BACKGROUND: The Clinical Randomisation of an Anti-fibrinolytic in Significant Hemorrhage-2 (CRASH-2) is the largest randomized control trial (RCT) examining circulatory resuscitation for trauma patients to date and concluded a statistically significant reduction in all-cause mortality in patients administered tranexamic acid (TXA) within 3 hours of injury. Since the publication of CRASH-2, significant geographical variance in the use of TXA for trauma patients exists. This study aims to assess TXA use for major trauma patients with hemorrhagic shock in Ireland after the publication of CRASH-2.
METHODS: A retrospective cohort study was conducted using data derived from the Trauma Audit and Research Network (TARN). All injured patients in Ireland between January 2013 and December 2018 who had evidence of hemorrhagic shock on presentation (as defined by systolic blood pressure [SBP] <100 mmHg [1 mmHg=0.133 kPa] and administration of blood products) were eligible for inclusion. Death at hospital discharge was the primary outcome.
RESULTS: During the study period, a total of 234 patients met the inclusion criteria. Among injured patients presenting with hemorrhagic shock, 133 (56.8%; 95% confidence interval [CI] 50.2%-63.3%) received TXA. Of patients that received TXA, a higher proportion of patients presented with shock index >1 (70.68% vs.57.43%) and higher Injury Severity Score (ISS >25; 49.62% vs. 23.76%). Administration of TXA was not associated with mortality at hospital discharge (odds ratio [OR] 0.86, 95% CI 0.31-2.38).
CONCLUSIONS: Among injured Irish patients presenting with hemorrhagic shock, TXA was administered to 56.8% of patients. Patients administered with TXA were on average more severely injured. However, a mortality benefit could not be demonstrated.

BACKGROUND: We aimed to explore the impact of the emergency department length of stay (EDLOS) on the outcome of trauma patients.

METHODS: A retrospective study was conducted on all trauma patients requiring hospitalization between 2015 and 2019. Patients were categorized into 4 groups based on the EDLOS (<4 h, 4-12 h,12-24 h, and >24 h). Data were analyzed using Chi-square test (categorical variables), Student’s t-test (continuous variables), correlation coefficient, analysis of variance and multivariate logistic regression analysis for identifying predictors of short EDLOS and hospital mortality.

RESULTS: The study involved 7,026 patients with a mean age of 32.1±15.6 years. One-fifth of patients had a short EDLOS (<4 h) and had higher level trauma team T1 activation (TTA-1), higher Injury Severity Score (ISS), higher shock index (SI), and more head injuries than the other groups (P=0.001). Patients with an EDLOS >24 h were older (P=0.001) and had more comorbidities (P=0.001) and fewer deaths (P=0.001). Multivariate regression analysis showed that the predictors of short EDLOS were female gender, GCS, SI, hemoglobin level, ISS, and blood transfusion. The predictors of mortality were TTA-1 (odds ratio [OR]=4.081, 95%CI: 2.364-7.045), head injury (OR=3.920, 95%CI: 2.413-6.368), blood transfusion (OR=2.773, 95%CI: 1.668-4.609), SI (OR=2.132, 95%CI: 1.364-3.332), ISS (OR=1.077, 95%CI: 1.057-1.096), and age (OR=1.040, 95%CI: 1.026-1.054).

CONCLUSIONS Patients with shorter EDLOS had different baseline characteristics and hospital outcomes compared with patients with longer EDLOS. Patients with prolonged EDLOS had better outcomes; however, the burden of prolonged boarding in the ED needs further elaboration.

BACKGROUND: Despite the rapid development of pediatric intensive care medicine, there are still limited data in the literature regarding the follow-up of pediatric trauma patients in pediatric intensive care units (PICUs). In this study, we aim to evaluate our experience with children admitted and followed up with the diagnosis of trauma at our PICU.

METHODS: We evaluated the retrospective data of 77 pediatric trauma patients who were admitted to the PICU at Sancaktepe Sehit Prof. Dr. IlhanVarank Training and Research Hospital from August 2020 to December 2022. The demographic data, clinical parameters and laboratory results were recorded. The primary outcome was the mortality in PICU. The performances of markers in predicting mortality were evaluated with receiver operating characteristic (ROC) curves.

RESULTS: The median age of the patients was 70 (33-157) months, and the median duration of hospitalization in the PICU was 6 (2-11) d. Of the 77 patients, 9 died due to trauma (11,1%). Among the clinical parameters, Pediatric Risk of Mortality III (PRISM III) Score, inotrope requirement, extracorporeal treatment requirement, and mechanical ventilator requirement were significantly higher in non-survivors than in survivors. Among the laboratory parameters, procalcitonin (PCT), lactate/albumin ratio (LAR), neutrophil/lymphocyte ratio (NLR), and transfusion requirement were significantly higher in non-survivors than in survivors.

CONCLUSION: In pediatric trauma patients, baseline PCT, LAR, and NLR values can be used to identify patients at risk for mortality.

BACKGROUND: Few contemporary studies have assessed physicians’ knowledge of radiation exposure associated with common imaging studies, especially in trauma care. The purpose of this study was to assess the knowledge of physicians involved in caring for trauma patients regarding the effective radiation doses of musculoskeletal (MSK) imaging studies routinely utilized in the trauma setting.
METHODS: An electronic survey was distributed to United States orthopaedic surgery, general surgery, and emergency medicine (EM) residency programs. Participants were asked to estimate the radiation dose for common imaging modalities of the pelvis, lumbar spine, and lower extremity, in terms of chest X-ray (CXR) equivalents. Physician estimates were compared to the true effective radiation doses. Additionally, participants were asked to report the frequency of discussing radiation risk with patients.
RESULTS: A total of 218 physicians completed the survey; 102 (46.8%) were EM physicians, 88 (40.4%) were orthopaedic surgeons, and 28 (12.8%) were general surgeons. Physicians underestimated the effective radiation doses of nearly all imaging modalities, most notably for pelvic computed tomaography (CT) (median 50 CXR estimation vs. 162 CXR actual) and lumbar CT (median 50 CXR estimation vs. 638 CXR actual). There was no difference between physician specialties regarding estimation accuracy (P=0.133). Physicians who regularly discussed radiation risks with patients more accurately estimated radiation exposure (P=0.007).
CONCLUSION: The knowledge among orthopaedic and general surgeons and EM physicians regarding the radiation exposure associated with common MSK trauma imaging is lacking. Further investigation with larger scale studies is warranted, and additional education in this area may improve care.

BACKGROUND: Trauma-induced coagulopathy (TIC) due to serious injuries significantly leads to increased mortality and morbidity among elderly patients. However, the risk factors of TIC are not well elucidated. This study aimed to explore the risk factors of TIC in elderly patients who have major trauma.

METHODS: In this retrospective study, the risk factors for TIC in elderly trauma patients at a single trauma center were investigated between January 2015 and September 2020. The demographic information including gender, age, trauma parts, injury severity, use of blood products, use of vasopressors, need of emergency surgery, duration of mechanical ventilation, length of stay in the intensive care unit (ICU) and hospital, and clinical outcomes were extracted from electric medical records. Multivariate logistic regression analysis was performed to differentiate risk factors, and the performance of the model was evaluated using receiver operating characteristics (ROC) curves.

RESULTS: Among the 371 elderly trauma patients, 248 (66.8%) were male, with the age of 72.5 ± 6.8 years, median injury severity score (ISS) of 24 (IQR: 17-29), and Glasgow coma score (GCS) of 14 (IQR: 7-15). Of these patients, 129 (34.8%) were diagnosed with TIC, whereas 242 (65.2%) were diagnosed with non-TIC. The severity scores such as ISS (25 [20-34] vs. 21 [16-29], P<0.001) and shock index (SI), (0.90±0.66 vs. 0.58 ± 0.18, P<0.001) was significantly higher in the TIC group than in the non-TIC group. Serum calcium levels (1.97±0.19 mmol/L vs. 2.15±0.16 mmol/L, P<0.001), fibrinogen levels (1.7±0.8 g/L vs. 2.8±0.9 g/L, P<0.001), and base excess (BE, -4.9±4.6 mmol/L vs. -1.2 ± 3.1 mmol/L, P<0.001) were significantly lower in the TIC group than in the non-TIC group. Multivariate logistic regression analysis revealed that ISS>16 (OR: 3.404, 95%CI: 1.471-7.880; P=0.004), SI>1 (OR: 5.641, 95%CI: 1.700-18.719; P=0.005), low BE (OR: 0.868, 95%CI: 0.760-0.991; P=0.037), hypocalcemia (OR: 0.060, 95%CI: 0.009-0.392; P=0.003), and hypofibrinogenemia (OR: 0.266, 95%CI: 0.168-0.419; P<0.001) were independent risk factors for TIC in elderly trauma patients. The AUC of the prediction model included all these risk factors was 0.887 (95%CI: 0.851-0.923) with a sensitivity and specificity of 83.6% and 82.6%, respectively.

CONCLUSION: Higher ISS (more than 16), higher SI (more than 1), acidosis, hypocalcemia, and hypofibrinogenemia emerged as independent risk factors for TIC in elderly trauma patients.

BACKGROUND: The objective of this retrospective hospital-based study was to describe the epidemiological features of traumatic spinal cord injury (TSCI) in the intensive care unit (ICU) and assess the incidence and possible risk factors for venous thromboembolism (VTE) following TSCI.

METHODS: We retrospectively reviewed the medical records of 370 patients with TSCI who were admitted between January 2018 and March 2023. The following parameters were collected: age, sex, body mass index, occupation, underlying diseases, smoking history, education level, etiology of injury, injury segments, American Spinal Injury Association (ASIA) Impairment Scale score, severity of injury, injury severity score (ISS), VTE risk score (Caprini score), treatment, VTE prophylaxis, ICU length of stay, length of hospital stay, concomitant injuries, and complications. Descriptive statistics were used to summarize the demographic and clinical characteristics of the study participants. Logistic regression analysis was used to determine the risk factors for VTE.

RESULTS: The mean age of patients with TSCI was 55.5 ± 13.4 years, with a male-to-female ratio of 6.5:1. The leading cause of TSCI was falls from height (46.5%), followed by traffic accidents (36.5%). The cervical spinal cord was the most affected segment, followed by the thoracolumbar region. Among all the patients, 362 (97.8%) had concomitant injuries. Complications were observed in 255 patients (68.9%) during hospitalization. The incidence rate of VTE was 25.1%. Logistic regression analysis revealed that age (OR=1.721, 95%CI: 1.207-2.454, P=0.003), mechanical ventilation (OR=3.427, 95%CI: 1.873-6.271, P<0.001), and non-use of chemical prophylaxis (OR=2.986, 95%CI: 1.749-5.099, P<0.001) were risk factors for VTE.

CONCLUSION: Falls from height and traffic accidents were the main causes of TSCIs in the ICU, especially for male patients with cervical spinal cord injuries. VTE is a frequent complication in patients with TSCI in the ICU. Age, mechanical ventilation, and non-use of chemical prophylaxis were found to be independent risk factors for VTE following TSCI.

BACKGROUND: This study aimed to review bicycle-related injuries during the COVID-19 pandemic to assist with reinforcement or implementation of new policies for injury prevention.

METHODS: This is a retrospective descriptive analysis of injuries sustained during cycling for patients 18 years old and above who presented to Singapore General Hospital from January to June 2021. Medical records were reviewed and consolidated. Descriptive analyses were used to summarize patient characteristics, and differences in characteristics subgrouped by triage acuity and discharge status were analyzed.

RESULTS: The study included 272 patients with a mean age of 43 years and a male predominance (71.7%). Most presented without referrals (88.2%) and were not conveyed by ambulances (70.6%). Based on acuity category, there were 24 (8.8%) Priority 1 (P1) patients with 7 trauma activations, 174 (64.0%) and 74 (27.2%) P2 and P3 patients respectively. The most common injuries were fractures (34.2%), followed by superficial abrasion/contusion (29.4%) and laceration/wound (19.1%). Thirteen (4.8%) patients experienced head injury and 85 patients (31.3%) were documented to be wearing a helmet. The majority occurred on the roads as traffic accidents (32.7%). Forty-two patients (15.4%) were admitted with a mean length of stay of 4.1 d and 17 (6.3%) undergone surgical procedures. Out of 214 (78.7%) discharged patients, no re-attendances or mortality were observed. In the subgroup analysis, higher acuity patients were generally older, with higher proportions of head injuries leading to admission.

CONCLUSION: Our study highlights significant morbidities in bicycle-related injuries. There is also a high proportion of fractures in the young healthy male population. Injury prevention is paramount and we propose emphasizing helmet use and road user safety.

BACKGROUND: As advocated in advanced trauma life support and prehospital trauma life support protocols, cervical immobilization is applied until cervical spine injury is excluded. This study aimed to show the difference in optic nerve sheath diameter (ONSD) between patients with and without a cervical collar using computed tomography (CT).

METHODS: This was a single-center, retrospective study examining trauma patients who presented to the emergency department between January 1, 2021, and December 31, 2021. The ONSD on brain CT of the trauma patients was measured and analyzed to determine whether there was a difference between the ONSD with and without the cervical collar.

RESULTS: The study population consisted of 169 patients. On CT imaging of patients with (n=66) and without (n=103) cervical collars, the mean ONSD in the axial plane were 5.43 ± 0.50 mm and 5.04 ± 0.46 mm respectively for the right eye and 5.50 ± 0.52 mm and 5.11 ± 0.46 mm respectively for the left eye. The results revealed an association between the presence of a cervical collar and the mean ONSD, which was statistically significant (P<0.001) for both the right and left eyes.

CONCLUSION: A cervical collar may be associated with increased ONSD. The effect of this increase in the ONSD on clinical outcomes needs to be investigated, and the actual need for cervical collar in the emergency department should be evaluated on a case-by-case basis.

BACKGROUND: Postpartum posttraumatic stress disorder (PTSD) can occur in women who give birth after emergency admission. The identification of risk factors for this condition is crucial for developing effective preventive measures. This retrospective study aimed to explore the incidence and risk factors for postpartum PTSD in women who give birth after emergency admission.

METHODS: Medical records of women who gave birth after emergency admission were collected between March 2021 and April 2023. The patients’ general conditions and perinatal clinical indicators were recorded. The puerperae were divided into PTSD group and control group based on symptom occurrence at six weeks postpartum. Multivariate logistic regression analysis was performed to identify risk factors.

RESULTS: A total of 276 puerperae were included, with a PTSD incidence of 20.3% at six weeks postpartum. Multivariate logistic regression analysis identified emergency cesarean section (odds ratio [OR]=2.102; 95% confidence interval [CI]: 1.114-3.966, P=0.022), admission to the emergency department after midnight (12:00 AM) (OR=2.245; 95%CI: 1.170-4.305, P<0.001), and cervical dilation (OR=3.203; 95%CI 1.670-6.141, P=0.039) as independent risk factors for postpartum PTSD. Analgesia pump use (OR= 0.500; 95%CI 0.259-0.966, P=0.015) was found to be a protective factor against postpartum PTSD.

CONCLUSION: Emergency cesarean section, admission to the emergency department after midnight, and cervical dilation were identified as independent risk factors for postpartum PTSD, while analgesic pump use was a protective factor. These findings provide insights for developing more effective preventive measures for women who give birth after emergency admission.

BACKGROUND: Traumatic cardiac arrest (TCA) is a major contributor to mortality and morbidity in all age groups and poses a significant burden on the healthcare system. Although there have been advances in treatment modalities, survival rates for TCA patients remain low. This narrative literature review critically examines the indications and effectiveness of current therapeutic approaches in treating TCA.
METHODS: We performed a literature search in the PubMed and Scopus databases for studies published before December 31, 2022. The search was refined by combining search terms, examining relevant study references, and restricting publications to the English language. Following the search, 943 articles were retrieved, and two independent reviewers conducted a screening process.
RESULTS: A review of various studies on pre- and intra-arrest prognostic factors showed that survival rates were higher when patients had an initial shockable rhythm. There were conflicting results regarding other prognostic factors, such as witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and the use of prehospital or in-hospital epinephrine. Emergency thoracotomy was found to result in more favorable outcomes in cases of penetrating trauma than in those with blunt trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides an advantage to emergency thoracotomy in terms of occupational safety for the operator as an alternative in managing hemorrhagic shock. When implemented in the setting of aortic occlusion, emergency thoracotomy and REBOA resulted in comparable mortality rates. Veno-venous extracorporeal life support (V-V ECLS) and veno-arterial extracorporeal life support (V-A ECLS) are viable options for treating respiratory failure and cardiogenic shock, respectively. In the context of traumatic injuries, V-V ECLS has been associated with higher rates of survival to discharge than V-A ECLS.
CONCLUSION: TCA remains a significant challenge for emergency medical services due to its high morbidity and mortality rates. Pre- and intra-arrest prognostic factors can help identify patients who are likely to benefit from aggressive and resource-intensive resuscitation measures. Further research is needed to enhance guidelines for the clinical use of established and emerging therapeutic approaches that can help optimize treatment efficacy and ameliorate survival outcomes.