UNASSIGNED: The most common cause of preventable death after injury is haemorrhage. Resuscitative endovascular balloon occlusion of the aorta is intended to provide earlier, temporary haemorrhage control, to facilitate transfer to an operating theatre or interventional radiology suite for definitive haemostasis.
UNASSIGNED: To compare standard care plus resuscitative endovascular balloon occlusion of the aorta versus standard care in patients with exsanguinating haemorrhage in the emergency department.
UNASSIGNED: Pragmatic, multicentre, Bayesian, group-sequential, registry-enabled, open-label, parallel-group randomised controlled trial to determine the clinical and cost-effectiveness of standard care plus resuscitative endovascular balloon occlusion of the aorta, compared to standard care alone.
UNASSIGNED: United Kingdom Major Trauma Centres.
UNASSIGNED: Trauma patients aged 16 years or older with confirmed or suspected life-threatening torso haemorrhage deemed amenable to adjunctive treatment with resuscitative endovascular balloon occlusion of the aorta.
UNASSIGNED: Participants were randomly assigned 1 : 1 to: standard care, as expected in a major trauma centre standard care plus resuscitative endovascular balloon occlusion of the aorta.
UNASSIGNED: Primary: Mortality at 90 days. Secondary: Mortality at 6 months, while in hospital, and within 24, 6 and 3 hours; need for haemorrhage control procedures, time to commencement of haemorrhage procedure, complications, length of stay (hospital and intensive care unit-free days), blood product use. Health economic: Expected United Kingdom National Health Service perspective costs, life-years and quality-adjusted life-years, modelled over a lifetime horizon.
UNASSIGNED: Case report forms, Trauma Audit and Research Network registry, NHS Digital (Hospital Episode Statistics and Office of National Statistics data).
UNASSIGNED: Ninety patients were enrolled: 46 were randomised to standard care plus resuscitative endovascular balloon occlusion of the aorta and 44 to standard care. Mortality at 90 days was higher in the standard care plus resuscitative endovascular balloon occlusion of the aorta group (54%) compared to the standard care group (42%). The odds ratio was 1.58 (95% credible interval 0.72 to 3.52). The posterior probability of an odds ratio > 1 (indicating increased odds of death with resuscitative endovascular balloon occlusion of the aorta) was 86.9%. The overall effect did not change when an enthusiastic prior was used or when the estimate was adjusted for baseline characteristics. For the secondary outcomes (3, 6 and 24 hours mortality), the posterior probability that standard care plus resuscitative endovascular balloon occlusion of the aorta was harmful was higher than for the primary outcome. Additional analyses to account for intercurrent events did not change the direction of the estimate for mortality at any time point. Death due to haemorrhage was more common in the standard care plus resuscitative endovascular balloon occlusion of the aorta group than in the standard care group. There were no serious adverse device effects. Resuscitative endovascular balloon occlusion of the aorta is less costly (probability 99%), due to the competing mortality risk but also substantially less effective in terms of lifetime quality-adjusted life-years (probability 91%).
UNASSIGNED: The size of the study reflects the relative infrequency of exsanguinating traumatic haemorrhage in the United Kingdom. There were some baseline imbalances between groups, but adjusted analyses had little effect on the estimates.
UNASSIGNED: This is the first randomised trial of the addition of resuscitative endovascular balloon occlusion of the aorta to standard care in the management of exsanguinating haemorrhage. All the analyses suggest that a strategy of standard care plus resuscitative endovascular balloon occlusion of the aorta is potentially harmful.
UNASSIGNED: The role (if any) of resuscitative endovascular balloon occlusion of the aorta in the pre-hospital setting remains unclear. Further research to clarify its potential (or not) may be required.
UNASSIGNED: This trial is registered as ISRCTN16184981.
UNASSIGNED: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/199/09) and is published in full in Health Technology Assessment; Vol. 28, No. 54. See the NIHR Funding and Awards website for further award information.
Trauma (physical injury) is a major cause of death and disability. The most common cause of preventable death after injury is uncontrolled bleeding. Resuscitative endovascular balloon occlusion of the aorta is a technique whereby a small balloon is inflated in the aorta (main blood vessel) which aims to limit blood loss until an operation can be done to stop the bleeding. In this study, which is the first randomised trial in the world of this technique, we investigated whether adding resuscitative endovascular balloon occlusion of the aorta to the standard care received in a major trauma centre reduced the risk of death in trauma patients who had life-threatening uncontrolled bleeding. The study took place in 16 major trauma centres in the United Kingdom. Ninety adult trauma patients with confirmed or suspected uncontrolled bleeding took part and were randomly divided into two groups: (1) those who received standard care and (2) those who received standard care plus resuscitative endovascular balloon occlusion of the aorta. We followed participants for 6 months using routinely collected data from the National Health Service and from the Trauma Audit Research Network registry. We also contacted surviving patients at 6 months to ask about their quality of life. In the standard care group, 42% of participants died within 90 days of their injury compared to 54% of participants in the standard care plus resuscitative endovascular balloon occlusion of the aorta group. Risk of death was also higher in the standard care plus resuscitative endovascular balloon occlusion of the aorta group at all other time points (3, 6 and 24 hours, in hospital and at 6 months). Overall, the study showed that the use of resuscitative endovascular balloon occlusion of the aorta in hospital increased the risk of death.

BACKGROUND: Children experiencing trauma are at risk of developing acute and chronic stress disorders. In 2022, the American College of Surgeons Committee on Trauma required verified pediatric trauma centers to screen at-risk patients and provide mental health provider referrals as needed.
OBJECTIVE: The study objective is to assess the current readiness of pediatric trauma centers to meet the new American College of Surgeons requirements.
METHODS: This study used an exploratory, electronic, cross-sectional survey design. The Pediatric Trauma Society distributed a survey on mental health screening practices to its members in February 2023. Results were summarized with descriptive statistics. Chi-square test was used to compare responses of Levels I and II pediatric trauma centers.
RESULTS: There were 91 survey responses from the PTS membership of 1247 (response rate of 7.3%). Fifty-nine participants were from Level I and 27 from Level II pediatric trauma centers. 63.8% of Level I and 51.9% of Level II center respondents currently screened for acute stress (χ2(1) = 1.09, p = .30). Of these, 75.7% of Level I and 57.1% of Level II center respondents routinely screened all admitted trauma patients (χ2(1) = 1.68, p = .19). However, only 32.4% of Level I and 21.4% of Level II respondents reported having outpatient acute stress referral protocols. For pediatric trauma centers currently without screening, 65% of Level I and 46.2% of Level II pediatric trauma center respondents felt they needed more than six months to establish a program (χ2(1) = 1.15, p = .28). Most respondents (68.9%) reported staff shortages as a barrier to the delivery of acute stress services.
CONCLUSIONS: Pediatric trauma center compliance with acute stress screening requirements for verification is variable. Pediatric trauma centers may benefit from technical assistance with acute stress screening.

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BACKGROUND: The balanced transfusion of blood components plays a leading role in traumatic hemostatic resuscitation. Yet, previous whole blood studies have only focused on urban trauma center settings.
OBJECTIVE: To compare component vs whole blood therapy on wastage rates and mortality in the rural setting.
METHODS: This study was a nonrandomized, retrospective, observational, single-center study on a cold-stored whole blood program implementation for adult massive transfusions from 2020 to 2022 at a Level II trauma center. Trauma registry data determined the facility\'s whole blood needs and facilitated sustainable blood supplies. Whole blood use protocols were established, and utilization and laboratory compliance for incompatible ABO antibody hemolysis was monitored and reviewed monthly at stakeholder and trauma services meetings.
RESULTS: From 2018 to 2019, the facility initiated component therapy massive transfusions every 9 days (n = 41). Therefore, four units of low-titer, O-positive whole blood delivered fortnightly was determined to provide patient coverage and minimize wastage. Across the study time frame (2020-2022), there were n = 68 hemodynamically unstable patients, consisting of those receiving whole blood, n = 37, and patients receiving component therapy, n = 31. Mortality rates were significantly lower (p = .030) in the whole blood population (n = 3, 8%) compared to those solely receiving component therapy (n = 9, 29%). Wastage rates were constantly evaluated; in 2021, 43.4% was not utilized, and in 2022, this was reduced to 38.7%. Anecdotally, nurses appreciated the ease of administration and documentation of transfusing whole blood, as it negated ratio compliance.
CONCLUSIONS: This evidence-based whole blood program provides vital care to severely injured trauma patients in a vast, rural region.

BACKGROUND: There is a need for activation criteria that reflect the different factors affecting rural trauma patients.
OBJECTIVE: To develop effective activation criteria for a rural trauma center among adults, incorporating variables specific to the geography, mechanisms of injury, and population served.
METHODS: This is a single-center, retrospective cohort study conducted from (23 years) January 1, 2000, to July 31, 2023. The data collected patient demographics, injury details, morbidity, and preexisting comorbidity. This research included all adult (≥15 years) true Level I trauma activations defined as an injury severity score > 25 and met the need for trauma intervention criteria. The patients were grouped into adult and elderly categories. The analysis utilized a logistic regression model with the outcome of a true Level I trauma activation.
RESULTS: A total of 19,480 patients were included in the sample; 2,858 (14.6%) met the Level I activation criteria. Elderly Level I activation included assault, pedestrian struck, multiple pelvic fractures, traumatic pneumo/hemothorax, mediastinal fracture, sternum fracture, and flail rib fracture.
CONCLUSIONS: Using the findings of the logistic regression model, this center has made more robust activation guidelines adapted to its rural population.

BACKGROUND: Needle thoracostomy is a potentially life-saving intervention for tension pneumothorax but may be overused, potentially leading to unnecessary morbidity.
OBJECTIVE: To review prehospital needle thoracostomy indications, effectiveness, and adverse outcomes.
METHODS: A retrospective cohort study was conducted based on registry data for a United States Midwestern Level I trauma center for a 7.5-year period (January 2015 to May 2022). Included were patients who received prehospital needle thoracostomy and trauma activation before hospital arrival. The primary outcomes were correct indications and improvement in vital signs. Secondary outcomes were the need for chest tubes, correct needle placement, complications, and survival.
RESULTS: A total of n = 67 patients were reviewed, of which n = 63 (94%) received a prehospital thoracostomy. Of the 63 prehospital thoracostomies, 54 (86%) survived to arrival. Of these 54, 44 (n = 81%) had documented reduced/absent breath sounds, 15 (28%) hypotension, and 19 (35%) with difficulty breathing/ventilating. Only four patients met all three prehospital trauma life support criteria: hypotension, difficulty ventilating, and absent breath sounds. There were no significant changes in prehospital vitals before and after receiving needle thoracostomy. In patients receiving imaging (n = 54), there was evidence of 15 (28%) lung lacerations, 6 (11%) of which had a pneumothorax and 3 (5%) near misses of important structures. Review of needle catheters visible on computer tomography imaging found 11 outside the chest and 1 in the abdominal cavity.
CONCLUSIONS: The study presents evidence of potential needle thoracostomy overuse and morbidity. Adherence to specific guidelines for needle decompression is needed.

BACKGROUND: Poor communication about serious injury in older adults can lead to treatment that is inconsistent with patient preferences, create conflict and strain healthcare resources. We developed a communication intervention called Best Case/Worst Case-intensive care unit (ICU) that uses daily scenario planning, that is, a narrative description of plausible futures, to support prognostication and facilitate dialogue among patients, their families and the trauma ICU team. This article describes a protocol for a multisite, randomised, stepped-wedge study to test the effectiveness of the intervention on the quality of communication (QOC) in the ICU.
METHODS: We will follow all patients aged 50 and older admitted to the trauma ICU for 3 or more days after a serious injury at eight high-volume level 1 trauma centres. We aim to survey one family or \'like family\' member per eligible patient 5-7 days following their loved ones\' admission and clinicians providing care in the trauma ICU. Using a stepped-wedge design, we will use permuted block randomisation to assign the timing for each site to begin implementation of the intervention and routine use of the Best Case/Worst Case-ICU tool. We will use a linear mixed-effects model to test the effect of the tool on family-reported QOC (using the QOC scale) as compared with usual care. Secondary outcomes include the effect of the tool on reducing clinician moral distress (using the Measure of Moral Distress for Healthcare Professionals scale) and patients\' length of stay in the ICU.
BACKGROUND: Institutional review board (IRB) approval was granted at the University of Wisconsin, and all study sites ceded review to the primary IRB. We plan to report results in peer-reviewed publications and national meetings.
BACKGROUND: NCT05780918.

BACKGROUND: The aim of our work was to examine differences between trauma patients in rural and urban areas who presented to a tertiary trauma centre in the province of Saskatchewan, Canada.
METHODS: We identified a historical cohort of all level 1 trauma activations presenting to Royal University Hospital (RUH) from April 1, 2020, to March 31, 2022. We divided the cohort into 2 groups (urban and rural), according to the trauma location. The primary outcome of interest was 30-day mortality. Secondary outcomes of interest were hospital length of stay, readmission to hospital within 30 days of discharge, and complication rate.
RESULTS: Trauma patients in rural areas were younger (34.1 v. 37 yr; p = 0.002) and more likely to be male (80.3% v. 74.4%; p = 0.040), with higher Injury Severity Scores (12.3 v. 8.3; p < 0.0001). Trauma patients in urban areas were more likely to sustain penetrating trauma (42.5% v. 28.5%; p < 0.0001). We saw no differences in morbidity and mortality between the 2 groups, but the rural trauma group had longer median lengths of stay (5 v. 3 d; p < 0.0007).
CONCLUSIONS: Although we identified key differences in patient demographics, injury type, and injury severity, outcomes were largely similar between the urban and rural trauma groups. This finding contradicts comparable studies within Canada and the United States, a difference that may be attributable to the lack of inclusion of prehospital mortality in the rural trauma group. The longer length of stay in trauma patients from rural areas may be attributed to disposition challenges for patients who live remotely.

UNASSIGNED: Screening, brief intervention, and referral to treatment (SBIRT) for adolescent alcohol and drug (AOD) use is recommended to occur with adolescents admitted to pediatric trauma centers. Most metrics on SBIRT service delivery only reference medical record documentation. In this analysis we examined changes in adolescents\' perception of SBIRT services and concordance of adolescent-report and medical record data, among a sample of adolescents admitted before and after institutional SBIRT implementation.
UNASSIGNED: We implemented SBIRT for adolescent AOD use using the Science to Service Laboratory implementation strategy and enrolled adolescents at 9 pediatric trauma centers. The recommended clinical workflow was for nursing to screen, social work to provide adolescents screening positive with brief intervention and referral to their PCP for continued AOD discussions with those. Adolescents screening as high-risk also referred to specialty services. Adolescents were enrolled and contacted 30 days after discharge and asked about their perception of any SBIRT services received. Data were also extracted from enrolled patient\'s medical record.
UNASSIGNED: There were 430 adolescents enrolled, with 424 that were matched to their EHR data and 329 completed the 30-day survey. In this sample, EHR documented screening increased from pre-implementation to post-implementation (16.3%-65.7%) and brief interventions increased (27.1%-40.7%). Adolescents self-reported higher rates of being asked about alcohol or drug use than in EHR data both pre- and post-implementation (80.7%-81%). Both EHR data and adolescent self-reported data demonstrated low referral back to PCP for continued AOD discussions.
UNASSIGNED: Implementation of SBIRT at pediatric trauma centers was not associated with change in adolescent perceptions of SBIRT, despite improved documentation of delivery of AOD screening and interventions. Adolescents perceived being asked about AOD use more often than was documented. Referral to PCP or specialty care for continued AOD discussion remains an area of needed attention.
UNASSIGNED: Clinicaltrials.gov NCT03297060.

BACKGROUND: Injuries are a leading cause of death in the United States. Trauma systems aim to ensure all injured patients receive appropriate care. Hospitals that participate in a trauma system, trauma centers (TCs), are designated with different levels according to guidelines that dictate access to medical and research resources but not specific surgical care. This study aimed to identify patterns of injury care that distinguish different TCs and hospitals without trauma designation, non-trauma centers (non-TCs).
METHODS: We extracted hospital-level features from the state inpatient hospital discharge data in Washington state, including all TCs and non-TCs, in 2016. We provided summary statistics and tested the differences of each feature across the TC/non-TC levels. We then conducted 3 sets of unsupervised clustering analyses using the Partition Around Medoids method to determine which hospitals had similar features. Set 1 and 2 included hospital surgical care (volume or distribution) features and other features (e.g., the average age of patients, payer mix, etc.). Set 3 explored surgical care without additional features.
RESULTS: The clusters only partially aligned with the TC designations. Set 1 found the volume and variation of surgical care distinguished the hospitals, while in Set 2 orthopedic procedures and other features such as age, social vulnerability indices, and payer types drove the clusters. Set 3 results showed that procedure volume rather than the relative proportions of procedures aligned more, though not completely, with TC designation.
CONCLUSIONS: Unsupervised machine learning identified surgical care delivery patterns that explained variation beyond level designation. This research provides insights into how systems leaders could optimize the level allocation for TCs/non-TCs in a mature trauma system by better understanding the distribution of care in the system.