Head Abbreviated Injury Scale Score Research Articles

Evaluating mortality and 6-month functional outcomes of patients with dural venous sinus thrombosis in traumatic brain injury.

Patients with dural venous sinus thrombosis (DVST) in select populations following traumatic brain injury (TBI), including those with blunt mechanism or depressed skull fractures, have been shown to have an increased risk of mortality. The purpose of this study was to assess these findings in a mixed population of head trauma patients. The authors performed a case-control study using propensity score matching by reviewing 17 years (2004-2021) of data from their institutional trauma registry. Patients with imaging-confirmed DVST were matched to a control group of TBI patients without identified DVST based on age, sex, postresuscitation Glasgow Coma Scale (GCS) score, and Injury Severity Score. All age groups and injury mechanisms were included with a head Abbreviated Injury Scale score ≥ 3. Data on demographics, injury and radiographic characteristics, and patient outcomes were collected. Multivariable logistic regression was performed to identify predictors of inpatient mortality. An additional subgroup analysis of patients with concurrent DVST and blunt cerebrovascular injury (BCVI) was planned a priori. The authors identified 9875 patients who presented to their institution over the study period with TBIs, with a 1.64% incidence of DVST. Concurrent BCVI was diagnosed in 23.5% of patients with a DVST. Following matching, the presence of DVST itself was not significantly associated with inpatient mortality (OR 0.68, 95% CI 0.24-1.88). On regression analysis, penetrating injuries (8.19, 95% CI 1.21-80.0) and lower postresuscitation GCS scores (0.69, 95% CI 0.53-0.84) were independently associated with inpatient mortality for patients with traumatic DVST. Significantly worse functional outcomes were observed in those with DVST at 3 months, with no significant difference at 6 months. The authors observed a prevalence of traumatic DVST of 1.64% in a mixed population of head-injured patients, with 23.5% of patients with DVST having concurrent BCVI. Traumatic DVST alone was not associated with a significantly increased risk of inpatient mortality.

Does Lower Extremity Fracture Fixation Technique Influence Neurologic Outcomes in Patients with Traumatic Brain Injury? The EAST Brain vs. Bone Multicenter Trial.

To determine whether lower extremity (LE) fracture fixation technique & timing (≤ 24 vs > 24 hours) impact neurologic outcomes in TBI patients. A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age ≥ 18, head abbreviated injury scale (AIS) score > 2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN) or open reduction and internal fixation (ORIF). The analysis was conducted using ANOVA, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Score (RLAS-R). Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe LE injuries (AIS 4-5) compared to the IMN group (16% vs 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix 15 [8-24] vs. ORIF 26 [12-85] vs. IMN 31[12-70], p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of LE fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (OR 1.02, 95% CI 1.002-1.03 and OR 2.37, 95% CI 1.75-3.22) and a higher GCS motor score on admission (OR 0.84, 95% CI 0.73,0.97) was associated with higher RLAS-R score at discharge. Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of LE fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients. Level III (Prognostic/Epidemiological).

Early Venous Thromboembolism Prophylaxis in Patients with Trauma Intracranial Hemorrhage: Analysis of the Prospective Multicenter CLOTT Study.

The optimal time to initiate venous thromboembolism prophylaxis (VTEp) for patients with intracranial hemorrhage (ICH) is controversial and must balance the risks of VTE with potential progression of ICH. We sought to evaluate the efficacy and safety of early VTEp initiation after traumatic ICH. This is a secondary analysis of the prospective multicenter Consortium of Leaders in the Study of Thromboembolism (CLOTT) study. Patients with head AIS > 2 and with immediate VTEp held due to ICH were included. Patients were divided into VTEp ≤ or > 48 hours and compared. Outcome variables included overall VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), progression of ICH (pICH), or other bleeding events. Univariate and multivariate logistic regressions were performed. There were 881 patients in total, 378 (43%) started VTEp ≤48 hours (early). Patients starting VTEp >48 hours (late) had higher VTE (12.4% vs 7.2%, p = .01) and DVT (11.0% vs 6.1%, p = .01) rates than the early group. The incidence of PE (2.1% vs 2.2%, p = .94), pICH (1.9% vs 1.8%, p = .95) or any other bleeding event (1.9% vs 3.0%, p = .28) were equivalent between early and late VTEp groups. On multivariate logistic regression analysis, VTEp >48 hours (OR 1.86), ventilator days >3 (OR 2.00), and risk assessment profile score ≥ 5 (OR 6.70) were independent risk factors for VTE (all p < 0.05), while VTEp with enoxaparin was associated with decreased VTE (OR 0.54, p < 0.05). Importantly, VTEp ≤48 hours was not associated with pICH (OR 0.75) or risk of other bleeding events (OR 1.28) (both p = NS). Early initiation of VTEp (≤48 h) for patients with ICH was associated with decreased VTE/DVT rates without increased risk of pICH or other significant bleeding events. Enoxaparin is superior to unfractionated heparin as VTE prophylaxis in patients with severe TBI. Level IV; Therapeutic/Care management.

Predictive Factors of the Fatality of Motor Vehicle Passengers Involved in Far-Side Lateral Collisions: A National Crash Database Study.

Although the risks faced by passengers in near-side lateral collisions are understood, and despite the presence of side airbags for injury prevention, passengers involved in far-side lateral collisions also suffer serious and fatal injuries. The objective of this study was to determine the independent predictive factors of fatality of motor vehicle passengers involved in far-side lateral collisions. Using 2010 records from the National Automotive Sampling System/Crashworthiness Data System (NASS/CDS), we selected 86 fatal and 325 non-fatal passengers with an Abbreviated Injury Scale (AIS) score of 2 or more. The background and injury severity of the passengers and collision characteristics were compared between the two groups. In a multivariable logistic regression analysis, variables independently associated with fatalities were female sex (Ref, male) (odds ratio [OR], 0.396), age (OR, 1.029), body mass index (OR, 1.057), total delta-V (OR, 1.031), head AIS score (OR, 1.679), chest AIS score (OR, 1.330), and abdomen AIS score (OR, 1.294). This is the first report to determine factors affecting fatality in passengers involved in far-side lateral collisions. Improving the safety of the vehicle interior, such as by including additional seatbelt systems or a side airbag that deploys between seats, might help to avoid fatalities, and reduce injury severity.

Improved survival for severely injured patients receiving massive transfusion at US teaching hospitals: A nationwide analysis.

Previous studies have shown improved survival for patients treated at American College of Surgeons (ACS)-verified level I trauma centers compared with level II, level III, and undesignated centers. This mortality difference is more pronounced in severely injured patients. However, a survival benefit for severely injured trauma patients has not been established at teaching institutions compared with nonteaching centers. Because massive transfusion (MT) is associated with high mortality, we hypothesize that patients receiving MT have lower mortality at teaching hospitals than at nonteaching hospitals. All adult ACS Trauma Quality Improvement Program-eligible patients who underwent MT, defined as >10 U of packed red blood cells in the first 4 hours after arrival, in the 2019 ACS Trauma Quality Programs participant use file were eligible. Patients with severe head injury (head Abbreviated Injury Scale score, ≥3), prehospital cardiac arrest, and interhospital transfers were excluded. Logistic regression models were used to assess the effects of trauma center hospital teaching status on the adjusted odds of 3-hour, 6-hour, and 24-hour mortality. A total of 1,849 patients received MT (81% male; median Injury Severity Score, 26 [18-35]), 72% were admitted to level I trauma centers, and 28% were admitted to level II centers. Overall hospital mortality was 41%; 17% of patients died in 3 hours, 25% in 6 hours, and 33% in 24 hours. Teaching hospitals were associated with decreased 3-hour (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.27-0.75), 6-hour (OR, 0.37; 95% CI, 0.24-0.56), 24-hour (OR, 0.50; 95% CI, 0.34-0.75), and overall mortality (OR, 0.66; 95% CI, 0.44-0.98), compared with nonteaching hospitals, controlling for sex, age, heart rate, injury severity, injury mechanism, and trauma center verification level. Severely injured patients requiring MT experience significantly lower mortality at teaching hospitals compared with nonteaching hospitals, independently of trauma center verification level. Therapeutic/Care Management; Level III.

Timing is everything: Early versus late palliative care consults in trauma.

The incorporation of dedicated palliative care (PC) services in the care of the critically injured trauma patient is not yet universal. Preexisting data demonstrate both economic and clinical value of PC consults, yet patient selection and optimal timing of these consults are poorly defined, possibly leading to underutilization of PC services. Prior studies in geriatric patients have shown benefits of PC when PC clinicians are engaged earlier during hospitalization. We aim to compare hospitalization metrics of early versus late PC consultation in trauma patients. All patients 18 years or older admitted to the trauma service between January 1, 2019, and March 31, 2021, who received a PC consult were included. Patients were assigned to EARLY (PC consult ≤3 days after admission) and LATE (PC consult >3 days after admission) cohorts. Demographics, injury and underlying disease characteristics, outcomes, and financial data were compared. Length of stay (LOS) in the EARLY group is compared with LOS-3 in the LATE group. A total of 154 patient records met the inclusion criteria (60 EARLY and 94 LATE). Injury Severity Score, head Abbreviated Injury Scale score, and medical comorbidities (congestive heart failure, dementia, previous stroke, chronic obstructive pulmonary disease, malignancy) were similar between the groups. The LATE group was younger (69.9 vs. 75.3, p = 0.04). Patients in the LATE group had significantly longer LOS (17.5 vs. 7.0 days, p < 0.01) and higher median hospital costs ($53,165 vs. $17,654, p < 0.01). Patients in the EARLY group had reduced ventilator days (2.4 vs. 7.0, p < 0.01) and reduced rates of tracheostomies and surgical feeding tubes (1.7% vs. 11.7%, p = 0.03). Trauma patients with early PC consultation had shorter LOS, reduced ventilator days, reduced rates of invasive procedures, and lower costs even after correcting for delay to consult in the late group. These findings suggest the need for mechanisms leading to earlier PC consult in critically injured patients. Therapeutic/Care Management; Level IV.

Abstract 191: Alcohol Consumption Before Injury Did Not Improve Neurological Outcomes In Patients With Severe Traumatic Brain Injury: A Nationwide, Retrospective Cohort Study

Introduction: Traumatic brain injury (TBI) is a major global public health concern. Notably, alcohol may confer neuroprotective effects by inhibiting of N-methyl-D-aspartate receptors; however, the impact of alcohol exposure before injury on neurological outcomes in patients with TBI has not been well studied. Hypothesis: We evaluated whether alcohol consumption before injury was associated with favorable neurological outcomes in patients with severe TBI using a large, national trauma registry. Methods: This study was a retrospective analysis of data collected into the Japan Trauma Data Bank from 2017 to 2021. Patients over 20 years old with severe TBI, defined as head Abbreviated Injury Scale score of 4 or 5, were included. We excluded patients with unknown alcohol status or outcomes. Subjects were divided into two groups (alcohol group vs. non-alcohol group) based on whether or not they were exposed to alcohol before injury. The primary outcome was favorable neurological outcomes (Glasgow Outcome Scale score of 4 or 5) at hospital discharge. A multivariate logistic regression analysis was conducted to adjust potential cofounders including age, sex, injury severity, emergency treatment, and emergency transfusion. Results: A total of 1,482 patients were included, with a median age of 73 years old; 381 of the patients were women. Median Injury Severity Score was 24. Of the 1,482 patients, 284 were in the alcohol group and 1,208 were in the non-alcohol group. Favorable neurological outcomes were observed in 159 (56%) and 563 (47%) of patients, with median hospital length of stay of 21 days and 18 days in the alcohol group and non-alcohol group, respectively. Multivariate logistic regression analysis showed alcohol consumption before injury was not associated with favorable neurological outcomes (adjusted OR: 0.96, 95% CI: 0.72 - 1.29). Conclusions: Alcohol consumption before injury had no positive impact on neurological outcomes in patients with severe TBI.

Prehospital Intubation of Patients with Severe Traumatic Brain Injury: A Dutch Nationwide Trauma Registry Analysis

Objective Patients with severe traumatic brain injury (TBI) are commonly intubated during prehospital treatment despite a lack of evidence that this is beneficial. Accumulating evidence even suggests that prehospital intubation may be hazardous, in particular when performed by inexperienced EMS clinicians. To expand the limited knowledge base, we studied the relationship between prehospital intubation and hospital mortality in patients with severe TBI in a large Dutch trauma database. We specifically hypothesized that the relationship differs depending on whether a physician-based emergency medical service (EMS) was involved in the treatment, as opposed to intubation by paramedics. Methods A retrospective analysis was performed using the Dutch Nationwide Trauma Registry that includes all trauma patients in the Netherlands who are admitted to any hospital with an emergency department. All patients treated for severe TBI (Head Abbreviated Injury Scale score ≥4) between January 2015 and December 2019 were selected. Multivariable logistic regression was used to assess the relationship between prehospital intubation and mortality while adjusting for potential confounders. An interaction term between prehospital intubation and the involvement of physician-based EMS was added to the model. Complete case analysis as well as multiple imputation were performed. Results 8946 patients (62% male, median age 63 years) were analyzed. The hospital mortality was 26.4%. Overall, a relationship between prehospital intubation and higher mortality was observed (complete case: OR 1.86, 95% CI 1.35–2.57, p < 0.001; multiple imputation: OR 1.92, 95% CI 1.56–2.36, p < 0.001). Adding the interaction revealed that the relationship of prehospital intubation may depend on whether physician-based EMS is involved in the treatment (complete case: p = 0.044; multiple imputation: p = 0.062). Physician-based EMS involvement attenuated but did not completely remove the detrimental association between prehospital intubation and mortality. Conclusion The data do not support the common practice of prehospital intubation. The effect of prehospital intubation on mortality might depend on EMS clinician experience, and it seems prudent to involve prehospital personnel well proficient in prehospital intubation whenever intubation is potentially required. The decision to perform prehospital intubation should not merely be based on the largely unsupported dogma that it is generally needed in severe TBI, but should rather individually weigh potential benefits and harms.

Persistent coagulopathy after gunshot traumatic brain injury: the importance of INR and the SPIN score.

Penetrating ballistic brain injury (gunshot traumatic brain injury or GTBI) is associated with a high mortality. Admission Glascow Coma Scale (GCS), injury severity score and neurological findings, cardiopulmonary instability, coagulopathy and radiological finding such as bullet trajectory and mass effect are shown to predict survival after GTBI. We aimed to examine the dynamics of the observed coagulopathy and its association with outcome. In this single-centered retrospective cohort study, we examined 88 patients with GTBI between 2015 and 2021. Variables analyzed include patient age; temperature, hemodynamic and respiratory variables, admission Glasgow Coma Scale (GCS); injury severity score (ISS); head abbreviated injury scale (AIS); Marshall, Rotterdam, SPIN and Baylor scores, and laboratory data including PTT, INR and platelet count. Receiver operating characteristic analysis was conducted to evaluate the performance of the predictive models. The average age of our sample was 28.5years and a majority were male subjects (92%). Fifty-four (62%) of the patients survived to discharge. The GCS score, as well as the motor, verbal, and eye-opening sub-scores were higher in survivors (P < 0.001). As was expected, radiologic findings including the Marshall and Rotterdam Scores were also associated with survival (P < 0.001). Although the ISS and Head AIS scores were higher (P < 0.001), extracranial injuries were not more prevalent in non-survivors (P= 0.567). Non-survivors had lower platelet counts and elevated PTT and INR (P < 0.001) on admission. PTT normalized within 24h but INR continued to increase in non-survivors. SPIN score, which includes INR, was a better predictor for mortality than Rotterdam, Marshall, and Baylor etc. CONCLUSION: Progressively increasing INR after GTBI is associated with poor outcome and may indicate consumption coagulopathy from activation of the extrinsic pathway of coagulation and metabolic derangements that are triggered and sustained by the brain injury. The SPIN score, which incorporates INR as a major survival score component, outperforms other available prediction models for predicting outcome after GTBI.

Predictors for Withdrawal of Life-Sustaining Therapies in Patients With Traumatic Brain Injury: A Retrospective Trauma Quality Improvement Program Database Study.

Many patients with severe traumatic brain injuries (TBIs) undergo withdrawal of life-sustaining therapies (WLSTs) or transition to comfort measures, but noninjury factors that influence this decision have not been well characterized. We hypothesized that WLST would be associated with institutional and geographic noninjury factors. All patients with a head Abbreviated Injury Scale score ≥3 were identified from 2016 Trauma Quality Improvement Program data. We analyzed factors that might be associated with WLST, including procedure type, age, sex, race, insurance, Glasgow Coma Scale score, mechanism of injury, geographic region, and institutional size and teaching status. Adjusted logistic regression was performed to examine factors associated with WLST. Sixty-nine thousand fifty-three patients were identified: 66% male, 77% with isolated TBI, and 7.8% had WLST. The median age was 56 years (34-73). A positive correlation was found between increasing age and WLST. Women were less likely to undergo WLST than men (odds ratio 0.91 [0.84-0.98]) and took more time to for WLST (3 vs 2 days, P < .001). African Americans underwent WLST at a significantly lower rate (odds ratio 0.66 [0.58-0.75]). Variations were also discovered based on US region, hospital characteristics, and neurosurgical procedures. WLST in severe TBI is independently associated with noninjury factors such as sex, age, race, hospital characteristics, and geographic region. The effect of noninjury factors on these decisions is poorly understood; further study of WLST patterns can aid health care providers in decision making for patients with severe TBI.

N -acetylcysteine is associated with reduction of postconcussive symptoms in elderly patients: A pilot study.

N -acetylcysteine (NAC) may be neuroprotective by minimizing postconcussion symptoms after mild traumatic brain injury (TBI), but limited data exist. This study evaluated the effects of NAC on postconcussion symptoms in elderly patients diagnosed with mild TBI. This prospective, quasirandomized, controlled trial enrolled patients 60 years or older who suffered mild TBI. Patients were excluded if cognitive function could not be assessed within 3-hours postinjury. Patients were allocated to receive NAC plus standard care, or standard care alone, based on the trauma center where they presented. The primary study outcome was the severity of concussive symptoms measured using the Rivermeade Postconcussion Symptoms Questionnaire (RPQ). Symptoms were evaluated on days 0, 7, and 30. The RPQ scores were compared both within and between treatment groups. There were 65 patients analyzed (NAC, n = 34; control, n = 31) with an average age of 76 ± 10 years. Baseline demographics and clinical variables were similar. No group differences in head Abbreviated Injury Scale score or Glasgow Coma Scale score were observed. Baseline RPQ scores (6 [0-20] vs. 11 [4-20], p = 0.300) were indistinguishable. The RPQ scores on day 7 (2 [0-8] vs. 10 [3-18], p = 0.004) and 30 (0 [0-4] vs. 4 [0-13], p = 0.021) were significantly lower in the NAC group. Within-group differences were significantly lower in the NAC ( p < 0.001) but not control group ( p = 0.319). N -acetylcysteine was associated with significant improvements in concussion symptoms in elderly patients with mild TBI. These results justify further research into using NAC to treat TBI. Therapeutic/Care Management; Level IV.

Early Antibiotic Administration is Independently Associated with Improved Survival in Traumatic Brain Injury

Central and systemic immune dysfunction after traumatic brain injury (TBI) can lead to infectious-related complications, which may result in delayed mortality. The role of early empiric antibiotics after TBI has not been characterized to date, but is recommended in select cases to decrease complications. We aimed to determine the relationship between early antibiotic use and in-hospital mortality in TBI patients. A retrospective review was conducted of TBI patients requiring ICU admission at an urban, academic, Level I trauma center from 01/2014 to 08/2016. Data collection included demographics, injury characteristics, details regarding antibiotic use, and outcomes. Early antibiotic administration was defined as any antibiotic given within 48 hs from admission. Patients given early antibiotics (EARLY) were compared to those who received their first dose later or did not receive any antibiotics (non-EARLY). Of the 488 TBI patients meeting inclusion criteria, 189 (38.7%) received early antibiotics. EARLY patients were younger (EARLY 54.2 versus non-EARLY 61.5 ys, P <0.01) and more likely to be male (71.4% versus 60.9%, P=0.02). Injury severity scores (23.6 versus 17.2, P <0.01) and regional head abbreviated injury scale scores (3.9 versus 3.7, P <0.01) were significantly higher in patients who received early antibiotics. Unadjusted in-hospital mortality rates were similar, however EARLY was associated with a lower mortality rate (AOR 0.17, 95% CI: 0.07 - 0.43, adjusted P <0.01) after adjusting for confounders. Despite presenting with a higher injury burden, TBI patients who received early antibiotics had a lower associated mortality rate compared to their counterparts. Future investigations are necessary to understand the underlying mechanisms that result in this potential survival benefit.

Eastern Association for the Surgery of Trauma Multicenter Trial: Comparison of pre-injury antithrombotic use and reversal strategies among severe traumatic brain injury patients.

Trauma teams are often faced with patients on antithrombotic (AT) drugs, which is challenging when bleeding occurs. We sought to compare the effects of different AT medications on head injury severity and hypothesized that AT reversal would not improve mortality in severe traumatic brain injury (TBI) patients. An Eastern Association for the Surgery of Trauma-sponsored prospective, multicentered, observational study of 15 trauma centers was performed. Patient demographics, injury burden, comorbidities, AT agents, and reversal attempts were collected. Outcomes of interest were head injury severity and in-hospital mortality. Analysis was performed on 2,793 patients. The majority of patients were on aspirin (acetylsalicylic acid [ASA], 46.1%). Patients on a platelet chemoreceptor blocker (P2Y12) had the highest mean Injury Severity Score (9.1 ± 8.1). Patients taking P2Y12 inhibitors ± ASA, and ASA-warfarin had the highest head Abbreviated Injury Scale (AIS) mean (1.2 ± 1.6). On risk-adjusted analysis, warfarin-ASA was associated with a higher head AIS (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.34-4.42) after controlling for Injury Severity Score, Charlson Comorbidity Index, initial Glasgow Coma Scale score, and initial systolic blood pressure. Among patients with severe TBI (head AIS score, ≥3) on antiplatelet therapy, reversal with desmopressin (DDAVP) and/or platelet transfusion did not improve survival (82.9% reversal vs. 90.4% none, p = 0.30). In severe TBI patients taking Xa inhibitors who received prothrombin complex concentrate, survival was not improved (84.6% reversal vs. 84.6% none, p = 0.68). With risk adjustment as described previously, mortality was not improved with reversal attempts (antiplatelet agents: OR 0.83; 85% CI, 0.12-5.9 [p = 0.85]; Xa inhibitors: OR, 0.76; 95% CI, 0.12-4.64; p = 0.77). Reversal attempts appear to confer no mortality benefit in severe TBI patients on antiplatelet agents or Xa inhibitors. Combination therapy was associated with severity of head injury among patients taking preinjury AT therapy, with ASA-warfarin possessing the greatest risk. Prognostic, level II.

The Association Between D-dimer Levels and Long-Term Neurological Outcomes of Patients with Traumatic Brain Injury: An Analysis of a Nationwide Observational Neurotrauma Database in Japan.

We evaluated the association between D-dimer (DD) levels and long-term neurological prognoses among patients with isolated traumatic brain injury. Using data from multiple centers in the Japanese Neurotrauma Data Bank, we conducted an observational retrospective cohort study. Patients with isolated traumatic brain injury (head Abbreviated Injury Scale score > 2; any other Abbreviated Injury Scale score < 3) who were registered in the Japanese Neurotrauma Data Bank from 2015 to 2017 were recruited. We excluded patients younger than age 16years and those who developed cardiac arrest at hospital admission. We also excluded patients with unknown Glasgow Outcome Scale (GOS) scores at 6months after injury and those with unknown DD levels. The primary outcome was the association of DD levels with GOS scores at 6months. We defined GOS scores 1 to 3 as poor and GOS scores 4 and 5 as good. The secondary outcome was the association of DD levels with mortality at 6months after injury. We conducted multivariate logistic regression analyses to calculate the adjusted odds ratios of DD levels at hospital admission and GOS scores at 6months as tertiles with 95% confidence intervals (CIs). A total of 293 patients were enrolled (median age 67years; interquartile range 51-79years). The median DD level was 27.1mg/L (interquartile range 9.7-70.8mg/L), and 58.0% (n = 170) had poor GOS scores at 6months. The multivariable logistic regression analysis indicated that the adjusted odds ratios were 2.52 (95% CI 1.10-5.77) for middle DD levels with poor GOS scores at 6months and 5.81 (95% CI 2.37-14.2) for high DD levels with poor GOS scores at 6months. We revealed an association between DD levels and poor long-term neurological outcomes among patients with isolated traumatic brain injury.

Inner Ear Symptoms Are Prevalent in Patients with High Head Abbreviated Injury Scale Scores after Blunt Head Trauma

Introduction: The purpose of this article was to determine the prevalence of inner ear symptoms in patients with blunt head trauma and to explore whether the severity of head trauma was associated with the incidence of such symptoms. Methods: We performed a retrospective review of 56 patients admitted with blunt head trauma who underwent audiovestibular evaluation within 1 month after injury. Two scales were used to measure the severity of trauma; these were the Glasgow Coma Scale (GCS) and the Head Abbreviated Injury Scale (H-AIS). Patients with sensorineural-type hearing loss, or dizziness with nystagmus, were considered to have inner ear symptoms. Results: About half of all patients (45%) with blunt head trauma showed trauma-related inner ear symptoms. Patients with inner ear symptoms were significantly more likely to have H-AIS scores ≥4 than those without inner ear symptoms (p = 0.004), even without concomitant temporal bone fracture (p > 0.05). Also, patients with inner ear symptoms required a statistically significantly longer time (measured from admission) before undergoing their ontological evaluations than did those without such symptoms (p = 0.002), possibly due to prolonged bed rest and use of sedatives. Conclusion: Thus, detailed history-taking and early evaluation using trauma scales are essential for all patients suffering from severe head trauma. It may be necessary to initiate early treatment of traumatic inner ear diseases.

Acute intensive care unit resuscitation of severely injured trauma patients: Do we need a new strategy?

Unlike recent advances in blood product resuscitation, intravenous crystalloid (IVF) use after intensive care unit (ICU) admission in hemorrhagic shock has received less attention and current recommendations are based on limited evidence. To address this knowledge gap, we aimed to determine associations between IVF administration during acute ICU resuscitation and outcomes. We hypothesized that larger IVF volumes are associated with worse outcomes. We linked our trauma registry with electronic health record data (2012-2015) to identify adults with an initial lactate level of ≥4 mmol/L and documented lactate normalization (≤2 mmol/L), excluding those with isolated head Abbreviated Injury Scale score ≥3. We focused on the period from ICU admission to lactate normalization, analyzing duration, volume of IVF, and proportion of volume as 1-L boluses. We used linear regression to determine associations with ICU length of stay and duration of mechanical ventilation in survivors, and logistic regression to identify associations with acute kidney injury and home discharge while adjusting for important covariates. We included 337 subjects. Median time to lactate normalization was 15 hours (interquartile range, 7-25 hours), and median IVF volume was 3.7 L (interquartile range, 1.5-6.4 L). The fourfold difference between the upper and lower quartiles of both duration and volume remained after stratifying by injury severity. Hourly volumes tapered over time but persistently aggregated at 0.5 and 1 L, with 167 subjects receiving at least one 0.5-L bolus for 6 hours after ICU admission. Administration of larger volumes was associated with longer ICU length of stay and duration of mechanical ventilation, as well as acute kidney injury. There is substantial variation in volume administered during acute ICU resuscitation, both absolutely and temporally, despite accounting for injury severity. Administration of larger volumes during acute ICU resuscitation is associated with worse outcomes. There is an opportunity to improve outcomes by further investigating and standardizing this important phase of care. Therapeutic/care management, level IV.

Surgical stabilization of rib fractures in octogenarians and beyond-what are the outcomes?

Prospective studies of surgical stabilization of rib fractures (SSRF) have excluded elderly patients, and no study has exclusively addressed the ≥80-year-old subgroup. We hypothesized that SSRF is associated with decreased mortality in trauma patients 80 years or older. Multicenter retrospective cohort study involving eight centers. Patients who underwent SSRF from 2015 to 2020 were matched to controls by study center, age, injury severity score, and presence of intracranial hemorrhage. Patients with chest Abbreviated Injury Scale score less than 3, head Abbreviated Injury Scale score greater than 2, death within 24 hours, and desire for no escalation of care were excluded. A subgroup analysis compared early (0-2 days postinjury) to late (3-7 days postinjury) SSRF. Poisson regression accounting for clustered data by center calculated the relative risk (RR) of the primary outcome of mortality for SSRF versus nonoperative management. Of 360 patients, 133 (36.9%) underwent SSRF. Compared with nonoperative patients, SSRF patients were more severely injured and more likely to receive locoregional analgesia. There were 31 hospital deaths among the entire sample (8.6%). Multivariable regression demonstrated a decreased risk of mortality for the SSRF group, as compared with the nonoperative group (RR, 0.41; 95% confidence interval, 0.24-0.69; p < 0.01). However, SSRF patients were more likely to develop pneumonia, and had an increased duration of both mechanical ventilation and intensive care unit stay. There were no differences in discharge destination, although the SSRF group was less likely to be discharged on narcotics (RR, 0.66; 95% confidence interval, 0.48-0.90; p = 0.01). There was no difference in adjusted mortality between the early and late SSRF subgroups. Patients selected for SSRF were substantially more injured versus those managed nonoperatively. Despite this, SSRF was independently associated with decreased mortality. With careful patient selection, SSRF may be considered a viable treatment option in octogenarian/nonagenarians. Therapeutic, Level IV.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study.

Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. Therapeutic/care management, Level IV.

Critical traumatic brain injury is associated with worse coagulopathy.

As thromboelastography (TEG) becomes the standard of care in patients with hemorrhagic shock (HS), an association between concomitant traumatic brain injury (TBI) and coagulopathy by TEG parameters is not well understood and is thus investigated. Retrospective analysis of trauma registry data at a single level 1 trauma center of 772 patients admitted with head Abbreviated Injury Scale (AIS) score of 3 and TEG studies between 2014 and 2017. Patients were stratified to moderate-severe TBI by head AIS scores of 3 and 4 (435 patients) and critical TBI by head AIS score of 5 (328 patients). Hemorrhagic shock was defined by base deficit of 4 or shock index of 0.9. Statistical analysis with unpaired t tests compared patients with critical TBI with patients with moderate-severe TBI, and patients were grouped by presence or absence of HS. A comparison of TBI data with conventional coagulation studies was also evaluated. In the setting of HS, critical TBI versus moderate-severe TBI was associated with longer R time (p = 0.004), longer K time (p < 0.05), less acute angle (p = 0.001), and lower clot strength and stability (maximum amplitude [MA]) (p = 0.01). Worse TBI did not correlate with increased fibrinolysis by clot lysis measured by the percentage decrease in amplitude at 30 minutes after MA (p = 0.3). Prothrombin time and international normalized ratio failed to demonstrate more severe coagulopathy, while partial thromboplastin time was found to correlate with severity of TBI (p = 0.01). In patients with critical TBI, the presence of HS correlated with a statistically significant worsening of all parameters (p < 0.05) except for clot lysis measured by the percentage decrease in amplitude at 30 minutes after MA (LY-30). Thromboelastography demonstrates that, with and without hemorrhagic shock, critical TBI correlates with a significant worsening of traumatic coagulopathy in comparison with moderate/severe TBI. In HS, critical TBI correlates with impaired clot initiation, impaired clot kinetics, and impaired platelet-associated clot strength and stability versus parameters found in moderate-severe TBI. Hemorrhagic shock correlates with worse traumatic coagulopathy in all evaluated patient groups with TBI. Conventional coagulation studies underestimate TBI-associated coagulopathy. Traumatic brain injury-associated coagulopathy is not associated with fibrinolysis. Prognostic/epidemiological, level IV; prognostic/epidemiological, level III.

Isolated traumatic brain injury: Routine intubation for Glasgow Coma Scale 7 or 8 may be harmful!

Despite strong recommendations, there is no direct evidence supporting routine intubation of trauma patients with Glasgow Coma Scale (GCS) score of 7 or 8. We hypothesized that routine intubation may not be beneficial in isolated blunt head injury. A retrospective Trauma Quality Improvement Program study, including adult blunt trauma patients with GCS score of 7 or 8 and isolated head injury, was performed. Epidemiological and clinical characteristics, neurosurgical procedures, timing of intubation, and outcome variables were collected. The study population was stratified by the intubation procedure: immediate intubation (≤1 hour of admission), delayed intubation (>1 hour of admission), and no intubation. Multivariable regression analysis was used to determine risk factors for mortality and complications, as well as factors predictive of the decision to intubate. Of 2,727 patients with GCS score of 7 or 8 and isolated blunt head trauma, 1,866 patients (68.4%) were intubated within 1 hour of admission (immediate intubation), 223 (8.2%) had an intubation >1 hour of admission (delayed intubation), and 638 patients (23.4%) were not intubated at all. After correcting for age, sex, overall comorbidities, tachycardia, GCS, alcohol, illegal drug use, and head injury severity, immediate intubation was independently associated with higher mortality (odds ratio, 1.79; 95% confidence interval, 1.31-2.44; p < 0.001) and more overall complications (odds ratio, 2.46; 95% confidence interval, 1.62-3.73; p < 0.001). Increasing head Abbreviated Injury Scale (AIS) score, GCS score of 7, and tachycardia were identified as independent clinical factors associated with the decision to intubate. A policy of intubating all isolated blunt head injury patients 45 years or younger with head AIS score of 5 and GCS score of 7 would have improved intubation management, with seven immediate instead of delayed intubations and only three potentially unnecessary intubations. In patients with GCS score of 7 or 8 and isolated head injury, immediate intubation was associated with higher mortality and more overall complications. Intubation management could have been improved by intubating all patients younger than 45 years with head AIS score of 5 and a GCS score of 7 on admission. Therapeutic, level III.