The effect of prehospital time related variables on mortality following severe thoracic trauma

Immediate versus expedient emergent laparotomy in unstable isolated abdominal trauma patients

INTRODUCTION

Unstable abdominal trauma patients should be treated with emergent laparotomy. However, few studies have evaluated the association between time to surgery and survival in these patients. We aimed to assess the influence of time to laparotomy on outcomes in blunt and penetrating unstable abdominal trauma patients.

METHODS

This retrospective study includes patients with abdominal injuries, systolic blood pressure <90mmHg on arrival, admitted in Israel during 2000-2018. Data regarding patients' characteristics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), time to surgery, length of hospital stay and mortality were collected via The Israeli National Trauma Registry.

RESULTS

Overall, 69 blunt and 127 penetrating injury patients were included in the study. For blunt and penetrating trauma patients with ISS ≤14, no differences in outcome were found between patients who underwent laparotomy within 60min of admission and those who underwent laparotomy within 60-120min of admission. In patients with blunt trauma, ISS ≥16, and GCS <15, mortality was higher in the immediate laparotomy group (p = 0.004 and 0.049, respectively).

CONCLUSIONS

In patients with a penetrating injury, no differences in mortality between immediate and expedient laparotomy were demonstrated. In patients with a blunt injury, with ISS ≥16 and GCS <15, mortality was higher among the immediate laparotomy group.

The implications of using maternity care deserts to measure progress in access to obstetric care: a mixed-integer optimization analysis

BACKGROUND

Lack of access to risk-appropriate maternity services, particularly for rural residents, is thought to be a leading contributor to disparities in maternal morbidity and mortality. There are several existing measures of access to obstetric care in the literature and popular media. In this study, we explored how current measures of obstetric access inform the number and location of additional obstetric care facilities required to improve access.

METHODS

We formulated two facility location optimization models to determine the number of new facilities required to minimize the number of reproductive-aged women who lack access to obstetric care. We define regions with a lack of access as either maternity care deserts, designated by the March of Dimes to be counties with no obstetric care facility or obstetric providers, or regions further than 50 miles from critical care obstetric (CCO) services. We gathered information on hospitals with obstetric services from Georgia Department of Public Health public reports and estimated the female reproductive-age population by census block group using the American Community Survey.

RESULTS

Out of the 1,910,308 reproductive-aged women who live in Georgia, 104,158 (5.5%) live in maternity care deserts, 150,563 (7.9%) reproductive-aged women live further than 50 miles from CCO services, and 38,202 (2.0%) live in both maternity care desert and further than 50 miles from CCO services. Our optimization analysis suggests that at least 56 new obstetric care facilities (a 67% increase) would be required to eliminate maternity care deserts in Georgia. However, the expansion of 8 facilities would ensure all women in Georgia live within 50 miles of CCO services.

CONCLUSIONS

Current measures of access to obstetric care may not be sufficient for evaluating access and planning action toward improvements. In a state like Georgia with a large number of small counties, eliminating maternity care deserts would require a prohibitively large number of new obstetric care facilities. This work suggests that additional measures and tools are needed to estimate the number and type of obstetric care facilities that best match practical resources to meet obstetric care needs.

The implications of using maternity care deserts to measure progress in access to obstetric care: A mixed-integer optimization analysis

Background

Lack of access to risk-appropriate maternity services, particularly for rural residents, is thought to be a leading contributor to disparities in maternal morbidity and mortality. There are several existing measures of access to obstetric care in the literature and popular media. In this study, we explored how current measures of obstetric access inform the number and location of additional obstetric care facilities required to improve access.

Methods

We formulated two facility location optimization models to determine the number of new facilities required to minimize the number of reproductive-aged women who lack access to obstetric care. We define regions with a lack of access as either maternity care deserts, designated by the March of Dimes to be counties with no obstetric care facility or obstetric providers, or regions further than 50 miles from critical care obstetric (CCO) services. We gathered information on hospitals with obstetric services from Georgia Department of Public Health public reports and estimated the female reproductive-age population by census block group using the American Community Survey.

Results

Out of the 1,910,308 reproductive-aged women who live in Georgia, 104,158 (5.5%) live in maternity care deserts, 150,563 (7.9%) reproductive-aged women live further than 50 miles from CCO services, and 38,202 (2.0%) live in both maternity care desert and further than 50 miles from CCO services. Our optimization analysis suggests that at least 56 new obstetric care facilities (a 67% increase) would be required to eliminate maternity care deserts in Georgia. However, and the expansion of 8 facilities would ensure all women in Georgia live within 50 miles of CCO services.

Conclusions

Current measures of access to obstetric care may not be sufficient for evaluating access and planning action toward improvements. In a state like Georgia with a large number of small counties, eliminating maternity care deserts would require a prohibitively large number of new obstetric care facilities. This work suggests that additional measures and tools are needed to estimate the number and type of obstetric care facilities that best match practical resources to meet obstetric care needs.

Association of Scene Time with Mortality in Major Traumatic Injuries Arrived by Emergency Medical Service

Introduction

Trauma is a major cause of death worldwide, and prehospital care is critical to improve patient outcomes. However, there is controversy surrounding the effectiveness of limiting scene time to 10 min or less in the care of major trauma patients. This study aimed to investigate the association between scene time and mortality in major trauma patients.

Methods

A retrospective cohort study was conducted on major trauma patients treated by the Thammasat University Hospital Emergency Medical Services (EMS) team from 2020 to 2022. We included traumatic adult patients who had an injury severity score (ISS) of 16 or higher. The primary outcome was 24-h mortality. Multivariable risk regression analysis was used to evaluate the independent effect of scene time on 24-h mortality.

Results

A total of 104 patients were included, of whom 11.5% died within 24 h. After adjusting for age, systolic blood pressure, Glasgow Coma Scale, and ISS, patients who had a scene time over 10 min showed a significant association with mortality (33.3% vs. 8.7%, P = 0.031). Intravenous fluid administration at the scene showed a trend toward a significant association with mortality.

Conclusions

This study provides evidence to support the importance of minimizing scene time for major trauma patients. The findings suggest that a balance between timely interventions and adequate resources should be considered to optimize patient outcomes. Further studies to investigate the impact of prehospital interventions on trauma patient outcomes are needed.

Association of Time to Definitive Hemostasis With Mortality in Patients With Solid Organ Injuries

Introduction The Golden Hour is a term used in the trauma setting to refer to the first 60 minutes after injury. Traditionally, definitive care within this period was believed to dramatically increase a patient's survival. Though the period of 60 minutes is unlikely to represent a point of distinct inflection in survival, the effect of time to definitive care on survival remains incompletely understood. This study aims to measure the association of time to definitive hemostasis with mortality in patients with solid organ injuries as well as the effect of survival bias and a form of selection bias known as indication by severity on the relationship between time to treatment and survival. Methodology This is a retrospective cohort study using data obtained from the American College of Surgeons National Trauma Data Bank (NTDB) from the years 2017 through 2019 selecting patients treated for blunt liver, spleen, or kidney injury who required angioembolization or surgical hemostasis within six hours. A Cox proportional hazards regression was used to analyze time to death. The association of probability of death with time was examined with a multivariate logistic regression initially treating the relationship as linear and subsequently transforming time to hemostasis with restricted cubic splines to model a non-linear association with the outcome. To model survival and indication by severity bias, we created a computer-generated data set and used LOESS regressions to display curves of the simulated data. Results The multivariate Cox proportional hazards analysis shows a coefficient of negative 0.004 for minutes to hemostasis with an adjusted hazard ratio of 0.9959 showing the adjusted hazard of death slightly diminishes with each increasing minute to hemostasis. The likelihood ratio chi-square difference between the model with time to hemostasis included as a linear term versus the model with the restricted cubic spline transformation is 97.46 (p<0.0001) showing the model with restricted cubic splines is a better fit for the data. The computer-generated data simulating treatment of solid organ injury with no programmed bias displays an almost linear association of mortality with increased treatment delay. When indications by severity bias and survival bias are introduced, the risk of death decreases with time to hemostasis as in the real-world data. Conclusion Decreasing mortality with increasing delay to hemostasis in trauma patients with solid organ injury is likely due to confounding due to indication by severity and survival bias. After taking these biases into account, the association of delayed hemostasis with better survival is not likely due to the benefit of delay but rather the delay sorts patients by severity of injury with those more likely to die being treated first. These biases are extremely difficult to eliminate which limits the ability to measure the true effect of delay with retrospective data. The findings may however be of value as a predictive model to anticipate the acuity of a patient after an interval of unavoidable delay such as with a long transfer time.

Team Approach: The Unstable Trauma Patient

» A multidisciplinary, integrated, and synergistic team approach to the unstable polytrauma patient is critical to optimize outcomes, minimize morbidity, and reduce mortality.» The use of Advanced Trauma Life Support protocols helps standardize the assessment and avoid missing critical injuries» Effective and open dialog with consulting specialists is paramount for effective team-based care.» Orthopaedic surgeons should play an important role in the rapid assessment of potentially life-threatening and/or limb-threatening injuries including pelvic ring disruption, open fractures with substantial blood loss, and dysvascular limbs.

Factors Associated with an Increase in On-Site Time of Pediatric Trauma Patients in a Prehospital Setting: A Nationwide Observational Study in Japan

The factors that prolong the on-site time in pediatric trauma cases in a prehospital setting are unknown. We investigated these factors using a national trauma registry in Japan. We identified pediatric trauma patients aged ≤18 years, from January 2004 to May 2019. We categorized cases into shorter (≤13 min) and longer (>13 min) prehospital on-site time groups. We performed multivariable logistic regression analysis with multiple imputations to assess the factors associated with longer prehospital on-site time. Overall, 14,535 patients qualified for inclusion. The median prehospital on-site time was 13 min. In the multivariable logistic regression analysis, the longer prehospital on-site time was associated with higher age; suicide (Odds ratio [OR] 1.27; 95% confidence interval [CI] 1.03−1.57); violence (OR 1.74; 95%CI 1.27−2.38); higher revised trauma score, abbreviated injury scale > 3 in the spine (OR 1.25; 95%CI 1.04−1.50), upper extremity (OR 1.26; 95%CI 1.11−1.44), and lower extremity (OR 1.25; 95%CI 1.14−1.37); immobilization (OR 1.16; 95%CI 1.06−1.27); and comorbid mental retardation (OR 1.56; 95%CI 1.11−2.18). In light of these factors, time in the field could be reduced by having more pediatric emergency physicians and orthopedic surgeons available.

The impact of prehospital time intervals on mortality in moderately and severely injured patients

BACKGROUND

Modern trauma systems and emergency medical services aim to reduce prehospital time intervals to achieve optimal outcomes. However, current literature remains inconclusive on the relationship between time to definitive treatment and mortality. The aim of this study was to investigate the association between prehospital time and mortality.

METHODS

All moderately and severely injured trauma patients (i.e., patients with an Injury Severity Score of 9 or greater) who were transported from the scene of injury to a trauma center by ground ambulances of the participating emergency medical services between 2015 and 2017 were included. Exposures of interest were total prehospital time, on-scene time, and transport time. Outcomes were 24-hour and 30-day mortality. Generalized linear models including inverse probability weights for several potential confounders were constructed. A generalized additive model was constructed to enable visual inspection of the association.

RESULTS

We included 22,525 moderately and severely injured patients. Twenty-four-hour and 30-day mortality were 1.3% and 7.3%, respectively. On-scene time per minute was significantly associated with 24-hour (relative risk [RR], 1.029; 95% confidence interval, 1.018-1.040) and 30-day mortality (RR, 1.013; 1.008-1.017). We found that this association was also present in patients with severe injuries, traumatic brain injury, severe abdominal injury, and stab or gunshot wound. An on-scene time of 20 minutes or longer demonstrated a strong association with 24-hour (RR, 1.797; 1.406-2.296) and 30-day mortality (RR, 1.298; 1.180-1.428). Total prehospital (24-hour: RR, 0.998; 0.990-1.007; 30-day: RR, 1.000, 0.997-1.004) and transport (24-hour: RR, 0.996; 0.982-1.010; 30-day: RR, 0.995; 0.989-1.001) time were not associated with mortality.

CONCLUSION

A prolonged on-scene time is associated with mortality in moderately and severely injured patients, which suggests that a reduced on-scene time may be favorable for these patients. In addition, transport time was found not to be associated with mortality.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; level III.

Association of traumatic brain injury severity and time to definitive care in three low-middle-income European countries

BACKGROUND

Low-middle-income countries experience among the highest rates of traumatic brain injury in the world. Much of this burden may be preventable with faster intervention, including reducing the time to definitive care. This study examines the relationship between traumatic brain injury severity and time to definitive care in major trauma hospitals in three low-middle-income countries.

METHODS

A prospective traumatic brain injury registry was implemented in six trauma hospitals in Armenia, Georgia and the Republic of Moldova for 6 months in 2019. Brain injury severity was measured using the Glasgow Coma Scale (GCS) at admission. Time to definitive care was the time from injury until arrival at the hospital. Cox proportionate hazards models predicted time to care by severity, controlling for age, sex, mechanism, mode of transportation, location of injury and country.

RESULTS

Among 1135 patients, 749 (66.0%) were paediatric and 386 (34.0%) were adults. Falls and road traffic were the most common mechanisms. A higher proportion of adult (23.6%) than paediatric (5.4%) patients had GCS scores indicating moderate (GCS 9-11) or severe injury (GCS 0-8) (p<0.001). Less severe injury was associated with shorter times to care, while more severe injury was associated with longer times to care (HR=1.05, 95% CI 1.01 to 1.09). Age interacted with time to care, with paediatric cases receiving faster care.

CONCLUSIONS

Implementation of standard triage and transport protocols may reduce mortality and improve outcomes from traumatic brain injury, and trauma systems should focus on the most severe injuries.

The Casualty Stabilization–Transportation Problem in a Large-Scale Disaster

We address the problem of picking up, stabilizing, and transporting casualties in response to mass-injury disasters. Our proposed methodology establishes the itinerary for collecting, on-site stabilization, and transporting victims considering capacitated vehicles and medical care centers. Unlike previous works, we minimize the time required to achieve on-site stabilization of each victim according to his age and level of severity of the injuries for their subsequent transfer to specialized medical centers. Thus, more critical patients will be the first to be stabilized, maximizing their chances of survival. In our methodology, the victims’ age, the injuries’ severity level, and their deterioration over time are considered critical factors in prioritizing care for each victim. We tested our approach using simulated earthquake scenarios in the city of Iquique, Chile, with multiple injuries. The results show that explicitly considering the on-site stabilization of the vital functions of the prioritized victims as an objective, before their transfer to a specialized medical center, allows treating and stabilizing patients earlier than with traditional objectives.

Association between Scene Time Interval and Survival in EMS-Treated Major Trauma Admitted to the Intensive Care Unit: A Multinational, Multicenter Observational Study

Objective: Major trauma is a major concern in public health and a leading cause of mortality worldwide. This study aimed to evaluate the association between the prehospital scene time interval (STI) and survival in emergency medical service (EMS)-assessed major trauma patients admitted to the intensive care unit (ICU). Methods: A retrospective observational study using the Pan-Asian Trauma Outcomes Study (PATOS) database was conducted. Adult trauma patients with injury severity scores (ISSs) greater than 15 who were admitted to the ICU were selected. EMS STIs were categorized into three groups: short (0-8 minutes), intermediate (9-16 minutes), and long (over 16 minutes). The primary outcome was survival to hospital discharge, and the secondary outcome was good neurological outcome at hospital discharge. Multivariable logistic regression analysis was conducted to calculate odds ratios and confidence intervals, adjusting for age, sex, mechanism of injury, prehospital alertness, prehospital shock index, response time interval, and EMS intervention (airway, oxygen supplementation, and intravenous fluid administration). Sensitivity analysis for patients who underwent surgery or nontraumatic brain injury cases and interaction analysis by EMS intervention were performed. Results: Data from a total of 1,874 eligible patients were analyzed. Intermediate and long STIs showed significant associations with outcomes, with adjusted ORs (95% CI) of 1.21 (1.07-1.38) in the intermediate STI group and 1.74 (1.55-1.96) in the long STI group for survival and 1.37 (1.32-1.40) in the intermediate STI group and 1.31 (1.22-1.41) in the long STI group for neurological outcome. In the sensitivity analysis, the highest ORs were found in the intermediate STI group, with adjusted ORs (95% CI) of 1.40 (1.37-1.42) for survival and 1.32 (1.26-1.38) for neurological outcome. In the interaction analysis, EMS intervention showed a positive interaction effect with an intermediate STI on survival. Conclusion: In EMS-assessed adult major trauma patients admitted to the ICU, we found significant associations between STIs longer than 8 minutes and outcomes. EMS intervention has a positive interaction effect with an intermediate STI on survival. More research is needed to understand the implications of practice for major trauma in the field.

Severe penetrating trauma in Switzerland: first analysis of the Swiss Trauma Registry (STR)

PURPOSE

The purpose of this study was to examine the epidemiology, demographics, injury characteristics and outcomes of patients who presented to Swiss trauma centers following severe penetrating trauma.

METHODS

Swiss Trauma Registry (STR)-cohort analysis including patients with severe (ISS ≥ 16 or AIS head ≥ 3) penetrating trauma between 2017 and 2019. Primary outcome was mortality. Secondary outcomes were hospital and intensive care unit (ICU) length of stay (LOS), and prehospital times.

RESULTS

During the 3-year study period, 134 (1.6% of entire STR) patients with severe penetrating trauma were identified [64 (48%) gunshot wounds (GSW), 70 (52%) stab wounds (SW)]. Median age was 40.5 (IQR 29.0-59.0) and 82.8% were male. Mortality rate was 50% for GSW; 9% for SW. Overall, prehospital time [incident to arrival emergency department (ED)] was 65 (IQR 45-94) minutes. The median number of patients admitted for a severe GSW/SW per center and year was 2 (range 0-14). Of 64 patients who sustained a GSW, 42 (65.6%) were self-inflicted. Mortality in self-inflicted GSW reached 66.7%, with the head being severely injured in 78.6%. The 67 patients with severe isolated torso GSW/SW had an ISS of 20 (IQR 16-26) and a mortality of 15%. Multivariable analysis identified severe chest trauma, ED Glasgow Coma Scale ≤ 8, age, self-infliction, massive blood transfusion and ISS as independent predictors for mortality.

CONCLUSION

Severe penetrating trauma is very rare in Switzerland. Mortality ranges from 9% in SW to 67% in self-inflicted GSW. Particularly in the setting of GSW/SW to the torso, reduction in prehospital time may further improve patient outcomes.

Bleeding to death in a big city: An analysis of all trauma deaths from hemorrhage in a metropolitan area during 1 year

BACKGROUND

Hemorrhage is the most common cause of potentially preventable trauma deaths, but no studies have focused on all civilian traumatic deaths from hemorrhage, so we describe a year of these deaths from a large county to identify opportunities for preventing hemorrhagic deaths.

METHODS

All trauma-related deaths in Harris County, Texas, in 2014 underwent examination by the medical examiner; patients were excluded if hemorrhage was not their primary reason for death. Deaths were then categorized as preventable/potentially preventable hemorrhage (PPH) or nonpreventable hemorrhage. These categories were compared across mechanism of injury, death location, and anatomic locations of hemorrhage to determine significant differences.

RESULTS

A total of 1,848 deaths were reviewed, and 305 were from uncontrolled hemorrhage. One hundred thirty-seven (44.9%) of these deaths were PPH. Of these PPH, 49 (35.8%) occurred prehospital and an additional 28 (20.4%) died within 1 hour of arriving at an acute care setting. Of the 83 PPH who arrived at a hospital, 21 (25.3%) died at a center not designated as level 1. Isolated truncal bleeding was the source of hemorrhage in 102 (74.5%) of the PPH. Of those who died with truncal PPH, the distribution was 22 chest (21.6%), 39 chest and abdomen (38.2%), 16 abdomen (15.7%), and 25 all other combinations (24.5%). When patients who died within 1 hour of arrival to a hospital were combined with the 168 deaths that occurred prehospital, 223 (74.3%) of 300 deaths occurred before spending 1 hour in a hospital and 77 (34.5%) of 223 of these deaths were PPH.

CONCLUSION

In a well-developed, urban trauma system, 34.5% of patients died from PPH in the prehospital setting or within an hour of hospitalization. Earlier, more effective prehospital resuscitation and truncal hemorrhage control strategies are needed to decrease deaths from PPH.

LEVEL OF EVIDENCE

Therapeutic/Care management, level IV.

A scoping review of worldwide studies evaluating the effects of prehospital time on trauma outcomes

BACKGROUND

Annually, over 1 billion people sustain traumatic injuries, resulting in over 900,000 deaths in Africa and 6 million deaths globally. Timely response, intervention, and transportation in the prehospital setting reduce morbidity and mortality of trauma victims. Our objective was to describe the existing literature evaluating trauma morbidity and mortality outcomes as a function of prehospital care time to identify gaps in literature and inform future investigation.

MAIN BODY

We performed a scoping review of published literature in MEDLINE. Results were limited to English language publications from 2009 to 2020. Included articles reported trauma outcomes and prehospital time. We excluded case reports, reviews, systematic reviews, meta-analyses, comments, editorials, letters, and conference proceedings. In total, 808 articles were identified for title and abstract review. Of those, 96 articles met all inclusion criteria and were fully reviewed. Higher quality studies used data derived from trauma registries. There was a paucity of literature from studies in low- and middle-income countries (LMIC), with only 3 (3%) of articles explicitly including African populations. Mortality was an outcome measure in 93% of articles, predominantly defined as "in-hospital mortality" as opposed to mortality within a specified time frame. Prehospital time was most commonly assessed as crude time from EMS dispatch to arrival at a tertiary trauma center. Few studies evaluated physiologic morbidity outcomes such as multi-organ failure.

CONCLUSION

The existing literature disproportionately represents high-income settings and most commonly assessed in-hospital mortality as a function of crude prehospital time. Future studies should focus on how specific prehospital intervals impact morbidity outcomes (e.g., organ failure) and mortality at earlier time points (e.g., 3 or 7 days) to better reflect the effect of early prehospital resuscitation and transport. Trauma registries may be a tool to facilitate such research and may promote higher quality investigations in Africa and LMICs.

The Impact of Prehospital Transport Mode on Mortality of Penetrating Trauma Patients

OBJECTIVE

The optimal mode of transport of trauma patients from the scene to the hospital remains unknown. We aimed to study the impact of different prehospital modes of transport of penetrating trauma patients on hospital mortality.

METHODS

Using the Trauma Quality Improvement Program 2010 to 2016 database, we identified all adults with a penetrating injury. Univariate then multivariable logistic regression analyses were performed to study the correlation between the mode of transport and in-hospital mortality, adjusting for several covariates.

RESULTS

A total of 92,427 subjects were included. The overall mean transport time for patients transported by a ground ambulance, helicopter, fixed wing ambulance, and police/private vehicle were 32.2, 61.2, 68.9, and 28.2 minutes, respectively. Multivariable analyses revealed that compared with ground ambulance, helicopter transport was associated with a 34% decrease in the odds of mortality (odds ratio = 0.66, P < .0001), whereas police transport and private vehicle transport were associated with a 52% decrease in the odds of mortality (odds ratio = 0.48, P < .0001).

CONCLUSION

Helicopter, police, and private vehicle transports are associated with a decreased odds of mortality compared with ground ambulance. Further research should examine the variation in levels of care within different modes of prehospital transport.

Association between prehospital time and outcome of trauma patients in 4 Asian countries: A cross-national, multicenter cohort study

BACKGROUND

Whether rapid transportation can benefit patients with trauma remains controversial. We determined the association between prehospital time and outcome to explore the concept of the "golden hour" for injured patients.

METHODS AND FINDINGS

We conducted a retrospective cohort study of trauma patients transported from the scene to hospitals by emergency medical service (EMS) from January 1, 2016, to November 30, 2018, using data from the Pan-Asia Trauma Outcomes Study (PATOS) database. Prehospital time intervals were categorized into response time (RT), scene to hospital time (SH), and total prehospital time (TPT). The outcomes were 30-day mortality and functional status at hospital discharge. Multivariable logistic regression was used to investigate the association of prehospital time and outcomes to adjust for factors including age, sex, mechanism and type of injury, Injury Severity Score (ISS), Revised Trauma Score (RTS), and prehospital interventions. Overall, 24,365 patients from 4 countries (645 patients from Japan, 16,476 patients from Korea, 5,358 patients from Malaysia, and 1,886 patients from Taiwan) were included in the analysis. Among included patients, the median age was 45 years (lower quartile [Q1]-upper quartile [Q3]: 25-62), and 15,498 (63.6%) patients were male. Median (Q1-Q3) RT, SH, and TPT were 20 (Q1-Q3: 12-39), 21 (Q1-Q3: 16-29), and 47 (Q1-Q3: 32-60) minutes, respectively. In all, 280 patients (1.1%) died within 30 days after injury. Prehospital time intervals were not associated with 30-day mortality. The adjusted odds ratios (aORs) per 10 minutes of RT, SH, and TPT were 0.99 (95% CI 0.92-1.06, p = 0.740), 1.08 (95% CI 1.00-1.17, p = 0.065), and 1.03 (95% CI 0.98-1.09, p = 0.236), respectively. However, long prehospital time was detrimental to functional survival. The aORs of RT, SH, and TPT per 10-minute delay were 1.06 (95% CI 1.04-1.08, p < 0.001), 1.05 (95% CI 1.01-1.08, p = 0.007), and 1.06 (95% CI 1.04-1.08, p < 0.001), respectively. The key limitation of our study is the missing data inherent to the retrospective design. Another major limitation is the aggregate nature of the data from different countries and unaccounted confounders such as in-hospital management.

CONCLUSIONS

Longer prehospital time was not associated with an increased risk of 30-day mortality, but it may be associated with increased risk of poor functional outcomes in injured patients. This finding supports the concept of the "golden hour" for trauma patients during prehospital care in the countries studied.

Most of the Variation in Prehospital Scene Time Is Not Related to Patient Factors, Injury Characteristics, or Geography

OBJECTIVE

The time spent on scene by emergency medical services remains highly variable. We sought to investigate how much of the prehospital scene time variation in penetrating trauma patients could be explained by prehospital factors.

METHODS

Using the 2010 to 2016 Trauma Quality and Improvement database, all adult penetrating trauma patients were included. The prehospital scene time was defined as the time from emergency medical service scene arrival to departure. Using all Trauma Quality and Improvement database variables including patient, injury (eg, Injury Severity Score), geography, and logistical (eg, transport mode) factors, multivariable linear regression models were created to predict the prehospital scene time. The prehospital scene time was treated as a continuous variable, and the degree to which the models could explain the variation in scene time was measured using the coefficient of determination (R).

RESULTS

A total of 45,560 patients were included. The median prehospital scene time was 6 minutes (interquartile range, 3-10 minutes). The R for factors in the multivariable regression model was 0.06, suggesting that 94% of the prehospital scene time variation cannot be explained by the wide range of prehospital factors.

CONCLUSION

Most of the variation in prehospital scene time cannot be explained by injury characteristics. The variation may be caused by logistical delays or system-related factors.

Prehospital Intervals and In-Hospital Trauma Mortality: A Retrospective Study from a Level I Trauma Center

BACKGROUND

The increase in mortality and total prehospital time (TPT) seen in Qatar appear to be realistic. However, existing reports on the influence of TPT on mortality in trauma patients are conflicting. This study aimed to explore the impact of prehospital time on the in-hospital outcomes.

METHODS

A retrospective analysis of data on patients transferred alive by Emergency Medical Services (EMS) and admitted to Hamad Trauma Center (HTC) of Hamad General Hospital (HGH; Doha, Qatar) from June 2017 through May 2018 was conducted. This study was centered on the National Trauma Registry database. Patients were categorized based on the trauma triage activation and prehospital intervals, and comparative analysis was performed.

RESULTS

A total of 1,455 patients were included, of which nearly one-quarter of patients required urgent and life-saving care at a trauma center (T1 activations). The overall TPT was 70 minutes and the on-scene time (OST) was 24 minutes. When compared to T2 activations, T1 patients were more likely to have been involved in road traffic injuries (RTIs); experienced head and chest injuries; presented with higher Injury Severity Score (ISS: median = 22); and had prolonged OST (27 minutes) and reduced TPT (65 minutes; P = .001). Prolonged OST was found to be associated with higher mortality in T1 patients, whereas TPT was not associated.

CONCLUSIONS

In-hospital mortality was independent of TPT but associated with longer OST in severely injured patients. The survival benefit may extend beyond the golden hour and may depend on the injury characteristics, prehospital, and in-hospital settings.

Every minute counts: The impact of pre-hospital response time and scene time on mortality of penetrating trauma patients

BACKGROUND

Prompt surgical control of hemorrhage is crucial in penetrating trauma patients. We aimed to study the impact of prehospital response time (PreRespT) and scene time (SceneT) on hospital mortality.

METHODS

Using the Trauma Quality Improvement Program (TQIP) 2010-2016 database, we identified all adults with penetrating injury. We defined PreRespT as time from EMS dispatch to scene arrival, and SceneT as time spent on scene. Univariate then multivariable logistic regression analyses were performed to study the independent correlation between PreRespT and SceneT on hospital mortality, adjusting for several covariates.

RESULTS

Out of a total of 1,403,470 patients, 43,467 patients were included. Multivariable analyses suggested that: 1) every minute increase in PreRespT independently correlates with a 2% increase in mortality (OR 1.02, p < 0.0001), and 2) every minute increase in SceneT independently correlates with a 1% increase in mortality (OR 1.01, p = 0.001).

CONCLUSION

In the penetrating injury trauma patient, PreRespT and SceneT independently correlate with hospital mortality. This data suggests that a faster PreRespT and a "scoop and run" strategy may be more beneficial in this population.

The ticking clock: does actively making an enhanced care team aware of the passage of time improve pre-hospital scene time following traumatic incidents?

Introduction

Pre-hospital enhanced care teams like Helicopter Emergency Medical Services (HEMS) are often dispatched to major trauma patients, including patients with traumatic brain injuries and those with major haemorrhage. For these patients, minimizing the time to definitive care is vital. The aim of this study was to determine whether increased awareness of elapsed on scene time produces a relevant time performance improvement for major trauma patients attended by HEMS, and weather introducing such a timer was feasible and acceptable to clinicians.

Methods

We performed a prospective cohort study of all single casualty traumatic incidents attended by Air Ambulance Kent Surrey Sussex (AAKSS) between 15 October 2016 and 23 May 2017 to test if introduction of a prompting scene timer within the service resulted in a reduction in pre-hospital scene times.

Results

The majority of the patients attended were male (74%) and sustained blunt trauma (92%). Overall, median scene time was 25.5 [IQR16.3] minutes before introduction of the scene timer and 23.0 [11.0] minutes after introduction, p = 0.13). Scene times for patients with a GCS < 8 and for patients requiring prehospital anaesthesia were significantly lower after introduction of the timer (28 [IQR 14] vs 25 [1], p = 0.017 and 34 [IQR 13] vs 28 [IQR11] minutes, p = 0.007 respectively). The majority of clinicians felt the timer made them more aware of passing time (91%) but that this had not made a difference to scene time (62%) or their practice (57%).

Conclusion

Audible scene timers may have the potential to reduce pre-hospital scene time for certain single casualty trauma patients treated by a HEMS team, particularly for those patients needing pre-hospital anaesthesia. Regular use of on-scene timers may improve outcomes by reducing time to definitive care for certain subgroups of trauma patients.

Revision of 'golden hour' for hemodynamically unstable trauma patients: an analysis of nationwide hospital-based registry in Japan

Background

The ‘golden hour’ is a well-known concept, suggesting that shortening time from injury to definitive care is critically important for better outcome of trauma patients. However, there was no established evidence to support it. We aimed to validate the association between time to definitive care and mortality in hemodynamically unstable patients for the current trauma care settings.

Methods

The data were collected from the Japan Trauma Data Bank between 2006 and 2015. The inclusion criteria were patients with systolic blood pressure (SBP) <90 mm Hg and heart rate (HR) >110 beats/min or SBP <70 mm Hg who underwent definitive care within 4 hours from the onset of injury and survived for more than 4 hours. The outcome measure was in-hospital mortality. We evaluated the relationship between time to definitive care and mortality using the generalized additive model (GAM). Subgroup analysis was also conducted using GAM after dividing the patients into the severe (SBP <70 mm Hg) and moderate (SBP ≥70 mm Hg and <90 mm Hg, and HR >110 beats/min) shock group.

Results

1169 patients were enrolled in this study. Of these, 386 (33.0%) died. Median time from injury to definitive care was 137 min. Only 61 patients (5.2%) received definitive care within 60 min. The GAM models demonstrated that mortality remained stable for the early phase, followed by a decrease over time. The severe shock group presented with a paradoxical decline of mortality with time, whereas the moderate shock group had a time-dependent increase in mortality.

Discussion

We did not observe the association of shorter time to definitive care with a decrease in mortality. However, this was likely an offset result of severe and moderate shock groups. The result indicated that early definitive care could have a positive impact on survival outcome of patients with moderate shock.

Level of evidence

Level Ⅳ, prognostic study,

Analysis of Casualties That Underwent Airway Management Before Reaching Role 2 Facilities in the Afghanistan Conflict 2008-2014

INTRODUCTION

Airway compromise is the second leading cause of potentially survivable death on the battlefield. The purpose of this study was to better understand wartime prehospital airway patients.

MATERIALS AND METHODS

The Role 2 Database (R2D) was retrospectively reviewed for adult patients injured in Afghanistan between February 2008 and September 2014. Of primary interest were prehospital airway interventions and mortality. Prehospital combat mortality index (CMI-PH), hemodynamic interventions, injury mechanism, and demographic data were also included in various statistical analyses.

RESULTS

A total of 12,780 trauma patients were recorded in the R2D of whom 890 (7.0%) received prehospital airway intervention. Airway intervention was more common in patients who ultimately died (25.3% vs. 5.6%); however, no statistical association was found in a multivariable logistic regression model (OR 1.28, 95% CI 0.98-1.68). Compared with U.S. military personnel, other military patients were more likely to receive airway intervention after adjusting for CMI-PH (OR 1.33, 95% CI 1.07-1.64).

CONCLUSIONS

In the R2D, airway intervention was associated with increased odds of mortality, although this was not statistically significant. Other patients had higher odds of undergoing an airway intervention than U.S. military. Awareness of these findings will facilitate training and equipment for future management of prehospital/prolonged field care airway interventions.

The effect of prehospital transport time, injury severity, and blood transfusion on survival of US military casualties in Iraq

BACKGROUND

Reducing time from injury to care can optimize trauma patient outcomes. A previous study of prehospital transport of US military casualties during the Afghanistan conflict demonstrated the importance of time and treatment capability for combat casualty survival.

METHODS

A retrospective descriptive analysis was conducted to analyze battlefield data collected on US military combat casualties during the Iraq conflict from March 19, 2003, to August 31, 2010. All casualties were analyzed by mortality outcome (killed in action, died of wounds, case fatality rate) and compared with Afghanistan conflict. Detailed data for those who underwent prehospital transport were analyzed for effects of transport time, injury severity, and blood transfusion on survival.

RESULTS

For the total population, percent killed in action (16.6% vs. 11.1%), percent died of wounds (5.9% vs. 4.3%), and case fatality rate (10.0 vs. 8.6) were higher for Iraq versus Afghanistan (p < 0.001). Among 1,692 casualties (mean New Injury Severity Score, 22.5; mortality, 17.6%) with detailed data, the injury mechanism included 77.7% from explosions and 22.1% from gunshot wounds. For prehospital transport, 67.6% of casualties were transported within 60 minutes, and 32.4% of casualties were transported in greater than 60 minutes. Although 97.0% of deaths occurred in critical casualties (New Injury Severity Score, 25-75), 52.7% of critical casualties survived. Critical casualties were transported more rapidly (p < 0.01) and more frequently within 60 minutes (p < 0.01) than other casualties. Critical casualties had lower mortality when blood was received (p < 0.01). Among critical casualties, blood transfusion was associated with survival irrespective of transport time within or greater than 60 minutes (p < 0.01).

CONCLUSION

Although data were limited, early blood transfusion was associated with battlefield survival in Iraq as it was in Afghanistan.

LEVEL OF EVIDENCE

Performance improvement and epidemiological, level IV.

Longer Prehospital Time was not Associated with Mortality in Major Trauma: A Retrospective Cohort Study

Objective: The objective of this study was to determine the association between prehospital time and outcomes in adult major trauma patients, transported by ambulance paramedics. Methods: A retrospective cohort study of major trauma patients (Injury Severity Score >15) attended by St John Ambulance paramedics in Perth, Western Australia, who were transported to hospital between January 1, 2013 and December 31, 2016. Inverse probability of treatment weighting (IPTW) using the propensity score was performed to limit selection bias and confounding. The primary outcome was 30-day mortality and the secondary outcome was the length of hospital stay (LOS) for 30-day survivors. Multivariate logistic and log-linear regression analyses with IPTW were used to determine if prehospital time of more than the one hour (from receipt of the emergency call to arrival at hospital) or any individual prehospital time interval (response, on-scene, transport, or total time) was associated with 30-day mortality or LOS. Results: A total of 1,625 major trauma patients were included and 1,553 included in the IPTW sample. No significant association between prehospital time of one hour and 30-day mortality was found (adjusted odds ratio 1.10, 95% confidence interval (CI) 0.71-1.69). No association between any individual prehospital time interval and 30-day mortality was identified. In the 30-day survivors, one-minute increase of on-scene time was associated with 1.16 times (95% CI 1.03-1.31) longer LOS. Conclusion: Longer prehospital times were not associated with an increased likelihood of 30-day mortality in major trauma patients transported to hospital by ambulance paramedics. We found no evidence to support the hypothesis that prehospital time longer than one hour resulted in an increased risk of 30-day mortality. However, longer on-scene time was associated with longer hospital LOS (for 30-day survivors). Our recommendation is that prehospital care is delivered in a timely fashion and delivery of the patient to hospital is reasonably prompt.

When Minutes Fly by: What is the True “Golden Hour” for Air Care?

Air transport was developed to hasten patient transport based on the “golden hour” belief that delayed care leads to poorer outcome. The primary aim of our study was to identify the critical inflection point of increased nonsurvivors on total prehospital time. This was a multicenter review of adult trauma patients transported by air between November 2014 and August 2015. Primary outcome of interest was all-cause inhospital mortality. Total helicopter emergency medical services times of nonsurvivors were plotted to visualize the distribution of prehospital time. Of 636 patients included, 71 per cent were male and 86 per cent suffered blunt trauma. Among non-survivors, mortality doubled once total helicopter emergency medical services time exceeded 30 minutes (P < 0.001). Nonsurvivors presented with significantly lower median [interquartile range (IQR)] Glasgow Coma Score compared with survivors [3 (3–13) vs 15 (12–15), respectively; P < 0.001] as well as a significantly higher median (IQR) Injury Severity Score [26 (19–41) vs 12 (5–22); P < 0.001], increased incidence of penetrating mechanism of injury [21 vs 8%; P = 0.002], and higher median (IQR) shock index [0.84 (0.63–1.06) vs 0.71 (0.6–0.87); P = 0.023]. We identified an inflection point of doubling in mortality after 30 minutes. This suggests a possible threshold effect between time and mortality in severely injured patients. Revised field criteria for determining which injured patients would most benefit from helicopter transport are needed.

Does Prehospital Time Influence Clinical Outcomes in Severe Trauma Patients?: A Cross Sectional Study

OBJECTIVE

Prehospital time potentially impacts clinical outcomes in severely injured trauma patients. The importance of individual components, including scene and response time, however, is controversial. Our objective was to determine the impact of prehospital times on survival in severely injured patients.

METHODS

We reviewed injured trauma patients enrolled in a Korean EMS trauma registry during 2012. Severe trauma patients were defined as having either a "V" or lower in the AVPU system, a systolic blood pressure ≤90mmHg, or respiratory rate <10 or >29. Patients with Injury Severity Scores(ISS) < 9 were excluded. Patients were categorized by scene time into 4 groups as follows: <3 minutes, 3-6 minutes, 6-9 minutes, and ≥9 minutes and by prehospital time as follows: <16 minutes, 16-24 minutes, 24-32 minutes, and ≥32 minutes. The primary outcome was in-hospital mortality. Multiple linear regression analysis was used to adjust for possible confounders.

RESULTS

A total of 2,257 eligible patients were analyzed. Scene time was <3 minutes in 220 (9.7%), 3-6 in 865 (38.3%), 6-9 in 587 (26.0%), and ≥9 in 585 (25.9%). In-hospital mortality was 396 (17.5%). Compared to a scene time 6 to 9 minutes, mortality was higher as the scene time decreased: odds ratio (OR) = 1.3(3 to <6), OR = 1.9(0 to <3). Mortality was slightly decreased as prehospital time increased, OR = 1.0(16 to <24), OR = 0.9(24 to <32), OR = 0.7(≥32).

CONCLUSION

Longer prehospital times did not increase mortality in severely injured trauma patients in Korea. Furthermore, longer scene times were associated with lower mortality.

Microcirculatory alterations during haemorrhagic shock and after resuscitation in a paediatric animal model

BACKGROUND

Haemorrhagic shock is frequent in paediatric trauma patients and after cardiac surgery, especially after cardiopulmonary bypass. It has demonstrated to be related to bad outcome.

OBJECTIVES

To evaluate changes on microcirculatory parameters during haemorrhagic shock and resuscitation in a paediatric animal model. To determine correlation between microcirculatory parameters and other variables routinely used in the monitoring of haemorrhagic shock.

METHODS

Experimental study on 17 Maryland pigs. Thirty minutes after haemorrhagic shock induction by controlled bleed animals were randomly assigned to three treatment groups receiving 0.9% normal saline, 5% albumin with 3% hypertonic saline, or 5% albumin with 3% hypertonic saline plus a bolus of terlipressin. Changes on microcirculation (perfused vessel density (PVD), microvascular blood flow (MFI) and heterogeneity index (HI)) were evaluated and compared with changes on macrocirculation and tisular perfusion parameters.

RESULTS

Shock altered microcirculation: PVD decreased from 13.5 to 12.3 mm mm(-2) (p=0.05), MFI decreased from 2.7 to 1.9 (p<0.001) and HI increased from 0.2 to 0.5 (p<0.001). After treatment, microcirculatory parameters returned to baseline (PVD 13.6 mm mm(-2) (p<0.05), MFI 2.6 (p<0.001) and HI 0.3 (p<0.05)). Microcirculatory parameters showed moderate correlation with other parameters of tissue perfusion. There were no differences between treatments.

CONCLUSIONS

Haemorrhagic shock causes important microcirculatory alterations, which are reversed after treatment. Microcirculation should be assessed during haemorrhagic shock providing additional information to guide resuscitation.

Helicopter emergency medical services for adults with major trauma

BACKGROUND

Although helicopters are presently an integral part of trauma systems in most developed nations, previous reviews and studies to date have raised questions about which groups of traumatically injured people derive the greatest benefit.

OBJECTIVES

To determine if helicopter emergency medical services (HEMS) transport, compared with ground emergency medical services (GEMS) transport, is associated with improved morbidity and mortality for adults with major trauma.

SEARCH METHODS

We ran the most recent search on 29 April 2015. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library (Cochrane Central Register of Controlled Trials; CENTRAL), MEDLINE (OvidSP), EMBASE Classic + EMBASE (OvidSP), CINAHL Plus (EBSCOhost), four other sources, and clinical trials registers. We screened reference lists.

SELECTION CRITERIA

Eligible trials included randomized controlled trials (RCTs) and nonrandomized intervention studies. We also evaluated nonrandomized studies (NRS), including controlled trials and cohort studies. Each study was required to have a GEMS comparison group. An Injury Severity Score (ISS) of at least 15 or an equivalent marker for injury severity was required. We included adults age 16 years or older.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data and assessed the risk of bias of included studies. We applied the Downs and Black quality assessment tool for NRS. We analyzed the results in a narrative review, and with studies grouped by methodology and injury type. We constructed 'Summary of findings' tables in accordance with the GRADE Working Group criteria.

MAIN RESULTS

This review includes 38 studies, of which 34 studies examined survival following transportation by HEMS compared with GEMS for adults with major trauma. Four studies were of inter-facility transfer to a higher level trauma center by HEMS compared with GEMS. All studies were NRS; we found no RCTs. The primary outcome was survival at hospital discharge. We calculated unadjusted mortality using data from 282,258 people from 28 of the 38 studies included in the primary analysis. Overall, there was considerable heterogeneity and we could not determine an accurate estimate of overall effect.Based on the unadjusted mortality data from six trials that focused on traumatic brain injury, there was no decreased risk of death with HEMS. Twenty-one studies used multivariate regression to adjust for confounding. Results varied, some studies found a benefit of HEMS while others did not. Trauma-Related Injury Severity Score (TRISS)-based analysis methods were used in 14 studies; studies showed survival benefits in both the HEMS and GEMS groups as compared with MTOS. We found no studies evaluating the secondary outcome, morbidity, as assessed by quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs). Four studies suggested a small to moderate benefit when HEMS was used to transfer people to higher level trauma centers. Road traffic and helicopter crashes are adverse effects which can occur with either method of transport. Data regarding safety were not available in any of the included studies. Overall, the quality of the included studies was very low as assessed by the GRADE Working Group criteria.

AUTHORS' CONCLUSIONS

Due to the methodological weakness of the available literature, and the considerable heterogeneity of effects and study methodologies, we could not determine an accurate composite estimate of the benefit of HEMS. Although some of the 19 multivariate regression studies indicated improved survival associated with HEMS, others did not. This was also the case for the TRISS-based studies. All were subject to a low quality of evidence as assessed by the GRADE Working Group criteria due to their nonrandomized design. The question of which elements of HEMS may be beneficial has not been fully answered. The results from this review provide motivation for future work in this area. This includes an ongoing need for diligent reporting of research methods, which is imperative for transparency and to maximize the potential utility of results. Large, multicenter studies are warranted as these will help produce more robust estimates of treatment effects. Future work in this area should also examine the costs and safety of HEMS, since multiple contextual determinants must be considered when evaluating the effects of HEMS for adults with major trauma.

The influence of prehospital time on trauma patients outcome: a systematic review

OBJECTIVE

Time is considered an essential determinant in the initial care of trauma patients. Salient tenet of trauma care is the 'golden hour', the immediate time after injury when resuscitation and stabilization are perceived to be most beneficial. Several prehospital strategies exist regarding time and transport of trauma patients. Literature shows little empirical knowledge on the exact influence of prehospital times on trauma patient outcome. The objective of this study was to systematically review the correlation between prehospital time intervals and the outcome of trauma patients.

METHODS

A systematic review was performed in MEDLINE, Embase and the Cochrane Library from inception to May 19th, 2014. Studies reporting on prehospital time intervals for emergency medical services (EMS), outcome parameters and potential confounders for trauma patients were included. Two reviewers collected data and assessed the outcomes and risk of bias using the STROBE-tool. The primary outcome was the influence on mortality.

RESULTS

Twenty level III-evidence articles were considered eligible for this systematic review. Results demonstrate a decrease in odds of mortality for the undifferentiated trauma patient when response-time or transfer-time are shorter. On the contrary increased on-scene time and total prehospital time are associated with increased odds of survival for this population. Nevertheless rapid transport does seem beneficial for patients suffering penetrating trauma, in particular hypotensive penetratingly injured patients and patients with a traumatic brain injury.

CONCLUSION

Swift transport is beneficial for patients suffering neurotrauma and the haemodynamically unstable penetratingly injured patient. For haemodynamically stable undifferentiated trauma patients, increased on-scene-time and total prehospital time does not increase odds of mortality. For undifferentiated trauma patients, focus should be on the type of care delivered prehospital and not on rapid transport.

The effect of hospital care on early survival after penetrating trauma

Background

The effectiveness of emergency medical interventions can be best evaluated using time-to-event statistical methods with time-varying covariates (TVC), but this approach is complicated by uncertainty about the actual times of death. We therefore sought to evaluate the effect of hospital intervention on mortality after penetrating trauma using a method that allowed for interval censoring of the precise times of death.

Methods

Data on persons with penetrating trauma due to interpersonal assault were combined from the 2008 to 2010 National Trauma Data Bank (NTDB) and the 2004 to 2010 National Violent Death Reporting System (NVDRS). Cox and Weibull proportional hazards models for survival time (t_SURV) were estimated, with TVC assumed to have constant effects for specified time intervals following hospital arrival. The Weibull model was repeated with t_SURV interval-censored to reflect uncertainty about the precise times of death, using an imputation method to accommodate interval censoring along with TVC.

Results

All models showed that mortality was increased by older age, female sex, firearm mechanism, and injuries involving the head/neck or trunk. Uncensored models showed a paradoxical increase in mortality associated with the first hour in a hospital. The interval-censored model showed that mortality was markedly reduced after admission to a hospital, with a hazard ratio (HR) of 0.68 (95% CI 0.63, 0.73) during the first 30 min declining to a HR of 0.01 after 120 min. Admission to a verified level I trauma center (compared to other hospitals in the NTDB) was associated with a further reduction in mortality, with a HR of 0.93 (95% CI 0.82, 0.97).

Conclusions

Time-to-event models with TVC and interval censoring can be used to estimate the effect of hospital care on early mortality after penetrating trauma or other acute medical conditions and could potentially be used for interhospital comparisons.

Electronic supplementary material

The online version of this article (doi:10.1186/s40621-014-0024-1) contains supplementary material, which is available to authorized users.

The evaluation of different treatment protocols for trauma-induced lung injury in rats

BACKGROUND

Lung contusion is an important factor that affects mortality and morbidity of lung injury after blunt chest trauma (BCT). The present study aims to evaluate the effectiveness of different treatment regimens on BCT-induced lung injury.

METHODS

A total of 35 Sprague Dawley rats were divided into five experimental groups (n=7): sham, control; BCT; BCT + MP, BCT group treated with methylprednisolone (MP; 30 mg/kg on first day and 3 mg/kg/d on the following days); BCT + Q, BCT group treated with quercetin (Q; 50 mg/kg/d for seven days); and BCT + MP + Q, BCT group treated with the same doses of MP and Q. Serum Clara Cell Protein-16 (CC-16), thiobarbituric acid reactive substances (TBARS), and superoxide dismutase (SOD) levels were analyzed to determine histopathological changes in the lung tissues.

RESULTS

Elevated serum CC-16 and TBARS levels and reduced serum SOD levels were found in the BCT group compared to the Sham group. There was a significant change in the serum CC-16 levels in the BCT + MP group compared to the Sham group. Serum TBARS levels were significantly lower in the BCT + MP and BCT + Q group compared to the BCT group. The combined therapy regimen yielded significantly decreased CC-16 levels and increased serum SOD levels compared to the individual treatment groups. Serum TBARS levels did not significantly differ between the BCT + MP + Q group and the other treatment groups. Compared to the BCT + MP + Q group, the BCT + MP group showed significantly lower alveolar edema (AED) and alveolar exudate (AEX) scores, while the BCT + Q group showed significantly lower peribronchial inflammatory cell infiltration (PICI) and AED scores.

CONCLUSIONS

The combined usage of quercetin and low dose MP treatment after initial high dose MP at the early stage of lung injury after BCT is more effective.