Explore the vast range of titles available.

Since 1974, the Glasgow Coma Scale has provided a practical method for bedside assessment of impairment of conscious level, the clinical hallmark of acute brain injury. The scale was designed to be easy to use in clinical practice in general and specialist units and to replace previous ill-defined and inconsistent methods. 40 years later, the Glasgow Coma Scale has become an integral part of clinical practice and research worldwide. Findings using the scale have shown strong associations with those obtained by use of other early indices of severity and outcome. However, predictive statements should only be made in combination with other variables in a multivariate model. Individual patients are best described by the three components of the coma scale; whereas the derived total coma score should be used to characterise groups. Adherence to this principle and enhancement of the reliable practical use of the scale through continuing education of health professionals, standardisation across different settings, and consensus on methods to address confounders will maintain its role in clinical practice and research in the future.

Since 1990 National Trauma Registries, - taking the form of \"not for profit\" small and medium enterprises (SME) - have been integral to improvements in major injury case fatality in high income settings. This is laudable but unsatisfactory as globally most years of life lost to injury occur in low and middle income countries. IJHPHM recently published a scoping review of neurotrauma registries in low and middle income countries by Barthelemy et al; from this the commentary reflects on the state of the art and how these LMIC registries could be taken to \"the next level\" as meaningful tools for improving major injury patient care.

The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval [CI]: 11.7%–15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%–4.9%), and death 1.4% (95% CI: 0.8%–2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED.

Introduction Retrospective trauma scores are often used to categorise trauma, however, they have little utility in the prehospital or hyper-acute setting and do not define major trauma to non-specialists. This study employed a Delphi process in order to gauge degrees of consensus/disagreement amongst expert panel members to define major trauma. Method A two round modified Delphi technique was used to explore subject-expert consensus and identify variables to define major trauma through systematically collating questionnaire responses. After initial descriptive analysis of variables, Kruskal-Wallis tests were used to determine statistically significant differences ( p   <  0.05) in response to the Delphi statements between professional groups. A hierarchical cluster analysis was undertaken to identify patterns of similarity/difference of response. A grounded theory approach to qualitative analysis of data allowed for potentially multiple iterations of the Delphi process to be influenced by identified themes. Results Of 55 expert panel members invited to participate, round 1 had 43 participants (Doctor n  = 20, Paramedic n  = 20, Nurse n  = 5, other n  = 2). No consistent patterns of opinion emerged with regards to professional group. Cluster analysis identified three patterns of similar responses and coded as trauma minimisers, the middle ground and the risk averse. Round 2 had 35 respondents with minimum change in opinion between rounds. Consensus of >  70% was achieved on many variables which included the identification of life/limb threatening injuries, deranged physiology, need for intensive care interventions and that extremes of age need special consideration. It was also acknowledged that retrospective injury severity scoring has a role to play but is not the only method of defining major trauma. Various factors had a majority of agreement/disagreement but did not meet the pre-set criteria of 70% agreement. These included the topics of burns, spinal immobilisation and whether a major trauma centre is the only place where major trauma can be managed. Conclusion Based upon the output of this Delphi study, major trauma may be defined as: “Significant injury or injuries that have potential to be life-threatening or life-changing sustained from either high energy mechanisms or low energy mechanisms in those rendered vulnerable by extremes of age”.

Single-centre studies suggest that successive Coronavirus Disease 2019 (COVID-19)-related \"lockdown\" restrictions in England may have led to significant changes in the characteristics of major trauma patients. There is also evidence from other countries that diversion of intensive care capacity and other healthcare resources to treating patients with COVID-19 may have impacted on outcomes for major trauma patients. We aimed to assess the impact of the COVID-19 pandemic on the number, characteristics, care pathways, and outcomes of major trauma patients presenting to hospitals in England. We completed an observational cohort study and interrupted time series analysis including all patients eligible for inclusion in England in the national clinical audit for major trauma presenting between 1 January 2017 and 31 of August 2021 (354,202 patients). Demographic characteristics (age, sex, physiology, and injury severity) and clinical pathways of major trauma patients in the first lockdown (17,510 patients) and second lockdown (38,262 patients) were compared to pre-COVID-19 periods in 2018 to 2019 (comparator period 1: 22,243 patients; comparator period 2: 18,099 patients). Discontinuities in trends for weekly estimated excess survival rate were estimated when lockdown measures were introduced using segmented linear regression. The first lockdown had a larger associated reduction in numbers of major trauma patients (-4,733 (21%)) compared to the pre-COVID period than the second lockdown (-2,754 (6.7%)). The largest reductions observed were in numbers of people injured in road traffic collisions excepting cyclists where numbers increased. During the second lockdown, there were increases in the numbers of people injured aged 65 and over (665 (3%)) and 85 and over (828 (9.3%)). In the second week of March 2020, there was a reduction in level of major trauma excess survival rate (-1.71%; 95% CI: -2.76% to -0.66%) associated with the first lockdown. This was followed by a weekly trend of improving survival until the lifting of restrictions in July 2020 (0.25; 95% CI: 0.14 to 0.35). Limitations include eligibility criteria for inclusion to the audit and COVID status of patients not being recorded. This national evaluation of the impact of COVID on major trauma presentations to English hospitals has observed important public health findings: The large reduction in overall numbers injured has been primarily driven by reductions in road traffic collisions, while numbers of older people injured at home increased over the second lockdown. Future research is needed to better understand the initial reduction in likelihood of survival after major trauma observed with the implementation of the first lockdown.

We aimed to derive and validate a triage tool, based on clinical assessment alone, for predicting adverse outcome in acutely ill adults with suspected COVID-19 infection. We undertook a mixed prospective and retrospective observational cohort study in 70 emergency departments across the United Kingdom (UK). We collected presenting data from 22445 people attending with suspected COVID-19 between 26 March 2020 and 28 May 2020. The primary outcome was death or organ support (respiratory, cardiovascular, or renal) by record review at 30 days. We split the cohort into derivation and validation sets, developed a clinical score based on the coefficients from multivariable analysis using the derivation set, and the estimated discriminant performance using the validation set. We analysed 11773 derivation and 9118 validation cases. Multivariable analysis identified that age, sex, respiratory rate, systolic blood pressure, oxygen saturation/inspired oxygen ratio, performance status, consciousness, history of renal impairment, and respiratory distress were retained in analyses restricted to the ten or fewer predictors. We used findings from multivariable analysis and clinical judgement to develop a score based on the NEWS2 score, age, sex, and performance status. This had a c-statistic of 0.80 (95% confidence interval 0.79-0.81) in the validation cohort and predicted adverse outcome with sensitivity 0.98 (0.97-0.98) and specificity 0.34 (0.34-0.35) for scores above four points. A clinical score based on NEWS2, age, sex, and performance status predicts adverse outcome with good discrimination in adults with suspected COVID-19 and can be used to support decision-making in emergency care. ISRCTN registry, ISRCTN28342533, http://www.isrctn.com/ISRCTN28342533.

Abstract ObjectivesTo identify risk factors for poor outcome one year post-mild traumatic brain injury (mTBI).DesignThis study was a prospective observational study using consecutive adult hospital admissions with mTBI.SubjectsA total of 869 consecutive mTBI patients were enrolled in this study.MethodsAll patients were reviewed by the specialist TBI rehabilitation team at six weeks and one year following mTBI. Demographic and injury data collected included: age, gender, TBI severity and Glasgow Coma Scale (GCS). At twelve months, global outcome was assessed by the Extended Glasgow Outcome Score (GOSE) and participation restriction by the Rivermead Head Injury Follow-up Questionnaire (RHFUQ) via semi-structured interview. An ordinal regression (OR) was used to identify associated factors for poor GOSE outcome and a linear regression for a poor RHFUQ outcome.ResultsIn the GOSE analysis, lower GCS (p < 0.001), medical comorbidity (p = 0.027), depression (p < 0.001) and male gender (p = 0.008) were identified as risk factors for poor outcome. The RHFUQ analysis identified: lower GCS (p = 0.002), female gender (p = 0.001) and injuries from assault (p = 0.003) were variables associated with worse social functioning at one year.ConclusionmTBI is associated with a significant impact upon the physical health and psychosocial function of affected individuals. The results of this study demonstrate that differences in mTBI outcome can be identified at twelve months post-mTBI and that certain features, particularly GCS, are associated with poorer outcomes.

BackgroundTrauma contributes significantly to childhood morbidity and mortality. Uncontrolled haemorrhage leading to cardiovascular collapse remains the leading cause of preventable death in paediatric trauma. Evidence to support the early and accurate identification of paediatric trauma patients requiring blood products is growing. Consensus guidelines advocating for more liberal blood product use based on the concept of damage control resuscitation and the introduction of risk predictor tools to identify children requiring resuscitation with blood products may have altered use in recent years. We aimed to identify trends in blood product prescribing practice in paediatric trauma resuscitation over the last decade.MethodsIn this retrospective, observational study, data were abstracted from Trauma Audit Research Network (TARN) from sites in England, Wales and Northern Ireland over a 10-year period (2012–2021). Eligible cases were defined as injured children or young people aged less than 16 years who received blood products, including in the prehospital environment.ResultsDuring the study period, 2.5% (n=678) of injured children received blood products within 24 hours of hospital arrival, including the prehospital environment. Blood product administration over the study period remained largely unchanged (p=0.190). Over the 10-year period, we saw a significant increase in blood product use among paediatric trauma patients of increasing age and those with penetrating injuries (p<0.03). By contrast, there was a decrease in blood product use across the same 10-year period among paediatric trauma related to road traffic collisions (p=0.01). On analysing the paediatric trauma population that received blood products, the distribution across locations can be seen as follows: 60.5% received blood products at the scene of the incident, 25% in the ED and 12.8% in critical care settings. The most common blood product given was packed red blood cells (84%), with fresh frozen plasma, platelets and cryoprecipitate administered in 9.7%, 2.4% and 1.6% of cases, respectively.ConclusionUK trauma centres have not significantly changed blood product use in paediatric trauma over the last decade. Monitoring and understanding national blood product use in paediatric trauma is integral to understanding trends and current practice.

Background Ocular trauma is a significant cause of blindness and is often missed in polytrauma. No contemporary studies report eye injuries in the setting of severe trauma in the UK. We investigated ocular injury epidemiology and trends among patients suffering major trauma in England and Wales from 2004 to 2021. Methods We conducted a retrospective study utilising the Trauma Audit and Research Network (TARN) registry. Major trauma cases with concomitant eye injuries were included. Major trauma was defined as Injury Severity Score >15. Ocular injuries included globe, cranial nerve II, III, IV, and VI, and tear duct injuries. Orbital fractures and adnexal and lid injuries were not included. Demographics, injury profiles, and outcomes were extracted. We report descriptive statistics and 3-yearly trends. Results Of 287 267 major trauma cases, 2368 (0.82%) had ocular injuries: prevalence decreased from 1.87% to 0.66% over the 2004–2021 period ( P  < 0.0001). Males comprised 72.2% of ocular injury cases, median age was 34.5 years. The proportion of ocular injuries from road traffic collisions fell from 43.1% to 25.3% while fall-related injuries increased and predominated (37.6% in 2019/21). Concomitant head injury occurred in 86.6%. The most common site of ocular injury was the conjunctiva (29.3%). Compared to previous TARN data (1989–2004), retinal injuries were threefold more prevalent (5.9% vs 18.5%), while corneal injuries were less (31.0% vs 6.6%). Conclusions Whilst identifying eye injuries in major trauma is challenging, it appears ocular injury epidemiology in this setting has shifted, though overall prevalence is low. These findings may inform prevention strategies, guideline development and resource allocation.

ObjectivesData on sport and physical activity (PA) injury risk can guide intervention and prevention efforts. However, there are limited national-level data, and no estimates for England or Wales. This study sought to estimate sport and PA-related major trauma incidence in England and Wales.MethodsNationwide, hospital registry-based cohort study between January 2012 and December 2017. Following Trauma Audit and Research Network Registry Research Committee approval, data were extracted in April 2018 for people ≥16 years of age, admitted following sport or PA-related injury in England and Wales. The population-based Active Lives Survey was used to estimate national sport and PA participation (ie, running, cycling, fitness activities). The cumulative injury incidence rate was estimated for each activity. Injury severity was described by Injury Severity Score (ISS) >15.Results11 702 trauma incidents occurred (mean age 41.2±16.2 years, 59.0% male), with an ISS >15 for 28.0% of cases, and 1.3% were fatal. The overall annual injury incidence rate was 5.40 injuries per 100 000 participants. The incidence rate was higher in men (6.44 per 100 000) than women (3.34 per 100 000), and for sporting activities (9.88 per 100 000) than cycling (2.81 per 100 000), fitness (0.21 per 100 000) or walking (0.03 per 100 000). The highest annual incidence rate activities were motorsports (532.31 per 100 000), equestrian (235.28 per 100 000) and gliding (190.81 per 100 000).ConclusionInjury incidence was higher in motorsports, equestrian activity and gliding. Targeted prevention in high-risk activities may reduce admissions and their associated burden, facilitating safer sport and PA participation.