Clinical retrospective and comparative study on diaphragm injuries in 46 cases

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Acute diabetes insipidus in severe head injury: a prospective study

BACKGROUND: The incidence and risk factors for acute diabetes insipidus after severe head injury and the effect of this complication on outcomes have not been evaluated in any large prospective studies. STUDY DESIGN: We conducted a prospective study of all patients admitted to the surgical ICU of a Level I trauma center with severe head injury (head Abbreviated Injury Score [AIS] >or= 3). The following potential risk factors with p < 0.2 on bivariate analysis were included in a stepwise logistic regression to identify independent risk factors for diabetes insipidus and its association with mortality: age, mechanism of injury (blunt or penetrating), blood pressure, Glasgow Coma Scale, Injury Severity Score, head and other body area AIS, skull fracture, cerebral edema and shift, intracranial hemorrhage, and pneumocephaly. RESULTS: There were 436 patients (blunt injuries, 392; penetrating injuries, 44); 387 patients had isolated head injury. Diabetes insipidus occurred in 15.4% of all patients (blunt, 12.5%; penetrating, 40.9%; p < 0.0001) and in 14.7% of patients with isolated head injury (blunt, 11.8%; penetrating, 39.5%; p < 0.0001). The presence of major extracranial injuries did not influence the incidence of diabetes insipidus. Independent risk factors for diabetes insipidus in isolated head injury were Glasgow Coma Scale3. Diabetes insipidus was an independent risk factor for death (adjusted odds ratio, 3.96; 95% CI [1.65, 9.72]; adjusted p value = 0.002). CONCLUSIONS: The incidence of acute diabetes insipidus in severe head injury is high, especially in penetrating injuries. Independent risk factors for diabetes insipidus include a Glasgow Coma Scale3. Acute diabetes insipidus was associated with significantly increased mortality.     

Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury

OBJECTIVES: There is an absence of prospective data evaluating the impact of prehospital intubation in adult trauma patients. Our objectives were to determine the outcome of trauma patients intubated in the field who did not have an acutely lethal traumatic brain injury (death within 48 hours) compared with patients who were intubated immediately on arrival to the hospital. METHODS: Prospective data were collected on 191 consecutive patients admitted to the trauma center with a field Glasgow Coma Scale score < or = 8 and a head Abbreviated Injury Scale score > or = 3 who were either intubated in the field or intubated immediately at admission to the hospital. Patients who died within 48 hours of admission and transfers were excluded from the study. RESULTS: Of the 191 patients, 176 (92%) sustained blunt trauma and 25 (8%) were victims of penetrating trauma. Seventy-eight (41%) of the 191 patients were intubated in the field and 113 (59%) were intubated immediately at admission. There was no significant difference in age, Glasgow Coma Scale score, head Abbreviated Injury Scale score, or Injury Severity Score between the two groups. Patients who were intubated in the field had a significantly higher morbidity (ventilator days, 14.7 vs. 10.4; hospital days, 20.2 vs. 16.7; and intensive care unit days, 15.2 vs. 11.7) compared with patients intubated on immediate arrival to the hospital and nearly double the mortality (23% vs. 12.4). Field-intubated patients had a 1.5 times greater risk of nosocomial pneumonia compared with hospital-intubated patients. CONCLUSION: Prehospital intubation is associated with a significant increase in morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury. A randomized, prospective study is warranted to confirm these results.     

Early prediction of mortality in isolated head injury patients: a new predictive model

BACKGROUND: To construct a predictive model of survival in isolated head injury patients, on the basis of easily available parameters that are independent risk factors for survival outcome. METHODS: Trauma registry-based study of head injury patients who had no other major extracranial injuries and were not hypotensive at admission. A predictive model of probability of death was constructed using discriminant analysis, on the basis of admission Glasgow Coma Scale (GCS) score, head Abbreviated Injury Score (AIS), age, and mechanism of injury. RESULTS: The study included 7,191 patients with head trauma. The overall correct classification rate of the proposed predictive model was 94.2% as compared with 89.0% of the admission GCS score (p < 0.05) and 92.8% of the head AIS (p < 0.05). The correct classification rate of the predictive model developed for the severe head trauma (GCS score 4-8) patients was 79.9%, as compared with 72.6% using the admission GCS score alone or 75.1% (p < 0.05). A one-page, easy to use table summarizing the predicted mortality on the basis of GCS score, head AIS, mechanism of injury, and age was developed. CONCLUSIONS: The proposed model has a significantly better predictive power, especially in severe head trauma, than the extensively used GCS and head AIS. A simple table on the probability of death of a particular patient based on admission GCS score, head AIS, mechanism of injury and age of patient can provide instant information.     

Mortality prediction of head Abbreviated Injury Score and Glasgow Coma Scale: analysis of 7,764 head injuries

BACKGROUND: We assessed the prognostic value and limitations of Glasgow Coma Scale (GCS) and head Abbreviated Injury Score (AIS) and correlated head AIS with GCS. STUDY DESIGN: We studied 7,764 patients with head injuries. Bivariate analysis was performed to examine the relationship of GCS, head AIS, age, gender, and mechanism of injury with mortality. Stepwise logistic regression analysis was used to identify the independent risk factors associated with mortality. RESULTS: The overall mortality in the group of head injury patients with no other major extracranial injuries and no hypotension on admission was 9.3%. Logistic regression analysis identified head AIS, GCS, age, and mechanism of injury as significant independent risk factors of death. The prognostic value of GCS and head AIS was significantly affected by the mechanism of injury and the age of the patient. Patients with similar GCS or head AIS but different mechanisms of injury or ages had significantly different outcomes. The adjusted odds ratio of death in penetrating trauma was 5.2 (3.9, 7.0), p < 0.0001, and in the age group > or = 55 years the adjusted odds ratio was 3.4 (2.6, 4.6), p < 0.0001. There was no correlation between head AIS and GCS (correlation coefficient -0.31). CONCLUSIONS: Mechanism of injury and age have a major effect in the predictive value of GCS and head AIS. There is no good correlation between GCS and head AIS.     

Hyperglycemia and outcomes from pediatric traumatic brain injury

BACKGROUND: The clinical significance of hyperglycemia after pediatric traumatic brain injury is controversial. This study addresses the relationship between hyperglycemia and outcomes after traumatic brain injury in pediatric patients. METHODS: We identified trauma patients admitted during a single year to our regional pediatric referral center with head regional Abbreviated Injury Scale scores > or = 3. We studied identified patients for admission characteristics potentially influencing their outcomes. The primary outcome measure was Glasgow Outcome Scale score. RESULTS: Patients who died had significantly higher admission serum glucose values than those patients who survived (267 mg/dL vs. 135 mg/dL; p = 0.000). Admission serum glucose > or = 300 mg/dL was uniformly associated with death. Admission Glasgow Coma Scale score (odds ratio, 0.560; 95% confidence interval, 0.358-0.877) and serum glucose (odds ratio, 1.013; 95% confidence interval, 1.003-1.023) are independent predictors of mortality in children with traumatic head injuries. CONCLUSION Hyperglycemia and poor neurologic outcome in head-injured children are associated. The pathophysiology of hyperglycemia in neurologic injury after head trauma remains unclear.     

Predictors of the need for nephrectomy after renal trauma

BACKGROUND: Initial management of solid organ injuries in hemodynamically stable patients is nonoperative. Therefore, early identification of those injuries likely to require surgical intervention is key. We sought to identify factors predictive of the need for nephrectomy after trauma. METHODS: This is a retrospective review of renal injuries admitted over a 12-year period to a Level I trauma center. RESULTS: Ninety-seven patients (73% male) sustained a kidney injury (mean age, 27 +/- 16; mean Injury Severity Score, 13 +/- 10). Of the 72 blunt trauma patients, 5 patients (7%) underwent urgent nephrectomy, 3 (4%) had repair and/or stenting, and 89% were observed despite a 29% laparotomy rate for associated intraabdominal injuries in this group. Twenty-five patients with penetrating trauma underwent eight nephrectomies (31%), one partial nephrectomy, and two renal repairs. Regardless of the mechanism of injury, patients requiring nephrectomy were in shock, had a higher 24-hour transfusion requirement, and were more likely to have a high-grade renal laceration (all p < 0.05). Bluntly injured patients requiring nephrectomy had more concurrent intraabdominal injuries (p < 0.0001). Overall, patients after penetrating trauma were more severely injured, had higher 24-hour transfusion requirements, and a higher nephrectomy rate (all p < 0.05). Despite a higher injury severity in the penetrating group, however, mortality was higher in the bluntly injured group (p < 0.0001). Univariate predictors for nephrectomy included: revised trauma score, injury severity score, Glasgow Coma Scale score, shock on presentation, renal injury grade, and 24-hour transfusion requirement. No patient with a mild or moderate renal injury required nephrectomy, whereas 6 of 12 (50%) grade 4 injuries and 7 of 8 (88%) grade 5 injuries required nephrectomy. Multiple logistic regression analysis confirmed penetrating injury, renal injury grade, and Glasgow Coma Scale score as predictive of nephrectomy. CONCLUSION: Overall, injury severity, severity of renal injury grade, hemodynamic instability, and transfusion requirements are predictive of nephrectomy after both blunt and penetrating trauma. Nephrectomy is more likely after penetrating injury.     

Blunt vascular neck injuries: diagnosis and outcomes of extracranial vessel injury

BACKGROUND: Blunt vascular neck injuries (BVNIs) are rare, often occult, and potentially devastating injuries. The purpose of this study was to identify a high-risk group, which would benefit from screening. METHODS: Patients with BVNIs were identified from our trauma registry and charts were reviewed. Potential risk factors for BVNI were evaluated by univariate and multivariate logistic regression. RESULTS: Thirty-one BVNIs were identified in 22 patients. The stroke rate was 60% and the mortality rate was 25%. Univariate analysis showed Glasgow Coma Scale score < or = 8, head injury (Abbreviated Injury Scale [AIS] score > or = 3), basal skull fracture, facial injury, other neck injury, thorax injury (AIS score > or = 3), abdominal injury, and cervical spine injury to be significant (p < 0.05). The multivariate predictive model had two predictors remaining significant: thorax injury (AIS [thorax] score > or = 3) and Glasgow Coma Scale score < or = 8. CONCLUSION: Screening should be undertaken for patients at increased risk for BVNI: those with risk factors identified in our regression analysis and factors previously reported.     

Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome

BACKGROUND: Geriatric trauma patients have a worse outcome than the young with comparable injuries. The contribution of traumatic brain injury (TBI) to this increased mortality is unknown and has been confounded by the presence of other injuries. The purpose of this study was to investigate the role of age in the mortality and early outcome from isolated TBI. METHODS: This was a retrospective analysis of all adult patients with isolated TBI (Abbreviated Injury Scale score > or = 3) admitted during a 5-year period to two Level I trauma centers. Mortality, Glasgow Outcome Scale score at discharge, therapy, and complications were compared for elderly (age > or = 65 years) and younger patients. RESULTS: Of 694 patients, 22% were defined as elderly. The mortality for the elderly group was twice that of their younger counterparts (30% vs. 14%, p < 0.001), even for those with mild to moderate TBI (Glasgow Coma Scale score of 9-15). Thirteen percent of elderly survivors had a poor functional outcome (Glasgow Outcome Scale score of 2 or 3) at hospital discharge versus 5% in the young group (p < 0.01). Independent factors associated with a high mortality were age and Glasgow Coma Scale score. CONCLUSION: The mortality from TBI is higher in the geriatric population at all levels of head injury. In addition, functional outcome at hospital discharge is worse. Although some of this increased mortality may be explained by complications or type of head injury, age itself is an independent predictor for mortality in TBI.     

Trauma fatalities: time and location of hospital deaths

BACKGROUND: Analysis of the epidemiology, temporal distribution, and place of traumatic hospital deaths can be a useful tool in identifying areas for research, education, and allocation of resources. STUDY DESIGN: Trauma registry-based study of all traumatic hospital deaths at a Level I urban trauma center during the period 1993 to 2002. The time and hospital location where deaths occurred were analyzed according to mechanism of injury, age, Glasgow Coma Score, and body areas with severe injury (Abbreviated Injury Scale [AIS] >/= 4). Logistic regression analysis was used to identify risk factors associated with death at various times after admission. RESULTS: During the study period there were 2,648 hospital trauma deaths. The most common body area with critical injuries (AIS >/= 4) was the head (43%), followed by the chest (28%) and the abdomen (19%). Overall, 37% of victims had no vital signs present on admission. Chest AIS >/= 4, penetrating trauma, and age greater than 60 years were significant risk factors associated with no vital signs on admission. Patients with severe chest trauma (AIS >/= 4) reaching the hospital alive were significantly more likely to die within the first 60 minutes than were patients with severe abdominal or head injuries (17% versus 11% versus 7%). In patients reaching the hospital alive, the time and place of death varied according to mechanism of injury and injured body area. Deaths caused by severe head trauma peaked at 6 to 24 hours, and deaths caused by severe chest or abdominal trauma peaked at 1 to 6 hours after admission. CONCLUSIONS: The temporal distribution and location of trauma deaths are influenced by the mechanism of injury, age, and the injured body area. These findings may help in focusing research, education, and resource allocation in a more targeted manner to reduce trauma deaths.     

Evaluation of massive transfusion protocol practices by type of trauma at a level I trauma center

Purpose

To evaluate massive transfusion protocol practices by trauma type at a level I trauma center.

Blunt gastric injuries

Gastric rupture after blunt abdominal trauma is a rare injury with few reports in the literature. The purpose of this study was to review our experience with blunt gastric injuries and compare outcomes with small bowel or colon injuries. All patients with hollow viscus perforations after blunt abdominal trauma from 1992 to 2005 at our level I trauma center were reviewed. Of 35,033 blunt trauma admissions, there were 268 (0.7%) patients with a total of 319 perforating hollow viscus injuries, 25 (0.07%) of which were blunt gastric injuries. When compared with the small bowel or colon injuries, the blunt gastric injury group had a higher Injury Severity Score (22 versus 17, P = 0.04), more patients with a chest Abbreviated Injury Score greater than 2 (36% versus 12%, P < 0.01), and a shorter interval from injury to laparotomy (221 versus 366 minutes, P = 0.017). Multivariate analysis identified five independent risk factors for mortality: age older than 55 years, head Abbreviated Injury Score greater than 2, chest Abbreviated Injury Score greater than 2, the presence of hypotension on admission, and Glasgow Coma Scale 8 or less. The results of this study suggest that mortality in patients with blunt hollow viscus injuries can be attributed to concurrent head and chest injuries, but not the specific hollow viscus organ that is injured.     

Profile of chest trauma in a level I trauma center

BACKGROUND: Chest injuries are seen with increasing frequency in urban hospitals. The profile of chest injuries depends on the size of the hospital and the level of trauma center. The data regarding the true incidence of chest trauma are scant. METHODS: One thousand three hundred fifty-nine consecutive patients seen at a Level I trauma center were analyzed. The nature of injury, methods of treatment, and morbidity and mortality were recorded in a prospective manner and analyzed retrospectively. Multiple logistic regression analysis was used to determine the independent predictors of mortality after chest trauma. RESULTS: The overall mortality was 9.41%. Low Glasgow Coma Scale score, older age, presence of penetrating chest injury, long bone fractures, fracture of more than five ribs, and liver and spleen injuries were independent predictors of death after chest trauma. A model was created for predicting the mortality based on various factors. CONCLUSION: Most chest injuries can be treated with simple observation. Only 18.32% of patients required tube thoracostomy and 2.6% needed thoracotomy. Low Glasgow Coma Scale score and advanced age are the most significant independent predictors of mortality.     

Adrenal gland trauma is associated with high injury severity and mortality

PURPOSE: To review a statewide experience of adrenal gland trauma (AGT), incidence, demographics, associated injuries, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), mechanisms of injury, and complications, associated with AGT. METHODS: A retrospective analysis of patients admitted to accredited trauma centers in the Commonwealth of Pennsylvania who sustained AGT from January 1, 1989 to December 31, 2000. RESULTS: Adrenal trauma was found in 322 of 210,508 cases (0.15%). There were 76.4% men and 23.6% women. Seventy-one percent of patients had an ISS greater than 20. The overall mortality was 32.6%. The mechanism of injury was blunt in 81.4% of the cases and penetrating in 18.6%. Vehicular accidents constituted 48.8% of the cases. Younger age was associated with male predominance and greater proportion of penetrating injuries. Although exact indications are not known, advanced imaging studies were done in 163 of 322 (50.6%) patients: computed tomography in 133 (41.3%), ultrasound in 26 (8.1%), and angiography in 4 cases (1.2%). Exploratory laparotomy was done in 60 (18.6%), splenectomy in 25 (7.8%), nephrectomy in 14 (4.3%), and adrenalectomy in 8 (2.5%). Penetrating injuries had a 43.8% rate of exploratory laparotomy, whereas it was 12.4% in blunt trauma. Associated injuries included liver injury (57.8%), rib fractures (50.9%), kidney injury (41.3%), and spleen injury (32.9%). Pulmonary complications were most common, followed by infection/sepsis, and cardiovascular. Nearly 45% of patients were discharged home, 17% of patients were discharged to a rehabilitation facility, and 3.4% to nursing homes. CONCLUSIONS: Adrenal gland trauma is a rare and largely coincidental finding diagnosed either during an initial radiologic examination or surgical exploration for other injuries. Surgical exploration was carried out in 21.4% of patients, with adrenalectomy in 2.5% of cases and nephrectomy in 4.3% of cases. Adrenal injury is associated with high injury severity, and with mortality rates up to 5 times higher than non-AGT trauma.     

Determinants of mortality in patients with severe blunt head injury

CONTEXT: Head injury is the leading cause of traumatic death in the United States. HYPOTHESIS: A set of clinical parameters available soon after injury can be used to accurately predict outcome in patients with severe blunt head trauma. DESIGN: Validation cohort study. SETTING: Urban level I trauma center. PATIENTS AND METHODS: Data from patients with severe blunt head injury, as defined by inability to follow commands, were prospectively entered into a neurosurgical database and analyzed. The impact on survival of 23 potentially predictive parameters was studied using univariate analysis. Logistic regression models were used to control for confounding factors and to assess interactions between variables, whose significance was determined by univariate analysis. Goodness of fit was calculated with the Hosmer-Lemeshow c statistic. The predictability of the logistic model was evaluated by measuring the area under the receiver operating characteristic curve (AUC). RESULTS: Logistic regression analysis revealed that 5 risk factors were independently associated with death. These variables included systemic hypotension in the emergency department, midline shift on computed tomographic scan, intracranial hypertension, and absence of pupillary light reflex. A low Glasgow Coma Scale score and advanced age were found to be highly correlated risk factors that, when combined, were independently associated with mortality. The model showed acceptable goodness of fit, and the AUC was 80.5%. CONCLUSIONS: Systemic hypotension and intracranial hypertension are the only independent risk factors for mortality that can be readily treated during the initial management of patients with severe head injuries. When used together, Glasgow Coma Scale score and age are significant predictors of mortality.     

Use of hypertonic saline/acetate infusion in treatment of cerebral edema in patients with head trauma: experience at a single center.

BACKGROUND: Hypertonic saline (HS) recently has been introduced as a new form of hyperosmolar treatment in patients with brain injury from diverse causes. We reviewed our experience with the use of continuous hypertonic saline/acetate infusion in patients with cerebral edema attributable to head trauma. METHODS: We performed a retrospective chart review of all patients admitted with severe head injury, defined as admission Glasgow Coma Scale score of 8 or less, in the neurocritical care unit of a University hospital. Intravenous infusion of 2% or 3% saline/acetate for treatment of cerebral edema was introduced in the unit in April of 1993. The clinical characteristics, interventions required, and outcomes in patients who received HS were compared with patients who received 0.9% saline infusion only. Multivariate analyses were used to evaluate the impact of HS use on in-hospital mortality and Glasgow Outcome Scale score at discharge. RESULTS: Thirty-six patients with cerebral edema caused by head trauma received infusion of HS initiated within 48 hours of admission for a mean period of 72 +/- 85 hours. Compared with 46 patients who did not receive HS, there were no differences observed in age and admission Glasgow Coma Scale scores. Patients who received HS were more likely to have a penetrating injury (p = 0.07) and a mass lesion on initial computed tomographic scan (p = 0.07). There was no difference between frequency of use of hyperventilation, mannitol, cerebrospinal fluid drainage, and vasopressors between the two groups. The requirement for pentobarbital coma was higher in HS group (n = 7 patients) versus control group (n = 2,p = 0.04). After adjusting for differences between both groups, infusion of HS was associated with higher in-hospital mortality (OR, 3.1; 95% CI, 1.1-10.2). CONCLUSION: HS administration as prolonged infusion does not seem to favorably impact on requirement for other interventions and in-hospital mortality in our experience. Further efforts should be directed toward use of HS as bolus administrations or short infusions.     

The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury

BACKGROUND: Although early intubation to prevent the mortality that accompanies hypoxia is considered the standard of care for severe traumatic brain injury (TBI), the efficacy of this approach remains unproven. METHODS: Patients with moderate to severe TBI (Head/Neck Abbreviated Injury Scale [AIS] score 3+) were identified from our county trauma registry. Logistic regression was used to explore the impact of prehospital intubation on outcome, controlling for age, gender, mechanism, Glasgow Coma Scale score, Head/Neck AIS score, Injury Severity Score, and hypotension. Neural network analysis was performed to identify patients predicted to benefit from prehospital intubation. RESULTS: A total of 13,625 patients from five trauma centers were included; overall mortality was 22.9%, and 19.3% underwent prehospital intubation. Logistic regression revealed an increase in mortality with prehospital intubation (odds ratio, 0.36; 95% confidence interval, 0.32-0.42; p < 0.001). This was true for all patients, for those with severe TBI (Head/Neck AIS score 4+ and/or Glasgow Coma Scale score of 3-8), and with exclusion of patients transported by aeromedical crews. Patients intubated in the field versus the emergency department had worse outcomes. Neural network analysis identified a subgroup of patients with more significant injuries as potentially benefiting from prehospital intubation. CONCLUSION: Prehospital intubation is associated with a decrease in survival among patients with moderate-to-severe TBI. More critically injured patients may benefit from prehospital intubation but may be difficult to identify prospectively.     

Blunt abdominal trauma patients: can organ injury be excluded without performing computed tomography?

PURPOSE: The purpose of this study was to determine whether admission non-computed tomography (CT) criteria can exclude intra-abdominal injury in stable patients sustaining blunt abdominal trauma. METHODS: Seven hundred fourteen hemodynamically stable patients with suspicion of blunt abdominal trauma were included in the study. Admission data for clinical examination, sonography, routine laboratory studies, chest/pelvic radiographic findings, and Glasgow Coma Scale (GCS) score were recorded. Each patient underwent helical abdominal CT. Injuries were considered major if they required surgery or angiographic intervention. At the authors' institution, angiography is routinely performed if there is a splenic injury of American Association for the Surgery of Trauma grade II or higher or a liver injury of American Association for the Surgery of Trauma grade III or higher. Statistical analysis was performed to determine the value of isolated and combined clinical, radiologic, and laboratory parameters in depicting an intra-abdominal injury with regard to CT results and clinical follow-up. RESULTS: The best combination of criteria to identify a major abdominal injury was obtained when sonography, chest radiography, and three laboratory parameters (serum glutamic oxaloacetic transaminase, white blood cell count, and hematocrit) were normal: 22% (129 of 589) of patients without major injuries fulfilled these criteria. The only combination of criteria that completely excluded intra-abdominal injury was obtained when clinical criteria combined with a Glasgow Coma Scale score > 13, bedside radiologic studies, and laboratory data were all normal, but only 12% (68 of 578) of patients without abdominal injury fulfilled these criteria. CONCLUSION: After blunt abdominal trauma, admission non-CT criteria can at best identify 12% of patients without intra-abdominal injuries and 22% of patients without major injuries.     

Usefulness of the abbreviated injury score and the injury severity score in comparison to the Glasgow Coma Scale in predicting outcome after traumatic brain injury

BACKGROUND: Assessment of injury severity is important in the management of patients with brain trauma. We aimed to analyze the usefulness of the head abbreviated injury score (AIS), the injury severity score (ISS), and the Glasgow Coma Scale (GCS) as measures of injury severity and predictors of outcome after traumatic brain injury (TBI). METHODS: Data were prospectively collected from 410 patients with TBI. AIS, ISS, and GCS were recorded at admission. Subjects' outcomes after TBI were measured using the Glasgow Outcome Scale (GOS-E) at 12 months postinjury. Uni- and multivariate analyses were performed. RESULTS: Outcome information was obtained from 270 patients (66%). ISS was the best predictor of GOS-E (rs = -0.341, p < 0.001), followed by GCS score (rs = 0.227, p < 0.001), and head AIS (rs = -0.222, p < 0.001). When considered in combination, GCS score and ISS modestly improved the correlation with GOS-E (R = 0.335, p < 0.001). The combination of GCS score and head AIS had a similar effect (R = 0.275, p < 0.001). Correlations were stronger from patients 8). CONCLUSIONS: GCS score, AIS, and ISS are weakly correlated with 12-month outcome. However, anatomic measures modestly outperform GCS as predictors of GOS-E. The combination of GCS and AIS/ISS correlate with outcome better than do any of the three measures alone. Results support the addition of anatomic measures such as AIS and ISS in clinical studies of TBI. Additionally, most of the variance in outcome is not accounted for by currently available measures of injury severity.