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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 (>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.
The objective of this study was to systematically review the published literature for risk factors associated with adverse outcomes in older adults sustaining blunt chest trauma.
EMBASE and MEDLINE were searched from inception until March 2017 for prognostic factors associated with adverse outcomes in older adults sustaining blunt chest trauma using a pre-specified search strategy. References were independently screened for inclusion by two reviewers. Study quality was assessed using the Quality in Prognostic Studies tool. Where appropriate, descriptive statistics were used to evaluate study characteristics and predictors of adverse outcomes.
Thirteen cohort studies representing 79,313 patients satisfied our selection criteria. Overall, 26 prognostic factors were examined across studies and were reported for morbidity (8 studies), length of stay (7 studies), mortality (6 studies), and loss of independence (1 study). No studies examined patient quality of life or emergency department recidivism. Prognostic factors associated with morbidity and mortality included age, number of rib fractures, and injury severity score. Although age and rib fractures were found to be associated with adverse outcomes in more than 3 studies, meta-analysis was not performed due to heterogeneity amongst included studies in how these variables were measured.
While blunt chest wall trauma in older adults is relatively common, the literature on prognostic factors for adverse outcomes in this patient population remains inadequate due to a paucity of high quality studies and lack of consistent reporting standards.
While 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.
An 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.
266 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).
We were unable to detect any difference in survival between a trauma team and an emergency physician delivered model.
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.
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).
Predicted post-scene intervals were found to be highly correlated with documented post-scene intervals (β 1.05, p<0.001). Using the model, it was found that 88.1% and 42.7% of the population had access to Level III and Level I trauma care within 60 minutes of prehospital time from their residence, respectively. Access for victims of MVCs was lower, with 84.3% and 29.7% of the cohort having access to Level III and Level I trauma care within 60 minutes of the location of injury, respectively.
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.
Various 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.
A 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.
The 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).
Most 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.
A small proportion of pediatric sport- and recreation-related injuries are serious enough to be considered “major trauma.” However, the immediate and long-term consequences in cases of pediatric major trauma are significant and potentially life-threatening. The objective of this study was to describe the incidence and outcomes of pediatric major traumas related to sport and recreational activities in Nova Scotia.
This study was a retrospective case series. Data on major pediatric traumas related to sport and recreational activities on a provincial scope were extracted from the Nova Scotia Trauma Program Registry between 2000 and 2013. We evaluated frequency, type, severity, and outcomes of major traumas. Outcomes assessed included length of hospital stay, admission to a special care unit (SCU), and mortality.
Overall, 107 children aged three to 18 years sustained a major trauma (mean age 12.5 [SD 3.8]; 84% male). Most injuries were blunt traumas (97%). The greatest proportion were from cycling (59, 53%), followed by hockey (8, 7%), skateboarding (7, 7%) and skiing (7, 7%). The Nova Scotia Pediatric Trauma Team was activated in 27% of cases. Mean in-hospital length of stay was five days (SD 5.6), and nearly half (49%) of patients required SCU admission. Severe traumatic brain injury occurred in 52% of cases, and mortality in five cases.
Over a 13-year period, the highest incidence of pediatric major trauma related to sport and recreational activities was from cycling, followed by hockey. Severe traumatic brain injury occurred in over half of pediatric major trauma patients.
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