In November 2017, the Lancet Neurology Commission on Traumatic Brain Injury (TBI) highlighted existing deficiencies in epidemiology, patient characterization, identifying best practice, outcome assessment, and evidence generation. The Commission concluded that C needed to address deficiencies in prevention , and made a recommendation for large collaborative studies which could provide the framework for precision medicine and comparative effectiveness research (CER).

Objective: To determine whether the statewide system of trauma care introduced in 2000 has resulted in improved survival for all major trauma patients in Victoria. Design, setting and participants: Population‐based cohort study using data from the Victorian State Trauma Registry (VSTR), a registry of all hospitalised major trauma patients in Victoria. The study included major trauma patients with an Injury Severity Score > 15 captured by the VSTR between July 2001 and June 2006. Main outcome measure: In‐hospital mortality. Results: The number of major trauma cases captured by the registry rose from 1153  in 2001–02 to 1737 in 2005–06. Adjusting for key predictors of mortality, there was a significant overall reduction between 2001–02 and 2005–06 in the risk of death for patients treated in the trauma system (adjusted odds ratio [AOR], 0.62 [95% CI, 0.48–0.80]). The reduced risk of death was also significant when road trauma cases (AOR, 0.56 [95% CI, 0.39–0.80]) and serious head injury cases (AOR, 0.62 [95% CI, 0.46–0.83]) were analysed separately. The proportion of road trauma patients definitively treated at one of the three major trauma service (MTS) hospitals in Victoria rose by 7% over the 5‐year period. Direct transfers from the scene of injury to MTS hospitals rose by 8% for all cases and 13% for road trauma cases over the same period. Conclusions: Introduction of a statewide trauma system was associated with a significant reduction in risk‐adjusted mortality. Such inclusive systems of trauma care should be regarded as a minimum standard for health jurisdictions.

IMPORTANCE After severe traumatic brain injury, induction of prophylactic hypothermia has been suggested to be neuroprotective and improve long-term neurologic outcomes. OBJECTIVE To determine the effectiveness of early prophylactic hypothermia compared with normothermic management of patients after severe traumatic brain injury. DESIGN, SETTING, AND PARTICIPANTS The Prophylactic Hypothermia Trial to Lessen Traumatic Brain Injury-Randomized Clinical Trial (POLAR-RCT) was a multicenter randomized trial in 6 countries that recruited 511 patients both out-of-hospital and in emergency departments after severe traumatic brain injury. The first patient was enrolled on December 5, 2010, and the last on November 10, 2017. The final date of follow-up was May 15, 2018. INTERVENTIONS There were 266 patients randomized to the prophylactic hypothermia group and 245 to normothermic management. Prophylactic hypothermia targeted the early induction of hypothermia (33°C-35°C) for at least 72 hours and up to 7 days if intracranial pressures were elevated, followed by gradual rewarming. Normothermia targeted 37°C, using surface-cooling wraps when required. Temperature was managed in both groups for 7 days. All other care was at the discretion of the treating physician. MAIN OUTCOMES AND MEASURES The primary outcome was favorable neurologic outcomes or independent living (Glasgow Outcome Scale-Extended score, 5-8 [scale range, 1-8]) obtained by blinded assessors 6 months after injury. RESULTS Among 511 patients who were randomized, 500 provided ongoing consent (mean age, 34.5 years [SD, 13.4]; 402 men [80.2%]) and 466 completed the primary outcome evaluation. Hypothermia was initiated rapidly after injury (median, 1.8 hours [IQR, 1.0-2.7 hours]) and rewarming occurred slowly (median, 22.5 hours [IQR, 16-27 hours]). Favorable outcomes (Glasgow Outcome Scale-Extended score, 5-8) at 6 months occurred in 117 patients (48.8%) in the hypothermia group and 111 (49.1%) in the normothermia group (risk difference, 0.4% [95% CI,-9.4% to 8.7%]; relative risk with hypothermia, 0.99 [95% CI, 0.82-1.19]; P = .94). In the hypothermia and normothermia groups, the rates of pneumonia were 55.0% vs 51.3%, respectively, and rates of increased intracranial bleeding were 18.1% vs 15.4%, respectively. CONCLUSIONS AND RELEVANCE Among patients with severe traumatic brain injury, early prophylactic hypothermia compared with normothermia did not improve neurologic outcomes at 6 months. These findings do not support the use of early prophylactic hypothermia for patients with severe traumatic brain injury.

Objective: To measure the growth in emergency ambulance use across metropolitan Melbourne since 1995, to measure the impact of population growth and ageing on these services, and to forecast demand for these services in 2015. Design and setting: A population‐based retrospective analysis of Ambulance Victoria's metropolitan emergency ambulance transportation data for the period from financial year 1994–95 to 2007–08, and modelling of demand in the financial year 2014–15. Main outcome measures: Numbers and rates of emergency ambulance transportations. Results: The crude annual rate of emergency transportations across all age groups increased from 32 per 1000 people in 1994–95 to 58 per 1000 people in 2007–08. The rate of transportation for all ages increased by 75% (95% CI, 62%–89%) over the 14‐year study period, representing an average annual growth rate of 4.8% (95% CI, 4.3%–5.3%) beyond that explained by demographic changes. Patients aged ≥ 85 years were eight times (incident rate ratio, 7.9 [95% CI, 7.6–8.3]) as likely to be transported than those aged 45–69 years over this period. Forecast models suggest that the number of transportations will increase by 46%–69% between 2007–08 and 2014–15, disproportionately driven by increasing usage by patients aged ≥ 85 years. Conclusions: These findings confirm a dramatic rise in emergency transportations over the study period, beyond that expected from demographic changes. Rates increased across all age groups, but more so in older patients. In the future, such acceleration is likely to have major effects on ambulance services and acute hospital capacity. This calls for further investigation of underlying causes and alternative models of care.

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Objective: To determine the relationship between compensable status in a “no‐fault” compensation scheme and long‐term outcomes after orthopaedic trauma. Design and setting: Prospective cohort study within two adult Level 1 trauma centres in Victoria, Australia. Participants: Blunt trauma patients aged 18–64 years, admitted between September 2003 and August 2004 with orthopaedic injuries and funded by the no‐fault compensation scheme for transport‐related injury, or deemed non‐compensable. Main outcome measures: 12‐item Short Form Health Survey (SF‐12) and return to work or study at 12 months after injury. Results: Of 1033 eligible patients, 707 (68.8%) provided follow‐up data; 450 compensable and 247 non‐compensable patients completed the study. After adjusting for differences across the groups (age, injury severity, head injury status, injury group, and discharge destination) using multivariate analyses, compensable patients were more likely than non‐compensable patients to report moderate to severe disability at follow‐up for the physical (adjusted odds ratio [AOR], 2.0; 95% CI, 1.3–2.9), and mental (AOR, 1.6; 95% CI, 1.1–2.5) summary scores of the SF‐12. Compensable patients were less likely than non‐compensable patients to have returned to work or study, even after adjusting for injury severity, age, head injury status and discharge destination (AOR, 0.6; 95% CI, 0.3–0.9). Conclusions: Patients covered by the no‐fault compensation system for transport‐related injuries in Victoria had worse outcomes than non‐compensable patients.

Objective: To compare the survival rate from out-of-hospital cardiac arrest in rural and urban areas of Victoria, and to investigate the factors associated with these differences. Design: Retrospective case series using data from the Victorian Ambulance Cardiac Arrest Registry. Setting: All out-of-hospital cardiac arrests occurring in Victoria that were attended by Rural Ambulance Victoria or the Metropolitan Ambulance Service. Participants: 1790 people who suffered a bystander-witnessed cardiac arrest between January 2002 and December 2003. Results: Bystander cardiopulmonary resuscitation was more likely in rural (65.7%) than urban areas (48.4%) (P = 0.001). Urban patients with bystander-witnessed cardiac arrest were more likely to arrive at an emergency department with a cardiac output (odds ratio [OR], 2.92; 95% CI, 1.65-5.17; P < 0.001), and to be discharged from hospital alive than rural patients (urban, 125/1685 [7.4%]; rural, 2/105 [1.9%]; OR, 4.13; 95% CI, 1.09-34.91). Major factors associated with survival to hospital admission were distance of cardiac arrest from the closest ambulance branch (OR, 0.87; 95% CI, 0.82-0.92), endotracheal intubation (OR, 3.46; 95% CI, 2.49-4.80), and the presence of asystole (OR, 0.50; 95% CI, 0.38-0.67) or pulseless electrical activity (OR, 0.73; 95% CI, 0.56-0.95) on arrival of the first ambulance crew. Conclusions: Survival rates differ between urban and rural cardiac arrest patients. This is largely due to a difference in ambulance response time. As it is impractical to substantially decrease response times in rural areas, other strategies that may improve MJA 2006; 185: 135-139 outcome after cardiac arrest require investigation.