Influence of Injury Pattern on Incidence and Severity of Posttraumatic Inflammatory Complications in Severely Injured Patients

Abstract Background: Severe trauma causes systemic inflammatory response syndrome (SIRS) which may lead to multiple organ dysfunction syndrome (MODS) or multiple organ failure (MOF). The aim of this study was to evaluate the influence of the injury pattern on the incidence and severity of SIRS, sepsis, MODS, and mortality. Methods: A total of 1,273 patients with an injury severity score (ISS) of ≥ 9 points and survival of more than 3 days were included in this retrospective study. Outcome parameters were various grades of SIRS, sepsis, MODS, and mortality. Results: Severe non-infectious SIRS occurred in 23%, sepsis in 14%, and severe MODS in 14% of the patients. Serious (abbreviated injury scale (AIS) ≥ 3 points) head injury and the ISS represented the most potent risk factors for severe SIRS. As estimated by multivariate logistic regression analysis, the presence of severe extremity and pelvic injuries, the ISS, and the male gender were found to be independent risk factors for sepsis. Severe injuries of the abdomen were associated with an increased risk for sepsis in the univariate analysis. Severe injuries to the head or abdomen, the ISS, and the male gender represented independent risk factors for the development of severe MODS. Regarding the late (> 3 days after trauma) hospital mortality, severe head injury, the ISS, and the patient’s age were independent risk factors. Conclusions: Head injury predominantly determines the incidence of non-infectious systemic inflammation, MOF, and late hospital mortality of patients with severe trauma. Skeletal or abdominal injuries represent relevant risk factors for septic complications. Thus, the incidence of posttraumatic, life-threatening inflammatory complications is related with certain injury patterns in addition to the gender and the severity of trauma.     

Blunt Abdominal Trauma Requiring Laparotomy: an Analysis of 342 Polytraumatized Patients

Abstract Introduction: Hemorrhage due to abdominal trauma is one of the most frequent causes of early mortality in polytraumatized patients. Therefore, the initial management of abdominal trauma is an important factor in determining the outcome. The aim of this study was to evaluate the clinical course in multiple trauma patients who sustained abdominal trauma requiring operative intervention. Patients and Methods: In this retrospective analysis, a database containing prospectively collected data on polytraumatized patients from a European level I trauma center was used. The following inclusion criteria were applied: (1) operative intervention for blunt abdominal injuries with positive intraoperative findings, (2) injury severity score (ISS) > 18, and (3) age 16–65 years. Results: The inclusion criteria were met by 342 patients (229 male and 113 female patients, mean ISS 39.9±8.9). The most frequently observed intra-abdominal injuries were to the spleen (62.1%) and the liver (47.7%). The most common extra-abdominal injury observed in combination with abdominal trauma was trauma to the chest (71.9%). One hundred forty-three patients (41%) died during their hospital stay. The most frequent reasons for death were hemorrhagic shock (26.7%), ARDS (27.6%) and head trauma (23.2%). The severity of liver injury correlated positively with mortality. In contrast, no correlation between splenic injuries and mortality was observed. Significantly more deaths were attributed to primarily extra-abdominal injuries (111 patients, 77.6%) and then to intra-abdominal injuries (12 patients, 8.4%). In 20 patients (14%), a combination of intra- and extra-abdominal injuries caused posttraumatic death. Conclusion: Mortality was significantly higher for extra-abdominal injuries and their associated complications compared to intra-abdominal injuries. These findings should be considered in the development of treatment algorithms for blunt trauma.     

Age-adjusted shock index: From injury to arrival

BackgroundStudies have demonstrated the superiority of the shock index, pediatric age-adjusted (SIPA) in predicting outcomes in pediatric blunt trauma patients. However, all have utilized SIPA calculated on emergency department (ED) arrival. We sought to evaluate the utility of SIPA at the trauma scene and describe changes in SIPA from the trauma scene to the ED.MethodsWe used 2014–2016 Trauma Quality Improvement Program Data to identify blunt trauma patients 1–15 years old with an injury severity score (ISS) > 15. We calculated SIPA using vitals obtained at the trauma scene and on ED arrival. Outcome measures included ISS, transfusion within 24 h, intensive care unit (ICU), hospital length of stay (LOS), ventilator days, and mortality.ResultsWe identified 2917 patients, and 34.2% had a persistently elevated SI from the injury scene to ED arrival, whereas 17.9% had a persistently elevated SIPA. An elevated SIPA at the trauma scene was more predictive of greater ISS, LOS, and ventilator requirements. Furthermore, a SIPA that remained abnormal was associated with greater ISS, LOS, ICU admission, mechanical ventilation, and mortality.ConclusionsPrehospital SIPA values predict worse outcomes in pediatric trauma patients, and their change over time may have greater predictive utility than a single value alone.Level of EvidenceIIType of StudyPrognosis Study.     

Geriatric assault victims treated at U.S. trauma centers: Five-year analysis of the national trauma data bank

IntroductionWhile geriatric trauma patients have begun to receive increased attention, little research has investigated assault-related injuries among older adults. Our goal was to describe characteristics, treatment, and outcomes of geriatric assault victims and compare them both to geriatric victims of accidental injury and younger assault victims.Patients and methodsWe conducted a retrospective analysis of the 2008–2012 National Trauma Data Bank. We identified cases of assault-related injury admitted to trauma centers in patients aged ≥60 using the variable “intent of injury.”Results3564 victims of assault-related injury in patients aged ≥60 were identified and compared to 200,194 geriatric accident victims and 94,511 assault victims aged 18–59. Geriatric assault victims were more likely than geriatric accidental injury victims to be male (81% vs. 47%) and were younger than accidental injury victims (67 ± 7 vs. 74 ± 9 years). More geriatric assault victims tested positive for alcohol or drugs than geriatric accident victims (30% vs. 9%). Injuries for geriatric assault victims were more commonly on the face (30%) and head (27%) than for either comparison group. Traumatic brain injury (34%) and penetrating injury (32%) occurred commonly. The median injury severity score (ISS) for geriatric assault victims was 9, with 34% having severe trauma (ISS ≥ 16). Median length of stay was 3 days, 39% required ICU care, and in-hospital mortality was 8%. Injury severity was greater in geriatric than younger adult assault victims, and, even when controlling for injury severity, in-hospital mortality, length of hospitalization, and need for ICU-level care were significantly higher in older adults.ConclusionsGeriatric assault victims have characteristics and injury patterns that differ significantly from geriatric accidental injury victims. These victims also have more severe injuries, higher mortality, and poorer outcomes than younger victims. Additional research is necessary to improve identification of these victims and inform treatment strategies for this unique population.     

Abdominal vena caval injuries: outcomes remain dismal

BACKGROUND: The mortality rate for abdominal vena caval injuries remains high. We examined the experience of a level I trauma center to determine factors significant to the outcome in these injuries. METHODS: Forty-seven patients were identified in a retrospective review (1989 to 1999) of patients were identified with abdominal vena caval injury. Data were analyzed by uni- and multivariate methods, including logistic regression. RESULTS: Most of the individuals with abdominal vena caval injuries were young male patients who were injured by penetrating trauma and who were hypotensive on arrival. The severity of injury and the number of organs injured was high. The overall mortality rate was 55%. Nonsurvivors were more often hypotensive in the field with physiologic derangement consistent with hemorrhagic shock. Type and location of injury as well as method of repair were associated with death. Multiple regression analysis revealed that prehospital initial systolic blood pressure and intraoperative bicarbonate levels were independent predictors of survival. CONCLUSIONS: We identified factors related to poor outcome, including suprarenal and retrohepatic location of injury and variables that reflected the evolution of shock. Management should include appropriate resuscitation and ultimately may require novel operative techniques.     

A contemporary prospective review of 205 consecutive patients with penetrating colon injuries

BackgroundManagement of colon injuries has significantly evolved in the recent decades resulting in considerably decreased morbidity and mortality. We set out to investigate penetrating colon injuries in a high-volume urban academic trauma center in South Africa.MethodsAll patients with penetrating colon injuries admitted between 1/2015 and 1/2018 were prospectively enrolled. Data collection included demographics, injury profile and outcomes. Primary outcome was in-hospital mortality. Secondary outcome was morbidity.ResultsTwo-hundred and five patients were included in the analysis. Stab and gunshot wounds constituted 18% and 82% of the cases, respectively. Mean age was 28.9 (10.2) years and 96.1% were male. Median injury severity score (ISS) and penetrating abdominal trauma index (PATI) were 16 (9-25) and 19 (10-26), respectively. A total of 47.8% of the patients had a complication per Clavien-Dindo classification. Colon leak rate was 2.4%. Wound and abdominal organ/space infection rate was 15.1 and 6.3%, respectively. Overall in-hospital mortality was 9.3%. Risk factors for mortality were higher ISS and PATI, shock on admission, need for blood transfusion, intra-abdominal vascular injury, damage control surgery, and extra-abdominal severe injuries.ConclusionsContemporary overall complication rate remains high in penetrating colon injuries, however, anastomotic leak rate is decreasing. Colon injury associated mortality is related to overall injury burden and hemorrhage rather than to colon injuries.     

High-energy trauma patients with pelvic fractures: Management trends in Ontario,Canada

IntroductionAlthough fractures of the pelvic ring account for only 2–3% of all fractures, they are present in approximately 7–20% of patients with high-energy polytrauma. High-energy pelvic fractures are life-threatening injuries, with mortality estimates ranging from 6 to 35%. The purpose of this study was to examine trends in the incidence, diagnosis, treatment, and mortality rates of high-energy pelvic fractures in Ontario, Canada over a 10-year period.MethodsA cohort of 3915 patients who sustained a high-energy pelvic fracture in Ontario between 01 April 2005 and 31 March 2015 was identified using the Ontario Trauma Registry and administrative healthcare data linked by the Institute for Clinical Evaluative Science (ICES). Severely injured patients (defined as having an Injury Severity Score (ISS) of ≥16) with pelvic fractures following high-velocity mechanisms of injury were identified using applicable ICD-10 codes. Trends were assessed statistically using the Poisson and the Cochrane-Armitage tests for trend. Modified Poisson regression was used to model the adjusted risk ratio of mortality by pelvic fracture treatment.ResultsThe incidence of pelvic fracture remained constant at approximately 4.6 cases per 100,000 population annually between 2005 and 2011. From 2012, there was a decrease in patients with ISS ≥ 16 due to changes in the calculation of the ISS. The proportion of patients presenting with ISS > 50 increased from 8.2% to 14.1% (p = 0.008) over the study period. Automobile collisions or pedestrians struck by vehicles accounted for over half of injuries. Approximately 6% of patients underwent angioembolisation. Treatment with external fixation (15.5%–20.2%) or no surgical intervention (46.2%–61.3%) increased from 2005 to 2015. Mortality remained constant (11% at 30 days), and laparotomy was the only major intervention not associated with decreased risk of death.ConclusionsStable mortality despite increasing injury severity suggests that the quality of care provided to patients with high-energy pelvic fractures has improved over time. However, unchanged incidence suggests the need for ongoing efforts aimed towards injury prevention. ISS at presentation was the most significant predictor of mortality in this patient population.     

Factors affecting mortality in older trauma patients—A systematic review and meta-analysis

IntroductionMajor trauma in older people is a significant health burden in the developed world. The aging of the population has resulted in larger numbers of older patients suffering serious injury. Older trauma patients are at greater risk of death from major trauma, but the reasons for this are less well understood. The aim of this review was to identify the factors affecting mortality in older patients suffering major injury.Materials and methodsA systematic review of Medline, Cinhal and the Cochrane database, supplemented by a manual search of relevant papers was undertaken, with meta-analysis.Multi-centre cohort studies of existing trauma registries that reported risk-adjusted mortality (adjusted odds ratios, AOR) in their outcomes and which analysed patients aged 65 and older as a separate cohort were included in the review.Results3609 papers were identified from the electronic databases, and 28 from manual searches. Of these, 15 papers fulfilled the inclusion criteria. Demographic variables (age and gender), pre-existing conditions (comorbidities and medication), and injury-related factors (injury severity, pattern and mechanism) were found to affect mortality.The ‘oldest old’, aged 75 and older, had higher mortality rates than younger patients, aged 65–74 years. Older men had a significantly higher mortality rate than women (cumulative odds ratio 1.51, 95% CI 1.37–1.66). Three papers reported a higher risk of death in patients with pre-existing conditions. Two studies reported increased mortality in patients on warfarin (cumulative odds ratio 1.32, 95% CI 1.05–1.66). Higher mortality was seen in patients with lower Glasgow coma scores and systolic blood pressures. Mortality increased with increased injury severity and number of injuries sustained. Low level falls were associated with higher mortality than motor vehicle collisions (cumulative odds ratio 2.88, 95% CI 1.26–6.60).ConclusionsMultiple factors contribute to mortality risk in older trauma patients. The relation between these factors and mortality is complex, and a fuller understanding of the contribution of each factor is needed to develop a better predictive model for trauma outcomes in older people. More research is required to identify patient and process factors affecting mortality in older patients.     

New injury severity score (NISS) outperforms injury severity score (ISS) in the evaluation of severe blunt trauma patients

Purpose: The injury severity score (ISS) and new injury severity score (NISS) have been widely used in trauma evaluation. However, which scoring system is better in trauma outcome prediction is still disputed. The purpose of this study is to evaluate the value of the two scoring systems in predicting trauma outcomes, including mortality, intensive care unit (ICU) admission and ICU length of stay. Methods: The data were collected retrospectively from three hospitals in Zhejiang province, China. The comparisons of NISS and ISS in predicting outcomes were performed by using receiver operator characteristic (ROC) curves and Hosmer-Lemeshow statistics. Results: A total of 1825 blunt trauma patients were enrolled in our study. Finally, 1243 patients were admitted to ICU, and 215 patients died before discharge. The ISS and NISS were equivalent in predicting mortality (area under ORC curve [AUC]: 0.886 vs. 0.887, p ¼ 0.9113). But for the patients with ISS 25, NISS showed better performance in predicting mortality. NISS was also significantly better than ISS in predicting ICU admission and prolonged ICU length of stay. Conclusion: NISS outperforms ISS in predicting the outcomes for severe blunt trauma and can be an essential supplement of ISS. Considering the convenience of NISS in calculation, it is advantageous to promote NISS in China’s primary hospitals.     

Functional outcomes of traumatic midfoot injuries

IntroductionMidfoot injuries are rare injuries, often the result of high-energy trauma and occurring in the context of multiple trauma. This study aimed to evaluate functional outcomes and health-related quality of life after open reduction and internal fixation for midfoot injuries at a level 1 trauma center treating complex foot injuries.MethodsRetrospective single level 1 center study with follow-up by questionnaire. All adult patients who underwent open reduction and internal fixation (ORIF) for Lisfranc and/or Chopart injuries between 2000 and 2016 were included and invited to complete the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score, the EuroQOL Visual Analog Scale (EQ-VAS), and the EuroQOL five-dimensional questionnaire (EQ-5D-5L). Chart reviews were performed to collect demographic, injury, and treatment characteristics.ResultsForty patients with 45 midfoot injuries were included. Follow-up was available for 29 patients (31 feet), leading to a response rate of 83%. The majority of patients suffered high-energy trauma and nearly all patients had a concomitant injury. Secondary arthrodesis was performed in 7/45 injuries. Median AOFAS score was 64 (IQR 47–78). Higher injury severity score (ISS) was associated with poorer functionality as measured with the AOFAS Midfoot Score (p = 0.046), concomitant injuries were associated with lower quality of life (p = 0.01). EQ-5D scores were significantly lower when compared to the Dutch reference population (p< 0.001).ConclusionsInjuries of the midfoot have negative effects on mid- to long-term quality of life after trauma, with considerable potential for long-term impaired functionality. When counseling patients with these rare injuries after high-energy trauma mechanisms or in the context of multiple trauma, realistic expectations on postoperative recovery should be given.     

A comparison of severely injured trauma patients admitted to level 1 trauma centres in Queensland and Germany

Background: The allocation of a trauma network in Queensland is still in the developmental phase. In a search for indicators to improve trauma care both locally as state‐wide, a study was carried out comparing trauma patients in Queensland to trauma patients in Germany, a country with 82.4 million inhabitants and a well‐established trauma system. Methods: Trauma patients ≥15 years of age, with an Injury Severity Score (ISS) ≥ 16 admitted to the Princess Alexandra Hospital (PAH) and to the 59 German hospitals participating in the Trauma Registry of the German Society for Trauma Surgery (DGU‐G) during the year 2005 were retrospectively identified and analysed. Results: Both cohorts are comparable when it comes to demographics and injury mechanism, but differ significantly in other important aspects. Striking is the low number of primary admitted patients in the PAH cohort: 58% versus 83% in the DGU‐G cohort. PAH patients were less physiologically deranged and less severely injured: ISS 25.2 ± 9.9 versus 29.9 ± 13.1 (P < 0.001). Subsequently, they less often needed surgery (61% versus 79%), ICU admission (49% versus 92%) and had a lower mortality: 9.8% versus 17.9% of the DGU‐G cohort. Conclusions: Relevant differences were the low number of primary admissions, the lesser severity of injuries, and the low mortality of the patients treated at the PAH. These differences are likely to be interrelated and Queensland's size and suboptimal organization of trauma care may have played an important role.     

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

Background

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

Methods

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

Results

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

Conclusion

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

Defining major trauma using the 2008 Abbreviated Injury Scale

BackgroundThe Injury Severity Score (ISS) is the most ubiquitous summary score derived from Abbreviated Injury Scale (AIS) data. It is frequently used to classify patients as ‘major trauma’ using a threshold of ISS >15. However, it is not known whether this is still appropriate, given the changes which have been made to the AIS codeset since this threshold was first used. This study aimed to identify appropriate ISS and New Injury Severity Score (NISS) thresholds for use with the 2008 AIS (AIS08) which predict mortality and in-hospital resource use comparably to ISS >15 using AIS98.MethodsData from 37,760 patients in a state trauma registry were retrieved and reviewed. AIS data coded using the 1998 AIS (AIS98) were mapped to AIS08. ISS and NISS were calculated, and their effects on patient classification compared. The ability of selected ISS and NISS thresholds to predict mortality or high-level in-hospital resource use (the need for ICU or urgent surgery) was assessed.ResultsAn ISS >12 using AIS08 was similar to an ISS >15 using AIS98 in terms of both the number of patients classified major trauma, and overall major trauma mortality. A 10% mortality level was only seen for ISS 25 or greater. A NISS >15 performed similarly to both of these ISS thresholds. However, the AIS08-based ISS >12 threshold correctly classified significantly more patients than a NISS >15 threshold for all three severity measures assessed.ConclusionsWhen coding injuries using AIS08, an ISS >12 appears to function similarly to an ISS >15 in AIS98 for the purposes of identifying a population with an elevated risk of death after injury. Where mortality is a primary outcome of trauma monitoring, an ISS >12 threshold could be adopted to identify major trauma patients.Level of evidenceLevel II evidence—diagnostic tests and criteria.     

Factors Influencing Geriatric Orthopaedic Trauma Mortality

IntroductionThis study aimed to: (1) evaluate the independent risk factors related to survival and mortality and (2) predict survival in geriatric orthopaedic trauma patients admitted to our institution's ICU as a Level 1 or 2 trauma activation.MethodsA retrospective review was performed on patients age >60, over a 10 year period, who were involved in a multi-trauma with orthopaedic injuries. Variables evaluated include: sex, age, Injury Severity Score (ISS), mechanism of injury, number and type of orthopaedic injury, anticoagulant use, comorbidities, length of stay in intensive care unit (ICU), type of ICU, ventilator use, vasopressors use, incidence of multiple organ dysfunction syndrome (MODS), number of surgeries, and 1-month and 6-month mortality. A Kaplan-Meier estimator and Cox proportional hazards analysis were used to predict and assess survival probability.Results174 patients were included, with an average mortality of 47.7%. Deceased patients had a significantly greater age, ISS, vasopressor usage, ICU stay, incidence of MODF, incidence of genitourinary disease, anticoagulant usage, ventilator usage, number of orthopaedic surgeries, and orthopaedic injuries. The relative risk for mortality within the first month was significantly associated with increased age, ISS, high-energy trauma, length of ICU stay, MODS, psychiatric disease, and anticoagulant use. Patients with an ISS ≤30 were significantly more likely to survive than patients with an ISS of >30. Greater age, ISS, length of ICU stay, incidence of MODS, anticoagulant, and ventilator use were significantly predictive of lower survival rates. Mechanism of injury, number of orthopaedic surgeries and orthopaedic injuries, and type of orthopaedic injury were not found to be predictive of survival.ConclusionsAn ISS >30 at admission is strongly predictive of a lower probability of survival. Genitourinary disease was associated with increased mortality. Low age, ISS, length of stay in ICU, incidence of MODS, anticoagulant use, and ventilator use, are significantly predictive of survival. Number of orthopaedic surgeries, orthopaedic injuries, and type of orthopaedic injury were not found to be predictive of survival. These indications help us to better understand factors predictive of death among geriatric orthopaedic trauma patients, and improve the way we can diagnose and care for them.     

Comparing the accuracy of ICD-based severity estimates to trauma registry-based injury severity estimates for predicting mortality outcomes

IntroductionTrauma registries have been used internationally for several decades to measure the quality of trauma care between hospitals. Given the significant costs involved in establishing and maintaining trauma registries, and increasing availability of routinely collected, linked health data describing a patient's journey (and inherent cost savings in data re-use), there is significant interest in development of integrated, comprehensive trauma data repositories. However, approaches to estimating injury severity using routinely collected data would need to be developed if routinely collected hospital data were to be used as an alternative/supplement to registries.ObjectivesThis study aimed to compare the accuracy of registry-based injury severity estimates with ICD-based injury severity estimates in predicting mortality outcomes in a cohort of minor and major trauma patients in Queensland, using retrospectively linked trauma registry and hospital admissions data.MethodsQueensland Trauma Registry (QTR) data with an admission date between 1 January 2005 and 31 December 2011 was linked with all acute care patients included in the Queensland Hospital Admitted Patient Data Collection (QHAPDC) with a Principal Diagnosis coded with an ICD-10-AM code within Chapter 19 (S00–T98). Abbreviated Injury Scale coding was undertaken manually by QTR trauma data nurses for the registry data. ICD-based injury severity scores (ICISS) were calculated automatically using all injury-related diagnoses captured in the QHAPDC data using the ICISS multiplicative and worst injury method.ResultsThere were 92,140 QTR patients admitted between January 2005 and December 2011 with a valid ISS with a matching QHAPDC record (98.4% survived, 1.6% died). ICISS (multiplicative and worst injury approach) showed marginally better predictive accuracy than ISS when predicting mortality across minor and major injury and ICISS showed marginally better predictive accuracy to ISS when restricted to major trauma/high threat to life cases. Both ICISS and ISS restricted to major trauma/high threat to life showed poorer accuracy compared to the predictive performance when both minor and major cases were included.ConclusionICD-based predictions were as accurate as ISS-based predictions for this cohort and this study provides evidence to support the potential for using routinely coded hospital data for risk adjustment within State-based trauma data repositories.     

Outcomes and costs of penetrating trauma injury in England and Wales

BACKGROUND: Penetrating trauma injury is generally associated with higher short-term mortality than blunt trauma, and results in substantial societal costs given the young age of those typically injured. Little information exists on the patient and treatment characteristics for penetrating trauma in England and Wales, and the acute outcomes and costs of care have not been documented and analysed in detail. METHODS: Using the Trauma Audit Research Network (TARN) database, we examined patient records for persons aged 18+ years hospitalised for penetrating trauma injury between January 2000 and December 2005. Patients were stratified by injury severity score (ISS). RESULTS: 1365 patients were identified; 16% with ISS 1-8, 50% ISS 9-15, 15% ISS 16-24, 16% ISS 25-34, and 4% with ISS 35-75. The median age was 30 years and 91% of patients were men. Over 90% of the injuries occurred in alleged assaults. Stabbings were the most common cause of injury (73%), followed by shootings (19%). Forty-seven percent were admitted to critical care for a median length of stay of 2 days; median total hospital length of stay was 7 days. Sixty-nine percent of patients underwent at least one surgical procedure. Eight percent of the patients died before discharge, with a mean time to death of 1.6 days (S.D. 4.0). Mortality ranged from 0% among patients with ISS 1-8 to 55% in patients with ISS>34. The mean hospital cost per patient was pound7983, ranging from pound6035 in patients with ISS 9-15 to pound16,438 among patients with ISS>34. Costs varied significantly by ISS, hospital mortality, cause and body region of injury. CONCLUSION: The acute treatment costs of penetrating trauma injury in England and Wales vary by patient, injury and treatment characteristics. Measures designed to reduce the incidence and severity of penetrating trauma may result in significant hospital cost savings.     

Relationship between American College of Surgeons trauma center designation and mortality in patients with severe trauma (injury severity score > 15)

BACKGROUND: We studied the association of the American College of Surgeons (ACS) trauma center designation and mortality in adult patients with severe trauma (Injury Severity Score > 15). ACS designation of trauma centers into different levels requires substantial financial and human resources commitments. There is very little work published on the association of ACS trauma center designation and outcomes in severe trauma. STUDY DESIGN: National Trauma Data Bank study including all adult trauma admissions (older than 14 years of age) with Injury Severity Score (ISS) > 15. The relationship between ACS level of trauma designation and survival outcomes was evaluated after adjusting for age, mechanism of injury, ISS, hypotension on admission, severe liver trauma, aortic, vena cava, iliac vascular, and penetrating cardiac injuries. RESULTS: A total of 130,154 patients from 256 trauma centers met the inclusion criteria. Adjusted mortality in ACS-designated Level II centers and undesignated centers was notably higher than in Level I centers (adjusted odds ratio, 1.14; 95% CI, 1.09-120; p < 0.0001 and adjusted odds ratio, 1.09; CI, 1.05-1.13; p < 0.0001, respectively). CONCLUSIONS: Severely injured patients with ISS > 15 treated in ACS Level I trauma centers have considerably better survival outcomes than those treated in ACS Level II centers.     

Change in outcomes for trauma patients over time: Two decades of a state trauma system

BackgroundTrauma center mortality rates are benchmarked to expected rates of death based on patient and injury characteristics. The expected mortality rate is recalculated from pooled outcomes across a trauma system each year, obscuring system-level change across years. We hypothesized that risk-adjusted mortality would decrease over time within a state-wide trauma system.MethodsWe identified adult trauma patients presenting to Level I and II Pennsylvania trauma centers, 1999–2018, using the Pennsylvania Trauma Outcomes Study. Multivariable logistic regression generated risk-adjusted models for mortality in all patients, and in key subgroups: penetrating torso injury, blunt multisystem trauma, and patients presenting in shock.ResultsOf 162,646 included patients, 123,518 (76.1%) were white and 108,936 (67.0%) were male. The median age was 49 (interquartile range [IQR] 29–70), median injury severity score was 16 (IQR 10–24), and 87.5% of injuries were blunt. Overall, 9.9% of patients died, and compared to 1999, no year had significantly higher adjusted odds of mortality. Overall mortality was significantly lower in 2007–2009 and 2011–2018. Of patients with blunt, multisystem injuries, 17.7% died, and adjusted mortality improved over time. Mortality rates were 24.9% for penetrating torso injury, and 56.9% for shock, with no significant change. Mortality improved for patients with ISS < 25, but not for the most severely injured.ConclusionsOver 20 years, Pennsylvania trauma centers demonstrated improved risk-adjusted mortality rates overall, but improvement remains lacking in high-risk groups despite numerous innovations and practice changes in this time period. Identifying change over time can help guide focus to these critical gaps.     

Changing Demographic Trends in spine trauma: The presentation and outcome of Major Spine Trauma in the elderly

IntroductionMajor trauma has seen a demographic shift in recent years and it is expected that the elderly population will comprise a greater burden on the major trauma service in the near future. However, whether a similar trend exists in those undergoing operative intervention for spinal trauma remains to be elucidated.AimsTo compare the presentation and outcomes of patients ≥65 years of age sustaining spine trauma to those <65 years at a national tertiary referral spine centre.MethodsThe local Trauma Audit Research Network (TARN) database was analysed to identify spinal patients referred to our institution, a national tertiary referral centre, between 01/2016 and 05/2019. Patients were divided into a young cohort (16–64 years old) and an elderly cohort (> 64 years old). No explicit distinction was made between major and minor spine trauma cases. Variables analysed included patient demographics, injury severity, mortality, interventions, mechanism of injury and length of hospital stay.ResultsA total of 669 patients were admitted of which 480 patients underwent operative intervention for spinal trauma. Within the elderly cohort, this represented 75.3% of cases. Among the younger population, road traffic collisions were the most common mechanism of injury (37.1%), while low falls (<2 m) (57.4%) were the most common mechanism among the older population. Patients ≥65 years old had significantly longer length of stay (21 days [1–194] v 14 days [1–183]) and suffered higher 30-day mortality rates (4.6% [0–12] v 0.97% [0–4]).ConclusionOrthopaedic spinal trauma in older people is associated with a significantly higher mortality rate as well as a longer duration of hospitalization. Even though severity of injury is similar for both young and old patients, the mechanism of injury for the older population is of typically much lower energy compared to the high energy trauma affecting younger patients.