Randomized clinical trial comparing the effect of computed tomography in the trauma room versus the radiology department on injury outcomes
Teun Peter SaltzherrF. C. BakkerLudo F.M. BeenenMarcel G. W. DijkgraafJohannes B. ReitsmaJ. Carel Goslings
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Abstract Background Computed tomography (CT) of injured patients in the radiology department requires potentially dangerous and time-consuming patient transports and transfers. It was hypothesized that CT in the trauma room would improve patient outcome and workflow. Methods A randomized trial compared the effect of locating a CT scanner in the trauma room versus the radiology department in two Dutch trauma hospitals. Injured patients aged at least 16 years were assigned randomly to one of these hospitals at the time of transport. The primary outcome measure was the number of non-institutionalized days within the first year after randomization. Subgroup analyses were performed in patients with multiple trauma or severe traumatic brain injury (TBI). Results Some 1124 patients were included, of whom 1045 were available for analysis. The median number of non-institutionalized days was 360 days in the intervention group versus 362 days for the control group (P = 0·068). The time from arrival to the first CT imaging was 13 min shorter in the intervention group (36 versus 49 min; P < 0·001). Patient transfers and transports were reduced by more than half in the intervention group. For both multiple trauma (265 patients) and TBI (121) subgroups, differences in mortality and out-of-hospital days favoured the intervention group, but were not statistically significant. Conclusion A CT scanner located in the trauma room reduces the time to acquire CT images and improves workflow, but does not lead to substantial improvements in clinical outcomes in a general trauma population. Observed beneficial effects on outcomes in patients with multiple trauma or severe TBI were not statistically significant. Registration number: ISRCTN55332315 (http://www.controlled-trials.com).Keywords:
Trauma Center
To examine the relationships between emergency department length of stay (EDLOS) with hospital length of stay (HLOS) and clinical outcome in hemodynamically stable trauma patients. Prospective data collected for 2 years from consecutive trauma patients admitted to the trauma resuscitation bay. Only stable blunt trauma patients with appropriate trauma triage criteria requiring trauma team activation were included in the study. EDLOS was determined short if patient spent less than 2 h in the emergency department (ER) and long for more than 2 h. A total of 248 patients were enrolled in the study. The mean total EDLOS was 125 min (range 78–180). Injury severity score (ISS) were significantly higher in the long EDLOS group (17 ± 13 versus 11 ± 9, p < 0.001). However, when leveled according to ISS, there were no differences in mean in diagnostic workup, admission rate to intensive care unit (ICU) or HLOS between the short and long EDLOS groups. EDLOS is not a significant parameter for HLOS in stable trauma patients.
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Abstract Background Prehospital triage protocols typically try to select patients with Injury Severity Score (ISS) above 15 for direct transportation to a Level-1 trauma center. However, ISS does not necessarily discriminate between patients who benefit from immediate care at Level-1 trauma centers. The aim of this study was to assess which patients benefit from direct transportation to Level-1 trauma centers. Methods We used the American National Trauma Data Bank (NTDB), a retrospective observational cohort. All adult patients (ISS > 3) between 2015 and 2016 were included. Patients who were self-presenting or had isolated limb injury were excluded. We used logistic regression to assess the association of direct transportation to Level-1 trauma centers with in-hospital mortality adjusted for clinically relevant confounders. We used this model to define benefit as predicted probability of mortality associated with transportation to a non-Level-1 trauma center minus predicted probability associated with transportation to a Level-1 trauma center. We used a threshold of 1% as absolute benefit. Potential interaction terms with transportation to Level-1 trauma centers were included in a penalized logistic regression model to study which patients benefit. Results We included 388,845 trauma patients from 232 Level-1 centers and 429 Level-2/3 centers. A small beneficial effect was found for direct transportation to Level-1 trauma centers (adjusted Odds Ratio: 0.96, 95% Confidence Interval: 0.92–0.99) which disappeared when comparing Level-1 and 2 versus Level-3 trauma centers. In the risk approach, predicted benefit ranged between 0 and 1%. When allowing for interactions, 7% of the patients ( n = 27,753) had more than 1% absolute benefit from direct transportation to Level-1 trauma centers. These patients had higher AIS Head and Thorax scores, lower GCS and lower SBP. A quarter of the patients with ISS > 15 were predicted to benefit from transportation to Level-1 centers ( n = 26,522, 22%). Conclusions Benefit of transportation to a Level-1 trauma centers is quite heterogeneous across patients and the difference between Level-1 and Level-2 trauma centers is small. In particular, patients with head injury and signs of shock may benefit from care in a Level-1 trauma center. Future prehospital triage models should incorporate more complete risk profiles.
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Controversy exists over association of blood transfusions with complications. The purpose was to assess effects of limited transfusions on complication rates and hospital course.Level 1 trauma center.Three hundred seventy-one consecutive patients with Injury Severity Score ≥16 underwent fixation of fractures of spine (n = 111), pelvis (n = 72), acetabulum (n = 57), and/or femur (n = 179). Those receiving >3 units of packed red blood cell were excluded.Fracture type, associated injuries, treatment details, ventilation time, complications, and hospital stay were prospectively recorded.Ninety-eight patients with 107 fractures received limited transfusion, and 119 patients with 123 fractures were not transfused. The groups did not differ in age, fracture types, time to fixation, or associated injuries. Lowest hematocrit was lower in the transfused group (22.8 vs. 30.0, P < 0.0001). Surgical duration (3:23 vs. 2:28) and estimated blood loss (462 vs. 211 mL) were higher in transfused patients (all P < 0.003). Pulmonary complications occurred in 12% of transfused and 4% of nontransfused, (P = 0.10). Mean days of mechanical ventilation (2.51 vs. 0.45), intensive care unit days (4.5 vs. 1.5) and total hospital stay (8.8 vs. 5.7) were higher in transfused patients (all P ≤ 0.006). After multivariate analysis, limited transfusion was associated with increased hospital and intensive care unit stays and mechanical ventilation time, but not with complications.Patients receiving ≤3 units of packed red blood cell had lower hematocrit and greater surgical burden, but no difference in complications versus the nontransfused group. Limited blood transfusions are likely safe, excepting a possible association with longer mechanical ventilation times and hospital stays.Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.
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There is a plethora of trauma scoring systems currently in place. A lot of these scoring systems, however, are complex and thus have a limited utility in the emergency department. The present study was conducted to evaluate the relatively easy to calculate quick Sequential Organ Failure Assessment (qSOFA) Score in blunt trauma victims. We ought to study its utility in predicting outcomes in blunt trauma patients and its usefulness to guide resource allocation in the emergency department.A prospective observational study was performed on blunt trauma patients who had presented to the emergency department of our tertiary care center, over a period of 6 months. Their qSOFA scores were calculated and these patients were observed for their course in the hospital. The predictive validity of this score was then studied for the outcome prediction in these patients.A total of 246 patients were enrolled. Maximum 36.4% of patients had a qSOFA score of 0 and 10.1% were with a score of 3. Higher qSOFA scores were associated with higher in-hospital mortality, higher needs for an ICU admission, higher needs for mechanical ventilation. However, it did not reliably predict the need for an emergency surgery in these patients.qSOFA score serves as a reliable tool to predict adverse outcomes in blunt trauma victims. It helps with the quick allocation of resources in the emergency department.
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