Intensive care unit outcome of vehicle-related injury in elderly trauma patients

Vehicle-related trauma is a common mechanism of injury in elderly (age > or = 65 years) trauma patients. Several hospital-based studies have shown that patients with pedestrian injury have a higher mortality compared with those with motor vehicle collision (MVC) injury partially because of older patients found in the former group. In addition the injury patterns also differ significantly between these two mechanisms of vehicle-related trauma. The purpose of the present study is to compare the demographics, injury severity, injury patterns, and outcomes of elderly patients with pedestrian injury admitted to a surgical intensive care unit (SICU) of a Level I trauma center between January 1, 1994 and December 31, 2000 with those admitted with MVC injury. During the study period there were 187 elderly patients admitted to the surgical intensive care unit with vehicle-related injury. Fifty-one per cent of the patients had MVC injury. Patients were divided into two groups based on their mechanisms of injury (pedestrian vs MVC) for comparison. There was no difference in the mean age and gender between the two groups. Injury Severity Score, admission Simplified Acute Physiology Score, and mortality were significantly higher in the pedestrian group compared with the MVC group. Using logistic regression analysis three factors were found to be independently predictive of mortality: Simplified Acute Physiology Score, intracranial hemorrhage with mass effect on CT scan, and cardiac complications.     

Utility of neurosurgical consultation for mild traumatic brain injury

Trauma patients presenting with a Glasgow Coma Scale (GCS) score of 14-15 are considered to have mild traumatic brain injury (TBI) with overall good neurologic outcomes. Current practice consists of initial stabilization, followed by a head CT, and neurosurgical consultation. Aside from serial neurologic examinations, patients with a GCS of 15 rarely require neurosurgical intervention. In this study, we examined the added value of neurosurgical consultation in the care of patients after TBI with a GCS of 15. We retrospectively reviewed the medical records of patients presenting after blunt trauma with an abnormal head CT and GCS of 15 between January 2004 and January 2005. Patients with a normal head CT and <48 hours hospital stay were excluded. Data included demographics, mechanisms of injury, Injury Severity Score, the radiologists' dictated interpretations of the head CT, and neurosurgical interventions. Fifty-six patients met the inclusion criteria. The mean age was 41+/-2.3 years, and the mean Injury Severity Scores was 10.2 +/-0.6. Mechanisms of injury included 64 per cent motor vehicle crash, 16 per cent motorcycle crash, 13 per cent fall, and 7 per cent all-terrain vehicle crash. The initial CT scans showed 43 per cent parenchymal contusions, 38 per cent subarachnoid hemorrhage, 14 per cent subdural hematomas, and 5 per cent epidural hematomas. All patients received a routine follow-up head CT, and 16 per cent showed changes (five improved and four were worse compared with initial CT scans). None of these patients received a neurosurgical intervention, and two were transferred to a rehabilitation service. In this era of limited resources, trauma patients who present with a GCS score of 15 after mild TBI can be safely managed without neurosurgical consultation, even in the presence of an abnormal head CT scan.     

Assessment of three different mortality prediction models in four well-defined critical care patient groups at two points in time: a prospective cohort study

BACKGROUND AND OBJECTIVE: Mortality prediction systems have been calculated and validated from large mixed ICU populations. However, in daily practice it is often more important to know how a model performs in a patient subgroup at a specific ICU. Thus, we assessed the performance of three mortality prediction models in four well-defined patient groups in one centre. METHODS: A total of 960 consecutive adult patients with either severe head injury (n = 299), multiple injuries (n = 208), abdominal aortic aneurysm (n = 267) or spontaneous subarachnoid haemorrhage (n = 186) were included. Calibration, discrimination and standardized mortality ratios were determined for Simplified Acute Physiology Score II, Mortality Probability Model II (at 0 and 24 h) and Injury Severity Score. Effective mortality was assessed at hospital discharge and after 1 yr. RESULTS: Eight hundred and fifty-five (89%) patients survived until hospital discharge. Over all four patient groups, Mortality Probability Model II (24 h) had the best predictive accuracy (standardized mortality ratio 0.62) and discrimination (area under the receiver operating characteristic curve 0.9), but Simplified Acute Physiology Score II performed well for patients with subarachnoid haemorrhage. Overall calibration was poor for all models (Hosmer-Lemeshow Type C-values between 20 and 26). Injury Severity Score had the worst discrimination in trauma patients. All models over-estimated hospital mortality in all four patient groups, and these estimates were more like the mortality after 1 yr. CONCLUSIONS: In our surgical ICU, Mortality Probability Model II (24 h) performed slightly better than Simplified Acute Physiology Score II in terms of overall mortality prediction and discrimination; Injury Severity Score was the worst model for mortality prediction in trauma patients.     

Blast injury in a civilian trauma setting is associated with a delay in diagnosis of traumatic brain injury

High-pressure waves (blast) account for the majority of combat injuries and are becoming increasingly common in terrorist attacks. To our knowledge, there are no data evaluating the epidemiology of blast injury in a domestic nonterrorist setting. Data were analyzed retrospectively on patients admitted with any type of blast injury over a 10-year period at a busy urban trauma center. Injuries were classified by etiology of explosion and anatomical location. Eighty-nine cases of blast injury were identified in 57,392 patients (0.2%) treated over the study period. The majority of patients were male (78%) with a mean age of 40 +/- 17 years. The mean Injury Severity Score was 13 +/- 11 with an admission Trauma and Injury Severity Score of 0.9 +/- 0.2 and Revised Trauma Score of 7.5 +/- 0.8. The mean intensive care unit and hospital length of stay was 2 +/- 7 days and 4.6 +/- 10 days, respectively, with an overall mortality rate of 4.5 per cent. Private dwelling explosion [n = 31 (35%)] was the most common etiology followed by industrial pressure blast [n = 20 (22%)], industrial gas explosion [n = 16 (18%)], military training-related explosion [n = 15 (17%)], home explosive device [n = 8 (9%)], and fireworks explosion [n = 1 (1%)]. Maxillofacial injuries were the most common injury (n = 78) followed by upper extremity orthopedic (n = 29), head injury (n = 32), abdominal (n = 30), lower extremity orthopedic (n = 29), and thoracic (n = 19). The majority of patients with head injury [28 of 32 (88%)] presented with a Glasgow Coma Scale score of 15. CT scans on admission were initially positive for brain injury in 14 of 28 patients (50%). Seven patients (25%) who did not have a CT scan on admission had a CT performed later in their hospital course as a result of mental status change and were positive for traumatic brain injury (TBI). Three patients (11%) had a negative admission CT with a subsequently positive CT for TBI over the next 48 hours. The remaining four patients (14%) were diagnosed with skull fractures. All patients (n = 4) with an admission Glasgow Coma Scale score of less than 8 died from diffuse axonal injury. Blast injury is a complicated disease process, which may evolve over time, particularly with TBI. The missed injury rate for TBI in patients with a Glasgow Coma Scale score of 15 was 36 per cent. More studies are needed in the area of blast injury to better understand this disease process.     

Indicators for tracheostomy in patients with traumatic brain injury

Our objective was to develop criteria to identify patients with traumatic brain injury (TBI) who require a tracheostomy (TR). From January 1994 to May 2000 all TBI patients requiring intubation on presentation and who survived >7 days were identified from our trauma registry. Demographics, Glasgow Coma Score (GCS), Injury Severity Score (ISS), and ventilator days, ICU days, hospital days, need for TR, and development of pneumonia were statistically analyzed. Of 246 patients with TBI 211 without TR and 35 with TR were identified (mean time to TR 13.3+/-7.0 days). Logistic regression analysis identified presenting GCS < or =8, ISS > or =25, and ventilator days >7 as significant predictors for TR. Applying these three predictors to our population identified 48 patients (21 with TR, 18 without TR, and nine who died on the ventilator without TR) with a sensitivity of 60 per cent, a specificity of 87 per cent, a positive predictive value of 44 per cent, and a negative predictive value of 93 per cent. Patients with TR had lower presenting GCS and higher ventilator, ICU, and hospital days (P < 0.05). Pneumonia rates were similar. Time to neurologic recovery (GCS > or =9) was longer for the TR patients as compared with the patients without TR. We conclude that patients with TBI presenting with a GCS < or =8, an ISS > or =25, and ventilator days >7 are more likely to require TR. Performing TR late did not reduce pneumonia rates or ventilator, ICU, or hospital days. By identifying the at-risk population early TR could be performed in an attempt to decrease morbidity and length of stay.     

How we die: the impact of nonneurologic organ dysfunction after severe traumatic brain injury

Although nonneurologic organ dysfunction (NNOD) has been shown to significantly affect mortality in subarachnoid hemorrhage, the contribution of NNOD to mortality after severe traumatic brain injury (TBI) has yet to be defined. We hypothesized that NNOD has a significant impact on mortality after severe TBI. The trauma registry was queried for all patients admitted between January 2004 and December 2004 who died during their initial hospitalization after severe TBI (head Abbreviated Injury Score 3 or greater). Cause of death and contributing factors to mortality were determined by an attending trauma surgeon from the medical record. The data were analyzed using both Fisher's exact and Wilcoxon rank sum. One hundred thirty-five patients met inclusion criteria. Sixty-seven per cent were males, 83 per cent were white, and the mean age was 38.5 years. Mean length of stay was 2.9 days. Fifty-four patients (40%) had isolated TBI (chest Abbreviated Injury Score = 0, abdominal Abbreviated Injury Score = 0). Of the 81 deaths attributed to a single cause, 48 (60%) patients died from nonsurvivable TBI or brain death, whereas 33 (40%) died of a nonneurologic cause. Cardiovascular and respiratory dysfunction (excluding pneumonia) contributed to mortality in 51.1 per cent and 34.1 per cent of patients, respectively. NNOD contributes to approximately two-thirds of all deaths after severe TBI. These complications occur early and are seen even among those with isolated head injuries. These findings demonstrate the impact of the extracranial manifestations of severe TBI on overall mortality and highlight potential areas for future intervention and research.     

Ten years of mechanical complications of central venous catheterization in trauma patients

The study purpose was to determine the incidence of mechanical complications (MC) associated with central venous catheterization (CVC) and to evaluate their impact on outcomes. This was a retrospective review of trauma morbidity and mortality records at a Level I trauma center (1999 to 2009). Demographics and outcomes were extracted for all trauma patients with CVC. Patients developing MC were compared with those who did not. Four thousand eight hundred eighteen lines were placed in 2935 patients. Of these, 1.5 per cent (n = 73) had MC. A total of 64.4 per cent (n = 47) were pneumothoraces followed by arterial cannulation at 8.2 per cent (n = 6) and thrombosis at 6.8 per cent (n = 5). The rate of MC by access site was: subclavian 1.8 per cent (n = 52), internal jugular 1.2 per cent (n = 10), and femoral 0.3 per cent (n = 3) (P value for trend = 0.001). Change in management was required in 31.5 per cent (n = 23). Number of lines (P < 0.001), Injury Severity Score (P < 0.001), body mass index less than 20 kg/m(2) (P = 0.036), and chest Abbreviated Injury Score greater than 3 (P = 0.034) were significant predictors of MC. Patients with MC had a longer intensive care unit length of stay (18.8 ± 25.7 vs 11.4 ± 13.3; adjusted odds ratio, 5.75; 95% confidence interval, 2.24-9.25; P = 0.001). Incidence of MC was 1.5 per cent. Complications were clinically significant in 31.5 per cent and resulted in longer intensive care unit stays.     

The role of repeat computed tomography scan in the evaluation of blunt bowel injury

The precise role of repeat abdominal computed tomography (CT) imaging in the diagnosis and management of bowel injury is unclear. We reviewed 540 patients with blunt abdominal trauma managed at a Level II trauma center over a 5-year period to better define the role of repeat imaging. One hundred patients had a repeat abdominal CT scan within 72 hours of admission. These patients were young with multisystem injuries (mean ± standard deviation age, 34 ± 15 years; Injury Severity Score, 21 ± 12; Glasgow Coma Score [GCS], 12 ± 5). There were 14 patients with bowel injuries. All bowel-injured patients survived without abdominal morbidity. Time to repeat CT was shortest in the bowel injured group (20 ± 10 hours). The repeat CT was most helpful in patients with significant closed head injury (mean GCS, 3 ± 1) and in those with occult bowel injury. The repeat scan resulted in a change in clinical management in 26 patients. Regarding the presence of bowel perforation, the follow-up scan enhanced sensitivity from 30 to 82 per cent. The repeat abdominal CT is best used selectively in patients with blunt abdominal trauma and can provide clinically useful information to exclude bowel injury.     

Efficacy of computed tomography in the diagnosis of pancreatic injury in adult blunt trauma patients: a single-institutional study

Blunt trauma to the pancreas is an uncommon injury, which can be difficult to diagnose. Most studies are multi-institutional, include both helical and axial CT, and report sensitivities of 40 to 67 per cent. We evaluated the efficacy of spiral CT for the diagnosis of blunt pancreatic injury in a single large-volume institution. We retrospectively reviewed 22,000 blunt trauma patients seen between 1996 and 2000. Pancreatic injury was identified in 40 patients (0.2%). All patients evaluated with spiral CT were given both oral and intravenous contrast. A total of 40 blunt pancreatic injuries were identified. The mean age was 35 years. Seventy-five per cent were male. Mean Injury Severity Scale score was 29 and overall mortality 12.5 per cent. Thirty-one patients (78%) underwent laparotomy. Twelve patients went directly to the operating room for urgent exploration and 19 had a preoperative CT. CT was positive for pancreatic injury in 13 patients (sensitivity 68%). All 13 patients had confirmed pancreatic injury at the time of surgery (positive predictive value = 100%). Using the American Association for the Surgery of Trauma grading system operative findings and CT correlated in 68 per cent of those patients who had both CT and laparotomy. CT underestimated pancreatic injury in the remaining 31 per cent. Nine patients were managed nonoperatively without complication, and six had pancreatic injury on CT. The other three had a negative CT but had clinical and laboratory evidence of pancreatic injury. Overall CT scan was 68 per cent (19 of 28) accurate in diagnosing pancreatic injury. We conclude that CT scan is only moderately sensitive and can underestimate or miss pancreatic injury. Although CT moderately correlated with injury grade it was highly predictive for presence of injury. The new multidetector helical scanner may improve our diagnostic ability.     

Do facial fractures protect the brain or are they a marker for severe head injury?

Facial fractures (FF) have been suggested to protect the brain from severe injury. However, others have stated that facial fractures are a marker for increased risk of brain injury. The aim of this study is to evaluate the association between facial fractures, brain injury, and functional outcome. A retrospective review of our prospective trauma database was performed for blunt trauma patients during a 7-year period (January 1993 through December 1999) at the University of Louisville Hospital. We identified 7324 blunt trauma patients at a Level 1 trauma center. Severity of head injury in patients with and without FF was compared. The severity of brain injury was evaluated by admission Glasgow Coma Score (GCS) as well as specific head, neck, cervical spine, and face Acute Injury Score (AIS). Length of intensive care unit (ICU) stay, hospital stay, and Functional Independence Measures (FIM) score were also identified. A total of 1068 (14.6%) patients were diagnosed with FF; of these 848 (79.4%) patients suffered some form of brain injury by CT abnormality, clinical examination, or both. A total of 2192 patients were treated for head injury without FF; 220 patients were treated for FF without head injury. FF with traumatic brain injury (TBI) were found to occur significantly greater than FFs without TBI (P < 0.001). The mean GCS on admission for FF with head injury was 12, which was similar to that of patients with head injury alone with a GCS of 10 but was significantly less than that of patients with FF alone with a GCS of 15 (P < 0.05). Injury Severity Score for patients with FF and head injury was significantly worse compared with patients with head injury alone and those with FF alone (P < 0.0001). Mean ICU stay and hospital stay were similar for all three groups (ranges 3-6 and 6-12 days); and were not significant (P < 0.06). FIM score was significantly lower for patients with FF and head injury compared with FF alone (P = 0.0003) and similar to that of patients with head injury. FF were found to have a significantly greater incidence of TBI. FF with TBI had a similar severity of head injury when compared with patients with head injury alone by demonstrating similar GCS, AIS of the head and neck, and early functional recovery. This analysis does not support the hypothesis that the face provides a protective effect for the brain and therefore leading to a more favorable short-term outcome. Thus patients with facial fractures should be treated with the same caution as patients with significant blunt head trauma.     

A successful multimodality strategy for management of liver injuries

The treatment of liver injuries involves many strategies ranging from observation to operative intervention and includes numerous options such as angiography, packing, and damage-control procedures. In July 1994 we instituted a protocol for the management of traumatic liver injuries. The main objective of this study was to evaluate the management of liver injuries occurring since the institution of the protocol. Two hundred three consecutive adult patients with liver injuries were evaluated at our Level I trauma center between July 1994 and May 1999. Eighty-eight per cent of the injuries were blunt with a mean Injury Severity Score (ISS) of 24.3 +/- 0.8 and a survival probability (Ps) of 90.0 +/- 1.5 per cent. The overall mortality was 6.4 per cent. A comparison between patients with minor liver injuries and patients with more severe injuries [Abbreviated Injury Score (AIS) <3 vs >3] demonstrated no difference in mortality between the two groups despite a Ps of 93.8 +/- 1.3 per cent in patients with an AIS <3 versus 84.1 +/- 3.3 per cent in patients with an AIS >3. The most common complication in our patient population was posthemorrhagic anemia, which was seen in 10.8 per cent of cases. Severity of injury did not result in a significant difference in the complication rate. Patients who underwent laparotomy had a statistically higher ISS, a lower Ps, and a mortality rate of 11.5 per cent compared with 3.7 per cent (P = 0.03) in patients managed nonoperatively. However, a comparison of patients undergoing laparotomy with those who did not and who had equivalent ISS demonstrated no difference in mortality. Our results demonstrated that a preplanned management strategy was a successful way in which to treat patients with traumatic liver injuries. Although nonoperative management of liver injuries has been common practice a management plan that involves a multimodal surgical strategy is essential.     

Cerebral oxygenation, vascular reactivity, and neurochemistry following decompressive craniectomy for severe traumatic brain injury

OBJECT: This study addresses the changes in brain oxygenation, cerebrovascular reactivity, and cerebral neurochemistry in patients following decompressive craniectomy for the control of elevated intracranial pressure (ICP) after severe traumatic brain injury (TBI). METHODS: Sixteen consecutive patients with isolated TBI and elevated ICP, who were refractory to maximal medical therapy, underwent decompressive craniectomy over a 1-year period. Thirteen patients were male and 3 were female. The mean age of the patients was 38 years and the median Glasgow Coma Scale score on admission was 5. RESULTS Six months following TBI, 11 patients had a poor outcome (Group 1, Glasgow Outcome Scale [GOS] Score 1-3), whereas the remaining 5 patients had a favorable outcome (Group 2, GOS Score 4 or 5). Decompressive craniectomy resulted in a significant reduction (p < 0.001) in the mean ICP and cerebrovascular pressure reactivity index to autoregulatory values (< 0.3) in both groups of patients. There was a significant improvement in brain tissue oxygenation (PbtO(2)) in Group 2 patients from 3 to 17 mm Hg and an 85% reduction in episodes of cerebral ischemia. In addition, the durations of abnormal PbtO(2) and biochemical indices were significantly reduced in Group 2 patients after decompressive craniectomy, but there was no improvement in the biochemical indices in Group 1 patients despite surgery. CONCLUSIONS: Decompressive craniectomy, when used appropriately in protocol-driven intensive care regimens for the treatment of recalcitrant elevated ICP, is associated with a return of abnormal metabolic parameters to normal values in patients with eventually favorable outcomes.     

Prevalence of delayed hemothorax in blunt thoracic trauma

Delayed hemothorax (DHTX) is rarely seen. On an 8-year retrospective analysis of blunt thoracic trauma (BTT), hemothorax (HTX) was diagnosed in 167 patients: 18 children, 113 adults, and 36 elderly. No statistical differences were seen in any age groups regarding Injury Severity Score (mean ISS, 30.54), critical care length of stay (CLOS, 9.0), and hospital LOS (HLOS, 11.21). Mortality rate was 18 per cent in adults and 28 per cent in elderly (P value < 0.0001). HTX was acute in 160 and delayed in 7 patients. Two-thirds of HTX patients were males and 75 per cent had rib fractures. All of our DHTX patients were males (5 adults and 2 elderly) and had rib fractures. Acute HTX was seen in younger patients (43.3 vs 56.1 years, P value 0.46), with higher ISS (31.44 vs 14.43, P value < 0.001), CLOS (7.19 vs 3.0 days, P value 0.511) and HLOS (11.9 vs 11.6, P value 0.468). Mortality was 22.5 per cent in AHTX and none in DHTX. Eighty-six per cent of DHTX and 49 per cent of AHTX patients went home on discharge. DHTX was rare (5%) in the current report with lower ISS, HLOS, and no mortality. Patients with rib fractures should be watched for development of DHTX as timely diagnosis and treatment is essential for favorable outcome.     

Effect on outcome of early intensive management of geriatric trauma patients

BACKGROUND: Despite significant injuries elderly patients (aged 70 years or more) often do not exhibit any of the standard physiological criteria for trauma team activation (TTA), i.e. hypotension, tachycardia or unresponsiveness to pain. As a result of these findings the authors' TTA criteria were modified to include age 70 years or more, and a protocol of early aggressive monitoring and resuscitation was introduced. The aim of the present study was to assess the effect of the new policy on outcome. METHODS: This trauma registry study included patients aged 70 years or more with an Injury Severity Score (ISS) greater than 15 who were admitted over a period of 8 years and 8 months. The patients were divided into two groups: group 1 included patients admitted before age 70 years and above became a TTA criterion and group 2 included patients admitted during the period when age 70 years or more was a TTA criterion and the new management protocol was in place. The two groups were compared with regard to survival, functional status on discharge and hospital charges. RESULTS: There were 336 trauma patients who met the criteria, 260 in group 1 and 76 in group 2. The two groups were similar with respect to mechanism of injury, age, gender, ISS and body area Abbreviated Injury Score. The mortality rate in group 1 was 53.8 per cent and that in group 2 was 34.2 per cent (P = 0.003) (relative risk (RR) 1.57 (95 per cent confidence interval 1.13 to 2.19)). The incidence of permanent disability in the two groups was 16.7 and 12.0 per cent respectively (P = 0.49) (RR 1.39 (0.59 to 3.25)). In subgroups of patients with an ISS of more than 20 the mortality rate was 68.4 and 46.9 per cent in groups 1 and 2 respectively (P = 0.01) (RR 1.46 (1.06 to 2.00)); 12 of 49 survivors in group 1 and two of 26 in group 2 suffered permanent disability (P = 0.12) (RR 3.18 (0.77 to 13.20)). CONCLUSION: Activation of the trauma team and early intensive monitoring, evaluation and resuscitation of geriatric trauma patients improves survival.     

Increased intra-abdominal, intrathoracic, and intracranial pressure after severe brain injury: multiple compartment syndrome

OBJECTIVES: Fluid therapy and/or acute lung injury may increase intra-abdominal pressure (IAP) and intrathoracic pressure, thereby increasing intracranial pressure (ICP) after traumatic brain injury (TBI). Further fluid administration to support cerebral perfusion or increasing ventilatory support to treat acute lung injury further increases ICP. This can create a cycle that ultimately produces multiple compartment syndrome (MCS). Both decompressive craniectomy (DC) and decompressive laparotomy (DL) decrease ICP. DL can also decrease IAP and ICP. We evaluated the serial application of DC and DL to treat MCS. METHODS: Data were analyzed for 102 consecutive patients with severe TBI who underwent DC alone to decrease ICP or in combination with DL to treat MCS. RESULTS: All 102 patients sustained blunt injury. Seventy percent were men with a mean age of 29.5 years, an Injury Severity Score of 34.4, and admission Glasgow Coma Scale score of 7.1. Fifty-one patients had diffuse brain injury and 51 had mass lesions. Seventy-eight patients (76%) underwent DC alone. Twenty-four (22%) had both therapies for MCS. Fifteen patients had DC before DL and nine had DL before DC. Mean time between DC and DL was 3.4 +/- 6 days. The mean IAP before DL was 28 +/- 5 mm Hg. Twenty-four-hour cumulative mean intrathoracic pressure decreased significantly after DL in the MCS group (p = 0.01). Mean ICP decreased significantly after both DC and DL (p < 0.05). CONCLUSION: Increased ICP may be from primary TBI or MCS. Patients with MCS have a higher Injury Severity Score, ICP, and fluid requirements, but no increase in mortality. Both DC and DL reduce ICP and can be used in sequence. MCS should be considered in multiply injured patients with increased ICP that does not respond to therapy.     

Study of the outcome of patients transferred to a level I hospital after stabilization at an outlying hospital in a rural setting

OBJECTIVE: To determine the characteristics and outcome of transferred trauma patients in a rural setting. METHODS: We conducted a case-control study of all trauma admissions to a rural Level I trauma center to examine a 3.5-year (1993-1996) comparison of trauma patients admitted directly with those transferred (RTTP) after being initially stabilized at an outlying hospital. We used prehospital times, Injury Severity Score (ISS), LD50ISS (the ISS at which 50% of patients died), Revised Trauma Score, probability of survival, Acute Physiology and Chronic Health Evaluation II, and observed survival as main outcome measures. RESULTS: RTTPs (39.4%) spent an average of 182+/-139 minutes at the outlying hospital and 72+/-42 minutes in transport to the trauma center. Proportionately more head/neck and patients with multiple injuries composed the RTTP group. The RTTP were more severely injured (ISS 11.1+/-8.5; Acute Physiology and Chronic Health Evaluation II 16.2+/-5.8; Revised Trauma Score 7.44+/-1.1) than the trauma patients admitted directly (ISS 7.9+/-5.3; Acute Physiology and Chronic Health Evaluation II 13.1+/-6.3; Revised Trauma Score 7.8+/-0.4; p < 0.05). However, both groups had the same LD50ISS (ISS = 35). When logistic regression was applied with death as the dependent variable, both ISS and age contributed significantly (p = 0.0001) but transfer status did not (p = 0.473). CONCLUSION: Rural trauma centers admit a high percentage of RTTP. These RTTP have a higher injury severity and acuity than their trauma patients admitted directly counterparts. Trauma care in rural areas that involves initial stabilization at outlying hospitals does not adversely affect mortality.     

Decompressive craniectomy for elderly patients with traumatic brain injury: it's probably not worth the while

Decompressive craniectomy (DC) has been regarded as an ultima ratio measure in the treatment of refractory intracranial hypertension after brain injury. Most discussion about its benefits is based on studies performed in patients who are <65 years of age. The aim of this study was to identify patients aged ≥66 years who underwent DC after traumatic brain injury (TBI), in order to assess patient outcome and to correlate the values of potential predictors of survival on prognosis. From January 2002 to December 2009, 44 patients aged ≥66 underwent DC (follow-up, 12-102 months). Potential predictors of outcome were analyzed, including age, post-resuscitation Glasgow Coma Scale (GCS) score, presence of mass lesion, Simplified Acute Physiology Score (SAPS) II, Injury Severity Score (ISS), and timing of surgical decompression. Mortality was 48% at discharge from the intensive care unit (ICU), 57% at hospital discharge, and 77% at 1-year follow-up and at last follow-up. A bad outcome Glasgow Outcome Scale Dead-Vegetative State-Severely Disabled (GOS D-VS-SD) was observed in 36/44 patients both at hospital discharge and at 1-year follow-up. Mean SAPS II was 45.2 for patients who survived and 57.3 for patients who had died (p=0.0022). Patients who survived had a higher mean post-resuscitation GCS score (p=0.02). Logistical regression analysis indicated post-resuscitation GCS score as the only independent predictive factor for outcome. None of the 22 patients with a post-resuscitation GCS score of 3-5 had a good outcome, 2/10 (20%) patients with a post-resuscitation GCS score of 6-8 and 6/12 patients (50%) with a post-resuscitation GCS score ≥9 had a good outcome.     

An appraisal of trauma in the elderly

To review the trends of trauma in the elderly experienced at our trauma center compared with other Level I trauma centers. This was a retrospective trauma registry analysis (1996-2003) of 2783 blunt trauma in elderly (BTE) and 4568 adult (BTA) patients in a Level 1 trauma center. Falls and motor vehicular crashes were the most common mechanisms noted in 47 per cent and 31 per cent (84% and 13% in BTE, 25% and 42% in BTA). BTE were sicker, with higher Injury Severity Scores (ISS), lengths of stay, and mortality (5% vs 2%, P value < 0.05). ISS was 5.2-fold higher in nonsurvivors to survivors in BTA and 2.4-fold in BTE. Elevation in ISS resulted in higher linear increase in mortality in BTE (vs BTA) at any ISS level. Mortality in patients with ISS > or = 25 was 43.5 per cent vs 23.8 per cent. ISS > or = 50 had 31 per cent adult survivors but no elderly survivors. Among isolated injuries, head trauma in the elderly carried the highest mortality, at 12 per cent (19% in patients with an Abbreviated Injury Score > or = 3). Abdominal injuries were the most lethal (18.3% and 41.2% in patients with an Abbreviated Injury Score > or = 3) in multiple trauma victims (41% vs 18% in isolated trauma). There was 4.4-fold increased mortality in the presence of thoracic trauma. Combined head, chest, and abdominal trauma carried the worst prognosis. Thirty-four per cent of BTE and 88 per cent of BTA patients were discharged home. Elderly patients need more aggressive therapy, as they are sicker with higher mortality.     

Black children experience worse clinical and functional outcomes after traumatic brain injury: an analysis of the National Pediatric Trauma Registry

BACKGROUND: Recent studies suggest racial disparities in the treatment and outcomes of children with traumatic brain injury (TBI). This study aims to identify race-based clinical and functional outcome differences among pediatric TBI patients in a national database. METHODS: A total of 41,122 patients (ages 2-16 years) who were included in the National Pediatric Trauma Registry (from 1996-2001) were studied. TBI was categorized by Relative Head Injury Severity Score (RHISS) and patients with moderate to severe TBI were included. Individual race groups were compared with white as the majority group. Differences between races in functional outcomes at discharge in three domains-speech, locomotion, and feeding-were determined using multiple logistic regression. Cases were adjusted for age, sex, severity of head injury (using RHISS), severity of injury (using New Injury Severity Score and Pediatric Trauma Score), premorbidities, mechanism, and injury intent. RESULTS: A total of 7,778 children had moderate or severe TBI with or without associated injuries. All races had similar demographics. Hispanics (n=1,041) had outcomes comparable to whites (n=4,762). Black children (n=1,238) had significantly increased premorbidities, penetrating trauma, and violent intent. They also had higher unadjusted mortality and longer mean intensive care unit and floor stays. After adjustment, there was no difference in the odds of death between black and white children. However, black patients were more likely to be discharged to an inpatient rehabilitation facility and had increased odds of possessing a functional deficit at discharge for all three domains studied. CONCLUSION: Black children with traumatic brain injury have worse clinical and functional outcomes at discharge when compared with equivalently injured white children.     

Scout anteroposterior and lateral CT scans as a screening test for thoracolumbar spine injury in blunt trauma

Anteroposterior and lateral radiographs have traditionally been required to clear the thoracolumbar spine (TLS) after blunt trauma. The routine use of CT scans led to a pilot trial to determine if CT scout images can accurately evaluate the TLS after blunt trauma. The purpose of the study was to determine the sensitivity, specificity, positive and negative predictive values of CT scout images for the evaluation of the TLS. Patients admitted to our level II trauma center requiring CT evaluation of the chest, abdomen, and pelvis were considered for this study. Patients with blunt trauma, without neurologic deficits, or other evidence of spinal trauma on physical examination were included. Charts were reviewed for demographics, scout CT image findings, and full CT scan findings. Scout CT images were compared with reconstructed spine CT scans from chest, abdomen, and pelvis CT scans. Injuries to the TLS were defined as compression fractures, burst fractures, and subluxation. One hundred seventeen patients were included. Average Injury Severity Score was 25.1 (+/-9.4) and average age was 42.5 years. Twenty-three patients had diffuse back tenderness, three had ecchymosis, and 64 had distracting injuries. Twelve injuries to the TLS were present; 11 were seen on scout images. Sensitivity was 92 per cent, specificity 100 per cent, positive predictive value 100 per cent, and negative predictive value 99 per cent. Scout CT images provide an accurate assessment of the TLS after blunt trauma. We are encouraged by the results and will continue to investigate to identify the criteria that allow scout CT images to safely replace anteroposterior and lateral radiographs in the evaluation of the TLS in blunt trauma.