Cervical spine injury in young children: a National Trauma Data Bank review

Background

Blunt cervical spine injury (CSI) is rare in the pediatric population. The objective of this study was to better characterize the incidence and type of CSI in young children (age <3 years) using a large, trauma center-based data set.

Methods

The National Trauma Data Bank (NTDB) was reviewed for the period January 2001 to December 2005 for patients younger than 3 years of age with a blunt CSI (International Classification of Diseases, Ninth Revision, 805×, 806×, 952×). Demographic, injury, and outcome information were reviewed. Data management was performed using SAS (SAS, Cary, NC) and Stata (Stata Corp, College Station, TX). Patients with CSI were compared to patients without CSI of similar age. Means were compared with the Wilcoxon rank sum test, medians were compared with a nonparametric test, and count data were compared with the χ² test, with significance set at <.05.

Results

For the period of review, 95,654 young children (age <3 years) with blunt trauma were identified in the NTDB. The overall population had a median Injury Severity Score (ISS) of 4, and most patients (77.01%) had a Glasgow Coma Score (GCS) of 15. There were 1523 (1.59%) patients with a CSI (spinal cord and/or column), including 366 patients (0.38%) with a spinal cord injury (with or without column injury) and 182 (0.19%) with an isolated spinal cord injury (SCIWORA). The CSI and non-CSI populations did not differ regarding median GCS (15 for both groups), but the CSI population had a significantly higher median ISS (14 vs 4, respectively; P < .001). Compared to patients without CSI, the CSI population was more likely to die in the emergency department (2.04% vs 1.25%; P = .007) or be admitted to the intensive care unit (45.3% vs 16.9%; P < .001). Nearly half of all cervical spine fractures (48%) and more than half of cervical spinal cord injuries (53%) were in the lower cervical spine (C5-7). MVCs were the most common injury mechanism (66%) followed by falls (15%). A CSI was observed in 3.2% of all motor vehicle crashes (MVCs).

Conclusions

In this trauma center population, these findings confirm the infrequency of blunt CSI in the youngest (age <3 years) trauma patients. The frequency of injuries to the lower cervical spine is higher than previously appreciated. MVCs are the most likely injury mechanism for this potentially devastating injury.     

Pre-hospital endotracheal intubation and positive pressure ventilation is associated with hypotension and decreased survival in hypovolemic trauma patients: an analysis of the National Trauma Data Bank

BACKGROUND: Studies of pre-hospital endotracheal intubation (ETI) from single EMS systems have shown contradictory results, which may represent local differences in paramedic training and experience. An alternative hypothesis is that positive pressure ventilation increases mortality because positive pressure ventilation causes hypotension in severely injured hypovolemic patients. METHODS: A national sample (National Trauma Data Bank, 1994-2002) was used to minimize effects of local paramedic training and experience. All patients with pre-hospital GCS < 8 (most likely to warrant early ETI) and ISS > 16 (most likely to be hypovolemic) were included. Patients intubated in the field (pre-hospital group, n = 871) and in the emergency department (ED group, n = 6581) were compared. To determine whether pre-hospital ETI was an independent predictor of hypotension and mortality, logistic regression was used to control for potential confounders, including age, ISS, body region injured, AIS scores, pre-hospital IV fluids, and other variables. Physiologic variables were not used, as they may be influenced by ETI and positive pressure ventilation, and were therefore considered outcomes, rather than predictors. RESULTS: Groups were comparable in age, gender, anatomic distribution of injuries, likelihood of at least one severe injury (AIS >3) and other variables, except for head injury (ED 83%, pre-hospital 71%, p < 0.001) and ISS (ED 33 +/- 0.2, pre-hospital 36 +/- 0.6, p < 0.001). Patients intubated in the field were more likely to be hypotensive upon arrival in the ED (SBP < or = 90 mm Hg; ED 33%, pre-hospital 54%, p < 0.001), and had worse survival (ED 45% versus pre-hospital 24%, p < 0.001). Even after controlling for potential confounders, pre-hospital ETI was still an independent predictor of hypotension upon arrival in ED (OR 1.7, 95% CI 1.46 -2.09, p < 0.001) and decreased survival (OR 0.51, 95% C.I. 0.43-0.62, p < 0.001). CONCLUSIONS: Pre-hospital endotracheal intubation in trauma patients is associated with hypotension and decreased survival. This may be mediated by the effect of positive pressure ventilation during hypovolemic states.     

Effect of age on cervical spine injury in pediatric population: a National Trauma Data Bank review

Background

The objective of this study was to characterize the incidence, risk factors, and patterns of cervical spine injury (CSI) in different pediatric developmental ages.

Methods

A retrospective review of the National Trauma Data Bank was conducted for the period of January 2002 through December 2006 to identify pediatric patients admitted following blunt trauma. Patients were stratified into 4 developmental age groups: infants/toddlers (age 0-3 years), preschool/young children (age 4-9 years), preadolescents (age 10-13 years), and adolescents (age 14-17 years). Patients with a CSI were identified by the International Classification of Diseases, Ninth Revision codes. Demographics, clinical injury data, level of CSI, and outcomes were abstracted and analyzed.

Results

A total of 240,647 patients met the inclusion criteria. Of these, 1.3% (n = 3,035) sustained a CSI. The incidence of CSI in the stratified age groups was 0.4% in infants/toddlers, 0.4% in preschool/young children, 0.8% in preadolescents, and 2.6% in adolescents. The level of CSI (upper [C1-C4] vs lower [C5-C7]) according to the age groups was as follows: infants and toddlers, 70% vs 25%; preschool/young children, 74% vs 17%; preadolescents, 52% vs 37%; and adolescents, 40% vs 45%, respectively. The adjusted risk for CSI increased 2-fold in preadolescents and 5-fold in adolescents.

Conclusion

The incidence of pediatric CSI increases in a stepwise fashion after 9 years of age. We noted an increase in lower CSI and a decrease in upper CSI after the age of 9 years. The incidence of upper CSI compared with lower CSI was higher in preadolescents (52% vs 37%) and almost equal in adolescents (40% vs 45%).     

Non-iatrogenic esophageal injury: a retrospective analysis from the National Trauma Data Bank

Lower endoscopy (LE) is the standard diagnostic modality for lower gastrointestinal bleeding (LGIB). Conversely, computed tomographic angiography (CTA) offers an immediate non-invasive diagnosis visualizing the entire gastrointestinal tract. The aim of this study was to compare these 2 modalities with regards to diagnostic value and bleeding control. Tertiary center retrospective analysis of consecutive patients admitted for LGIB between 2006 and 2012. Comparison of patients with LE vs. CTA as first exam, respectively, with emphasis on diagnostic accuracy and bleeding control. Final analysis included 183 patients; 122 (66.7%) had LE first, while 32 (17.5%) had CTA; 29 (15.8%) had neither of both exams. Median time to CTA was shorter compared to LE (3 (IQR = 8.2) vs. 22 (IQR = 36.9) hours, P < 0.001). Active bleeding was identified in 31% with CTA vs. 15% with LE (P = 0.031); a non-actively bleeding source was found by CTA and LE in 22 vs. 31%, respectively (P = 0.305). Bleeding control required endoscopy in 19%, surgery in 14% and embolization in 1.6%, while 66% were treated conservatively. Post-interventional bleeding was mostly controlled by endoscopic therapy (57%). 80% of patients with active bleeding on CTA required surgery. Post-interventional LGIB was effectively addressed by LE. For other causes of LGIB, CTA was efficient, and more available than colonoscopy. Treatment was conservative for most patients. In case of active bleeding, CTA could localize the bleeding source and predict the need for surgery.     

Demographics,mechanism of injury,and associated injuries of 25,615 patients with talus fractures in the National Trauma Data Bank

BackgroundExtensive research has been conducted concerning the epidemiology of fractures of the calcaneus and ankle. However, less work has characterized the population sustaining talus fractures, necessitating the analysis of a large, national sample to assess the presentation of this important injury.MethodsThe current study included adult patients from the 2011 through 2015 National Trauma Data Bank (NTDB) who had talus fractures. Modified Charlson Comorbidity Index (CCI), mechanism of injury (MOI), Injury Severity Score (ISS), and associated injuries were evaluated.ResultsOut of 25,615 talus fracture patients, 15,607 (61%) were males. The age distribution showed a general decline in frequency as age increased after a peak incidence at 21 years of age. As expected, CCI increased as age increased. The mechanism of injury analysis showed a decline in motor vehicle accidents (MVAs) and an increase in falls as age increased. ISS was generally higher for MVAs compared to falls and other injuries.Overall, 89% of patients with a talus fracture had an associated injury. Among associated bony injuries, non-talus lower extremity fractures were common, with ankle fractures (noted in 42.7%) and calcaneus fractures (noted in 27.8%) being the most notable. The most common associated internal organ injuries were lung (noted in 19.0%) and intracranial injuries (noted in 14.9%).ConclusionThis large cohort of patients with talus fractures defined the demographics of those who sustain this injury and demonstrated ankle and calcaneus fractures to be the most commonly associated injuries. Other associated orthopaedic and non-orthopaedic injuries were also defined. In fact, the incidence of associated lumbar spine fracture was similar to that seen for calcaneus fractures (14%) and nearly 1 in 5 patients had a thoracic organ injury. Clinicians need to maintain a high suspicion for such associated injuries for those who present with talus fractures.Level of EvidenceLevel II, retrospective study     

Prevalence of brachial plexus injuries in patients with scapular fractures: A National Trauma Data Bank review

BACKGROUND:

Studies investigating the prevalence of brachial plexus injuries associated with scapular fractures are sparse, and are frequently limited by small sample sizes and often restricted to single-centre experience.

OBJECTIVE:

To determine the prevalence of brachial plexus injuries associated with scapular fractures; to determine how the prevalence varies with the region of the scapula injured; and to assess which specific nerves of the brachial plexus were involved.

METHODS:

The present study was a retrospective review of data from the National Trauma Data Bank over a five-year period (2007 to 2011).

RESULTS:

Of 68,118 patients with scapular fractures, brachial plexus injury was present in 1173 (1.72%). In patients with multiple scapular fractures, the prevalence of brachial plexus injury was 3.12%, and ranged from 1.52% to 2.22% in patients with single scapular fractures depending on the specific anatomical location of the fracture. Of the 426 injuries with detailed information on nerve injury, 208 (49%) involved the radial nerve, 113 (26.5%) the ulnar nerve, 65 (15%) the median nerve, 36 (8.5%) the axillary nerve and four (1%) the musculocutaneous nerve.

CONCLUSION:

The prevalence of brachial plexus injuries in patients with scapular fractures was 1.72%. The prevalence was similar across anatomical regions for single scapular fracture and was higher with multiple fractures. The largest percentage of nerve injuries were to the radial nerve.     

Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss

PURPOSE: We sought to analyze the results of lower limb arterial injury (LLAI) management in a busy metropolitan vascular unit and to identify risk factors associated with limb loss.Patients and Methods: Between 1987 and 1997, prospectively collected data on 550 patients with 641 lower limb arterial injuries were analyzed. RESULTS: The mechanism of LLAI was gunshot wounds in 46.1%, blunt in 19%, stabbing in 11.8%, and shotgun in 9.1%. The most frequently injured vessel was the superficial femoral artery (37.2%), followed by the popliteal (30.7%), crural (11%), common femoral (8.7%), and deep femoral (5.3%) arteries. In 3.4% of cases, there was a combined injury on either side of the knee (ipsilaterally). Associated injuries included bony injury in 35.1% of cases, nerve injury in 7.6%, and remote affecting the head, chest, or abdomen in 3.6%. Surgery was carried out on 96.2% of cases with a limb salvage rate of 83.8% and a survival of 98.5%. In spite of a rising trend in LLAI, our total and delayed amputation rates remained stable. On stepwise logistic regression analysis, significant (P <.01) independent risk factors for amputation were occluded graft (odds ratio [OR] 16.7), combined above- and below-knee injury (OR 4.4), tense compartment (OR 4.2), arterial transsection (OR 2.8), and associated compound fracture (OR 2.7). CONCLUSION: LLAI carries a high amputation rate. Stab injuries are the least likely to lead to amputations, whereas high-velocity firearm injuries are the most likely to do so. The most significant independent risk factor for limb loss was failed revascularization.     

Penetrating cardiac injuries: predictive model for outcomes based on 2016 patients from the National Trauma Data Bank

Background

Penetrating cardiac injuries are uncommon and lethal. The objectives of this study are to examine the national profile of cardiac injuries, identify independent predictors of outcome, generate, compare and validate previous predictive models for outcomes. We hypothesized that National Trauma Data Bank (NTDB) given its large number of patients, would validate these models.

Methods

The NTDB was queried for data on cardiac injuries, using survival as the main outcome measure. Statistical analysis was performed utilizing univariate and stepwise logistic regression. The stepwise logistic regression model was then compared with other predictive models of outcome.

Results

There were 2016 patients with penetrating cardiac injuries identified from 1,310,720 patients. Incidence: 0.16%. Mechanism of injury: GSWs—1264 (63%), SWs—716 (36%), Shotgun/impalement—19/16 (1%). Mean RTS 1.75, mean ISS 27 ± 23. Overall survival 675 (33%). 830 patients (41%) underwent ED thoracotomy, 47 survived (6%). Survival stratified by mechanism: GSWs 114/1264 (10%), SWs 564/717 (76%). Predictors of outcome for mortality—univariate analysis: vital signs, RTS, ISS, GCS: Field CPR, ED intubation, ED thoracotomy and aortic cross-clamping (p < 0.001). Stepwise logistic regression identified cardiac GSW’s (p < 0.001; AOR 26.85; 95% CI 17.21–41.89), field CPR (p = 0.003; AOR 3.65; 95% CI 1.53–8.69), the absence of spontaneous ventilation (p = 0.008; AOR 1.08, 95% CI 1.02–1.14), the presence of an associated abdominal GSW (p = 0.009; AOR 2.58, 95% CI 1.26–5.26) need for ED airway (p = 0.0003 AOR 1386.30; 95% CI 126.0–15251.71) and aortic cross-clamping (p = 0.0003 AOR 0.18; 95% CI 0.11–0.28) as independent predictors for mortality. Overall predictive power of model—93%.

Conclusion

Predictors of outcome were identified. Overall survival rates are lower than prospective studies report. Predictive model from NTDB generated larger number of strong independent predictors of outcomes, correlated and validated previous predictive models.

     

Survival prediction of trauma patients: a study on US National Trauma Data Bank

Background

Exceptional circumstances like major incidents or natural disasters may cause a huge number of victims that might not be immediately and simultaneously saved. In these cases it is important to define priorities avoiding to waste time and resources for not savable victims. Trauma and Injury Severity Score (TRISS) methodology is the well-known and standard system usually used by practitioners to predict the survival probability of trauma patients. However, practitioners have noted that the accuracy of TRISS predictions is unacceptable especially for severely injured patients. Thus, alternative methods should be proposed.

Methods

In this work we evaluate different approaches for predicting whether a patient will survive or not according to simple and easily measurable observations. We conducted a rigorous, comparative study based on the most important prediction techniques using real clinical data of the US National Trauma Data Bank.

Results

Empirical results show that well-known Machine Learning classifiers can outperform the TRISS methodology. Based on our findings, we can say that the best approach we evaluated is Random Forest: it has the best accuracy, the best area under the curve, and k-statistic, as well as the second-best sensitivity and specificity. It has also a good calibration curve. Furthermore, its performance monotonically increases as the dataset size grows, meaning that it can be very effective to exploit incoming knowledge. Considering the whole dataset, it is always better than TRISS. Finally, we implemented a new tool to compute the survival of victims. This will help medical practitioners to obtain a better accuracy than the TRISS tools.

Conclusion

Random Forests may be a good candidate solution for improving the predictions on survival upon the standard TRISS methodology.

     

Factors associated with mortality in trauma: re-evaluation of the TRISS method using the National Trauma Data Bank

BACKGROUND: TRISS remains a standard method for predicting survival and correcting for severity in outcome analysis. The National Trauma Data Bank (NTDB) is emerging as a major source of trauma data that will be used for both primary research and outcome benchmarking. We used NTDB data, to determine whether TRISS is still an accurate predictor of survival coefficients and to determine whether the ability of TRISS to predict survival could be improved by updating the coefficients or by building predictive models that include information on co-morbidities. METHODS: To compare the utility of different methods of TRISS calculation we identified the records of 72,517 trauma patients (62,103 blunt trauma and 10,414 penetrating trauma) who had complete information for all of the covariates to be considered in the analysis. Multiple logistic regression was used to recalculate the TRISS coefficients in models using both the original TRISS covariates and in models which also included variables for co-morbidities that could potentially affect survival. Model discrimination was evaluated by calculating the area under the receiver operating characteristic curves (AUC), and model calibration was evaluated with the Hosmer-Lemeshow Goodness-of-Fit Statistic (H-L). RESULTS: For penetrating trauma the original TRISS equation had good discriminative ability (AUC=0.98), but was poorly calibrated (H-L=267.04). When logistic regression was used to generate revised coefficients, discrimination was unchanged, but calibration improved (H-L=38.66). The only co-morbid factor significantly associated with survival after penetrating trauma was acute alcohol consumption, which was associated with increased survival (p < 0.0001). However, its inclusion in a logistic model did not improve discrimination, but improved calibration somewhat (AUC =0.98; H-L=19.95). The original TRISS equation was a less accurate predictor of survival after blunt trauma (AUC = 0.84; H-L= 10,720.7). When logistic regression was used to generate revised coefficients for the original TRISS covariates, predictions after blunt trauma improved (AUC = 0.94; H-L=25.45). With blunt trauma, acute alcohol consumption and prior hypertension were associated with increased survival, and male gender, congestive failure, cirrhosis, and prior myocardial infarction were associated with decreased survival. However, inclusion of these covariates in a logistic model did not improve predictions of survival (AUC = 0.94; H-L= 34.83). CONCLUSIONS: In the NTDB the traditional TRISS had limited ability to predict survival after trauma. Accuracy of prediction was improved by recalculating the TRISS coefficients, but further improvements were not seen with models that included information about co-morbidities.     

Management and hospital outcomes of blunt renal artery injuries: analysis of 517 patients from the National Trauma Data Bank

BACKGROUND: Blunt renal artery injuries are rare and no single trauma center can accumulate substantial experience for meaningful conclusions about optimal therapeutic strategies. The purpose of this study was to assess the incidence of renal artery injuries after different types of blunt trauma, and evaluate the current therapeutic approaches practiced by American trauma surgeons and the effect of various therapeutic modalities on hospital outcomes. STUDY DESIGN: This was a National Trauma Data Bank study including all blunt trauma admissions with renal artery injuries. Demographics, mechanism of injury, Injury Severity Score, Abbreviated Injury Score for each body area (head, chest, abdomen, extremities) injuries, type of management (nephrectomy, arterial reconstruction, or observation), time from admission to definitive treatment, and hospital outcomes (mortality, ICU, and hospital stay) were analyzed. Multiple and logistic regression analyses were used to examine the relationship between type of management and hospital outcomes. RESULTS: Of a total of 945,326 blunt trauma admissions, 517 patients (0.05%) had injuries to the renal artery. Of the 517 patients, the kidney was not explored in 376 (73%), 95 (18%) patients had immediate nephrectomy, and 45 (9%) patients underwent surgical revascularization. In 87 of 517 (17%) patients, renal artery injury was the only intraabdominal injury. Of the 87 patients with isolated renal artery injuries, 73 (84%) were observed, 7 (8%) underwent surgical revascularization, and 7 (8%) had early nephrectomy. Multiple regression analysis demonstrated that patients who had surgical revascularization had a considerably longer ICU and hospital stay than observed patients. Patients who had nephrectomy had a considerably longer hospital stay than observed patients. CONCLUSIONS: Blunt renal artery injury is rare. Nonoperative management should be considered as an acceptable therapeutic option.     

Patterns of injury and functional outcome after hanging: analysis of the National Trauma Data Bank

PURPOSE: Hanging has become the second most common method of attempted suicide among adolescents, but there is little relevant epidemiologic or outcome data in the trauma literature. Additionally, there are no studies examining the degree of functional disability among survivors of hanging injury. METHODS: The National Trauma Data Bank was queried for all patients with an E-code diagnosis of hanging injury. Demographic and injury pattern data were analyzed. Disability at discharge was assessed using the functional independence measure (FIM) scores for feeding, locomotion, and expression (range 1 = full disability to 4 = no disability). Univariate and multivariate analysis was performed to identify independent predictors of mortality and degree of functional disability at discharge. RESULTS: There were 655 patients identified (84% male) with a mean age of 30.3 years and mean injury severity score (ISS) of 9. There were 92 (14%) deaths in the emergency department (ED) and 119 (18%) deaths after admission, for an overall mortality rate of 33%. Excluding ED deaths, survivors had significantly higher Glasgow coma scores (GCS) at the scene (8 vs. 4) and in the ED (9 vs. 3), a lower ED base deficit (4 vs. 9), and lower ISS (6 vs. 15, all P < .01) compared with nonsurvivors. The strongest independent predictor of hospital mortality was ED GCS <15 (odds ratio 16.1, P < .01); the mortality rate was 1.5% for patients with an ED GCS of 15 versus 29% for any GCS <15. Of patients who survived to discharge (n = 277), 84% were functionally independent (total FIM = 12), and 10% had severe functional disabilities in feeding, expression, or locomotion (FIM <3). Patients with severe disability had a higher incidence of intracranial (38% vs. 19%) and chest injury (19% vs. 5%) but surprisingly demonstrated equivalent rates of vascular (0% vs. 2.6%) and spinal injury (11% vs. 12%) compared with those without severe disability. Independent predictors of functional outcome were ISS and ED GCS (both P < .01). There was no severe functional disability at discharge among patients with an ED GCS of 15 compared with a 15% severe disability rate if the ED GCS was <15. CONCLUSIONS: Hanging injuries are associated with a high overall mortality rate, with the admission GCS being the best independent predictor of outcome. However, the majority of survivors have little to no functional disability. The presence of severe disability at discharge is mainly attributed to intracranial and thoracic injury.     

Timing of mortality in pediatric trauma patients: A National Trauma Data Bank analysis

Background/purpose

The classic “trimodal” distribution of death has been described in adult patients, but the timing of mortality in injured children is not well understood. The purpose of this study was to define the temporal distribution of mortality in pediatric trauma patients.

Epidemiology of pediatric cardiac injuries: a National Trauma Data Bank analysis

Background

Few studies of pediatric cardiac injuries have been conducted in large cohorts. We, therefore, investigated the epidemiology of these injuries in the United States.

Methods

We identified patients with traumatic cardiac injury from the National Trauma Data Bank, using the International Classification of Diseases, Ninth Revision, codes. Demographic data, clinical data, and inhospital outcomes were compared among 5 age groups. A logistic regression model was used to determine adjusted mortality among these groups.

Results

Six hundred twenty-six patients met criteria. Fifty-nine percent sustained cardiac contusion; 36%, laceration. Penetrating injuries proved more severe than blunt, having lower average Glasgow Coma Scale (6.8 vs 8.7) and higher percentage of patients with Glasgow Coma Scale of 8 or lower (68% vs 53%). Associated injuries occurred in 484 (77%), most common being lung injuries (46%), hemopneumothorax (37%), and rib fractures (26%). Eleven percent underwent laparotomy; 9%, thoracotomy; 2%, craniotomy/craniectomy; and 0.2%, sternotomy. Complications occurred in 80 (13%), most common being cardiac arrest (4%). Firearm injuries result in the highest mortality rate (76%), compared with other mechanisms (26%-31%). Crude mortality in different age strata showed significant differences that were lost after adjustment for confounding variables.

Conclusions

The predominant cardiac injury was blunt (65%; 35% sustained penetrating insults), frequently paired with contusion. Pediatric cardiac injury is associated with excessive inhospital mortality (40%), with no age-related difference in adjusted mortality.