Greater Injury Severity Score Research Articles

Low-molecular-weight heparin is superior to unfractionated heparin in lowering the risk of venous thromboembolism after traumatic lower extremity amputation

BackgroundPatients undergoing lower extremity amputation after trauma are at high risk of venous thromboembolism. Practice variations persist regarding the optimal pharmacologic agent for venous thromboembolism prophylaxis in this patient population. We aimed to compare the efficacy of unfractionated heparin versus low-molecular-weight heparin in preventing venous thromboembolism. MethodsUsing the 2013 to 2019 American College of Surgeons Pediatric Trauma Quality Improvement Program database, all trauma patients (≥18) who underwent lower limb amputation and received venous thromboembolism thromboprophylaxis in the form of unfractionated heparin or low-molecular-weight heparin were included. We excluded patients who died within 24 hours of admission or those who received no thromboprophylaxis. The primary outcome was the rate of venous thromboembolism. Multivariable logistic regression was used to evaluate the independent relationship between the type of pharmacologic prophylaxis and the risk of venous thromboembolism. ResultsA total of 4,103 patients who underwent lower extremity amputation were identified. Patients were primarily young (median age 43 years) with blunt injuries (83%). The overall rate of venous thromboembolism was 8.6%. Most (77%) patients received low-molecular-weight heparin-based prophylaxis. Compared with patients without venous thromboembolism, the venous thromboembolism cohort had a greater injury severity score (19 vs 13, P < .001), had more patients undergoing above-the-knee amputation (48% vs 36%, P < .001), and less frequently received low-molecular-weight heparin (64% vs 78%, P < .001). Multivariable analysis showed that low-molecular-weight heparin was associated with a significantly lower venous thromboembolism rate than unfractionated heparin (odds ratio: 0.65 [0.51–0.83], P < .001). ConclusionThromboprophylaxis with low-molecular-weight heparin was found to be superior to unfractionated heparin in lowering the risk of venous thromboembolism among traumatic amputees and should be the preferred pharmacologic agent in this patient population prone to venous thromboembolism.

Pre-Existing Anxiety and Depression in Injured Older Adults: An Under-Recognized Comorbidity With Major Health Implications.

Little is known about the prevalence and impact of psychiatric comorbidities on early postinjury depression and anxiety in nonneurologically injured older adults. This was a retrospective post-hoc analysis of data from the Trauma Medical Home, a multicenter randomized controlled trial (R01AG052493-01A1) that explored the effect of a collaborative care model on postinjury recovery for older adults compared to usual care. Nearly half of the patients screened positive for at least mild depressive symptoms as measured by the Patient Health Questionnaire-9. Forty-one percent of the patients screened positive for at least mild anxiety symptoms as measured by the Generalized Anxiety Disorder Scale. Female patients with a history of concurrent anxiety and depression, greater injury severity scores, and higher Charlson scores were more likely to have mild anxiety at baseline assessment. Patients with a history of depression only, a prior history of depression and concurrent anxiety, and higher Charlson scores (greater medical comorbidity) had greater odds of at least mild depression at the time of hospital discharge after traumatic injury. Anxiety and depression are prevalent in the older adult trauma population, and affect women disproportionately. A dual diagnosis of depression and anxiety is particularly morbid. Mental illness must be considered and addressed with the same importance as other medical diagnoses in patients with injuries.

A Retrospective Analysis of Intracranial Pressure Monitoring and Outcomes in Adults after Severe Traumatic Brain Injury at Kaiser Permanente Trauma Centers.

The role of intracranial pressure (ICP) monitoring in improving outcomes after severe traumatic brain injury especially at level II trauma centers remains controversial. A retrospective analysis was undertaken to assess the impact of ICP monitoring on mortality and long-term functional outcome in adults after severe traumatic brain injury at level II trauma centers. The data were extracted from the Kaiser Permanente trauma database. Inclusion criteria were adults (≥ 18 years) with severe traumatic brain injury (Glasgow Coma Scale score, < 9) admitted to 2 level II trauma centers in Northern California from 2014 to 2019. Of 199 patients, 58 (29.1%) underwent ICP monitoring. The monitored subgroup was significantly younger (< 65 years), had lower Glasgow Coma Scale scores (3-5), underwent cranial procedures (craniotomy or decompressive craniectomy) more often, and had greater injury severity scores (≥ 15). Despite monitored patients being more severely injured, there was no significant difference in mortality or 6-month favorable outcomes between monitored and nonmonitored patients, including patients who underwent cranial procedures. Increased monitoring frequency and reduction in overall mortality was seen throughout the study period yet with a parallel reduction in both groups. ICP monitoring may not impact in-patient mortality or long-term outcomes at level II trauma centers. Improved outcomes may be more related to identifying patients who may benefit from ICP-guided therapy rather than simply increasing the overall use of it. Last, our pattern of care and outcomes are comparable to level I trauma centers and our findings may serve as a benchmark for future studies.

Surgical management of traumatic diaphragmatic hernia: a single institutional experience of more than two decades

BackgroundWe present here our experience with surgical management of traumatic diaphragmatic hernia, trying to find out the era impact of different periods on the outcome and risk factors of mortality.MethodsA series of 63 patients with traumatic diaphragmatic hernia were referred to us and operated on during March, 1990-August, 2017. The patient records were reviewed and statistically analyzed to demonstrate injury characteristics and to find out optimal treatment strategy, risk factors of death as well as the difference between two periods (1990–2005, 2005–2017) divided by introduction of computed tomography at our institution.ResultsThe overall mean age was 31.2 ± 16.3 years old with a female to male ratio of 11/52. The mechanism was penetrating trauma in 19 cases (30.2%), and blunt trauma in 44 cases (69.9%). Two thirds of the patients in the second group (2005–2017) yet none in the first group (1990–2005) underwent computed tomography. Ten patients (15.9%), of which 8 in the first and the other 2 in the second group (p = .042), had late diagnoses. The most commonly used incision was a thoracotomy (n = 43, 89.6%). There was no statistical difference in etiology or mortality between the two periods. Univariate analysis showed survivors were younger, and had lesser injury severity scores (ISS) and lower American Association for the Surgery of Trauma (AAST) grade than non-survivors. By multivariate logistic regression analysis, increased age (odds ratio, 1.275; p = .013) and greater ISS (OR, 1.174; p = .028) were risk factors of death in all patients.ConclusionsHigh-definition computed tomography has significantly improved the preoperative diagnosis rate. The transthoracic approach could be used in selected cases with traumatic diaphragmatic hernia with good outcomes. Patients with greater ISS and advanced ages are at a higher risk of death.

Use of Intracranial Pressure Monitoring in Patients with Severe Traumatic Brain Injury

The Brain Trauma Foundation (BTF) recommends intracranial pressure (ICP) monitoring for all salvageable patients with an abnormal computed tomography (CT) scan and a Glasgow Coma Scale <9. Studies have shown that compliance with this recommendation is low. We sought to obtain contemporary national rates of ICP monitor placement in patients with severe traumatic brain injury (TBI). Patients from the National Trauma Data Bank from 2013 to 2017 who met BTF criteria for ICP monitoring were included. Placement of an intraparenchymal ICP monitor or an external ventricular drain was queried. Binary logistic regression was used to determine factors that influenced the placement of an ICP monitor. A total of 21,374 patients with severe TBI and an abnormal CT scan were included in the study. An ICP monitor was placed in 6543 patients (30.6%). ICP monitor placement increased modestly from 28.6% in 2013 to 32.8% in 2017. The pooled odds of ICP monitor placement between 2014 and 2017 were not different from 2013 (odds ratio, 1.04; 95% confidence interval, 0.99-1.09), but the adjusted odds of ICP monitor placement in 2017 were significantly greater (odds ratio, 1.18; 95% confidence interval, 1.06-1.30). Treatment at a teaching hospital, subdural hematoma, multiple intracranial abnormalities on CT, and greater Injury Severity Score were associated with ICP monitor placement, whereas older age was negatively associated with ICP monitor placement. The rate of ICP monitoring in patients with severe TBI who meet BTF criteria is low and increased only slightly from 2013 to2017.

Risk factors and outcome of acute kidney injury in elderly trauma patients

BackgroundAcute Kidney Injury (AKI) is associated with significant morbidity. The risk factors for AKI in elderly trauma patients have not been defined. MethodsInjured patients 75 years old or older from 2014 to 2016 were evaluated. AKI was identified by RIFLE criteria. Patients with and without AKI were compared with chi square, ANOVA, and logistic regression. Results836 patients were 75 years old or older. Patients with AKI were more commonly male, hypotensive on admission with a greater Injury Severity Score but age, diabetes, hypertension and baseline creatinine were similar. Patients with AKI had a higher mortality that did not increase with RIFLE stage. Male sex, ISS, hypotension on admission and presence of an extremity injury were independently associated with AKI by logistic regression. ConclusionAKI in elderly trauma patients is associated with magnitude of injury and shock but not pre-existing medical comorbidities and it significantly increased the risk of death.

The clinical utility of shock index to predict the need for blood transfusion and outcomes in trauma

BackgroundWe aimed to evaluate the clinical utility of shock index (SI) to assess the need for blood transfusion and predict the outcomes in trauma. Materials and methodsWe conducted a retrospective analysis for trauma patients between 2012 and 2016 in a level-1 trauma center. Data included patient demographics, vital signs, mechanism of injury, Injury Severity Score (ISS), New Injury Severity Score (NISS), Trauma and Injury Severity Score (TRISS), blood transfusion, hospital length of stay (HLOS), and mortality. Patients were classified into group I (SI < 0.8) and group II (SI ≥ 0.8). ResultsOut of 8710 admitted patients, 1535 (22%) had SI ≥ 0.8 and 976 (12.5%) received blood transfusion (89 received massive transfusion, following massive blood transfusion protocol [MTP]). In comparison to lower SI, patients with SI ≥ 0.8 were mostly female patients, 8 y younger (43 ± 22 versus 51 ± 23), had greater ISS (15 ± 12 versus 10.5 ± 8), higher NISS (19 ± 15 versus 14 ± 11), lower pulse pressure (43 ± 14 versus 62 ± 18), lower TRISS (0.892 ± 0.20 versus 0.953 ± 0.11), and received more blood transfusion (28.6% versus 9.0%) or MTP (17.7% versus 3%), P = 0.001. Also, they had mostly exploratory laparotomy (13.3% versus 6.6%, P = 0.001), longer HLOS (11.3 versus 7.0 d, P = 0.001), and higher mortality (7.0% versus 3.1%, P = 0.001). SI was correlated with age (r = −0.188), pulse pressure (r = −0.51), HLOS (r = 0.168), ISS (r = 0.251), NISS (r = 0.211), amount of blood transfused (r = 0.27), Glasgow Coma Scale (r = −0.96), and TRISS (r = −0.230). After adjusting for age and sex, ISS, and Glasgow Coma Scale in two multivariable analyses, high SI was found to be an independent predictor for mortality (odd ratio, 2.553; 95% confidence intervals: 1.604-4.062) and blood transfusion (odd ratio, 3.57; 95% confidence intervals: 3.012-4.239). The cutoff point of SI for predicting MTP is 0.81 (sensitivity, 85%; specificity, 64%; positive predictive value, 16%; and negative predictive value, 98%). ConclusionsThe SI after injury can be used early to predict the need for MTP and laparotomy and mortality. It correlates with other physiological and anatomical variables. However, its cutoff values for risk stratification and prognostication need further evaluation.

Venous thromboembolism after major venous injuries: Competing priorities.

Venous thromboembolism (VTE) after major vascular injury (MVI) is particularly challenging because the competing risk of thrombosis and embolization after direct vessel injury must be balanced with risk of bleeding after surgical repair. We hypothesized that venous injuries, repair type, and intraoperative anticoagulation would influence VTE formation after MVI. A multi-institution, retrospective cohort study of consecutive MVI patients was conducted at three urban, Level I centers (2005-2013). Patients with MVI of the neck, torso, or proximal extremities (to elbows/knees) were included. Our primary study endpoint was the development of VTE (DVT or pulmonary embolism [PE]). The 435 major vascular injury patients were primarily young (27 years) men (89%) with penetrating (84%) injuries. When patients with (n = 108) and without (n = 327) VTE were compared, we observed no difference in age, mechanism, extremity injury, tourniquet use, orthopedic and spine injuries, damage control, local heparinized saline, or vascular surgery consultation (all p > 0.05). VTE patients had greater Injury Severity Score (ISS) (17 vs. 12), shock indices (1 vs. 0.9), and more torso (58% vs. 35%) and venous (73% vs. 48%) injuries, but less often received systemic intraoperative anticoagulation (39% vs. 53%) or postoperative enoxaparin (47% vs. 61%) prophylaxis (all p < 0.05). After controlling for ISS, hemodynamics, injured vessel, intraoperative anticoagulation, and postoperative prophylaxis, multivariable analysis revealed venous injury was independently predictive of VTE (odds ratio, 2.7; p = 0.002). Multivariable analysis of the venous injuries subset (n = 237) then determined that only delay in starting VTE chemoprophylaxis (odds ratio, 1.3/day; p = 0.013) independently predicted VTE after controlling for ISS, hemodynamics, injured vessel, surgical subspecialty, intraoperative anticoagulation, and postoperative prophylaxis. Overall, 3.4% of venous injury patients developed PE, but PE rates were not related to their operative management (p = 0.72). Patients with major venous injuries are at high risk for VTE, regardless of intraoperative management. Our results support the immediate initiation of postoperative chemoprophylaxis in patients with major venous injuries. Therapeutic/care management, level IV.

Missed injuries and unplanned readmissions in pediatric trauma patients

BackgroundWe sought to determine the incidence and characteristics of missed injuries and unplanned readmissions at a Level-1 pediatric trauma center. MethodsWe conducted a retrospective review of all trauma patients who presented to our ACS-verified Level-1 pediatric trauma center from 2009 to 2014. ResultsOverall, there were 27 readmissions and 27 missed injuries (0.38%). Patients who were unplanned readmissions had a greater Injury Severity Score (ISS) (8.6 vs 5.2, p=0.03), had longer hospitalizations (4.9 vs 2.5days, p=0.02), and were more likely to have required operative intervention (51.9% vs 32.3%, p=0.04). Similarly, patients identified with missed injuries had a higher ISS (15.2 vs 5.2, p<0.0001), greater length of stay (12.7 vs 2.5days, p<0.0001), and were also more likely to be intubated (25.9% vs 3.6%, p<0.0001) or require critical care (48.1% vs 10.3%, p<0.0001). Seven missed injuries were in patients who were deemed nonaccidental trauma (25.9%) and significantly altered their hospital course while 10 patients (37%) required operative intervention. On multivariate analysis, only ISS was found to be an independent risk factor for readmissions and missed injuries. ConclusionsMissed injuries and unplanned readmissions were rare occurrences among our pediatric patient population. These events, however, did result in longer hospitalizations and additional procedures. Patients with multisystem injuries and compromised physical exam are at higher risk.Level of Evidence: IV.

The Negative Impact of Anemia in Outcome from Traumatic Brain Injury

Whether anemia complicating traumatic brain injury (TBI) has an impact on patient outcomes is controversial; therefore, recommendations for blood transfusions for such patients are inconsistent. We hypothesized that patient outcome after TBI would be worse in patients with lower hemoglobin levels. We retrospectively reviewed records of patients with TBI and head Abbreviated Injury Scale >3 with abnormal head computed tomography findings and neurologic injury. The relationships between initial hemoglobin and lowest hemoglobin during hospitalization at threshold values of ≤7, ≤8, ≤9, and ≤10 g/dL were investigated relative to Glasgow Outcome Score at last follow-up not exceeding 1 year. Of 939 patients meeting inclusion criteria, initial and lowest hemoglobin concentrations were significant predictors of poor outcome (P < 0.0001). For each 1 g/dL higher hemoglobin value, the likelihood of a good outcome increased by 33%. More severe levels of initial anemia were associated with lower Glasgow Coma Scale, greater head Abbreviated Injury Scale, and greater Injury Severity Score (P < 0.0001). Female patients had worse outcome than male patients only for initial hemoglobin between 7 and 8 g/dL (P < 0.05). Blood transfusion was associated with poorer outcome at hemoglobin levels ≤9 and ≤10 g/dL (P < 0.05), but not at lower hemoglobin thresholds. Patient outcome after TBI is worse in patients with lower hemoglobin. Initial hemoglobin and lowest hemoglobin after admission are independently associated with poor outcome. Our data support consideration of blood transfusion when hemoglobin is ≤8 g/dl.

Underutilization of occupant restraint systems in motor vehicle injury crashes: A quantitative analysis from Qatar

ABSTRACTIntroduction: Restraint systems (seat belts and airbags) are important tools that improve vehicle occupant safety during motor vehicle crashes (MVCs). We aimed to identify the pattern and impact of the utilization of passenger restraint systems on the outcomes of MVC victims in Qatar.Methods: A retrospective study was conducted for all admitted patients who sustained MVC-related injuries between March 2011 and March 2014 inclusive.Results: Out of 2,730 road traffic injury cases, 1,830 (67%) sustained MVC-related injuries, of whom 88% were young males, 70% were expatriates, and 53% were drivers. The use of seat belts and airbags was documented in 26 and 2.5% of cases, respectively. Unrestrained passengers had greater injury severity scores, longer hospital stays, and higher rates of pneumonia and mortality compared to restrained passengers (P = .001 for all). There were 311 (17%) ejected cases. Seat belt use was significantly lower and the mortality rate was 3-fold higher in the ejected group compared to the nonejected group (P = .001). The overall mortality was 8.3%. On multivariate regression analysis, predictors of not using a seat belt were being a front seat passenger, driver, or Qatari national and young age. Unrestrained males had a 3-fold increase in mortality in comparison to unrestrained females. The risk of severe injury (relative risk [RR] = 1.82, 95% confidence interval [CI], 1.49–2.26, P = .001) and death (RR = 4.13, 95% CI, 2.31–7.38, P = .001) was significantly greater among unrestrained passengers.Conclusion: The nonuse of seat belts is associated with worse outcomes during MVCs in Qatar. Our study highlights the lower rate of seat belt compliance in young car occupants that results in more severe injuries, longer hospital stays, and higher mortality rates. Therefore, we recommend more effective seat belt awareness and education campaigns, the enforcement of current seat belt laws, their extension to all vehicle occupants, and the adoption of proven interventions that will assure sustained behavioral changes toward improvements in seat belt use in Qatar.

A chest trauma scoring system to predict outcomes

Rib fractures (RIBFX) are a common injury and are associated with substantial morbidity and mortality. Using a previously published RIBFX scoring system, we sought to validate the system by applying it to a larger patient population. We hypothesized that the RIBFX scoring system reliably predicts morbidity and mortality in patients with chest wall injury at the time of initial evaluation. A 3-year, registry-based, retrospective study involving 1,361 trauma patients was performed. Patients were divided into two groups with a Chest Trauma Score (CTS)<5 and ≥5 (n=724 and 637, respectively). Each cohort was analyzed for specific outcomes (mortality, pneumonia, acute respiratory failure). CTS was defined by age, severity of pulmonary contusion, number of RIBFX, and the presence of bilateral RIBFX with a maximum score of 12. Receiver operating characteristics were used to determine the use of CTS ≥5 cut point. Patients with a CTS of 5 or more were (P≤.05) older (61 vs 50years), had greater Injury Severity Scores (21.6 vs 16.2), and had a greater prevalence of pneumonia (10.1 vs 3.5%), tracheostomy (7.4 vs 2.9%), and mortality (9.0 vs 2.2%). Patients with CTS ≥ 5 had nearly 4-fold increased odds of mortality (odds ratio 3.99, 95% confidence interval 1.92-8.31, P=.001) compared with those who had CTS<5. A CTS of at least 5 is associated with worse patient outcomes. Increased vigilance is needed with trauma patients who present with RIBFX and a CTS ≥ 5 at initial presentation. This simple RIBFX scoring system may improve early identification of vulnerable patients and expedite therapeutic interventions.

Regional collaboration across hospital systems to develop and implement trauma protocols saves lives within 2 years

The Northern Ohio Trauma System (NOTS) was created with the expressed goal of improving trauma care through collaboration, system-wide protocol implementation, and evidence-based process improvement. The primary goal of this study was to evaluate the mortality of trauma patients seen across the region after 2 years of beginning NOTS. Regional data was compared with the 2 years pre-NOTS (2008 and 2009) to the 2 years post-NOTS (2010 and 2011). The regional system consisted of two large hospital systems, initially including one level 1 center, four level 2 centers, seven nontrauma hospitals, and local emergency medical services groups. Two level 2 trauma centers closed during the study period. Mortality was the primary outcome for this study. Multivariate logistic regression also was performed to evaluate for independent predictors of mortality. An odds ratio (OR) and 95% confidence interval (CI) of survival were determined after we adjusted for other factors associated with mortality. During the 4-year period 29,890 trauma patients were seen throughout NOTS. The mean age was 44 with a mean Injury Severity Score (ISS) of 8; 65% of the patients were male. Racial breakdown demonstrated that 64.0% were white, 31.9% were black, and 4.1% were other races. The hospital stay (mean ± SD) was 3.0 ± 5.2 days, and overall mortality was 3.4%. A separate analysis in which we used multivariate logistic regression demonstrated that patients treated in the post-NOTS period was an independent predictor for survival when we controlled for age, sex, ethnicity, mechanism, and ISS. The OR of survival of post NOTS was 0.81 (95% CI 0.70-0.94) when we evaluated all patients. The OR for admitted patients was 0.79 (95% CI 0.67-0.94) and 0.76 (0.62-0.95) in patients with ISS > 24. There was an increase in the percentage of patients seen at the level 1 center in the post-NOTS period, which was especially demonstrated in patients with greater ISS. NOTS appears to have contributed to the saving of lives within 2 years of its formation. Regionalized protocols, collaboration, and consolidation resulted in an improvement in mortality.

Maternal death in the emergency department from trauma

Trauma during pregnancy is among leading causes of non-pregnancy-related maternal death (MD). This study describes risk factors for MD from trauma during pregnancy in a large urban population. We queried an urban Level One Trauma Center registry for the medical records of pregnant women suffering trauma from 1990 to 2007. Associations were examined between maternal demographics, injury mode details, injury characteristics, and risk of maternal death upon arrival to the emergency room. Overall, 351 patients were identified. Most traumas was caused by motor vehicle collision (71.8 %), accounting for 78.9 % of MD, followed by gun shot wound (10.3 %), stabbing (8.5 %), falls (4.3 %), and assaults (4 %). Abdominal and head injuries were more frequent in cases of MD compared with patients admitted to the hospital (33.3 vs. 25.1 % abdominal, 55.6 vs. 29.4 % head; p < 0.001). A greater proportion of MDs were characterized by lack of restraint use (66.7 %) compared to women admitted to the hospital (47.7 %) and women discharged after observation (43.1 %); p = 0.014. ER deaths had more negative base excess scores than women who were admitted or discharged (-14 vs. -3 vs. -2; p < 0.001), lower blood pH values (6.96 vs. 7.40 vs. 7.44; p < 0.001), greater Injury Severity Scores (ISS) (44.4 vs. 11.49 vs. 2.66; p < 0.001), and lower Revised Trauma Scores (RTS) (0.5 vs. 7.49 vs. 7.83; p < 0.001). Lack of restraint use in the pregnant population is associated with increased MD. Although not validated in the pregnant population, the ISS and RTS were associated with maternal mortality outcomes.

Association of Cryoprecipitate and Tranexamic Acid With Improved Survival Following Wartime Injury

To quantify the impact of fibrinogen-containing cryoprecipitate in addition to the antifibrinolytic tranexamic acid on survival in combat injured. Retrospective observational study comparing the mortality of 4 groups: tranexamic acid only, cryoprecipitate only, tranexamic acid and cryoprecipitate, and neither tranexamic acid nor cryoprecipitate. To balance comparisons, propensity scores were developed and added as covariates to logistic regression models predicting mortality. A Role 3 Combat Surgical Hospital in southern Afghanistan. A total of 1332 patients were identified from prospectively collected U.K. and U.S. trauma registries who required 1 U or more of packed red blood cells and composed the following groups: tranexamic acid (n = 148), cryoprecipitate (n = 168), tranexamic acid/cryoprecipitate (n = 258), and no tranexamic acid/cryoprecipitate (n = 758). In-hospital mortality. Injury severity scores were highest in the cryoprecipitate (mean [SD], 28.3 [15.7]) and tranexamic acid/cryoprecipitate (mean [SD], 26 [14.9]) groups compared with the tranexamic acid (mean [SD], 23.0 [19.2]) and no tranexamic acid/cryoprecipitate (mean [SD], 21.2 [18.5]) (P < .001) groups. Despite greater Injury Severity Scores and packed red blood cell requirements, mortality was lowest in the tranexamic acid/cryoprecipitate (11.6%) and tranexamic acid (18.2%) groups compared with the cryoprecipitate (21.4%) and no tranexamic acid/cryoprecipitate (23.6%) groups. Tranexamic acid and cryoprecipitate were independently associated with a similarly reduced mortality (odds ratio, 0.61; 95% CI, 0.42-0.89; P = .01 and odds ratio, 0.61; 95% CI, 0.40-0.94; P = .02, respectively). The combined tranexamic acid and cryoprecipitate effect vs. neither in a synergy model had an odds ratio of 0.34 (95% CI, 0.20-0.58; P < .001), reflecting nonsignificant interaction (P = .21). Cryoprecipitate may independently add to the survival benefit of tranexamic acid in the seriously injured requiring transfusion. Additional study is necessary to define the role of fibrinogen in resuscitation from hemorrhagic shock.

Falls From Height: Injury and Mortality

ObjectivesTo determine how Injury Severity Score (ISS) and mortality relate to height fallen, and to determine other predictors of mortality including intent and body region injured.MethodsA pre-hospital retrospective, observational database...

Monitoring and prediction of intracranial hypertension in pediatric traumatic brain injury

Control of intracranial hypertension (ICH) in patients with traumatic brain injury (TBI) is standard care. However, predicting risk for ICH is essential to balance risks and benefits of intracranial pressure (ICP) monitoring. Current recommendations for ICP monitoring in pediatric trauma patients are extrapolated from adult studies. This retrospective study evaluated 299 children admitted to Primary Children's Medical Center with moderate to severe TBI. ICP monitors were used in 120. Demographic, injury, and admission computed tomography (CT) scan characteristics were compared with determine factors associated with monitoring among those with less severe head CT findings. Among all monitored patients, clinical and radiographic features were compared for early ICH defined as any sustained ICP ≥20 mm Hg in the first 24 hours. Factors independently associated with monitoring children with Marshall I or II scores included presence of intraventricular hemorrhage (odds ratio [OR], 21.4; 95% confidence interval [CI], 4.0-114.7) and greater injury severity scores (ISS) (OR, 9.5 [95% CI, 2.9-31.1] for ISS 21 to 29 and OR, 14.3 [95% CI, 4.3-50.5] for ISS >29 compared with ISS <21). Among those with a normal head CT, 9 of 68 had an ICP monitor placed because of the inability to localize pain. Of these, 78% (7 of 9) had early ICH. Among monitored patients radiologic and clinical features of injury severity were not useful to distinguish risk for early ICH. Among children with severe TBI, a normal head CT does not exclude ICH. Need for ICP monitoring should be determined by depth of coma in addition to radiographic imaging.

Characteristics and Outcomes of Injured Older Adults After Hospital Admission

To describe the seriously injured adult population aged 65 and older; compare the differences in injury characteristics and outcomes in three subgroups aged 65 to 74, 75 to 84, and 85 and older; and identify predictors of death, complications, and hospital discharge destination. Retrospective secondary analysis of data from the Queensland Trauma Registry (QTR) using all patients aged 65 and older admitted from 2003 through 2006. Data from 15 regional and tertiary hospitals throughout Queensland, Australia. Six thousand sixty-nine patients: 2,291 (37.7%) aged 65 to 74, 2,265 (37.3%) aged 75 to 84, and 1,513 (24.9%) aged 85 and older. Outcome variables included mortality, complications, and discharge destination (usual residence, rehabilitation, nursing home, convalescence). Predictive factors incorporated demographic details, injury characteristics, and acute care factors. Hospital survival was 95.0%, with a median length of hospital stay of 8 days (interquartile range 5-15), and 33.8% of cases with a major injury developed a complication. Predictors of death included older age, male sex, admission to the intensive care unit (ICU), greater Injury Severity Score (ISS), injury caused by a fall, and two or more injuries; those who had surgery were less likely to die. Predictors of complications included ICU admission, older age, longer hospital stay, and two or more injuries. Predictors of discharge to a nursing home included older age, greater ISS, longer hospital stay, and injury caused by a fall, among others. Older adults with severe injuries are at risk of poor outcomes. These findings suggest opportunities for improving geriatric trauma care that could lead to better outcomes.

Traumatic diaphragmatic injury: Experience from a level I trauma center

Traumatic diaphragmatic injuries (TDI) are uncommon but associated with substantial morbidity and mortality. We sought to analyze patients with TDI at a large trauma center and associated county coroner to identify characteristics predictive of increased mortality. We queried a level I university trauma center and associated county coroner databases containing >20,000 patients to identify patients with ICD-9 diagnoses pertaining to TDI from January 1992 through May 2005. Once identified, hospital records, operative details, and autopsy reports were reviewed to determine injury characteristics, treatment provided, and outcome. Statistical analyses were performed using the Student t-test, chi-square analysis, analysis of variance, and multiple logistic regression. TDI were identified in 254 individuals. Two hundred (79%) survived to undergo operation. Of the 81 (32%) deaths, 33 (41%) occurred before arrival at the trauma center. Survivors were younger, had lesser injury severity scores (ISS), were more likely to be female, and had more bilateral injuries (P < or = .002 all) than nonsurvivors. By multiple logistic regression analyses, increased age (odds ratio [OR], 1.044; 95% confidence interval [CI], 1.015-1.074; P = .0029) and greater ISS (OR, 1.145; 95% CI, 1.103-1.188; P < .0001) were predictors of the probability of death in all patients. Although TDI may indicate substantive trauma burden in any patient, those with greater ISS and advanced age are at the greatest risk of death.

Trauma Team Activation and the Impact on Mortality

Trauma centers use injury mechanism, physiology, and anatomic criteria to determine the extent of trauma team activation (TTA). We examined whether physiologic variables in our three-tier TTA system stratified patients appropriately by injury severity and mortality. The trauma registry at our Level I trauma center was retrospectively reviewed for full (level 1 or L1), partial (level 2 or L2), and limited (level 3) adult TTA. Data were collected on age, injury severity score (ISS), hospital length of stay, systolic blood pressure (SBP), heart rate, respiratory rate (RR), Glasgow coma score (GCS), and intubation status. Penetrating injuries, traumatic arrests, and interfacility transfers were excluded. Data are median (25%75%). Statistical analysis included hazard ratios (HzR), Kruskal-Wallis, chi, and survival analyses. The p value overall was <0.05, and pair wise was <0.05 versus L1. There were 494 adult TTAs for blunt injury from the scene out of 1,969 admissions. Variables associated with mortality (HzR; 95% confidence interval) by univariate analysis include SBP <90 (9.4; 4.2, 21.2), RR >29 or <10 (17.8; 4.8, 66.0), intubation status (4.5; 2.3, 8.9), and GCS <8 (9.7; 4.8, 19.9). When combined in a multivariate model to evaluate multiple predictors simultaneously, SBP <90 and GCS <8 appear to be the strongest predictors of mortality (RR and intubation were not significant in the presence of SBP and GCS). The three-tier system identified patients with increased ISS and early (< or =4 weeks) mortality risk. There was a statistically significant difference in survival between L1 and L2 at 38 days, but not for >38 days (p = 0.739). TTA criteria selected patients with greater ISS and early mortality, but impact on long-term survival may not be appreciated. Full TTA criteria for blunt injury may be limited to GCS <8, SBP <90, RR >29 or <10, and intubation status.