Does trauma team activation associate with the time to CT scan for those suspected of serious head injuries?

BACKGROUND: Traumatic brain injury (TBI) constitutes the leading cause of posttraumatic mortality. Practically, the major interventions required to treat TBI predicate expedited transfer to CT after excluding other immediately life-threatening conditions. At our center, trauma responses variably consist of either full trauma activation (FTA) including an attending trauma surgeon or a non-trauma team response (NTTR). We sought to explore whether FTAs expedited the time to CT head (TTCTH). METHODS: Retrospective review of augmented demographics of 88 serious head injuries identified from a Regional Trauma Registry within one year at a level I trauma center. The inclusion criteria consisted of a diagnosis of head injury recorded as intubated or GCS < 13; and CT-head scanning after arriving the emergency department. Data was analyzed using STATA. RESULTS: There were 58 FTAs and 30 NTTRs; 86% of FTAs and 17% of NTTRs were intubated prehospital out of 101 charts reviewed in detail; 13 were excluded due to missing data. Although FTAs were more seriously injured (median ISS 29, MAIS head 19, GCS score at scene 6.0), NTTRs were also severely injured (median ISS 25, MAIS head 21, GCS at scene 10) and older (median 54 vs. 26 years). Median TTCTH was double without dedicated FTA (median 50 vs. 26 minutes, p < 0.001), despite similar justifiable delays (53% NTTR, 52% FTA). Without FTA, most delays (69%) were for emergency intubation. TTCTH after securing the airway was longer for NTTR group (median 38 vs. 26 minutes, p =0.0013). Even with no requirements for ED interventions, TTCTH for FTA was less than half versus NTTR (25 vs. 61 minutes, p =0.0013). Multivariate regression analysis indicated age and FTA with an attending surgeon as significant predictors of TTCTH, although the majority of variability in TTCTH was not explained by these two variables (R² = 0.33). CONCLUSION: Full trauma activations involving attending trauma surgeons were quicker at transferring serious head injury patients to CT. Patients with FTA were younger and more seriously injured. Discerning the reasons for delays to CT should be used to refine protocols aimed at minimizing unnecessary delays and enhancing workforce efficiency and clinical outcome

North Pacific Surgical Association A booming economy means a bursting trauma system: association between hospital admission for major injury and indicators of economic activity in a large Canadian health region

Abstract BACKGROUND: Injury epidemiology fluctuates with economic activity in many countries. These relationships remain unclear in Canada. METHODS: The annual risk of admission for major injury (Injury Severity Score R12) to a highvolume, level-1 Canadian trauma center was compared with indicators of economic activity over a 16-year period using linear regression

Low-value clinical practices in adult traumatic brain injury : an umbrella review

Despite numerous interventions and treatment options, the outcomes of traumatic brain injury (TBI) have improved little over the last 3 decades, which raises concern about the value of care in this patient population. We aimed to synthesize the evidence on 14 potentially low-value clinical practices in TBI care. Using umbrella review methodology, we identified systematic reviews evaluating the effectiveness of 14 potentially low-value practices in adults with acute TBI. We present data on methodological quality (Assessing the Methodological Quality of Systematic Reviews), reported effect sizes, and credibility of evidence (I to IV). The only clinical practice with evidence of benefit was therapeutic hypothermia (credibility of evidence II to IV). However, the most recent meta-analysis on hypothermia based on high-quality trials suggested harm (credibility of evidence IV). Meta-analyses on platelet transfusion for patients on antiplatelet therapy were all consistent with harm but were statistically non-significant. For the following practices, effect estimates were consistently close to the null: computed tomography (CT) in adults with mild TBI who are low-risk on a validated clinical decision rule; repeat CT in adults with mild TBI on anticoagulant therapy with no clinical deterioration; antibiotic prophylaxis for external ventricular drain placement; and decompressive craniectomy for refractory intracranial hypertension. We identified five clinical practices with evidence of lack of benefit or harm. However, evidence could not be considered to be strong for any clinical practice as effect measures were imprecise and heterogeneous, systematic reviews were often of low quality, and most included studies had a high risk of bias

Complications related to deep venous thrombosis prophylaxis in trauma: a systematic review of the literature

Deep venous thrombosis prophylaxis is essential to the appropriate management of multisystem trauma patients. Without thromboprophylaxis, the rate of venous thrombosis and subsequent pulmonary embolism is substantial. Three prophylactic modalities are common: pharmacologic anticoagulation, mechanical compression devices, and inferior vena cava filtration. A systematic review was completed using PRISMA guidelines to evaluate the potential complications of DVT prophylactic options. Level one evidence currently supports the use of low molecular weight heparins for thromboprophylaxis in the trauma patient. Unfortunately, multiple techniques are not infrequently required for complex multisystem trauma patients. Each modality has potential complications. The risks of heparin include bleeding and heparin induced thrombocytopenia. Mechanical compression devices can result in local soft tissue injury, bleeding and patient non-compliance. Inferior vena cava filters migrate, cause inferior vena cava occlusion, and penetrate the vessel wall. While the use of these techniques can be life saving, they must be appropriately utilized

A Case Report of Acute Airway Compromise due to Subcutaneous Emphysema

In the acute management of a trauma patient, airway patency is of utmost importance. The present case describes a male patient who presented with delayed severe upper airway obstruction secondary to massive subcutaneous emphysema following blunt traumatic injury two days previously. Airway compromise is a rarely described but serious complication of subcutaneous emphysema. Current management of subcutaneous emphysema and its association with pneumothorax is summarized. Early decompression of underlying pneumothoraces in patients with significant subcutaneous emphysema should be performed to avoid this rare complication

A population-based assessment of major trauma in a large Canadian region

Background: The cause of major trauma has not been well defined using population-based methodologies. Methods: We performed a population-based surveillance of major traumatic injuries in adult residents of the Calgary Health Region over a period of 3 years. Results: A total of 1,475 victims of major trauma were identified (69.5 per 100,000/y). Males were at significantly higher risk as compared with females (104.5 vs. 35.2 per 100,000; relative risk = 3.0, 95% confidence interval = 2.64-3.35), as were urban as compared with rural residents (70.7 vs. 49.0 per 100,000; relative risk = 1.4; 95% confidence interval = 1.11-1.91). A strikingly high incidence rate of major trauma was observed among those aged 85 years or more at 242.3 per 100,000 per year; elderly men were at 16.8-fold (95% confidence interval = 11.04-24.79) higher risk than young females. The majority were unintentional (53.9 per 100,000/y). Suicide, assault, and homicide occurred at annualized rates of 8.5, 4.8, and 1.6 per 100,000, respectively. Motor vehicle-related injuries (39%), falls or jumps (33%), and being struck by an object or animal (10%) were responsible for the majority of traumas. Firearm injuries were relatively uncommon (2.0 per 100,000/y). The annual mortality rate was 20.0 per 100,000. Conclusions: This study provides rigorous, population-based data on the cause of severe injury in the Calgary Health Region. It is hoped that ongoing work in this area will be useful in the development of effective injury prevention and health resource allocation strategies.</p

Thrombolysis of Postoperative Acute Pulmonary Embolism with a Thrombus in Transit

Right heart thrombus in transit clot (RHTT) associated with a pulmonary thromboembolism (PTE) is a rare but potentially fatal diagnosis. Early diagnosis and immediate intervention are crucial. This report describes the case of a healthy, physically active 32-year-old female who presented 19 days postoperatively, following an anterior cruciate ligament reconstruction and partial lateral meniscectomy with a saddle PE, RHTT, and right ventricular (RV) strain. The patient received half of the standard dose of intravenous tissue plasminogen activator (TPA) in combination with anticoagulation and survived. Case reports of RHTT will inform future studies designed to evaluate whether and when thrombolysis should be administered

Long-term mortality outcome associated with prolonged admission to the ICU

Study objectives: Patients requiring prolonged admission to the ICU consume significant health-care resources and have a high rate of in-hospital death. The long-term mortality outcome of these patients has not been well defined in a nonselected cohort. The objective of this study was to describe the occurrence and factors predictive of prolonged ICU stay at admission, and to define the long-term (≥ 1 year) mortality outcome. Design: Population-based cohort. Setting: All adult multisystem and cardiovascular surgical ICUs in the Calgary Health Region (CHR) from July 1, 1999, to March 31, 2002. Patients: Adult (≥ 18 years old) residents of the CHR admitted to regional ICUs. Interventions: None. Measurements and results: During the study, 4,845 patients had a median length of stay of 2 days (interquartile range, 1 to 4 days); 2,115 patients (44%) were admitted for < 2 days, 1,496 patients (31%) were admitted for 2 to 3 days; 1,018 patients (21%) were admitted from 4 to 13 days; and 216 patients (4%) had a prolonged (≥ 14 day) admission to the ICU. A higher severity of illness, the presence of shock, and bloodstream infection were independently associated with a prolonged ICU admission, and cardiovascular surgery was associated with a lower risk. Patients with prolonged ICU admissions were nearly twice as likely to die as patients with shorter ICU admissions: 53 of 216 patients (25%) vs 584 of 4,629 patients (13%) [p = 0.0001]. Among the 3,924 survivors to hospital discharge, the rates of mortality during the year following ICU admission were as follows: 59 deaths in 1,758 patients (3%) admitted < 2 days, 74 deaths in 1,267 patients (6%) with 2- to 3-day admissions, 78 deaths in 766 patients (10%) with 4- to 13-day admissions, and 10 deaths in 133 patients (8%) with admissions ≥ 14 days. Conclusions: One in 25 critically ill patients will have prolonged ICU admission and higher ICU-related mortality. However, survivors of prolonged ICU admission have good long-term mortality outcome after acute illness.</p