Article Figures & Data
Figures
- Figure 1
Training curriculum. Emergency physicians were trained in emergency medicine, radiology, general surgery, and cardiovascular surgery. In the emergency department, they were responsible for the initial management, anesthesia, surgery, and endovascular treatment of hemodynamically unstable patients with severe trauma, using the techniques that had been taught during their rotation through the radiology, general surgery, and cardiovascular surgery departments. Moreover, trained emergency physicians (TEPs) have handled hemodynamically stable torso-trauma patients and some hemodynamically unstable non-trauma patients who required surgical or interventional treatment. We evaluated each trainee’s competency based on their management of cases in our emergency department.
- Figure 2
Difference in decision-making and practice for initial management between the original trauma management system and the streamlined trauma management system. EPs, emergency physicians; IR, interventional radiology; REBOA, resuscitative endovascular balloon occlusion of the aorta; TEPs, trained emergency physicians.
- Figure 3
Patient inclusion flowchart and cohort assignment. ISS, Injury Severity Score; SBP, systolic blood pressure.
Tables
- Table 1
Patient characteristics according to the date of hospital admission
Characteristic All patients
(n=125)Before cohort
(n=59)*After cohort
(n=66)†P value Age (years) 54.0 (35.0–70.0) 51.0 (35.0–68.0) 57.0 (39.3–74.0) 0.50 Male sex (%) 84 (66.1) 41 (69.5) 43 (65.2) 0.61 Mechanism of injury (%) 0.21 Motor vehicle crash 59 (47.2) 26 (44.1) 33 (50.0) Fall from a height 47 (37.6) 20 (33.9) 27 (40.9) Stabbing 14 (11.2) 9 (15.3) 5 (7.6) Compression 5 (4.0) 4 (6.8) 1 (1.5) Vital signs at admission GCS total score 11.0 (5.5–14.0) 14.0 (6.0–15.0) 10.0 (5.5–14.0) 0.49 GCS <9 (%) 56 (44.8) 25 (42.4) 31 (47.0) 0.61 RR (cycles/min) 24.0 (18.0–30.0) 26.0 (20.0–32.0) 24.0 (18.0–30.0) 0.15 SBP (mm Hg) 70.0 (54.0–87.0) 70.0 (54.0–80.0) 72.0 (55.0–90.0) 0.38 Lowest SBP before PH (mm Hg) 50.0 (0–60.0) 64.0 (40.0–70.0) 48.5 (0.0–60.0) 0.003 BT (°C) 36.0 (35.5–36.7) 36.0 (35.5–36.5) 36.0 (35.4–36.8) 0.26 Pulse rate (beats/min) 110.0 (90.0–130.8) 118.0 (90.0–135.0) 107.0 (90.0–127.5) 0.25 Laboratory evaluations at admission pH 7.3 (7.1–7.4) 7.3 (7.1–7.3) 7.3 (7.1–7.4) 0.49 Base excess (mmol/L) −10.7 (−18.0, −5.2) −11.4 (−18.1, −5.9) −9.7 (−17.8, −4.5) 0.48 Lactate (mg/dL) 65.0 (36.0–100.0) 66.0 (39.8–101.3) 65.0 (35.5–99.0) 0.32 D-dimer (μg/mL) 43.1 (16.8–99.9) 27.0 (11.7–60.2) 63.1 (28.8–111.8) 0.21 PT-INR 1.2 (1.0–1.4) 1.1 (1.0–1.3) 1.2 (1.1–1.4) 0.01 Trauma score RTS 5.6 (3.5–6.6) 5.6 (4.1–6.4) 5.6 (3.0–6.8) 0.77 ISS 43.0 (32.0–57.0) 34.0 (27.0–50.0) 50.0 (39.3–66.0) <0.001 TRISS-PS (%) 34.8 (5.0–74.7) 53.2 (12.9–83.5) 23.0 (1.7–64.2) 0.005 *Admitted between January 2011 and September 2014.
†Admitted between October 2014 and January 2019.
BT, body temperature; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; PH, primary hemostasis; PT-INR, prothrombin time-international normalized ratio; RR, respiratory rate; RTS, Revised Trauma Score; SBP, systolic blood pressure; TRISS-PS, probability of survival calculated by the Trauma and Injury Severity Score.
- Table 2
Patient management and outcomes according to the intervention period
Parameter All patients
(n=125)Before cohort
(n=59)*After cohort
(n=66)†P value Outcomes (%) 24 h mortality 36 (28.8) 23 (39.0) 13 (19.7) 0.02 In-hospital mortality 62 (49.6) 38 (64.4) 24 (36.4) 0.002 Mortality owing to exsanguination 35 (28.0) 23 (39.0) 12 (18.2) 0.005 Survivor with TRISS-PS<25% 14 (11.2) 1 (1.7) 13 (19.7) <0.001 Number of patients who underwent CT before hemostasis 85 (68.0) 40 (67.8) 45 (68.2) 0.96 REBOA (%) 20 (16.0) 4 (6.8) 16 (24.2) 0.008 Time to initiate primary hemostasis (min) 55.0 (34.0–82.0) 71.5 (53.8–130.8) 41.0 (27.0–59.0) <0.001 Number of patients who underwent IR for primary hemostasis 62 (49.6) 28 (47.5) 34 (51.5) 0.65 Prehemostasis-administered transfusions (mL) RBCs 560.0 (280.0–1120.0) 560.0 (0.0–840.0) 560.0 (560.0–1120.0) 0.001 FFP 0.0 (0–240.0) 0.0 (0–60.0) 240.0 (0–480.0) <0.001 FFP:RBCs 0.0 (0.0–0.4) 0.0 (0.0–0.0) 0.2 (0.0–0.4) <0.001 Total amount of blood transfusions in the first 24 h (units) RBCs 16.0 (8.0–25.5) 19.0 (6.0–32.5) 15.0 (8.0–20.0) 0.46 FFP 8.0 (4.0–18.0) 12.0 (4.0–20.5) 9.0 (6.0–20.0) 0.20 FFP:RBCs 0.7 (0.4–1.0) 0.6 (0.3–0.7) 0.8 (0.5–1.0) <0.001 Platelet 10.0 (0.0–20.0) 10.0 (0.0–20.0) 0.0 (0.0–20.0) 0.59 Massive transfusion (≥10 units of RBCs within 24 h) (%) 86 (68.8) 36 (61.0) 50 (75.8) 0.08 *Admitted between January 2011 and September 2014.
†Admitted between October 2014 and January 2019.
FFP, fresh frozen plasma; IR, interventional radiology; RBCs, red blood cells; REBOA, resuscitative endovascular balloon occlusion of the aorta; TRISS-PS, probability of survival calculated by the Trauma and Injury Severity Score.
- Table 3
Primary determinants of in-hospital mortality
Variable Adjusted OR of survival
(95% CI)P value Age (years) 0.95 (0.92 to 0.98) 0.001 RTS 2.17 (1.46 to 3.21) <0.001 ISS 0.94 (0.90 to 0.98) 0.004 Prehemostasis-RBCs (units) 0.78 (0.64 to 0.95) 0.01 Prehemostasis-FFP (units) 1.49 (1.04 to 2.14) 0.03 REBOA 9.48 (1.25 to 72.0) 0.03 Time to initiation of surgery/IR (min) 0.97 (0.96 to 0.99) <0.001 FFP, fresh frozen plasma; IR, interventional radiology; ISS, Injury Severity Score; RBCs, red blood cells; REBOA, resuscitative endovascular balloon occlusion of the aorta; RTS, Revised Trauma Score.
