Toll of methamphetamine on the trauma system

HYPOTHESIS: Methamphetamine use affects length of hospital stay in the minimally injured patient. DESIGN: Case series. SETTING: The only tertiary trauma center serving Hawaii. PATIENTS: Trauma patients examined during a 12-month period with an Injury Severity Score of 1 to 5 and an age of 18 to 55 years undergoing urine toxicology screen for suspected suicide attempt or altered sensorium. MAIN OUTCOME MEASURES: Presence or absence of amphetamine or methamphetamine on urine toxicology screen, intention of injury, hospital admission rate, length of stay, and hospital charges. RESULTS: During the study period, 1650 trauma patients were examined, with 544 meeting study criteria. Urine toxicology screens were performed in 212 patients, with 57 positive and 155 negative for amphetamine or methamphetamine. There was no difference in sex (77% vs 73% male; P =.53), Injury Severity Score (3.2 for both groups), or total number of computed tomographic scans performed (mean +/- SEM, 3.0 +/- 0.3 vs 4.0 +/- 0.3; P =.07). Patients in the positive group were more likely to have intentional self-inflicted injury or intentional assaults than patients in the negative group (37% vs 22%; P =.04). The positive group was older than the negative group (33.6 +/- 1.3 vs 29.9 +/- 0.8 years; P =.02), had a significantly longer hospital stay (2.7 +/- 0.4 vs 1.7 +/- 0.1 days; P =.003), had significantly higher hospital charges (15 617 dollars +/- 1866 dollars vs 11 600 dollars +/- 648 dollars; P =.01), and was more likely admitted to the hospital (91% vs 70%; P =.001) despite the low Injury Severity Score. CONCLUSION: Methamphetamine use results in trauma center resource utilization out of proportion to injury severity.     

Liver cirrhosis in patients undergoing laparotomy for trauma: effect on outcomes

BACKGROUND: There is little published work on the effect of cirrhosis on outcomes in trauma patients undergoing laparotomy. The aim of this study was to evaluate the risk of death or serious complications in cirrhotic trauma patients undergoing laparotomy as compared with that in a similar group of patients without cirrhosis. STUDY DESIGN: During a 12-year period, there were 46 patients with the diagnosis of liver cirrhosis made during laparotomy for trauma. Each patient was matched with two noncirrhotic controls on the basis of 7 criteria: age (>55, 25), head Abbreviated Injury Score (<3, >/=3), chest Abbreviated Injury Score (<3, >/=3), and abdominal Abbreviated Injury Score (<3, >/=3). Six cirrhotic patients were excluded because matching was not possible. The remaining 40 patients were matched with 80 noncirrhotic control patients selected from a pool of 4,771 patients who had trauma laparotomies. Outcomes included mortality, ARDS, pneumonia, renal failure, abdominal sepsis, disseminated intravascular coagulopathy, ICU and hospital stay, and hospital charges. Outcomes between the two study groups were compared with conditional logistic analysis. Hazard ratio (95% CI) and adjusted p value with the stepdown Bonferroni method were derived. RESULTS: The overall mortality in the cirrhotic group was significantly higher than that in the matched noncirrhotic group (45% versus 24%, hazard ratio: 7.60 [2.00, 28.94], p = 0.021). Mortality in patients with Injury Severity Score 相似文献   

"Shift work" improves survival and reduces intensive care unit use in seriously injured patients

We assessed whether a trauma service model with an emphasis on continuity of care by using "shift work" will improve trauma outcomes and cost. This was a case-control cohort study that took place at a university-affiliated Level I trauma center. All patients (n=4283) evaluated for traumatic injuries between May 1, 2002 and April 30, 2004 were included. During Period I (May 1, 2002 to April 30, 2003), a rotating off-service team provided initial management between 5:00 PM and 7:00 AM. The "day team" provided all other care and was responsible for continuity of care. In Period II (May 1, 2003 to April 30, 2004), a dedicated trauma service consisting of two resident teams evaluated all injured patients. Variables included hospital and intensive care unit length of stay (LOS), mechanical ventilation requirements, hospital mortality, and hospital care costs. Demographics and injury mechanism for both periods were similar, but Injury Severity Score (ISS) in Period II was greater (ISS, 8.2% vs. 7.2%, P < 0.0001; ISS > 15, 18.5% vs. 15.4%). In the more severely injured (ISS > 15), patients in Period II had shorter hospital LOS (8.6 vs. 9.7 days, P = 0.98), a shorter ICU LOS (5.5 vs. 7.7 days, P = 0.039), shorter mechanical ventilator requirements (5.5 vs. 7.7 days, P = 0.32), improved hospital mortality rate (19.9% vs. 26.8%, P = 0.029), and decreased hospital costs (19,146 dollars vs. 21,274 dollars, P = 0.36). On multivariate analysis, factors affecting mortality and LOS included age, initial vital signs, injury type, and ISS. Overall, the two trauma service models resulted in similar outcomes. Although multivariate analysis revealed that treatment period did not affect mortality, our study revealed improved patient survival and reduction in LOS and cost for the severely injured in Period II.     

The decreasing incidence and mortality of acute respiratory distress syndrome after injury: a 5-year observational study

BACKGROUND: Acute respiratory distress syndrome (ARDS) after major trauma has been associated with increased morbidity and mortality rates. Recently, there have been marked advances in defining etiologic factors and optimal management strategies for ARDS. We sought to examine whether there has been a corresponding change in the incidence and outcomes of ARDS after injury in recent years. METHODS: A prospective observational study of all adult trauma intensive care unit (ICU) admissions over 5 years. Patients were evaluated daily for predefined ARDS criteria. Patient data, illness and injury severity, and ARDS incidence were compared by year of admission. Logistic regression analysis was used to identify independent predictors of ARDS and mortality. RESULTS: There were 1,913 patients identified; the majority were male (79%) and suffered blunt trauma (62%). Two hundred seventy-four patients (14%) met criteria for ARDS. The incidence of ARDS showed a significant decrease from 23% in 2000 to rates of 8.4% and 9% for 2003 and 2004 (p < 0.01), respectively. There was no significant difference by year for trauma mechanism, age, sex, Injury Severity Score, Acute Physiology and Chronic Health Evaluation, ICU length of stay, or mortality. The strongest independent predictor of ARDS was year of ICU admission, with an odds ratio of 2.9 (95% confidence interval, 1.7-5.0) for admission in 2000 versus subsequent years (p < 0.001). After adjusting for age and injury severity, patients with ARDS had more days on mechanical ventilation and longer hospital and ICU stays (all p < 0.01), but there was no significant difference in mortality with or without ARDS (p = 0.57). CONCLUSION: There has been a more than 50% reduction in the incidence of ARDS after injury during the past 5 years in our institution despite similar patient demographics and injury severities. Development of ARDS increased hospital and ICU stays but not hospital mortality.     

Penetrating trauma in patients older than 55 years: a case-control study

BACKGROUND: Multiple studies have compared young and elderly blunt trauma patients, and concluded that, because elderly patients have outcomes similar to young patients, aggressive resuscitation should be offered regardless of age. Similar data on penetrating trauma patients are limited. STUDY DESIGN: In a retrospective review, 79 patients with penetrating injuries and age > or =55 were blindly matched for Injury Severity Score (ISS) and Abbreviated Injury Scores (AIS) with 79 penetrating trauma patients aged 15-35 years, who were admitted to the hospital over the same 4 year period (June 1994-June 1998). Mortality rates and length of stay in the intensive care unit (ICU) and the hospital were compared between the two groups. RESULTS: The average ISS for all patients was 12 (range 1-75) and identical for both groups. Both groups had similar injuries and were evaluated by an equal number and type of diagnostic studies. The mean ISS was not different between severely injured older and younger patients who required ICU admission or died. Among 32 nonsurvivors (18 older and 14 younger), older patients were more likely than younger patients to present with normal vital signs, although the comparison did not reach statistical significance (50% vs. 13%, P=0.25). There was a clinically significant trend for longer ICU (15+/-30 vs. 3+/-2 days, P=0.096) and hospital stay (10+/-18 vs. 6+/-8 days, P=0.08) among older patients, but mortality rates were similar (23% in older vs. 18% in younger, P=NS). Furthermore, these outcome parameters showed no difference when both groups were classified according to severity of injury or physiologic response. CONCLUSIONS: Following penetrating trauma, older patients arriving alive and admitted to the hospital are as likely to survive as younger patients who have injuries of similar severity, but at the expense of longer ICU and hospital stays.     

Impact of obesity in the critically ill trauma patient: a prospective study

BACKGROUND: Obesity has risen at an epidemic rate over the past 20 years in the US. To our knowledge, there is an absence of data evaluating the impact of obesity in the critically ill trauma patient. METHODS: Prospective data were collected on 1,167 patients admitted to the ICU over a 2-year period. Obesity was defined as a body mass index (calculated as weight [kg]/height [m(2)]) of 30 or higher. Outcomes analyzed included infection rate, hospital and ICU length of stay, and mortality. Multiple logistic regression was used to evaluate outcomes between obese and nonobese patients for infection (infection versus noninfection) and mortality (deceased versus not deceased). Continuous outcomes such as hospital and ICU lengths of stay were evaluated using multiple linear regression analyses. RESULTS: Sixty-two of 1,167 (5.3%) patients were obese. The majority (71%) of injuries in the study cohort were blunt. Although the majority of patients were men (76%), women (10% versus 4%) were more likely to be obese (p < 0.001). Obese patients had a more than twofold increase in risk of acquiring a bloodstream, urinary tract, or respiratory infection, or being admitted to the ICU (p < 0.001), after statistically controlling for age and Injury Severity Score. When controlling for diabetes, gender, obesity, age, COPD, and Injury Severity Score, obese patients were 7.1 times (95% CI, 2.06-8.9) more likely to die in the hospital. CONCLUSIONS: Obesity is associated with a substantial increase in morbidity and mortality in the critically ill trauma patient. Future studies are warranted in both the prevention of infection and intensive care management of the obese trauma patient.     

The general surgery model: a more appealing and sustainable alternative for the care of trauma patients

The contemporary model of trauma care where dedicated trauma/critical care surgeons exclusively manage trauma patients has become progressively unsustainable. Little objective data, however, is available documenting that a better model exists. From September 2002 through August 2003, the trauma model at a 735-bed level I trauma teaching hospital was changed from the contemporary model to a new one where selected general surgeons with Advanced Trauma Life Support (ATLS) certification covered in-house trauma and emergency surgery call on a rotational basis. As well, each pursued elective practices, admitting all inpatients (trauma, emergent, elective) to a single teaching service (formerly the trauma service). Critical care was managed by a separate group of intensivists. The purpose of this study was to objectively compare the two models. Quantitative, financial, and qualitative data were derived from August 2001 to January 2002 (trauma/critical care model) and compared to August 2003 to January 2004 (general surgery model). During the two periods (trauma/critical care vs general surgery), the mean Revised Trauma Score (7.1 vs 7.2; P = 0.029), the mean Injury Severity Score (ISS) (10.9 vs 10.8; P = 0.84), and the percentage of penetrating trauma (12.5% vs 13.2%; P = 0.79) were similar. Differences (trauma/critical care vs general surgery, % increase/P value) included average daily census (24 vs 54, 225%), cases/attending (262 vs 543, 207%), cases/resident (54 vs 262, 485%), charges/attending (353,811 dollars vs 471,725 dollars, 133%), collections/attending (106,143 dollars vs 165,103 dollars, 156%), number of trauma patients (643 vs 748, 116%), trauma mortality (7.3% vs 4.0%; P = 0.007), trauma mortality with ISS >15 (21.7% vs 12.0%; P = 0.035), trauma complications (33.1% vs 17%; P < 0.001), and ICU morbidity (66.8% vs 43.9%; P < .001). The new general surgery model produced superior financial results and better quantitative surgical experience while exceeding trauma and ICU quality outcomes compared to the former trauma/critical care model. These data objectively support a model such as ours--one that is financially sustainable and more professionally attractive.     

Trauma-specific intensive care units can be cost effective and contribute to reduced hospital length of stay.

Our hypothesis was that clinical outcomes are improved and cost and hospital length of stay (LOS) reduced as a result of the opening of a closed trauma intensive care unit (ICU). We conducted a cross-sectional study in a university-affiliated Level I trauma center. Our study population comprised trauma patients admitted to the ICU between June 1, 1996 and July 1, 1998 for at least 24 hours and with an Injury Severity Score (ISS) >16 (excluding those with severe brain injury). The main outcome measures were changes in LOS and number of ventilator days, prevalence of complications, changes in patient charges, and hospital costs. Two hundred four patients were included [trauma ICU (TICU) 60, surgical ICU 144]. The two groups were not statistically different in age, ISS, mechanism of injury, infection rate, and mortality; however, the TICU patients had a lower number of ventilator hours (83.1 vs 100.0; P = 0.007), lower ICU LOS (9.4 vs 12.1 days; P = 0.06), and lower total hospital LOS (15.6 vs 22.3 days; P = 0.01). Although this was not of statistical significance TICU patients had lower hospital charges ($125,383 vs $152,994; P = 0.06) and lower cost per case ($42,306 vs $47,548; P = 0.35) for a net savings of $314,520 during the first 6 months of operation of the TICU. This study suggests that improved clinical outcomes and decreases in cost and LOS are directly related to the opening of a closed trauma ICU.     

Which AIS based scoring system is the best predictor of outcome in orthopaedic blunt trauma patients?

BACKGROUND: Abbreviated Injury Scale (AIS)-based systems-the Injury Severity Score (ISS), New Injury Severity Score (NISS), and AISmax-are used to assess trauma patients. The merits of each in predicting outcome are controversial. METHODS: A large prospective database was used to assess their predictive capacity using receiver operator characteristic curves. RESULTS: In all, 10,062 adult, blunt-trauma patients met the inclusion criteria. All systems were significant outcome predictors for sepsis, multiple organ failure (MOF), length of hospital stay, length of intensive care unit (ICU) admission and mortality (p < 0.0001). NISS was a significantly better predictor than the ISS for mortality (p < 0.0001). NISS was equivalent to the AISmax for mortality prediction and superior in patients with orthopaedic injuries. NISS was significantly better for sepsis, MOF, ICU stay, and total hospital stay (p < 0.0001). CONCLUSIONS: NISS is superior or equivalent to the ISS and AISmax for prediction of all investigated outcomes in a population of blunt trauma patients. As NISS is easier to calculate, its use is recommended to stratify patients for clinical and research purposes.     

Early unreamed intramedullary nailing of femoral fractures is safe in patients with severe thoracic trauma

BACKGROUND: The timing of fixation of femoral fractures in multiply injured patients with severe thoracic trauma is discussed controversially. Some authors recommend damage control surgery, whereas other authors prefer early definitive treatment. The aim of our study was to investigate the effect of early definitive fixation of femoral fractures on outcomes in multiply injured patients with severe thoracic trauma. METHODS: Between May 1, 1998 and December 31, 2004, 578 severely injured patients were admitted to our institution. Forty-five patients met the inclusion criteria for the study cohort (severe thoracic trauma and femoral fracture stabilized with unreamed intramedullary nailing [IMN] within the first 24 hours) and 107 patients were selected for the control cohort (severe thoracic trauma without any lower extremity fracture). Inclusion criteria for both cohorts were age 15 to 55 years with blunt trauma (e.g. motor vehicle collisions, falls) including severe thoracic trauma (Abbreviated Injury Scale [AIS] score >or=3) and Injury Severity Score (ISS) >or=18. For comparison between the cohorts data on patients status (Glasgow Coma Scale score at arrival, Revised Trauma Score, Trauma and Injury Severity Score survival prognosis, Simplified Acute Physiology Score II score), treatment (intubation rate, thoracic drainage, surgery), and outcomes (duration of intensive care unit stay and ventilation, rate of adult respiratory distress syndrome [ARDS], multiple organ failure syndrome [MOFS], and mortality) were selected from hospital databases. Dichotomous data were analyzed by chi test; continuous data were analyzed by Student's t test. Any values of p < 0.05 were considered significant for any test. RESULTS: Both cohorts were comparable with regard to demographic data, ISS, AIS score in the thoracic region, and incidence and severity of brain injury. There was no difference in dependent parameters in both cohorts. Rates of ARDS, MOFS, and mortality were not negatively influenced by early unreamed IMN. CONCLUSION: Early unreamed IMN of femoral fractures in multiply injured patients with severe thoracic trauma is a safe procedure and seems to be justified to achieve early definitive care.     

Mortality after reamed intramedullary nailing of bilateral femur fractures

We performed retrospective review of 743 patients treated with reamed intramedullary nailing of a femoral shaft fracture was done to assess the clinical impact of bilateral femur fractures on the mortality, hospital stay, and length of intensive care treatment in patients with blunt trauma. Unilateral injuries occurred in 689 patients and bilateral injuries occurred in 54 patients. Mortality in patients with bilateral femur fractures was 5.6% compared with 1.5% in patients with unilateral femur fractures. The two groups were analyzed using multiple linear regression and logistic regression with age and Injury Severity Scores as covariants to allow for comparison of similarly injured groups as predicted by the Injury Severity Scores. Bilateral femur fractures still were associated with a significantly higher mortality, longer length of stay in the hospital, and longer length of stay in the intensive care unit. As expected, when analyzed separately, patients with bilateral femur fractures had significantly higher Injury Severity Scores, longer lengths of stay in the intensive care unit, and longer lengths of stay in the hospital. Patients with bilateral femur fractures have an increased mortality when compared with patients with unilateral femur fractures after controlling for Injury Severity Score and age. When used alone, the Injury Severity Score underestimates the contribution of a second femur fracture.     

Admission hyperglycemia as a prognostic indicator in trauma

OBJECTIVE: The purpose of this study was to assess the utility of two levels of hyperglycemia as predictors for mortality and infectious morbidity in traumatically injured patients. METHODS: All patients >or= 17 years old presenting to a Level I trauma center as a "trauma alert" or a "trauma code" from January 1, 2000, through December 31, 2000, were reviewed. Hypoglycemic patients (glucose concentration < 70 mg/dL) were excluded (n = 4). Patients were considered hyperglycemic with an admission glucose concentration > 200 mg/dL (moderate hyperglycemia) or an admission glucose concentration in the upper quartile for the group (mild hyperglycemia [glucose concentration > 135 mg/dL]). RESULTS: Seven hundred thirty-eight patients were included in the study. Hyperglycemia was associated with increased mortality among both patients with moderate hyperglycemia (34.1% vs. 3.7%, p < 0.01) and those with mild hyperglycemia (15.5% vs. 2%, p < 0.01) compared with corresponding normoglycemic groups. Hyperglycemia proved to be an independent predictor of mortality and of hospital and intensive care unit length of stay after multiple logistic regression while controlling for age, Injury Severity Score, Revised Trauma Score, and gender. Infectious complications, including pneumonia (9.4% vs. 2%, p = 0.001), urinary tract infections (6.6% vs. 1.4%, p = 0.001), wound infections (4.9% vs. 0.6%, p = 0.039), and bacteremia (5% vs. 1.1%, p = 0.004), were significantly increased in patients with elevated glucose concentrations. Hyperglycemia is an independent predictor of increased infectious morbidity controlling for age, gender, and Injury Severity Score in multiple logistic regression models. CONCLUSION: Hyperglycemia independently predicts increased intensive care unit and hospital length of stay and mortality in the trauma population. It is associated with increased infectious morbidity. These associations hold true for mild hyperglycemia (glucose concentration > 135 mg/dL) and moderate hyperglycemia (glucose concentration > 200 mg/dL).     

Obesity and outcomes after blunt trauma

BACKGROUND: Obesity has proven to be an independent risk factor of mortality in the intensive care unit (ICU) in both nontrauma and trauma patients. The purpose of this study was to determine whether the detrimental effect of obesity extend to morbidity as well as mortality in the intensive and nonintensive care blunt trauma patients. METHODS: A retrospective comparison of obese (body mass index [BMI] > 30 kg/m2) to nonobese (BMI < 30 kg/m2) blunt trauma patients was performed between January 2004 and December 2005. Patient demographics, morbidity, mortality and ventilator, ICU, and hospital length of stays were analyzed. Continuous variables were evaluated using the Wilcoxon Rank test and the nominal variables were evaluated using the Fisher's exact test. RESULTS: A cohort of 338 nonobese patients was compared with 115 obese patients during the study. These groups were similar in age (p = 0.19), gender (p = 0.37), and mechanism (p = 0.13). Their severity of injury were similar, demonstrated by nonsignificant differences in Injury Severity Score (p = 0.45), New Injury Severity Score (p = 0.51), Abdomen Abbreviated Injury Score (AIS; p = 0.49), and head AIS (p = 0.64). The subset of obese patients who never went to the ICU had a slightly longer hospital stay with a p value of 0.055. Overall the mortality rates were not different between the groups (3.5% obese versus 7.1% nonobese, p = 0.26). CONCLUSIONS: This group of obese blunt trauma patients had similar mortality rates to their leaner counterparts possibly because their complications were minimized. Despite this finding, a subset of obese patients had longer hospital stays which increases the financial burden to the patient and hospital. Effort should be made to facilitate their discharge to avoid complications and minimize cost.     

Prone ventilation in trauma or surgical patients with acute lung injury and adult respiratory distress syndrome: is it beneficial?

BACKGROUND: To compare the effectiveness of supine versus prone kinetic therapy in mechanically ventilated trauma and surgical patients with acute lung injury (ALI) and adult respiratory distress syndrome (ARDS). METHODS: A retrospective review of all patients with ALI/ARDS who were placed on either a supine (roto-rest) or prone (roto-prone) oscillating bed was performed. Data obtained included age, revised trauma score (RTS), base deficit, Injury Severity Score (ISS), head Abbreviated Injury Scale score (AIS), chest (AIS), PaO2/FiO2 ratio, FiO2 requirement, central venous pressure (CVP), days on the bed, ventilator days, use of pressors, complications, mortality, and pulmonary-associated mortality. Data are expressed as mean+/-SE with significance attributed to p<0.05. RESULTS: From March 1, 2004 through May 31, 2006, 4,507 trauma patients were admitted and 221 were identified in the trauma registry as having ALI or ARDS. Of these, 53 met inclusion criteria. Additionally, 8 general surgery patients met inclusion criteria. Of these 61 patients, 44 patients were positioned supine, 13 were placed prone, and 4 patients that were initially placed supine were changed to prone positioning. There was no difference between the groups in age, CVP, ISS, RTS, base deficit, head AIS score, chest AIS score, abdominal AIS score, or probability of survival. The PaO2/FiO2 ratios were not different at study entry (149 vs. 153, p=NS), and both groups showed improvement in PaO2/FiO2 ratios. However, the prone group had better PaO2/FiO2 ratios than the supine group by day 5 (243 vs. 200, p=0.066). The prone group had fewer days on the ventilator (13.6 vs. 24.2, p=0.12), and shorter hospital lengths of stay (22 days vs. 40 days, p=0.08). There were four patients who failed to improve with supine kinetic therapy that were changed to prone kinetic therapy. These patients had significant improvements in PaO2/FiO2 ratio, and significantly lower FiO2 requirements. There were 18 deaths (7 pulmonary related) in the supine group and 1 death in the prone group (p < 0.01 by chi test). CONCLUSIONS: ALI/ARDS patients who received prone kinetic therapy had greater improvement in PaO2/FiO2 ratio, lower mortality, and less pulmonary-related mortality than did supine positioned patients. The use of a prone-oscillating bed appears advantageous for trauma and surgical patients with ALI/ARDS and a prospective, randomized trial is warranted.     

The presence of the adult respiratory distress syndrome does not worsen mortality or discharge disability in blunt trauma patients with severe traumatic brain injury

PURPOSE: To evaluate the prevalence of the acute respiratory distress syndrome (ARDS) among blunt trauma patients with severe traumatic brain injury (TBI) and to determine if ARDS is associated with higher mortality, morbidity and worse discharge outcome. METHODS: Blunt trauma patients with TBI (head abbreviated injury score (AIS)> or =4) who developed predefined ARDS criteria between January 2000 and December 2004 were prospectively collected as part of an ongoing ARDS database. Each patient in the TBI+ARDS group was matched with two control TBI patients based on age, injury severity score (ISS) and head AIS. Outcomes including complications, mortality and discharge disability were compared between the two groups. RESULTS: Among 362 TBI patients, 28 (7.7%) developed ARDS. There were no differences between the two groups with respect to age, sex, ISS, Glasgow coma score (GCS), head, abdomen and extremity AIS. The TBI+ARDS group had significantly more patients with chest AIS> or =3 (57.1% versus 32.1%, p=0.03). There was no difference with respect to overall mortality between the TBI+ARDS group (50.0%) and the TBI group (51.8%) (OR 0.79: 95% CI 0.31-2.03, p=0.63). There was no significant difference with respect to discharge functional capacity between the two groups. There were significantly more overall complications in the TBI+ARDS group (42.9%) compared to the TBI group (16.1%) (OR 3.66: 95% CI 1.19-11.24, p=0.02). The TBI+ARDS group had an overall mean intensive care unit (ICU) length of stay of 15.6 days, versus 8.4 days in the TBI group (p<0.01). The TBI+ARDS group had significantly higher hospital charges than the TBI group ($210,097 versus $115,342, p<0.01). CONCLUSION: The presence of ARDS was not associated with higher mortality or worse discharge disability. It was, however, associated with higher hospital morbidity, longer ICU and hospital length of stay.     

The impact of pre-existing end-stage renal disease on survival in acutely injured trauma patients.

End-stage renal disease and associated dialysis procedures alter homeostatic mechanisms and adversely affect the respiratory, cardiac, and central nervous systems. Currently outcomes research in acutely injured trauma patients utilizes Trauma and Injury Severity Score methodology with the Injury Severity Score and Revised Trauma Score, which do not account for comorbidities. Literature has yet to emerge that analyzes the effects of end-stage renal disease on acutely injured trauma patients. A retrospective review at an urban Level I trauma center was performed of all end-stage renal disease patients' medical records who were admitted for acute traumatic injury from 1994 through 1997. The charts were abstracted for age, sex, race, method of dialysis, specific injury, need for operation, etiology of trauma, length of stay, disposition from hospital, morbidity, and mortality. The Injury Severity Score; probability of survival; and W, M, and Z statistics were then calculated. The data collected were then compared with the overall data for the trauma center including patients with and those without end-stage renal disease during this time period. Mortality for patients with end-stage renal disease after suffering an acute traumatic injury is 2.45 that of the general population. Increased mortality was most prevalent in operative patients and those with Injury Severity Score >15. The average length of stay in the hospital was 55.3 per cent longer for patients with end-stage renal disease. Pre-existing end-stage renal disease negatively impacts survival after traumatic injury. A prospective multicentered study comparing renal patients with nonrenal patients is warranted. This would confirm the need for databases to account for the increased morbidity and mortality associated with end-stage renal disease when calculating probability of survival values for acutely injured trauma patients. Similarly future studies analyzing the affects of other comorbidities such as diabetes, chronic obstructive pulmonary disease, and hypertension on acutely injured trauma patients would help develop a more accurate method of predicting outcomes.     

Major trauma with multiple injuries in German children: a retrospective review

BACKGROUND: The aim of this study was to evaluate the demographics, mechanisms, pattern, injury severity, and the outcome (ie, length of intensive care unit [ICU] stay, length of mechanical ventilation, total length of stay, mortality) in multiple-injured children based on a review from the German trauma registry study ("Traumaregister") of the German Society of Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie e.V.). METHODS: One hundred three German trauma centers took part in the German trauma registry study from January 1997 to December 2003. Five hundred seventeen children (aged 0-15 years) with multiple injuries and an Injury Severity Score of more than 15 in comparison to 11,025 adults were included. Sex, age, and mechanisms and pattern of injury were assessed. The mechanisms of trauma and the anatomical distribution of severe injury (Abbreviated Injury Scale of 3 or more) were analyzed. The Injury Severity Score, the Revised Trauma Score, and the Trauma Score Injury Severity Score were calculated to estimate the severity of injury and mortality. RESULTS: The predominant sex was male. Most cases were caused by traffic-related accidents. Head injuries were most common in children, and severe thoracic injuries increased with age. Mean length of ICU treatment, mechanical ventilation, and total length of stay were shorter in children than in adults. A total of 22.6% of the children aged 0 to 5 years died in the hospital in comparison with in-hospital mortality rate of 13.7% in the 6- to 10-, 20.3% in the 11- to 15-, and 17.0% in the 16- to 55-year-old patients. CONCLUSIONS: There were differences between multiple-injured children and adults concerning injury mechanisms and pattern of injuries. Adults needed a longer mechanical ventilation and a longer ICU therapy. Most deaths could be seen in the youngest patients aged 0 to 5 years.     

Blood transfusion,independent of shock severity,is associated with worse outcome in trauma

BACKGROUND: We have previously shown that blood transfusion in the first 24 hours is an independent predictor of mortality, intensive care unit (ICU) admission, and increased ICU length of stay in the acute trauma setting when controlling for Injury Severity Score, Glasgow Coma Scale score, and age. Indices of shock such as base deficit, serum lactate level, and admission hemodynamic status (systolic blood pressure, heart rate) and admission hematocrit were considered potential confounding variables in that study. The objectives of this study were to evaluate admission anemia and blood transfusion within the first 24 hours as independent predictors of mortality, ICU admission, ICU length of stay (LOS), and hospital LOS, with serum lactate level, base deficit, and shock index (heart rate/systolic blood pressure) as covariates. METHODS: Prospective data were collected on 15,534 patients admitted to a Level I trauma center over a 3-year period (1998-2000) and stratified by age, gender, race, Glasgow Coma Scale score, and Injury Severity Score. Admission anemia and blood transfusion were assessed as independent predictors of mortality, ICU admission, ICU LOS, and hospital LOS by logistic regression analysis, with base deficit, serum lactate, and shock index as covariates. RESULTS: Blood transfusion was a strong independent predictor of mortality (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.82-4.40; p < 0.001), ICU admission (OR, 3.27; 95% CI, 2.69-3.99; p < 0.001), ICU LOS (p < 0.001), and hospital LOS (Coef, 4.37; 95% CI, 2.79-5.94; p < 0.001) when stratified by indices of shock (base deficit, serum lactate, shock index, and anemia). Patients who underwent blood transfusion were almost three times more likely to die and greater than three times more likely to be admitted to the ICU. Admission anemia (hematocrit < 36%) was an independent predictor of ICU admission (p = 0.008), ICU LOS (p = 0.012), and hospital LOS (p < 0.001). CONCLUSION: Blood transfusion is confirmed as an independent predictor of mortality, ICU admission, ICU LOS, and hospital LOS in trauma after controlling for severity of shock by admission base deficit, lactate, shock index, and anemia. The use of other hemoglobin-based oxygen-carrying resuscitation fluids (such as human or bovine hemoglobin substitutes) in the acute postinjury period warrants further investigation.     

Trauma in the elderly: intensive care unit resource use and outcome

BACKGROUND: As the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly suffer more severe consequences from traumatic injuries compared with the young, presumably resulting in increased resource use. In this study, we sought to examine ICU resource use in trauma on the basis of age and injury severity. METHODS: This study was a retrospective review of trauma registry data prospectively collected on 26,237 blunt trauma patients admitted to all trauma centers (n = 26) in one state over 24 months (January 1996-December 1997). Age-dependent and injury severity-dependent differences in mortality, ICU length of stay (LOS), and hospital LOS were evaluated by logistic regression analysis. RESULTS: Elderly (age > or = 65 years, n = 7,117) patients had significantly higher mortality rates than younger (age < 65 years) trauma patients after stratification by Injury Severity Score (ISS), Revised Trauma Score, and other preexisting comorbidities. Age > 65 years was associated with a two- to threefold increased mortality risk in mild (ISS < 15, 3.2% vs. 0.4%; < 0.001), moderate (ISS 15-29, 19.7% vs. 5.4%; < 0.001), and severe traumatic injury (ISS > or = 30, 47.8% vs. 21.7%; < 0.001) compared with patients aged < 65 years. Logistic regression analysis confirmed that elderly patients had a nearly twofold increased mortality risk (odds ratio, 1.87; confidence interval, 1.60-2.18; < 0.001). Elderly patients also had significantly longer hospital LOS after stratifying for severity of injury by ISS (1.9 fewer days in the age 18-45 group, 0.89 fewer days in the age 46-64 group compared with the age > or = 65 group). Mortality rates were higher for men than for women only in the ISS < 15 (4.4% vs. 2.6%, < 0.001) and ISS 15 to 29 (21.7% vs. 17.6%, = 0.031) groups. ICU LOS was significantly decreased in elderly patients with ISS > or = 30. CONCLUSION: Age is confirmed as an independent predictor of outcome (mortality) in trauma after stratification for injury severity in this largest study of elderly trauma patients to date. Elderly patients with severe injury (ISS > 30) have decreased ICU resource use secondary to associated increased mortality rates.     

Early versus late tracheostomy in patients with severe traumatic head injury

BACKGROUND AND PURPOSE: A majority of patients with severe traumatic brain injury (TBI) need ventilatory support and require endotracheal intubation. There has been substantial debate regarding the timing of tracheostomy. We reviewed our data to determine the impact of early tracheostomy on our resources. STUDY DESIGN: Retrospective review of a consecutive series of patients with severe TBI treated at a Level II trauma center. METHOD: All 55 patients admitted to the surgical intensive care unit (ICU) with severe TBI from January, 2002 through September, 2005 were reviewed through the trauma registry. The inclusion criteria were severe TBI with a Glasgow Coma Scale (GCS) score < or = eight points at the time of admission and expected survival for longer than three days. All of these patients required mechanical ventilation and subsequently underwent tracheostomy. According to the timing of tracheostomy, subjects were classified as early group (< or = 7 days; N = 27) or late group (> 7 days; N = 28). The Wilcoxon rank sum test, the log-rank test, and Fisher exact tests were used to compare these groups. RESULT: The average time of the tracheostomy procedure was 5.5 +/- 1.8 (SD) days in the early group and 11.0 +/- 4.3 days in the late group. There were no significant differences between the groups in terms of age, proportion of female sex, GCS, Injury Severity Score, or need for blood transfusion. However, patients in the early group had a significantly shorter stay in the ICU than patients in the late group (19.0 +/- 7.7 vs. 25.8 +/- 11.8 days; P = 0.008). There was no difference between the groups in ventilator days (15.7 +/- 6.0 vs. 20.0 +/- 16.0 days; p = 0.57). There were no significant differences between the groups regarding overall mortality (15% vs. 4%; p = 0.19), incidence of pneumonia prior to tracheostomy (41% vs. 50%; p = 0.59), median total hospital length of stay (24 days vs. 28 days; p = 0.42), discharged to rehabilitation (74% vs. 82%; p = 0.53), or median total hospital cost (292,329 dollars vs. 332,601 dollars; p = 0.26). CONCLUSION: Early tracheostomy was beneficial, resulting in a shorter ICU stay.