Sex hormone binding and peritumoural oedema in meningiomas: Is there a correlation?

Summary 136 patients older than 70 years, admitted to our neurosurgical ward directly after head trauma, were analysed. 40% of them were admitted with low GCS, below 9 points, and showed a mortality of 85%. 45 patients had intracranial mass lesions — the commonest was subdural haematoma, with a low incidence of epidural haematomas. In patients admitted with GCS above 12, mortality was 20%, mainly due to pneumonia. Satisfactory results were achieved in 30% of trauma victims. From patients with intracranial space occupying lesions and GCS below 9 points on admission practically all died, despite aggresive surgical treatment and intensive care. Thus, especially in departments with limited resources, therapy can be limited, or even no therapy may be introduced in this group. Surgical treatment can be limited only to patients who are conscious on admission. In patients with non-surgical lesions, low GCS — below 9 points — leads to mortality of 80%, and in this group we propose aggresive intensive care for 24 hours and the limitation of further maximal therapy only to those, who significantly improve within this period of time. If the patient has a non-surgical lesion and is conscious after trauma, aggresive treatment of extracranial complication is the most important, because brain injury can usually be well tolerated by these patients. If pneumonia or heart complications do not occur this group of old patients often have a good prognosis.     

Head-injured adult patients with GCS of 3 on admission — Who have a chance to survive?

Summary The authors analysed a series of 111 adult patients admitted to the Department of Neurosurgery, Medical University of ód directly after trauma with initial GCS of 3 points. 74% of them had intracranial haematoma, mainly subdural, and were treated surgically within the first 3 hours after trauma. 8 patients had no abnormalities on CT scans.99 (89%) patients died 2 to 30 days after injury, 8 (7%) survived in a vegetative state, and only in 4 (4%) was a satisfactory result noted, but 2 of them had a stable neurological deficit. 3 of these 4 patients had epidural haematomas and 1 had not abnormalities on repeated CT examinations.We conclude, that among patients with GCS of 3 on admission, only those without major CT abnormalities or with epidural haematoma have a chance of survival. Cases with cerebral leasions on the initial CT examination have an invariably bad prognosis. They could be taken into account as a potential organ donor from the very moment of admission, but only after cerebral circulatory arrest occured and brain death has been proved according to internationally accepted standarts.     

Spontaneous intracerebral haematomas: surgical versus conservative treatment based on Glascow Coma Scale score and computer tomography data

Eighty cases of spontaneous intracerebral haematomas were studied retrospectively in order to find clinical and computer tomography parameters; such parameters would be useful for the neurosurgeon, as criteria in the process of deciding surgical or conservative treatment. We found Glascow Coma Scale (GCS) score on admission an excellent criterion. Scores between 3-5 and 12-14 were a contraindication for surgery. Scores between 6-8 indicated surgery, while scores between 9-11 indicated an increased level of readiness. Up to a haematoma size of 16 cm2, size had no influence on GCS score and surgical mortality. For haematoma size larger than 16 cm2, the percentage of patients with low GCS score had increased substantially as well as the surgically mortality. This study has not revealed any lethal haematoma size. No effect of midline shift on mortality was found when shift did not exceed 5 mm. Hypertension was found in 40% of the patients and increased mortality in both types of treatment.     

Prognostic impact of intra-aortic balloon pump insertion before versus after cardiac surgical intervention in a veteran population

Background

The relative prognostic impact of intra-aortic balloon pump (IABP) placement before versus after cardiac surgery is not well defined.

Methods

We reviewed data from all cardiac surgical patients who received perioperative IABP support at a veterans' hospital between April 1992 and April 2008. We compared outcomes between patients who received an IABP before surgery (BS, n = 36) and after surgery (AS, n = 28).

Results

The AS group had higher operative morbidity (71% vs 42%) and mortality (43% vs 14%) rates than the BS group (P < .02 for both). Furthermore, survival rates were lower in the AS group than in the BS group at 1 year (50% vs 83%) and 3 years (46% vs 80%) (log-rank test, P < .004).

Conclusions

Patients who require IABP after cardiac surgery may have worse outcomes than patients who receive IABP support before surgery. In both groups, after an early peak in mortality, the midterm outcomes were characterized by a reassuring plateau in the survival rates.     

Chronological evaluation of acute traumatic intracerebral haematoma

Summary Serial computed tomographic (CT) studies were performed in 48 patients with brain contusion. Traumatic intracerebral haematoma (TIH) had developed within 6 hours in 56% of the cases, within 12 hours in 81% and 100% within 24 hours from the onset. TIH reached its maximal size in 84% of the cases within 12 hours. The incidence of the appearance of TIH from brain contusion was 52%. The performance of frequent CT examination within 24 hours following head injury would help to lower the mortality rate of such trauma.     

Management of severe traumatic brain injury by decompressive craniectomy

OBJECTIVE: The beneficial effect of decompressive craniectomy in the treatment of head trauma patients is controversial. The aim of our study was to assess the value of unilateral decompressive craniectomy in patients with severe traumatic brain injury. METHODS: We retrospectively investigated 49 patients who underwent decompressive craniectomy. Intracranial pressure, cerebral perfusion pressure, therapy intensity level, and cranial computed tomographic scan features (midline shift, visibility of ventricles, gyral pattern, and mesencephalic cisterns) were evaluated before and after craniectomy. The gain of intracranial space was calculated from cranial computed tomographic scans. Patient outcome was graded using the Glasgow Outcome Scale. RESULTS: Thirty-one patients (63.3%) underwent rapid surgical decompression within 4.5 +/- 3.8 hours after trauma; in 18 patients (36.7%), delayed surgical decompression was performed 56.2 +/- 57.0 hours after injury. Patients younger than 50 years or patients who underwent rapid surgical decompression had a significantly better outcome than older patients or patients who underwent delayed surgical decompression. Craniectomy significantly decreased midline shift and improved visibility of the mesencephalic cisterns. The state of the mesencephalic cisterns correlated with the distance of the lower border of the craniectomy to the temporal cranial base. Alterations in intracranial pressure, cerebral perfusion pressure, and therapy intensity level were not significant. The overall mortality of the patients corresponded to the reports of the Traumatic Coma Data Bank (1991). CONCLUSION: Although there was a significant decrease in midline shift after craniectomy, this did not translate into decompressive craniectomy demonstrating a beneficial effect on patient outcome.     

Brain CT perfusion provides additional useful information in severe traumatic brain injury

Background

The role of brain CT perfusion (CTP) imaging in severe traumatic brain injury (STBI) is unclear. We hypothesised that in STBI early CTP may provide additional information beyond the non contrast CT (NCCT).

Methods

Subset analysis of an ongoing prospective observational study on trauma patients with STBI who did not require craniectomy and deteriorated or failed to improve neurologically during the first 48 h from trauma. Subsequently to follow-up NCCT, a CTP was obtained. Additional findings were defined as an area of altered perfusion on CTP larger than the abnormal area detected by the simultaneous NCCT. Patients who had additional finding (A-CTP) were compared with patients who did not have additional findings (NA-CTP).

Results

Study population was 30 patients [male: 90%, mean age: 38.6 (SD 16.9), blunt trauma: 100%; prehospital intubation: 6 (20%); lowest GCS before intubation: 5.1 (SD 2.0); mean ISS: 30.5 (SD 8.3); mean head and neck AIS: 4.4 (SD 0.8). Days in ICU: 10.2 (SD 6.3). Intracranial pressure (ICP) monitored in 12 (40%). Mean highest ICP in mmHg: 30.1 (SD14.1). There were five (17%) deaths. Findings of NCCT: primarily diffuse axonal injury (DAI) pattern in seven (23%), primarily haematoma in ten (33%), and primarily intracerebral contusion in nine (30%). CTP was performed 24.9 (SD 13) hours from trauma. There were 18 (60%) patients in the A-CTP group and 12 (40.0%) in NA-CTP. The A-CTP group was older (41.7 (SD16.9) vs 27.7 (SD 12.8): P < 0.02) and showed on admission NCCT presence of cerebral contusion and absence of DAI. The degree of hypoperfusion was found to be severe enough to be in the ischaemic range in eight patients (27%). CTP altered clinical management in three patients (10%), who were diagnosed with massive and unsurvivable strokes despite minimal changes on NCCT.

Conclusion

When compared to NCCT, CTP provided additional diagnostic information in 60% of patients with STBI. CTP altered clinical management in 10% of patients.     

Surgical results of intracranial ruptured aneurysms in the acute stage

Summary To evaluate the operative mortality and morbidity of definitive intracranial microsurgical aneurysm obliteration as a function of timing of early operative intervention and as a function of clinical condition at the acute stage, we retrospectively review 164 consecutive patients who underwent surgery within 72 hours following haemorrhage. The series was divided into four operation periods (0–6, 6–12, 12–24, 24–72 hours), and patients were graded according to five clinical conditions described by Hunt and Hess. The mortality of the individual clinical condition at each operation period was to great extent independent of the timing of operation, and there was a distinct correlation between the surgical results and the form of bleeding visualized by C. T. In poor condition (grade 3, 4, and 5) patients, satisfactory surgical results were obtained in patients in whom cisternal blood clots, intracerebral haematoma, and subdural haematoma had been shown by C.T. The optimum operation times for each group were suggested.     

Prognosis of isolated acute post-traumatic subdural haematoma

AIM: Acute subdural haematoma (ASDH) is seldom an isolated lesion and it is difficult to understand the mechanisms which determine the poor prognosis associated to this occurrence. Aim of this study was estimating the outcome of patients with ASDH without any companion lesions by analysing the haematoma volume, its thickness and midline shift. METHODS: Twenty-eight severely head injured patients (Glasgow Coma Scale, GCS =/<8) with isolated unilateral ASDH admitted in intensive care unit (ICU) were retrospectively studied. The haematoma thickness, the midline shift, the ASDH volume were obtained from the first emergency computerized tomography (CT) scan and analysed by a computer assisted programme (Osiris). Patients' outcome was scored according to the Glasgow Outcome Scale (GOS) 6 months after the event. According to their GOS the patients were further divided in 2 groups (favourable outcome: GOS 4-5, poor outcome: GOS 1-2-3). RESULTS: Midline shift ranged from 0 to 19.2 mm; we found a larger midline shift in those patients who died and in patients with severe disability or vegetative state 6 months after the trauma. CONCLUSION: The presence and size of midline shift was a more important determinant of outcome than ASDH volume or its thickness.     

Chronic bilateral subdural haematoma in adults

Summary Twenty-nine patients with chronic bilateral subdural haematomas were surgically treated during 1966 to 1977. Twenty-four of them (83%) had a history of head injury, which caused unconsciousness in eight cases. The mean interval from trauma to operation was eleven weeks. The mean age of the patients was 60 years. The prevalence of the most commonly encountered symptoms and signs was: headache 72%, mental symptoms 48%, papilloedema 41%, vertigo 31%, nausea 28%, reduced consciousness 28%, walking difficulties 24%, hemiparesis 24%, and paraparesis 14%. The aggregate thickness of haematomas was 34 mm, 36 mm, and 40 mm in age groups of 20–39, 40–59, and over 60 years, respectively. All patients were operated on, four of them only unilaterally. Three patients in the whole series died. Two of them had been operated upon only on one side in the first session, the haematoma of the other side being evacuated 81/2 hours and four days later, respectively. Unilateral operation is likely to cause sever e distortion of the midline structures and the brain stem and thus aggravates the cerebral situation. Therefore the necessity of simultaneous evacuation of the haematomas on both sides is stressed. The reason for the death of the third patient was delay in diagnosis.All three patients who died belonged to the group of eight patients with a reduced level of consciousness before surgery.Twenty-three of the survivors were fully independent in their daily lives, and three needed some help after operative treatment.     

Volume of chronic subdural haematoma: Is it one of the radiographic factors related to recurrence?

Background

Recurrence of chronic subdural haematoma (CSDH) is a significant issue in neurosurgical practice, and to distinguish individuals at high risk is important. In this study, we aim to clarify the relationship between quantitative haematoma volume and recurrence of CSDH.

Methods

For this two-year retrospective study, 94 patients with CSDH were enrolled and all underwent burr-hole craniostomy with closed-system drainage. The volume of haematoma before surgery was quantitatively analysed by computed tomography (CT) of the brain. The patients were subdivided into 2 groups based on whether recurrence of CSDH was present or not. We investigated the intergroup differences in the volume of haematoma and other radiographic parameters.

Results

Recurrence of CSDH was identified in 13 of 94 patients (14%). Univariable analysis of CT features revealed significant differences in the volume of haematoma, bilateral cerebral convexity, and layering of the haematoma. To adjust for the confounding effect, these 3 parameters were entered into multivariable logistic regression analysis. Ultimately, neither the volume of haematoma (p = 0.449) or bilateral cerebral convexity (p = 0.123) was relevant in this model. Only the presence of layering of the haematoma was independently associated with recurrence of CSDH (p = 0.009).

Conclusion

The volume of CSDH is not related to recurrence in patients undergoing burr-hole craniostomy with closed-system drainage. Layering of the haematoma was the only independent risk factor on CT images for recurrence of CSDH in our series.     

Is a skull X-ray necessary after milder head trauma?

During the 2-year period 1985-86 a total of 1,876 patients were admitted to our hospital after milder head trauma including cerebral concussion. Two hundred and eighty four patients who had a skull X-ray were not selected from guidelines. In 1,592 patients without a skull X-ray, signs of an intracranial complication developed in six cases and were verified by CT. In the 284 patients with skull X-ray a fracture was demonstrated in 25, and of these 25 patients only one patient disclosed a cerebral contusion. In the 259 patients with skull X-ray, but without demonstration of fracture, there were subsequently seen one subdural haematoma and one cerebral contusion. The incidence of intracranial complications in patients without and with skull X-ray with or without fracture does not differ significantly. In these circumstances we do not find any justification for routine skull X-ray after milder head trauma.     

Course of brain shift during microsurgical resection of supratentorial cerebral lesions: limits of conventional neuronavigation

Summary Background. The authors have conducted a prospective study to evaluate the amount and course of brain shift during microsurgical removal of supratentorial cerebral lesions, and to assess factors which potentially influence these shifts.Method. In 61 patients the displacement of 2–3 cortical landmarks on the cerebral surface was dynamically quantified during surgery, i.e. during dissection of the tumour at the estimated half-time of surgery, and at the end of microsurgical removal of the cerebral lesion using the neuronavigation system EasyGuide Neuro. In 14 of these patients the displacement of a subcortical landmark was additionally analysed. Age of the patients, preoperative midline shift, location of the lesion, lesion volume, depth of the lesion below the cortical surface, presence or absence of oedema, and size of the craniotomy were analysed for potential influence on the amount of brain shift. Correlations were analysed for all patients together and for the subgroups of vault meningiomas (n=10), gliomas (n=30), and nonglial intra-axial lesions (n=21).Findings. The mean displacement of the cortical landmarks ranged between 0.8 and 14.3mm (mean: 6.1mm, standard deviation: 3.4mm) during surgery (10–210 minutes [mean: 50.7 minutes, standard deviation: 34.5 minutes] after dura opening) and between 2.4 and 15.2mm (mean: 6.6mm, standard deviation: 3.2mm) at the end of microsurgical removal of the tumourous cerebral lesions (20–375 minutes [mean: 107.2 minutes, standard deviation: 65.6 minutes] after dura opening). Significant correlations (p<0.01) for the entire patient group were found between brain shift and tumour volume, midline shift, and size of the craniotomy, respectively. For the subgroup of vault meningiomas a significant correlation (p<0.01) between brain shift and patient age was found. For the subgroup of gliomas a significant correlation (p<0.01) between brain shift and tumour volume, midline shift and size of the craniotomy, respectively, was found. For the subgroup of nonglial intra-axial lesions a significant correlation (p<0.01) between brain shift and midline shift and between brain shift and size of the craniotomy was found. The quantity of shared common variance ranged between 10–50%. Performing a discriminant analysis, lesion volume was the only certain factor influencing brain shift intra-operatively as well as at the end of lesion removal. 58.5% of the extent of brain shift could be correctly classified by the tumour volume as the only discriminating variable during dissection of the tumour and at the end of surgery.Comparing superficial with subcortical brain shift over the same time period, a mean superficial shift of 4.6mm (1.6–10.8mm, standard deviation: 2.8mm) and a mean subcortical shift of 3.5mm (1.0–7.7mm, standard deviation: 2.3mm) was found. A highly significant Spearman correlation (Rho: .97, p<0.001) between superficial and subcortical brain shift emerged. Shifting of superficial landmarks exceeded shifting of subcortical structures in all patients.Conclusions. The data demonstrate the dynamics of brain shift and the limits of conventional neuronavigation and add additional support for the unavoidable inaccuracy of contemporary neuronavigational systems once the cranium is opened. Brain shift leads to a significant loss of reliability of neuronavigation systems during microsurgical removal of intracranial lesions and there are differences of the course and the amount of brain shift in relation to special subgroups of supratentorial cerebral lesions. However, because of the heterogeneous nature of lesions neurosurgeons have to remove, the modest quantity of shared common variance, and the differences between superficial and subcortical brain shift, it seems unlikely that the amount and course of brain shift become exactly predictable pre-operatively. Only an intra-operative update of image data should have the capacity to overcome this fundamental problem of modern neuronavigation.     

Serum activities of hydroxybutyrate dehydrogenase (HBD) and the isoenzymes of lactate dehydrogenase (LD) as an index of traumatic brain injury

Summary The lactate dehydrogenase (LD), the hydroxybutyrate dehydrogenase (HBD), and the LD isoenzyme activities in serum were followed in the posttraumatic period in 113 patients with cranio-cerebral injury, 70 of whom had verified brain confusion—laceration.In patients with brain contusion the HBD activity, known to be exerted mainly by the anodal LD isoenzyme fractions dominating in brain tissue, was significantly raised in 91% of the blood samples taken within four hours, and in 92% of the samples taken between 12 and 24 hours after trauma, while it was within normal limits in all the samples taken within four hours in patients with brain concussion, and increased in only 17% of the concussion patients 12–24 hours after trauma. The LD₁ and the LD₁₊₂ activities were of less diagnostic importance in blood samples taken during the first 24 hours. However, after 24 hours the LD₁ activity was as informative as the HBD activity. The LD₁ activity was normal in all concussion patients from the third day after trauma, while 78% of the contusion patients still showed raised LD₁ activity then.The determination of HBD activity in serum in the immediate post-traumatic period is recommended as an appropriate method for screening parenchymatous brain injury. A complete LD isoenzyme separation may later add some further information in doubtful cases.     

Outcomes and recurrence rates in chronic subdural haematoma

The object of this study was to determine the relationship between outcome (assessed by Glasgow Outcome Scale) and recurrence in chronic subdural haematoma (CSDH). Eighty-two consecutive patients who underwent surgery for CSDH were included in this study. The relationship between the following variables and CSDH recurrence was studied: sex; age; history of trauma; Glasgow Coma Scale (GCS) at the time of admission (stage 1: GCS>12, stage 2: GCS: 8 - 12, stage 3: GCS<8); interval between head injury (when a history of trauma was present) and surgery; presence of a midline shift on CT scans; presence of intracranial air 7 days after surgery; haematoma density; haematoma width; presence of brain atrophy; and Glasgow Outcome Scale (GOS, both quantitative and non-quantitative) at the time of discharge. Throughout the analysis, p<0.05 was considered statistically significant. The results showed lower GCS (p<0.001), higher GOS (p<0.001), presence of intracranial air 7 days after surgery (p=0.002), and a high density haematoma (p<0.001) were significantly associated with recurrence of CSDH. It was concluded that GOS is related with recurrence in CSDH.     

A comparison of surgical delays in directly admitted versus transferred patients with hip fractures: Opportunities for improvement?

Background

The increasing incidence of hip fractures in our aging population challenges orthopedic surgeons and hospital administrators to effectively care for these patients. Many patients present to regional hospitals and are transferred to tertiary care centres for surgical management, resulting in long delays to surgery. Providing timely care may improve outcomes, as delay carries an increased risk of morbidity and mortality.

Methods

We retrospectively reviewed the cases of all patients with hip fractures treated in a single Level 1 trauma centre in Canada between 2005 and 2012. We compared quality indicators and outcomes between patients transferred from a peripheral hospital and those directly admitted to the trauma centre.

Results

Of the 1191 patients retrospectively reviewed, 890 met our inclusion criteria: 175 who were transferred and 715 admitted directly to the trauma centre. Transfer patients’ median delay from admission to operation was 93 hours, whereas nontransfer patients waited 44 hours (p < 0.001). The delay predominantly occurred before transfer, as the patients had to wait for a bed to become available at the trauma centre. The median length of stay in hospital was 20 days for transfer patients compared with 13 days for nontransfer patients (p < 0.001). Regional policy changes enacted in 2011 decreased the median transfer delay from regional hospital to tertiary care centre from 47 to 27 hours (p = 0.005).

Conclusion

Policy changes can have a significant impact on patient care. Prioritizing patients and expediting transfer will decrease overall mortality, reduce hospital stay and reduce the cost of hip fracture care.     

Relationship between haematoma in femoral neck fractures contamination and early postoperative prosthetic joint infection

Introduction

Prosthetic joint infection (PJI) after femoral neck fracture is associated with a higher mortality, morbidity and economic costs. Although is well known that the presence of a postsurgical haematoma is associated with infection, in our knowledge there are no articles evaluating the contamination of the femoral neck fracture haematoma and the possible relationship with early postoperative PJI. The aim of our study was to evaluate the prevalence of positive cultures from haematoma in patients with femoral neck fracture and the relationship with early PJI.

Methods

A prospective observational study was performed. All patients who underwent hip hemiarthroplasty for a femoral neck fracture from April’08 to February’09 were included. Three samples were taken just after the arthrotomy, a tissue sample, a swab of haematoma and blood of haematoma inoculated into blood culture flasks. Patients received the standard prophylaxis.

Results

A total of 109 patients were treated during this period in our center, 16 were excluded for mistakes during taking samples or for receiving extra antibiotic treatment after or before the surgery of the fracture. In 29 patients (31.2%) one or more intraoperative cultures were positive. Four patients developed an early PJI caused by Gram-negative bacilli (GNB) in all cases. The early PJI rate in the group of patients with negative intraopertive cultures was 3.1% while in the group with one or more positive cultures was 6.9% (p = 0.3). In 3 cases the haematoma was contaminated with a GNB. The PJI rate in patients with intraoperative cultures positive for a GNB was 66.6% (2/3) while in the group of patients without a GNB the infection rate was 2.2% (2/89, p = 0.004, Fisher exact-test). Furthermore in these two patients the microorganism that caused the PJI was the same that had been isolated from the haematoma.

Conclusion

The haematoma in femoral neck fractures was contaminated in 31.2% of cases before surgery. The contamination of the haematoma with a GNB was associated with a higher risk of early postoperative PJI.     

Medicine versus surgery/anesthesiology intensivists: a retrospective review and comparison of outcomes in a mixed medical–surgical–trauma ICU

Background

With various types of complex patients being treated in a mixed medical–surgical–trauma intensive care unit (ICU), we hypothesized that there should be no difference in patient mortality with respect to the core training of the intensivist.

Methods

We reviewed the cases of all patients admitted to a mixed medical–surgical–trauma ICU at a Canadian university teaching hospital in 2007. Patients were assigned to 1 of 2 treatment groups (internal medicine, surgery/anesthesiology) based on the treating intensivist’s training. Our primary outcome was to compare patient mortality in the ICU between the groups. We used generalized estimating equations to determine 10-day mortality after admission to the ICU. A multivariate Cox hazard model was used to determine statistical significance and 95% confidence intervals (CIs) for 11- to 60-day mortality in the ICU.

Results

A total of 961 patients were admitted from January to December, 2007. We found no significant difference between the groups in 10-day mortality (odds ratio 0.73, 95% CI 0.46–1.18, p = 0.20) and 11- to 60-day mortality (hazard ratio 1.43, 95% CI 0.62–3.30, p = 0.40) after admission to the ICU.

Conclusion

In a large university trauma centre that operates a mixed medicine–surgical–trauma ICU, there was no significant difference in mortality between patients managed by intensivists with core training in internal medicine and those managed by intensivists with training in surgery/anesthesiology.     

Major cardiothoracic trauma: Eleven-year review of outcomes in the North West of England

Introduction

Up to 15% of patients with cardiothoracic trauma require emergency surgery, and death can be prevented in a substantial proportion of this group. UK reports have emphasised the need for improvement in this field. We assessed major cardiothoracic trauma (MCT) outcomes in North West England over 11 years.

Methods

The database from the Trauma Audit and Research Network was used to retrieve data for all patients who had suffered MCT between 2000 and 2011 in North West England and the findings analysed. Trauma that led to thoracotomy/thoracoscopy or sternotomy was defined as MCT.

Results

A total of 146 patients were identified, and a considerable male predominance (88.4%) noted. A total of 54.1% had sustained penetrating cardiothoracic trauma. Also, 53.4% had been admitted to tertiary-care hospitals for trauma (TCHT) and 46.6% had been admitted to non-TCHT. Overall prevalence of mortality was 35.6%. No significant difference was found in mortality between TCHT vs non-TCHT. Prevalence of mortality was significantly higher in the subgroup of patients cared for exclusively in non-TCHT compared with patients transferred from non-TCHT to TCHT (41% vs 13.8%, p<0.05).

Conclusions

No significant difference was demonstrated in length of stay in hospital/length of stay in the intensive treatment unit and prevalence of mortality between patients originally presenting in TCHT and those presenting in non-TCHT. However, patients transferred from non-TCHT to TCHT had a lower prevalence of mortality. These findings may constitute a valuable benchmark for comparison with results arising after introduction of trauma centres in the UK.     

Implantable cardioverter defibrillators and permanent pacemakers: prevalence and patient outcomes after trauma

Background

The prevalence and outcomes of older trauma patients with implantable cardioverter defibrillators (ICDs) or permanent pacemakers (PPMs) is unknown.

Methods

The trauma registry at a regional trauma center was reviewed for blunt trauma patients, aged ≥ 60 years, admitted between 2007 and 2014. Medical records of cardiac devices patients were reviewed.

Results

Of 4,193 admissions, there were 146 ICD, 233 PPM, and 3,814 no device patients; median Injury Severity Score was 9. Most cardiac device patients had substantial underlying heart disease. Patients with ICDs (13.0%) and PPMs (8.6%) had higher mortality rates than no device patients (5.6%, P = .0002). Among cardiac device patients who died, the device was functioning properly in all that were interrogated; the most common cause of death was intracranial hemorrhage. On propensity score analysis, cardiac devices were not independent predictors of mortality but rather surrogate variables associated with other predictors of mortality.

Conclusions

Approximately 9.0% of admitted older patients had cardiac devices. Their presence identified patients who had higher mortality rates, likely because of their underlying comorbidities, including cardiac dysfunction.