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Globally, very few settings have undertaken prehospital randomized controlled trials. Given this lack of experience, there is a risk that such trials in these settings may result in protocol deviations, increased prehospital intervals, and increased cognitive load, leading to error. Ultimately, this may affect patient safety and mortality. The aim of this study was to assess the effect of trial-related procedures on simulated scene interval, self-reported cognitive load, medical errors, and time to action. This was a prospective simulation study. Using a cross-over design, ten teams of prehospital clinicians were allocated to three separate simulation arms in a random order. Simulations were: (1) Eligibility assessment and administration of freeze-dried plasma (FDP) and a hemoglobin-based oxygen carrier (HBOC), (2) Eligibility assessment and administration of HBOC, (3) Eligibility assessment and standard care. All simulations also required clinical management of hemorrhagic shock. Simulated scene interval, error rates, cognitive load (measured by NASA Task Load Index), and competency in clinical care (assessed using the Simulation Assessment Tool Limiting Assessment Bias (SATLAB)) were measured. Mean differences between simulations with and without trial-related procedures were sought using one-way ANOVA or Kruskal-Wallis test. A p-value of <0.05 within the 95% confidence interval was considered significant. Thirty simulations were undertaken, representing our powered sample size. The mean scene intervals were 00:16:56 for Simulation 1 (FDP and HBOC), 00:17:22 for Simulation 2 (HBOC only), and 00:14:24 for Simulation 3 (standard care). Scene interval did not differ between the groups (p = 0.27). There were also no significant differences in error rates (p = 0.28) or cognitive load (p = 0.67) between the simulation groups. There was no correlation between cognitive load and error rates (r = 0.15, p = 0.42). Competency was achieved in all the assessment criteria for all simulation groups. In a simulated environment, eligibility screening, performance of trial-related procedures, and clinical management of patients with hemorrhagic shock can be completed competently by prehospital advanced life support clinicians without delaying transport or emergency care. Future prehospital clinical trials may use a similar approach to help ensure graded and cautious implementation of clinical trial procedures into prehospital emergency care systems. [ABSTRACT FROM AUTHOR]

Background: Injuries account for 8% or 4.4 million deaths annually worldwide, with 90% of injury deaths occurring in low‐ and middle‐income countries. Inter‐personal violence and road traffic injuries account for most injury deaths in South Africa, with rates among the highest globally. Understanding the location, timing, and factors of trauma deaths can identify opportunities to strengthen care. Methods: This is a retrospective cross‐sectional secondary analysis of trauma deaths from 2021 to 2022 in the Western Cape of South Africa. Healthcare system trauma deaths were identified from a multicenter study paired with a dataset for on‐scene (i.e., prior to ambulance or hospital) trauma deaths in the same jurisdictions. We describe locations, timing, injury factors, and cause of death. We assess associations between those factors. Results: There were 2418 deaths, predominantly young men, with most (2274, 94.0%) occurring on‐scene. The most frequent mechanism of injury for all deaths was firearms (32.6%), followed by road traffic collisions (17.8%). On‐scene deaths (33.2%) were significantly more likely to be injured by firearms compared to healthcare system deaths (23.6%) (p‐value <0.01). Most healthcare system deaths within 4–24 h of injury occurred in a hospital emergency center. Among healthcare system decedents, half died in the emergency unit. Conclusions: We identified a large burden of deaths from interpersonal violence and road traffic collisions, mostly on‐scene. In addition to primary prevention, shortening delays to care can improve mortality outcomes especially for deaths occurring within 4–24 h in emergency centers. [ABSTRACT FROM AUTHOR]

Introduction: Management of head trauma in austere military environments is challenging as current head injury scoring systems have limited triage utility in the absence of advanced imaging. Additionally, unlike the recent past, future conflicts will be characterized by limited opportunities for aeromedical evacuation. We hypothesize that safe hospital discharge within 48 h may be an effective surrogate endpoint to identify patients appropriate for averted or delayed evacuation in military settings. To analyze this, we assess mild head-injured patients for associations between clinical factors and serious head injury patterns or hospital discharge within 48 h., Materials and Methods: This is a secondary analysis of case data collected in a DoD-funded study, "EpiC," a prospective, multicenter cohort study of major trauma in the Western Cape, South Africa, with median time to definitive care of 12.5 h. Patients aged 18-50 years who presented from March 2021 to October 2023 with mild head injury, defined as lowest Glasgow Coma Scale (GCS) ≥14 in the first 24 h, were eligible. Exclusions include any nonminor injury outside the head (Abbreviated Injury Scale score >1). Serious head injury was defined as nonnasal bone facial fractures, skull fractures, or intracranial injury. Clinical characteristics were evaluated for association with serious head injury or hospital discharge before 48 h, calculated as odds ratios (ORs) with 95% confidence intervals., Results: We identified 2031 patients among whom: the mechanism of injury was blunt in 60%, penetrating in 30%, and both in 11%. A total of 87% of patients were discharged within 48 h. Among patients with blunt head injury, factors most strongly associated with ≤48-h discharge include GCS of 15 (89.3% of patients, OR 5.73, 95% CI 3.84-8.54) and negative or no ordered head imaging (89.3% of patients, OR 13.96, 95% CI 9.58-20.33). Combinations of factors including GCS of 14 and SBP >160 (1.6% of patients, OR 0.14, 95% CI 0.06-0.35) or SBP < 100 (2.2% of patients, OR 0.35, 95% CI 0.15-0.83) were less likely to be discharged by 48 h., Conclusions: In a military-relevant, austere, prolonged-care, civilian trauma setting, we identified factors associated with discharge after 48 h or an abnormal computed tomography head. We believe that further evaluation of individual and combinations of clinical factors may prove beneficial in imaging and transport decision-making in remote military settings., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2025. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Injury-related deaths claim millions of lives annually, with severe hemorrhage a leading cause. This study assesses tranexamic acid (TXA) administered within 3 h post-injury on mortality in trauma patients., Study Design and Methods: We conducted secondary database analysis of EpiC, a multicenter, prospective cohort of trauma patients in South Africa. We compared mortality between severely injured patients at risk for traumatic hemorrhage receiving TXA within 3 h post-injury versus untreated patients. Inverse probability of treatment weighting adjusted for confounders, and multivariate logistic regression assessed 24-h mortality, with extended secondary outcome analyses., Results: Of 3607 analyzed patients, 502 received TXA within 3 h. TXA reduced 24-h mortality by 38% (marginal odds ratio [mOR], 0.62; 95% confidence interval [CI], 0.49-0.78) versus untreated patients. Similar reductions were observed for longer-term mortality. Subgroup analyses revealed reduced mortality when TXA was given within 2 h post-injury (mOR, 0.57; 95% CI, 0.45-0.73), doses of 1 g of TXA within 3 h (mOR, 0.73; 95% CI, 0.56-0.94), and those with the highest risk of hemorrhage (mOR, 0.40; 95% CI, 0.30-0.53). The 24-h mortality reduction was significant for patients with penetrating injury (mOR, 0.58; 95% CI, 0.43-0.78) but not for blunt injury patients. Sensitivity analyses confirmed the robustness of these findings, with TXA consistently reducing mortality odds by 28%-39% across subgroups., Discussion: Early TXA administration significantly reduced mortality in trauma patients, especially with penetrating injuries and those with the highest risk of hemorrhage. One-gram dosing was as effective as higher doses, and mortality reduction was notable when TXA was given within 2 h post-injury. These findings support TXA use in resource-limited trauma protocols., (© 2025 The Author(s). Transfusion published by Wiley Periodicals LLC on behalf of AABB.)

Background Trauma is a leading cause of death and disability in low-resource settings, yet trauma severity scores are seldom validated in these contexts. There is a pressing need to better characterize and compare trauma scoring tools, especially within research frameworks. This study aimed to evaluate the performance of various trauma scoring tools in predicting in-hospital mortality among trauma patients in South Africa. Methods This study conducted a secondary analysis of existing data from the multicenter Epidemiology and Outcomes of Prolonged Trauma Care (EpiC) study, which included 13,548 adult trauma patients aged 18 years and older, collected between August 2021 and March 2024. The predictive ability of the scoring tools was assessed by calculating the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC). Results The mortality rate was 2.5% (n = 298). The Kampala Trauma Score (KTS) demonstrated the highest predictive ability for seven-day in-hospital mortality, with an AUROC of 0.95 and an AUPRC of 0.53. Similarly, the Trauma and Injury Severity Score (TRISS) and the New Injury Severity Score (NISS) also exhibited strong predictive capabilities, with AUROC values of 0.96 and AUPRC values of 0.62 for TRISS and an AUROC of 0.96 and AUPRC of 0.53 for NISS. In contrast, the Revised Trauma Score and Mechanism, Glasgow Coma Scale, Age, and Arterial Pressure (MGAP) showed lower predictive performance, with AUROC values of 0.87 (AUPRC = 0.51) and 0.86 (AUPRC = 0.47), respectively. Conclusions The KTS exhibited optimal performance characteristics for retrospectively predicting mortality in our cohort, outperforming other scoring tools. Notably, it is also the simplest scoring tool, featuring the fewest variables compared to other trauma severity assessments. These findings highlight the necessity for external validation of trauma scoring tools in resource-limited populations to ensure their applicability and effectiveness in trauma research across diverse healthcare settings., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Stellenbosch University Health Research Ethics Committee issued approval N20/03/036. The Stellenbosch University Health Research Ethics Committee was the primary IRB that provided approval for the EpiC study (N20/03/036), with a reliance agreement provided by the Colorado Multiple Institutional Review Board (COMIRB) and a concurrence memo from the US Department of Defense. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: This work was funded by United States Department of Defense (US DOD) research grant awards (W81XWH-20-2-0042/BA190049 and W81XWH-22-1-0883/RC210170). The views expressed in this paper are those of the authors and do not represent the official position or policy of the US DOD. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Collora et al.)