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This study aimed at determining predictors of in-hospital mortality and prehospital monitoring limitations in severely injured intubated blunt trauma patients. We retrospectively reviewed patients' charts. Prehospital vital signs, Injury Severity Score (ISS), initial Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), arterial blood gases, and lactate were compared in two study groups: survivors (n = 40) and nonsurvivors (n = 30). There were no significant differences in prehospital vital signs between compared groups. Nonsurvivors were older (P = 0.006), with lower initial GCS (P < 0.001) and higher ISS (P < 0.001), along with higher lactate (P < 0.001) and larger base deficit (BD; P = 0.006), whereas RTS (P = 0.001) was lower in nonsurvivors. For predicting mortality, area under the curve (AUC) was calculated: for lactate 0.82 (P < 0.001), for ISS 0.82 (P < 0.001), and for BD 0.69 (P = 0.006). Lactate level of 3.4 mmol/L or more was 82% sensitive and 75% specific for predicting in-hospital death. In a multivariate logistic regression model, ISS (P = 0.037), GCS (P = 0.033), and age (P = 0.002) were found to be independent predictors of in-hospital mortality. The AUC for regression model was 0.93 (P < 0.001). Increased levels of lactate and BD on admission indicate more severe occult hypoperfusion in nonsurvivors whereas vital signs did not differ between the groups.

Background: Trauma is a leading cause of morbidity and mortality worldwide. The traumatized patient outcome is multi-factorial through combination of the clinical diagnosis and presence and severity of comorbidities. Mortality predictors among head trauma patients are still far from being reported. Aim: This study aimed to enhance the outcome of the polytrauma patients admitted to intensive care unit ICU through construct a predictive model for mortality on the basis of easily available parameters. Methods: Our cohort prospective study consisted of 60 Egyptian patients from January2020 to January2021 over 16 years old with Glasgow coma scale (GCS) 4-14 followed traumatic brain injury and full clinical evaluation on admission was done including a full history, clinical examination, radiological and laboratory investigations. All patients were evaluated according to GCS, APACHE II and RTS scores. In addition, all patients were followed-up for 2weeks from the day of admission .The primary outcome assessed the mortality with analysis of different clinical and lab parameters for detection of predictors of mortality. Results: Sixty patients were with mean age/year was 40.43 ± 16.9 with 58.3% were males. A mortality rate of 45% as non-survivor was detected with a predominance of road traffic accidents as a mode of injury (51.7%). There is statistically significance of lower scores of GCS and RTS but higher scores of APACHE II in non- survivors than survivors. Multivariate logistic regression detects that diabetes mellitus (DM) is the most significant predictor of non survivors. Conclusion: Multiple significant predictors of mortality were found as: advanced age, low PLT count, high renal function tests and radiological CT brain findings. DM is the most significant predictor of mortality. [ABSTRACT FROM AUTHOR]

Objectives: Hyperlactatemia is associated with increased risk of mortality. Point-of-care (POC) lactate levels have been used worldwide in the emergency department (ED) and critical care units for risk stratification. The aim of this study was to determine whether POC lactate levels are predictive of outcomes in our low-resource setting. Materials and Methods: This was a non-interventional prospective cohort study carried out at the ED Critical Care wards in Kenyatta National Hospital between June 12, 2021, and July 25, 2021. The study included consecutively consenting adults above 18 years at the ED who were critically ill as indicated by a Modified Early Warning Score of equal to or above 5. Lactate was measured using a handheld Statstrip lactate meter. Patients were followed up for 7 days, and outcomes were documented. Results: Two hundred and eighty-one patients were enrolled in the study. The mean lactate level was 4.0 mmoL/L with a median interquartile range of 3.0. Hyperlactatemia was evident in 161 (57%) using a cutoff of 2.5 mmoL/L. The allcause mortality rate was 33.8%. Type A hyperlactatemia was the most common at 84.3% and 17.7% in Type B. Type A hyperlactatemia mortality rate was 37.1% and Type B 15.9% (odds ratio [OR]: 3.1, 95% confidence interval [CI]: 1.3-7.3, P = 0.006). In the high lactate group, the 7-day mortality rate was 42.2% compared to a mortality rate of 22.5% in the normal lactate group (OR: 2.5, 95% CI: 1.5-4.3, P = 0.001). Hyperlactatemia was associated with an increased need for intensive care unit admission (OR: 2.2, 95% CI: 1.3-3.7, P = 0.002) and organ support mainly mechanical ventilation (OR: 2.6, 95% CI: 1.5-4.4, P = 0.001) and inotropic/vasopressors support (OR: 2.7, 95% CI: 1.2-6.2, P = 0.016). Conclusion: POC lactate is an independent predictor of 7-day mortality with a 2-a fold increased risk of mortality and was associated with increased need for organ support. [ABSTRACT FROM AUTHOR]

Purpose: In the prehospital care of potentially seriously injured patients resource allocation adapted to injury severity (triage) is a challenging. Insufficiently specified triage algorithms lead to the unnecessary activation of a trauma team (over-triage), resulting in ineffective consumption of economic and human resources. A prehospital trauma triage algorithm must reliably identify a patient bleeding or suffering from significant brain injuries. By supplementing the prehospital triage algorithm with in-hospital established point-of-care (POC) tools the sensitivity of the prehospital triage is potentially increased. Possible POC tools are lactate measurement and sonography of the thorax, the abdomen and the vena cava, the sonographic intracranial pressure measurement and the capnometry in the spontaneously breathing patient. The aim of this review was to assess the potential and to determine diagnostic cut-off values of selected instrument-based POC tools and the integration of these findings into a modified ABCDE based triage algorithm. Methods: A systemic search on MEDLINE via PubMed, LIVIVO and Embase was performed for patients in an acute setting on the topic of preclinical use of the selected POC tools to identify critical cranial and peripheral bleeding and the recognition of cerebral trauma sequelae. For the determination of the final cut-off values the selected papers were assessed with the Newcastle–Ottawa scale for determining the risk of bias and according to various quality criteria to subsequently be classified as suitable or unsuitable. PROSPERO Registration: CRD 42022339193. Results: 267 papers were identified as potentially relevant and processed in full text form. 61 papers were selected for the final evaluation, of which 13 papers were decisive for determining the cut-off values. Findings illustrate that a preclinical use of point-of-care diagnostic is possible. These adjuncts can provide additional information about the expected long-term clinical course of patients. Clinical outcomes like mortality, need of emergency surgery, intensive care unit stay etc. were taken into account and a hypothetic cut-off value for trauma team activation could be determined for each adjunct. The cut-off values are as follows: end-expiratory CO2: < 30 mm/hg; sonography thorax + abdomen: abnormality detected; lactate measurement: > 2 mmol/L; optic nerve diameter in sonography: > 4.7 mm. Discussion: A preliminary version of a modified triage algorithm with hypothetic cut-off values for a trauma team activation was created. However, further studies should be conducted to optimize the final cut-off values in the future. Furthermore, studies need to evaluate the practical application of the modified algorithm in terms of feasibility (e.g. duration of application, technique, etc.) and the effects of the new algorithm on over-triage. Limiting factors are the restriction with the search and the heterogeneity between the studies (e.g. varying measurement devices, techniques etc.). [ABSTRACT FROM AUTHOR]

Purpose: The objective of this systematic review was to examine current evidence on the risks versus benefit of pre-hospital intubation when compared with in-hospital intubation in adult patients with traumatic brain injuries. Methods: We conducted electronic searches of PubMed, Medline, Embase, CIANHL and the Cochrane library up to March 2021. Data extracted compared mortality, length of hospital and intensive care stay, pneumonia and functional outcomes in traumatic brain injured patients undergoing pre-hospital intubation versus in-hospital intubation. The risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation. Results: Ten studies including 25,766 patients were analysed. Seven were retrospective studies, two prospective cohort studies and one randomised control study. The mean mortality rate in patients who underwent pre-hospital intubation was 44.5% and 31.98% for in-hospital intubation. The odds ratio for an effect of pre-hospital intubation on mortality ranged from 0.31 (favouring in-hospital intubation) to 3.99 (favouring pre-hospital). The overall quality of evidence is low; however, the only randomised control study showed an improved functional outcome for pre-hospital intubation at 6 months. Conclusions: The existing evidence does not support widespread pre-hospital intubation in all traumatic brain injured patients. This does not, however, contradict the need for the intervention when there is severe airway compromise; instead, it must be assessed by experienced personnel if a time critical transfer to hospital is more advantageous. Favourable neurological outcomes highlighted by the randomised control trial favours pre-hospital intubation, but further research is required in this field. [ABSTRACT FROM AUTHOR]

Introduction: Occult hypoperfusion (OH) is defined as persistent lactic acidosis despite normalization of vital parameters following trauma. The aim of this study was to analyze the association of occult hypoperfusion with local circulation and inflammation of injured soft tissue in a porcine polytrauma model. Methods: This experimental study was performed with male landrace pigs who suffered a standardized polytrauma, including a femoral fracture, blunt chest trauma, liver laceration and a mean arterial pressure (MAP) controlled hemorrhagic shock. One hour after induction of trauma, the animals were resuscitated with retrograde femoral nailing, liver packing and volume replacement. Animals were stratified into Group Norm (normalizing lactate levels after resuscitation) and Group occult hypoperfusion (OH) (persistent lactate levels above 2 mmol/l with normalizing vital parameters after resuscitation). Local circulation (oxygen saturation, hemoglobin amount, blood flow) was measured with optical sensors at the subcutaneous soft tissue at the fractured extremity as well as at the stomach and colon. Local inflammatory parameters [interleukin (IL) 6, 8, 10, and heat shock protein (HSP)] were analyzed in the subcutaneous tissue of the fractured extremity. Results: Group Norm (n = 19) and Group OH (n = 5) were comparable in baseline vital and laboratory parameters. The shock severity and total amount of blood loss were comparable among Group Norm and Group OH. Following resuscitation Group OH had significantly lower local relative hemoglobin amount at the injured soft tissue of the fractured extremity when compared with Group Norm (39.4, SD 5.3 vs. 63.9, SD 27.6 A.U., p = 0.031). The local oxygenation was significantly lower in Group OH compared to Group Norm (60.4, SD 4.6 vs. 75.8, SD 12.8, p = 0.049). Local IL-6 in the fatty tissue was significantly higher in Group OH (318.3, SD 326.6 [pg/ml]) when compared with Group Norm (73.9,SD 96.3[pg/ml], p = 0.03). The local circulation at the abdominal organs was comparable in both groups. Conclusion: OH is associated with decreased local circulation and increased local inflammation at the injured soft tissue of the extremity in polytrauma. OH might reflect the severity of local soft tissue injuries, and guide treatment strategies. [ABSTRACT FROM AUTHOR]

Hyperoxemia commonly occurs in clinical practice and is often left untreated. Many studies have shown increased mortality in patients with hyperoxemia, but data on neurological outcome in these patients are conflicting, despite worsened neurological outcome found in preclinical studies. To investigate the association between hyperoxemia and neurological outcome in adult patients, we performed a systematic review and meta-analysis of observational studies. We searched MEDLINE, Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and ClinicalTrials.gov from inception to May 2020 for observational studies correlating arterial oxygen partial pressure (PaO2) with neurological status in adults hospitalized with acute conditions. Studies of chronic pulmonary disease or hyperbaric oxygenation were excluded. Relative risks (RRs) were pooled at the study level by using a random-effects model to compare the risk of poor neurological outcome in patients with hyperoxemia and patients without hyperoxemia. Sensitivity and subgroup analyses and assessments of publication bias and risk of bias were performed. Maximum and mean PaO2 in patients with favorable and unfavorable outcomes were compared using standardized mean difference (SMD). Of 6255 records screened, 32 studies were analyzed. Overall, hyperoxemia was significantly associated with an increased risk of poor neurological outcome (RR 1.13, 95% confidence interval [CI] 1.05–1.23, statistical heterogeneity I2 58.8%, 22 studies). The results were robust across sensitivity analyses. Patients with unfavorable outcome also showed a significantly higher maximum PaO2 (SMD 0.17, 95% CI 0.04–0.30, I2 78.4%, 15 studies) and mean PaO2 (SMD 0.25, 95% CI 0.04–0.45, I2 91.0%, 13 studies). These associations were pronounced in patients with subarachnoid hemorrhage (RR 1.34, 95% CI 1.14–1.56) and ischemic stroke (RR 1.41, 95% CI 1.14–1.74), but not in patients with cardiac arrest, traumatic brain injury, or following cardiopulmonary bypass. Hyperoxemia is associated with poor neurological outcome, especially in patients with subarachnoid hemorrhage and ischemic stroke. Although our study cannot establish causality, PaO2 should be monitored closely because hyperoxemia may be associated with worsened patient outcome and consequently affect the patient's quality of life. [ABSTRACT FROM AUTHOR]

Objective: To describe the characteristics and outcomes of older adult (≥65 years) major trauma patients in comparison with younger adults (16–64 years). To determine whether older age is associated with a reduced likelihood of transport (directly or indirectly) to a major trauma centre and whether this is associated with in‐hospital mortality. Methods: A retrospective cohort study of major trauma patients transported to hospital by St John Ambulance paramedics in Perth, Western Australia, between 1 January 2013 and 31 December 2016. Multivariate logistic regression was used to test the relationship between age and major trauma centre transport. Multivariate logistic regression analysis using inverse probability of treatment weighting was used to determine if major trauma centre transport was associated with in‐hospital mortality in older adults. Results: One thousand six hundred and twenty‐five patients were included; of these 576 (35%) were ≥65 years. In comparison with younger adults, older adults had more falls as their mechanism of injury (n = 358 [62%] versus n = 102 [10%], P ≤ 0.001) and more major head injuries (n = 472 [82%] versus n = 609 [58%], P ≤ 0.001). Older adults had lower odds (adjusted odds ratio 0.52, 95% confidence interval [CI] 0.35–0.78) of major trauma centre transport and this was associated with 1.7 times the likelihood of in‐hospital mortality (95% CI 1.04–2.7). Conclusions: Older adults who were not transported to the trauma centre had an increased odds of in‐hospital mortality. However, older age was associated with a significantly reduced likelihood of trauma centre transport. With the aging population, the development of specific prehospital triage criteria to enable the complexities of this higher‐risk population to be identified is important. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to determine the association between prehospital time and outcomes in adult major trauma patients, transported by ambulance paramedics. Methods: A retrospective cohort study of major trauma patients (Injury Severity Score >15) attended by St John Ambulance paramedics in Perth, Western Australia, who were transported to hospital between January 1, 2013 and December 31, 2016. Inverse probability of treatment weighting (IPTW) using the propensity score was performed to limit selection bias and confounding. The primary outcome was 30-day mortality and the secondary outcome was the length of hospital stay (LOS) for 30-day survivors. Multivariate logistic and log-linear regression analyses with IPTW were used to determine if prehospital time of more than the one hour (from receipt of the emergency call to arrival at hospital) or any individual prehospital time interval (response, on-scene, transport, or total time) was associated with 30-day mortality or LOS. Results: A total of 1,625 major trauma patients were included and 1,553 included in the IPTW sample. No significant association between prehospital time of one hour and 30-day mortality was found (adjusted odds ratio 1.10, 95% confidence interval (CI) 0.71–1.69). No association between any individual prehospital time interval and 30-day mortality was identified. In the 30-day survivors, one-minute increase of on-scene time was associated with 1.16 times (95% CI 1.03–1.31) longer LOS. Conclusion: Longer prehospital times were not associated with an increased likelihood of 30-day mortality in major trauma patients transported to hospital by ambulance paramedics. We found no evidence to support the hypothesis that prehospital time longer than one hour resulted in an increased risk of 30-day mortality. However, longer on-scene time was associated with longer hospital LOS (for 30-day survivors). Our recommendation is that prehospital care is delivered in a timely fashion and delivery of the patient to hospital is reasonably prompt. [ABSTRACT FROM AUTHOR]

Trauma is one of the leading causes of death worldwide, with road traffic collisions, suicides, and homicides accounting for the majority of injury-related deaths. Since trauma mainly affects young age groups, it is recognized as a serious social and economic threat, as annually, almost 16,000 posttrauma individuals are expected to lose their lives and many more to end up disabled. The purpose of this research is to summarize current knowledge on factors predicting outcome – specifically mortality risk – in severely injured patients. Development of this review was mainly based on the systematic search of PubMed medical library, Cochrane database, and advanced trauma life support Guiding Manuals. The research was based on publications between 1994 and 2016. Although hypovolemic, obstructive, cardiogenic, and septic shock can all be seen in multi-trauma patients, hemorrhage-induced shock is by far the most common cause of shock. In this review, we summarize current knowledge on factors predicting outcome – more specifically mortality risk – in severely injured patients. The main mortality-predicting factors in trauma patients are those associated with basic human physiology and tissue perfusion status, coagulation adequacy, and resuscitation requirements. On the contrary, advanced age and the presence of comorbidities predispose patients to a poor outcome because of the loss of physiological reserves. Trauma resuscitation teams considering mortality prediction factors can not only guide resuscitation but also identify patients with high mortality risk who were previously considered less severely injured. [ABSTRACT FROM AUTHOR]

Background: Trauma is an increasing cause of morbidity and mortality in India. This study was done to improve the understanding of the mode of trauma, severity of injuries, and outcome of trauma victims in our hospital. Materials and Methods: This was a retrospective observational study of all adult trauma patients more than 18-year-old presenting to our emergency department (ED). Details of the incident, injuries, and outcome were noted. Results: The ED attended to 16,169 patients during the 3-month study period with 10% (1624/16,169) being adult trauma incidents. The gender distribution was 73.6% males and 26.4% females. The mean age was 40.2 ± 16.7 years. The median duration from time of incident to time of arrival to the ED was 3 h (interquartile range [IQR]: 1.5-6.5) for priority one patients, 3 h (IQR: 1.5-7.7) for priority two patients, and 1.5 h (IQR: 1-7) for priority three patients. The average number of trauma incidents increased by 28% during the weekends. Road traffic accident (RTA) (65%) was the most common mode of injury, followed by fall on level ground (13.5%), fall from height (6.3%), work place injuries (6.3%), and others. Traumatic brain injury was seen in 17% of patients while 13.3% had polytrauma with two-wheeler accidents contributing to the majority. The ED team alone managed 23.4% of patients while the remaining 76.6% required evaluation and treatment by the trauma, surgical teams. The in-hospital mortality rate was 2.3%. Multivariate analysis showed low Glasgow coma score (odds ratio [OR]: 0.65, 95% confidence interval [CI]: 0.55-0.76, P < 0.001) and high respiratory rate (OR: 1.15, 95% CI: 1.07-1.24, P < 0.001) to be independent predictors of mortality among polytrauma victims. Conclusions: RTA and falls are the predominant causes of trauma. A simple physiological variable-based scoring system such as the revised trauma score may be used to prioritize patients with polytrauma. [ABSTRACT FROM AUTHOR]