Analysis of incidence of traumatic brain injury in blunt trauma patients with Glasgow Coma Scale of 12 or less

Purpose

Early diagnosis of traumatic brain injury (TBI) is important for improving survival and neurologic outcome in trauma victims. The purpose of this study was to assess whether Glasgow Coma Scale (GCS) of 12 or less can predict the presence of TBI and the severity of associated injuries in blunt trauma patients.

Are CT scans obtained at referring institutions justified prior to transfer to a pediatric trauma center?

Purpose

To assess whether pediatric trauma patients initially evaluated at referring institutions met Massachusetts statewide trauma field triage criteria for stabilization and immediate transfer to a Pediatric Trauma Center (PTC) without pre-transfer CT imaging.

Methods

A 3-year retrospective cohort study was completed at our level 1 PTC. Patients with CT imaging at referring institutions were classified according to a triage scheme based on Massachusetts statewide trauma field triage criteria. Demographic data and injury profile characteristics were abstracted from patient medical records and our pediatric trauma registry.

Results

A total of 262 patients with 413 CT scans were reviewed from 2008 to 2011. 172 patients scanned (66%, 95% CI: 60%, 71%) met criteria for immediate transfer to a pediatric trauma center. Notably, 110 scans (27% of the total performed at referring institutions) were duplicated within four hours upon arrival to our PTC. GCS score < 14 (45%) was the most common requirement for transfer, and CT scan of the head was the most frequent scan obtained (53%).

Conclusion

The majority of pediatric trauma patients were subjected to CT scans at referring institutions despite meeting Massachusetts trauma triage guidelines that call for stabilization and immediate transfer to a pediatric trauma center without any CT imaging.     

The effect of delay in rehabilitation on outcome of severe traumatic brain injury

Background

Expeditious care within minutes of severe injury improves outcome and is the driving force for development of trauma care systems. Transition from hospital care to rehabilitation is an important step in recovery after trauma-related injury. We hypothesize that delay in the transition from acute care to rehabilitation adversely affects outcome and diminishes recovery after traumatic brain injury (TBI).

Methods

After institutional review board approval, the trauma registry of our regional level I pediatric trauma center was queried for all children with severe blunt TBI (initial Glasgow Coma Scale score ≤8) that required inpatient rehabilitation. Records were stratified as severe TBI (Glasgow Coma Scale [GCS] scores 3, 4, 5) and moderate TBI (GSC scores 6, 7, 8). Intensity of acute care was defined by need for mechanical ventilation and length of intensive care unit stay. Outcome was defined by functional independence measurement (FIM) scores at time of transfer to inpatient rehabilitation. Linear regression was used to compare time in days between discharge from intensive care and admission to inpatient rehabilitation (delay) to rehabilitation efficiency (RE), defined as the ratio of FIM score improvement to length of stay for inpatient rehabilitation. Functional improvement was determined by analysis of FIM score improvement (ΔFIM) between initiation and completion of inpatient rehabilitation.

Results

Between January 2000 and December 2006, 60 children (38 males, mean age, 11.2 years; 22 females, mean age, 10.6 years) with blunt TBI and an initial GCS score of 8 or lower required resuscitation, comprehensive critical care, and inpatient rehabilitation. Mean length of stay in the intensive care unit was 11.1 ± 7.4 days. Fifty-two children required an average of 9.4 ± 6.8 ventilator days. Delay ranged between 0 and 24 days (mean, 4.1 days) and was significantly correlated with RE and ΔFIM (correlation coefficient = −0.346, P = .0068). For children with the highest potential for salvage (GCS scores 6, 7, 8), RE correlation increased to −0.457 (P = .011), whereas those with most severe injury (GCS scores 3, 4, 5) demonstrated a weaker correlation that was not significant. For children with most severe injury (GCS scores 3,4,5), the correlation of ΔFIM was significant (−0.38; P = .035); however, RE was not.

Conclusions

These data demonstrate the price of delay of comprehensive rehabilitation, especially for the most vulnerable TBI children with best potential for salvage. The “golden hour,” which has become the mantra for continued refinement of systems of emergency and trauma care, must progress without interruption to the “golden day,” during which comprehensive critical care seamlessly transitions to timely and aggressive rehabilitation to effect the greatest functional recovery.     

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.

Peut-on prédire l’aggravation neurologique des patients traumatisés crâniens mineurs et modérés par le dosage sanguin de la protéine S-100β ?

Introduction

Patients with moderate traumatic brain injury (TBI) (Glasgow Coma Scale, GCS, 9–13) or minor TBI (GCS 14–15) are at risk for subsequent neurological deterioration. Serum protein S-100 is believed to reflect brain damage following TBI. In patients with normal or minor CT scan abnormalities on admission, we tested whether the determination of serum protein S-100 beta could predict secondary neurological deterioration.

Methods

Sixty-seven patients with moderate or minor TBI were prospectively studied. Serum samples were collected on admission within 12 hours postinjury to measure serum protein S-100 levels. Neurological outcome was assessed up to seven days after trauma. Secondary neurological deterioration was defined as two points or more decrease from the initial GCS, or any treatment for neurological deterioration.

Results

Nine patients had a secondary neurological deterioration after trauma. No differences in serum levels of protein S-100 were found between these patients and those without neurological aggravation (n = 58 patients): 0.93 μg/l (0.14–4.85) vs 0.39 μg/l (0.04–6.40), respectively. The proportion of patients with abnormal levels of serum protein S-100 at admission according to two admitted cut-off levels (> 0.1 and > 0.5 μg/l) was comparable between the two groups of patients. Elevated serum levels of protein S-100 were found in patients with Injury Severity Score (ISS) of more than 16 (n = 23 patients): 1.26 μg/l (0.14–6.40) vs 0.22 μg/l (0.04–6.20) in patients with ISS less than 16 (n = 44 patients).

Discussion

The dosage of serum protein S-100 on admission failed to predict patients at risk for neurological deterioration after minor or moderate TBI. Extracranial injuries can increase serum protein S-100 levels, then limiting the usefulness of this dosage in this clinical setting.     

The impact of intensivists' base specialty of training on care process and outcomes of critically ill trauma patients

Background

The care of the critically ill trauma patients is provided by intensivists with various base specialties of training. The purpose of this study was to investigate the impact of intensivists’ base specialty of training on the disparity of care process and patient outcome.

Methods

We performed a retrospective review of an institutional trauma registry at an academic level 1 trauma center. Two intensive care unit teams staffed by either board-certified surgery or anesthesiology intensivists were assigned to manage critically ill trauma patients. Both teams provided care, collaborating with a trauma surgeon in house. We compared patient characteristics, care processes, and outcomes between surgery and anesthesiology groups using Wilcoxon tests or chi-square tests, as appropriate.

Results

We identified a total of 620 patients. Patient baseline characteristics including age, sex, transfer status, injury type, injury severity score, and Glasgow coma scale were similar between groups. We found no significant difference in care processes and outcomes between groups. In a logistic regression model, intensivists’ base specialty of training was not a significant factor for mortality (odds ratio, 1.46; 95% confidence interval; 0.79–2.80; P = 0.22) and major complication (odds ratio, 1.11; 95% confidence interval, 0.73–1.67; P = 0.63).

Conclusions

Intensive care unit teams collaborating with trauma surgeons had minimal disparity of care processes and similar patient outcomes regardless of intensivists’ base specialty of training.     

Thigh compartment syndrome in urban trauma: bullets to blame,not collisions

Background

Compartment syndrome of the thigh is a surgical emergency rarely reported in the literature. The most common etiologies include blunt trauma, vascular injuries from penetrating trauma, and hematoma formation. Thigh compartment syndrome (TCS) is important as it is often associated with concomitant severe injury with mortality rates as high as 47%. This study aims to identify mechanisms of injury, clinical presentation, and outcomes associated with TCS in the urban trauma patient population.

Methods

Demographic and clinical information for all patients with a diagnosis of TCS at a level 1 urban trauma center over a 10.5-y period were reviewed. Collected data included age, sex, mechanism of injury, method of diagnosis, time taken for diagnosis and management, methods of decompression, wound management, lengths of stay in the intensive care unit and hospital, amputation rate, and hospital disposition.

Results

Ten patients were identified with diagnosis of TCS. The mechanism of injury was penetrating in six patients and blunt in four. The mean time from injury to diagnosis was 23.4 h. Intensive care unit and hospital lengths of stay were significantly increased among patients sustaining penetrating injuries compared with blunt injuries. Two of the six penetrating injury patients underwent an amputation. Eight of 10 patients were ambulatory on discharge. There were no mortalities.

Conclusions

Among urban trauma patients, penetrating injuries of the thigh and adjacent vascular structures and the need for decompressive fasciotomy of the lower leg are the major risk factors for TCS. Clinical diagnosis and early intervention with fasciotomy remain the mainstay of treatment.     

Pelvic trauma: What are the predictors of mortality and cardiac,venous thrombo-embolic and infectious complications following injury?

Introduction

This study sought to determine risk factors that influence mortality, cardiac events, venous thrombo-embolic disease (VTED), and infection following fractures of the pelvis and/or acetabulum.

Methods

The 2008 National Sample Program (NSP) of the National Trauma Databank was queried to identify all patients who sustained pelvic and acetabular fractures. Demographic data, injury-specific and surgical characteristics, and medical co-morbidities were abstracted. The occurrence of in-hospital mortality, cardiac events, VTED and infections were documented. Univariate testing, weighted logistic regression, and sensitivity analyses were performed to identify significant independent predictors of mortality and the complications under study.

Results

The NSP contained 41,297 cases of pelvic trauma. In-hospital mortality was documented in 3055 (7%) and one or more complications occurred in 6932 (17%). Cardiac events transpired in 2% of patients, VTED in 4% and infections in 3%. Increasing age, shock, time to procedure, ISS, and GCS were predictive of mortality. Cardiac events were found to be influenced by obesity, diabetes, ISS, GCS, age, and trauma mechanism. VTED was impacted by obesity, history of respiratory disease, male sex, ISS, GCS, medical co-morbidities, and time to procedure. Injuries caused by mechanisms other than blunt trauma, shock, age, ISS, GCS, medical co-morbidities, and time to procedure were associated with infection.

Conclusions

Several important predictors were identified for specific complications and mortality following pelvic trauma. The design of this study may render it more generalisable to American patients with pelvic injuries.

Level of evidence

II – Prognostic retrospective study of a prospective dataset.     

Is the Trauma Mortality Prediction Model (TMPM-ICD-9) a valid predictor of mortality in pediatric trauma patients?

Background/Purpose

Researchers are constantly challenged to identify optimal mortality risk adjustment methodologies that perform accurately in pediatric trauma patients. This study evaluated the new Trauma Mortality Prediction Model (TMPM-ICD-9) in pediatric trauma patients.

Methods

Data were analyzed on 107,104 pediatric trauma patients included in the NTDB® in 2010 who had both a valid ISS and probability of death using TMPM-ICD-9. Discrimination was compared using the area under the receiver operator characteristic curve (AUC) and by age, blunt vs penetrating, intent, Glasgow Coma Scale (GCS), and number of injuries.

Results

The AUC for TMPM-ICD-9 demonstrated excellent discrimination in predicting mortality versus ISS overall, 11 to 17 years of age (0.96 vs 0.93), by injury type, intent, and in the lowest GCS scores. The TMPM-ICD-9 showed superior discrimination over ISS in patients with more than two injuries.

Conclusions

The TMPM demonstrated superior discrimination compared to ISS. The TMPM shows promise of a much needed and simple to use risk adjustment tool with application to both adult and pediatric patients. Researchers should continue to validate this tool in robust pediatric data sets.     

Counting the lives lost: how many black trauma deaths are attributable to disparities?

Background

The number of black trauma deaths attributable to racial disparities is unknown. The objective of this study was to quantify the excess mortality experienced by black patients given disparities in the risk of mortality.

Materials and methods

We performed a retrospective analysis of patients aged 16–65 y with blunt and penetrating injuries, who were included in the National Trauma Data Bank from 2007–2010. Generalized linear modeling estimated the relative risk of death for black patients versus white patients, adjusting for known confounders. This analysis determined the difference in the observed number of black trauma deaths at Level I and II centers and the expected number of deaths if the risk of mortality for black patients had been equivalent to that of white patients.

Results

A total of 1.06 million patients were included. Among patients with blunt and penetrating injuries at Level I trauma centers, white males and females had a relative risk of death of 0.82 (95% confidence interval [CI], 0.80–0.85) and 0.78 (95% CI, 0.74–0.83), respectively, compared with black patients. Similarly, at Level II trauma centers, white males and females had a relative risk of death of 0.84 (95% CI, 0.80–0.88) and 0.82 (95% CI, 0.73–0.91). Overall, of the estimated 41,613 deaths that occurred at Level I and II centers, 2206 (5.3%) were excess deaths among black patients.

Conclusions

Over a 4-y period, approximately 5% of trauma center deaths could be attributed to racial disparities in trauma outcomes. These data underscore the need to better understand and intervene against the mechanisms that lead to trauma outcomes disparities.     

The effect of admission spontaneous hypothermia on patients with severe traumatic brain injury

Introduction

Recent information has emerged regarding the harmful effects of spontaneous hypothermia at time of admission in trauma patients. However the volume of evidence regarding the role of spontaneous hypothermia in TBI patients is inadequate.

Methods

We performed secondary data analysis of 10 years of the Pennsylvania trauma outcome study (PTOS) database. Unadjusted comparisons of the association of admission spontaneous hypothermia with mortality were performed. In addition, full assessment of the association of hypothermia with mortality was conducted using multivariable logistic regressions reporting the odds ratios (OR) with the 95% confidence intervals (CI) and P-values.

Results

There were 11,033 patients identified from the PTOS with severe TBI. There were 4839 deaths (43.9%). The proportion of deaths in hypothermic patients was higher than the proportion of deaths in normothermic patients (53.9% vs. 37.4% respectively; P value < 0.001). In a multivariable logistic regression model adjusted for demographics, injury characteristics, and information at admission to the trauma centre, the odds of death among patients with hypothermia were 1.70 times the odds of death among patients with normothermia (OR 1.70, 95% CI 1.50–1.93), indicating that the probability of death was significantly higher when patients arrived hypothermic at the trauma centre.

Conclusion

The presence of spontaneous hypothermia at hospital admission is associated with a significant increase in the risk of mortality in patients with severe TBI. The benefit of maintaining normothermia in severe TBI patients, the impact of prolonged re-warming in patients with established hypothermia and the introduction of prophylactic measures to complications of hypothermia are key points that require further investigation.     

Implantable cardioverter defibrillators and permanent pacemakers: prevalence and patient outcomes after trauma

Background

The prevalence and outcomes of older trauma patients with implantable cardioverter defibrillators (ICDs) or permanent pacemakers (PPMs) is unknown.

Methods

The trauma registry at a regional trauma center was reviewed for blunt trauma patients, aged ≥ 60 years, admitted between 2007 and 2014. Medical records of cardiac devices patients were reviewed.

Results

Of 4,193 admissions, there were 146 ICD, 233 PPM, and 3,814 no device patients; median Injury Severity Score was 9. Most cardiac device patients had substantial underlying heart disease. Patients with ICDs (13.0%) and PPMs (8.6%) had higher mortality rates than no device patients (5.6%, P = .0002). Among cardiac device patients who died, the device was functioning properly in all that were interrogated; the most common cause of death was intracranial hemorrhage. On propensity score analysis, cardiac devices were not independent predictors of mortality but rather surrogate variables associated with other predictors of mortality.

Conclusions

Approximately 9.0% of admitted older patients had cardiac devices. Their presence identified patients who had higher mortality rates, likely because of their underlying comorbidities, including cardiac dysfunction.     

Is there a need for a clinical decision rule in blunt wrist trauma?

Background

Blunt wrist trauma is a very common injury in emergency medicine. However, in contrast to other extremity trauma, there is no clinical decision rule for radiography in patients with blunt wrist trauma.

Objective

The purpose of this study is to describe current practice and to assess the need and feasibility for a clinical decision rule for radiography in patients with blunt wrist trauma.

Methods

All patients with blunt wrist trauma who presented to our Emergency Department (ED) during a 6-month period were included in this study. Basic demographics were analysed and the radiography ratio was determined. The radiography results were compared for different demographic groups. Current practice and the need and feasibility for a decision rule were evaluated using Stiell's checklist for clinical decision rules.

Results

A total of 1019 patients with 1032 blunt wrist injuries presented at our ED in a period of 6 months. In 91.4% of patients, radiographs were taken. In 41.6% of those radiographed, a fracture was visible on plain radiography. Fractures were most common in the paediatric and senior age groups. However, even in the lower-risk groups we observed a fracture incidence of about 20%.

Conclusion

There is no need for a clinical decision rule for radiography in patients with blunt wrist trauma because the fracture ratio is high. Neither does it seem feasible to develop a highly sensitive and efficient decision rule. Therefore, the authors recommend radiography in all patients with blunt wrist trauma presenting to the ED.     

Head injury and unclear mechanism of injury: Initial hematocrit less than 30 is predictive of abusive head trauma in young children

Purpose

Head injury secondary to abusive head trauma (AHT) is a major cause of morbidity and mortality in susceptible young infants and children. Diagnosing AHT remains challenging and is often complicated by a questionable mechanism of injury. Concern of ionizing radiation risk to children undergoing head CT imaging warrants a selective approach. We aimed to evaluate initial findings that could direct further investigation of AHT.

Methods

A retrospective review of the trauma databases at a two level one pediatric trauma centers was performed. We reviewed all patients age five years and under with a diagnosis of traumatic brain injury (TBI) from 2002–2011.

Results

A total of 1129 patients (mean age 1.7 ± 1.7 years; 64% male) with TBI were identified, 429 (38%) of which were the result of AHT. Complete data was available for 921 patients (82%) and were included in statistical evaluation. Forty-eight percent of patients in the AHT group had a hematocrit ≤ 30% on presentation compared to 19% of patients in the non-AHT group. On univariate analysis, a hematocrit of ≤ 30% was predictive of AHT as the cause of injury (P < .0001), as was a platelet count of greater than 400,000 (P < .0001). After controlling for age, sex, ISS, GCS on presentation, need for CPR, and survival to hospital discharge, hematocrit of ≤ 30% and platelets of greater than 400,000 were predictive of AHT as the cause of TBI (P < .05).

Conclusions

In the setting of head injury and unclear history of trauma, a hematocrit of ≤ 30% on presentation increases the likelihood of abusive head trauma in children up to the age of 5 years.     

Tracheostomy in craniectomised survivors after traumatic brain injury: A cross-sectional analytical study

Background

Decompressive craniectomy (DC) is a life-saving measure for traumatic brain injury (TBI). However, survivors may remain in a vegetative or minimally conscious state and require tracheostomy to facilitate airway management. In this cross-sectional analytical study, we investigated the predictors for tracheostomy requirement and influence of tracheostomy timing on outcomes in craniectomised survivors after TBI.

Methods

We enrolled 160 patients undergoing DC and surviving >7 days after TBI in this 3-year retrospective study. The patients were subdivided into 2 groups based on whether tracheostomy was (N = 38) or was not (N = 122) performed. We identified intergroup differences in early clinical parameters. Multivariable logistic regression was used to adjust for independent predictors of the need for tracheostomy. Early tracheostomy was defined as the performance of the procedure within the first 10 days after DC. Intensive care unit (ICU) stay, hospital stay, mortality, and Glasgow outcome scale (GOS) were analysed according to the timing of the tracheostomy procedure.

Results

After TBI, 24% of craniectomised survivors required tracheostomy. In the multivariate logistic regression mode, the significant factors related to the need for tracheostomy were age (odds ratio = 1.041; p = 0.002), the Glasgow coma score (GCS) at admission (odds ratio = 0.733; p = 0.005), and normal status of basal cisterns (odds ratio = 0.000; p = 0.008). The ICU stay was shorter for patients with early tracheostomy than for those undergoing late tracheostomy (p = 0.004). The timing of tracheostomy had no influence on the hospital stay, mortality, or GOS.

Conclusion

Age and admission GCS were independent predictors of the need for tracheostomy in craniectomised survivors after TBI. If tracheostomy is necessary, an earlier procedure may assist in patient care.     

ATLS adherence in the transfer of rural trauma patients to a level I facility

Background

Injury sustained in rural areas has been shown to carry higher mortality rates than trauma in urban settings. This disparity is partially attributed to increased distance from definitive care and underscores the importance of proper primary trauma management prior to transfer to a trauma facility. The purpose of this study was to assess Advanced Trauma Life Support (ATLS) guideline adherence in the management of adult trauma patients transferred from rural hospitals to a level I facility.

Methods

We performed a retrospective analysis of all adult major trauma patients transferred ≥50 km from an outlying hospital to a level I trauma centre from 2007 through 2009. Transfer practices were evaluated using ATLS guidelines.

Results

646 patients were analyzed. Mean age was 40.5 years and 94% sustained blunt injuries with a median Injury Severity Score (ISS) of 22. Median transport distance was 253 km. Among all patients, there were notable deficiencies (<80% adherence) in 8 of 11 ATLS recommended interventions, including patient rewarming (8% adherence), chest tube insertion (53%), adequate IV access (53%), and motor/sensory exam (72%). Patients with higher ISS scores, and those transferred by air were more likely to receive ATLS recommended interventions.

Conclusions

Key aspects of ATLS resuscitation guidelines are frequently missed during transfer of trauma patients from the periphery to level I trauma centres. Comprehensive quality improvement initiatives, including targeted education, telemedicine and trauma team training programmes could improve quality of care.     

Effect of alcohol in traumatic brain injury: is it really protective?

Background

Studies have proposed a neuroprotective role for alcohol (ETOH) in traumatic brain injury (TBI). We hypothesized that ETOH intoxication is associated with mortality in patients with severe TBI.

Methods

Version 7.2 of the National Trauma Data Bank (2007–2010) was queried for all patients with isolated blunt severe TBI (Head Abbreviated Injury Score ≥4) and blood ETOH levels recorded on admission. Primary outcome measure was mortality. Multivariate logistic regression analysis was performed to assess factors predicting mortality and in-hospital complications.

Results

A total of 23,983 patients with severe TBI were evaluated of which 22.8% (n = 5461) patients tested positive for ETOH intoxication. ETOH-positive patients were more likely to have in-hospital complications (P = 0.001) and have a higher mortality rate (P = 0.01). ETOH intoxication was an independent predictor for mortality (odds ratio: 1.2, 95% confidence interval: 1.1–2.1, P = 0.01) and development of in-hospital complications (odds ratio: 1.3, 95% confidence interval: 1.1–2.8, P = 0.009) in patients with isolated severe TBI.

Conclusions

ETOH intoxication is an independent predictor for mortality in patients with severe TBI patients and is associated with higher complication rates. Our results from the National Trauma Data Standards differ from those previously reported. The proposed neuroprotective role of ETOH needs further clarification.     

CT scan-detected pneumoperitoneum: An unreliable predictor of intra-abdominal injury in blunt trauma

Introduction

Free intra-peritoneal air in blunt trauma is a classic sign associated with hollow viscus injury, traditionally mandating laparotomy. In blunt abdominal trauma, the CT scan has become the diagnostic modality of choice. The increased sensitivity of CT scans may lead to detection of free intra-peritoneal air that is not clinically significant.

Objective

To characterize conditions and findings that allow for the safe observation of blunt trauma patients with free air and to propose a patient management algorithm to decrease rates of non-therapeutic laparotomy.

Design

A retrospective review of 5877 blunt trauma patients who had an abdominal CT scan upon admission to our hospital from 2003 to 2011. A secondary CT review was performed by a single radiologist to further characterize the CT findings in the 74 patients with free air reported on initial scan. Management and hospital course were reviewed in these patients.

Results

Of the 74 patients with intra-abdominal free air, 36 patients with a benign clinical picture were observed and 38 patients underwent urgent exploratory laparotomy. Eleven patients received a non-therapeutic laparotomy. The majority (61%) of patients, 45 of 74, had free air and no significant injury suggesting the presence of benign free air. Patients who had intra-abdominal injury also typically had other clinical or radiologic signs of injury. Findings that were highly predictive of intra-abdominal injury in the setting of free air were free fluid (P < 0.001), radiographic signs of bowel trauma (P < 0.001) as well as clinical and/or radiographic seatbelt sign (P = 0.004).

Conclusions

CT scans may detect free air that is not always clinically significant. Free fluid, seatbelt sign or radiographic signs of bowel trauma in the presence of pneumoperitoneum is highly predictive of injury and these patients should be explored. Based on the results of our study, we created an algorithm to aid in identifying those patients with intra-abdominal free air who may be observed safely.     

Hypercoagulability following blunt solid abdominal organ injury: when to initiate anticoagulation

Background

The optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown.

Methods

Postinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours.

Results

Forty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance).

Conclusions

Patients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention.     

Nonoperative Management of Blunt Splenic Trauma in Patients with Traumatic Brain Injury: Feasibility and Outcomes

Introduction

Preventing secondary insult to the brain is imperative following traumatic brain injury (TBI). Although TBI does not preclude nonoperative management (NOM) of splenic injuries, development of hypotension in this setting may be detrimental and could therefore lead trauma surgeons to a lower threshold for operative intervention and a potentially higher risk of failure of NOM (FNOM). We hypothesized that the presence of a TBI in patients with blunt splenic injury would lead to a higher risk of FNOM.

Methods

Patients with blunt splenic injury were selected from the National Trauma Data Bank research datasets from 2007 to 2011. TBI was defined as AIS head ≥ 3 and FNOM as patients who underwent a spleen-related operation after 2 h from admission. TBI patients were compared to those without head injury. The primary outcome was FNOM.

Results

Of 47,713 patients identified, 41,436 (86.8%) underwent a trial of NOM. FNOM was identical (10.6 vs. 10.8%, p = 0.601) among patients with and without TBI. TBI patients had lower adjusted odds for FNOM (AOR 0.66, p < 0.001), even among those with a high-grade splenic injury (AOR 0.68, p < 0.001). No difference in adjusted mortality was noted when comparing TBI patients with and without FNOM (AOR 1.01, p = 0.95).

Conclusions

NOM of blunt splenic trauma in TBI patients has higher adjusted odds for success. This could be related to interventions targeting prevention of secondary brain injury. Further studies are required to identify those specific practices that lead to a higher success rate of NOM of splenic trauma in TBI patients.