Abbreviated Injury Scale Head Score Research Articles

Association of timing and agent for venous thromboembolism prophylaxis in patients with severe traumatic brain injury on venous thromboembolism events, mortality, neurosurgical intervention, and discharge disposition.

Trauma patients are at increased risk for venous thromboembolism events (VTEs). The decision of when to initiate VTE chemoprophylaxis (VTEP) and with what agent remains controversial in patients with severe traumatic brain injury (TBI). This comparative effectiveness study evaluated the impact of timing and agent for VTEP on outcomes for patients with severe TBI (Abbreviated Injury Scale head score of 3, 4, or 5). Data were collected at 35 Level 1 and 2 trauma centers from January 1, 2017, to June 1, 2022. Patients were placed into analysis cohorts: no VTEP, low-molecular-weight heparin (LMWH) ≤48 hours, LMWH >48 hours, heparin ≤48 hours, and heparin >48 hours. Propensity score matching accounting for patient factors and injury characteristics was used with logistic regression modeling to evaluate in-hospital mortality, VTEs, and discharge disposition. Neurosurgical intervention after initiation of VTEP was used to evaluate extension of intracranial hemorrhage. Of 12,879 patients, 32% had no VTEP, 36% had LMWH, and 32% had heparin. Overall mortality was 8.3% and lowest among patients receiving LMWH ≤48 hours (4.1%). Venous thromboembolism event rates were lower with use of LMWH (1.6% vs. 4.5%; odds ratio, 2.98; 95% confidence interval, 1.40-6.34; p = 0.005) without increasing mortality or neurosurgical interventions. Venous thromboembolism event rates were lower with early prophylaxis (2.0% vs. 3.5%; odds ratio, 1.76; 95% confidence interval, 1.15-2.71; p = 0.01) without increasing mortality ( p = 1.0). Early VTEP was associated with more nonfatal intracranial operations ( p < 0.001). However, patients undergoing neurosurgical intervention after VTEP initiation had no difference in rates of mortality, withdrawal of care, or unfavorable discharge disposition ( p = 0.7, p = 0.1, p = 0.5). In patients with severe TBI, LMWH usage was associated with lower VTE incidence without increasing mortality or neurosurgical interventions. Initiation of VTEP ≤48 hours decreased VTE incidence and increased nonfatal neurosurgical interventions without affecting mortality. Low-molecular-weight heparin is the preferred VTEP agent for severe TBI, and initiation ≤48 hours should be considered in relation to these risks and benefits. Therapeutic/Care Management; Level III.

Four-factor prothrombin complex concentrate versus andexanet alfa for the reversal of traumatic brain injuries

BackgroundAndexanet alfa was approved in 2018 for reversal of direct oral anticoagulants but due to issues of cost and access, four-factor prothrombin complex concentrate (4F-PCC) continues to be used for...

Alcohol withdrawal syndrome in trauma patients: a study using the Trauma Quality Program Participant User File

ObjectiveTo identify the rates and possible predictors of alcohol withdrawal syndrome (AWS) among adult trauma patients.MethodsThis is a retrospective review of all adult patients (18 years or older) included in...

Does treatment delay for blunt cerebrovascular injury affect stroke rate?: An EAST multicenter study

BackgroundThe purpose of this study was to analyze injury characteristics and stroke rates between blunt cerebrovascular injury (BCVI) with delayed vs non-delayed medical therapy. We hypothesized there would be increased stroke formation with delayed medical therapy. MethodsThis is a sub-analysis of a 16 center, prospective, observational trial on BCVI. Delayed medial therapy was defined as initiation >24 hours after admission. BCVI which did not receive medical therapy were excluded. Subgroups for injury presence were created using Abbreviated Injury Scale (AIS) score >0 for AIS categories. Results636 BCVI were included. Median time to first medical therapy was 62 hours in the delayed group and 11 hours in the non-delayed group (p < 0.001). The injury severity score (ISS) was greater in the delayed group (24.0 vs the non-delayed group 22.0, p < 0.001) as was the median AIS head score (2.0 vs 1.0, p < 0.001). The overall stroke rate was not different between the delayed vs non-delayed groups respectively (9.7% vs 9.5%, p = 1.00). Further evaluation of carotid vs vertebral artery injury showed no difference in stroke rate, 13.6% and 13.2%, p = 1.00 vs 7.3% and 6.5%, p = 0.84. Additionally, within all AIS categories there was no difference in stroke rate between delayed and non-delayed medical therapy (all N.S.), with AIS head >0 13.8% vs 9.2%, p = 0.20 and AIS spine >0 11.0% vs 9.3%, p = 0.63 respectively. ConclusionsModern BCVI therapy is administered early. BCVI with delayed therapy were more severely injured. However, a higher stroke rate was not seen with delayed therapy, even for BCVI with head or spine injuries. This data suggests with competing injuries or other clinical concerns there is not an increased stroke rate with necessary delays of medical treatment for BCVI.

811 Lesional Hemorrhage and Hemorrhage-Negative Patients May Confound the Study of Severe TBI Using Institutional Trauma Databases: Results from a Single Level I Trauma Center

INTRODUCTION: Single institution trauma databases are frequently used for outcomes studies in severe traumatic brain injury (sTBI). The etiology of hemorrhage is commonly uncertain at the time of presentation in the neurologically impaired patient, who may be considered potentially traumatic during initial resuscitation. The complexity of intracranial hemorrhage and coding practices serve as barriers to the effective characterization of sTBI patients. METHODS: The LAC+USC trauma database was queried from 2010 to 2018. Patients greater than 18 years of age with initial Glasgow Coma Scale 3 to 8 and abbreviated injury scale head score (AIS-H) of 3 to 5 were selected as those with putative sTBI. Initial and subsequent CT scans of the head and radiology reports were reviewed. Hemorrhages suggestive of spontaneous etiologies including lesional hemorrhages and hypertensive hemorrhages were noted. Review of angiographic studies was performed when relevant. RESULTS: Of 24,763 database patients, 1,310 (5.3%) were adults with putative blunt sTBI. Among this cohort, 119 (9.1%) did not survive to CT scan. Among patients receiving CTH, 87 patients (6.6%) had no acute intracranial findings, and 12 (0.9%) had ischemic stroke or diffuse anoxic injury. Non-traumatic etiologies were present in 31 patients (2.4%), consisting of 8 lesional hemorrhages and 23 hypertensive hemorrhages. CONCLUSIONS: 19% of patients did not meet sTBI criteria. The study of sTBI in institutional databases may be confounded by non-hemorrhagic injuries and non-traumatic intracranial hemorrhages.

Traumatic brain injury provokes low fibrinolytic activity in severely injured patients.

Traumatic brain injury (TBI) in combination with shock has been associated with hypocoagulability. However, recent data suggest that TBI itself can promote a systemic procoagulant state via the release of brain-derived extracellular vesicles. The objective of our study was to identify if TBI was associated with differences in thrombelastography indices when controlling for other variables associated with coagulopathy following trauma. We hypothesized that TBI is independently associated with a less coagulopathic state. Prospective study includes all highest-level trauma activations at an urban Level I trauma center, from 2014 to 2020. Traumatic brain injury was defined as Abbreviated Injury Scale head score greater than 3. Blood samples were drawn at emergency department admission. Linear regression was used to assess the role of independent predictors on trauma induced coagulopathy. Models adjusted for Injury Severity Score (ISS), shock (defined as ED SBP<70, or ED SBP<90 and ED HR>108, or first hospital base deficit >10), and prehospital Glasgow Coma Scale score. Of the 1,023 patients included, 291 (28%) suffered a TBI. Traumatic brain injury patients more often were female (26% vs. 19%, p = 0.01), had blunt trauma (83% vs. 43%, p < 0.0001), shock (33% vs. 25%, p = 0.009), and higher median ISS (29 vs. 10, p < 0.0001). Fibrinolysis shutdown (25% vs. 18%) was more common in the TBI group (p < 0.0001). When controlled for the confounding effects of ISS and shock, the presence of TBI independently decreases lysis at 30 minutes (LY30) (beta estimate: -0.16 ± 0.06, p = 0.004). This effect of TBI on LY30 persisted when controlling for sex and mechanism of injury in addition to ISS and shock (beta estimate: -0.13 ± 0.06, p = 0.022). Traumatic brain injury is associated with lower LY30 independent of shock, tissue injury, sex, and mechanism of injury. These findings suggest a propensity toward a hypercoagulable state in patients with TBI, possibly due to fibrinolysis shutdown. Prognostic and Epidemiologic; Level III.

The Relationship Between Trauma Scoring Systems and Outcomes in Patients With Severe Traumatic Brain Injury.

This study investigated the relationship between trauma scoring systems and outcomes in patients with severe traumatic brain injury (TBI). From January 2018 to June 2021, 1,122 patients with severe TBI were registered in the Korean Neuro-Trauma Data Bank System. Among them, 697 patients with data on trauma scoring systems were included in the study. According to the Glasgow Outcome Scale-Extended score, the patients were divided into unfavorable and favorable outcome groups. The abbreviated injury scale (AIS), injury severity score (ISS), revised trauma score (RTS), and trauma and injury severity score (TRISS) were evaluated. The AIS head score was higher in the unfavorable outcome group than in the favorable outcome group (4.39 vs. 4.06, p<0.001). ISS was also higher in the unfavorable outcome group (27.27 vs. 24.22, p=0.001). The RTS and TRISS were higher in the favorable outcome group (RTS, 4.74 vs. 5.45, p<0.001; TRISS, 48.05 vs. 71.02, p<0.001). In comparing the survival and death groups, the ISS was lower in the survival group (25.76 vs. 27.29, p=0.036). Furthermore, RTS was higher in the survival group (5.26 vs. 4.54, p<0.001), as was TRISS (62.11 vs. 44.91, p<0.001). Trauma scoring systems, including ISS, RTS, and TRISS, provide tools for quantifying posttraumatic risk and can be used to predict prognosis. Among these, TRISS is an indicator of the predicted survival rate and is considered a clinically useful tool for predicting unfavorable and favorable outcomes in patients with severe TBI.

Hospital Volume-Outcome Relationship in Severe Traumatic Brain Injury: A Nationwide Observational Study in Japan

The hospital volume-outcome relationship in patients with severe traumatic brain injury (TBI) remains unclear. This study investigated the association between the volume of patients with severe TBI and in-hospital mortality. This observational study identified patients with severe TBI (Glasgow Coma Scale score <9 and Abbreviated Injury Scale head score ≥3) from the Japan Trauma Databank (2010-2018). Hospitals were grouped on the basis of annual patient volume as follows: low-volume (4-19 patients/year); middle-volume (20-35 patients/year); and high-volume (36-51 patients/year) groups. The association between hospital volume categories and in-hospital mortality was examined using a multivariate mixed-effect logistic regression analysis. A subgroup analysis was performed based on the presence of severe extracranial injuries. A total of 11,344 patients from 64 hospitals were included. The median age of the patients was 57 years (interquartile range, 40-77), and 7933 (70.0%) patients were men. A total of 4879 (43.1%) patients died in the hospital. The medium-volume (adjusted odds ratio [OR], 0.76; 95% confidence interval [CI], 0.62-0.93) and high-volume (adjusted OR, 0.69; 95% CI, 0.52-0.94) groups were significantly associated with lower in-hospital mortality. The subgroup analysis revealed that the medium-volume (adjusted OR, 0.70; 95% CI, 0.54-0.92) and high-volume (adjusted OR, 0.64; 95% CI, 0.42-0.96) groups were significantly associated with lower in-hospital mortality for isolated TBI patients. Higher hospital volumes were significantly associated with lower in-hospital mortality after severe TBI. Regionalization and referral to higher-volume hospitals are beneficial for severe TBI patients.

Long-Term Trends in the Epidemiology of Major Traumatic Brain Injury.

Traumatic brain injury (TBI) is a leading cause of death and disability among adults. Falls and motor vehicle collisions (MVCs) are the most common causes of TBI hospitalizations in Canada. The purpose of this study was to determine whether, at the provincial level, there have been significant changes in the injury rate and causes of major TBI. This was a retrospective cohort study of all patients in Nova Scotia who presented with major TBI (Abbreviated Injury Scale Head score ≥ 3) between 2002 and 2018. Prospectively entered data were collected from the Nova Scotia Trauma Registry. Annual injury rates were calculated based on 100,000 population (all ages) using population estimates from Statistics Canada. Linear regression was performed to analyze annual trends of major TBI within the province. There were 5590 major TBI patients in Nova Scotia during the 16-year study period. The overall annual rate of major TBI was 37 per 100,000 population. There was a 39% increase in the rate of major TBI over the study period (r = - 0.72, R2 = 0.51, p < 0.002). Patients had a mean age of 51 ± 25years; 72% were male. The proportion of TBIs in males decreased significantly from 76% in 2002 to 69% in 2017 (p < 0.001). Mechanisms of injury were predominantly falls (45%) and MVCs (29%); the proportion of violent injuries was 11.5%. The rate of fall-related TBIs more than doubled between 2002 and 2017, increasing from 9.1 to 20.5 injuries per 100,000 (p < 0.001). Our findings demonstrate an increasing incidence of major TBI over a 16-year period with a greater than two-fold increase in the rate of fall-related TBI. These results are important for targeting TBI prevention efforts in reducing falls, especially in older adults.

E-bike and classic bicycle-related traumatic brain injuries presenting to the emergency department

BackgroundE-bike usage is increasingly popular and concerns about e-bike-related injuries and safety have risen as more injured e-bikers attend the emergency department (ED). Traumatic brain injury (TBI) is the main...

Transport Time and Mortality in Critically Ill Patients with Severe Traumatic Brain Injury.

Severe traumatic brain injury (TBI) is a major cause of morbidity and mortality in critically ill patients. Pre-hospital care and transportation time may impact their outcomes. Using the British Columbia Trauma Registry, we included 2,860 adult (≥18 years) patients with severe TBI (abbreviated injury scale head score ≥4), who were admitted to an intensive care unit (ICU) in a centre with neurosurgical services from January 1, 2000 to March 31, 2013. We evaluated the impact of transportation time (time of injury to time of arrival at a neurosurgical trauma centre) on in-hospital mortality and discharge disposition, adjusting for age, sex, year of injury, injury severity score (ISS), revised trauma score at the scene, location of injury, socio-economic status and direct versus indirect transfer. Patients had a median age of 43 years (interquartile range [IQR] 26-59) and 676 (23.6%) were female. They had a median ISS of 33 (IQR 26-43). Median transportation time was 80 minutes (IQR 40-315). ICU and hospital length of stay were 6 days (IQR 2-12) and 20 days (IQR 7-42), respectively. Six hundred and ninety-six (24.3%) patients died in hospital. After adjustment, there was no significant impact of transportation time on in-hospital mortality (odds ratio 0.98, 95% confidence interval 0.95-1.01). There was also no significant effect on discharge disposition. No association was found between pre-hospital transportation time and in-hospital mortality in critically ill patients with severe TBI.

Analysis of Aspiration Risk Factors in Severe Trauma Patients: Based on Findings of Aspiration Lung Disease in Chest Computed Tomography

Purpose: The present study will identify risk factors for aspiration in severe trauma patients by comparing patients who showed a sign of aspiration lung disease on chest computed tomography (CT) and those who did not. Methods: We conducted a retrospective review of the Korean Trauma Data Bank between January 2014 and December 2019 in a single regional trauma center. The inclusion criteria were patients aged ≥18 years with chest CT, and who had an Injury Severity Score ≥16. Patients with Abbreviated Injury Scale (AIS)-chest score ≥1 and lack of medical records were excluded. General characteristics and patient status were analyzed. Results: 425 patients were included in the final analysis. There were 48 patients showing aspiration on CT (11.2%) and 377 patients showing no aspiration (88.7%). Aspiration group showed more endotracheal intubation in the ER (p=0.000) and a significantly higher proportion of severe Glasgow Coma Scale (GCS) (p=0.000) patients than the non-aspiration group. In AIS as well, the median AIS head score was higher in the aspiration group (p=0.046). Median oxygen saturation was significantly lower in the aspiration group (p=0.002). In a logistic regression analysis, relative to the GCS mild group, the moderate group showed an odds ratio (OR) for aspiration of 2.976 (CI, 1.024-8.647), and the severe group showed an OR of 5.073 (CI, 2.442-10.539). Conclusions: Poor mental state and head injury increase the risk of aspiration. To confirm for aspiration, it would be useful to perform chest CT for severe trauma patients with a head injury.

Delayed Intracranial Hemorrhage in Anticoagulated Geriatric Patients After Ground Level Falls.

The reported risk of delayed intracranial hemorrhage (ICH) in a trauma patient on warfarin is estimated to be between 0.6% and 6%. The risk of delayed ICH in trauma patients taking novel oral anticoagulants (NOACs) is not well-defined. We hypothesized that there was a significant number of delayed presentations of ICH in patients on NOACs. A retrospective review of our trauma registry was performed on geriatric patients (age older than 64years) who were initially evaluated at our level I trauma center, had fall from standing height or less, and were anticoagulated (warfarin or NOACs), from April 2017 to March2018. Seventy-seven patients met inclusion criteria. The mean age was 80±7.7years and 46% of patients were male. The admission head computed tomography scan was positive in 20.8% of patients. Positive scans were more common in patients on warfarin vs. NOACs (30% vs. 14%; p=0.074) and had a significantly higher Injury Severity Score (median [interquartile range]: 9 [3-15] vs. 5 [1-9]; p=0.030) and Abbreviated Injury Scale-Head score (median [interquartile range]: 1 [0-3] vs. 1 [0-2]; p=0.035). The agreement between loss of consciousness (LOC) and ICH was 72% (κ=-0.064; p=0.263). Fifty-one percent of patients had a repeat head CT. New ICH was diagnosed in 9.6% of patients. All of these patients were on NOACs. A fall from standing or less in anticoagulated geriatric patients is a significant mechanism of injury resulting in ICH. The absence of LOC does not eliminate the possibility of ICH. There is a significant risk of delayed ICH for patients on NOACs and repeat evaluations should be performed. A prospective multicenter evaluation of this finding is warranted.

Factors associated with organ donation by trauma patients in Nova Scotia.

Trauma patients represent a significant pool of potential organ donors (PODs), and previous research suggests that this population is underutilized for organ donation (OD). Our objective was to assess factors associated with OD in the trauma population. We retrospectively analyzed OD in Nova Scotia over a 7-year period (2009-2016) using data from the Nova Scotia Trauma Registry and Nova Scotia Legacy of Life Donor Registry. All trauma patients who died in the hospital were included. Multiple logistic regression was used to assess factors associated with donation. We also evaluated characteristics, donation types, and reasons for nondonation among trauma PODs. There were 689 trauma-related deaths in all hospitals in NS during the study period, of which 39.8% (274 of 689) met the Nova Scotia Trauma Registry definition of a POD. Data on OD were available for 108 of these patients who were referred to the Legacy of Life Program. The conversion rate was 84%. Compared with nondonors, organ donors were significantly younger, had a higher Abbreviated Injury Scale head score and a lower scene Glasgow Coma Scale score, were more likely to suffer ischemia from drowning or asphyxia and to require air transport, and were less likely to have comorbidities. Regression analysis showed that donation was associated with younger age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95-0.99) and lower Glasgow Coma Scale score at the scene (OR, 0.76; 95% CI, 0.66-0.88). Odds of donation were increased with air transport compared with land ambulance (OR, 8.27; 95% CI, 2.07-33.08) and injury within Halifax Regional Municipality compared with injury outside Halifax Regional Municipality (OR, 4.64; 95% CI, 1.42-15.10). Among the 60 referred PODs who did not donate, family refusal of consent was the most common reason (28 [46.7%] of 60). Younger age, greater severity of injury, and shorter time to tertiary care were associated with OD in trauma patients. Prognostic and Epidemiological, Level III.

Sex Differences in In-hospital Complications Among Older Adults After Traumatic Brain Injury

BackgroundOlder adults have the highest rates of hospitalization and mortality after traumatic brain injury (TBI) and suffer poorer outcomes compared with younger adults with similar injuries. Non-neurological complications can significantly impact outcomes. Evidence suggests that women may have better outcomes after TBI. However, sex differences in in-hospital complications among older adults after TBI have not been studied. The objective of this study was to assess sex differences in in-hospital complications after TBI among adults aged 65 y and older. MethodsWe conducted a retrospective cohort study of adults aged ≥65 y treated for isolated moderate to severe TBI at the R Adams Cowley Shock Trauma Center between 1996 and 2012. Using the Shock Trauma Center registry, we identified TBI using the International Classification of Disease, Ninth Revision, Clinical Modification codes and required an abbreviated injury scale head score ≥3, abbreviated injury scale scores for other body regions ≤2, and a blunt injury mechanism. We searched the Shock Trauma Center registry for the International Classification of Disease, Ninth Revision, Clinical Modification codes representing in-hospital complications. ResultsOf 2511 patients meeting inclusion criteria, 1283 (51.1%) were men and 635 (25.1%) developed an in-hospital complication. Men were more likely than women to develop an in-hospital complication (28.1% versus 22.0, P < 0.001). In an adjusted analysis, men were at increased risk of any in-hospital complication (hazards ratio 1.23; 95% confidence interval 1.05, 1.44) compared with women. ConclusionsOlder men were more likely to have any in-hospital complications than women.

LO67: Association between hypotension and mortality in critically ill patients with severe traumatic brain injury: experience at a single Canadian trauma center

Introduction: Hypotension is known to be associated with increased mortality in severe traumatic brain injury (TBI) patients. Systolic blood pressure (SBP) of &amp;lt;90 mmHg is the threshold for hypotension in consensus TBI treatment guidelines; however, evidence suggests hypotension should be defined at higher levels for these patients. Our objective was to determine the influence of hypotension on mortality in TBI patients requiring ICU admission using different thresholds of SBP on arrival at the emergency department (ED). Methods: Retrospective cohort study of patients with severe TBI (Abbreviated Injury Scale Head score ≥3) admitted to ICU at the QEII Health Sciences Centre (Halifax, Canada) between 2002 and 2013. Patients were grouped by SBP on ED arrival ( &amp;lt;90 mmHg, &amp;lt;100 mmHg, &amp;lt;110 mmHg). We performed multiple logistic regression analysis with mortality as the dependent variable. Models were adjusted for confounders including age, gender, Injury Severity Score (ISS), injury mechanism, and trauma team activation (TTA). Results: A total of 1233 patients sustained a severe TBI and were admitted to the ICU during the study period. The mean age was 43.4 ± 23.9 years and most patients were male (919/1233; 74.5%). The most common mechanism of injury was motor vehicle collision (491/1233; 41.2%) followed by falls (427/1233; 35.8%). Mean length of stay in the ICU was 6.1 ± 6.4 days, and the overall mortality rate was 22.7%. SBP on arrival was available for 1182 patients. The &amp;lt;90 mmHg group had 4.6% (54/1182) of these patients; mean ISS was 20.6 ± 7.8 and mortality was 40.7% (22/54). The &amp;lt;100 mmHg had 9.3% (110/1182) of patients; mean ISS was 19.3 ± 7.9 and mortality was 34.5% (38/110). The &amp;lt;110 mmHg group had 16.8% (198/1182) of patients; mean ISS was 17.9 ± 8.0 and mortality was 28.8% (57/198). After adjusting for confounders, the association between hypotension and mortality was 2.22 (95% CI 1.19-4.16) using a &amp;lt;90 mmHg cutoff, 1.79 (95% CI 1.12-2.86) using a &amp;lt;100 mmHg cutoff, and 1.50 (95% CI 1.02-2.21) using a &amp;lt;110 mmHg cutoff. Conclusion: While we found that TBI patients with a SBP &amp;lt;90 mmHg were over 2 times more likely to die, patients with an SBP &amp;lt;110 mmHg on ED arrival were still 1.5 times more likely to die from their injuries compared to patients without hypotension. These results suggest that establishing a higher threshold for clinically meaningful hypotension in TBI patients is warranted.

Racial Differences in Discharge Location After a Traumatic Brain Injury Among Older Adults

ObjectiveTo determine if there were racial differences in discharge location among older adults treated for traumatic brain injury (TBI) at a level 1 trauma center. DesignRetrospective cohort study. SettingR Adams Cowley Shock Trauma Center. ParticipantsBlack and white adults aged ≥65 years treated for TBI between 1998 and 2012 and discharged to home without services or inpatient rehabilitation (N=2902). Main Outcome MeasuresWe assessed the association between race and discharge location via logistic regression. Covariates included age, sex, Abbreviated Injury Scale-Head score, insurance type, Glasgow Coma Scale score, and comorbidities. ResultsThere were 2487 (86%) whites and 415 blacks (14%) in the sample. A total of 1513 (52%) were discharged to inpatient rehabilitation and 1389 (48%) were discharged home without services. In adjusted logistic regression, blacks were more likely to be discharged to inpatient rehabilitation than to home without services compared to whites (odds ratio 1.34, 95% confidence interval, 1.06-1.70). ConclusionsIn this group of Medicare-eligible older adults, blacks were more likely to be discharged to inpatient rehabilitation compared to whites.

Ventilator-associated events, not ventilator-associated pneumonia, is associated with higher mortality in trauma patients.

Ventilator-associated events (VAE), using objective diagnostic criteria, are the preferred quality indicator for patients requiring mechanical ventilation (MV) for greater than 48 hours. We aim to identify the occurrence of VAE in our trauma population, the impact on survival, and length of stay, as compared to the traditional definition of ventilator-associated pneumonia (VAP). This retrospective review included adult trauma patients, who were Washington residents, admitted between 2012 and 2017, and required at least 3 days of MV. Exclusions included patients with Abbreviated Injury Scale head score greater than 4 and burn related mechanisms of injury. We matched trauma registry data with our institutional, physician-adjudicated, and culture-confirmed ventilator event database. We compared the clinical outcomes of ventilator-free days, intensive care unit length of stay, hospital length of stay, and likelihood of death between VAE and VAP. One thousand five hundred thirty-three trauma patients met criteria; 124 (8.1%) patients developed VAE, 114 (7.4%) patients developed VAP, and 63 (4.1%) patients met criteria for both VAE and VAP. After adjusted analyses, patients with VAE were more likely to die (hazard ratio [HR], 2.86; 95% confidence interval [CI], 1.44-5.68), than those with VAP, as well those patients with neither diagnosis (HR, 2.83; 95% CI, 1.83-4.38). Patients with VAP were no more likely to die (HR, 1.55; 95% CI, 0.91-2.68) than those with neither diagnosis. Patients with VAE had fewer ventilator-free days than those with VAP (HR, -2.71; 95% CI, -4.74 to -0.68). Critically injured trauma patients who develop VAE are three times more likely to die and utilize almost 3 days more MV than those that develop VAP. The objective criteria of VAE make it a promising indicator on which quality indicator efforts should be focused. Future studies should be aimed at identification of modifiable risk factors for VAE and their impact on outcome, as these patients are at high risk for death. Retrospective cohort study, level III.

Twelve-Year Review of Urban Versus Rural Off-road Vehicle Injuries at a Level 1 Trauma Center

ObjectiveTraditionally, all-terrain vehicles (ATVs) and dirt bikes (DBs) have been used in rural locations for recreation and work. Recently, there has been an increase in the use of these vehicles in an urban environment. The aim of this study is to compare the injury patterns of patients involved in crashes while riding off-road vehicles in both urban (UORV) and rural (RORV) environment. MethodsA retrospective review (2005-2016) of patients who presented to an urban level 1 trauma center as a result of any ATV or DB crash was performed. UORV was defined as any ATV or DB accident that occurred on paved inner city, suburban, or major roadways. RORV was defined as those accidents that occurred on secondary roadways or off-road. Patients who presented more than 48 h from time of accident were excluded. A P < 0.05 was considered significant. ResultsFive hundred and twenty-eight patients were identified to have an ATV or DB injury (RORV n = 296 [56%]; UORV n = 232 [44%]). UORV accidents had a higher Injury Severity Score (12.2 versus 9.7; P < 0.05), lower presenting Glasgow Coma Scale (13.8 versus 14.3; P < 0.05), more likely to need emergent trauma bay procedures (28.5% versus 17.9%; P < 0.05), were less likely to have been helmeted (39.6% versus 71.2%; P < 0.05) with a higher unhelmeted Abbreviated Injury Scale head of ≥3 (13.5% versus 5%; <0.05), and more likely to have extremity injuries (53.5% versus 41.2%; P < 0.05). There were no significant differences in additional injury patterns or hospital outcomes including mortality for the two groups. ConclusionsOur data suggest that UORV use was associated with decreased helmet use, higher mean Injury Severity Score, lower presenting Glasgow Coma Scale, an increased need for emergent trauma bay procedures, higher unhelmeted Abbreviated Injury Scale head scores, and higher rates of extremity injuries.

Activated prothrombin complex concentrate for warfarin reversal in traumatic intracranial hemorrhage

BackgroundPatients with traumatic intracranial hemorrhage (TIH) anticoagulated with warfarin are at an increased risk of mortality. Fresh frozen plasma (FFP) and vitamin K have been the standard treatment for warfarin reversal; however, guidelines now recommend the use of prothrombin complex concentrate (PCC) for warfarin reversal in patients with life-threatening bleeding. Our protocol uses one vial (∼1000 units) of activated PCC (aPCC) for warfarin reversal, regardless of the weight or presenting international normalized ratio (INR). The purpose of this study was to determine the safety and efficacy of using fixed, low-dose aPCC for warfarin reversal in patients with TIH. MethodsThis was a retrospective chart review that included patients with an Abbreviated Injury Scale Head score of ≥3, TIH, and initial INR ≥ 1.5 on warfarin. Patients aged <18 years and those with no repeat INR were excluded. The primary outcome was to compare the percentage of patients with INR ≤ 1.4 after receiving aPCC versus FFP within 24 hours. ResultsEighty-nine patients were in the FFP group and 31 patients in the aPCC group. The INR was reversed more effectively in the aPCC group compared with the FFP group (90.3% versus 69.7%, P = 0.029). The median time (hours) to reversal was also significantly shorter in the aPCC group compared with the FFP group (3.75 versus 6.75, P = 0.003). However, there was no difference in mortality (35.5% aPCC versus 22.2% control, P = 0.162) or incidences of thrombosis. ConclusionFixed, low-dose aPCC is safe and more effective at reversing the effects of warfarin than FFP in patients with TIH.