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Lee H, Dilday J, Johnson A, Kuchler A, Rott M, Cole F, Barbosa R, Long W, Martin MJ. Real-time attending trauma surgeon assessment of direct-to-operating room trauma resuscitations: Results from a prospective observational study. J Trauma Acute Care Surg 2024:01586154-990000000-00805. [PMID: 39269308 DOI: 10.1097/ta.0000000000004447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2024]
Abstract
BACKGROUND Direct-to-operating room (DOR) resuscitation expedites interventions for trauma patients. Perceived benefit from the surgeon's perspective is not well known. This study assesses the integration of a real-time surgeon assessment tool into a DOR protocol. METHODS Surgeon assessment tool results from a prospective study of DOR cases were analyzed. Analysis assessed patient factors and surgeon perception for appropriateness and benefit of DOR. Multivariate analysis identified independent factors associated with perceived DOR benefit. RESULTS A total of 104 trauma patients underwent DOR resuscitation; 84% were perceived as appropriate triage, and 48% as beneficial. Patients with Injury Severity Score of >15 (50% vs. 28%), systolic blood pressure of <90 mm Hg (24% vs. 9%), and severe abdominal injury (28% vs. 9%) had higher perceived DOR benefits (all p < 0.05). Patients deemed to benefit from DOR underwent more emergent interventions or truncal surgery (44% vs. 92%, p < 0.01). No difference in benefit was seen based on age, sex, Glasgow Coma Scale score of <9, or injury mechanism. Forty-four percent had perceived benefit from DOR resuscitation despite requiring imaging after initial evaluation. Patients with perceived benefit had a higher rate of unplanned return to the operating room (16% vs. 2%, p < 0.05), but no differences in complication rates, Glasgow Outcome Score, or mortality. Injury Severity Score of >15 was the only independently associated variable with a perceived benefit on surgeon assessment tool (odds ratio, 3.5; p < 0.05). CONCLUSION The majority of DOR resuscitations were deemed as appropriately triaged, and approximately half had a perceived benefit. Benefit was associated with higher injury severity and the need for urgent interventions but was not predicted by injury mechanism or other triage variables. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Heewon Lee
- From the Division of Trauma and Acute Care Surgery, Department of Surgery (H.L., J.D., M.M.), Los Angeles General Medical Center, Los Angeles, California; and Trauma and Acute Care Surgery Service, Department of Surgery (A.J., A.K., M.R., F.C., R.B., W.L.), Legacy Emanuel Medical Center, Portland, Oregon
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Feng T, Ajdari A, Boyle LN, Kannan N, Burd R, Groner JI, Farneth RA, Vavilala MS. Computer Simulation to Assess Emergency Department Length of Stay in Pediatric Traumatic Brain Injury. Pediatr Emerg Care 2024; 40:421-425. [PMID: 38227782 PMCID: PMC11141338 DOI: 10.1097/pec.0000000000003088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
OBJECTIVES Our study aimed to identify how emergency department (ED) arrival rate, process of care, and physical layout can impact ED length of stay (LOS) in pediatric traumatic brain injury care. METHODS Process flows and value stream maps were developed for 3 level I pediatric trauma centers. Computer simulation models were also used to examine "what if" scenarios based on ED arrival rates. RESULTS Differences were observed in prearrival preparation time, ED physical layouts, and time spent on processes. Shorter prearrival preparation time, trauma bed location far from diagnostic or treatment areas, and ED arrival rates that exceed 20 patients/day prolonged ED LOS. This was particularly apparent in 1 center where computer simulation showed that relocation of trauma beds can reduce ED LOS regardless of the number of patients that arrive per day. CONCLUSIONS Exceeding certain threshold ED arrival rates of children with traumatic brain injury can substantially increase pediatric trauma center ED LOS but modifications to ED processes and bed location may mitigate this increase.
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Affiliation(s)
| | - Ali Ajdari
- Harvard Medical School & Massachusetts General Hospital, Boston, MA
| | | | | | - Randall Burd
- Children’s National Medical Center, Washington, DC
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L'Huillier JC, Jalal K, Nohra E, Boccardo JD, Olafuyi O, Jordan MB, Myneni AA, Schwaitzberg SD, Flynn WJ, Brewer JJ, Noyes K, Cooper CA. Challenging Dogma by Skipping the Emergency Department Thoracotomy: A Propensity Score Matched Analysis of the Trauma Quality Improvement Database. J Surg Res 2024; 298:24-35. [PMID: 38552587 DOI: 10.1016/j.jss.2024.02.020] [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: 09/20/2023] [Revised: 02/06/2024] [Accepted: 02/29/2024] [Indexed: 06/03/2024]
Abstract
INTRODUCTION Survival following emergency department thoracotomy (EDT) for patients in extremis is poor. Whether intervention in the operating room instead of EDT in select patients could lead to improved outcomes is unknown. We hypothesized that patients who underwent intervention in the operating room would have improved outcomes compared to those who underwent EDT. METHODS We conducted a retrospective review of the Trauma Quality Improvement Program database from 2017 to 2021. All adult patients who underwent EDT, operating room thoracotomy (ORT), or sternotomy as the first form of surgical intervention within 1 h of arrival were included. Of patients without prehospital cardiac arrest, propensity score matching was utilized to create three comparable groups. The primary outcome was survival. Secondary outcomes included time to procedure. RESULTS There were 1865 EDT patients, 835 ORT patients, and 456 sternotomy patients who met the inclusion criteria. There were 349 EDT, 344 ORT, and 408 sternotomy patients in the matched analysis. On Cox multivariate regression, there was an increased risk of mortality with EDT versus sternotomy (HR 4.64, P < 0.0001), EDT versus ORT (HR 1.65, P < 0.0001), and ORT versus sternotomy (HR 2.81, P < 0.0001). Time to procedure was shorter with EDT versus sternotomy (22 min versus 34 min, P < 0.0001) and versus ORT (22 min versus 37 min, P < 0.0001). CONCLUSIONS There was an association between sternotomy and ORT versus EDT and improved mortality. In select patients, operative approaches rather than the traditional EDT could be considered.
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Affiliation(s)
- Joseph C L'Huillier
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Kabir Jalal
- Department of Biostatistics, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York
| | - Eden Nohra
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Joseph D Boccardo
- Department of Biostatistics, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York
| | - Olatoyosi Olafuyi
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Marcy Bubar Jordan
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Ajay A Myneni
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York
| | - Steven D Schwaitzberg
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - William J Flynn
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Jeffrey J Brewer
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York
| | - Katia Noyes
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, University at Buffalo, School of Public Health and Health Professions, Buffalo, New York
| | - Clairice A Cooper
- Department of Surgery, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Erie County Medical Center, Buffalo, New York.
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Seo D, Heo I, Choi D, Jung K, Jung H. Efficacy of direct-to-operating room trauma resuscitation: a systematic review. World J Emerg Surg 2024; 19:3. [PMID: 38238854 PMCID: PMC10795202 DOI: 10.1186/s13017-023-00532-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 12/26/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Hemorrhage control is a time-critical task, and recent studies have demonstrated that a shorter time to definitive care is positively associated with patient survival and functional outcomes. The concept of direct transport to the operating room was proposed in the 1960s to reduce treatment time. Some trauma centers have developed protocols for direct-to-operating room resuscitation (DOR) programs. Moreover, few studies have reported the clinical outcomes of DOR in patients with trauma; however, their clinical effect in improving the efficiency and quality of care remains unclear. In this systematic review, we aimed to consolidate all published studies reporting the effect of DOR on severe trauma and evaluate its utility. METHODS The PubMed, EMBASE, and Cochrane databases were searched from inception to April 2023, to identify all articles published in English that reported the effect of direct-to-operating room trauma resuscitation for severe trauma. The articles were reviewed as references of interest. RESULTS We reviewed six studies reporting the clinical effect of operating room trauma resuscitation. A total of 3232 patients were identified. Five studies compared the actual mortality with the predicted mortality using the trauma score and injury severity score, while one study compared mortality using propensity matching. Four studies reported that the actual survival rate for overall injuries was better than the predicted survival rate, whereas two studies reported no difference. Some studies performed subgroup analyses. Two studies showed that the survival rate for penetrating injuries was better than the predicted survival rate, and one showed that the survival rate for blunt injuries was better than the predicted survival rate. Five studies reported the time to surgical intervention, which was within 30 min. Two studies time-compared surgical intervention, which was shorter in patients who underwent DOR. CONCLUSION Implementing DOR is likely to have a beneficial effect on mortality and can facilitate rapid intervention in patients with severe shock. Future studies, possibly clinical trials, are needed to ensure a proper comparison of the efficiency.
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Affiliation(s)
- Dongmin Seo
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
- Regional Trauma Center of Southern Gyeong-Gi Province, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Inhae Heo
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
- Regional Trauma Center of Southern Gyeong-Gi Province, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Donghwan Choi
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
- Regional Trauma Center of Southern Gyeong-Gi Province, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
- Regional Trauma Center of Southern Gyeong-Gi Province, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Hohyung Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea.
- Regional Trauma Center of Southern Gyeong-Gi Province, Ajou University School of Medicine, Suwon, Republic of Korea.
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Kelley JK, Jaje KE, Smitterberg CW, Reed CR, Pounders SJ, Krech LA, Groseclose RS, Fisk CS, Chapman AJ, Yang AY. Direct to Operating Room for Decompressive Craniotomy/Craniectomy in Patients With Traumatic Brain Injury. J Trauma Nurs 2023; 30:282-289. [PMID: 37702731 DOI: 10.1097/jtn.0000000000000742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND Emergent decompressive craniotomy/craniectomy can be a lifesaving surgical intervention for select patients with traumatic brain injury. Prompt management is critical as early decompression can impact traumatic brain injury outcomes. OBJECTIVE This study aims to describe the feasibility and clinical impact of a new pathway for transporting patients with severe traumatic brain injury directly to the operating room from the trauma bay for decompressive craniotomy/craniectomy. METHODS This is a retrospective cohort preintervention and postintervention study of severe traumatic brain injury patients undergoing decompressive craniectomy/craniotomy at a Midwestern U.S. Level I trauma center between 2016 and 2022. In the new pathway, the in-house trauma surgeon takes the patient directly to the operating room with the neurosurgery advanced practice provider to drape and prepare the patient for surgery while the neurosurgeon is en route to the hospital. RESULTS A total of 44 patients were studied, five (5/44, 11.4%) of which were in the preintervention group and 39 (39/44, 88.6%) in the postintervention group. The median arrival-to-operating room time was shorter in the postintervention cohort (1.4 hr) than in the preintervention cohort (1.5 hr). In examining night shifts only, the preintervention cohort had shorter arrival-to-operating room times (1.2 hr) than the postintervention cohort (1.5 hr). CONCLUSION The study demonstrated that the new pathway is feasible and expedites patient transport to the operating room while awaiting the arrival of the on-call neurosurgeon.
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Affiliation(s)
- Jesse K Kelley
- Department of General Surgery, Corewell Health, Grand Rapids, Michigan (Drs Kelley, Chapman, and Yang); Michigan State University College of Human Medicine, Grand Rapids (Ms Jaje and Messrs Smitterberg and Reed); and Trauma Research Institute, Corewell Health, Grand Rapids, Michigan (Messrs Pounders and Groseclose, Mss Krech and Fisk, and Drs Chapman and Yang)
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Balch JA, Loftus TJ, Ruppert MM, Rosenthal MD, Mohr AM, Efron PA, Upchurch GR, Smith RS. Retrospective value assessment of a dedicated, trauma hybrid operating room. J Trauma Acute Care Surg 2023; 94:814-822. [PMID: 36727772 PMCID: PMC10205659 DOI: 10.1097/ta.0000000000003873] [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] [Indexed: 02/03/2023]
Abstract
BACKGROUND In traumatic hemorrhage, hybrid operating rooms offer near simultaneous performance of endovascular and open techniques, with correlations to earlier hemorrhage control, fewer transfusions, and possible decreased mortality. However, hybrid operating rooms are resource intensive. This study quantifies and describes a single-center experience with the complications, cost-utility, and value of a dedicated trauma hybrid operating room. METHODS This retrospective cohort study evaluated 292 consecutive adult trauma patients who underwent immediate (<4 hours) operative intervention at a Level I trauma center. A total of 106 patients treated before the construction of a hybrid operating room served as historical controls to the 186 patients treated thereafter. Demographics, hemorrhage-control procedures, and financial data as well as postoperative complications and outcomes were collected via electronic medical records. Value and incremental cost-utility ratio were calculated. RESULTS Demographics and severity of illness were similar between cohorts. Resuscitative endovascular occlusion of the aorta was more frequently used in the hybrid operating room. Hemorrhage control occurred faster (60 vs. 49 minutes, p = 0.005) and, in the 4- to 24-hour postadmission period, required less red blood cell (mean, 1.0 vs. 0 U, p = 0.001) and plasma (mean, 1.0 vs. 0 U, p < 0.001) transfusions. Complications were similar except for a significant decrease in pneumonia (7% vs. 4%, p = 0.008). Severe complications (Clavien-Dindo classification, ≥3) were similar. Across the patient admission, costs were not significantly different ($50,023 vs. $54,740, p = 0.637). There was no change in overall value (1.00 vs. 1.07, p = 0.778). CONCLUSION The conversion of our standard trauma operating room to an endovascular hybrid operating room provided measurable improvements in hemorrhage control, red blood cell and plasma transfusions, and postoperative pneumonia without significant increase in cost. Value was unchanged. LEVEL OF EVIDENCE Economic/Value-Based Evaluations; Level III.
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Affiliation(s)
- Jeremy A. Balch
- University of Florida Health, Department of Surgery, Gainesville, Florida
| | - Tyler J. Loftus
- University of Florida Health, Department of Surgery, Gainesville, Florida
| | - Matthew M. Ruppert
- University of Florida Health, Department of Medicine, Gainesville, Florida
| | | | - Alicia M. Mohr
- University of Florida Health, Department of Surgery, Gainesville, Florida
| | - Philip A. Efron
- University of Florida Health, Department of Surgery, Gainesville, Florida
| | | | - R. Stephen Smith
- University of Florida Health, Department of Surgery, Gainesville, Florida
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Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023; 27:80. [PMID: 36859355 PMCID: PMC9977110 DOI: 10.1186/s13054-023-04327-7] [Citation(s) in RCA: 122] [Impact Index Per Article: 122.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.
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Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| | - Arash Afshari
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Bertil Bouillon
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- grid.424917.d0000 0001 1379 0994Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anaesthesiology and Intensive Care Medicine, Charles University Faculty of Medicine, Simkova 870, CZ-50003 Hradec Králové, Czech Republic
| | - Diana Cimpoesu
- grid.411038.f0000 0001 0685 1605Department of Emergency Medicine, Emergency County Hospital “Sf. Spiridon” Iasi, University of Medicine and Pharmacy ”Grigore T. Popa” Iasi, Blvd. Independentei 1, RO-700111 Iasi, Romania
| | - Nicola Curry
- grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE UK ,grid.4991.50000 0004 1936 8948Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Jacques Duranteau
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- grid.8194.40000 0000 9828 7548Department of Cardiac Anaesthesia and Intensive Care, “Prof. Dr. C. C. Iliescu” Emergency Institute of Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Oliver Grottke
- grid.1957.a0000 0001 0728 696XDepartment of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| | - Lars Grønlykke
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anatole Harrois
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Beverley J. Hunt
- grid.420545.20000 0004 0489 3985Thrombosis and Haemophilia Centre, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Alexander Kaserer
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Radko Komadina
- grid.8954.00000 0001 0721 6013Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty, Ljubljana University, Oblakova ulica 5, SI-3000 Celje, Slovenia
| | - Mikkel Herold Madsen
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Lidia Mora
- grid.7080.f0000 0001 2296 0625Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, ES-08035 Barcelona, Spain
| | - Louis Riddez
- grid.24381.3c0000 0000 9241 5705Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Carolina S. Romero
- grid.106023.60000 0004 1770 977XDepartment of Anaesthesia, Intensive Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, Universidad Europea of Valencia Methodology Research Department, Avenida Tres Cruces 2, ES-46014 Valencia, Spain
| | - Charles-Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre - Université Paris Cité - Cochin Hospital, 27 rue du Faubourg St. Jacques, F-75014 Paris, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Sebastian Wiberg
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Donat R. Spahn
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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Nguyen MT, Kim AH, Barthel ER, Castle SL. Outcomes After Transfer of Pediatric Trauma Patients: Does Everyone Need to Visit the Trauma Bay? J Surg Res 2022; 279:164-169. [PMID: 35779446 DOI: 10.1016/j.jss.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 05/02/2022] [Accepted: 06/07/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Critically injured children and teens often present to adult trauma centers or nontrauma facilities prior to transfer to a pediatric trauma center. For pediatric patients wanting transfer to the intensive care unit (ICU), there is little data to guide which can be safely transferred directly to the unit, and which should be evaluated first in the trauma bay. METHODS We used our institutional trauma registry to evaluate transferred trauma patients over a three year period. We compared time to imaging, time to operating room, and overall mortality between the group evaluated first in the emergency room and those transferred directly to the ICU. RESULTS When adjusted for other variables, there was no increased mortality in those transferred directly to the ICU. While there was a higher nonadjusted mortality in those transferred to the ICU (13% versus 3.7%), these nonsurvivors had a lower GCS (3 versus 13), higher Pediatric Risk of Mortality scores, and a high rate of severe head trauma. There was no significant delay in ordered imaging or procedures. CONCLUSIONS In patients, who have been assessed at another institution prior to transfer to the pediatric ICU, transfer directly to the ICU, bypassing the emergency department, does not delay interventions and does not appear to worsen outcomes.
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Affiliation(s)
- Michelle T Nguyen
- Department of Pediatrics, Valley Children's Hospital, Madera, California
| | - Andrew H Kim
- Department of Anesthesia and Critical Care, Valley Children's Hospital, Madera, California
| | - Erik R Barthel
- Department of Surgery, Valley Children's Hospital, Madera, California
| | - Shannon L Castle
- Department of Surgery, Valley Children's Hospital, Madera, California.
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Development of practical triage methods for critical trauma patients: machine-learning algorithm for evaluating hybrid operation theatre entry of trauma patients (THETA). Eur J Trauma Emerg Surg 2022; 48:4755-4760. [PMID: 35616704 DOI: 10.1007/s00068-022-02002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/07/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Hybrid operating rooms benefit patients with severe trauma but have a prerequisite of significant resources. This paper proposes a practical triage method to determine patients that should enter the hybrid operating room considering a limited availability of medical resources. METHODS This retrospective observational study was conducted using the database from the Japan Trauma Data Bank comprising information collected between January 2004 and December 2018. A machine-learning-based triage algorithm was developed using the baseline demographics, injury mechanisms, and vital signs obtained from the database. The analysis dataset comprised information regarding 117,771 trauma patients with an abbreviated injury scale (AIS) > 3. The performance of the proposed model was compared against those of other statistical models [logistic regression and classification and regression tree (CART) models] while considering the status quo entry condition (systolic blood pressure < 90 mmHg). RESULTS The proposed trauma hybrid-suite entry algorithm (THETA) outperformed other pre-existing algorithms [precision-recall area under the curve: THETA (0.59), logistic regression model (0.22), and classification and regression tree (0.20)]. CONCLUSION A machine-learning-based algorithm was developed to triage patient entry into hybrid operating rooms. Although the validation in a prospective multicentre arrangement is warranted, the proposed algorithm could be a potentially useful tool in clinical practice.
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Dauer E, Beard JH, Maher Z, Sjoholm L, Santora T, Pathak A, Anderson J, Goldberg A. Talk and Die: A Descriptive Analysis of Penetrating Trauma Patients. J Surg Res 2022; 278:1-6. [PMID: 35588570 DOI: 10.1016/j.jss.2022.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION "Talk and die" traditionally described occult presentations of fatal intracranial injuries, but we broaden its definition to victims of penetrating trauma. METHODS We conducted a descriptive analysis of patients with penetrating torso trauma who presented with a Glasgow Coma Scale verbal score ≥3 and died within 48 h of arrival from 2008 to 2018. RESULTS Sixty patients were identified. Eighteen (30.0%) required resuscitative thoracotomy with 7 (11.7%) dying in the trauma bay. Fifty-three (86.9%) patients went to the operating room, and 35 (66.0%) required multicavitary exploration. The most common injuries were hollow viscous (58.5%), intra-abdominal vascular (49.0%), liver (28.3%), pulmonary (26.4%), intrathoracic vascular (18.9%), and cardiac (15.75) injuries. Twenty-three (43.4%) patients survived their initial operation, but died in the first 48 h postoperatively. CONCLUSIONS Patients who "talk and die" most frequently have intra-abdominal vascular injures and require multicavitary exploration.
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Affiliation(s)
| | | | - Zoë Maher
- Temple University Hospital, Philadelphia, Pennsylvania
| | - Lars Sjoholm
- Temple University Hospital, Philadelphia, Pennsylvania
| | | | | | | | - Amy Goldberg
- Temple University Hospital, Philadelphia, Pennsylvania
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Gamberini L, Tartaglione M, Giugni A, Alban L, Allegri D, Coniglio C, Lupi C, Chiarini V, Mazzoli CA, Heusch-Lazzeri E, Tugnoli G, Gordini G. The role of prehospital ultrasound in reducing time to definitive care in abdominal trauma patients with moderate to severe liver and spleen injuries. Injury 2022; 53:1587-1595. [PMID: 34920877 DOI: 10.1016/j.injury.2021.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/04/2021] [Accepted: 12/01/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The role of prehospital focused assessment sonography for trauma (FAST) is still under debate and no definitive recommendations are available in actual guidelines, moreover, the availability of ultrasound machines in emergency medical services (EMS) is still inhomogeneous. On the other hand, time to definitive care is strictly related to survival in bleeding trauma patients. This study aimed at investigating if a positive prehospital FAST in abdominal trauma patients could have a role in reducing door-to-CT scan or door-to-operating room (OR) time. METHODS This retrospective observational study included all the patients affected by an abdominal trauma with an abdominal abbreviated injury score ≥ 2 and a spleen or liver injury admitted to Maggiore Hospital Carlo Alberto Pizzardi, a level 1 trauma centre between 2014 and 2019. Prehospital and emergency department (ED) clinical and laboratory variables were collected, as well as in-hospital times during the diagnostic and therapeutic pathways of these patients. RESULTS 199 patients were included in the final analysis. Of these, 44 had a prehospital FAST performed and in 27 of them, peritoneal free fluid was detected in the prehospital setting, while 128 out of 199 patients had a positive ED-FAST. Sensitivity was 62.9% (95% CI: 42.4%-80.6%) and specificity 100% (95% CI: 80.5% - 100%). Patients with a positive prehospital FAST reported a significantly lower door-to-CT or door-to-OR median time (46 vs 69 min, p < 0.001). Prehospital hypotension and Glasgow coma scale, first arterial blood lactate, ISS, age, positive prehospital and ED FAST were inserted in a stepwise selection for a multivariable Cox proportional regression hazards model. Only ISS and prehospital FAST resulted significantly associated with a reduction in the door-to-CT scan or door-to-operating theatre time in the multivariable model. CONCLUSION Prehospital FAST information of intraperitoneal free fluid could significantly hasten door-to-CT scan or door-to-operating theatre time in abdominal trauma patients if established hospital response protocols are available. LEVEL OF EVIDENCE III, (Therapeutic / Care Management).
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Affiliation(s)
- Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Largo Nigrisoli 2, Bologna 40133, Italy
| | - Marco Tartaglione
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Largo Nigrisoli 2, Bologna 40133, Italy.
| | - Aimone Giugni
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Largo Nigrisoli 2, Bologna 40133, Italy
| | - Laura Alban
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Largo Nigrisoli 2, Bologna 40133, Italy
| | - Davide Allegri
- Department of Clinical Governance and Quality, Bologna Local Healthcare Authority, Bologna, Italy
| | - Carlo Coniglio
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Largo Nigrisoli 2, Bologna 40133, Italy
| | - Cristian Lupi
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Largo Nigrisoli 2, Bologna 40133, Italy
| | - Valentina Chiarini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Largo Nigrisoli 2, Bologna 40133, Italy
| | - Carlo Alberto Mazzoli
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Largo Nigrisoli 2, Bologna 40133, Italy
| | - Elena Heusch-Lazzeri
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Largo Nigrisoli 2, Bologna 40133, Italy
| | - Gregorio Tugnoli
- Trauma Surgery Unit, Emergency Department, Maggiore Hospital, Bologna, Italy
| | - Giovanni Gordini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Largo Nigrisoli 2, Bologna 40133, Italy
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Habarth-Morales TE, Rios-Diaz AJ, Gadomski SP, Stanley T, Donnelly JP, Koenig GJ, Cohen MJ, Marks JA. Direct to OR resuscitation of abdominal trauma: An NTDB propensity matched outcomes study. J Trauma Acute Care Surg 2022; 92:792-799. [PMID: 35045059 DOI: 10.1097/ta.0000000000003536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Direct to operating room resuscitation (DOR) is used by some trauma centers for severely injured trauma patients as an approach to minimize time to hemorrhage control. It is unknown whether this strategy results in favorable outcomes. We hypothesized that utilization of an emergency department operating room (EDOR) for resuscitation of patients with abdominal trauma at an urban Level I trauma center would be associated with decreased time to laparotomy and improved outcomes. METHODS We included patients 15 years or older with abdominal trauma who underwent emergent laparotomy within 120 minutes of arrival both at our institution and within a National Trauma Data Bank sample between 2007 to 2019 and 2013 to 2016, respectively. Our institutional sample was matched 1:1 to an American College of Surgeons National Trauma Databank sample using propensity score matching based on age, sex, mechanism of injury, and abdominal Abbreviated Injury Scale score. The primary outcome was time to laparotomy incision. Secondary outcomes included blood transfusion requirement, intensive care unit (ICU) length of stay (LOS), ventilator days, hospital LOS, and in-hospital mortality. RESULTS Two hundred forty patients were included (120 institutional, 120 national). Both samples were well balanced, and 83.3% sustained penetrating trauma. There were 84.2% young adults between the ages of 15 and 47, 91.7% were male, 47.5% Black/African American, with a median Injury Severity Score of 14 (interquartile range [IQR], 8-29), Glasgow Coma Scale score of 15 (IQR, 13-15), 71.7% had an systolic blood pressure of >90 mm Hg, and had a shock index of 0.9 (IQR, 0.7-1.1) which did not differ between groups (p > 0.05). Treatment in the EDOR was associated with decreased time to incision (25.5 minutes vs. 40 minutes; p ≤ 0.001), ICU LOS (1 vs. 3.1 days; p < 0.001), transfusion requirement within 24 hours (3 units vs. 5.8 units packed red blood cells; p = 0.025), hospital LOS (5 days vs. 8.5 days, p = 0.014), and ventilator days (1 day vs. 2 days; p ≤ 0.001). There were no significant differences in in-hospital mortality (22.5% vs. 15.0%; p = 0.14) or outcome-free days (4.9 days vs. 4.5 days, p = 0.55). CONCLUSION The use of an EDOR is associated with decreased time to hemorrhage control as evidenced by the decreased time to incision, blood transfusion requirement, ICU LOS, hospital LOS, and ventilator days. These findings support DOR for patients sustaining operative abdominal trauma. LEVEL OF EVIDENCE Therapeutic/Care Management, Level III.
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Affiliation(s)
- Theodore E Habarth-Morales
- From the Division of Trauma and Acute Care Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
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13
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Direct Admission to the Operating Room for Severe Trauma. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00515-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Qasim Z, Butler FK, Holcomb JB, Kotora JG, Eastridge BJ, Brohi K, Scalea TM, Schwab CW, Drew B, Gurney J, Jansen JO, Kaplan LJ, Martin MJ, Rasmussen TE, Shackelford SA, Bank EA, Braude D, Brenner M, Guyette FX, Joseph B, Hinckley WR, Sperry JL, Duchesne J. Selective Prehospital Advanced Resuscitative Care - Developing a Strategy to Prevent Prehospital Deaths From Noncompressible Torso Hemorrhage. Shock 2022; 57:7-14. [PMID: 34033617 DOI: 10.1097/shk.0000000000001816] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemorrhage, and particularly noncompressible torso hemorrhage remains a leading cause of potentially preventable prehospital death from trauma in the United States and globally. A subset of severely injured patients either die in the field or develop irreversible hemorrhagic shock before they can receive hospital definitive care, resulting in poor outcomes. The focus of this opinion paper is to delineate (a) the need for existing trauma systems to adapt so that potentially life-saving advanced resuscitation and truncal hemorrhage control interventions can be delivered closer to the point-of-injury in select patients, and (b) a possible mechanism through which some trauma systems can train and incorporate select prehospital advanced resuscitative care teams to deliver those interventions.
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Affiliation(s)
- Zaffer Qasim
- Departments of Emergency Medicine and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frank K Butler
- Uniformed Services University, Consultant in Tactical Combat Casualty Care, Joint Trauma System, San Antonio, Texas
| | - John B Holcomb
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joseph G Kotora
- Navy Medicine Readiness and Training Command, Naval Medical Forces Atlantic, Portsmouth, Virginia
| | - Brian J Eastridge
- Division of Trauma and Emergency General Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Karim Brohi
- Center for Trauma Sciences, Queen Mary, University of London, London, UK
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - C William Schwab
- Division of Traumatology and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brendon Drew
- Joint Trauma System Committee on Tactical Combat Casualty Care, Camp Pendleton, California
| | - Jennifer Gurney
- US Army Institute of Surgical Research, Defense Committee on Trauma, Joint Trauma System, San Antonio, Texas
| | - Jan O Jansen
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lewis J Kaplan
- Division of Traumatology and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew J Martin
- Department of Surgery, Scripps Mercy Hospital, San Diego, California
| | - Todd E Rasmussen
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Stacy A Shackelford
- US Army Institute of Surgical Research, Defense Committee on Trauma, Joint Trauma System, San Antonio, Texas
| | - Eric A Bank
- Harris County Emergency Services District, Houston, Texas
| | - Darren Braude
- Division of Prehospital, Austere, and Disaster Medicine, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Megan Brenner
- Department of Surgery, University of California, Riverside, Riverside, California
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, The University of Arizona, Tucson, Arizona
| | - William R Hinckley
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jason L Sperry
- Section of Trauma and Acute Care Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Juan Duchesne
- Division of Trauma, Acute Care, and Critical Care Surgery, Tulane University, New Orleans, Louisiana
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Lee DJK, Kang ML, Christie LMJ, Lim WW, Tay DXH, Patel S, Goo JTT. Improving trauma care in exsanguinating patients with CHOP (critical haemorrhage to operating-room patient) resuscitation protocol-A cumulative summation (CUSUM) analysis. Injury 2021; 52:2508-2514. [PMID: 34127275 DOI: 10.1016/j.injury.2021.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/03/2021] [Accepted: 05/21/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The standard protocol for exsanguinating trauma patients involves initial evaluation and resuscitation in the emergency department which then sets the stage for subsequent definitive care and disposition. This involves major coordination and mobilisation of resources which may cause a delay in intervention especially when most of these cases present after office hours. Our centre has employed a second-tier activation system (CHOP protocol) that immediately mobilises all respective trauma specialists including interventional radiologists and allows rapid access to the operating room. OBJECTIVE We hypothesised that exsanguinating patients managed by CHOP protocol have better overall outcome and survival. METHODS We identified trauma patients that fulfilled CHOP criteria from 2016 to 2019 and divided them into two groups: preCHOP (standard protocol) and CHOP. Data was extracted from a prospectively maintained trauma registry. Demographics, injury pattern and in-hospital data were analysed. The key outcome studied was the impact of CHOP protocol on the mortality rate. Success and failure of the two groups were analysed using CUSUM methodology. RESULTS Thirty-seven patients were managed by CHOP protocol since its introduction in March 2018 compared to 36 patients who underwent standard protocol. Majority of the cases were blunt trauma (89% CHOP vs 92% preCHOP). The mean Injury Severity Score was 37 for CHOP group and 39 for preCHOP group. We observed a significant improvement in time to intervention in CHOP patients (78 min vs 113 min), both during and after office hours. CHOP patients had lower mortality compared to preCHOP group (11% vs 31%) and the effectiveness of the protocol was seen in achieving significantly lower mortality compared to the predicted model. CHOP protocol was able to produce a consistent trend of desired outcomes leading to the CUSUM curve exhibiting a sustained downward slope. CONCLUSION The CHOP protocol, a relatively novel system in the local context, was able to achieve sustained improved outcomes compared to standard protocol. The CUSUM analysis concurred that implementation of CHOP protocol has helped to achieve consistent desired outcomes. It also suggested that the uptake and use of this protocol has integrated well into the existing workflow.
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Affiliation(s)
- Daniel Jin Keat Lee
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, 768828 Singapore.
| | - Min Li Kang
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, 768828 Singapore
| | | | - Woan Wui Lim
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, 768828 Singapore
| | - Dorithy Xiu-Hui Tay
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, 768828 Singapore
| | - Sanjay Patel
- Department of Acute and Emergency Care, Khoo Teck Puat Hospital, 90 Yishun Central, 768828 Singapore
| | - Jerry Tiong Thye Goo
- Department of Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, 768828 Singapore
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de la Mar ACJ, Lokerman RD, Waalwijk JF, Ochen Y, van der Vliet QMJ, Hietbrink F, Houwert RM, Leenen LPH, van Heijl M. In-house versus on-call trauma surgeon coverage: A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 91:435-444. [PMID: 33852558 DOI: 10.1097/ta.0000000000003226] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND A rapid trauma response is essential to provide optimal care for severely injured patients. However, it is currently unclear if the presence of an in-house trauma surgeon affects this response during call and influences outcomes. This study compares in-hospital mortality and process-related outcomes of trauma patients treated by a 24/7 in-house versus an on-call trauma surgeon. METHODS PubMed/Medline, Embase, and CENTRAL databases were searched on the first of November 2020. All studies comparing patients treated by a 24/7 in-house versus an on-call trauma surgeon were considered eligible for inclusion. A meta-analysis of mortality rates including all severely injured patients (i.e., Injury Severity Score of ≥16) was performed. Random-effect models were used to pool mortality rates, reported as risk ratios. The main outcome measure was in-hospital mortality. Process-related outcomes were chosen as secondary outcome measures. RESULTS In total, 16 observational studies, combining 64,337 trauma patients, were included. The meta-analysis included 8 studies, comprising 7,490 severely injured patients. A significant reduction in mortality rate was found in patients treated in the 24/7 in-house trauma surgeon group compared with patients treated in the on-call trauma surgeon group (risk ratio, 0.86; 95% confidence interval, 0.78-0.95; p = 0.002; I2 = 0%). In 10 of 16 studies, at least 1 process-related outcome improved after the in-house trauma surgeon policy was implemented. CONCLUSION A 24/7 in-house trauma surgeon policy is associated with reduced mortality rates for severely injured patients treated at level I trauma centers. In addition, presence of an in-house trauma surgeon during call may improve process-related outcomes. This review recommends implementation of a 24/7 in-house attending trauma surgeon at level I trauma centers. However, the final decision on attendance policy might depend on center and region-specific conditions. LEVEL OF EVIDENCE Systematic review/meta-analysis, level III.
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Affiliation(s)
- Alexander C J de la Mar
- From the Department of Surgery (A.C.J.d.l.M., R.D.L., J.F.W., Y.O., Q.M.J.v.d.V., F.H., R.M.H., M.v.H., L.P.H.L.), University Medical Center Utrecht, Utrecht; Department of Clinical Epidemiology (Y.O.), Leiden University Medical Center, Leiden; and Department of Surgery (M.v.H.), Diakonessenhuis, Zeist, Doorn, Utrecht, the Netherlands
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Martin MJ, Johnson A, Rott M, Kuchler A, Cole F, Ramzy A, Barbosa R, Long WB. Choosing wisely: A prospective study of direct to operating room trauma resuscitation including real-time trauma surgeon after-action review. J Trauma Acute Care Surg 2021; 91:S146-S153. [PMID: 33797495 DOI: 10.1097/ta.0000000000003176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Although several centers have direct to operating room (DOR) resuscitation programs, there are no published prospective studies on optimal patient selection, interventions, outcomes, or real-time surgeon assessments. METHODS Direct to operating room cases for 1 year were prospectively enrolled. Demographics, injury types/severity, triage criteria, interventions, and outcomes including Glasgow Outcome Scale score were collected. Detailed time-to-event and sequence data on initial lifesaving interventions (LSIs) or emergent surgeries were analyzed. A structured real-time attending surgeon assessment tool for each case was collected. Direct to operating room activation criteria were grouped into categories: mechanism, physiology, injury pattern, or emergency medical services (EMS) suspicion. RESULTS There were 104 DOR cases: male, 84%; penetrating, 80%; and severely injured (Injury Severity Score, >15), 39%. The majority (65%) required at least one LSI (median of 7 minutes from arrival), and 41% underwent immediate emergent surgery (median, 26 minutes). Blunt patients were more severely injured and more likely to undergo LSI (86% vs. 59%) but less likely to require emergent surgery (19% vs. 47%, all p < 0.05). Analysis of DOR criteria categories showed unique patterns in each group for interventions and outcomes, with EMS suspicion associated with the lowest need for DOR. Surgeon assessment tool results found that DOR was indicated in 84% and improved care in 63%, with a small subset identified (9%) where DOR had a negative impact. CONCLUSION Direct to operating room resuscitation facilitated timely emergent interventions in penetrating truncal trauma and a select subset of critically ill blunt patients. Unique intervention/outcome profiles were identified by activation criteria groups, with little utility among activations for EMS suspicion. Real-time surgeon assessment tool identified high- and low-yield DOR groups. LEVEL OF EVIDENCE Prospective observational study, level III.
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Affiliation(s)
- Matthew J Martin
- From the Trauma and Emergency Surgery Service (M.J.M., A.J., M.R., A.K., F.C., A.R., R.B., W.B.L.), Legacy Emanuel Medical Center, Portland, Oregon; Trauma Research Program (M.J.M.), Scripps Mercy Hospital, San Diego, California; and Department of Surgery (M.J.M.), Madigan Army Medical Center, Tacoma, Washington
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Kalkwarf KJ, Goodman MD, Press GM, Wade CE, Cotton BA. Prehospital ABC Score Accurately Forecasts Patients Who Will Require Immediate Resource Utilization. South Med J 2021; 114:193-198. [PMID: 33787930 DOI: 10.14423/smj.0000000000001236] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Scoring systems, such as the Assessment of Blood Consumption (ABC) Score, are used to identify patients at risk for massive transfusion (MT, ≥10 U red blood cells in 24 hours). Our aeromedical transport helicopter uses ultrasound to perform the Focused Assessment with Sonography for Trauma (FAST) examination. Our objective was to evaluate the ability of the Prehospital ABC (PhABC) Score to predict blood transfusions and the need for emergent laparotomy. METHODS Post hoc analysis of a prospective observational study of trauma patients who underwent an in-flight FAST during aeromedical transport during a 7-month period. PhABC Score was positive if ≥2 of the following were present in flight: penetrating trauma, heart rate >120 bpm, systolic blood pressure <90 mm Hg, or a positive abdominal FAST. The PhABC Score was evaluated by area under the receiver operating characteristic (AUROC) curves and logistic regression. RESULTS A total of 291 trauma patients met inclusion criteria, 23 underwent emergent laparotomy, and 12 received an MT. A positive PhABC Score predicted emergent laparotomy, with a positive predictive value of 48% and a negative predictive value of 95% (sensitivity 46%, specificity 96%, AUROC curve 0.83). A positive PhABC Score also predicted receipt of an MT with a positive predictive value of 28% and a negative predictive value of 94% (sensitivity 33%, specificity 93%, AUROC curve 0.77). Multiple logistic regression identified FAST as the most powerful contributor of the PhABC Score to the prediction of both emergent laparotomy (odds ratio 8.5, P < 0.001) and MT (odds ratio 5.9, P < 0.001). CONCLUSIONS The PhABC Score effectively predicts in-hospital resource utilization. It provides an outstanding undertriage rate from the prehospital setting, and it is helpful to improve trauma team activation, mobilize blood products, and prepare the operating room.
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Affiliation(s)
- Kyle J Kalkwarf
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
| | - Michael D Goodman
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
| | - Gregory M Press
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
| | - Charles E Wade
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
| | - Bryan A Cotton
- From the Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, the Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, the Department of Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, and the Center for Translational Injury Research and the Department of Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Houston
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Umemura Y, Watanabe A, Kinoshita T, Morita N, Yamakawa K, Fujimi S. Hybrid emergency room shows maximum effect on trauma resuscitation when used in patients with higher severity. J Trauma Acute Care Surg 2021; 90:232-239. [PMID: 33165282 DOI: 10.1097/ta.0000000000003020] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The hybrid emergency room (ER) system is a novel trauma workflow that uses angio-computed tomography equipment in a trauma resuscitation room. Although the hybrid ER system decreases time to start surgery and endovascular treatments and improves mortality, the optimal target benefitting from this system remained unclear. We aimed to identify a subset of trauma patients likely to receive the greatest benefits from the hybrid ER. METHODS This retrospective cohort study was conducted in a tertiary hospital in Japan from August 2007 to January 2020. We consecutively included severe adult blunt trauma patients (Injury Severity Score [ISS], ≥16) and divided them into two groups: conventional group (August 2007 to July 2011) and hybrid ER (August 2011 to January 2020) group. We evaluated the association between the hybrid ER group and 28-day mortality using multivariable logistic regression analysis. The 28-day mortality trend during the study period was evaluated with restricted cubic spline analysis. To evaluate heterogeneity of effects within various patient severities, we evaluated whether the patients' ISS modified the effect of the hybrid ER on survival. RESULTS Among 1,050 trauma patients, the conventional group comprised 360 patients and the hybrid ER group comprised 690 patients. Injury Severity Score and probability of survival (Ps) were not significantly different between the groups. Twenty-eight-day mortality was significantly lower in the hybrid ER group (Ps-adjusted odds ratio, 0.48; 95% confidence interval, 0.32-0.71; p < 0.001). Restricted cubic spline analysis revealed that Ps-adjusted 28-day mortality sharply decreased approximately 200 days after installation of the hybrid ER. Increase of survival probabilities according to the increase of ISS was significantly improved in hybrid ER group (p = 0.014). Because ISS increased to >25, survival probabilities in the hybrid ER group were higher compared with those in the conventional group. CONCLUSION The hybrid ER may improve posttraumatic mortality, especially in patients with higher baseline severity. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Affiliation(s)
- Yutaka Umemura
- From the Division of Trauma and Surgical Critical Care (Y.U., A.W., N.M., S.F.), Osaka General Medical Center, Osaka; Department of Traumatology and Acute Critical Medicine (T.K.), Graduate School of Medicine, Osaka University, Suita; and Department of Emergency Medicine (K.Y.), Osaka Medical College, Osaka, Japan
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Predictors for Direct to Operating Room Admission in Severe Trauma. J Surg Res 2021; 261:274-281. [PMID: 33460973 DOI: 10.1016/j.jss.2020.12.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/17/2020] [Accepted: 12/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Protocols for expediting critical trauma patients directly from the helipad to the operating room tend to vary by center, rely heavily on physician gestalt, and lack supporting evidence. We evaluated a population of severely injured trauma patients with the aim of determining objective factors associated with the need for immediate surgical intervention. METHODS All highest-activation trauma patients transported by air ambulance between 1/1/16 and 12/31/17 were enrolled retrospectively. Transfer, pediatric, isolated burn, and isolated head trauma patients were excluded. Patients who underwent emergency general surgery within 30 min of arrival without the aid of cross-sectional imaging were compared to the remainder of the cohort. RESULTS Of the 863 patients who were enrolled, 85 (10%) spent less than 30 min in the emergency department (ED) before undergoing an emergency operation. The remaining 778 patients (90%) formed the comparison group. The ED ≤ 30 min group had a higher percentage of penetrating injuries, lower blood pressure, and was more likely to have a positive FAST exam. The "Direct to Operating Room" (DTOR) score is a predictive scoring system devised to identify patients most likely to benefit from bypassing the ED. The odds ratio of emergency operation within 30 min of hospital arrival increased by 2.71 (95% confidence interval 2.23-3.29; P < 0.001) for every 1-point increase in DTOR score. CONCLUSIONS Trauma patients with profound hypotension or acidosis and positive FAST were more likely to require surgery within 30 min of hospital presentation. Use of a scoring system may allow early identification of these patients in the prehospital setting by nonphysician providers.
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Butler WJ, Smith JE, Tadlock MD, Martin MJ. Initial Assessment and Resuscitation of the Battlefield Casualty—an Overview. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00200-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Direct to operating room trauma resuscitation: Optimizing patient selection and time-critical outcomes when minutes count. J Trauma Acute Care Surg 2020; 89:160-166. [PMID: 32218021 DOI: 10.1097/ta.0000000000002703] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although several trauma centers have developed direct to operating room (DOR) trauma resuscitation programs, there is little published data on optimal patient selection, practices, and outcomes. We sought to analyze triage criteria and interventions associated with optimal DOR outcomes and resource utilization. METHODS Retrospective review of all adult DOR resuscitations for a 6-year period was performed. Triage criteria were analyzed individually and grouped into categories: mechanism, physiology, anatomy/injury, or other. The best univariate and multivariate predictors of requiring lifesaving interventions (LSIs) or emergent surgery (ES) were analyzed. Actual and predicted mortality were compared for all patients and for predefined time-sensitive subgroups. RESULTS There were 628 DOR patients (5% of all admissions) identified; the majority were male (79%), penetrating mechanism (70%), severely injured (40% ISS >15), and 17% died. Half of patients required LSI and 23% required ES, with significantly greater need for ES and lower need for LSI after penetrating versus blunt injury (p < 0.01). Although injury mechanism criteria triggered most DOR cases and best predicted need for ES, the physiology and anatomy/injury criteria were associated with greater need for LSI and mortality. Observed mortality was significantly lower than predicted mortality with DOR for several key subgroups. Triage schemes for both ES and LSI could be simplified to four to six independent predictors by regression analysis. CONCLUSION The DOR program identified severely injured trauma patients at increased risk for requiring LSI and/or ES. Different triage variable categories drive the need for ES versus LSI and could be simplified or optimized based on local needs or preferences. Direct to operating room was associated with better than expected survival among specific time-sensitive subgroups. LEVEL OF EVIDENCE Therapeutic/Care Management, Level IV.
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Jang JY, Oh J, Shim H, Kim S, Jung PY, Kim S, Bae KS. The need for a rapid transfer to a hybrid operating theatre: Do we lose benefit with poor efficiency? Injury 2020; 51:1987-1993. [PMID: 32360089 DOI: 10.1016/j.injury.2020.04.029] [Citation(s) in RCA: 5] [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: 11/27/2019] [Revised: 03/29/2020] [Accepted: 04/17/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Recent studies on hybrid operating rooms (ORs) have mainly reported their applications in orthopaedic surgery and interventional radiology (IR); there are few studies assessing severely injured patients who underwent IR or surgery in hybrid ORs for haemostasis. Therefore, this study aimed to evaluate our early experience with the use of hybrid OR to control haemorrhage in severe trauma patients. METHODS Medical charts of patients who underwent an emergency surgery or IR for haemostasis were analysed retrospectively between January and December 2015. RESULTS Of the 95 patients directly transported to the general or hybrid OR, 69 (73%) were transported to the non-hybrid OR and underwent emergency surgeries, whereas 26 (27%) were transported to the hybrid OR and underwent emergency IR or surgery on-site. Patients transported to the hybrid OR had a higher median Injury Severity Score (median: 29, interquartile range[IQR]: 21-36.5 vs median: 21, IQR: 16-27) and lower median initial systolic blood pressure (median: 96, IQR: 82.75-128.75 vs median: 114, IQR: 95-151.5) than those transported to the non-hybrid OR. The median time from the emergency room (ER) arrival to the start of the emergency procedure in the hybrid OR group was similar with that in the non-hybrid OR group (median: 80, IQR: 62.75-91.5 vs median: 75, IQR: 56.5-99). Seven patients underwent IR and surgery concurrently in the hybrid OR because of a haemodynamically unstable pelvic fracture, severe liver injury, and severe brain haemorrhage. The median time from the ER arrival to the start of the haemostatic procedure or operation was 64(43-97) minutes. CONCLUSIONS Although the hybrid OR may be used for haemostasis in severely injured patients, the long median time from ER arrival to the start of a haemostatic procedure in hybrid OR indicates the need for a new workflow to reduce this time and to facilitate hybrid OR use.
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Affiliation(s)
- Ji Young Jang
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Republic of Korea.
| | - Jiwoong Oh
- Department of Neurosurgery, Yonsei University College of Medicine, Republic of Korea
| | - Hongjin Shim
- Department of Surgery, Yonsei University Wonju College of Medicine, Republic of Korea; Regional Trauma Centre, Wonju Severance Christian Hospital, Republic of Korea
| | - Seongyup Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Republic of Korea; Regional Trauma Centre, Wonju Severance Christian Hospital, Republic of Korea
| | - Pil Young Jung
- Department of Surgery, Yonsei University Wonju College of Medicine, Republic of Korea; Regional Trauma Centre, Wonju Severance Christian Hospital, Republic of Korea
| | - Sohyun Kim
- Department of Physiology, Yonsei University College of Medicine, Republic of Korea
| | - Keum Seok Bae
- Department of Surgery, Yonsei University Wonju College of Medicine, Republic of Korea; Regional Trauma Centre, Wonju Severance Christian Hospital, Republic of Korea
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Maxwell BG, Greenlaw A, Smith WJ, Barbosa RR, Ropp KM, Lundeberg MR. Pregnant trauma patients may be at increased risk of mortality compared to nonpregnant women of reproductive age: trends and outcomes over 10 years at a level I trauma center. ACTA ACUST UNITED AC 2020; 16:1745506520933021. [PMID: 32578516 PMCID: PMC7315661 DOI: 10.1177/1745506520933021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: Pregnancy has been identified as a risk factor for poor outcomes after traumatic injury, but prior outcome analyses are conflicting and dated. We sought to examine outcomes in a contemporary cohort. Methods: Retrospective cohort analysis at a level I trauma center’s institutional registry from 2009 to 2018, with comparison to population-level demographic trends in women of reproductive age and pregnancy prevalence. Unadjusted cohorts of pregnant versus nonpregnant trauma patients were compared. Pregnant patients then were matched on age, mechanism of injury, year, and injury severity score with nonpregnant controls for adjusted analysis with a primary outcome of maternal mortality. Results: Despite declining birth and pregnancy rates in the population, pregnant women comprised a stable 5.3% of female trauma patients of reproductive age without decline over the study period (p = 0.53). Compared with nonpregnant women, pregnant trauma patients had a lower injury severity score (1 [1–5] vs 5 [1–10] p < 0.0001) and a shorter length of stay (1 [1–2] vs 1 [1–4] p = 0.04), were less likely to have CT imaging (48.8% vs 67.4%, p < 0.0001) and more likely to be admitted (89.3% vs 79.2%, p = 0.003). Positive toxicology screens were less prevalent in pregnant women, but only for ethanol (5.4% vs 31.4%, p < 0.0001); there was no difference in rates of cannabis, opiates, or cocaine. After matching to adjust for age, year, mechanism of injury, and injury severity score, mortality occurred significantly more frequently in the pregnant cohort (2.1% vs 0.2%, OR = 13.5 [1.39–130.9], p = 0.02). Conclusion: Pregnant trauma patients have not declined in our population despite population-level declines in pregnancy. After adjusting for lower injury severity, pregnant women were at substantially greater risk of mortality. This supports ongoing concern for pregnant trauma patients as a vulnerable population. Further efforts should optimize systems of care to maximize the chances of rescue for both mother and fetus.
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Affiliation(s)
- Bryan G Maxwell
- Department of Anesthesiology, Legacy Emanuel Medical Center, Portland, OR, USA
| | - Andrea Greenlaw
- Department of Trauma Services, Legacy Emanuel Medical Center, Portland, OR, USA
| | - Wendy J Smith
- Department of Obstetrics, Legacy Emanuel Medical Center, Portland, OR, USA
| | - Ronald R Barbosa
- Department of Surgery; Legacy Emanuel Medical Center, Portland, OR, USA
| | - Kate M Ropp
- Department of Anesthesiology, Legacy Emanuel Medical Center, Portland, OR, USA
| | - Megan R Lundeberg
- Department of Surgery; Legacy Emanuel Medical Center, Portland, OR, USA
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Evaluation and management of abdominal gunshot wounds: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2020; 87:1220-1227. [PMID: 31233440 DOI: 10.1097/ta.0000000000002410] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Braz LG, Carlucci MTO, Braz JRC, Módolo NSP, do Nascimento P, Braz MG. Perioperative cardiac arrest and mortality in trauma patients: A systematic review of observational studies. J Clin Anesth 2020; 64:109813. [PMID: 32304957 DOI: 10.1016/j.jclinane.2020.109813] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/18/2020] [Accepted: 04/04/2020] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE Factors that influence the occurrence of perioperative cardiac arrest (CA) and its outcomes in trauma patients are not well known. The novelty of our study lies in the performance of a systematic review conducted worldwide on the occurrence of perioperative CA and/or mortality in trauma patients. DESIGN A systematic review was performed to identify observational studies that reported the occurrence of CA and/or mortality due to trauma and CA and/or mortality rates in trauma patients up to 24 h postoperatively. We searched the MEDLINE, EMBASE, LILACS and SciELO databases through January 29, 2020. SETTING Perioperative period. MEASUREMENTS The primary outcomes evaluated were data on the epidemiology of perioperative CA and/or mortality in trauma patients. MAIN RESULTS Nine studies were selected, with the first study being published in 1994 and the most recent being published in 2019. Trauma was an important factor in perioperative CA and mortality, with rates of 168 and 74 per 10,000 anesthetic procedures, respectively. The studies reported a higher proportion of perioperative CA and mortality in trauma patients who were males, young adults and adults, patients with American Society of Anesthesiologists (ASA) physical status ≥ III, patients undergoing general anesthesia, and in abdominal or neurological surgeries. Uncontrolled hemorrhage was the main cause of perioperative CA and mortality after trauma. Survival rates after perioperative CA were low. CONCLUSIONS Trauma is an important factor in perioperative CA and mortality, especially in young adult and adult males and in patients classified as having an ASA physical status ≥ III mainly due to uncontrollable bleeding after blunt and perforating injuries. Trauma is a global public health problem and has a strong impact on perioperative morbidity and mortality.
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Affiliation(s)
- Leandro G Braz
- Anesthesia Cardiac Arrest and Mortality Study Commission, Sao Paulo State University - UNESP, Botucatu Medical School, Department of Anesthesiology, Brazil.
| | - Marcelo T O Carlucci
- Anesthesia Cardiac Arrest and Mortality Study Commission, Sao Paulo State University - UNESP, Botucatu Medical School, Department of Anesthesiology, Brazil
| | - José Reinaldo C Braz
- Anesthesia Cardiac Arrest and Mortality Study Commission, Sao Paulo State University - UNESP, Botucatu Medical School, Department of Anesthesiology, Brazil
| | - Norma S P Módolo
- Anesthesia Cardiac Arrest and Mortality Study Commission, Sao Paulo State University - UNESP, Botucatu Medical School, Department of Anesthesiology, Brazil
| | - Paulo do Nascimento
- Anesthesia Cardiac Arrest and Mortality Study Commission, Sao Paulo State University - UNESP, Botucatu Medical School, Department of Anesthesiology, Brazil
| | - Mariana G Braz
- Anesthesia Cardiac Arrest and Mortality Study Commission, Sao Paulo State University - UNESP, Botucatu Medical School, Department of Anesthesiology, Brazil
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Direct to operating room trauma resuscitation decreases mortality among severely injured children. J Trauma Acute Care Surg 2019; 85:659-664. [PMID: 29554039 DOI: 10.1097/ta.0000000000001908] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Expediting evaluation and intervention for severely injured patients has remained a mainstay of advanced trauma care. One technique, direct to operating room (DOR) resuscitation, for selective adult patients has demonstrated decreased mortality. We sought to investigate the application of this protocol in children. METHODS All DOR pediatric patients from 2009 to 2016 at a pediatric Level I trauma center were identified. Direct to OR criteria included penetrating injury, chest injuries, amputations, significant blood loss, cardiopulmonary resuscitation, and surgeon discretion. Demographics, injury patterns, interventions, and outcomes were analyzed. Observed mortality was compared with expected mortality, calculated using Trauma Injury Severity Score methodology, with two-tailed t tests, and a p value less than 0.5 was considered significant. RESULTS Of 2,956 total pediatric trauma activations, 82 (2.8%) patients (age range, 1 month to 17 years) received DOR resuscitation during the study period. The most common indications for DOR were penetrating injuries (62%) and chest injuries (32%). Forty-four percent had Injury Severity Score (ISS) greater than 15, 33% had Glasgow Coma Scale (GCS) score of 8 or less, and 9% were hypotensive. The most commonly injured body regions were external (66%), head (34%), chest (30%), and abdomen (27%). Sixty-seven (82%) patients required emergent procedural intervention, most commonly wound exploration/repair (35%), central venous access (22%), tube thoracostomy (19%), and laparotomy (18%). Predictors of intervention were ISS greater than 15 (odds ratio, 14; p = 0.013) and GCS < 9 (odds ratio = 8.5, p = 0.044). The survival rate to discharge for DOR patients was 84% compared with an expected survival of 79% (Trauma Injury Severity Score) (p = 0.4). The greatest improvement relative to expected mortality was seen in the subgroup with penetrating trauma (84.5% vs 74.4%; p = 0.002). CONCLUSION A selective policy of resuscitating the most severely injured children in the OR can decrease mortality. Patients suffering penetrating trauma with the highest ISS, and diminished GCS scores have the greatest benefit. Trauma centers with appropriate resources should evaluate implementing similar policies. LEVEL OF EVIDENCE Diagnostic tests or criteria, level II.
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Matsumoto N, Yamamoto S, Endo I, Yoshida O, Kubo M, Udaka T, Sogabe O, Maeda H, Kawata C, Kurokawa H. The efficacy of a trauma call system: challenges in managing severe trauma at a rural emergency center without full-time emergency physicians. Acute Med Surg 2019; 6:259-264. [PMID: 31304027 PMCID: PMC6603310 DOI: 10.1002/ams2.406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 02/05/2019] [Indexed: 11/27/2022] Open
Abstract
AIMS There have been some reports about the efficacy of trauma team activation. In November 2015, we implemented a trauma call system, wherein a general surgeon, neurosurgeon, and orthopedic surgeon are called to the emergency department when severe trauma patients are transferred to our emergency department. In this study, we evaluated the efficacy of this trauma call system. METHODS The purpose of the present study was to evaluate the efficacy of a trauma call system for trauma cases with an Injury Severity Score ≥16. We compared the mortality of trauma cases and the time from arrival to the start of the examination and intervention before and after implementing this trauma call system. RESULTS There was no significant difference in the mortality rates before and after the implementation of the trauma call system. The median time from arrival to the start of contrast-enhanced computed tomography or transcatheter arterial embolization improved from 54 to 19 min (P = 0.015) and 171 to 84 min (P = 0.030), respectively, after the implementation of the trauma call system. CONCLUSION Our trauma call system did not significantly improve the mortality of trauma patients with an Injury Severity Score ≥16. However, it was effective for reducing the time from the arrival to the start of contrast-enhanced computed tomography or transcatheter arterial embolization.
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Affiliation(s)
- Naoya Matsumoto
- Department of SurgeryMitoyo General HospitalKanonji‐shiJapan
| | | | - Izuru Endo
- Department of SurgeryMitoyo General HospitalKanonji‐shiJapan
| | - Osamu Yoshida
- Department of SurgeryMitoyo General HospitalKanonji‐shiJapan
| | - Masatoshi Kubo
- Department of SurgeryMitoyo General HospitalKanonji‐shiJapan
| | - Tetsunobu Udaka
- Department of SurgeryMitoyo General HospitalKanonji‐shiJapan
| | - Osanori Sogabe
- Department of SurgeryMitoyo General HospitalKanonji‐shiJapan
| | - Hiroya Maeda
- Department of SurgeryMitoyo General HospitalKanonji‐shiJapan
| | - Chika Kawata
- Post‐graduate Education Center, Mitoyo General HospitalKanonji‐shiJapan
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Kuckelman J, Cuadrado D, Martin M. Thoracic Trauma: a Combat and Military Perspective. CURRENT TRAUMA REPORTS 2018. [DOI: 10.1007/s40719-018-0112-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Arevalo MK, Sheth KR, Menon VS, Ostrov L, Hennes H, Singla N, Koral K, Schlomer BJ, Baker LA. Straight to the Operating Room: An Emergent Surgery Track for Acute Testicular Torsion Transfers. J Pediatr 2018; 192:178-183. [PMID: 29246339 PMCID: PMC5737783 DOI: 10.1016/j.jpeds.2017.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/19/2017] [Accepted: 09/07/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the effect of implementing an emergency surgery track for testicular torsion transfers. We hypothesized that transferring children from other facilities diagnosed with torsion straight to the operating room (STOR) would decrease ischemia time, lower costs, and reduce testicular loss. STUDY DESIGN Demographics, arrival to incision time, hospital cost in dollars, and testicular outcome (determined by testicular ultrasound) at follow-up were retrospectively compared in all patients transferred to our tertiary care children's hospital with a diagnosis of testicular torsion from 2012 to 2016. Clinical data for STOR and non-STOR patients were compared by Wilcoxon rank-sum, 2-tailed t test, or Fisher exact test as appropriate. RESULTS Sixty-eight patients met inclusion criteria: 35 STOR and 33 non-STOR. Children taken STOR had a shorter median arrival to incision time (STOR: 54 minutes vs non-STOR: 94 minutes, P < .0001) and lower median total hospital costs (STOR: $3882 vs non-STOR: $4419, P < .0001). However, only 46.8% of STOR patients and 48.4% of non-STOR patients achieved surgery within 6 hours of symptom onset. Testicular salvage rates in STOR and non-STOR patients were not significantly different (STOR: 68.4% vs non-STOR: 36.8%, P = .1), but follow-up was poor. CONCLUSIONS STOR decreased arrival to incision time and hospital cost but did not affect testicular loss. The bulk of ischemia time in torsion transfers occurred before arrival at our tertiary care center. Further interventions addressing delays in diagnosis and transfer are needed to truly improve testicular salvage rates in these patients.
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Affiliation(s)
| | - Kunj R Sheth
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Vani S Menon
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Halim Hennes
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | - Nirmish Singla
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Korgun Koral
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | - Bruce J Schlomer
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
| | - Linda A Baker
- Children’s Health, Dallas, TX,University of Texas Southwestern Medical Center, Dallas, TX
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Effect of time to operation on mortality for hypotensive patients with gunshot wounds to the torso: The golden 10 minutes. J Trauma Acute Care Surg 2017; 81:685-91. [PMID: 27488491 DOI: 10.1097/ta.0000000000001198] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Timely hemorrhage control is paramount in trauma; however, a critical time interval from emergency department arrival to operation for hypotensive gunshot wound (GSW) victims is not established. We hypothesize that delaying surgery for more than 10 minutes from arrival increases all-cause mortality in hypotensive patients with GSW. METHODS Data of adults (n = 309) with hypotension and GSW to the torso requiring immediate operation from January 2004 to September 2013 were retrospectively reviewed. Patients with resuscitative thoracotomies, traumatic brain injury, transfer from outside institutions, and operations occurring more than 1 hour after arrival were excluded. Survival analysis using multivariate Cox regression models was used for comparison. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. Statistical significance was considered at p ≤ 0.05. RESULTS The study population was aged 32 ± 12 years, 92% were male, Injury Severity Score was 24 ± 15, systolic blood pressure was 81 ± 29 mm Hg, Glasgow Coma Scale score was 13 ± 4. Overall mortality was 27%. Mean time to operation was 19 ± 13 minutes. After controlling for organ injury, patients who arrived to the operating room after 10 minutes had a higher likelihood of mortality compared with those who arrived in 10 minutes or less (HR, 1.89; 95% CI, 1.10-3.26; p = 0.02); this was also true in the severely hypotensive patients with systolic blood pressure of 70 mm Hg or less (HR, 2.67; 95% CI, 0.97-7.34; p = 0.05). The time associated with a 50% cumulative mortality was 16 minutes. CONCLUSIONS Delay to the operating room of more than 10 minutes increases the risk of mortality by almost threefold in hypotensive patients with GSW. Protocols should be designed to shorten time in the emergency department. Further prospective observational studies are required to validate these findings. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Matsumoto H, Hara Y, Yagi T, Saito N, Mashiko K, Iida H, Motomura T, Nakayama F, Okada K, Yasumatsu H, Sakamoto T, Seo T, Konda Y, Hattori Y, Yokota H. Impact of urgent resuscitative surgery for life-threatening torso trauma. Surg Today 2016; 47:827-835. [PMID: 27888344 PMCID: PMC5486610 DOI: 10.1007/s00595-016-1451-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 10/28/2016] [Indexed: 11/28/2022]
Abstract
Purpose This study investigated the advantages of performing urgent resuscitative surgery (URS) in the emergency department (ED); namely, our URS policy, to avoid a delay in hemorrhage control for patients with severe torso trauma and unstable vital signs. Methods We divided 264 eligible cases into a URS group (n = 97) and a non-URS group (n = 167) to compare, retrospectively, the observed survival rate with the predicted survival using the Trauma and Injury Severity Score (TRISS). Results While the revised trauma score and the injury severity score were significantly lower in the URS group than in the non-URS group, the observed survival rate was significantly higher than the predicted rate in the URS (48.5 vs. 40.2%; p = 0.038). URS group patients with a systolic blood pressure (SBP) <90 mmHg and a Glasgow coma scale (GCS) score of ≥9 had significantly higher observed survival rates than predicted survival rates (0.433 vs. 0.309, p = 0.008), (0.795 vs. 0.681, p = 0.004). The implementation of damage control surgery (DCS) was found to be a significant predictor of survival (OR 5.23, 95% CI 0.113–0.526, p < 0.010). Conclusion The best indications for the URS policy are an SBP <90 mmHg, a GCS ≥9 on ED arrival, and/or the need for DCS. By implementing our URS policy, satisfactory survival of patients requiring immediate hemostatic surgery was achieved.
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Affiliation(s)
- Hisashi Matsumoto
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, 1715, Kamakari, Inzai, Chiba Prefecture, 270-1694, Japan. .,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan.
| | - Yoshiaki Hara
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, 1715, Kamakari, Inzai, Chiba Prefecture, 270-1694, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Takanori Yagi
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, 1715, Kamakari, Inzai, Chiba Prefecture, 270-1694, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Nobuyuki Saito
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, 1715, Kamakari, Inzai, Chiba Prefecture, 270-1694, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazuki Mashiko
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, 1715, Kamakari, Inzai, Chiba Prefecture, 270-1694, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroaki Iida
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, 1715, Kamakari, Inzai, Chiba Prefecture, 270-1694, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Tomokazu Motomura
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, 1715, Kamakari, Inzai, Chiba Prefecture, 270-1694, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Fumihiko Nakayama
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, 1715, Kamakari, Inzai, Chiba Prefecture, 270-1694, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazuhiro Okada
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, 1715, Kamakari, Inzai, Chiba Prefecture, 270-1694, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroshi Yasumatsu
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, 1715, Kamakari, Inzai, Chiba Prefecture, 270-1694, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Taigo Sakamoto
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, 1715, Kamakari, Inzai, Chiba Prefecture, 270-1694, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Takao Seo
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, 1715, Kamakari, Inzai, Chiba Prefecture, 270-1694, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Yusuke Konda
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, 1715, Kamakari, Inzai, Chiba Prefecture, 270-1694, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - You Hattori
- Shock and Trauma Centre, Nippon Medical School Chiba Hokusoh Hospital, 1715, Kamakari, Inzai, Chiba Prefecture, 270-1694, Japan.,Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
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The potential benefit of a hybrid operating environment among severely injured patients with persistent hemorrhage: How often could we get it right? J Trauma Acute Care Surg 2016; 80:457-60. [PMID: 26713967 DOI: 10.1097/ta.0000000000000951] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Selecting the appropriate initial destination (operating theater [OR], angiography suite, or intensive care unit [ICU]) in persistently hypotensive injured patients can be extremely challenging. The purpose of this study was to define the flow, interventions, and outcomes of these patients. METHODS All persistently hypotensive (two or more systolic blood pressures < 90 mmHg) severely injured (Injury Severity Score [ISS] ≥ 12) adult patients (1995-2012) were analyzed over the first 24 hours at a Level I trauma referral center. Standard statistical methodology was used (p < 0.05). RESULTS Of 911 patients with an initial systolic blood pressure of less than 90 mm Hg (prehospital or initial trauma bay reading), 56% remained persistently hypotensive. These patients had a mean age of 41 years, were 73% male, and blunt injured in 87% of the cases. Initial destinations included the OR (53%), ICU (29%), trauma ward (13%) after resuscitation and diagnostic imaging, and interventional angiography suite (5%). Of all hypotensive patients, 67% received computed tomography either before or after initial transfer from the trauma bay. Of the patients who were moved to the OR, 64% were subsequently transferred to the ICU and 23% to the ward, and 14% died in the OR itself. Within the OR, 97% of the patients underwent an intervention (79% laparotomies). A total of 7% of the patients required both emergent operative and angiographic interventions. These were most commonly due to ongoing hemorrhage from pelvic fractures or major hepatic lacerations. Mortality was higher in patients who underwent operation before angiography (90% vs. 32%, p = 0.002). The median hospital length of stay was 22 days (ICU stay, 8 days). The mortality (<24 hours) of all persistently hypotensive patients was 22%. CONCLUSION Up to 7% of patients in this cohort could benefit from the utility of a hybrid RAPTOR [Resuscitation with Angiography, Percutaneous Therapy Operative Repair] suite. A "direct to the RAPTOR suite" policy (i.e., bypass emergency department) must be used with caution. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Initial Evaluation and Triage of the Injured Patient: Mechanisms of Injury and Triggers for Operating Room Versus Emergency Department Stabilization. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0148-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Utility of simultaneous interventional radiology and operative surgery in a dedicated suite for seriously injured patients. Curr Opin Crit Care 2014; 19:587-93. [PMID: 24240824 DOI: 10.1097/mcc.0000000000000031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW In recent years, combined interventional radiology and operative suites have been proposed and are now becoming operational in select trauma centres. Given the infancy of this technology, this review aims to review the rationale, benefits and challenges of hybrid suites in the management of seriously injured patients. RECENT FINDINGS No specific studies exist that investigate outcomes within hybrid trauma suites. Endovascular and interventional radiology techniques have been successfully employed in thoracic, abdominal, pelvic and extremity trauma. Although the association between delayed haemorrhage control and poorer patient outcomes is intuitive, most supporting scientific data are outdated. The hybrid suite model offers the potential to expedite haemorrhage control through synergistic operative, interventional radiology and resuscitative platforms. Maximizing the utility of these suites requires trained multidisciplinary teams, ergonomic and workplace considerations, as well as a fundamental paradigm shift of trauma care. This often translates into a more damage-control orientated philosophy. SUMMARY Hybrid suites offer tremendous potential to expedite haemorrhage control in trauma patients. Outcome evaluations from trauma units that currently have operational hybrid suites are required to establish clearer guidelines and criteria for patient management.
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