Search

The Centers for Disease Control and Prevention's field triage guidelines (FTG) are routinely used by emergency medical services personnel for triaging injured patients. The most recent (2011) FTG contains physiologic, anatomic, mechanism, and special consideration steps. Our objective was to systematically review the criteria in the mechanism and special consideration steps that might be predictive of serious injury or need for a trauma center.We conducted a systematic review of the predictive utility of mechanism and special consideration criteria for predicting serious injury. A research librarian searched in Ovid Medline, EMBASE, and the Cochrane databases for studies published between January 2011 and February 2021. Eligible studies were identified using a priori inclusion and exclusion criteria. Studies were excluded if they lacked an outcome for serious injury, such as measures of resource use, injury severity scores, mortality, or composite measures using a combination of outcomes. Given the heterogeneity in populations, measures, and outcomes, results were synthesized qualitatively focusing on positive likelihood ratios (LR+) whenever these could be calculated from presented data or adjusted odds ratios (aOR).We reviewed 2418 abstracts and 315 full-text publications and identified 42 relevant studies. The factors most predictive of serious injury across multiple studies were death in the same vehicle (LR+ 2.2-7.4), ejection (aOR 3.2-266.2), extrication (LR+ 1.1-6.6), lack of seat belt use (aOR 4.4-11.3), high speeds (aOR 2.0-2.9), concerning crash variables identified by vehicle telemetry systems (LR+ 4.7-22.2), falls from height (LR+ 2.4-5.9), and axial load or diving (aOR 2.5-17.6). Minor or inconsistent predictors of serious injury were vehicle intrusion (LR+ 0.8-7.2), cardiopulmonary or neurologic comorbidities (LR+ 0.8-3.1), older age (LR+ 0.6-6.8), or anticoagulant use (LR+ 1.1-1.8).Select mechanism and special consideration criteria contribute positively to appropriate field triage of potentially injured patients.

Background Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. Research Question What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? Study Design and Methods We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and Pa o 2 to F io 2 ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H2O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed. Results A total of 2,466 patients were enrolled. Median baseline Pa o 2 to F io 2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H2O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR. Interpretation Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes. Trial Registry ClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov

The Field Triage Guidelines (FTG) are used across North America to identify seriously injured patients for transport to appropriate level trauma centers, with a goal of under-triaging no more than 5% and over-triaging between 25% and 35%. Our objective was to systematically review the literature on under-triage and over-triage rates of the FTG. We conducted a systematic review of the FTG performance. Ovid Medline, EMBASE, and the Cochrane databases were searched for studies published between January 2011 and February 2021. Two investigators dual-reviewed eligibility of abstracts and full-text. We included studies evaluating under- or over-triage of patients using the FTG in the prehospital setting. We excluded studies not reporting an outcome of under- or over-triage, studies evaluating other triage tools, or studies of triage not in the prehospital setting. Two investigators independently assessed the risk of bias for each included article. The primary accuracy measures to assess the FTG were under-triage, defined as seriously injured patients transported to non-trauma hospitals (1-sensitivity), and over-triage, defined as non-injured patients transported to trauma hospitals (1-specificity). Due to heterogeneity, results were synthesized qualitatively. We screened 2,418 abstracts, reviewed 315 full-text publications, and identified 17 studies that evaluated the accuracy of the FTG. Among eight studies evaluating the entire FTG (steps 1–4), under-triage rates ranged from 1.6% to 72.0% and were higher for older (≥55 or ≥65 years) adults (20.1–72.0%) and pediatric (

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) is a rescue therapy for treatment of refractory out-of-hospital cardiac arrests (OHCA). We describe the incidence of traumatic and hemorrhagic complications among patients undergoing ECPR for OHCA and the association between CPR duration and ECPR-related injuries or bleeding. Methods: We examined prospectively collected data from the Extracorporeal Resuscitation Outcomes Database (EROD), which includes ECPR-treated OHCAs from participating hospitals (Oct 2014 - Aug 2019). The primary outcome was traumatic or hemorrhagic complications, defined as injury to the chest, abdomen, or vasculature, or bleeding requiring transfusion or surgery. The primary exposure was the cardiac arrest to ECPR initiation interval (CA-ECPR interval), measured as the time from arrest to initiation of ECPR. Descriptive statistics were used to compare demographic, cardiac arrest, and ECPR characteristics among patients with and without CPR-related traumatic or bleeding complications. Multivariable logistic regression was used to examine the association between CPR duration and traumatic or bleeding complications. Results: A total of 68 patients from 4 hospitals received ECPR for OHCA were entered into EROD and met inclusion criteria. Median age was 51 (IQR 38-58), 81% were male, 40% had BMI > 30, and 70% had pre-existing medical comorbidities. A total of 65% had an initial shockable cardiac rhythm, mechanical CPR was utilized in at least 29% of patients, and 27% were discharged alive. A total of 37% experienced a traumatic or bleeding complication, with major bleeding (32%), vascular injury (18%), and cannula site bleeding (15%) being the most common. Compared to patients with shorter CPR times, patients with a 10 minute longer CA-ECPR interval had 18% (95% CI -2-42%) higher odds of suffering a mechanical or bleeding complication, but this did not reach statistical significance (p=0.08). Conclusions: Traumatic injuries and bleeding complications are common among patients undergoing ECPR. Further study is needed to investigate the relation between arrest duration and complications. Clinicians performing ECPR should anticipate and assess for injuries and bleeding in this high-risk population.

As trauma surgeons, we focus on the immediate care and needs of the injured patient every day. Historically, trauma and injury research has focused on outcomes such as mortality, complications, and length of stay; and process metrics such as time to CT scan, resuscitation checklist frequencies, or venous thromboembolism prophylaxis rates. These outcomes are perceived by healthcare providers to be important, but patients likely have different perceptions of what outcomes are most important to measure and improve. True patient-centered outcomes research involves the healthcare providers, and the entire team of stakeholders including patients and the community. Understanding the process of stakeholder engagement and the barriers trauma researchers must overcome to effectively enter this field of research is important. This summary aims to inform the trauma research community on the basics of patient-centered outcomes research, priorities for funding from the Patient-Centered Outcomes Research Institute, resources for collaboration around patient-centered outcomes research, and a unique career development and training opportunity for early career trauma surgeons to develop a skill set in patient-centered outcomes research.

Trauma surgery moves fast. Clinical decisions and treatment of injured patients must occur expeditiously, or patients suffer. Trauma research also moves fast, and new high-quality studies about treatment of injured patients frequently reshape the field and our understanding of best practices. Historically, medicine relied on the dissemination of best practices through publication of manuscripts and the endorsement of trusted physicians to change practices. However, implementation of research has proven to be slow. When research does not reach the bedside, patients are not offered proven therapies or are treated with dated or ineffective therapies. Implementation science, or the rigorous studying of the timely uptake of evidence into routine practice, is the next vital frontier in surgery,1 with the potential to have a profound positive effect on the care provided to our patients. The purpose of this paper is to describe the principles of implementation science and propose their wider use in trauma care. This paper is published as an initiative of the Coalition for National Trauma Research (CNTR) to further advance high-quality research and promote sustainable research funding to improve the care of injured patients, commensurate with the burden of disease in the USA. We will review definitions of implementation, dissemination, and de-implementation, as well as research frameworks, study design, and funding opportunities. Implementation science is an umbrella term that includes implementation research, dissemination research, and de-implementation research. The key with implementation science is focusing on “how to do it” rather than “what to do.” As a result, the outcomes of interest are not those typically considered in outcomes research such as mortality or morbidity. To study implementation, we assume that the “best practice” treatment is already known. Implementation science focuses on how to obtain sustained use of the best practice treatment in real-world settings. Implementation research is the study …

Out-of-hospital trauma triage is the process of using field-based information to determine which patients require immediate transport to a trauma center. Although simple in concept, the practice of out-of-hospital triage is quite complex. Identification of high-risk injured patients in the field is based on limited information obtained during a relatively short period of time in an often chaotic setting, all of which contribute to an imperfect process. The original out-of-hospital trauma triage criteria were generated by national consensus conferences and published by the American College of Surgeons Committee on Trauma (ACSCOT) in 1976.1 The first “step” of these criteria includes physiologic measures, which are intended to identify the highest risk trauma patients. Target ranges for the three core physiologic measures (i.e., Glasgow Coma Scale [GCS] score, systolic blood pressure [SBP], and respiratory rate) have changed very little during the last 20 years.1,2 Although there have been numerous studies evaluating the out-of-hospital trauma triage guidelines,3-16 few studies have rigorously evaluated potential revisions of the ACSCOT step 1 physiologic criteria. The current step 1 physiologic criteria are believed to identify the highest risk trauma patients,4,5,7,8,12,13 although questions persist regarding the utility of certain components of the criteria (e.g., respiratory rate), the ranges used, and whether additional physiologic measures would further improve predictive value. Previous studies assessing these measures have primarily focused on patients transported directly to major trauma centers, which can introduce selection bias and inflate the apparent predictive value of the criteria. The potential value of additional physiologic measures (e.g., shock index [pulse/SBP], pulse rate, and pulse oximetry) remains unclear, as does the relative utility of combining physiologic measures. Further, although out-of-hospital intubation has been suggested to be predictive of mortality and poor neurologic outcome,17 intubation is not explicitly included in the ACSCOT guidelines. Other authors have questioned field intubation as an indicator of resource need.18 Improving field triage guidelines may allow for more accurate selection of patients in need of immediate trauma center resources, identification of those most likely to benefit from early aggressive resuscitative care, and assist in selecting appropriate patients for field-based interventional therapies. Among injured adults evaluated by emergency medical service (EMS) providers in 11 North American sites, we sought to (1) provide an unbiased estimate of the incidence of mortality and prolonged hospital stay among patients meeting ACSCOT step 1 field physiologic criteria and (2) assess whether more restrictive criteria (with or without demographic and mechanism information) would improve the specificity of this step without missing an excessive number of high-risk patients.

The objective was to compare the type, rate, and selection of injured patients for out-of-hospital airway procedures among emergency medical services (EMS) agencies in 10 sites across North America.The authors analyzed a consecutive patient, prospective cohort registry of injured adults and children with an out-of-hospital advanced airway attempt, collected from December 1, 2005, through February 28, 2007, by 181 EMS agencies in 10 sites across the United States and Canada. Advanced airway procedures were defined as orotracheal intubation, nasotracheal intubation, supraglottic airway, or cricothyrotomy. Airway procedure rates were calculated based on age-specific population values for the 10 sites and the number of injured patients with field physiologic abnormality (systolic blood pressure ofor = 90 mm Hg, respiratory rate of10 or29 breaths/min, Glasgow Coma Scale [GCS] score ofor = 12). Descriptive measures were used to compare patients between sites.A total 1,738 patients had at least one advanced airway attempt and were included in the analysis. There was wide variation between sites in the types of airway procedures performed, including orotracheal intubation (63% to 99%), supraglottic airways (0 to 27%), nasotracheal intubation (0 to 21%), and cricothyrotomy (0 to 2%). Use of rapid sequence intubation (RSI) varied from 0% to 65%. The population-adjusted rates of field airway intervention (by site) ranged from 1.2 to 22.8 per 100,000 adults and 0.2 to 4.0 per 100,000 children. Among trauma patients with physiologic abnormality, some sites performed airway procedures in almost 50% of patients, while other sites used these procedures in fewer than 10%. There was also large variation in demographic characteristics, physiologic measures, mechanism of injury, mode of transport, field cardiopulmonary resuscitation, and unadjusted mortality among airway patients.Among 10 sites across North America, there was wide variation in the types of out-of-hospital airway procedures performed, population-based rates of airway intervention, and the selection of injured patients for such procedures.

Introduction: The American College of Surgeons (ACS) recommends immediate transport to a trauma center for all injured persons with field physiologic derangement (ACS Step 1 trauma triage criteria). However, it remains unclear whether these criteria could be refined to identify high-risk trauma patients with improved predictive value. Hypothesis: We assessed the hypothesis that an easily applied, prehospital, clinical decision rule could be developed to better identify high-risk injured persons meeting ACS Step 1 criteria. Methods: We conducted a prehospital prospective cohort study of injured adults > 15 years where field resuscitation was attempted and ACS physiologic criteria were present: SBP <90, RR 29 breaths/minute, GCS <12, or field intubation. Population-based data were collected from December 1, 2005 through November 30, 2006 by 268 EMS agencies transporting to 287 acute care hospitals (trauma and non-trauma centers) in 11 sites across the U.S. and Canada. Ten prehospital variables were assessed: SBP, RR, GCS, pulse, pulse oximetry, shock index (pulse/SBP), mechanism of injury, penetrating injury, age, and gender. High risk injured persons included: death (before or after admission) or hospital LOS >2 days. 60% of the sample was randomly selected for rule derivation and analyzed using classification and regression tree analysis. The remaining 40% were used for rule validation. The final rule was based on a targeted sensitivity of >90%. Results: Of 4,983 eligible patients, 4,326 injured persons had complete outcome information and were included in the analysis. The sample included 2,495 (58%) persons with death or LOS >2 days, as well as 1,061 (25%) patients that did not require admission. The final rule included the following variables (in order): field intubation, GCS < 8, shock index > 1.4, mechanism of injury, and age >=70 years. Rule validation demonstrated the following accuracy measures: sensitivity 94.9% (95% CI 93.5–96.3%), specificity 14.1% (95% CI 11.6 –16.6%). Conclusions: While we were able to generate a highly sensitive decision rule, the rule appears too complex for field application and is non-specific. Further refining ACS physiologic triage criteria to increase predictive value remains an ongoing challenge.

Strict control of serum glucose with insulin has been associated with a reduction in the development of multiple organ dysfunction syndrome potentially through alterations in macrophage activation. Although the mechanism responsible for this effect remains poorly elucidated, recent work has suggested that this may occur through the PI3K/AKT pathway. As a result, we set out to investigate the role and means of activation of this pathway by insulin on endotoxin-mediated activation of tissue-fixed macrophages.THP-1 cells were stimulated with endotoxin with or without 24 h of insulin pretreatment. Cellular protein was extracted and analyzed by immunoblot for factors essential to Toll-like receptor 4 signaling. Supernatants were analyzed by enzyme-linked immunosorbent assay for TNF-alpha and IL-8 production. In addition, potential effect of the transforming growth factor superfamily was analyzed through selective inhibition of either the transforming growth factor beta or activin A receptors.Endotoxin exposure resulted in the activation of extracellular signal-regulated kinase 1/2, p38 and Jun kinase, the degradation of IkappaB, the activation of nuclear factor kappaB, and the production of TNF-alpha and IL-8. Insulin pretreatment delayed endotoxin-mediated extracellular signal-regulated kinase 1/2, p38 and Jun kinase, the degradation of IkappaB, the activation of nuclear factor kappaB, and the production of TNF-alpha and IL-8. Insulin alone was associated with an increase in cytoplasmic SH2-containing inositol 5'-phosphatase (SHIP) but a decrease in lipid raft bound SHIP. The changes induced by insulin on SHIP and endotoxin-mediated signaling were reversed by activin A blockade.Insulin results in regulation of macrophage activity in response to endotoxin through the release of activin A and subsequent production of SHIP. This increase in cytoplasmic SHIP results in attenuated endotoxin-mediated intracellular signaling and inflammatory mediator production.