Head Abbreviated Injury Score Research Articles

Thirty-day re-admission after traumatic brain injury: Results from MarketScan®

Objective: To estimate the national 30-day re-admission rate after traumatic brain injury (TBI) in insured patients under age 65 and to examine factors that predict re-admission.Methods: This study reviewed data on patients hospitalized with a primary diagnosis of TBI in the MarketScan® database from 2010–2012. Patients with substantial concurrent injury to non-head regions were excluded. This study identified all hospitalizations within 30 days after index discharge and compared characteristics of patients who were re-admitted vs those who were not.Results: This study identified 26 831 patients with a primary diagnosis of TBI who survived the index hospitalization. Overall, 6.6% of patients were re-admitted within 30 days. TBI was the most common primary diagnosis for re-admission (28.5%), followed by psychiatric disorders (12.5%). Patients who were older, had a head Abbreviated Injury Score of 3 or more, one or more comorbidities, longer length of stay or who were discharged to an inpatient rehabilitation facility demonstrated greater odds of being re-admitted within 30 days.Conclusions: Factors associated with re-admission after TBI should be considered in discharge planning. Further research is warranted to examine re-admission beyond 30 days and further elucidate causes of re-admission in order to develop strategies to reduce re-admission among patients with TBI.

Normalization of coagulopathy is associated with improved outcome after isolated traumatic brain injury

Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and is associated with poor outcomes. We aimed to evaluate the effectiveness of procoagulant agents administered to patients with ATC and iTBI during resuscitation, hypothesizing that timely normalization of coagulopathy may be associated with a decrease in mortality. A retrospective review of the Alfred Hospital trauma registry, Australia, was conducted and patients with iTBI (head Abbreviated Injury Score [AIS] ⩾3 and all other body AIS <3) and coagulopathy (international normalized ratio ⩾1.3) were selected for analysis. Data on procoagulant agents used (fresh frozen plasma, platelets, cryoprecipitate, prothrombin complex concentrates, tranexamic acid, vitamin K) were extracted. Among patients who had achieved normalization of INR or survived beyond 24hours and were not taking oral anticoagulants, the association of normalization of INR and death at hospital discharge was analyzed using multivariable logistic regression analysis. There were 157 patients with ATC of whom 68 (43.3%) received procoagulant products within 24hours of presentation. The median time to delivery of first products was 182.5 (interquartile range [IQR] 115–375) minutes, and following administration of coagulants, time to normalization of INR was 605 (IQR 274–1146) minutes. Normalization of INR was independently associated with significantly lower mortality (adjusted odds ratio 0.10; 95% confidence interval 0.03–0.38). Normalization of INR was associated with improved mortality in patients with ATC in the setting of iTBI. As there was a substantial time lag between delivery of products and eventual normalization of coagulation, specific management of coagulopathy should be implemented as early as possible.

Adenosine diphosphate platelet dysfunction on thromboelastogram is independently associated with increased morality in traumatic brain injury.

The purpose of this study is to determine if adenosine diphosphate (ADP) platelet dysfunction on thromboelastogram (TEG) is associated with increased in-hospital mortality in patients with head trauma. The hypothesis is that ADP dysfunction is associated with increased mortality. This retrospective review evaluated trauma patients admitted to a level 1 trauma center from February 2011 to October 2013 who received a TEG. Patients were included if the TEG was drawn within the first 24h of admission and the head abbreviated injury score was greater than or equal to three. Patients were categorized as severe ADP dysfunction if the degree of ADP inhibition on TEG exceeded 60%. A total of 90 patients were included (no ADP dysfunction n=37; ADP dysfunction n=53). Initial Glasgow Coma Scale [GCS (12±4 vs. 11±5; p=0.26)] and use of pre-injury antiplatelet agents (30 vs. 28%; p=0.88) were similar. Patients with ADP dysfunction on TEG had a higher in-hospital mortality rate (8 vs. 32%; p<0.01). ADP dysfunction was independently associated with in-hospital mortality upon fixed logistic regression (OR 6.2; 95% CI 1.2-33) while controlling for age, gender, hypotension, pre-injury antiplatelet agents, GCS and Injury Severity Score. ADP dysfunction on TEG is associated with increased mortality in patients with traumatic brain injury.

Mortality after emergency department thoracotomy for pediatric blunt trauma: Analysis of the National Trauma Data Bank 2007–2012

PurposeThe purpose of this study was to determine the proportion of children who survived after emergency department thoracotomy (EDT) for blunt trauma using a national database. MethodsA review of the National Trauma Data Bank was performed for years 2007–2012 to identify children <18years of age who underwent EDT for blunt trauma. ResultsEighty-four children <18years of age underwent EDT after blunt trauma. Every child died during their hospitalization. The median age was 15 (IQR 6–17) years. Mean injury severity score (ISS) was 34.2 (SD 20.8), and 56% had an ISS of 26–75. Data for “signs of life” were available for 21 children. Fifteen (71%) had signs of life upon ED arrival. Sixty percent of children died in the ED. Of those who survived to the operating room (OR), 66% died in the OR. Four children (5%) survived more than 24hours in the intensive care unit, three of whom had a maximum head abbreviated injury score of 5. ConclusionThere were no survivors after EDT for blunt trauma in the pediatric population in this national dataset. Usual indicators for EDT after blunt trauma in adults may not apply in children, and use should be discouraged without compelling evidence of a reversible cause of extremis.

Isolated Blunt Duodenal Trauma: Simple Repair, Low Mortality

Optimal surgical management of traumatic duodenal injury (DI) remains controversial. The National Trauma Data Bank was queried for all blunt trauma patients with DI. Patients with isolated injury were identified by excluding chest and head Abbreviated Injury Score > 3 and nonduodenal intra-abdominal Organ Injury Scale ≥ 3. Demographics, OIS, and operative intervention were collected. Outcomes included mortality and hospital length of stay (HLOS). During the study period, 3,456,098 blunt trauma patients were entered into the National Trauma Data Bank, 388,137 of which had abdominal trauma. Overall, 1.0 per cent patients with abdominal trauma had DI with isolated DI in only 0.6 per cent (n = 2220). The majority of isolated DI was low grade with only 158 patients sustaining severe injury and overall mortality was 5.2 per cent. Overall 743 patients were operated, of which 353 (47.5%) patients underwent duodenal operation, 280 (37.7%) had primary repair (PR), and 68 (9.2%) had gastroenterostomy (GE). Patients with PR had similar mortality to those with GE (6.6% vs 4.5%, P = 0.777); however, HLOS was shorter (median 11 days, vs 18 days, P < 0.001). In only OIS 4 and 5 injuries, PR was also associated with shorter HLOS (P = 0.004) and similar mortality (P = 1.000) when compared with GE. Isolated DI after blunt abdominal trauma is rare. In severe injuries, PR is associated with a shorter HLOS without effecting mortality when compared with GE.

Cardiac dysfunction following brain death after severe pediatric traumatic brain injury: A preliminary study of 32 children.

Background:Cardiac dysfunction after brain death has been described in a variety of brain injury paradigms but is not well understood after severe pediatric traumatic brain injury (TBI). Cardiac dysfunction may have implications for organ donation in this patient population.Materials and Methods:We conducted a retrospective cohort study of pediatric patients with severe TBI, both with and without a diagnosis of brain death, who underwent echocardiography during the first 2 weeks after TBI, between the period of 2003–2011. We examined cardiac dysfunction in patients with and without a diagnosis of brain death.Results:In all, 32 (2.3%) of 1,413 severe pediatric TBI patients underwent echocardiogram evaluation. Most patients had head abbreviated injury score 5 (range 2–6) and subdural hematoma (34.4%). Ten patients with TBI had brain death compared with 22 severe TBI patients who did not have brain death. Four (40%) of 10 pediatric TBI patients with brain death had a low ejection fraction (EF) compared with 1 (4.5%) of 22 pediatric TBI patients without brain death who had low EF (OR = 14, P = 0.024).Conclusions:The incidence of cardiac dysfunction is higher among pediatric severe TBI patients with a diagnosis of brain death, as compared to patients without brain death. This finding may have implications for cardiac organ donation from this population and deserves further study.

PRESENTING GCS IN ELDERLY PATIENTS WITH ISOLATED TRAUMATIC BRAIN INJURY IS HIGHER THAN IN YOUNGER ADULTS

Objectives & BackgroundThe relationship between age and presenting Glasgow Coma Scale (GCS) in adults with traumatic brain injury (TBI) has not so far been explored in detail. We have previously...

Effect of alcohol in traumatic brain injury: is it really protective?

BackgroundStudies have proposed a neuroprotective role for alcohol (ETOH) in traumatic brain injury (TBI). We hypothesized that ETOH intoxication is associated with mortality in patients with severe TBI. MethodsVersion 7.2 of the National Trauma Data Bank (2007–2010) was queried for all patients with isolated blunt severe TBI (Head Abbreviated Injury Score ≥4) and blood ETOH levels recorded on admission. Primary outcome measure was mortality. Multivariate logistic regression analysis was performed to assess factors predicting mortality and in-hospital complications. ResultsA total of 23,983 patients with severe TBI were evaluated of which 22.8% (n = 5461) patients tested positive for ETOH intoxication. ETOH-positive patients were more likely to have in-hospital complications (P = 0.001) and have a higher mortality rate (P = 0.01). ETOH intoxication was an independent predictor for mortality (odds ratio: 1.2, 95% confidence interval: 1.1–2.1, P = 0.01) and development of in-hospital complications (odds ratio: 1.3, 95% confidence interval: 1.1–2.8, P = 0.009) in patients with isolated severe TBI. ConclusionsETOH intoxication is an independent predictor for mortality in patients with severe TBI patients and is associated with higher complication rates. Our results from the National Trauma Data Standards differ from those previously reported. The proposed neuroprotective role of ETOH needs further clarification.

A standardized trauma care protocol decreased in-hospital mortality of patients with severe traumatic brain injury at a teaching hospital in a middle-income country

IntroductionStandardized trauma protocols (STP) have reduced morbidity and in-hospital mortality in mature trauma systems. Most hospitals in low- and middle-income countries (LMICs) have not implemented STPs, often because of financial and logistic limitations. We report the impact of an STP designed for the care of trauma patients in the emergency department (ED) at an LMIC hospital on patients with severe traumatic brain injury (STBI). MethodsWe developed an STP based on generally accepted best practices and damage control resuscitation for a level I trauma centre in Colombia. Without a pre-existing trauma registry, we adapted an administrative electronic database to capture clinical information of adult patients with TBI, a head abbreviated injury score (AIS) ≥3, and who presented ≤12h from injury. Demographics, mechanisms of injury, and injury severity were compared. Primary outcome was in-hospital mortality. Secondary outcomes were Glasgow Coma Score (GCS), length of hospital and ICU stay, and prevalence of ED interventions recommended in the STP. Logistic regression was used to control for potential confounders. ResultsThe pre-STP group was hospitalized between August 2010 and August 2011, the post-STP group between September 2011 and June 2012. There were 108 patients meeting inclusion criteria, 68 pre-STP implementation and 40 post-STP. The pre- and post-STP groups were similar in age (mean 37.1 vs. 38.6, p=0.644), head AIS (median 4.5 vs. 4.0, p=0.857), Injury Severity Scale (median 25 vs. 25, p=0.757), and initial GCS (median 7 vs. 7, p=0.384). Post-STP in-hospital mortality decreased (38% vs. 18%, p=0.024), and discharge GCS increased (median 10 vs. 14, p=0.034). After controlling for potential confounders, odds of in-hospital mortality post-STP compared to pre-STP were 0.248 (95%CI: 0.074–0.838, p=0.025). Hospital and ICU stay did not significantly change. The use of many ED interventions increased post-STP, including bladder catheterization (49% vs. 73%, p=0.015), hypertonic saline (38% vs. 63%, p=0.014), arterial blood gas draws (25% vs. 43%, p=0.059), and blood transfusions (3% vs. 18%, p=0.008). ConclusionsAn STP in an LMIC decreased in-hospital mortality, increased discharge GCS, and increased use of vital ED interventions for patients with STBI. An STP in an LMIC can be implemented and measured without a pre-existing trauma registry.

Intensive care unit design and mortality in trauma patients

BackgroundThe architecture of medical care facilities ca affect the safety of a patient, but it is unknown if the architecture affects outcomes. We hypothesized that patients in rooms who are more visible from the central nursing station would experience better outcomes than those patients in less visible rooms. Materials and methodsA total of 773 patients admitted to the trauma intensive care service over a 12-mo period were retrospectively evaluated. Outcomes were hospital mortality and intensive care unit (ICU) length of stay (LOS). The unit is designed with a bank of high-visibility rooms (HVRs) directly across from the nursing station and two side sections of low-visibility rooms (LVRs). No formal triage occurs, but patients are prioritized to HVRs as available. ResultsPatients in the HVRs had a 16% mortality (52 of 320); meanwhile, the patients in the LVRs experienced an 11% mortality (49 of 448, P = 0.03). ICU mortality did not differ significantly when controlling for age, Charlson Comorbidity Index (CCI), Head Abbreviated Injury Score, and the Injury Severity Score (ISS) (P = 0.076). Age, CCI, Head Abbreviated Injury Score, and ISS did individually correlate with mortality (age: P = 0.0008; CCI: P = 0.017; and ISS: P < 0.0001). Visibility was not a predictor of ICU LOS or complications among survivors (mean ICU HVR LOS = 4.8 d; mean ICU LVR LOS = 4.7; P = 0.88, n = 661). Only ISS was a significant predictor of ICU LOS and complications (P < 0.0001). ConclusionsTrauma patient room placement within the ICU does not relate to mortality rate significantly when corrected for patient acuity. Instead, variables such as age, ISS, and CCI are associated with mortality. A policy of placing more critically ill patients in HVRs may prevent increased mortality in high-acuity patients.

To TQIP or Not to TQIP? that is the Question

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

Prehospital versus Emergency Room Intubation of Trauma Patients in Qatar: A-2-year Observational Study

Background:The impact of prehospital intubation (PHI) in improving outcome of trauma patients has not been adequately evaluated in the developing countries.Aims:The present study analyzed the outcome of PHI versus emergency room intubation (ERI) among trauma patients in Qatar.Materials and Methods:Data were retrospectively reviewed for all intubated trauma patients between 2010 and 2011. Patients were classified according to location of intubation (PHI: Group-1 versus ERI: Group-2). Data were analyzed and compared.Results:Out of 570 intubated patients; 482 patients (239 in group-1 and 243 in group-2) met the inclusion criteria with a mean age of 32 ΁ 14.6 years Head injury (P = 0.003) and multiple trauma (P = 0.004) were more prevalent in group-1, whereas solid organ injury predominated in group-2 (P = 0.02). Group-1 had significantly higher mean injury severity scoring (ISS), lower Glasgow coma scale (GCS), greater head abbreviated injury score and longer activation, response, scene and total emergency medical services times. The mortality was higher in group-1 (53% vs. 18.5%; P = 0.001). Multivariate analysis showed that GCS [odds ratio (OR) 0.78, P = 0.005) and ISS (OR 1.12, P = 0.001) were independent predictors of mortality.Conclusions:PHI is associated with high mortality when compared with ERI. However, selection bias cannot be ruled out and therefore, PHI needs further critical assessment in Qatar.

A Comparison of the Prehospital Motor Component of the Glasgow Coma Scale (mGCS) to the Prehospital Total GCS (tGCS) as a Prehospital Risk Adjustment Measure for Trauma Patients

Objective. This study compared the prehospital motor component subscale of the Glasgow Coma Scale (mGCS) to the prehospital total GCS (tGCS) score for its ability to predict the need for intubation, survival to hospital discharge, and neurosurgical intervention in trauma patients. Methods. This is a retrospective analysis of an urban level 1 trauma registry. All trauma patients presenting to the trauma center emergency department via emergency medical services from July 2008 through June 2010 were included. The area under the receiver operating characteristics curve (AUC) analysis was used to compare the predictive ability of the prehospital mGCS to tGCS for three outcomes: intubation, survival to hospital discharge, and neurosurgical intervention. Two subgroups (patients with injury severity score [ISS] ≥ 16 and traumatic brain injury [TBI] [head abbreviated injury score (AIS) ≥ 3]) were analyzed. An a priori statistically significant absolute difference of 0.050 in AUC between mGCS and tGCS for these clinical outcomes was used as a clinically significant difference. Multiple imputation was used for missing prehospital GCS data. Results. There were 9,816 patients, of which 4% were intubated, 3.8% had neurosurgical intervention, and 97.1% survived to hospital discharge. The absolute difference in AUC (prehospital tGCS minus mGCS) for all cases was statistically significant for all three outcomes but did not reach the clinical significance threshold: survival = 0.010 (95% CI: 0.002–0.018), intubation = 0.018 (95% CI: 0.011–0.024), and neurosurgical intervention = 0.019 (95% CI: 0.007–0.029). The difference in AUC between tGCS and mGCS for the subgroups ISS ≥ 16 (n = 1,151) and TBI (n = 1,165) did not reach clinical significance for the three outcomes. The discriminatory ability of the prehospital mGCS was good for survival (AUC: all patients = 0.89, ISS ≥ 16 = 0.84, traumatic brain injury = 0.86) excellent for intubation (AUC: all patients = 0.95, ISS ≥ 16 = 0.91, traumatic brain injury = 0.91), and poor for neurosurgical intervention (AUC: all patients = 0.67, ISS ≥ 16 = 0.57, traumatic brain injury = 0.60). Conclusion. The prehospital mGCS appears have good discriminatory power and is equivalent to the prehospital tGCS for predicting intubation and survival to hospital discharge in this trauma population as a whole, those with ISS ≥ 16, or TBI.

Recreational-related head injuries in Qatar

Background: The incidence of recreation related-injuries (RRI) among the physically active population is increasing. This study aimed to analyse frequency and characteristics of RRI in Qatar.Methods: A retrospective chart review was conducted for all patients with head injuries who sustained a RRI and were admitted to the trauma unit between 2008–2011. Patients’ demographics, injuries, complications and mortality were analysed.Results: Of 1665 cases of head injury, 107 (6.4%) had RRI. The majority of cases were males with mean age of 27 ± 12, injury severity score of 14 ± 8 and head abbreviated injury score of 3.2 ± 0.9. Mechanisms of injury included All-Terrain Vehicle, Jet-skiing, football and water-boat. Patients sustained RRI mainly had contusion followed by subarachnoid haemorrhage, subdural and epidural haematoma. Upper extremities and the chest were the most frequently associated injuries. Severe head injuries were observed in 18% of patients with Glasgow Coma Score <8. Median length of stay was 4 (1–67) days. The incidence of RRI was highest amongst Asians (66%) and nationals (23%). The overall mortality among patients with RRI was 7%.Conclusion: RRI causes significant morbidity and mortality. An urgent need is recommended for legislative amendment and public awareness for safety regulations during recreational activities involving potential risk of trauma.

Rehabilitation after trauma; does age matter?

BackgroundVariability exits in the ability to predict overall recovery after trauma and inpatient rehabilitation. The aim of this study was to identify factors predicting functional improvement in trauma patients undergoing inpatient rehabilitation. MethodsWe performed a 3-y retrospective cohort analysis on a prospectively collected database of all trauma patients discharged from a level I trauma center to a single inpatient rehabilitation center. Patient's Functional Independence Measures (FIM) scores on hospital discharge and on discharge from the rehabilitation center were collected. Delta FIM was defined as the difference in FIM between rehabilitation center discharge and hospital discharge. Multiple linear regressions were performed to identify hospital admission factors associated with delta FIM. ResultsWe included 160 patients, 69% were male, mean age 54.6 ± 22 y, and median Injury Severity Score 14 [10–50]. Based on rehabilitation admission FIM scores, 29 were totally dependent and 131 were partially dependent. The mean change in FIM was 39.4 ± 13. Age, gender, Glasgow Coma Scale on presentation, Injury Severity Score, systolic blood pressure on presentation, and intensive care unit length of stay were not predictive of delta FIM. Hospital length of stay and head Abbreviated Injury Score on hospital admission were negative predictors of delta FIM. ConclusionsIn our study, age as an independent factor was not predictive of functional outcome after injury. The extent of head injury continues to negatively affect the overall functional improvement based on FIM.

The coast and benefits of helicopter emergency medical services instead of the ground unit in traumatic patients: A cost-effectiveness analysis

Study objective: Aero medical crews offer an advanced level of practice and rapid transport to definitive care; however, their efficacy remains unproven. Previous studies have used relatively small sample sizes or have been unable to adequately control the effect of other potentially influential variables. Here we explore the impact of aeromedical response in patients with moderate to severe traumatic brain injury. Methods: This was a cross-sectional study using our county trauma registry. All patients with trauma injury, who referred to our emergency department by helicopter or car, were included. The impact of aeromedical response was determined using logistic regression, adjusting for age, sex, mechanism, preadmissionGlasgowComa Scale score and Injury Severity Score. Finally, the aeromedical patients undergoing field intubation were compared with ground patients undergoing emergency department (ED) intubation. Results: A total of 243 patients meeting all inclusion and exclusion criteria and with complete data sets were identified. Overall mortality was 25% in the air- and ground-transported cohorts, but outcomes were not significantly better for the aeromedical patients when adjusted for age, sex, mechanism of injury, hypotension, Glasgow Coma Scale score, head Abbreviated Injury Score, and Injury Severity Score (adjusted odds ratio [OR] 1.90; 95% confidence interval [CI] 1.60 to 2.25; P: 0001). Good outcomes (discharge to home, jail, psychiatric facility, rehabilitation, or leaving against medical advice) were also higher in aeromedical patients (adjusted OR 1.36; 95% CI 1.18 to 1.58; P: 0001). Conclusion: Here we analyze a large database of patients with moderate to severe traumatic brain injury. Aeromedical response appears to yield no significantly improved outcomes after adjustment for multiple influential factors in patients with moderate to severe traumatic brain injury.

Decreased Intracranial Pressure Monitor Use at Level II Trauma Centers is Associated with Increased Mortality

Previous investigations suggest outcome differences at Level I and Level II trauma centers. We examined use of intracranial pressure (ICP) monitors at Level I and Level II trauma centers after traumatic brain injury (TBI) and its effect on mortality. The 2007 to 2008 National Trauma Databank was reviewed for patients with an indication for ICP monitoring based on Brain Trauma Foundation (BTF) guidelines. Demographic and clinical outcomes at Level I and Level II centers were compared by regression modeling. Overall, 15,921 patients met inclusion criteria; 11,017 were admitted to a Level I and 4,904 to a Level II trauma center. Patients with TBI admitted to a Level II trauma center had a lower rate of Injury Severity Score greater than 16 (80 vs 82%, P<0.01) and lower frequency of head Abbreviated Injury Score greater than 3 (80 vs 82%, P<0.01). After regression modeling, patients with TBI admitted to a Level II trauma center were 31 per cent less likely to receive an ICP monitor (adjusted odds ratio [AOR], 0.69; P<0.01) and had a significantly higher mortality (AOR, 1.12; P<0.01). Admission to a Level II trauma center after severe TBI is associated with a decreased use of ICP monitoring in patients who meet BTF criteria as well as an increased mortality. These differences should be validated prospectively to narrow these discrepancies in care and outcomes between Level I and Level II centers.

Elevated systolic blood pressure after trauma: Tolerated in the elderly

BackgroundWe undertook the current study to determine the impact of elevated admission systolic blood pressure (SBP) on trauma patients without severe brain injury. Materials and methodsWe conducted a retrospective review of the Los Angeles County Trauma System database to identify all patients with moderate to severe injuries (injury severity score >9) admitted between 2003 and 2008. Patients with head abbreviated injury score >3 were excluded. We divided the remaining patients into three age cohorts and conducted multivariate regression modeling at increasing SBP thresholds to identify independent predictors of mortality. ResultsA total of 23,931 patients met inclusion criteria. Overall mortality was 8.6% and it increased with age across the three groups. The admission SBP thresholds associated with significantly increased mortality in the young and middle-aged were >190 mm Hg (AOR 1.5, P = 0.04) and >180 mm Hg (AOR 1.5, P = 0.01), respectively. In the elderly, no admission SBP threshold was associated with significantly increased mortality. Interestingly, several elevated admission SBP thresholds were associated with significantly reduced mortality in the elderly (>150 mm Hg AOR 0.6, P < 0.01; >160 mm Hg AOR 0.6, P < 0.01; and >170 mm Hg AOR 0.7, P = 0.02). ConclusionsThe admission SBP thresholds that predicted higher mortality for the young and middle-aged were >190 mm Hg and >180 mm Hg, respectively. Elderly trauma patients tolerated higher admission SBP than their younger counterparts and multiple elevated SBP thresholds were associated with significantly reduced mortality in the elderly.

Impact of Compliance with the American College of Surgeons Trauma Center Verification Requirements on Organ Donation-Related Outcomes

In order to maximize organ donation opportunities, the American College of Surgeons (ACS) requires verified trauma centers to have a relationship with an organ procurement organization (OPO), a policy for notification of the OPO, a process to review organ donation rates, and a protocol for declaring neurologic death. We hypothesized that meeting the ACS requirements will be associated with improved donation outcomes. Twenty-four ACS-verified Level I and Level II trauma centers were surveyed for the following registry data points from 2004 to 2008: admissions, ICU admissions, patients with a head Abbreviated Injury Score ≥ 5, deaths, and organ donors. Centers were also queried for the presence of the ACS requirements as well as other process measures and characteristics. The main outcomes measure was the number of organ donors per center normalized for patient volume and injury severity. The relationship between center characteristics and outcomes was determined. Twenty-one centers (88%) completed the survey and referred 2,626 trauma patients to the OPO during the study period, 1,008 were eligible to donate, and 699 became organ donors. Compliance with the 4 ACS requirements was not associated with increased organ donation outcomes. However, having catastrophic brain injury guidelines (CBIGs) and the presence of a trauma surgeon on a donor council were associated with significantly more organ donors per 1,000 trauma admissions (6.3 vs 4.2 and 6.0 vs 4.2, respectively, p < 0.05). Although the ACS trauma center organ donation-related requirements were not associated with improved organ donor outcomes, involvement of trauma surgeons on donor councils and CBIGs were and should be encouraged. Additionally, incorporation of quantitative organ donation measures into the verification process should be considered.

Beta-blocker exposure in the absence of significant head injuries is associated with reduced mortality in critically ill patients

BackgroundThe effect of β-blockade in trauma patients without significant head injuries is unknown. The purpose of this investigation was to determine the impact of β-blocker exposure on mortality in critically injured trauma patients who did not sustain significant head injuries. MethodsCritically ill trauma patients (Injury Severity Score ≥ 25) admitted to the surgical intensive care unit from January 2000 to December 2008 without severe traumatic brain injuries (head Abbreviated Injury Score ≥ 3) were included in this retrospective review. Patients who received β-blockers within 30 days of intensive care unit admission were compared with those who did not. The primary outcome measure evaluated was in-hospital mortality. ResultsDuring the 9-year study period, 663 critically injured patients (Injury Severity Score ≥ 25) were admitted to the intensive care unit. Of these, 98 patients (14.8%) received β-blockers. Patients exposed to β-blockers had significantly lower in-hospital mortality (11.2% vs 19.3%, P = .006). Stepwise logistic regression identified β-blocker use as an independent protective factor for mortality (adjusted odds ratio, .37; P = .007) in critically injured patients. ConclusionsBeta-blocker exposure was associated with reduced mortality in critically injured patients without head injuries. Prospective validation of this finding is warranted.