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Introduction: The neutrophil-to-lymphocyte ratio (NLR) has been proposed as a marker of systemic inflammation in major trauma patients that is associated with in-hospital mortality. We aimed to determine the discriminative ability of initial NLR as a predictor of outcomes following major trauma. Methods: This was a registry-based cohort study involving all major trauma patients meeting criteria for inclusion into the Alfred Health Trauma Registry who presented directly from the scene of injury over a 24-month period (January 2018 to December 2019). The initial NLR was calculated for each patient and was compared against the Shock Index (SI), lactate and Revised Trauma Score (RTS). Outcomes observed were mortality at hospital discharge and intensive care unit (ICU) admission. We assessed the predictive capacity of each test using the receiver operating characteristic (ROC) curve and performed area under the ROC curve (AUROC) analysis to compare their performance. Results: Data were extracted for 1687 major trauma patients, of which 72% were male, the median age was 49 years (IQR 31–68) and most (90%) of patients presented after a blunt mechanism of injury. In-hospital mortality occurred in 165 (9.77%) patients, and 725 (42.92%) patients required ICU admission. The median NLR was 6.84 (IQR 3.89–11.52). Initial NLR performed poorly with an AUROC of 0.46 (95% confidence interval (CI): 0.40–0.52) for prediction of mortality and AUROC of 0.53 (95% CI: 0.50–0.56) for prediction of ICU admission. The AUROCs of initial NLR for both mortality at hospital discharge and ICU admission were significantly lower than SI, lactate and RTS. Conclusion: Initial NLR was not predictive of outcomes in major trauma. NLR at other time-points may provide better predictive capacity for outcomes. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to report the procedural incidence and patient outcomes after the 2009 introduction of an institutional resuscitative thoracotomy (RT) programme. Emergency physicians, general surgeons and emergency nursing trauma team members were trained to perform RT on thoracic trauma patients with an unresponsive systolic blood pressure (SBP) <70 mmHg within 30 min of arrival, prior to cardiothoracic team back‐up. Methods: A retrospective cohort study was conducted on patients who underwent RT from 2009 to 2017. The primary outcome measures were the incidence of the procedure and patients' survival to hospital discharge. Variables associated with survival were assessed using univariable logistic regression analyses. Results: There were 12 399 major trauma patients, including 7657 with major thoracic trauma and 315 presenting with SBP <70 mmHg. There were 32 RTs performed (incidence of 0.4%; 95% confidence interval [CI] 0.3–0.6) among patients with major thoracic trauma and 10.2% (99% CI 7.3–13.4) among patients with major thoracic trauma and SBP <70 mmHg. There were eight (25%; 95% CI 13.2–42.1) survivors to hospital discharge and no late mortality (mean follow‐up 2.8 years). Survival was significantly associated with the procedure performed within 30 min of arrival (odds ratio 0.09; 95% CI 0.01–0.67) while mortality was associated with the procedure being performed in the setting of traumatic cardiac arrest (odds ratio 18.3; 95% CI 2.4–140.4). Conclusions: A formal training and credentialing programme was associated with a low incidence of the procedure, yet achieved a survival rate of 25%, which is comparable to other reported literature. [ABSTRACT FROM AUTHOR]

Objective: This prospective, observational, interventional study sought to determine if the introduction of resuscitative balloon occlusion of the aorta (REBOA) at an Australian adult major trauma centre would improve survival for major trauma patients. Methods: Patients aged 18–60 years, transported directly from scene with exsanguinating, sub‐diaphragmatic haemorrhage and hypovolaemic shock (systolic BP <70 mmHg or hypovolaemic cardiac arrest) were eligible for recruitment and followed up until hospital discharge (ACTRN12618000550202). Results: During the 14‐month study period (17 January 2015 to 12 March 2016) 3032 patients were admitted direct from scene with an overall mortality of 97 (3.71%). Of these patients 3019 had trauma centre vital signs recorded in the data set (99.57%) and 1523 were between the ages of 18–60, including 143 patients with a shock index of >1.0 (4.74%). There were 13 (0.43%) patients with a systolic BP <70 mmHg and/or cardiorespiratory arrest on arrival. The mortality in this group was six out of 13 (46.15%). Of these 13 patients, there were two (0.07% of the total cohort) where REBOA was attempted. There were no eligible patients for whom REBOA was achieved. None of the six patients who died would have benefited from REBOA deployment. Conclusions: Despite considerable training and resource allocation to ensure 24‐h availability, the introduction of REBOA failed to effectively demonstrate any impact on patient outcome. Despite retrospective literature supporting the introduction of REBOA, in this 14‐month prospective study there was no evidence of benefit. Further studies may define indications and subgroups of patients who may benefit. [ABSTRACT FROM AUTHOR]

Objectives A multidisciplinary approach that emphasised improved triage, early pelvic binder application, early administration of blood and blood products, adherence to algorithmic pathways, screening with focused sonography ( FAST), early computed tomography scanning with contrast angiography, angio-embolisation and early operative intervention by specialist pelvic surgeons was implemented in the last decade to improve outcomes after pelvic trauma. The manuscript evaluated the effect of this multi-faceted change over a 12-year period. Methods A retrospective cohort study was conducted comparing patients presenting with serious pelvic injury in 2002 to those presenting in 2013. The primary exposure and comparator variables were the year of presentation and the primary outcome variable was mortality at hospital discharge. Potential confounders were evaluated using multivariable logistic regression analysis. Results There were 1213 patients with a serious pelvic injury ( Abbreviated Injury Scale ≥3), increasing from 51 in 2002 to 156 in 2013. Demographics, injury severity and presenting clinical characteristics were similar between the two time periods. There was a statistically significant difference in mortality from 20% in 2002 to 7.7% in 2013 ( P = 0.02). The association between the primary exposure variable of being injured in 2013 and mortality remained statistically significant (adjusted odds ratio 0.10; 95% confidence interval: 0.02-0.60) when adjusted for potential clinically important confounders. Conclusions Multi-faceted interventions directed at the spectrum of trauma resuscitation from pre-hospital care to definitive surgical management were associated with significant reduction in mortality of patients with severe pelvic injury from 2002 to 2013. This demonstrates the effectiveness of an integrated, inclusive trauma system in achieving improved outcomes. [ABSTRACT FROM AUTHOR]

Objective: The longer-term impact of injury is increasingly recognized, but the early phases of recovery are less well understood. The best tools to measure early recovery of mobility and physical function following traumatic injury are unclear. The purpose of this study was to assess the clinical utility, validity, reliability, and responsiveness of 4 mobility and physical function measures in patients following traumatic injury. Methods: In this cohort, measurement-focused study (n = 100), the modified Iowa Level of Assistance Score, Acute Care Index of Function, Activity Measure for Post-Acute Care "6 Clicks" short forms, and Functional Independence Measure were completed during first and last physical therapy sessions. Clinical utility and floor and ceiling effects were documented. Known-groups validity (early vs late in admission and by discharge destination), predictive validity (using 6-month postinjury outcomes data), and responsiveness were established. Interrater reliability was assessed in 30 patients with stable mobility and function. Results: Participants had a median age of 52 years (interquartile range = 33–68 years), and 68% were male. The modified Iowa Level of Assistance Score, Acute Care Index of Function, and "6 Clicks" short forms were quick to administer (an extra median time of 30 seconds–1 minute), but the Functional Independence Measure took much longer (extra median time of 5 minutes). At the last physical therapy session, ceiling effects were present for all measures except the Functional Independence Measure (18%–33% of participants). All had strong known-groups validity (early vs late in admission and by discharge destination). All were responsive (effect sizes >1.0) and had excellent interrater reliability (intraclass correlation coefficients = 0.79–0.94). Conclusion: All 4 measures were reliable, valid, and responsive; however, their clinical utility varied, and ceiling effects were common at physical therapy discharge. Impact: This study is an important step toward evidence-based measurement in acute trauma physical therapy care. It provides critical information to guide assessment of mobility and physical function in acute trauma physical therapy, which may facilitate benchmarking across different hospitals and trauma centers and further progress the science and practice of physical therapy following traumatic injury. [ABSTRACT FROM AUTHOR]

Objective: Rib fractures are not only painful but are associated with morbidity and mortality, especially in older patients. The serratus anterior plane block (SAPB) is a plane block distant from major neurovascular bundles and may provide anaesthesia to a substantial area of the hemithorax. This pilot study was designed to assess if the SAPB can be safely and efficiently incorporated to the trauma reception workflow of an adult, level 1 trauma centre. Methods: A convenience sample of 20 adult patients with at least two or more unilateral rib fractures received a SAPB performed by an emergency physician in addition to their standard analgesic regime. Time to perform the procedure, the number of attempts and complications were recorded as feasibility measures. Secondary outcome was the safety of the block. Numerical pain scores at pre‐determined time points over 4 h, the diagnosis of hospital‐acquired pneumonia, hospital length of stay and mortality at hospital discharge were collected to provide pilot data on effectiveness. Results: The median time to perform the procedure was 5.5 (interquartile range 4.6–10) mins with a range of 2–10.5 min. Most (16; 80%) SAPBs were completed in a single attempt. There were no documented complications. Median pain scores reduced from 6.5 (6–8) and were maintained at 3 (2–5) at 4 h after the SAPB. Conclusions: The present study demonstrated the feasibility of ultrasound‐guided SAPB among patients with multiple rib fractures in the ED. No complications were observed. Further prospective evaluation of analgesic effects in a larger cohort is indicated. [ABSTRACT FROM AUTHOR]

The aim of this study was to explore older adults' experiences of and approaches to managing their long-term health and mobility after traumatic injury. A longitudinal qualitative study was undertaken with older adults following traumatic injury in Victoria, Australia. Fifteen participants (≥65 years) were interviewed at three years post-injury (n = 15), and re-interviewed at four (n = 14) and five years (n = 12) post-injury. Using a framework approach, a longitudinal thematic analysis was performed. Older age at the time of injury was identified by participants as a key factor influencing their recovery. Many participants reported actively attempting to regain their strength and fitness in the first five years following injury. However, their age, injury impacts, other health conditions, and weight gain made it difficult to achieve recovery goals. Many older adults reported a decline in their physical function over time. While these experiences and persistent disability constrained or changed the quality of social relationships, community participation, and independence, several participants described adapting to their functional limitations, and managing their secondary conditions over time. In our cohort, the intertwined combination of ageing, injury, and comorbid conditions negatively affected health and mobility, reinforcing the need for preventative strategies. Older adults recovering from traumatic injury may benefit from specialised care pathways that offer long-term and tailored therapies, with programs and services specific to their needs and goals. An integrated service approach by injury insurers, health care, primary care, disability, and aged care could more clearly identify and effectively address the individual needs and goals of older adults with complex conditions. Health and social services that work with people with injuries to develop personalised coping strategies can reduce anxiety related to uncertainty about the future, promote well-being, and support participation in valued activities. [ABSTRACT FROM AUTHOR]

Objective: In response to COVID‐19, we introduced and examined the effect of a raft of modifications to standard practice on adverse events and first‐attempt success (FAS) associated with ED intubation. Methods: An analysis of prospectively collected registry data of all ED intubations over a 3‐year period at an Australian Major Trauma Centre. During the first 6 months of the COVID‐19 pandemic in Australia, we introduced modifications to standard practice to reduce the risk to staff including: aerosolisation reduction, comprehensive personal protective equipment for all intubations, regular low fidelity simulation with 'sign‐off' for all medical and nursing staff, senior clinician laryngoscopist and the introduction of pre‐drawn medications. Results: There were 783 patients, 136 in the COVID‐19 era and 647 in the pre‐COVID‐19 comparator group. The rate of hypoxia was higher during the COVID‐19 era compared to pre‐COVID‐19 (18.4% vs 9.6%, P < 0.005). This occurred despite the FAS rate remaining very high (95.6% vs 93.8%, P = 0.42) and intubation being undertaken by more senior laryngoscopists (consultant 55.9% during COVID‐19 vs 22.6% pre‐COVID‐19, P < 0.001). Other adverse events were similar before and during COVID‐19 (hypotension 12.5% vs 7.9%, P = 0.082; bradycardia 1.5% vs 0.5%, P = 0.21). Video laryngoscopy was more likely to be used during COVID‐19 (95.6% vs 82.5%, P < 0.001) and induction of anaesthesia more often used ketamine (66.9% vs 42.3%, P < 0.001) and rocuronium (86.8% vs 52.1%, P < 0.001). Conclusions: This raft of modifications to ED intubation was associated with significant increase in hypoxia despite a very high FAS rate and more senior first laryngoscopist. [ABSTRACT FROM AUTHOR]

Objective: Procedural complication rates associated with tube thoracostomy for pleural decompression is estimated to be between 2 and 25%, with incorrect insertion site being a common problem. We hypothesised that the inferior-most hair follicle in the axillary region would provide an accurate biometric marker to identify the fourth to sixth intercostal space. Methods: A prospective cohort of patients requiring computed tomography scan of the chest was recruited from February 2015 to March 2016 at The Alfred Hospital. The inferior-most hair follicle on the patient's axillary region was tagged with a paperclip, and a radiologist reported this location with reference to the corresponding intercostal spaces. Results: Of the 254 enrolled patients, a total of 310 paperclip positions over intercostal spaces were analysed. There were 101 (32.5%) paperclips positioned in the fourth and fifth intercostal spaces with the remainder at the second or third intercostal spaces, and no paperclips placed at the sixth intercostal space or lower. Conclusions: This study demonstrated that the inferior-most hair follicle in the axilla corresponded to an area between the second and fifth intercostal spaces. Recognition of this surface anatomy has the potential to eliminate iatrogenic injuries to the diaphragm and sub-diaphragmatic organs, but should not be used as the sole marker due to potential risks from high placement of pleural drains. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of finger thoracostomy performed by intensive care flight paramedics after the introduction of a training programme in this procedure and complications of the procedure that were diagnosed after hospital arrival. Methods: This was a retrospective cohort study of adult and paediatric trauma patients undergoing finger thoracostomy performed by paramedics on a helicopter emergency medical service between June 2015 and May 2018. Hospital data were obtained through a manual search of the medical records at each of the three receiving major trauma services. Additional data were sourced from the Victorian State Trauma Registry. Results: The final analysis included 103 cases, of which 73.8% underwent bilateral procedures with a total of 179 finger thoracostomies performed. The mean age of patients was 42.8 (standard deviation 21.4) years and 73.8% were male. Motor vehicle collision was the most common mechanism of injury accounting for 54.4% of cases. The median Injury Severity Score was 41 (interquartile range 29–54). There were 30 patients who died pre‐hospital, with most (n = 25) having finger thoracostomy performed in the setting of a traumatic cardiac arrest. A supine chest X‐ray was performed prior to intercostal catheter insertion in 38 of 73 patients arriving at hospital; of these, none demonstrated a tension pneumothorax. There were three cases of potential complications related to the finger thoracostomy. Conclusion: Finger thoracostomy was frequently performed by intensive care flight paramedics. It was associated with a low rate of major complications and given the deficiencies of needle thoracostomy, should be the preferred approach for chest decompression. [ABSTRACT FROM AUTHOR]

Objective History, clinical examination and throat culture may be inadequate to rule in or out the presence of group A streptococci (GAS) infection in patients with sore throat in a remote location. We correlated the diagnostic accuracy for guiding antibiotic prescription of clinical decision and physiological scoring systems to a rapid diagnostic point of care (POC) test result in paediatric patients presenting with sore throat. Methods Prospective diagnostic accuracy study conducted between 30 June 2014 and 27 February 2015 in a remote Australian ED using a convenience sample. Among paediatric patients presenting with sore throat, the Centor criteria and clinical decision were documented. Simultaneously, patients without sore throat or respiratory tract infection were tested to determine the number of carriers. A throat swab on all patients was tested using a POC test (Alere TestPack +Plus Strep A with on board control), considered as reference standard to detect GAS infection. Results A total of 101 patients with sore throat were tested with 26 (25.7%) positive for GAS. One hundred and forty-seven patients without sore throat were tested with one positive POC test result (specificity 99%; 95% CI 96-100). Positive predictive value for clinician decision-making for a positive GAS swab (bacterial infection) was 29% (95% CI 17-43), negative predictive value 78% (95% CI 63-88). Area under ROC for the Centor score was 0.70 (95% CI 0.58-0.81). Conclusion Clinician judgement and Centor score are inadequate tools for clinical decision-making for children presenting with sore throat. Adjunctive POC testing provides sufficient accuracy to guide antibiotic prescription on first presentation. [ABSTRACT FROM AUTHOR]

Objective To determine the proportion of non-motorised road users involved in road traffic crashes that presents to hospital intoxicated. Methods We undertook a retrospective cohort study using data collected from the Alfred Trauma Registry. All patients presenting to an adult major trauma centre in Victoria, Australia from July 2009 to June 2014 who were involved in a road traffic crash as a non-motorised road user - pedestrians, pedal-cyclists, non-motorised scooter users, horse riders - were included. Patients who had a blood alcohol measurement were included, and intoxication was defined as a blood alcohol concentration ≥0.05 g/100 mL. Results There were 1323 patients included for analysis with data on presenting blood alcohol concentration. Alcohol was detected in 248 (18.7%; 95% CI: 16.7-20.9) patients, whereas 211 (15.9%; 95% CI: 14.1-18.0) were intoxicated. Among all included pedestrians, 161 (24.7%) were intoxicated; among all included pedal-cyclists, 47 (7.3%) were intoxicated. Intoxicated patients were significantly younger, and a higher proportion were males and more likely to present after hours and on public holidays ( P < 0.01). Survival to hospital discharge and inpatient rehabilitation requirements were similar among intoxicated and non-intoxicated patients. Conclusions Intoxication was common among non-motorised road users, and the proportion of intoxicated patients in this subgroup appears unchanged over time despite public awareness programmes. The true burden of intoxication in non-motorised road users remains unknown because of a lack of routine testing. Legislation directed at testing for intoxication of non-motorised users and introduction of penalties should be considered to improve safety of all road users. [ABSTRACT FROM AUTHOR]