BACKGROUND:Major trauma is a leading cause of death and disability. Specialised care in major trauma centres has been associated with improved outcomes and prehospital triage tools are used to ensure injured patients are treated in the right place and the right time. However, there is a trade-off between under- and over-triage, and this study aimed to externally validate current and newly developed major trauma triage tools. METHODS:A diagnostic case-cohort study was performed between November 2019 and February 2020 in 4 English regional trauma networks as part of the Major Trauma Triage Study (MATTS). The accuracy of 22 adult major trauma triage tools, including 3 newly developed MATTS tools was evaluated. Consecutive patients with acute non-trivial injury presenting to participating ambulance services were included and matched to data from the English national major trauma database. Theoretical accuracy was examined, with index tests assessed according to objective ambulance service data, regardless of the final triage decision or hospital destination. The primary reference standard was a consensus definition of serious injury that would benefit from expedited major trauma centre care. RESULTS:The case-cohort sample consisted of 2,607 patients, including 928 primary reference standard positive patients. The population weighted prevalence of major trauma meeting the primary reference standard definition was 3.1% (95% CI 2.3-4.0). Four optimally performing triage tools were identified with Pareto decision analysis: the Trauma score (sensitivity 0.1, specificity 0.99), MATTS specific tool (sensitivity 0.37, specificity 0.95), MATTS balanced tool (sensitivity 0.58, specificity 0.87), and the MATTS sensitive tool (sensitivity 0.72, specificity 0.76). This finding was unchanged in subgroup analyses of different age-groups and injury mechanisms; secondary analyses examining alternative reference standards (ISS ≥ 16, US consensus definition); and sensitivity analyses exploring missing data. CONCLUSIONS:Four optimal triage tools, demonstrating a trade-off between sensitivity and specificity, were identified by this validation study. The choice of ideal tool will depend on prevalence of major trauma, and valuation of false positive and false negative cases. Further prospective investigation of real-life triage tool performance, including compliance and clinical judgment, is necessary.

BackgroundRecent 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.MethodsThis 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.ResultsIn 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).ConclusionsThe 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.

We reviewed a Major Trauma Centre (MTC) in the UK over an Emergency Department (ED) transition using the World Health Organization (WHO) Hospital Emergency Unit Assessment Tool (HEAT). HEAT has previously been used in low- and middle-income countries. This is the first time it has been used to explore resource constraints and predict potential barriers to emergency care capacity in a higher-income country. Our primary outcome was to find any difference in emergency care capacity with a change in emergency care resources. Secondary outcomes included qualitative data collected by key informant (KI) interviews both on the suitability of the tool itself and on its use in a higher-resourced system. All areas of the MTC that impact emergency care capacity were studied, with multiple KIs in each area interviewed. The HEAT-adjusted Emergency Care Capacity Score (HEAT-ECCS) was used for quantitative analysis of the MTC’s emergency care capacity. Qualitative data was collected for analysis of barriers to availability of emergency care. Data collection was before and after an ED transition in 2024, with the extension to the original ED of an additional 12-cubicle resuscitation unit and associated infrastructure. The overall HEAT-ECCS improved from 77

Background:There is currently wide variation in prehospital major trauma triage across the National Health Service, with regional ambulance services using different triage tools, varying in format, structure and variables. Objectives:To develop a national triage tool that is acceptable, usable, accurate, and optimises under- and over-triage. Design:A three-phase research programme, comprising Phase 1: development of a new triage tool by expert consensus informed by existing evidence, a systematic review of elderly triage, document analysis of current tools, decision-analytic modelling, expert consensus definition of a major trauma reference standard, and a qualitative examination of current triage; Phase 2: case-cohort study validating triage tools identified and developed in Phase 1, with identification of an optimally performing candidate triage tool; Phase 3: evaluation of the candidate triage tool following implementation, including cohort study investigating accuracy of triage decisions, cost-effectiveness analysis, and examination of user experiences. Setting:English regional trauma networks served by the South-Western, West Midlands, Yorkshire and London Ambulance Services. Phase 2 case-cohort study and Phase 3 cohort studies performed between 1 November 2019 and 28 February 2020, and 1 November 2021 and 15 May 2022, respectively. Participants:Injured patients presenting to ambulance services in participating regional trauma networks. Results:In Phase 1, document analysis identified 19 United Kingdom triage tools and 34 published international tools. The systematic review demonstrated limited diagnostic accuracy of triage tools in the elderly, with divergent real-life triage decisions. The reference standard included the need for critical trauma-related interventions, significant individual anatomical injuries, burden of multiple minor injuries and specific patient attributes. Decision-analytic modelling indicated that high-specificity triage tools were favoured. Triage tool simplicity and the option for clinical judgement were valued by stakeholders, but real-world triage was a multifaceted, nonlinear, dynamic and multiagency process. Following review of Phase 1 evidence, a three-step Major Trauma Triage Study candidate triage tool targeting relatively higher specificity was developed through expert consensus. The Phase 2 case-cohort sample included 2757 patients, with a weighted prevalence of major trauma of 3.1% (95% confidence interval 2.3% to 4.0%). The Major Trauma Triage Study tool performed optimally compared to under- and over-triage targets (sensitivity 37.3%, specificity 95.1%). In Phase 3, the newly implemented Major Trauma Triage Study triage tool was received favourably by stakeholders. Prehospital triage decisions using the new tool demonstrated a sensitivity of 55.3% (95% confidence interval 51.8% to 58.7%) and specificity of 94.3% (95% confidence interval 94.1% to 94.6%, n = 38,010, 2.2% prevalence of major trauma). Minimal differences were apparent between the costs (£149) and benefits (0.006 quality-adjusted life-years) of triage decisions, regardless of the triage tool used, reflecting similar real-life triage accuracy. However, the new Major Trauma Triage Study tool appeared cost-effective when theoretical triage tool performance was examined, demonstrating an incremental cost effectiveness ratio of £21,163. Conclusions:The Major Trauma Triage Study triage tool performed optimally, targeted an appropriate under-/over-triage trade-off, and was perceived to perform well by stakeholders. National implementation could ensure evidence-based, standardised and cost-effective triage. Limitations:Significant variation in National Health Service ambulance service and trauma network configurations could limit the generalisability of results. Future work:Paediatric triage, pre-alerting and the benefit of remote clinical support could benefit from future research. Trial registration:This trial is registered as Current Controlled Trials ISRCTN17968752. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/16/04) and is published in full in Health Technology Assessment; Vol. 30, No. 34. See the NIHR Funding and Awards website for further award information.

Introduction The Major Trauma Triage Study (‘MATTS’) triage tool was designed to identify patients with major trauma who could benefit from expedited care in specialist major trauma centres (MTCs). We aimed to investigate the impact of the MATTS tool on major trauma triage decisions after implementation. Methods Consecutive patients were included in a multicentre, prospective cohort study conducted between 1 November 2021 and 15 May 2022 in six trauma networks served by West Midlands and Yorkshire Ambulance Services. Electronic data from ambulance service patient report forms were linked to data from the Trauma Audit and Research Network trauma registry. The accuracy of prehospital triage decisions (conveyance to an MTC with pre-alert) against a bespoke MATTS reference standard to define major trauma was calculated. This was compared with optimal undertriage/overtriage trade-off indicated by previous economic modelling. Additional analyses investigated theoretical triage tool accuracy based on recorded data irrespective of hospital destination, examined important injury subgroups, evaluated alternative reference standards and described triage tool use. Results In total, 38 010 injured patients were included, with 2.2% prevalence of major trauma. The MATTS triage tool demonstrated 55.3% sensitivity (95% CI 51.8% to 58.7%) and 94.3% specificity (95% CI 94.1% to 94.6%). There was evidence of triage tool use in a minority of patients (6.3%), with senior clinical advice sought in 9.3% of patients. Theoretical triage tool sensitivity was 51.1% (95% CI 47.6% to 54.5%) with specificity 93.6% (95% CI 92.7% to 94.4%). Agreement between the theoretical triage tool result and the observed triage decision was good (absolute agreement 90.4%, Gwet’s agreement coefficient 1 (AC1) statistic 0.89, 95% CI 0.89 to 0.89). Accuracy varied across different ages, mechanisms of injury subgroups and alternative reference standards for major trauma. Conclusions The MATTS triage tool achieved an appropriate undertriage/overtriage trade-off compared with previously established targets. However, documented adherence to MATTS was low. Dedicated training and further evaluation are necessary prior to national wider implementation.

Our objective was to determine the extent to which clinical outcomes at 3 months predict the 6- to 12-month trajectory in people presenting with mild or moderate traumatic brain injury (TBI). We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched MEDLINE, EMBASE, EBSCO, and the Web of Science Citation Index from 2005 until May 2025. All observational or interventional study designs that reported clinical outcomes in patients at 3 months, and at a later time point, following mild or moderate TBI were eligible for inclusion. Two authors independently selected and extracted data. Risk of bias was assessed using the Downs and Black checklist. Thirty studies (29 observational, 1 interventional) involving 7993 patients (7781 with mild TBI [mTBI]) met the inclusion criteria. Study quality was variable, and heterogeneity in study inclusion criteria and outcome reporting precluded meta-analyses and identification of patient and injury predictors of post 3-month outcome trajectory. Vulnerable populations-including older adults, those with pre-existing cognitive impairment, psychiatric illness, or intoxication-were frequently excluded. Analysis of the four most commonly reported outcome measures (Rivermead Post-Concussion Symptoms Questionnaire, Extended Glasgow Outcome Scale, Short Form 36 Health Survey, and Quality of Life after Brain Injury)-revealed symptom and functional improvement over time, particularly from hospital discharge to 3 months post-injury. However, substantial problems persist thereafter with 21-65% of patients continuing to experience symptoms or impairment, depending on cohort and outcome measure. The small number of patients with moderate TBI precluded comparison of outcomes to patients with mTBI. To improve clinical care, research, and patient experience, future targeted studies should identify factors determining the post-TBI outcome trajectory.

Introduction Traumatic brain injury (TBI) presents significant challenges in prehospital care, particularly during on-scene triage, where accurate decision-making is crucial for improving patient outcomes. This study, part of a mixed-methods project, aims to explore these challenges and identify gaps in current on-scene triage practices. Additionally, it seeks to understand paramedics’ perspectives on potential diagnostic tools such as brain biomarkers, near-infrared spectroscopy, and decision aids. Methods This study involved conducting semi-structured interviews by video conference, including interviews with paramedics of various experience levels who were recruited from UK ambulance trusts. The interviews were guided by a predeveloped and piloted topic guide. The interviews were audio-recorded, transcribed, and analysed using a thematic analysis approach. Results Between June and December 2022, twenty participants (15 males and 5 females) with 4 to 24 years of experience were interviewed. Four key themes were identified. Theme 1, “Challenges in TBI Recognition,” highlighted difficulties in identifying non-obvious TBI, especially in older adults or patients with comorbidities, and differentiating TBI from other conditions. Theme 2, "Need for Specific Triage and Diagnostic Tools," emphasised paramedics' need for a simple, evidence-based head injury-specific triage tool, as they felt that current tools lack the necessary specificity. Participants also highlighted the potential of new diagnostic technologies to improve decision-making. Theme 3, “Need for Evidence to Support Diagnostic Tools,” stressed the importance of clinical effectiveness, feasibility, and cost before implementing new diagnostic technologies. Theme 4, “Implementation Requires Planning and Training,” highlighted the need for effective implementation strategies, as well as adequate and ongoing training to ensure proficiency and proper use in the prehospital setting. Conclusions This study provides critical insights into the complexities of on-scene prehospital triage for patients with suspected TBI. Key recommendations include developing specific triage tools, exploring advanced technologies to support on-scene decision-making, enhancing paramedic training on TBI recognition, and addressing both barriers and facilitators to the implementation of new diagnostic technologies.

OBJECTIVE:To investigate the moderating effects of socio-demographic social determinants of health (SDH) in the relationship between types of childhood hospitalisation (ie, none, injury, non-injury, injury+non-injury) and academic performance. DESIGN, SETTING AND PATIENTS:Children residing in Wales 2009-2016 (N=369 310). Secure Anonymised Information Linkage databank linked Tagged Electronic Cohort Cymru (five data sources) from the Wales Electronic Cohort for Children. MAIN OUTCOME MEASURE:Binary educational achievement (EA) measured across three key educational stage time points: grade 6 (mean age 11 years, SD 0.3), 9 (mean age 14 years, SD 0.3) and 11 (mean age 16 years, SD 0.3). RESULTS:Of the 369 310 children, 51% were males, 25.4% of children were born in the lowest two Townsend deciles. Females were more likely to meet EA than males (adjusted risk ratio (aRR) (95% CI): 1.047 (1.039, 1.055)). EA was lower for injury admissions in males and any admission type in females (interactions: female×non-injury 0.982 (0.975, 0.989); female×injury+non-injury 0.980 (0.966, 0.994)). Children born into a more deprived decile were less likely to achieve EA (0.979 (0.977, 0.980)) and worsened by an injury admission (interactions: townsend×injury 0.991 (0.988, 0.994); Townsend×injury+non-injury 0.997 (0.994, 1.000)). Children with special educational needs (SEN) were less likely to meet EA (0.471 (0.459, 0.484) especially for an injury admission (interactions: SEN×injury 0.932 (0.892, 0.974)). CONCLUSION:SDH moderated the impact of hospital admission type on educational outcomes prompting future investigation into the viability of in-hospital routine screening of families for SDH and relevant post-hospital interventions to help reduce the impact of SDH on educational outcomes post-hospitalisation.

OBJECTIVE:To develop metrics for pediatric-specific quality indicators (QIs) for trauma care using trauma registry data and evaluate their validity. BACKGROUND:A set of 23 QIs specific to pediatric trauma care and applicable to both pediatric and non-pediatric trauma centers (PTCs) was recently developed. Their validity needs to be assessed before implementation. METHODS:We extracted data on children admitted to any trauma center in a Canadian provincial trauma system between April 2016 and March 2022. We evaluated QIs using Agency for Healthcare Research and Quality criteria. RESULTS:The study sample comprised 10,711 pediatric trauma admissions. We developed metrics for 15 QIs. Six had moderate-to-high validity on all evaluable criteria: head computed tomography <60 minutes for children with Glasgow Coma Scale <13, documentation of a full set of vital signs in the emergency department, initial head computed tomography in patients at low-risk on a clinical decision rule, stabilization of femoral shaft fractures <24 hours, intracranial pressure monitoring in severe traumatic brain injury, and nutritional support <48 hours of intensive care unit admission. Four had moderate-to-high validity on all but one criterion: PTC transfer for neurotrauma and major multisystem trauma, PTC transfer for major orthopedic trauma, and antibiotics <60 minutes in open long bone fractures. CONCLUSIONS:This study shows the feasibility of operationalizing QIs for pediatric trauma using trauma registry data, and we provide coding definitions to do so. Results provide evidence on validity that may be used to guide the selection of QIs for performance improvement programs.

BACKGROUND:Trauma 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. METHODS:In 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. RESULTS:During 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. CONCLUSION:UK 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.

This article explores the diagnostic performance of a panel of six biomarkers (glial fibrillary acidic protein [GFAP], neurofilament light [NFL], neuron-specific enolase [NSE], S100 calcium-binding protein B [S100B], total tau [t-tau], and ubiquitin C-terminal hydrolase L1 [UCH-L1]) in the context of the "2023 UK National Institute for Health and Care Excellence (NICE) Head Injury: Assessment and early management (NG232)" guideline. Emphasis is placed on subjects where clinical equipoise remains concerning the decision for head computed tomography (CT), medium-risk subjects. All adult subjects from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) dataset with a complete biomarker profile and interpretable CT scan within 24 h of injury were classified as high, medium, and low-risk according to the NICE NG232 Clinical Decision Rule (CDR) for CT head imaging following head injury. In subjects classified as medium-risk, the area under the receiver operating characteristic curve (AUC) was used to assess the diagnostic performance of biomarkers to identify those with (1) CT abnormality or (2) potential neurosurgical lesion, with CT considered the gold standard diagnosis. A time-to-biomarker sub-analysis was performed in subjects with a time from injury to sampling within 6 h, in keeping with current clinical usage of biomarkers. Among 1979 CENTER-TBI participants with sufficient clinical information to facilitate classification, 385 subjects were classified as medium-risk. Biomarker concentrations were significantly higher in those with traumatic CT abnormalities as compared with those without for all biomarkers aside from NSE (all p < 0.05). When sampled within 24 h of injury, GFAP demonstrated the best diagnostic performance for CT abnormality (AUC 0.81 [0.77-0.86]), with NFL, t-tau, and UCH-L1 showing moderate performance. At a threshold to provide a 95% sensitivity, GFAP, NFL, t-tau, and UCH-L1 demonstrated specificities ranging from 18% to 33% corresponding to a potential reduction of total CT images performed in these subjects by 14-23%. S100B and UCH-L1 showed improved performance when biomarker sampling time was limited to 6 h following injury. In intoxicated subjects with a persistent Glasgow Coma Score of 13-14, biomarker levels were significantly higher in subjects with CT abnormality as compared with those without. In conclusion, serum biomarkers demonstrate potential for the reduction in CT scan requirements in those classified as medium-risk in reference to the NG232 CDR criteria. These results highlight a need for further prospective studies on the use of diagnostic TBI biomarkers in current emergency medicine practice, with future consideration given to the integration of biomarkers in the NICE NG232 head injury guidelines.

Importance:Despite the unique physiological characteristics and health care needs of pediatric trauma patients, there is a lack of quality indicators (QIs) based on pediatric-specific evidence to support quality improvement in this population. Objective:To develop a consensus-based set of QIs for acute pediatric trauma care that considers evidence on effectiveness, safety, cost-effectiveness, equity, and caregiver perspectives and is applicable in pediatric and nonpediatric trauma centers. Design, Setting, and Participants:A modified Research and Development (RAND)/University of California Los Angeles (UCLA) expert consensus study was conducted consisting of an online survey and a virtual workshop, led by an independent moderator. Panelists represented key areas of pediatric trauma patient management, diverse care settings (from level I pediatric trauma centers to level III referring centers), 5 high-resource countries, and caregivers. Data were analyzed from May to August 2024. Exposure:Likert-scale ratings of 41 QIs. Main Outcomes and Measures:Panelists rated 41 QIs on a 7-point Likert scale according to 4 criteria: importance, supporting evidence, actionability, and measurability. QIs with a global score of 24 of 28 or greater and an importance score of 6 of 7 or greater were considered accepted by consensus. Results:A total of 65 experts were invited, of whom 59 accepted (91%; 25 over 50 years of age [44.7%]; 34 female [60.7%]), 56 (95%) completed the first round, and 54 (92%) completed both rounds. Twenty-three QIs were selected covering key areas of acute pediatric trauma management (eg, transfer to a pediatric trauma center for neurotrauma or major multisystem trauma, documentation of vital signs, early rehabilitation, nutritional support), the most common types of injuries (eg, hypertonic saline in severe traumatic brain injury, stabilization of femoral shaft fractures, nonoperative management of solid organ injuries), value in care (eg, imaging in children at low risk on a clinical decision rule), patient-centered care (eg, designated support person, caregiver presence), and equity (eg, mental health screening). Conclusions:These results may be used by trauma quality improvement programs in high-resource countries to select context-specific quality indicators to improve the effectiveness, safety, cost-effectiveness, equity, and patient-centered nature of pediatric trauma care.

Introduction: The aim of this trial was to investigate the impact of early thoracic and shoulder girdle exercises on chronic pain and Health-Related Quality of Life in patients with blunt chest wall trauma, when compared to normal care. Methods: A multi-centre, parallel, randomised controlled trial, in which adult patients presenting to hospital with blunt chest wall trauma were allocated to either control or intervention group. The intervention was an exercise programme consisting of four simple thoracic and shoulder girdle exercises, completed for one week. Outcomes measures included prevalence and severity of chronic pain using the Brief Pain Inventory, health-related quality of life using EQ-5D-5 L, and cost effectiveness, measured at initial presentation and three months post-injury. Results: 360 participants were recruited. Participants' mean age was 63.6 years (standard deviation (SD): 17.9 years) and 213 (59.8 %) were men. After loss-to-follow-up, the survey response rate at three months was 73.0 % (251/344 participants). The primary analysis, for chronic pain prevalence at three months post-injury, found no statistically significant differences between intervention and control groups, with lower rates in the control (intervention: 35/126 (27.8 %), control: 20/117 (17.1 %); adjusted odds ratio 1.862; 95% CI: 0.892 to 3.893, p = 0.098). There were no statistically significant differences between intervention and control groups for pain severity at three months post-injury, (intervention mean (SD): 2.15 (2.49), control: 1.81 (2.10); adjusted difference 0.196, 95 % CI:0.340 to 0.731; p = 0.473); or Health-Related Quality of Life (intervention mean (SD): 0.715 (0.291), control: 0.704 (0.265); adjusted difference: 0.030; 95% CI:0.033 to 0.094; p = 0.350). The health economic analysis found the intervention was associated with higher costs compared to normal care. Conclusion: The results of this trial did not support a 'one-size fits all' simple, early exercise programme for patients with blunt chest wall trauma. Future research should consider the impact of a personalised exercise programme, commenced by the patient at least one week post-injury.

The current classification of traumatic brain injury (TBI) primarily uses the Glasgow Coma Scale (GCS) to categorize injuries as mild (GCS 13-15), moderate (GCS 9-12), or severe (GCS ≤8). However, this system is unsatisfactory, as it overlooks variations in injury severity, clinical needs, and prognosis. A recent report by the National Academies of Sciences, Engineering, and Medicine (USA) recommended updating the classification system, leading to a workshop in 2024 by the National Institute of Neurological Disorders and Stroke. This resulted in the development of a new clinical, biomarker, imaging, and modifier (CBI-M) framework, with input from six working groups, including the Clinical/Symptoms Working Group (CSWG). The CSWG included both clinical and non-clinical experts and was informed by individuals with lived experience of TBI and public consultation. The CSWG primarily focused on acute clinical assessment of TBI in hospital settings, with discussion and recommendations based on pragmatic expert reviews of literature. Key areas reviewed included: assessment of neurological status; performance-based assessment tools; age and frailty, pre-existing comorbidities, and prior medication; extracranial injuries; neuroworsening; early physiological insults; and physiological monitoring in critical care. This article reports their discussions and recommendations. The CSWG concluded that the GCS remains central to TBI characterization but must include detailed scoring of eye, verbal, and motor components, with identification of confounding factors and clear documentation of non-assessable components. Pupillary reactivity should be documented in all patients, but recorded separately from the GCS, rather than as an integrated GCS-Pupils score. At ceiling scores on the GCS (14/15), history of loss of consciousness (LoC) and the presence and duration of post-traumatic amnesia should be recorded using validated tools, and acute symptoms documented in patients with a GCS verbal score of 4/5 using standardized rating scales. Additional variables to consider for a more complete characterization of TBI include injury mechanism, acute physiological insults and seizures; and biopsychosocial-environmental factors (comorbidities, age, frailty, socioeconomic status, education, and employment). The CSWG recommended that, for a complete characterization of TBI, disease progression/resolution should be monitored over 14 days. While there was a good basis for the recommendations listed above, evidence for the use of other variables is still emerging. These include: detailed documentation of neurological deficits, vestibulo-oculomotor dysfunction, cognition, mental health symptoms, and (for hospitalized patients) data-driven integrated measures of physiological status and therapy intensity. These recommendations are based on expert consensus due to limited high-quality evidence. Further research is needed to validate and refine these guidelines, ensuring they can be effectively integrated into the CBI-M framework and clinical practice.

Background:Traumatic brachial plexus injuries (TBPI) are often devastating and life-changing and are thought to be becoming more prevalent. Several studies have investigated the epidemiology of TBPI in other countries (e.g., United States, Brazil); however, a similar analysis is yet to be undertaken in England and Wales. The aim of this cohort study was to determine the incidence and epidemiology of TBPI in England and Wales. Methods:The Trauma Audit and Research Network database was reviewed to identify 1,297 eligible patients admitted with TBPI between 1990 and 2022. Patient demographics, injury mechanism, associated injuries, and outcomes were analyzed. Results:The median age of patients with TBPI was 41 years, and 77% (n = 997) were male. There was a significant difference in age between male patients and female patients, with male patients aged younger than 18 years (confidence interval 14.4-21.3) at the time of injury. The predominant injury mechanism was vehicle collision (65%), with 62% riding motorcycle or quad bikes. The majority of other injuries resulted from falls less than 2 m (19%). Falls less than 2 m were particularly prevalent in patients aged older than 65 years, who represented 19% of the cohort. TBPI was commonly associated with other injuries (94%), predominately bony injuries including dislocations and fractures. Conclusion:This is the first epidemiological study of TBPI within England and Wales. Vehicle incidents, particularly involving motorcycles, are the commonest cause of TBPI; however, there is a substantial cohort of elderly patients sustaining TBPI, often from falls. These findings may aid improved and earlier recognition of TBPI, enabling timely management. Level of Evidence:Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Care for injured patients in England is provided by inclusive regional trauma networks. Ambulance services use triage tools to identify patients with major trauma who would benefit from expedited Major Trauma Centre (MTC) care. However, there has been no investigation of triage performance, despite its role in ensuring effective and efficient MTC care. This study aimed to investigate the accuracy of prehospital major trauma triage in representative English trauma networks.Methods A diagnostic case-cohort study was performed between November 2019 and February 2020 in 4 English regional trauma networks as part of the Major Trauma Triage Study (MATTS). Consecutive patients with acute injury presenting to participating ambulance services were included, together with all reference standard positive cases, and matched to data from the English national major trauma database. The index test was prehospital provider triage decision making, with a positive result defined as patient transport with a pre-alert call to the MTC. The primary reference standard was a consensus definition of serious injury that would benefit from expedited major trauma centre care. Secondary analyses explored different reference standards and compared theoretical triage tool accuracy to real-life triage decisions.Results The complete-case case-cohort sample consisted of 2,757 patients, including 959 primary reference standard positive patients. The prevalence of major trauma meeting the primary reference standard definition was 3.1% (n=54/1,722, 95% CI 2.3 - 4.0). Observed prehospital provider triage decisions demonstrated overall sensitivity of 46.7% (n=446/959, 95% CI 43.5-49.9) and specificity of 94.5% (n=1,703/1,798, 95% CI 93.4-95.6) for the primary reference standard. There was a clear trend of decreasing sensitivity and increasing specificity from younger to older age groups. Prehospital provider triage decisions commonly differed from the theoretical triage tool result, with ambulance service clinician judgement resulting in higher specificity.Conclusions Prehospital decision making for injured patients in English trauma networks demonstrated high specificity and low sensitivity, consistent with the targets for cost-effective triage defined in previous economic evaluations. Actual triage decisions differed from theoretical triage tool results, with a decreasing sensitivity and increasing specificity from younger to older ages.

Background Ocular trauma is a major cause of vision loss and injuries are often missed in multiply injured patients. Major trauma demographics in the UK have changed but no contemporary studies report ocular injuries in this cohort. We aimed to investigate ocular injury epidemiology and trends amongst major trauma patients in England and Wales from 2004–2021. Methods A retrospective analysis of prospectively collected Trauma Audit and Research Network (TARN) registry data was conducted. Major trauma was defined as injury severity score > 15, and ocular injuries were identified using AIS codes. Demographics, injury profiles, and outcomes were extracted. Descriptive statistics and 3-yearly trend data are reported. Results Of 287 267 major trauma cases, 2368 (0.8%) had ocular injuries, decreasing significantly from 1.87% (2004/06) to 0.66% (2019/21) (P < 0.0001). Males comprised 72.2% and median age was 34.5 years which increased (p < 0.0001). Road traffic collisions declined from 43.1–25.3% of ocular injury cases while falls increased and became the predominant mechanism (37.6% in 2019/21). Nonaccidental injuries increased from 15% (2004/06) to 26.5% (2016/18) (p < 0.0001). Concomitant head injury was present in 86.6% of cases. Ophthalmic procedures increased from 1.2% (2004/06) to 5% (2019/21) (p < 0.0001). Compared to previous TARN data, retinal injuries increased 3-fold to 18.6% and corneal injuries decreased from 31–6.6%. Conclusions Identifying sight-threatening injuries in polytrauma is challenging. Ocular injury epidemiology has changed significantly, though overall incidence is low. These findings may inform guideline development, resource allocation, and training priorities.