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To determine how many Level 1 and Level 2 trauma centres in Canada have implemented a resuscitative endovascular balloon occlusion of the aorta (REBOA) program, and to identify facilitators and barriers to successful implementation of REBOA programs. An electronic survey was developed and administered in November 2019 (updated in July 2021) via email to directors at all 32 Level 1 and Level 2 trauma centres across Canada, and to the medical director in PEI (no Level 1 or Level 2 capacity). Survey responses were supplemented by an online search in PubMed and the grey literature. Responses were analyzed using simple descriptive statistics including frequencies and proportions. We received responses from directors at 22 sites (17 Level 1 trauma centres, 4 Level 2 trauma centres, PEI) for a response rate of 66.7%. There are 6 Level 1 trauma centres with REBOA programs; all were implemented between 2017 and 2019. One additional Level 1 trauma centre that did not respond was found to have a REBOA program; thus, 21.9% (7/32) of Canadian Level 1 and Level 2 trauma centres have an existing REBOA program. These programs are located in three provinces (British Columbia, Ontario, Quebec). Five other centres are planning on implementing a REBOA program in the next 2 years. The number of REBOA cases performed ranged from 0 to 30 (median 2). Factors contributing most to successful program implementation were having physician champions and patient populations with sufficient REBOA candidates, while cost and lack of expertise were the greatest barriers identified. As of July 2021, 21.9% (7/32) of Canadian Level 1 and Level 2 trauma centres have a REBOA program. Physician champions and a patient population with sufficient numbers of REBOA candidates were the most important factors contributing to successful implementation of these programs.

Traumatic brain injury (TBI) is a leading cause of death and disability among adults. Falls and motor vehicle collisions (MVCs) are the most common causes of TBI hospitalizations in Canada. The purpose of this study was to determine whether, at the provincial level, there have been significant changes in the injury rate and causes of major TBI. This was a retrospective cohort study of all patients in Nova Scotia who presented with major TBI (Abbreviated Injury Scale Head score ≥ 3) between 2002 and 2018. Prospectively entered data were collected from the Nova Scotia Trauma Registry. Annual injury rates were calculated based on 100,000 population (all ages) using population estimates from Statistics Canada. Linear regression was performed to analyze annual trends of major TBI within the province. There were 5590 major TBI patients in Nova Scotia during the 16-year study period. The overall annual rate of major TBI was 37 per 100,000 population. There was a 39% increase in the rate of major TBI over the study period (r = − 0.72, R2 = 0.51, p

Respiratory failure and acute respiratory distress syndrome can occur in burn patients with or without inhalational injury and can significantly increase mortality. For patients with severe respiratory failure who fail conventional therapy with mechanical ventilation, the use of venovenous extracorporeal membrane oxygenation (ECMO) may be a life-saving salvage therapy. There have been a series of case reports detailing the use of ECMO in burn patients over the last 20 years, but very little is currently known about the status of ECMO use at burn centers in North America. Using a web-based survey of burn center directors in Canada and the United States, we examined the rate of usage of ECMO in burn care, barriers to its use, and the perioperative management of burn patients receiving ECMO therapy. Our findings indicate that approximately half of the burn centers have used ECMO in the care of burn patients, but patient volume is very low on average (less than 1 per year). Of centers that do use ECMO in burn care, only 40% have a specified protocol for doing so. Approximately half have operated on patients being actively treated with ECMO therapy, but perioperative management of anticoagulation varies widely. A lack of experience and institutional support and a perceived lack of evidence to support ECMO use in burn patients were the most commonly identified barriers to more widespread uptake. Better collaboration between burn centers will allow for the creation of consensus statements and protocols to improve outcomes for burn patients who require ECMO.

To perform a province-wide evaluation of adult major traumas and determine the proportion of patients who met clinical and/or anatomical criteria for resuscitative endovascular balloon occlusion of the aorta (REBOA). This is a retrospective analysis of all major trauma patients (age > 16) presenting to the sole adult level 1 trauma centre in Nova Scotia over a 5-year period (2012–2017). Data were collected from the Nova Scotia Trauma Registry and medical charts. We identified potential REBOA candidates using either: (1) clinical criteria (primary survey, Focused Assessment with Sonography for Trauma, pelvic/chest X-ray); or (2) anatomical criteria (ICD-10-CA codes). Potential candidates with persistent hypotension were considered true REBOA candidates. Overall 2885 patients were included in the analysis, of whom 248 (8.6%) patients were in shock (including 106 transfer patients) and had their charts reviewed. A total of 137 patients met clinical criteria for REBOA; 44 (1.5%) had persistent hypotension 10–20 min into resuscitation and were considered true REBOA candidates. There were 59 patients who met anatomical criteria for REBOA, of whom 15 (0.5%) patients had persistent hypotension and were true REBOA candidates. The 15 REBOA candidates based on anatomical criteria also met clinical criteria for REBOA. In this registry-based retrospective analysis, 1.5% of adult major trauma patients Nova Scotia were REBOA candidates based on resuscitative clinical presentation, while 0.5% were candidates based on post hoc anatomical injury patterns. Our findings suggest that using clinical findings and bedside imaging modalities as criteria may overestimate the number of candidates for REBOA.

Firearm-related trauma is a significant cause of preventable mortality. In 2020, Nova Scotia experienced the largest mass shooting in Canadian history. The objective of this study was to describe the epidemiology of firearm-related injury and death in Nova Scotia and to assess for factors associated with mortality.A retrospective observational study of all major trauma patients in Nova Scotia who sustained firearm-related injuries between 2001 and 2020 was conducted. Data was collected from the Nova Scotia Trauma Registry and the Nova Scotia Medical Examiner Service. Injury rates were evaluated over time, by age/sex, and by intent (assault/homicide, self-harm, other), and were mapped by municipality. Characteristics of survivors and non-survivors were compared using t-tests and chi-square analysis. A multivariate logistic regression model was created to assess for predictors of mortality.A total of 776 firearm-related injuries occurred over the 19-year study period, for an overall age- and sex-adjusted firearm injury rate of 4.44 per 100,000 population. Patients ranged in age from 6 to 92 years (mean 45.0±19.2 years) and most were male (95.6%; 742/776). Injuries were predominantly self-inflicted (65%; 504/776). The majority of patients died from their injuries (72%; 558/776); 64% (497/776) died at the scene. The overall age- and sex-adjusted firearm mortality rate was 3.18 per 100,000. Most non-survivors had injuries that were self-inflicted (83.2%; 464/558). Increasing age (OR 1.02, 95% CI 1.00-1.04) and increasing Injury Severity Score (OR 1.11, 95% CI 1.07-1.15) were associated with greater likelihood of mortality. Activation of the trauma team was associated with survival (OR 0.04, 95% CI 0.02-0.10).Trauma patients with firearm-related injuries were predominantly male and most injuries were self-inflicted among middle-aged to older patients. Younger patients tended to be victims of homicide/assault and were more likely to survive their injuries.

Mandatory gunshot wound reporting laws have been enacted in much of Canada, yet there is a lack of evidence on whether these laws are effective in preventing firearm injuries. Our objective was to determine if the Gunshot Wounds Reporting Act in Nova Scotia had an effect on the number of firearm-related injuries in the province.Pre-post-study of major trauma patients in Nova Scotia who sustained a gunshot wound injury before and after enactment of the Gunshot Wounds Reporting Act (Bill 10) in 2008. Data were collected from the Nova Scotia Trauma Registry and the Nova Scotia Medical Examiner Service for a 6-year pre-period (2002-2007) and an 11-year post-period (2009-2019), allowing for a 1-year washout period. Patient characteristics in the pre- and post-periods were compared using t tests and Chi-square analysis. Gunshot wound traumas were analyzed as a time series using the AutoRegressive Integrated Moving Average (ARIMA) model.A total of 722 firearm injuries were observed during the study period (pre-period = 259, post-period = 463). Mean age was 45.2 ± 19.3 years with males accounting for 95.3% (688/722) of cases. The majority of injuries were self-inflicted (65.1%; 470/722). The mean overall annualized rate of firearm injuries was 4.61 per 100,000 population in the pre-period and 4.45 per 100,000 in the post-period (reduction of 3.4%). No linear trends in the annual number of firearm injuries were observed over the study period. ARIMA modelling was an extremely poor predictor for gunshot wound trauma (RAlthough our findings suggest that there is no association between the Gunshot Wounds Reporting Act and the incidence of firearm injury, it is difficult to draw firm conclusions due to the complexity of this topic. Physicians need to be aware of the legal requirements of mandatory reporting when they encounter patients with gunshot wounds.RéSUMé: OBJECTIF: Des lois obligatoires sur le signalement des blessures par balle ont été promulguées dans une grande partie du Canada, mais on manque de données probantes sur l'efficacité de ces lois pour prévenir les blessures par balle. Notre objectif était de déterminer si la Gunshot Wounds Reporting Act de la Nouvelle-Écosse a eu un effet sur le nombre de blessures liées aux armes à feu dans la province. MéTHODES: Étude pré-post des patients souffrant de traumatismes majeurs en Nouvelle-Écosse et ayant subi une blessure par balle avant et après la promulgation de la loi sur la déclaration des blessures par balle (projet de loi 10) en 2008. Les données ont été recueillies auprès du Nova Scotia Trauma Registry et du Nova Scotia Medical Examiner Service pour une période de 6 ans avant (2002–2007) et de 11 ans après (2009–2019), en tenant compte d'une période d'élimination d'un an. Les caractéristiques des patients avant et après les périodes ont été comparées à l’aide de tests- t et d’une analyse du chi-carré. Les traumatismes liés aux blessures par balle ont été analysés comme une série chronologique à l'aide du modèle ARIMA (AutoRegressive Integrated Moving Average). RéSULTATS: Au total, 722 blessures par arme à feu ont été observées au cours de la période d'étude (avant la période = 259, après la période = 463). L'âge moyen était de 45,2 ± 19,3 ans, les hommes représentant 95,3% (688/722) des cas. La majorité des blessures étaient auto-infligées (65,1%; 470/722). Le taux global moyen annualisé de blessures par arme à feu était de 4,61 pour 100 000 habitants pendant la période antérieure et de 4,45 pour 100 000 pendant la période postérieure (réduction de 3,4%). Aucune tendance linéaire du nombre annuel de blessures par arme à feu n'a été observée au cours de la période d'étude. Le modèle ARIMA s'est avéré être un très mauvais prédicteur des traumatismes liés aux blessures par balle (R2 = 0,012). CONCLUSIONS: Bien que nos résultats suggèrent qu'il n'y a pas de lien entre la loi sur le signalement des blessures par balle et l'incidence des blessures par arme à feu, il est difficile de tirer des conclusions définitives en raison de la complexité de ce sujet. Les médecins doivent être conscients des obligations légales de déclaration obligatoire lorsqu'ils rencontrent des patients présentant des blessures par balle.

BackgroundThe risk of death and complications after major trauma in patients with chronic kidney disease (CKD) is higher than in the general population, but whether this association holds true among Canadian trauma patients is unknown.ObjectivesTo characterize patients with CKD/receiving dialysis within a regional major trauma cohort and compare their outcomes with patients without CKD.MethodsAll major traumas requiring hospitalization between 2006 and 2017 were identified from a provincial trauma registry in Nova Scotia, Canada. Trauma patients with stage ≥3 CKD (estimated glomerular filtration rate 2) or receiving dialysis were identified by cross-referencing two regional databases for nephrology clinics and dialysis treatments. The primary outcome was in-hospital mortality; secondary outcomes included hospital/intensive care unit (ICU) length of stay (LOS) and ventilator-days. Cox regression was used to adjust for the effects of patient characteristics on in-hospital mortality.ResultsIn total, 6237 trauma patients were identified, of whom 4997 lived within the regional nephrology catchment area. CKD/dialysis trauma patients (n=101; 28 on dialysis) were older than patients without CKD (n=4896), with higher rates of hypertension, diabetes, and cardiovascular disease, and had increased risk of in-hospital mortality (31% vs 11%, pConclusionIndependent of injury severity, patients without CKD/dialysis have significantly increased risk of in-hospital mortality after major trauma.

Despite advances in burn care, mortality in adult patients with extensive burn injuries remains a concern, particularly in those who develop concurrent acute respiratory distress syndrome (ARDS). In cases of ARDS refractory to conventional treatments, venovenous extracorporeal membrane oxygenation (ECMO) may represent a viable salvage therapy, even in the major burn population. We present the case of a 38-year-old man with full thickness burns to over 80% of his body, who developed severe ARDS 4 days postburn. After failing to respond to deep sedation, paralysis, and proning, ECMO therapy was initiated to maintain oxygenation and ventilation. Over the next 14 days, while the patient was treated with ECMO, he successfully underwent three major operations to debride and allograft approximately 65% of his body surface area, including one in the prone position. ECMO therapy was discontinued on postburn day 18, and the patient had his wounds reconstructed and survived his injuries. To the best of our knowledge, this is the first report of a burn patient with such severe burns requiring surgical intervention that has been treated with ECMO and survived, and the first case of a burn patient on ECMO having surgery in the prone position. They conclude this case serves as a “proof of concept” that ECMO is a potential treatment for appropriately selected major burn patients with ARDS who fail to respond to other therapies.

Background Trauma patients represent a significant pool of potential organ donors (PODs), and previous research suggests that this population is underutilized for organ donation (OD). Our objective was to assess factors associated with OD in the trauma population. Methods We retrospectively analyzed OD in Nova Scotia over a 7-year period (2009-2016) using data from the Nova Scotia Trauma Registry and Nova Scotia Legacy of Life Donor Registry. All trauma patients who died in the hospital were included. Multiple logistic regression was used to assess factors associated with donation. We also evaluated characteristics, donation types, and reasons for nondonation among trauma PODs. Results There were 689 trauma-related deaths in all hospitals in NS during the study period, of which 39.8% (274 of 689) met the Nova Scotia Trauma Registry definition of a POD. Data on OD were available for 108 of these patients who were referred to the Legacy of Life Program. The conversion rate was 84%. Compared with nondonors, organ donors were significantly younger, had a higher Abbreviated Injury Scale head score and a lower scene Glasgow Coma Scale score, were more likely to suffer ischemia from drowning or asphyxia and to require air transport, and were less likely to have comorbidities. Regression analysis showed that donation was associated with younger age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95-0.99) and lower Glasgow Coma Scale score at the scene (OR, 0.76; 95% CI, 0.66-0.88). Odds of donation were increased with air transport compared with land ambulance (OR, 8.27; 95% CI, 2.07-33.08) and injury within Halifax Regional Municipality compared with injury outside Halifax Regional Municipality (OR, 4.64; 95% CI, 1.42-15.10). Among the 60 referred PODs who did not donate, family refusal of consent was the most common reason (28 [46.7%] of 60). Conclusion Younger age, greater severity of injury, and shorter time to tertiary care were associated with OD in trauma patients. Level of evidence Prognostic and Epidemiological, Level III.

Trauma is a leading contributor to the burden of disease in Canada, accounting for more than 15 000 deaths annually. Although caring for injured patients at designated trauma centres (TCs) is consistently associated with survival benefits, it is unclear how travel time to definitive care influences outcomes. Using a population-based sample of trauma patients, we studied the association between predicted travel time (PTT) to TCs and mortality for patients assigned to ground transport.Victims of penetrating trauma or motor vehicle collisions (MVCs) in Nova Scotia between 2005 and 2014 were identified from a provincial trauma registry. We conducted cost distance analyses to quantify PTT for each injury location to the nearest TC. Adjusted associations between TC access and injury-related mortality were then estimated using logistic regression.Greater than 30 minutes of PTT to a TC was associated with a 66% increased risk of death for MVC victims (p = 0.045). This association was lost when scene deaths were excluded from the analysis. Sustaining a penetrating trauma greater than 30 minutes from a TC was associated with a 3.4-fold increase in risk of death. Following the exclusion of scene deaths, this association remained and approached significance (odds ratio 3.48, 95% confidence interval 0.98–14.5, p = 0.053).Predicted travel times greater than 30 minutes were associated with worse outcomes for victims of MVCs and penetrating injuries. Improving communication across the trauma system and reducing prehospital times may help optimize outcomes for rural trauma patients.Les traumatismes contribuent pour une bonne part au fardeau de la maladie au Canada; on leur attribue plus de 15 000 décès annuellement. Même si les soins prodigués aux patients victimes de traumatismes dans les centres de traumatologie désignés (CTD) sont toujours associés à des gains au plan de la survie, on ignore quelle est l’influence du temps de transfert vers le CTD sur l’issue. À partir d’un échantillon de patients polytraumatisés basé dans la population, nous avons analysé le lien entre le temps de transfert prévu (TTP) vers le CTD et la mortalité des patients transportés par voie terrestre.On a identifié les victimes de traumatismes pénétrants ou d’accidents de la route en Nouvelle-Écosse entre 2005 et 2014 à partir d’un registre provincial de traumatologie. Nous avons analysé la distance de coût pour quantifier le TTP à partir de chaque scène vers le CTD le plus proche. Les liens ajustés entre l’accès au CTD et la mortalité liée au traumatisme ont ensuite été estimés par régression logistique.Un délai de TTP de plus de 30 minutes pour arriver au CTD a été associé à un accroissement de 66 % du risque de décès chez les patients polytraumatisés (p = 0,045). Ce lien s’annulait si on excluait de l’analyse les décès survenus sur la scène de l’accident. Subir un traumatisme ouvert à plus de 30 minutes de distance d’un CTD a été associé à une augmentation par un facteur de 3,4 du risque de décès. Une fois les décès sur la scène de l’accident exclus, ce lien a persisté et s’est rapproché du seuil de signification (rapport des cotes 3,48, intervalle de confiance de 95 % 0,98–14,5, p = 0,053).Des temps de transfert prévus supérieurs à 30 minutes ont été associés une issue plus défavorable pour les victimes d’accidents de la route et de traumatismes pénétrants. L’amélioration de la communication entre les divers éléments du système de traumatologie et la réduction du temps préhospitalier pourrait optimiser l’issue pour les patients victimes de traumatismes en région rurale.

To determine the rate of recurrent major trauma (i.e., trauma recidivism) using a provincial population-based trauma registry. We compared outcomes between recidivists and non-recidivists, and assessed factors associated with recidivism and mortality.Review of all adult (gt;17 years) major trauma patients in Nova Scotia (2001-2015) using data from the Nova Scotia Trauma Registry. Outcomes of interest were mortality, duration of hospital stay, and in-hospital complications. Multiple regression was used to assess factors associated with recidivism and mortality.Of 9,365 major trauma patients, 2% (150/9365) were recidivists. Mean age at initial injury was 52 ± 21.5 years; 73% were male. The mortality rate for both recidivists and non-recidivists was 31%. However, after adjusting for potential confounders the likelihood of mortality was over 3 times greater for recidivists compared to non-recidivists (OR 3.67, 95% CI 2.06-6.54). Other factors associated with mortality included age, male gender, penetrating injury, Injury Severity Score, trauma team activation (TTA) and admission to the intensive care unit. The only variables associated with recidivism were age (OR 0.98, 95% CI 0.97-1.00) and TTA (OR 0.59, 95% CI 0.34-0.96).This is the first provincial investigation of major trauma recidivism in Canada. While recidivism was infrequent (2%), the adjusted odds of mortality were over three times greater for recidivists. Further research is warranted to determine the effectiveness of strategies for reducing rates of major trauma recidivism such as screening and brief intervention in cases of violence or substance abuse.L’étude visait à déterminer le taux de répétition (ou de récidive) de traumas graves à l'aide d'un registre provincial de traumas, fondé sur la population. Ont d'abord été comparés les résultats cliniques chez les « récidivistes » et les « non-récidivistes », puis évalués les facteurs associés aux répétitions et à la mortalité.L’étude consistait en un examen des dossiers de tous les adultes (17 ans) ayant subi un trauma grave en Nouvelle-Écosse (2001–2015), à l'aide de données tirées du registre Nova Scotia Trauma Registry. Les résultats cliniques d'intérêt étaient la mortalité, la durée de séjour à l'hôpital et les complications survenues à l'hôpital. Par ailleurs, il y a eu régression multiple afin d’évaluer les facteurs associés aux répétitions et à la mortalité.Sur 9365 patients ayant subi un trauma grave, 150 (2%) étaient des récidivistes. L’âge moyen au moment du premier accident était de 52 ± 21,5 ans, et 73% des patients étaient des hommes. Le taux de mortalité dans les deux groupes s’élevait à 31%. Toutefois, après rajustement du taux pour tenir compte de possibles facteurs parasites, les probabilités de mort étaient 3 fois plus élevées chez les récidivistes que chez les non-récidivistes (risque relatif approché [RRA] : 3,67; IC à 95% : 2,6–6,54). D'autres facteurs associés à la mortalité comprenaient l’âge, le sexe masculin, les blessures par pénétration, le score selon l'indice de gravité des blessures, l'appel à l’équipe de soins en traumatologie (EST) et l'admission au service de soins intensifs. Toutefois, seules deux variables ont été associées aux répétitions de traumas, soit l’âge (RRA : 0,98; IC à 95% : 0,97–1,00) et l'appel à l'EST (RRA : 0,59; IC à 95% : 0,34–0,96).Il s'agit là de la première étude sur les répétitions de traumas graves, menée à l’échelle provinciale, au Canada. Si le taux de répétition était faible (2%), les probabilités rajustées de mort chez les récidivistes étaient plus de 3 fois supérieures à celles enregistrées chez les non-récidivistes. Il faudrait donc approfondir le sujet afin de déterminer l'efficacité des stratégies de réduction du taux de répétition de traumas graves, telles que le dépistage et les interventions brèves dans les cas de violence ou d'un usage abusif d'alcool ou de drogues.

To perform a province-wide evaluation of adult major traumas and determine the proportion of patients who met clinical and/or anatomical criteria for resuscitative endovascular balloon occlusion of the aorta (REBOA).This is a retrospective analysis of all major trauma patients (age 16) presenting to the sole adult level 1 trauma centre in Nova Scotia over a 5-year period (2012-2017). Data were collected from the Nova Scotia Trauma Registry and medical charts. We identified potential REBOA candidates using either: (1) clinical criteria (primary survey, Focused Assessment with Sonography for Trauma, pelvic/chest X-ray); or (2) anatomical criteria (ICD-10-CA codes). Potential candidates with persistent hypotension were considered true REBOA candidates.Overall 2885 patients were included in the analysis, of whom 248 (8.6%) patients were in shock (including 106 transfer patients) and had their charts reviewed. A total of 137 patients met clinical criteria for REBOA; 44 (1.5%) had persistent hypotension 10-20 min into resuscitation and were considered true REBOA candidates. There were 59 patients who met anatomical criteria for REBOA, of whom 15 (0.5%) patients had persistent hypotension and were true REBOA candidates. The 15 REBOA candidates based on anatomical criteria also met clinical criteria for REBOA.In this registry-based retrospective analysis, 1.5% of adult major trauma patients Nova Scotia were REBOA candidates based on resuscitative clinical presentation, while 0.5% were candidates based on post hoc anatomical injury patterns. Our findings suggest that using clinical findings and bedside imaging modalities as criteria may overestimate the number of candidates for REBOA.RéSUMé: OBJECTIFS: Effectuer une évaluation à l'échelle de la province des traumatismes majeurs chez l'adulte et déterminer la proportion de patients qui répondaient aux critères cliniques et/ou anatomiques de l’occlusion endovasculaire par ballonnet de réanimation de l'aorte (REBOA). LES MéTHODES: Analyse rétrospective de tous les patients ayant subi un traumatisme majeur (âge16 ans) qui se sont présentés au seul centre de traumatologie de niveau 1 pour adultes en Nouvelle-Écosse sur une période de 5 ans (2012-2017). Les données ont été recueillies à partir du registre des traumatismes de la Nouvelle-Écosse et des dossiers médicaux. Nous avons identifié des candidats potentiels à la REBOA en utilisant l'un ou l'autre : 1) des critères cliniques (enquête primaire, évaluation ciblée avec échographie pour les traumatismes, radiographie pelvienne/du thorax) ; ou 2) des critères anatomiques (codes CIM-10-CA). Les candidats potentiels présentant une hypotension persistante étaient considérés comme de véritables candidats au REBOA. RéSULTATS: Au total, 2 885 patients ont été inclus dans l'analyse, dont 248 (8,6 %) étaient en état de choc (dont 106 patients transférés) et ont vu leur dossier révisé. Au total, 137 patients répondaient aux critères cliniques pour la REBOA ; 44 (1,5 %) présentaient une hypotension persistante de 10 à 20 minutes en réanimation et étaient considérés comme de véritables candidats à la REBOA. Il y avait 59 patients qui répondaient aux critères anatomiques pour le REBOA, dont 15 (0,5 %) avaient une hypotension persistante et étaient de véritables candidats au REBOA. Les 15 candidats REBOA basés sur des critères anatomiques répondaient également aux critères cliniques de REBOA. CONCLUSIONS: Dans cette analyse rétrospective basée sur un registre, 1,5 % des patients adultes ayant subi un traumatisme majeur en Nouvelle-Écosse étaient des candidats au REBOA sur la base d'une présentation clinique de réanimation, tandis que 0,5 % étaient des candidats sur la base de modèles de blessures anatomiques post-hoc. Nos conclusions suggèrent que l'utilisation des résultats cliniques et des modalités d'imagerie au chevet du patient comme critères peut surestimer le nombre de candidats à la REBOA.

Background Prolonged immobility has detrimental consequences for critically ill patients admitted to the intensive care unit (ICU). Previous work has shown that early mobilization of ICU patients is a safe, feasible and effective strategy to improve outcomes; however, few of these studies focused on trauma ICU patients. Our objective was to assess the impact of implementing an ICU early mobilization protocol (EMP) on trauma outcomes. Methods We conducted a retrospective pre-post study of adult trauma patients (>18 years old) admitted to ICU at a Level I trauma center over a 2-year period prior to and following EMP implementation, allowing for a 1-year transition period. Data were collected from the Nova Scotia Trauma Registry. We compared outcomes (mortality, length of stay [LOS], ventilator-free days) between patients admitted during pre-EMP and post-EMP periods, and assessed for factors associated with outcomes using binary logistic regression and generalized linear models. Results Overall, 526 patients were included in the analysis (292 pre-EMP, 234 post-EMP). Ages ranged from 18 years to 92 years (mean, 49.0 ± 20.4 years) and 74.3% were men. The post-EMP group had lower ICU mortality (21.6% vs. 12.8%; p = 0.009) and in-hospital mortality (25.3% vs. 17.5%; p = 0.031). After controlling for confounders, patients in the post-EMP group were less likely to die in the ICU (odds ratio, 0.43; 95% confidence interval, 0.24-0.79; p = 0.006) or in-hospital (odds ratio, 0.55; 95% confidence interval; 0.32-0.94; p = 0.03). In-hospital LOS, ICU LOS, ICU-free days, and number of ventilator-free days were similar between the two groups. Conclusion Trauma patients admitted to ICU during the post-EMP period had decreased odds of ICU mortality and in-hospital mortality. This is the first study to demonstrate a significant reduction in trauma mortality following implementation of an ICU mobility protocol. Level of evidence Therapeutic, level III.

Purpose We aimed to evaluate the association between transfusion practices and clinical outcomes in patients with traumatic brain injury. Material and methods We conducted a retrospective cohort study of adult patients with moderate or severe traumatic brain injury admitted to the intensive care unit (ICU) of a level I trauma center between 2009 and 2013. The associations between hemoglobin (Hb) level, red blood cell (RBC) transfusion and clinical outcomes were estimated using robust Poisson models and proportional hazard models with time-dependent variables, adjusted for confounders. Results We included 215 patients. Sixty-six patients (30.7%) were transfused during ICU stay. The median pre-transfusion Hb among transfused patients was 81 g/L (IQR 67–100), while median nadir Hb among non-transfused patients was 110 g/L (IQR 93–123). Poor outcomes were significantly more frequent in patients who were transfused (mortality risk ratio [RR]: 2.15 [95% CI 1.37–3.38] and hazard ratio: 3.06 [95% CI 1.57–5.97]; neurological complications RR: 3.40 [95% CI 1.35–8.56]; trauma complications RR: 1.65 [95% CI 1.31–2.08]; ICU length of stay geometric mean ratio: 1.42 [95% CI 1.06–1.92]). Conclusions During ICU stay, transfused patients tended to have lower Hb levels and worse outcomes than patients who did not receive RBCs, after adjustment for confounders.

BACKGROUND Blood transfusion is common in the resuscitation of patients with traumatic injury. However, the clinical impact of the length of storage of transfused blood is unclear in this population. STUDY DESIGN AND METHODS We undertook a prespecified nested analysis of 372 trauma victims of the 2510 critically ill patients from 64 centers treated as part of the Age of Blood Evaluation (ABLE) randomized controlled trial. Patients were randomized according to their trauma status to receive either a transfusion of fresh blood stored not more than 7 days or standard-issue blood. Our primary outcome was 90-day all-cause mortality. RESULTS Overall, 186 trauma patients received fresh blood and 186 received standard-issue blood. Adherence to transfusion protocol was 94% (915/971) for all fresh blood transfused and 100% (753/753) for all standard-issue blood transfused. Mean ± SD blood storage duration was 5.6 ± 3.8 days in the fresh group and 22.7 ± 8.4 days in the standard-issue group (p

Context: With increasing ownership of mobile devices (i.e., cell phones and smartphones), it is important to better understand the role of these devices in motor vehicle collision (MVC)-related trauma. Aims: The primary objective was to synthesize evidence on the proportion of drivers injured or killed in an MVC attributed to driver distraction by a mobile device. As a secondary objective, we assessed for associations between injury risk and mobile device use while driving. Settings and Design: This study was a systematic review. Subjects and Methods: We searched five electronic databases (PubMed, Embase, CINAHL, TRIS, and Web of Science) and the gray literature to identify reports of drivers injured (regardless of the severity) or killed in MVCs attributed to mobile device-related distraction by the driver. We evaluated study and driver characteristics, as well as associations between injury risk and mobile device use by drivers. Statistical Analysis Used: Descriptive statistics were used to report study characteristics. The proportion of injuries related to driver distraction by mobile devices was calculated for each study. Results: Overall, 4907 articles were screened, of which 13 met eligibility criteria. The median proportion of distracted-driving-related trauma was 3.4% (range: 0.04% to 44.7%). Three studies evaluated the association between mobile device use and road traffic injury; all found use of a mobile device while driving significantly increased crash risk. Conclusions: The proportion of road traffic injuries and fatalities attributed to driver distraction by a mobile device ranges from 0.04% to 44.7%. Studies were subject to limitations in the collection of reliable data on distraction-related MVCs.

The objective of this study was to evaluate adverse patient outcomes associated with the choice of intravenous fluid administered during general anaesthesia.This study was a retrospective chart review of vascular surgery patients at a Canadian tertiary care hospital. Patients were separated into three groups: those who were intraoperatively administered normal saline (NS), balanced crystalloids, or a combination of both solutions. Multivariate analysis was performed to determine association between volume of each fluid type administered and adverse outcomes including in-hospital mortality, prolonged intensive care unit admission, vasopressor requirement, ventilator requirement, hemodialysis requirement, and a composite endpoint of any of these adverse events occurring.Overall, 796 vascular surgery patients were included in the analysis. There were 425 patients who received balanced crystalloids, 158 patients who received NS, and 213 patients received both balanced crystalloids and NS. Groups were similar in age (P=0.06), but varied in gender (P0.001) and overall health (ASA≥2; P=0.027). The most common adverse event was ventilator requirement (NS: 27.9%, balanced: 7.5%, both: 38.0%; P0.001). Mortality was lowest in the group that received balanced fluids (NS: 12.0%, balanced: 5.9%, both: 10.8%; P=0.018). Patients who were administered NS or both fluids were more likely to reach the composite endpoint than patients receiving balanced crystalloid alone.The administration of an unbalanced crystalloid solution was associated with poor patient outcomes in our study population.

BackgroundTwo distinct Emergency Medical Services (EMS) systems exist in Atlantic Canada. Nova Scotia operates an Advanced Emergency Medical System (AEMS) and New Brunswick operates a Basic Emergency Medical System (BEMS). We sought to determine if survival rates differed between the two systems.MethodsThis study examined patients with trauma who were transported directly to a level 1 trauma centre in New Brunswick or Nova Scotia between 1 April 2011 and 31 March 2013. Data were extracted from the respective provincial trauma registries; the lowest common Injury Severity Score (ISS) collected by both registries was ISS≥13. Survival to hospital and survival to discharge or 30 days were the primary endpoints. A separate analysis was performed on severely injured patients. Hypothesis testing was conducted using Fisher’s exact test and the Student’s t-test.Results101 cases met inclusion criteria in New Brunswick and were compared with 251 cases in Nova Scotia. Overall mortality was low with 93% of patients surviving to hospital and 80% of patients surviving to discharge or 30 days. There was no difference in survival to hospital between the AEMS (232/251, 92%) and BEMS (97/101, 96%; OR 1.98, 95% CI 0.66 to 5.99; p=0.34) groups. Furthermore, when comparing patients with more severe injuries (ISS>24) there was no significant difference in survival (71/80, 89% vs 31/33, 94%; OR 1.96, 95% CI 0.40 to 9.63; p=0.50).ConclusionOverall survival to hospital was the same between advanced and basic Canadian EMS systems. As numbers included are low, individual case benefit cannot be excluded.

ObjectivesWhile the use of formal trauma teams is widely promoted, the literature is not clear that this structure provides improved outcomes over emergency physician delivered trauma care. The goal of this investigation was to examine if a trauma team model with a formalized, specialty-based trauma team, with specific activation criteria and staff composition, performs differently than an emergency physician delivered model. Our primary outcome was survival to discharge or 30 days.MethodsAn observational registry-based study using aggregate data from both the New Brunswick and Nova Scotia trauma registries was performed with data from April 1, 2011 to March 31, 2013. Inclusion criteria included patients 16 years-old and older who had an Injury Severity Score greater than 12, who suffered a kinetic injury and arrived with signs of life to a level-1 trauma centre.Results266 patients from the trauma team model and 111 from the emergency physician model were compared. No difference was found in the primary outcome of proportion of survival to discharge or 30 days between the two systems (0.88, n=266 vs. 0.89, n=111; p=0.8608).ConclusionsWe were unable to detect any difference in survival between a trauma team and an emergency physician delivered model.

Objectives Trauma systems have been widely implemented across Canada, but access to trauma care remains a challenge for much of the population. This study aims to develop and validate a model to quantify the accessibility of definitive care within one provincial trauma system and identify populations with poor access to trauma care. Methods A geographic information system (GIS) was used to generate models of pre-scene and post-scene intervals, respectively. Models were validated using a population-based trauma registry containing data on prehospital time intervals and injury locations for Nova Scotia (NS). Validated models were then applied to describe the population-level accessibility of trauma care for the NS population as well as a cohort of patients injured in motor vehicle collisions (MVCs). Results Predicted post-scene intervals were found to be highly correlated with documented post-scene intervals (β 1.05, p Conclusion GIS models can be used to identify populations with poor access to care and inform service planning in Canada. Although only 43% of the provincial population has access to Level I care within 60 minutes, the majority of the population of NS has access to Level III trauma care.

Although used primarily in the pediatric population for decades, the use of intraosseous (IO) devices in the resuscitation of severely injured adult trauma patients has recently become more commonplace. The objective of this study was to determine the experience level, beliefs and attitudes of trauma practitioners in Canada, Australia and New Zealand regarding the use of IO devices in adult trauma patients.We administered a web-based survey to all members of 4 national trauma and emergency medicine organizations in Canada, Australia and New Zealand. Survey responses were analyzed using descriptive statistics, univariate comparisons and a proportional odds model.Overall, 425 of 1771 members completed the survey, with 375 being trauma practitioners. IO devices were available to 97% (353 of 363), with EZ-IO being the most common. Nearly all physicians (98%, 357 of 366) had previous training with IO devices, and 85% (223 of 261) had previously used an IO device in adult trauma patients. Most respondents (79%, 285 of 361) were very comfortable placing an IO catheter in the proximal tibia. Most physicians would always or often use an IO catheter in a patient without intravenous access undergoing CPR for traumatic cardiac arrest (84%, 274 of 326) or in a hypotensive patient (without peripheral intravenous access) after 2 attempts or 90 s of trying to establish vascular access (81%, 264 of 326).Intraosseous devices are readily available to trauma practitioners in Canada, Australia and New Zealand, and most physicians are trained in device placement. Most physicians surveyed felt comfortable using an IO device in resuscitation of adult trauma patients and would do so for indications broader than current guidelines.Bien que le dispositif de perfusion intraosseuse soit depuis des décennies utilisé principalement chez les enfants, son utilisation lors de la réanimation d’adultes victimes de trauma grièvement blessés a récemment gagné en popularité. Notre étude vise à déterminer le niveau d’expérience, les croyances et les attitudes des spécialistes en traumatologie canadiens, australiens et néo-zélandais en ce qui concerne l’utilisation de ces dispositifs chez des patients adultes victimes de trauma.Nous avons fait parvenir un sondage Web à tous les membres de 4 organisations nationales de traumatologie et d’urgentologie au Canada, en Australie et en Nouvelle-Zélande. Les réponses ont été analysées au moyen de statistiques descriptives, de comparaisons univariées et d’un modèle à cotes proportionnelles.Au total, parmi les 1771 personnes visées, 425 ont répondu au sondage, dont 375 spécialistes en traumatologie. De tous les répondants, 97 % avaient accès à un dispositif de perfusion intraosseuse, et le modèle EZ-IO était le plus répandu. Presque tous les médecins (98 %) avaient été formés pour utiliser cet appareil, et 85 % d’entre eux l’avaient déjà utilisé chez des adultes victimes de trauma. De plus, la plupart des répondants (79 %) étaient très à l’aise de poser un cathéter intraosseux dans la voie tibiale proximale. La plupart auraient toujours ou souvent recours à ces cathéters pour traiter un patient sans accès intraveineux subissant des manoeuvres de réanimation à la suite d’un arrêt cardiaque traumatique (84 %) ou un patient hypotendu (aucun accès veineux périphérique) sur lequel on a tenté à 2 reprises ou pendant 90 s d’établir un accès vasculaire (81 %).Les spécialistes en traumatologie canadiens, australiens et néo-zélandais ont facilement accès à des dispositifs de perfusion intraosseuse, et la plupart d’entre eux ont été formés sur leur mise en place. La plupart des répondants au sondage se sont dits à l’aise d’utiliser le dispositif lors de la réanimation d’adultes victimes de trauma et prêts à s’en servir pour traiter des cas plus variés que ce que recommandent les lignes directrices actuelles.

Objective To determine the effect of early mobilization (EM) in trauma patients admitted to the ICU. Outcomes of interest included mortality, hospital and ICU length of stay (LOS), and duration of mechanical ventilation. Methods We performed a systematic review of 4 electronic databases (Ovid MEDLINE, Embase, CINAHL, Cochrane Library) and the grey literature. Eligible study designs included randomized control trials, prospective cohorts, or retrospective cohorts. Studies must have compared EM to usual care (i.e., delayed or no mobilization) in trauma patients admitted to ICU. Overall, there were 2982 articles screened and 9 were included in the analysis. Two authors independently performed data extraction using a standardized form. Pertinent study design and population characteristics were recorded, as were prespecified outcome measures. Meta-analyses were performed using random effects models. Study quality was assessed using the Newcastle-Ottawa Scale. Results Study cohorts ranged from 15 to 1132 patients (median 63) and varied in their inclusion criteria. Most studies utilized a progressive mobility protocol as their intervention. Mortality was reported in 5 studies, of which 3 observed a lower rate with EM; however, meta-analysis showed no difference in mortality between patients mobilized early and those receiving usual care. Eight studies reported on LOS (in-hospital and ICU); although all 8 studies found EM reduced LOS, the difference in LOS was not significant on meta-analysis. Finally, 3 studies reported on ventilator days, all of which observed a reduction in the EM group. On meta-analysis, duration of mechanical ventilation was significantly lower with EM (mean difference −1.18 days, 95% CI, −2.17 – −0.19). Conclusions Few studies have investigated the effects of EM in trauma ICU patients. The available evidence suggests that patients who receive EM require fewer days of mechanical ventilation, but have similar mortality and LOS compared to those receiving usual care.

Author(s): Green, MD, Robert S.; Fergusson, PhD, Dean A.; Turgeon, MD, MSc, Alexis F.; McIntyre, MD, MHSc, Lauralyn A.; Kovacs, MD, MHPE, George J.; Griesdale, MD, MPH, Donald E.; Zarychanski, MD, MSc, Ryan; Butler, MSc, Michael B.; Kureshi, MBBS, Nelofar; Erdogan, PhD, Mete | Abstract: Introduction: Respiratory failure is a common problem in emergency medicine (EM) and critical care medicine (CCM). However, little is known about the resuscitation of critically ill patients prior to emergency endotracheal intubation (EETI). Our aim was to describe the resuscitation practices of EM and CCM physicians prior to EETI. Methods: A cross-sectional survey was developed and tested for content validity and retest reliability by members of the Canadian Critical Care Trials Group. The questionnaire was distributed to all EM and CCM physician members of three national organizations. Using three clinical scenarios (trauma, pneumonia, congestive heart failure), we assessed physician preferences for use and types of fluid and vasopressor medication in pre-EETI resuscitation of critically ill patients. Results: In total, 1,758 physicians were surveyed (response rate 50.2%, 882/1758). Overall, physicians would perform pre-EETI resuscitation using either fluids or vasopressors in 54% (1,193/2,203) of cases. Most physicians would “always/often” administer intravenous fluid pre-EETI in the three clinical scenarios (81%, 1,484/1,830). Crystalloids were the most common fluid physicians would “always/often” administer in congestive heart failure (EM 43%; CCM 44%), pneumonia (EM 97%; CCM 95%) and trauma (EM 96%; CCM 96%). Pre-EETI resuscitation using vasopressors was uncommon (4.9%). Training in CCM was associated with performing pre-EETI resuscitation (odds ratio, 2.20; 95% CI, 1.44-3.36, p l 0.001). Conclusion: Pre-EETI resuscitation is common among Canadian EM and CCM physicians. Most physicians use crystalloids pre-EETI as a resuscitation fluid, while few would give vasopressors. Physicians with CCM training were more likely to perform pre-EETI resuscitation. [West J Emerg Med. 2016;17(5)542-548.]

ObjectivesVarious medications and devices are available for facilitation of emergent endotracheal intubations (EETIs). The objective of this study was to survey which medications and devices are being utilized for intubation by Canadian physicians.MethodsA clinical scenario-based survey was developed to determine which medications physicians would administer to facilitate EETI, their first choice of intubation device, and backup strategy should their first choice fail. The survey was distributed to Canadian emergency medicine (EM) and intensive care unit (ICU) physicians using web-based and postal methods. Physicians were asked questions based on three scenarios (trauma; pneumonia; heart failure) and responded using a 5-point scale ranging from “always” to “never” to capture usual practice.ResultsThe survey response rate was 50.2% (882/1,758). Most physicians indicated a Macintosh blade with direct laryngoscopy would “always/often” be their first choice of intubation device in the three scenarios (mean 85% [79%-89%]) followed by video laryngoscopy (mean 37% [30%-49%]). The most common backup device chosen was an extraglottic device (mean 59% [56%-60%]). The medications most physicians would “always/often” administer were fentanyl (mean 45% [42%-51%]) and etomidate (mean 38% [25%-50%]). EM physicians were more likely than ICU physicians to paralyze patients for EETI (adjusted odds ratio 3.40; 95% CI 2.90-4.00).ConclusionsMost EM and ICU physicians utilize direct laryngoscopy with a Macintosh blade as a primary device for EETI and an extraglottic device as a backup strategy. This survey highlights variation in Canadian practice patterns for some aspects of intubation in critically ill patients.

Objective To assess the effect of using hydroxyethyl starch (HES) for intraoperative fluid therapy on outcomes in high-risk vascular surgery patients. Design Retrospective case series. Setting Single-center academic hospital. Participants The study included 1,395 adult vascular surgery patients with peripheral vascular disease. Interventions Retrospective review of hospital databases. Measurements and Main Results Outcomes were compared between patients who were intraoperatively administered HES (Voluven [Fresenius Kabi, Bad Homburg, Germany] or Pentaspan [Bristol-Myers Squibb Canada, Montreal, Quebec, Canada]) versus patients who received only crystalloids during their procedure. Logistic regression was used to assess for association between these groups and mortality (in-hospital, 30-day), intensive care unit admission, hemodialysis requirement, vasopressor requirement, and ventilator requirement. Overall, 796 patients had complete fluid records and were included in the analysis. After adjustment for potential confounders, receiving an HES solution was associated with increased likelihood of 30-day mortality (odds ratio [OR] 2.11, 95% confidence interval [CI] 1.05-3.80), postoperative requirement for hemodialysis (OR 6.17, 95% CI 1.09-35.10), intensive care unit admission (OR 3.52, 95% CI 2.15-5.74), and mechanical ventilation (OR 3.16, 95% CI 1.84-5.41). Conclusions Intraoperative administration of HES was associated with an increased likelihood of adverse outcomes compared with use of crystalloids alone.

Small research grants can provide a funding source for novice physician-scientists during residency or as junior investigators. However, it is unknown if emergency medicine (EM) grant recipients benefit beyond the immediate monetary infusion of these modest awards (

Background. Patients with sepsis benefit from early diagnosis and treatment. Accurate paramedic recognition of sepsis is important to initiate care promptly for patients who arrive by Emergency Medical Services.Methods. Prospective observational study of adult patients (age ≥ 16 years) transported by paramedics to the emergency department (ED) of a Canadian tertiary hospital. Paramedic identification of sepsis was assessed using a novel prehospital sepsis screening tool developed by the study team and compared to blind, independent documentation of ED diagnoses by attending emergency physicians (EPs). Specificity, sensitivity, accuracy, positive and negative predictive value, and likelihood ratios were calculated with 95% confidence intervals.Results. Overall, 629 patients were included in the analysis. Sepsis was identified by paramedics in 170 (27.0%) patients and by EPs in 71 (11.3%) patients. Sensitivity of paramedic sepsis identification compared to EP diagnosis was 73.2% (95% CI 61.4–83.0), while specificity was 78.8% (95% CI 75.2–82.2). The accuracy of paramedic identification of sepsis was 78.2% (492/629, 52 true positive, 440 true negative). Positive and negative predictive values were 30.6% (95% CI 23.8–38.1) and 95.9% (95% CI 93.6–97.5), respectively.Conclusion. Using a novel prehospital sepsis screening tool, paramedic recognition of sepsis had greater specificity than sensitivity with reasonable accuracy.

Background People who experience trauma represent a large pool of potential organ donors. Our objective was to describe organ donation by patients with and without trauma in Nova Scotia. Methods We performed a retrospective cohort study of all patients with trauma in the Nova Scotia Trauma Registry who were injured between Apr. 1, 2009, and Mar. 31, 2016, and died in hospital, as well as all potential organ donors captured in the Nova Scotia Legacy of Life Donor Registry over the same period. We compared characteristics of the 2 groups with respect to organ donation and identified reasons for nondonation. Results Overall, 940 patients were included in the analysis, of whom 689 (73.3%) had experienced trauma. Patients with trauma accounted for 37.2% (48/129) of donors. A total of 274 (39.8%) of the patients with trauma were identified as potential organ donors, and 48 (7.0%) donated organs. Only 108 (39.4%) of the 274 were referred to the Legacy of Life Program. The conversion rate (proportion of potential donors who went on to donate an organ) was 84.2% (48/57) among patients with trauma and 83.5% (81/97) among those without trauma. Donation after circulatory death occurred in 8 patients (17%) with trauma and 13 (16%) of those without trauma. Family refusal (28/60 [47%]) and medical unsuitability (16/60 [27%]) were the most common reasons for nondonation among patients with trauma. Interpretation In Nova Scotia, 40% of patients with trauma who died in hospital were potential organ donors, yet only 39% of these patients were referred for donation. More work is required to improve organ donation within the trauma population.

BACKGROUND Although trauma patients represent a large pool of potential organ donors (PODs), the donor conversion rates (DCRs) in this population are unclear. Our primary objective was to synthesize published evidence on DCRs in trauma patients. As a secondary objective, we investigated factors that affect organ donation (OD) in the trauma population. METHODS We searched four electronic databases (PubMed, Embase, Web of Science, and Cochrane Library) and gray literature for articles on OD in trauma patients (PROSPERO 2017: CRD42017070388). Articles were excluded if it was not possible to calculate the DCR (actual organ donors divided by PODs). We pooled DCRs and performed subgroups analysis by trauma subpopulation, patients' age, and study publication date. RESULTS We identified 27 articles with a total of 123,142 participants. Cohorts ranged in size from 28 to 120,512 patients (median, 132), with most studies performed in the United States. Conversion rates among individual studies ranged from 14.0% to 75.2% (median, 49.3%). All 27 studies were included in the meta-analysis. We found a pooled DCR of 48.1% using the random effects model. There was a high level of heterogeneity between studies (I = 97.4%). Upon subgroup analysis, we found DCRs were higher in head trauma patients compared with traumatic cardiac arrest patients (45.3% vs 20.9%, p < 0.001), in pediatric patients compared with adults (61.0% vs 38.0%, p = 0.018), and in studies published after 2007 compared with those published before (50.8% vs 43.9%, p < 0.001). Few studies assessed for factors associated with OD in trauma patients. CONCLUSIONS We found variation in DCRs among trauma patients (range, 14.0-75.2%) and estimated a pooled DCR of 48.1%. Our results are limited by heterogeneity across studies, which may be attributable to differences in study design and population, definitions of a POD, and in the institutional criteria and processes regarding OD. LEVEL OF EVIDENCE Systematic reviews and meta-analyses level III.

Purpose To determine the incidence of postintubation hypotension (PIH) and associated outcomes in critically ill patients requiring endotracheal intubation. Materials and Methods Medical records were reviewed for 479 consecutive critically ill adult patients who required intubation by an intensive care unit (ICU) service at 1 of 4 academic tertiary care hospitals. The primary outcome measure was the incidence of PIH. Secondary outcome measures included mortality, ICU length of stay, requirement for renal replacement therapy, and a composite end point consisting of overall mortality, ICU length of stay greater than 14 days, duration of mechanical ventilation longer than 7 days, and renal replacement therapy requirement. Results Overall, the incidence of PIH among ICU patients requiring intubation was 46% (218/479 patients). On univariate analysis, patients who developed PIH had increased ICU mortality (37% PIH vs 28% no PIH, P = .049) and overall mortality (39% PIH vs 30% no PIH, P = .045). After adjusting for important risk factors, development of PIH was associated with the composite end point of major morbidity and mortality (odds ratio, 2.00; 95% confidence interval, 1.30-3.07; P = .0017). Conclusions The development of PIH is common in ICU patients requiring emergency airway control and is associated with poor patient outcomes.