Single-centre studies suggest that successive Coronavirus Disease 2019 (COVID-19)-related "lockdown" restrictions in England may have led to significant changes in the characteristics of major trauma ...patients. There is also evidence from other countries that diversion of intensive care capacity and other healthcare resources to treating patients with COVID-19 may have impacted on outcomes for major trauma patients. We aimed to assess the impact of the COVID-19 pandemic on the number, characteristics, care pathways, and outcomes of major trauma patients presenting to hospitals in England.
We completed an observational cohort study and interrupted time series analysis including all patients eligible for inclusion in England in the national clinical audit for major trauma presenting between 1 January 2017 and 31 of August 2021 (354,202 patients). Demographic characteristics (age, sex, physiology, and injury severity) and clinical pathways of major trauma patients in the first lockdown (17,510 patients) and second lockdown (38,262 patients) were compared to pre-COVID-19 periods in 2018 to 2019 (comparator period 1: 22,243 patients; comparator period 2: 18,099 patients). Discontinuities in trends for weekly estimated excess survival rate were estimated when lockdown measures were introduced using segmented linear regression. The first lockdown had a larger associated reduction in numbers of major trauma patients (-4,733 (21%)) compared to the pre-COVID period than the second lockdown (-2,754 (6.7%)). The largest reductions observed were in numbers of people injured in road traffic collisions excepting cyclists where numbers increased. During the second lockdown, there were increases in the numbers of people injured aged 65 and over (665 (3%)) and 85 and over (828 (9.3%)). In the second week of March 2020, there was a reduction in level of major trauma excess survival rate (-1.71%; 95% CI: -2.76% to -0.66%) associated with the first lockdown. This was followed by a weekly trend of improving survival until the lifting of restrictions in July 2020 (0.25; 95% CI: 0.14 to 0.35). Limitations include eligibility criteria for inclusion to the audit and COVID status of patients not being recorded.
This national evaluation of the impact of COVID on major trauma presentations to English hospitals has observed important public health findings: The large reduction in overall numbers injured has been primarily driven by reductions in road traffic collisions, while numbers of older people injured at home increased over the second lockdown. Future research is needed to better understand the initial reduction in likelihood of survival after major trauma observed with the implementation of the first lockdown.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Systolic blood pressure (SBP), heart rate (HR), and respiratory rate are poor predictors of trauma outcome. We postulate that HR/SBP (shock index SI) and novel new markers SI × age (SIA), SBP / age ...(BPAI), maximum HR (220 - age) - HR (minpulse MP), and HR / maximum HR (pulse max index PMI) are better predictors of 48-hour mortality compared with traditional vital signs.
Data were extracted from the Trauma Audit and Research Network database. Exclusions included any head or spine injury and prehospital intubation or cardiac arrest. Area under receiver operator characteristic curve (AUROC) was determined for 48-hour mortality for all variables and age. A threshold for each marker was derived using the specificity (rule-in) cutoffs at both 90% and 95% from the receiver operator characteristic curve. Positive likelihood ratios were described for each marker's derived threshold.
Vital signs, markers, and age were all significantly associated with 48-hour mortality (p < 0.001). HR, SBP, and respiratory rate fared worst overall (AUROC = 0.69, 0.66, and 0.66, respectively). SIA, MP, PMI, BPAI, and SI were significantly (p < 0.05) better than age at predicting 48-hour mortality (AUROC = 0.79, 0.77, 0.77, 0.74, 0.73, and 0.68, respectively; AUROC for age = 0.68). Thresholds derived for these five markers were values 55 or greater, 44 or less, 70% or greater, 1.5 or less, and 0.9 or greater, respectively, each with a specificity of 95% for 48-hour mortality (positive likelihood ratios were 8.4, 6.1, 6.7, 6.6, and 7.5, respectively). The likelihood of death in 48 hours was 8.4 times more likely if SIA was greater than 55 than if it was lower.
Older age seems to be significantly associated with early mortality. Newer markers, especially those combining traditional vital signs with age (SIA, BPAI, MP, and PMI), may contribute to better trauma triage of patients with blunt injuries than traditional vital signs.
Prognostic/epidemiologic study, level III.
Trauma care in England was re-organised in 2012 with ambulance bypass of local hospitals to newly designated Major Trauma Centres (MTCs). There is still controversy about the optimal way to organise ...health series for patients suffering severe injury.
A longitudinal series of annual cross-sectional studies of care process and outcomes from April 2008 to March 2017. Data was collected through the national clinical audit of major trauma care. The primary analysis was carried out on the 110,863 patients admitted to 35 hospitals that were 'consistent submitters' throughout the study period. The main outcome was longitudinal analysis of risk adjusted survival.
Major Trauma networks were associated with significant changes in (1) patient flow (with increased numbers treated in Major Trauma Centres), (2) treatment systems (more consultant led care and more rapid imaging), (3) patient factors (an increase in older trauma), and (4) clinical care (new massive transfusion policies and use of tranexamic acid). There were 10,247 (9.2%) deaths in the 110,863 patients with an ISS of 9 or more. There were no changes in unadjusted mortality. The analysis of trends in risk adjusted survival for study hospitals shows a 19% (95% CI 3%-36%) increase in the case mix adjusted odds of survival from severe injury over the 9-year study period. Interrupted time series analysis showed a significant positive change in the slope after the intervention time point of April 2012 (+ 0.08% excess survivors per quarter, p = 0.023), in other words an increase of 0.08 more survivors per 100 patients every quarter.
A whole system national change was associated with significant improvements in both the care process and outcomes of patients after severe injury.
This analysis was carried out independently and did not receive funding. The data collection for the national clinical audit was funded by subscriptions from participating hospitals.
Postcardiotomy cardiogenic shock (PCCS) refractory to inotropic support and intra-aortic balloon pump (IABP) occurs rarely but is almost universally fatal without mechanical circulatory support. In ...this systematic review and meta-analysis we looked at the evidence behind the use of veno-arterial extra-corporeal membrane oxygenation (VA ECMO) in refractory PCCS from a patient survival rate and determinants of outcome viewpoint.
A systematic review was performed in January 2017 using PubMed (with no defined time period) using the keywords "postcardiotomy", "cardiogenic shock", "extracorporeal membrane oxygenation" and "cardiac surgery". We excluded papers pertaining to ECMO following paediatric cardiac surgery, medical causes of cardiogenic shock, as well as case reports, review articles, expert opinions, and letters to the editor. Once the studies were collated, a meta-analysis was performed on the proportion of survivors in those papers that met the inclusion criteria. Meta-regression was performed for the most commonly reported adverse prognostic indicators (API).
We identified 24 studies and a cumulative pool of 1926 patients from 1992 to 2016. We tabulated the demographic data, including the strengths and weaknesses for each of the studies, outcomes of VA ECMO for refractory PCCS, complications, and APIs. All the studies were retrospective cohort studies. Meta-analysis of the moderately heterogeneous data (95% CI 0.29 to 0.34, p < 0.01, I
= 60%) revealed overall survival rate to hospital discharge of 30.8%. Some of the commonly reported APIs were advanced age (>70 years, 95% CI -0.057 to 0.001, P = 0.058), and long ECMO support (95% CI -0.068 to 0.166, P = 0.412). Postoperative renal failure, high EuroSCORE (>20%), diabetes mellitus, obesity, rising lactate whilst on ECMO, gastrointestinal complications had also been reported.
Haemodynamic support with VA ECMO provides a survival benefit with reasonable intermediate and long-term outcomes. Many studies had reported advanced age, renal failure and prolonged VA ECMO support as the most likely APIs for VA ECMO in PCCS. EuroSCORE can be utilized to anticipate the need for prophylactic perioperative VA ECMO in the high-risk category. APIs can be used to aid decision-making regarding both the institution and weaning of ECMO for refractory PCCS.
Abstract
Objectives
To observe variation in imaging requests after publication of the Royal College of Radiologists UK Paediatric Trauma Protocols in 2014, recommending limited use of thoracic ...computed tomography (CT) to appropriately clinically risk stratified children.
Method
A retrospective observational study using data from the Trauma Audit & Research Network in the United Kingdom, for children (0–16 years of age) for the years 2012–2021. Percentages were calculated to facilitate comparison between year groups (under 1 year of age, 1–10 years of age, 11–15 years of age), and CT imaging categories reviewed: (1) whole‐body CT (WBCT); (2) abdominopelvic CT (CTAP) with chest radiograph (CXR); (3) chest, abdomen, and pelvic CT (CTCAP) with CXR; (4) CTCAP without CXR; and (5) other imaging.
Results
Increased use of the recommended protocol (CXR with CTAP) was observed after guidance publication but was not sustained: infants under 1 year old, 0.0% in 2012, 7% in 2017, 0.0% in 2021; 1–10‐year‐olds, 4% in 2012, 13.9% in 2017, 5.5% in 2021; 11–15‐year‐olds, 7.1% in 2012, 10.2% in 2017, 6.6% in 2021. Requests for WBCT increased from 2012–2021 (all age groups, 2.4%, 2012, to 5.3%, 2021) and requests for CTCAP were consistently at a higher level than that of the recommended protocol.
Conclusion
The increased use of CXR with CTAP after publication of the guidelines, was not sustained with a decreasing trend observed from ∼2017, raising concern for the ionizing radiation burden in this population.
ObjectivesTo identify the differences between women and men in the probability of entrapment, frequency of injury and outcomes following a motor vehicle collision. Publishing sex-disaggregated data, ...understanding differential patterns and exploring the reasons for these will assist with ensuring equity of outcomes especially in respect to triage, rescue and treatment of all patients.DesignWe examined data from the Trauma Audit and Research Network (TARN) registry to explore sex differences in entrapment, injuries and outcomes. We explored the relationship between age, sex and trapped status using multivariate logistical regression.SettingTARN is a UK-based trauma registry covering England and Wales.ParticipantsWe examined data for 450 357 patients submitted to TARN during the study period (2012–2019), of which 70 027 met the inclusion criteria. There were 18 175 (26%) female and 51 852 (74%) male patients.Primary and secondary outcome measuresWe report difference in entrapment status, injury and outcome between female and male patients. For trapped patients, we examined the effect of sex and age on death from any cause.ResultsFemale patients were more frequently trapped than male patients (female patients (F) 15.8%, male patients (M) 9.4%; p<0.0001). Trapped male patients more frequently suffered head (M 1318 (27.0%), F 578 (20.1%)), face, (M 46 (0.9%), F 6 (0.2%)), thoracic (M 2721 (55.8%), F 1438 (49.9%)) and limb injuries (M 1744 (35.8%), F 778 (27.0%); all p<0.0001). Female patients had more injuries to the pelvis (F 420 (14.6%), M 475 (9.7%); p<0.0001) and spine (F 359 (12.5%), M 485 (9.9%); p=0.001). Following adjustment for the interaction between age and sex, injury severity score, Glasgow Coma Scale and the Charlson Comorbidity Index, no difference in mortality was found between female and male patients.ConclusionsThere are significant differences between female and male patients in the frequency at which patients are trapped and the injuries these patients sustain. This sex-disaggregated data may help vehicle manufacturers, road safety organisations and emergency services to tailor responses with the aim of equitable outcomes by targeting equal performance of safety measures and reducing excessive risk to one sex or gender.
Motor vehicle collisions (MVCs) are a common cause of major trauma and death. Following an MVC, up to 40% of patients will be trapped in their vehicle. Extrication methods are focused on the ...prevention of secondary spinal injury through movement minimisation and mitigation. This approach is time consuming and patients may have time-critical injuries. The purpose of this study is to describe the outcomes and injuries of those trapped following an MVC: this will help guide meaningful patient-focused interventions and future extrication strategies.
We undertook a retrospective database study using the Trauma Audit and Research Network database. Patients were included if they were admitted to an English hospital following an MVC from 2012 to 2018. Patients were excluded when their outcomes were not known or if they were secondary transfers.
This analysis identified 426,135 cases of which 63,625 patients were included: 6983 trapped and 56,642 not trapped. Trapped patients had a higher mortality (8.9% vs 5.0%, p < 0.001). Spinal cord injuries were rare (0.71% of all extrications) but frequently (50.1%) associated with other severe injuries. Spinal cord injuries were more common in patients who were trapped (p < 0.001). Injury Severity Score (ISS) was higher in the trapped group 18 (IQR 10-29) vs 13 (IQR 9-22). Trapped patients had more deranged physiology with lower blood pressures, lower oxygen saturations and lower Glasgow Coma Scale, GCS (all p < 0.001). Trapped patients had more significant injuries of the head chest, abdomen and spine (all p < 0.001) and an increased rate of pelvic injures with significant blood loss, blood loss from other areas or tension pneumothorax (all p < 0.001).
Trapped patients are more likely to die than those who are not trapped. The frequency of spinal cord injuries is low, accounting for < 0.7% of all patients extricated. Patients who are trapped are more likely to have time-critical injuries requiring intervention. Extrication takes time and when considering the frequency, type and severity of injuries reported here, the benefit of movement minimisation may be outweighed by the additional time taken. Improved extrication strategies should be developed which are evidence-based and allow for the expedient management of other life-threatening injuries.
Introduction
Trauma is one of the leading causes of mortality worldwide, but little is known of the temporal variation in major trauma across England, Wales and Northern Ireland. Proper workforce and ...infrastructure planning requires identification of the caseload burden and its temporal variation.
Materials and Methods
The Trauma Audit Research Network (TARN) database for admissions attending Major Trauma Centres (MTCs) between 1st April 2011 and 31st March 2018 was analysed. TARN records data on all trauma patients admitted to hospital who are alive at the time of admission to hospital. Major trauma was classified as an Injury Severity Score (ISS) >15.
Results
A total of 158,440 cases were analysed. Case ascertainment was over 95% for 2013 onwards. There was a statistically significant variation in caseload by year (p < 0.0001), times of admissions (p < 0.0001), caseload admitted during weekends vs weekdays, 53% vs 47% (p < 0.0001), caseload by season with most patients admitted during summer (p < 0.0001). The ISS varied by time of admission with most patients admitted between 1800 and 0559 (p < 0.0001), weekend vs weekday with more severely injured patients admitted during the weekend (p < 0.0001) and by season p < 0.0001).
Discussion and Conclusion: There is a significant national temporal variation in major trauma workload. The reasons are complex and there are multiple theories and confounding factors to explain it. This is the largest dataset for hospitals submitting to TARN which can help guide workforce and resource allocation to further improve trauma outcomes.
Statistical models for outcome prediction are central to traumatic brain injury research and critical to baseline risk adjustment. Glasgow coma score (GCS) and pupil reactivity are crucial covariates ...in all such models but may be measured at multiple time points between the time of injury and hospital and are subject to a variable degree of unreliability and/or missingness. Imputation of missing data may be undertaken using full multiple imputation or by simple substitution of measurements from other time points. However, it is unknown which strategy is best or which time points are more predictive. We evaluated the pseudo-R.sup.2 of logistic regression models (dichotomous survival) and proportional odds models (Glasgow Outcome Score-extended) using different imputation strategies on the The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study dataset. Substitution strategies were easy to implement, achieved low levels of missingness (<< 10%) and could outperform multiple imputation without the need for computationally costly calculations and pooling multiple final models. While model performance was sensitive to imputation strategy, this effect was small in absolute terms and clinical relevance. A strategy of using the emergency department discharge assessments and working back in time when these were missing generally performed well. Full multiple imputation had the advantage of preserving time-dependence in the models: the pre-hospital assessments were found to be relatively unreliable predictors of survival or outcome. The predictive performance of later assessments was model-dependent. In conclusion, simple substitution strategies for imputing baseline GCS and pupil response can perform well and may be a simple alternative to full multiple imputation in many cases.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
ObjectivesThe aim is to compare adolescent (10–24.99 years) trauma patterns and interventions to adult (≥25) and paediatric cases (<10) and to identify any transition points.Design and settingData ...were collected from the Trauma and Audit Research Network (TARN) over a 10-year period. We conducted a retrospective cross-sectional analysis.ParticipantsAfter exclusions there were 505 162 TARN eligible cases.Primary and secondary outcome measuresTo compare adolescent trauma patterns and interventions to those in paediatric and adult cohorts. Identify transition points for mechanism of injury (MOI) and interventions by individual year over the adolescent age range (10–24.99).ResultsRoad traffic accidents are the most common MOI in the adolescent group, in contrast to both the paediatric and adult group where falls <2 m are most common. Violence-related injury (shootings and stabbings) are more common in the adolescent group, 9.4% compared with 0.3% and 1.5% in the paediatric and adult groups, respectively. The adolescent grouping had the highest median Injury Severity Score (ISS) and the highest proportion of interventions. The proportion of cases due to stabbing peaked at age 17 (11.8%) becoming the second most common MOI. The median ISS peaked at 13 at age 18. The percentage of cases that fulfil the definition of polytrauma enters double figures (11.8%) at age 15 reaching a peak of 17.6% at age 18. The use of blood products within the first 6 hours remains around 2% (1.6%–2.8%) until age 15 (3.4%), increasing to 4.7% at age 16.ConclusionsTrauma patterns are more closely aligned between adult and paediatric cohorts than adolescence. The highest proportion of trauma interventions occur in the adolescent population. Analysing the adolescent cohort by year of age identified some common points for when descriptors or outcomes altered in frequency, predominantly between the ages of 15–17 years.
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