Impact of a streamlined trauma management approach and determinants of mortality among hemodynamically unstable patients with severe multiple injuries: a before-and-after retrospective cohort study

Abstract

BackgroundTrauma management requires a multidisciplinary approach, but coordination of staff and procedures is challenging in patients with severe trauma. In October 2014, we implemented a streamlined trauma management system involving emergency physicians trained in severe trauma management, surgical techniques, and interventional radiology. We evaluated the impact of streamlined trauma management on patient management and outcomes (study 1) and evaluated determinants of mortality in patients with severe trauma (study 2).MethodsWe conducted a retrospective cohort study of 125 patients admitted between January 2011 and 2019 with severe trauma (Injury Severity Score ≥16) and persistent hypotension (≥2 systolic blood pressure measurements <90 mm Hg). Patients were divided into a Before cohort (January 2011 to September 2014) and an After cohort (October 2014 to January 2019) according to whether they were admitted before or after the new approach was implemented. The primary outcome was in-hospital mortality.ResultsCompared with the Before cohort (n=59), the After cohort (n=66) had a significantly lower in-hospital mortality (36.4% vs. 64.4%); required less time from hospital arrival to initiation of surgery/interventional radiology (median, 41.0 vs. 71.5 minutes); and was more likely to undergo resuscitative endovascular balloon occlusion of the aorta (24.2% vs. 6.8%). Plasma administration before initiating hemostasis (adjusted OR 1.49 (95% CI 1.04 to 2.14)), resuscitative endovascular balloon occlusion of the aorta (9.48 (95% CI 1.25 to 71.96)), and shorter time to initiation of surgery/interventional radiology (0.97 (95% CI 0.96 to 0.99)) were associated with significantly lower mortality.DiscussionImplementing a streamlined trauma management protocol improved outcomes among hemodynamically unstable patients with severe multiple trauma.Level of evidenceLevel III.

The impact of time to hemostatic intervention and delayed care for patients with traumatic hemorrhage: A systematic review

“…Twenty-three of 24 studies had mortality or survival as outcomes of interest 9,16,18–38 . Most studies (15 of 23 [65.2%]) reported in-hospital mortality, while four reported 30-day mortality, three examined 24-hour mortality, two assessed 28-day mortality, and one reported time to mortality (Table 1).…”

Team Approach: The Unstable Trauma Patient

“…4) and elevated lactic acid; therefore damage control techniques were used and the patient underwent temporizing spanning knee fixation. outcomes 68 . Effective communication including clearly establishing roles and working together as a team to enhance the level of care provided is critical to success.…”

“…Overall, thoughtful and timely care of the unstable trauma patient through a multidisciplinary team optimizes outcomes 68 . Effective communication including clearly establishing roles and working together as a team to enhance the level of care provided is critical to success.…”

Is resuscitative endovascular balloon occlusion of the aorta for computed tomography diagnosis feasible or not? A Japanese single-center, retrospective, observational study

“…It is also possible to perform surgery and IR immediately. 19,20 Therefore, we have performed REBOA for a limited number of patients, preventing unnecessary use. 21 Recently, it is possible to perform a pan-CT scan in approximately 10 minutes.…”

“…In our hospital, the CT, angiography suite, and OR are integrated beside the ED and are available for use at any time. It is also possible to perform surgery and IR immediately 19,20 . Therefore, we have performed REBOA for a limited number of patients, preventing unnecessary use 21 .…”