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Objective: To describe the frequency of hospitalisation and in‐hospital death following moderate to severe traumatic brain injury (TBI) in Australia, both overall and by patient demographic characteristics and the nature and severity of the injury. Design, setting: Cross‐sectional study; analysis of Australia New Zealand Trauma Registry data. Participants: People with moderate to severe TBI (Abbreviated Injury Score [head] greater than 2) who were admitted to or died in one of the twenty‐three major Australian trauma services that contributed data to the ATR throughout the study period, 1 July 2015 – 30 June 2020. Major outcome measures: Primary outcome: number of hospitalisations with moderate to severe TBI; secondary outcome: number of deaths in hospital following moderate to severe TBI. Results: During 2015–20, 16 350 people were hospitalised with moderate to severe TBI (mean, 3270 per year), of whom 2437 died in hospital (14.9%; mean, 487 per year). The mean age at admission was 50.5 years (standard deviation [SD], 26.1 years), and 11 644 patients were male (71.2%); the mean age of people who died in hospital was 60.4 years (SD, 25.2 years), and 1686 deaths were of male patients (69.2%). The overall number of hospitalisations did not change during 2015–20 (per year: incidence rate ratio [IRR], 1.00; 95% confidence interval [CI], 0.99–1.02) and death (IRR, 1.00; 95% CI, 0.97–1.03). Conclusion: Injury prevention and trauma care interventions for people with moderate to severe TBI in Australia reduced neither the incidence of the condition nor the associated in‐hospital mortality during 2015–20. More effective care strategies are required to reduce the burden of TBI, particularly among younger men. [ABSTRACT FROM AUTHOR]

Introduction: Traumatic haemorrhagic shock can be difficult to diagnose. Models for predicting critical bleeding and massive transfusion have been developed to aid clinicians. The aim of this review is to outline the various available models and report on their performance and validation. Methods: A review of the English and non-English literature in Medline, PubMed and Google Scholar was conducted from 1990 to September 2015. We combined several terms for i) haemorrhage AND ii) prediction, in the setting of iii) trauma. We included models that had at least two data points. We extracted information about the models, their developments, performance and validation. Results: There were 36 different models identified that diagnose critical bleeding, which included a total of 36 unique variables. All models were developed retrospectively. The models performed with variable predictive abilities-the most superior with an area under the receiver operating characteristics curve of 0.985, but included detailed findings on imaging and was based on a small cohort. The most commonly included variable was systolic blood pressure, featuring in all but five models. Pattern or mechanism of injury were used by 16 models. Pathology results were used by 15 models, of which nine included base deficit and eight models included haemoglobin. Imaging was utilised in eight models. Thirteen models were known to be validated, with only one being prospectively validated. Conclusions: Several models for predicting critical bleeding exist, however none were deemed accurate enough to dictate treatment. Potential areas of improvement identified include measures of variability in vital signs and point of care imaging and pathology testing. [ABSTRACT FROM AUTHOR]

Objective: The objectives of the present study were to report the proportion of older teenagers, including the subgroup operating a motor vehicle, presenting to an adult major trauma centre after injury with a positive blood alcohol concentration (BAC) over a 12‐year period. Methods: This was a registry‐based cohort study, including all patients aged 16–19 years presenting to an adult major trauma centre in Victoria, Australia from January 2008 to December 2019 and included in the trauma registry. A Poisson regression model was used to test for change in incidence of positive BAC associated trauma and summarised using incidence rate ratios (IRRs) and 95% confidence intervals (CIs). Results: There were 1658 patients included for analysis and alcohol was detected in 368 (22.2%; 95% CI 20.2–24.3). Most alcohol positive presentations were on weekend days (n = 207; 56.3%) and most were males (n = 307). Over the 12‐year period, there was a reduction in the incidence of older teenagers presenting with a positive BAC (IRR 0.95; 95% CI 0.93–0.98; P = 0.001). Among patients presenting after trauma in the setting of operating a motor vehicle (n = 545), alcohol was detected in 80 (14.7%) with no significant change in incidence of positive BAC (IRR 0.95; 95% CI 0.89–1.02; P = 0.17). Conclusions: A substantial proportion of older teenagers included in the registry had alcohol exposure prior to trauma. Despite a modest down‐trending incidence, the need for continuing preventive measures is emphasised. In particular, preventive efforts should be targeted at male, older teenagers undertaking drinking activities on weekend days and driving motor vehicles. [ABSTRACT FROM AUTHOR]

Background: After trauma, clearance of the cervical spine refers to the exclusion of underlying serious injuries. Accurate assessment of computed tomography (CT) is commonly required prior to clearance of the cervical spine. Delays to clearance can lead to prolonged immobilization with associated patient discomfort and adverse effects. This systematic review aimed to determine performance of non‐radiologists to evaluate cervical spine CT. Methods: MEDLINE, EMBASE, Cochrane library with sources of grey literature and reference lists of selected articles were appraised from inception to April 2021. We included manuscripts that reported discordance in CT cervical spine interpretation between non‐radiologists and radiologists. The Newcastle–Ottawa scale (NOS) was used to assess quality of included studies and statistical heterogeneity was assessed using the I2 statistic. Results: There were 43 studies identified for eligibility and 4 manuscripts included in the final analysis. There were two studies that reported on the performance of radiology residents, one study on the performance of surgical residents and one on emergency physicians. The pooled discordance was 0.25 (95%CI 0.21–0.28) but was lower for radiology residents (range 0.007–0.05). There was significant statistical heterogeneity (I2 = 99.6%, P < 0.001) among studies. Conclusion: There is a paucity of evidence documenting the ability of non‐radiologists in accurately interpreting CT of the cervical spine. A number of discordant findings suggest that studies with larger sample sizes are indicated to accurately ascertain the ability of non‐radiologists in this area. [ABSTRACT FROM AUTHOR]

Objective: Inconsistency in the structure and function of team-based major trauma reception and resuscitation is common. A standardised trauma team training programme was initiated to improve quality and consistency among trauma teams across a large, mature trauma system. The aim of this manuscript is to outline the programme and report on the initial perception of participants. Methods: The Alfred Trauma Team Reception and Resuscitation Training (TTRRT) programme commenced in March 2019. Participants included critical care and surgical craft group members commonly involved in trauma teams. Training was sitespecific and included rural, urban and tertiary referral centres. The programme consisted of prescribed pre-learning, didactic lectures, skill stations and simulated team-based scenarios. Participant perceptions of the programme were collected before and after the programme for analysis. Results: The TTRRT was delivered to 252 participants and 120 responses were received. Significant improvement in participant-reported confidence was identified across all key topic areas. There was also a significant increase in both confidence and clinical exposure to trauma team leadership roles after participation in the programme (from 53 [44.2%] to 74 [61.7%; P = 0.007]). This finding was independent of clinician experience. Conclusions: A team-based trauma reception and resuscitation education programme, introduced in a large, mature trauma system led to positive participant-reported outcomes in clinical confidence and real-life team leadership participation. Wider implementation combined with longitudinal data collection will facilitate correlation with patient and staff-centred outcomes. [ABSTRACT FROM AUTHOR]

Haemorrhagic shock after trauma is a leading cause of death worldwide, particularly in young individuals. Despite advances in trauma systems and resuscitation strategies, mortality from haemorrhagic shock has not declined over the previous two decades. A proportion of shocked trauma patients may experience a deficiency of cortisol relative to the severity of their injury. The benefit of exogenous steroid administration in patients suffering haemorrhagic shock as a result of injury is unclear. A systematic review of four databases (Ovid Medline, Ovid Embase, Cochrane, Scopus) was undertaken. Inclusion and exclusion criteria were pre-determined and two reviewers independently screened the articles with disagreements arbitrated by a third reviewer. The primary outcome variable was 28-day mortality. Quality of studies were assessed using the Cochrane-risk-of-bias (RoB 2) tool. Of the 2919 studies yielded by the search strategy, 1274 duplicates were removed and 1645 screened on title and abstract. After the full text of 33 studies were assessed, two articles were included. Both studies were over 30 years old with small numbers of participants and with primary outcomes not including mortality. Of the data available, no statistically significant difference in mortality was detected. Hospital length of stay, reversal of shock or adverse events were not reported. Both studies were at risk of bias. There are no high quality or recent studies in the English literature investigating the use of steroids for haemorrhagic shocked trauma patients. [ABSTRACT FROM AUTHOR]

Background: Traumatic brain injury (TBI) is the largest contributor to death and disability in people who have experienced physical trauma. There are no national data on outcomes for people with moderate to severe TBI in Australia.Objectives: To determine the incidence and key determinants of outcomes for patients with moderate to severe TBI, both for Australia and for selected population subgroups, including Aboriginal and Torres Strait Islander Australians.Methods and Analysis: The Australian Traumatic Brain Injury National Data (ATBIND) project will analyse Australia New Zealand Trauma Registry (ATR) data and National Coronial Information Service (NCIS) deaths data. The ATR documents the demographic characteristics, injury event description and severity, processes of care, and outcomes for people with major injury, including TBI, assessed and managed at the 27 major trauma services in Australia. We will include data for people with moderate to severe TBI (Abbreviated Injury Scale [AIS] (head) score higher than 2) who had Injury Severity Scores [ISS] higher than 12 or who died in hospital. People will also be included if they died before reaching a major trauma service and the coronial report details were consistent with moderate to severe TBI. The primary research outcome will be survival to discharge. Secondary outcomes will be hospital discharge destination, hospital length of stay, ventilator-free days, and health service cost.Ethics Approval: The Alfred Ethics Committee approved ATR data extraction (project reference number 670/21). Further ethics approval has been sought from the NCIS and multiple Aboriginal health research ethics committees. The ATBIND project will conform with Indigenous data sovereignty principles.Dissemination Of Results: Our findings will be disseminated by project partners with the aim of informing improvements in equitable system-level care for all people in Australia with moderate to severe TBI.Study Registration: Not applicable. [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: This retrospective observational study aimed to compare the impact of the Prevent Alcohol and Risk‐Related Trauma Youth (P.A.R.T.Y.) Program when delivered as In‐hospital or Outreach models to rural and regional students. Methods: The study population were consented participants from regional areas between 2013 and 2017 who completed pre‐programme, immediately post‐programme and 3–5 months post‐programme surveys. Responses from the metropolitan In‐hospital programme participants and regional Outreach programme participants were analysed within groups across the three time points. The primary outcome variable was a change in self‐reported perception of driving after drinking alcohol. Secondary outcome variables were designating a safe driver after drinking, perception of risk of injury if not wearing a seatbelt, risks of injury if undertaking physical risk‐taking activities and likelihood of the programme changing perceptions. Results: There were 1314 participants invited to participate and 547 (42%) sets of complete surveys were received, of whom 296 (54%) were Outreach participants. Pre‐programme, a significantly lower proportion of Outreach participants reported 'definitely not' to driving after drinking (84% vs 91%), and perceived a 'definite' likelihood of sustaining injury if not wearing a seatbelt (57% vs 66%). Outreach participants displayed improvements in likelihood to drive after drinking alcohol immediately post‐programme and on follow up (P = 0.028). Responses to all other secondary outcome measures demonstrated some improvement. Conclusions: Although demographically similar, baseline perceptions toward alcohol, risk‐taking and injury differed between groups. Improvements in perception were demonstrated across both models. These findings support P.A.R.T.Y. as an injury prevention initiative for regional youth. [ABSTRACT FROM AUTHOR]

Patients treated with splenic artery embolization (SAE) >48 hours after a blunt injury for a delayed splenic rupture (DSR) were assessed for the need for a subsequent splenectomy. Thirty-four patients underwent SAE for DSR over 10 years at our level 1 trauma center, performed at a median of 4.5 days after the injury (interquartile range = 5.5), and the patients were followed up for a median of 11 months (interquartile range = 31). There were 3 occurrences of rebleeds, and 2 patients required splenectomy (5.9%). This study showed that treatment with SAE after DSR results in splenic salvage in 94.1% of patients. [ABSTRACT FROM AUTHOR]

Introduction: Delayed Intracranial Hemorrhage (D-ICH), defined as finding of ICH on subsequent imaging after a normal computed tomography of the brain (CTB), is a feared complication after head trauma. The aim of this study was to determine the incidence and severity of D-ICH. Methods: This retrospective cohort study included patients that presented directly from the scene of injury to an adult major trauma center from Jan 2013 to Dec 2018. Results: There were 6536 patients who had an initial normal CTB and 23 (0.3%; 95%CI: 0.20–0.47) had D-ICH. There were 653 patients who had a repeat CTB (incidence of D-ICH 3.5%; 95%CI: 2.2–5.2). There was no significant association of D-ICH with age>65 years (OR 1.33; 95%CI: 0.54–3.29), presenting GCS <15 (OR 1.21; 95% CI: 0.52–2.80) and anti-platelet medications (OR 0.68; 95%CI: 0.26–1.74). Exposure to anti-coagulant medications was associated with lower odds of D-ICH (OR 0.23; 95%CI: 0.05–0.99). All cases of D-ICH were diffuse injury type II lesions on the Marshall classification. There were no cases that underwent neurosurgical intervention and no deaths were attributed to D-ICH. Conclusions: These results question observation of patients with head injury in hospital after a normal CTB for the sole purpose of excluding D-ICH. [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: 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]

Objectives To assess the effect of a mobile phone application for prehospital notification on resuscitation and patient outcomes. Design Longitudinal prospective cohort study with preintervention and postintervention cohorts. Setting Major trauma centre in India. Participants Injured patients being transported by ambulance and allocated to red (highest) and yellow (medium) triage categories. Intervention A prehospital notification application for use by ambulance and emergency clinicians to notify emergency departments (EDs) of an impending arrival of a patient requiring advanced lifesaving care. Main outcome measures The primary outcome was the proportion of eligible patients arriving at the hospital for which prehospital notification occurred. Secondary outcomes were the availability of a trauma cubicle, presence of a trauma team on patient arrival, time to first chest X-ray, and ED and in-hospital mortality. Results Data from January 2017 to January 2018 were collected with 208 patients in the preintervention and 263 patients in the postintervention period. The proportion of patients arriving after prehospital notification improved from 0% to 11% (p<0.001). After the intervention, more patients were managed with a trauma call-out (relative risk (RR) 1.30; 95% CI: 1.10 to 1.52); a trauma bay was ready for more patients (RR 1.47; 95% CI: 1.05 to 2.05) and a trauma team leader present for more patients (RR 1.50; 95% CI: 1.07 to 2.10). There was no difference in time to the initial chest X-ray (p=0.45). There was no association with mortality at hospital discharge (RR 0.94; 95% CI: 0.72 to 1.23), but the intervention was associated with significantly less risk of patients dying in the ED (RR 0.11; 95% CI: 0.03 to 0.39). Conclusions The prehospital notification application for severely injured patients had limited uptake but implementation was associated with improved trauma reception and reduction in early deaths. Quality improvement efforts with ongoing data collection using the trauma registry are indicated to drive improvements in trauma outcomes in India. [ABSTRACT FROM AUTHOR]

Moderate to severe traumatic brain injury (TBI) contributes to a significant burden across Australia. However, the data required to inform targeted equitable system‐level improvements in emergency TBI care do not exist. The incidence and determinants of outcomes following moderate to severe TBI in Australia remain unknown. The variation in the impact of moderate to severe TBI, according to patient demographics and injury mechanism, is poorly defined. The Australian Traumatic Brain Injury National Data Project will lead to a clear understanding, across Australia and pre‐specified subgroups (including Aboriginal and Torres Strait Islander peoples), of the incidence, determinants and impact of priority outcomes following moderate to severe TBI, including survival to discharge home. Furthermore, this project will establish a set of national clinical quality indicators for patients experiencing a moderate to severe TBI. The Australian Traumatic Brain Injury National Data Project will inform where to target emergency care system‐wide improvements. Without baseline data, efforts are wasted. [ABSTRACT FROM AUTHOR]

Background and Objectives: Haemorrhage‐associated calcium loss may lead to disruption of platelet function, intrinsic and extrinsic pathway‐mediated haemostasis and cardiac contractility. Among shocked major trauma patients, we aimed to investigate the association between admission hypocalcaemia and adverse outcomes. Materials and Methods: Data were extracted from the Alfred Trauma Registry and the Alfred Applications and Knowledge Management Department for all adult major trauma patients presenting directly from the scene with a shock index ≥1 from 1 July 2014 to 30 June 2018. Patients with pre‐hospital blood transfusion were excluded. Ionized hypocalcaemia was defined as <1·11 mmol/l, and acute traumatic coagulopathy was defined as initial INR >1·5. Multivariable logistic regression analysis was used to assess the association between admission hypocalcaemia and acute traumatic coagulopathy that was adjusted for Injury Severity Score, initial GCS, bicarbonate and lactate. Results: There were 226 patients included in final analysis with 113 (50%) patients recording ionized hypocalcaemia on presentation prior to any blood product transfusion. Ionized hypocalcaemia was associated with coagulopathy in patients with shock index ≥1 (adjusted OR 2·9; 95% CI: 1·01–8·3, P = 0·048). Admission ionized hypocalcaemia was also associated with blood transfusion requirement in the first 24 h post‐admission in 62·5% of hypocalcaemic patients as compared to 37·5% of normocalcaemic patients (P < 0·001). Admission ionized hypocalcaemia was associated with death at hospital discharge (25·6% among hypocalcaemic patients compared to 15·0% of normocalcaemic patients (P = 0·047)). Conclusion: Hypocalcaemia was a common finding in shocked trauma patients and was independently associated with acute traumatic coagulopathy. The early, protocolized administration of calcium to trauma patients in haemorrhagic shock warrants further assessment in randomized controlled trials. [ABSTRACT FROM AUTHOR]

Introduction: Traumatic aortic injury is an uncommon condition. Timely diagnosis may enable early haemostatic resuscitation, essential to prevent worsening of the injury prior to definitive management. The aim of this study was to assess the utility of initial vital signs and presenting clinical characteristics to confirm or rule out aortic injury. Methods: A retrospective review of patients from The Alfred Trauma Registry was conducted. Patients presenting between January 2006 and July 2014 and diagnosed with aortic injury were identified. Demographics and presenting clinical characteristics were extracted. Sensitivity of individual clinical variables for the detection of aortic injury was calculated. Results: There were 77 patients identified with aortic injury, with an in-hospital mortality rate of 19.5% (95% CI: 10.6–28.3%). Of these, 68 (88.3%) patients presented after high-energy blunt mechanisms. Clinical signs and early chest X-ray findings were poorly sensitive to detect aortic injury. Patients who presented with hypotension had a greater severity of aortic injury, more commonly had associated abnormal investigation findings and were more likely to require blood products and inotropic agents (p < 0.05). However, sensitivity of initial hypotension to rule out aortic injury was 39.0% (95% CI: 28.1–49.9%). Conclusions: The diagnosis of aortic injury was uncommon in hospital. Most injuries were secondary to high-velocity road traffic crashes or high falls. Clinical signs were not adequately sensitive to be used for the exclusion of aortic injury. We recommend a high degree of clinical suspicion and liberal imaging among cases where aortic injury is possible. [ABSTRACT FROM AUTHOR]

Background: The completeness of a trauma registry's data is essential for its valid use. This study aimed to evaluate the extent of missing data in a new multicentre trauma registry in India and to assess the association between data completeness and potential predictors of missing data, particularly mortality. Methods: The proportion of missing data for variables among all adults was determined from data collected from 19 April 2016 to 30 April 2017. In-hospital physiological data were defined as missing if any of initial systolic blood pressure, heart rate, respiratory rate, or Glasgow Coma Scale were missing. Univariable logistic regression and multivariable logistic regression, using manual stepwise selection, were used to investigate the association between mortality (and other potential predictors) and missing physiological data. Results: Data on the 4466 trauma patients in the registry were analysed. Out of 59 variables, most (n = 51; 86.4%) were missing less than 20% of observations. There were 808 (18.1%) patients missing at least one of the first in-hospital physiological observations. Hospital death was associated with missing in-hospital physiological data (adjusted OR 1.4; 95% CI 1.02–2.01; p = 0.04). Other significant associations with missing data were: patient arrival time out of hours, hospital of care, 'other' place of injury, and specific injury mechanisms. Assault/homicide injury intent and occurrence of chest X-ray were associated with not missing any of first in-hospital physiological variables. Conclusion: Most variables were well collected. Hospital death, a proxy for more severe injury, was associated with missing first in-hospital physiological observations. This remains an important limitation for trauma registries. [ABSTRACT FROM AUTHOR]

Background: In patients who are awake with normal mental and neurologic status, it has been suggested that the thoracolumbar (TL) spine may be cleared by clinical examination, irrespective of the mechanism of injury. The aim of this pilot study was to test the feasibility and accuracy of a clinical decision tool focused towards clearance of the TL spine during assessment of patients in the emergency department after trauma. Methods: A prospective interventional study was conducted at two major trauma centres. The intervention of a clinical decision tool for assessment of the TL spine was applied prospectively to all patients with subsequent imaging results acting as the comparator. The primary outcome variable was fracture of the thoracic or lumbar vertebra(e). The clinical decision tool was assessed using sensitivity and specificity for detecting a TL fracture and reported with 95% confidence intervals (CIs). Results: There were 188 cases included for analysis that all underwent imaging of the thoracic and/or lumbar vertebrae. There were 34 (18%) patients diagnosed with fractures of the thoracic and/or lumbar vertebrae. In this pilot study, sensitivity of the clinical decision tool was 100% (95% CI 87.3–100%) and specificity was 37.0% (95% CI 29.5–45.2%) for the detection of a thoracic or lumbar vertebral fracture. Conclusions: Feasibility of clinical clearance of the TL spine in two major trauma centres was demonstrated in a clinical study setting. Evaluation of this clinical decision tool in patients following blunt trauma, particularly in reducing imaging rates, is indicated using a larger prospective study. [ABSTRACT FROM AUTHOR]

Objective: To investigate trends in the incidence and causes of traumatic spinal cord injury (TSCI) in Victoria over a 10-year period.Design, Setting, Participants: Retrospective cohort study: analysis of Victorian State Trauma Registry (VSTR) data for people who sustained TSCIs during 2007-2016.Main Outcomes and Measures: Temporal trends in population-based incidence rates of TSCI (injury to the spinal cord with an Abbreviated Injury Scale [AIS] score of 4 or more).Results: There were 706 cases of TSCI, most the result of transport events (269 cases, 38%) or low falls (197 cases, 28%). The overall crude incidence of TSCI was 1.26 cases per 100 000 population (95% CI, 1.17-1.36 per 100 000 population), and did not change over the study period (incidence rate ratio [IRR], 1.01; 95% CI, 0.99-1.04). However, the incidence of TSCI resulting from low falls increased by 9% per year (95% CI, 4-15%). The proportion of TSCI cases classified as incomplete tetraplegia increased from 41% in 2007 to 55% in 2016 (P < 0.001). Overall in-hospital mortality was 15% (104 deaths), and was highest among people aged 65 years or more (31%, 70 deaths).Conclusions: Given the devastating consequences of TSCI, improved primary prevention strategies are needed, particularly as the incidence of TSCI did not decline over the study period. The epidemiologic profile of TSCI has shifted, with an increasing number of TSCI events in older adults. This change has implications for prevention, acute and post-discharge care, and support. [ABSTRACT FROM AUTHOR]

Introduction: Injuries are a major cause of disability and lost productivity. The case for a national trauma registry has been recognized by the Australian Commission on Safety and Quality in Health Care and at a policy level. Background: The need was flagged in 1993 by the Royal Australasian College of Surgeons and the Australasian Trauma Society. In 2003, the Centre of National Research and Disability funded the Australian and New Zealand National Trauma Registry Consortium, which produced three consecutive annual reports. The bi‐national trauma minimum dataset was also developed during this time. Operations were suspended thereafter. Method: In response to sustained lobbying the Australian Trauma Quality Improvement Program including the Australian Trauma Registry (ATR) commenced in 2012, with data collection from 26 major trauma centres. An inaugural report was released in late 2014. Result The Federal Government provided funding in December 2016 enabling the work of the ATR to continue. Data are currently being collected for cases that meet inclusion criteria with dates of injury in the 2017–2018 financial year. Since implementation, the number of submitted records has been increased from fewer than 7000 per year to over 8000 as completeness has improved. Four reports have been released and are available to stakeholders. Conclusion: The commitment shown by the College, other organizations and individuals to the vision of a national trauma registry has been consistent since 1993. The ATR is now well placed to improve the care of injured people. [ABSTRACT FROM AUTHOR]

Background: Blunt thoracic aortic injury (BTAI) is an uncommon diagnosis, usually developing as a consequence of high-impact acceleration-deceleration mechanisms. Timely diagnosis may enable early resuscitation and reduction of shear forces, essential to prevent worsening of the injury prior to definitive management. Death is commonly due to haemorrhagic shock, but clinical features may be absent until sudden and massive haemorrhage.Objectives: The aim of this systematic review was to determine the proportion of patients with BTAI who present with unstable vital signs.Methods: Manuscripts were identified through a search of MEDLINE, EMBASE and the Cochrane Library databases, focusing on subject headings and keywords related to the aorta and trauma. Mechanisms of injury, haemodynamic status and mortality from the included manuscripts were reviewed. Meta-analysis of presenting haemodynamic status among a select group of similar papers was conducted.Results: Nineteen studies were included, with five selected for meta-analysis. Most reported cases of BTAI (80.0%-100%) were caused by road traffic incidents, with mortality consistently higher among initially unstable patients. There was statistically significant heterogeneity among the included studies (P<0.01). The pooled proportion of patients with haemodynamic instability in the setting of BTAI was 48.8% (95% CI 8.3 to 89.4).Conclusions: Normal vital signs do not rule out aortic injury. A high degree of clinical suspicion and liberal use of imaging is necessary to prevent missed or delayed diagnoses. [ABSTRACT FROM AUTHOR]

Objective: To investigate temporal trends in the incidence, mortality, disability-adjusted life-years (DALYs), and costs of health loss caused by serious road traffic injury.Design, Setting and Participants: A retrospective review of data from the population-based Victorian State Trauma Registry and the National Coronial Information System on road traffic-related deaths (pre- and in-hospital) and major trauma (Injury Severity Score > 12) during 2007-2015.Main outcomes and measures: Temporal trends in the incidence of road traffic-related major trauma, mortality, DALYs, and costs of health loss, by road user type.Results: There were 8066 hospitalised road traffic major trauma cases and 2588 road traffic fatalities in Victoria over the 9-year study period. There was no change in the incidence of hospitalised major trauma for motor vehicle occupants (incidence rate ratio [IRR] per year, 1.00; 95% CI, 0.99-1.01; P = 0.70), motorcyclists (IRR, 0.99; 95% CI, 0.97-1.01; P = 0.45) or pedestrians (IRR, 1.00; 95% CI, 0.97-1.02; P = 0.73), but the incidence for pedal cyclists increased 8% per year (IRR, 1.08; 95% CI; 1.05-1.10; P < 0.001). While DALYs declined for motor vehicle occupants (by 13% between 2007 and 2015), motorcyclists (32%), and pedestrians (5%), there was a 56% increase in DALYs for pedal cyclists. The estimated costs of health loss associated with road traffic injuries exceeded $14 billion during 2007-2015, although the cost per patient declined for all road user groups.Conclusions: As serious injury rates have not declined, current road safety targets will be difficult to meet. Greater attention to preventing serious injury is needed, as is further investment in road safety, particularly for pedal cyclists. [ABSTRACT FROM AUTHOR]

Background and Objectives: CT of the brain (CTB) is one of the most common radiological investigations performed in the emergency department (ED). Emergency clinicians rely upon this imaging modality to aid diagnosis and guide management. However, their capacity to accurately interpret CTB is unclear. This systematic review aims to determine this capacity and identify the potential need for interventions directed towards improving the ability of emergency clinicians in this important area.Methods: A systematic review of the literature was conducted without date restrictions. We searched MEDLINE, EMBASE and Cochrane databases and studies reporting the primary outcome of concordance of CTB interpretation between a non-radiologist and a radiology specialist were identified. Studies were assessed for heterogeneity and a subgroup analysis of pooled data based on medical specialty was carried out to specifically identify the concordance of ED clinicians. The quality of evidence was assessed using the GRADE criteria.Results: There were 21 studies included in this review. Among the included studies, 12 reported on the concordance of emergency clinicians, 5 reported on radiology trainees and 4 on surgeons. Clinical and statistical heterogeneity between studies was high (I2=97.8%, p<0.01). The concordance in the emergency subgroup was the lowest among all subgroups with a range of 0.63-0.95 and a clinically significant error rate ranging from 0.02 to 0.24.Conclusions: Heterogeneity and the presence of bias limit our confidence in these findings. However, the variance in the interpretation of CTB between emergency clinicians and radiologists suggests that interventions towards improving accuracy may be useful. [ABSTRACT FROM AUTHOR]

Background: Cardiac injury is uncommon, but it is important to diagnose, in order to prevent subsequent complications. Extended focused assessment with sonography in trauma (eFAST) allows rapid evaluation of the pericardium and thorax. The objective of this study was to describe cardiac injuries presenting to a major trauma centre and the diagnostic performance of eFAST in detecting haemopericardium as well as broader cardiac injuries. Methods: Data of patients with severe injuries and diagnosed cardiac injuries (Injury Severity Score .12 and AIS 2008 codes for cardiac injuries) were extracted from The Alfred Trauma Registry over a four-year period from July 2010 to June 2014. The initial eFAST results were compared to those of the final diagnosis, which were determined after analysing imaging results and intraoperative findings. Results: Thirty patients who were identified with cardiac injuries met the inclusion criteria. Among these, 22 patients sustained injuries under the scope of eFAST, of which a positive eFAST scan in the pericardium was reported in 13 (59%) patients, while nine (41%) patients had a negative scan. This resulted in a sensitivity of 59% (95% CI: 36.7%-78.5%). The sensitivity of detecting any cardiac injuries was lower at 43.3% (95% CI: 26.0-62.3). Conclusions: The low sensitivities of eFAST for detecting cardiac injuries and haemopericardium demonstrate that a negative result cannot be used in isolation to exclude cardiac injuries. A high index of suspicion for cardiac injury remains essential. Adjunct diagnostic modalities are indicated for the diagnosis of cardiac injury following major trauma. [ABSTRACT FROM AUTHOR]

Background: During assessment after injury, the log roll examination, in particular palpation of the thoracolumbar spine, has low sensitivity for detecting spinal injury. The manoeuvre itself requires a pause during trauma resuscitation. The aim of this study was to assess the utility of the log roll examination in unconscious trauma patients for the diagnosis of soft tissue and thoracolumbar spine injuries.Methods: A retrospective cohort study was undertaken, reviewing the cases of unconscious (Glasgow Coma Scale (GCS) <9) and/or intubated major trauma (Injury Severity Scale (ISS) >12, abbreviated injury scale 2008) patients from the Alfred Trauma Registry, over a 2-year period from January 2011 to December 2012. Log roll examination findings, as documented in the medical record, were compared with CT reports. Out of the 624 screened records, 222 (35.6%) were excluded as the log roll or CT/MRI had not been performed.Results: There were a total of 2028 major trauma presentations to the Alfred Hospital Emergency and Trauma Centre during the study period. Excluded cases comprised 147 patients who did not have a documented log roll, and 75 patients who did not have a CT or MRI. Of the 402 cases that met inclusion criteria, 35.3% had a thoracolumbar fracture, and the sensitivity of log roll examination was found to be 27.5%, with a specificity of 91%. The negative likelihood ratio for abnormalities on log roll was low (0.8).Conclusions: Examination of the back in unconscious trauma patients could be limited to visual inspection only to allow identification of penetrating wounds and other soft tissue injuries (including of the posterior scalp) and removal of foreign bodies, in patients planned for CT scans. The low sensitivity and poor negative likelihood ratio suggest that a normal log roll examination does not accurately predict the absence of bony injury to the thoracolumbar spine. [ABSTRACT FROM AUTHOR]

AbstractIntroductionMethodsResultsDiscussionThe Glasgow Coma Scale (GCS) and pupil response to light are commonly used to assess brain injury severity and predict outcomes. The aim of this study was to investigate whether the GCS combined with pupil response (GCS-P), compared to the GCS alone, could be a better predictor of hospital mortality for patients with traumatic brain injury (TBI).A retrospective cohort study was undertaken at an adult level one trauma centre including patients with isolated TBI of Abbreviated Injury Scale above three. The GCS and pupil response were combined to an arithmetic score (GCS score (range 3–15) minus the number of nonreacting pupils (0, 1, or 2)), or by treating each factor as separate categorical variables. The association of in-hospital mortality with GCS-P as a categorical variable was evaluated using Nagelkerke’s R2 and compared using areas under the receiver operating characteristic (AUROC) curve.There were 392 patients included over the study period of 1 July 2014 and 30 September 2017, with an overall mortality rate of 15.2%. Mortality was highest at GCS-P of 1 (79%), with lowest mortality at a GCS-P 15 (1.6%). Nagelkerke’s R2 was 0.427 for GCS alone and 0.486 for GCS-P. The AUROC for GCS-P to predict mortality was 0.87 (95%CI: 0.82–0.72), higher than for GCS alone (0.85; 95%CI: 0.80–0.90; p < .001).GCS-P provided a better predictor of mortality compared to the GCS. As both the GCS and pupillary response are routinely recorded on all patients, combination of these pieces of information into a single score can further simplify assessment of patients with TBI, with some improvement in performance. [ABSTRACT FROM AUTHOR]

Abstract: The Australian health system is generally well prepared for mass casualty events. Fortunately, there have been very few terrorist attacks and these have involved low numbers of casualties compared with events overseas. Nevertheless, Australian health professionals need to be prepared to treat mass casualties with blast and ballistic trauma. The US military and its allies including Australia have had extensive experience with mass casualty management in the Middle East and Afghanistan wars for more than a decade. To define their experience, they developed the Tactical Combat Casualty Care Guidelines that have saved many lives. It is now prudent to incorporate this knowledge and experience into civilian practice in Australia. [ABSTRACT FROM AUTHOR]