What is the effect of a formalised trauma tertiary survey procedure on missed injury rates in multi-trauma patients? Study protocol for a randomised controlled trial

Background: Missed injury is commonly used as a quality indicator in trauma care. The trauma tertiary survey (TTS) has been proposed to reduce missed injuries. However a systematic review assessing the effect of the TTS on missed injury rates in trauma patients found only observational studies, only suggesting a possible increase in early detection and reduction in missed injuries, with significant potential biases. Therefore, more robust methods are necessary to test whether implementation of a formal TTS will increase early in-hospital injury detection, decrease delayed diagnosis and decrease missed injuries after hospital discharge. Methods/Design: We propose a cluster-randomised, controlled trial to evaluate trauma care enhanced with a formalised TTS procedure. Currently, 20 to 25% of trauma patients routinely have a TTS performed. We expect this to increase to at least 75%. The design is for 6,380 multi-trauma patients in approximately 16 hospitals recruited over 24 months. In the first 12 months, patients will be randomised (by hospital) and allocated 1:1 to receive either the intervention (Group 1) or usual care (Group 2). The recruitment for the second 12 months will entail Group 1 hospitals continuing the TTS, and the Group 2 hospitals beginning it to enable estimates of the persistence of the intervention. The intervention is complex: implementation of formal TTS form, small group education, and executive directive to mandate both. Outcome data will be prospectively collected from (electronic) medical records and patient (telephone follow-up) questionnaires. Missed injuries will be adjudicated by a blinded expert panel. The primary outcome is missed injuries after hospital discharge; secondary outcomes are maintenance of the intervention effect, in-hospital missed injuries, tertiary survey performance rate, hospital and ICU bed days, interventions required for missed injuries, advanced diagnostic imaging requirements, readmissions to hospital, days of work and quality of life (EQ-5D-5 L) and mortality. Discussion: The findings of this study may alter the delivery of international trauma care. If formal TTS is (cost-) effective this intervention should be implemented widely. If not, where already partly implemented, it should be abandoned. Study findings will be disseminated widely to relevant clinicians and health funders.Griffith Health, School of MedicineFull Tex

Twente spine model:A complete and coherent dataset for musculo-skeletal modeling of the lumbar region of the human spine

Item does not contain fulltextMusculo-skeletal modeling can greatly help in understanding normal and pathological functioning of the spine. For such models to produce reliable muscle and joint force estimations, an adequate set of musculo-skeletal data is necessary. In this study, we present a complete and coherent dataset for the lumbar spine, based on medical images and dissection measurements from one embalmed human cadaver. We divided muscles into muscle-tendon elements, digitized their attachments at the bones and measured morphological parameters. In total, we measured 11 muscles from one body side, using 96 elements. For every muscle element, we measured three-dimensional coordinates of its attachments, fiber length, tendon length, sarcomere length, optimal fiber length, pennation angle, mass, and physiological cross-sectional area together with the geometry of the lumbar spine. Results were consistent with other anatomical studies and included new data for the serratus posterior inferior muscle. The dataset presented in this paper enables a complete and coherent musculo-skeletal model for the lumbar spine and will improve the current state-of-the art in predicting spinal loading

The effect of tertiary surveys on missed injuries in trauma:A systematic review

BACKGROUND: Trauma tertiary surveys (TTS) are advocated to reduce the rate of missed injuries in hospitalized trauma patients. Moreover, the missed injury rate can be a quality indicator of trauma care performance. Current variation of the definition of missed injury restricts interpretation of the effect of the TTS and limits the use of missed injury for benchmarking. Only a few studies have specifically assessed the effect of the TTS on missed injury. We aimed to systematically appraise these studies using outcomes of two common definitions of missed injury rates and long-term health outcomes. METHODS: A systematic review was performed. An electronic search (without language or publication restrictions) of the Cochrane Library, Medline and Ovid was used to identify studies assessing TTS with short-term measures of missed injuries and long-term health outcomes. ‘Missed injury’ was defined as either: Type I) any injury missed at primary and secondary survey and detected by the TTS; or Type II) any injury missed at primary and secondary survey and missed by the TTS, detected during hospital stay. Two authors independently selected studies. Risk of bias for observational studies was assessed using the Newcastle-Ottawa scale. RESULTS: Ten observational studies met our inclusion criteria. None was randomized and none reported long-term health outcomes. Their risk of bias varied considerably. Nine studies assessed Type I missed injury and found an overall rate of 4.3%. A single study reported Type II missed injury with a rate of 1.5%. Three studies reported outcome data on missed injuries for both control and intervention cohorts, with two reporting an increase in Type I missed injuries (3% vs. 7%, P<0.01), and one a decrease in Type II missed injuries (2.4% vs. 1.5%, P=0.01). CONCLUSIONS: Overall Type I and Type II missed injury rates were 4.3% and 1.5%. Routine TTS performance increased Type I and reduced Type II missed injuries. However, evidence is sub-optimal: few observational studies, non-uniform outcome definitions and moderate risk of bias. Future studies should address these issues to allow for the use of missed injury rate as a quality indicator for trauma care performance and benchmarking

Which surgical technique may yield the best results in large, infected, segmental non-unions of the tibial shaft?:A scoping review

Purpose: Infected nonunion of the tibia with a large segmental bone defect is a complex and challenging condition for the patient and surgeon. This scoping review was conducted to identify existing evidence and knowledge gaps regarding this clinical scenario. Secondly, the objective of this study was to search for a valid recommendation on the optimal treatment. Methods: A comprehensive search was conducted in the bibliographic databases: PubMed, Embase.com, and Web of Science Core Collection. Studies reporting on bone transport techniques, the Masquelet technique, and vascularized fibular grafts in bone defects greater than 5 cm were included. Bone healing results and functional results were compared according to duration of nonunion, infection recurrence, bone consolidation, complication rate, external fixation time, and time until full weight-bearing. Results: Of the 2753 articles retrieved, 37 studies could be included on bone transport techniques (n = 23), the Masquelet technique (n = 7), and vascularized fibular grafts (n = 7). Respective bone union percentages were 94.3%, 89.5%, and 96.5%. The percentages of infection recurrence respectively were 1.6%, 14.4% and 7.0%, followed by respectively 1.58, 0.78, and 0.73 complications per patient. Conclusion: Bone transport was found to be the most widely studied technique in the literature. Depending on the surgeon’s expertise, vascularized fibular grafts may be held as a favourable alternative. This review indicates that further high-quality research on large bone defects (≥ 5 cm) in patients with infected tibial nonunions is necessary to gain more insight into the potentially beneficial results of vascularized fibular grafts and the Masquelet technique.</p

Which surgical technique may yield the best results in large, infected, segmental non-unions of the tibial shaft?:A scoping review

Purpose: Infected nonunion of the tibia with a large segmental bone defect is a complex and challenging condition for the patient and surgeon. This scoping review was conducted to identify existing evidence and knowledge gaps regarding this clinical scenario. Secondly, the objective of this study was to search for a valid recommendation on the optimal treatment. Methods: A comprehensive search was conducted in the bibliographic databases: PubMed, Embase.com, and Web of Science Core Collection. Studies reporting on bone transport techniques, the Masquelet technique, and vascularized fibular grafts in bone defects greater than 5 cm were included. Bone healing results and functional results were compared according to duration of nonunion, infection recurrence, bone consolidation, complication rate, external fixation time, and time until full weight-bearing. Results: Of the 2753 articles retrieved, 37 studies could be included on bone transport techniques (n = 23), the Masquelet technique (n = 7), and vascularized fibular grafts (n = 7). Respective bone union percentages were 94.3%, 89.5%, and 96.5%. The percentages of infection recurrence respectively were 1.6%, 14.4% and 7.0%, followed by respectively 1.58, 0.78, and 0.73 complications per patient. Conclusion: Bone transport was found to be the most widely studied technique in the literature. Depending on the surgeon’s expertise, vascularized fibular grafts may be held as a favourable alternative. This review indicates that further high-quality research on large bone defects (≥ 5 cm) in patients with infected tibial nonunions is necessary to gain more insight into the potentially beneficial results of vascularized fibular grafts and the Masquelet technique.</p

Ten-year evolution of a massive transfusion protocol in a level 1 trauma centre : have outcomes improved?

Background: We aimed to evaluate the evolution and implementation of the massive transfusion protocol (MTP) in an urban level 1 trauma centre. Most data on this topic comes from trauma centres with high exposure to life‐threatening haemorrhage. This study examines the effect of the introduction of an MTP in an Australian level 1 trauma centre. Methods: A retrospective study of prospectively collected data was performed over a 14‐year period. Three groups of trauma patients, who received more than 10 units of packed red blood cells (PRBC), were compared: a pre‐MTP group (2002–2006), an MTP‐I group (2006–2010) and an MTP‐II group (2010–2016) when the protocol was updated. Key outcomes were mortality, complications and number of blood products transfused. Results: A total of 168 patients were included: 54 pre‐MTP patients were compared to 47 MTP‐I and 67 MTP‐II patients. In the MTP‐II group, fewer units of PRBC and platelets were administered within the first 24 h: 17 versus 14 (P = 0.01) and 12 versus 8 (P < 0.001), respectively. Less infections were noted in the MTP‐I group: 51.9% versus 31.9% (P = 0.04). No significant differences were found regarding mortality, ventilator days, intensive care unit and total hospital lengths of stay. Conclusion: Introduction of an MTP‐II in our level 1 civilian trauma centre significantly reduced the amount of PRBC and platelets used during damage control resuscitation. Introduction of the MTP did not directly impact survival or the incidence of complications. Nevertheless, this study reflects the complexity of real‐life medical care in a level 1 civilian trauma centre

Optimization of trauma care: A two-tiered inhospital trauma team response system

Background: To improve utilization of resources and reduce overtriage, two-tiered trauma team activation (TTA) system was implemented. The system activates a complete or selective trauma team (CTT, STT). Activation is based on the mechanism of injury (MOI), prehospital vital signs and injuries. Objectives: The objective was to evaluate the feasibility, effectiveness and safety of the implementation of a two-tiered system and whether the triage is done according to the TTA criteria. Methods: A prospective observational study was performed at the emergency department (ED) of a Level I trauma center. Data were collected on TTA criteria, patient demographics, MOI, prehospital vital signs, imaging modalities and blood gas analysis in the ED and inhospital data. Results: In 3 months, 186 patients were presented to the trauma resuscitation room. Thirty-four patients were excluded, 152 patients were included for analysis. Median age was 48 years (range 193), 64 were males. In 73, the CTT was activated, in 27 the STT, the STT was upgraded three times. Seventy-nine patients had to be admitted, the median length of stay was 5 days (range 162). Thirty-eight patients needed Intensive Care Unit (ICU) admission; the median ICU stay was 3 days (range 133). Three patients died in the resuscitation room, in total, nine patients died. Overtriage was 29 and undertriage 7. No significant difference was found for mortality, duration of hospital admission or ICU admission across the four groups (correct activation STT, undertriage, overtriage, and correct activation CTT). Conclusions: This TTA system identifies those patients in need of a CTT adequately with an undertriage percentage of 7, indicative of improved care for the severely injured and a more appropriate use of resources. With this model, the overtriage is set to an acceptable percentage of 29

Sex Differences in Outcome of Trauma Patients Presented with Severe Traumatic Brain Injury:A Multicenter Cohort Study

The objective of this study was to determine whether there is an association between sex and outcome in trauma patients presented with severe traumatic brain injury (TBI). A retrospective multicenter study was performed in trauma patients aged ≥ 16 years who presented with severe TBI (Head Abbreviated Injury Scale (AIS) ≥ 4) over a 4-year-period. Subgroup analyses were performed for ages 16–44 and ≥45 years. Also, patients with isolated severe TBI (other AIS ≤ 2) were assessed, likewise, with subgroup analysis for age. Sex differences in mortality, Glasgow Outcome Score (GOS), ICU admission/length of stay (LOS), hospital LOS, and mechanical ventilation (MV) were examined. A total of 1566 severe TBI patients were included (831 patients with isolated TBI). Crude analysis shows an association between female sex and lower ICU admission rates, shorter ICU/hospital LOS, and less frequent and shorter MV in severe TBI patients ≥ 45 years. After adjusting, female sex appears to be associated with shorter ICU/hospital LOS. Sex differences in mortality and GOS were not found. In conclusion, this study found sex differences in patient outcomes following severe TBI, potentially favoring (older) females, which appear to indicate shorter ICU/hospital LOS (adjusted analysis). Large prospective studies are warranted to help unravel sex differences in outcomes after severe TBI.</p

Tertiary Survey Performance in a Regional Trauma Hospital Without a Dedicated Trauma Service

Background: Initial management of trauma patients is focused on identifying life- and limb-threatening injuries and may lead to missed injuries. A tertiary survey can minimise the number and effect of missed injuries and involves a physical re-examination and review of all investigations within 24 h of admission. There is little information on current practice of tertiary survey performance in hospitals without a dedicated trauma service. We aimed to determine the rate of tertiary survey performance and the detail of documentation as well as the baseline rate of missed injuries. Methods: We performed a retrospective, descriptive study of all multitrauma patients who presented to an Australian level II regional trauma centre without a dedicated trauma service between May 2008 and February 2009. A medical records review was conducted to determine tertiary survey performance and missed injury rate. Results: Of 252 included trauma patients, 20% (n = 51) had a tertiary survey performed. A total of nine missed injuries were detected in eight patients (3.2%). Of the multiple components of the tertiary survey, most were poorly documented. Documentation was more comprehensive in the subgroup of patients who did have a formal tertiary survey. Conclusions: Tertiary survey performance was poor, as indicated by low documentation rates. The baseline missed injury rate was comparable to previous that of retrospective studies, although in this study an underestimation of true missed injury rates is likely. Implementing a formal, institutional tertiary survey may lead to improved tertiary survey performance and documentation and therefore improved trauma care in hospitals without a dedicated trauma service