Rapid Review of Trauma Literature
The rapid and effective assessment of trauma patients is paramount.
Objectives
The purpose of this literature review is to encourage emergency medicine providers to consider what interventions and systems reduce mortality in trauma patients. This review is intended to be brief. For a more in-depth review, please see the references below.
Interventions and Systems
Emergency medicine providers work in a variety of settings and often work closely with EMS systems and EMS protocols. As such, it is important for providers to consider where trauma patients should be managed. Large multicenter studies clearly suggest that evaluation and management of trauma patients at trauma centers reduces mortality [1].
The rapid and effective assessment of trauma patients is paramount. We in emergency medicine understand that “Time is brain” or “Time is heart” and have implemented protocols to meet “door-to-needle” or “door-to-balloon” metrics. It makes sense that “time-to-definitive care” is beneficial in all patients, including those with traumatic injuries. A nationwide cohort study in Japan showed that reduced time to CT in patients presenting with severe trauma led to reduced mortality [2]. Similarly, reduced time to CT for traumatic brain injury led to reduced mortality in multiple studies [3,4].
As emergency departments are remodeled, staffing and supplies are paramount in facilitating quality patient care. However, reduced distance to CT was also associated with reduced mortality [5].
Advanced Trauma Life Support (ATLS) training itself does not have a mortality reduction [6,7]. However, it is likely beneficial to have a standardized assessment model, particularly for trauma teams that are composed of team members who may have trained at different institutions.
Clear communication is essential in the resuscitation of both medical and trauma patients. In practice, there remains significant opportunity to improve. In one study, communication was audible in 43% and understandable in 33% of trauma resuscitations [8].
Leadership of Resuscitation Teams: ‘Lighthouse Leadership’ found that when team leaders participated ‘hands on’, they were less likely to build a structured team, the teams were less dynamic, and the tasks of resuscitation were performed less effectively [9].Similarly, a retrospective study of ED malpractice incidents noted more than half of the deaths and permanent disabilities that occurred were avoidable and 54 incidents were preventable by better teamwork [10]. Thus, identifying a team leader prior to any resuscitation will likely lead to improvement in communication and team work as well as a decrease in preventable mistakes,
take-aways
Do the fundamentals well:
Trauma patients should go to a trauma center
Thorough and efficient evaluation
Appropriate and timely imaging
Clear communication:
Roles and responsibilities
Clear priorities
Closed loop communication
Life-long learning:
Stay up-to-date on current literature to practice evidence-based medicine
AUTHOR: Christopher Koehler is a third-year emergency medicine resident at Brown Emergency Medicine Residency.
FACULTY REVIEWER: Michelle Myles is an attending physician and clinician educator at Brown Emergency Medicine.
references
MacKenzie, Ellen J., et al. "A national evaluation of the effect of trauma-center care on mortality." New England Journal of Medicine 354.4 (2006): 366-378.
Kiguchi, Takeyuki, et al. "Timing of computed tomography imaging in adult patients with severe trauma: A nationwide cohort study in Japan." The American Journal of Emergency Medicine 73 (2023): 109-115.
Kheirbek, T., Luhrs, A. R., Marawha, J., Stephen, A. H., Adams, C. A., & Lueckel, S. N. (2021). Time to Head Computed Tomography Protocol in Traumatic Brain Injury: A Quality Improvement Metric. Rhode Island Medical Journal (2013), 104(6), 28-32.
Techar, Kristina, et al. "Early imaging associated with improved survival in older patients with mild traumatic brain injuries." Journal of surgical research 242 (2019): 4-10.
Huber-Wagner, Stefan, et al. "Effect of the localisation of the CT scanner during trauma resuscitation on survival—a retrospective, multicentre study." Injury 45 (2014): S76-S82.
Bergs, Engelbert AG, et al. "Communication during trauma resuscitation: do we know what is happening?." Injury 36.8 (2005): 905-911.
Cooper, Simon, and Alan Wakelam. "Leadership of resuscitation teams:‘Lighthouse Leadership’." Resuscitation 42.1 (1999): 27-45.
Risser, Daniel T., et al. "The potential for improved teamwork to reduce medical errors in the emergency department." Annals of emergency medicine 34.3 (1999): 373-383.