Study objective The first hour after the onset of out-of-hospital traumatic injury is referred to as the “golden hour,” yet the relationship between time and outcome remains unclear. We evaluate the ...association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality. Methods This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged ≥15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was inhospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders. Results There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio OR 1.00; 95% confidence interval CI 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings. Conclusion In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.
Posttraumatic stress disorder (PTSD) symptoms, firearm violence events, alcohol and drug use problems, and major depression and suicidal ideation are endemic among patients admitted to US trauma ...centers. Despite increasing policy importance, the current availability of screening and intervention services for this constellation of conditions in US trauma centers is unknown.
Trauma program staff at all Level I and Level II trauma centers in the US. (N = 627) were contacted to complete a survey describing screening and intervention procedures for alcohol and drug use problems, PTSD symptoms, depression and suicidality, and firearm violence. Additional questions asked trauma centers about the delivery of peer interventions and information technology capacity for screening and intervention procedures.
Fifty-one percent of trauma centers (n = 322) responded to the survey. More than 95% of responding sites endorsed routinely screening and/or intervening for alcohol use problems. Routine services addressing PTSD were less common, with 28% of centers reporting routine screening. More than 50% of sites that screened for PTSD used previously established trauma center alcohol use services. Programmatic screening and intervention for firearm injury sequelae was occurring at 30% of sites.
Alcohol screening and intervention is occurring frequently at US trauma centers and appears to be responsive to American College of Surgeons Committee on Trauma verification requirements. Routine screening and intervention services for PTSD and firearm injury were occurring less frequently. Regular national surveys may be a key element of tracking progress in national mental health and substance use screening, intervention, and referral policy.
To identify causes and timing of mortality in trauma patients to determine targets for future studies.
In trials conducted by the Resuscitation Outcomes Consortium in patients with traumatic ...hypovolemic shock (shock) or traumatic brain injury (TBI), hypertonic saline failed to improve survival. Selecting appropriate candidates is challenging.
Retrospective review of patients enrolled in multicenter, randomized trials performed from 2006 to 2009. Inclusion criteria were as follows: injured patients, age 15 years or more with hypovolemic shock systolic blood pressure (SBP) ≤ 70 mm Hg or SBP 71-90 mm Hg with heart rate ≥ 108) or severe TBI Glasgow Coma Score (GCS) ≤ 8. Initial fluid administered was 250 mL of either 7.5% saline with 6% dextran 70, 7.5% saline or 0.9% saline.
A total of 2061 subjects were enrolled (809 shock, 1252 TBI) and 571 (27.7%) died. Survivors were younger than nonsurvivors 30 (interquartile range 23) vs 42 (34) and had a higher GCS, though similar hemodynamics. Most deaths occurred despite ongoing resuscitation. Forty-six percent of deaths in the TBI cohort were within 24 hours, compared with 82% in the shock cohort and 72% in the cohort with both shock and TBI. Median time to death was 29 hours in the TBI cohort, 2 hours in the shock cohort, and 4 hours in patients with both. Sepsis and multiple organ dysfunction accounted for 2% of deaths.
Most deaths from trauma with shock or TBI occur within 24 hours from hypovolemic shock or TBI. Novel resuscitation strategies should focus on early deaths, though prevention may have a greater impact.
Current severity of disease in the Covid-19 population As of 26 March 2020, the Centers for Disease Control and Prevention (CDC) reported 68 440 total confirmed plus presumptive cases of Covid-19 in ...the USA, with 994 deaths.1 These numbers are expected to change daily as more data are collected and more testing for the virus is performed. In Wuhan, China, 40 of 138 hospitalized patients were healthcare providers who were infected from presumed hospital spread.6 With the current pandemic, significant attention has been focused on the safety of healthcare workers, and many organizations have published guidance on infection prevention and control for these essential personnel.9–12 Considerations for indications and timing Surgeons should consider both short-term and long-term outcomes of tracheostomy along with the risks of exposure of the clinical team. In all patients with Covid-19 who need a tracheostomy, an acceptable strategy is to wait for the disease to become non-transmissible* prior to performing a high-risk aerosol-generating procedure such as tracheostomy. *See CDC recommendations for discontinuation of transmission-based precautions.16 Procedural guidance for Open and Percutaneous Tracheostomy Here we provide practical guidance for the performance of OT and PT in patients with known or suspected Covid-19 infection. If an AIIR is not available, avoid entry into room by non-essential personnel for up to 3 hours due to persistence of viable virus in aerosols.18 Limit the number of participants in the room to essential personnel only.19 An experienced attending surgeon or other experienced practitioner should perform the procedure.
The liver is one of the most frequently injured abdominal organs. Hepatic hemorrhage is a complex and challenging complication following hepatic trauma. Significant shifts in the treatment of hepatic ...hemorrhage, including the increasing use of angioembolization, are believed to have improved patient outcomes. We aimed to describe the efficacy of angioembolization in the setting of acute hepatic arterial hemorrhage as well as the complications associated with this treatment modality.
A systematic review of published literature (MEDLINE, SCOPUS, and Cochrane Library) describing hepatic angioembolization in the setting of trauma was performed. Articles that fulfilled the predetermined inclusion and exclusion criteria were included. We analyzed the efficacy rate of angioembolization in the setting of traumatic hepatic hemorrhage as well as the complications associated with hepatic angioembolization.
Four hundred fifty-nine articles were identified in the literature search. Of these, 10 retrospective studies and 1 prospective study met inclusion and exclusion criteria. Efficacy rate of angioembolization was 93%. The most frequently reported complications following hepatic angioembolization included hepatic necrosis (15%), abscess formation (7.5%), and bile leaks.
Although the outcomes of hepatic angioembolization were generally favorable with a high success rate, the treatment modality is not without associated morbidity. The most frequently associated major complication was hepatic necrosis. Rates of complications were affected by study heterogeneity and should be better defined in future studies.
Systematic review, level III.
Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI.
To determine whether tranexamic acid ...treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI.
Multicenter, double-blinded, randomized clinical trial at 20 trauma centers and 39 emergency medical services agencies in the US and Canada from May 2015 to November 2017. Eligible participants (N = 1280) included out-of-hospital patients with TBI aged 15 years or older with Glasgow Coma Scale score of 12 or less and systolic blood pressure of 90 mm Hg or higher.
Three interventions were evaluated, with treatment initiated within 2 hours of TBI: out-of-hospital tranexamic acid (1 g) bolus and in-hospital tranexamic acid (1 g) 8-hour infusion (bolus maintenance group; n = 312), out-of-hospital tranexamic acid (2 g) bolus and in-hospital placebo 8-hour infusion (bolus only group; n = 345), and out-of-hospital placebo bolus and in-hospital placebo 8-hour infusion (placebo group; n = 309).
The primary outcome was favorable neurologic function at 6 months (Glasgow Outcome Scale-Extended score >4 moderate disability or good recovery) in the combined tranexamic acid group vs the placebo group. Asymmetric significance thresholds were set at 0.1 for benefit and 0.025 for harm. There were 18 secondary end points, of which 5 are reported in this article: 28-day mortality, 6-month Disability Rating Scale score (range, 0 no disability to 30 death), progression of intracranial hemorrhage, incidence of seizures, and incidence of thromboembolic events.
Among 1063 participants, a study drug was not administered to 96 randomized participants and 1 participant was excluded, resulting in 966 participants in the analysis population (mean age, 42 years; 255 74% male participants; mean Glasgow Coma Scale score, 8). Of these participants, 819 (84.8%) were available for primary outcome analysis at 6-month follow-up. The primary outcome occurred in 65% of patients in the tranexamic acid groups vs 62% in the placebo group (difference, 3.5%; 90% 1-sided confidence limit for benefit, -0.9%; P = .16; 97.5% 1-sided confidence limit for harm, 10.2%; P = .84). There was no statistically significant difference in 28-day mortality between the tranexamic acid groups vs the placebo group (14% vs 17%; difference, -2.9% 95% CI, -7.9% to 2.1%; P = .26), 6-month Disability Rating Scale score (6.8 vs 7.6; difference, -0.9 95% CI, -2.5 to 0.7; P = .29), or progression of intracranial hemorrhage (16% vs 20%; difference, -5.4% 95% CI, -12.8% to 2.1%; P = .16).
Among patients with moderate to severe TBI, out-of-hospital tranexamic acid administration within 2 hours of injury compared with placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended.
ClinicalTrials.gov Identifier: NCT01990768.
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