Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2021
Background Motor vehicle collisions (MVCs) are a common cause of major trauma and death. Followin... more Background Motor vehicle collisions (MVCs) are a common cause of major trauma and death. Following an MVC, up to 40% of patients will be trapped in their vehicle. Extrication methods are focused on the prevention of secondary spinal injury through movement minimisation and mitigation. This approach is time consuming and patients may have time-critical injuries. The purpose of this study is to describe the outcomes and injuries of those trapped following an MVC: this will help guide meaningful patient-focused interventions and future extrication strategies. Methods We undertook a retrospective database study using the Trauma Audit and Research Network database. Patients were included if they were admitted to an English hospital following an MVC from 2012 to 2018. Patients were excluded when their outcomes were not known or if they were secondary transfers. Results This analysis identified 426,135 cases of which 63,625 patients were included: 6983 trapped and 56,642 not trapped. Trapp...
Background A ‘whole body’ or ‘pan-scan’ computed tomography (CT) imaging approach is now becoming... more Background A ‘whole body’ or ‘pan-scan’ computed tomography (CT) imaging approach is now becoming the standard of care during the early management of adult patients with suspected severe blunt multitrauma. A number of studies have variously reported a mortality benefit or no benefit from a pan-scan approach compared to that of carrying out body region-focused CT and/or plain radiographs or a mixture of imaging modalities. However, unanswered questions still remain due to the significant heterogeneity in practice between institutions, and the limitations of published studies. The potential risk for harm from ionising radiation or intravenous contrast-induced nephropathy is still a concern, especially where mortality benefit from an unselective pan-scan approach is yet to be definitively proven. We present the results of our latest analysis of the Trauma Audit and Research Network (TARN) database; updated to take into account the establishment of the regional trauma network system and focusing on the Major Trauma Centre’s (MTC’s). Methods We analysed retrospective, multicentre data of severe blunt multitrauma (ISS >15) direct MTC admissions aged >15 years recorded in the UK TARN database from 2012–2017 to compare survival at 30 days between two groups of patients: (1) those undergoing pan-scan, and (2) those in receipt of a focussed/non-pan-scan approach as part of their initial management within the first 4 hours in the Emergency Department (ED). The final dataset included 44 407 cases. Results 15 645 (35.2%) of 44 407 cases underwent pan-scan from the ED. The median ISS for the pan-scan group was 18 (IQR 10–29) compared to 16 (IQR 9–25) for the non-pan-scan group. The calculated crude mortality rate for the pan-scan group was 11.2% compared to 10.6% in the focussed CT group (p=0.0673). Patient characteristics are shown in table 1. Table 1 Patients characteristics Propensity scoring (PS) was used to create a balance in patient characteristics between the two groups and various statistical models derived to analyse the effect of imaging type (exposure factor) on outcome (mortality at 30 days) as shown in table 2. Table 2 Modelling morality using pan-scan as exposure factor The results show that pan-scan has an adverse effect on outcome in all of the models, although not statistically significant in all except Model 2 (adjustment based only on stratified PS). Conclusion The results of our investigation demonstrate that there is no risk adjusted mortality benefit observed from current practice in MTCs in England and Wales. Key issues remain to be addressed such as pan-scan selection criteria and the significant heterogeneity observed in practice across institutions.
Background The recent introduction of major trauma networks throughout England in 2012 has change... more Background The recent introduction of major trauma networks throughout England in 2012 has changed how patients with suspected traumatic brain injury (TBI) are managed at the scene of injury. Selecting certain head trauma patients with suspected TBI for bypass to a more distant specialist neurological centre (SNC) is the networks function but may delay resuscitation whilst expediting neurosurgical/critical care. This comparative effectiveness research study analysed the impact of this strategy on the risk adjusted survival rates of patients confirmed to have a TBI on brain CT scan. Method and results The study employed data from the Trauma Audit and Research Network. Adult patients with a TBI on CT scan were included if they presented between June 2015 to February 2016 to SNCs or non-specialist acute hospitals (NSAH) in the North of England (South Cumbria, Lancashire and the North East Region). Patients were identified as having bypassed a nearer NSAH emergency department (ED) to a ...
Statistical models for outcome prediction are central to traumatic brain injury research and crit... more Statistical models for outcome prediction are central to traumatic brain injury research and critical to baseline risk adjustment. Glasgow coma score (GCS) and pupil reactivity are crucial covariates in all such models but may be measured at multiple time points between the time of injury and hospital and are subject to a variable degree of unreliability and/or missingness. Imputation of missing data may be undertaken using full multiple imputation or by simple substitution of measurements from other time points. However, it is unknown which strategy is best or which time points are more predictive. We evaluated the pseudo-R2 of logistic regression models (dichotomous survival) and proportional odds models (Glasgow Outcome Score—extended) using different imputation strategies on the The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study dataset. Substitution strategies were easy to implement, achieved low levels of missingness (<...
ObjectivesTrauma contributes significantly to adolescent morbidity and mortality. We aimed to asc... more ObjectivesTrauma contributes significantly to adolescent morbidity and mortality. We aimed to ascertain the epidemiology of adolescent trauma to inform prevention strategies.MethodsData were abstracted from TARN (Trauma Audit Research Network) from English sites over a 10-year period (2008–2017). Adolescents were defined as 10–24 completed years. Descriptive statistical analysis was used in this study.ResultsThere were 40 680 recorded cases of adolescent trauma. The majority were male (77.3%) and aged 16–24 years old (80.5%). There was a 2.6-fold increase during the study time frame (p<0.0001) in the total annual number of cases reported to TARN. To account for increasing hospital participation, the unit trauma cases per hospital per year was used, noting an increasing trend (p=0.048). Road traffic collision (RTC) was the leading cause of adolescent trauma (50.3%). Pedestrians (41.2%) and cyclists (32.6%) were more prevalent in the 10–15 year group, while drivers (22.9%) and pass...
Triage is a key principle in the effective management of a major incident. Existing triage tools ... more Triage is a key principle in the effective management of a major incident. Existing triage tools have demonstrated limited performance at predicting need for life-saving intervention (LSI). Derived on a military cohort, the Modified Physiological Triage Tool (MPTT) has demonstrated improved performance. Using a civilian trauma registry, this study aimed to validate the MPTT in a civilian environment. Retrospective database review of the Trauma Audit and Research Network (TARN) database for all adult patients (>18 years) between 2006 and 2014. Patients were defined as Priority One if they received one or more LSIs from a previously defined list. Only patients with complete physiological data were included. Patients were categorised by the MPTT and existing triage tools using first recorded hospital physiology. Performance characteristics were evaluated using sensitivity, specificity and area under receiver operating characteristic (AUROC). During the study period, 218 985 adult pa...
Whole-body CT (WBCT) use in patients with trauma in England and Wales is not well documented. WBC... more Whole-body CT (WBCT) use in patients with trauma in England and Wales is not well documented. WBCT in trauma can reduce time to definitive care, thereby increasing survival. However, its use varies significantly worldwide. We performed a retrospective observational study of Trauma Audit and Research Network (TARN) data from 2012 to 2014. The proportion of adult patients receiving WBCT during initial resuscitation at major trauma centres (MTCs) and trauma units/non-designated hospitals (TUs/NDHs) was compared. A model was developed that included factors associated with WBCT use, and centre effects within the model were explored to determine variation in usage beyond that expected from the model. Of the 115 664 study participants, 16.5% had WBCT. WBCT was performed five times more frequently in MTCs than in TUs/NDHs (31% vs 6.6%). In the multivariate model, increased injury severity, low GCS, shock, comorbidities and triage category increased the chances of having a WBCT, but there wa...
Damage Control Management in the Polytrauma Patient, 2017
We previously reported the epidemiology, aetiology, injury patterns and outcomes of polytrauma fr... more We previously reported the epidemiology, aetiology, injury patterns and outcomes of polytrauma from the largest European Trauma Registry over the 1989-2003 time period. Polytrauma was identfied as a disease of young males predominately caused by road traffic collisions and characterised by traumatic brain and skeletal injury. We report a more current (2008–13) large series of from the same registry and show how polytrauma patient demographics, aetiology and outcomes have changed dramatically in the intervening decade.
First rib fractures are considered indicators of increased morbidity and mortality in major traum... more First rib fractures are considered indicators of increased morbidity and mortality in major trauma. However, this has not been definitively proven. With an increased use of CT and the potential increase in detection of first rib fractures, re-evaluation of these injuries as a marker for life-threatening injuries is warranted. Patients sustaining rib fractures between January 2012 and December 2013 were investigated using data from the UK Trauma Audit and Research Network. The prevalence of life-threatening injuries was compared in patients with first rib fractures and those with other rib fractures. Multivariate logistic regression was performed to determine the association between first rib fractures, injury severity, polytrauma and mortality. There were 1683 patients with first rib fractures and 8369 with fractures of other ribs. Life-threatening intrathoracic and extrathoracic injuries were more likely in patients with first rib fractures. The presence of first rib fractures was ...
Many previous studies have shown that patients admitted to hospital at weekends have worse outcom... more Many previous studies have shown that patients admitted to hospital at weekends have worse outcomes than those on other days. It has been proposed that parity of clinical services throughout the week could mitigate the 'weekend effect'. This study aimed to determine whether or not a weekend effect is observed within an all-hours consultant-led major trauma service. We undertook an observational cohort study using data submitted by all 22 major trauma centres (MTCs) in England to the Trauma Audit & Research Network. The inclusion criteria were all major trauma patients admitted for at least 3 days, admitted to a high-dependency area, or deceased following arrival at hospital. Patients with Injury Severity Score (ISS) >15 were also analysed separately. The outcome measures were length of stay, in-hospital mortality and Glasgow Outcome Score (GOS). Secondary transfer of patients between hospitals was also included as a process outcome. There were 49 070 patients, 22 248 (45....
The Trauma Audit &amp;amp;amp;amp;amp; Research Network (TARN) collects and audits major inju... more The Trauma Audit &amp;amp;amp;amp;amp; Research Network (TARN) collects and audits major injury data from half of all trauma receiving hospitals in England and Wales. At the time of extraction for this analysis there were 183,550 cases on the database. Included patients reach hospital alive and subsequently either die as a result of injury, require intensive/high dependency care or interhospital transfer,
Introduction The aim of this study was to investigate the differences between open vs closed femo... more Introduction The aim of this study was to investigate the differences between open vs closed femoral fractures with regard to the epidemiology, classification and outcome. Patients & methods Data collected prospectively from MTOS and TARN-UK. Between 2001 and 2005, 67,665 trauma patients found and 8,591 were identified having sustained femoral shaft fractures. Demographics, pre and in-hospital data were recorded. The AIS and ISS were calculated. Outcomes and mortality rates were recorded. Four groups of patients were identified namely isolated/open (IO), polytrauma/open (PO), isolated /closed (IC), polytrauma/closed (PC). ANOVA analysis was contacted to determine the effect of fracture classification and severity of trauma to mortality using SPSS 11.0 software. Results 7,978 patients having full data were included. There were 6,780 (85%) Isolated and 1,198 (15%) Polytrauma femoral fractures. When looking at Open vs Closed fractures we found 786 (9.8%) and 7,192 (90.2%) respectively. Combining the groups we recorded 502 IO, 6,278 IC, 284 PO, 914 PC. The median age was 53.9 years, the male/female ratio was 1.15 and the median ISS was 9. Males predominantly presented with open fractures with age distribution prevalence between 16-44 years. Elderly females >74 presented prevalence in IC fractures. Polytrauma related fractures had over six times higher mortality rates than isolated ones. A trimodal distribution of death was confirmed. The incidence of immediate deaths ( 1st week), mostly attributed to hospitalisation and late post-injury complications. Conclusions Young males predominate in this musculoskeletal entity. Elderly females present prevalence of closed fractures vs elderly males possibly due to osteoporosis. Open femoral fractures have a higher mortality rate as they represent high energy absorption. The combination of multiple trauma and femoral fractures shows higher mortality rates at all age groups.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2021
Background Motor vehicle collisions (MVCs) are a common cause of major trauma and death. Followin... more Background Motor vehicle collisions (MVCs) are a common cause of major trauma and death. Following an MVC, up to 40% of patients will be trapped in their vehicle. Extrication methods are focused on the prevention of secondary spinal injury through movement minimisation and mitigation. This approach is time consuming and patients may have time-critical injuries. The purpose of this study is to describe the outcomes and injuries of those trapped following an MVC: this will help guide meaningful patient-focused interventions and future extrication strategies. Methods We undertook a retrospective database study using the Trauma Audit and Research Network database. Patients were included if they were admitted to an English hospital following an MVC from 2012 to 2018. Patients were excluded when their outcomes were not known or if they were secondary transfers. Results This analysis identified 426,135 cases of which 63,625 patients were included: 6983 trapped and 56,642 not trapped. Trapp...
Background A ‘whole body’ or ‘pan-scan’ computed tomography (CT) imaging approach is now becoming... more Background A ‘whole body’ or ‘pan-scan’ computed tomography (CT) imaging approach is now becoming the standard of care during the early management of adult patients with suspected severe blunt multitrauma. A number of studies have variously reported a mortality benefit or no benefit from a pan-scan approach compared to that of carrying out body region-focused CT and/or plain radiographs or a mixture of imaging modalities. However, unanswered questions still remain due to the significant heterogeneity in practice between institutions, and the limitations of published studies. The potential risk for harm from ionising radiation or intravenous contrast-induced nephropathy is still a concern, especially where mortality benefit from an unselective pan-scan approach is yet to be definitively proven. We present the results of our latest analysis of the Trauma Audit and Research Network (TARN) database; updated to take into account the establishment of the regional trauma network system and focusing on the Major Trauma Centre’s (MTC’s). Methods We analysed retrospective, multicentre data of severe blunt multitrauma (ISS >15) direct MTC admissions aged >15 years recorded in the UK TARN database from 2012–2017 to compare survival at 30 days between two groups of patients: (1) those undergoing pan-scan, and (2) those in receipt of a focussed/non-pan-scan approach as part of their initial management within the first 4 hours in the Emergency Department (ED). The final dataset included 44 407 cases. Results 15 645 (35.2%) of 44 407 cases underwent pan-scan from the ED. The median ISS for the pan-scan group was 18 (IQR 10–29) compared to 16 (IQR 9–25) for the non-pan-scan group. The calculated crude mortality rate for the pan-scan group was 11.2% compared to 10.6% in the focussed CT group (p=0.0673). Patient characteristics are shown in table 1. Table 1 Patients characteristics Propensity scoring (PS) was used to create a balance in patient characteristics between the two groups and various statistical models derived to analyse the effect of imaging type (exposure factor) on outcome (mortality at 30 days) as shown in table 2. Table 2 Modelling morality using pan-scan as exposure factor The results show that pan-scan has an adverse effect on outcome in all of the models, although not statistically significant in all except Model 2 (adjustment based only on stratified PS). Conclusion The results of our investigation demonstrate that there is no risk adjusted mortality benefit observed from current practice in MTCs in England and Wales. Key issues remain to be addressed such as pan-scan selection criteria and the significant heterogeneity observed in practice across institutions.
Background The recent introduction of major trauma networks throughout England in 2012 has change... more Background The recent introduction of major trauma networks throughout England in 2012 has changed how patients with suspected traumatic brain injury (TBI) are managed at the scene of injury. Selecting certain head trauma patients with suspected TBI for bypass to a more distant specialist neurological centre (SNC) is the networks function but may delay resuscitation whilst expediting neurosurgical/critical care. This comparative effectiveness research study analysed the impact of this strategy on the risk adjusted survival rates of patients confirmed to have a TBI on brain CT scan. Method and results The study employed data from the Trauma Audit and Research Network. Adult patients with a TBI on CT scan were included if they presented between June 2015 to February 2016 to SNCs or non-specialist acute hospitals (NSAH) in the North of England (South Cumbria, Lancashire and the North East Region). Patients were identified as having bypassed a nearer NSAH emergency department (ED) to a ...
Statistical models for outcome prediction are central to traumatic brain injury research and crit... more Statistical models for outcome prediction are central to traumatic brain injury research and critical to baseline risk adjustment. Glasgow coma score (GCS) and pupil reactivity are crucial covariates in all such models but may be measured at multiple time points between the time of injury and hospital and are subject to a variable degree of unreliability and/or missingness. Imputation of missing data may be undertaken using full multiple imputation or by simple substitution of measurements from other time points. However, it is unknown which strategy is best or which time points are more predictive. We evaluated the pseudo-R2 of logistic regression models (dichotomous survival) and proportional odds models (Glasgow Outcome Score—extended) using different imputation strategies on the The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study dataset. Substitution strategies were easy to implement, achieved low levels of missingness (<...
ObjectivesTrauma contributes significantly to adolescent morbidity and mortality. We aimed to asc... more ObjectivesTrauma contributes significantly to adolescent morbidity and mortality. We aimed to ascertain the epidemiology of adolescent trauma to inform prevention strategies.MethodsData were abstracted from TARN (Trauma Audit Research Network) from English sites over a 10-year period (2008–2017). Adolescents were defined as 10–24 completed years. Descriptive statistical analysis was used in this study.ResultsThere were 40 680 recorded cases of adolescent trauma. The majority were male (77.3%) and aged 16–24 years old (80.5%). There was a 2.6-fold increase during the study time frame (p<0.0001) in the total annual number of cases reported to TARN. To account for increasing hospital participation, the unit trauma cases per hospital per year was used, noting an increasing trend (p=0.048). Road traffic collision (RTC) was the leading cause of adolescent trauma (50.3%). Pedestrians (41.2%) and cyclists (32.6%) were more prevalent in the 10–15 year group, while drivers (22.9%) and pass...
Triage is a key principle in the effective management of a major incident. Existing triage tools ... more Triage is a key principle in the effective management of a major incident. Existing triage tools have demonstrated limited performance at predicting need for life-saving intervention (LSI). Derived on a military cohort, the Modified Physiological Triage Tool (MPTT) has demonstrated improved performance. Using a civilian trauma registry, this study aimed to validate the MPTT in a civilian environment. Retrospective database review of the Trauma Audit and Research Network (TARN) database for all adult patients (>18 years) between 2006 and 2014. Patients were defined as Priority One if they received one or more LSIs from a previously defined list. Only patients with complete physiological data were included. Patients were categorised by the MPTT and existing triage tools using first recorded hospital physiology. Performance characteristics were evaluated using sensitivity, specificity and area under receiver operating characteristic (AUROC). During the study period, 218 985 adult pa...
Whole-body CT (WBCT) use in patients with trauma in England and Wales is not well documented. WBC... more Whole-body CT (WBCT) use in patients with trauma in England and Wales is not well documented. WBCT in trauma can reduce time to definitive care, thereby increasing survival. However, its use varies significantly worldwide. We performed a retrospective observational study of Trauma Audit and Research Network (TARN) data from 2012 to 2014. The proportion of adult patients receiving WBCT during initial resuscitation at major trauma centres (MTCs) and trauma units/non-designated hospitals (TUs/NDHs) was compared. A model was developed that included factors associated with WBCT use, and centre effects within the model were explored to determine variation in usage beyond that expected from the model. Of the 115 664 study participants, 16.5% had WBCT. WBCT was performed five times more frequently in MTCs than in TUs/NDHs (31% vs 6.6%). In the multivariate model, increased injury severity, low GCS, shock, comorbidities and triage category increased the chances of having a WBCT, but there wa...
Damage Control Management in the Polytrauma Patient, 2017
We previously reported the epidemiology, aetiology, injury patterns and outcomes of polytrauma fr... more We previously reported the epidemiology, aetiology, injury patterns and outcomes of polytrauma from the largest European Trauma Registry over the 1989-2003 time period. Polytrauma was identfied as a disease of young males predominately caused by road traffic collisions and characterised by traumatic brain and skeletal injury. We report a more current (2008–13) large series of from the same registry and show how polytrauma patient demographics, aetiology and outcomes have changed dramatically in the intervening decade.
First rib fractures are considered indicators of increased morbidity and mortality in major traum... more First rib fractures are considered indicators of increased morbidity and mortality in major trauma. However, this has not been definitively proven. With an increased use of CT and the potential increase in detection of first rib fractures, re-evaluation of these injuries as a marker for life-threatening injuries is warranted. Patients sustaining rib fractures between January 2012 and December 2013 were investigated using data from the UK Trauma Audit and Research Network. The prevalence of life-threatening injuries was compared in patients with first rib fractures and those with other rib fractures. Multivariate logistic regression was performed to determine the association between first rib fractures, injury severity, polytrauma and mortality. There were 1683 patients with first rib fractures and 8369 with fractures of other ribs. Life-threatening intrathoracic and extrathoracic injuries were more likely in patients with first rib fractures. The presence of first rib fractures was ...
Many previous studies have shown that patients admitted to hospital at weekends have worse outcom... more Many previous studies have shown that patients admitted to hospital at weekends have worse outcomes than those on other days. It has been proposed that parity of clinical services throughout the week could mitigate the 'weekend effect'. This study aimed to determine whether or not a weekend effect is observed within an all-hours consultant-led major trauma service. We undertook an observational cohort study using data submitted by all 22 major trauma centres (MTCs) in England to the Trauma Audit & Research Network. The inclusion criteria were all major trauma patients admitted for at least 3 days, admitted to a high-dependency area, or deceased following arrival at hospital. Patients with Injury Severity Score (ISS) >15 were also analysed separately. The outcome measures were length of stay, in-hospital mortality and Glasgow Outcome Score (GOS). Secondary transfer of patients between hospitals was also included as a process outcome. There were 49 070 patients, 22 248 (45....
The Trauma Audit &amp;amp;amp;amp;amp; Research Network (TARN) collects and audits major inju... more The Trauma Audit &amp;amp;amp;amp;amp; Research Network (TARN) collects and audits major injury data from half of all trauma receiving hospitals in England and Wales. At the time of extraction for this analysis there were 183,550 cases on the database. Included patients reach hospital alive and subsequently either die as a result of injury, require intensive/high dependency care or interhospital transfer,
Introduction The aim of this study was to investigate the differences between open vs closed femo... more Introduction The aim of this study was to investigate the differences between open vs closed femoral fractures with regard to the epidemiology, classification and outcome. Patients & methods Data collected prospectively from MTOS and TARN-UK. Between 2001 and 2005, 67,665 trauma patients found and 8,591 were identified having sustained femoral shaft fractures. Demographics, pre and in-hospital data were recorded. The AIS and ISS were calculated. Outcomes and mortality rates were recorded. Four groups of patients were identified namely isolated/open (IO), polytrauma/open (PO), isolated /closed (IC), polytrauma/closed (PC). ANOVA analysis was contacted to determine the effect of fracture classification and severity of trauma to mortality using SPSS 11.0 software. Results 7,978 patients having full data were included. There were 6,780 (85%) Isolated and 1,198 (15%) Polytrauma femoral fractures. When looking at Open vs Closed fractures we found 786 (9.8%) and 7,192 (90.2%) respectively. Combining the groups we recorded 502 IO, 6,278 IC, 284 PO, 914 PC. The median age was 53.9 years, the male/female ratio was 1.15 and the median ISS was 9. Males predominantly presented with open fractures with age distribution prevalence between 16-44 years. Elderly females >74 presented prevalence in IC fractures. Polytrauma related fractures had over six times higher mortality rates than isolated ones. A trimodal distribution of death was confirmed. The incidence of immediate deaths ( 1st week), mostly attributed to hospitalisation and late post-injury complications. Conclusions Young males predominate in this musculoskeletal entity. Elderly females present prevalence of closed fractures vs elderly males possibly due to osteoporosis. Open femoral fractures have a higher mortality rate as they represent high energy absorption. The combination of multiple trauma and femoral fractures shows higher mortality rates at all age groups.
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