Included Injury Severity Score Research Articles

The variation of acute treatment costs of trauma in high-income countries

Background: In order to assist health service planning, understanding factors that influence higher trauma treatment costs is essential. The majority of trauma costing research reports the cost of trauma from the perspective of the receiving hospital. There has been no comprehensive synthesis and little assessment of the drivers of cost variation, such as country, trauma, subgroups and methods. The aim of this review is to provide a synthesis of research reporting the trauma treatment costs and factors associated with higher treatment costs in high income countries. Methods: A systematic search for articles relating to the cost of acute trauma care was performed and included studies reporting injury severity scores (ISS), per patient cost/charge estimates; and costing methods. Cost and charge values were indexed to 2011 cost equivalents and converted to US dollars using purchasing power parities. Results: A total of twenty-seven studies were reviewed. Eighty-one percent of these studies were conducted in high income countries including USA, Australia, Europe and UK. Studies either reported a cost (74.1%) or charge estimate (25.9%) for the acute treatment of trauma. Across studies, the median per patient cost of acute trauma treatment was $22,448 (IQR: $11,819-$33,701). However, there was variability in costing methods used with 18% of studies providing comprehensive cost methods. Sixty-three percent of studies reported cost or charge items incorporated in their cost analysis and 52% reported items excluded in their analysis. In all publications reviewed, predictors of cost included Injury Severity Score (ISS), surgical intervention, hospital and intensive care, length of stay, polytrauma and age. Conclusion: The acute treatment cost of trauma is higher than other disease groups. Research has been largely conducted in high income countries and variability exists in reporting costing methods as well as the actual costs. Patient populations studied and the cost methods employed are the primary drivers for the treatment costs. Targeted research into the costs of trauma care is required to facilitate informed health service planning.

The variation of acute treatment costs of trauma in high-income countries.

BackgroundIn order to assist health service planning, understanding factors that influence higher trauma treatment costs is essential. The majority of trauma costing research reports the cost of trauma from the perspective of the receiving hospital. There has been no comprehensive synthesis and little assessment of the drivers of cost variation, such as country, trauma, subgroups and methods. The aim of this review is to provide a synthesis of research reporting the trauma treatment costs and factors associated with higher treatment costs in high income countries.MethodsA systematic search for articles relating to the cost of acute trauma care was performed and included studies reporting injury severity scores (ISS), per patient cost/charge estimates; and costing methods. Cost and charge values were indexed to 2011 cost equivalents and converted to US dollars using purchasing power parities.ResultsA total of twenty-seven studies were reviewed. Eighty-one percent of these studies were conducted in high income countries including USA, Australia, Europe and UK. Studies either reported a cost (74.1%) or charge estimate (25.9%) for the acute treatment of trauma. Across studies, the median per patient cost of acute trauma treatment was $22,448 (IQR: $11,819-$33,701). However, there was variability in costing methods used with 18% of studies providing comprehensive cost methods. Sixty-three percent of studies reported cost or charge items incorporated in their cost analysis and 52% reported items excluded in their analysis. In all publications reviewed, predictors of cost included Injury Severity Score (ISS), surgical intervention, hospital and intensive care, length of stay, polytrauma and age.ConclusionThe acute treatment cost of trauma is higher than other disease groups. Research has been largely conducted in high income countries and variability exists in reporting costing methods as well as the actual costs. Patient populations studied and the cost methods employed are the primary drivers for the treatment costs. Targeted research into the costs of trauma care is required to facilitate informed health service planning.

Injury patterns of seniors in traffic accidents: A technical and medical analysis

To investigate the actual injury situation of seniors in traffic accidents and to evaluate the different injury patterns. Injury data, environmental circumstances and crash circumstances of accidents were collected shortly after the accident event at the scene. With these data, a technical and medical analysis was performed, including Injury Severity Score, Abbreviated Injury Scale and Maximum Abbreviated Injury Scale. The method of data collection is named the German In-Depth Accident Study and can be seen as representative. A total of 4430 injured seniors in traffic accidents were evaluated. The incidence of sustaining severe injuries to extremities, head and maxillofacial region was significantly higher in the group of elderly people compared to a younger age (P < 0.05). The number of accident-related injuries was higher in the group of seniors compared to other groups. Seniors are more likely to be involved in traffic injuries and to sustain serious to severe injuries compared to other groups.

Significance of early detection of N-terminal pro-B-type natriuretic peptide in patients with severe trauma

Objective To detect the serum NT-proBNP level in patients with severe trauma 24 hours after injury in order to find the possible correlated factors for the evaluation of the clinical application.Methods Sixty patients with severe trauma admitted to the emergency ICU were enrolled. Serum NTproBNP level was detected 24 hours after injury for comparison between survivors and nonsurvivors. The validity of NT-proBNP for predicting outcome was analyzed by receiver operating characteristic ( ROC )curve. The factors with significant correlation between NT-proBNP level and the length of ICU stay as well as the duration of mechanical ventilation support were determined in those survivors with correlation and stepwise linear regression analysis. These factors included injury severity score (ISS), head abbreviated injury score (AIS), acute physiology and chronic health evaluation Ⅱ ( APACHE I ), Glasgow coma score (GCS), creatine kinase-MB (CK-MB), cardiac troponin-I (cTn-I) and central venous pressure. Results The median NT-proBNP levels were 762 pg/ml (IQR, 400-1131 pg/mL) in nonsurvivors versus 200 pg/ml (IQR, 80-383 pg/mL) in survivors (Z =-3. 972, P ＜0.01 ). The area under ROC curve of NTproBNP was not statistically different to that of ISS and that of APACHE Ⅱ. The best threshold value of NTproBN to predict the outcome was 384 pg/ml ( sensitivity 0. 846, specifity 0. 766). A positive correlation was found between NT-proBNP and the length of ICU stay ( r =0. 32, P ＜ 0. 05 ) as well as the duration of mechanical ventilation ( r =0. 37, P ＜ 0. 05 ) in survivors. Stepwise linear regression analysis indicated there were significant correlations between APACHE Ⅱ, CK-MB and NT-proBNP. Conclusions Serum NT-proBNP level 24 hours after injury is correlated with the severity and outcome of patients with severe trauma. It may be used as a complementary biomarker for the rapid assessment of the severity of trauma. Key words: Major trauma; N-terminal pro-B-type natriuretic peptide; Prognosis

Active and passive cigarette smoking and acute lung injury after severe blunt trauma.

Cigarette smoking has been demonstrated in laboratory studies to have effects on lung epithelial and endothelial function similar to those observed in acute lung injury (ALI). However, the association between active and passive cigarette smoke exposure and susceptibility to ALI has not been prospectively studied. We hypothesized that both active and passive cigarette smoke exposure would be associated with increased susceptibility to ALI after severe blunt trauma. We measured levels of cotinine, a metabolite of nicotine and validated biomarker of tobacco use, in plasma samples obtained immediately on arrival at the emergency department from 144 adult subjects after severe blunt trauma. Patients were then followed for the development of ALI. Increasing quartiles of plasma cotinine were associated with the development of ALI (odds ratio [OR] for developing ALI in highest cotinine quartile, 3.25; 95% confidence interval [CI], 1.22-8.68; P = 0.017 for trend across quartiles). Moderate to heavy passive smoke exposure was associated with nearly the same odds of developing ALI as active smoking (OR for moderate to heavy passive smoking compared with no exposure or low level exposure, 3.03; 95% CI, 1.15-8.04; OR for active smoking, 2.77; 95% CI, 1.28-5.99). This association persisted after adjusting for other predictors of ALI, including Injury Severity Score and alcohol abuse. Both moderate to heavy passive smoking and active smoking are independently associated with the development of ALI after severe blunt trauma. This finding has important implications both for public health and for understanding the pathogenesis of ALI.

Socio-economic outcome after blunt orthopaedic trauma: Implications on injury prevention

BackgroundSeveral large studies have identified factors associated with long-term outcome after orthopaedic injuries. However, long-term social and economic implications have not been published so far. The aim of this investigation is to study the long-term socio-economic consequences of patients sustaining severe trauma.MethodsPatients treated at a level one trauma center were invited for a follow-up (at least 10 years) examination. There were 637 patients who responded and were examined. Inclusion criteria included injury severity score (ISS) ≥ 16 points, presence of lower and upper extremity fractures, and age between 3 and 60 years. Exclusion criteria included the presence of amputations and paraplegia. The socio-economic outcome was evaluated in three age groups: group I (< 18 years), group II (19 - 50 years), and group III (> 50 years). The following parameters were analyzed using a standardized questionnaire: financial losses, net income losses, pension precaution losses, need for a bank loan, and the decrease in number of friends.Results510 patients matched all study criteria, and breakdown of groups were as follows: 140 patients in group I, 341 patients in group II, and 29 patients in group III. Financial losses were reported in all age groups (20%-44%). Younger patients (group I) were associated with less income losses when compared with other groups (p < 0.05). Financial deterioration was more frequently reported in age group II (p < 0.05). Social consequences (number of friends decreased) were predominantly stated in patients younger than 18 years old (p < 0.05).ConclusionsEconomic consequences are reported by polytraumatized patients even ten or more years after injury. Financial losses appear to be common in patients between 19 and 50 years. In contrast, social deprivation appears to be most pronounced in the younger age groups. Early socio-economic support and measures of injury prevention should focus on these specific age groups.

Urgent thoracotomy for penetrating chest trauma: Analysis of 158 patients of a single center

Background Penetrating injuries to the chest present a frequent and challenging problem, but the majority of these injuries can be managed non-\\operatively. The aim of this study was to describe the incidence of penetrating chest trauma and the ultimate techniques used for operative management, as well as the diagnosis, complications, morbidity and mortality. Methods A retrospective 9-year review of patients who underwent an operative procedure following penetrating chest trauma was performed. The mechanism of injury, gender, age, physiological and outcome parameters, including injury severity score (ISS), chest abbreviated injury scale (AIS) score, lung injury scale score, concomitant injuries, time from admission to operating room, transfusion requirement, indications for thoracotomy, intra-operative findings, operative procedures, length of hospital stay (LOS) and rate of mortality were recorded. Results A total of 1123 patients who were admitted with penetrating thoracic trauma were investigated. Of these, 158 patients (93 stabbings, 65 gunshots) underwent a thoracotomy within 24 h after the penetrating trauma. There were 146 (92.4%) male and 12 (7.6%) female patients, and their mean age was 25.72 ± 9.33 (range, 15–54) years. The mean LOS was 10.65 ± 8.30 (range, 5–65) days. Patients admitted after a gunshot had a significantly longer LOS than those admitted with a stab wound (gunshot, 13.53 ± 9.92 days; stab wound, 8.76 ± 6.42 days, p < 0.001). Patients who died had a significantly lower systolic blood pressure (SBP) on presentation in the emergency room (42.94 ± 36.702 mm Hg) compared with those who survived (83.96 ± 27.842 mm Hg, p = 0.001). The overall mortality rate was 10.8% ( n = 17). Mortality for patients with stab wounds was 8/93 (8.6%) compared with 9/65 (13.8%) for patients with gunshot wounds ( p = 0.29). Concomitant abdominal injuries ( p = 0.01), diaphragmatic injury ( p = 0.01), ISS ( p = 0.001), chest AIS score ( p < 0.05), ongoing output ( p = 0.001), blood transfusion volume ( p < 0.01) and SBP ( p = 0.001) were associated with mortality. Conclusion Penetrating injuries to the chest requiring a thoracotomy are uncommon, and lung-sparing techniques have become the most frequently used procedures for lung injuries. The presence of associated abdominal injuries increased the mortality five-fold. Factors that affected mortality were ISS, chest AIS score, SBP, ongoing chest output, blood transfusion volume, diaphragmatic injury and associated abdominal injury.

Does Platelet Administration Affect Mortality in Elderly Head-Injured Patients Taking Antiplatelet Medications?

A significant portion of patients sustaining traumatic brain injury (TBI) take antiplatelet medications (aspirin or clopidogrel), which have been associated with increased morbidity and mortality. In an attempt to alleviate the risk of increased bleeding, platelet transfusion has become standard practice in some institutions. This study was designed to determine if platelet transfusion reduces mortality in patients with TBI on antiplatelet medications. Databases from two Level I trauma centers were reviewed. Patients with TBI 50 years of age or older with documented preinjury use of clopidogrel or aspirin were included in our cohort. Patients who received platelet transfusions were compared with those who did not to assess outcome differences between them. Demographics and other patient characteristics abstracted included Injury Severity Score, Glasgow Coma Scale, hospital length of stay, and warfarin use. Three hundred twenty-eight patients comprised the study group. Of these patients, 166 received platelet transfusion and 162 patients did not. Patients who received platelets had a mortality rate of 17.5 per cent (29 of 166), whereas those who did not receive platelets had a mortality rate of 16.7 per cent (27 of 162) (P = 0.85). Transfusion of platelets in patients with TBI using antiplatelet therapy did not reduce mortality.

Severity of Injury and Outcomes Among Obese Trauma Patients With Fractures of the Femur and Tibia: A Crash Injury Research and Engineering Network Study

To understand the influence of obesity on the morbidity and mortality outcomes of patients who have sustained fractures of the femur and tibia. Retrospective review. Multicenter level I trauma facilities. Motor vehicle crash victims enrolled in multicenter databases were reviewed. Outcome measurements for obese (body mass index, BMI > or = 30 kg/m) versus nonobese (BMI < 30 kg/m) patients included Injury Severity Score, Abbreviated Injury Scores, OTA fracture types, length of hospital stay, disposition, complications, and 36-Item Short Form Survey Instrument. We included 665 cases from the database, of which 461 (69%) were nonobese and 204 (31%) were obese. There was no difference in sex, mechanism of injury, Injury Severity Score, and Abbreviated Injury Score. The obese population was older with a mean age of 44 years compared with 41 years for the nonobese (P < 0.01) and had a greater incidence of reported baseline cardiac disease (P < 0.01) and diabetes (P < 0.01). Obese patients had more severe injury patterns (OTA B and C type) in the distal femur fractures (90% versus 61%, P < 0.01). Mortality rates did not show a statistically significant difference (5.6% versus 9.4%, P = 0.07). The baseline physical component on the 36-Item Short Form Survey Instrument was lower among the obese but not statistically different (P = 0.08). At 6 and 12 months post injury, a decline was noted in both groups; however, no differential decline was noted between the groups (P > 0.05). Obese patients are significantly more likely to have more severe distal femur fractures compared with nonobese when involved in motor vehicle crashes. In this study, there was no statistically significant difference in length of stay, complications, or mortality in obese patients.

A Brief Report: The Use of High-Frequency Oscillatory Ventilation for Severe Pulmonary Contusion

Severe pulmonary contusions are a common cause of acute respiratory distress syndrome (ARDS) and are associated with significant morbidity. High frequency oscillatory ventilation (HFOV) is a ventilatory mode that employs a lung protective strategy consistent with the ARDSNet low tidal volume ventilation strategy and may result in reduced morbidity. The objective of this report is to examine the impact of HFOV on blunt trauma patients with severe pulmonary contusions who failed or were at a high risk of failing conventional mechanical ventilation. We undertook a retrospective chart review of all patients at our institution who received HFOV for severe pulmonary contusions. Patients were placed on HFOV when their mean airway pressure (mP(aw)) surpassed 30 cm H2O and their FIO2 was greater than 0.6. Baseline demographic data including injury severity score (ISS), length of time requiring HFOV, total ventilator days, and inhospital mortality were collected. Serial determinations of oxygenation index (OI) and the PaO2/FIO2 ratio (P/F) were made up to 72 hours after initiation of HFOV. A linear mixed model was used to analyze the slope (beta) of the regression line of P/F versus time and that of OI versus time. Seventeen patients were identified who underwent HFOV for ARDS due primarily to pulmonary contusions. Mean ISS was 36.6, mean APACHE II score was 21.7, and the mean time before initiation of HFOV was 2.0 days. P/F increased significantly after HFOV was initiated (beta = 12.1; 95% confidence interval 7.9 to 16.4, p < 0.001). OI significantly decreased after HFOV implementation (beta = -1.8; 95% confidence interval -2.3 to -1.3, p < 0.001). Mortality rate was 17.6%. The early use of HFOV appears to be safe and efficacious in blunt trauma patients sustaining pulmonary contusions, and results in a rapid improvement in OI and the P/F ratio.

Car Surfing: Case Studies of a Growing Dangerous Phenomenon

Car surfing is a dangerous new pastime for American youth. Car surfing is an activity that is defined as standing (or lying) on a vehicle while it is being driven. This activity frequently results in severe injuries that often require significant surgical intervention. Despite its destructive nature, however, there are many Internet sites that encourage this behavior and view it as amusing. As a result, car surfing is becoming increasingly popular. We conducted a retrospective chart review of all patients injured as a result of car surfing over the last 4 years at our Urban Level II trauma center. Data collected included Injury Severity Score (ISS), Revised Trauma Score (RTS), age, gender, injury pattern, surgical intervention, and length of stay. Eight car surfers were identified. The average age was 17. The average Revised Trauma Score was 6.8 with an average Injury Severity Score of 16.9. Five patients were admitted to the intensive care unit. Four of these five patients needed to be intubated for ventilatory support. Five of the eight patients had significant intracranial injuries. Two patients had epidural hematomas that required evacuation. Two other patients had subdural hematomas that were treated nonoperatively, and one patient had a subarachnoid hemorrhage that was also treated nonoperatively. Four of the eight patients required surgical intervention. There were no deaths in this study. Car surfing leads to severe injuries that can result in significant morbidity. American youth have access to Internet sites that project this activity as an acceptable behavior. Five of our eight patients had a significant intracranial injury. Trauma surgeons need to be more aware of this injury phenomenon.

Interhospital Transfer Occurs More Slowly for Elderly Acute Trauma Patients

The objective of this study was to determine whether elderly acutely injured patients take longer to be transferred from referring hospitals to a regional trauma center than younger patients. We reviewed all trauma patients transferred urgently to a regional trauma center over 2 years. We considered age ≥ 65 years to be elderly. We performed multivariable linear regression to determine the extra time spent at the referring hospital attributable to elderly status, after adjustment for confounders. For 371 transfers, mean Injury Severity Score was 12, and 12% of patients had hypotension before transfer. Mean time spent at the referring hospital was 233 ± 110 min. After adjustment for confounders, including Injury Severity Score and computed tomography (CT) scanning before transfer, elderly patients spent 32 min more at referring hospitals than non-elderly patients (95% confidence interval 1–63 min). We conclude that interhospital transfer of elderly acutely injured trauma patients takes longer than for younger patients. Providers may be less aggressive in treating elderly trauma patients.

Motorcycle Collisions Involving White-Tailed Deer in Central and Northern Wisconsin: A Rural Trauma Center Experience

Risk of deer motorcycle collisions (DMC) continues to increase in Midwestern and East Coast States and is a growing regional public health issue. We conducted a retrospective chart review of all motorcycle collisions involving animals over a 9-year period from October 1993 to October 2002. Data collected included Injury Severity Score (ISS), injury type, outcome, use of helmets/alcohol, time of year/day. Fifty-five DMC were identified, 49 drivers, and 6 passengers. ISS for helmeted patients was 6.02+/-4.6 and 17.6+/-14.9 for non-helmeted patients. There were 7 human fatalities (all without helmets). Of the 55 patients, 16% of those injured were intoxicated, without helmets, and had average ISS higher than those non-intoxicated. Head, chest and orthopedic extremity trauma accounted for >70% of injuries seen within the entire population. Incidence peaked in June/July, and 55% of the collisions occurred between the hours of 1800 and 2200. DMC are a significant public health issue in mid-western states. Education about helmet and alcohol use and safety on rural roads may be the best prevention. Continued research focusing on prevention is necessary.

A leap in faith: the impact of removing the surgeon from the level II trauma response

Background Limitation of resident work hours has created the need to explore alternatives to surgeon presence during initial assessment and resuscitation for selected life-threatening injuries in children. We recently eliminated the requirement for surgeon presence during Level II alerts. The purpose of this study was to evaluate the impact of this change on patient care. Methods A retrospective analysis of trauma alert activity was performed using data from our trauma registry. In March 2003, responsibility for level II alerts was transferred from the pediatric surgeons (PSs) to the Emergency Department (ED) physicians. We compared the activity in the 18-month period before this change (period 1; n = 627) to that afterward (period 2; n = 587). Outcome measures included injury severity score, emergency department length of stay, missed injuries, abdominal computed tomography use, and mortality. Data were analyzed using log-rank statistic, χ 2, or t test, where appropriate, with significance level at P < .05. Results During the entire study period, 1499 patients met the trauma alert activation criteria of which 1214 (81%) were level II alerts. The mean injury severity score for period 1 (8.5 ± 7.3 SD) was similar to period 2 (9.0 ± 7.1 SD). When ED physicians replaced PS for Level II alerts, ED length of stay increased from 135 minutes to 165 minutes ( P < .001). In addition, the use of abdominal computed tomography was significantly decreased (53.6% vs 42.6%; P < .001). However, there were no missed injuries and no significant differences in the rate of mortality. Conclusions When ED physicians replaced PS for Level II alerts, trauma room length of stay was increased, but use of abdominal imaging was decreased with no differences in rate of missed injury or mortality. Emergency Department physicians can safely replace PS during Level II alerts. These findings may be useful to institutions experiencing surgical workforce limitations for trauma alerts.

Profile of mothers at risk: An analysis of injury and pregnancy loss in 1,195 trauma patients

Trauma is the number one cause of maternal death during pregnancy, but incidence of fetal loss exceeds maternal loss by more than 3 to 1. We hypothesized that we could identify women at risk for injury during pregnancy and focus our prevention efforts. Women of childbearing age in the American College of Surgeon's National Trauma Data Bank served as the study population. Pregnant patients were compared with nonpregnant patients with respect to age, race, mechanism of injury, injury patterns and severity, risk-taking behaviors, and outcomes. Multivariate logistic regression analysis was used to identify risk factors for loss of pregnancy in mothers who survived their trauma. Pregnant trauma patients (n = 1,195) were younger, less severely injured, and more likely to be African American or Hispanic as compared with the nonpregnant cohort (n = 76,126). Twenty percent of injured pregnant patients tested positive for drugs or alcohol, and approximately one-third of those involved in motor vehicle crashes were not using seatbelts. Independent risk factors for fetal loss after trauma included Injury Severity Score > 15; Adjusted Injury Score > or = 3 in the head, abdomen, thorax, or lower extremities; and Glasgow Coma Score < or = 8. Young, African-American, and Hispanic pregnant women are at higher risk for trauma in pregnancy and are most likely to benefit from primary trauma prevention efforts. Those with severe head, abdominal, thoracic, or lower extremity injuries are at high risk for pregnancy loss. Reduction of secondary insults and early recognition of fetal distress may improve outcomes for both the mother and fetus in this high-risk group.

Angiographic embolization for liver injuries: low mortality, high morbidity.

Angiographic embolization (AE) is a safe and effective method for controlling hemorrhage in both blunt and penetrating liver injuries. Improved survival after hepatic injuries has been documented using a multimodality approach; however, patients still have significant long-term morbidity. This study examines further the role of AE in both blunt and penetrating liver injuries and the outcomes of its use. The medical records of 37 consecutive patients admitted from 1995 to 2002 to a Level I trauma center who underwent hepatic angiography with the intent to embolize were reviewed. Demographic and clinical information including Injury Severity Score, length of stay, mortality, intra-abdominal complications, admission physiologic variables, and the number and type of abdominal operations performed were collected. Thirty-seven patients underwent hepatic angiography and 26 patients had hepatic embolization performed. Eleven patients underwent early-AE, immediately after computed tomographic scanning, and 15 underwent late-AE, after liver-related operations or later in their hospital course. There was a 27% mortality rate overall. There were 11 liver-related complications in the 26 embolizations. Excluding the early deaths, the associated morbidity was 58%, which included hepatic necrosis, hepatic abscesses, and bile leaks. There is increasing adjunctive use of AE in patients managed both operatively and nonoperatively. Intra-abdominal complications are common in these salvaged patients with severe liver injuries. Those patients that underwent early-AE received significantly fewer blood transfusions and more commonly had sterile hepatic collections. Only 26% of patients required liver-related surgery after AE. Therefore, the integration of AE as an adjunctive modality for patients with high-grade liver injuries is a safe and effective therapeutic option.

Are automated blood pressure measurements accurate in trauma patients?

Automated blood pressure (BP) determinations by oscillometry are reported to be as accurate as invasive monitoring for systolic pressures as low as 80 mm Hg. Automated BP devices are widely used by prehospital providers and in hospital operating rooms, emergency departments, and intensive care units, although the accuracy of automated BP has not been demonstrated in trauma patients. We hypothesized that automated BP is less accurate than manual BP in trauma patients. The purpose of this study was to determine the accuracy of automated BP versus manual BP in trauma patients. A retrospective review of patients who met trauma activation criteria admitted to a Level I trauma center over a 30-month period was conducted. Patients were included if both manual BP and automated BP were measured within 5 minutes of admission. Additional data collected included Injury Severity Score, base deficit, and emergency department resuscitation volume. Statistical analysis was performed using paired t test, chi2, and linear regression analysis. Significance was attributed to a value of p < 0.05. From January 2000 through June 2002, 388 patients met inclusion criteria. Patients were grouped by manual BP levels: group 1, BP < or = 90 mm Hg (n = 92); group 2, BP 91-110 mm Hg (n = 119); and group 3, BP > or = 110 mm Hg (n = 177). The mean automated BP measurements were significantly higher than the manual measurements in groups 1 and 2 (26 and 16 mm Hg, respectively; p < 0.001). Of the 92 patients with manual BP < or = 90, 45 (49%) had automated BP > or = 100. The base deficit (-5, -3, and -2 for groups 1, 2, and 3, respectively; p < 0.01), Injury Severity Score (30, 25, and 18; p < 0.01), and volume of resuscitative fluid and blood (p < 0.001) all decreased with higher BP group. Injury severity, degree of acidosis, and resuscitation volume were more accurately reflected by manual BP. Automated BP determinations were consistently higher than manual BP, particularly in hypotensive patients. Automated BP devices should not be used for field or hospital triage decisions. Manual BP determinations should be used until systolic blood pressure is consistently > or = 110 mm Hg.

Life on the farm—children at risk

Background: More than 1 million children live, play, and work on farms, surrounded by animals and machinery. This symbiotic relationship between work and home exposes children to unique risks. Methods: Children presenting with a farm-related injury (November 1994 to August 2001, 82 months) were included. Trauma registry parameters included injury severity score (ISS); Glascow Coma Scale (GCS); time to presentation; season and day of injury; emergency room, intensive care unit, and total length of stay type; and mechanism of injury; and operations. Results: A total of 1,832 pediatric trauma patients were evaluated. Ninety-four children were identified with farm-related injuries. Mean age was 10.75 years. Mean ISS was 7.38. Three children died. Four children wore protective equipment. Forty-four percent of injuries occurred during summer, 31% during spring, and 55% on weekends. Average time to initial presentation was 39 minutes. A total of 177 minutes elapsed before transfer to regional trauma center. Seventy-two children required admission. LOS was 0 to 28 days, mean, 2.76 days. Twenty-six children (28%) required operations. Injuries included dislocations/fractures (52%), lacerations/avulsions (38%), concussions (31%), contusions (30%), and burns (14%). Mechanism included animals (41%), falls (34%), motor vehicles (28%), all-terrain vehicles (20%), and firearms (4%). Conclusions: Farm injuries occur most commonly during weekends, summer, and spring months, resulting in significant morbidity. Most injuries required hospitalization. Unless unstable, initial transfer to a regional pediatric trauma center should result in the most cost-effective, prompt, and highest quality of care. J Pediatr Surg 38:804-807. © 2003 Elsevier Inc. All rights reserved.

A statewide population-based study of gender differences in trauma: validation of a prior single-institution study.

Women usually have lower mortality rates than men do at any age. This pattern is observed for most causes of death from chronic diseases. Significant controversy still exists about gender differences in outcomes in trauma. We previously reported no differences in in-hospital mortality based on gender in a large single-institution study (n= 18,892) that had a significant limitation in that it was not population based. This current study was performed to validate our earlier findings in a separate, statewide, population-based dataset of trauma victims. Prospective data were collected on 22,332 trauma patients (18,432 blunt, 3,900 penetrating) admitted to all trauma centers (n = 26) in Pennsylvania over 24 months (January 1996 to December 1997). Gender differences in in-hospital mortality were determined for the entire dataset and for the subsets of blunt and penetrating injury patients. A second analysis examined all blunt injury patients and excluded all patients with a hospital length of stay of less than 24 hours, eliminating patients who expired soon after admission. The null hypothesis was that female gender is protective in trauma outcomes. Multiple logistic regression analysis identified age (odds ratio [OR] 1.03, confidence interval [CI] 1.02 to 1.03), Injury Severity Score (OR 1.06, CI 1.05 to 1.06), non-Caucasian race (OR 1.72, CI 1.39 to 2.15), blunt injury type (OR 0.327, CI 0.26 to 0.41), and Revised Trauma Score (OR 0.44, CI 0.41 to 0.47) as independent predictors of in-hospital mortality in trauma. Preexisting diseases, including cardiac disease (OR 1.53, CI 1.12 to 2.09) and malignancy (OR 4.08, CI 1.64 to 10.17), were also identified as independent predictors of in-hospital mortality in trauma. Female gender was not associated with decreased mortality (OR 0.83, CI 0.67 to 1.03, p = 0.093). A second multiple regression analysis in blunt trauma patients admitted for longer than 24 hours (which eliminated early deaths and patients with minor injuries) determined that in-hospital mortality was not significantly different in male or female blunt trauma patients stratified by Injury Severity Score and age. The same factors that were predictive of in-hospital mortality in the total dataset were also significant in this secondary analysis. These population-based data confirm that female gender does not adversely affect in-hospital mortality in trauma when patients are appropriately stratified for other variables, including Injury Severity Score and age, that do significantly affect outcomes.

Validation of new trauma triage rules for trauma attending response to the emergency department.

The American College of Surgeons Committee on Trauma has suggested triage criteria for the immediate attendance of a trauma surgeon to an injured patient in the emergency department. This study validates the accuracy of these criteria in identifying high-risk trauma patients and assesses the impact of trauma surgeon response time. A study group of trauma patients with a systolic blood pressure (SBP) < 90 mm Hg, Glasgow Coma Scale (GCS) score < 8, airway compromise managed with endotracheal intubation (ETI) or surgical airway, or gunshot wound (GSW) to the neck or torso were compared with a control group of patients meeting none of these criteria. Outcome measurements included Injury Severity Score (ISS), duration of hospitalization (length of stay [LOS]), intensive care unit (ICU) days, direct transfer to the ICU or operating room, and mortality. For the study group, trauma surgeon response times, < or = 15 minutes and > 15 minutes, were compared for age, ISS, LOS, ICU days, mortality, and direct transfer to the ICU or operating room. Statistical analysis was performed using the t test and the Yates-corrected chi(2) test (p < 0.05), with odds ratios calculated on the basis of trauma activation criteria and outcome measures. Multiple logistic regression was used to assess the relation between the independent variables SBP, GCS, ETI, and GSW with direct transfer to the ICU or operating room and mortality. A total of 4,910 patients were identified, including 791 study group patients. The mean ISS, LOS, ICU days, and mortality were significantly higher in the study group (p < 0.01). Odds ratios of the study group for direct transfer to the ICU or operating room were 91 and 2 for ETI, 23 and 1.4 for GCS score < 8, 8 and 2.2 for GSW, and 7 and 1.6 for SBP < 90 mm Hg, respectively. The odds ratios for mortality were 39 for ETI, 104 for GCS score < 8, 12 for GSW, and 74 for SBP < 90 mm Hg. Regression analysis demonstrated that GSW, SBP < 90 mm Hg, and ETI predicted ICU admission; GSW, SBP < 90 mm Hg, and ETI predicted operative intervention; and GCS score < 8, SBP < 90 mm Hg, and ETI were associated with mortality. Trauma surgeon response times were available for 658 (83%) of the study group patients. No significant differences were found between the two response groups. Trauma patients meeting the triage criteria proposed by the American College of Surgeons Committee on Trauma have more severe injuries, a higher mortality rate, and longer hospital and ICU stays than control patients. SBP < 90 mm Hg, ETI, and GSW are predictive of urgent operating room use and ICU admission. A significantly higher mortality rate is associated with SBP < 90 mm Hg, ETI, and GCS score < 8. Incorporating these criteria into trauma center triage rules to identify high-risk injured patients is warranted. However, trauma surgeon response time < or = 15 minutes was not associated with improved patient outcome, and optimal response time remains uncertain.