Waiting for the patient to "sober up": Effect of alcohol intoxication on glasgow coma scale score of brain injured patients

BACKGROUND: Between 35% to 50% of traumatic brain injury (TBI) patients are under the influence of alcohol. Alcohol intoxication may limit the ability of the Glasgow Coma Scale (GCS) to accurately assess severity of TBI. We hypothesized that alcohol intoxication significantly depresses GCS scores of TBI patients. METHODS: A 10-year, retrospective analysis of a Level I trauma center registry was undertaken. The study population consisted of all blunt injured TBI patients tested for blood alcohol concentration (BAC, n = 1,075). Patients were divided into two groups; intoxicated (mean BAC 202 +/- 77 mg/dL, n = 504) and nonintoxicated (BAC = 0, n = 571). TBI was classified using ICD-9 codes as concussion alone (ICD-9 850, n = 90) and intracranial injury (ICI, ICD-9 851-854, n = 985). Severity was further classified using the Abbreviated Injury Score (AIS). Mean GCS score was compared between the two groups. Patients who were either intubated or hypotensive upon arrival were analyzed separately to rule out confounding effects on GCS score. Severely intoxicated patients (BAC >250 mg/dL, [mean +/- SD] 309 +/- 54 SD, n = 118) were similarly compared. Finally, multivariate linear regression analysis was undertaken to determine whether BAC level was an independent predictor of GCS score while controlling for confounding factors. RESULTS: Intoxicated and nonintoxicated TBI patients were clinically similar. Alcohol intoxication had little effect on GCS score, with less than a single point difference in all types of TBI, except the most severely injured (AIS 5 injuries, GCS score difference 1.4 points). These results were not altered by endotracheal intubation, systemic hypotension, or severe intoxication. Similarly, BAC was not a significant independent predictor of GCS score in a multivariate model. CONCLUSION: Alcohol intoxication does not result in clinically significant changes in GCS score for patients with blunt TBI. Hence, alterations in GCS score after TBI should not be attributed to alcohol intoxication, as doing so might result in inappropriate delays in monitoring and therapeutic interventions.     

Prognostic value of trauma scores in pediatric patients with multiple injuries

BACKGROUND: For the quantification of multiple injuries in children, a range of different trauma scores are available, the actual prognostic value of which has, however, not so far been investigated and compared in a group of patients. METHODS: In 261 polytraumatized children and adolescents, 11 trauma scores (Abbreviated Injury Scale [AIS], Injury Severity Score [ISS], Glasgow Coma Scale [GCS], Acute Trauma Index [ATI], Shock Index [SI], Trauma Score [TS], Revised Trauma Score [RTS], Modified Injury Severity Score [MISS], Trauma and Injury Severity Score [TRISS]-Scan, Hannover Polytrauma Score [HPTS], and Pediatric Trauma Score [PTS]) were calculated, and their prognostic relevance in terms of survival, duration of intensive care treatment, hospital stay, and long-term outcome analyzed. RESULTS: With a specificity of 80%, physiologic scores (TS, RTS, GCS, ATI) showed a greater accuracy (79-86% vs. 73-79%) with regard to survival prediction than did the anatomic scores (AIS, HPTS, ISS, PTS); combined forms of these two types of score (TRISS-Scan, MISS) did not provide any additional information (76-80%). Overall, the TRISS-Scan was the score that showed the highest correlation with duration of treatment and long-term outcome. Trauma scores specially conceived for use with children (PTS, MISS) failed to show any superiority vis-à-vis trauma scores in general. CONCLUSION: With regard to prognostic quality and ease of use in the practical setting, TS and the TRISS-Scan are recommended for polytrauma in children and adolescents. Special pediatric scores are not necessary.     

Traumatic brain injury outcomes in pre- and post- menopausal females versus age-matched males

Gender differences in outcomes from major trauma have been described previously, and exogenous female hormone administration appears to be neuroprotective following traumatic brain injury (TBI). This analysis explored outcomes in pre- and post-menopausal females versus age-matched males. A total of 13,437 patients (n = 3,178 females, n = 10,259 males) with moderate-to-severe TBI (head AIS > or = 3) were identified from our county trauma registry. Overall mortality was similar between males and females (22% for both). Logistic regression was used to compare gender outcome differences, with a separate analysis performed for premenopausal (< 50 years) versus postmenopausal (> or = 50 years) patients, and after stratification by decade of life. No statistically significant difference in outcomes was observed for pre-menopausal females versus males (odds ratio [OR] 1.06; 95% confidence interval [CI] 0.83, 1.35; p = 0.633), but outcomes were significantly better in postmenopausal females versus males (OR 0.63, 95% CI 0.48-0.81, p < 0.001) after adjusting for age, mechanism of injury, Glasgow Coma Scale (GCS), hypotension (SBP < or = 90 mm Hg), head Abbreviated Injury Score (AIS), and Injury Severity Score (ISS). Stratification by decade of life revealed the gender survival differential inflection point to occur between ages 40-49 (OR 1.06, 95% CI 0.66-1.71, p = 0.798) and ages 50-59 (OR 0.38, 95% CI 0.20-0.74, p = 0.005). In addition, Revised Trauma Score and Injury Severity Score (TRISS) was used to calculate probability of survival (PS); all patients were then stratified by decade of life, and males and females were compared with regard to mean survival differential (outcome - PS). The identical pattern of improved outcomes in post-menopausal but not pre-menopausal females versus age-matched males was observed. These data suggest that endogenous female sex hormone production is not neuroprotective.     

Prediction of outcomes in trauma: anatomic or physiologic parameters?

BACKGROUND: Prediction of outcomes after injury has traditionally incorporated measures of injury severity, but recent studies suggest that including physiologic and shock measures can improve accuracy of anatomic-based models. A recent single-institution study described a mortality predictive equation [f(x) = 3.48 - .22 (GCS) - .08 (BE) + .08 (Tx) + .05 (ISS) + .04 (Age)], where GSC is Glasgow Coma Score, BE is base excess, Tx is transfusion requirement, and ISS is Injury Severity Score, which had 63% sensitivity, 94% specificity, (receiver operating characteristic [ROC] 0.96), but did not provide comparative data for other models. We have previously documented that the Physiologic Trauma Score, including only physiologic variables (systemic inflammatory response syndrome, Glasgow Coma Score, age) also accurately predicts mortality in trauma. The objective of this study was to compare the predictive abilities of these statistical models in trauma outcomes. METHODS: Area under the ROC curve of sensitivity versus 1-specificity was used to assess predictive ability and measured discrimination of the models. RESULTS: The study cohort consisted of 15,534 trauma patients (80% blunt mechanism) admitted to a Level I trauma center over a 3-year period (mean age 37 +/- 18 years; mean Injury Severity Score 10 +/- 10; mortality 4%). Sensitivity of the new predictive model was 45%, specificity was 96%, ROC was 0.91, validating this new trauma outcomes model in our institution. This was comparable with area under the ROC for Revised Trauma Score (ROC 0.88), Trauma and Injury Severity Score (ROC 0.97), and Physiologic Trauma Score (ROC 0.95), but superior compared with admission Glasgow Coma Score (ROC 0.79), Injury Severity Score (ROC 0.79), and age (ROC 0.60). CONCLUSIONS: The predictive ability of this new model is superior to anatomic-based models such as Injury Severity Score, but comparable with other physiologic-based models such as Revised Trauma Score, Physiologic Trauma Score and Trauma, and Injury Severity Score.     

Retrospective evaluation of anemia and transfusion in traumatic brain injury

BACKGROUND: Despite clear evidence in critical care that blood transfusion has an adverse impact on outcome, neurosurgical textbooks still recommend transfusion of patients with traumatic brain injury (TBI) to a hematocrit (HCT) of 30%. There is little empirical evidence to support this practice. The current study addresses transfusion requirements in TBI in terms of neurologic outcome. METHODS: Retrospective record review of patients with severe TBI. Outcome measures were Glasgow Coma Scale score (GCS), Glasgow Outcome Score (GOS), and Ranchos Los Amigos Score (RLA) at hospital discharge (D/C); and GOS and Functional Independence Measures at follow-up. Association of outcomes with the number of days the HCT <30% and lowest measured HCT were evaluated. RESULTS: In all, 169 patients reviewed; 150 with D/C outcome data and 72 with long-term follow-up data. Univariate analysis showed that lowest measured HCT was associated with lower D/C GCS, D/C GOS, and RLA scores. Linear regression showed that more days with HCT <30% were associated with improved neurologic outcomes measured by GOS (R2 = 0.424, p < 0.001), GCS (R2 = 0.381, p < 0.001) and RLA (R2 = 0.392, p < 0.001) scores on D/C. Both transfusion and lowest measured HCT were significantly associated with all lower outcome scores on D/C. Additional factors with adverse impact on outcome were head Abbreviated Injury Score (AIS), Injury Severity Score, hyperglycemia, and hypotension. Long-term outcomes were only significantly associated with head AIS. CONCLUSIONS: Patients with severe TBI should not have a different transfusion threshold than other critical care patients. Prospective studies are needed to evaluate the effects of anemia in TBI.     

Clinical retrospective and comparative study on diaphragm injuries in 46 cases

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Serum ethanol levels in patients with moderate to severe traumatic brain injury influence outcomes: a surprising finding

Animal studies routinely demonstrate an alcohol (ETOH) -mediated increase in survival after experimental traumatic brain injury (TBI). Recent clinical studies also suggest ETOH plays a neuroprotective role in moderate to severe TBI. We sought to investigate the relationship between ETOH and outcomes in patients with moderate to severe TBI using a countywide database. The Los Angeles County Trauma System database was queried for all adult (older than 14 years) patients with isolated moderate to severe TBI trauma (head Abbreviated Injury Score [AIS] 3 or greater, all other AIS 3 or less) who had ETOH levels measured on admission between 1998 and 2005. A total of 7304 patients were evaluated with 3219 (44.1%) patients testing positive for serum ETOH. ETOH-positive patients with TBI had a significantly lower mortality rate compared with ETOH negative patients (8.5 vs. 10.5%, P = 0.005). Even after logistic regression analysis, a positive ETOH was associated with reduced mortality (adjusted OR 0.82, 95% CI: 0.69-0.99, P = 0.035). Therefore, a positive serum ETOH level was independently associated with significantly improved survival in patients with isolated moderate to severe TBI. The neuroprotective role ETOH plays in TBI is in contrast to previous findings and deserves further attention as a potential therapeutic.     

Does health care insurance affect outcomes after traumatic brain injury? Analysis of the National Trauma Databank

Increasing evidence indicates insurance status plays a role in the outcome of trauma patients; however its role on outcomes after traumatic brain injury (TBI) remains unclear. A retrospective review was queried within the National Trauma Data Bank. Moderate to severe TBI insured patients were compared with their uninsured counterparts with respect to demographics, Injury Severity Score, Glasgow Coma Scale score, and outcome. Multivariate logistic regression analysis was used to determine independent risk factors for mortality. Of 52,344 moderate to severe TBI patients, 41,711 (79.7%) were insured. Compared with the uninsured, insured TBI patients were older (46.1 +/- 22.4 vs. 37.3 +/- 16.3 years, P < 0.0001), more severely injured (ISS > or =16: 78.4% vs. 74.4%, P < 0.0001), had longer intensive care unit length of stay (6.0 +/- 9.4 vs. 5.1 +/- 7.6, P < 0.0001) and had higher mortality (9.3% vs. 8.0%, P < 0.0001). However, when controlling for confounding variables, the presence of insurance had a significant protective effect on mortality (adjusted odds ratio 0.89; 95% confidence interval: 0.82-0.97, P = 0.007). This effect was most noticeable in patients with head abbreviated injury score = 5 (adjusted odds ratio 0.7; 95% confidence interval: 0.6-0.8, P < 0.0001), indicating insured severe TBI patients have improved outcomes compared with their uninsured counterparts. There is no clear explanation for this finding however the role of insurance in outcomes after trauma remains a topic for further investigation.     

Early versus late tracheostomy in patients with severe traumatic head injury

BACKGROUND AND PURPOSE: A majority of patients with severe traumatic brain injury (TBI) need ventilatory support and require endotracheal intubation. There has been substantial debate regarding the timing of tracheostomy. We reviewed our data to determine the impact of early tracheostomy on our resources. STUDY DESIGN: Retrospective review of a consecutive series of patients with severe TBI treated at a Level II trauma center. METHOD: All 55 patients admitted to the surgical intensive care unit (ICU) with severe TBI from January, 2002 through September, 2005 were reviewed through the trauma registry. The inclusion criteria were severe TBI with a Glasgow Coma Scale (GCS) score < or = eight points at the time of admission and expected survival for longer than three days. All of these patients required mechanical ventilation and subsequently underwent tracheostomy. According to the timing of tracheostomy, subjects were classified as early group (< or = 7 days; N = 27) or late group (> 7 days; N = 28). The Wilcoxon rank sum test, the log-rank test, and Fisher exact tests were used to compare these groups. RESULT: The average time of the tracheostomy procedure was 5.5 +/- 1.8 (SD) days in the early group and 11.0 +/- 4.3 days in the late group. There were no significant differences between the groups in terms of age, proportion of female sex, GCS, Injury Severity Score, or need for blood transfusion. However, patients in the early group had a significantly shorter stay in the ICU than patients in the late group (19.0 +/- 7.7 vs. 25.8 +/- 11.8 days; P = 0.008). There was no difference between the groups in ventilator days (15.7 +/- 6.0 vs. 20.0 +/- 16.0 days; p = 0.57). There were no significant differences between the groups regarding overall mortality (15% vs. 4%; p = 0.19), incidence of pneumonia prior to tracheostomy (41% vs. 50%; p = 0.59), median total hospital length of stay (24 days vs. 28 days; p = 0.42), discharged to rehabilitation (74% vs. 82%; p = 0.53), or median total hospital cost (292,329 dollars vs. 332,601 dollars; p = 0.26). CONCLUSION: Early tracheostomy was beneficial, resulting in a shorter ICU stay.     

Incorporating recent advances to make the TRISS approach universally available

BACKGROUND: The Trauma and Injury Severity Score (TRISS), used to garner predictions of survival from the Injury Severity Score (ISS), the Revised Trauma Score (RTS, for physiologic reserve), and age is difficult for many trauma facilities to compute because it requires 8 to 10 variables and ISS depends on the specialized Abbreviated Injury Scale (AIS) scale rather than the International Classification of Diseases scale (ICD-9). It has been shown that metrics describing a patient's worst injury (WORSTSRR) are a powerful predictor of survival (regardless of coding type, AIS versus ICD-9) and that the Glasgow Coma Scale (GCS) motor component contains the majority of the information found in the full GCS score. This study hypothesized that the TRISS approach could be made more predictive and efficient with fewer variables by incorporating these advances. METHODS: A total of 310,958 patients with nonmissing TRISS variables were subset from the National Trauma Data Bank (NTDB). Logistic regression was used to model mortality as a function of anatomic, physiologic and age variables. A traditional TRISS model was computed (with NTDB-derived coefficients) that uses ISS, RTS, age index, and mechanism to predict survival. Four smaller three- or four-variable models employed the ICD-9 WORSTSRR, the GCS motor component, and age (both continuously and dichotomously). Two of the four models also use mechanism. These models were compared using the concordance index (c-index, a measure of model discrimination) and the pseudo-R statistic (estimates proportion of variance explained). RESULTS: Each experimental model (two models with 3 variables and two models with 4 variables) have superior discrimination and explain more variance than the traditional TRISS model that employs 8-10 variables. CONCLUSIONS: Recent advances in anatomic and physiologic scoring markedly simplify TRISS-type models at no cost to prediction. This approach uses routinely available data, requires up to seven fewer terms, and predicts at least as well as the original TRISS. These findings could increase the availability of accurate trauma scoring tools to smaller trauma facilities.     

Beta-blocker exposure is associated with improved survival after severe traumatic brain injury

BACKGROUND: Beta-blocker use in elective noncardiac surgery has been associated with a reduction in mortality and cardiovascular complications. Traumatic brain injury (TBI) is often associated with a hyperadrenergic state. We hypothesized that adrenergic blockade would confer improved survival among TBI patients. METHODS: Retrospective review of the Trauma Registry of the American College of Surgeons database at a Level I trauma center was conducted. All trauma patients admitted from January 2004 to March 2005 with head Abbreviated Injury Scale score of 3 or greater were evaluated. Patients with length of stay <4 or >30 days were excluded. Beta-blocker exposure was defined as receiving beta-blockers for 2 or more consecutive days. RESULTS: In all, 420 patients met inclusion criteria: 174 patients exposed to beta-blockers [BB(+)] and 246 not exposed [BB(-)]. Mean age in BB(+) group was 50 years and 36 years in BB(-) group (p < 0.001). Mean Injury Severity Score was 33.6 for BB(+) group and 30.8 for BB(-) group (p = 0.01). Predicted survival (by Trauma and Injury Severity Score) for BB(+) group was 59.1% compared with 70.3% for BB(-) group (p < 0.001). Observed mortality for BB(+) group was 5.1%, 10.8% for BB(-) group (p = 0.036). Adjusted incidence rate ratio of mortality among those exposed to beta-blockers compared with those not exposed was 0.29 (95% confidence interval). CONCLUSIONS: Beta-blocker exposure was associated with a significant reduction in mortality in patients with severe TBI. This reduction in mortality is even more impressive, considering that the BB(+) group was older, more severely injured, and had lower predicted survival.     

Prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation

BACKGROUND: Few data exist supporting a survival benefit to prehospital endotracheal intubation (ETI) over bag-valve-mask ventilation (BVM) in trauma patients. METHODS: Data were reviewed from all trauma patients transported to our Level I trauma center receiving prehospital ETI or BVM. Mortality was adjusted by age, Revised Trauma Score, Injury Severity Score, and mechanism of injury (penetrating vs. blunt). RESULTS: Of 5,773 patients, 316 (5.5%) had ETI and 217 (3.8%) had BVM. Patients receiving ETI were significantly more like to die (88.9% vs. 30.9%, p < 0.0001). When corrected for Injury Severity Score, Revised Trauma Score, and mechanism of injury, ETI was associated with similar or greater mortality than BVM. ETI patients had longer prehospital times (22.0 vs. 20.1 minutes, p = 0.0241). CONCLUSION: In our trauma system, when corrected for mechanism and severity of anatomic and physiologic injury, ETI confers no survival advantage over BVM and slightly increases prehospital time.     

The relationship of Injury Severity Score and Glasgow Coma Score to rehabilitative potential in patients suffering traumatic brain injury

The predictive utility of the Injury Severity Score (ISS) and Glasgow Coma Score (GCS) in relation to rehabilitative potential and functional outcome in traumatic brain injury (TBI) is untested. The purpose of this study was to define the relationship of ISS and GCS to rehabilitative potential using the functional independence measure (FIM) score. Trauma and inpatient rehabilitation (IR) registries were queried for demographic, disposition, and injury scoring data. FIM scores at admission (A) and discharge (D) were assessed including IR FIM gain (G). Analysis of variance was used to examine the relationship of ISS and GCS to FIM with predictive utility investigated through bivariate analysis. Of 5488 patients admitted to a Level I trauma center (1999-2000) 1437 suffered TBI with 285 (20%) entering IR. Compared with low-ISS patients the high-ISS patients had significantly lower FIM-A and FIM-D, but FIM-G was static. GCS results were similar, excluding FIM-G which was significantly higher for GCS < or = 8 compared with GCS > 8. Bivariate analysis revealed no ISS correlation with FIM-G (r = 0.16) and a weak GCS correlation (FIM-G r = -0.15). As prospective predictive measures ISS and GCS correlate weakly with rehabilitative potential in TBI patients. Severely injured patients including those with severe TBI have a rehabilitative gain toward functional independence that is similar to that of when compared with those less severely injured.     

Pulmonary contusions: quantifying the lesions on chest X-ray films and the factors affecting prognosis.

OBJECTIVES: To quantify pulmonary contusions on chest x-ray film and to evaluate factors correlating with the size of the pulmonary contusions, changes in the first 24 hours, the need for ventilatory assistance, and death. METHODS: The medical records and chest x-ray films of 103 patients with blunt chest trauma diagnosed as having a pulmonary contusion were reviewed. RESULTS: A pulmonary contusion score was developed (3 = one third of a lung; 9 = an entire lung). In the emergency department, pulmonary contusions were not present in 11, were mild (one ninth to two ninths of a lung) in 15 patients, moderate-severe (three ninths to nine ninths of a lung) in 53 patients, and very severe in 24 patients. Within 24 hours, the pulmonary contusion score increased in 26 patients by 7.9 +/- 5.5 (SD). The 26 patients with an increasing contusion had a higher mortality rate (38% vs. 17%) (p = 0.044) and tended to need ventilatory assistance more frequently (73% vs. 49%) (p = 0.061). The 35 patients with very severe pulmonary contusions (pulmonary contusion score = 10-18) had the lowest PaO2:FIO2 ratio at 24 hours (175 +/- 103 mm Hg), longest hospital length of stay (28 +/- 35 days), and the highest Injury Severity Score (26 +/- 9). The factors correlating highest with a need for ventilatory support (57/103) were the 24 hour or initial PaO2/FIO2 ratio < 300, an Injury Severity Score > or = 24, Revised Trauma Score < 6.4, Glasgow Coma Scale score < or = 12, and shock or need for blood in the first 24 hours (p < 0.001). Death correlated highly with a need for ventilatory assistance, Injury Severity Score > or = 26, Revised Trauma Score < or = 6.3, and Glasgow Coma Scale score < or = 11 (p < 0.001). CONCLUSION: Quantifying and noting changes in the extent of the pulmonary contusions and PaO2/FIO2 ratio during the first 24 hours may be of value in determining the need for ventilatory assistance and predicting outcome.     

Diagnostic value of the Glasgow Coma Scale for traumatic brain injury in 18,002 patients with severe multiple injuries

Although patients with severe multiple injuries may have other reasons for unconsciousness, traumatic brain injury (TBI) in these patients is frequently defined by the Glasgow Coma Scale (GCS). Nevertheless, the diagnostic value of GCS for severe TBI in the multiple-injured patient is unknown. Therefore, we investigated the diagnostic value of GCS to identify severe TBI in multiple-injured patients. The records of 18,002 severely injured adult (ISS >16) patients from the Trauma Register of the German Society for Trauma Surgery were analyzed and initial GCS and Abbreviated Injury Scale (head) (AIS(head)) were recorded. A severe TBI was defined by an AIS(head) ≥ 3. On the other hand, unconsciousness was defined by an initial GCS ≤ 8. By these criteria, 6546 patients (36.3%) were unconscious, and 8746 patients (48.6%) had severe TBI. Nine percent of all cases (n=1643) had a GCS ≤ 8 without severe TBI. Only 56.1% of patients with severe TBI (n=4903) had been unconscious. Decreasing levels of unconsciousness (as defined by GCS) showed consistent rising prevalence of severe TBI (correlation coefficient r=-0.52). Approximately 20% of all multiple-injured patients arriving in the emergency department with an initial GCS of 15 had severe TBI (AIS(head) ≥ 3). The diagnostic value of GCS ≤ 8 for severe TBI in patients with multiple injuries has low sensitivity (56.1%) but higher specificity (82.2%). Our study indicates that the GCS (as defined ≤ 8) in unconsciousness patients with multiple injuries shows only a moderate correlation with the diagnosis of severe TBI. Nevertheless, the main reason for unconsciousness in patients with multiple injuries is TBI, since only 9% of these patients had another reason for unconsciousness. However, due to the poor sensitivity of GCS, we suggest the use of the anatomical scoring system with AIS(head) ≥ 3 to define severe TBI in patients with multiple injuries.     

Impact of cirrhosis on outcomes in trauma

BACKGROUND: Cirrhosis as an independent predictor of poor outcomes in trauma patients was identified in 1990. We hypothesized that the degree of preinjury hepatic dysfunction is, by itself, an independent predictor of mortality. STUDY DESIGN: The trauma registry at our Level I trauma center was queried for all ICD-9 codes for liver disease from 1999 to 2003, and patients were categorized as having Child-Turcotte-Pugh (CTP) class A, B, or C cirrhosis. Data analyzed included age, mechanism of injury, Abbreviated Injury Score (AIS), Injury Severity Score (ISS), Glasgow Coma Score (GCS), hospital length of stay, ventilator days, procedures performed, transfusion of blood products, admission lactate, base deficit, and mortality. Trauma Related Injury Severity Score (TRISS) methodology was used to calculate the probability of survival. Outcomes data were analyzed, and statistical comparison was performed using group t-test. RESULTS: Of the 50 patients meeting study criteria, 31 had alcohol-related cirrhosis, 18 had a history of hepatitis C, and 1 had cryptogenic cirrhosis. Twenty (40%) met CTP A classification, 16 (32%) met CTP B criteria, and 14 (28%) had CTP class C cirrhosis. One death occurred in the CTP A and B groups. Comparison between the five survivors and nine nonsurvivors from CTP class C showed no statistical significance in terms of age, ISS, TRISS, or GCS. CONCLUSIONS: The mortality rate for class C cirrhotic patients posttrauma continues to be higher than that predicted by TRISS, although patients with less severe hepatic dysfunction do not appear to have significantly lower than predicted survival. The degree of hepatic dysfunction remains an independent predictor of mortality and CTP C criteria must be considered when determining outcomes for patients posttrauma.     

Human immunodeficiency virus infection in trauma patients: where do we stand?

OBJECTIVE: The human immunodeficiency virus (HIV) epidemic is a growing health care problem. The purpose of this study was to examine the relationship between HIV infection and trauma patient treatment, complications, and mortality. METHODS: The Pennsylvania Trauma Outcome Study database was used to identify trauma patients with known HIV-positive status (HP) and randomly selected age-matched controls (CL). Demographics, Injury Severity Score, Glasgow Coma Scale score, mechanism of injury, preexisting conditions, complications, mortality, hospital length of stay (HLOS), intensive care unit length of stay (ILOS), and operative interventions were compared. RESULTS: Demographics, vital signs on presentation, and Injury Severity Score were similar between the HP and CL groups. There was no difference in mortality between the two groups (3.6% vs. 3.1%, p = 0.6447). HP patients were more likely to present with penetrating injuries (22.6% vs. 15.8%, p < 0.0031) and had significantly fewer major orthopedic injuries than CL patients (p < 0.01). HP patients were more likely to have a history of a neurologic condition; chronic drug/alcohol use; psychiatric diagnosis; or liver, pulmonary, and/or renal disease (all p < 0.01). HP patients had more pulmonary complications (12.3% vs. 4.1%), renal complications, and infectious/septic complications (all p < 0.01) than controls. Infection/sepsis and pulmonary complications were associated with significant mortality in HP patients. HP patients underwent more thoracostomies (7.5% vs. 4.4%, p = 0.0235) and exploratory laparotomies (7.0% vs. 2.4%, p = 0.0002). HLOS (10.2 +/- 10 vs. 6.8 +/- 8.6 days, p = 0.001) and ILOS (2.3 +/- 7.2 vs. 1.5 +/- 4.9 days, p = 0.0178) were greater for HP patients. HP patients were less likely than controls to be discharged directly to home (67.8% vs. 82.7%, p = 0.0001). CONCLUSION: HP patients had more preexisting conditions and complications than controls. There was no difference in overall mortality between the two groups. However, pulmonary/infectious complications were associated with significant mortality in HP patients. HP patients consumed more health care resources than controls, as exemplified by greater ILOS and HLOS and more operative procedures.     

Toll of methamphetamine on the trauma system

HYPOTHESIS: Methamphetamine use affects length of hospital stay in the minimally injured patient. DESIGN: Case series. SETTING: The only tertiary trauma center serving Hawaii. PATIENTS: Trauma patients examined during a 12-month period with an Injury Severity Score of 1 to 5 and an age of 18 to 55 years undergoing urine toxicology screen for suspected suicide attempt or altered sensorium. MAIN OUTCOME MEASURES: Presence or absence of amphetamine or methamphetamine on urine toxicology screen, intention of injury, hospital admission rate, length of stay, and hospital charges. RESULTS: During the study period, 1650 trauma patients were examined, with 544 meeting study criteria. Urine toxicology screens were performed in 212 patients, with 57 positive and 155 negative for amphetamine or methamphetamine. There was no difference in sex (77% vs 73% male; P =.53), Injury Severity Score (3.2 for both groups), or total number of computed tomographic scans performed (mean +/- SEM, 3.0 +/- 0.3 vs 4.0 +/- 0.3; P =.07). Patients in the positive group were more likely to have intentional self-inflicted injury or intentional assaults than patients in the negative group (37% vs 22%; P =.04). The positive group was older than the negative group (33.6 +/- 1.3 vs 29.9 +/- 0.8 years; P =.02), had a significantly longer hospital stay (2.7 +/- 0.4 vs 1.7 +/- 0.1 days; P =.003), had significantly higher hospital charges (15 617 dollars +/- 1866 dollars vs 11 600 dollars +/- 648 dollars; P =.01), and was more likely admitted to the hospital (91% vs 70%; P =.001) despite the low Injury Severity Score. CONCLUSION: Methamphetamine use results in trauma center resource utilization out of proportion to injury severity.     

The predictive value of field versus arrival Glasgow Coma Scale score and TRISS calculations in moderate-to-severe traumatic brain injury

BACKGROUND: Glasgow Coma Scale (GCS) scores are widely used to quantify level of consciousness in the prehospital environment. The predictive value of field versus arrival GCS is not well defined but has tremendous implications with regard to triage and therapeutic decisions as well as the use of various predictive scoring systems, such as Trauma Score and Injury Severity Score (TRISS). This study explores the predictive value of field GCS (fGCS) and arrival GCS (aGCS) as well as TRISS calculations using field (fTRISS) and arrival (aTRISS) data in patients with moderate-to-severe traumatic brain injury (TBI). METHODS: Major trauma victims with head Abbreviated Injury Scores of 3 or greater were identified from our county trauma registry over a 16-year period. The predictive ability of fGCS with regard to aGCS was explored using univariate statistics and linear regression modeling. The difference between aGCS and fGCS was also modeled against mortality and the composite endpoint using logistic regression, adjusting for fGCS. The predictive value of preadmission GCS (pGCS), defined as either fGCS or aGCS in nonintubated patients without a documented fGCS, with regard to mortality and a composite endpoint representing the need for neurosurgical care (death, craniotomy, invasive intracranial pressure monitoring, or intensive care unit care >48 hours) was determined using receiver-operator curve (ROC) analysis. Finally, fTRISS and aTRISS predicted survival values were compared with each other and to observed survival. RESULTS: A total of 12,882 patients were included. Mean values for fGCS and aGCS were similar (11.4 and 11.5, respectively, p = 0.336), and a strong correlation (r = 0.67, 95% CI 0.66-0.69, p < 0.0001) was observed between them. The difference between fGCS and aGCS was also predictive of outcome after adjusting for fGCS. Good predictive ability was observed for pGCS with regard to both mortality and neurosurgical intervention. Both fTRISS and aTRISS predicted survival values were nearly identical to observed survival. Observed and fTRISS predicted survival were nearly identical in patients undergoing prehospital intubation CONCLUSIONS: Values for fGCS are highly predictive of aGCS, and both are associated with outcome from TBI. A change in GCS from the field to arrival is highly predictive of outcome. The use of field data for TRISS calculations appears to be a valid methodological approach, even in severely injured TBI patients undergoing prehospital intubation.     

The effect of patient age upon survival in pediatric trauma

Developmental changes in the anatomy and physiology of growing children are thought to improve the survivability of older children to significant injury. The effect of age upon survival, however, is poorly defined. Data for 4,615 patients less than 15 years old from a statewide trauma center registry were analyzed. Injury and survival were characterized by Abbreviated Injury Scale (AIS, 1985 revision), Injury Severity Score (ISS), Revised Trauma Score (RTS), and probability of survival [P(s)] and Z by TRISS. Patients were separated into age groups of 0 through 4, 5 through 9, and 10 through 14 years. The survival rate for patients with a maximum AIS 3 for any region was significantly higher in the 10-14-year age group. There were no significant differences in survival rates from head, thoracic, and abdominal injuries stratified by AIS among the three age groups. Survival rates for ISS cohorts were consistently lowest in the 0-4-year age group, but differences failed to reach significance. Survival for RTS and P(s) intervals were similar for all ages. The Z statistic reached significance for all children (Z = 4.717, W = 1.049), and for each group (Z = 2.203-3.029). Corresponding values of the W statistic suggest approximately one additional unexpected survivor per 100 admitted children when compared with the Major Trauma Outcome Study. Logistic regression for patients with all data required for TRISS showed no significant effect for any of the three age groups. We conclude that for this patient set, survival after childhood injury is independent of the age groups used in this study, after controlling for injury severity.