Defining major trauma: a literature review

Scand J Trauma Resusc Emerg Med

Lecky

et al. 2021

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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”.

Section: Methodsmentioning

confidence: 99%

“…Although potentially linked to the definitions of polytrauma, the definition of major trauma may differ. A literature review [ 12 ] identified that the most common definition for major trauma is a retrospective ISS of > 15. The injury severity score is an aggregation of the main injuries from each body region.…”

Section: Introductionmentioning

confidence: 99%

Defining major trauma: a Delphi study

Scand J Trauma Resusc Emerg Med

Lecky

et al. 2021

Self Cite

“…The survey was designed to re ect the outcomes of a literature review (5) and the output from three focus groups (14). This included:…”

Section: De Nition Of Consensusmentioning

confidence: 99%

“…A literature review (5) identi ed that the most common de nition for major trauma is a retrospective ISS of >15. The injury severity score is an aggregation of the main injuries from each body region.…”

Section: Introductionmentioning

confidence: 99%

Defining major trauma: A Delphi study.

Lecky

et al. 2020

Preprint

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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 surgical intervention, use of Tranexamic Acid, 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”.

“…However, a lack of consensus exists in relation to what constitutes a useful or standard definition of major trauma (Alberdi, Garcia, Atutxa, Zabarte, & Trauma and Neurointensive Care Work Group of the SEMICYUC, 2014). One approach involves retrospective scoring such as the Injury Severity Score (ISS) (Thompson, Hill, & Shaw, 2019). Unfortunately, injury scoring systems are often calculated after all imaging and interventions are completed, making them unsuitable for the pre-hospital phase of care.…”

Section: Problem Formulationmentioning

confidence: 99%

Defining major trauma: a pre-hospital perspective using focus groups

British Paramedic Journal

McMeekin

et al. 2019

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Background: Pre-hospital trauma is complex and challenging, with limited clinical exposure for clinicians. In addition, there is no standardised definition for major trauma, and retrospective scores commonly quantify injury severity, such as the injury severity score. This qualitative study aimed to explore the pre-hospital perspectives of major trauma and how pre-hospital trauma care providers define major trauma.Method: Three focus groups of 40‐60 minutes’ duration were conducted with paramedics, ambulance technicians, police, firefighters and emergency dispatchers. Digital recordings were transcribed verbatim, coded and reviewed to identify emerging themes. Constant comparison was undertaken throughout and codes were identified for qualitative thematic analysis.Results: Three overarching themes emerged: clinician factors, patient factors and situational factors. Clinician factors highlighted issues of experience and exposure (or lack of) to major trauma and its relationship to clinical concern, communication issues and the complex nature of pre-hospital trauma. Patient factors identified deranged physiology, actual injuries, life changing trauma, potential need for surgical intervention and rehabilitation as defining major trauma. These variables are often complicated by the extremities of age as well as previous medical history and medications. The situational factors identified that every traumatic encounter is unique, requiring bespoke management where high and low energy mechanisms of injury should be considered.Conclusion: Based on the analysis of the focus groups, a working pre-hospital definition is: Any injury (or injuries) that have the potential to be life-threatening or life-changing, including those sustained from low energy mechanisms in people rendered vulnerable by extremes of age, comorbidities or frailty, resulting in significant physiological compromise (haemodynamic instability, reduced consciousness, respiratory compromise) and/or significant anatomical abnormality that may require immediate intervention.