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To assess whether different cervical spine immobilisation strategies (full immobilisation, movement minimisation or no immobilisation), impact neurological and/or other outcomes for patients with suspected cervical spinal injury in the pre-hospital and emergency department setting. Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, EMBASE, CINAHL, Cochrane Library and two research registers were searched until September 2023. All comparative studies (prospective or retrospective) that examined the potential benefits and/or harms of immobilisation practices during pre-hospital and emergency care of patients with a potential cervical spine injury (pre-imaging) following blunt trauma. Two authors independently selected and extracted data. Risk of bias was appraised using the Cochrane ROBINS-I tool for non-randomised studies. Data were synthesised without meta-analysis. Six observational studies met the inclusion criteria. The methodological quality was variable, with most studies having serious or critical risk of bias. The effect of cervical spine immobilisation practices such as full immobilisation or movement minimisation during pre-hospital and emergency care did not show clear evidence of benefit for the prevention of neurological deterioration, spinal injuries and death compared with no immobilisation. However, increased pain, discomfort and anatomical complications were associated with collar application during immobilisation. Despite the limited evidence, weak designs and limited generalisability, the available data suggest that pre-hospital cervical spine immobilisation (full immobilisation or movement minimisation) was of uncertain value due to the lack of demonstrable benefit and may lead to potential complications and adverse outcomes. High-quality randomised comparative studies are required to address this important question. PROSPERO REGISTRATION Fiona Lecky, Abdullah Pandor, Munira Essat, Anthea Sutton, Carl Marincowitz, Gordon Fuller, Stuart Reid, Jason Smith. A systematic review of cervical spine immobilisation following blunt trauma in pre-hospital and emergency care. PROSPERO 2022 CRD42022349600 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022349600.

Recent trends in high-income countries indicate a shift in the causes of major trauma, with low-energy transfer mechanisms, particularly falls from less than two meters, becoming increasingly prevalent. This study aimed to compare the demographics, care processes, and outcomes of major trauma patients injured by low and high-energy transfer mechanisms. This comparative cohort study utilized anonymized data from adult patients recorded in the Trauma Audit and Research Network in 2019. Patients were categorized into low-energy (falls less than 2 meters) and high-energy (other mechanisms) groups. The study focused on patients with an Injury Severity Score (ISS) greater than 15. Data from up to 179 English and Welsh hospitals were included. In 2019, 53.6% (n = 16,087) of major trauma patients were injured by low-energy falls. When compared to the high-energy cohort, these affected older patients (median age 80 vs. 47 years; p < 0.001), with a higher prevalence of pre-existing comorbidities (90.4% [95%CI 89.9-90.8] vs. 56.2% [95%CI 55.4-57.0]; p < 0.001) and traumatic brain injuries (74.0% [95%CI 73.3-74.7] vs. 49.8% [95%CI 48.9-50.6]; p < 0.001). Low-energy fall patients were more likely to be initially treated in Trauma Units rather than Major Trauma Centres and received fewer interventions such as surgery and critical care admission. Low-energy falls patients had a higher in-hospital mortality rate (14.0% [95%CI 13.5% - 14.6%] vs. 10.3% [95%CI 9.8% - 10.8%]; p < 0.0001). The increasing burden of major trauma from low-energy falls necessitates a re-evaluation of current trauma care systems and injury prevention strategies to better serve this distinct and growing patient population. Future research should focus on optimizing care pathways, defining patient orientated outcomes and improving outcomes for patients injured by low-energy falls.

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.

BackgroundThe utilization of helicopter emergency medical services (HEMS) in modern trauma systems has been a source of debate for many years. This study set to establish the true impact of HEMS in England on survival for patients with major trauma.MethodsA comparative cohort design using prospectively recorded data from the UK Trauma Audit and Research Network registry. 279 107 patients were identified between January 2012 and March 2017. The primary outcome measure was risk adjusted in-hospital mortality within propensity score matched cohorts using logistic regression analysis. Subset analyses were performed for subjects with prehospital Glasgow Coma Scale <8, respiratory rate <10 or >29 and systolic blood pressure <90.ResultsThe analysis was based on 61 733 adult patients directly admitted to major trauma centers: 54 185 ground emergency medical services (GEMS) and 7548 HEMS. HEMS patients were more likely male, younger, more severely injured, more likely to be victims of road traffic collisions and intubated at scene. Crude mortality was higher for HEMS patients. Logistic regression demonstrated a 15% reduction in the risk adjusted odds of death (OR=0.846; 95% CI 0.684 to 1.046) in favor of HEMS. When analyzed for patients previously noted to benefit most from HEMS, the odds of death were reduced further but remained statistically consistent with no effect. Sensitivity analysis on 5685 patients attended by a doctor on scene but transported by GEMS demonstrated a protective effect on mortality versus the standard GEMS response (OR 0.77; 95% CI 0.62 to 0.95).DiscussionThis prospective, level 3 cohort analysis demonstrates a non-significant survival advantage for patients transported by HEMS versus GEMS. Despite the large size of the cohort, the intrinsic mismatch in patient demographics limits the ability to statistically assess HEMS true benefit. It does, however, demonstrate an improved survival for patients attended by doctors on scene in addition to the GEMS response. Improvements in prehospital data and increased trauma unit reporting are required to accurately assess HEMS clinical and cost-effectiveness.

Aims/Objectives/BackgroundLow energy transfer mechanisms – predominately falls from a standing height – have been identified as the most prevalent cause of major trauma in higher-income countries. This study examines the epidemiological trends in major trauma in England and Wales between 2000 – 2019, incorporating changes in mechanism of injury, imaging practices, case ascertainment and national demographic shifts. In addition, changes in the whole cohort of major trauma patients and differences between patients who suffered high energy and low energy mechanism of injury are described.Methods/DesignA retrospective observational cohort study was conducted using Trauma Audit and Research Network (TARN) data. Patients with an injury severity score (ISS) >15 admitted to hospital in England and Wales between 1 January 2000 to 31 December 2019 were included. The primary outcome was the temporal trend in the proportion of major trauma sustained through low energy transfer, and its association with imaging practices, case ascertainment and demographic changes.Results/Conclusions241,484 participants were included in the analysis, of which 96,833 were classified as low energy. Low energy trauma accounted for 12.5% in 2000 (n = 373), rising to 52.6% (n=16,087) in 2019. Over the same period the proportion of patients receiving CT imaging increased from 20.7% (n=676) to 88.9% (n=27,174). TARN hospital membership doubled from 96 to 179 hospitals, and the annual mean numbers of cases per hospital per annum increased sixfold from 31 to 174. Case ascertainment improved from 42% in 2008 to 95% in 2019. Significant differences were observed in the demographics, injury patterns, presenting physiology, care pathways, and outcomes between the high and low energy cohorts.Changes in imaging and reporting practices have revealed a previously hidden burden of injury resulting from low energy transfer mechanisms. It is essential that future research recognises this distinct cohort and investigates how trauma systems can be changed to optimise outcomes.

Comparisons across trauma systems are key to identifying opportunities to improve trauma care. We aimed to compare trauma service structures, processes and outcomes between the English National Health Service (NHS) and the province of Quebec, Canada. We conducted a multicentre cohort study including admissions of patients aged older than 15 years with major trauma to major trauma centres (MTCs) from 2014/15 to 2016/17. We compared structures descriptively, and time to MTC and time in the emergency department (ED) using Wilcoxon tests. We compared mortality, and hospital and intensive care unit (ICU) length of stay (LOS) using multilevel logistic regression with propensity score adjustment, stratified by body region of the worst injury. The sample comprised 36 337 patients from the NHS and 6484 patients from Quebec. Structural differences in the NHS included advanced prehospital medical teams (v. “scoop and run” in Quebec), helicopter transport (v. fixed-wing aircraft) and trauma team leaders. The median time to an MTC was shorter in Quebec than in the NHS for direct transports (1 h v. 1.5 h, p < 0.001) but longer for transfers (2.5 h v. 6 h, p < 0.001). Time in the ED was longer in Quebec than in the NHS (6.5 h v. 4.0 h, p < 0.001). The adjusted odds of death were higher in Quebec for head injury (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.09–1.51) but lower for thoracoabdominal injuries (OR 0.69, 95% CI 0.52–0.90). The adjusted median hospital LOS was longer for spine, torso and extremity injuries in the NHS than in Quebec, and the median ICU LOS was longer for spine injuries. We observed significant differences in the structure of trauma care, delays in access and risk-adjusted outcomes between Quebec and the NHS. Future research should assess associations between structures, processes and outcomes to identify opportunities for quality improvement. Il est indispensable de comparer entre eux les différents systèmes intégrés de traumatologie pour identifier les secteurs où les soins peuvent y être améliorés. Nous avons donc procédé à une comparaison descriptive des structures, du fonctionnement et des résultats entre le National Health Service (NHS) du Royaume-Uni et le Québec, au Canada. Nous avons réalisé une étude de cohorte multicentrique regroupant des victimes de traumatismes majeurs âgées de 15 ans et plus hospitalisées dans de grands centres intégrés de traumatologie (CIT) de 2014/15 à 2016/17. Nous avons procédé à une comparaison descriptive des structures, de l’intervalle médian avant l’arrivée au CIT et de la durée du séjour aux urgences à l’aide de tests de Wilcoxon. Nous avons comparé la mortalité et la durée des séjours à l’hôpital et à l’unité de soins intensifs (USI) par analyse de régression logistique multiniveau avec redressement des scores de propension stratifiée selon les structures anatomiques les plus gravement touchées. L’échantillon comprenait 36 337 cas du NHS et 6484 cas du Québec. Les différences structurelles du NHS incluaient des équipes médicales de soins préhospitaliers d’urgence avancés (c. transport rapide vers un CIT [« scoop and run »] au Québec), le transport par hélicoptère (c. avion à voilure fixe) et des chefs d’équipes de traumatologie. L’intervalle médian avant l’arrivée au CIT a été plus court au Québec par rapport au NHS pour les transports directs (1 h c. 1,5 h, p < 0,001), mais plus long pour les transferts (2,5 h c. 6 h, p < 0,001). La durée du séjour aux urgences a été plus longue au Québec par rapport au NHS (6,5 h c. 4,0 h, p < 0,001). Le risque de mortalité ajusté a été plus élevé au Québec dans les cas de traumatisme crânien (rapport des cotes [RC] 1,28, intervalle de confiance de 95 % [IC] 1,09–1,51), mais moins élevé dans les cas de traumatisme thoraco-abdominal (RC 0,69, IC de 95 % 0,52–0,90). La durée médiane ajustée des séjours hospitaliers a été plus longue dans les cas de traumatisme à la colonne vertébrale, aux membres et au thorax avec le NHS qu’au Québec, et la durée médiane des séjours à l’USI a été plus longue dans les cas de traumatisme à la colonne vertébrale. Nous avons observé des différences significatives quant à la structure des soins en traumatologie, quant aux délais pour y accéder et quant aux résultats ajustés en fonction du risque entre le Québec et le NHS. La recherche future devrait se pencher sur les liens entre les structures, le fonctionnement et les résultats afin de mieux cibler les secteurs où il serait possible d’apporter des améliorations.