Search

Objective: To measure the prevalence of alcohol and/or other drug (AOD) detections in suspected major trauma patients with non-transport injuries who presented to an adult major trauma centre., Methods: This registry-based cohort study examined the prevalence of AOD detections in patients aged ≥18 years who: (i) sustained non-transport injuries; and (ii) met predefined trauma call-out criteria and were therefore managed by an interdisciplinary trauma team between 1 July 2021 and 31 December 2022. Prevalence was measured using routine in-hospital blood alcohol and urine drug screens., Results: A total of 1469 cases met the inclusion criteria. Of cases with a valid blood test (n = 1248, 85.0%), alcohol was detected in 313 (25.1%) patients. Of the 733 (49.9%) cases with urine drug screen results, cannabinoids were most commonly detected (n = 103, 14.1%), followed by benzodiazepines (n = 98, 13.4%), amphetamine-type substances (n = 80, 10.9%), opioids (n = 28, 3.8%) and cocaine (n = 17, 2.3%). Alcohol and/or at least one other drug was detected in 37.4% (n = 472) of cases with either a blood alcohol or urine drug test completed (n = 1263, 86.0%). Multiple substances were detected in 16.6% (n = 119) of cases with both blood alcohol and urine drug screens (n = 718, 48.9%). Detections were prevalent in cases of interpersonal violence (n = 123/179, 68.7%) and intentional self-harm (n = 50/106, 47.2%), and in those occurring on Friday and Saturday nights (n = 118/191, 61.8%)., Conclusion: AOD detections were common in trauma patients with non-transport injury causes. Population-level surveillance is needed to inform prevention strategies that address AOD use as a significant risk factor for serious injury., (© 2023 The Authors. Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for Emergency Medicine.)

Background: Whether prehospital administration of tranexamic acid increases the likelihood of survival with a favorable functional outcome among patients with major trauma and suspected trauma-induced coagulopathy who are being treated in advanced trauma systems is uncertain., Methods: We randomly assigned adults with major trauma who were at risk for trauma-induced coagulopathy to receive tranexamic acid (administered intravenously as a bolus dose of 1 g before hospital admission, followed by a 1-g infusion over a period of 8 hours after arrival at the hospital) or matched placebo. The primary outcome was survival with a favorable functional outcome at 6 months after injury, as assessed with the use of the Glasgow Outcome Scale-Extended (GOS-E). Levels on the GOS-E range from 1 (death) to 8 ("upper good recovery" [no injury-related problems]). We defined survival with a favorable functional outcome as a GOS-E level of 5 ("lower moderate disability") or higher. Secondary outcomes included death from any cause within 28 days and within 6 months after injury., Results: A total of 1310 patients were recruited by 15 emergency medical services in Australia, New Zealand, and Germany. Of these patients, 661 were assigned to receive tranexamic acid, and 646 were assigned to receive placebo; the trial-group assignment was unknown for 3 patients. Survival with a favorable functional outcome at 6 months occurred in 307 of 572 patients (53.7%) in the tranexamic acid group and in 299 of 559 (53.5%) in the placebo group (risk ratio, 1.00; 95% confidence interval [CI], 0.90 to 1.12; P = 0.95). At 28 days after injury, 113 of 653 patients (17.3%) in the tranexamic acid group and 139 of 637 (21.8%) in the placebo group had died (risk ratio, 0.79; 95% CI, 0.63 to 0.99). By 6 months, 123 of 648 patients (19.0%) in the tranexamic acid group and 144 of 629 (22.9%) in the placebo group had died (risk ratio, 0.83; 95% CI, 0.67 to 1.03). The number of serious adverse events, including vascular occlusive events, did not differ meaningfully between the groups., Conclusions: Among adults with major trauma and suspected trauma-induced coagulopathy who were being treated in advanced trauma systems, prehospital administration of tranexamic acid followed by an infusion over 8 hours did not result in a greater number of patients surviving with a favorable functional outcome at 6 months than placebo. (Funded by the Australian National Health and Medical Research Council and others; PATCH-Trauma ClinicalTrials.gov number, NCT02187120.)., (Copyright © 2023 Massachusetts Medical Society.)

Road trauma remains a significant public health problem. We aimed to identify sub-groups of motor vehicle collisions in Victoria, Australia, and the association between collision characteristics and outcomes up to 24 months post-injury. Data were extracted from the Victorian State Trauma Registry for injured drivers aged ≥16 years, from 2010 to 2016, with a compensation claim who survived ≥12 months post-injury. People with intentional or severe head injury were excluded, resulting in 2735 cases. Latent class analysis was used to identify collision classes for driver fault and blood alcohol concentration (BAC), day and time of collision, weather conditions, single vs. multi-vehicle and regional vs. metropolitan injury location. Five classes were identified: (1) daytime multi-vehicle collisions, no other at fault; (2) daytime single-vehicle predominantly weekday collisions; (3) evening single-vehicle collisions, no other at fault, 36% with BAC ≥ 0.05; (4) sunrise or sunset weekday collisions; and (5) dusk and evening multi-vehicle in metropolitan areas with BAC < 0.05. Mixed linear and logistic regression analyses examined associations between collision class and return to work, health (EQ-5D-3L summary score) and independent function Glasgow Outcome Scale - Extended at 6, 12 and 24 months. After adjusting for demographic, health and injury characteristics, collision class was not associated with outcomes. Rather, risk of poor outcomes was associated with age, sex and socioeconomic disadvantage, education, pre-injury health and injury severity. People at risk of poor recovery may be identified from factors available during the hospital admission and may benefit from clinical assessment and targeted referrals and treatments.

Objectives: To develop a hospital indicator of resource use for injury admissions., Methods: We focused on resource use for acute injury care and therefore adopted a hospital perspective. We included patients ≥16 years old with an Injury Severity Score >9 admitted to any of the 57 trauma centers of an inclusive Canadian trauma system from 2014 to 2018. We extracted data from the trauma registry and hospital financial reports and estimated resource use with activity-based costing. We developed risk-adjustment models by trauma center designation level (I/II and III/IV) for the whole sample, traumatic brain injuries, thoraco-abdominal injuries, orthopedic injuries, and patients ≥65 years old. Candidate variables were selected using bootstrap resampling. We performed benchmarking by comparing the adjusted mean cost in each center, obtained using shrinkage estimates, to the provincial mean., Results: We included 38 713 patients. The models explained between 12% and 36% (optimism-corrected r 2 ) of the variation in resource use. In the whole sample and in all subgroups, we identified centers with higher- or lower-than-expected resource use across level I/II and III/IV centers., Conclusions: We propose an algorithm to produce the indicator using data routinely collected in trauma registries to prompt targeted exploration of potential areas for improvement in resource use for injury admissions. The r 2 of our models suggest that between 64% and 88% of the variation in resource use for injury care is dictated by factors other than patient baseline risk., (Copyright © 2020 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Introduction: Anatomical injury as measured by the AIS often accounts for only a small proportion of variability in outcomes after injury. The predictive Functional Capacity Index (FCI) appended to the 2008 AIS claims to provide a widely available method of predicting 12-month function following injury., Objectives: To determine the extent to which AIS-based and FCI-based scoring is able to add to a simple predictive model of 12-month function following severe injury., Methods: Adult trauma patients were drawn from the population-based Victorian State Trauma Registry. Major trauma and severely injured orthopaedic trauma patients were followed up via telephone interview including Glasgow Outcome Scale-Extended, the EQ-5D-3L and return to work status. A battery of AIS-based and FCI-based scores, and a simple count of AIS-coded injuries were added in turn to a base model using age and gender., Results: A total of 20 813 patients survived to 12 months and had at least one functional outcome recorded, representing 85% follow-up. Predictions using the base model varied substantially across outcome measures. Irrespective of the method used to classify the severity of injury, adding injury severity to the model significantly, but only slightly improved model fit. Across the outcomes evaluated, no method of injury severity assessment consistently outperformed any other., Conclusions: Anatomical injury is a predictor of trauma outcome. However, injury severity as described by the FCI does not consistently improve discrimination, or even provide the best discrimination compared with AIS-based severity scores or a simple injury count., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Trauma registries are essential to trauma systems, to enable collection of the data needed to enhance clinical knowledge and monitor system performance. The King Saud Medical City (KSMC) in Riyadh, Kingdom of Saudi Arabia (KSA) is aiming to become a Level 1 Trauma Centre, and required a trauma registry in order to do so. Our objective was to establish the Saudi TraumA Registry (STAR) at the (KSMC) and ready it for national deployment. The challenge was that no formal trauma data collection had occurred previously and clinicians had no prior experience of trauma registries., Methods: To develop the registry, a novel 12 step implementation plan was created and followed at the KSMC. Registry criteria and a Minimum Dataset were selected; training was delivered; database specifications were written; operating procedures were developed and regular reporting was initiated., Results: Data collection commenced on August 1st 2017. The registry was fully operational by April 2018, eight months ahead of schedule. During the first year of data collection an average of 216 records per month were entered into the database. An inaugural report was presented at the Saudi Trauma Conference in February 2019., Conclusions: The strategy deployed at the KSMC has successfully established the STAR. In the short term, process indicators will track the development of the hospital into a Level 1 Trauma Centre. In the medium to long term the STAR will be rolled out nationally to capture the impact of public health initiatives aimed at reducing injury in the KSA. The effect of the STAR will be that the country is better equipped to deliver continuous improvements in trauma systems and quality of care.

Background: Pedestrians, cyclists and motorcyclists are vulnerable to serious injury due to limited external protective devices. Understanding the level of recovery, and differences between these road user groups, is an important step towards improved understanding of the burden of road trauma, and prioritisation of prevention efforts. This study aimed to characterise and describe patient-reported outcomes of vulnerable road users at 6 and 12 months following orthopaedic trauma., Methods: A registry-based cohort study was conducted using data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) and included pedestrians, cyclists and motorcyclists who were hospitalised for an orthopaedic injury following an on-road collision that occurred between January 2009 and December 2016. Outcomes were measured using the 3-level EuroQol 5 dimensions questionnaire (EQ-5D-3 L), Glasgow Outcome Scale - Extended (GOS-E) and return to work questions. Outcomes were collected at 6 and 12 months post-injury. Multivariable generalized estimating equations (GEE), adjusted for confounders, were used to compare outcomes between the road user groups over time., Results: 6186 orthopaedic trauma patients met the inclusion criteria during the 8-year period. Most patients were motorcyclists (42.8%) followed by cyclists (32.6%) and pedestrians (24.6%). Problems were most prevalent on the usual activities item of the EQ-5D-3 L at 6-months post-injury, and the pain/discomfort item of the EQ-5D-3 L at 12 months. The adjusted odds of reporting problems on all EQ-5D-3 L items were lower for cyclists when compared to pedestrians. Moreover, an average cyclist had a greater odds of a good recovery on the GOS-E, (AOR 2.75, 95% CI 2.33, 3.25) and a greater odds of returning to work (AOR = 3.13, 95% CI 2.46, 3.99) compared to an average pedestrian., Conclusion: Pedestrians and motorcyclists involved in on-road collisions experienced poorer patient-reported outcomes at 6 and 12 months post-injury when compared to cyclists. A focus on both primary injury prevention strategies, and investment in ongoing support and treatment to maximise recovery, is necessary to reduce the burden of road trauma for vulnerable road users., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Despite the reliance on administrative data in epidemiological studies, there is little information on the completeness of co-morbidities in administrative data coded from medical records., Objective: The aim of this study was to quantify the agreement between the International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) administrative coding of mental health, drug and alcohol co-morbidities and medical records in a severely injured patient population., Method: A random sample of patients ( n = 500) captured by the Victorian State Trauma Registry and definitively managed at the state's adult major trauma services was selected for the study. Retrospective medical record review was conducted to collect data about documented co-morbidities. The agreement between ICD-10-AM data generated from routine hospital coding and medical record-based co-morbidities was determined using Cohen's κ and prevalence-adjusted bias-adjusted kappa (PABAK) statistics., Results: The percentage of agreement between the medical record and ICD-10-AM coding for mental health, drug and alcohol co-morbidities was 72.8%, and the PABAK showed moderate agreement (PABAK = 0.46; 95% confidence interval (CI): 0.37, 0.54). There was no difference in agreement between unintentional injury patients (PABAK = 0.52; 95% CI: 0.42, 0.62) compared with intentional injury patients (PABAK = 0.36, 95% CI: 0.23, 0.49), and no change in agreement for patients admitted before (PABAK = 0.40; 95% CI: 0.30, 0.50) and after the introduction of mandatory co-morbidity coding (PABAK = 0.46; 95% CI: 0.37, 0.54)., Conclusion: Despite documentation in the medical record, a large proportion of mental health, drug and alcohol conditions were not coded in ICD-10-AM. Acknowledgement of these limitations is needed when using ICD-10-AM coded co-morbidities in research studies and health policy development., Implications: This work has implications for researchers of drug and alcohol abuse; mental health; accidents and injuries; workers' compensation; health workforce; health services; and policy decisions for healthcare, emergency services, insurance industry, national productivity and welfare costings reliant on those research outcomes.

Background: Variations in adjusted costs have been observed among trauma centres in the United States but patient outcomes were not better in centres with higher costs. Attempts to improve injury care efficiency are hampered by insufficient patient-level information on resource use and on the drivers of resource use intensity., Objectives: To estimate patient-level resource use for injury admissions, identify determinants of resource use intensity, and evaluate inter-hospital variations in resource use., Methods: We conducted a retrospective cohort study including ≥16-year-olds admitted to adult trauma centres in a mature, inclusive Canadian trauma system between 2014 and 2016. We extracted data from the trauma registry and hospital financial reports. We estimated resource use with activity-based costs, identified determinants of resource use intensity using a multilevel linear model and assessed the relative importance of each determinant with Cohen's f 2 . We evaluated inter-provider variations with intraclass correlation coefficients (ICC) and 95% confidence intervals., Results: We included 32,411 patients. Median costs per admission were $4857 (Quartiles 1 and 3 2961-8448). The most important contributors to total resource use were the medical ward (57%), followed by the operating room (OR; 23%) and the intensive care unit (13%). The strongest determinant of resource use intensity was discharge destination (Cohen's f 2  = 7%). The most resource intense patient group was spinal cord injuries with $11,193 (7115-17,606) per admission. While resource use increased with increasing age for the medical ward, it decreased with increasing age for the OR. Resource use was 18% higher in level I centres compared to level IV centres and we observed significant variations in resource use across centres (ICC = 5% [4-6]), particularly for the OR (28% [20-40])., Conclusions: Resource use for acute injury care in Quebec is not solely due to the clinical status of patients. We identified determinants of resource use that can be used to establish evidence-based resource allocations and improve injury care efficiency. The method we developed for estimating patient-level, in-hospital resource use for injury admissions and identifying related determinants could be reproduced using local trauma registry data and our unit costs or unit costs specific to each setting., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: To characterize patterns of engagement in work during the 4-year period after major traumatic injury, and to identify factors associated with those patterns., Background: Employment is an important marker of functional recovery from injury. There are few population-based studies of long-term employment outcomes, and limited data on the patterns of return to work (RTW) after injury., Methods: A population-based, prospective cohort study using the Victorian State Trauma Registry. A total of 1086 working age individuals, in paid employment or full-time education before injury, were followed-up through telephone interview at 6, 12, 24, 36, and 48 months post-injury. Responses to RTW questions were used to define 4 discrete patterns: early and sustained; delayed; failed; no RTW. Predictors of RTW patterns were assessed using multivariate multinomial logistic regression., Results: Slightly more than half of respondents (51.6%) recorded early sustained RTW. A further 15.5% had delayed and 13.3% failed RTW. One in 5 (19.7%) did not RTW. Compared with early sustained RTW, predictors of delayed and no RTW included being in a manual occupation and injury in a motor vehicle accident. Older age and receiving compensation predicted both failed and no RTW patterns. Preinjury disability was an additional predictor of failed RTW. Presence of comorbidity was an additional predictor of no RTW., Conclusions: A range of personal, occupational, injury, health, and compensation system factors influence RTW patterns after serious injury. Early identification of people at risk for delayed, failed, or no RTW is needed so that targeted interventions can be delivered.

Introduction: Injuries are a major cause of disability and lost productivity. The case for a national trauma registry has been recognized by the Australian Commission on Safety and Quality in Health Care and at a policy level., Background: The need was flagged in 1993 by the Royal Australasian College of Surgeons and the Australasian Trauma Society. In 2003, the Centre of National Research and Disability funded the Australian and New Zealand National Trauma Registry Consortium, which produced three consecutive annual reports. The bi-national trauma minimum dataset was also developed during this time. Operations were suspended thereafter., Method: In response to sustained lobbying the Australian Trauma Quality Improvement Program including the Australian Trauma Registry (ATR) commenced in 2012, with data collection from 26 major trauma centres. An inaugural report was released in late 2014., Result: The Federal Government provided funding in December 2016 enabling the work of the ATR to continue. Data are currently being collected for cases that meet inclusion criteria with dates of injury in the 2017-2018 financial year. Since implementation, the number of submitted records has been increased from fewer than 7000 per year to over 8000 as completeness has improved. Four reports have been released and are available to stakeholders., Conclusion: The commitment shown by the College, other organizations and individuals to the vision of a national trauma registry has been consistent since 1993. The ATR is now well placed to improve the care of injured people., (© 2018 The Authors ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Introduction: Regionalised trauma systems have been shown to improve outcomes for trauma patients. However, the evaluation of these trauma systems has been oriented towards in-hospital care. Therefore, the epidemiology and care delivered to the injured patients who died in the prehospital setting remain poorly studied. This study aims to provide an overview of a methodological approach to reviewing trauma deaths in order to assess the preventability, identify areas for improvements in the system of care provided to these patients and evaluate the potential for novel interventions to improve outcomes for seriously injured trauma patients., Methods and Analysis: The planned study is a retrospective review of prehospital and early in-hospital (<24 hours) deaths following traumatic out-of-hospital cardiac arrest that were attended by Ambulance Victoria between 2008 and 2014. Eligible patients will be identified from the Victorian Ambulance Cardiac Arrest Registry and linked with the National Coronial Information System. For patients who were transported to hospital, data will be linked the Victoria State Trauma Registry. The project will be undertaken in four phases: (1) survivability assessment; (2) preventability assessment; (3) identification of potential areas for improvement; and (4) identification of potentially useful novel technologies. Survivability assessment will be based on predetermined anatomical injuries considered unsurvivable. For patients with potentially survivable injuries, multidisciplinary expert panel reviews will be conducted to assess the preventability as well as the identification of potential areas for improvement and the utility of novel technologies., Ethics and Dissemination: The present study was approved by the Victorian Department of Justice and Regulation HREC (CF/16/272) and the Monash University HREC (CF16/532 - 2016000259). Results of the study will be published in peer-reviewed journals and reports provided to Ambulance Victoria, the Victorian State Trauma Committee and the Victorian State Government Department of Health and Human Services., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Many outcome studies capture the presence of mental health, drug and alcohol comorbidities from administrative datasets and medical records. How these sources compare as predictors of patient outcomes has not been determined. The purpose of the present study was to compare mental health, drug and alcohol comorbidities based on ICD-10-AM coding and medical record documentation for predicting longer-term outcomes in injured patients., Methods: A random sample of patients (n = 500) captured by the Victorian State Trauma Registry was selected for the study. Retrospective medical record reviews were conducted to collect data about documented mental health, drug and alcohol comorbidities while ICD-10-AM codes were obtained from routinely collected hospital data. Outcomes at 12-months post-injury were the Glasgow Outcome Scale - Extended (GOS-E), European Quality of Life Five Dimensions (EQ-5D-3L), and return to work. Linear and logistic regression models, adjusted for age and gender, using medical record derived comorbidity and ICD-10-AM were compared using measures of calibration (Hosmer-Lemeshow statistic) and discrimination (C-statistic and R 2 )., Results: There was no demonstrable difference in predictive performance between the medical record and ICD-10-AM models for predicting the GOS-E, EQ-5D-3L utility sore and EQ-5D-3L mobility, self-care, usual activities and pain/discomfort items. The area under the receiver operating characteristic (AUC) for models using medical record derived comorbidity (AUC 0.68, 95% CI: 0.63, 0.73) was higher than the model using ICD-10-AM data (AUC 0.62, 95% CI: 0.57, 0.67) for predicting the EQ-5D-3L anxiety/depression item. The discrimination of the model for predicting return to work was higher with inclusion of the medical record data (AUC 0.69, 95% CI: 0.63, 0.76) than the ICD-10-AM data (AUC 0.59, 95% CL: 0.52, 0.65)., Conclusions: Mental health, drug and alcohol comorbidity information derived from medical record review was not clearly superior for predicting the majority of the outcomes assessed when compared to ICD-10-AM. While information available in medical records may be more comprehensive than in the ICD-10-AM, there appears to be little difference in the discriminative capacity of comorbidities coded in the two sources.

The aim of the present study was to describe the trauma case review process and its role in a regionalised trauma system. Victoria has a population of 5.9 million people, accounting for 26% of Australia's population. Victoria has been serviced by an inclusive, organised trauma system since 2000 comprising 138 health services with trauma designations and three major trauma services. Pre- and interhospital guidelines prescribe the timely transport of patients to the appropriate level of trauma service. A review of the role and contribution of 10 years of operation of the trauma case review group (CRG) was undertaken to describe the aims, processes and governance surrounding the implementation of an individual case review for specified major trauma patients. Specified patients were those identified by the Victorian State Trauma Registry as being managed outside of established Victorian State Trauma System prehospital and interhospital guidelines. A state-wide trauma case review process was implemented across the trauma system using data-informed detection flags and screening criteria. Using data from the Victorian State Trauma Registry, detection flags were correlated with patients at risk of a poorer outcome, thereby ensuring that all patients managed outside of the requirements of established trauma triage and transfer guidelines were subject to review. The CRG provides an individual review process as a technique for assessing and monitoring major trauma patient care and compliance with trauma system triage and transfer guidelines. The process has been effective as a quality and safety strategy by improving clinician knowledge of major trauma triage and transfer guidelines and facilitating improved compliance, particularly with interhospital transfers. Strong compliance has been achieved from health services with the requirement to internally review and respond to CRG concerns regarding 'high-risk' trauma cases. Anecdotal feedback from health services regarding participation in the CRG process has been positive. The trauma case review process is an embedded feature of the Victorian State Trauma System that aims to improve compliance with major trauma guidelines by reviewing major trauma cases that have been managed outside of established triage and transfer guidelines. All trauma-designated Victorian health services, Ambulance Victoria and Victorian adult and paediatric patient retrieval services might receive trauma cases for review. The process is also an integral component of trauma system clinical governance, which enables the identification of system-level issues for escalation to the State Trauma Committee and the Victorian Department of Health and Human Services., (© 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Background: Pulmonary thromboembolism (PTE) is a dangerous complication of traumatic injury, with varied risk profiles and treatment options. This review aims to describe reported incidence and variables associated with PTE among severely injured patients., Methods: Searches were conducted using PubMed, Cochrane and MEDLINE. Relevant studies were identified by two independent reviewers based on predetermined inclusion criteria. Incidence of PTE was the primary outcome measure. Variables associated with PTE was the secondary outcome measure. The Newcastle-Ottawa Scale was used to assess quality of included studies., Results: There were eight studies that satisfied inclusion criteria. The diagnosed incidence of PTE in these populations ranged from 0.35 to 24%. The most common variables associated with PTE were pelvic or lower limb injury, chest injury, higher total Injury Severity Score, male sex and age. Variables that were less commonly associated with PTE were previous warfarin use, head injury, high serum lactate, soft tissue injury, more than one operation, more than three days on a ventilator, presence of a subclavian central venous catheter, need for a blood transfusion, systolic blood pressure <90mmHg, abdominal injury, presence of a deep venous thrombosis, inferior vena cava filter placement and isolated liver spleen or spinal injuries., Conclusions: The reported incidence of PTE after major trauma is variable and dependent on inclusion criteria, diagnostic criteria and study design. Identified variables differed to those reported for venous thromboembolism in other populations. It is difficult to predict populations at risk of clinically significant PTE following injury using available evidence. Further studies linked to patient-specific variables will assist in more precise risk-stratification and interventions., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Objective: To investigate temporal trends in the incidence, mortality, disability-adjusted life-years (DALYs), and costs of health loss caused by serious road traffic injury., Design, Setting and Participants: A retrospective review of data from the population-based Victorian State Trauma Registry and the National Coronial Information System on road traffic-related deaths (pre- and in-hospital) and major trauma (Injury Severity Score > 12) during 2007-2015.Main outcomes and measures: Temporal trends in the incidence of road traffic-related major trauma, mortality, DALYs, and costs of health loss, by road user type., Results: There were 8066 hospitalised road traffic major trauma cases and 2588 road traffic fatalities in Victoria over the 9-year study period. There was no change in the incidence of hospitalised major trauma for motor vehicle occupants (incidence rate ratio [IRR] per year, 1.00; 95% CI, 0.99-1.01; P = 0.70), motorcyclists (IRR, 0.99; 95% CI, 0.97-1.01; P = 0.45) or pedestrians (IRR, 1.00; 95% CI, 0.97-1.02; P = 0.73), but the incidence for pedal cyclists increased 8% per year (IRR, 1.08; 95% CI; 1.05-1.10; P < 0.001). While DALYs declined for motor vehicle occupants (by 13% between 2007 and 2015), motorcyclists (32%), and pedestrians (5%), there was a 56% increase in DALYs for pedal cyclists. The estimated costs of health loss associated with road traffic injuries exceeded $14 billion during 2007-2015, although the cost per patient declined for all road user groups., Conclusions: As serious injury rates have not declined, current road safety targets will be difficult to meet. Greater attention to preventing serious injury is needed, as is further investment in road safety, particularly for pedal cyclists.

Background: Improved understanding of the quality of survival of patients is crucial in evaluating trauma care, understanding recovery patterns and timeframes, and informing healthcare, social, and disability service provision. We aimed to describe the longer-term health status of seriously injured patients, identify predictors of outcome, and establish recovery trajectories by population characteristics., Methods and Findings: A population-based, prospective cohort study using the Victorian State Trauma Registry (VSTR) was undertaken. We followed up 2,757 adult patients, injured between July 2011 and June 2012, through deaths registry linkage and telephone interview at 6-, 12-, 24-, and 36-months postinjury. The 3-level EuroQol 5 dimensions questionnaire (EQ-5D-3L) was collected, and mixed-effects regression modelling was used to identify predictors of outcome, and recovery trajectories, for the EQ-5D-3L items and summary score. Mean (SD) age of participants was 50.8 (21.6) years, and 72% were male. Twelve percent (n = 333) died during their hospital stay, 8.1% (n = 222) of patients died postdischarge, and 155 (7.0%) were known to have survived to 36-months postinjury but were lost to follow-up at all time points. The prevalence of reporting problems at 36-months postinjury was 37% for mobility, 21% for self-care, 47% for usual activities, 50% for pain/discomfort, and 41% for anxiety/depression. Continued improvement to 36-months postinjury was only present for the usual activities item; the adjusted relative risk (ARR) of reporting problems decreased from 6 to 12 (ARR 0.87, 95% CI: 0.83-0.90), 12 to 24 (ARR 0.94, 95% CI: 0.90-0.98), and 24 to 36 months (ARR 0.95, 95% CI: 0.95-0.99). The risk of reporting problems with pain or discomfort increased from 24- to 36-months postinjury (ARR 1.06, 95% CI: 1.01, 1.12). While loss to follow-up was low, there was responder bias with patients injured in intentional events, younger, and less seriously injured patients less likely to participate; therefore, these patient subgroups were underrepresented in the study findings., Conclusions: The prevalence of ongoing problems at 3-years postinjury is high, confirming that serious injury is frequently a chronic disorder. These findings have implications for trauma system design. Investment in interventions to reduce the longer-term impact of injuries is needed, and greater investment in primary prevention is needed.

Background: Traumatic injury can lead to loss, suffering and feelings of injustice. Previous research has shown that perceived injustice is associated with poorer physical and mental wellbeing in persons with chronic pain. This study aimed to identify the relative association between injury, compensation and pain-related characteristics and perceived injustice 12-months after traumatic injury., Methods: 433 participants were recruited from the Victorian Orthopedic Trauma Outcomes Registry and Victorian State Trauma Registry, and completed questionnaires at 12-14 months after injury as part of an observational cohort study. Using hierarchical linear regression we examined the relationships between baseline demographics (sex, age, education, comorbidities), injury (injury severity, hospital length of stay), compensation (compensation status, fault, lawyer involvement), and health outcomes (SF-12) and perceived injustice. We then examined how much additional variance in perceived injustice was related to worse pain severity, interference, self-efficacy, catastrophizing, kinesiophobia or disability., Results: Only a small portion of variance in perceived injustice was related to baseline demographics (especially education level), and injury severity. Attribution of fault to another, consulting a lawyer, health-related quality of life, disability and the severity of pain-related cognitions explained the majority of variance in perceived injustice. While univariate analyses showed that compensable injury led to higher perceptions of injustice, this did not remain significant when adjusting for all other factors, including fault attribution and consulting a lawyer., Conclusions: In addition to the "justice" aspects of traumatic injury, the health impacts of injury, emotional distress related to pain (catastrophizing), and the perceived impact of pain on activity (pain self-efficacy), had stronger associations with perceptions of injustice than either injury or pain severity. To attenuate the likelihood of poor recovery from injury, clinical interventions that support restoration of health-related quality of life, and adjustment to the impacts of trauma are needed.

Purpose Traumatic injury is a leading cause of work disability. Receiving compensation post-injury has been consistently found to be associated with poorer return to work. This study investigated whether the relationship between receiving compensation and return to work was associated with elevated symptoms of psychological distress (i.e., anxiety, depression, and posttraumatic stress disorder) and perceived injustice. Methods Injured persons, who were employed at the time of injury (n = 364), were recruited from the Victorian State Trauma Registry, and Victorian Orthopaedic Trauma Outcomes Registry. Participants completed the Hospital Anxiety and Depression Scale, Posttraumatic Stress Disorder Checklist, Injustice Experience Questionnaire, and appraisals of pain and work status 12-months following traumatic injury. Results Greater financial worry and indicators of actual/perceived injustice (e.g., consulting a lawyer, attributing fault to another, perceived injustice, sustaining compensable injury), trauma severity (e.g., days in hospital and intensive care, discharge to rehabilitation), and distress symptoms (i.e., anxiety, depression, PTSD) led to a twofold to sevenfold increase in the risk of failing to return to work. Anxiety, post-traumatic stress and perceived injustice were elevated following compensable injury compared with non-compensable injury. Perceived injustice uniquely mediated the association between compensation and return to work after adjusting for age at injury, trauma severity (length of hospital, admission to intensive, and discharge location) and pain severity. Conclusions Given  that perceived injustice is associated with poor return to work after compensable injury, we recommend greater attention be given to appropriately addressing psychological distress and perceived injustice in injured workers to facilitate a smoother transition of return to work.

Introduction: Fibrinogen may be reduced following traumatic injury due to loss from haemorrhage, increased consumption and reduced synthesis. In the absence of clinical trials, guidelines for fibrinogen replacement are based on expert opinion and vary internationally. We aimed to determine prevalence and predictors of low fibrinogen on admission in major trauma patients and investigate association of fibrinogen levels with patient outcomes., Patients and Methods: Data on all major trauma patients (January 2007-July 2011) identified through a prospective statewide trauma registry in Victoria, Australia were linked with laboratory and transfusion data. Major trauma included any of the following: death after injury, injury severity score (ISS) >15, admission to intensive care unit requiring mechanical ventilation, or urgent surgery for intrathoracic, intracranial, intra-abdominal procedures or fixation of pelvic or spinal fractures. Associations between initial fibrinogen level and in-hospital mortality were analysed using multiple logistic regression., Results: Of 4773 patients identified, 114 (2.4%) had fibrinogen less than 1g/L, 283 (5.9%) 1.0-1.5g/L, 617 (12.9%) 1.6-1.9g/L, 3024 (63.4%) 2-4g/L and 735 (15%) >4g/L. Median fibrinogen was 2.6g/L (interquartile range 2.1-3.4). After adjusting for age, gender, ISS, injury type, pH, temperature, Glasgow Coma Score (GCS), initial international normalised ratio and platelet count, the lowest fibrinogen categories, compared with normal range, were associated with increased in-hospital mortality (adjusted odds ratio [OR] for less than 1g/L 3.28 [95% CI 1.71-6.28, p<0.01], 1-1.5g/L adjusted OR 2.08 [95% CI 1.36-3.16, p<0.01] and 1.6-1.9g/L adjusted OR 1.39 [95% CI 0.97-2.00, p=0.08]). Predictors of initial fibrinogen <1.5g/L were younger age, lower GCS, systolic blood pressure <90mmHg, chest decompression, penetrating injury, ISS >25 and lower pH and temperature., Conclusions: Initial fibrinogen levels less than the normal range are independently associated with higher in-hospital mortality in major trauma patients. Future studies are warranted to investigate whether earlier and/or greater fibrinogen replacement improves clinical outcomes., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Multiply injured patients represent a particularly demanding subgroup of trauma patients as they require urgent simultaneous clinical assessments using physical examination, ultrasound and invasive monitoring together with critical management, including tracheal intubation, thoracostomies and central venous access. Concurrent access to multiple body regions is essential to facilitate the concept of 'horizontal' resuscitation. The current positioning of trauma patient, with arms adducted, restricts this approach. Instead, the therapeutic cruciform positioning, with arms abducted at 90°, allows planning and performing of multiple life-saving interventions simultaneously. This positioning also provides a practical surgical field with improved sterility and procedural access., (© 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

The measurement of functional outcomes following severe trauma has been widely recognised as a priority for countries with developed trauma systems. In this respect, the Functional Capacity Index (FCI), a multi-attribute index which has been incorporated into the most recent Abbreviated Injury Scale (AIS) dictionary, is potentially attractive as it offers 12-month functional outcome predictions for patients captured by existing AIS-coded datasets. This review paper outlines the development, construction and validation of the predictive form of the FCI (termed the pFCI), the modifications made which produced the currently available 'revised' pFCI, and the extent to which the revised pFCI has been validated and used. The original pFCI performed poorly in validation studies. The revised pFCI does not address many of the identified limitations of the original version, and despite the ready availability of a truncated version in the AIS dictionary, it has only been used in a handful of studies since its introduction several years ago. Additionally, there is little evidence for its validity. It is suggested that the pFCI should be better validated, whether in the narrow population group of young, healthy individuals for which it was developed, or in the wider population of severely injured patients. Methods for accounting for the presence of multiple injures (of which two have currently been used) should also be evaluated. Many factors other than anatomical injury are known to affect functional outcomes following trauma. However, it is intuitive that any model which attempts to predict the ongoing morbidity burden in a trauma population should consider the effects of the injuries sustained. Although the revised pFCI potentially offers a low-cost assessment of likely functional limitations resulting from anatomical injury, it must be more rigorously evaluated before more comprehensive predictive tools can be developed from it., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: To describe the long-term outcomes of major trauma patients and factors associated with the rate of recovery., Background: As injury-related mortality decreases, there is increased focus on improving the quality of survival and reducing nonfatal injury burden., Methods: Adult major trauma survivors to discharge, injured between July 2007 and June 2012 in Victoria, Australia, were followed up at 6, 12, and 24 months after injury to measure function (Glasgow Outcome Scale-Extended) and return to work/study. Random-effects regression models were fitted to identify predictors of outcome and differences in the rate of change in each outcome between patient subgroups., Results: Among the 8844 survivors, 8128 (92%) were followed up. Also, 23% had achieved a good functional recovery, and 70% had returned to work/study at 24 months. The adjusted odds of reporting better function at 12 months was 27% (adjusted odds ratio 1.27, 95% confidence interval [CI] 1.19-1.36) higher compared with 6 months, and 9% (adjusted odds ratio 1.09, 95% CI, 1.02-1.17) higher at 24 months compared with 12 months. The adjusted relative risk (RR) of returning to work was 14% higher at 12 months compared with 6 months (adjusted RR 1.14, 95% CI, 1.12-1.16) and 8% (adjusted RR 1.08, 95% CI, 1.06-1.10) higher at 24 months compared with 12 months., Conclusions: Improvement in outcomes over the study period was observed, although ongoing disability was common at 24 months. Recovery trajectories differed by patient characteristics, providing valuable information for informing prognostication and service planning, and improving our understanding of the burden of nonfatal injury.

Introduction: Globally, injury is a major cause of death and disability. Improvements in trauma care have been driven by trauma registries. The capacity of a trauma registry to inform improvements in the quality of trauma care is dependent upon the quality of data. The literature on data quality in disease registries is inconsistent and ambiguous; methods used for classifying, measuring, and improving data quality are not standardised. The aim of this study was to review the literature to determine the methods used to classify, measure and improve data quality in trauma registries., Methods: A scoping review of the literature was performed. Databases were searched using the term "trauma registry" and its synonyms, combined with multiple terms denoting data quality. There was no restriction on year. Full-length manuscripts were included if the classification, measurement or improvement of data quality in one or more trauma registries was a study objective. Data were abstracted regarding registry demographics, study design, data quality classification, and the reported methods used to measure and improve the pre-defined data quality dimensions of accuracy, completeness and capture., Results: Sixty-nine publications met the inclusion criteria. Four publications classified data quality. The most frequently described methods for measuring data accuracy (n=47) were checks against other datasets (n=18) and checks of injury coding (n=17). The most frequently described methods for measuring data completeness (n=47) were the percentage of included cases, for a given variable or list of variables, for which there was an observation in the registry (n=29). The most frequently described methods for measuring data capture (n=37) were the percentage of cases in a linked reference dataset that were also captured in the primary dataset being evaluated (n=24). Most publications dealing with the measurement of a dimension of data quality did not specify the methods used; most publications dealing with the improvement of data quality did not specify the dimension being targeted., Conclusion: The classification, measurement and improvement of data quality in trauma registries is inconsistent. To maintain confidence in the usefulness of trauma registries, the metrics and reporting of data quality need to be standardised., (Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.)

Introduction: The international burden of injury is an increasing concern in global healthcare. Developed trauma care systems have reduced death and disability following injury. The ideal platform for surveillance and clinical governance in trauma care quality improvement is the trauma registry. There is a great disparity in the prevalence of active trauma registries between developed and developing countries. More detailed information on lessons learnt would guide those settings, hospitals and regions looking to establish a sustainable trauma registry. The aim of this study was to explore the experiences and perceptions of trauma registry custodians regarding the development of successful and sustainable trauma registries., Methods: This was a qualitative study using semi-structured interviews of trauma registry custodians. Trauma registries were selected from a wide range of jurisdictions, including single hospital and multi-hospital registries, based in developed and developing countries. Interview transcripts were analysed using thematic analysis; recurrent themes were identified, and a coding frame developed. Quotes were identified to illustrate the themes in the participants' own words., Results: Twenty-seven interviews, representing 29 registries, were completed. Fourteen of the source registries were based in developed countries (6 single hospital, 8 multi-hospital) and 15 were based in developing countries (9 single hospital, 6 multi-hospital). The analysis generated 15 themes covering resources, data and strategies. The themes dealing with resources were: funding, staffing, information technology and tools for guidance. The themes dealing with data were: data quality, simplicity, injury coding and data utilisation. The themes dealing with strategies were: having a local champion and a clear purpose, stakeholder buy-in, governance, integration, getting started and persistence. For developing countries, the need for a local champion, dealing with data quality through prospective data collection, integration into local resources and keeping it simple were considered particularly important., Conclusion: The general consensus was that, for a trauma registry to be successful, in addition to adequate funding and trained staff, it needs to be led by a local champion with engagement of key local stakeholders. It should have a clear purpose, pay close attention to data quality and ensure that the data is well used., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: The Injury Severity Score (ISS) is the most ubiquitous summary score derived from Abbreviated Injury Scale (AIS) data. It is frequently used to classify patients as 'major trauma' using a threshold of ISS >15. However, it is not known whether this is still appropriate, given the changes which have been made to the AIS codeset since this threshold was first used. This study aimed to identify appropriate ISS and New Injury Severity Score (NISS) thresholds for use with the 2008 AIS (AIS08) which predict mortality and in-hospital resource use comparably to ISS >15 using AIS98., Methods: Data from 37,760 patients in a state trauma registry were retrieved and reviewed. AIS data coded using the 1998 AIS (AIS98) were mapped to AIS08. ISS and NISS were calculated, and their effects on patient classification compared. The ability of selected ISS and NISS thresholds to predict mortality or high-level in-hospital resource use (the need for ICU or urgent surgery) was assessed., Results: An ISS >12 using AIS08 was similar to an ISS >15 using AIS98 in terms of both the number of patients classified major trauma, and overall major trauma mortality. A 10% mortality level was only seen for ISS 25 or greater. A NISS >15 performed similarly to both of these ISS thresholds. However, the AIS08-based ISS >12 threshold correctly classified significantly more patients than a NISS >15 threshold for all three severity measures assessed., Conclusions: When coding injuries using AIS08, an ISS >12 appears to function similarly to an ISS >15 in AIS98 for the purposes of identifying a population with an elevated risk of death after injury. Where mortality is a primary outcome of trauma monitoring, an ISS >12 threshold could be adopted to identify major trauma patients., Level of Evidence: Level II evidence--diagnostic tests and criteria., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Traumatic injury is a leading contributor to the overall global burden of disease. However, there is a worldwide shortage of population data to inform understanding of non-fatal injury burden. An improved understanding of the pattern of recovery following trauma is needed to better estimate the burden of injury, guide provision of rehabilitation services and care to injured people, and inform guidelines for the monitoring and evaluation of disability outcomes., Objective: To provide a comprehensive overview of patient outcomes and experiences in the first 5 years after serious injury., Design: This is a population-based, nested prospective cohort study using quantitative data methods, supplemented by a qualitative study of a seriously injured participant sample., Participants: All 2547 paediatric and adult major trauma patients captured by the Victorian State Trauma Registry with a date of injury from 1 July 2011 to 30 June 2012 who survived to hospital discharge and did not opt-off from the registry., Analysis: To analyse the quantitative data and identify factors that predict poor or good outcome, whether there is change over time, differences in rates of recovery and change between key participant subgroups, multilevel mixed effects regression models will be fitted. To analyse the qualitative data, thematic analysis will be used to identify important themes and the relationships between themes., Contribution to the Field: The results of this project have the potential to inform clinical decisions and public health policy, which can reduce the burden of non-fatal injury and improve the lives of people living with the consequences of severe injury., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To describe the burden of road transport-related serious injury in Victoria, Australia, over a 10-year period, after the introduction of an integrated trauma system., Background: Road traffic injury is a leading cause of death and disability worldwide. Efforts to improve care of the injured are important for reducing burden, but the impact of trauma care systems on burden and cost of road traffic injury has not been evaluated., Methods: All road transport-related deaths and major trauma (injury severity score >12) cases were extracted from population-based coroner and trauma registry data sets for July 2001 to June 2011. Modeling was used to assess changes in population incidence rates and odds of in-hospital mortality. Disability-adjusted life years, combining years of life lost and years lived with disability, were calculated. Cost of health loss was calculated from estimates of the value of a disability-adjusted life year., Results: Incidence of road transport-related deaths decreased (incidence rate ratio 0.95, 95% confidence interval: 0.94-0.96), whereas the incidence of hospitalized major trauma increased (incidence rate ratio 1.03, 95% confidence interval: 1.02-1.04). Years of life lost decreased by 43%, and years lived with disability increased by 32%, with an overall 28% reduction in disability-adjusted life years over the decade. There was a cost saving per case of A$633,446 in 2010-2011 compared with the 2001-2002 financial year., Conclusions: Since introduction of the trauma system in Victoria, Australia, the burden of road transport-related serious injury has decreased. Hospitalized major trauma cases increased, whereas disability burden per case declined. Increased survival does not necessarily result in an overall increase in nonfatal injury burden.

Introduction: The global burden of injury is enormous, especially in developing countries. Trauma systems in highincome countries have reduced mortality and disability. An important component of trauma quality improvement programmes is the trauma registry which monitors the epidemiology, processes and outcomes of trauma care. There is a severe deficit of trauma registries in developing countries and there are few resources to support the development of trauma registries. Specifically, publicly available information of trauma registry methodology in developed trauma registries is sparse. The aim of this study was to describe and compare trauma registries globally., Methods: A survey of trauma registry custodians was conducted. Purposive sampling was used to select trauma registries following a structured review of the literature. Registries for which there were at least two included abstracts over the five-year period were defined as active and selected. Following piloting and revision, a detailed survey covering physical and human resources, administration and methodology was distributed. The survey responses were analysed; single hospital and multi-hospital registries were compared., Results: Eighty-four registries were emailed the survey. Sixty-five trauma registries participated, giving a response rate of 77%. Of the 65 participating registries, 40 were single hospital registries and 25 were multi-hospital registries. Fifteen countries were represented; more than half of the participating registries were based in the USA. There was considerable variation in resourcing and methodology between registries. A trauma registry most commonly had at least three staff, reported to both the hospital and government, included more than 1000 cases annually, listed admission, death and transfer amongst inclusion criteria, mandated collection of more than 100 data elements, used AIS Version 2005 (2008 update) and used age, the Glasgow Coma Scale and the Injury Severity Score for injury severity adjustment., Conclusion: Whilst some characteristics were common across many trauma registries, the resourcing and methodology varied markedly. The common features identified may serve as a guide to those looking to establish a trauma registry. However much remains to be done for trauma registries to determine the best standardised approach., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Introduction: Red blood cell (RBC) transfusion is often essential during trauma resuscitation but is associated with high cost and potential adverse outcomes. This study aimed to determine the incidence of potentially avoidable RBC transfusions (PAT) among adult major trauma patients., Materials and Methods: A retrospective review of data collected by Registry on patients presenting between Jan 2006 and Dec 2011 was conducted. Eligible patients received at least 1 unit of RBC in the first 24h following presentation to the Emergency Department (ED). Episodes of PAT were determined according to haemodynamic stability and post-transfusion haemoglobin levels., Results: There were 621 patients included, of whom 224 (36.1%; 95% CI: 32.3-40.0) received PAT. Of them, 132 (58.9%) were haemodynamically stable on arrival and did not require a surgical procedure. Patients with PAT had significantly lower injury severity scores (30 vs 34, p<0.01), higher presenting systolic blood pressure (129 vs 112mm Hg, p<0.01) and a lower frequency of a shock index ≥1 (24.1 vs 65.0%, p<0.01), compared to those without PAT. They also had a significantly lower mortality (13.4 vs 21.7%, p<0.01)., Conclusions: PAT after trauma was common and often delivered to haemodynamically stable patients who did not require surgical procedures. Clinical decision pathways for trauma resuscitation should aim to limit PAT., (Copyright © 2014. Published by Elsevier Ltd.)

Resuscitation of patients presenting with hemorrhagic shock after major trauma has evolved to incorporate multiple strategies to maintain tissue perfusion and oxygenation while managing coagulation disorders. We aimed to study changes across time in long-term outcomes in patients with major trauma. A retrospective observational study in a single major trauma center in Australia was conducted. We included all patients with major trauma and massive blood transfusion within the first 24 h during a 6-year period (from 2006 to 2011). The main outcome measures were Glasgow Outcome Score-Extended (GOSE) and work capacity at 6 and 12 months. There were 5,915 patients with major trauma of which 365 (6.2%; 95% confidence interval [95% CI], 5.6 - 6.8) received a massive transfusion. The proportion of major trauma patients receiving a massive transfusion decreased across time from 8.2% to 4.4% (P < 0.01). There were statistically significant trends toward lower volumes of red blood cell transfusion and higher ratios of fresh-frozen plasma to red blood cells (P < 0.01). Among massively transfused patients, there was no significant change in measured outcomes during the study period, with a persistent 23% mortality in hospital, 52% unfavorable GOSE at 6 months, and 44% unfavorable GOSE at 12 months. Massive transfusion was independently associated with unfavorable outcomes at 6 months after injury (adjusted odds ratio, 1.56; 95% CI, 1.05 - 2.31) but not at 12 months (adjusted odds ratio, 0.85; 95% CI, 0.72 - 1.01). A significant reduction in massive transfusion rates was observed. Unfavorable long-term outcomes among patients receiving a massive transfusion after trauma were frequent with a substantial proportion of survivors experiencing poor functional status 1 year after injury.

Introduction: The effectiveness of massive transfusion protocols (MTPs) has been assumed from low quality studies with multiple biases. This review aimed to (i) evaluate the association between the institution of an MTP and mortality and (ii) determine the effect of MTPs on transfusion practice post trauma., Methods: A systematic review of studies that examined patient outcomes before and after the institution of an MTP in the same centre was conducted. The design and results of each study were described. Heterogeneity was assessed using the Q test and the I(2) statistic. Odds ratios (ORs) for dichotomous outcomes from each study were pooled., Results: There were eight studies that satisfied inclusion criteria with marked heterogeneity in study populations (I(2) = 72.1%, P = 0.001). Two studies showed significantly improved mortality following implementation of an MTP, and six studies showed no significant change. Pooled OR for the effect of an MTP on short-term mortality was 0.73 (95% confidence interval: 0.48-1.11). The effect of MTPs on transfusion practice was varied., Conclusion: Despite the popularity of MTPs and directives mandating their use in trauma centres, in before-after studies, MTPs have not always been associated with improved mortality. Evidence-based standardization of MTPs, improved compliance and analysis of broader endpoints were identified as areas for further research., (© 2013 Royal Australasian College of Surgeons.)

Background: Head injury is the leading cause of death and long term disability from bicycle injuries and may be prevented by helmet wearing. We compared the pattern of injury in major trauma victims resulting from bicyclist injury admitted to hospitals in the State of Victoria, Australia and South-West Netherlands, with respective high and low prevalence of helmet use among bicyclists., Methods: A cohort of bicycle injured patients with serious injury (defined as Injury Severity Score>15) in South-West Netherlands, was compared to a cohort of serious injured bicyclists in the State of Victoria, Australia. Additionally, the cohorts of patients with serious injury admitted to a Dutch level 1 trauma centre in Rotterdam, the Netherlands and an Australian level 1 trauma centre in Melbourne, Australia were compared. Both cohorts included patients admitted between July 2001 and June 2009. Primary outcome was in-hospital mortality and secondary outcome was prevalence of severe injury per body region. Outcome was compared using univariate analysis and mortality outcomes were also calculated using multivariable logistic regression models., Results: A total of 219 cases in South-West Netherlands and 500 cases in Victoria were analyzed. Further analyses comparing the major trauma centres in each region, showed the percentage of bicycle-related death was higher in the Dutch population than in the Australian (n=45 (24%) vs n=13(7%); P<0.001). After adjusting for age, mechanism of injury, GCS and head injury severity in both hospitals, there was no significant difference in mortality (adjusted odds ratio 1.4; 95% confidence interval=0.6, 3.5). Patients in Netherlands trauma centre suffered from more serious head injuries (Abbreviated Injury Scale≥3) than patients in the Australian trauma centre (n=165 (88.2%) vs n=121 (62.4%); P<0.001). The other body regions demonstrated significant differences in the AIS scores with significantly more serious injuries (AIS≥3) of the chest, abdominal and extremities regions in the Australian group., Conclusion: Bicycle related major trauma admissions in the Netherlands trauma centre, and in South-West Netherlands had a higher mortality rate associated with a higher percentage of serious head injuries compared with that in the Australian trauma centre and the State of Victoria., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: The burden of injury is greatest in developing countries. Trauma systems have reduced mortality in developed countries and trauma registries are known to be integral to monitoring and improving trauma care. There are relatively few trauma registries in developing countries and no reviews describing the experience of each registry. The aim of this study was to examine the collective published experience of trauma registries in developing countries., Methods: A structured review of the literature was performed. Relevant abstracts were identified by searching databases for all articles regarding a trauma registry in a developing country. A tool was used to abstract trauma registry details, including processes of data collection and analysis., Results: There were 84 articles, 76 of which were sourced from 47 registries. The remaining eight articles were perspectives. Most were from Iran, followed by China, Jamaica, South Africa and Uganda. Only two registries used the Injury Severity Score (ISS) to define inclusion criteria. Most registries collected data on variables from all five variable groups (demographics, injury event, process of care, injury severity and outcome). Several registries collected data for less than a total of 20 variables. Only three registries measured disability using a score. The most commonly used scores of injury severity were the ISS, followed by Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and the Kampala Trauma Score (KTS)., Conclusion: Amongst the small number of trauma registries in developing countries, there is a large variation in processes. The implementation of trauma systems with trauma registries is feasible in under-resourced environments where they are desperately needed., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Understanding the factors that impact on disability is necessary to inform trauma care and enable adequate risk adjustment for benchmarking and monitoring. A key consideration is how to adjust for pre-existing conditions when assessing injury outcomes, and whether the inclusion of comorbidity is needed in addition to adjustment for age. This study compared different approaches to modelling the impact of comorbidity, collected as part of the routine hospital episode data, on disability outcomes following orthopaedic injury., Methods: 12-month Glasgow Outcome Scale - Extended (GOS-E) outcomes for 13,519 survivors to discharge were drawn from the Victorian Orthopaedic Trauma Outcomes Registry, a prospective cohort study of admitted orthopaedic injury patients. ICD-10-AM comorbidity codes were mapped to four comorbidity indices. Cases with a GOS-E score of 7-8 were considered "recovered". A split dataset approach was used with cases randomly assigned to development or test datasets. Logistic regression models were fitted with "recovery" as the outcome and the performance of the models based on each comorbidity index (adjusted for injury and age) measured using calibration (Hosmer-Lemshow (H-L) statistics and calibration curves) and discrimination (Area under the Receiver Operating Characteristic (AUC)) statistics., Results: All comorbidity indices improved model fit over models with age and injuries sustained alone. None of the models demonstrated acceptable model calibration (H-L statistic p < 0.05 for all models). There was little difference between the discrimination of the indices for predicting recovery: Charlson Comorbidity Index (AUC 0.70, 95% CI: 0.68, 0.71); number of ICD-10 chapters represented (AUC 0.70, 95% CI: 0.69, 0.72); number of six frequent chronic conditions represented (AUC 0.70, 95% CI: 0.69, 0.71); and the Functional Comorbidity Index (AUC 0.69, 95% CI: 0.68, 0.71)., Conclusions: The presence of ICD-10 recorded comorbid conditions is an important predictor of long term functional outcome following orthopaedic injury and adjustment for comorbidity is indicated when assessing risk-adjusted functional outcomes over time or across jurisdictions.

Objective: To evaluate recovery after major trauma over a 24-month time frame., Background: Measuring disability after injury is seen as increasingly important but requires knowledge not only of the measures that should be implemented but also of the critical time points for follow-up., Methods: Six hundred sixty-two adult major trauma patients from 2 level 1 trauma centers (October 2006 to March 2007) were followed up by telephone at 6-, 12-, 18-, and 24 months after injury. SF-12, Glasgow Outcome Scale-Extended (GOS-E), pain scores, and return to work (RTW) were collected. Multilevel mixed-effects regression models were fitted to analyze change in outcomes over time., Results: Six hundred seventeen (93%) were followed up for at least 1 time point. Functional recovery (GOS-E = 8) [odds ratio (OR) 3.1, 95% CI: 1.9, 5.0] and RTW (OR 2.4, 95% CI: 1.4, 4.0) improved, and physical health (PCS-12) scores were better (mean difference 1.9, 95% CI: 0.9, 2.9), from 6 to 12 months after injury, but changed little from 12 months. Pain scores were unchanged from 6 to 12 months but were higher at 18 months than at 12 months (OR 1.8, 95% CI: 1.2, 2.8). SF-12 mental health (MCS-12) scores decreased until 18 months but improved from 18 to 24 months (mean difference 1.5, 95% CI: 0.2, 2.8). The rate of recovery differed by injury group and age., Conclusions: Different patterns of recovery were evident for each outcome, and there was a variation in the rate of recovery for some subgroups. The selection of time points for follow-up requires consideration of the outcome measurements of interest and the population being studied.

Background: Critically bleeding trauma patients require coordinated and efficient decision-making processes to ensure optimal management of their massive transfusion (MT) requirements. Human factors (HFs) is a discipline that investigates factors influencing work processes from the organizational, group, and individual levels. Given the complexity of trauma resuscitation, implementing any intervention for decision support in MT is challenging and may benefit from a HFs-assisted approach., Study Design and Methods: A systematic review was performed to identify reports of the introduction of any type of decision support for the provision of MT in critically bleeding adult trauma patients. Crucial contributions reported to influence design and uptake of the intervention were categorized into four HFs categories (environment, human, machine, and task). Extracted information was supplemented by surveying the contact authors. Evidence of clinical practice changes resulting from the intervention was also considered., Results: We identified nine studies that had reported an intervention implementing new practice guidelines or a MT protocol. All were before-and-after comparative cohort studies and used historical controls as the preintervention cohort., Conclusion: Based on the identified reports, this review provides a HFs-assisted approach to aid clinicians and policy makers with the implementation of decision support for MT in the trauma care setting., (© 2012 American Association of Blood Banks.)

Background: Trauma registry data are almost always incomplete. Multiple imputation can reduce bias in registry analyses but the ideal approach would be to improve data capture. The aim of this study was to identify, using multiple imputation, which type of patients were most likely to have incomplete data., Methods: An analysis of prospectively collected regional trauma registry data over one year was performed. Analyses were conducted following complete data estimation using multiple imputation. Variables necessary for TRISS analysis and with incomplete data were analysed. For each variable, logistic regression analyses were performed to identify predictors of missingness. A p-value of less than 0.05 was considered to be statistically significant., Results: There were 2520 cases. The variables with the greatest proportion of missing observations were respiratory rate, GCS, Qualifier (of GCS and respiratory rate) and systolic blood pressure. The Qualifier variable described whether or not the patient was intubated and mechanically ventilated at the time the first hospital GCS and respiratory rate were recorded. GCS and respiratory rate were more likely to be missing (imputed) when abnormal (unadjusted ORs: 8.6 (p<0.001) and 2.1 (p=0.02), respectively). The most important determinant of a valid GCS or respiratory rate was the Qualifier. There was no association between whether the systolic blood pressure and Qualifier were missing (imputed) and whether they were estimated to be abnormal. Following multivariable analysis, data for all four variables were more likely to be missing when the patient died in hospital. Additional independent predictors of a missing GCS or respiratory rate were an abnormal pre-hospital GCS and severe chest injury. The Qualifier and systolic blood pressure were more likely to be missing where the patient was transferred from the primary hospital., Conclusion: The major independent predictor of missing primary hospital physiological variables was death in hospital. An abnormal GCS was more likely to be missing from the regional trauma registry dataset. Predictors of a missing GCS or respiratory rate included whether the patient was intubated, an abnormal pre-hospital GCS and severe chest injury. Augmenting resources to record the initial observations of the more severely injured patients would improve data quality. Multiple imputation can be used to inform data capture., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Introduction: The use of recombinant factor VIIa (rFVIIa) in trauma patients is usually part of rescue therapy when haemorrhage and coagulopathy have not responded to conventional treatment. In this scenario, trauma patients are likely to have one or more components of the 'triad of death' (coagulopathy, acidosis and hypothermia). The aim of this study was to report on the outcome of trauma patients with the 'triad of death' immediately prior to receiving rFVIIa., Materials and Methods: Trauma patients receiving rFVIIa with the 'triad of death' were identified from the Australia and New Zealand Haemostasis Registry (ANZHR) and included in the study. The 'triad of death' was defined as an INR of >1.5, serum pH of <7.2 and a core temperature of <35 °C. Pre-dose clinical signs, investigations, adverse events and outcomes were analysed., Results: There were 2792 patients in the ANZHR, of which 386 were trauma patients and 45 patients had the 'triad of death'. Patients with the 'triad of death' were significantly older and had higher injury severity scores than other trauma patients, with a mortality of 68.9%. Survivors were significantly less acidaemic (p<0.001) and had significantly less packed red blood cell (PRBC) transfusion prior to rFVIIa administration (p=0.041) than non-survivors with the triad of death., Discussion: In the face of refractory bleeding, coagulopathy, acidosis and hypothermia following conventional resuscitation, the use of rFVIIa in trauma patients was associated with survival in 31% of patients and may be considered as a management option. Administration of rFVIIa in patients with a pH of <6.91 appears futile., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: To examine trends in mechanism and outcome of major traumatic injury in adults since the implementation of the New South Wales trauma monitoring program, and to identify factors associated with mortality., Design and Setting: Retrospective review of NSW Trauma Registry data from 1 January 2003 to 31 December 2007, including patient demographics, year of injury, and level of trauma centre where definitive treatment was provided., Participants: 9769 people aged ≥ 15 years hospitalised for trauma, with an injury severity score (ISS) > 15., Main Outcome Measures: The NSW Trauma Registry outcome measures included were overall hospital length of stay, length of stay in an intensive care unit and in ospital mortality., Results: There was a decreasing trend in severe trauma presentations in the age group 16-34 years, and an increasing trend in presentations of older people, particularly those aged ≥ 75 years. Road trauma and falls were consistently the commonest injury mechanisms. There were 1328 inhospital deaths (13.6%). Year of injury, level of trauma centre, ISS, head/neck injury and age were all independent predictors of mortality. The odds of mortality was significantly higher among patients receiving definitive care at regional trauma centres compared with Level I centres (odds ratio, 1.34; 95% CI, 1.10-1.63)., Conclusions: Deaths from major trauma in NSW trauma centres have declined since 2003, and definitive care at a Level 1 trauma centre was associated with a survival benefit. More comprehensive trauma data collection with timely analysis will improve injury surveillance and better inform health policy in NSW.

Objective: Early detection of acute traumatic coagulopathy (ATC) might be useful to guide trauma resuscitation. This study aimed to compare results from a point-of-care (POC) international normalised ratio (INR) measuring device with plasma INR in acute trauma patients., Methods: This was a single-centre, prospective, blinded comparative study. All trauma patients meeting trauma call-out criteria in a major trauma centre were screened. Patients predicted to have ATC were identified by the Coagulopathy of Severe Trauma score and a convenience sample of 72 patients included in this study. Whole blood was used to measure INR at the bedside, whereas blood from the same sample was sent to the hospital laboratory for plasma INR testing. Agreement between the laboratory and bedside INR was determined using a Bland-Altman plot., Results: There were 38 (52.8%) patients with ATC by laboratory measure, defined as INR >1.5 or activated partial thrombin time >60 s, whereas the POC system identified 28 (38.9%) patients with an INR >1.5. Assuming the laboratory measure as the gold standard, the POC system had a specificity of 88.2% (95% confidence interval 71.6-96.2) and a sensitivity of 63.1% (95% confidence interval 46.0-77.7). Bland-Altman plots demonstrated inadequate agreement between the two methods of INR measurement for the major trauma patient., Conclusions: POC INR measurements using this method during the trauma reception and resuscitative phases cannot be used to identify or exclude patients with ATC. Further studies are required to determine if there is any role for POC INR measures during trauma resuscitation., (© 2012 The Authors. EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Background: The burden of injury is very high in developing countries. Trauma systems reduce mortality; the trauma registry is a key driver of improvements in trauma care. Developing countries have begun to develop trauma systems but the level of local trauma registry activity is unclear. The aim of this study was to determine a global estimate of trauma registry activity., Methods: A structured review of the literature was performed. All abstracts referring to a trauma registry over a two-year period were included. For the trauma registry described in each abstract, the source country was recorded. An additional search of web pages posted over a one year period was conducted. Those linked to an active trauma registry website were included and the country of the trauma registry was recorded. A selection of trauma registries from countries of different levels of development were identified and compared., Results: 571 abstracts were included in the review. Most articles utilised "general" trauma registries (436(76%)) and were based at a single hospital (279(49%)). Other registries were limited to military or paediatric populations (36(6%) and 35(6%) articles respectively). Most articles sourced registries from the US (288(50%)), followed by Australia (45(8%)), Germany (32(6%)), Canada (27(5%)), UK (13(2%)), China (13(2%)) and Israel (12(2%)). The Americas produced most trauma registry articles and South East Asia the least. The majority of trauma registry articles originated from very highly developed countries 467(82%). Least developed countries had the fewest (5(1%)). The additional search yielded 37 web pages linked to 27 different trauma registry websites. Most of these were based in the US (16(59%)). The basic features of trauma registries, such as inclusion criteria, number and type of variables and injury severity scoring, varied widely depending on the country's level of development., Conclusion: This review, using a combination of the number of trauma registry articles and web pages to locate active trauma registries, demonstrated the disparity in trauma registry activity between the most and least developed countries. The absence of trauma care information systems remains a challenge to trauma system development globally., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Health-related quality of life represents a patient's experiences and expectations and should be collected from the patient. In trauma, collection of information from the patient can be challenging, particularly for subgroups where cognitive impairment is prevalent, increasing reliance on proxy reporting. This study assessed the agreement between patient and proxy reporting of health-related quality of life 12 months after injury., Methods: The Victorian State Trauma Registry and Victorian Orthopaedic Trauma Outcomes Registry collect EQ-5D data at 12 months after injury. Cases where data were collected from the patient and proxy were extracted. Agreement between patient and proxy responses was compared using kappa (K) coefficients for the individual EQ-5D items, and Bland-Altman plots and Wilcoxon signed-rank tests for the EQ-5D summary score and visual analog scale (VAS)., Results: Agreement between patient and proxy respondents was substantial for the mobility (K = 0.61) and personal care items (K = 0.67) and moderate for the usual activities (K = 0.50), pain/discomfort (K = 0.42), and anxiety/depression items (K = 0.47). The mean difference between proxy and patient-reported scores for the VAS (0.74, 95% confidence interval: -2.73, 4.21) and the EQ-5D summary score (-0.02, 95% confidence interval: -0.07, 0.03) was small, but the limits of agreement were wide (-34.22 to 35.71 for VAS and -0.55 to 0.51 for summary score), suggesting no systematic bias., Conclusions: Although proxy and patient responses for the EQ-5D VAS may differ, the differences show random variability rather than systematic bias. Group comparisons using proxy responses are unlikely to be biased, but proxy responses should be used with caution when assessing individual patient recovery.

Introduction: To evaluate the validity of the 12-item Short Form Health Survey (SF-12), Sickness Impact Profile (SIP) and the Short Musculoskeletal Functional Assessment Questionnaire (SMFA) for use in an orthopaedic trauma population., Materials and Methods: A prospective validation trial was completed at a Level 1 adult trauma centre in Melbourne, Australia. One hundred and fifty four patients with orthopaedic trauma managed or followed-up by an orthopaedic unit were prospectively recruited. Patients with pathological fractures related to metastatic disease and/or an isolated orthopaedic injury, a documented history of mental illness or dementia or those for whom follow-up was likely to be difficult were excluded. The SF-12, SIP and SMFA were administered by a trained interviewer at one and six months. Each questionnaire was scored for the physical and mental components and then compared for content and construct validity at each time point., Results: Complete data were collected for 134 patients at one and six months. The one and six month component scores correlated strongly between the SF-12 physical, SIP physical (r=0.513-0.669) and SMFA dysfunction (r=0.529-0.778); the SF-12 mental, SIP mental (r=0.643-0.719) and SMFA bother (r=0.564-0.602) components. The strength of association was greater for the six month time point compared to the one month measure. The SF-12 demonstrated no ceiling or floor effects, and provided a lower time burden on participants and researchers when compared to the SIP and SMFA., Conclusions: For large population-based surveillance research into orthopaedic injury the SF-12 provides a valid and versatile tool., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Introduction: The inability to accurately predict acute traumatic coagulopathy (ATC) has been a key factor in the low level of evidence guiding its management. The aim of this study was to develop a tool to accurately identify patients with ATC using pre-hospital variables without the use of pathology or radiological testing., Methods: Retrospective data from the trauma registry on major trauma patients were used to identify variables independently associated with coagulopathy. These variables were clinically evaluated to develop a scoring system to predict ATC, which was prospectively validated in the same setting., Results: There were 1680 major trauma patients in the derivation dataset, with 151 patients being coagulopathic. Pre-hospital variables independently associated with ATC were entrapment (OR 1.85; 95% CI: 1.12-3.06), temperature (OR 0.60; 95% CI: 0.60-0.72), systolic blood pressure (OR 0.99; 95% CI: 0.98-0.99), abdominal or pelvic content injury (OR 2.0; 95% CI: 1.27-3.12) and pre-hospital chest decompression (OR 4.99; 2.77-8.99). The COAST score was developed, scoring points for entrapment, temperature <35°C, systolic blood pressure < 100 mm Hg, abdominal or pelvic content injury and chest decompression. Prospectively validated using 1225 major trauma patients, a COAST score of ≥ 3 had a specificity of 96.4% with a sensitivity of 60.0%, with an area under the receiver operating characteristic curve of 0.83 (0.78-0.88)., Conclusions: The COAST score accurately identified a group of patients with ATC using pre-hospital observations. This predictive tool can be used to select patients for inclusion into prospective studies examining management options for ATC. Mortality in these patients is high, potentially improving feasibility of outcome studies., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: Pediatric trauma results in lower mortality than adults and a high potential for lifelong functional impairment and reduced health-related quality of life (HRQL). There is no consensus regarding the best approach to measuring outcomes in this group., Methods: One hundred and fifty injured children admitted to a pediatric trauma center participated in this study. The Pediatric Quality of Life Inventory (PedsQL), Child Health Questionnaire (CHQ-PF28), King's Outcome Scale for Childhood Head Injury (KOSCHI), modified Glasgow Outcome Scale (mGOS), and the Functional Independence Measure (FIM) were administered at 1 month, 6 months, and 12 months after injury by telephone. Change in instrument scores was assessed using multilevel mixed effects models. Mean HRQL scores were compared with population norms for the CHQ-PF28 and with healthy children for the PedsQL., Results: Follow-up at all time points was completed for 144 (96%) cases. The median injury severity score was 10, and 65% of the patients enrolled were men. At 12 months, the percentage of cases with ongoing disability was 14% for the FIM, 61% using the mGOS, and 58% for the KOSCHI. CHQ-PF28 physical and PedsQL psychosocial health scores were below healthy child norms at 12 months. Improvement across all time points was demonstrated for the KOSCHI, mGOS, CHQ-PF28 physical, and PedsQL psychosocial summary scores., Conclusions: Seriously injured children showed ongoing disability and reduced HRQL 12 months after injury. The CHQ-PF28 and PedsQL, and the mGOS and KOSCHI, performed comparably. The FIM demonstrated considerable ceiling effects, and improvement over time was not shown. The results inform the methodology of pediatric outcomes studies and protocol development for the routine follow-up of pediatric trauma patients.

Objectives: 'Massive' transfusion is a poorly defined inclusion criteria for studies examining the blood and blood product that are used during trauma resuscitation. We aimed to compare the traditional definition of massive transfusion (≥10 units in 24 h) to a more acute definition of at least 5 units in 4 h., Methods: Multitrauma patients were subgrouped according to the traditional definition and compared with the acute definition. Demographics, presenting vital signs and blood results, management including transfusion practice and outcomes were retrospectively studied. Associations of transfused fresh frozen plasma:packed red blood cells (PRBC) ratios with mortality were studied., Results: There were 927 patients who received PRBCs in the first 24 h, with 314 patients identified using the traditional definition and 303 patients using the acute definition. The patients identified using the traditional definition received 18 (12-29) units of PRBC in 24 h, significantly higher than those identified using the acute definition [15 (9-29) units, P<0.001]. The traditional definition excluded a significant proportion of patients who died in the emergency department. By using the acute definition to select a study sample, there seems to be an increase in mortality with fresh frozen plasma:PRBC ratio of 1 : 1 ratio compared with a 1 : 2 ratio., Conclusion: The traditional 'massive' transfusion definition not only 'dilutes' the potential study samples with a less acute group of patients, but also further excludes patients who die early. This latter group is most likely to be benefitted from any change to resuscitation practice. An acute definition of massive transfusion should be adopted when examining clinical practice during initial trauma resuscitation.