SOFA is superior to MOD score for the determination of non-neurologic organ dysfunction in patients with severe traumatic brain injury: a cohort study

INTRODUCTION: The objective of the present study was to compare the discriminative ability of the Sequential Organ Failure Assessment (SOFA) and Multiple Organ Dysfunction (MOD) scoring systems with respect to hospital mortality and unfavorable neurologic outcome in patients with severe traumatic brain injury admitted to the intensive care unit. METHOD: We performed a prospective cohort study at Foothills Medical Centre, the sole adult tertiary care trauma center servicing southern Alberta (population about 1.3 million). All patients aged 16 years or older with severe traumatic brain injury and intensive care unit length of stay greater than 48 hours between 1 May 2000 and 31 April 2003 were included. Non-neurologic organ dysfunction was measured using the SOFA and MODS scoring systems. Determination of organ dysfunction for each non-neurologic organ system was compared between the two systems by calculating the proportion of patients with SOFA and MOD component score defined organ failure. Consistent with previous literature, organ system failure was defined as a component score of three or greater. RESULTS: The odds of death and unfavorable neurologic outcome in patients with SOFA defined cardiovascular failure were 14.7 times (95% confidence interval [CI] 5.9–36.3) and 7.6 times (95% CI 3.5–16.3) that of those without cardiovascular failure, respectively. The development of SOFA-defined cardiovascular failure was a reasonable discriminator of hospital mortality and unfavorable neurologic outcome (area under the receiver operating characteristic [ROC] curve 0.75 and 0.73, respectively). The odds of death and unfavorable neurologic outcome in patients with MOD-defined cardiovascular failure were 2.6 times (95% CI 1.24–5.26) and 4.1 times (95% CI 1.3–12.4) that of those without cardiovascular failure, respectively. The development of MOD-defined cardiovascular failure was a poor discriminator of hospital mortality and unfavorable neurologic outcome (area under the ROC curve 0.57 and 0.59, respectively). Neither SOFA-defined nor MOD-defined respiratory failure was significantly associated with hospital mortality. CONCLUSION: In patients with brain injury, the SOFA scoring system has superior discriminative ability and stronger association with outcome compared with the MOD scoring system with respect to hospital mortality and unfavorable neurologic outcome

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

Breast cancer care in Alberta: a Patients perspective

Introduction Each year in Alberta, over 2,300 women are affected by breast cancer. In Alberta, a multi-year Breast Health Initiative is underway to improve breast cancer care; reduce wait times, coordinate care, and enhance patient experience. Patient reported experience measurements are important to inform and advance patient and family-centred care. Objectives and Approach The aim is to assess breast cancer patients’ experiences at two survey points; after surgeon consult and after breast surgery. Patients meeting inclusion criteria; highly suspicious of cancer on imaging result (i.e. BI-RADS 5), referral to Calgary or Edmonton breast program, English speaking, and having an email address are recruited by RN coordinators or nurse navigators. Automated survey invitations from REDCap are used. Seven days after the surgeon consult the first survey is sent and seven days after breast surgery the second survey is sent. Results Patient recruitment began November 27, 2017 and January 2, 2018 for Edmonton and Calgary, respectively. As of February, 2018, 45 patients had been recruited. Of these, the first survey was sent to 34 (i.e. seven days post surgeon consult) and 19 (56%) had completed the survey. All those eligible (18) agreed to participate in the upcoming second survey. Of those, six had provided their surgery date and the second survey which both were completed. Recruitment is ongoing until the conference, at that time there will be sufficient numbers to report findings. Conclusion/Implications Patient and family-centred care is an element of high-quality healthcare which AHS has identified as a priority. These results will report on the breast cancer patients’ perspectives and generate important information for clinicians and administrators to use for decision making and quality improvement of health services

Impact of Trauma System Structure on Injury Outcomes : A Systematic Review and Meta-Analysis

The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes. We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria. We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization. This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.Peer reviewe

Impact of Trauma System Structure on Injury Outcomes : A Systematic Review and Meta-Analysis

The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes. We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria. We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization. This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.Peer reviewe

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

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

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

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

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