Head Abbreviated Injury Score Research Articles

Association of initial assessment variables and mortality in severe pediatric traumatic brain injury

BackgroundPredictive scales have been used to prognosticate long-term outcomes of traumatic brain injury (TBI), but gaps remain in predicting mortality using initial trauma resuscitation data. We sought to evaluate the...

Are geriatric transfer patients with traumatic brain injury at risk for worse outcomes compared to non-geriatric? Propensity-matched study

ABSTRACT Objective To compare outcomes between geriatric andnon-geriatric patients with traumatic brain injury (TBI) transferred to traumacenter and effects of anticoagulants/antiplatelets (AC/AP) and reversaltherapy. Methods A retrospective review of 1,118 patients with TBI transferred from acute care facilities tolevel 1 trauma center compared in groups: geriatric versus non-geriatric,geriatric with AC/AP therapy versus without, and geriatric AC/AP with AC/APreversal therapy versus without. Results Patients with TBI constituted 54.4% oftrauma transfers. Mean transfer time was 3.9 h. Propensity matched byInjury Severity Score and Abbreviated Injury Score (AIS) head geriatriccompared to non-geriatric patients had more AC/AP use (53.9% vs 8.8%), repeathead computed tomography (93.7% vs 86.1%), intensive care unit (ICU) admissions(57.4% vs 45.7%) and mortality (9.8% vs 3.2%), all p < 0.004. Patients onAC/AP versus without had more ICU admissions (69.1% vs 51.8%, p < 0.001).Patients with AC/AP reversals compared to without reversals had more AIS head 5(32.0% vs 13.1%), brain surgeries (17.8% vs 3.5%) and ICU admissions (84.8% vs57.1%), all p < 0.001. Conclusion TBI constituted half of trauma transfers and10% required surgery. Based on higher ICU admissions, mortality, and prevalenceof AC/AP therapy requiring reversal, geriatric patients with TBI onanticoagulants/antiplatelets should be considered for direct trauma centeradmission.

434 Concurrent Vascular and Traumatic Brain Injury: Effect on Patient Outcomes

INTRODUCTION: Dural venous sinus thrombosis (DVST) in select populations following traumatic brain injury (TBI), including those with blunt mechanism or depressed skull fractures, have been associated with an increased risk of mortality. METHODS: We performed a retrospective case-control study of data from our institutional trauma registry from 2004-2021. Patients were divided into three groups: those with imaging confirmed DVST, those with imaging confirmed DVST and blunt cerebrovascular injury (BCVI), and a control group of TBI patients with cerebrovascular imaging without DVST or BCVI. All age groups and injury mechanisms were included with a head abbreviated injury score (AIS) of = 3. Demographics, injury characteristics, and patient outcomes were collected. Between group differences were compared with non-parametric tests as appropriate. Multivariate logistic regression was carried out to identify predictors of inpatient mortality. RESULTS: We identified 9,875 patients over the time-period with TBIs, with a 1.64% incidence of DVST and 23.4% incidence of concurrent BCVI. Despite a more severe presenting injury profile in those with DVST, the presence of DVST itself was not significantly associated with inpatient mortality (OR 1.02; 0.26-3.69). On regression analysis an occlusive DVST (OR 1.34; 1.15-1.56) and not receiving treatment (OR 1.27; 1.01-1.60) were independently associated with inpatient mortality. Significantly worse functional outcomes were observed in those with DVST+BCVI at 6-months, though a high proportion of patients achieved a GOSE of 7 or 8. CONCLUSIONS: We observed an incidence of traumatic DVST of 1.64% in a mixed population of head injured patients, with 23.4% of patients having concurrent BCVI. The presence of DVST alone was not significantly associated with inpatient mortality.

Radiographic sarcopenic obesity measurements in elderly trauma patients do not predict adverse discharge disposition over injury severity score

Introduction There is a need for a predictive tool for adverse discharge disposition in the injured elderly patient population. However, many measurements of frailty are not practical and radiographic measurements of muscle and adipose tissue have yet to be correlated with adverse discharge disposition in this population. Methods A retrospective review of a prospectively gathered trauma database at a level one trauma center was performed, studying all adult trauma patients aged 55 years or older with an inpatient stay of greater than 2 days. Patients with a non-survivable head trauma (head Abbreviated Injury Score of 6) or serious central nervous system injury, history of cirrhosis or solid organ transplantation, those actively being treated with immunosuppressive medications, and those without an abdominal computerized tomography (CT) scan within the first 48 h of admission were excluded. Sarcopenia, sarcopenic obesity (SO), and five-item frailty index (5-iFI) score were obtained and analyzed against adverse discharge disposition. Results The study evaluated 444 patients, of which 48.9% were male with a median age of 78 years (range 55–99 years). All patients sustained blunt trauma, shock index was positive in 13.7%, and median ISS was 10 (range 1–43). SO was not independently predictive of adverse discharge disposition. Additionally, neither sarcopenia nor 5-iFI scores were found to be independently predictive. Lower ISS and age were found to be protective against adverse discharge disposition. Conclusion CT-based measurements of muscle and adipose tissue may not add value over traditional injury scores in older trauma patients.

Effect of Increasing Blood Pressure on Brain Tissue Oxygenation in Adults After Severe Traumatic Brain Injury.

To examine if increasing blood pressure improves brain tissue oxygenation (PbtO 2 ) in adults with severe traumatic brain injury (TBI). Retrospective review of prospectively collected data. Level-I trauma center teaching hospital. Included patients greater than or equal to 18 years of age and with severe (admission Glasgow Coma Scale [GCS] score < 9) TBI who had advanced neuromonitoring (intracranial blood pressure [ICP], PbtO 2 , and cerebral autoregulation testing). The exposure was mean arterial pressure (MAP) augmentation with a vasopressor, and the primary outcome was a PbtO 2 response. Cerebral hypoxia was defined as PbtO 2 less than 20 mm Hg (low). MAP challenge test results conducted between ICU admission days 1-3 from 93 patients (median age 31; interquartile range [IQR], 24-44 yr), 69.9% male, White ( n = 69, 74.2%), median head abbreviated injury score 5 (IQR 4-5), and median admission GCS 3 (IQR 3-5) were examined. Across all 93 tests, a MAP increase of 25.7% resulted in a 34.2% cerebral perfusion pressure (CPP) increase and 16.3% PbtO 2 increase (no MAP or CPP correlation with PbtO 2 [both R2 = 0.00]). MAP augmentation increased ICP when cerebral autoregulation was impaired (8.9% vs. 3.8%, p = 0.06). MAP augmentation resulted in four PbtO 2 responses (normal and maintained [group 1: 58.5%], normal and deteriorated [group 2: 2.2%; average 45.2% PbtO 2 decrease], low and improved [group 3: 12.8%; average 44% PbtO 2 increase], and low and not improved [group 4: 25.8%]). The average end-tidal carbon dioxide (ETCO 2 ) increase of 5.9% was associated with group 2 when cerebral autoregulation was impaired ( p = 0.02). MAP augmentation after severe TBI resulted in four distinct PbtO 2 response patterns, including PbtO 2 improvement and cerebral hypoxia. Traditionally considered clinical factors were not significant, but cerebral autoregulation status and ICP responses may have moderated MAP and ETCO 2 effects on PbtO 2 response. Further study is needed to examine the role of MAP augmentation as a strategy to improve PbtO 2 in some patients.

Impact of Triage Systems on Time to Diagnosis and Treatment of Traumatic Brain Injuries

BackgroundIntracerebral hemorrhage (ICH) is a potential complication from traumatic brain injury, with a 30-day mortality rate of 35–52%. Rapid diagnosis allows for earlier treatment, which impacts patient outcomes. A trauma activation (TA) is called when injury severity meets institutional criteria. The patient is immediately roomed, and a multispecialty team is present. A trauma evaluation (TE) occurs when injuries are identified after standard triage processes. ObjectivesOur aim was to determine whether TA patients with ICH were diagnosed and treated more rapidly than TE patients. MethodsThis was a retrospective study of patients presenting to trauma centers within a large hospital system diagnosed with traumatic ICH between January 2018 and December 2018. Patients were categorized as TA or TE patients. The time to diagnosis was compared between groups, and additional times were evaluated, including time to imaging, computed tomography interpretation, and treatment. ResultsA total of 294 patients were included. Groups had similar demographic characteristics and medical history; there was no difference in head Abbreviated Injury Score, Injury Severity Score, or anticoagulant use. Time to diagnosis was decreased for TA patients compared with TE patients (p < 0.0001). In addition, TA patients received treatment sooner (median 107 min) than TE patients (184.5 min) (p < 0.0001). ConclusionsDiagnosis and treatment times were significantly faster in TA patients than in TE patients. Given the similarities in injury severity between groups, the increased time to treatment may be detrimental for patients. Trauma activations are a resource-heavy process, but TE delays care. These data suggest that an intermediary process may be beneficial.

Admission S100B fails as neuro-marker but is a good predictor for intrahospital mortality in major trauma patients

BackgroundS100 B is an extensively studied neuro-trauma marker, but its specificity and subsequently interpretation in major trauma patients might be limited, since extracerebral injuries are known to increase serum levels. Thus, we evaluated the potential role of S100B in the assessment of severe traumatic brain injury (TBI) in multiple injured patients upon emergency room (ER) admission and the first days of intensive care unit (ICU) stay. MethodsRetrospective study employing trauma registry data derived from a level 1 trauma center. Four cohorts of patients were grouped: isolated TBI (iTBI), polytrauma patients with TBI (PT + TBI), polytrauma patients without TBI (PT-TBI) and patients without polytrauma or TBI (control). S100B-serum levels were assessed immediately after admission in the emergency room and during the subsequent ICU stay. Values were correlated with injury severity score (ISS), Glasgow Coma Score (GCS) and in-hospital mortality. Results780 predominantly male patients (76 %) with a median age of 48 (30–63) and a median ISS of 24 (17–30) were enrolled in the study. Admission S100B correlated with ISS and TBI severity defined by the GCS (both p < 0.0001) but not with head abbreviated injury score (AIS) (p = 0.38). Compared with survivors, non-survivors had significantly higher median S100B levels in the ER (6.14 μg/L vs. 2.06 μg/L; p < 0.0001) and at ICU-day 1 (0.69 μg/L vs. 0.17 μg/L; p < 0.0001). S100B in the ER predicted mortality with an area under curve (AUC) of 0.77 (95 % CI 0,70–0,83, p < 0.0001), vs. 0.86 at ICU-day 1 (95 % CI 0,80–0,91, p < 0.0001). ConclusionIn conclusion, S100B is a valid biomarker for prediction of mortality in major trauma patients with a higher accuracy when assessed at the first day of ICU stay vs. immediately after ER admission. Since S100B did not correlate with pathologic TBI findings in multiple injured patients, it failed as predictive neuro-marker because extracerebral injuries demonstrated a higher influence on admission levels than neurotrauma. Although S100B levels are indicative for injury severity they should be interpreted with caution in polytrauma patients.

Age, admission platelet count, and mortality in severe isolated traumatic brain injury: A retrospective cohort study.

We asked whether patients >50 years of age with acute traumatic brain injury (TBI) present with lower platelet counts and whether lower platelet counts are independently associated with mortality. We combined trauma registry and laboratory data on a retrospective cohort of all patients ≥18 years of age admitted to our Level 1 US regional trauma center 2015-2021 with severe (Head Abbreviated Injury Score [AIS] ≥3), isolated (all other AIS <3) TBI who had a first platelet count within 1 h of arrival. Age and platelet count were assessed continuously and as groups (age 18-50 vs. >50, platelet normals, and at conventional transfusion thresholds). Outcomes such as mean admission platelet counts and in-hospital mortality were assessed categorically and with logistic regression. Of 44,056 patients, 1298 (3%, median age: 52 [IQR 33,68], 76.1% male) met all inclusion criteria with no differences between younger and older age groups for (ISS; 18 [14,26] vs. 17 [14,26], p = .22), New ISS (NISS; 29 [19,50] vs. 28 [17,50], p = .36), or AIS-Head (4 [3,5] vs. 4 [3,5]; p = .87). Patients aged >50 had lower admission platelet counts (219,000 ± 93,000 vs. 242,000 ± 76,000/μL; p < .001) and greater in-hospital mortality (24.5% vs. 15.6%, p < .001) than those 18-50. In multivariable regression, firearms injuries (OR9.08), increasing age (OR1.004), NISS (OR1.007), and AIS-Head (OR1.05), and decreasing admission platelet counts (OR0.998) were independently associated with mortality (p < .001-.041). Platelet transfusion in the first 4 h of care was more frequent among older patients (p < .001). Older patients with TBI had lower admission platelet counts, which were independently associated with greater mortality.

Association Between Admission Ionized Calcium Level and Neurological Outcome of Patients with Isolated Severe Traumatic Brain Injury: A Retrospective Cohort Study.

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Pathophysiological processes following initial insult are complex and not fully understood. Ionized calcium (Ca++) is an essential cofactor in the coagulation cascade and platelet aggregation, and hypocalcemia may contribute to the progression of intracranial bleeding. On the other hand, Ca++ is an important mediator of cell damage after TBI and cellular hypocalcemia may have a neuroprotective effect after brain injury. We hypothesized that early hypocalcemia might have an adverse effect on the neurological outcome of patients suffering from isolated severe TBI. In this study, we aimed to evaluate the relationship between admission Ca++ level and the neurological outcome of these patients. This was a retrospective, single-center, cohort study of all patients admitted between January 2014 and December 2020 due to isolated severe TBI, which was defined as head abbreviated injury score ≥ 4 and an absence of severe (abbreviated injury score > 2) extracranial injuries. The primary outcome was a favorable neurological status at discharge, defined by a modified Rankin Scale of 0-2. Multivariable logistic regression was performed to determine whether admission hypocalcemia (Ca++ < 1.16mmol L-1) is an independent predictor of neurological status at discharge. The final analysis included 201 patients. Hypocalcemia was common among patients with isolated severe TBI (73.1%). Most of the patients had mild hypocalcemia (1 < Ca++ < 1.16mmol L-1), and only 13 (6.5%) patients had Ca++ ≤ 1.00mmol L-1. In the entire cohort, hypocalcemia was independently associated with higher rates of good neurological status at discharge (adjusted odds ratio of 3.03, 95% confidence interval 1.11-8.33, p = 0.03). In the subgroup of 81 patients with an admission Glasgow Coma Scale > 8, 52 (64.2%) had hypocalcemia. Good neurological status at discharge was recorded in 28 (53.8%) of hypocalcemic patients compared with 14 (17.2%) of those with normal Ca++ (p = 0.002). In multivariate analyses, hypocalcemia was independently associated with good neurological status at discharge (adjusted odds ratio of 6.67, 95% confidence interval 1.39-33.33, p = 0.02). Our study demonstrates that among patients with isolated severe TBI, mild admission hypocalcemia is associated with better neurological status at hospital discharge. The prognostic value of Ca++ may be greater among patients with admission Glasgow Coma Scale > 8. Trials are needed to investigate the role of hypocalcemia in brain injury.

Long-term health-related quality of life after trauma with and without traumatic brain injury: a prospective cohort study

To purpose was to assess and compare the health-related quality of life (HRQoL) and risk of depression two years after trauma, between patients with and without traumatic brain injury (TBI) in a mixed Swedish trauma cohort. In this prospective cohort study, TBI and non-TBI trauma patients included in the Swedish Trauma registry 2019 at a level II trauma center in Stockholm, Sweden, were contacted two years after admission. HRQoL was assessed with RAND-36 and EQ-5D-3L, and depression with Montgomery Åsberg depression Rating Scale self-report (MADRS-S). Abbreviated Injury Score (AIS) head was used to grade TBI severity, and American Society of Anesthesiologists (ASA) score was used to assess comorbidities. Data were compared using Chi-squared test, Mann Whitney U test and ordered logistic regression, and Bonferroni correction was applied. A total of 170 of 737 eligible patients were included. TBI was associated with higher scores in 5/8 domains of RAND-36 and 3/5 domains of EQ-5D (p < 0.05). No significant difference in MADRS-S. An AIS (head) of three or higher was associated with lower scores in five domains of RAND-36 and two domains of EQ-5D but not for MADRS-S. An ASA-score of three was associated with lower scores in all domains of both RAND-36 (p < 0.05, except mental health) and EQ-5D (p < 0.001, except anxiety/depression), but not for MADRS-S. In conclusion, patients without TBI reported a lower HRQoL than TBI patients two years after trauma. TBI severity assessed according to AIS (head) was associated with HRQoL, and ASA-score was found to be a predictor of HRQoL, emphasizing the importance of considering pre-injury health status when assessing outcomes in TBI patients.

Racial Disparity in Placement of Intracranial Pressure Monitoring: A TQIP Analysis.

The Brain Trauma Foundation recommends intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (TBI). Race is associated with worse outcomes after TBI. The reasons for racial disparities in clinical decision-making around ICP monitor placement remain unclear. We queried the TQIP database from 2017 to 2019 and included patients 16 years or older, with blunt severe TBI, defined as a head abbreviated injury score 3 or greater. Exclusion criteria were missing race, those without signs of life on admission, length of stay 1 day or less, and AIS of 6 in any body region. The primary outcome was ICP monitor placement, which was calculated using a Poisson regression model with robust SEs while adjusting for confounders. A total of 260,814 patients were included: 218,939 White, 29,873 Black, 8,322 Asian, 2,884 American Indian, and 796 Native Hawaiian or Other Pacific Islander. Asian and American Indian patients had the highest rates of midline shift (16.5% and 16.9%). Native Hawaiian or Other Pacific Islanders had the highest rates of neurosurgical intervention (19.3%) and ICP monitor placement (6.5%). Asian patients were found to be 19% more likely to receive ICP monitoring (adjusted incident rate ratio 1.19; 95% CI 1.06 to 1.33; p = 0.003], and American Indian patients were 38% less likely (adjusted incident rate ratio 0.62; 95% CI 0.49 to 0.79; p < 0.001), compared with White patients, respectively. No differences were detected between White and Black patients. ICP monitoring use differs by race. Further work is needed to elucidate modifiable causes of this difference in the management of severe TBI.

Extracellular Vesicle Levels of Nervous System Injury Biomarkers in Critically Ill Trauma Patients with and without Traumatic Brain Injury.

Moderate/severe traumatic brain injury (TBI) causes injury patterns with heterogeneous pathology producing varying outcomes for recovery. Extracellular vesicles (EVs) are particles containing a myriad of molecules involved in cell signaling. EVs may hold promise as biomarkers in TBI because of their encapsulation, including improved stability/decreased degradation. A subset of subjects with and without TBI from a prospective, observational trial of critically ill trauma patients were analyzed. Total EV levels of glial (glial fibrillary acidic protein; GFAP) and neuronal/axonal (ubiquitin carboxy-terminal hydrolase L1 [UCH-L1], neurofilament light chain [NfL], and total-tau) proteins were measured using single-molecule array technology. Protein levels were winsorized to address outliers and log transformed for analysis. Patients with multiple injuries (n = 41) and isolated body injury (n = 73) were of similar age and sex. Patients with multiple injuries were, as expected, more severely injured with higher Injury Severity Scores (29 [26-41] vs. 21 [14-26], p < 0.001) and lower Glasgow Coma Scale scores (12 [4-13] vs. 13 [13-13], p < 0.001). Total body EVs of GFAP, UCH-L1, and NfL were higher in those with multiple injuries (1768 [932-4780] vs. 239 [63-589], p < 0.001; 75.4 [47.8-158.3] vs. 41.5 [21.5-67.1], p = 0.03; 7.5 [3.3-12.3] vs. 2.9 [2.1-4.8], p < 0.001, respectively). There was a moderate correlation between the Head Abbreviated Injury Score and GFAP (free circulating rho = 0.62, EV rho = 0.64; both p < 0.001). Brain-derived proteins contained in EV holds promise as an informative approach to biomarker measurement after TBI in hospitalized patients. Future evaluation and longitudinal studies are necessary to draw conclusions regarding the clinical utility of these biomarkers.

Gender Discrepancy in Patients with Traumatic Brain Injury: A Retrospective Study from a Level 1 Trauma Center

Objectives The objective of this study is to explore the gender discrepancy in patients with traumatic brain injury (TBI). Methods A retrospective analysis of Qatar Trauma Registry (QTR) was conducted among patients (age ≥14y) who were hospitalized with TBI. Data were collected and analyzed based on the gender and age. Results Over 5 years (2014-2019), 9, 309 trauma patients (90% males and 10% females) were admitted to the trauma center. Of these, 1, 620 (17.4%) patients were hospitalized with TBI (94% males and 6% females). Motor vehicle crash was the main mechanism of injury (MOI) in females, and fall from height was predominant among males. Subdural hematoma (SDH) was the more frequent type of TBI in both genders, but it was more prevalent in male patients ≥55 years. Injury severity score, Glasgow coma scale, and head abbreviated injury score were comparable between males and females. The length of stay in the ICU and hospital and mortality were similar in both genders. However, mortality was higher among males ≥55 years when compared to 14-54 years within the same gender (21% vs. 12%, p = 0.002). The crude and adjusted odds ratio did not show that gender is a significant predictor of mortality among TBI patients. Conclusions Although the incidence and MOI of TBI show significant differences between male and female patients, the severity and outcomes are comparable.

Effect of Delay and Disruption in Venous Thromboembolism Prophylaxis in Trauma Patients: Case-Control Study.

Trauma patients are at high risk for venous thromboembolism (VTE) and bleeding. The purpose of this study was to characterize percentage of VTE chemoprophylaxis given to trauma patients with and without a VTE. This retrospective case-control study evaluated trauma patients admitted to a Level I trauma center. Adult patients were included when hospitalized at least 2 days and had a head abbreviated injury score of 1 or less. Non-VTE patients were matched by decade of life and injury severity score (ISS). The primary outcome was percentage of VTE chemoprophylaxis received over the first 14 days of admission. Descriptive statistics, chi-squared test, Student's t-test, and Cox proportional hazard were used for analysis. A total of 44 VTE patients were included with 125 matched non-VTE patients. Baseline demographics included age in years (50.7 ± 19.6 vs 49.6 ± 19.4), ISS (18.9 ± 11.3 vs 19 ± 11.6), and lower extremity fracture (54.5% vs 40%), for VTE and non-VTE groups, respectively. The primary outcome of VTE chemoprophylaxis doses given was significantly lower for VTE patients than non-VTE patients (49.3% vs 59.3%, p = 0.0069). Significant predictors of VTE were percentage of VTE chemoprophylaxis doses given (p < 0.0001) and weight (p = 0.0042) based on regression analysis. Notably, there was a 7% decrease in the hazard for VTE for every 1% increase in VTE chemoprophylaxis given. Patients who developed VTE were more likely to have delays and disruptions in VTE chemoprophylaxis, even after controlling for age, sex, ISS, lower extremity fractures, and number of operations.

Predicting prolonged length of stay in patients with traumatic brain injury: A machine learning approach

BackgroundProviding timely care while keeping an efficient bed turnover rate is a challenge hospitals usually face. Early prediction of prolonged hospital length of stay may help devise personalized plans of care that facilitate early discharge and ensure the timely availability of a bed for the next patient. ObjectivesThis study aims to design an Artificial Neural Network (ANN) machine learning model to help early predict patients at risk for prolonged hospital length of stay (PLOS) following Traumatic Brain Injury (TBI). MethodsPLOS was defined as the 75th percentile of the in-hospital length of stay of the entire patient cohort (PLOS ≥23 days). The study targeted adult patients with TBI who were admitted to the trauma surgery between January 2014 and February 2019 with head abbreviated injury score (HAIS) ≥ 3.1417 eligible patients were included (PLOS = 350 and non-PLOS = 1067). ResultsANN achieved good performance with accuracy of 84.3%, area under receiver operating characteristic curve (AUROC) 91.5%, precision 69%, negative predictive value 89%, sensitivity 69%, specificity 89% and F-score 69%. ConclusionThe study discusses the health economic aspects of PLOS and the potential benefits of utilizing machine learning models in enhancing hospital bed utilization.

Admission Lymphopenia Predicts Infectious Complications and Mortality in Traumatic Brain Injury Victims.

Traumatic brain injury (TBI) is a major cause of mortality and disability associated with increased risk of secondary infections. Identifying a readily available biomarker may help direct TBI patient care. Herein, we evaluated whether admission lymphopenia could predict outcomes of TBI patients. This is a 10-year retrospective review of TBI patients with a head Abbreviated Injury Score 2 to 6 and absolute lymphocyte counts (ALC) collected within 24 h of admission. Exclusion criteria were death within 24 h of admission and presence of bowel perforation on admission. Demographics, admission data, injury severity score, mechanism of injury, and outcomes were collected. Association between baseline variables and outcomes was analyzed. We included 2,570 patients; 946 (36.8%) presented an ALC ≤1,000 on admission (lymphopenic group). Lymphopenic patients were significantly older, less likely to smoke, and more likely to have heart failure, hypertension, or chronic kidney disease. Lymphopenia was associated with increased risks of mortality (OR = 1.903 [1.389-2.608]; P < 0.001) and pneumonia (OR = 1.510 [1.081-2.111]; P = 0.016), increased LOS (OR = 1.337 [1.217-1.469]; P < 0.001), and likelihood of requiring additional healthcare resources at discharge (OR = 1.669 [1.344-2.073], P < 0.001). Additionally, lymphopenia increased the risk of early in-hospital death (OR = 1.459 [1.097-1.941]; P = 0.009). Subgroup analysis showed that lymphopenia was associated with mortality in polytrauma patients and those who presented with two or more concurrent types of TBI. In all subgroup analyses, lymphopenia was associated with longer length of stay and discharge requiring higher level of care. A routine complete blood count with differential for all TBI patients may help predict patient outcomes and direct care accordingly.

Definitive Surgery Is Safe in Borderline Patients Who Respond to Resuscitation.

We hypothesize that in adequately resuscitated borderline polytrauma patients with long bone fractures (femur and tibia) or pelvic fractures, early (within 4 days) definitive stabilization (EDS) can be performed without an increase in postoperative ventilation and postoperative complications. Retrospective cohort study. Level 1 trauma center. In total, 103 patients were included in this study; of whom, 18 (17.5%) were female and 85 (82.5%) were male. These patients were borderline trauma patients who had the following parameters before definitive surgery, normal coagulation profile, lactate of <2.5 mmol/L, pH of ≥7.25, and base excess of ≥5.5. These patients were treated according to Early Total Care, definitive surgery on day of admission, or Damage Control Orthopaedics principles, temporizing external fixation followed by definitive surgery at a later date. Timing of definitive surgical fixation was recorded as EDS or late definitive surgical fixation (>4 days). Primary outcome measured was the duration of ventilation more than 3 days post definitive surgery and presence of postoperative complications. Thirty-five patients (34.0%) received Early Total Care, whereas 68 (66.0%) patients were treated with Damage Control Orthopaedics. In total, 51 (49.5%) of all patients had late definitive surgery, whereas 52 patients (50.5%) had EDS. On logistic regression, the following factors were found to be predictive of higher rates of postoperative ventilation ≥ 3 days, units of blood transfused, and time to definitive surgery > 4 days. Increased age, head abbreviated injury score of 3 or more and time to definitive surgery were found to be associated with an increased risk of postoperative complications. Borderline polytrauma patients with no severe soft tissue injuries, such as chest or head injuries, may be treated with EDS if adequately resuscitated with no increase in need for postoperative ventilation and complications. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association between alcohol intoxication and mortality in severe traumatic brain injury in the emergency department: a retrospective cohort.

Acute alcohol intoxication is very common in patients with severe traumatic brain injury (TBI). Whether there is an independent association between alcohol intoxication and mortality is debated. This study hypothesized that alcohol intoxication is independently associated with less mortality after severe TBI (sTBI). This retrospective observational cohort study included all patients with sTBI [head-Abbreviated Injury Score (AIS) ≥3, corresponding to serious head injury or worse] admitted from 1 January 2011 to 31 December 2016 in an academic level I trauma center. Patients were classified as with alcohol intoxication or without intoxication based on blood alcohol concentration or description of alcohol intoxication on admission. The primary endpoint was in-hospital mortality. Multivariable logistic regression analysis, including patient and injury characteristics, was used to assess independent association with alcohol intoxication. Of the 2865 TBI patients, 715 (25%) suffered from alcohol intoxication. They were younger (mean age 46 vs. 68 years), more often male (80 vs. 57%) and had a lower median Glasgow Coma Scale upon arrival (14 vs. 15) compared to the no-intoxication group. There was no difference in injury severity by head AIS or Rotterdam CT. Alcohol intoxication had an unadjusted association with in-hospital mortality [unadjusted odds ratio (OR) 0.51; 95% confidence interval (CI), 0.38-0.68]; however, there was no independent association after adjusting for potentially confounding patient and injury characteristics (adjusted OR 0.72; 95% CI, 0.48-1.09). In this retrospective study, there was no independent association between alcohol intoxication and higher in-hospital mortality in emergency patients with sTBI.

173 Trauma Activations Are Associated with Decreased Time to Diagnosis & Treatment of Intracerebral Hemorrhage When Compared to Trauma Evaluations

Intracerebral hemorrhage (ICH) is a major complication from traumatic brain injury. The 30-day mortality rate is 35-52%, with half occurring within 24 hours. Early diagnosis leads to early treatment and potentially better patient outcomes. To expedite patient care, when injury severity meets institutional criteria, a trauma activation is called. Trauma activations are immediately roomed and evaluated by a multispecialty resuscitation team. A trauma evaluation occurs when injuries do not meet trauma activation criteria. Instead patients are triaged and assigned a room as one becomes available. Trauma evaluations potentially have increased wait times and increased length of stay. The objective of this study was to evaluate whether or not trauma activation patients with ICH were diagnosed more rapidly than trauma evaluation patients and to assess the impact of this diagnosis on the time to treatment in this population. This was a retrospective cohort study of patients presenting to one of three trauma centers within a large hospital system between January 2018 and December 2018 who were diagnosed with acute traumatic ICH. Time to diagnosis, defined as minutes from patient arrival in the ED to computed tomography (CT) results received by treating provider, was evaluated between the two groups. Additional time points evaluated between groups were time to imaging, time to CT interpretation by radiology, and time to treatment of ICH. Demographics, patient medical history, and injury details were also abstracted. Categorical variables were described using frequencies and percentages and differences between groups were tested using Pearson chi-squared tests. Continuous variables are presented as median and standard deviation and differences between groups tested using t-tests. A total of 398 subjects met inclusion criteria for this study. Demographics and past medical history were similar and there was no difference in head abbreviated injury score, injury severity score, or anticoagulant use between groups. Trauma evaluation patients were older, predominately suffered a fall, and had an increased incidence of hypertension and chronic kidney disorder. Time to diagnosis was decreased for trauma activation compared to trauma evaluation patients (p<0.0001). Additionally, median treatment time for trauma activation was 107 minutes compared to 184.5 minutes for trauma evaluation patients (p-value < 0. 0001). Diagnosis and treatment times for traumatic intracerebral hemorrhage were significantly faster in trauma activation patients when compared to trauma evaluation patients. Given the similarities in injury severity between the two groups, the increased time of treatment could have detrimental impact on the treatment of patients. While trauma activations are a resource heavy process, our data suggests that an intermediary process may be beneficial.

Long-Term Analysis of Functional Outcomes in Traumatic Brain Injury Patients.

Traumatic brain injury (TBI) remains a significant cause of morbidity and mortality. The purpose of this study is to examine outcomes after discharge and identify factors from the index admission that may contribute to long-term mortality. The study population is composed of patients who survived to discharge from a previously published study examining TBI. Demographics, injury severity, and length of stay were abstracted from the index study. Phone surveys of surviving patients were performed to evaluate each patient's Glasgow Outcome Scale-Extended (GOSE). Patients who were deceased at the time of the survey were compared with those who were alive. 1615 patients were alive at the end of the first study period and 211 (13%) comprised the study population. Overall, the median age was 54 years, and the majority were male (74%). The median time to follow-up was 80 months. The population was severely injured, with a median injury severity score (ISS) of 25 and a median head abbreviated injury score (AIS) of 4. Overall mortality was 57%. The group that survived at the time of the survey was younger, more injured, less likely to have received beta-blockers (BB) during the index admission, and had a longer time to follow-up. After adjusting for ISS, age, base deficit, and BB, age was the only variable predictive of mortality (HR 1.03; HL 1.02-1.04). Despite being more severely injured, younger patients were more likely to survive to follow-up. Further investigation is needed to determine if aggressive care in older TBI patients in the acute phase leads to good long-term outcomes.