Fibrinogen is an independent predictor of mortality in major trauma patients: A five-year statewide cohort study

IntroductionFibrinogen may be reduced following traumatic injury due to loss from haemorrhage, increased consumption and reduced synthesis. In the absence of clinical trials, guidelines for fibrinogen replacement are based on expert opinion and vary internationally. We aimed to determine prevalence and predictors of low fibrinogen on admission in major trauma patients and investigate association of fibrinogen levels with patient outcomes.Patients and methodsData on all major trauma patients (January 2007–July 2011) identified through a prospective statewide trauma registry in Victoria, Australia were linked with laboratory and transfusion data. Major trauma included any of the following: death after injury, injury severity score (ISS) >15, admission to intensive care unit requiring mechanical ventilation, or urgent surgery for intrathoracic, intracranial, intra-abdominal procedures or fixation of pelvic or spinal fractures. Associations between initial fibrinogen level and in-hospital mortality were analysed using multiple logistic regression.ResultsOf 4773 patients identified, 114 (2.4%) had fibrinogen less than 1 g/L, 283 (5.9%) 1.0–1.5 g/L, 617 (12.9%) 1.6–1.9 g/L, 3024 (63.4%) 2–4 g/L and 735 (15%) >4 g/L. Median fibrinogen was 2.6 g/L (interquartile range 2.1–3.4). After adjusting for age, gender, ISS, injury type, pH, temperature, Glasgow Coma Score (GCS), initial international normalised ratio and platelet count, the lowest fibrinogen categories, compared with normal range, were associated with increased in-hospital mortality (adjusted odds ratio [OR] for less than 1 g/L 3.28 [95% CI 1.71–6.28, p < 0.01], 1–1.5 g/L adjusted OR 2.08 [95% CI 1.36–3.16, p < 0.01] and 1.6–1.9 g/L adjusted OR 1.39 [95% CI 0.97–2.00, p = 0.08]). Predictors of initial fibrinogen <1.5 g/L were younger age, lower GCS, systolic blood pressure <90 mmHg, chest decompression, penetrating injury, ISS >25 and lower pH and temperature.ConclusionsInitial fibrinogen levels less than the normal range are independently associated with higher in-hospital mortality in major trauma patients. Future studies are warranted to investigate whether earlier and/or greater fibrinogen replacement improves clinical outcomes.     

Decreased mortality in patients with isolated severe blunt traumatic brain injury receiving higher plasma to packed red blood cells transfusion ratios

IntroductionHigher transfusion ratios of plasma to packed red blood cells (PRBC) and platelets (PLT) to PRBC have been shown to be associated with decreased mortality in major trauma patients. However, little is known about the effect of transfusion ratios on mortality in patients with isolated severe traumatic brain injury (TBI). The aim of this study was to investigate the effect of transfusion ratios on mortality in patients with isolated severe blunt TBI. We hypothesized that higher transfusion ratios of plasma to PRBC and PLT to PRBC are associated with a lower mortality rate in these patients.MethodsRetrospective observational study. Patients with isolated severe blunt TBI (AIS head ≥ 3, AIS extracranial < 3) admitted to an urban level I trauma centre were included. Clinical data were extracted from the institution’s trauma registry, blood transfusion data from the blood bank database. The effect of higher transfusion ratios on in-hospital mortality was analysed using univariate and multivariable regression analysis.ResultsA total of 385 patients were included. Median age was 32 years (IQR 2–50), 71.4% were male, and 76.6% had an ISS ≥ 16. Plasma:PRBC transfusion ratios ≥ 1 were identified as an independent predictor for decreased in-hospital mortality (adjusted OR 0.43 [CI 0.22–0.81]). PLT:PRBC transfusion ratios ≥ 1 were not significantly associated with mortality (adjusted OR 0.39 [CI 0.08–1.92]).ConclusionThis study revealed plasma to PRBC transfusion ratios ≥ 1 as an independent predictor for decreased in-hospital mortality in patients with isolated severe blunt TBI.     

A modified Kampala trauma score (KTS) effectively predicts mortality in trauma patients

BackgroundMortality prediction in trauma patients has relied upon injury severity scoring tools focused on anatomical injury. This study sought to examine whether an injury severity scoring system which includes physiologic data performs as well as anatomic injury scores in mortality prediction.MethodsUsing data collected from 18 Level I trauma centers and 51 non-trauma center hospitals in the US, anatomy based injury severity scores (ISS), new injury severity scores (NISS) were calculated as were scores based on a modified version of the physiology-based Kampala trauma score (KTS). Because pre-hospital intubation, when required, is standard of care in the US, a modified KTS was calculated excluding respiratory rate. The predictive ability of the modified KTS for mortality was compared with the ISS and NISS using receiver operating characteristic (ROC) curves.ResultsA total of 4716 individuals were eligible for study. Each of the three scores was a statistically significant predictor of mortality. In this sample, the modified KTS significantly outperformed the ISS (AUC = 0.83, 95% CI 0.81–0.84 vs. 0.77, 95% CI 0.76–0.79, respectively) and demonstrated similar predictive ability compared to the NISS (AUC = 0.83, 95% CI 0.81–0.84 vs. 0.82, 95% CI 0.80–0.83, respectively).ConclusionsThe modified KTS may represent a useful tool for assessing trauma mortality risk in real time, as well as in administrative data where physiologic measures are available. Further research is warranted and these findings suggest that the collection of physiologic measures in large databases may improve outcome prediction.     

Prediction of intra-hospital mortality after severe trauma: which pre-hospital score is the most accurate?

PurposeComputing trauma scores in the field allows immediate severity assessment for appropriate triage. Two pre-hospital scores can be useful in this context: the Triage-Revised Trauma Score (T-RTS) and the Mechanism, Glasgow, Age and arterial Pressure (MGAP) score. The Trauma Revised Injury Severity Score (TRISS), not applicable in the pre-hospital setting, is the reference score to predict in-hospital mortality after severe trauma. The aim of this study was to compare T-RTS, MGAP and TRISS in a cohort of consecutive patients admitted in the Trauma system of the Northern French Alps(TRENAU).Materials and methodsFrom 2009 to 2011, 3260 patients with suspected severe trauma according to the Vittel criteria were included in the TRENAU registry. All data necessary to compute T-RTS, MGAP and TRISS were collected in patients admitted to one level-I, two level-II and ten level-III trauma centers. The primary endpoint was death from any cause during hospital stay. Discriminative power of each score to predict mortality was measured using receiver operating curve (ROC) analysis. To test the relevancy of each score for triage, we also tested their sensitivity at usual cut-offs. We expected a sensitivity higher than 95% to limit undertriage.ResultsThe TRISS score showed the highest area under the ROC curve (0.95 [CI 95% 0.94–0.97], p < 0.01). Pre-hospital MGAP score had significantly higher AUC compared to T-RTS (0.93 [CI 95% 0.91–0.95] vs 0.86 [CI 95% 0.83–0.89], respectively, p < 0.01). MGAP score < 23 had a sensitivity of 88% to detect mortality. Sensitivities of T-RTS < 12 and TRISS < 0.91 were 79% and 87%, respectively.Discussion/conclusionPre-hospital calculation of the MGAP score appeared superior to T-RTS score in predicting intra-hospital mortality in a cohort of trauma patients. Although TRISS had the highest AUC, this score can only be available after hospital admission. These findings suggest that the MGAP score could be of interest in the pre-hospital setting to assess patients’ severity. However, its lack of sensitivity indicates that MGAP should not replace the decision scheme to direct the most severe patients to level-I trauma center.     

Management of paediatric splenic injury in the New South Wales trauma system

Since the 1980’s, paediatric surgeons have increasingly managed blunt splenic injury (BSI) in children non-operatively. However, studies in North America have shown higher operation rates in non-paediatric centres and by adult surgeons. This association has not been examined elsewhere.ObjectiveTo investigate the management of BSI in New South Wales (NSW) children, to determine the patient and hospital factors related to the odds of operation. Secondarily, to investigate whether the likelihood of operation varied by year.MethodsChildren age 0–16 admitted to a NSW hospital between July 2000 and December 2011 with a diagnosis of BSI were identified in the NSW Admitted Patient Data Collection, and linked to deaths data from Registry of Births Deaths and Marriages, and Bureau of Statistics. The operation rate was calculated and compared between different hospital types. Univariable analysis was used to determine patient and hospital factors associated with operative management. The difference in the odds of operation between the oldest data (July 2000–December 2005) and most recent (January 2006–December 2011) was also examined. Multivariable logistic regression with stepwise elimination was then performed to determine likelihood of operative management according to hospital category and era, adjusting for potential confounders.Results955 cases were identified, with 101(10.6%) managed operatively. On multivariable analysis, factors associated with operation included age (OR 1.11, 95% CI 1.01–1.18, p < 0.05), massive splenic disruption (OR 3.10, 95% CI 1.61–6.19, p < 0.001), hollow viscus injury (OR 11.03, 95% CI 3.46–34.28, p < 0.001) and transfusion (OR 7.70, 95% CI 4.54–13.16, p < 0.001). Management outside a paediatric trauma centre remained significantly associated with operation, whether it be metropolitan adult trauma centre (OR 4.22 95% CI 1.70–10.52, p < 0.01), rural trauma centre (OR 3.72 95% CI 1.83–7.83, p < 0.001) or metropolitan local hospital (OR 5.23, 95% CI 1.22–18.93 p < 0.05). Comparing the 2 eras, the overall operation rate fell, although not significantly, from 12.9% to 8.7% (OR 1.3, 95% CI 0.89–243 p = 0.13)ConclusionWhile Paediatric Surgeons have wholeheartedly adopted non-operative management, away from paediatric centres, children in NSW are still being operated on for BSI unnecessarily. While the factors at play may be complex, further evaluation of the management and movement of injured children within the broad NSW trauma system is required.     

Survival and health related quality of life after severe trauma − a 15 years follow up study

IntroductionAs the primary treatment of patients with severe trauma continues to improve, increasing interest has been directed towards long-term survival and Health Related Quality of Life (HRQoL). In trauma patients, there are few studies describing long-term outcome using tools specifically directed at HRQoL.HypothesisHRQoL measured with EQ-5D is significantly reduced compared to the Danish norm score 15 years after severe injury.Materials and methodsAll patients more than 18 years of age, admitted to a level 1 trauma center from March 1996 to September 1997 were prospectively included and scored with Injury Severity Score (ISS). Survival status was recorded in May 2012 and EQ-5D questionnaires were sent out.Results95 of the original 154 trauma patients were eligible for participation. The response rate was 66%. The average EQ-5D index score in the trauma population was significantly reduced compared to the index score in the Danish norm population (P = 0.00, one-sample t-test). In addition, ISS is associated with HRQoL and ISS ≥ 16 predicts poorer HRQoL.ConclusionEQ-5D is significantly reduced 15 years after severe trauma High ISS was associated with low HRQoL. Knowledge of the distribution and predictors of long-term disability can be used to develop more efficient prevention policies and to improve trauma care in general.     

Hypothermia indices among severely injured trauma patients undergoing urgent surgery: A single-centred retrospective quality review and analysis

BackgroundHypothermia (<36 °C) exacerbates trauma-induced coagulopathy and worsens morbidity and mortality among severely injured trauma patients; there is a paucity of published data describing how well trauma centres adhere to standards regarding measurement of temperature, and best practices for preventing and treating hypothermia.MethodsWe completed a retrospective quality audit of all severely injured trauma patients (Injury Severity Score (ISS ≥ 20)) who had urgent surgery at Sunnybrook Health Sciences Centre (SHSC) between 2010 and 2014. Information regarding temperature monitoring was evaluated over the course of the initial resuscitation and admission. Independent risk factors for in-hospital mortality were elucidated through a multivariable regression analysis.ResultsOut of a total of 4492 trauma patients, 495 were severely-injured and went to the operating room (OPR) after being treated in the trauma bay (TB) at SHSC between 2010 and 2014. The majority of the patients were male (n = 384, 77.6%) and had a blunt mechanism of injury (n = 391, 79.0%). The median ISS score was 29 (interquartile range (IQR) 26, 35). Eighty-nine (17.9%) patients died; 26 (5.2%) of these patients died intra-operatively. Less than one fifth of patients (n = 82,16.6%) received a temperature measurement during pre-hospital transport phase. Upon arrival to the TB, almost two-thirds (n = 301, 60.8%) of patients had their temperature recorded and a similar proportion (n = 175, 58.1%) of those patients were hypothermic (<36 °C). In the OPR, close to 80% (n = 389, 78.6%) of patients had their temperature measured on both arrival; almost 60% (n = 223, 57.3%) were hypothermic on arrival. Almost all patients had their temperature measured upon arrival to the ICU or specialized ward (n = 450, 98.3%). Warming initiatives were documented in only 36 (7.3%) patients in the TB, yet documented in almost all patients in OR (n = 464, 93.7%). An increased risk of in-hospital mortality was correlated with not taking a temperature measurement in the TB (Odds Ratio (OR) 2.86 (95% Confidence Interval (CI) [1.64–4.99]) or OPR (OR 4.66 (95% CI [2.50–8.69]).ConclusionsA majority of severely injured trauma patients are hypothermic well into the perioperative period after initial admission. An absence of having temperature measurement during initial hospitalization is associated with increased in-hospital mortality amongst this patient group. Quality improvement initiatives should aim to strive for ongoing temperature measurement as a key performance indicator and early prevention and treatment of hypothermia during initial resuscitation.     

Perioperative hypotension and discharge outcomes in non-critically injured trauma patients,a single centre retrospective cohort study

BackgroundThere is a lack of information on the effect of age on perioperative care and outcomes after minor trauma in the elderly. We examined the association between perioperative hypotension and discharge outcome among non-critically injured adult patients.MethodsWe conducted a retrospective study of non-critically ill patients (ISS <9 or discharged within less than 24 h) who received anaesthesia care for surgery and Recovery Room care at a level-1 trauma centre between 5/1/2012 and 11/30/2013. Perioperative hypotension was defined as systolic blood pressure (SBP) <90 mmHg (traditional measure) for all patients, and SBP <110 mmHg (strict measure) for patients ≥65 years. Poor outcome was defined as death or discharge to skilled nursing facility/hospice.Results1744 patients with mean ISS 4.4 across age groups were included; 169 (10%) were ≥65 years. Among patients ≥ 65 years, intraoperative hypotension occurred in >75% (131/169, traditional measure) and in >95% (162/169, strict measure); recovery room hypotension occurred in 2% (4/169) and 29% (49/169), respectively. Mean age-adjusted anaesthetic agent concentration (MAC) was similar across age groups. Opioid use decreased from 9.3 (SD 5.7) mg/h morphine equivalents in patients <55 years to 6.2 (SD 4.0) mg/h in patients over 85 years. Adjusted for gender, ASA score, anaesthesia duration, morphine equivalent/hr, fluid balance, MAC and surgery type, and using traditional definition, older patients were more likely than patients <55 to experience perioperative hypotension: aRR 1.21, 95% CI 1.11–1.30 for 55–64 and aRR 1.19, 95% CI 1.07–1.32 for ages 65–74. Perioperative hypotension was associated with poor discharge outcome (aRR 1.55; 95% CI 1.04–2.31 and aRR 1.87; 95% CI 1.17–2.98, respectively).ConclusionDespite age related reduction in doses of volatile anaesthetic and opioids administered during anaesthesia care, and regardless of hypotension definition used, non-critically injured patients undergoing surgery experience a large perioperative hypotension burden. This burden is higher for patients 55–74 years and older and is a risk factor for poor discharge outcomes, independent of age and ASA status.     

The impact of the Major Trauma Network: will trauma units continue to treat complex foot and ankle injuries?

IntroductionApril 1st 2012 saw the introduction of National Trauma Networks in England. The aim to optimise the management of major trauma. Patients with an ISS ≥ 16 would be transferred to the regional Major Trauma Centre (level 1). Our premise was that trauma units (level 2) would no longer manage complex foot and ankle injuries thereby obviating the need for a foot and ankle specialist service.MethodsRetrospective analysis of the epidemiology of foot and ankle injuries, using the Gloucestershire trauma database, from a trauma unit with a population of 750,000. Rates of open fractures, complex foot and ankle injuries and requirement for stabilisation with external fixation were reviewed before and after the introduction of the regional Trauma Network. Secondly, using the Trauma Audit & Research Network (TARN) database, all foot and ankle injuries triaged to the regional Major Trauma Centre (MTC) were reviewed.ResultsIncidence of open foot and ankle injuries was 2.9 per 100,000 per year. There were 5.1% open injuries before the network and 3.2% after (p > 0.05). Frequency of complex foot and ankle injuries was 4.2% before and 7.5% after the network commenced, showing no significant change. There was no statistically significant change in the numbers of patients with complex foot and ankle injuries treated by application of external fixators. Analysis of TARN data revealed that only 18% of patients with foot and ankle injuries taken to the MTC had an ISS ≥ 16. The majority of these patients were identified as requiring plastic surgical intervention for open fractures (69%) or were polytrauma patients (43%). Only 4.5% of patients had isolated, closed foot and ankle injuries.ConclusionWe found that at the trauma unit there was no decrease in the numbers of complex foot and ankle injuries, open fractures, or the applications of external fixators, following the introduction of the Trauma Network. These patients will continue to attend trauma units as they usually have an ISS < 16. Our findings suggest that there is still a need for foot and ankle specialists at trauma units, in order to manage patients with complex foot and ankle injuries.     

Trends in 1029 trauma deaths at a level 1 trauma center: Impact of a bleeding control bundle of care

BackgroundOver the last decade the age of trauma patients and injury mortality has increased. At the same time, many centers have implemented multiple interventions focused on improved hemorrhage control, effectively resulting in a bleeding control bundle of care. The objective of our study was to analyze the temporal distribution of trauma-related deaths, the factors that characterize that distribution and how those factors have changed over time at our urban level 1 trauma center.MethodsRecords at an urban Level 1 trauma center were reviewed. Two time periods (2005–2006 and 2012–2013) were included in the analysis. Mortality rates were directly adjusted for age, gender and mechanism of injury. The Mann-Whitney and chi square tests were used to compare variables between periods, with significance set at 0.05.Results7080 patients (498 deaths) were examined in 2005–2006, while 8767 patients (531 deaths) were reviewed in 2012–2013. The median age increased 6 years, with a similar increase in those who died. In patients that died, no differences by gender, race or ethnicity were observed. Fall-related deaths are now the leading cause of death. Traumatic brain injury (TBI) and hemorrhage accounted for >91% of all deaths. TBI (61%) and multiple organ failure or sepsis (6.2%) deaths were unchanged, while deaths associated with hemorrhage decreased from 36% to 25% (p < 0.01). Across time periods, 26% of all deaths occurred within one hour of hospital arrival, while 59% occurred within 24 h. Unadjusted mortality dropped from 7.0% to 6.1 (p = 0.01) and in-hospital mortality dropped from 6.0% to 5.0% (p < 0.01). Adjusted mortality dropped 24% from 7.6% (95% CI: 6.9–8.2) to 5.8% (95% CI: 5.3–6.3) and in-hospital mortality decreased 30% from 6.6% (95% CI: 6.0–7.2) to 4.7 (95% CI: 4.2–5.1).ConclusionsOver the same time frame of this study, increases in trauma death across the globe have been reported. This single-site study demonstrated a significant reduction in mortality, attributable to decreased hemorrhagic death. It is possible that efforts focused on hemorrhage control interventions (a bleeding control bundle) resulted in this reduction. These changing factors provide guidance on future prevention and intervention efforts.     

Burn induced nervous system morbidity among burn and non-burn trauma patients compared with non-injured people

ObjectiveBurns cause acute damage to the peripheral nervous system with published reports identifying that neurological changes after injury remain for a prolonged period. To shed some light on potential mechanisms, we assessed injury etiology and patterns of nervous system morbidity after injury by comparing long-term hospital admissions data of burns patients and other non-burn trauma patients with uninjured people.MethodsLinked hospital and death data of a burn patient cohort (n = 30,997) in Western Australia during the period 1980–2012 were analysed along with two age and gender frequency matched comparison cohorts: non-burn trauma patients (n = 28,647) and; non-injured people (n = 123,399). The number of annual NS disease admissions and length of stay (LOS) were used as outcome measures. Multivariable negative binomial regression modelling was used to derive adjusted incidence rate ratios and 95% confidence intervals (IRR, 95% CI) and adjusted Cox regression models and hazard ratios (HR) were used to examine time to first nervous system admission after burn and incident admission rates.ResultsThe most common peripheral nervous system condition identified in each cohort (burn, non-burn trauma, uninjured) were episodic and paroxysmal disorders followed by nerve root and plexus disorders and polyneuropathies/peripheral NS conditions. Significantly elevated admission rates for NS conditions (IRR, 95% CI) were found for the burn (2.20, 1.86–2.61) and non-burn trauma (1.85, 1.51–2.27), compared to uninjured. Peripheral nervous system admission rates after injury (IRR, 95% CI) were significantly higher regardless of age at time of injury for the burn (<15years: 1.97, 1.49–2.61; 15–45: 2.70, 2.016–3.55; ≥45 year: 1.62, 1.33–1.97) and non-burn trauma cohorts (<15years: 1.91, 1.55–2.35; 15–45: 1.94, 1.51–2.49; ≥45 year: 1.42, 1.18–1.72), when compared to the uninjured. Significantly higher rates of incident NS hospitalisations were found for the burn cohort vs. uninjured cohort for a period of 15-years after discharge (0–5 years: HR, 95% CI: 1.97, 1.75–2.22; 5–15 years; HR, 95% CI: 1.44, 1.28–1.63). The non-burn trauma cohort had significantly higher incident nervous system admissions for 10 years after discharge (0–30 days: HR, 95% CI: 4.75, 2.44–9.23; 30 days to 1-year HR, 95% CI: 2.95, 2.34–3.74; 1–5 years; HR, 95% CI: 1.47, 1.26–1.70; 5–10 years; HR, 95% CI: 1.34, 1.13–1.58).ConclusionsResults suggest that injury patients are at increased risk of peripheral nervous system morbidity after discharge for a prolonged period of time. The time patterns associated with incident nervous system conditions suggest possible differences in underlying pathology and long-term patient care needs. Further research is needed to elucidate the underlying neuropathology.     

Diagnostic accuracy of the Kampala Trauma Score using estimated Abbreviated Injury Scale scores and physician opinion

BackgroundThe Kampala Trauma Score (KTS) has been proposed as a triage tool for use in low- and middle-income countries (LMICs). This study aimed to examine the diagnostic accuracy of KTS in predicting emergency department outcomes using timely injury estimation with Abbreviated Injury Scale (AIS) score and physician opinion to calculate KTS scores.MethodsThis was a diagnostic accuracy study of KTS among injured patients presenting to Komfo Anokye Teaching Hospital A&E, Ghana. South African Triage Scale (SATS); KTS component variables, including AIS scores and physician opinion for serious injury quantification; and ED disposition were collected. Agreement between estimated AIS score and physician opinion were analyzed with normal, linear weighted, and maximum kappa. Receiver operating characteristic (ROC) analysis of KTS-AIS and KTS-physician opinion was performed to evaluate each measure’s ability to predict A&E mortality and need for hospital admission to the ward or theatre.ResultsA total of 1053 patients were sampled. There was moderate agreement between AIS criteria and physician opinion by normal (κ = 0.41), weighted (κ_lin = 0.47), and maximum (κ_max = 0.53) kappa. A&E mortality ROC area for KTS-AIS was 0.93, KTS-physician opinion 0.89, and SATS 0.88 with overlapping 95% confidence intervals (95%CI). Hospital admission ROC area for KTS-AIS was 0.73, KTS-physician opinion 0.79, and SATS 0.71 with statistical similarity. When evaluating only patients with serious injuries, KTS-AIS (ROC 0.88) and KTS-physician opinion (ROC 0.88) performed similarly to SATS (ROC 0.78) in predicting A&E mortality. The ROC area for KTS-AIS (ROC 0.71; 95%CI 0.66–0.75) and KTS-physician opinion (ROC 0.74; 95%CI 0.69–0.79) was significantly greater than SATS (ROC 0.57; 0.53–0.60) with regard to need for admission.ConclusionsKTS predicted mortality and need for admission from the ED well when early estimation of the number of serious injuries was used, regardless of method (i.e. AIS criteria or physician opinion). This study provides evidence for KTS to be used as a practical and valid triage tool to predict patient prognosis, ED outcomes and inform referral decision-making from first- or second-level hospitals in LMICs.     

CT scan and Diagnostic Peritoneal Lavage: towards a better diagnosis in the area of nonoperative management of blunt abdominal trauma

BackgroundThe diagnosis of small bowel and mesenteric injuries (BBMI) after blunt abdominal trauma remains difficult, which results in delayed treatment and increased mortality and morbidity. Diagnostic peritoneal lavage (DPL) in patients with 1 or 2 abnormal CT findings that are suggestive of BBMI was proposed, but the rate of unnecessary surgical exploration remains high.Patients and methodsBlunt abdominal trauma patients with 1 or 2 CT findings predictive of BBMI from 2001 to 2014 underwent a DPL with calculation of a cell count ratio (CCR) dividing the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid by the WBC/RBC ratio in peripheral blood. Surgical exploration of the abdomen was performed immediately in cases with a CCR ≥ 1. CT findings, DPL and surgery results, and global outcome were analyzed.ResultsThirty-seven were included in the study (27 males, median age of 30 years (range, 17–69 years)). Exploratory laparotomy was performed in 24 patients (65%). Sixteen patients (67%) had BBMI: 7 hollow organ perforations or tears (29%), including 4 bowel resection with primary anastomosis and 3 single sutures, and 9 patients had mesenteric injuries. CT findings associated with BBMI and hollow organ perforation were large peritoneal effusion (p = 0.02) and small bowel wall abnormalities (p = 0.002). No postoperative complications were observed. Sensitivity and specificity of DPL for the diagnosis of bowel injuries were respectively 100% (CI 95% [59–100]) and 43% (CI 95% [25–63]). The sensitivity remained 100% (CI 95% [59–100]) when the ratio was ≥4 (n = 10 patients), and the specificity reached 90% (CI 95% [73–98]).ConclusionDPL is sensitive for the diagnosis of BBMI in stable trauma patients with 1 or 2 unexplained CT abnormalities, but specificity is low with a high rate of nontherapeutic laparotomy in case of CCR ≥ 1. Indications for exploratory laparotomy could be restricted to patients with a CCR ≥ 4 to improve the specificity of diagnosis management.     

Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients

BackgroundVarious scoring systems have been developed to predict need for massive transfusion in traumatically injured patients. Assessments of Blood Consumption (ABC) score and Shock Index (SI) have been shown to be reliable predictors for Massive Transfusion Protocol (MTP) activation. However, no study has directly compared these two scoring systems to determine which is a better predictor for MTP activation. The primary objective was to determine whether ABC or SI better predicted the need for MTP in adult trauma patients with severe hemorrhage.MethodsThis was a retrospective cohort study which included all injured patients who were trauma activations between January 1, 2009 and December 31, 2013 at an urban Level I trauma center. Patients <18 years old or with traumatic brain injury (TBI) were excluded. ABC and SI were calculated for each patient. MTP was defined as need for >10 units PRBC transfusion within 24 h of emergency department arrival. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) were used to evaluate scoring systems’ ability to predict effective MTP utilization.ResultsA total of 645 patients had complete data for analysis. Shock Index ≥1 had sensitivity of 67.7% (95% CI 49.5%–82.6%) and specificity of 81.3% (95% CI 78.0%–84.3%) for predicting MTP, and ABC score ≥2 had sensitivity of 47.0% (95% CI 29.8%–64.9%) and specificity of 89.8% (95% CI 87.2%–92.1%). AUROC analyses showed SI to be the strongest predictor followed by ABC score with AUROC values of 0.83 and 0.74, respectively. SI had a significantly greater sensitivity (P = 0.035), but a significantly weaker specificity (P < 0.001) compared to ABC score.ConclusionABC score and Shock Index can both be used to predict need for massive transfusion in trauma patients, however SI is more sensitive and requires less technical skill than ABC score.     

A meta-analysis of the efficacy of whole-body computed tomography imaging in the management of trauma and injury

BackgroundTraumatic injury is the third leading cause of death overall. To optimize the outcomes in these patients, hospitals employ whole-body computed tomography (WBCT) imaging due to the high diagnostic yield and potential to identify missed injuries. However, this delays time-critical interventions. Currently, there is an absence of any high-level evidence to support or refute either view. We present a meta-analysis of the available literature to elucidate the efficacy of WBCT in improving the outcomes of trauma, specifically the mortality rate.MethodsA systematic review of studies comparing WBCT and selective CT imaging in secondary survey was conducted, using MEDLINE, EMBASE, the Cochrane Review and Scopus databases. The articles were evaluated for intervention using WBCT to reduce mortality rate, followed by subgroup analysis for other secondary measures, using Review Manager 5.3 software.ResultsEleven studies of 32,207 patients were included. There were lower overall (OR = 0.79; 95% CI 0.74,0.83, p < 0.05) and 24 h mortality rates (OR = 0.72, 95% CI 0.66,0.79, p < 0.05) in the WBCT cohort. Additionally, patients in the WBCT arm spent less time in the emergency room (MD = −14.81; 95% CI −17.02, −12.60, p < 0.00001) and needing ventilation (MD = −2.01; 95% CI −2.41, −1.62, p < 0.05) despite a higher baseline injury severity score.ConclusionThe analysis shows that WBCT is associated with better outcomes, including a lower overall and 24 h mortality rate, however the included studies are mostly observational and show considerable heterogeneity. Further work is required to make definitive clinical recommendations for a tailored algorithm in managing trauma patients.     

“Oh the weather outside is frightful”: Severe injury secondary to falls while installing residential Christmas lights

IntroductionFalls are an increasingly common source of severe traumatic injury. They now account for approximately 40% of both overall trauma volumes and injury-related deaths within Canada. In northern climates, the risk of all types of falls may increase during the fall/winter months when conditions become increasingly dangerous. The purpose of this study was to define the injury and patient demographics of severe trauma that occurs during falls associated with the installation of Christmas lights.Patients and methodsAll patients who were admitted to a referral level 1 trauma center (2002–2012) with severe injuries (ISS ≥ 12) caused during Christmas light installation were retrospectively reviewed. Standard statistical methodology was utilised (p < 0.05 = significant).ResultsA total of 40 patients were severely injured (95% male; mean age = 55 years; mean ISS = 25.7 (range: 12–75)) while installing Christmas lights. Injuries included: neurologic (68%), thoracic (68%), spinal (43%), extremity (40%), and multiple other sites. Fall mechanisms were: ladder (65%), roof (30%), ground (3%) and railing (3%). Interventions included intubation and critical care (20%), as well as orthopaedic and neurosurgical operative repairs (30%). The median length of hospital stay was 15.6 days (range: 2–165). The fall-related morbidity (28%) and mortality (5%) were significant with a total of 12.5% patients requiring transfer to a long-term care or rehabilitation facility.ConclusionsFalls while installing Christmas lights during the fall/winter seasons can result in severe life-altering injuries with considerable morbidity and mortality. Caution should be employed when installing lights at any height.     

Morbidity or mortality? Variations in trauma centres in the rescue of older injured patients

IntroductionPrior analysis demonstrates improved survival for older trauma patients (age > 64 years) treated at trauma centres that manage a higher proportion of geriatric patients. We hypothesised that ‘failure to rescue’ (death after a complication during an in-hospital stay) may be responsible for part of this variation. The objective of the study was to determine if trauma centre failure to rescue rates are associated with the proportion of older trauma seen.MethodsWe analysed data from high volume level 1 and 2 trauma centres participating in the National Trauma Data Bank, years 2007–2011. Centres were categorised by the proportion of older trauma patients seen. Logistic regression analyses were used to provide risk-adjusted rates for major complications (MC) and, separately, for mortality following a MC. Models were adjusted for patient demographics, comorbid conditions, mechanism and type of injury, presenting vital signs, injury severity, and multiple facility-level covariates. Risk-adjusted rates were plotted against the proportion of older trauma seen and trends determined.ResultsOf the 396,449 older patients at 293 trauma centres that met inclusion criteria, 30,761 (8%) suffered a MC. No difference was found in the risk-adjusted incidence of MC by proportion of older trauma seen. A MC was associated with 34% of all deaths. Of those that suffered a MC, 7413 (24%) died and 76% were successfully rescued. Centres treating higher proportions of older trauma were more successful at rescuing patients after a MC occurred. Patients seen at centres that treat >50% older trauma were 33% (OR = 0.67, 95% CI 0.47–0.96) less likely to die following a MC than in centres treating a low proportion (10%) of older trauma.ConclusionsCentres more experienced at managing geriatric trauma are more successful at rescuing older patients with serious complications. Processes of care at these centres need to be further examined and used to inform appropriate interventions.     

Does perceived injustice correlate with pain intensity and disability in orthopaedic trauma patients?

IntroductionIndividuals who experience musculoskeletal trauma may construe the experience as unjust and themselves as victims. Perceived injustice is a cognitive construct comprised by negative appraisals of the severity of loss as a consequence of injury, blame, injury-related loss, and unfairness. It has been associated with worse physical and psychological outcomes in the context of chronic health conditions. The purpose of this study is to explore the association of perceived injustice to pain intensity and physical function in patients with orthopaedic trauma.MethodsA total of 124 orthopaedic trauma patients completed the Injustice Experience Questionnaire (IEQ), the PROMIS Physical Function Computer Adaptive Testing (CAT), the PROMIS Pain Intensity instruments, the short form Patient Health Questionnaire for depression (PHQ-2), the short form Pain Self-Efficacy Questionnaire (PSEQ-2), and the short form Pain Catastrophizing Scale (PCS-4) on a tablet computer. A stepwise linear regression model was used to identify the best combination of predictors explaining variance in PROMIS Physical Function and PROMIS Pain Intensity.ResultsThe IEQ was associated with PROMIS Physical Function (r = −0.36; P < 0.001) and PROMIS Pain Intensity (r = 0.43; P < 0.001). In multivariable analysis, however, Caucasian race (β = 5.1, SE: 2.0, P = 0.013, 95% CI: 1.1–9.2), employed work status (β = 5.1, SE: 1.5, P = 0.001, 95% CI: 2.1–8.2), any cause of injury other than sports, mvc, or fall (β = 7.7, SE: 2.1, P < 0.001, 95% CI: 3.5–12), and higher self-efficacy (PSEQ-2; β = 0.93, SE: 0.23, P < 0.001, 95% CI: 0.48–1.4) were selected as part of the best model predicting variance in PROMIS Physical Function. Only a higher degree of catastrophic thinking (PCS-4; β = 1.2, SE: 0.12, P < 0.001, 95% CI: 0.99 to 1.5) was selected as important in predicting higher PROMIS Pain Intensity.ConclusionPerceived injustice was associated with both physical function and pain intensity in bivariate correlations, but was not deemed as an important predictor when assessed along with other demographic and psychosocial variables in multivariable analysis. This study confirms prior research on the pivotal role of catastrophic thinking and self-efficacy in reports of pain intensity and physical function in patients with acute traumatic musculoskeletal pain.     

Early predictors for massive transfusion in older adult severe trauma patients

BackgroundMany scoring systems for the early prediction of the need for massive transfusion (MT) have been reported; in most of these, vital signs are regarded as important. However, the validity of these scoring systems in older patients remains unclear because older trauma patients often present with normal vital signs. In this study, we investigated the effectiveness of previously described scoring systems, as well as risk factors that can provide early prediction of the need for MT in older severe trauma patients.MethodsWe prospectively collected data from a cohort of severe trauma patients (ISS ≥16 and age ≥16 years) admitted from January 2007 to March 2015. Trauma Associated Severe Hemorrhage (TASH), Assessment of Blood Consumption (ABC), and Prince of Wales Hospital (PWH) scores were compared between a younger and an older group. Furthermore, the predictors associated with MT in older severe trauma patients were assessed using multivariable logistic regression analyses.ResultsThe area under the curve (AUC) was significantly smaller for older group than for younger group for all three scoring systems (p < 0.05). The most important risk factors to predict the need for MT were related to anatomical factors including FAST results (odds ratio (OR): 5.58, 95% confidence interval (CI): 2.10–14.99), unstable pelvic fracture (OR: 21.56, 95% CI: 6.05–90.78), and long bone open fracture of the lower limbs (OR: 12.21, 95% CI: 4.04–39.09), along with pre-injury anticoagulant agent use (OR: 5.22, 95% CI: 1.30–19.61), antiplatelet agent use (OR: 3.81, 95% CI: 1.57–9.04), lactate levels (OR: 1.20, 95% CI: 1.04–1.39) and shock index (OR: 2.67, 95% CI: 1.05–6.84). Traditional vital signs were not early risk factors.ConclusionWe suggest that MT in older trauma patients should be considered on the basis of anatomical factors, pre-injury anticoagulant or antiplatelet agent use, lactate level and SI even if traditional vital signs are normal.