Abdominal Abbreviated Injury Score Research Articles

Time and Risk Factors of Trauma-Related Mortality: A 5-Year Retrospective Analysis From a National Level I Trauma Center.

Background: We aimed to analyze in-hospital timing and risk factors for mortality in a level 1 trauma center. Methods: This is a retrospective analysis of all trauma-related mortality between 2013 and 2018. Patients were divided and analyzed based on the time of mortality (early (≤48 h) vs late (>48 h)), and within different age groups. Multivariate regression analysis was performed to predict in-hospital mortality. Results: 8624 trauma admissions and 677 trauma-related deaths occurred (47.7% at the scene and 52.3% in-hospital). Among in-hospital mortality, the majority were males, with a mean age of 35.8 ± 17.2 years. Most deaths occurred within 3-7 days (35%), followed by 33% after 1 week, 20% on the first day, and 12% on the second day of admission. Patients with early mortality were more likely to have a lower Glasgow coma scale, a higher shock index, a higher chest and abdominal abbreviated injury score, and frequently required exploratory laparotomy and massive blood transfusion (P < .005). The injury severity scores and proportions of head injuries were higher in the late mortality group than in the early group. The severity of injuries, blood transfusion, in-hospital complications, and length of intensive care unit stay were comparable among the age groups, whereas mortality was higher in the age group of 19 to 44. The higher proportions of early and late in-hospital deaths were evident in the age group of 24 to 29. In multivariate analysis, the shock index (OR 2.26; 95%CI 1.04-4.925; P = .04) was an independent predictor of early death, whereas head injury was a predictor of late death (OR 4.54; 95%CI 1.92-11.11; P = .001). Conclusion: One-third of trauma-related mortalities occur early after injury. The initial shock index appears to be a reliable hemodynamic indicator for predicting early mortality. Therefore, timely hemostatic resuscitation and appropriate interventions for bleeding control may prevent early mortality.

Factors Associated with Traumatic Diaphragmatic Rupture among Patients with Chest or Abdominal Injury: A Nationwide Study from Japan.

Background: Blunt traumatic diaphragmatic rupture (TDR) is a rare condition that is seen in patients with blunt thoracoabdominal trauma. However, factors that are associated with blunt TDR have not been fully revealed. The purpose of this study was to evaluate the factors that are associated with blunt TDR in trauma patients with a chest or abdominal injury using nationwide trauma registry data in Japan. Method: This study was a retrospective observational study with a 15-year study period from 2004 to 2018. We included trauma patients with a chest or abdominal Abbreviated Injury Score of two or more. We evaluated the relationship between confounding factors such as mechanism of injury and blunt TDR with multivariable logistic regression analysis. Results: This study included 65,110 patients, of whom 496 patients (0.8%) suffered blunt TDR. Factors that were associated with blunt TDR were disturbance of consciousness (adjusted OR [AOR]: 1.639, 95% CI: 1.326–2.026), FAST positive (AOR: 2.120, 95% CI: 1.751–2.567), front seat passenger (AOR: 1.748, 95% CI: 1.129–2.706), and compression injury by heavy object (AOR: 1.677, 95% CI: 1.017–2.765). Conclusion: This study revealed several factors that are associated with blunt TDR. The results of this study may be useful for clinicians when estimating blunt TDR.

The role of prehospital ultrasound in reducing time to definitive care in abdominal trauma patients with moderate to severe liver and spleen injuries

BackgroundThe role of prehospital focused assessment sonography for trauma (FAST) is still under debate and no definitive recommendations are available in actual guidelines, moreover, the availability of ultrasound machines in emergency medical services (EMS) is still inhomogeneous. On the other hand, time to definitive care is strictly related to survival in bleeding trauma patients.This study aimed at investigating if a positive prehospital FAST in abdominal trauma patients could have a role in reducing door-to-CT scan or door-to-operating room (OR) time. MethodsThis retrospective observational study included all the patients affected by an abdominal trauma with an abdominal abbreviated injury score ≥ 2 and a spleen or liver injury admitted to Maggiore Hospital Carlo Alberto Pizzardi, a level 1 trauma centre between 2014 and 2019. Prehospital and emergency department (ED) clinical and laboratory variables were collected, as well as in-hospital times during the diagnostic and therapeutic pathways of these patients. Results199 patients were included in the final analysis. Of these, 44 had a prehospital FAST performed and in 27 of them, peritoneal free fluid was detected in the prehospital setting, while 128 out of 199 patients had a positive ED-FAST. Sensitivity was 62.9% (95% CI: 42.4%–80.6%) and specificity 100% (95% CI: 80.5% - 100%). Patients with a positive prehospital FAST reported a significantly lower door-to-CT or door-to-OR median time (46 vs 69 min, p < 0.001). Prehospital hypotension and Glasgow coma scale, first arterial blood lactate, ISS, age, positive prehospital and ED FAST were inserted in a stepwise selection for a multivariable Cox proportional regression hazards model. Only ISS and prehospital FAST resulted significantly associated with a reduction in the door-to-CT scan or door-to-operating theatre time in the multivariable model. ConclusionPrehospital FAST information of intraperitoneal free fluid could significantly hasten door-to-CT scan or door-to-operating theatre time in abdominal trauma patients if established hospital response protocols are available. Level of evidenceIII, (Therapeutic / Care Management)

Factors Associated With Increased Mortality in Severe Abdominopelvic Injury.

Associated injuries are thought to increase mortality in patients with severe abdominopelvic trauma. This study aimed to identify clinical factors contributing to increased mortality in patients with severe abdominopelvic trauma, with the hypothesis that a greater number of concomitant injuries would result in increased mortality. This was a retrospective review of the Trauma Quality Improvement Program (TQIP) database of patients ≥ 18 years with severe abdominopelvic trauma defined as having an abdominal Abbreviated Injury Score (AIS) ≥ 3 with pelvic fractures and/or iliac vessel injury (2015-2017). Primary outcome was in-hospital mortality based on concomitant body region injuries. Secondary outcomes included mortality at 6 h, 6 to 24 h, and after 24 h based on concomitant injuries, procedures performed, and transfusion requirements. A total of 185,257 patients were included in this study. Survivors had more severely injured body regions than non-survivors (4 vs. 3, P < 0.001). Among those who died within 6 h, 28.5% of patients required a thoracic procedure and 43% required laparotomy compared to 6.3% and 22.1% among those who died after 24 h (P < 0.001). Head AIS ≥ 3 was the only body region that significantly contributed to overall mortality (OR 1.26, P < 0.001) along with laparotomy (OR 3.02, P < 0.001), neurosurgical procedures (2.82, P < 0.001) and thoracic procedures (2.28, P < 0.001). Non-survivors who died in < 6 h and 6-24 h had greater pRBC requirements than those who died after 24 h (15.5 and 19.5 vs. 8 units, P < 0.001). Increased number of body regions injured does not contribute to greater mortality. Uncontrolled noncompressible torso hemorrhage rather than the burden of concomitant injuries is the major contributor to the high mortality associated with severe abdominopelvic injury.

Defining an intra-operative blunt mesenteric injury grading system and its use as a tool for surgical-decision making

BackgroundThe mesentery may be injured in trauma and few grading systems describe mesenteric injury severity. We aimed to develop and validate an intra-operative mesenteric injury grading system. MethodsA modified Delphi technique was used to generate an intraoperative grading system for blunt mesenteric injury called the mesenteric injury score (MIS). We performed a retrospective review (2010–2016) of patients >15 years old with blunt abdominal trauma. Patient demographics, injury severity score (ISS) and mechanism, clinical, operative, and outcome data were abstracted. The intraoperative grading system was used to describe patient outcomes including duration of stay and management approach. We compared the correlation of abdominal abbreviated injury score, Blunt Injury Prediction Score (BIPS) and the MIS with clinical outcomes using Spearman’s rho. ResultsThere were fifty-one patients of which 86% were male. Injury mechanisms included motor vehicle accidents (n = 37, 73%), pedestrian vehicle accidents (n = 7, 13%), assaults (n = 4, 8%), falls (n = 2, 4%), and a single airplane crash (2%). Median [IQR] ISS was 16 [10–25] and GCS at hospital admission was 15 [15–15]. The median [IQR] international normalized ratio was 1.2 [1.1–1.5], lactate was 2.7 [1.7–4.9], and hemoglobin was 11.4 [8.6–12.2]. The distributions of MIS included Grade I (3, 5%), Grade II (10, 20%), Grade III (10, 20%), Grade IV, 5 (10%), and Grade V (23, 45%). Increasing mesenteric injury grade was associated with longer duration of stay, need for bowel resection, and damage control laparotomy. ConclusionsWe developed an intra-operative mesenteric injury grading system (MIS) and provided an initial retrospective validation using a series of patients with blunt abdominal trauma. The proposed MIS corresponded with both the AIS and the BIPS. Future study comparing cross sectional imaging and operative findings based on MIS criteria is needed.

Splenectomy is associated with higher infection and pneumonia rates among trauma laparotomy patients

Splenectomy increases lifetime risk of thromboembolism (VTE) and is associated with long-term infectious complications, primarily, overwhelming post-splenectomy infection (OPSI). Our objective was to evaluate risk of VTE and infection at index hospitalization post-splenectomy.Retrospective review of all patients who received a laparotomy in the NTDB.Propensity score matching for splenectomy was performed, based on ISS, abdominal abbreviated injury score >3, GCS, sex and mechanism. Major complications, VTE, and infection rates were compared. Multiple logistic regression models were utilized to evaluate splenectomy-associated complications.93,221 laparotomies were performed and 17% underwent splenectomy. Multiple logistic regression models did not demonstrate an association between splenectomy and major complications (OR 0.96, 95% CI 0.91–1.03, p = 0.25) or VTE (OR 1.05, 95% CI 0.96–1.14, p = 0.33). Splenectomy was independently associated with infection (OR 1.07, 95% CI 1.00–1.14, p = 0.045). Subgroup analysis of patients with infection demonstrated that splenectomy was most strongly associated with pneumonia (OR 1.41, 95% CI 1.26–1.57, p < 0.001).Splenectomy is not associated with higher overall complication or VTE rates during index hospitalization. However, splenectomy is associated with a higher rate of pneumonia.

Prevalence and Associated Factors of Acute Traumatic Coagulopathy; a Cross Sectional Study.

Acute traumatic coagulopathy (ATC) is defined as having evidence of coagulopathy in patients with severe trauma. The aim of this preliminary study was to assess the prevalence and associated factors of ATC in severely traumatic patients presenting to emergency department (ED). In this retrospective cross sectional study, all patients with severe traumatic injury and available coagulation profile, presenting to the EDs of two major trauma centers in Tehran, Iran, during one year, were studied. Rate of ATC was determined and the associations with various variables as well as outcome were analyzed using SPSS 21. 246 patients with the mean age of 36.57±17.11 years were included (88.2% male). The mean injury severity score (ISS) was 21.83 ± 7.37 (16 - 54). Patients were resuscitated with 676.83 ± 452.02 (0 - 1500) ml intravenous fluid before arriving at the ED. The maximum and minimum frequencies of ATC were 31.3% based on PTT > 36s and 2.4% based on PT > 18s, respectively. There was a significant association between the occurrence of ATC (PT ratio > 1.2) and ISS > 23 (p = 0.001), abdominal abbreviated injury score (AIS) > 3 (p = 0.003), base deficit > 4 (p = 0.019), pulse rate > 90/minute (p = 0.041), and pH < 7.30 (p = 0.043). The frequency of ATC in the present series varied from 2.4% to 31.3% based on different ATC definitions. Abdominal AIS > 3 and base deficit > 4 were among the significant independent factors related to ATC occurrence based on stepwise logistic regression analysis.

Acute Traumatic Coagulopathy in Iran; Incidence and Possible Risk Factors

Abstract Introduction: Acute traumatic coagulopathy (ATC) is a disruption of hemostasis at the moment of impact and is associated with increased mortality. Without quickly available diagnostic tests, risk factors play an important role in identifying those at risk. We aim to determine the incidence of ATC and find its risk factors in a previously unreported population. Methods: A retrograde analysis of records was done on all severe trauma patients at two major trauma centers in Tehran for whom a coagulation panel had been ordered on admission. Rate of ATC was determined with different definitions and association with outcome measures was analyzed. Association between risk factors and ATC was analyzed first in a cross-sectional manner and then using logistic regression via SPSS21 software. Results: Overall 246 patients were included (88.2% male). PTratio>1.2 was seen in 11.4% and best predicted outcomes. ISS score>23 (P=0.001), abdominal Abbreviated Injury Score (AIS)>3 (P=0.003), BE more negative than -4 (P=0.019), PR in the ED>90 (P=0.041), pH 90 (P=0.046) were found to be associated with the development of ATC. Of these abdominal AIS more than 3 (P=0.001), and BE more negative than -4 (P=0.011) were found to be independent predictors of ATC in logistic regression. Conclusion: We determined the rate of ATC for the first time in a Middle Eastern country and found it to be closer to the lower margin of previously reported frequencies. Our findings also cement previous reports that both severe injury and hypoperfusion put patients at risk for ATC.

Selective Nonoperative Management of Abdominal Stab Wounds

Stab wounds (SW) to the abdomen traditionally require urgent exploration when associated with shock, evisceration, or peritonitis. Hemodynamically stable patients without evisceration may benefit from serial exams even with peritonitis. We compared patients taken directly to the operating room with abdominal SWs (ED-OR) to those admitted for serial exams (ADMIT). We retrospectively reviewed hemodynamically stable patients presenting with any abdominal SW between January 2000 and December 2012. Exclusions included evidence of evisceration, systolic blood pressure ≤110 mm Hg, or blood transfusion. NON-THER was defined as abdominal exploration without identification of intra-abdominal injury requiring repair. Of 142 patients included, 104 were ED-OR and 38 were ADMIT. When ED-OR was compared with ADMIT, abdominal Abbreviated Injury Score was higher (2.4 vs 2.1; P = 0.01) and hospital length of stay was longer (4.8 vs 3.3 days; P = 0.04). Incidence of NON-THER was higher in ED-OR cohort (71% vs 13%; P ≤ 0.001). In a regression model, ED-OR was a predictor of NON-THER (adjusted odds ratio 16.6; P < 0.001). One patient from ED-OR expired after complications from NON-THER. There were no deaths in the ADMIT group. For those patients with abdominal SWs who present with systolic blood pressure ≥110 mm Hg, no blood product transfusion in the emergency department and lacking evisceration, admission for serial abdominal exams may be preferred regardless of abdominal exam.

Optimal timing of tracheostomy after trauma without associated head injury

BackgroundControversy exists over optimal timing of tracheostomy in patients with respiratory failure after blunt trauma. The study aimed to determine whether the timing of tracheostomy affects mortality in this population. MethodsThe 2008–2011 National Trauma Data Bank was queried to identify blunt trauma patients without concomitant head injury who required tracheostomy for respiratory failure between hospital days 4 and 21. Restricted cubic spline analysis was performed to evaluate the relationship between tracheostomy timing and the odds of inhospital mortality. The cohort was stratified based on this analysis. Unadjusted characteristics and outcomes were compared. Multivariable logistic regression was used to evaluate the effect of tracheostomy timing on mortality after adjustment for age, gender, race, payor status, level of trauma center, injury severity score, presentation Glasgow coma scale, and thoracic and abdominal abbreviated injury score. ResultsThere were 9662 patients included in the study. Restricted cubic spline analysis demonstrated a nonlinear relationship between timing of tracheostomy and mortality, with higher odds of mortality occurring with tracheostomy placement within 10 d of admission compared with later time points. The cohort was therefore stratified into early and delayed tracheostomy groups relative to this time point. The resulting groups contained 5402 (55.9%) and 4260 (44.1%) patients, respectively. After multivariable adjustment, the delayed tracheostomy group continued to have significantly reduced odds of mortality (Adjusted odds ratio, 0.82, 95% confidence interval, 0.71–0.95, C-statistic, 0.700). ConclusionsAmong non–head injured blunt trauma patients with prolonged respiratory failure, tracheostomy placement within 10 d of admission may result in increased mortality compared with later time points.

Early unplanned hospital readmission after acute traumatic injury: the experience at a state-designated level-I trauma center

BackgroundThere is limited literature on early unplanned hospital readmission after acute traumatic injury, especially at suburban facilities. MethodsA retrospective review of the trauma registry at a suburban, state-designated, level-I academic trauma center from July 2009 to June 2012 was performed for all admitted (≥24 hours) adult (age ≥18 years) trauma patients who were discharged alive, including unplanned readmissions within 30 days of discharge. ResultsOf 3,622 admitted adult trauma patients, 6.57% were readmitted at a median of 9 days. Major surgery was required in 15.9% patients on readmission. The mortality rate at readmission was 4.6%. Multiple factors were associated with readmission on univariate analysis; however, on multivariate analysis, only major comorbidities (odds ratio [OR], 1.53), hospital length of stay (OR, 1.01), abdominal Abbreviated Injury Score greater than or equal to 3 (OR, 2.10), and discharge to a skilled nursing facility or subacute facility (OR, 1.56) were significant predictors. Meanwhile, index admission to surgical services was associated with a significantly lower readmission risk (OR, .60). ConclusionsTrauma patients are infrequently readmitted. Index admission to a surgical service reduces the risk of readmission. Earlier medical follow-up should be considered.

Damage Control Resuscitation Protocol and the Management of Open Abdomens in Trauma Patients

Although the use of damage control laparotomy (DCL) is well established, the effect of damage control resuscitation (DCR) on the management of open abdomens is relatively poorly studied. The aim of the present study was to determine the predictors for failure to achieve primary fascial closure (PFC) after DCL in the setting of a massive transfusion (MT) and DCR. This is a retrospective review over a 12-year period of all patients that underwent MT and DCL. Patients who achieved PFC were compared with those who did not (NPFC). Student's t tests were used to compare the two groups. A multiple logistic regression model was performed to identify independent risk factors for failure to attain PFC. Of 174 patients, 101 achieved PFC. Mean (± standard deviation) age was 35.6 ± 14.9 years for PFC and 36.3 ± 14.0 years for NPFC (P = 0.75). Admission Glasgow Coma Scale score was 11.4 ± 4.6 for PFC and 10.6 ± 5.0 for NPFC (P = 0.25). Initial lactate (7.3 ± 3.8 vs 7.7 ± 4.1, P = 0.50), hemoglobin (11.3 ± 1.9 vs 11.0 ± 2.2, P = 0.43), systolic blood pressure (108 ± 44 vs 107 ± 35, P = 0.82), Injury Severity Score (34 ± 14 vs 36 ± 15, P = 0.32), and abdominal Abbreviated Injury Score (3.6 ± 1.1 vs 3.9 ± 1.0, P = 0.13) were similar between the two groups. There was no difference in total blood products administered at 24 hours (46 ± 26 vs 49 ± 29 units, P = 0.45). Logistic regression identified increasing volume of crystalloid at 24 hours (odds ratio, 0.86; 95% confidence interval, 0.74 to 0.99; P = 0.047), earlier operative year (2.1; 1.52 to 2.91; P < 0.001), and increased number of procedures (0.32, 0.18 to 0.58; P < 0.001) as independent predictors for failure to obtain PFC. Injury severity is not associated with failure to achieve PFC, whereas administration of large-volume crystalloid resuscitation, increasing number procedures, and earlier year of DCL are independent predictors for failure to achieve PFC. Application of DCR to DCL techniques results in an improvement in ability to achieve PFC.

To TQIP or Not to TQIP? that is the Question

The Trauma Quality Improvement Program (TQIP) reports a feasible mortality prediction model. We hypothesize that our institutional characteristics differ from TQIP aggregate data, questioning its applicability. We conducted a 2-year (2008 to 2009) retrospective analysis of all trauma activations at a Level 1 trauma center. Data were analyzed using TQIP methodology (three groups: blunt single system, blunt multisystem, and penetrating) to develop a mortality prediction model using multiple logistic regression. These data were compared with TQIP data. Four hundred fifty-seven patients met TQIP inclusion criteria. Penetrating and blunt trauma differed significantly at our institution versus TQIP aggregates (61.9 vs 7.8%; 38.0 vs 92.2%, P < 0.01). There were more firearm mechanisms of injury and less falls compared with TQIP aggregates (28.9 vs 4.2%; 8.5 vs 34.8%, P < 0.01). All other mechanisms were not significantly different. Variables significant in the TQIP model but not found to be predictors of mortality included Glasgow Coma Score motor 2 to 5, systolic blood pressure greater than 90 mmHg, age, initial pulse rate in the emergency department, mechanism of injury, head Abbreviated Injury Score, and abdominal Abbreviated Injury Score. External benchmarking of trauma center performance using mortality prediction models is important in quality improvement for trauma patient care. From our results, TQIP methodology from the pilot study may not be applicable to all institutions.

The influence of unit-based nurse practitioners on hospital outcomes and readmission rates for patients with trauma

With the increased restrictions on resident work hours, hospitals increasingly are relying on advance practice nurses and physician assistants to help meet the patient care demand. We have created a workflow model wherein unit-based nurse practitioners (UBNPs) provide the minute-to-minute care for patients with trauma in one specific unit in our hospital, with supervision by the attending surgeons. Patients with trauma may also be admitted to other units, where the care model is a traditional resident-run (RR) service, again with supervision by the attending staff. Our aim was to determine if there were differences between the care provided by UBNPs and residents. We queried our trauma database for all patients admitted to our urban, academic, Level I trauma center from January 1, 2007, to August 31, 2010. Patients discharged alive from the trauma service were identified and cross-referenced with an administrative database to collect demographics, injury characteristics, comorbidities, complications, and discharge information. Patients cared for by the UBNPs were compared with those cared for by the RR service. χ², Fisher's exact, and Student's t tests were used to determine significance. Significant factors were then tested with a multivariate linear regression analysis. p < 0.05 was considered significant. During the study period, 3,859 patients were discharged alive from the trauma service, 2,759 (71.5%) from the UBNPs service, and 1,100 (28.5%) from the RR service. Demographic data and mean Injury Severity Score (11.6 vs. 11.1, p = 0.24) were similar for the two groups, although mean abdominal Abbreviated Injury Score was higher for the UBNP group (0.6 vs. 0.5, p = 0.02). UBNP patients were more likely to be diagnosed with deep venous thrombosis (4% vs. 2.5%, p = 0.02) and were more likely to be discharged to home (67% vs. 60%, p = 0.002). Mean (SD) length of stay for UBNP patients was 6.5 (8.8) days compared with 7 (10.8) days for RR patients, although this difference did not reach statistical significance ( p = 0.17). The 30-day hospital readmission rates were similar for both groups (4.0% vs. 4.4%, p = 0.63). Care provided by UBNPs is equivalent to that provided by residents. With the restriction on resident work hours and greater reliance on nurse practitioners, patient care does not suffer. Moreover, a difference of 0.5 days in mean length of stay for the UBNP patients equates with more than 1,300 fewer patient care days. This difference, although not statistically significant, may be clinically relevant to physicians and administrators and may offset the cost of hiring UBNPs to help meet the patient care demand.

Risk Factors for Traumatic Injury Findings on Thoracic Computed Tomography Among Patients With Blunt Trauma Having a Normal Chest Radiograph

We sought to identify risk factors that might predict acute traumatic injury findings on thoracic computed tomography (TCT) among patients having a normal initial chest radiograph (CR). In this retrospective analysis, Abbreviated Injury Score cutoffs were chosen to correspond with obvious physical examination findings. Multivariate logistic regression analysis was performed to identify risk factors predicting acute traumatic injury findings. Urban level I trauma center. All patients with blunt trauma having both CR and TCT between July 1, 2005, and June 30, 2007. Patients with abnormalities on their CR were excluded. Finding of any acute traumatic abnormality on TCT, despite a normal CR. A total of 2435 patients with blunt trauma were identified; 1744 (71.6%) had a normal initial CR, and 394 (22.6%) of these had acute traumatic findings on TCT. Multivariate logistic regression demonstrated that an abdominal Abbreviated Injury Score of 3 or higher (P = .001; odds ratio, 2.6), a pelvic or extremity Abbreviated Injury Score of 2 or higher (P < .001; odds ratio, 2.0), age older than 30 years (P = .004; odds ratio, 1.4), and male sex (P = .04; odds ratio, 1.3) were significantly associated with traumatic findings on TCT. No aortic injuries were diagnosed in patients with a normal CR. Limiting TCT to patients with 1 or more risk factors predicting acute traumatic injury findings would have resulted in reduced radiation exposure and in a cost savings of almost $250,000 over the 2-year period. Limiting TCT to this degree would not have missed any clinically significant vertebral fractures or vascular injuries. Among patients with a normal screening CR, reserving TCT for older male patients with abdominal or extremity blunt trauma seems safe and cost-effective.

Examination of the Impact of Airbags on Renal Injury Using a National Database

Little is known about preventative measures to lessen solid organ injury in motor vehicle collisions (MVCs). To evaluate the efficacy of airbags in reducing renal injuries in MVC, we analyzed renal injury rates in vehicles with and without airbags using the Crash Injury Research and Engineering Network (CIREN) database. The CIREN database was queried for MVC and renal injury from 1996 to September 2008. CIREN is weighted toward late model vehicles and selects more severely injured patients. Search fields were primary direction of force (PDOF), presence of airbags, and location of airbags (steering wheel, instrument panel, seat back, door panel, and roof-side curtain). Abdominal Abbreviated Injury Score was converted to AAST renal injury grade. Renal injury rates were compared between vehicles with and without frontal and side airbags. We reviewed 2,864 records and identified 139 renal injuries (28.9% AAST grade III to V). In MVCs with renal injuries, frontal impact was 54.7% of total (n = 76) and side impact was 45.3% of total (n = 63). Most occupants in frontal impact MVCs had exposure to a steering wheel airbag (74.9%); 16.6% had an instrument panel (passenger) airbags. In side impact MVCs, 32.2% of occupants had a side airbag. Compared with the non-airbags cohort, frontal airbags and side airbags were associated with a 45.3% and 52.8% reduction in renal injury, respectively. Passengers in automobiles with frontal and side airbags have a reduced rate of renal injury compared with those without airbags. Our data support further study of the role of airbags in reducing renal injury after MVC.

A Diagnostic Delay of 5 Hours Increases the Risk of Death After Blunt Hollow Viscus Injury

Hollow viscus injuries (HVI) are uncommon after blunt trauma, and accomplishing a timely diagnosis can be difficult. Time to operative intervention has been implicated as a risk factor for mortality, but reports are conflicting. All blunt trauma admissions to an academic level 1 trauma center from January 1992 to September 2005 were retrospectively reviewed. Patients with a diagnosis of blunt HVI were included. Patients who died within 24 hours were excluded. Data regarding patient demographics, injuries, time from admission until laparotomy, length of stay, and mortality were recorded, and a multivariate analysis to determine independent risk factors for mortality was carried out. A p < 0.05 was considered significant. Of 35,033 blunt trauma admissions, there were 195 (0.6%) HVI patients with the following characteristics (data expressed as mean +/- 1 SD): mean age of 35 years +/- 16 years, Injury Severity Score of 17 +/- 11, time from admission to laparotomy of 5.9 hours +/- 5.8 hours, operative blood loss of 1500 mL +/- 1800 mL, and length of stay of 19 days +/- 23 days. Twelve percent presented with a systolic pressure <90 mm Hg and 9% died. Independent risk factors for mortality were age (odds ratio [OR] = 1.04, p = 0.005), Abdominal Abbreviated Injury Score (OR = 2.5, p = 0.011), the presence of a significant extra-abdominal injury (OR = 3.4, p = 0.043), and a delay of more than 5 hours between admission and laparotomy (OR = 3.2, p = 0.0499). Eighty-six percent of the deaths in patients who had a delay of >5 hours were because of abdominal-related sepsis. HVI occurred in less than 1% of all blunt trauma admissions. Delays in operative intervention are associated with an increased mortality. A high index of suspicion is needed to make a timely diagnosis and minimize risk.

Characteristics of Pediatric Trauma in an Urban City in Japan

To clarify the characteristics of recent pediatric injuries in an urban city in Japan. Any patient who was under 13 years old and admitted for treatment of trauma between January 2000 and December 2007 was retrospectively investigated. The subjects were divided into 2 groups, the head injury (HI) and the control groups. The HI group had an abbreviated injury score (AIS) of the head greater than 1, and the control group had an AIS of the head equal to 0 or 1. The number of patients in the HI group was 95; and in the control group, 74. There were no penetrating injuries. The proportion of patients who were run over in the HI group was smaller than that in the control group. The injury severity score in the HI group was greater than that in the control group. The abdominal AIS in the HI group was smaller than that in the control group. The number of extracranial injuries (sum of all AIS except for the head) in the HI group was smaller than that in the control group. The survival rate in the HI group was smaller than that in the control group. All causes of death in the HI group were cerebral complications. The severity and outcome of pediatric blunt traumas were dependent on HI. Because the extracranial injuries with an HI were not severe, the successful treatment of the cerebral complications could lead to favorable outcome.

Crash and Occupant Predictors of Pulmonary Contusion

Pulmonary contusions (PCs) are a common injury sustained in motor vehicle collisions. The crash and occupant characteristics of PC in motor vehicle collisions are currently unknown. Additionally, the clinical significance and the impact on mortality have not been determined. A retrospective review of the Crash Injury Research and Engineering Network database with inclusion criteria of frontal (F) and near-side lateral (L) crashes involving occupants older than 15 years, yielded 2,184 case occupants. Pearson's chi and multivariate logistic regression were used with a p < 0.05 conferring statistical significance. Median age was 38 years, 80% were drivers and mortality was 16%. Forty-nine percent of case occupants were not wearing lap-shoulder belts. Chest trauma was sustained by 1,131 (52%), of whom 379 had PC. Crash characteristics included: 38 kph median change in velocity (delta V), 72% frontal deformation, and 35% struck a fixed object. Injury characteristics included median Injury Severity Score 17 with the following Abbreviated Injury Score (AIS) >2 injuries: thoracic 40%, abdominal 19%, and head 24%. Univariate predictors of PC included: age <25, male, higher Injury Severity Score, fatality, delta V >45 kph, L impacts, and collision with fixed object. PC was significantly associated with occupant compartment intrusion in F but not L crashes. In multivariate analysis, significant predictors of PC included: age <25 (odds ratios [OR] = 1.5), delta V >45 kph (OR = 1.9), and fixed object (frontal crash only) (OR = 1.8). Controlling for head, spine, abdominal, and extremity injuries AIS >2, PC was not a statistically significant risk factor for mortality. This was consistent whether or not another AIS >2 thoracic injury was present. The effectiveness of side-impact airbags was not evaluated due to the small sample size. Crash severity as demonstrated by higher delta V was strongly associated with PC in all crashes. Frontal crashes with a fixed object or intrusion are more likely to result in a PC. The risk of PC is greatly increased in near-side lateral impacts regardless of intrusion or object struck; suggesting occupant proximity may be the most important factor. Further investigations of the efficacy of side airbags as a counter measure should be considered and continued public education of the efficacy of lap-shoulder restrains should continue. Unexpectedly, although a marker for crash severity, PC is not an independent marker of mortality.

How We Die: The Impact of Nonneurologic Organ Dysfunction after Severe Traumatic Brain Injury

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