Trauma nursing is fast-paced and high-pressure work that can affect nurses' physical and mental health. However, these effects remain unexplored among novice trauma nurses in a newly established trauma center in India. To examine relationships between professional quality of life, sleep disturbances, anxiety, and resilience and to explore the experiences of novice trauma nurses in a newly established trauma center in India. This sequential mixed-methods study was conducted between April and June 2024 in a newly established trauma center in India. A purposive sample of 80 nurses was surveyed using a demographic questionnaire, the Brief Resilience Scale, the Generalized Anxiety Disorder Scale, the Insomnia Severity Index, and the Professional Quality of Life Scale. Nine nurses were interviewed to explore their trauma experiences. The analysis included descriptive and inferential statistics, bootstrap-based mediation testing, and thematic content analysis. A total of 80 nurses completed the survey (response rate: 67.8%) with a mean age of 27.7 years (standard deviation [SD] = 2.89) and average years of trauma experience of 2.08 years (SD = 1.93). Higher compassion satisfaction correlated with fewer sleep disturbances (r = -.23, p = .037). Burnout positively correlated with anxiety (r = .24, p = .033) and sleep disturbances (r = .34, p = .023), and negatively with nurses' resilience (r = -.12, p = .049). Professional quality of life significantly correlated with resilience (r = .18, p = .048). Resilience mediated the relationship between anxiety and both burnout (β = .24, bootstrap confidence interval [BCI] = 0.04, 0.46, p = .041) and secondary traumatic stress (β = .24, BCI = 0.03, 0.52, p = .029). Qualitative analysis revealed three major themes: personal and professional adaptation to trauma life, adverse physical and psychological issues, and challenges faced in trauma care. Our findings highlight the adverse impact of trauma nursing on sleep, resilience, anxiety, and professional quality of life among novice nurses in a newly established Level I trauma center in India. Targeted interventions are required to enhance resilience and mitigate the impact of caring for trauma patients.
Trauma is a leading cause of death and a significant financial burden, requiring highly skilled and confident nursing care to improve patient outcomes. Despite the increasing adoption of simulation for trauma training, evidence of its effectiveness in building comprehensive interdisciplinary trauma skills remains limited. To synthesize current evidence on the effectiveness of trauma simulation in enhancing both technical and non-technical skills in interdisciplinary trauma teams. Source data were obtained from CINAHL, MEDLINE, the Cochrane Library, and Google Scholar literature review. Inclusion criteria included all study types from January 2018 to September 2023 addressing the use of trauma simulation, trauma simulation in nursing education, trauma training, interdisciplinary trauma teams, and high-fidelity trauma simulation, regardless of methodology. Exclusion criteria included those articles that were not related to the impact of trauma simulations, training, or education on technical or non-technical skills. The search strategy was last executed on December 10, 2023. A total of 27 articles met the inclusion criteria. Four themes emerged from the data synthesis, including teamwork, non-technical skills, technical skills, and task completion. The available evidence supports trauma simulation as an educational tool in improving teamwork, non-technical, and technical skills during trauma resuscitations, though more data is needed to determine its effect on patient outcomes.
Vicarious trauma results from repeated exposure to the emotional or physical suffering of others and is considered an occupational hazard for those in caring professions. It can negatively impact clinicians' personal and professional lives and the quality of patient care. However, research specifically examining vicarious trauma among trauma clinicians remains limited. This study aims to examine vicarious trauma experienced by trauma clinicians providing direct care to trauma patients. This is an explanatory sequential mixed-methods study involving trauma clinicians over a period of 5 months (May-October 2024) at a Level I trauma center in West Virginia. Quantitative data were collected through an electronic survey using Vicarious Trauma Scale items, followed by qualitative data from individual interviews. A total of 76 clinicians completed the survey, with nurses comprising the majority of participants, followed by attending physicians, resident physicians, and nurse practitioners. On average, trauma clinicians reported strong agreement with "exposure to distressing materials and experiences" [6.38 (1.08)] and "exposure to traumatized or distressed clients" [6.70 (0.78)]. Vicarious trauma appeared more pronounced among nurses compared to other clinical roles. Awareness and utilization of organizational well-being interventions were limited due to the added burden of responsibilities and fear of judgment. Vicarious trauma was found to be evident among trauma clinicians, which could be consequential both professionally and personally. Health care organizations and trauma leadership need to consider the risk of vicarious trauma among trauma clinicians and proactively safeguard clinicians to mitigate its impact.
The Glasgow Coma Scale has been a standard tool for assessing consciousness in trauma patients for five decades, but its utility is limited by the omission of brainstem reflexes such as pupillary response. This study aimed to compare the prognostic accuracy of the Pediatric Glasgow Coma Scale (pGCS) and the Pediatric Glasgow Coma Scale - Pupils Score (pGCS-P) in predicting mortality and functional outcomes among pediatric patients with traumatic brain injury (TBI). This single-center observational cohort study was conducted from May 2022 to May 2023 at Bursa Training and Research Hospital, Health Sciences University, Turkey. Pediatric patients (age <18 years) presenting with TBI were evaluated for level of consciousness and pupillary responses on admission. Both the pGCS and pGCS-P scores were calculated for each patient. For patients with anisocoria but preserved light reflexes in both pupils, scoring adjustments were made. Of the 134 patients studied, 59.7% were male, and the mean (SD) age was 6.3 (5.4) years. In-hospital mortality was 12.7%, and 5.1% had unfavorable functional outcomes (UFOs) at discharge. Both the pGCS-P and pGCS demonstrated excellent ability to predict mortality (AUC, 0.97, 95% CI: 0.94-0.99 and 0.97, 95% CI: 0.94-0.96, respectively). There was no statistically significant difference in prognostic performance between the two scores using either binomial (p = .165) or nonparametric (p = .445) analyses (p >.05). In pediatric patients with TBI, the prognostic accuracy of the pGCS with pupil response (pGCS-P) was comparable to that of the pGCS alone for predicting mortality and UFOs. Incorporation of the pupil score did not significantly improve prognostic discrimination in this cohort.
Acute agitation in the trauma population complicates emergency care. While droperidol effectively treats agitation in general emergency department populations, literature specific to trauma patients is limited. This study aims to describe the safety outcomes and clinical success rates of droperidol for acute agitation in trauma patients. This retrospective, observational cohort study at a Southeastern, U.S. Level I trauma center included adults who presented as a trauma activation and received droperidol in the emergency department between February 1, 2020 and August 31, 2024. Patients were excluded if the droperidol dose was <2.5 mg or received antiemetics or sedatives prior to droperidol. The primary outcome was the need for rescue sedation within 60 minutes of droperidol administration. Secondary outcomes included intubation, hypoxia, and hypotension. There were 66 patients included. Patients were primarily white males with a median age of 44 years. Majority of patients received droperidol 2.5 mg ( n = 48, 73%) intravenously ( n = 60, 91%). Twenty-six (39.4%) patients required rescue sedation within 60 minutes of droperidol administration, 16 of which required additional droperidol. These patients were younger and had a shorter time to initial droperidol administration. Fourteen (21%) patients had a new oxygen requirement, two of which were intubated. One patient experienced hypotension not attributed to hypovolemia. This study provides descriptive data suggesting droperidol may be useful for agitation in trauma patients with few serious adverse events. However, prospective randomized controlled studies are required before routine use can be recommended over other agents.
Traumatic brain injuries (TBIs) are a leading cause of death among adults, resulting in approximately 214,110 TBI-related hospitalizations and 69,473 TBI-related deaths in the United States. There remains some debate regarding the optimal timing of craniotomy particularly as it relates to the use of intracranial pressure (ICP) monitoring. Our study aims to determine the association of time to craniotomy intervention (≤6 or >6 hr), ICP monitoring, and trauma center level on patient outcomes in blunt, severe, non-subarachnoid TBI with skull fracture. This retrospective study utilized the American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP) database to examine adult trauma patients (age ≥18 years, Injury Severity Score ≥15) between 2017 and 2023. The study included patients with isolated, severe, blunt, non-subarachnoid hemorrhage TBIs (Glasgow Coma Scale ≤8, Abbreviated Injury Scale ≥2) measuring ≥8 mm. Outcomes of interest were stratified by trauma center level and whether they underwent ICP monitoring. A total of 3,265 adult patients with isolated, blunt, severe, non-subarachnoid TBIs were included in this analysis. Patients who had ICP monitoring and received craniotomy within 6 hr had no significant difference in odds of mortality (aOR: 0.662, 95% CI: 0.326-1.345, p = .254). Patients who received craniotomy beyond 6 hr were 2.5 times more likely to be associated with in-hospital mortality (aOR: 2.54, 95% CI: 1.19-5.39, p = .016). ICP monitoring correlated with a 1.4-day longer intensive care unit length of stay (β = 1.40, 95% CI: 0.56-2.25, p = .001) and 2.0 fewer ventilator-free days (β = -1.95, 95% CI: -3.16 to -0.74, p = .002). ICP-monitored patients had 50% lower odds of discharge to home (aOR: 0.50, 95% CI: 0.30-0.82, p = .006). In patients with severe TBI, our findings indicate that late craniotomy had increased odds of in-hospital mortality, suggesting a benefit to craniotomy prior to 6 hr. ICP monitoring should be evaluated on a case-by-case basis in this patient population to ensure proper and effective use toward improving patient outcomes and overall prognosis.
Proper triage and transport to trauma centers improve outcomes for severe trauma patients. However, little is known regarding these processes across Latin American healthcare systems, limiting regional improvement efforts. This study aims to evaluate the association of prehospital care level and triage accuracy with hospital outcomes in trauma patients in Latin America. This prospective cohort study was conducted in 14 hospitals across Argentina, Brazil, and Colombia. Inclusion criteria were adult trauma patients aged ≥18 years admitted directly from the scene of injury. Data collection occurred over 30 consecutive days at each hospital between 2019 and 2021. Predictor variables included the level of prehospital care (none, basic, or intermediate/advanced) and triage accuracy (correct, undertriage, or overtriage). The primary outcomes were hospital length of stay and mortality. Associations were analyzed using linear regression for hospital stay and logistic regression for mortality. A total of 1,193 trauma patients were included (62.4% male, mean age 43.5 years. Motor vehicle crashes (43.3%) and falls (36.1%) were the leading causes of injury. Emergency medical services assisted 58.7% of patients, mainly at a basic level ( n = 530). Overtriage occurred in 50.0%. Intermediate/advanced prehospital care was associated with longer hospital stays (β3.64, 95% CI [1.39, 5.89], p = .002). Neither prehospital care level nor triage accuracy was associated with hospital mortality ( p ≥.050). In our study of 14 hospitals across Argentina, Brazil, and Colombia, intermediate/advanced prehospital care was associated with longer hospital stays. Neither prehospital care level nor triage categorization was associated with hospital mortality.
There is mixed evidence on the optimal timing of veno-venous extracorporeal membrane oxygenation (VV-ECMO) following significant trauma. This study aims to assess the timing of VV-ECMO initiation and its effect on clinical outcomes in adult patients with moderate-severe blunt thoracic trauma. This retrospective cohort study utilized the American College of Surgeons Trauma Quality Improvement Program Participant Use File (ACS-TQIP-PUF) database between 2015 and 2023 to evaluate the clinical effects of VV-ECMO in adult patients (≥18 years) with blunt, moderate-severe thoracic and thoraco-abdominal trauma. Outcomes of interest included in-hospital mortality, intensive care unit length of stay (ICU-LOS), complications such as deep vein thrombosis, pulmonary embolism, acute kidney injury, and discharge disposition. There were 412 adult patients with moderate-severe blunt thoracic and thoraco-abdominal trauma who received VV-ECMO, of which 256 (61.8%) were initiated within ≤7 days and 105 (25.4%) after 7 days. Patients with VV-ECMO initiation within ≤7 days had no difference in mortality rates (adjusted odds ratio [aOR] .655, p = .246) but had five fewer ICU-LOS days (β: -5.364, p = .002). Additionally, patients receiving early VV-ECMO were less likely to be discharged home (aOR: .192, p = .017) than all other discharge dispositions. No differences were observed in transfusion needs or complication rates. Initiation of VV-ECMO within ≤7 days was associated with significantly shorter ICU-LOS and comparable odds of mortality, without significant differences in complications or adverse events, including transfusion requirements and venous thromboembolism. Trauma and critical care societies should consider these findings when revisiting existing ECMO protocols concerning the early initiation of VV-ECMO to improve outcomes in this population.
Existing literature on pediatric traumatic brain injury (TBI) transfers to higher-level trauma centers is limited. Most studies focus on inhospital mortality and neurosurgical intervention rates, often overlooking outcomes such as early discharge without neurosurgical intervention, intensive care unit length of stay, and discharge disposition. To assess the impact of transfer to a higher-level trauma center on clinical outcomes of pediatric severe TBI patients. This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program database between 2017 and 2023 to evaluate pediatric trauma patients with isolated severe TBI transferred from lower-level to higher-level trauma centers. The primary outcome was the odds of discharge within 24 or 48 h without requiring neurosurgical intervention and rates of neurosurgical intervention. Secondary outcomes included emergency department and 24-h mortality, initial and repeat computerized tomography scan rates, intensive care unit length of stay, ventilator-free days, and discharge home. Of the 4,154 pediatric patients with isolated severe TBI, 1,723 (41.5%) were transferred, and 2,418 (58.2%) were not. Transferred patients had a 42% lower odds of discharge within 24 h without neurosurgical intervention (OR: 0.58, 95% CI [0.41, 0.80], p < .001), were more likely to undergo neurosurgical intervention (OR: 1.26, 95% CI [1.04, 1.53], p = .016), and were more likely to be discharged home (OR: 1.58, 95% CI [1.30, 1.92], p < .001). Mortality rates did not differ significantly between groups. Transfer to higher-level trauma centers is associated with increased neurosurgical intervention and higher rates of discharge home in pediatric patients with severe TBI, without differences in mortality.
The low incidence of non-iatrogenic extremity vascular injuries in children, combined with the anatomical and physiological characteristics of children, poses challenges for diagnosis, operative treatment, and recovery. No national guidelines are available to inform the care of children with vascular injuries to the extremities. The objective of this concise report is to describe the incidence and contributing mechanisms of injury resulting in pediatric extremity vascular trauma and summarize currently cited approaches for management. English-language publications in PubMed and CINAHL that focus on extremity vascular injuries in children aged 0-17 years were reviewed. Publications from 2014 to the present were prioritized; however, as relevant research remains sparse, sentinel papers published before 2014 were also reviewed. Bibliographies from retrieved articles were also scanned. Retrospective studies, case studies, and single institution studies were included in the analysis. Data were manually extracted from journal publications using established inclusion and exclusion criteria. A panel of pediatric trauma experts reviewed a total of 29 papers, seeking evidence-based methodology and brief summaries of the available literature. These injuries are rare, and the anatomical and physiological characteristics of pediatric vascular injuries mandate a multidisciplinary approach. To minimize the consequences of extremity vascular injuries, successful treatment requires a high index of suspicion that allows for early diagnosis and prompt management. Clear recommendations regarding diagnosis and treatment are needed.
Injury is the leading cause of death and a cause of disability in children and negatively affects physical health, mental health, and quality of life in both the short- and long-term. The goal of a pediatric trauma system is to optimize the care for children within a state, regional, or national trauma system across the entire continuum of care, regardless of where they live or where the traumatic event occurs. This continuum includes injury prevention, prehospital care, interfacility transport between hospitals providing different levels of care, acute and critical inpatient care, inpatient and outpatient rehabilitation, and reintegration into the community and primary care medical home. A systems-based approach, one that requires distinct elements of structure and function to perform together in an interrelated and cohesive manner to improve care quality, is essential. To improve outcomes after injury, a cohesive system must effectively provide optimal care for the "right child, at the right place, at the right time" across this continuum.
Injury is the leading cause of death and a frequent cause of disability in children and negatively affects physical health, mental health, and quality of life in both the short- and long-term. The goal of a pediatric trauma system is to optimize the care for children within a state or region encompassing the entire continuum of care, regardless of where children live or where traumatic events occur. This continuum includes injury prevention, prehospital care, emergency department care, interfacility transport, acute and critical inpatient care, inpatient and outpatient rehabilitation, and reintegration into the community and primary care medical home. A systems-based approach requires distinct elements of structure and function to perform together in an interrelated and cohesive manner to improve care quality. In this case, it represents a sequential practice of evidence-based evaluation and management along the continuum of care. To improve outcomes after injury, a cohesive system must effectively provide optimal care for the "right child, at the right place, at the right time" across this continuum.
Injury leads to long-term physical and mental health challenges, yet inpatient screening for post-traumatic stress disorder and depression remains inconsistent, and postdischarge mental health is poorly understood, particularly in less resourced trauma centers where emerging symptoms may go unrecognized. To evaluate the feasibility of using the electronic medical record to identify postdischarge mental health screening documentation in adult trauma patients within 6 months after discharge. This retrospective descriptive feasibility study was conducted at a midwestern US regional Level II trauma center serving a predominantly rural catchment area. Adult trauma patients admitted between January 1 and December 31, 2024, were eligible for inclusion. A stratified sampling strategy was used, selecting up to 4 records per month, with follow-up data collected for 6 months postdischarge. The final sample included 48 patients with a median age of 67 (IQR: 18) years, predominantly male (n = 35, 73%), and White (n = 40, 83%). A total of 7 patients (15%) screened positive for post-traumatic stress disorder risk, depression risk, or both during inpatient admission. Trauma-related follow-up was documented in the electronic medical record for 37 patients (77%), with a median of 15 days (IQR: 16) to first follow-up appointment and a median of 2 provider contacts (IQR: 1) within 6 months of discharge. Despite this follow-up, only 1 of 37 patients (3%) with documented follow-up had a documented mental health screening during the postdischarge period. This feasibility study found that the electronic medical record alone was insufficient to capture postdischarge mental health screening documentation, with only 1 screening identified across 37 patients with documented follow-up, highlighting a critical gap in care continuity that warrants further investigation.
Geriatric trauma patients frequently require massive transfusion, yet clear guidelines on transfusion futility thresholds (TFTs) remain underdeveloped, particularly in patients with thoracoabdominal injuries and concomitant traumatic brain injury (TBI). To investigate TFT in geriatric trauma patients with moderate-to-severe chest and/or abdominal injuries with or without TBI. This retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database from 2017 to 2021 investigated geriatric trauma patients (age ≥65) with moderate-severe abdominal (abbreviated injury score [AIS] abdomen ≥ 2) and/or chest (AIS chest ≥ 2) injuries with or without concomitant TBI. Outcomes included mortality, transfusion threshold, ventilation-free days, complications, and intensive care unit length of stay (ICU-LOS). There were 1,072 non-TBI and 289 TBI patients included in this analysis. The TFT was 12 units of packed red blood cells (pRBCs) among non-TBI patients and 6 units of pRBCs among TBI patients within 4 hr of arrival. Patients exceeding the TFT in both groups had significantly higher odds of 48-hr mortality (OR: 3.949, 95% CI: [2.270, 6.870], p < .001; OR: 6.426, 95% CI: [1.772, 23.311], p = .005). Non-TBI patients exceeding the TFT had higher odds of developing acute kidney injury (AKI) (OR: 2.606, 95% CI: [1.136, 5.980], p = .024), severe sepsis (OR: 6.146, 95% CI: [1.485, 25.445], p = .012), and a significantly longer ICU-LOS (B: 3.445, 95% CI: [0.903, 5.987], p = .008). Among geriatric trauma patients with abdominal and/or chest injuries with or without concomitant moderate-severe TBI, those exceeding the TFT had significantly higher odds of 48-hr mortality. Additionally, non-TBI patients exceeding the TFT had higher odds of severe sepsis and AKI. This study offers strong evidence for the establishment of massive transfusion guidelines specific to the geriatric population, particularly with or without TBI.
Assessment of triage procedures is crucial for improving patient care. Most programs evaluate under- and over-triage using the ISS-based Cribari Matrix Method (CMM), but tools such as the critical-intervention-based Need for Trauma Intervention (NFTI) and its time-critical modified version (mNFTI) focus on identifying patients who need immediate resources. The mNFTI has seen limited empirical inquiry in assessing triage procedures. To assess accuracy and agreement rates between mNFTI and CMM. This multicenter, retrospective cohort study compared triage classifications in trauma patients using 2019 trauma registry data from trauma centers across 5 trauma systems in Ohio, United States. Patients meeting Ohio/National Trauma Data Standards for traumatic injury were included. Triage classifications were assigned by mNFTI and CMM and compared across all patients and injury subgroups using statistical tests (McNemar, symmetry, Cohen Kappa) to determine agreement and differences between the 2 methods. The final analysis included 27,637 patients. Patient count tables show classification differences for all patients and injury subgroups. The statistical tests reveal differences in retrospective triage assessment by the mNFTI and CMM. Among 27,637 patients, mNFTI and CMM classifications differed significantly at both the population and subgroup levels ( p < .05 for all comparisons). The agreement between methods was weak to moderate. This study demonstrates that mNFTI produces significantly different trauma triage classifications compared with the Cribari Matrix Method, with moderate agreement between the 2. These differences suggest that mNFTI may better identify patients who require immediate trauma intervention and could help address undertriage in trauma systems. Further research is warranted to validate mNFTI as a stand-alone quality metric for trauma triage.
Venous thromboembolism (VTE) following solid, blunt, isolated abdominal organ injuries remains a common posttrauma complication in adults. Accordingly, gaining a better understanding of the effect of early versus late VTE prophylaxis to reduce rates of this complication is prudent. The purpose of this study is to evaluate the impact of early versus late VTE prophylaxis on clinical outcomes in adult trauma patients with isolated blunt solid abdominal organ injuries. This retrospective cohort study utilized the American College of Surgeons Trauma Quality Improvement Program Participant Use File database between 2017 and 2021 to compare clinical outcomes between early (≤48 hours) and late (>48 hours) VTE prophylaxis, including deep vein thrombosis (DVT), pulmonary embolism (PE), and other secondary outcomes. This study included adult (age ≥ 16) trauma patients with severe (ISS > 15) and isolated Abbreviated Injury Scale (AIS) abdomen ≥ 3, all other body regions < 3, blunt American Association for the Surgery of Trauma (AAST) grade ≥ 3 solid abdominal organ injuries without traumatic brain injury (TBI) (AIS head < 2) who received early or late chemical VTE prophylaxis. A total of 3,365 non-TBI patients with isolated blunt solid abdominal organ injuries, with 2,033 patients (60.4%) receiving early VTE prophylaxis and 1,332 (39.6%) receiving late prophylaxis, were included. Early prophylaxis was associated with a 57% lower risk of DVT (OR 0.4, 95% CI [0.19, 0.98], p = .044). Adult non-TBI trauma patients with isolated, moderate-severe, blunt solid abdominal organ injuries receiving early VTE prophylaxis have significantly lower odds of developing specifically DVT compared to patients receiving late prophylaxis.
Implicit biases and color blindness attitudes among health care providers negatively impact health outcomes and decision-making, particularly for marginalized trauma patients. While research highlights perspective-taking as a method to mitigate health care bias, effective educational strategies to reduce such biases among trauma care professionals remain understudied. To evaluate the effectiveness of "A Brain Game: Deconstructing Bias" as an intervention for levels of perspective-taking and color blindness attitudes among trauma care professionals. This is a single-center, prospective cohort survey study. Using a modified snowball sampling approach, participants were recruited and represented various trauma system roles, including clinicians, researchers, data analysts, social workers, and outpatient providers. Pre- and postintervention surveys assessed perspective-taking, color blindness attitudes, and willingness to consider bias. A total of 132 participants initiated a presurvey with a total of 58 (44%) participants completing both pre- and postintervention surveys included in the analysis. Statistically significant changes observed with increases in perspective-taking scores ( p < .001), understanding social constructs ( p < .001), alongside decreases in color blindness ( p = .049), and unawareness of institutional racism ( p = .020). Additionally, 82.8% ( n = 48) of participants expressed a willingness to consider their biases before patient interactions. This pilot study found that the theatrical intervention, "A Brain Game: Deconstructing Bias," improved trauma professionals' understanding of social constructs, enhanced perspective-taking, reduced color blindness attitudes, and increased willingness to consider bias in patient care. Despite its feasibility, moderate completion rates and single-center design limit generalizability. Further research is warranted.
In adult patients with head trauma, the location and characteristics of the visible head injury have been associated with adverse outcomes, such as traumatic intracranial hemorrhage and cervical spine injuries. This study aimed to evaluate the reliability of head injury location and characteristics between Emergency Medical Dispatcher (EMD) and Emergency Department (ED) assessments in patients contacting an EMD for head injuries. A secondary objective was to assess how this reliability varied depending on the individual contacting the EMD. This study was a planned sub-analysis of a multicenter, prospective, observational cohort study conducted over three 3 days in March 2023 in France (EPI-TC study). Main outcome was visible head injury location and characteristics. Standardized data collection occurred during the EMD call and upon ED admission. Interobserver reliability between EMD and ED assessments was measured using kappa coefficient. Overall, 241 patients from 20 participating EMD and 20 EDs were included in this sub-analysis and most of them (79.3%) were community-dwelling patients. The EMD was most frequently contacted by unrelated witnesses (27.8%). Head injury location and characteristic were reliable between EMD and ED, with kappa coefficients of 0.76 (95% CI 0.73-0.79) and 0.76 (95% CI 0.72-0.81), respectively. However, this reliability was low when EMD was called by the patient himself (kappa coefficient 0.59 (95% CI 0.50-0.69) and 0.52 (95% CI 0.38-0.66) respectively). In cases of head injuries, phone-based assessments by EMD regarding head injury location and characteristics are reliable in adult patients when reported by a witness. However, caution is recommended if the patients call the EMD themselves. In these cases, alternative evaluation methods could be considered, such as onsite assessment by a health care professional or telemedicine-based photographic transmission.
Massive transfusion protocol (MTP) activations at rural Level III trauma centers often face blood delivery delays, limited support, and product waste. While MTPs are well described in higher-level centers, their effectiveness and staff perceptions in rural Level III settings are unclear. Process breakdowns at one such center, including staffing gaps, delivery delays, and product waste, prompted implementation of a targeted MTP response system. This project aims to evaluate the effectiveness of an MTP activation response system in a rural Level III trauma center setting. This quality improvement project, using a descriptive design with qualitative methods, was conducted at two rural Midwestern, US Level III trauma centers within the same health system from August 1, 2023, to February 1, 2024. The population included all interdisciplinary team members participating in MTP activations. The project's revised MTP activation response system featured centralized dispatcher notifications, new modes of communication, multidisciplinary education, and clarification of team roles and processes. After each activation, project participants received a secure, online, anonymous questionnaire assessing perceived system effectiveness, resource delivery, communication, and documentation. Responses were analyzed using descriptive statistics for quantitative data and narrative analysis for open-ended responses to identify thematic outcomes. A total of N = 35 team members responded across eight MTP activations using the revised response system, including 16 (46%) nurses, 7 (20%) blood bank staff, 5 (14%) pharmacists, 5 (14%) administrative supervisors, and 2 (6%) physicians. Key barriers included inaccurate paging (50%), communication challenges (62.5%), and rapid infuser issues (50%). Appropriate calcium administration occurred in 87.5% of cases; compliance with documentation was high, with 89% noting unit documentation and 83% order confirmation. Implementing a structured multidisciplinary MTP response system in rural Level III trauma centers improved resource delivery, team coordination, and documentation, although communication and workflow challenges persisted.
Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in older adults, often necessitating tracheostomy for prolonged ventilation. The optimal timing of tracheostomy in severe TBI remains debated. To compare clinical outcomes of early (≤7 days) versus late (>7 days) tracheostomy in older patients with isolated severe TBI. This retrospective cohort study utilized the American College of Surgeons Trauma Quality Improvement Participant Use File database from 2017 to 2023 to evaluate clinical outcomes of older trauma patients with isolated severe TBI treated with early (≤7 days) versus late (>7 days) tracheostomy placement. Of 1,565 older patients with severe TBI, 21.7% received an early tracheostomy and 72.5% a late tracheostomy. Early tracheostomy was associated with significantly shorter intensive care unit length of stay (ICU-LOS) (β= -7.26, 95% CI [-8.95, -5.58], p < .001), more ventilator-free days (β= 4.02, 95% CI [2.75, 5.29], p < .001), fewer ventilator days (β= -6.23, 95% CI [-8.05, -4.41, p < .001), and lower risk of ventilator-associated pneumonia (adjusted odds ratio, aOR = 0.37, 95% CI [0.18, 0.77], p = .008). No significant associations existed between tracheostomy timing and inhospital mortality (aOR = 1.13, 95% CI [0.64, 1.99], p = .670) or remaining complication rates. Early tracheostomy within 7 days for older patients with severe TBI is a safe management option, with significantly decreased ICU-LOS and ventilation time, improved or comparable complication rates, and no significant increase in mortality rates compared to late tracheostomy.