Influence of a new province-wide trauma system on motor vehicle trauma care and mortality

BACKGROUND: Mature trauma systems have evolved to respond to high rates of major injury morbidity and mortality. Characterized by prehospital care, triage, transportation, aggressive resuscitation, surgery, and rehabilitation, trauma systems have been found to improve survival for seriously injured patients. In Nova Scotia, a province-wide trauma system was implemented between 1995 and 1998. This study investigated the influence of the province-wide trauma system on motor vehicle trauma care and mortality in its first 2 years of existence. METHODS: Subjects over the age of 15 years were identified using E-codes pertaining to motor vehicle traffic crashes from population-based hospital claims and vital statistics data. Individuals who were hospitalized or died because of a motor vehicle crash in 1993 through 1994, before trauma system implementation, were compared with those who were hospitalized or died in 1999 through 2000, after the trauma system was implemented. RESULTS: In the 2-year period after trauma system implementation, there was a 21% increase in the number of seriously injured individuals with a primary admission to tertiary care. This increase was both clinically and statistically significant even after adjustment for age, gender, multiple injuries, head injury, municipality of residence, and vital status at discharge (RR, 1.21, 95% CI, 1.05-1.35). There was no evidence that the probability of dying while in hospital significantly changed in the first 2 years after trauma system implementation. INTERPRETATION: These results indicate that individuals seriously injured in motor vehicle crashes in Nova Scotia are more likely to be admitted to tertiary care in the postimplementation period.     

The influence of prehospital trauma care on motor vehicle crash mortality

BACKGROUND: This study evaluated the impact of the prehospital trauma care system on the mortality from motor vehicle crashes and on the temporal distribution between the crash and related death. METHODS: Autopsies performed by the Forensic Medical Institute on all deaths caused by motor vehicle crashes 1 year before and 1 year after the beginning of the prehospital trauma care system were evaluated. RESULTS: In the first period, 128 deaths occurred, 53.9% of them in the first hour after the crash, 36.7% between the first hour and the seventh day, and 9.4% after 1 week. In the second period, 115 deaths occurred, 40.8% of them in the first hour, 52.2% between the first hour and the seventh day, and 7% after 1 week. Central nervous system injury was the most frequent cause of death in both periods. Mortality was greatest among young people as well as male victims in both periods. CONCLUSION: After starting the prehospital trauma care system in our city, there was a decrease in the deaths occurring before hospital admission, a change in temporal distribution of deaths, and a reduction in the motor vehicle crash mortality rate.     

Mitral and tricuspid valve rupture from blunt trauma sustained during a motor vehicle collision

The incidence of mitral valve injury resulting from blunt trauma is low. This report presents the case of a 36-year-old male who survived the rupture of both his mitral and tricuspid valves after striking the steering wheel during a motor vehicle accident. Echocardiograms were used to make the diagnosis.     

Effect of trauma systems on motor vehicle occupant mortality: A comparison between states with and without a formal system

BACKGROUND: Population-based studies using a "before-and-after" methodology report a reduction in motor vehicle collision mortality with implementation of statewide trauma systems (TS). However, concurrent improvements in roads, cars, restraint systems, and changes in rates of drunk driving, socioeconomics, speed limits, urban or rural mix, and traffic density may also be responsible for the progressive reduction in mortality rates. We hypothesized that a statewide TS independently reduces injury mortality, irrespective of other factors. METHODS: Data were acquired from several federal agencies including the Centers for Disease Control (CDC), The National Highway Traffic Safety Administration (NHTSA), the United States Department of Transportation (DOT), and the United States Census Bureau. Age-adjusted motor vehicle occupant (MVO) death rates per 100,000 population were compared in states with and without a TS. Negative binomial regression was used to calculate risk ratios (RR) comparing mortality in TS and non-TS states after adjusting for effects of gender, race, primary seat belt laws, seat belt use, alcohol use, miles traveled, population density, per capita income, types of registered vehicles, and rural or urban mix. RESULTS:: The number of states with a TS increased from 7 in 1981 to 36 in 2002. Concurrently, nationwide MVO death rates decreased by 2.6 per 100,000 (95% confidence interval 1.2-3.9; p < 0.001). Income, primary seat belt laws, restraint use, speed limits, and rural or urban population distribution (p < 0.05 for all), were independent predictors of MVO mortality, but not presence of a TS (RR 0.95, 95% confidence interval 0.73-1.23; p = 0.68). CONCLUSIONS: MVO death rates have declined over time, and are lower in TS states. However, the cause is multi-factorial, and cannot be attributed solely to presence of TS. Further studies are needed to identify beneficial components of a statewide trauma system.     

Chronic bronchitis: a 10-year follow-up

A 10-year follow-up of 327 civil servants with bronchitis (301 men and 26 women) is presented. A further 14 were lost sight of during the period, so that the follow-up was 96% complete. More than one half (54%) of the men died during the 10-year period, some 57% of the deaths being attributed to respiratory causes and a further 8% to carcinoma of the bronchus. Mortality from these diseases was higher than among the general population, but other causes of death showed the normal pattern. The degree of dyspnoea noted at the first interview gave a useful estimate of prognosis, the mild, moderate, and severe groups showing progressively higher death rates. Neither the length of history nor the age at onset of symptoms could be related to mortality. The proportion of smokers among the patients was greater than expected in the general population, and although this may have been a factor contributing to the excess mortality of the group as a whole, it was not possible to determine any effect of smoking within this study.     

Low incidence of penetrating trauma in a high-volume tertiary center: 10-year mortality review

Background

Trauma morbidity and mortality outcome is better in high-volume trauma centers. However, there are few publications investigating the experience of high-volume centers with high non-trauma emergency load but seeing a relatively low incidence of trauma. The objective of this study is to review the presentation and outcomes for the low volume of patients presenting with penetrating injuries in a high-volume hospital.

Methods

Data were extracted from the Singapore General Hospital database between 1998 and 2007. There were 1,233 patients who sustained penetrating injuries and were brought to the hospital during the 10-year period. Of these, only 78 patients had injury severity score (ISS) values of 16 or more. In the same period, there were 1,270 patients with ISS > 15 who were admitted with blunt injury. SPSS 10.1 was used to conduct univariate and multivariate analyses to elucidate risk factors for mortality.

Results

Age, ISS, and trauma injury severity score (TRISS) were significant predictors of mortality. Gender and type of injury were not predictive of mortality. Mortality outcomes were independently predicted by age, TRISS, and ISS. The most common site of injury was the chest, followed closely by the head and neck. The abdomen/pelvis was the third most common site of injury. There was no significant difference in anatomical site injury pattern between the survivors and non-survivors. For both groups, chest injuries and head and neck injuries dominated, with maximal abdominal/pelvic injuries a distant third.

Conclusion

With a trauma system in place, high-volume centers with a low volume of penetrating injury patients can still manage uncommon injuries without jeopardizing patient care.     

Mountain biking injuries requiring trauma center admission: a 10-year regional trauma system experience

BACKGROUND: Mountain biking has become an increasingly popular recreational and competitive sport with increasingly recognized risks. The purpose of this study was to review a population based approach to serious injuries requiring trauma center admission related to mountain biking, identify trends and develop directions for related injury prevention programs. METHODS: Three trauma centers in the Greater Vancouver area exclusively serve a major mountain bike park and the North Shore Mountains biking trails. The Trauma Registries and the patient charts were reviewed for mountain bike injuries from 1992 to 2002. The data were analyzed according to demographics, distribution, and severity of injuries, and need for operative intervention. Findings were reviewed with injury prevention experts and regional and national mountain-biking stakeholders to provide direction to injury prevention programs. RESULTS: A total of 1,037 patients were identified as having bicycling-related injuries. Of these, 399 patients sustained 1,092 injuries while mountain biking. There was a threefold increase in the incidence of mountain biking injuries over a 10-year period. Young males were most commonly affected. Orthopedic injuries were most common (46.5%) followed by head (12.2%), spine (12%), chest (10.3%), facial (10.2%), abdominal (5.4%), genitourinary (2.2%), and neck injuries (1%). High operative rate was observed: 38% of injuries and 66% of patients required surgery. One patient died from his injuries. Injury prevention programs were developed and successfully engaged the target population. CONCLUSION: Mountain biking is a growing cause of serious injuries. Young males are principally at risk and serious injuries result from intended activity and despite protective equipment. Injury prevention programs were developed to address these concerns.     

Implementation of a trauma care system: evolution through evaluation

BACKGROUND: The regionalization of trauma services has been implemented in many health care systems and communities over the past 10 to 20 years. As these trauma systems mature and evolve, changes are made to improve the care and efficiency of the system. Trauma care regionalization was introduced in Quebec in 1993. This study looked at the evolution of trauma care in Quebec over the past 13 years, from the preregionalization era to the present. METHODS: A retrospective review scientifically evaluated a trauma system, the implementation of evidence-based changes, and the efficacy of these changes. RESULTS: Various changes have been made in the Quebec trauma system since the introduction of regionalization. These changes have led to an incremental decrease in mortality caused by severe trauma from 51.8% in 1992 to 8.6% in 2002. CONCLUSION: A trauma system is fluid and constantly evolving. Research and constant reevaluation are necessary for continuous evaluation of the system and improvement of its outcomes and efficiency.     

Long-term mortality following trauma: 10 year follow-up in a population-based sample of injured adults

BACKGROUND: The aim of the study was to quantify trauma-related mortality in injured adults over 10 years postinjury. METHODS: A population-based matched cohort study used linked administrative data from Manitoba, Canada, to identify an inception cohort (1988-1991) of hospitalized trauma cases (ICD-9-CM 800-959.9) aged 18-64 years (n = 18,210) and a matched noninjured comparison group (n = 18,210). Mortality outcomes were obtained by linking the two cohorts with the Manitoba Population Registry for a period of 10 years postinjury. RESULTS: The adjusted all-cause mortality rate ratio (MRR) was 7.29 (95% CI 4.53-11.74) for the 60 days immediately postinjury. The MRRs ranged between 1.17 and 2.41 for the remainder of the 10 year follow-up period. The index injury was estimated to be responsible for 41% of all recorded deaths in the injured cohort. CONCLUSIONS: Estimates of the total mortality burden, based on the early inpatient period alone, substantially underestimates the true burden from injury.     

Liver trauma: a 10-year experience.

The management of 73 patients with liver trauma (58 male, 15 female; mean age 30 (range 6-68) years) presenting from January 1980 to August 1990 is reviewed. There were 29 cases of penetrating injury and 44 of blunt trauma. Seven patients were successfully managed without operation (five with blunt injury) and were discharged after a mean hospital stay of 8 days. Fifty-one cases were classified as simple injuries (grade I or II) and were managed by suture (with or without drainage) or required no intervention, with three deaths. Fifteen cases were classified as complex injuries (grade III or IV) and underwent one or more of the following: perihepatic packing, resectional debridement, hemihepatectomy and hepatotomy with direct suture ligation. Six of these patients died from uncontrolled haemorrhage. The continued use of suture for simple injuries and of resectional debridement and/or packing for complex injuries is supported. Judicious clinical assessment and radiological monitoring may reduce the number of unnecessary laparotomies.     

Hip squeaking: a 10-year follow-up study

The aim of the study was to analyze the incidence of squeaking with ceramic-on-ceramic total hip arthroplasty (THA) after 10 years of follow-up and the potential complications that could occur related to this phenomenon. One hundred THAs implanted between November 1999 and December 2000 were evaluated. Incidence of squeaking was investigated clinically with a questionnaire. Implant positioning was analyzed on x-rays and computer tomography. Of the 100 THAs, 5 patients presented with squeaking. All of them were active, sporty, and heavy men. Functional scores were comparable with nonsqueaking patients. There was no malpositioning on the x-ray analysis, no wear, and no loosening. We could not demonstrate any relation between squeaking and ceramic fracture. Squeaking noise appeared at a mean of 66 months postsurgery. It appears to be an isolated phenomenon without any consequences at 10-year follow-up.     

Health-related quality of life of trauma patients after intensive care: a 2-year follow-up study

Purpose  

This study aimed to assess the health-related quality of life (HRQOL) in trauma patients 2 years after discharge from an intensive care unit (ICU) in Zunyi, China, and to investigate the possible determinants of HRQOL.     

Influence of trauma system implementation on process of care delivered to seriously injured patients in rural trauma centers

BACKGROUND: Statewide trauma systems are implemented by health care policy makers whose intent is to improve the process of care delivered to seriously injured patients. In Oregon, Advanced Trauma Life Support (ATLS) training was mandated for all physicians employed in the emergency department of trauma centers. The purpose of this study was to test the hypothesis that mandatory ATLS training favorably influenced processes of care. METHODS: Seriously injured patients treated at 9 rural Level 3 and Level 4 hospitals were studied before (PRE) and after (POST) implementation of Oregon's trauma system. The processes of care evaluated on the basis of chart review were 20 diagnostic and therapeutic interventions advocated in the ATLS course. A cumulative process score (CPS) between 0 and 1 was assigned on the basis of the processes of care delivered. A CPS of 1 indicated optimal process of care. RESULTS: Mean CPS for 506 PRE period patients (0.44 +/- 0.27) was significantly lower than the mean CPS for 512 POST period patients (0.57 +/- 0.27) with an unpaired t test (P <.001). For the subgroup with injury severity score of 16 to 34, the mean CPS of survivors (0.67 +/- 0.19) was significantly higher than the mean CPS of decedents (0.57 +/- 0.25). CONCLUSIONS: Process of care for seriously injured patients improved after categorization of rural trauma centers in Oregon. Evidence shows improved process of care may have benefitted patients with serious but survivable injuries. Measurement of process of care is an alternative to mortality analysis as an indication of the quality of care.     

Angiography and the pediatric trauma patient: a 10-year review

Background/Purpose

Although interventional radiology has played an increasing role in the management of adult trauma patients, little has been written regarding its application in the care of the injured child. This study analyzed the indications, results, and complications for angiography in pediatric trauma patients.

Methods

A retrospective review of pediatric patients (14 years or younger) admitted to Los Angeles County-University of Southern California Medical Center, Los Angeles, Calif (an urban level I trauma center), over a 10-year period (1993-2003) was performed. Patients who underwent angiography were identified using hospital angiography records, and further information was recorded from the trauma registry and medical records. Variables collected included age, sex, mechanism of injury, and injury severity score (ISS). Angiographic data analyzed included indications, results, therapeutic interventions, and procedure-related complications.

Results

Twenty-five pediatric trauma patients who underwent angiography were identified (18 boys, 7 girls). The average age was 11 years (range, 1-14 years), with an ISS of 16 ± 10. Indications for angiography included suspected limb ischemia (n = 9), suspected pelvic (n = 8) or solid organ bleeding (n = 8), suspected aortic injury (n = 6), and expanding hematoma (n = 1). Eleven patients (44%) had an abnormal finding, and 10 of 11 underwent a subsequent therapeutic intervention. There was 1 minor procedure-related complication and no procedure-related mortality.

Conclusions

Though used infrequently in pediatric trauma patients, the result of the angiography was abnormal in almost half of the children in this series. An abnormal finding prompted further therapeutic intervention in most cases. Angiography was associated with minimal morbidity and should be considered as a useful and safe adjunct when caring for injured children.