Sustaining a coordinated, regional approach to trauma and emergency care is critical to patient health care needs.

Trauma systems provide an organized approach to the care of injured patients within a defined geographic region. When fully operational, the systems ensure a continuum of care involving public access through 911 calls, emergency medical services, timely triage and transport to acute care, and transfer to rehabilitation services. Substantial progress has been made in establishing statewide trauma systems, which are seen as the prototype for regionalized care for other time-sensitive, emergency conditions such as stroke. Trauma systems provide a model of care that is consistent with the goals of the Affordable Care Act, which authorizes $100 million in annual grants to ensure the continued availability of trauma services. Full funding of these provisions is needed to stabilize statewide systems that are struggling to survive. We describe the components of a regionalized trauma system, review the evidence in support of this approach, and discuss the challenges to sustaining systems that are accountable and affordable.

Immunologic function after splenic embolization, is there a difference?

BACKGROUND: To define the immunologic status of patients undergoing splenic embolization (SE) after traumatic injury. This information may lead to the development of immunization protocols based on scientific data. METHODS: Patients with traumatic splenic injury, treated at one level II Trauma Center were eligible for study. SE patients were compared with splenectomy (SP) patients and controls (C = blunt abdominal trauma patients with negative abdominal computed tomography scans). Clinical examination, medical survey, blood sampling, and nuclear medicine spleen scans were performed. IgM, IgG, C3 complement, complement factor B, helper T cells (CD3, CD4), suppressor T-cells (CD8), complete blood counts, and HIV status were tested. Radionuclide spleen scans were analyzed for total spleen volume, splenic defects, abnormal radionuclide uptake, and ectopic sites of tracer uptake. RESULTS: There were no significant differences in age, gender, or injury severity score among groups. Follow-up time was comparable (SP = 2.67 years; SE = 2.88 years). There were no significant differences in all studies measured except for higher CD8 levels in the SP group (730.1 vs. SE 452.1 vs. C 480.6; p = 0.002), although all values were within the normal range. CD3 levels showed a trend of being higher in the SP group (1709.3 vs. SE 1397.2 vs. C 1371.9), but were not statistically significant. CONCLUSION: The data suggest that the immunologic profile of embolized patients is similar to controls. This supports the safe use of SE in managing the traumatically injured spleen. Larger studies examining the immune function after SE will be needed to make definitive vaccination recommendations.

Air medical response to traumatic brain injury: a computer learning algorithm analysis.

BACKGROUND: The role of air medicine in traumatic brain injury (TBI) has been studied extensively using trauma registries but remains unclear. Learning algorithms, such as artificial neural networks (ANN), support vector machines (SVM), and decision trees, can identify relationships between data set variables but are not empirically useful for hypothesis testing. OBJECTIVE: To use ANN, SVM, and decision trees to explore the role of air medicine in TBI. METHODS: Patients with Head Abbreviated Injury Score 3+ were identified from our county trauma registry. Predictive models were generated using ANN, SVM, and decision trees. The three best-performing ANN models were used to calculate differential survival values (actual and predicted outcome) for each patient. In addition, predicted survival values with transport mode artificially input as "air" or "ground" were calculated for each patient to identify those who benefit from air transport. For SVM analysis, chi was used to compare the ratio of unexpected survivors to unexpected deaths for air- and ground-transported patients. Finally, decision tree analysis was used to explore the indications for various transport modes in optimized survival algorithms. RESULTS: A total of 11,961 patients were included. All three learning algorithms predicted a survival benefit with air transport across all patients, especially those with higher Head Abbreviated Injury Score or Injury Severity Score values, lower Glasgow Coma Scale scores, or hypotension. CONCLUSION: Air medical response in TBI seems to confer a survival advantage, especially in more critically injured patients.

Asphyxia: a rare cause of death for motor vehicle crash occupants.

Motor vehicle related trauma is one of the leading causes of traumatic death. Although most of these deaths are because of severe blunt force trauma, there are people without severe injury who die of asphyxia related to the motor vehicle collision. There were 37 deaths because of motor vehicle related asphyxia in San Diego County during 1995-2004. Almost half (48.6%) of these deaths were because of compression asphyxia, 29.7% were positional asphyxia deaths, and 16.2% died of a combination of compression and positional asphyxia. We were unable to classify the mechanism of asphyxia for the remaining 5.4% of asphyxia deaths. Almost all occupants dying from asphyxia were involved in rollover crashes and may have been incapacitated by obesity, drug or alcohol intoxication, or blunt force trauma. Compression asphyxia deaths occurred both from vehicle crush with intrusion into the passenger compartment and from ejection of the occupant and subsequent crushing by the vehicle. Positional asphyxia occurred in positions interfering with normal respiration, including inversion. None of the occupants had injury severe enough to result in death at the scene if they had not first died of asphyxia. This study suggests classifying the mechanism of asphyxia for these fatalities may be a challenge to forensic pathologists who seldom see these rare deaths.

Fatal positional asphyxia associated with rollover crashes.

Motor vehicle rollover crashes result in complex occupant kinematics with the potential for severe injury. Five cases of fatal asphyxia in occupants suspended from their safety belt upside down after a rollover crash are presented. These fatalities accounted for 13.5% of all motor vehicle related asphyxia deaths in San Diego County over a 10-year period. This study supports previous research noting that incapacitation due to other injuries, alcohol, or obesity may be associated with fatal positional asphyxia due to inversion during rollovers. Safety belts are proven to prevent serious injury in motor vehicle crashes and should always be worn. However, redesign of the buckle could be considered to permit easier release by an occupant. We also suggest that pre-existing heart disease may contribute to the possibility of a fatal asphyxia outcome. Although this is a rare cause of motor vehicle related death, our results suggest that these are potentially preventable deaths.

The impact of safety belt use on liver injuries in motor vehicle crashes: the importance of motor vehicle safety systems.

BACKGROUND: Liver injuries (LIs) are one of the most serious and common consequences of motor vehicle crashes (MVCs). In the unstable patient, early detection of LI based on clinical suspicion will improve acute trauma care and outcomes. The specific objectives of this analysis are to identify crash scene and occupant risk factors for LI from MVC. METHODS: Crash Injury Research and Engineering Network data were used to identify risk factors for LI; age, sex, safety belt use, air bag deployment, DeltaV (change in velocity), principal direction of force, vehicle crush, and intrusion. Occupants with LI were compared with four control groups without LI; (1) no abdominal (ABD) injury (NO_ABD), (2) any ABD (ANY_ABD), (3) ABD Abbreviated Injury Scale score of 1 to 2 (ABD_1-2), and (4) ABD Abbreviated Injury Scale score of 3 or more (ABD_3+). LI occupants were compared with each control group and odds ratios (OR) for risk of LI were computed. RESULTS: There were 311 Crash Injury Research and Engineering Network subjects aged 5 or more years with LI. The total mean Injury Severity Score was 37.6. LI was strongly and significantly associated with safety belt restraint use without air bag deployment, compared with each control group: Liver injury - restrained + air bag not deployed versus (1) NO_ABD, N = 1,519; OR = 4.4, (2) ANY_ABD, N = 317; OR = 2.6, (3) ABD_1 to 2, N = 155; OR = 3.1, (4) ABD_3+, N = 217; OR = 2.4 (p < 0.001). This association was independent of driver or passenger status and principal direction of force. LIs were also strongly and significantly associated with greater vehicle interior intrusion. CONCLUSIONS: LIs were strongly associated with a safety belt restraint in use in the absence of air bag deployment during MVC. This data may have profound importance to the trauma surgeon as an early indicator for LI during resuscitation. These findings also have important implications for future research efforts to improve safety systems in motor vehicles and reduce morbidity and mortality from MVCs in the United States.