https://heeoe.hee.nhs.uk/sites/default/files/130220p_whole_body_ct.pdf

Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study

In the United States, injury is the leading cause of death for persons aged 1-44 years. In 2008, approximately 30 million injuries were serious enough to require the injured person to visit a hospital emergency department (ED); 5.4 million (18%) of these injured patients were transported by Emergency Medical Services (EMS). On arrival at the scene of an injury, the EMS provider must determine the severity of injury, initiate management of the patient's injuries, and decide the most appropriate destination hospital for the individual patient. These destination decisions are made through a process known as "field triage," which involves an assessment not only of the physiology and anatomy of injury but also of the mechanism of the injury and special patient and system considerations. Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process through its "Field Triage Decision Scheme." This guidance was updated with each version of the decision scheme (published in 1986, 1990, 1993, and 1999). In 2005, CDC, with financial support from the National Highway Traffic Safety Administration, collaborated with ACS-COT to convene the initial meetings of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme; the revised version was published in 2006 by ACS-COT (American College of Surgeons. Resources for the optimal care of the injured patient: 2006. Chicago, IL: American College of Surgeons; 2006). In 2009, CDC published a detailed description of the scientific rationale for revising the field triage criteria (CDC. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR 2009;58[No. RR-1]). In 2011, CDC reconvened the Panel to review the 2006 Guidelines in the context of recently published literature, assess the experiences of states and local communities working to implement the Guidelines, and recommend any needed changes or modifications to the Guidelines. This report describes the dissemination and impact of the 2006 Guidelines; outlines the methodology used by the Panel for its 2011 review; explains the revisions and modifications to the physiologic, anatomic, mechanism-of-injury, and special considerations criteria; updates the schematic of the 2006 Guidelines; and provides the rationale used by the Panel for these changes. This report is intended to help prehospital-care providers in their daily duties recognize individual injured patients who are most likely to benefit from specialized trauma center resources and is not intended as a mass casualty or disaster triage tool. The Panel anticipates a review of these Guidelines approximately every 5 years.

Guidelines for field triage of injured patients recommendations of the national expert panel on field triage.

BACKGROUND: The opinion that injuries sustained in Iraq and Afghanistan have increased in severity is widely held by clinicians who have deployed multiple times To continuously improve combat casualty care, the Department of Defense has enacted numerous evidence-based policies and clinical practice guidelines We hypothesized that the severity of wounds has increased over time Furthermore, we examined cause of death looking for opportunities of improvement for research and training METHODS: Autopsies of the earliest combat deaths from Iraq and Afghanistan and the latest deaths of 2006 were analyzed to assess changes in injury severity and causes of death Fatalities were classified as nonsurvivable (NS) or potentially survivable (PS) PS deaths were then reviewed in depth to analyze mechanism and cause RESULTS: There were 486 cases from March 2003 to April 2004 (group 1) and 496 from June 2006 to December 2006 (group 2) that met inclusion criteria Of the PS fatalities (group 1: 93 and group 2: 139), the injury severity score was lower in the first group (27 +/- 14 vs 37 +/- 16, p or=4 (11 +/- 079 vs 15 +/- 083 per person, p < 0001) The main cause of death in the PS fatalities was truncal hemorrhage (51% vs 49%, p = NS) Deaths per month between groups doubled (35 vs 71), whereas the case fatality rates between the two time periods were equivalent (110 vs 98, p = NS) DISCUSSION: In the time periods of the war studied, deaths per month has doubled, with increases in both injury severity and number of wounds per casualty Truncal hemorrhage is the leading cause of potentially survivable deaths Arguably, the success of the medical improvements during this war has served to maintain the lowest case fatality rate on record Language: en

Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006.

Background: We have previously shown that blood transfusion in the first 24 hours is an independent predictor of mortality, intensive care unit (ICU) admission, and increased ICU length of stay in the acute trauma setting when controlling for Injury Severity Score, Glasgow Coma Scale score, and age. Indices of shock such as base deficit, serum lactate level, and admission hemodynamic status (systolic blood pressure, heart rate) and admission hematocrit were considered potential confounding variables in that study. The objectives of this study were to evaluate admission anemia and blood transfusion within the first 24 hours as independent predictors of mortality, ICU admission, ICU length of stay (LOS), and hospital LOS, with serum lactate level, base deficit, and shock index (heart rate/ systolic blood pressure) as covariates. Methods: Prospective data were collected on 15,534 patients admitted to a Level I trauma center over a 3-year period (1998-2000) and stratified by age, gender, race, Glasgow Coma Scale score, and Injury Severity Score. Admission anemia and blood transfusion were assessed as independent predictors of mortality, ICU admission, ICU LOS, and hospital LOS by logistic regression analysis, with base deficit, serum lactate, and shock index as covariates. Results: Blood transfusion was a strong independent predictor of mortality (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.82-4.40; p < 0.001), ICU admission (OR, 3.27; 95% CI, 2.69-3.99; p < 0.001), ICU LOS (p < 0.001), and hospital LOS (Coef, 4.37; 95% CI, 2.79-5.94; p < 0.001) when stratified by indices of shock (base deficit, serum lactate, shock index, and anemia). Patients who underwent blood transfusion were almost three times more likely to die and greater than three times more likely to be admitted to the ICU. Admission anemia (hematocrit < 36%) was an independent predictor of ICU admission (p = 0.008), ICU LOS (p = 0.012), and hospital LOS (p < 0.001). Conclusion: Blood transfusion is confirmed as an independent predictor of mortality, ICU admission, ICU LOS, and hospital LOS in trauma after controlling for severity of shock by admission base deficit, lactate, shock index, and anemia. The use of other hemoglobin-based oxygen-carrying resuscitation fluids (such as human or bovine hemoglobin substitutes) in the acute postinjury period warrants further investigation.

Blood transfusion, independent of shock severity, is associated with worse outcome in trauma.

Background:The establishment of trauma systems was anticipated to improve overall survival for the severely injured patient. We systematically reviewed the published literature to assess if outcome from severe traumatic injury is improved for patients following the establishment of a trauma system.M

A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems.

The Major Trauma Outcome Study (MTOS) is a retrospective descriptive study of injury severity and outcome coordinated through the American College of Surgeons' Committee on Trauma. From 1982 through 1987, 139 North American hospitals submitted demographic, etiologic, injury severity, and outcome data for 80,544 trauma patients. Motor vehicle related injuries were most frequent (34.7%). Twenty-one per cent of patients had penetrating injuries. The overall mortality rate was 9.0%. The mortality rate for direct admissions was strongly related to the presence of serious head injury, 5.0% and 40.0%, when head injuries were less than or equal to AIS (Abbreviated Injury Scale) 3 or greater than or equal to AIS 4, respectively. Survival probability norms use the Revised Trauma Score, Injury Severity Score, patient age, and injury mechanism. Patients with unexpected outcomes were identified and statistical comparisons of actual and expected numbers of survivors made for each institution. Results provide a description of injury and outcome and support evaluation and quality assurance activities.

The Major Trauma Outcome Study: establishing national norms for trauma care.

The injury severity score (5) (iss) is a scalar (single number) measure of anatomic injury, widely used in and an important contribution to trauma research. The iss is the sum of squares of the highest abbreviated injury scale (1-3) (AIS) grade in each of the three most severely injured body regions. Thus the iss is a summary measure of trauma to single or multiple body regions. Per cent mortality for blunt injured patients has been shown to be related to iss (based on AIS-76) and patient age (4-6). Patients used to establish those relationships were treated in 1961 and 1967-1968. Similar relationships for penetrating injuries have not been prepared because, until the 1985 version, the AIS provided severity grades for blunt injuries only. The iss is frequently used to assess or compare the injury severity of patient populations (7, 10, 13, 16) and as the anatomic component of trauma patient characterizations used in evaluation of care and quality assurance methods (8). The AIS first published in 1971, was developed to classify anatomic injury from motor vehicle-related trauma. It has been revised and broadened in scope in 1976, 1980, and 1985. Changes in injury coding, trauma care delivery, and clinical management mandate the updating of relationships between severity measures and mortality from which conclusions regarding patient management or healthcare policy issues may be drawn. The present study uses the most recent AIS version (AIS-85) to derive relationships between mortality rate and the iss for comtemporary patients with blunt or penetrating injuries and identifies important properties of the iss which should be considered when the measure is used to compare case mix severity in different populations.(Author/TRRL)

Susan L. Keast

Papers

The Major Trauma Outcome Study: establishing national norms for trauma care.

The Injury Severity Score revisited

Progress toward a new injury severity characterization: severity profiles.