trauma deaths in an African hospital, identify the potential effect of improvements in trauma care over the past decade and identify deficiencies in care that still need to be addressed.

METHODS

A multidisciplinary panel assessed pre-hospital, hospital, and postmortem data on 89 consecutive in-hospital trauma deaths over 5 months in 2017 at the Komfo Anokye Teaching Hospital. The panel judged the preventability of each death. For definitely and potentially preventable deaths, the panel identified deficiencies in care.

RESULTS

Thirteen percent (13%) of trauma deaths were definitely preventable, 47% potentially preventable, and 39% non-preventable. In comparison with a panel review in 2007, there was no change in total preventable deaths, but there had been a modest decrease in definitely preventable deaths (25% in 2007 to 13% in 2017, p = 0.07) There was a notable change in the pattern of deficiency (p = 0.001) with decreases in pre-hospital delay (19% of all trauma deaths in 2007 to 3% in 2017) and inadequate resuscitation (17 to 8%), but an increase in delay in treatment at the hospital (23 to 40%).

CONCLUSIONS

Over the past decade, there have been improvements in pre-hospital transport and in-hospital resuscitation. However, the preventable death rate remains unacceptably high and there are still deficiencies to address. This study also demonstrates that preventable death panel reviews are a feasible method of trauma quality improvement in the low- and middle-income country setting.

French lyophilized plasma versus normal saline for post-traumatic coagulopathy prevention and correction: PREHO-PLYO protocol for a multicenter randomized controlled clinical trial

BACKGROUND

Post-trauma bleeding induces an acute deficiency in clotting factors, which promotes bleeding and hemorrhagic shock. However, early plasma administration may reduce the severity of trauma-induced coagulopathy (TIC). Unlike fresh frozen plasma, which requires specific hospital logistics, French lyophilized plasma (FLYP) is storable at room temperature and compatible with all blood types, supporting its use in prehospital emergency care. We aim to test the hypothesis that by attenuating TIC, FLYP administered by prehospital emergency physicians would benefit the severely injured civilian patient at risk for hemorrhagic shock.

METHODS/DESIGN

This multicenter randomized clinical trial will include adults severely injured and at risk for hemorrhagic shock, with a systolic blood pressure < 70 mmHg or a Shock Index > 1.1. Two parallel groups of 70 patients will receive either FLYP or normal saline in addition to usual treatment. The primary endpoint is the International Normalized Ratio (INR) at hospital admission. Secondary endpoints are transfusion requirement, length of stay in the intensive care unit, survival rate at day 30, usability and safety related to FLYP use, and other biological coagulation parameters.

CONCLUSION

With this trial, we aim to confirm the efficacy of FLYP in TIC and its safety in civilian prehospital care. The study results will contribute to optimizing guidelines for treating hemorrhagic shock in civilian settings.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02736812. Registered on 13 April 2016. The trial protocol has been approved by the French ethics committee (CPP 3342) and the French Agency for the Safety of Medicines and Health Products (IDRCB 2015-A00866-43).

Patterns of Anatomic Injury in Critically Injured Combat Casualties: A Network Analysis

A mortality review of death caused by injury requires a determination of injury survivability prior to a determination of death preventability. If injuries are nonsurvivable, only non-medical primary prevention strategies have potential to prevent the death. Therefore, objective measures are needed to empirically inform injury survivability from complex anatomic patterns of injury. As a component of injury mortality reviews, network structures show promise to objectively elucidate survivability from complex anatomic patterns of injury resulting from explosive and firearm mechanisms. In this network analysis of 5,703 critically injured combat casualties, patterns of injury among fatalities from explosive mechanisms were associated with both a higher number and severity of anatomic injuries to regions such as the extremities, abdomen, and thorax. Patterns of injuries from a firearm were more isolated to individual body regions with fatal patterns involving more severe injuries to the head and thorax. Each injury generates a specific level of risk as part of an overall anatomic pattern to inform injury survivability not always captured by traditional trauma scoring systems. Network models have potential to further elucidate differences between potentially survivable and nonsurvivable anatomic patterns of injury as part of the mortality review process relevant to improving both the military and civilian trauma care systems.

External injuries, trauma and avoidable deaths in Agincourt, South Africa: a retrospective observational and qualitative study

OBJECTIVE

Injury burden is highest in low-income and middle-income countries. To reduce avoidable deaths, it is necessary to identify health system deficiencies preventing timely, quality care. We developed criteria to use verbal autopsy (VA) data to identify avoidable deaths and associated health system deficiencies.

SETTING

Agincourt, a rural Bushbuckridge municipality, Mpumalanga Province, South Africa.

PARTICIPANTS

Agincourt Health and Socio-Demographic Surveillance System and healthcare providers (HCPs) from local hospitals.

METHODS

A literature review to explore definitions of avoidable deaths after trauma and barriers to access to care using the 'three delays framework' (seeking, reaching and receiving care) was performed. Based on these definitions, this study developed criteria, applicable for use with VA data, for identifying avoidable death and which of the three delays contributed to avoidable deaths. These criteria were then applied retrospectively to the VA-defined category external injury deaths (EIDs-a subset of which are trauma deaths) from 2012 to 2015. The findings were validated by external expert review. Key informant interviews (KIIs) with HCPs were performed to further explore delays to care.

RESULTS

Using VA data, avoidable death was defined with a focus on survivability, using level of consciousness at the scene and ability to seek care as indicators. Of 260 EIDs (189 trauma deaths), there were 104 (40%) avoidable EIDs and 78 (30%) avoidable trauma deaths (41% of trauma deaths). Delay in receiving care was the largest contributor to avoidable EIDs (61%) and trauma deaths (59%), followed by delay in seeking care (24% and 23%) and in reaching care (15% and 18%). KIIs revealed context-specific factors contributing to the third delay, including difficult referral systems.

CONCLUSIONS

A substantial proportion of EIDs and trauma deaths were avoidable, mainly occurring due to facility-based delays in care. Interventions, including strengthening referral networks, may substantially reduce trauma deaths.

Tranexamic acid in severe trauma patients managed in a mature trauma care system

BACKGROUND

Tranexamic acid (TXA) use in severe trauma remains controversial notably because of concerns of the applicability of the CRASH-2 study findings in mature trauma systems. The aim of our study was to evaluate the outcomes of TXA administration in severely injured trauma patients managed in a mature trauma care system.

METHODS

We performed a retrospective study of data prospectively collected in the TraumaBase registry (a regional registry collecting the prehospital and hospital data of trauma patients admitted in six Level I trauma centers in Paris Area, France). In hospital mortality was compared between patients having received TXA or not in the early phase of resuscitation among those presenting an unstable hemodynamic state. Propensity score for TXA administration was calculated and results were adjusted for this score. Hemodynamic instability was defined by the need of packed red blood cells (pRBC) transfusion and/or vasopressor administration in the emergency room (ER).

RESULTS

Among patients meeting inclusion criteria (n = 1,476), the propensity score could be calculated in 797, and survival analysis could be achieved in 684 of 797. Four hundred seventy (59%) received TXA, and 327 (41%) did not. The overall hospital mortality rate was 25.7%. There was no effect of TXA use in the whole population but mortality was lowered by the use of TXA in patients requiring pRBC transfusion in the ER (hazard ratio, 0.3; 95% confidence interval, 0.3-0.6).

CONCLUSION

The use of TXA in the management of severely injured trauma patients, in a mature trauma care system, was not associated with reduction in the hospital mortality. An independent association with a better survival was found in a selected population of patients requiring pRBC transfusion in the ER.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Validation of a noninvasive monitor to continuously trend individual responses to hypovolemia

BACKGROUND

Humans are able to compensate for significant blood loss with little change in traditional vital signs, limiting early detection and intervention. We hypothesized that the Compensatory Reserve Index (CRI), a new hemodynamic parameter that trends changes in intravascular volume relative to the individual patient's response to hypovolemia, would accurately trend each subject's progression from normovolemia to decompensation (systolic blood pressure < 80) and back to normovolemia in humans.

METHODS

Men and women, ages 19 years to 36 years, underwent stepwise (~333 mL aliquot) removal and replacement of 20% blood volume (men, 15 mL/kg; women, 13 mL/kg) via a large bore intravenous (i.v.) line. During each experiment, subjects were monitored with four CipherOx CRI Tablets. Withdrawn blood was reinfused at the end of each experiment.

RESULTS

Forty-two subjects (24 men; 18 women) were enrolled in the study, of which 32 completed the protocol. Seven subjects became symptomatic and collapsed (systolic blood pressure < 80), six never achieving maximum blood loss; each was rescued with a saline infusion followed by reinfusion of their stored blood. The mean CRI at baseline for all 42 subjects was 0.9 ± 0.04. The mean CRI for the 32 subjects while asymptomatic at maximum blood loss was 0.611 ± 0.028. For the asymptomatic subjects, the average blood loss volume was 1018 mL ± 286 mL. In comparison, the mean CRI at maximum blood loss for the seven subjects who collapsed was 0.15 ± 0.007 and their average blood loss volume was 860 ± 183 mL. Mean CRI after reinfusion of blood was 0.89 ± 0.02. In addition symptomatic subjects demonstrated three times larger average decrease in CRI per liter of blood removed, 0.85 versus 0.28 for asymptomatic subjects.

CONCLUSION

CRI trends change in intravascular volume relative to an individual's response to hypovolemia and is sensitive to the differing risks associated with individuals' differing tolerance to volume loss.

LEVEL OF EVIDENCE

Prognostic study, level II.

Earlier Endpoints are Required for Hemorrhagic Shock Trials Among Severely Injured Patients

BACKGROUND

Choosing the appropriate endpoint for a trauma hemorrhage control trial can determine the likelihood of its success. Recent Phase 3 trials and observational studies have used 24-h and/or 30-day all-cause mortality as the primary endpoint and some have not used exception from informed consent (EFIC), resulting in multiple failed trials. Five recent high-quality prospective studies among 4,064 hemorrhaging trauma patients provide new evidence to support earlier primary endpoints.

METHODS

The goal of this project was to determine the optimal endpoint for hemorrhage control trials using existing literature and new analyses of previously published data.

RESULTS

Recent studies among bleeding trauma patients show that hemorrhagic deaths occur rapidly, at a high rate, and in a consistent pattern. Early preventable deaths among trauma patients are largely due to hemorrhage and the median time to hemorrhagic death from admission is 2.0 to 2.6 h. Approximately 85% of hemorrhagic deaths occur within 6 h. The hourly mortality rate due to traumatic injury decreases rapidly after enrollment from 4.6% per hour at 1 hour postenrollment to 1% per hour at 6 h to <0.1% per hour by 9 h and thereafter. Early primary endpoints (within 6 h) have critically important benefits for hemorrhage control trials, including being congruent with the median time to hemorrhagic death, biologic plausibility, and enabling the use of all-cause mortality, which is definitive and objective.

CONCLUSIONS

Primary endpoints should be congruent with the timing of the disease process. Therefore, if a resuscitation/hemorrhage control intervention is under study, a primary endpoint of all-cause mortality evaluated within the first 6 h is appropriate. Before choosing the timing of the primary endpoint for a large multicenter trial, we recommend performing a Phase 2 trial under EFIC to better understand the effects of the hemorrhage control intervention and distribution of time to death. When early primary endpoints are used, patients should be monitored for multiple subsequent secondary safety endpoints, including 24 h and 30-day all-cause mortality as well as the customary safety endpoints.

Assessment of Progress in Early Trauma Care in Japan over the Past Decade: Achievements and Areas for Future Improvement

BACKGROUND

Strategies to optimize early trauma care have been introduced in Japan; however, detailed evaluation of the progress achieved has not been reported.

STUDY DESIGN

In this retrospective observational study, patients registered in the Japanese nationwide trauma registry were stratified according to probability of survival (Ps) > 0.5 or ≤ 0.5, respectively. Mortality rates during the first 2 days and in-hospital mortality rates were compared between early (2004 to 2009) and late cohorts (2010 to 2014) in each group, using mixed effects logistic regression analysis. Improvement in mortality rates during the first 2 days among subgroups were also assessed.

RESULTS

We analyzed 80,949 patients with Ps > 0.5 (early, 25,917; late, 55,032) and 8,898 patients with Ps ≤ 0.5 (early, 3,511; late, 5,387). Mortality rates during the first 2 days in both groups were significantly reduced (adjusted odds ratio [AOR; 95% CI] 0.61 [0.53 to 0.69] in the Ps > 0.5 group and 0.67 [0.60 to 0.76] in the Ps ≤ 0.5 group). In-hospital mortality rates in both groups were also significantly reduced (AOR [95% CI] 0.70 [0.64 to 0.76] and 0.73 [0.64 to 0.82], respectively). Significant improvements were observed in patients with a Revised Trauma Score ≥ 7 on arrival or an Abbreviated Injury Scale (AIS) of the abdomen ≥ 3. Limited improvements were observed in patients with head AIS ≥ 3 and in patients who underwent thoracotomy.

CONCLUSIONS

Although early trauma care has generally improved, specific progress was variable. Focused panel review of patients with severe head injury or undergoing thoracotomy may be an efficient strategy for further improvement.