A predictive model of early mortality in trauma patients

Background

Rapid thrombelastography (rTEG) is a real-time whole-blood viscoelastic coagulation assay. We hypothesized that admission rTEG and clinical data are independent predictors of trauma-related mortality.

Methods

Prospective observational data (patient demographics, admission vital signs, laboratory studies, and injury characteristics) from trauma patients enrolled within 6 hours of injury were collected. Mann–Whitney U test and analysis of variance test assessed significance (P ≤ .05). Logistic regression analyses determined the association of the studied variables with 24-hour mortality.

Results

Seven hundred ninety-five trauma patients were enrolled, of which 55 died within 24 hours of admission. Admission variables which independently predicted 24-hour mortality were as follows: Glasgow Coma Scale ≤8, hemoglobin <11 g/dL, international normalized ratio >1.5, Ly30 >8%, and penetrating injury (P < .05). This 5-variable model's area under the receiver operator characteristic curve was .88. The Hosmer–Lemeshow goodness-of-fit test was .90.

Conclusions

This 5-variable model provides a rapid prediction of 24-hour mortality. The inclusion of rTEG Ly30 demonstrates the association of fibrinolysis with outcome and may support the early use of antifibrinolytic therapies.     

Predictors of mortality in trauma patients

The purpose of this study was to ascertain risk factors for death from trauma. The large cohort allows for simultaneous evaluation of known mortality risk factors along with controlling for factors to assess the influence of each independently. Individually, base deficit, temperature, hypotension, age, and injury severity have been shown to be associated with an increased risk of death. However, in the English literature, there is no data on the independent predictive power and interaction of these risk factors. A review of trauma registry parameters from 1995 to 2000 was used. Demographics, injury severity, physiological and hematological parameters, and time data were evaluated in a univariate analysis. Variables significantly associated with mortality were entered into a stepwise backward multiple logistic regression. There were 1276 deaths (8.9%) with 25 per cent of the deaths within 3 hours. The top four predictors of mortality in this group were partial thromboplastin time (OR 3.37, 95% CI: 2.51-4.52), positive head computed tomography result (OR, 2.47; 95% CI, 1.95-3.04), initial hemoglobin (OR, 1.69; 95% CI, 1.23-2.31), base deficit (OR, 1.62; 95% CI, 1.29-2.04), and trauma resuscitation bay systolic blood pressure (OR, 1.45; 95% CI, 1.11-1.88). We conclude that prognostic indicators of all-cause mortality after trauma, which remain independent in the presence of all other factors and are potentially treatable, included low hemoglobin, elevated prothrombin and partial thromboplastin time, low scene and trauma bay systolic pressure, and elevated base deficit. The independent indicators of mortality, which are untreatable, included head injury, increasing age, and Injury Severity Score.     

The TRAAGIC score: early predictors of inpatient mortality in adult trauma patients

BackgroundScoring systems are important in prognostication and decision-making in the management of trauma patients. However, they often include an extensive list of factors not easily recalled by clinicians on admission. Additionally, multivariable analyses examining predictors of mortality in these patients is lacking. This study aimed to develop and validate a mortality prediction score for adult trauma inpatients. The intention was to create a scoring tool that could be easily remembered and implemented by clinicians.MethodsThis is a retrospective analysis of 5175 adult trauma patients treated at a level 1 trauma centre in Hamilton, Ontario, from 2002 to 2013. For derivation of the score, logistic regression was applied to data collected from 2002 to 2006 to identify potential predictors. Variables with p ≤ 0.10 identified from univariable analysis were entered in the multivariable logistic regression. Statistical significance was set at a value of 0.05. The prediction performance of the score was then assessed and validated on data for trauma patients treated from 2007 to 2013. The discrimination ability and calibration of the validation model were assessed. Frequencies, odds ratios with 95% confidence intervals (CIs) and C-statistics were reported.ResultsThe TRAAGIC prediction score (transfusion, age, airway, hyperglycemia, international normalized ratio, creatinine) showed a C-index of 0.85 (95% CI 0.83–0.87) in the derivation cohort. The TRAAGIC score had high discrimination and good calibration when applied to the validation cohort.ConclusionThe TRAAGIC score is an easily remembered and straightforward tool that can reasonably predict inpatient mortality for adult trauma patients.     

Admission hyperglycemia is predictive of outcome in critically ill trauma patients

OBJECTIVES: There is a paucity of data evaluating whether hyperglycemia at admission is associated with adverse outcome in trauma patients. Our objectives were to determine whether admission hyperglycemia was predictive of outcome in critically ill trauma patients. METHODS: Prospective data were collected daily on 1,003 consecutive trauma patients admitted to the intensive care unit over a 2-year period. Diabetics were excluded. Patients were stratified by admission serum glucose level (<200 mg/dL vs. > or =200 mg/dL) age, gender, Injury Severity Score, and other preexisting risk factors. Outcome was measured by incidence of infection, ventilator days, hospital length of stay and intensive care unit length of stay, and mortality. Multiple linear regression models were used to determine level of significance. RESULTS: Two hundred fifty-five of 1,003 (25%) patients were admitted with hyperglycemia over the study period. The majority (78%) of the admissions were caused by blunt injury. Male patients accounted for the majority of the study population (73%); however, female patients were more likely to be hyperglycemic at admission (p = 0.015). Patients with hyperglycemia had an overall greater infection rate and hospital length of stay. The hyperglycemic group had a 2.2-times greater risk of mortality when adjusted for age and Injury Severity Score. CONCLUSION: Hyperglycemia at admission is an independent predictor of outcome and infection in trauma patients. Future investigation on the effects of hyperglycemia are warranted.     

Persistent hyperglycemia is predictive of outcome in critically ill trauma patients

OBJECTIVES: Our objectives were to determine whether persistent hyperglycemia was predictive of outcome in critically ill trauma patients. METHODS: Prospective data were collected daily on 942 consecutive trauma patients admitted to the ICU over a 2-year period. Patients were stratified by serum glucose level from day 1 to day 7 (low = 0-139 mg/dL, medium = 140-219 mg/dL, and high >220 mg/dL) age, gender, and ISS. Patients were further stratified by pattern of glucose control (all low, all moderate, all high, improving, worsening, highly variable (HV). Outcome was measured by ventilator days, infection, hospital (HLOS) and ICU (ILOS) length of stay and mortality. Multiple linear regression models were used to determine level of significance. RESULTS: 71% were victims of blunt trauma. The majority (74%) were male with a mean ISS of 21.3 +/- 15. 41% of patients acquired an infection. Patients with medium, high, worsening, and highly variable hyperglycemia were found to have increased ILOS, HLOS, ventilator days, infection rate and mortality by univariate analysis (p < 0.01). When controlling for age, ISS, and glucose pattern, patients with high, worsening and HV hyperglycemia were most predictive of increased ventilator days, ILOS, HLOS, infection and mortality. (p < 0.01). CONCLUSION: Trauma patients with persistent hyperglycemia have a significantly greater degree of morbidity and mortality. A prospective randomized controlled study instituting aggressive hyperglycemic control is warranted.     

Morbidity and mortality in elderly trauma patients

BACKGROUND: Despite an increasing incidence, relatively few studies have examined the factors that predict morbidity and mortality in older patients and several reports have found standard predictors such as the Injury Severity Score to be less useful in this patient population. Similarly, the effect of skeletal injury has not been examined with regard to complications and mortality. The purpose of this study was to review a large multicenter experience with elderly trauma patients to isolate factors that might predict morbidity and mortality. The potential effect of skeletal long-bone injury was of particular interest. METHODS: The charts of all patients older than 60 years who were admitted to one of four Level I trauma centers after sustaining blunt trauma were reviewed. Mechanisms of injury included in the study were motor vehicle crash, pedestrian struck, fall from a height, and crush injury. Slip-and-fall injuries were excluded. A total of 326 patients met inclusion criteria. Variables studied included age, sex, mechanism of injury, Injury Severity Score (ISS), Revised Trauma Score, Glasgow Coma Scale (GCS) score, blood transfusion, fluid resuscitation, surgery performed (laparotomy, long-bone fracture stabilization, both), and timing of surgery. Outcome variables measured included incidence of adult respiratory distress syndrome, pneumonia, sepsis, myocardial infarction, deep venous thromboembolism, gastrointestinal complications, and death. chi2, logistic regression, t test, and nonparametric analyses were done as appropriate for the type of variable. RESULTS: The average age of the patients was 72.2+/-8 years. Overall, 59 patients (18.1%) died, of whom 52 of 59 survived at least 24 hours. Statistical significance for continuous variables (p < 0.05) using univariate analysis was reached for the following factors for the patients who died: higher ISS (33.1 vs. 16.4), lower GCS score (11.5 vs. 13.9), greater transfusion requirement (10.9 vs. 2.9 U), and more fluid infused (12.4 vs. 4.9 L). Logistic regression analysis was performed to determine the factors that predicted mortality. They included (odds ratios and p values in parentheses) transfusion (1.11, p = 0.01), ISS (1.04, p = 0.008), GCS score (0.87, p = 0.007), and fluid requirement (1.06, p = 0.06). Regarding surgery, orthopedic surgery alone had an odds ratio of 0.53, indicating that orthopedic patients was less likely to die than patients who did not undergo any surgery. Patients who underwent only a general surgical procedure were 2.5 times more likely to die (p = 0.03) and patients who underwent both general and orthopedic procedures were 1.5 times more likely to die (p = 0.32) than patients who did not require surgery. Early (< or =24 hours) versus late (>24 hours) surgery for bony stabilization did not have a statistical effect on mortality (11% early vs. 18% late). Two patients in need of bony stabilization, however, died before these procedures were performed. With regard to complications, regression analysis revealed that ISS predicted adult respiratory distress syndrome, pneumonia, sepsis, and gastrointestinal complications; fluid transfusion predicted myocardial infusion; and need for surgery and transfusion requirements predicted sepsis. These complications, in turn, were significant risk factors for mortality. This large series of elderly patients demonstrates that mortality correlates closely with ISS and is influenced by blood and fluid requirements and by GCS score. The institution-specific mortality was the same when adjusted for ISS. The need for orthopedic surgery and the timing of the surgery was not a risk factor for systemic complications or mortality in this series. CONCLUSION: Mortality is predicted by ISS and by complications in older patients. Seventy-seven percent of the orthopedic injuries were stabilized early, but the timing of surgery did not have any statistical effect on the incidence of complications or mortality. (ABSTRACT TRUNCA     

Triage and mortality in 2875 consecutive trauma patients

Background: Most studies on trauma and trauma systems have been conducted in the United States. We aimed to describe the factors predicting mortality in European trauma patients, with focus on triage. Methods: We prospectively registered all trauma patients in Eastern Denmark over 12 consecutive months. We analysed the flow of trauma patients through the system, the time spent at different locations, and we assessed the risk factors of mortality. Results: We included 2875 trauma patients, of whom 158 (5.5%) died before arrival at the hospital. Most patients (75.3%) were brought to local hospitals and patients primarily (n=82) or secondarily triaged (n=203) to the level I trauma centre were the most severely injured. Secondarily transferred patients spent a median of 150 min in the local hospital before transfer to the level I trauma centre and 48 min on transportation. Severe injury with an injury severity score >15 was seen in 345 patients, of whom 118 stayed at the local hospital. They had a significantly higher mortality than 116 of those secondarily transferred [45/118, 38.1% vs. 11/116, 9.7% (P<0.0001)]. Mortality within 30 days was 4.3% in admitted patients, and significant risk factors of death were violence [odds ratio (OR)=5.72], unconsciousness (OR=4.87), hypotension (OR=4.96), injury severity score >15 (OR=27.42), and age. Conclusions: Around 50% of all trauma deaths occurred at the scene. Increased survival of severely injured patients may be achieved by early transfer to highly specialised care.     

Preexisting conditions and mortality in older trauma patients

BACKGROUND: Among older trauma patients, those with preexisting chronic medical conditions (CMCs) appear to have an elevated risk of death. Whether this association is dependent on the severity of injury or other occult factors remains unanswered. This study evaluated the association between preexisting CMCs and risk of death among older trauma patients according to injury severity. METHODS: This was a retrospective cohort study using data from the National Trauma Data Bank, a registry of trauma patients admitted to 131 trauma centers across the United States. The main outcome measure was in-hospital mortality. RESULTS: In patients 50 to 64 years of age who sustain severe (Injury Severity Score [ISS] of 26+) and moderate injuries (ISS of 16-25), the presence of one or more CMCs is not associated with an increased relative risk (RR) of death (RR, 0.80 and 95% confidence interval [CI], 0.71-0.90; RR, 1.09 and 95% CI, 0.95-1.24, respectively). Those with minor injuries (ISS < 16) have increased risk of death (RR, 2.80; 95% CI, 2.33-3.36). For those patients 65 years of age and older who sustain severe, moderate, and minor injuries, the pattern of results is similar (RR, 0.91 and 95% CI, 0.83-1.00; RR, 1.13 and 95% CI, 1.04-1.23; and RR, 1.88 and 95% CI, 1.73-2.05, respectively). CONCLUSION: Older trauma patients with CMCs who present with minor injuries should be considered to have an increased risk of death when compared with their nonchronically ill counterparts.     

The impact of etomidate on mortality in trauma patients

Introduction

Etomidate has a neutral hemodynamic profile which has made it an attractive medication for emergent intubation. Despite theoretical advantages of etomidate administration in the trauma patient, there are incomplete data to support its use. This study examined the association of etomidate use for emergent intubation in traumatic illness with patient mortality.

Methods

This is a historical cohort study using the Nova Scotia Trauma Registry. It included all major adult trauma patients who required tracheal intubation at the Queen Elizabeth II Health Sciences Centre in Halifax, Canada from January 23, 2000 to March 25, 2012. Prospectively recorded data were analyzed, including patient demographics, presence of comorbidities, trauma specific variables, admission and discharge vitals, length of stay in the intensive care unit (ICU) and hospital, mechanical ventilation-free days, and mortality. Associations between the use of etomidate and 28-day mortality are presented as odds ratios. Multivariable logistic regression models were created adjusting for age, injury severity score (ISS), sex, comorbidities, presence of traumatic brain injury, and injury type. The effects of etomidate on other relevant outcome variables were assessed using unpaired Student’s t-tests.

Results

Three hundred eight patients were included in the study, and there were 42 deaths. Patients receiving etomidate were similar to those who did not, including ISS and pre-intubation blood pressure. The 28-day mortality was 18.7% in the etomidate group and 11.1% in the non-etomidate group (odds ratio = 1.85; 95% confidence interval [CI] 0.96 to 3.57; P = 0.07). After adjustment for age, female sex, ISS, and comorbidity, the odds ratio was 1.94 (95% CI 0.87 to 4.37; P = 0.11). There were no differences between the two groups in ICU length of stay, hospital length of stay, or number of ventilation-free days.

Conclusion

The association between use of a single dose of etomidate for emergency tracheal intubation in the trauma patient and mortality is inconclusive. Etomidate administration should be used with caution in trauma patients requiring tracheal intubation. Further data are required to determine the safety and risk-benefit of etomidate use in this patient population.     

应激性高血糖与外科病人预后的关系

严重创伤、感染等应激状况下，机体能量和物质代谢异常，表现为以高血糖为特征的糖代谢紊乱。临床上，应激性高血糖非常普遍，近年来已经有很多证据表明应激性高血糖可增加危重病人病死率。但是，目前临床工作中对应激性高血糖的忽视则十分普遍，因而造成在认识和管理上缺乏足够重视和统一的防治对策。现就近期该领域研究为基础，阐述应激性高血糖病因、发生机制、与预后的关系及防治对策，希望藉此引起临床工作者对应激性高血糖及其治疗的重视和理解。     

Rising mortality in patients with combined burn and trauma

Combined trauma in the burn patient has been previously shown to have higher mortality. With improved critical care and multidisciplinary approach, we hypothesized the risk of mortality in combined burn and trauma has decreased. A retrospective analysis of trauma, burn and combined burn-trauma patients in the National Trauma Data Bank was performed comparing years 2007–2015 to years 1994–2002. The impact of burn injuries on mortality in patients with minor trauma has decreased (OR 2.45, CI 2.26–2.66, p < 0.001 compared to OR 4.04, CI 4.51–4.66, p < 0.001) in years 2007–2015 while the impact of burn injuries on mortality in patients with severe trauma has increased (OR 1.37, CI 1.29–1.47, p < 0.001 compared to OR 1.26, CI 1.05–1.51, p < 0.001). When controlling for known risk factors of mortality in burn and trauma, the contribution of the severity of trauma on mortality in combined burn-trauma patients with total body surface area ≥20% is negligible. In contrast, an increase in percentage of total body surface area burned is associated with a step-wise increase in mortality for all combined burn-trauma patients. However, the largest impact is seen in patients with minor trauma. This population represents a unique overlap of patients where future collaborative research can help identify best practices and improve outcomes.     

Intensive care unit design and mortality in trauma patients

Background

The architecture of medical care facilities ca affect the safety of a patient, but it is unknown if the architecture affects outcomes. We hypothesized that patients in rooms who are more visible from the central nursing station would experience better outcomes than those patients in less visible rooms.

Materials and methods

A total of 773 patients admitted to the trauma intensive care service over a 12-mo period were retrospectively evaluated. Outcomes were hospital mortality and intensive care unit (ICU) length of stay (LOS). The unit is designed with a bank of high-visibility rooms (HVRs) directly across from the nursing station and two side sections of low-visibility rooms (LVRs). No formal triage occurs, but patients are prioritized to HVRs as available.

Results

Patients in the HVRs had a 16% mortality (52 of 320); meanwhile, the patients in the LVRs experienced an 11% mortality (49 of 448, P = 0.03). ICU mortality did not differ significantly when controlling for age, Charlson Comorbidity Index (CCI), Head Abbreviated Injury Score, and the Injury Severity Score (ISS) (P = 0.076). Age, CCI, Head Abbreviated Injury Score, and ISS did individually correlate with mortality (age: P = 0.0008; CCI: P = 0.017; and ISS: P < 0.0001). Visibility was not a predictor of ICU LOS or complications among survivors (mean ICU HVR LOS = 4.8 d; mean ICU LVR LOS = 4.7; P = 0.88, n = 661). Only ISS was a significant predictor of ICU LOS and complications (P < 0.0001).

Conclusions

Trauma patient room placement within the ICU does not relate to mortality rate significantly when corrected for patient acuity. Instead, variables such as age, ISS, and CCI are associated with mortality. A policy of placing more critically ill patients in HVRs may prevent increased mortality in high-acuity patients.     

Epidemiology, mortality and morbidity in multiple trauma patients

Three hundred, twenty-nine multiple trauma patients with skeletal injuries admitted to Hennepin County Medical Center, Minneapolis were analyzed for mortality and morbidity based on injury severity score (ISS) and timing of fracture stabilization. Fifty-three deaths (16%) occurred with 38% dying during the first six hours. Survival prospects with injury severity score over 40 were bleak. Age, sex, mechanism of injury, and time of occurrence of injury was also tabulated. Two hundred, twenty-nine patients with 474 long bone fractures were analyzed based on timing of fracture stabilization: immediate stabilization within 24 hours; delayed primary stabilization over 24 hours to one week; secondary osteosynthesis more than one week; non-operative treatment. Respiratory distress syndromes occurred in 6%, 2.4%, 9%, and 12%; mortality rate of 3%, 0%, 6.4%, and 26% for treatment groups A, B, C, and D respectively. However, it must be noted that treatment group B with lower ARDS and mortality rate had no type III open fractures and lower injury severity score.     

Dementia as a predictor of mortality in adult trauma patients

Background

The specific contribution of dementia towards mortality in trauma patients is not well defined. The purpose of the study was to evaluate dementia as a predictor of mortality in trauma patients when compared to case-matched controls.

意外创伤者早期自我表露与创伤后成长的关系研究

目的探讨意外创伤者早期创伤后成长水平及与自我表露的关系。方法采用情感表达矛盾问卷、伯克利情绪表达量表和中文版创伤后成长问卷对320例意外伤者于受伤90 d内进行调查。结果患者创伤后成长总分(41.89±13.06)分,与积极情绪表达、消极情绪表达、积极情绪表达强度和消极情绪表达强度呈正相关,控制人口学变量后,积极情绪表达强度和消极情绪表达强度可正向预测创伤后成长(均P0.05)。结论意外创伤者早期阶段创伤后成长处于中等偏下水平,临床护士需尽早干预,鼓励伤者深层次表露各种情绪以促其个人成长。