Effect of under triage on early mortality after major pediatric trauma: a registry-based propensity score matching analysis.

BACKGROUND: Little is known about the effect of under triage on early mortality in trauma in a pediatric population. Our objective is to describe the effect of under triage on 24-h mortality after major pediatric trauma in a regional trauma system. METHODS: This cohort study was conducted from January 2009 to December 2017. Data were obtained from the registry of the Northern French Alps Trauma System. The network guidelines triage pediatric trauma patients according to an algorithm shared with adult patients. Under triage was defined by the number of pediatric trauma patients that required specialized trauma care transported to a non-level I pediatric trauma center on the total number of injured patients with critical resource use. The effect of under triage on 24-h mortality was assessed with inverse probability treatment weighting (IPTW) and a propensity score (Ps) matching analysis. RESULTS: A total of 1143 pediatric patients were included (mean [SD], age 10 [5] years), mainly after a blunt trauma (1130 [99%]). Of the children, 402 (35%) had an ISS higher than 15 and 547 (48%) required specialized trauma care. Nineteen (1.7%) patients died within 24 h. Under triage rate was 33% based on the need of specialized trauma care. Under triage of children requiring specialized trauma care increased the risk of death in IPTW (risk difference 6.0 [95% CI 1.3-10.7]) and Ps matching analyses (risk difference 3.1 [95% CI 0.8-5.4]). CONCLUSIONS: In a regional inclusive trauma system, under triage increased the risk of early death after pediatric major trauma.

Association of helicopter transportation and improved mortality for patients with major trauma in the northern French Alps trauma system: an observational study based on the TRENAU registry.

BACKGROUND: Prompt prehospital triage and transportation are essential in an organised trauma system. The benefits of helicopter transportation on mortality in a physician-staffed pre-hospital trauma system remains unknown. The aim of the study was to assess the impact of helicopter transportation on mortality and prehospital triage. METHODS: Data collection was based on trauma registry for all consecutive major trauma patients transported by helicopter or ground ambulance in the Northern French Alps Trauma system between 2009 and 2017. The primary endpoint was in-hospital death. We performed multivariate logistic regression to compare death between helicopter and ground ambulance. RESULTS: Overall, 9458 major trauma patients were included. 37% (n = 3524) were transported by helicopter, and 56% (n = 5253) by ground ambulance. Prehospital time from the first call to the arrival at hospital was longer in the helicopter group compared to the ground ambulance group, respectively median time 95 [72-124] minutes and 85 [63-113] minutes (P < 0.001). Median transport time was similar between groups, 20 min [13-30] for helicopter and 21 min [14-32] for ground ambulance. Using multivariate logistic regression, helicopter was associated with reduced mortality compared to ground ambulance (adjusted OR 0.70; 95% CI, 0.53-0.92; P = 0.01) and with reduced undertriage (OR 0.69 95% CI, 0.60-0.80; P < 0.001). CONCLUSION: Helicopter was associated with reduced in-hospital death and undertriage by one third. It did not decrease prehospital and transport times in a system with the same crew using both helicopter or ground ambulance. The mortality and undertriage benefits observed suggest that the helicopter is the proper mode for long-distant transport to a regional trauma centre.

EPICANCER-Cancer Patients Presenting to the Emergency Departments in France: A Prospective Nationwide Study.

BACKGROUND: We aimed to estimate the prevalence of cancer patients who presented to Emergency Departments (EDs), report their chief complaint and identify the predictors of 30-day all-cause mortality. PATIENTS AND METHODS: we undertook a prospective, cross-sectional study during three consecutive days in 138 EDs and performed a logistic regression to identify the predictors of 30-day mortality in hospitalized patients. RESULTS: A total of 1380 cancer patients were included. The prevalence of cancer patients among ED patients was 2.8%. The most frequent reasons patients sought ED care were fatigue (16.6%), dyspnea (16.3%), gastro-intestinal disorders (15.1%), trauma (13.0%), fever (12.5%) and neurological disorders (12.5%). Patients were admitted to the hospital in 64.9% of cases, of which 13.4% died at day 30. Variables independently associated with a higher mortality at day 30 were male gender (Odds Ratio (OR), 1.63; 95% CI, 1.04-2.56), fatigue (OR, 1.65; 95% CI, 1.01-2.67), poor performance status (OR, 3.00; 95% CI, 1.87-4.80), solid malignancy (OR, 3.05; 95% CI, 1.26-7.40), uncontrolled malignancy (OR, 2.27; 95% CI, 1.36-3.80), ED attendance for a neurological disorder (OR, 2.38; 95% CI, 1.36-4.19), high shock-index (OR, 1.80; 95% CI, 1.03-3.13) and oxygen therapy (OR, 2.68; 95% CI, 1.68-4.29). CONCLUSION: Cancer patients showed heterogeneity among their reasons for ED attendance and a high need for hospitalization and case fatality. Malignancy and general health status played a major role in the patient outcomes. This study suggests that the emergency care of cancer patients may be complex. Thus, studies to assess the impact of a dedicated oncology curriculum for ED physicians are warranted.

Epidemiology of severe paediatric trauma following winter sport accidents.

AIM: This study describes the epidemiology of severe injuries related to winter sports (skiing, snowboarding and sledding) in children and assesses potential preventive actions. METHODS: A single-centre retrospective study performed at Pediatric or Adult Intensive Care Unit in the French Alps. All patients less than 15 years old, admitted to the Intensive Care Unit following a skiing, snowboarding or sledding accident from 2011 to 2018, were included. RESULTS: We included 186 patients (mean age 10.6 years and 68% were male); of which 136 (73%), 21 (11%) and 29 (16%) had skiing, snowboarding and sledding accidents, respectively. The average ISS (injury severity score) was 16. The major lesions were head (n = 94 patients, 51%) and intra-abdominal (n = 56 patients, 30%) injuries. Compared to skiing/snowboarding, sledding accidents affected younger children (7 vs 11 years, P < .001); most of whom did not wear a helmet (89% vs 8%, P < .001). Severity scores were statistically different amongst winter sports (ISS = 16 (IQR 9-24) for skiing, 9 (IQR 4-16) for snowboarding and 16 (IQR 13-20) for sledding accident, P = .02). CONCLUSION: Winter sports can cause severe trauma in children. Sledding accidents affect younger children that may benefit from wearing protective equipment.

Modeling the Influence of Age on Neurological Outcome and Quality of Life One Year after Traumatic Brain Injury: A Prospective Multi-Center Cohort Study.

After traumatic brain injury (TBI), the relationship between age and outcome at 1 year, including quality of life, has been poorly explored. The aim of our study was to describe this relationship in a cohort of TBI patients in a regional trauma system. Consecutive TBI patients with severe lesions on initial brain computed tomography (CT) scan were included from July 2014 to July 2016 in two French level-1 trauma centers. The primary outcome was the mortality at 1 year and secondary outcomes were Glasgow Outcome Scale-Extended (GOS-E) and quality of life using the Short Form Health Survey (SF-12). The relationship between age and outcome was modeled using the generalized linear model (GLM). Within the study period, 427 patients with TBI and type 3 Abbreviated Injury Scale (AIS) lesions were included. Finally, 380 patients were assessed for mortality. Ninety-six (25%) patients died at 1 year. The detailed neurological status was available for 317 patients. One year after the trauma, 141 (44%) patients had a favorable outcome (GOS-E 7 and 8), whereas 53 (17%) patients had a moderate disability (GOS-E 5-6), 27 (9%) patients had a severe disability or were in a vegetative state (GOS-E 2-4), and 96 (30%) patients had died (GOS-E 1). After 70 years of age, a dramatic increase in the odds of death and poor neurological outcome was found using GLM. No difference according to age was found for the quality of life. After TBI, the mortality at 1 year dramatically increased with age after 70 years. For elderly survivors, impairment of quality of life was not different from younger patients.