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INTRODUCTION: 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 AND ANALYSIS: 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. ETHICS AND DISSEMINATION: 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. TRIAL REGISTRATION NUMBER: NCT05780918.

BACKGROUND: The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS: Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patients directives, family feelings and representatives desires, and all decisions should be shared. CONCLUSIONS: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

This study aims to explore the experiences of frontline hospital nurses over 18 months of struggle with the COVID-19 pandemic. The qualitative thematic analysis method was applied. Twenty-three nurses from nine tertiary hospitals in Israel were interviewed using semi-structured interviews via the ZOOM platform between August and September 2021. Interviews were video recorded and transcribed verbatim. Trustworthiness was assured by using qualitative criteria and the COREQ checklist. Results: Both negative and positive experiences were reported: threat and uncertainty along with awareness of their important mission; anxiety and helplessness alongside courage and heroism. Personal management strategies emerged: regulating overwhelming emotions and managing work–life balance. Team support emerged as the most meaningful source of nurses’ struggle with the pandemic. A sense of intimacy and solidarity enabled the processing of the shared traumatic experiences. Conclusions: A deeper understanding of nurses’ experiences through the pandemic was gained. Informal peer support has proven effective in struggling with the events. Formal interventions, such as affective–cognitive processing of traumatic events, need to be integrated into practice. Healthcare policymakers should promote better support for caregivers, which will contribute to their well-being and impact the quality of care they provide.

Abstract Background Advanced Trauma Life Support (ATLS) is the gold standard of initial assessment of trauma patients and therefore a widely used training program for medical professionals. Practical application of the knowledge taught can be challenging for medical students and inexperienced clinicians. Simulation-based training, including virtual reality (VR), has proven to be a valuable adjunct to real-world experiences in trauma education. Previous studies have demonstrated the effectiveness of VR simulations for surgical and technical skills training. However, there is limited evidence on VR simulation training specifically for trauma education, particularly within the ATLS curriculum. The purpose of this pilot study is to evaluate the feasibility, effectiveness, and acceptance of using a fully immersive VR trauma simulation to prepare medical students for the ATLS course. Methods This was a prospective randomised controlled pilot study on a convenience sample of advanced medical students (n = 56; intervention group with adjunct training using a commercially available semi-automated trauma VR simulation, n = 28, vs control group, n = 28) taking part in the ATLS course of the Military Physician Officer School. Feasibility was assessed by evaluating factors related to technical factors of the VR training (e.g. rate of interruptions and premature termination). Objective and subjective effectiveness was assessed using confidence ratings at four pre-specified points in the curriculum, validated surveys, clinical scenario scores, multiple choice knowledge tests, and ATLS final clinical scenario and course pass rates. Acceptance was measured using validated instruments to assess variables of media use (Technology acceptance, usability, presence and immersion, workload, and user satisfaction). Results The feasibility assessment demonstrated that only one premature termination occurred and that all remaining participants in the intervention group correctly stabilised the patient. No significant differences between the two groups in terms of objective effectiveness were observed (p = 0.832 and p = 0.237 for the pretest and final knowledge test, respectively; p = 0.485 for the pass rates for the final clinical scenario on the first attempt; all participants passed the ATLS course). In terms of subjective effectiveness, the authors found significantly improved confidence post-VR intervention (p

Purpose: To determine the impact of structured debriefings (SD) with audio/video review of trauma patients' resuscitation events on trauma team (TT) technical and non-technical skills. Methods: Single-center prospective observational cohort study. The study included all emergency department patients aged 18 years or older who received resuscitation from the TT. Virtual meeting was held with the TT using SD to review one trauma patient resuscitation video. Technical skills improvement was based on adherence to the ATLS protocol and non-technical skills based on T-NOTECHS scale. Results: There was statistically significant improvement in adherence to the ATLS protocol: 73% [55–82%] vs 91% [82–100%] (p < 0.001); and improvement in T-NOTECHS scale: 12 [10–14] vs 16 [14–19] points (p < 0.001). Conclusion: In this study, we found that structured debriefings with review of patients' resuscitation video recordings can have a significant positive impact on trauma team performance in the emergency department in both technical and non-technical skills. [ABSTRACT FROM AUTHOR]

This study aims to explore the experiences of frontline hospital nurses over 18 months of struggle with the COVID-19 pandemic. The qualitative thematic analysis method was applied. Twenty-three nurses from nine tertiary hospitals in Israel were interviewed using semi-structured interviews via the ZOOM platform between August and September 2021. Interviews were video recorded and transcribed verbatim. Trustworthiness was assured by using qualitative criteria and the COREQ checklist. Results: Both negative and positive experiences were reported: threat and uncertainty along with awareness of their important mission; anxiety and helplessness alongside courage and heroism. Personal management strategies emerged: regulating overwhelming emotions and managing work–life balance. Team support emerged as the most meaningful source of nurses' struggle with the pandemic. A sense of intimacy and solidarity enabled the processing of the shared traumatic experiences. Conclusions: A deeper understanding of nurses' experiences through the pandemic was gained. Informal peer support has proven effective in struggling with the events. Formal interventions, such as affective–cognitive processing of traumatic events, need to be integrated into practice. Healthcare policymakers should promote better support for caregivers, which will contribute to their well-being and impact the quality of care they provide. [ABSTRACT FROM AUTHOR]

The Philippine Journal of Orthopaedics remains a cornerstone in the academic and research landscape of Philippine orthopaedics. Orthopaedic surgery is continually evolving, driven by improvements in musculoskeletal and trauma care outcomes. In this issue, we focus on trauma involving the pelvis, acetabulum, tibia, spine, and hand, as well as innovations that could shape the Philippine orthopaedic landscape. Trauma management may differ from the ideal, yet outcomes can still be optimized. Delaying surgery for acetabular fractures by two weeks has been shown to yield similar outcomes to immediate treatment. Closed management of tibial fractures may also be a viable option for patients nearing skeletal maturity. Understanding the epidemiology of spine disorders in our population is crucial. In a tertiary hospital setting, traumatic spine disorders were the most common causes of admission (66%), while among non-traumatic causes, tuberculous infection was the most common etiology (74.7%). Surgery for patients with intermediate SINS (Spinal Instability Neoplastic Score) was found to reduce both functional decline and the risk of revision surgery compared to medical management. Percutaneous pinning of proximal phalanges and metacarpals under conventional radiographic guidance in the emergency room resulted in 47% of patients achieving good or excellent outcomes in terms of total active motion of the fingers on follow-up. A randomized controlled study on WALANT (Wide Awake Local Anesthesia No Tourniquet) for hand surgery concluded that lower concentrations of lidocaine may be sufficient for short procedures. Another study comparing the classic Atasoy flap to the Pentagonal flap for fingertip injuries found no significant differences in terms of technique, sensation, patient satisfaction, return to work, and complications. However, the Pentagonal flap was advantageous for larger defects where tension-free closure might be challenging. Two papers reported innovative materials research. Digital finite element analysis was used to design and simulate biomechanical testing of materials for an external fixator clamp. The resulting 3D-printed plastic resin was then used to create iFix clamp prototypes, which displayed comparable deformation under axial loading when compared with conventional Roger-Anderson clamps. Titanium nail-spanning systems have also been designed and manufactured locally for limb salvage surgery (primary knee resection-arthrodesis) in tumors around the knee, and they have proven useful when a prosthesis is not available. I would like to congratulate the authors for their steadfast commitment to advancing Philippine orthopaedic research. As the field continues to evolve, the PJO will remain at the forefront of driving positive change, improving patient outcomes, and shaping the future of orthopaedic practice in the Philippines and beyond. As we enter our third year of publication, I wish everyone a Blessed Christmas and a Prosperous New Year on behalf of our Editor-in-Chief, Associate Editors, and dedicated editorial staff. Mabuhay!

Abstract Background The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. Methods Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. Results The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient’s directives, family feelings and representatives' desires, and all decisions should be shared. Conclusions The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes. Graphical abstract

Research has shown that barriers and facilitators in psychotherapy exhibit similarities. The authors of this study are of the view that to effectively address the difficulties encountered in psychotherapy for children and adolescents, it is crucial to consider the points of view of professionals who have firsthand encounters with children. The purpose of this study was to effectively explore barriers and facilitators in the treatment of children exposed to trauma and violence. Exploratory and descriptive methods, as components of a qualitative research design, were employed to investigate and articulate the barriers and facilitators involved in managing childhood trauma. An advertisement was used to recruit participants. It was developed and distributed to psychologists and social workers recommended by the Thohoyandou Victim Empowerment Programme. Seventeen professionals were individually interviewed using semi-structured interview schedules. The interviews were recorded, transcribed verbatim, and analysed using interpretative phenomenological analysis (IPA). The findings of the study indicated a lack of commitment from parents in honouring appointments, financial challenges, a fear of perpetrators associated with the poor reporting of incidences, professional boundaries, and referral route challenges. Familiar facilitators in the management of childhood trauma included continuous training and workshops for all people working with childhood trauma and violence, the employment of more victim advocates, and awareness campaigns. Additionally, the referral pathway for traumatised children presents logistical, psychological, and educational hurdles, underscoring the complex nature of meeting the needs of these vulnerable populations within the healthcare system. In conclusion, even while the currently available research supports the barriers and facilitators for this population, more investigation is required to examine how these factors affect treatment outcomes, particularly in community-based settings. [ABSTRACT FROM AUTHOR]

The Substance Abuse and Mental Health Services Administration trauma model was used as conceptual framework in guiding the development of the Teacher Trauma Identification and Management Scale completed by 284 teachers in inclusive schools in Egypt. In addition, the Statistical Package for the Social Sciences Analysis of Moment Structures (SPSS AMOS) and Andrew Haye’s moderation model were used to estimate the relationship between perceived knowledge of trauma identification and practices among teachers. The result supported the hypothesized relationship between trauma identification and trauma-informed practice. The study concludes with recommendations for developing a homegrown trauma policy to guide schools and teachers. [ABSTRACT FROM AUTHOR]

The management of spinal trauma in the pre-hospital setting is based on techniques of immobilization for prevention of secondary neurological damage in high-risk patients during transportation.1 Since the ’70s, the traditional form of Preventive Spinal Immobilization (PSI) has been carried out using a long spinal board, head blocks, and immobilization straps often associated with the placement of a cervical collar.2 The first documentation of this practice comes from the early 19th century, when pre-hospital trauma care was introduced on the battlefields of the Napoleonic Wars.3 This strategy is still adopted by many pre-hospital medical services worldwide and taught as the gold standard on many trauma courses. The traditional form of PSI is indeed based more on pragmatism than on high-quality studies supporting its efficacy.3 [...]

Background: Although trauma is one of the leading causes of behaviour problems among children with disabilities, there has been limited scholarly interest in trauma management within the discourse of implementation of inclusive education. Objectives: The Substance Abuse and Mental Health Services Administration (SAMHSA) trauma management model was used to study teachers’ awareness of trauma management among students with disabilities studying in regular classrooms. Method: A total of 271 teachers were recruited from two municipalities in the central region of Ghana to complete the Teacher Trauma Management Scale developed for this study. The data were analysed using confirmatory factor analysis, mean scores, multivariate analysis of variances, and linear regression. Results: The results showed teachers’ uncertainty towards trauma management, and a positive correlation was also found between the tenets of the study framework. Conclusion: The study concluded with a recommendation for contextual development of the curriculum to guide teacher training in trauma management. Contribution: Studies on trauma management within the discourse of implementation of inclusive education are scarce. This study extends the literature on inclusive education to teacher development to support trauma management among students with disabilities in regular schools.

Research has shown that barriers and facilitators in psychotherapy exhibit similarities. The authors of this study are of the view that to effectively address the difficulties encountered in psychotherapy for children and adolescents, it is crucial to consider the points of view of professionals who have firsthand encounters with children. The purpose of this study was to effectively explore barriers and facilitators in the treatment of children exposed to trauma and violence. Exploratory and descriptive methods, as components of a qualitative research design, were employed to investigate and articulate the barriers and facilitators involved in managing childhood trauma. An advertisement was used to recruit participants. It was developed and distributed to psychologists and social workers recommended by the Thohoyandou Victim Empowerment Programme. Seventeen professionals were individually interviewed using semi-structured interview schedules. The interviews were recorded, transcribed verbatim, and analysed using interpretative phenomenological analysis (IPA). The findings of the study indicated a lack of commitment from parents in honouring appointments, financial challenges, a fear of perpetrators associated with the poor reporting of incidences, professional boundaries, and referral route challenges. Familiar facilitators in the management of childhood trauma included continuous training and workshops for all people working with childhood trauma and violence, the employment of more victim advocates, and awareness campaigns. Additionally, the referral pathway for traumatised children presents logistical, psychological, and educational hurdles, underscoring the complex nature of meeting the needs of these vulnerable populations within the healthcare system. In conclusion, even while the currently available research supports the barriers and facilitators for this population, more investigation is required to examine how these factors affect treatment outcomes, particularly in community-based settings.

Introduction: Dismounted blast has the potential to cause life-threatening injuries to multiple simultaneous casualties, including injury to the cervical spine (c-spine). Spinal immobilisation can be costly in terms of time and personnel required to apply and sustain it. C-spine 'clearing' tools frequently do not apply to the blast-injured casualty, so clinical judgement must be used to determine those requiring c-spine immobilisation. This will be strongly influenced by the likelihood of such an injury, but currently, the incidence of c-spine injury in dismounted blasts is not known., Methods: We searched PubMed, EMBASE and the Cumulative Index to Nursing and Allied Health for original research reporting the number of patients suffering c-spine injury as a result of the dismounted blast, as well as indices of injury severity such as incidence of limb amputation. Rates were combined to give an overall incidence. The systematic review was preregistered with PROSPERO (CRD42024527592)., Results: 2775 unique studies were identified, 13 of which were analysed. Reported incidences of c-spine injuries ranged from 0% to 5.85% across all 13 studies, and unstable injuries ranged from 0% to 1.23% in the nine studies in which this could be calculated. After excluding one study due to an overlapping population, in 7889 patients the rate of c-spine injury was 0.89%. In the 4618 patients for which the incidence of unstable c-spine injury could be calculated, the rate was 0.30%. There was no correlation between the rate of amputation and the rate of c-spine injury (Spearman's ρ=0.226, p=0.667)., Conclusion: Dismounted blasts result in a very low rate of c-spine injury. The populations sampled included a number of seriously injured casualties with potentially life-threatening wounds, such as limb amputation. We recommend deprioritising c-spine control in dismounted victims of the blast in favour of focusing the limited time and resources on addressing potentially life-threatening injuries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Morbidity and mortality from pelvic ring injuries can be mitigated by early and effective external pelvic stabilisation. The field-expedient pelvic splint (FEPS) is a recently described technique to improvise an effective pelvic binder for an austere environment. This technique has not been biomechanically validated. We hypothesise that the FEPS will be biomechanically equivalent to a commercially available pelvic binder routinely used in the austere environment., Methods: Compressive force generation of the FEPS was measured using a commercial load frame. A SAM Pelvic Sling was used as a control. The FEPS was tested for initial force generation, persistence of force generation over a 6-hour longitudinal test period and force generation after repeated assembly/disassembly., Results: The FEPS generated 203N (±7N) with one windlass turn and 420N (±34N) with two windlass turns. The SAM Pelvic Sling generated 197N (±11N) of force. There was no significant difference between FEPS after one windlass crank and the SAM Pelvic Sling but the force generated by the FEPS with two windlass cranks was significantly higher than the SAM Pelvic Sling. Longitudinal testing showed that after 6 hours of continuous compression, the FEPS generated 189N (±19N) and the force generated at hour 6 was not significantly different from the initial force generated by SAM Pelvic Sling. Reusability testing showed no significant difference with force generation by the FEPS after repeated assembly/disassembly with one crank of the windlass but there was a significantly increased force generation by FEPS after repeated use trials with two cranks of the windlass., Conclusion: The FEPS exerted equivalent pelvic compressive forces to its commercial equivalent and this force generation persists at effective levels over a 6-hour time course. The FEPS remained effective after repeated use. The FEPS is a viable alternative in the austere or resource-limited environment for temporary pelvic stabilisation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: In light of the risks of over-reliance on opioid analgesia during recovery from rib fractures, there is increased interest in the efficacy of non-pharmacological approaches to pain management. This paper describes the protocol for a double-blind randomised controlled trial to evaluate the efficacy of an mHealth intervention for reducing pain intensity, pain-related distress and opioid use during early recovery from rib fractures., Methods and Analysis: Adults (N=120) with isolated rib fractures will be recruited within 24 hours of admission to a large public hospital in Sydney, Australia (single site), and randomised (1:1 allocation) to an intervention or active control group. Clinicians, participants and statisticians will be blind to participants' group allocation. The intervention (PainSupport) consists of a brief pain self-management educational video, followed by twice daily supportive Short Message Service (SMS) text messages for 14 days. Participants in the active control group receive the same video but not the supportive text messages. Participants in both groups continue to receive usual care throughout the trial. The primary outcome will be self-reported pain intensity on respiration measured using a Numerical Rating Scale. Secondary outcomes will include opioid use, pain-related distress, adherence to behavioural pain management strategies and the acceptability and feasibility of the intervention. Participants will complete questionnaires at baseline and then on days 1-7 and day 14 of the trial. A feedback survey will be completed at the end of the trial (day 15). Linear mixed models will be used to evaluate the main effect of the group on the primary and secondary outcomes and to explore differences between outcome trends recorded over the trial. Analyses will be based on the intention-to-treat principle to minimise bias secondary to missing data or dropouts., Ethics and Dissemination: The study protocol has been reviewed and approved by the Northern Sydney Local Health District Human Research Ethics Committee (Australia). Informed consent is a requirement for participation in the study. Study results will be published in peer-reviewed journals and presented at scientific and professional meetings., Trial Registration Number: ACTRN12623000006640., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The introduction of wireless sensors will enable military care providers to continuously and remotely assess/monitor vital signs. Prediction models are needed to use such data adequately and aid military care providers in their on-scene decision-making to optimise prehospital triage and improve patient outcomes., Methods: A prospective cohort comprising data from eight Emergency Medical Services and seven inclusive trauma regions was used to develop and validate prediction models that could aid military care providers in their prehospital triage decisions. Healthy (American Society of Anesthesiologists physical status classification 1 or 2) admitted adult trauma patients (aged ≥16 and ≤50 years), who suffered from a trauma mechanism that could occur to military personnel and were transported by ambulance from the scene of injury to a hospital, were included. A full model strategy was used, including prehospital predictors that are expected to be automaticly collectible by wireless sensors or to be incorporated in a personalised device that could run the models. Models were developed to predict early critical-resource use (ECRU), severe head injury (Abbreviated Injury Scale (AIS) ≥4), serious thoracic injury (AIS ≥3) and severe internal bleeding (>20% blood loss). Model performance was evaluated in terms of discrimination and calibration., Results: Prediction models were developed with data from 4625 patients (80.0%) and validated with data from 1157 patients (20.0%). The models had good to excellent discriminative performance for the predicted outcomes in the validation cohort, with an area under the curve of 0.80 (95% CI 0.76 to 0.84) for ECRU, 0.83 (0.76 to 0.91) for severe head injury, 0.75 (0.70 to 0.80) for serious thoracic injury and 0.85 (0.78 to 0.93) for severe internal bleeding. All models showed satisfactory calibration in the validation cohort., Conclusion: The developed models could reliably predict outcomes in a simulated military trauma population and potentially support prehospital care providers in their triage decisions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Breast trauma in elderly patients with multiple comorbidities can result in severe complications such as hemorrhagic shock due to the highly vascular nature of breast tissue. This case involves a 65-year-old female with a history of rheumatoid arthritis and prior breast cancer who developed a significant breast hematoma following a motor vehicle accident. Initially stable, she rapidly deteriorated with hypotension and altered mental status after imaging revealed a large hematoma with active hemorrhage. Immediate intervention, including blood transfusion and intubation, was essential for stabilization. While spontaneous cessation of bleeding and hematoma stabilization can negate the need for further intervention, persistent bleeding requires prompt action. Options include surgical exploration, hematoma evacuation, vessel ligation, interventional radiology for embolization, additional blood transfusions, and pharmacological hemostatic agents. Breast hematoma can lead to hemorrhagic shock if severe enough in elderly patients with reduced physiological reserve., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Introduction: Intraosseous devices have become an alternative to peripheral intravenous (PIV) access. Despite the established success of intraosseous devices in laboratory and simulator studies, there is a lack of data regarding their real-world utilisation in prehospital settings. Therefore, this study aims to evaluate the success rates of intraosseous access in a prehospital military context and identify factors associated with failure., Methods: Using the Israel Defense Forces (IDF) Trauma Registry, we retrospectively collected data from 2010 to 2023. The primary outcome was the first pass success rate of intraosseous access, and logistic regression models were applied to identify variables associated with first pass failure., Results: The study included 172 trauma patients who underwent attempted intraosseous access with 46.5% cases which were classified as military events. The median age was 22 years, and 17.3% were paediatric patients. First pass success was achieved in 67.4% of cases, with a cumulative success rate of 80.8% after multiple attempts. Moreover, significant differences were noted when examining the success rate of the three intraosseous devices used by the IDF teams, with the highest success rate being documented for the NIO Adult versus the EZ-IO or the BIG (81.4%; 76.7%; 62.4%). However, logistic regression analysis revealed that the number of PIV access attempts was the only variable significantly associated with decreased odds of achieving first pass intraosseous access., Conclusion: These findings suggest that intraosseous devices are a viable alternative for establishing vascular access in prehospital military settings. However, success rates were slightly lower than previous reports, potentially due to the severity of injuries in the study cohort. Our analyses revealed a higher number of PIV access attempts correlated with reduced first pass intraosseous success, possibly stemming from caregiver proficiency in obtaining vascular access. Further research is needed to explore additional factors affecting intraosseous access success rates., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Major trauma centres (MTCs) save lives but rehabilitation to support return-to-work (RTW) is lacking. This paper describes development of a vocational rehabilitation intervention (the ROWTATE intervention) to support RTW following traumatic injury., Design: Sequential and iterative person-based approach in four stages- Stage 1: review of evidence about the efficacy and mechanisms of RTW interventions; Stage 2: interviews (n=38) and focus groups (n=25) with trauma survivors and service providers in five UK MTCs to identify the issues, and challenges faced postinjury; Stage 3 : codesign workshops (n=43) with trauma stakeholders in MTCs to conceptually test and identify intervention delivery barriers/enablers; Stage 4: meetings (n=7) with intervention development working group (IDWG) to: (1) generate guiding principles, (2) identify key intervention features (process, components, mechanisms) to address unmet rehabilitation needs; (3) generate a logic model and programme theory to illustrate how the intervention works; and (4) develop a training package to support delivery., Results: Trauma survivors described unmet needs relating to early advice about RTW; psychological support; pain management; hidden disabilities (eg, fatigue); estimating recovery; and community, amputee and musculoskeletal rehabilitation. Mechanisms of effective interventions identified in the review included early intervention, colocation, employer engagement, case coordination and work accommodations. Intervention features identified by IDWG members (n=13) from stages 1 and 2 were use of stepped-care approaches by occupational therapists (OTs) and clinical psychologists (CPs), OT/CP formulation for complex cases, assessment of mental health problems, individually tailored rehabilitation including vocational goal setting, cross-sector coordination/communication, employer engagement, phased RTW, education/advice for family/employers, exploration of work alternatives, ongoing review of physical and mental health needs, work stability monitoring. Conceptual testing ratified the logic model. Geography and long waiting lists were identified as potential delivery barriers., Conclusions: Real-world testing of the intervention is underway in a randomised controlled trial., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Non-compressible abdominal haemorrhage (NCAH) is a potentially preventable cause of death due to injury. Limited exploratory laparotomy by a non-surgeon is a temporary intervention to sustain life until definitive surgical intervention by trauma surgeons can be obtained. This study aims to establish consensus on a protocol for general surgery physician assistants performing limited exploratory laparotomy to manage NCAH in an austere environment., Method: This study included anonymised trauma surgeons and general surgery physician assistants from military and civilian backgrounds. Participants were recruited from various professional surgical organisations, including direct interaction with trauma surgeons and surgical physician assistants. Participants used a modified Delphi survey with a 9-point Likert scale in two rounds. The two surveys were categorised into three parts: protocol for NCAH (part A), the potential role of general surgery physician assistants (part B) and measures of success (part C). A total of 24 statements were voted on and assessed. Votes were divided into three zones: agreement (median 7-9), uncertain (median 4-6) and disagreement (median 1-3). To reach a consensus, 70% agreement was required within a zone. If more than 30% of the votes fell outside of a specific zone, consensus was not achieved. After consensus, the original protocol was revised in an online meeting with experts., Results: The initial analysis involved 29 participants. After 2 survey rounds, 19 out of 24 statements reached a consensus. Part A: 10 statements gained consensus, including in austere environments, controlling NCAH can be challenging. A qualified general surgery physician assistant should intervene. A focused assessment with sonography for trauma examination can be used for screening. Bleeding can be managed with packing and pressure. After managing the haemorrhage, the abdominal wall should be left open with a temporary closure technique. Part B: nine statements gained consensus, including in austere locations, a licensed general surgery physician assistant with a minimum of 3 years of experience working under the supervision of a trauma/general surgeon can perform interventions for limited exploratory laparotomy for patients with NCAH. Part C: general surgery physician assistants will be required to have the same success rates as any qualified surgeon., Conclusion: Gaining consensus and implementing a revised protocol for managing NCAH by general surgery physician assistants is attainable. General surgery physician assistants will need formal training to manage NCAH. With the support of trauma surgeons who provide direct and indirect supervision, general surgery physician assistants can develop a comprehensive understanding of the necessary skills and make sound decisions when treating patients with this condition. This teamwork can also increase surgical capacity and potentially decrease mortality rates for patients with NCAH in austere environments., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Military service members need to be able to operate under conditions of extreme stress to ensure the success of their team's mission; however, an acute stress reaction (ASR) can compromise team safety and effectiveness by rendering an individual unable to function. Building on an intervention originally developed by the Israel Defense Forces, several countries have developed, tested, and disseminated a peer-based intervention to help service members manage acute stress in others. This paper reviews how five countries (Canada, Germany, Norway, the UK and the USA) adjusted the protocol to fit their organisational culture while retaining essential elements of the original procedure, suggesting there can be interoperability and mutual intelligibility in the management of ASR by military allies. Future research should examine the parameters of effectiveness for this intervention, the impact of intervention on long-term trajectories, and individual differences in managing ASR., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Unintentional injuries constitute a significant global public health issue with significant social and economic costs. Previous evidence suggests ambient temperatures are associated with unintentional injury occurrences. However, the impacts of ambient temperature on unintentional injury economic burden have received little research attention. The objective of the study was to examine the association between ambient temperature and economic burden of unintentional injury., Design: Time-stratified case-crossover study., Setting: This study was performed at Tianjin Hospital, the largest trauma centre in Tianjin, by applying a hospital-based time-stratified case-crossover study., Participants: The 12 241 patients admitted with unintentional injuries and meteorological data were collected in Tianjin, China in 2021., Primary and Secondary Outcome: The association between ambient temperature and unintentional injury hospitalisation was evaluated with a distributed lag non-linear model, further temperature-attributable economic burden of unintentional injuries was quantified, and adjusted for demographic characteristics, injury mechanism and injury location of injury., Results: The temperatures below 11.5°C were significantly associated with the increased risk of unintentional injury hospitalisation in Tianjin, in 2021. The effect was maximised on the current day. The relatively low temperature was responsible for 25.44% (95% CI 13.74, 33.09) of unintentional injury patients, and was associated with the number of unintentional injury patients (3114, 95% CI 1608, 4036). The relatively low temperature was associated with the excess economic burden for unintentional injury (¥197.52 million, 95% CI 102.00, 256.00; about 27.10 million dollars), accounting for 26.49% of the total economic burden. The cold temperatures generally had greater impacts on males (¥136.46 million, 95% CI 83.28, 172.42; about 18.67 million dollars) and the elderly (¥74.35 million, 95% CI 14.87, 102.14; about 10.24 million dollars)., Conclusion: The temperature was associated with approximately 3000 unintentional injury patients and ¥200 million (27 million dollars), accounting for 26% of the total economic burden in Tianjin, 2021., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Emergency resuscitative thoracotomy (ERT) is a resource-intensive procedure that can deplete a combat surgical team's supply and divert attention from casualties with more survivable injuries. An understanding of survival after ERT in the combat trauma population will inform surgical decision-making., Methods: We requested all encounters from 2007 to 2023 from the Department of Defense Trauma Registry (DoDTR). We analysed any documented thoracotomy in the emergency department and excluded any case for which it was not possible to distinguish ERT from operating room thoracotomy. The primary outcome was 24-hour mortality., Results: There were 48 301 casualties within the original dataset. Of those, 154 (0.3%) received ERT, with 114 non-survivors and 40 survivors at 24 hours. There were 26 (17%) survivors at 30 days. The majority were performed in role 3. The US military made up the largest proportion among the non-survivors and survivors. Explosives predominated in both groups (61% and 65%). Median Composite Injury Severity Scores were lower among the non-survivors (19 vs 33). Non-survivors had a lower proportion of serious head injuries (13% vs 40%) and thorax injuries (32% vs 58%). Median RBC consumption was lower among non-survivors (10 units vs 19 units), as was plasma (6 vs 16) and platelets (0 vs 3). The most frequent interventions and surgical procedures were exploratory thoracotomy (n=140), chest thoracostomy (n=137), open cardiac massage (n=131) and closed cardiac massage (n=121)., Conclusion: ERT in this group of combat casualties resulted in 26% survival at 24 hours. Although this proportion is higher than that reported in civilian data, more rigorous prospective studies would need to be conducted or improvement in the DoDTR data capture methods would need to be implemented to determine the utility of ERT in combat populations., Competing Interests: Competing interests: None declared., (This is a U.S. Government work and not under copyright protection in the US. To the extent copyright protection is available in other jurisdictions, it is owned by the authors. Published by BMJ.)

Objectives: Insufficient training and the absence of guidelines increase the risk of retraumatisation in torture survivors during surgical procedures. This study aims to develop guidelines to mitigate this risk and gather healthcare professionals' experiences treating torture survivors and insights on the guideline's feasibility and acceptability., Design: The study was conducted in two phases. Phase 'a' involved developing guidelines based on reviews of torture survivors' encounters in somatic care and potential retraumatisation triggers, as well as a qualitative study on survivors' experiences during surgical interventions. The development process adhered to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) principles and the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument for methodological rigour. Phase 'b' involved focus groups and individual interviews with healthcare professionals to explore challenges in caring for torture survivors and to evaluate the guidelines., Setting: The study, conducted from May to August 2023, involved participants from surgical departments in three hospitals in southern and southeastern Norway., Participants: Twenty-one healthcare professionals, including surgeons, anaesthesiologists, nurses and a dentist, participated in the study. Both focus group interviews and individual interviews were conducted., Results: Phase 'a': guidelines comprising six sections were developed: an introduction, general guidelines and four sections covering the preoperative, perioperative and postoperative surgical stages. Phase 'b': healthcare professionals struggled to understand torture's complexities and identify survivors' unique needs. They faced challenges using interpreters and assisting patients with strong reactions. While the guidelines were viewed as practical and useful for raising awareness, their length was questioned., Conclusions: We provide recommendations for preventing retraumatisation in torture survivors undergoing surgical treatment. The guidelines may serve as a starting point for offering safe and individualised care to torture survivors. Teaching institutions and hospitals may incorporate the guidelines into healthcare professionals' education., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Recurrent patellar dislocation is a debilitating musculoskeletal condition, affecting mainly adolescents and adults under the age of 30. It can persist for many decades, causing pain and cartilage and soft-tissue damage, potentially leading to osteoarthritis. Recurrent patellar dislocation can be managed with physiotherapy or surgery. However, it is not known which treatment is most effective., Methods and Analysis: Recurrent Patellar Dislocation: Personalised Therapy or Operative Treatment (REPPORT) is a pragmatic, multicentre, two-arm, superiority, randomised controlled trial. It will compare the clinical and cost-effectiveness of an initial management strategy of personalised, phased and progressive rehabilitation, termed personalised knee therapy versus surgery for recurrent patellar dislocation.The trial's target sample size is 276 participants who will be recruited from approximately 20 sites across the UK. Participants will be randomly allocated to the two treatment groups via a central computer-based minimisation system. Treatment allocation will be in a 1:1 ratio, stratified by age, presence of patella alta and recruitment site.The primary outcome is participant-reported function using the Knee injury and Osteoarthritis Outcome 4-domain score at 18 months post randomisation. Health economic evaluation will be conducted from a healthcare system and personal social services perspective. Secondary outcome data including patellar instability, health utility, work/education status, satisfaction with social roles and treatment, health resource use and adverse events will be collected at 6, 12, 18 and 24 months. Analysis will be on an intention-to-treat basis and reported in-line with the Consolidated Standards of Reporting Trials statement., Ethics and Dissemination: The trial was approved by the East Midlands-Nottingham 2 Research Ethics Committee on 30 March 2023.Results will be disseminated via peer-reviewed publications, presentations at national and international conferences, in lay summaries, and using the REPPORT website and social media channels., Trial Registration Number: ISRCTN17972668., Competing Interests: Competing interests: AM, MU, DRE, TS and HP are coinvestigators on two current (RACER-Knee and RACER-Hip) and one completed (START:REACTS) NIHR funded studies (AM chief investigator of two) that have, or have had, additional support from Stryker Ltd. There is no link to the current trial. AM, MU, HP, NEF and MF are coinvestigators on grants funded by the Australian NHMRC. MU is chief investigator or coinvestigator on multiple previous and current research grants from the UK National Institute for Health Research and is a coinvestigator on grants funded by the Norwegian MRC. He was an NIHR Senior Investigator until March 2021. He is a director and shareholder of Clinvivo Ltd that provides electronic data collection for health services research. He is part of an academic partnership with Serco Ltd, funded by the European Social Fund, related to return-to-work initiatives. NEF is chief investigator or coinvestigator on multiple previous and current research grants from the UK NIHR, and Australian NHMRC and MRFF. She was an NIHR Senior Investigator and is currently an Australian National Health and Medical Research Council (NHMRC) Investigator Fellow (ID: 2018182). MRW undertakes teaching on basic sciences for Orthopaedic trainees preparing for the FRCS. His institution receives market rate payment for this teaching from Heraeus. MRW was a coapplicant on a grant funded by Stryker Ltd to investigate the outcomes of the Triathlon total knee replacement which is unrelated to this study. MRW is PI of the National Joint Registry lot 2 contract (statistical analysis) team and PI or coapplicant on multiple previous NIHR funded studies., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Traumatic brain injury (TBI) and spinal cord injury (SCI) are both major contributors to permanent disability globally, with an estimated 27 million new cases of TBI and 0.93 million new cases of SCI globally in 2016. In Australia, the National Disability Insurance Scheme (NDIS) provides support to people with disability. Reports from the NDIS suggest that the cost of support for people with TBI and SCI has been increasing dramatically, and there is a lack of independent analysis of the drivers of these increases. This data linkage seeks to better understand the participant transition between rehabilitation hospitals and the NDIS and the correlation between functional independence in rehabilitation and resource allocation in the NDIS., Methods and Analysis: This is a retrospective, population-based cohort study using Australia-wide NDIS participant data and rehabilitation hospital episode data. The linked dataset provides a comparison of functional independence against which to compare the NDIS resource allocation to people with TBI and SCI. This protocol outlines the secure and separated data linkage approach employed in linking partially identified episode data from the Australasian Rehabilitation Outcomes Centre (AROC) with identified participant data from the NDIS. The linkage employs a stepwise deterministic linkage approach. Statistical analysis of the linked dataset will consider the relationship between the functional independence measure score from the rehabilitation hospital and the committed funding supports in the NDIS plan. This protocol sets the foundation for an ongoing data linkage between rehabilitation hospitals and the NDIS to assist transition to the NDIS., Ethics and Dissemination: Ethics approval is from the Macquarie University Human Research Ethics Committee. AROC Data Governance Committee and NDIS Data Management Committee have approved this project. Research findings will be disseminated to key stakeholders through peer-reviewed publications in scientific journals and presentations to clinical and policy audiences via AROC and NDIS., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In natural disasters like earthquakes, building collapses can trap individuals, causing crush syndrome and rhabdomyolysis. This life-threatening condition often leads to acute kidney injury. We aimed to determine the effectiveness of the McMahon score in predicting mortality due to rhabdomyolysis in patients affected by the earthquake., Methods: This is a retrospective observational study. In this study, the clinical and laboratory data of patients who presented to the emergency department due to the earthquake were analyzed. The McMahon score was calculated by evaluating factors such as creatine kinase, serum creatinine levels, age, and gender., Results: The study included 151 patients, of whom 74 (49.0%) were male and 77 (51.0%) were female. In the univariate model, significant (P < .05) effectiveness was observed in differentiating between patients with and without mortality for McMahon score and the risk of acute kidney injury. At a McMahon score cutoff of 6, significant effectiveness was also observed, with an area under the curve of 0.723. At this cutoff value, the sensitivity was 80.0% and the specificity was 64.5%., Conclusions: The use of the McMahon score in emergency medicine and disaster management plays a crucial role in rapid decision-making processes due to its effectiveness in predicting mortality., (© The Author(s) 2024. Published by Oxford University Press on behalf of Fellowship of Postgraduate Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Intraosseous (IO) administration of medication, fluids and blood products is accepted practice for critically injured patients in whom intravenous access is not immediately available. However, there are concerns that high intramedullary pressures resulting from IO infusion may cause bone marrow intravasation and subsequent fat embolisation. The aim of this systematic review is to synthesise the existing evidence describing fat intravasation, fat embolism and fat embolism syndrome (FES) following IO infusion., Methods: A systematic search of CINAHL, MEDLINE and Embase was undertaken using the search terms "intraosseous", "fat embolism", "fat intravasation" and "fat embolism syndrome". Two authors independently screened abstracts and full texts, against eligibility criteria and assessed risk of bias. A grey literature search (including references) was undertaken. Inclusion criteria were: all human and animal studies reporting novel data on IO-associated fat emboli. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis., Results: 22 papers were identified from the search, with a further 5 found from reference lists. N=7 full papers met inclusion criteria. These papers were all translational animal studies. The overall risk of bias was high. Studies demonstrated that fat intravasation and fat embolisation are near universal after IO infusion, but of uncertain clinical significance. The initial IO flush appears to cause the highest intramedullary pressure and highest chance of fat intravasation and embolisation. No conclusions could be drawn on FES., Conclusions: IO catheters remain a useful intervention in the armamentarium of trauma clinicians. Although their use is widely accepted, there is a paucity of evidence investigating fat embolisation in IO infusions. Despite this, pulmonary fat emboli after IO infusion are very common. The existing data are of low quality with a high risk of bias. More research is needed to address this important subject., Prospero Registration Number: CRD42023399333., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Research quality within the neurosurgical field remains suboptimal. Therefore, many studies published in the neurosurgical literature lack enough statistical power to establish the presence or absence of clinically important differences between treatment arms. The field of neurotrauma deals with additional challenges, with fewer financial incentives and restricted resources in low-income and middle-income countries with the highest burden of neurotrauma diseases. In this systematic review, we aim to estimate the prevalence of false claims of equivalence in the neurosurgical trauma literature and identify its predictive factors., Methods and Analysis: The Preferred Reporting Items for Systematic Review and Meta-Analyses recommendations were followed. Randomised clinical trials that enrolled only traumatic brain injury patients and investigated any type of intervention (surgical or non-surgical) will be eligible for inclusion. The MEDLINE/PubMed database will be searched for articles in English published from January 1960 to July 2020 in 15 top-ranked journals. A false claim of equivalence will be identified by insufficient power to detect a clinically meaningful effect: for categorical outcomes, a difference of at least 25% and 50%, and for continuous outcomes, a Cohen's d of at least 0.5 and 0.8. Using the number of patients in each treatment arm and the minimum effect sizes to be detected, the power of each study will be calculated with the assumption of a two-tailed alpha that equals 0.05. Standardised differences between the groups with and without a false claim of equivalence will be calculated, and the variables with a standardised difference equal or above 0.2 and 0.5 will be considered weakly and strongly associated with false claims of equivalence, respectively. The data analysis will be blinded to the authors and institutions of the studies., Ethics and Dissemination: This study will not involve primary data collection. Therefore, formal ethical approval will not be required. The final systematic review will be published in a peer-reviewed journal and presented at appropriate conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objective: To explore the experiences, current approaches, opinions and awareness of healthcare professionals (HCPs) caring for adults with traumatic brain injury (TBI) regarding the audio-vestibular consequences., Design/setting: Cross-sectional online survey study., Participants: HCPs with experience of caring for adults with TBI, who were not ENT (ear nose throat) specialists or audiologists., Methods: The study was conducted from May 2022 to December 2022. The online survey consisted of 16 closed and open-text questions in English and Turkish about clinical experience, current approaches and awareness of audio-vestibular consequences following TBI. Frequencies of responses to closed questions and associations between variables were analysed using SPSS V.28. Open-text responses were summarised in Microsoft Excel., Results: Seventy HCPs participated from 17 professions and 14 countries, with the majority from the UK (42.9%). HCPs stated that 'some' to 'all' of their patients had auditory problems such as 'inability to understand speech-in-noise' (66%), 'tinnitus' (64%), 'hyperacusis' (57%) and balance problems such as 'dizziness' (79%) and 'vertigo' (67%). Usually, HCPs asked about the balance status of patients at appointments and when they observed dizziness and/or balance disorder they used screening tests, most commonly finger-to-nose (53%). For auditory impairments, HCPs preferred referring patients with TBI to audiology/ENT services. However, 6% of HCPs felt that audio-vestibular conditions could be ignored on referral because patients with TBI struggled with many impairments. Additionally, 44% would suggest hearing aids to patients with TBI with hearing loss 'if they would like to use' rather than 'definitely'., Conclusions: Many audio-vestibular impairments are observed by HCPs caring for patients with TBI. The assessment and intervention opinions and awareness of HCPs for these impairments vary. However, non-expert HCPs may not be aware of negative consequences of untreated audio-vestibular impairments following TBI. Therefore, developing a simple framework for screening and indications of audio-vestibular impairments for referral may be helpful for non-audiological specialists regularly seeing these patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Pelvic fractures, encompassing a spectrum from minor to life-threatening injuries, pose challenges in trauma management. This study focuses on short-term outcomes, exploring morbidity and mortality within 30 days postoperative, among pelvic fracture patients at a tertiary care hospital in Karachi, Pakistan. The majority of pelvic injuries result from intense blunt trauma, with associated risks of concomitant injuries. Pelvic fractures are linked to early complications such as hemorrhage, thromboembolism, and infections, influencing mortality rates., Methodology: A prospective cohort study involving 53 surgically managed pelvic fracture patients was conducted at Aga Khan University Hospital, Karachi. Variables such as age, gender, comorbidities, mechanism of injury, associated injuries, and presenting vitals were documented. Thirty-day morbidity included surgical site infections, hemorrhagic shock, nerve injuries, and others. Statistical analyses assessed associations between patient characteristics and morbidity., Results: The study revealed a median age of 37 years, with 77% male patients. Most fractures result from motor vehicle accidents. Morbidity occurred in 31.6% of cases, primarily associated with the presence of associated injuries. Postoperative complications included neurological deficits (15.1%) and pulmonary complications (9.4%). No 30-day mortality was reported., Discussion: The study highlights the importance of a multidisciplinary approach in managing pelvic fractures, emphasizing the association between associated injuries and postoperative morbidity. Comorbidities did not significantly impact morbidity, emphasizing the traumatic nature's independent contribution. Timely presentation (median 20 hours) and efficient trauma systems are crucial for optimal outcomes., Conclusion: This research contributes insights into short-term outcomes following pelvic fracture fixation in a Pakistani tertiary care setting. By exploring a range of parameters, the study emphasizes the need for comprehensive management strategies to minimize complications and improve patient outcomes. Bridging critical knowledge gaps, this research informs clinical decision-making for pelvic fracture patients in this region., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Ethics Review Committee, AKUH issued approval 2022-0525-22307. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Shahid et al.)

Introduction: Administering supplemental oxygen is a standard of care for trauma casualties to minimise the deleterious effects of hypoxaemia. Forward deployment of oxygen using pressurised cylinders is challenging, for example, logistics (weight and finite resource) and environmental risk (fire and explosion). Oxygen concentrators may overcome these challenges. Although previous studies successfully demonstrated fractional inspired oxygen (FiO 2 ) >0.8 using oxygen concentrators and ventilators, the systems did not fulfil the size, weight and power requirements of agile military medical units. This study evaluated whether a modular system of commercially available clinical devices could supply high FiO 2 to either ventilated or spontaneously breathing casualties., Methods: As a proof of principle, we configured an Inogen One G5 oxygen concentrator, Ventway Sparrow ventilator and Wenoll rebreather system to ventilate a simulated lung (tidal volume 500 mL). Casualty oxygen consumption (gas withdrawal inspiratory limb) and carbon dioxide (CO 2 ) production (CO 2 added expiratory limb) were simulated (respiratory quotient of 0.7-0.8). Three circuit configurations were evaluated: open (supplementary oxygen introduced into air inlet of ventilator); semiclosed (ventilator replaces rebreather bag of Wenoll, oxygen connected to either ventilator or Wenoll); and semiclosed with reservoir tubing (addition of 'deadspace' tube between ventilator patient circuit and Wenoll). Data presented as mean and 95% reference range., Results: There were modest increases in FiO 2 with increasing Inogen settings in 'open' configuration 0.23 (0.23-0.24) and 0.30 (0.28-0.32) (Inogen output 420 and 1260 mL/min, respectively). With the 'semiclosed' configuration and oxygen added directly into rebreather circuit, FiO 2 increased to 0.36 (0.36-0.37). The addition of the 'reservoir tubing' elevated FiO 2 to 0.78 (0.71-0.85). FiO 2 remained stable over a 4-hour evaluation period. Fractional inspired carbon dioxide CO 2 increased over time, reaching 0.005 after 170 (157-182) min., Conclusion: Combining existing lightweight devices can deliver high (>0.8) FiO 2 and offers a potential solution for the forward deployment of oxygen without needing pressurised cylinders., Competing Interests: Competing interests: None declared., (© Crown copyright (2024), Dstl.)

Introduction: The French mobile neurosurgical unit (MNSU) is used to provide specific support to remote military medicosurgical units deployed in foreign theatres. If a neurosurgical casualty is present, the Role 2 team may request the MNSU to be deployed directly from France. The deployed neurosurgeon can then perform surgery in Role 2 or decide to evacuate the casualty and perform surgery in Role 4 in France. We provide an epidemiological analysis of MNSU missions between 2001 and 2023 and investigate the value of the MNSU for the French Armed Forces., Methods: We conducted a retrospective case series that included patients managed by the MNSU from 1 January 2001 to 31 January 2023. We collected epidemiological data (eg, age, military or civilian status, delay between transmission and takeoff, origin of the injury and mission location), clinical records (aetiologies of the injury and disease), data on surgical intervention (operator nature and type of surgery) and data on postoperative outcomes recorded at the time of discharge from hospital., Results: 51 patients were managed by the MNSU. 36 (70.5%) and 3 (5.8%) patients underwent surgery on Role 2 and Role 4, respectively. 39 (76.9%) interventions were due to traumatic injury, 4 (7.8%) due to hydrocephalus, 4 (7.8%) due to vascular causes, 3 (5.9%) due to tumour and 1 (2%) due to spine degeneration. In 30 (76.9%) of these cases, the first operator was a neurosurgeon from the MNSU, whereas in the remaining 9 (23.1%) cases, procedures were initially performed by a non-neurosurgeon., Conclusion: The MNSU contribution to D1 casualties' strategic evacuation (STRATEVAC) is important. The MNSU provides additional support for STRATEVAC during the reorganisation of French Armed Forces engaged in several fronts. With the return of high-intensity wars, the French MNSU must develop and adjust for the management of massive influxes of casualties., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Paediatric concussion is a common injury. Approximately 30% of youth with concussion will experience persisting postconcussion symptoms (PPCS) extending at least 1 month following injury. Recently, studies have shown the benefit of early, active, targeted therapeutic strategies. However, these are primarily prescribed from the specialty setting. Early access to concussion specialty care has been shown to improve recovery times for those at risk for persisting symptoms, but there are disparities in which youth are able to access such care. Mobile health (mHealth) technology has the potential to improve access to concussion specialists. This trial will evaluate the feasibility of a mHealth remote patient monitoring (RPM)-based care handoff model to facilitate access to specialty care, and the effectiveness of the handoff model in reducing the incidence of PPCS., Methods and Analysis: This study is a non-randomised type I, hybrid implementation-effectiveness trial. Youth with concussion ages 13-18 will be enrolled from the emergency department of a large paediatric healthcare network. Patients deemed a moderate-to-high risk for PPCS using the predicting and preventing postconcussive problems in paediatrics (5P) stratification tool will be registered for a web-based chat platform that uses RPM to collect information on symptoms and activity. Those patients with escalating or plateauing symptoms will be contacted for a specialty visit using data collected from RPM to guide management. The primary effectiveness outcome will be the incidence of PPCS, defined as at least three concussion-related symptoms above baseline at 28 days following injury. Secondary effectiveness outcomes will include the number of days until return to preinjury symptom score, clearance for full activity and return to school without accommodations. The primary implementation outcome will be fidelity, defined as the per cent of patients meeting specialty care referral criteria who are ultimately seen in concussion specialty care. Secondary implementation outcomes will include patient-defined and clinician-defined appropriateness and acceptability., Ethics and Dissemination: This study was approved by the Institutional Review Board of the Children's Hospital of Philadelphia (IRB 22-019755). Study findings will be published in peer-reviewed journals and disseminated at national and international meetings., Trial Registration Number: NCT05741411., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Advanced Trauma Life Support (ATLS) is the gold standard of initial assessment of trauma patients and therefore a widely used training program for medical professionals. Practical application of the knowledge taught can be challenging for medical students and inexperienced clinicians. Simulation-based training, including virtual reality (VR), has proven to be a valuable adjunct to real-world experiences in trauma education. Previous studies have demonstrated the effectiveness of VR simulations for surgical and technical skills training. However, there is limited evidence on VR simulation training specifically for trauma education, particularly within the ATLS curriculum. The purpose of this pilot study is to evaluate the feasibility, effectiveness, and acceptance of using a fully immersive VR trauma simulation to prepare medical students for the ATLS course., Methods: This was a prospective randomised controlled pilot study on a convenience sample of advanced medical students (n = 56; intervention group with adjunct training using a commercially available semi-automated trauma VR simulation, n = 28, vs control group, n = 28) taking part in the ATLS course of the Military Physician Officer School. Feasibility was assessed by evaluating factors related to technical factors of the VR training (e.g. rate of interruptions and premature termination). Objective and subjective effectiveness was assessed using confidence ratings at four pre-specified points in the curriculum, validated surveys, clinical scenario scores, multiple choice knowledge tests, and ATLS final clinical scenario and course pass rates. Acceptance was measured using validated instruments to assess variables of media use (Technology acceptance, usability, presence and immersion, workload, and user satisfaction)., Results: The feasibility assessment demonstrated that only one premature termination occurred and that all remaining participants in the intervention group correctly stabilised the patient. No significant differences between the two groups in terms of objective effectiveness were observed (p = 0.832 and p = 0.237 for the pretest and final knowledge test, respectively; p = 0.485 for the pass rates for the final clinical scenario on the first attempt; all participants passed the ATLS course). In terms of subjective effectiveness, the authors found significantly improved confidence post-VR intervention (p < .001) in providing emergency care using the ATLS principles. Perceived usefulness in the TEI was stated with a mean of 4 (SD 0.8; range 0-5). Overall acceptance and usability of the VR simulation was rated as positive (System Usability Scale total score mean 79.4 (SD 11.3, range 0-100)., Conclusions: The findings of this prospective pilot study indicate the potential of using VR trauma simulations as a feasible and acceptable supplementary tool for the ATLS training course. Where objective effectiveness regarding test and scenario scores remained unchanged, subjective effectiveness demonstrated improvement. Future research should focus on identifying specific scenarios and domains where VR can outperform or enhance traditional learning methods in trauma simulation., (© 2024. The Author(s).)

Objective: To develop scores for predicting the need for artificial airway procedures for acute trauma patients in the emergency department (ED)., Design: Retrospective case-control., Setting: A tertiary comprehensive hospital in China., Participants: 8288 trauma patients admitted to the ED within 24 hours of injury and who were admitted from 1 August 2012 to 31 July 2020., Primary and Secondary Outcome Measures: The study outcome was the establishment of an artificial airway within 24 hours of admission to the ED. Based on the different feature compositions, two scores were developed in the development cohort by multivariable logistic regression. The predictive performance was assessed in the validation cohort., Results: The O-SPACER (Oxygen saturation, Systolic blood pressure, Pulse rate, Age, Coma Scale, Eye response, Respiratory rate) score was developed based on the patient's basic information with an area under the curve (AUC) of 0.85 (95% CI 0.80 to 0.89) in the validation group. Based on the basic information and trauma scores, the IO-SPACER (Injury Severity Score, Oxygen saturation, Systolic blood pressure, Pulse rate, Age, Coma Scale, Eye response, Respiratory rate) score was developed, with an AUC of 0.88 (95% CI 0.84 to 0.92). According to the O-SPACER and IO-SPACER scores, the patients were stratified into low, medium and high-risk groups. According to these two scores, the high-risk patients were associated with an increased demand for artificial airways, with an OR of 40.16-40.67 compared with the low-risk patients., Conclusions: The O-SPACER score provides risk stratification for injured patients requiring urgent airway intervention in the ED and may be useful in guiding initial management. The IO-SPACER score may assist in further determining whether the patient needs planned intubation or tracheotomy early after trauma., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Traumatic pneumothoraces are present in one of five victims of severe trauma. Current guidelines advise chest drain insertion for most traumatic pneumothoraces, although very small pneumothoraces can be managed with observation at the treating clinician's discretion. There remains a large proportion of patients in whom there is clinical uncertainty as to whether an immediate chest drain is required, with no robust evidence to inform practice. Chest drains carry a high risk of complications such as bleeding and infection. The default to invasive treatment may be causing potentially avoidable pain, distress and complications. We are evaluating the clinical and cost-effectiveness of an initial conservative approach to the management of patients with traumatic pneumothoraces., Methods and Analysis: The CoMiTED (Conservative Management in Traumatic Pneumothoraces in the Emergency Department) trial is a multicentre, pragmatic parallel group, individually randomised controlled non-inferiority trial to establish whether initial conservative management of significant traumatic pneumothoraces is non-inferior to invasive management in terms of subsequent emergency pleural interventions, complications, pain, breathlessness and quality of life. We aim to recruit 750 patients from at least 40 UK National Health Service hospitals. Patients allocated to the control (invasive management) group will have a chest drain inserted in the emergency department. For those in the intervention (initial conservative management) group, the treating clinician will be advised to manage the participant without chest drain insertion and undertake observation. The primary outcome is a binary measure of the need for one or more subsequent emergency pleural interventions within 30 days of randomisation. Secondary outcomes include complications, cost-effectiveness, patient-reported quality of life and patient and clinician views of the two treatment options; participants are followed up for 6 months., Ethics and Dissemination: This trial received approval from the Wales Research Ethics Committee 4 (reference: 22/WA/0118) and the Health Research Authority. Results will be submitted for publication in a peer-reviewed journal., Trial Registration Number: ISRCTN35574247., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Traumatic brain injury (TBI) is a common presentation in the prehospital environment. At present, paramedics do not routinely use tools to identify low-risk patients who could be left at scene or taken to a local hospital rather than a major trauma centre. The Canadian CT Head Rule (CCHR) was developed to guide the use of CT imaging in hospital. It has not been evaluated in the prehospital setting. We aim to address this gap by evaluating the feasibility and acceptability of implementing the CCHR to patients and paramedics, and the feasibility of conducting a full-scale clinical trial of its use., Methods and Analysis: We will recruit adult patients who are being transported to an emergency department (ED) by ambulance after suffering a mild TBI. Paramedics will prospectively collect data for the CCHR. All patients will be transported to the ED, where deferred consent will be taken and the treating clinician will reassess the CCHR, blinded to paramedic interpretation. The primary clinical outcome will be neurosurgically significant TBI. Feasibility outcomes include recruitment and attrition rates. We will assess acceptability of the CCHR to paramedics using the Ottawa Acceptability of Decision Rules Instrument. Interobserver reliability of the CCHR will be assessed between paramedics and the treating clinician in the ED. Participating paramedics and patients will be invited to participate in semistructured interviews to explore the acceptability of trial processes and facilitators and barriers to the use of the CCHR in practice. Data will be analysed thematically. We anticipate recruiting approximately 100 patients over 6 months., Ethics and Dissemination: This study was approved by the Health Research Authority and the Research Ethics Committee (REC reference: 22/NW/0358). The results will be published in a peer-reviewed journal, presented at conferences and will be incorporated into a doctoral thesis., Trial Registration Number: ISRCTN92566288., Competing Interests: Competing interests: RB has consulted for Abbott Point of Care and is undertaking contract clinical research with BrainBox, which manufactures assays for biomarkers of TBI., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)