"Trauma-the forgotten pandemic?"

A comparative analysis of trauma-related mortality in South Korea using classification models

BACKGROUND

Reducing mortality among severe trauma patients requires the establishment of an effective emergency transportation system and the rapid transfer of patients to appropriate medical facilities. Machine learning offers significant potential to enhance the efficiency and quality of these emergency medical services.

METHODS

A retrospective secondary analysis was conducted using region-specific trauma survey data. The analysis focused on socio-economic characteristics, mechanisms of injury, injury severity, and variables indicating the effectiveness of the emergency medical system in optimizing machine learning algorithms for predicting severe patient transportation decisions.

RESULTS

Among the 8,769 patients with severe trauma, 7.2 % died in the hospital, with an average age of 50.06 years. The average injury severity score was 8.44, and the average time from accident reporting to arrival at the emergency medical facility was 55.39 min. The trend showed that as the level of the emergency medical institution increased, the patient transport time increased, while the mortality rate decreased. Additionally, XGBoost showed the best performance in mortality classification using a dataset sampled with SMOTE-ENN. Although the difference was minimal, undersampling slightly outperformed oversampling in the classification of emergency patients.

CONCLUSION

The treatment of emergency patients is influenced not only by transport time but also by the resources and staff levels of specialized emergency medical centers, which in turn affect survival rates. Furthermore, given the superior performance of composite sampling methods in analyzing imbalanced datasets, the importance of considering such imbalanced datasets in the analysis is evident.

Is the Concentration of Trace Elements Zinc, Selenium, Copper, Manganese, and Iron a Predictor of Clinical Outcomes in Critically Ill Trauma Patients?

Trace elements (TE) function as essential micronutrients involved in the biochemical and physiological processes of the human body. We evaluated the baseline serum concentrations of TE as a predictor of clinical outcomes in critically ill trauma patients and monitored the concentrations of TE during the patients intensive care unit (ICU) stay. A total of 89 patients were enrolled. Within the first 24 h of patients' admission, concentrations of TE, zinc (Zn), selenium (Se), copper (Cu), manganese (Mn), and iron (Fe) were measured and monitored on the 5th and 10th day of patients ICU stay. The concentrations of Zn, Se, Cu and Mn were determined from serum using atomic absorption spectrophotometry, whereas the concentration of Fe using the photometric method. ANOVA and logistic regression analyses were used for statistical analysis with the level of significance set at 0.05. At the time of ICU admission, deficiency of Cu was observed in 11 out of 89 (0.13), Zn in 82 (0.92), Se in 5 (0.06) and Fe in 52 (0.58) patients, while excess of Mn was detected in 27 (0.30) and Cu in 3 (0.03) patients. A significant increase of Zn and Cu concentrations was observed from admission to 10th day (P < 0.001 for both), although Zn concentrations did not reach the lower limit of the reference interval. Logistic regression analysis found that only a low concentration of Zn at admission was associated with mechanical ventilation (OR = 0.78; 95%CI: 0.64-0.96; P = 0.018). Furthermore, the concentrations of TE at admission in critically ill trauma patients did not have an impact on the overall length of the ICU and hospital stay, nor on mortality.

Unified total body CT image with multiple organ specific windowings: validating improved diagnostic accuracy and speed in trauma cases

Total-body CT scans are useful in saving trauma patients; however, interpreting numerous images with varied window settings slows injury detection. We developed an algorithm for "unified total-body CT image with multiple organ-specific windowings (Uni-CT)", and assessing its impact on physician accuracy and speed in trauma CT interpretation. From November 7, 2008, to June 19, 2020, 40 cases of total-body CT images for blunt trauma with multiple injuries, were collected from the emergency department of Osaka General Medical Center and randomly divided into two groups. In half of the cases, the Uni-CT algorithm using semantic segmentation assigned visibility-friendly window settings to each organ. Four physicians with varying levels of experience interpreted 20 cases using the algorithm and 20 cases in conventional settings. The performance was analyzed based on the accuracy, sensitivity, specificity of the target findings, and diagnosis speed. In the proposal and conventional groups, patients had an average of 2.6 and 2.5 targeting findings, mean ages of 51.8 and 57.7 years, and male proportions of 60% and 45%, respectively. The agreement rate for physicians' diagnoses was κ = 0.70. Average accuracy, sensitivity, and specificity of target findings were 84.8%, 74.3%, 96.9% and 85.5%, 81.2%, 91.5%, respectively, with no significant differences. Diagnostic speed per case averaged 71.9 and 110.4 s in each group (p < 0.05). The Uni-CT algorithm improved the diagnostic speed of total-body CT for trauma, maintaining accuracy comparable to that of conventional methods.

Traumatic injury leads to ovarian cell death and reproductive disturbances in Drosophila melanogaster

Traumatic injury (TI), or global blunt force trauma, can arise from many sources such as car crashes, sports and intimate partner violence. Effects from these injuries impact the whole organism and can lead to many different pathologies, such as inflammation, neurodegeneration, gut dysbiosis, and female reproductive detriments. Drosophila melanogaster has recently emerged as a powerful model to study traumatic injuries due to their high conservation of physiological effects post-trauma and the genetic toolset that they leverage. Previously, we reported female-specific reproductive deficits post mild TI in Drosophila. Here we investigate the effects of more severe trauma on females and found an increased retention of mature eggs and decrease in egg laying. Additionally, severe trauma led to an increase of midstage egg chamber death and formation of melanization, a known marker of immune activation. These studies provide a valuable invertebrate model to understand disturbances to female reproduction post-trauma.

The benefit of national clinical guidelines for open lower limb fractures in reducing healthcare burden: A length of inpatient stay cost-analysis

INTRODUCTION

Severe open lower limb fractures are complex and costly injuries. Studies reporting the costs associated with these injuries, the economic impact of complications, and the clinical benefit of adherence to national guidelines have been previously reported. However, the economic benefits of national guidelines and their relationship with length of inpatient stay have not been described.

METHODS

An international retrospective cohort study, using length of stay as a proxy for in-hospital economic impact, comparing the duration of inpatient stay in countries with national guidelines and those without.

RESULTS

In a cohort of 2641 patients from 16 countries, length of stay was 17 % lower in countries with national guidelines, equivalent to 2-3 fewer inpatient days per patient. This difference was primarily driven by a lower incidence of deep infection observed in countries with national clinical guidelines.

CONCLUSION

The presence of national guidelines for the management of severe lower limb injuries is associated with both improved clinical outcomes and reduced length of stay and therefore healthcare burden. Whilst application and adoption of national guidelines is not without challenges, their implementation is associated with significant clinical and economic benefits.

Accelerated fracture healing accompanied with traumatic brain injury: A review of clinical studies, animal models and potential mechanisms

The orthopaedic community frequently encounters polytrauma individuals with concomitant traumatic brain injury (TBI) and their fractures demonstrate accelerated fracture union, but the mechanisms remain far from clear. Animal and clinical studies demonstrate robust callus formation at the early healing process and expedited radiographical union. In humans, robust callus formation in TBI occurs independently of fracture fixation methods across multiple fracture sites. Animal studies of TBI replicate clinically relevant enlarged fracture callus as characterized by increased tissue volume and bone volume at the early stages. However, refinement and standardization of the TBI models requires further research. The quest for its underlying mechanisms began with the finding of increased osteogenesis in vitro using the serum and cerebral spinal fluid (CSF) from TBI individuals. This has led to the investigation of myriads of brain-derived factors including humoral factors, cytokines, exosomes, and mi-RNAs. Further, the emerging information of interplay between the skeletal system and central nervous system, the roles of peripheral nerves and their neuropeptides in regulating bone regeneration, offers valuable insights for future research. This review consolidates the findings from both experimental and clinical studies, elucidating the potential mechanisms underlying enhanced fracture healing in concurrent TBI scenarios that may lay down a foundation to develop innovative therapies for fracture healing enhancement and conquer fracture non-union. The translational potential of this article. This review comprehensively summarizes the observations of accelerated fracture healing in the presence of traumatic brain injury from both preclinical and clinical studies. In addition, it also delineates potential cellular and molecular mechanisms. Further detailed investigation into its underlying mechanisms may reveal innovative orthopaedic intervention strategies to improve fracture healing and thus offering promising avenues for future translational applications.

Transfusion in trauma: empiric or guided therapy?

A state of the art lecture titled "Transfusion therapy in trauma-what to give? Empiric vs guided" was presented at the International Society on Thrombosis and Haemostasis Congress in 2024. Uncontrolled bleeding is the commonest preventable cause of death after traumatic injury. Hemostatic resuscitation is the foundation of contemporary transfusion practice for traumatic bleeding and has 2 main aims: to immediately support the circulating blood volume and to treat/prevent the associated trauma-induced coagulopathy. There are 2 broad types of hemostatic resuscitation strategy: empiric ratio-based therapy, often using red blood cells and fresh frozen plasma in a 1:1 ratio, and targeted therapy where the use of platelets, plasma, or fibrinogen is guided by laboratory or viscoelastic hemostatic tests. There are benefits, and limitations, to each strategy and neither approach has yet been shown to improve outcomes across all patient groups. Questions remain, and future directions for improving transfusion therapy are likely to require novel approaches that have greater flexibility to evaluate and treat heterogeneous trauma cohorts. Such approaches may include the integration of machine learning technologies in clinical systems, with real-time linkage of clinical and laboratory data, to aid early recognition of patients at the greatest risk of bleeding and to direct and individualize transfusion therapies. Greater mechanistic understanding of the underlying pathobiology of trauma-induced coagulopathy and the direct effects of common treatments on this process will be of equal importance to the development of new treatments. Finally, we summarize relevant new data on this topic presented at the 2024 ISTH Congress.

The Intersection of Trauma and Immunity: Immune Dysfunction Following Hemorrhage

Hemorrhagic shock is caused by rapid loss of a significant blood volume, which leads to insufficient blood flow and oxygen delivery to organs and tissues, resulting in severe physiological derangements, organ failure, and death. Physiologic derangements after hemorrhage are due in a large part to the body's strong inflammatory response, which leads to severe immune dysfunction, and secondary complications such as chronic immunosuppression, increased susceptibility to infection, coagulopathy, multiple organ failure, and unregulated inflammation. Immediate management of hemorrhagic shock includes timely control of the source of bleeding, restoring intravascular volume, preferably with whole blood, and prevention of ischemia and organ failure by optimizing tissue oxygenation. However, currently, there are no clinically effective treatments available that can stabilize the immune response to hemorrhage and reinstate homeostatic conditions. In this review, we will discuss what is known about immunologic dysfunction following hemorrhage and potential therapeutic strategies.

Difficulty in financing fracture care in south-western Nigeria: a prospective cohort study of predictors and recommendations for improvement

BACKGROUND

Bone fractures remain a significant global public health issue despite preventive measures, leading to substantial health and economic consequences. Effective treatment options are difficult to access in most sub-Saharan African countries, leading to reliance on unqualified practitioners and resulting in serious complications that worsen poverty. In Nigeria, the main challenge is the need for out-of-pocket payment for healthcare, which is the primary method of health financing. However, anecdotal evidence suggests that some patients find it easier to finance their fracture care than others. This study aimed to identify the factors that predict difficult fracture-care financing among patients treated operatively for long-bone fractures (LBFs) in southwestern Nigeria.

METHODS

The study collected socio-demographic and clinical data on 690 consecutive adult patients with LBFs treated with SIGN nails between July 2014 and June 2024 at a mission teaching hospital in southwestern Nigeria. A literature review and preliminary interviews were conducted with patients, caregivers, and hospital staff to understand potential risk factors for difficult fracture-care financing. The patients were divided into two cohorts - easy fracture-care financing (EF) and difficult fracture-care financing (DF) - based on their promptness in paying the in-patient care bills. Potential risk factors for DF identified in the initial univariate analysis were entered as covariates into a binary logistic regression to determine the significant predictors of DF.

RESULTS

The mean age of the patients was 45.1 years (SD = 17.52). The DF cohort comprised 321 (46.5%) patients. Significant predictors of DF included younger age (p = 0.018), male gender (p = 0.002), lack of formal education or low level of education (p < 0.001), residence in the hospital city (p < 0.001), absence of health insurance (p = 0.013), lack of extended family support (p < 0.001), previous traditional bone setting treatment (p = 0.005), concomitant injury (p = 0.017), and a post-operative hospital stay longer than one week (p = 0.036).

CONCLUSIONS

The findings suggest that improving people's socioeconomic status through job creation, women's empowerment, reduction of gender inequality, higher education, comprehensive health insurance coverage, and stronger family bonds, as well as preventive strategies to reduce the occurrence and severity of injuries, can improve fracture-care financing in low-resource settings.

Resuscitation of adult shocked trauma patients using major haemorrhage protocol guided by viscoelastic haemostatic assays versus formulaic approach

BACKGROUND

The resuscitation of trauma patients with critical bleeding may follow a formulaic approach using high ratios of blood components or a viscoelastic haemostatic assay (VHA) guided approach. The aim of this study was to compare the two strategies for resuscitation of shocked trauma patients.

METHODS

This was a registry-based cohort study including shocked trauma patients from two trauma centres-one practising a formulaic approach, with VHA unavailable during trauma resuscitation and the other practicing a VHA-guided resuscitation strategy. The primary outcome was the total units of blood components transfused in 24 h after adjusting for differences in baseline characteristics and time to death.

RESULTS

Between 01 Jan 2020 and 31 Dec 2022, 152 eligible patients were categorised to the formulaic group and 40 to the VHA group. Prehospital times were longer in the formulaic group (2.0 vs. 1.4 h), and more patients in the VHA group (38% vs. 17%) were transfused prehospital blood components. Formulaic resuscitation was associated with significantly more blood components transfused (adjusted incidence rate ratio 1.5; 95%CI: 1.4-1.7, p < 0.001). Using a formulaic approach, patients were administered more red blood cells, plasma and platelets, but fewer cryoprecipitate. There was no significant association of the formulaic approach with in-hospital mortality (adjusted odds ratio 2.4; 95%CI: 0.7-8.0, p = 0.17).

CONCLUSIONS

Given the cost and potential adverse effects of blood component transfusions, VHA-guided transfusion strategies present an attractive option, particularly among centres managing high volumes of shocked patients. Further trials, enrolling the population most likely to benefit from precision transfusion strategies, are indicated.

Osmotic Demyelination Syndrome in the Setting of Normonatremia: A Case Report and Review of the Literature

Osmotic demyelination syndrome (ODS) is a rare complication associated with rapid sodium changes, typically encountered in patients with severe hyponatremia. ODS in patients with normonatremia (ODSIN) is less recognized. We describe a patient with MRI-detected ODSIN following neurotrauma and reviewed the relevant literature. We present a 57-year-old female with subdural hematoma following ground-level fall. Her initial sodium was 140 mEq/L but over 2 days, rose 17 mEq/L, peaking at 157 mEq/L. On exam, unexplainable, unexpected left-sided hemiplegia with weakness sparing her face were noted; ODS was suspected. MRI revealed central pontine T2 hyperintensity, T1 hypointensity, and FLAIR hyperintensity. Treatment included gradual lowering of sodium with normal saline and free water. She was discharged to a skilled nursing facility (SNF) with sodium 138 mEq/L and upon 4-year follow-up had moderate disability and required some assistance to support activities of daily living. Our literature search yielded 23 cases (22 normonatremic; 1 where normonatremia progressed to hypernatremia). Common signs/symptoms were hyperreflexia, dysarthria, and gait disturbance. Common comorbidities were alcoholism, dialysis, and renal disease/failure. Cranial MRI confirmed all cases, frequently revealing central pontine T2 and FLAIR hyperintensity and T1 hypointensity. Our review further characterizes the diverse etiologies, clinical course, and radiographic features of ODSIN. Clinicians should consider this diagnosis when neurological symptoms occur even in the setting of normonatremia.

Trauma Program Value Assessment at an Academic Health Network System Over 12 Years

BACKGROUND

Trauma is a leading cause of global death, with 200 000 deaths and over 3 million non-fatal injuries/year in the United States. We aim to assess trauma care value for patients who underwent urgent laparotomies (LAP) and thoracotomies (THO) in our Health Network System.

METHODS

Clinical variables (v = 84) from trauma patients (>18 yo) were retrieved retrospectively (Jan-2010 to July-2016) and prospectively (Aug-2016 to Sept-2021) from a Health System warehouse under IRB-approved protocols. Patients were divided according to their Injury Severity Score (ISS) into mild/moderate cases (ISS <15) and severe cases (ISS >15). Value was assessed using quality and cost domains. Quality surrogates included graded postoperative complications (PCs), length of stay (LOS), 30-day readmission (RA), patient satisfaction (PS), and textbook (TB) cases. Total charges (TCs) and reimbursement index (RI) were included as surrogates for cost. Value domains were displayed in scorecards comparing Observed (O) with Expected (E) (using the ACS risk calculator) outcomes. Uni-/multivariate analyses were performed using SPSS.

RESULTS

41,927 trauma evaluations were performed, leading to 16 044 admissions, with 528 (3.2%) patients requiring urgent surgical procedures (LAP = 413 and THO = 115). Although the M:F ratio (7:3) was similar in LAP vs THO groups, age and BMI were significantly different (41.8 ± 19.1 vs 51.8 ± 19.9 years, 28.6 ± 9.9 vs 27.4 ± 7 Kg/m2, respectively, P < .05). Blunt trauma was involved in 68.8/77.3% of the LAP/THO procedures, respectively (P < .05). Multivariate analyses showed ISS, age, ASA class, and medical center as factors significantly predicting PC (P < .05). Postoperative complication grades from the LAP/THO groups showed above-average outcomes; nonetheless, LOS was higher than the national averages.

CONCLUSIONS

The Trauma Program holds high value in our Health Network System. Protocols for decreasing LOS are being implemented.

Biomechanical analysis of spinal misalignment during Vehicular extrication maneuvers performed by professional rescue teams

Objective

To compare spinal misalignment and execution time of 3 rescue maneuvers for casualties in traffic accidents.

Materials and methods

Biomechanical analysis using inertial sensors to measure the range of spinal misalignment and execution time of 3 maneuvers: 1) standard manual rescue (SMR); 2) rapid extrication device (RED); 3) extrication device (ED). The sample consisted of 117 rescue professionals (firefighters) from 14 Autonomous Communities in Spain. The total range of motion and the execution time of maneuvers were compared using ANOVA.

Results

The highest range of cervical flexion-extension movement was recorded with RED (30° ± 9°). There were no statistically significant differences between SMR (21° ± 9°) and ED (21° ± 10°). In dorsal flexion-extension, the highest range of movement was with RED (36° ± 10°), followed by ED (30° ± 7°), with the lowest found for SMR (26° ± 11°). RED presented the least restriction of cervical (p < 0.001) and dorsal movement (p < 0.001). The quickest maneuver was SMR (average of 55″), followed by RED (average of 92″), with a considerable difference using ED (average of 225″) (p < 0.001).

Conclusion

The standard manual rescue maneuver (SMR) generated the smallest range of spinal movement and also required the shortest execution time.

Local and Systemic Hemostatic Agents: A Comprehensive Review

Traumatic hemorrhage is the leading preventable cause of death worldwide. Systemic administration of hemostatic agents requires trained personnel and preparation, limiting their use in combat environments and prehospital settings. However, local administration of hemostatic agents may ameliorate these challenges. Currently available hemostatic products are limited by risk of infection, immunogenicity, tissue damage, limited usage and efficacy, high costs, short shelf life, and storage requirements under specific conditions. Future studies should be considered to overcome these limitations and develop effective, multifunctional hemostatic materials for widespread usage. In this review, we will provide an overview of the most commonly used systemic and local hemostatic agents in hemorrhage control.

Machine learning models predict triage levels, massive transfusion protocol activation, and mortality in trauma utilizing patients hemodynamics on admission

BACKGROUND

The effective management of trauma patients necessitates efficient triaging, timely activation of Massive Blood Transfusion Protocols (MTP), and accurate prediction of in-hospital outcomes. Machine learning (ML) algorithms have emerged as up-and-coming tools in the domains of optimizing triage decisions, improving intervention strategies, and predicting clinical outcomes, consistently outperforming traditional methodologies. This study aimed to develop, assess, and compare several ML models for the triaging processes, activation of MTP, and mortality prediction.

METHODS

In a 10-year retrospective study, the predictive capabilities of seven ML models for trauma patients were systematically assessed using on-admission patients' hemodynamic data. All patient's data were randomly divided into training (80 %) and test (20 %) sets. Employing Python for data preprocessing, feature scaling, and model development, we evaluated K-Nearest Neighbors (KNN), Logistic Regression (LR), Decision Tree (DT), Support Vector Machines (SVM) with RBF kernels, Random Forest (RF), Extreme Gradient Boosting (XGBoost), and Artificial Neural Network (ANN). We employed various imputation techniques and addressed data imbalance through down-sampling, up-sampling, and synthetic minority for the over-sampling technique (SMOTE). Hyperparameter tuning, coupled with 5-fold cross-validation, was performed. The evaluation included essential metrics like sensitivity, specificity, F1 score, accuracy, Area Under the Receiver Operating Curve (AUC ROC), and Area Under the Precision recall Curve (AUC PR), ensuring robust predictive capability.

RESULT

This study included 17,390 adult trauma patients; of them, 19.5 % (3385) were triaged at a critical level, 3.8 % (664) required MTP, and 7.7 % (1335) died in the hospital. The model's performance improved using imputation and balancing techniques. The overall models demonstrated notable performance metrics for predicting triage, MTP activation, and mortality with F1 scores of 0.75, 0.42, and 0.79, sensitivities of 0.73, 0.82, and 0.9, and AUC ROC values of 0.89, 0.95 and 0.99 respectively.

CONCLUSION

Machine learning, especially RF models, effectively predicted trauma triage, MTP activation, and mortality. Featured critical hemodynamic variables include shock indices, systolic blood pressure, and mean arterial pressure. Therefore, models can do better than individual parameters for the early management and disposition of patients in the ED. Future research should focus on creating sensitive and interpretable models to enhance trauma care.

Accuracy between prehospital and hospital diagnosis in helicopter emergency medical services and its consequences for trauma care

PURPOSE

For optimal prehospital trauma care, it is essential to adequately recognize potential life-threatening injuries in order to correctly triage patients and to initiate life-saving measures. The aim of the present study was to determine the accuracy of prehospital diagnoses suspected by helicopter emergency medical services (HEMS).

METHODS

This retrospective multicenter study included patients from the Swiss Trauma Registry with ISS ≥ 16 or AIS head ≥ 3 transported by Switzerland's largest HEMS and subsequently admitted to one of twelve Swiss trauma centers from 01/2020 to 12/2020. The primary outcome was the comparison of injuries suspected prehospital with the final diagnoses obtained at the hospital using the abbreviated injury scale (AIS) per body region. As secondary outcomes, prehospital interventions were compared to corresponding relevant diagnoses.

RESULTS

Relevant head trauma was the most commonly injured body region and was identified in 96.3% (95% CI: 92.1%; 98.6%) of the cases prehospital. Relevant injuries to the chest, abdomen, and pelvis were also common but less often identified prehospital [62.7% (95% CI: 54.2%; 70.6%), 45.5% (95% CI: 30.4%; 61.2%), and 61.5% (95% CI: 44.6%; 76.6%)]. Overall, 7 of 95 (7.4%) patients with pneumothorax received a chest decompression and in 22 of 39 (56.4%) patients with an instable pelvic fracture a pelvic binder was applied prehospital.

CONCLUSION

Approximately half of severe chest, abdominal, and pelvic diagnoses made in hospital went undetected in the challenging prehospital environment. This underlines the difficult circumstances faced by the rescue teams. Potentially life-saving interventions such as prehospital chest decompression and increased use of a pelvic binder were identified as potential improvements to prehospital care.

Traumatic bleeding and mortality in mice are intensified by iron deficiency anemia and can be rescued with tranexamic acid

Background

Clinical evidence suggests that anemia exacerbates traumatic bleeding and worsens outcomes.

Objectives

To study the influence of iron deficiency anemia on traumatic bleeding, coagulopathy, and mortality.

Methods

C57BL/6J mice received an iron-deficient diet (8 weeks; ±1 mg intraperitoneal iron dextran 2 weeks before trauma). Control mice received a normal diet. Iron deficiency anemia was confirmed by hematocrit, red cell indices, and liver iron. Mice received saline or tranexamic acid (TXA; 10 mg/kg) just before liver laceration. Blood loss, coagulopathy (activated partial thromboplastin time, factor [F]II, FV, FVIII, FX, and fibrinogen), D-dimer, thrombin-antithrombin complexes, and plasmin-alpha-2-antiplasmin complexes were analyzed at 15 and 60 minutes, and a cytokine panel was performed at 60 minutes and 6 hours after trauma. Survival was monitored for 7 days.

Results

Compared with nonanemic mice, anemic mice had lower hematocrit and hepatic iron content. Anemic mice experienced higher blood loss compared with nonanemic mice, which was reduced by TXA. Both groups developed traumatic coagulopathy characterized by activated partial thromboplastin time prolongation, thrombin-antithrombin complex formation, and depletion of FV, FVIII, and fibrinogen. TXA corrected the coagulopathy. However, plasmin-alpha-2-antiplasmin complex formation and D-dimers, markers of fibrinolysis, were higher in anemic mice and were not corrected by TXA. Seven-day survival was low in anemic mice, and rescued by TXA, but high in nonanemic mice without additional improvement by TXA. Among cytokines, only interleukin-6 increased, which was prevented by TXA most notably in anemic mice.

Conclusion

These observations provide first and critical proof-of-principle evidence that anemia accelerates traumatic bleeding and increases mortality, which could be rescued by anemia correction (parenteral iron) or periprocedural TXA.

Standard or Fin SIGN® nail? which option is better for the treatment of femoral fractures in low and middle-income countries?

PURPOSE

Femoral fractures are common in low and middle-income countries (LMIC), predominantly caused by high-energy trauma. The surgical implant generation network (SIGN®) program offers two different intramedullary nails in LMIC which are designed to be used without image intensifier free of charge for the patients: the SIGN standard nail (SSN®) and the SIGN Fin nail (SFN®). This study aimed to compare the results of the SSN® and the SFN® for the treatment of middle and distal shaft femoral fractures through a retrograde approach.

MATERIAL AND METHODS

This was a retrospective, descriptive, and non-experimental study including all consecutive patients who underwent surgical management of middle or distal shaft femoral fracture between January 2017 and May 2022 in an NGO hospital located in Freetown, Sierra Leone. The duration of surgery, type of reduction, complications like screw loosening, implant migration, anterior knee pain and non-union rate at six months of follow up were evaluated.

RESULTS

A total of 122 patients were included in the study. Group A: 60 patients were managed with SSN® and Group B: 62 patients with SFN®. The mean operative time was 104 min with SSN® and 78 with SFN® (p < 0.001). Open reduction of the fracture was necessary in ten (16.7%) patients with SSN® and 12 (19.4%) patients treated with SFN® (p = 0.69). Non-union was observed in one (1.7%) patient with SSN® and two (3.2%) patients with SFN® (p = 0.57).

CONCLUSIONS

Both options seem equally effective in treating midshaft and distal femoral shaft fractures. The SFN® reduces the surgical time, due to this fact, in polytraumatized patients, patients with bilateral femur fracture or patients with ipsilateral tibia fracture, it can be considered as the best option to be used. There was no statistical difference in the complications presented by the two groups.

Acil servis tanıları ile paramediklerin ilk değerlendirme tanılarının karşılaştırılması

BACKGROUND

This study aims to evaluate the accuracy and quality of prehospital assessments and preliminary diagnoses made by Emergency Medical Services (EMS) providers compared to the final diagnoses given by Emergency Department physicians in a metropolitan area.

METHODS

This retrospective observational study utilized records from the Yenimahalle EMS Command Center in Ankara, Türkiye, from January 1, 2021, to December 31, 2022. Data were recorded as cases rather than individual patients, with repeated EMS admissions counted separately. Cases were categorized by EMS call time, reasons for EMS requests, age, gender, nationality, and weekday of hospital arrival to assess socioeconomic impacts and congestion patterns. The study included 2.528 pediatric cases, excluding patients aged 18 and older, those who refused EMS transfer, and cases resolved at the scene. Data analysis was conducted using IBM SPSS 27.0, with statistical significance set at p<0.05.

RESULTS

The study included 2.528 cases. The data revealed that EMS providers had an average of 9.9±4.7 years of experience. In 1.839 cases (72.7%), the EMS provider was female, and in 689 cases (27.3%), the EMS provider was male. Patients had an average age of 9.2±5.8 years, with 1.173 (46.4%) being female and 1.355 (53.6%) being male. Preliminary diagnosis accuracy was higher in cases involving younger and male patients. Additionally, a lower preliminary diagnosis accuracy rate was observed during office hours (08: 00-15: 59) compared to non-office hours (16: 00-23: 59). The majority of EMS calls were for medical reasons (1,783 cases, 70.5%), followed by trauma-related calls (745 cases, 29.5%).

CONCLUSION

This study highlights the need for improved on-field training for EMS providers to enhance the accuracy and quality of prehospital assessments and preliminary diagnoses. The findings suggest that younger and male patients have higher preliminary diagnosis accuracy rates, and there is a noticeable decrease in accuracy during office hours, indicating potential areas for targeted training and protocol adjustments.

Using the Kirkpatrick Model to Evaluate the Effect of a Primary Trauma Care Course on Health Care Workers' Knowledge, Attitude, and Practice in Two Vietnamese Local Hospitals: Prospective Intervention Study

Background

The Primary Trauma Care (PTC) course was originally developed to instruct health care workers in the management of patients with severe injuries in low- and middle-income countries (LMICs) with limited medical resources. PTC has now been taught for more than 25 years. Many studies have demonstrated that the 2-day PTC workshop is useful and informative to frontline health staff and has helped improve knowledge and confidence in trauma management; however, there is little evidence of the effect of the course on changes in clinical practice. The Kirkpatrick model (KM) and the knowledge, attitude, and practice (KAP) model are effective methods to evaluate this question.

Objective

The aim of this study was to investigate how the 2-day PTC course impacts the satisfaction, knowledge, and skills of health care workers in 2 Vietnamese hospitals using a conceptual framework incorporating the KAP model and the 4-level KM as evaluation tools.

Methods

The PTC course was delivered over 2 days in the emergency departments (EDs) of Thanh Hoa and Ninh Binh hospitals in February and March 2022, respectively. This study followed a prospective pre- and postintervention design. We used validated instruments to assess the participants' satisfaction, knowledge, and skills before, immediately after, and 6 months after course delivery. The Fisher exact test and the Wilcoxon matched-pairs signed rank test were used to compare the percentages and mean scores at the pretest, posttest, and 6-month postcourse follow-up time points among course participants.

Results

A total of 80 health care staff members attended the 2-day PTC course and nearly 100% of the participants were satisfied with the course. At level 2 of the KM (knowledge), the scores on multiple-choice questions and the confidence matrix improved significantly from 60% to 77% and from 59% to 71%, respectively (P<.001), and these improvements were seen in both subgroups (nurses and doctors). The focus of level 3 was on practice, demonstrating a significant incremental change, with scenarios checklist points increasing from a mean of 5.9 (SD 1.9) to 9.0 (SD 0.9) and bedside clinical checklist points increasing from a mean of 5 (SD 1.5) to 8.3 (SD 0.8) (both P<.001). At the 6-month follow-up, the scores for multiple-choice questions, the confidence matrix, and scenarios checklist all remained unchanged, except for the multiple-choice question score in the nurse subgroup (P=.005).

Conclusions

The PTC course undertaken in 2 local hospitals in Vietnam was successful in demonstrating improvements at 3 levels of the KM for ED health care staff. The improvements in the confidence matrix and scenarios checklist were maintained for at least 6 months after the course. PTC courses should be effective in providing and sustaining improvement in knowledge and trauma care practice in other LMICs such as Vietnam.

Trauma centers: an underfunded but essential asset to the community

Research indicates that specialized trauma centers, especially those of level I and II designation, can generate revenue if financial support is provided, and most importantly provide better outcomes for an injured patient by reducing length of stay and mortality when compared with treatment at hospitals without trauma center designation. Costs associated with trauma center operation have risen over the past few years in association with growing patient volumes and inflation. Documentation regarding costs for trauma center operations is sparse, and there exists a large variance between reported numbers based on their region. In most cases, the greatest proportion of funds are spent on clinical personnel while the smallest fraction is dedicated to educational and prevention programs. Studies confirm that as a product of these rising costs and a lack of state and federal funding that trauma centers remain uniquely financially vulnerable. Multiple strategies have been implemented to mitigate these costs but have proven insufficient. Legislations providing patients with expanded access to healthcare such as the Affordable Healthcare Act have failed to deliver on their intended purposes, and managed care organizations have moved to protect their own interest at the expense of trauma patient mortality. In lieu of concerted federal support, states and municipalities have explored solutions to support trauma centers such as small fees added to fines or encouraging charitable donations, although these programs have not seen ubiquitous implementation. Most trauma centers have begun incorporating activation costs to recoup losses from their low reimbursement rate, but these have continued to inflate, and pose a growing burden on vulnerable patients. Lack of funding from external sources such as state or federal appropriations poses a tangible threat to trauma centers for closure, and with multiple trauma centers acting as critical pillars of healthcare infrastructure for disadvantaged communities as well as the impact of this lack of funding being so broad and systemic, multiple 'trauma deserts' may emerge, leaving communities-especially disadvantaged communities which rely on the safety-net function of many high designation trauma centers-deprived of an essential treatment resource and increasing annual mortalities that could have otherwise been averted.

Novel high molecular weight polymerized hemoglobin in a non-obese model of cardiovascular and metabolic dysfunction

The widespread adoption of high-calorie, high-fat, high-sucrose diets (HFHSD) has become a global health concern, particularly due to their association with cardiovascular diseases and metabolic disorders. These comorbidities increase susceptibility to severe outcomes from viral infections and trauma, with trauma-related incidents significantly contributing to global mortality rates. This context underscores the critical need for a reliable blood supply. Recent research has focused on high molecular weight (MW) polymerized human hemoglobin (PolyhHb) as a promising alternative to red blood cells (RBCs), showing encouraging outcomes in previous studies. Given the overlap of metabolic disorders and trauma-related health issues, it is crucial to assess the potential toxicity of PolyhHb transfusions, particularly in models that represent these vulnerable populations. This study evaluated the effects of PolyhHb exchange transfusion in guinea pigs that had developed metabolic disorders due to a 12-week HFHSD regimen. The guinea pigs, underwent a 20 % blood volume exchange transfusion with either PolyhHb or the lower molecular weight polymerized bovine hemoglobin, Oxyglobin. Results revealed that both PolyhHb and Oxyglobin transfusions led to liver damage, with a more pronounced effect observed in HFHSD-fed animals. Additionally, markers of cardiac dysfunction indicated signs of cardiac injury in both the HFHSD and normal diet groups following the Oxyglobin transfusion. This study highlights how pre-existing metabolic disorders can exacerbate the potential side effects of hemoglobin-based oxygen carriers (HBOCs). Importantly, the newer generation of high MW PolyhHb showed lower cardiac toxicity compared to the earlier generation low MW PolyhHb, known as Oxyglobin, even in models with pre-existing endothelial and metabolic challenges.

Evaluation of Current and Future Medical Staff Knowledge on the Course of Trauma Patient Management

INTRODUCTION

Management of injuries, especially in life-threatening situations, is critical to morbidity and mortality for trauma patients. The qualifications of medical staff and students in medicine, emergency medical services, and nursing help to ensure consistent, high-quality care for patients. The study aimed to assess the knowledge of our staff and learners in the management of trauma patients.

MATERIAL AND METHODS

The study was carried out using a proprietary research tool consisting of 47 questions, including six independent variables. The knowledge assessment tool has been divided into five categories according to the degree of difficulty. The questions have been created based on the current guidelines of the ERC 2021, ITLS, PTLS, and TCCC.

RESULTS

The study included 295 subjects (medical students, nursing students, students of emergency medical services, physicians, paramedics, and nurses). The vast majority of respondents (79.7%) have never participated in a certified trauma course. Respondents could obtain a total of 117 points for answering all questions. The highest score was 111 points, and the lowest was 26 points. The average score was 63 points. Paramedics received the highest average score of 78 points. The question with the smallest number of correct answers concerned the priority procedure in the case of an electric shock victim.

CONCLUSION

Better training in trauma patient management is needed for both current medical staff and students. A certified trauma course is a good source of knowledge and skills, but it would need to be repeated periodically. This would ensure an increase in the competence of medical staff involved in the care of trauma patients.

Microbubble Contrast Agents Improve Detection of Active Hemorrhage

Assessment of trauma-induced hemorrhage with ultrasound is particularly challenging outside of the clinic, where its detection is crucial. The current clinical standard for hematoma detection - the focused assessment with sonography of trauma (FAST) exam - does not aim to detect ongoing blood loss, and thus is unable to detect injuries of increasing severity. To enhance detection of active bleeding, we propose the use of ultrasound contrast agents (UCAs), together with a novel flow phantom and contrast-sensitive processing techniques, to facilitate efficient, practical characterization of internal bleeding. Within a the custom phantom, UCAs and processing techniques enabled a significant enhancement of the hemorrhage visualization (mean increase in generalized contrast-to-noise ratio of 17%) compared to the contrast-free case over a range of flow rates up to 40 ml/min. Moreover, we have shown that the use of UCAs improves the probability of detection: the area under the receiver operating characteristic curve for a flow rate of 40 ml/min was 0.99, compared to 0.72 without contrast. We also demonstrate how additional processing of the spatial and temporal information further localizes the bleeding site. UCAs also enhanced Doppler signals over the non-contrast case. These results show that specialized nonlinear processing (NLP) pipelines together with UCAs may offer an efficient means to improve substantially the detection of slower hemorrhages and increase survival rates for trauma-induced injury in pre-hospital settings.

Impact of comorbidities in severely injured patients with blunt chest injury: A population-based retrospective cohort study

INTRODUCTION

Blunt chest injuries result in up to 10 % of major trauma admissions. Comorbidities can complicate recovery and increase the mortality rate in this patient cohort. A better understanding of the association between comorbidities and patient outcomes will facilitate enhanced models of care for particularly vulnerable groups of patients, such as older adults.

AIMS

i) compare the characteristics of severely injured patients with blunt chest injury with and without comorbidities and ii) examine the relationship between comorbidities and key patient outcomes: prolonged length of stay, re-admission within 28 days, and mortality within 30 days in a cohort of patients with blunt chest injury admitted after severe trauma.

METHODS

A retrospective cohort study using linked data from the NSW Trauma Registry and NSW mortality and hospitalisation records between 1st of January 2012 and 31st of December 2019.

RESULTS

After adjusting for potential confounding factors, patients with severe injuries, chest injuries, and comorbidities were found to have a 34 % increased likelihood of having a prolonged length of stay (OR = 1.34, 95 %I = 1.17-1.53) compared to patients with no comorbidities. There was no difference in 30-day mortality for patients with a severe chest injury who did or did not have comorbidities (OR = 1.05, 95 %CI = 0.80-1.39). No significant association was found between comorbidities and re-admission within 28 days.

CONCLUSION

Severely injured patients with blunt chest injury and comorbidities are at risk of prolonged length of stay.

Enhancing Cranio-Maxillofacial Fracture Care in Low- and Middle-Income Countries: A Systematic Review

Background: Cranio-maxillofacial (CMF) injuries represent a significant challenge in low- and middle-income countries (LMICs), exacerbated by inadequate infrastructure, resources, and training. This systematic review aims to evaluate the current strategies and solutions proposed in the literature to improve CMF fracture care in LMICs, focusing on education, patient transfer, and off-label solutions. Methods: A comprehensive literature search was conducted using PubMed/Medline from January 2000 to June 2023. Studies were selected based on the Preferred Reporting Items for Systematic Review and Meta-analysis Statement (PRISMA). Solutions were categorized into three main areas: education (digital and on-site teaching, fellowships abroad), patient transfer to specialized clinics, and off-label/non-operative solutions. Results: Twenty-three articles were included in the review, revealing a consensus on the necessity for enhanced education and training for local surgeons as the cornerstone for sustainable improvements in CMF care in LMICs. Digital platforms and on-site teaching were identified as key methods for delivering educational content. Furthermore, patient transfer to specialized national clinics and innovative off-label techniques were discussed as immediate solutions to provide quality care despite resource constraints. Conclusions: Effective CMF fracture care in LMICs requires a multifaceted approach, prioritizing the education and training of local healthcare professionals, facilitated patient transfer to specialized centers, and the adoption of off-label solutions to leverage available resources. Collaborative efforts between international organizations, local healthcare providers, and educational institutions are essential to implement these solutions effectively and improve patient outcomes in LMICs.

Breaking barriers in trauma research: A narrative review of opportunities to leverage veterinary trauma for accelerated translation to clinical solutions for pets and people

Trauma is a common cause of morbidity and mortality in humans and companion animals. Recent efforts in procedural development, training, quality systems, data collection, and research have positively impacted patient outcomes; however, significant unmet need still exists. Coordinated efforts by collaborative, translational, multidisciplinary teams to advance trauma care and improve outcomes have the potential to benefit both human and veterinary patient populations. Strategic use of veterinary clinical trials informed by expertise along the research spectrum (i.e., benchtop discovery, applied science and engineering, large laboratory animal models, clinical veterinary studies, and human randomized trials) can lead to increased therapeutic options for animals while accelerating and enhancing translation by providing early data to reduce the cost and the risk of failed human clinical trials. Active topics of collaboration across the translational continuum include advancements in resuscitation (including austere environments), acute traumatic coagulopathy, trauma-induced coagulopathy, traumatic brain injury, systems biology, and trauma immunology. Mechanisms to improve funding and support innovative team science approaches to current problems in trauma care can accelerate needed, sustainable, and impactful progress in the field. This review article summarizes our current understanding of veterinary and human trauma, thereby identifying knowledge gaps and opportunities for collaborative, translational research to improve multispecies outcomes. This translational trauma group of MDs, PhDs, and DVMs posit that a common understanding of injury patterns and resulting cellular dysregulation in humans and companion animals has the potential to accelerate translation of research findings into clinical solutions.

Non-operative management of high-grade splenic injury: a systematic review protocol

OBJECTIVE

The objective of this review is to establish whether embolization is more effective than clinical observation for adult patients with grade III-V splenic injuries. The findings will be used to guide future practice and, if necessary, inform future research design and conduct.

INTRODUCTION

The spleen is one of the most frequently injured intra-abdominal organs, with a reported adult mortality of 7% to 18% following trauma. Non-operative management has become a standard of care for hemodynamically stable patients. In clinical practice, the decision whether to prophylactically embolize or manage high-grade injuries with observation alone remains controversial.

INCLUSION CRITERIA

Sources including adult patients with grade III-V splenic injuries secondary to blunt trauma will be included in this review. Eligible studies must include comparisons between 2 cohorts of patients undergoing either prophylactic embolization or clinical observation only. Outcomes will include mortality rate, failure of treatment, intensive care unit admission, length of hospital stay, blood transfusion requirements, and patient satisfaction.

METHODS

A systematic review with meta-analysis will be conducted. PubMed, Embase, and CINAHL will be searched for eligible studies, as will trial registries and sources of gray literature. Study selection, quality appraisal, and data extraction of outcomes will be performed in duplicate. Methodological quality will be evaluated using JBI critical appraisal tools. Studies will, where possible, be pooled in statistical meta-analysis. A random effects model will be used and statistical analysis will be performed. The certainty of the findings will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

REVIEW REGISTRATION

PROSPERO CRD42023420220.

Usefulness of external fixation and reverse Sural fasciocutaneous flap: Treatment of grade III B open tibial fractures in resource-limited settings

PURPOSE

Sierra Leone is a low-income country located on the west coast of Africa where the majority of the population does not have free access to emergency medical and surgical services, the principal cause of open tibia fractures is motorcycle collision. Open fractures of the middle and distal third of the tibial segments, particularly those classified as type III B, represent a challenge for orthopedic surgeons because of the loss of soft tissue coverage. The Reverse Sural Fasciocutaneous Flap (RSFF) has been shown to be an ideal and reproducible option for the treatment of soft tissue defects. The main aim of this study was to demonstrate the experience in Resource Limited Settings (RLS) by means of a short series of the efficacy of using a combination of external fixation and RSFF in the treatment of grade III B open tibia fractures where plastic surgeons were not available.

METHODS

This retrospective, descriptive, and non-experimental study included 8 patients who underwent surgical intervention between September 2020 and September 2021.

RESULTS

The skin defects were of various sizes; the smallest size was 4 × 7 cm, and the biggest size of 12 × 18 cm. We obtained a success rate in seven of the eight cases.

CONCLUSIONS

External fixation and reverse sural fasciocutaneous sural flap are excellent therapeutic options for the treatment of open grade III B diaphyseal and metaphyseal distal tibial fractures.

Effects of Transport to Trauma Centers on Survival Outcomes Among Severe Trauma Patients in Korea: Nationwide Age-Stratified Analysis

BACKGROUND

Previous studies showed that the prognosis for severe trauma patients is better after transport to trauma centers compared to non-trauma centers. However, the benefit from transport to trauma centers may differ according to age group. The aim of this study was to compare the effects of transport to trauma centers on survival outcomes in different age groups among severe trauma patients in Korea.

METHODS

Cross-sectional study using Korean national emergency medical service (EMS) based severe trauma registry in 2018-2019 was conducted. EMS-treated trauma patients whose injury severity score was above or equal to 16, and who were not out-of-hospital cardiac arrest or death on arrival were included. Patients were classified into 3 groups: pediatrics (age < 19), working age (age 19-65), and elderly (age > 65). The primary outcome was in-hospital mortality. Multivariable logistic regression analysis was conducted to evaluate the effect of trauma center transport on outcome after adjusting of age, sex, comorbidity, mechanism of injury, Revised Trauma Score, and Injury Severity Score. All analysis was stratified according to the age group, and subgroup analysis for traumatic brain injury was also conducted.

RESULTS

Overall, total of 10,511 patients were included in the study, and the number of patients in each age group were 488 in pediatrics, 6,812 in working age, and 3,211 in elderly, respectively. The adjusted odds ratio (95% confidence interval [CI]) of trauma center transport on in-hospital mortality from were 0.76 (95% CI, 0.43-1.32) in pediatrics, 0.78 (95% CI, 0.68-0.90) in working age, 0.71(95% CI, 0.60-0.85) in elderly, respectively. In subgroup analysis of traumatic brain injury, the benefit from trauma center transport was observed only in elderly group.

CONCLUSION

We found out trauma centers showed better clinical outcomes for adult and elderly groups, excluding the pediatric group than non-trauma centers. Further research is warranted to evaluate and develop the response system for pediatric severe trauma patients in Korea.

Perceived trauma nursing core competency, interprofessional collaborative competency, and associated barriers among regional trauma center nurses

INTRODUCTION

As key members of interprofessional teams working in complex settings, nurses in trauma centers require trauma nursing core competency.

PURPOSE

This study sought to determine the levels and relationships of the perceived importance and performance of trauma nursing core competency, as well as the interprofessional collaborative competency and associated barriers among Korean regional trauma center nurses.

METHODS

This cross-sectional, descriptive, and correlational survey involved a convenience sample of 190 Korean trauma center nurses. Data were collected using a web-based self-reporting questionnaire about the perceived importance and performance of trauma nursing core competency, as well as the interprofessional collaborative competency and associated barriers. Data were analyzed using descriptive statistics, Pearson's correlation, and multiple regression (Enter method) analyses.

RESULTS

The perceived performance and importance of interprofessional collaborative competency, the perceived importance of trauma nursing core competency, and the perceived barriers to resources, training, competency, and interest significantly affected trauma nursing core competency performance, accounting for 64.5 % of the variance.

CONCLUSIONS

Training programs are needed to improve the core and interprofessional collaborative competencies of trauma nurses. Individual, team, and organizational approaches are essential to addressing the perceived barriers. The effects of training programs on the core competency of trauma nurses should be validated.

Validation of the 35-mm rule in traumatic pneumothorax in an Asian population

OBJECTIVES

Thoracic injury crucially threatens human health. Recent studies have suggested using computed tomography (CT) to observe traumatic pneumothorax (PTX). However, cross-ethnic validation is required to overcome potential barriers for the global application of this method. This study aimed to validate the 35-mm rule in traumatic PTX in a Korean population.

METHODS

Data from the institutional registry were analyzed, and chest CT images were reviewed. Factors for observation failure were evaluated via logistic regression analysis, and a receiver-operating curve was created to calculate the optimal cutoff value.

RESULTS

In total, 286 participants were included in this study. The average PTX size was 8.2 (3.2-26.5) mm, and 210 of 213 (95.3%) initially observed patients with a PTX size of ≤35 mm successfully completed the safety observation. Multivariate regression analysis revealed that a PTX size of >35 mm is associated with observation failure and suggested a cutoff of 24.5 mm.

CONCLUSION

Most patients with traumatic PTX of ≤35 mm on CT had undergone successful 4-h observation without thoracostomy. Additionally, PTX of >35 mm was an independent risk factor for observation failure. Considering the lower optimal cutoff value and high failure rates observed in this study, the current guidelines need modifications.

Tertiary Trauma Survey on Emergency Department Observational Units: A Systematic Literature Review

In today's competitive world with a fast-paced lifestyle, trauma is on the rise and is globally recognized as the leading cause of mortality, morbidity, and disability. Despite the development of major trauma centers and the introduction of advanced trauma training courses and management guidelines, there remains a substantial risk of missed or delayed diagnosis of injuries with potentially life-changing physical, emotional, and financial implications. The proportion of such incidents is potentially higher in busy emergency departments and developing countries with fewer dedicated major trauma centers or where focused emergency and trauma training and skills development is still in its infancy. In the last decade, tertiary trauma surveys have been recognized as an important re-assessment protocol in reducing such missed injuries or delayed diagnoses in patients involved in major trauma. This naturally leads to the presumption that tertiary trauma surveys could also play an important role in observational medicine. This also brings into question whether a standardized tertiary trauma survey of major trauma patients on emergency observation units could reduce missed injuries, especially in low-income countries with fewer resources and trauma expertise. Thus, the purpose of this systematic literature review is to explore the potential role of tertiary trauma survey as a tool to reducing missed or delayed diagnosis in the emergency observation units and its applicability and feasibility in less-developed healthcare systems and in low- and middle-income countries. A broad-based systematic literature review was conducted to include electronic databases, grey literature, reference lists, and bibliographies using the keywords: tertiary trauma survey, major trauma, observational medicine, emergency observation units, clinical decision unit, adult, missed injuries, and delayed diagnosis. Over 19,000 citations were identified on initial search. Following a review of abstracts, application of inclusion and exclusion criteria, and review of the full article, 19 publications were finally selected for the purpose of this systematic literature review. Current evidence shows a general trend that tertiary trauma surveys performed 24 hours after admission play an important role in identifying injuries missed at the time of initial primary and secondary survey, and its implementation in observational medicine could prove beneficial, especially in resource-depleted healthcare systems.

A comparison study between the Hemorrhage-Arresting Lever-Operated (HALO) tourniquet and the Combat Action Tourniquet (CAT) for the management of exsanguinating extremity hemorrhage

INTRODUCTION

Tourniquets have been demonstrated to reduce preventable deaths due to exsanguination. However, studies have suggested that the Combat Action Tourniquet (CAT®), a popular prehospital device, may have a 19-30 percent failure rate, thus prompting the creation of a new, lever-operated device for exsanguinating extremity hemorrhage. However, the efficacy of this device compared to the CAT has not been reported.

OBJECTIVE

To determine efficacy and ease of use of the Hemorrhage Arresting Lever Operated (HALO®) tourniquet compared to the CAT.

METHODS

This was a prospective crossover observational study where an arterial hemorrhage was created on the right anterior, medial calf of a softly embalmed middle-aged female cadaver. A Kamoer UIP-CK15 continuous high-precision peristaltic pump was sutured to the femoral artery that measured the efflux of simulated bleeding. Participants were given manufacturer instructions for each tourniquet, randomized regarding which device to apply first, and queried about perceived ease of use and preference. All tourniquet applications were timed. Chi-square, McNemar test, t-test, and analysis of variance were used to compare groups. Factors significant in the univariate analysis were used to construct multivariate models of tourniquet success for each device type.

RESULTS

Altogether, 135 participants were enrolled in the study, including 75 (55.5 percent) females, 13 (9.6 percent) ethnic minorities, 51 (37.7 percent) paramedics, 19 (14.1 percent) nurses, and 24 (17.7 percent) with prior military service. A total of 43 (31.8 percent) participants were able to achieve hemorrhage cessation with the HALO but not the CAT, compared with 6 (4.4 percent) of the participants who were able to achieve hemorrhage cessation with the CAT but not the HALO (p < .001). For participants who found the lever of the HALO easy to use, successful application of the HALO was 12.3 times more likely (odds ratio [OR] = 12.3; 95 percent confidence interval [CI]: 1.47-103.05). For those clinicians who applied the HALO properly compared with those who did not, hemorrhage cessation was 34.89 times more likely (OR = 34.89; 95 percent CI: 2.12-575.60). In contrast, there were no statistically significant predictors found for successful CAT -application.

CONCLUSIONS

With minimal practice, results suggest that the HALO tourniquet may be as effective and easier to use than the CAT tourniquet in the presence of exsanguinating lower extremity hemorrhage. Additional research is required for alternate locations and patient types.

Trauma and sexual abuse in children-Epidemiology, challenges, management strategies and prevention in lower- and middle-income countries

Trauma is rising as a cause of morbidity and mortality in lower- and middle-income countries (LMIC). This article describes the Epidemiology, Challenges, Management strategies and prevention of pediatric trauma in lower- and middle-income countries. The top five etiologies for non-intentional injuries leading to death are falls, road traffic injuries, burns, drowning and poisoning. The mortality rate in LMICs is twice that of High-Income Countries (HICs) irrespective of injury severity adjustment. The reasons for inadequate care include lack of facilities, transportation problems, lack of prehospital care, lack of resources and trained manpower to handle pediatric trauma. To overcome these challenges, attention to protocolized care and treatment adaptation based on resource availability is critical. Training in management of trauma helps to reduce the mortality and morbidity in pediatric polytrauma cases. There is also a need for more collaborative research to develop preventative measures to childhood trauma.

Association between trauma triage and time-to-vaso-occlusive events in patients with sickle cell disease after traumatic injury: a retrospective study

Introduction

Sickle cell disease (SCD) is associated with vaso-occlusive events (VOEs) that can lead to disease complications, including early mortality. Given that similar inflammatory responses characterize VOE and traumatic injury, injured patients with SCD may be vulnerable to acute complications. This study is the first to examine whether traumatic injury is associated with increased severity of future VOEs.

Methods

This cohort study was conducted using electronic health record data from an SCD clinic in Western Pennsylvania; 356 patients with SCD from January 2000 to July 2021 were identified via retrospective chart review. 55 patients were eligible based on continuous medical record data spanning 1 year preinjury and postinjury. Patients were sorted into three treatment groups based on injury management: (1) Neither triage to trauma team activation (TTA) nor inpatient admission (Early Discharge), (2) Triage but no inpatient admission (Triage Only), and (3) Triage and In-patient. Outcomes included time from injury to first VOE, annual VOE counts requiring an emergency department (ED) visit, and ED length of stay (LOS) for the first VOE after injury.

Results

Early Discharge individuals experienced a VOE event within 2.93 days of injury, significantly shorter time to event than Triage and In-patient individuals at 52.375 days and Triage Only individuals at 100.16 days (p=0.0058). No difference in annual VOE counts was noted postinjury across all groups. However, a significant increase in VOE LOS preinjury (16.1 hours) to postinjury (77.4 hours) was noted only for the Triage Only group (p=0.038). Cox regression model showed that shortened time to VOE events was marginally associated with TTA status (p=0.06).

Conclusion

Despite minimal changes in long-term VOE outcomes after injury, traumatic injuries may accelerate the time-to-VOE among the Early Discharge group. Therefore, future research is warranted to analyze whether the absence of postinjury triage assessment and intervention may cause unforeseen physiologic stressors contributing to VOE outcomes.

Level of evidence

Level IV: retrospective case-control study with three negative criteria.

The Use of Prehospital Intensive Care Units in Emergencies-A Scoping Review

BACKGROUND

Amidst a rising tide of trauma-related emergencies, emergency departments worldwide grapple with the challenges of overcrowding and prolonged patient wait times. Addressing these challenges, the integration of prehospital intensive care units has appeared as a promising solution, streamlining trauma care and enhancing patient safety. Nevertheless, the feasibility of such an initiative becomes murky when considered globally. This review delves into the intricacies of prehospital intensive care units' deployment for trauma care, scrutinizing their configurations, operational practices, and the inherent challenges and research priorities.

METHODS

A scoping review was performed for eligible studies. The result was uploaded to the RAYYAN research platform, facilitating simultaneous evaluation of the studies by all researchers.

RESULTS

A total of 42 studies were initially selected. Four studies were duplicates, and 25 studies were unanimously removed as irrelevant. The remaining studies (n = 13) were included in the review, and the outcomes were categorized into diverse subgroups.

CONCLUSIONS

A country's emergency medical services must achieve specific milestones in education, competency, resource availability, and performance to effectively harness the potential of a prehospital intensive care unit. While certain nations are equipped, others lag, highlighting a global disparity in readiness for such advanced care modalities.

Usefulness of the BIG Score in Predicting Massive Transfusion and In-Hospital Death in Adult Trauma Patients

The base deficit (B), international normalized ratio (I), and Glasgow coma scale (GCS) (BIG) score is useful in predicting mortality in pediatric trauma patients; however, studies on the use of BIG score in adult patients with trauma are sparse. In addition, studies on the correlation between the BIG score and massive transfusion (MT) have not yet been conducted. This study aimed to evaluate the predictive value of BIG score for mortality and the need for MT in adult trauma patients. This retrospective study used data collected between 2016 and 2020 at our hospital's trauma center and registry. The predictive value of BIG score was compared with that of the Injury Severity Score (ISS) and Revised Trauma Score (RTS). Logistic regression analysis was carried out to assess whether BIG score was an independent risk factor. Receiver operating characteristic (ROC) curve analysis was performed, and predictive values were evaluated by measuring the area under the ROC curve (AUROC). In total, 5,605 patients were included in this study. In logistic regression analysis, BIG score was independently associated with in-hospital mortality (odds ratio (OR): 1.1859; 95% confidence interval (CI): 1.1636-1.2086) and MT (OR: 1.0802; 95% CI: 1.0609-1.0999). The AUROCs of BIG score for in-hospital mortality and MT were 0.852 (0.842-0.861) and 0.848 (0.838-0.857), respectively. Contrastingly, the AUROCs of ISS and RTS for in-hospital mortality were 0.795 (0.784-0.805) and 0.859 (0.850-0.868), respectively. Moreover, AUROCs of ISS and RTS for MT were 0.812 (0.802-0.822) and 0.838 (0.828-0.848), respectively. The predictive value of BIG score for mortality and MT was significantly higher than that of the ISS. The BIG score also showed a better AUROC for predicting in-hospital mortality compared with RTS. In conclusion, the BIG score is a useful indicator for predicting mortality and the need for MT in adult trauma patients.

The forgotten cohort-lessons learned from prehospital trauma death: a retrospective cohort study

BACKGROUND

Trauma related deaths remain a relevant public health problem, in particular in the younger male population. A significant number of these deaths occur prehospitally without transfer to a hospital. These patients, sometimes termed "the forgotten cohort", are usually not included in clinical registries, resulting in a lack of information about prehospitally trauma deaths. The aim of the present study was to compare patients who died prehospital with those who sustained life-threatening injuries in order to analyze and potentially improve prehospital strategies.

METHODS

This cohort study included all primary operations carried out by Switzerland's largest helicopter emergency medical service (HEMS) between January 1, 2011, and December 31, 2021. We included all adult trauma patients with life-threatening or fatal conditions. The outcome of this study is the vital status of the patient at the end of mission, i.e. fatal or life-threatening. Injury, rescue characteristics, and interventions of the forgotten trauma cohort, defined as patients with a fatal injury (NACA score of VII), were compared with life-threatening injuries (NACA score V and VI).

RESULTS

Of 110,331 HEMS missions, 5534 primary operations were finally analyzed, including 5191 (93.8%) life-threatening and 343 (6.2%) fatal injuries. More than two-thirds of patients (n = 3772, 68.2%) had a traumatic brain injury without a significant difference between the two groups (p > 0.05). Thoracic trauma (44.6% vs. 28.7%, p < 0.001) and abdominal trauma (22.2% vs. 16.1%, p = 0.004) were more frequent in fatal missions whereas pelvic trauma was similar between the two groups (13.4% vs. 12.9%, p = 0.788). Pneumothorax decompression rate (17.2% vs. 3.7%, p < 0.001) was higher in the forgotten cohort group and measures for bleeding control (15.2% vs. 42.7%, p < 0.001) and pelvic belt application (2.9% vs. 13.1% p < 0.001) were more common in the life-threating injury group.

CONCLUSION

Chest decompression rates and measures for early hemorrhage control are areas for potential improvement in prehospital care.

Experimental Models of Traumatic Injuries: Do They Capture the Coagulopathy and Underlying Endotheliopathy Induced by Human Trauma?

Trauma-induced coagulopathy (TIC) is a major cause of morbidity and mortality in patients with traumatic injury. It describes the spectrum of coagulation abnormalities that occur because of the trauma itself and the body's response to the trauma. These coagulation abnormalities range from hypocoagulability and hyperfibrinolysis, resulting in potentially fatal bleeding, in the early stages of trauma to hypercoagulability, leading to widespread clot formation, in the later stages. Pathological changes in the vascular endothelium and its regulation of haemostasis, a phenomenon known as the endotheliopathy of trauma (EoT), are thought to underlie TIC. Our understanding of EoT and its contribution to TIC remains in its infancy largely due to the scarcity of experimental research. This review discusses the mechanisms employed by the vascular endothelium to regulate haemostasis and their dysregulation following traumatic injury before providing an overview of the available experimental in vitro and in vivo models of trauma and their applicability for the study of the EoT and its contribution to TIC.

Surgical load in major fractures - results of a survey on the optimal quantification and timing of surgery in polytraumatized patients

PURPOSE

It is known that the magnitude of surgery and timing of surgical procedures represents a crucial step of care in polytraumatized patients. In contrast, it is not clear which specific factors are most critical when evaluating the surgical load (physiologic burden to the patient incurred by surgical procedures). Additionally, there is a dearth of evidence for which body region and surgical procedures are associated with high surgical burden. The aim of this study was to identify key factors and quantify the surgical load for different types of fracture fixation in multiple anatomic regions.

METHODS

A standardized questionnaire was developed by experts from Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT)-Trauma committee. Questions included relevance and composition of the surgical load, operational staging criteria, and stratification of operation procedures in different anatomic regions. Quantitative values according to a five-point Likert scale were chosen by the correspondents to determine the surgical load value based on their expertise. The surgical load for different surgical procedures in different body regions could be chosen in a range between "1," defined as the surgical load equivalent to external (monolateral) fixator application, and "5," defined as the maximal surgical load possible in that specific anatomic region.

RESULTS

This questionnaire was completed online by 196 trauma surgeons from 61 countries in between Jun 26, 2022, and July 16, 2022 that are members of SICOT. The surgical load (SL) overall was considered very important by 77.0% of correspondents and important by 20.9% correspondents. Intraoperative blood loss (43.2%) and soft tissue damage (29.6%) were chosen as the most significant factors by participating surgeons. The decision for staged procedures was dictated by involved body region (56.1%), followed by bleeding risk (18.9%) and fracture complexity (9.2%). Percutaneous or intramedullary procedures as well as fractures in distal anatomic regions, such as hands, ankles, and feet, were consistently ranked lower in their surgical load.

CONCLUSION

This study demonstrates a consensus in the trauma community about the crucial relevance of the surgical load in polytrauma care. The surgical load is ranked higher with increased intraoperative bleeding and greater soft tissue damage/extent of surgical approach and depends relevantly on the anatomic region and kind of operative procedure. The experts especially consider anatomic regions and the risk of intraoperative bleeding as well as fracture complexity to guide staging protocols. Specialized guidance and teaching is required to assess both the patient's physiological status and the estimated surgical load reliably in the preoperative decision-making and operative staging.

Levelling up: prioritisation of global health

Trauma has been described as "The forgotten pandemic" (Rossiter in Int Orthop 46:3-11, 2022  https://doi.org/10.1007/s00264-021055213-z ) or "The hidden pandemic" (Graham SM, Laubscher M, Lalloo DG, Harrison WJ, Maqungo S in The Surg, 20, 231-236. https://doi.org/10.1016/j.surg.2021.04.005 , 2022). If you add all deaths and disability from all contagious disease including: HIV, TB, malaria and COVID-19 these do not come close to the numbers affected annually from trauma/injury (Rossiter in Int Orthop 46:3-11, 2022; Annual deaths from the WHO Global Health Observatory (25); in: Preventing Injuries and Violence: A Guide for Ministries of Health, WHO, Geneva, 26). Prior to the present pandemic contagious disease received approximately 35% of global healthcare spending, whilst trauma received just 1% (Wesson et al. in Health Policy Plan 29:795-808, 2014). The global healthcare spending on contagious disease in the last two years has doubled and that of trauma has proportionately decreased, highlighting the significant issue of prioritisation of healthcare globally. Trauma is the greatest cause of mortality and morbidity in the 5 to 30 age group (Wesson et al. in Health Policy Plan 29:795-808, 2014). Most of the world lives in a country where the majority of the population are under the age of 35, the working population, who are disproportionately affected by trauma. Investment into trauma/injury could dramatically improve the GDP of that country and the situation of the population ( https://www.thinkglobalhealth.org/article/golden-hour-critical-time-between-life-and-death ). It is also estimated that 5 billion people globally lack "Available Accessible Acceptable & Quality" (the AAAQ framework) Surgical Obstetric Trauma & Anaesthetic (SOTA) (Meara JG et al. in Lancet, 386(9993):569-624. https://doi.org/10.1016/S0140-6736(15)60160-X , 2015). Access to this care is an agreed human right (Price R, Makasa E, Hollands M in World J Surg, 39(9):2115-25. https://doi.org/10.1007/s00268-015-3153-y . PMID: 26239773, 2015). It forms part of the 17 Millennium Sustainable Development Goals from the United Nations to be achieved within 20 years ( https://sdgs.un.org/goals#goals ). By 2014, it was recognised that AAAQ SOTA care was not going to be achieved within the next 5 years and so the G4 Alliance was born with the aim of achieving this by 2030 ( https://www.theg4alliance.org ).

COVID-19 in Vietnam and Its Impact on Road Trauma: Retrospective Study Based on National Data

BACKGROUND

Despite significant improvement in the last decade, road trauma remains a substantial contributor to deaths in Vietnam. The COVID-19 pandemic necessitated public health measures that had an unforeseen benefit on road trauma in high-income countries. We investigate if this reduction was also seen in a low- to middle-income country like Vietnam.

OBJECTIVE

Our aim was to investigate how the COVID-19 pandemic and the government policies implemented in response to it impacted road trauma fatalities in Vietnam. We also compared this impact to other government policies related to road trauma implemented in the preceding 14 years (2007-2020).

METHODS

COVID-19 data were extracted from the Vietnamese Ministry of Health database. Road traffic deaths from 2007 to 2021 were derived from the Vietnamese General Statistical Office. We used Stata software (version 17; StataCorp) for statistical analysis. Poisson regression modeling was used to estimate trends in road fatality rates based on annual national mortality data for the 2007-2021 period. The actual change in road traffic mortality in 2021 was compared with calculated figures to demonstrate the effect of COVID-19 on road trauma fatalities. We also compared this impact to other government policies that aimed to reduce traffic-related fatalities from 2007 to 2020.

RESULTS

Between 2007 and 2020, the number of annual road traffic deaths decreased by more than 50%, from 15.3 to 7 per 100,000 population, resulting in an average reduction of 5.4% per annum. We estimated that the road traffic mortality rate declined by 12.1% (95% CI 8.9-15.3%) in 2021 relative to this trend. The actual number of road trauma deaths fell by 16.4%. This reduction was largely seen from August to October 2021 when lockdown and social distancing measures were in force.

CONCLUSIONS

In 2021, the road traffic-related death reduction in Vietnam was 3 times greater than the trend seen in the preceding 14 years. The public health response to the COVID-19 pandemic in Vietnam was associated with a third of this reduction. It can thus be concluded that government policies implemented to address the COVID-19 pandemic resulted in a 4.3% decrease in road traffic deaths in 2021. This has been observed in high-income countries, but we have demonstrated this for the first time in a low- and middle-income country.