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Havermans RJM, de Jongh MAC, van der Veen AH, Edwards M, Lansink KWW. Recovery to normal vital functions and acid-base status after a severe trauma in Level I versus Level II Trauma Centres. Eur J Trauma Emerg Surg 2024; 50:513-522. [PMID: 38093136 DOI: 10.1007/s00068-023-02390-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 11/02/2023] [Indexed: 04/23/2024]
Abstract
PURPOSE In the Netherlands, approximately 70% of severely injured patients (ISS ≥ 16) are transported directly to a Level I trauma center. This study compared the time needed to return to normal vital parameters and normal acid-base status in severely injured patients and some in-hospital processes in Level I versus Level II trauma centers. METHODS This retrospective cohort study included all adult severely injured patients or adult trauma patients admitted to the intensive care unit between 2015 and 2020 in a Dutch trauma region. The primary endpoint was time until normal vital parameters and acid-base status. Secondary endpoints were complication rate, hospital length of stay, emergency department length of stay, and time until a computed tomography (CT) scan. RESULTS A total of 2345 patients were included. Patients admitted to a Level I trauma center had a significantly higher rate of normalization of vital parameters over time (HR 1.51). There was no significant difference in normalization rate of the acid-base status over time (HR 1.10). In Level I trauma centers, time spent at the emergency department and time until the CT scan was significantly shorter (respectively, β - 38 min and β - 77 min), and the complication rate was significantly lower (OR 0.35). CONCLUSION Severely injured patients admitted to a Level I trauma center require less time to normalize their vital functions. Level I centers are better equipped, resulting in better in-hospital processes with shorter time at the emergency department and shorter time until a CT scan.
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Affiliation(s)
- Roos J M Havermans
- Department of Surgery, ETZ Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands.
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, The Netherlands.
| | - Mariska A C de Jongh
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, The Netherlands
| | | | - Michael Edwards
- Department of Trauma Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Koen W W Lansink
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, The Netherlands
- Department of Trauma Surgery, ETZ Hospital, Tilburg, The Netherlands
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van Wessem KJP, Hietbrink F, Leenen LPH. Early correction of base deficit decreases late mortality in polytrauma. Eur J Trauma Emerg Surg 2024; 50:121-129. [PMID: 36416947 PMCID: PMC10924017 DOI: 10.1007/s00068-022-02174-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Physiology-driven resuscitation has become the standard of care in severely injured patients. This has resulted in a decrease in acute deaths by hemorrhagic shock. With increased survival from hemorrhage, focus shifts towards death later during hospital stay. This population based cohort study investigated the association of initial physiology derangement correction and (late) mortality. METHODS Consecutive polytrauma patients aged > 15 years with deranged physiology who were admitted to a level-1 trauma center intensive care unit (ICU) from 2015 to 2021, and requiring surgical intervention < 24 h were included. Patients who acutely (< 48 h) died were excluded. Demographics, treatment, and outcome parameters were analyzed. Physiology was monitored by serial base deficits (BD) during the first 48 h. Correction of physiology was defined as BD return to normal values. Area under the curve (AUC) of BD in time was used as measurement for the correction of physiological derangement and related to mortality 3-6 days (early), and > 7 days (late). RESULTS Two hundred thirty-five patients were included with a median age of 44 years (70% male), and Injury Severity Score (ISS) of 33. Mortality rate was 16% (71% due to traumatic brain injury (TBI)). Median time to death was 11 (6-17) days; 71% died > 7 days after injury. There was no difference between the single base deficit measurements in the emergency department(ED), operating room (OR), nor ICU between patients who died and those who did not. However, patients who later died were more acidotic at 24 and 48 h after arrival, and had a higher AUC of BD in time. This was independent of time and cause of death. CONCLUSION Early physiological restoration based on serial BD measurements in the first 48 h after injury decreases late mortality.
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Affiliation(s)
- Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Falco Hietbrink
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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van Wessem KJP, Leenen LPH, Houwert RM, Benders KEM, Simmermacher RKJ, van Baal MCPM, de Bruin IGJM, de Jong MB, Nijs SJB, Hietbrink F. Outcome of severely injured patients in a unique trauma system with 24/7 double trauma surgeon on-call service. Scand J Trauma Resusc Emerg Med 2023; 31:60. [PMID: 37880795 PMCID: PMC10598943 DOI: 10.1186/s13049-023-01122-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/22/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The presence of in-house attending trauma surgeons has improved efficiency of processes in the treatment of polytrauma patients. However, literature remains equivocal regarding the influence of the presence of in-house attendings on mortality. In our hospital there is a double trauma surgeon on-call system. In this system an in-house trauma surgeon is 24/7 backed up by a second trauma surgeon to assist with urgent surgery or multiple casualties. The aim of this study was to evaluate outcome in severely injured patients in this unique trauma system. METHODS From 2014 to 2021, a prospective population-based cohort consisting of consecutive polytrauma patients aged ≥ 15 years requiring both urgent surgery (≤ 24h) and admission to Intensive Care Unit (ICU) was investigated. Demographics, treatment, outcome parameters and pre- and in-hospital transfer times were analyzed. RESULTS Three hundred thirteen patients with a median age of 44 years (71% male), and median Injury Severity Score (ISS) of 33 were included. Mortality rate was 19% (68% due to traumatic brain injury). All patients stayed ≤ 32 min in ED before transport to either CT or OR. Fifty-one percent of patients who needed damage control surgery (DCS) had a more deranged physiology, needed more blood products, were more quickly in OR with shorter time in OR, than patients with early definitive care (EDC). There was no difference in mortality rate between DCS and EDC patients. Fifty-six percent of patients had surgery during off-hours. There was no difference in outcome between patients who had surgery during daytime and during off-hours. Death could possibly have been prevented in 1 exsanguinating patient (1.7%). CONCLUSION In this cohort of severely injured patients in need of urgent surgery and ICU support it was demonstrated that surgical decision making was swift and accurate with low preventable death rates. 24/7 Physical presence of a dedicated trauma team has likely contributed to these good outcomes.
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Affiliation(s)
- Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - R Marijn Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Kim E M Benders
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Roger K J Simmermacher
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Mark C P M van Baal
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ivar G J M de Bruin
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Mirjam B de Jong
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Stefaan J B Nijs
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Badarni K, Harush N, Andrawus E, Bahouth H, Bar-Lavie Y, Raz A, Roimi M, Epstein D. Association Between Admission Ionized Calcium Level and Neurological Outcome of Patients with Isolated Severe Traumatic Brain Injury: A Retrospective Cohort Study. Neurocrit Care 2023; 39:386-398. [PMID: 36854866 DOI: 10.1007/s12028-023-01687-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/30/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Pathophysiological processes following initial insult are complex and not fully understood. Ionized calcium (Ca++) is an essential cofactor in the coagulation cascade and platelet aggregation, and hypocalcemia may contribute to the progression of intracranial bleeding. On the other hand, Ca++ is an important mediator of cell damage after TBI and cellular hypocalcemia may have a neuroprotective effect after brain injury. We hypothesized that early hypocalcemia might have an adverse effect on the neurological outcome of patients suffering from isolated severe TBI. In this study, we aimed to evaluate the relationship between admission Ca++ level and the neurological outcome of these patients. METHODS This was a retrospective, single-center, cohort study of all patients admitted between January 2014 and December 2020 due to isolated severe TBI, which was defined as head abbreviated injury score ≥ 4 and an absence of severe (abbreviated injury score > 2) extracranial injuries. The primary outcome was a favorable neurological status at discharge, defined by a modified Rankin Scale of 0-2. Multivariable logistic regression was performed to determine whether admission hypocalcemia (Ca++ < 1.16 mmol L-1) is an independent predictor of neurological status at discharge. RESULTS The final analysis included 201 patients. Hypocalcemia was common among patients with isolated severe TBI (73.1%). Most of the patients had mild hypocalcemia (1 < Ca++ < 1.16 mmol L-1), and only 13 (6.5%) patients had Ca++ ≤ 1.00 mmol L-1. In the entire cohort, hypocalcemia was independently associated with higher rates of good neurological status at discharge (adjusted odds ratio of 3.03, 95% confidence interval 1.11-8.33, p = 0.03). In the subgroup of 81 patients with an admission Glasgow Coma Scale > 8, 52 (64.2%) had hypocalcemia. Good neurological status at discharge was recorded in 28 (53.8%) of hypocalcemic patients compared with 14 (17.2%) of those with normal Ca++ (p = 0.002). In multivariate analyses, hypocalcemia was independently associated with good neurological status at discharge (adjusted odds ratio of 6.67, 95% confidence interval 1.39-33.33, p = 0.02). CONCLUSIONS Our study demonstrates that among patients with isolated severe TBI, mild admission hypocalcemia is associated with better neurological status at hospital discharge. The prognostic value of Ca++ may be greater among patients with admission Glasgow Coma Scale > 8. Trials are needed to investigate the role of hypocalcemia in brain injury.
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Affiliation(s)
- Karawan Badarni
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel.
| | - Noi Harush
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Elias Andrawus
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Hany Bahouth
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
- Trauma and Emergency Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Yaron Bar-Lavie
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Aeyal Raz
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
- Department of Anesthesiology, Rambam Health Care Campus, Haifa, Israel
| | - Michael Roimi
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Danny Epstein
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
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Gunning AC, Niemeyer MJS, van Heijl M, van Wessem KJP, Maier RV, Balogh ZJ, Leenen LPH. Inter-rater reliability of the Abbreviated Injury Scale scores in patients with severe head injury shows good inter-rater agreement but variability between countries. An inter-country comparison study. Eur J Trauma Emerg Surg 2023; 49:1183-1188. [PMID: 35974196 PMCID: PMC10229665 DOI: 10.1007/s00068-022-02059-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 07/09/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Substantial difference in mortality following severe traumatic brain injury (TBI) across international trauma centers has previously been demonstrated. This could be partly attributed to variability in the severity coding of the injuries. This study evaluated the inter-rater and intra-rater reliability of Abbreviated Injury Scale (AIS) scores of patients with severe TBI across three international level I trauma centers. METHODS A total 150 patients (50 per center) were randomly selected from each respective trauma registry: University Medical Center Utrecht (UMCU), the Netherlands; John Hunter Hospital (JHH), Australia; and Harborview Medical Center (HMC), the United States. Reliability between coders and trauma centers was measured with the intraclass correlation coefficient (ICC). RESULTS The reliability between the coders and the original trauma registry scores was 0.50, 0.50, and 0.41 in, respectively, UMCU, JHH, and HMC. The AIS coders at UMCU scored the most AIS codes of ≥ 4. Reliability within the trauma centers was substantial in UMCU (ICC = 0.62) and HMC (ICC = 0.78) and almost perfect in JHH (ICC = 0.85). Reliability between trauma centers was 0.70 between UMCU and JHH, 0.70 between JHH and HMC, and 0.59 between UMCU and HMC. CONCLUSION The results of this study demonstrated a substantial and almost perfect reliability of the AIS coders within the same trauma center, but variability across trauma centers. This indicates a need to improve inter-rater reliability in AIS coders and quality assessments of trauma registry data, specifically for patients with head injuries. Future research should study the effect of differences in AIS scoring on outcome predictions.
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Affiliation(s)
- Amy C Gunning
- Department of Trauma Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Menco J S Niemeyer
- Department of Trauma Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Mark van Heijl
- Department of Trauma Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ronald V Maier
- Department of Trauma Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Zsolt J Balogh
- Department of Traumatology and Surgery, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Wiebe LE, Alvesson HM, Stassen W. Companion restrictions in the emergency department during COVID-19: physician perceptions from the Western Cape, South Africa. BMJ Open 2023; 13:e070982. [PMID: 37147101 PMCID: PMC10163331 DOI: 10.1136/bmjopen-2022-070982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES To determine emergency department (ED) physicians' perceptions regarding hospital companions being prohibited from accompanying the patient during COVID-19. DESIGN Two qualitative datasets were combined. Data collected included voice recordings, narrative interviewing and semistructured interviews. A reflexive thematic analysis was conducted and guided by the Normalisation Process Theory. SETTING Six hospital EDs in the Western Cape, South Africa. PARTICIPANTS Convenience sampling was used to recruit a total of eight physicians working full time in the ED during COVID-19. RESULTS The lack of physical companions provided an opportunity for physicians to assess and reflect on a companion's role in efficient patient care. Physicians perceived that the COVID-19 restrictions illuminated that patient companions engaged in the ED as providers contributing to patient care by providing collateral information and patient support, while simultaneously engaging as consumers detracting physicians from their priorities and patient care. These restrictions prompted the physicians to consider how they understand their patients largely through the companions. When companions became virtual, the physicians were forced to shift how they perceive their patient, which included increased empathy. CONCLUSION The reflections of providers can feed into discussions about values within the healthcare system and can help explore the balance between medical and social safety, especially with companion restrictions still being practised in some hospitals. These perceptions illuminate various tradeoffs physicians had to consider throughout the pandemic and may be used to improve companion policies when planning for the continuation of the COVID-19 pandemic and future disease outbreaks.
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Affiliation(s)
- Lauren E Wiebe
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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Non-operative vs. operative treatment for multiple rib fractures after blunt thoracic trauma: a multicenter prospective cohort study. Eur J Trauma Emerg Surg 2023; 49:461-471. [PMID: 36008560 PMCID: PMC9925506 DOI: 10.1007/s00068-022-02093-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/16/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with multiple rib fractures without a clinical flail chest are increasingly being treated with rib fixation; however, high-quality evidence to support this development is lacking. METHODS We conducted a prospective multicenter observational study comparing rib fixation to non-operative treatment in all patients aged 18 years and older with computed tomography confirmed multiple rib fractures without a clinical flail chest. Three centers performed rib fixation as standard of care. For adequate comparison, the other three centers performed only non-operative treatment. As such clinical equipoise formed the basis for the comparison in this study. Patients were matched using propensity score matching. RESULTS In total 927 patients with multiple rib fractures were included. In the three hospitals that performed rib fixation, 80 (14%) out of 591 patients underwent rib fixation. From the nonoperative centers, on average 71 patients were adequately matched to 71 rib fixation patients after propensity score matching. Rib fixation was associated with an increase in hospital length of stay (HLOS) of 4.9 days (95%CI 0.8-9.1, p = 0.02) and a decrease in quality of life (QoL) measured by the EQ5D questionnaire at 1 year of 0.1 (95% CI - 0.2-0.0, p = 0.035) compared to non-operative treatment. A subgroup analysis of patients who received operative care within 72 h showed a similar decrease in QoL. Up to 22 patients (28%) who underwent surgery experienced implant-related irritation. CONCLUSIONS We found no benefits and only detrimental effects associated with rib fixation. Based on these results, we do not recommend rib fixation as the standard of care for patients with multiple rib fractures. TRIAL REGISTRATION Registered in the Netherlands Trial Register NTR6833 on 13/11/2017.
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van Wessem KJP, Niemeyer MJS, Leenen LPH. Polytrauma patients with severe cervical spine injuries are different than with severe TBI despite similar AIS scores. Sci Rep 2022; 12:21538. [PMID: 36513675 PMCID: PMC9747955 DOI: 10.1038/s41598-022-25809-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022] Open
Abstract
Traumatic cervical spine injuries (TCSI) are rare injuries. With increasing age the incidence of TCSI is on the rise. TCSI and traumatic brain injury (TBI) are often associated. Both TCSI and TBI are allocated to the Abbreviated Injury Scale (AIS) head region. However, the nature and outcome of these injuries are potentially different. Therefore, the aim of this study was to investigate the epidemiology, demographics and outcome of severely injured patients with severe TCSI, and compare them with polytrauma patients with severe TBI in the strict sense. Consecutive polytrauma patients aged ≥ 15 years with AIShead ≥ 3 who were admitted to a level-1 trauma center Intensive Care Unit (ICU) from 2013 to 2021 were included. Demographics, treatment, and outcome parameters were analyzed for patients who had AIShead ≥ 3 based on TCSI and compared to patients with AIShead ≥ 3 based on proper TBI. Data on follow-up were collected for TCSI patients. Two hundred eighty-four polytrauma patients (68% male, Injury Severity Score (ISS) 33) with AIShead ≥ 3 were included; Thirty-one patients (11%) had AIShead ≥ 3 based on TCSI whereas 253 (89%) had AIShead ≥ 3 based on TBI. TCSI patients had lower systolic blood pressure in the Emergency Department (ED) and stayed longer in ICU than TBI patients. There was no difference in morbidity and mortality rates. TCSI patients died due to high cervical spine injuries or respiratory insufficiency, whereas TBI patients died primarily due to TBI. TCSI was mainly located at C2, and 58% had associated spinal cord injury. Median follow-up time was 22 months. Twenty-two percent had improvement of the spinal cord injury, and 10% died during follow-up. In this study the incidence of severe TCSI in polytrauma was much lower than TBI. Cause of death in TCSI was different compared to TBI demonstrating that AIShead based on TCSI is a different entity than based on TBI. In order to avoid data misinterpretation injuries to the cervical spine should be distinguished from TBI in morbidity and mortality analysis.
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Affiliation(s)
- Karlijn J. P. van Wessem
- grid.7692.a0000000090126352Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands ,grid.7692.a0000000090126352Department of Trauma Surgery, University Medical Center Utrecht, Suite G04.232, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Menco J. S. Niemeyer
- grid.7692.a0000000090126352Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke P. H. Leenen
- grid.7692.a0000000090126352Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Computed tomographic bone mineral density is independently associated with adverse in-hospital outcomes in Dutch level-1 trauma patients. Eur J Trauma Emerg Surg 2022; 49:1393-1400. [DOI: 10.1007/s00068-022-02175-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 11/11/2022] [Indexed: 11/28/2022]
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Tanizaki S, Toma Y, Miyashita K, Maeda S. The Characteristics of Withdrawal or Withholding of Life-Sustaining Treatment in Severe Traumatic Brain Injury: A Single Japanese Institutional Study. World Neurosurg X 2022; 17:100144. [PMID: 36353247 PMCID: PMC9637969 DOI: 10.1016/j.wnsx.2022.100144] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/27/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES There is little evidence on the factors influencing the decision to withdraw or continue life-sustaining treatment in the setting of severe traumatic brain injury in Japanese institutions. We investigated the factors associated with the withdrawal or withholding of life-sustaining treatment (WLST) for severe traumatic brain injury at a single Japanese institution. METHODS A total of 161 patients with severe traumatic brain injury were retrospectively reviewed. Patient characteristics and injury types were compared between patients with and without the WLST. RESULTS Of the 161 patients, 87 (54%) died and 52 (32%) decided to undergo WLST. In 98% of the WLST cases, the decision was made within 24 h of admission. The mean duration between WLST and death was 2 days. The predicted probabilities for mortality and unfavorable outcomes were highest in patients with WLST within 24 h. Patients with WLST were older and had a higher frequency of falls on the ground, ischemic heart disease, and acute subdural hemorrhage than those without WLST. CONCLUSIONS The decisions of almost all WLST cases were made within 24 h of admission for severe traumatic brain injury in a Japanese institution because of Japanese patients' religious and cultural backgrounds.
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Affiliation(s)
- Shinsuke Tanizaki
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan,To whom correspondence should be addressed: Shinsuke Tanizaki, M.D.
| | - Yasuo Toma
- Department of Neurosurgery, Fukui Prefectural Hospital, Fukui, Japan
| | | | - Shigenobu Maeda
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
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11
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Patch DA, Reed LA, Hao KA, King JJ, Kaar SG, Horneff JG, Ahn J, Strelzow JA, Hebert-Davies J, Little MTM, Krause PC, Johnson JP, Spitler CA. Understanding postoperative rehabilitation preferences in operatively managed proximal humerus fractures: do trauma and shoulder surgeons differ? J Shoulder Elbow Surg 2022; 31:1106-1114. [PMID: 35143996 DOI: 10.1016/j.jse.2021.12.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 12/21/2021] [Accepted: 12/25/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal humerus fractures (PHFs) are common, and their incidence is increasing as the population ages. Despite this, postoperative rehabilitation remains unstandardized and little is known about surgeon preferences. The aim of this study was to assess differences in postoperative rehabilitation preferences and patient education between orthopedic trauma and shoulder surgeons. METHODS An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons to assess differences in postoperative rehabilitation preferences and patient counseling. Descriptive statistics were reported for all respondents, trauma surgeons, and shoulder surgeons. Chi-square and unpaired 2-sample t tests were used to compare responses. Multinomial regression was used to further elucidate the influence of fellowship training independent of confounding characteristics. RESULTS A total of 293 surgeons completed the survey, including 172 shoulder and 78 trauma surgeons. A greater proportion of trauma surgeons preferred an immediate weightbearing status after arthroplasty compared to shoulder surgeons (45% vs. 19%, P = .003), but not after open reduction and internal fixation (ORIF) (62% vs. 75%, P = .412). A greater proportion of shoulder surgeons preferred home exercise therapy taught by the physician or using a handout following reverse shoulder arthroplasty (RSA) (21% vs. 2%, P = .009). A greater proportion of trauma surgeons began passive range of motion (ROM) <2 weeks after 2-part fractures (70% vs. 41%, P < .001). Conversely, a greater proportion of shoulder surgeons began passive ROM between 2 and 6 weeks for 2-part (57% vs. 24%, P < .001) and 4-part fractures (65% vs. 43%, P = .020). On multinomial regression analysis, fellowship training in shoulder surgery was associated with preference for a nonweightbearing duration of >12 weeks vs. 6-12 weeks after ORIF. Similarly, fellowship training in shoulder surgery was associated with increased odds of preferring a nonweightbearing duration of <6 weeks vs. no restrictions and >12 weeks vs. 6-12 weeks after arthroplasty. Training in shoulder surgery was associated with greater odds of preferring a nonweightbearing duration prior to beginning passive ROM of 2-6 weeks vs. <2 weeks or >6 weeks for 2-part fractures, but not 4-part fractures. CONCLUSION Trauma surgeons have a more aggressive approach to rehabilitation following operative PHF repair compared to shoulder surgeons regarding time to weightbearing status and passive ROM. Given the increasing incidence of PHFs and substantial variations in reported treatment outcomes, differences in rehabilitation after PHF treatment should be further evaluated to determine the role it may play in the outcomes of treatment studies.
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Affiliation(s)
- David A Patch
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Logan A Reed
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Scott G Kaar
- Department of Orthopaedic Surgery, Saint Louis University, St Louis, MO, USA
| | - John G Horneff
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jason A Strelzow
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, USA
| | - Jonah Hebert-Davies
- Department of Orthopedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Milton T M Little
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Peter C Krause
- Department of Orthopaedic Surgery, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Joseph P Johnson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
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12
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Mortality in polytrauma patients with moderate to severe TBI on par with isolated TBI patients: TBI as last frontier in polytrauma patients. Injury 2022; 53:1443-1448. [PMID: 35067344 DOI: 10.1016/j.injury.2022.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/07/2021] [Accepted: 01/02/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Mortality caused by Traumatic Brain Injury (TBI) remains high, despite improvements in trauma and critical care. Polytrauma is naturally associated with high mortality. This study compared mortality rates between isolated TBI (ITBI) patients and polytrauma patients with TBI (PTBI) admitted to ICU to investigate if concomitant injuries lead to higher mortality amongst TBI patients. METHODS A 3-year cohort study compared polytrauma patients with TBI (PTBI) with AIS head ≥3 (and AIS of other body regions ≥3) from a prospective collected database to isolated TBI (ITBI) patients from a retrospective collected database with AIS head ≥3 (AIS of other body regions ≤2), both admitted to a single level-I trauma center ICU. Patients <16 years of age, injury caused by asphyxiation, drowning, burns and ICU transfers from and to other hospitals were excluded. Patient demographics, shock and resuscitation parameters, multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), and mortality data were collected and analyzed for group differences. RESULTS 259 patients were included; 111 PTBI and 148 ITBI patients. The median age was 54 [33-67] years, 177 (68%) patients were male, median ISS was 26 [20-33]. Seventy-nine (31%) patients died. Patients with PTBI developed more ARDS (7% vs. 1%, p = 0.041) but had similar MODS rates (18% vs. 10%, p = 0.066). They also stayed longer on the ventilator (7 vs. 3 days, p=<0.001), longer in ICU (9 vs. 4 days, p=<0.001) and longer in hospital (24 vs. 11 days, p=<0.001). TBI was the most prevalent cause of death in polytrauma patients. Patients with PTBI showed no higher in-hospital mortality rate. Moreover, mortality rates were skewed towards ITBI patients (24% vs. 35%, p = 0.06). DISCUSSION There was no difference in mortality rates between PTBI and ITBI patients, suggesting TBI-severity as the predominant factor for ICU mortality in an era of ever improving acute trauma care.
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van Wessem KJP, Leenen LPH, Hietbrink F. Physiology dictated treatment after severe trauma: timing is everything. Eur J Trauma Emerg Surg 2022; 48:3969-3979. [PMID: 35218406 PMCID: PMC9532323 DOI: 10.1007/s00068-022-01916-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/12/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Damage control strategies in resuscitation and (fracture) surgery have become standard of care in the treatment of severely injured patients. It is suggested that damage control improves survival and decreases the incidence of organ failure. However, these strategies can possibly increase the risk of complications such as infections. Indication for damage control procedures is guided by physiological parameters, type of injury, and the surgeon's experience. We analyzed outcomes of severely injured patients who underwent emergency surgery. METHODS Severely injured patients, admitted to a level-1 trauma center ICU from 2016 to 2020 who were in need of ventilator support and required immediate surgical intervention ( ≤24 h) were included. Demographics, treatment, and outcome parameters were analyzed. RESULTS Hundred ninety-five patients were identified with a median ISS of 33 (IQR 25-38). Ninety-seven patients underwent immediate definitive surgery (ETC group), while 98 patients were first treated according to damage control principles with abbreviated surgery (DCS group). Although ISS was similar in both groups, DCS patients were younger, suffered from more severe truncal injuries, were more frequently in shock with more severe acidosis and coagulopathy, and received more blood products. ETC patients with traumatic brain injury needed more often a craniotomy. Seventy-four percent of DCS patients received definitive surgery in the second surgical procedure. There was no difference in mortality, nor any other outcome including organ failure and infections. CONCLUSIONS When in severely injured patients treatment is dictated by physiology into either early definitive surgery or damage control with multiple shorter procedures stretched over several days combined with aggressive resuscitation with blood products, outcome is comparable in terms of complications.
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Affiliation(s)
- Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Darnell D, Areán PA, Dorsey S, Atkins DC, Tanana MJ, Hirsch T, Mooney SD, Boudreaux ED, Comtois KA. Harnessing Innovative Technologies to Train Nurses in Suicide Safety Planning With Hospitalized Patients: Protocol for Formative and Pilot Feasibility Research. JMIR Res Protoc 2021; 10:e33695. [PMID: 34914618 PMCID: PMC8717131 DOI: 10.2196/33695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/15/2021] [Accepted: 10/21/2021] [Indexed: 11/29/2022] Open
Abstract
Background Suicide is the 10th leading cause of death in the United States, with >47,000 deaths in 2019. Most people who died by suicide had contact with the health care system in the year before their death. Health care provider training is a top research priority identified by the National Action Alliance for Suicide Prevention; however, evidence-based approaches that target skill-building are resource intensive and difficult to implement. Advances in artificial intelligence technology hold promise for improving the scalability and sustainability of training methods, as it is now possible for computers to assess the intervention delivery skills of trainees and provide feedback to guide skill improvements. Much remains to be known about how best to integrate these novel technologies into continuing education for health care providers. Objective In Project WISE (Workplace Integrated Support and Education), we aim to develop e-learning training in suicide safety planning, enhanced with novel skill-building technologies that can be integrated into the routine workflow of nurses serving patients hospitalized for medical or surgical reasons or traumatic injury. The research aims include identifying strategies for the implementation and workflow integration of both the training and safety planning with patients, adapting 2 existing technologies to enhance general counseling skills for use in suicide safety planning (a conversational agent and an artificial intelligence–based feedback system), observing training acceptability and nurse engagement with the training components, and assessing the feasibility of recruitment, retention, and collection of longitudinal self-report and electronic health record data for patients identified as at risk of suicide. Methods Our developmental research includes qualitative and observational methods to explore the implementation context and technology usability, formative evaluation of the training paradigm, and pilot research to assess the feasibility of conducting a future cluster randomized pragmatic trial. The trial will examine whether patients hospitalized for medical or surgical reasons or traumatic injury who are at risk of suicide have better suicide-related postdischarge outcomes when admitted to a unit with nurses trained using the skill-building technology than those admitted to a unit with untrained nurses. The research takes place at a level 1 trauma center, which is also a safety-net hospital and academic medical center. Results Project WISE was funded in July 2019. As of September 2021, we have completed focus groups and usability testing with 27 acute care and 3 acute and intensive care nurses. We began data collection for research aims 3 and 4 in November 2021. All research has been approved by the University of Washington institutional review board. Conclusions Project WISE aims to further the national agenda to improve suicide prevention in health care settings by training nurses in suicide prevention with medically hospitalized patients using novel e-learning technologies. International Registered Report Identifier (IRRID) DERR1-10.2196/33695
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Affiliation(s)
- Doyanne Darnell
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Patricia A Areán
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Shannon Dorsey
- Department of Psychology, University of Washington, Seattle, WA, United States
| | - David C Atkins
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Michael J Tanana
- Social Research Institute, University of Utah, Salt Lake City, UT, United States
| | - Tad Hirsch
- College of Arts, Media, and Design, Northeastern University, Boston, MA, United States
| | - Sean D Mooney
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Edwin D Boudreaux
- University of Massachusetts Medical School, Worcester, MA, United States
| | - Katherine Anne Comtois
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
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van Wessem KJP, Jochems D, Leenen LPH. The effect of prehospital tranexamic acid on outcome in polytrauma patients with associated severe brain injury. Eur J Trauma Emerg Surg 2021; 48:1589-1599. [PMID: 34775510 PMCID: PMC8590807 DOI: 10.1007/s00068-021-01827-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/01/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Tranexamic acid (TXA) has shown to be beneficial in selected patients with hemorrhagic shock. Recently, TXA has gained interest in isolated traumatic brain injury (TBI) patients with variable results. There are limited data on TXA in polytrauma with associated TBI. This study investigated the role of TXA in severely injured patients with associated severe TBI. METHODS A 7.5-year prospective cohort study was performed to investigate the relation between prehospital TXA and mortality in consecutive trauma patients with associated severe TBI (Abbreviated Injury Scale (AIS)head ≥ 3) admitted to a Level-1 Trauma Center ICU. Indication for prehospital TXA administration was (suspicion of) hemorrhagic shock, and/or systolic blood pressure (SBP) ≤ 90 mmHg. Demographics, data on physiology, resuscitation, and outcomes were prospectively collected. RESULTS Two hundred thirty-four patients (67% males) with median age of 49 years and ISS 33 (98% blunt injuries) were included. Thirteen patients (6%) developed thromboembolic complications; mortality rate was 24%. Fifty-one percent of patients received prehospital TXA. TXA patients were younger, had more deranged physiology on arrival, and received more crystalloids and blood products ≤ 24 h. There was, however, no difference in overall outcome between TXA patients and no-TXA patients. CONCLUSIONS Despite having a more deranged physiology TXA patients had similar outcome compared to no-TXA patients who were much older. Thromboembolic complication rate was low. Prehospital tranexamic acid has no evident effect on outcome in polytrauma patients with associated critical brain injury.
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Affiliation(s)
- Karlijn J. P. van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Denise Jochems
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Luke P. H. Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Jochems D, van Rein E, Niemeijer M, van Heijl M, van Es MA, Nijboer T, Leenen LPH, Houwert RM, van Wessem KJP. Incidence, causes and consequences of moderate and severe traumatic brain injury as determined by Abbreviated Injury Score in the Netherlands. Sci Rep 2021; 11:19985. [PMID: 34620973 PMCID: PMC8497630 DOI: 10.1038/s41598-021-99484-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 09/08/2021] [Indexed: 11/29/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability. Epidemiology seems to be changing. TBIs are increasingly caused by falls amongst elderly, whilst we see less polytrauma due to road traffic accidents (RTA). Data on epidemiology is essential to target prevention strategies. A nationwide retrospective cohort study was conducted. The Dutch National Trauma Database was used to identify all patients over 17 years old who were admitted to a hospital with moderate and severe TBI (AIS ≥ 3) in the Netherlands from January 2015 until December 2017. Subgroup analyses were done for the elderly and polytrauma patients. 12,295 patients were included in this study. The incidence of moderate and severe TBI was 30/100.000 person-years, 13% of whom died. Median age was 65 years and falls were the most common trauma mechanism, followed by RTAs. Amongst elderly, RTAs consisted mostly of bicycle accidents. Mortality rates were higher for elderly (18%) and polytrauma patients (24%). In this national database more elderly patients who most often sustained the injury due to a fall or an RTA were seen. Bicycle accidents were very frequent, suggesting prevention could be an important aspect in order to decrease morbidity and mortality.
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Affiliation(s)
- Denise Jochems
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Eveline van Rein
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Menco Niemeijer
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Mark van Heijl
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Michael A van Es
- Department of Neurology, University Medical Center Utrecht and de Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Tanja Nijboer
- Department of Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, The Netherlands
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - R Marijn Houwert
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Karlijn J P van Wessem
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
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King KL, Balogh ZJ. Invited Commentary: A Decade Older Polytrauma Patients Do As Well Without As the Younger Ones with Tranexamic Acid. World J Surg 2021; 45:3031-3032. [PMID: 34287662 DOI: 10.1007/s00268-021-06253-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Kate L King
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Locked Bag 1., Hunter Region Mail Centre, Newcastle, NSW, 2310, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Locked Bag 1., Hunter Region Mail Centre, Newcastle, NSW, 2310, Australia.
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18
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van Wessem KJP, Leenen LPH. Does Liberal Prehospital and In-Hospital Tranexamic Acid Influence Outcome in Severely Injured Patients? A Prospective Cohort Study. World J Surg 2021; 45:2398-2407. [PMID: 33914131 PMCID: PMC8083099 DOI: 10.1007/s00268-021-06143-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 12/12/2022]
Abstract
Background Early hemorrhage control is important in trauma-related death prevention. Tranexamic acid (TXA) has shown to be beneficial in patients in hemorrhagic shock, although widespread adoption might result in incorrect TXA administration leading to increased morbidity and mortality. Methods A 7-year prospective cohort study with consecutive trauma patients admitted to a Level-1 Trauma Center ICU was performed to investigate administration of both pre- and in-hospital TXA and its relation to morbidity and mortality. Indication for prehospital and in-hospital TXA administration was (suspicion of) hemorrhagic shock, and/or systolic blood pressure (SBP) ≤ 90 mmHg. Demographics, data on physiology, resuscitation and outcomes were prospectively collected. Results Four hundred and twenty-two patients (71% males, median ISS 29, 95% blunt injuries) were included. Even though TXA patients were more severely injured with more deranged physiology, no differences in outcome were noted. Overall, thrombo-embolic complication rate was 8%. In half the patients, hemorrhagic shock was the indication for prehospital TXA, whereas 79% of in-hospital TXA was given based on suspicion of hemorrhagic shock. Thirteen percent of patients with SBP ≤ 90 mmHg in ED received no TXA at all. Based on SBP alone, 22% of prehospital TXA and 25% of in-hospital TXA were justified. Conclusions Despite being more severely injured, TXA patients had similar outcome compared to patients without TXA. Thrombo-embolic complication rate was low despite liberal use of both prehospital and in-hospital TXA. Caution should be exercised in selecting patients for TXA, although this might be challenging based on SBP alone in patients who do not yet show signs of deranged physiology on arrival in ED. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-021-06143-y.
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Affiliation(s)
- Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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19
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Jakobsen RK, Bonde A, Sillesen M. Assessment of post-trauma complications in eight million trauma cases over a decade in the USA. Trauma Surg Acute Care Open 2021; 6:e000667. [PMID: 33869787 PMCID: PMC8009234 DOI: 10.1136/tsaco-2020-000667] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/11/2021] [Accepted: 03/08/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Trauma is associated with a significant risk of post-trauma complications (PTCs). These include thromboembolic events, strokes, infections, and failure of organ systems (eg, kidney failure). Although care of the trauma patient has evolved during the last decade, whether this has resulted in a reduction in specific PTCs is unknown. We hypothesize that the incidence of PTCs has been decreasing during a 10-year period from 2007 to 2017. METHODS This is a descriptive study of trauma patients originating from level 1, 2, 3, and 4 trauma centers in the USA, obtained via the Trauma Quality Improvement Program (TQIP) database from 2007 to 2017. PTCs documented throughout the time frame were extracted along with demographic variables. Multiple regression modeling was used to associate admission year with PTCs, while controlling for age, gender, Glasgow Coma Scale score, and Injury Severity Score. RESULTS Data from 8 720 026 trauma patients were extracted from the TQIP database. A total of 366 768 patients experienced one or more PTCs. There was a general decrease in the incidence of PTCs during the study period, with the overall incidence dropping from 7.0% in 2007 to 2.8% in 2017. Multiple regression identified a slight decrease in incidence in all PTCs, although deep surgical site infection (SSI), deep venous thrombosis (DVT), and stroke incidences increased when controlled for confounders. DISCUSSION Overall the incidence of PTCs dropped during the 10-year study period, although deep SSI, DVT, stroke, and cardiac arrest increased during the study period. Better risk prediction tools, enabling a precision medicine approach, are warranted to identify at-risk patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Rasmus Kirial Jakobsen
- Department of Surgical Gastroenterology and Transplantation C-TX, Rigshospitalet, Kobenhavn, Denmark
- Center for Surgical Translational and Artificial Intelligence Research (CSTAR), Copenhagen, Denmark
| | - Alexander Bonde
- Department of Surgical Gastroenterology and Transplantation C-TX, Rigshospitalet, Kobenhavn, Denmark
- Center for Surgical Translational and Artificial Intelligence Research (CSTAR), Copenhagen, Denmark
| | - Martin Sillesen
- Department of Surgical Gastroenterology and Transplantation C-TX, Rigshospitalet, Kobenhavn, Denmark
- Center for Surgical Translational and Artificial Intelligence Research (CSTAR), Copenhagen, Denmark
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20
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van Wessem KJP, Leenen LPH. Process related decisions and in-hospital transport times in polytrauma patients benefit from 24/7 in-house presence of trauma surgeons. Injury 2021; 52:189-194. [PMID: 32958341 DOI: 10.1016/j.injury.2020.09.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/31/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Time and cause of death in polytrauma has shifted due to improvements in trauma and critical care. These include logistical improvements with dedicated trauma teams and in-house trauma surgeons. This study investigated in-hospital transport times and influence of process related decisions on mortality in polytrauma patients. STUDY DESIGN A 6.5-year prospective study included consecutive polytrauma patients ≥15 years admitted to a Level-1 Trauma Center ICU with 24/7 in-house trauma surgeons. Demographics, physiologic parameters, pre- and in-hospital transport times were prospectively collected. Data are presented as median(IQR). RESULTS 391 patients were included with median ISS of 29(22-36). 82 patients(21%) had a SBP≤90 mmHg on arrival in ED. 44 patients went from ED directly to OR for urgent surgery, all others had CT prior to OR and/or ICU. Patients who went directly to OR from ED had median transport time of 28(23-37) min. Patients who had CT after ED had median transport time of 31(25-42) min. 74(19%) patients died, majority caused by TBI(70%). Ten patients died <24 h after trauma (4 hemorrhage,3 TBI,2 ischemia,1 cardiac injury), 9 of them went straight to OR from ED. Death could possibly have been prevented in 1 patient (1%) who later died of hemorrhage but went to CT before urgent surgery. CONCLUSION In-hospital transport times from ED were half an hour regardless of the following destination (OR/CT). Decisions for transport order based on clinical signs in primary survey were rapid and accurate. This could be attributed to dedicated trauma teams and 24/7 physical presence of trauma surgeons.
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Affiliation(s)
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Netherlands
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21
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van Wessem KJP, Leenen LPH. Geriatric polytrauma patients should not be excluded from aggressive injury treatment based on age alone. Eur J Trauma Emerg Surg 2020; 48:357-365. [PMID: 33320284 PMCID: PMC7736672 DOI: 10.1007/s00068-020-01567-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 11/25/2020] [Indexed: 12/02/2022]
Abstract
Purpose Age in severely injured patients has been increasing for decades. Older age is associated with increasing mortality. However, morbidity and mortality could possibly be reduced when accurate and aggressive treatment is provided. This study investigated age-related morbidity and mortality in polytrauma including age-related decisions in initial injury management and withdrawal of life-sustaining therapy (WLST). Methods A 6.5-year prospective cohort study included consecutive severely injured trauma patients admitted to a Level-1 Trauma Center ICU. Demographics, data on physiology, resuscitation, MODS/ARDS, and infectious complications were prospectively collected. Patients were divided into age subgroups (< 25, 25–49, 50–69, and ≥ 70 years) to make clinically relevant comparisons. Results 391 patients (70% males) were included with median ISS of 29 (22–36), 95% sustained blunt injuries. There was no difference in injury severity, resuscitation, urgent surgeries, nor in ventilator days, ICU-LOS, and H-LOS between age groups. Adjusted odds of MODS, ARDS and infectious complications were similar between age groups. 47% of patients ≥ 70 years died, compared to 10–16% in other age groups (P < 0.001). WLST increased with older age, contributing to more than half of deaths ≥ 70 years. TBI was the most common cause of death and decision for treatment withdrawal in all age groups. Conclusions Patients ≥ 70 years had higher mortality risk even though injury severity and complication rates were similar to other age groups. WLST increased with age with the vast majority due to brain injury. More than half of patients ≥ 70 years survived suggesting geriatric polytrauma patients should not be excluded from aggressive injury treatment based on age alone. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-020-01567-y.
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Affiliation(s)
- Karlijn J P van Wessem
- Trauma Surgeon, Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Luke P H Leenen
- Professor of Trauma Surgery, Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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22
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van Wessem K, Hietbrink F, Leenen L. Dilemma of crystalloid resuscitation in non-exsanguinating polytrauma: what is too much? Trauma Surg Acute Care Open 2020; 5:e000593. [PMID: 33178897 PMCID: PMC7594544 DOI: 10.1136/tsaco-2020-000593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/25/2020] [Accepted: 09/27/2020] [Indexed: 11/21/2022] Open
Abstract
Background Aggressive crystalloid resuscitation increases morbidity and mortality in exsanguinating patients. Polytrauma patients with severe tissue injury and subsequent inflammatory response without major blood loss also need resuscitation. This study investigated crystalloid and blood product resuscitation in non-exsanguinating polytrauma patients and studied possible adverse outcomes. Methods A 6.5-year prospective cohort study included consecutive trauma patients admitted to a Level 1 Trauma Center intensive care unit (ICU) who survived 48 hours. Demographics, physiologic and resuscitation parameters in first 24 hours, Denver Multiple Organ Failure scores, adult respiratory distress syndrome (ARDS) data and infectious complications were prospectively collected. Patients were divided in 5 L crystalloid volume subgroups (0–5, 5–10, 10–15 and >15 L) to make clinically relevant comparisons. Data are presented as median (IQR); p value <0.05 was considered significant. Results 367 patients (70% men) were included with median age of 46 (28–61) years, median Injury Severity Score was 29 (22–35) and 95% sustained blunt injuries. 17% developed multiple organ dysfunction syndrome (MODS), 4% ARDS and 14% died. Increasing injury severity, acidosis and coagulopathy were associated with more crystalloid administration. Increasing crystalloid volumes were associated with more blood products, increased ventilator days, ICU length of stay, hospital length of stay, MODS, infectious complications and mortality rates. Urgent laparotomy was found to be the most important independent predictor for crystalloid resuscitation in multinominal regression analysis. Further, fresh frozen plasma (FFP) <8 hours was less likely to be administered in patients >5 L compared with the group 0–5 L. With increasing crystalloid volume, the adjusted odds of MODS, ARDS and infectious complications increased 3–4-fold, although not statistically significant. Mortality increased 6-fold in patients who received >15 L crystalloids (p=0.03). Discussion Polytrauma patients received large amounts of crystalloids with few FFPs <24 hours. In patients with <10 L crystalloids, <24-hour mortality and MODS rates were not influenced by crystalloid resuscitation. Mortality increased 6-fold in patients who received >15 L crystalloids ≤24 hours. Efforts should be made to balance resuscitation with modest crystalloids and sufficient amount of FFPs. Level of evidence Level 3. Study type Population-based cohort study.
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Affiliation(s)
- Karlijn van Wessem
- Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke Leenen
- Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Abstract
INTRODUCTION Organ dysfunction remains a major cause of morbidity after trauma. The development of organ dysfunction is determined by the inflammatory response, in which neutrophils are important effector cells. A femoral fracture particularly predisposes for the development of organ dysfunction. This study investigated the chronologic relation between neutrophil characteristics and organ dysfunction in trauma patients with a femoral fracture. METHODS Patients with a femoral fracture presenting at the University Medical Center Utrecht between 2007 and 2013 were included. Data of neutrophil characteristics from standard hematological analyzers were recorded on a daily basis until the 28th day of hospital stay or until discharge. Generalized Estimating Equations were used to compare outcome groups. RESULTS In total 157 patients were analyzed, of whom 81 had polytrauma and 76 monotrauma. Overall mortality within 90 days was 6.4% (n = 10). Eleven patients (7.0%) developed organ dysfunction. In patients who developed organ dysfunction a significant increase in neutrophil count (P = 0.024), a significant increase in neutrophil cell size (P = 0.026), a significant increase in neutrophil complexity (P < 0.004), and a significant decrease in neutrophil lobularity (P < 0.001) were seen after trauma. The rise in neutrophil cell size preceded the clinical manifestation of organ dysfunction in every patient. CONCLUSION Patients who develop organ dysfunction postinjury show changes in neutrophil characteristics before organ dysfunction becomes clinically evident. These findings regarding post-traumatic organ dysfunction may contribute to the development of new prognostic tools for immune-mediated complications in trauma patients. LEVEL OF EVIDENCE Level II, etiologic study.
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The Evaluation of Trauma Care: The Comparison of 2 High-Level Pediatric Emergency Departments in the United States and Turkey. Pediatr Emerg Care 2020; 35:611-617. [PMID: 28419017 DOI: 10.1097/pec.0000000000001110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The purpose of the study is to compare the outcomes of pediatric trauma patients with motor vehicle crashes (MVCs) and motor vehicle versus pedestrian crashes (MPCs) at a level 1 pediatric trauma center in the United States and a pediatric trauma center in Turkey. METHODS The medical records of all pediatric MVC and MPC subjects presenting to the emergency departments (EDs) of a level 3 hospital in Turkey (Izmir Tepecik Training and Research Hospital [ITTRH]) and a level 1 pediatric trauma center in the United States (Children's Medical Center Dallas [CMCD]) over a 1-year period were reviewed. Data that were collected include patient demographics, prehospital report (mechanism of injury, mode of transportation), injury severity score (ISS), abbreviated injury scale score, Glasgow Coma Scale score, ED length of stay, ED interventions, ED and hospital disposition, and mortality. Patients with moderate (ISS, 5-15) and severe (ISS, >15) trauma scores were included in the study. RESULTS One hundred six patient charts from the ITTRH and 125 patient charts from the CMCD with moderate and severe ISS due to MVCs and MPCs were reviewed. Most of the patients were pedestrians (86%) in the ITTRH group and passengers (60%) in the CMCD group. The percentage of patients transferred by ambulance (ground or air) to the CMCD and the ITTRH was 97.9% and 85%, respectively. Fifteen percent of ITTRH patients and 2.1% of CMCD patients arrived by private vehicle. Emergency department arrival ISS and Glasgow Coma Scale were similar between the 2 hospitals (P > 0.05). The overall mortality rate in the study population was 8.8% (11/125) at the CMCD and 4.7% (5/106) at the ITTRH. (P = 0.223). Blood product utilization was significantly higher in the CMCD group compared with the ITTRH group (P = 0.005). The use of hypertonic saline/mannitol/hyperventilation in patients with significant head trauma and increased intracranial pressure was higher in the ITTRH group (P = 0.000). CONCLUSIONS This is the first study that compared pediatric trauma care and outcome at a level 1 pediatric trauma center in the United States and a pediatric hospital in Turkey. Our findings highlight the opportunities to improve pediatric trauma care in Turkey. Specifically, there is a need for national trauma registries, enhanced trauma education, and standardized trauma patient care protocols. In addition, efforts should be directed toward improving prehospital care through better integration within the health care system and physician participation in educating prehospital providers. Data and organized trauma care will be instrumental in system-wide improvement and developing appropriate injury-prevention strategies.
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Hesselink L, Spijkerman R, de Fraiture E, Bongers S, Van Wessem KJP, Vrisekoop N, Koenderman L, Leenen LPH, Hietbrink F. New automated analysis to monitor neutrophil function point-of-care in the intensive care unit after trauma. Intensive Care Med Exp 2020; 8:12. [PMID: 32172430 PMCID: PMC7072076 DOI: 10.1186/s40635-020-0299-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 02/26/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Patients often develop infectious complications after severe trauma. No biomarkers exist that enable early identification of patients who are at risk. Neutrophils are important immune cells that combat these infections by phagocytosis and killing of pathogens. Analysis of neutrophil function used to be laborious and was therefore not applicable in routine diagnostics. Hence, we developed a quick and point-of-care method to assess a critical part of neutrophil function, neutrophil phagosomal acidification. The aim of this study was to investigate whether this method was able to analyze neutrophil functionality in severely injured patients and whether a relation with the development of infectious complications was present. RESULTS Fifteen severely injured patients (median ISS of 33) were included, of whom 6 developed an infection between day 4 and day 9 after trauma. The injury severity score did not significantly differ between patients who developed an infection and patients who did not (p = 0.529). Patients who developed an infection showed increased acidification immediately after trauma (p = 0.006) and after 3 days (p = 0.026) and a decrease in the days thereafter to levels in the lower normal range. In contrast, patients who did not develop infectious complications showed high-normal acidification within the first days and increased tasset to identify patients at risk for infections after trauma and to monitor the inflammatory state of these trauma patients. CONCLUSION Neutrophil function can be measured in the ICU setting by rapid point-of-care analysis of phagosomal acidification. This analysis differed between trauma patients who developed infectious complications and trauma patients who did not. Therefore, this assay might prove a valuable asset to identify patients at risk for infections after trauma and to monitor the inflammatory state of these trauma patients. TRIAL REGISTRATION Central Committee on Research Involving Human Subjects, NL43279.041.13. Registered 14 February 2014. https://www.toetsingonline.nl/to/ccmo_search.nsf/Searchform?OpenForm.
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Affiliation(s)
- Lillian Hesselink
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands.
- Center for Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands.
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.
| | - Roy Spijkerman
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Emma de Fraiture
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Suzanne Bongers
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Karlijn J P Van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Nienke Vrisekoop
- Center for Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Leo Koenderman
- Department of Respiratory Medicine, Wilhelmina Children's Hospital, Lundlaan 6, 3584, EA, Utrecht, the Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Falco Hietbrink
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
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van Wessem KJP, Hietbrink F, Leenen LPH. Attenuation of MODS-related and ARDS-related mortality makes infectious complications a remaining challenge in the severely injured. Trauma Surg Acute Care Open 2020; 5:e000398. [PMID: 32154377 PMCID: PMC7046953 DOI: 10.1136/tsaco-2019-000398] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 01/11/2020] [Accepted: 01/18/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction The recent decrease in multiple organ dysfunction syndrome (MODS)-associated and adult respiratory distress syndrome (ARDS)-associated mortality could be considered a success of improvements in trauma care. However, the incidence of infections remains high in patients with polytrauma, with high morbidity and hospital resources usage. Infectious complications might be a residual effect of the decrease in MODS-related/ARDS-related mortality. This study investigated the current incidence of infectious complications in polytrauma. Methods A 5.5-year prospective population-based cohort study included consecutive severely injured patients (age >15) admitted to a (Level-1) trauma center intensive care unit (ICU) who survived >48 hours. Demographics, physiologic and resuscitation parameters, multiple organ failure and ARDS scores, and infectious complications (pneumonia, fracture-related infection, meningitis, infections related to blood, wound, and urinary tract) were prospectively collected. Data are presented as median (IQR), p<0.05 was considered significant. Results 297 patients (216 (73%) men) were included with median age of 46 (27–60) years, median Injury Severity Score was 29 (22–35), 96% sustained blunt injuries. 44 patients (15%) died. One patient (2%) died of MODS and 1 died of ARDS. 134 patients (45%) developed 201 infectious complications. Pneumonia was the most common complication (50%). There was no difference in physiologic parameters on arrival in emergency department and ICU between patients with and without infectious complications. Patients who later developed infections underwent more often a laparotomy (32% vs 18%, p=0.009), had more often pelvic fractures (38% vs 25%, p=0.02), and received more blood products <8 hours. They had more often MODS (25% vs 13%, p=0.005), stayed longer on the ventilator (10 (5–15) vs 5 (2–8) days, p<0.001), longer in ICU (11 (6–17) vs 6 (3–10) days, p<0.001), and in hospital (30 (20–44) vs 16 (10–24) days, p<0.001). There was however no difference in mortality (12% vs 17%, p=0.41) between both groups. Conclusion 45% of patients developed infectious complications. These patients had similar mortality rates, but used more hospital resources. With low MODS-related and ARDS-related mortality, infections might be a residual effect, and are one of the remaining challenges in the treatment of patients with polytrauma. Level of evidence Level 3. Study type Population-based cohort study.
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Affiliation(s)
- Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Hietbrink F, Houwert RM, van Wessem KJP, Simmermacher RKJ, Govaert GAM, de Jong MB, de Bruin IGJ, de Graaf J, Leenen LPH. The evolution of trauma care in the Netherlands over 20 years. Eur J Trauma Emerg Surg 2019; 46:329-335. [PMID: 31760466 PMCID: PMC7113214 DOI: 10.1007/s00068-019-01273-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/15/2019] [Indexed: 12/14/2022]
Abstract
Introduction In 1999 an inclusive trauma system was initiated in the Netherlands and a nationwide trauma registry, including all admitted trauma patients to every hospital, was started. The Dutch trauma system is run by trauma surgeons who treat both the truncal (visceral) and extremity injuries (fractures). Materials and Methods In this comprehensive review based on previous published studies, data over the past 20 years from the central region of the Netherlands (Utrecht) was evaluated. Results It is demonstrated that the initiation of the trauma systems and the governance by the trauma surgeons led to a region-wide mortality reduction of 50% and a mortality reduction for the most severely injured of 75% in the level 1 trauma centre. Furthermore, major improvements were found in terms of efficiency, demonstrating the quality of the current system and its constructs such as the type of surgeon. Due to the major reduction in mortality over the past few years, the emphasis of trauma care evaluation shifts towards functional outcome of severely injured patients. For the upcoming years, centralisation of severely injured patients should also aim at the balance between skills in primary resuscitation and surgical stabilization versus longitudinal surgical involvement. Conclusion Further centralisation to a limited number of level 1 trauma centres in the Netherlands is necessary to consolidate experience and knowledge for the trauma surgeon. The future trauma surgeon, as specialist for injured patients, should be able to provide the vast majority of trauma care in this system. For the remaining part, intramural, regional and national collaboration is essential
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Affiliation(s)
- Falco Hietbrink
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Roderick M Houwert
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Karlijn J P van Wessem
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rogier K J Simmermacher
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Geertje A M Govaert
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Mirjam B de Jong
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ivar G J de Bruin
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Johan de Graaf
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Loek P H Leenen
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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van Wessem KJP, Leenen LPH. Is chest imaging relevant in diagnosing acute respiratory distress syndrome in polytrauma patients? A population-based cohort study. Eur J Trauma Emerg Surg 2019; 46:1393-1402. [PMID: 31401658 PMCID: PMC7689641 DOI: 10.1007/s00068-019-01204-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 08/05/2019] [Indexed: 11/24/2022]
Abstract
Purpose The definition of acute respiratory distress syndrome (ARDS) has often been modified with Berlin criteria being the most recent. ARDS is divided into three categories based on the degree of hypoxemia using PaO2/FiO2 ratio. Radiological findings are standardized with bilateral diffuse pulmonary infiltrates present on chest imaging. This study investigated whether chest imaging is relevant in diagnosing ARDS in polytrauma patients. Methods The 5-year prospective study included consecutive trauma patients admitted to a Level-1 Trauma Center ICU. Demographics, ISS, physiologic parameters, resuscitation parameters, and ARDS data were prospectively collected. Acute hypoxic respiratory failure (AHRF) was categorized as Berlin criteria without bilateral diffuse pulmonary infiltrates on imaging. Data are presented as median (IQR), p < 0.05 was considered significant. Results 267 patients were included. Median age was 45 (26–59) years, 199 (75%) males, ISS was 29 (22–35), 258 (97%) patients had blunt injuries. Thirty-five (13%) patients died. 192 (72%) patients developed AHRF. AHRF patients were older, more often male, had higher ISS, needed more crystalloids and blood products than patients without AHRF. They developed more pulmonary complications, stayed longer on the ventilator, in ICU and in hospital, and died more often. Fifteen (6%) patients developed ARDS. There was no difference in outcome between ARDS and AHRF patients. Conclusions Many patients developed AHRF and only a few ARDS. Patients with similar hypoxemia without bilateral diffuse pulmonary infiltrates had comparable outcome as ARDS patients. Chest imaging did not influence the outcome. Large-scale multicenter validation of ARDS criteria is warranted to investigate whether diffuse bilateral pulmonary infiltrates on chest imaging could be omitted as a mandatory part of the definition of ARDS in polytrauma patients. Electronic supplementary material The online version of this article (10.1007/s00068-019-01204-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Karlijn Julia Patricia van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Suite G04.232, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Luke Petrus Hendrikus Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Suite G04.232, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Xu AA, Breeze JL, Paulus JK, Bugaev N. Epidemiology of Traumatic Esophageal Injury: An Analysis of the National Trauma Data Bank. Am Surg 2019. [DOI: 10.1177/000313481908500422] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Existing literature on traumatic injury of the esophagus (TIE) is limited. We aimed to describe the clinical characteristics and outcomes of TIE. We reviewed the National Trauma Data Bank for the years 2010–2015. We described the demographics, characteristics, and outcomes of adult (age ≥16 years) TIE patients and also compared those factors in blunt versus penetrating TIE. The association between TIE and mortality was analyzed using multivariable logistic regression. Thousand four hundred eleven adult TIE patients were identified (37 per 100,000 trauma patients, 95% confidence intervals (CI): 35, 39). TIE patients were younger (38 vs 52 years), more likely to be male (81% vs 62%), and more severely injured (Injury Severity Score ≥ 25: 45% vs 7%) than patients without TIE (all P < 0.001). TIE was observed 16 times more frequently with penetrating injuries (257 per 100,000, 95% CI: 240, 270) than with blunt injuries (16 per 100,000, 95% CI: 15, 18). Inhospital TIE mortality was 19 per cent. TIE patients had greater risk of mortality than other trauma patients, after adjusting for age, gender, and Injury Severity Score (odds ratio = 1.4, 95% CI: 1.1, 1.7). Mortality in blunt and penetrating TIE did not differ. Although extremely rare, TIE is independently associated with a marked increase in mortality, even after adjusting for other risk factors.
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Affiliation(s)
| | - Janis L. Breeze
- Tufts Clinical and Translational Science Institute, Tufts University, and Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Jessica K. Paulus
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center/Tufts University School of Medicine, Boston, Massachusetts; and
| | - Nikolay Bugaev
- Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
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van Wessem KJP, Leenen LPH. Incidence of acute respiratory distress syndrome and associated mortality in a polytrauma population. Trauma Surg Acute Care Open 2018; 3:e000232. [PMID: 30623025 PMCID: PMC6307585 DOI: 10.1136/tsaco-2018-000232] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background The incidence of acute respiratory distress syndrome (ARDS) has decreased in the last decade by improvement in trauma and critical care. However, it still remains a major cause of morbidity and mortality. This study investigated the current incidence and mortality of ARDS in polytrauma patients. Methods A 4.5-year prospective study included consecutive trauma patients admitted to a level 1 trauma center intensive care unit (ICU). Isolated head injuries, drowning, asphyxiation, burns, and deaths <48 hours were excluded. Demographics, Injury Severity Score (ISS), physiologic parameters, resuscitation parameters, Denver Multiple Organ Failure scores, and ARDS data according to Berlin criteria were prospectively collected. Data are presented as median (IQR), and p<0.05 was considered significant. Results 241 patients were included. The median age was 45 (27–59) years, 178 (74%) were male, the ISS was 29 (22–36), and 232 (96%) patients had blunt injuries. Thirty-one patients (13%) died. Fifteen patients (6%) developed ARDS. The median time to ARDS onset was 3 (2–5) days after injury. The median duration of ARDS was 2.5 (1–3.5) days. All patients with ARDS were male compared with 61% of non-ARDS patients (p=0.003). Patients who developed ARDS had higher ISS (30 vs. 25, p=0.01), lower Partial Pressure of Oxygen in arterial blood (PaO2) both in the emergency department and ICU, and higher Partial Pressure of Carbon Dioxide in arterial blood (PaCo2) in the ICU. Patients with ARDS needed more crystalloids <24 hours (8.7 vs. 6.8 L, p=0.03), received more fresh frozen plasma <24 hours (3 vs. 0 U, p=0.04), and more platelet <8 hours and <24 hours. Further, they stayed longer on the ventilator (11 vs. 2 days, p<0.001), longer in the ICU (12 vs. 3 days, p<0.001), and in the hospital (33 vs. 15 days, p=0.004). Patients with ARDS developed more often multiple organ dysfunction syndrome (40% vs. 3%, p<0.001) and died more often (20% vs. 3%, p=0.01). Only one patient with ARDS (7%) died of ARDS. Discussion In this polytrauma population mortality was predominantly caused by brain injury. The incidence of ARDS was low; its presentation was only early onset, during a short time period, and accompanied by low mortality. Level of evidence Level III.
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Affiliation(s)
- Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Outcome in Patients with Isolated Moderate to Severe Traumatic Brain Injury. Crit Care Res Pract 2018; 2018:3769418. [PMID: 30345113 PMCID: PMC6174733 DOI: 10.1155/2018/3769418] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/16/2018] [Accepted: 08/14/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Traumatic brain injury (TBI) remains a major cause of death. Withdrawal of life-sustaining treatment (WLST) can be initiated if there is little anticipated chance of recovery to an acceptable quality of life. The aim of this study was firstly to investigate WLST rates in patients with moderate to severe isolated TBI and secondly to assess outcome data in the survivor group. Material and Methods A retrospective cohort study was performed. Patients aged ≥ 18 years with moderate or severe isolated TBI admitted to the ICU of a single academic hospital between 2011 and 2015 were included. Exclusion criteria were isolated spinal cord injury and referrals to and from other hospitals. Gathered data included demographics, mortality, cause of death, WLST, and Glasgow Outcome Scale (GOS) score after three months. Good functional outcome was defined as GOS > 3. Results Of 367 patients, 179 patients were included after applying inclusion and exclusion criteria. 55 died during admission (33%), of whom 45 (82%) after WLST. Patients undergoing WLST were older, had worse neurological performance at presentation, and had more radiological abnormalities than patients without WLST. The decision to withdraw life-sustaining treatment was made on the day of admission in 40% of patients. In 33% of these patients, this decision was made while the patient was in the Emergency Department. 71% of survivors had a good functional outcome after three months. No patient left hospital with an unresponsive wakefulness syndrome (UWS) or suffered from UWS after three months. One patient died within three months of discharge. Conclusion In-hospital mortality in isolated brain injured patients was 33%. The vast majority died after a decision to withdraw life-sustaining treatment. None of the patients were discharged with an unresponsive wakefulness syndrome.
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Jochems D, Leenen LPH, Hietbrink F, Houwert RM, van Wessem KJP. Increased reduction in exsanguination rates leaves brain injury as the only major cause of death in blunt trauma. Injury 2018; 49:1661-1667. [PMID: 29903577 DOI: 10.1016/j.injury.2018.05.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 05/01/2018] [Accepted: 05/18/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Central nervous system (CNS) related injuries and exsanguination have been the most common causes of death in trauma for decades. Despite improvements in haemorrhage control in recent years exsanguination is still a major cause of death. We conducted a prospective database study to investigate the current incidence of haemorrhage related mortality. MATERIALS AND METHODS A prospective database study of all trauma patients admitted to an urban major trauma centre between January 2007 and December 2016 was conducted. All in-hospital trauma deaths were included. Cause of death was reviewed by a panel of trauma surgeons. Patients who were dead on arrival were excluded. Trends in demographics and outcome were analysed per year. Further, 2 time periods (2007-2012 and 2013-2016) were selected representing periods before and after implementation of haemostatic resuscitation and damage control procedures in our hospital to analyse cause of death into detail. RESULTS 11,553 trauma patients were admitted, 596 patients (5.2%) died. Mean age of deceased patients was 61 years and 61% were male. Mechanism of injury (MOI) was blunt in 98% of cases. Mean ISS was 28 with head injury the most predominant injury (mean AIS head 3.4). There was no statistically significant difference in sex and MOI over time. Even though deceased patients were older in 2016 compared to 2007 (67 vs. 46 years, p < 0.001), mortality was lower in later years (p = 0.02). CNS related injury was the main cause of death in the whole decade; 58% of patients died of CNS in 2007-2012 compared to 76% of patients in 2013-2016 (p = 0.001). In 2007-2012 9% died of exsanguination compared to 3% in 2013-2016 (p = 0.001). DISCUSSION In this cohort in a major trauma centre death by exsanguination has decreased to 3% of trauma deaths. The proportion of traumatic brain injury has increased over time and has become the most common cause of death in blunt trauma. Besides on-going prevention of brain injury future studies should focus on treatment strategies preventing secondary damage of the brain once the injury has occurred.
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Affiliation(s)
- D Jochems
- Department of Trauma Surgery, University Medical Centre Utrecht, The Netherlands
| | - L P H Leenen
- Department of Trauma Surgery, University Medical Centre Utrecht, The Netherlands
| | - F Hietbrink
- Department of Trauma Surgery, University Medical Centre Utrecht, The Netherlands
| | - R M Houwert
- Department of Trauma Surgery, University Medical Centre Utrecht, The Netherlands
| | - K J P van Wessem
- Department of Trauma Surgery, University Medical Centre Utrecht, The Netherlands.
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Würdemann FS, Smeeing DPJ, Ferree S, Nawijn F, Verleisdonk EJMM, Leenen LPH, Houwert RM, Hietbrink F. Differentiation in an inclusive trauma system: allocation of lower extremity fractures. World J Emerg Surg 2018; 13:18. [PMID: 29682003 PMCID: PMC5899363 DOI: 10.1186/s13017-018-0178-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/28/2018] [Indexed: 11/26/2022] Open
Abstract
Background Implementation of an inclusive trauma system leads to reduced mortality rates, specifically in polytrauma patients. Field triage is essential in this mortality reduction. Triage systems are developed to identify patients with life-threatening injuries, and trauma mechanisms are important for triaging. Although complex extremity fractures are mostly non-lethal, these injuries are frequently the result of a high-energy trauma mechanism. The aim of this study is to compare injury and patient characteristics, as well as resource demands, of lower extremity fractures between a level (L)1 and level (L)2 trauma centre in a mature inclusive trauma system. Methods This is a retrospective cohort study. Patients with below-the-knee joint fractures diagnosed in a L1 or L2 trauma centre between July 2013 and June 2015 were included. Main outcome parameters were patient demographics, trauma mechanism, fracture pattern, and resource demands. Results One thousand two hundred sixty-seven patients with 1517 lower extremity fractures were included. Most patients were treated in the L2 centre (L1 = 417; L2 = 859). Complex fractures were more frequently triaged to the L1 centre. Patients in the L1 centre had more concomitant injuries to other body regions and ipsi- or contralateral lower extremity. Patients in the L1 centre were more resource demanding: more surgeries (> 1 surgery; 24.9% L1 vs 1.4% L2), higher immediate admission rates (70.1% L1 vs 37.6% L2), and longer length of stay (mean 13.4 days L1 vs 3.1 days L2). Conclusion The majority of patients were treated in the L2 trauma centre, whereas complex lower extremity injuries were mostly treated in the L1 centre, which placed higher demand on resources and labour per patient. This change in allocation is the next step in centralization of low-volume high complex care and high-volume low complex care.
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Affiliation(s)
- F S Würdemann
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands.,3Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - D P J Smeeing
- 2Traumacenter, University Medical Center Utrecht, Utrecht, The Netherlands.,3Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - S Ferree
- 3Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - F Nawijn
- 3Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | | | - L P H Leenen
- 3Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - R M Houwert
- 2Traumacenter, University Medical Center Utrecht, Utrecht, The Netherlands.,3Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - F Hietbrink
- 3Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Reduction in Mortality Rates of Postinjury Multiple Organ Dysfunction Syndrome: A Shifting Paradigm? A Prospective Population-Based Cohort Study. Shock 2018; 49:33-38. [DOI: 10.1097/shk.0000000000000938] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dijkink S, van der Wilden GM, Krijnen P, Dol L, Rhemrev S, King DR, DeMoya MA, Velmahos GC, Schipper IB. Polytrauma patients in the Netherlands and the USA: A bi-institutional comparison of processes and outcomes of care. Injury 2018; 49:104-109. [PMID: 29033079 DOI: 10.1016/j.injury.2017.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 09/29/2017] [Accepted: 10/09/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Modern trauma systems differ worldwide, possibly leading to disparities in outcomes. We aim to compare characteristics and outcomes of blunt polytrauma patients admitted to two Level 1 Trauma Centers in the US (USTC) and the Netherlands (NTC). METHODS For this retrospective study the records of 1367 adult blunt trauma patients with an Injury Severity Score (ISS) ≥ 16 admitted between July 1, 2011 and December 31, 2013 (640 from NTC, 727 from USTC) were analysed. RESULTS The USTC group had a higher Charlson Comorbidity Index (mean [standard deviation] 1.15 [2.2] vs. 1.73 [2.8], p<0.0001) and Injury Severity Score (median [interquartile range, IQR] 25 [17-29] vs. 21 [17-26], p<0.0001). The in-hospital mortality was similar in both centers (11% in USTC vs. 10% NTC), also after correction for baseline differences in patient population in a multivariable analysis (adjusted odds ratio 0.95, 95% confidence interval 0.61-1.48, p=0.83). USTC patients had a longer Intensive Care Unit stay (median [IQR] 4 [2-11] vs. 2 [2-7] days, p=0.006) but had a shorter hospital stay (median [IQR] 6 [3-13] vs. 8 [4-16] days, p<0.0001). USTC patients were discharged more often to a rehabilitation center (47% vs 10%) and less often to home (46% vs. 66%, p<0.0001), and had a higher readmission rate (8% vs. 4%, p=0.01). CONCLUSION Although several outcome parameters differ in two urban area trauma centers in the USA and the Netherlands, the quality of care for trauma patients, measured as survival, is equal. Other outcomes varied between both trauma centers, suggesting that differences in local policies and processes do influence the care system, but not so much the quality of care as reflected by survival.
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Affiliation(s)
- Suzan Dijkink
- Department of Surgery, Leiden University Medical Center, The Netherlands.
| | | | - Pieta Krijnen
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Lisa Dol
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Steven Rhemrev
- Department of Surgery, Haaglanden Medical Center, The Netherlands
| | - David R King
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, United States
| | - Marc A DeMoya
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, United States
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, United States
| | - Inger B Schipper
- Department of Surgery, Leiden University Medical Center, The Netherlands
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36
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Gipson JS, Wood EM, Cole-Sinclair MF, McQuilten Z, Waters N, Woodford NW. Major haemorrhage fatalities in the Australian national coronial database. Emerg Med Australas 2017; 30:382-388. [PMID: 29224237 DOI: 10.1111/1742-6723.12915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/02/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The aim of the study is to describe the epidemiology of major bleeding fatalities. METHODS A case series analysis of Australia's National Coronial Information System was conducted. Keywords were used to search for closed cases of major haemorrhage in the state of Victoria for the period 1 January 2009 to 31 December 2011. Coroners' findings, autopsy reports and police reports of cases were reviewed. Demographic data were extracted, and cases were assigned to a clinical bleeding context. RESULTS A total of 427 cases of major bleeding causing death were identified. The cohort was predominately men (69%), with a median age of 63 years (interquartile range 45-77 years). Trauma accounted for 38%, gastrointestinal haemorrhage 28%, surgical/procedural bleeding 14%, ruptured/leaking aneurysms 12% and other 8%. Most events began in homes (46%), hospitals (22%) and at the roadside (17%). Of those whose haemorrhage began in the community, 69% did not survive to hospital. CONCLUSIONS Major bleeding fatalities occurred across a diverse range of contexts, with trauma and gastrointestinal bleeding accounting for most deaths. The majority of patients did not survive to reach hospital. Major haemorrhage occurring entirely outside hospital may be underrecognised from analyses of datasets based primarily on traumatic or in-hospital bleeding. These findings have implications for management of pre-hospital resuscitation and development of clinical practice guidelines for identification and management of major bleeding in the community.
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Affiliation(s)
- Jacob S Gipson
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Erica M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Merrole F Cole-Sinclair
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Haematology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Zoe McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Neil Waters
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Noel W Woodford
- Victorian Institute of Forensic Medicine, Melbourne, Victoria, Australia.,Department of Forensic Medicine, Monash University, Melbourne, Victoria, Australia
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Kesmarky K, Delhumeau C, Zenobi M, Walder B. Comparison of Two Predictive Models for Short-Term Mortality in Patients after Severe Traumatic Brain Injury. J Neurotrauma 2017; 34:2235-2242. [PMID: 28323524 DOI: 10.1089/neu.2016.4606] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The Glasgow Coma Scale (GCS) and the Abbreviated Injury Score of the head region (HAIS) are validated prognostic factors in traumatic brain injury (TBI). The aim of this study was to compare the prognostic performance of an alternative predictive model including motor GCS, pupillary reactivity, age, HAIS, and presence of multi-trauma for short-term mortality with a reference predictive model including motor GCS, pupil reaction, and age (IMPACT core model). A secondary analysis of a prospective epidemiological cohort study in Switzerland including patients after severe TBI (HAIS >3) with the outcome death at 14 days was performed. Performance of prediction, accuracy of discrimination (area under the receiver operating characteristic curve [AUROC]), calibration, and validity of the two predictive models were investigated. The cohort included 808 patients (median age, 56; interquartile range, 33-71), median GCS at hospital admission 3 (3-14), abnormal pupil reaction 29%, with a death rate of 29.7% at 14 days. The alternative predictive model had a higher accuracy of discrimination to predict death at 14 days than the reference predictive model (AUROC 0.852, 95% confidence interval [CI] 0.824-0.880 vs. AUROC 0.826, 95% CI 0.795-0.857; p < 0.0001). The alternative predictive model had an equivalent calibration, compared with the reference predictive model Hosmer-Lemeshow p values (Chi2 8.52, Hosmer-Lemeshow p = 0.345 vs. Chi2 8.66, Hosmer-Lemeshow p = 0.372). The optimism-corrected value of AUROC for the alternative predictive model was 0.845. After severe TBI, a higher performance of prediction for short-term mortality was observed with the alternative predictive model, compared with the reference predictive model.
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Affiliation(s)
- Klara Kesmarky
- Department of Anesthesiology, Intensive Care and Clinical Pharmacology, University Hospitals of Geneva , Geneva, Switzerland
| | - Cecile Delhumeau
- Department of Anesthesiology, Intensive Care and Clinical Pharmacology, University Hospitals of Geneva , Geneva, Switzerland
| | - Marie Zenobi
- Department of Anesthesiology, Intensive Care and Clinical Pharmacology, University Hospitals of Geneva , Geneva, Switzerland
| | - Bernhard Walder
- Department of Anesthesiology, Intensive Care and Clinical Pharmacology, University Hospitals of Geneva , Geneva, Switzerland
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Developing a trauma care syllabus for intensive care nurses in the United Kingdom: A Delphi study. Intensive Crit Care Nurs 2016; 36:49-57. [PMID: 27157035 DOI: 10.1016/j.iccn.2016.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 03/14/2016] [Accepted: 03/18/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Increased rates of mortality in the intensive care unit (ICU) following injury have been associated with a lack of trauma specific training. Despite this, training relevant to nurses is limited. Currently, little consideration has been given to understanding the potential training needs of ICU nurses in caring for critically injured patients. OBJECTIVES The aim of this study was to construct a consensus syllabus of trauma care for registered nurses working in an intensive care setting. DESIGN A two round modified Delphi was conducted. METHODS Twenty-eight intensive care professionals participated in the study in 2014 in the United Kingdom. Data were analysed using content and descriptive statistics. RESULTS Round-1 generated 343 subjects. Following analysis these were categorised into 75 subjects and returned to the panel for rating. An 82% (23/28) response rate to round-2 identified high consensus (equal to or greater than 80%) in 55 subjects, which reflected the most severely injured patients needs. CONCLUSIONS There is a requirement for specific training to prepare the ICU nurse for caring for the critically injured patient. This survey presents a potential core syllabus in trauma care and should be considered by educators to develop a meaningful programme of trauma education for ICU nurses.
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