Identification of severely injured children at very low risk of emergent surgery: A national trauma registry study.

OBJECTIVE: The number of pediatric trauma patients requiring surgical interventions has been steadily decreasing allowing for a judicious approach to immediately available resources. This study aimed to derive and validate a prediction rule that reliably identifies injured children who are at very low risk for requiring emergency surgery upon emergency department (ED) arrival. METHODS: A retrospective cohort study of data included in the Israeli National Trauma Registry from January 1, 2011, through December 31, 2020, was conducted. We included children aged 0-14 years who presented to EDs from the scene of injury and were hospitalized. We excluded patients transferred between facilities or with isolated burns. The primary outcome was emergency operative intervention (EOI) performed within one hour of ED arrival. We tested mechanism, GCS, heart rate, and blood pressure as candidate predictors. We then randomized patients to two cohorts, derived and internally validated a prediction rule. RESULTS: During the study period, 83,859 children met enrollment criteria. The median age was 6 years (IQR 2-10) and 56,867 (67.8 %) were male; 75,450 (90.0 %) sustained blunt trauma. One hundred sixty-nine (0.20 %) children underwent EOI. In the derivation and validation cohorts, 34,138 (81.4 %) and 34,271 (81.7 %) patients, were classified as low risk based on blunt trauma mechanism, normal GCS (15), and low-risk heart rate (according to age). Of those, 8 (0.02 %) and 13 (0.04 %) required an EOI, respectively. In the validation cohort, the prediction rule for EOI had a sensitivity of 84 % (95 % CI 75-91), a specificity of 82 % (95 % CI 81-82), and a negative predictive value of 99.96 % (95 % CI 99.94-99.98). Among children with an Injury Severity Score>15, the sensitivity was 87 % (95 % CI 77-94), the specificity of 57 % (95 % CI 54-59), and the negative predictive value was 98.97 % (95 % CI 98.13-99.44). CONCLUSIONS: A limited set of physiologic parameters, readily available at hospital admission can effectively identify injured children at very low risk for emergent surgery. For these children, immediate deployment of surgical resources may not be necessary.

Long-Term Outcomes of Cricothyroidotomy Versus Endotracheal Intubation in Military Personnel: A Retrospective Comparative Analysis Cohort Study.

INTRODUCTION: Emergency airway management is critical in trauma care. Cricothyroidotomy (CRIC) is a salvage procedure commonly used in failed endotracheal intubation (ETI) or difficult airway cases. However, more data is needed regarding the short and long-term complications associated with CRIC. This study aimed to evaluate the Israel Defense Forces experience with CRIC over the past 2 decades and compare the short-term and long-term sequelae of prehospital CRIC and ETI. METHODS: Data on patients undergoing either CRIC or ETI in the prehospital setting between 1997 and 2021 were extracted from the Israel Defense Forces trauma registry. Patient data was then cross-referenced with the Israel national trauma registry, documenting in-hospital care, and the Israel Ministry of Defense rehabilitation department registry, containing long-term disability files of military personnel. RESULTS: Of the 122 patients with short-term follow-up through initial hospitalization, 81% underwent prehospital ETI, while 19% underwent CRIC. There was a higher prevalence of military-related and explosion injuries among the CRIC patients (96% versus 65%, P = 0.02). Patients who underwent CRIC more frequently exhibited oxygen saturations below 90% (52% versus 29%, P = 0.002). Injury Severity Score was comparable between groups.No significant difference was found in intensive care unit length of stay and need for tracheostomy. Regarding long-term complications, with a median follow-up time of 15 y, CRIC patients had more upper airway impairment, with most suffering from hoarseness alone. One patient in the CRIC group suffered from esophageal stricture. CONCLUSIONS: This retrospective comparative analysis did not reveal significant short or long-term sequelae among military personnel who underwent prehospital CRIC. The long-term follow-up did not indicate severe aerodigestive impairments, thus suggesting that this technique is safe. Along with the high success rates attributed to this procedure, we recommend that CRIC remains in the armamentarium of trauma care providers. The findings of this study could provide valuable insights into managing difficult airway in trauma care and inform clinical decision-making in emergency settings.

Demographic and injury trends for car crash casualties hospitalized in Level I Trauma centers over two decades: data from the National Trauma Registry.

BACKGROUND: During the past two decades, there have been many changes in automotive and medical technologies, road infrastructure, trauma systems, and demographic changes which may have influenced injury outcomes. The aim of this study was to examine injury trends among traffic casualties, specifically private car occupants, hospitalized in Level I Trauma Centers (TC). METHODS: A retrospective cohort study was performed based on data from the Israel National Trauma Registry. The data included occupants of private cars hospitalized in all six Level I TC due to a traffic collision related injury between January 1, 1998 and December 31, 2019. Demographic, injury and hospitalization characteristics and in-hospital mortality were analyzed. Chi-squared (X2) test, multivariable logistic regression models and Spearman's rank correlation were used to analyze injury data and trends. RESULTS: During the study period, 21,173 private car occupants (14,078 drivers, 4,527 front passengers, and 2,568 rear passengers) were hospitalized due to a traffic crash. The percentage of females hospitalized due to a car crash increased from 37.7% in 1998 to 53.7% in 2019. Over a twofold increase in hospitalizations among older adult drivers (ages 65+) was observed, from 6.5% in 1998 to 15.7% in 2018 and 12.6% in 2019. While no increase was observed for severe traumatic brain injury, a statistically significant increase in severe abdominal and thoracic injuries was observed among the non-Jewish population along with a constant decrease in in-hospital mortality. CONCLUSIONS: This study provides interesting findings regarding injury and demographic trends among car occupants during the past two decades. Mortality among private car occupant casualties decreased during the study period, however an increase in serious abdominal and thoracic injuries was identified. The results should be used to design and implement policies and interventions for reducing injury and disability among car occupants.

Predictors of Short-Term Trauma Laparotomy Outcomes in an Integrated Military-Civilian Health System: A 23-Year Retrospective Cohort Study.

Background: Trauma laparotomy (TL) remains a cornerstone of trauma care. We aimed to investigate prehospital measures associated with in-hospital mortality among casualties subsequently undergoing TLs in civilian hospitals. Methods: This retrospective cohort study cross-referenced the prehospital and hospitalization data of casualties treated by Israel Defense Forces-Medical Corps teams who later underwent TLs in civilian hospitals between 1997 and 2020. Results: Overall, we identified 217 casualties treated by IDF-MC teams that subsequently underwent a TL, with a mortality rate of 15.2% (33/217). The main mechanism of injury was documented as penetrating for 121/217 (55.8%). The median heart rate and blood pressure were within the normal limit for the entire cohort, with a low blood pressure predicting mortality (65 vs. 127, p < 0.001). In a multivariate analysis, prehospital endotracheal intubation (ETI), emergency department Glasgow coma scores of 3-8, and the need for a thoracotomy or bowel-related procedures were significantly associated with mortality (OR 6.8, p < 0.001, OR = 48.5, p < 0.001, and OR = 4.61, p = 0.002, respectively). Conclusions: Prehospital interventions introduced throughout the study period did not lead to an improvement in survival. Survival was negatively influenced by prehospital ETI, reinforcing previous observations of the potential deleterious effects of definitive airways on hemorrhaging trauma casualties. While a low blood pressure was a predictor of mortality, the median systolic blood pressure for even the sickest patients (ISS > 16) was within normal limits, highlighting the challenges in triage and risk stratification for trauma casualties.

The Association Between ADHD in Adolescence and Injury in Early Adulthood in Israel: A Nationwide Historical Cohort Study.

OBJECTIVE: To examine the association between late adolescence ADHD and the risk of serious injury in early adulthood. METHOD: A nationwide cohort study utilizing data from the Military Health Examinations Database for potential military recruits (age 16.5-18 years), cross-referenced with the Israeli National Trauma Registry (2008-2020). Individuals with and without ADHD (mild/severe) were compared for early adulthood injury risk using Cox models. RESULTS: This study compared 76,403 participants with mild ADHD (18.76%) and 330,792 without (81.24%), alongside 2,835 severe ADHD participants (1.11%) versus 252,626 without (98.89%). Adjusted hazard ratios for injury-related hospitalization were 1.27 (95% CI [1.17, 1.37]) for mild ADHD and 1.40 (95% CI [1.09, 1.79]) for severe ADHD, compared to non-ADHD. CONCLUSIONS: Adolescents with ADHD, regardless of severity, had a significantly higher risk of hospitalization due to injury that persists into early adulthood, underscoring the importance of recognizing ADHD as an injury risk and incorporating it into injury prevention strategies.

Hemorrhagic Shock in Isolated and Non-Isolated Pelvic Fractures: A Registries-Based Study.

BACKGROUND: Pelvic fractures resulting from high-energy trauma can frequently present with life-threatening hemodynamic instability that is associated with high mortality rates. The role of pelvic exsanguination in causing hemorrhagic shock is unclear, as associated injuries frequently accompany pelvic fractures. This study aims to compare the incidence of hemorrhagic shock and in-hospital outcomes in patients with isolated and non-isolated pelvic fractures. METHODS: Registries-based study of trauma patients hospitalized following pelvic fractures. Data from 1997 to 2021 were cross-referenced between the Israel Defense Forces Trauma Registry (IDF-TR), documenting prehospital care, and Israel National Trauma Registry (INTR) recording hospitalization data. Patients with isolated pelvic fractures were defined as having an Abbreviated Injury Scale (AIS) <3 in other anatomical regions, and compared with patients sustaining pelvic fracture and at least one associated injury (AIS ≥ 3). Signs of profound shock upon emergency department (ED) arrival were defined as either a systolic blood pressure <90 mmHg and/or a heart rate >130 beats per min. RESULTS: Overall, 244 hospitalized trauma patients with pelvic fractures were included, most of whom were males (84.4%) with a median age of 21 years. The most common injury mechanisms were motor vehicle collisions (64.8%), falls from height (13.1%) and gunshot wounds (11.5%). Of these, 68 (27.9%) patients sustained isolated pelvic fractures. In patients with non-isolated fractures, the most common regions with a severe associated injury were the thorax and abdomen. Signs of shock were recorded for 50 (20.5%) patients upon ED arrival, but only four of these had isolated pelvic fractures. In-hospital mortality occurred among 18 (7.4%) patients, all with non-isolated fractures. CONCLUSION: In young patients with pelvic fractures, severe associated injuries were common, but isolated pelvic fractures rarely presented with profound shock upon arrival. Prehospital management protocols for pelvic fractures should prioritize prompt evacuation and resuscitative measures aimed at addressing associated injuries.

Survival following Prehospital Traumatic Cardiac Arrest Resuscitation in the Israel Defense Forces: A Retrospective Study.

BACKGROUND: Prehospital traumatic cardiac arrest (TCA) is associated with a poor prognosis and requires urgent interventions to address its potentially reversible causes. Resuscitative efforts of TCA in the prehospital setting may entail significant resource allocation and impose added tolls on caregivers. The Israel Defense Forces Medical Corps (IDF-MC) instructs clinicians to perform a set protocol in the case of TCA, providing prompt oxygenation, chest decompression and volume resuscitation. This study investigates the settings, interventions, and outcomes of TCA resuscitation by IDF-MC teams over 25 years in both combat and civilian settings. METHODS: Retrospective study of the IDF-MC Trauma Registry between 1997-2022. Search criteria were applied to identify cases where the TCA protocol was initiated. A manual review of cases matching the search criteria was performed by two curators to determine the indications, interventions, and outcomes of casualties with prehospital TCA. Patients for whom interventions were performed outside of the TCA protocol, such as with measurable vital signs, were excluded. The primary outcome was survival to hospital admission, with the secondary outcome being return of vital signs in the prehospital setting. RESULTS: Following case review, 149 patients with prehospital TCA were included, with a median age of 21 (interquartile range 19-27). Eighty-four (56.4%) presented with TCA in military or combat settings, with gunshot wounds and blast injuries being the most common mechanisms in this group. For 56 casualties (37.8%), all components of the protocol were performed (oxygenation, chest decompression, and volume resuscitation). Five (3.4%) casualties had return of vital signs in the prehospital setting, but none survived to hospital admission. CONCLUSION: The prognosis of prehospital TCA is poor, and efforts to address its potentially reversible causes may often be futile. These notions may be further emphasized in military settings, where resources are limited, and extensive penetrating injuries are more common.

Dental and maxillofacial injuries associated with domestic violence against women in Israel: A report for 2011-2021.

BACKGROUND/AIM: The WHO, in its 2002 report, indicated the dramatic worldwide increase in the incidence of intentional injuries affecting people of all ages and both sexes, but especially children, women, and the elderly. The aim of this study was to analyze dental and maxillofacial injuries associated with domestic violence against women in Israel between the years 2011-2021. METHODS: This was a retrospective cohort study based on data from the Israeli National Trauma Registry (INTR). The INTR provides comprehensive data on hospitalized patients from all six Level I trauma centers (TC) and 15 of the 20 Level II TCs in Israel. Women, ages 14 and older, injured and hospitalized due to domestic violence between 2011 and 2021 were identified. RESULTS: Between 2011 and 2021, there were 1818 cases of women ages 14 + that were hospitalized due to violence, excluding terror, occupational trauma, and attempted suicide. Out of these injuries, 753 cases were attributed to domestic violence, 537 were defined as non-domestic violence and 528 were a result of a brawl/fight. Of the domestic violence cases, 5% (38) exhibited maxillofacial injuries compared to the non-domestic violence cases where 6.2% (33) exhibited maxillofacial injuries and the brawl group where 5.7% (30) exhibited maxillofacial injuries. The most injured areas in domestic violence cases were the maxilla followed by the zygomatic bone and the mandible. Almost half of the domestic violence cases (47.7%) required surgical intervention during their hospitalization. The spouse was the perpetrator responsible for the domestic violence in the majority of the cases. CONCLUSIONS: Dental professionals might be able, in some cases, to identify and report domestic violence signs and thus, better understanding of the specific characteristics of domestic violence related to traumatic injuries is important.

The Association Between Glasgow Coma Scale Scores and PTSD in Military Trauma Casualties: Does Mental Status Following Injury Play a Role in PTSD Development?

BACKGROUND: Posttraumatic stress disorder (PTSD) is prevalent among military personnel and may arise following a wide range of traumatic exposures. Consciousness level following traumatic injury may play a role in the development of PTSD, but its effects have been primarily investigated in the context of traumatic brain injury. METHODS: Registry-based study surveying three databases documenting care from point of injury to long-term rehabilitation of traumatic injuries among military personnel. The study population was divided according to Glasgow Coma Scale (GCS) scores upon emergency department admission (GCS scores 15, 13 and 14, 9-12, and 3-8), with PTSD diagnoses being determined according to disability claim records. Multivariable logistic regression was utilized to determine the association between GCS score at admission and PTSD. RESULTS: Overall, 3,376 military personnel hospitalized following traumatic injuries between 1997 and 2020 were included. The majority were male (92.3%), with a median age of 20 (interquartile range 19-22) at the injury time. Of these, 569 (16.9%) were diagnosed with PTSD according to disability claims, with a median follow-up time of 10.9 years. PTSD diagnosis was most prevalent (30.3% of patients), with a GCS score of 13 and 14. In the adjusted multivariable model, a GCS score of 13 and 14 was associated with significantly higher odds of PTSD diagnosis when compared to a GCS score of 15 (odds ratio 2.19, 95% CI, 1.21-3.88). The associations of other GCS groupings with PTSD diagnosis were nonsignificant. CONCLUSIONS: Minimally impaired consciousness following traumatic injuries is associated with increased odds of PTSD. The role of patient awareness, analgesia, and sedation following an injury in developing PTSD warrants further investigation and could guide early diagnosis and preventive interventions.

Implications for future humanitarian aid missions: Lessons from point-of injury and hospital care for Syrian refugees.

BACKGROUND: Warzone humanitarian medical aid missions are infrequent and applying lessons from these missions is vital to ensuring preparedness for future crises. Between 2013-2018, the Israel Defense Forces Medical Corps (IDF-MC) provided humanitarian medical aid to individuals injured in the Syrian Civil War who chose to seek medical assistance at the Israeli-Syrian border. Patients requiring care surgical or advanced care were transferred to civilian medical centers within Israel. This study aims to describe the injury characteristics and management of hospitalized Syrian Civil War trauma patients over a five-year period. METHODS: Retrospective cohort analysis cross-referencing data from the IDF trauma registry, documenting prehospital care, and the Israel National Trauma Registry, documenting in-hospital care, between 2013 and 2018. Syrian trauma patients hospitalized in Israeli hospitals were cross-referenced between the two registries. Multivariable logistic regression was applied to identify independent factors associated with in-hospital mortality. RESULTS: Overall, 856 hospitalized trauma patients were included following definitive cross-matching. The median age was 23 years, and 93.3% were males. Blast (n = 532; 62.1%) and gunshot (n = 241; 28.2%) were the most common injury mechanisms. Injury Severity Score was ≥25 for 28.8% of patients and most common body regions with severe injury (Abbreviated Injury Scale≥3) were the head (30.7%) and thorax (25.0%). Intensive care unit admission was required for 40.1% of patients, and the median hospital stay was 13 days. In-hospital mortality was recorded for 73 (8.5%). Signs of shock upon emergency department admission and severe head injury were significantly associated with mortality in the adjusted model whereas age of <18 years was associated with decreased odds for in-hospital mortality. CONCLUSIONS: Trauma patients hospitalized in Israel following injuries sustained in the Syrian Civil War were characterized by a high prevalence of blast injuries with concomitant involvement of several body regions. Future missions should ensure preparedness for complex multi-trauma, often involving the head, and ensure high intensive care and surgical capacities.

Severe trauma in Germany and Israel: are we speaking the same language? A trauma registry comparison.

Background: Trauma registries are a crucial component of trauma systems, as they could be utilized to perform a benchmarking of quality of care and enable research in a critical but important area of health care. The aim of this study is to compare the performance of two national trauma systems: Germany (TraumaRegister DGU®, TR-DGU) and Israel (Israeli National Trauma Registry, INTR). Methods: The present study was a retrospective analysis of data from the described above trauma registries in Israel and Germany. Adult patients from both registries treated during 2015-2019 with an Injury Severity Score (ISS) ≥ 16 points were included. Patient demographics, type, distribution, mechanism, and severity of injury, treatment delivered and length of stay (LOS) in the ICU and in the hospital were included in the analysis. Results: Data were available from 12,585 Israeli patients and 55,660 German patients. Age and sex distribution were comparable, and road traffic collisions were the most prevalent cause of injuries. The ISS of German patients was higher (ISS 24 vs. 20), more patients were treated on an intensive care unit (92 vs. 32%), and mortality was higher (19.4 vs. 9.5%) as well. Conclusion: Despite similar inclusion criteria (ISS ≥ 16), remarkable differences between the two national datasets were observed. Most probably, this was caused by different recruitment strategies of both registries, like trauma team activation and need for intensive care in TR-DGU. More detailed analyses are needed to uncover similarities and differences of both trauma systems.

The effectiveness of the manual pressure points technique for hemorrhage control-The 2022 THOR pre-conference meeting experience.

INTRODUCTION: Limb and junctional hemorrhage are leading causes of potentially preventable death among trauma casualties. Hemorrhage control for these regions could be achieved by direct or indirect pressure. The manual pressure points (MPP) involves applying manual pressure on the arterial supply to occlude distal blood flow without the need for specialized equipment. STUDY DESIGN AND METHODS: Prospective, non-randomized, human volunteer, controlled environment study involving 38 healthy military caregivers, with 26 participants attending a short instructional session. During a medical exercise, participants were requested to apply pressure on the supraclavicular and femoral points aiming to stop regional blood flow, measured by distal pulse palpation. The measures recorded included achievement of distal pulse cessation, success in achieving cessation for a full minute, and subjects' pain scores reported after each attempt. RESULTS: All participants succeeded in achieving distal pulse cessation for both the supraclavicular and femoral points for a full minute. The median time to initial success was 3.0 (interquartile range 2.0-5.0) seconds in the supraclavicular point and 4.5 (interquartile range 3.0-6.0) seconds in the femoral point. Pain scores ranging between 0 and 3 were reported by most subjects during supraclavicular (68.4%) and femoral occlusion (84.2%). CONCLUSION: The MPP technique was highly effective in occluding distal palpable pulses in healthy volunteers when applied to the supraclavicular and femoral arteries. Brief instruction on the technique can potentially improve the chances of achieving hemorrhage control within 5 s. Further research is required to determine efficacy among different populations and providers with varying experience levels.

Mortality Trends in Geriatric Proximal Femoral Fracture Treatments After National Payor Policy Changes: A National Study.

INTRODUCTION: Proximal femoral fractures (PFFs) are a major medical event in an elderly's life. The extent of conservative treatment is poorly evaluated in Western health systems. This study retrospectively examines a national cohort of patients older than 65 years with PFFs treated by early surgery (ES) (<48h), delayed surgery (DS) (>48h), and conservative treatment (COT) over the past decade (2010 to 2019). RESULTS: The study cohort included 38,841 patients; 18.4% were 65 to 74 years, 41.1% were 75 to 84 years, and 40.5% were older than 85 years; 68.5% were female. ES rose from 68.4% in 2013 to 85% in 2017 ( P < 0.0001). COT dropped from 8.2% in 2010 to 5.2% in 2019 ( P < 0.0001). Level I trauma centers chose 2.3 times less COT (7.75% in 2010 decreased to 3.37% in 2019) while regional hospitals chose COT only 1.4 times less over the years ( P < 0.001). Hospitalization periods differed: 6.3 ± 0.6d for COT, 8.6 ± 0.3d for ES, and 12 ± 0.4d for DS ( P < 0.001), and the in-hospital mortality rates were 10.5%, 2%, and 3.6%, respectively ( P < 0.0001). One-year mortality rates decreased for ES only ( P < 0.001). DISCUSSION: ES rose from 58.1% in 2010 to 84.9% in 2019 ( P = 0.00002). COT is diminishing throughout the Israeli health system, from 8.2% in 2010 to 5.2% in 2019. Tertiary hospitals consistently practice less COT than regional hospitals ( P < 0.001), probably related to surgeons' and anesthetists' appraisal of the patient's medical status and demand. COT had the shortest hospitalization period but carried the highest in-hospital mortality rates (10.5%). The mild difference in out-of-hospital mortality between the COT and DS groups suggests similar patient characteristics that require additional investigation. In conclusion, more PFFs are treated within 48h with a reduced mortality rate, and the 1-year mortality has improved for ES only. Treatment preferences vary between tertiary and regional hospitals.

Association Between Profound Shock Signs and Peripheral Intravenous Access Success Rates in Trauma Patients in the Prehospital Scenario: A Retrospective Study.

BACKGROUND: Hemorrhage is the leading cause of preventable death in trauma patients, and establishment of intravenous (IV) access is essential for volume resuscitation, a key component in the treatment of hemorrhagic shock. IV access among patients in shock is generally considered more challenging, although data to support this notion are lacking. METHODS: In this retrospective registry-based study, data were collected from the Israeli Defense Forces Trauma Registry (IDF-TR) regarding all prehospital trauma patients treated by IDF medical forces between January 2020 and April 2022, for whom IV access was attempted. Patients younger than 16 years, nonurgent patients, and patients with no detectable heart rate or blood pressure were excluded. Profound shock was defined as a heart rate >130 or a systolic blood pressure <90 mm Hg, and comparisons were made between patients with profound shock and those not exhibiting such signs. The primary outcome was the number of attempts required for first IV access success, which was regarded as an ordinal categorical variable: 1, 2, 3 and higher and ultimate failure. A multivariable ordinal logistic regression was performed to adjust for potential confounders. Patients' sex, age, mechanism of injury and best consciousness level, as well as type of event (military/nonmilitary), and the presence of multiple patients were included in the ordinal logistic regression multivariable analysis model based on previous publications. RESULTS: Five hundred thirty-seven patients were included, 15.7% of whom were recorded as having signs of profound shock. Peripheral IV access establishment first attempt success rates were higher in the nonshock group, and there was a lower rate of unsuccessful attempts in this group (80.8% vs 67.8% for the first attempt, 9.4% vs 16.7% for the second attempt, 3.8% vs 5.6% for the third and further attempts, and 6% vs 10% unsuccessful attempts, P = .04). In the univariable analysis, profound shock was associated with requirement for an increased number of IV attempts (odds ratio [OR], 1.94; confidence interval [CI], 1.17-3.15). The ordinal logistic regression multivariable analysis demonstrated that profound shock was associated with worse results regarding primary outcome (adjusted odds ratio [AOR], 1.84; CI, 1.07-3.10). CONCLUSIONS: The presence of profound shock in trauma patients in the prehospital scenario is associated with an increased number of attempts required for IV access establishment.

Prehospital Tranexamic Acid Administration in Pediatric Trauma Patients: A Propensity-Matched Analysis of the Israeli Defense Forces Registry.

OBJECTIVES: Tranexamic acid (TXA) administration confers a survival benefit in bleeding trauma patients; however, data regarding its use in pediatric patients are limited. This study evaluates the prehospital treatment with TXA in pediatric trauma patients treated by the Israel Defense Forces Medical Corps (IDF-MC). DESIGN: Retrospective, cohort study using the Israel Defense Forces registry, 2011-2021. PATIENTS: Pediatric trauma patients less than 18 years old. We excluded patients pronounced dead at the scene. INTERVENTIONS: None. SETTING: All cases of pediatric trauma in the registry were assessed for treatment with TXA. Propensity score matching was used to assess the association between prehospital TXA administration and mortality. MEASUREMENTS AND MAIN RESULTS: Overall, 911 pediatric trauma patients were treated with TXA by the IDF-MC teams; the median (interquartile) age was 10 years (5-15 yr), and 72.8% were male. Seventy patients (7.6%) received TXA, with 52 of 70 (74%) receiving a 1,000 mg dose (range 200-1,000 mg). There were no prehospital adverse events associated with the use of TXA (upper limit of 95% CI for 0/70 is 4.3%). Compared with pediatric patients who did not receive TXA, patients receiving TXA were more likely to suffer from shock (40% vs 10.7%; p < 0.001), sustain more penetrating injuries (72.9% vs 31.7%; p < 0.001), be treated with plasma or crystalloids (62.9% vs 11.4%; p < 0.001), and undergo more lifesaving interventions (24.3% vs 6.2%; p < 0.001). The propensity score matching failed to identify an association between TXA and lesser odds of mortality, although a lack of effect (or even adverse effect) could not be excluded (non-TXA: 7.1% vs TXA: 4.3%, odds ratio = 0.584; 95% CI 0.084-3.143; p = 0.718). CONCLUSIONS: Although prehospital TXA administration in the pediatric population is feasible with adverse event rate under 5%, more research is needed to determine the appropriate approach to pediatric hemostatic resuscitation and the role of TXA in this population.

Outcomes of basic versus advanced prehospital life support in severe pediatric trauma.

OBJECTIVE: The role of basic life support (BLS) vs. advanced life support (ALS) in pediatric trauma is controversial. Although ALS is widely accepted as the gold standard, previous studies have found no advantage of ALS over BLS care in adult trauma. The objective of this study was to evaluate whether ALS transport confers a survival advantage over BLS among severely injured children. METHODS: A retrospective cohort study of data included in the Israeli National Trauma Registry from January 1, 2011, through December 31, 2020 was conducted. All the severely injured children (age < 18 years and injury severity score [ISS] ≥16) were included. Patient survival by mode of transport was analyzed using logistic regression. RESULTS: Of 3167 patients included in the study, 65.1% were transported by ALS and 34.9% by BLS. Significantly more patients transported by ALS had ISS ≥25 as well as abnormal vital signs at admission. The ALS and BLS cohorts were comparable in age, gender, mechanism of injury, and prehospital time. Children transported by ALS had higher in-hospital mortality (9.2% vs. 0.9%, p < 0.001). Following risk adjustment, patients transported by ALS teams were significantly more likely to die than patients transported by BLS (adjusted OR 2.27, 95% CI 1.05-5.41, p = 0.04). Patients with ISS ≥50 had comparable mortality rates in both groups (45.9% vs. 55.6%, p = 0.837) while patients with GCS <9 transported by ALS had higher mortality (25.9% vs. 11.5%, p = 0.019). Admission to a level II trauma center vs. a level I hospital was also associated with increased mortality (adjusted OR 2.78 (95% CI 1.75-4.55, p < 0.001). CONCLUSIONS: Among severely injured children, prehospital ALS care was not associated with lower mortality rates relative to BLS care. Because of potential confounding by severity in this retrospective analysis, further studies are warranted to validate these results.

Rethinking the Current "Stage-and-Wait" Paradigm.

INTRODUCTION: The experience of terrorist incidents involving a secondary explosive device that targeted rescue forces led to changes in the safety protocols of these forces in most countries of the world. These protocols are the foundation of the current "Stage-and-Wait" paradigm that prohibits the entry of Emergency Medical Services (EMS) from entering the scene and treating casualties until it is deemed safe. These guidelines were established absent of an evidence-base detailing the risk to responders and the potential consequences to the injured on-scene. The lack of clarity is compounded by the fact that different situations, as well as operational considerations, such as the length of time until bomb squad arrival at the scene versus time of massive bleeding injuries, for example, impact outcomes must be taken into account. OBJECTIVE: This study sought to shed light on this matter while employing an evidence-based approach exploring the investigations of the frequency of secondary explosion threats in terrorist attacks over the last 20 years and discussing some of the ethical challenges and ramifications ensuing. While this study does not propose an outright change to current guidelines, in light of the evidence gathered, an open review and discussion based on the findings may be beneficial. METHODS: The Global Terrorism Database (GTD) was used as the data source of bombing incidents world-wide. RESULTS: The results revealed that approximately 70 per-1,000 bombing incidents involved secondary explosions across regions and countries within the study period. CONCLUSION: This study emphasizes the need to rethink the current "Stage-and-Wait" paradigm by recommending brainstorming conferences comprised of multi-sectoral experts aimed at deliberating the matter. World-wide experts in emergency medicine, bioethics, and disaster management should cautiously consider all aspects of bomb-related incidents. These brainstorming deliberations should consider the calculated risk of secondary explosions that account for approximately 70 per-1,000 bombing incidents. This study highlights the need to re-examine the current versus new paradigm to achieve a better balance between the need to ensure EMS safety while also providing the necessary and immediate care to improve casualty survival. This ethical dilemma of postponing urgent care needs to be confronted.

Do direct admissions to trauma centers have a survival benefit compared to inter-hospital transfers in severe trauma?

PURPOSE: To compare mortality among severe and critically injured patients who were directly admitted (DA) to level I trauma center (TCI) or level II trauma center (TCII) with those who were transferred to a TCI after being initially admitted to a TCII. METHODS: A cohort study of severe and critically injured patients (Injury Severity Score 16-75) hospitalized between 2010 and 2019 using data from the National Program for Trauma Registration. Multivariate logistic regression models estimated mortality risk, including stratified analyses. RESULTS: Of the 27,131 hospitalizations, 9.5% were transfers, 60.1% were DA to TCI and 30.4% were DA to TCII. Children ages ≤ 17 years, Non-Jews (minority), critical injuries (ISS 25-75), head injuries (AIS ≥ 3) and fall injuries were significantly more frequent among transfers, compared with the DA groups. Evacuation by emergency medical services was less frequent among transfers. After accounting for possible confounders, transfers had a greater risk of in-hospital mortality [DA to TCI vs transfer, OR (95% CI) 0.61 (0.52-0.72); DA to TCII vs transfer, OR (95% CI) 0.78 (0.65-0.94)]. In stratified analyses, these mortality differences persisted among the sub-group of patients who sustained critical injuries, among the patients with non-penetrating injuries, among the elderly ages ≥ 65 year and during the first 2 weeks of hospitalization. CONCLUSION: This study has intervention implications that should be directed primarily at prehospital triage and the inter-hospital transfer processes. In addition, there may be a need to optimize the capabilities of regional trauma systems along with continuous performance evaluations and actions as required.

Isolated limb fractures - the underestimated injury in the Israeli Defence Forces (IDF).

INTRODUCTION: Musculoskeletal injuries dominate warfare-related trauma and differ from civilian settings in higher hospitalization costs, morbidity, and mortality. Partly due to introduction of personal protective equipment in the Israel Defence Force (IDF) to minimize head and torso injuries while the extremities remained unprotected. This study describes military extremity injury patterns, prehospital treatment and injury sequela regarding return-to-duty and disability compensation. METHODS: This retrospective study examined cases of battle and non-battle trauma casualties treated by the IDF Medical Corps from 2013 to 2020. Data from the IDF Trauma Registry (IDF-TR) was merged with The Israeli National Trauma Registry (INTR). Cases with high morbidity discharged from military service were compared with lower morbidity patients who returned to active duty service. RESULTS: Out of 1360 injured soldiers, 280 (20.6%) were found to have isolated limb fractures (ILFs). High morbidity casualties had more open fractures (63% vs. 42%) and higher involvement of lower extremities (79% vs. 58%) (p < 0.001), higher rates of tourniquets use (28% compared to 9%, p < 0.001), external fixation (34% vs. 19%, p < 0.001) and amputations (9% vs. 1%, p = 0.003), required more rehabilitation (34% vs. 7%, p < 0.001), and had 46% medical disabilities compared to 24% with low morbidity (p < 0.001). CONCLUSIONS: ILFs are associated with significant morbidity and disability. High morbidity is associated with high energy, scar-producing, lower-extremity open fractured limbs treated by tourniquets. Future studies should evaluate whether junctional or extremity protective gear is combat feasible and whether introducing Clinical Practice Guidelines to manage suspected limb fractures can decrease morbidity rates and improve return to duty.