Increased Injury Severity Research Articles

Altered leucocyte progenitor profile in human bone marrow from patients with major trauma during the recovery phase

Changes in human bone marrow associated with the systemic inflammatory response to injury are little understood. It was hypothesized that major trauma results in an altered bone marrow leucocyte progenitor profile, with either uniform depletion or the balance between multipotent and committed progenitors varying, depending on whether self-renewal is favoured over differentiation. Bone marrow aspirate and peripheral blood samples were obtained at definitive surgery in adults with pelvic fractures from blunt trauma (major trauma with Injury Severity Score (ISS) at least 18, or isolated fractures) and control patients undergoing iliac crest bone grafting. ISS, interval to surgery and transfusion in the first 24 h were recorded. Bone marrow aspirate flow cytometry was used to identify haemopoietic progenitor cells (CD34(+) ), multipotent cells (CD34(+) CD45(+) CD38(-) ) and oligopotent cells (CD34(+) CD45(+) CD38(lo/+) and CD34(+) CD45(+) CD38(BRIGHT(++ +)) subsets). Peripheral blood levels of inflammatory markers were measured, and the ratio of immature to mature (CD35(-) /CD35(+) ) granulocytes was determined. The median (range) interval between injury and sampling was 7 (1-21) and 5 (1-21) days in the major trauma and isolated fracture groups respectively. The CD34(+) pool was significantly depleted in the major trauma group (P = 0·017), particularly the CD34(+) CD45(+) CD38(BRIGHT(++ +)) oligopotent pool (P = 0·003). Immature CD35(-) granulocytes increased in bone marrow with increasing injury severity (P = 0·024) and massive transfusion (P = 0·019), and in peripheral blood with increasing interval to surgery (P = 0·005). Major blunt trauma resulted in changes in the bone marrow CD34(+) progenitor pool. At the point in recovery when these samples were obtained, oligopotent progenitors were lost from the bone marrow, with continued release of immature cells.

Factors Associated With Early Magnetic Resonance Imaging Utilization for Acute Occupational Low Back Pain

A population-based, prospective cohort study. To identify demographic, job-related, psychosocial, and clinical factors associated with the use of magnetic resonance imaging (MRI) within 6 weeks from injury (early MRI) among workers' compensation claimants with acute occupational low back pain (LBP). Early MRI may be associated with increased use of services for treatment and costs. To understand utilization and most appropriately apply guidelines, it is important to identify factors associated with early imaging use for occupational LBP. Workers (N = 1830) were interviewed 3 weeks (median) after submitting a workers' compensation claim for a back injury. Demographic, work, health, clinical, and injury characteristics were ascertained from interviews, medical records, and administrative data. Modified Poisson regression analyses identified factors associated with early MRI use. Among respondents, 362 (19.8%) received an early MRI. Multivariable regression showed that male workers were 43% more likely to receive an early MRI than female workers (incident rate ratio [IRR]: 1.43, 95% confidence interval [CI]: 1.12-1.82). Initial visit type with a surgeon was associated with 78% greater likelihood of receiving an early MRI than that with a primary care physician (IRR: 1.78, 95% CI: 1.08-2.92). Having a chiropractor as the initial provider was associated with a reduced likelihood of early MRI (IRR: 0.53, 95% CI: 0.42-0.66). Workers with elevated work fear-avoidance, higher Roland scores, or increased injury severity were more likely to receive early MRI than counterparts with lower levels or scores. Nearly 20% of the injured workers with LBP receive early MRI, a rate similar to that reported elsewhere. Early MRI may lead to greater subsequent interventions, potentially poorer outcomes, and increased health care expenditures. On the basis of the characteristics of patients with uncomplicated occupational LBP, providers may be able to provide tailored care, and providers and policy makers may better understand the utilization of imaging and adherence to clinical guidelines.

Effect of the elderly and increasing injury severity on acute hospital resource utilization in a cohort of inner city trauma patients

This study aimed to determine the relative effect of elderly patients and increasing injury severity on acute hospital costs and inpatient length of stay. A prospective study of all trauma team activations at a single inner city trauma centre was conducted over a 1-year period. Costs were imputed using Australian Refined Diagnosis-Related Groups. Costs and inpatient length of stays were compared between elderly (age ≥65 years) and non-elderly patients. Relative effects of increasing injury severity score (ISS) and age categories were modelled using generalized linear regression. Over the study period, 1096 consecutive patients were studied. Falls were the most common mechanism and contributed the highest proportion of aggregate costs. There was a moderately high correlation between cost and ISS (Spearman's rank correlation coefficient 0.65, P < 0.001). Median costs for elderly patients were around three times higher than that for non-elderly patients and median length of stay was over twice that of non-elderly patients (7 days versus 3 days, P < 0.001). After adjusting for injury severity, the predicted costs of elderly trauma patients were around 30% higher compared with non-elderly patients. An increasing effect of injury severity on cost was observed across minor and major trauma. Both injury severity and elderly patients have a significant impact on acute hospital costs across the spectrum of major and minor trauma.

An examination of the environmental, driver and vehicle factors associated with the serious and fatal crashes of older rural drivers

Motor vehicle crashes involving rural drivers aged 75 years and over are more than twice as likely to result in a serious or fatal injury as those involving their urban counterparts. The current study examined some of the reasons for this using a database of police-reported crashes (2004–2008) to identify the environmental (lighting, road and weather conditions, road layout, road surface, speed limit), driver (driver error, crash type), and vehicle (vehicle age) factors that are associated with the crashes of older rural drivers. It also determined whether these same factors are associated with an increased likelihood of serious or fatal injury in younger drivers for whom frailty does not contribute to the resulting injury severity. A number of environmental (i.e., undivided, unsealed, curved and inclined roads, and areas with a speed limit of 100km/h or greater) and driver (i.e., collision with a fixed object and rolling over) factors were more frequent in the crashes of older rural drivers and additionally associated with increased injury severity in younger drivers. Moreover, when these environmental factors were entered into a logistic regression model to predict whether older drivers who were involved in crashes did or did not sustain a serious or fatal injury, it was found that each factor independently increased the likelihood of a serious or fatal injury. Changes, such as the provision of divided and sealed roads, greater protection from fixed roadside objects, and reduced speed limits, appear to be indicated in order to improve the safety of the rural driving environment for drivers of all ages. Additionally, older rural drivers should be encouraged to reduce their exposure to these risky circumstances.

Analysis of medical expenditure and socio-economic status in patients with ocular chemical burns in East China: a retrospective study

BackgroundLittle has been known regarding the relationship between ocular chemical injury and victims’ medical expenditure, income loss and socio-economic status changes. So we conduct this retrospective cross-sectional study in patients with ocular chemical burns in East China.MethodsFifty-six patients were enrolled and required to complete a self-report questionnaire consisting of the following contents: entire expenditure on medical treatment; the victims’ personal and household per capita income, and income loss caused by the injury; and the changes of socioeconomic status as well.ResultsThe median expense of medical treatment was CNY 40,000 (approximately US$5,900). The medical expenditure rose significantly with increased injury severity, prolonged hospital stay, and increased frequency of surgery. More than half victims (51.8 %, 29/56) paid all or the majority of medical expense by themselves. The expense of only 5 victims was mainly paid by medical insurance, accounting for less than ten percent (8.9 %, 5/56). The victims’ personal and household per capita income both decreased significantly after the injury, with the median reduction being CNY 24,000 and CNY 7,800 (approximately US$3600 and US$1200) per year respectively. The reduction amplitude of personal and household per capita income rose with increased injury severity and prolonged time of care required. The injury caused emotional depression or anxiety in 76.8 % (43/56) victims, and the relationship with their relatives got worse in 51.9 % (29/56) patients. Moreover, only 21.4 % (12/56) patients felt that the whole society gave them care and concern after the injury, whereas 46.4 % (26/56) and 28.6 % (16/56) felt indifference or discrimination from society as a whole (X2 = 16.916, P = 0.028).ConclusionsThe medical expense was a huge economic burden to most victims of ocular chemical burns, and personal and household per capita income of the victims decreased significantly after injury, both of which had a close relationship with the injury severity. Formal legislation was urgently needed to compel the employer to purchase injury or medical insurance and provide more compulsory protection to the population working in high risk occupations. In addition, psychological counseling and instruction shouldn’t be neglected in the aid and treatment of victims.

Elderly trauma patients have high circulating noradrenaline levels but attenuated release of adrenaline, platelets, and leukocytes in response to increasing injury severity

High patient age is a strong predictor of poor outcome in trauma patients. The present study investigated the effect of age on mortality and biomarkers of sympathoadrenal activation, tissue, endothelial, and glycocalyx damage, coagulation activation/inhibition, fibrinolysis, and inflammation in trauma patients at admission. Prospective observational study. Single level I trauma center. Eighty adult trauma patients (≥18 yrs) who met criteria for full trauma team activation and had an arterial cannula. Blood sampling a median of 68 min (interquartile range 48-88) post injury. Data on demography, biochemistry, Injury Severity Score, and 30-day mortality were recorded and plasma/serum was analyzed for biomarkers reflecting sympathoadrenal activation (adrenaline, noradrenaline), tissue/endothelial cell/glycocalyx damage (histone-complexed DNA fragments, annexin V, thrombomodulin, syndecan-1), platelet activation (soluble CD40 ligand), coagulation activation/inhibition (prothrombin fragment 1.2, thrombin/antithrombin complex, antithrombin, protein C, activated protein C, protein S, soluble endothelial protein C receptor, tissue factor pathway inhibitor, von Willebrand factor, fibrinogen, factor XIII), fibrinolysis (D-dimer, tissue-type plasminogen activator, plasminogen activator inhibitor-1), and inflammation (interleukin-6, terminal complement complex). Patients were stratified according to the median age (46 yrs) of the full cohort. Older trauma patients had markedly higher noradrenaline (p < .001) but an attenuated increase in adrenaline with increasing Injury Severity Score and lower platelets and leukocytes (both p < .05) compared to the younger patients. Older patients displayed a biomarker profile suggestive of enhanced release, activation, and consumption of the natural anticoagulants (low antithrombin, high activated protein C, protein S, and tissue factor pathway inhibitor) and hyperfibrinolysis (high tissue-type plasminogen activator) (all p < .05 vs. younger patients). Age was an independent predictor of mortality (hazard ratio 1.04 [95% confidence interval 1.01-1.07], p = .005) after adjusting for Injury Severity Score, prehospital Glasgow Coma Scale, and plasma catecholamines. In trauma patients, the association between age and mortality was confirmed. Older patients had high plasma noradrenaline but attenuated adrenaline release with higher Injury Severity Score, impaired platelet and leukocyte mobilization, enhanced consumption of anticoagulants, and hyperfibrinolysis, which may all contribute to the poor outcome in these patients.

Substance Use and Type and Severity of Injury Among Hospitalized Trauma Cases: Ohio, 2004–2007

The purpose of this study was to determine whether persons who were injured severely enough to require hospitalization suffered more severe injury when substance use was involved. This was accomplished by evaluating four proxy outcome measures with Ohio Trauma Registry data from January 2004 through December 2007. Four injury outcomes were identified: injury severity score, admission to an intensive care unit, presence of at least one medical complication, and hospital length of stay. We examined their association with substance (alcohol and/or other drug) use stratified by the likelihood of being tested for substance use, mechanism of injury, sex, age, race, and insurance status. Relative risks and t test scores were calculated. Among 89,129 trauma cases reported to the Ohio Trauma Registry during 2004-2007, more than 21% were substance users. Those younger than 45 years of age were 65% more likely to use substances than those 45 or older, men were 110% more likely than women, Blacks were 86% more likely than non-Blacks, and uninsured persons were 127% more likely than insured persons. Stratified analyses yielded 16 comparisons (4 Injury Outcomes × 4 Age-Insurance Subgroups). For 13 of these 16 comparisons, injury severity was significantly worse (p < .0001) among substance users than nonusers. The evidence is strong enough to conclude that, among hospitalized trauma patients, use of substances (alcohol and/or drug) was associated with increased injury severity. These findings appear to be true for the young and old, regardless of insurance status.

The Association of Social Functioning, Social Relationships and the Receipt of Compensation with Time to Return to Work Following Unintentional Injuries to Victorian Workers

Understanding individual factors associated with return to work (RTW) post-injury is an important goal of compensation systems research. The aim of the present study was to determine factors associated with time to return to work following acute unintentional injuries. A prospective cohort study was conducted in Victoria, Australia. The cohort comprised 133 persons who were employed at the time they were admitted to one of three study hospitals. Baseline health status data was obtained retrospectively at one-week post-injury and participants were further surveyed at 1, 6, 12, 26 and 52 weeks post-injury to measure recovery. Multivariate Cox proportional hazards regression analysis was used to examine the association between potential prognostic factors and time to RTW during the 12 month study. At the end of 12 months follow-up, 81.2% of the study cohort had returned to work. Older age, increased injury severity, self reported symptomatic pain and poor mental health at 1 week post-injury were associated with extended time to RTW. A significant statistical interaction between the receipt of compensation and high social functioning as measured by the SF-36 or strong social relationships as measured by the Assessment of Quality of Life was associated with earlier RTW. Participants reporting strong social relationships and high social functioning at 1 week post-injury and entitled to injury compensation returned to work 2.05 and 3.66 times earlier respectively, than similar participants with no entitlement to compensation. Both injury-related and psychosocial factors were associated with the duration of time to RTW following acute unintentional injuries. This study replicated previously reported findings on social functioning and compensation from an independent acute trauma sample. Programs or policies to improve social functioning early post-injury may provide opportunities to improve the duration of time to RTW following injury.

High levels of soluble VEGF receptor 1 early after trauma are associated with shock, sympathoadrenal activation, glycocalyx degradation and inflammation in severely injured patients: a prospective study

BackgroundThe level of soluble vascular endothelial growth factor receptor 1 (sVEGFR1) is increased in sepsis and strongly associated with disease severity and mortality. Endothelial activation and damage contribute to both sepsis and trauma pathology. Therefore, this study measured sVEGFR1 levels in trauma patients upon hospital admission hypothesizing that sVEGFR1 would increase with higher injury severity and predict a poor outcome.MethodsProspective observational study of 80 trauma patients admitted to a Level I Trauma Centre. Data on demography, biochemistry, Injury Severity Score (ISS), transfusions and 30-day mortality were recorded and plasma/serum (sampled a median of 68 min (IQR 48-88) post-injury) was analyzed for sVEGFR1 and biomarkers reflecting sympathoadrenal activation (adrenaline, noradrenaline), tissue injury (histone-complexed DNA fragments, hcDNA), endothelial activation and damage (von Willebrand Factor Antigen, Angiopoietin-2, soluble endothelial protein C receptor, syndecan-1, soluble thrombomodulin (sTM)), coagulation activation/inhibition and fibrinolysis (prothrombinfragment 1 + 2, protein C, activated Protein C, tissue-type plasminogen activator, plasminogen activator inhibitor-1, D-dimer) and inflammation (interleukin-6). Spearman correlations and regression analyses to identify variables associated with sVEGFR1 and its predictive value.ResultsCirculating sVEGFR1 correlated with injury severity (ISS, rho = 0.46), shock (SBE, rho = -0.38; adrenaline, rho = 0.47), tissue injury (hcDNA, rho = 0.44) and inflammation (IL-6, rho = 0.54) (all p < 0.01) but by multivariate linear regression analysis only lower SBE and higher adrenaline and IL-6 were independent predictors of higher sVEGFR1. sVEGFR1 also correlated with biomarkers indicative of endothelial glycocalyx degradation (syndecan-1, rho = 0.67), endothelial cell damage (sTM, rho = 0.66) and activation (Ang-2, rho = 0.31) and hyperfibrinolysis (tPA, rho = 0.39; D-dimer, rho = 0.58) and with activated protein C (rho = 0.31) (all p < 0.01). High circulating sVEGFR1 correlated with high early and late transfusion requirements (number of packed red blood cells (RBC) at 1 h (rho = 0.27, p = 0.016), 6 h (rho = 0.27, p = 0.017) and 24 h (rho = 0.31, p = 0.004) but was not associated with mortality.ConclusionssVEGFR1 increased with increasing injury severity, shock and inflammation early after trauma but only sympathoadrenal activation, hypoperfusion, and inflammation were independent predictors of sVEGFR1 levels. sVEGFR1 correlated strongly with other biomarkers of endothelial activation and damage and with RBC transfusion requirements. Sympathoadrenal activation, shock and inflammation may be critical drivers of endothelial activation and damage early after trauma.

Traumatic injury to the colon and rectum in Scotland: demographics and outcome

An analysis of a multi-centred database of trauma patients was performed. The study used data from a prospective multi-centre trauma database containing details of 52 887 trauma patients admitted to participating Scottish Hospitals over an 11-year period. Three hundred and forty (0.64%) of 52 887 trauma patients (284 male) with colorectal injuries were identified; 43.9% of colorectal injuries occurred following blunt trauma and 56.1% following penetrating injury. Patients in the latter group were younger, had less haemodynamic compromise and were less likely to die than those with blunt trauma (P < 0.01). The overall mortality rate was 25.6% and after rectal injury it was 21.2% (P > 0.05). Female gender, increased age, road traffic accidents and those admitted as a result of a blunt traumatic injury were associated with increased mortality. Age > 65 years (P = 0.01), increasing injury severity score (ISS) at presentation (P < 0.001), haemodynamic compromise (P = 0.045) and decreased Glasgow Coma Score (GCS) (P < 0.001) had the strongest independent associations with mortality. Colorectal injury after trauma has a high morbidity. Clinical features associated with death allow stratification of mortality risk.

Variation in the Use of Urgent Splenectomy After Blunt Splenic Injury in Adults

Recent reports indicate that mortality after trauma center admission may be directly related to the rate of operative intervention after blunt solid organ injury. These findings bring into question the role of urgent splenectomy after blunt splenic injury (BSI). The purpose of this study was to determine the role of urgent splenectomy (defined as splenectomy within 6 hours of admission) in the management of BSI as well as the relationship between urgent splenectomy and in-hospital mortality. The National Trauma Data Bank for 2007 was queried for adults (18-81) who suffered BSI. Patients who died in or were transferred from the emergency department were excluded. Hierarchical multivariate models were used to account for clustering of patients within hospitals and to identify hospital and patient factors associated with urgent splenectomy. Propensity score matching was used to analyze the relationship between urgent splenectomy and mortality. There were 507,202 total incidents identified. Of those, 11,793 met inclusion criteria. Urgent splenectomy was performed on 1,104 (9.4%). Hierarchical models revealed that age ≥55 years, arrival systolic blood pressure ≤90 mm Hg, no or mild head injury, increasing injury severity, and massive disruption of the spleen were associated with urgent splenectomy. Hospitals level factors associated with urgent splenectomy included hospital region, hospital type, and trauma center level. The propensity-matched cohorts revealed no association between urgent splenectomy and in-hospital mortality (odds ratio, 1.08; 95% confidence interval, 0.82-1.42). Despite ongoing variation in the use of urgent splenectomy after BSI in adults, urgent splenectomy was not associated with in-hospital mortality.

Risk of Venous Thromboembolism After Spinal Cord Injury: Not All Levels Are the Same

Venous thromboembolism (VTE), a diagnosis that includes both deep vein thrombosis and pulmonary embolism, is a well-recognized complication following injury. Previous studies have identified multiple risk factors including spinal cord injury (SCI). We hypothesized that the level of SCI also influences the likelihood of VTE. The National Trauma Data Bank was queried to identify all patients with SCI admitted in 2007 and 2008. Rates of VTE, demographics, admitting comorbidities, in-hospital complications, level of SCI (divided by National Trauma Data Bank into five groups), associated injuries, and outcome variables were abstracted. Multiple regression was used to identify independent risk factors for VTE. During the 2-year period, 18,302 patients were admitted with SCI. The overall rate of VTE was 4.3% but varied significantly depending on the level of SCI injury (χ(2), 44.8; p < 0.05). Patients with high cervical spine (C1-4) injury had a rate VTE of 3.4%, whereas patients with high thoracic spine (T1-6) injury had the highest rate of VTE at 6.3%. The lowest rate of VTE was in patients with lumbar injury (3.2%). There were no significant differences in the preexisting comorbidities or in-hospital complications among the five SCI groups with the exception of pneumonia. In a multiple logistic regression model, the level of SCI was an independent risk factor for VTE as was increasing age, increasing Injury Severity Score, male gender, traumatic brain injury, and chest trauma. The rate of VTE differs with various SCI levels. Patients with high thoracic (T1-6) injury seem to be at the highest risk and patients with high cervical (C1-4) injury at one of the lowest. A higher index of suspicion for VTE should therefore be maintained in patients with a high thoracic SCI. Further studies are required to elucidate the underlying mechanisms.

(A117) Outcomes and Quality of Life after Injury

BackgroundMost research into the outcomes of injury has focused on mortality rather than the physical, social, and psychological sequelae of non-fatal injuries. The health and long-term outcomes of a cohort of accidentally-injured patients were studied in order to assess the impact on quality of life.MethodsThe cohort of patients was derived from six previous studies spanning 1988–2003. Patients were followed-up with to ascertain if they were still alive, and survivors were sent a follow-up questionnaire in 2006. The questionnaire asked about current problems resulting from past injuries, use of health services, and measures of health related quality of life (the EQ-5D and SF-36 or Nottingham Health Profile (NHP)). A sample of 114 also received detailed face-to-face interviews.ResultsA total of 2,418 patients were followed-up on between 4–15 years post-injury, of whom 311 had died. There were 580 completed follow-up questionnaires, and of these 64% reported health problems related to past injuries. The mean EQ-5D score at follow-up was 0.132 tariff points below the mean for a normal age-sex matched population, and SF-36 scores were 5–15 points worse than population norms. At all ages, EQ-5D and SF-36 scores were similar to those of the normal population aged 75. Interviewed patients also reported substantially more disability than the general population. Increasing injury severity was associated with almost all aspects of worse health at follow-up, and severe lower extremity injuries were strongly associated with poorer outcomes.ConclusionsInjured patients continue to experience significant reductions in health and health-related quality of life for many years after their injury.

Analysis of factors associated with traffic injury severity on rural roads in Iran

:Background:Iran is a country with one of the highest rates of traffic crash fatality and injury, and seventy percent of these fatalities happen on rural roads. The objective of this study is to identify the significant factors influencing injury severity among drivers involved in crashes on two kinds of major rural roads in Iran: two-lane, two-way roads and freeways.Methods:According to the dataset, 213569 drivers were involved in rural road crashes in Iran, over the 3 years from 2006 to 2008. The Classification And Regression Tree method (CART) was applied for 13 independent variables, and one target variable of injury severity with 3 classes of no-injury, injury and fatality. Some of the independent variables were cause of crash, collision type, weather conditions, road surface conditions, driver's age and gender and seat belt usage. The CART model was trained by 70% of these data, and tested with the rest.Results:It was indicated that seat belt use is the most important safety factor for two-lane, two-way rural roads, but on freeways, the importance of this variable is less. Cause of crash, also turned out to be the next most important variable. The results showed that for two-lane, two-way rural roads, "improper overtaking" and "speeding", and for rural freeways, "inattention to traffic ahead", "vehicle defect", and "movement of pedestrians, livestock and unauthorized vehicles on freeways" are the most serious causes of increasing injury severity. Conclusions:The analysis results revealed seat belt use, cause of crash and collision type as the most important variables influencing the injury severity of traffic crashes. To deal with these problems, intensifying police enforcement by means of mobile patrol vehicles, constructing overtaking lanes where necessary, and prohibiting the crossing of pedestrians and livestock and the driving of unauthorized vehicles on freeways are necessary. Moreover, creating a rumble strip on the two edges of roads, and paying attention to the design consistency of roads can be a helpful factor in order to prevent events such as "overturning" and improve the overall safety of freeways.

Insurance Status, Not Race, Is a Determinant of Outcomes from Vehicular Injury

Hypothesizing that outcomes from specific injury mechanisms should not vary by race or socioeconomic status, we analyzed the relationship of race and ethnicity to fatality in motor vehicle crash victims treated during 2008 and 2009. Logistic regression analysis of pooled administrative data assessed the contribution of patient demographics and injury severity to outcome, defined as mortality during acute hospitalization. Demographic factors included age, sex, race, ethnicity, and insurance. Severe injury was defined using ICD-9 Injury Severity Score (survival probability) p < 0.85, presence of up to 3 comorbidities, and/or diagnosis of spinal cord injury and/or traumatic brain injury. Mortality was stratified by survival time after trauma center arrival to death within 24 hours or thereafter. Factors contributing to outcomes were tested using chi square analysis of the calculated model estimate. For 8,758 motor vehicle crash victims treated in state-designated trauma centers, age, sex, injury severity, and 2 or more comorbidities consistently predicted survival. Neither race nor ethnicity was associated with increased mortality risk. Being uninsured was related to death within 24 hours (p < 0.001). The majority of the uninsured who died within 24 hours had an ICD-9 Injury Severity Score p ≤ 0.5. Mortality risk after 24 hours was driven by traumatic brain injury and comorbidities. The results of this study indicated that higher immediate mortality of the uninsured is a behavioral and socioeconomic rather than physiologic marker. This higher mortality is driven by increased injury severity that increases cost of care in uninsured survivors. This disparity suggests that risk-taking behavior, especially relating to safety practices and licensing regulations, is an important etiologic factor. Improved outcomes require better public education and enforcement in conjunction with improvements in processes of care.

Fasciotomy Rates in Operations Enduring Freedom and Iraqi Freedom: Association with Injury Severity and Tourniquet Use

To compare fasciotomy rates and Injury Severity Scores (ISSs) before and after tourniquets were fielded for combat casualties in March 2005. A military trauma registry was used to identify 4332 casualties with limb injury between 2003 and 2006. Descriptive statistics and regression analysis were used to compare changes in ISSs, limb Abbreviated Injury Scale (AIS) scores, and fasciotomy rates. An item of specific interest was whether changes in fasciotomy rates occurred before and after March 2005, when tourniquets were fielded. Therefore, this time point served as a specific comparator in the statistical analyses. Among the 4332 limb casualties, 669 (15%) underwent fasciotomy. The ISS doubled (100% increase) during the study. Limb AIS increased 35%. The increase in limb AIS constituted most of the increase in ISS. Monthly fasciotomy rates increased 500% (5% to 30%) during the study. When controlling injury severity (both AIS and ISS), fasciotomy rates tripled (200% increase); but when comparing fasciotomy before and after tourniquet fielding by AIS and ISS, rates only doubled (100% increase). On logistic regression for predicting fasciotomy, the model was unable to determine a good fit for the data because the variables were not significant except weakly for injury severity. During the period of the study, fasciotomy rates increased as a result of a combination of factors: increasing injury severity, increasing use of tourniquets, and increased awareness of the need to perform prophylactic fasciotomy. Further research should be aimed at determining what the optimum rate of fasciotomy is in such an environment.

A Survey of Very-Long-Term Outcomes after Traumatic Brain Injury among Members of a Population-Based Incident Cohort

To assess quality of life and barriers to participation in vocational and community life for persons with traumatic brain injury (TBI) over the very-long term, a population-based cohort was identified in Olmsted County, Minnesota; 1623 individuals were identified as having experienced a confirmed TBI while a resident of Olmsted County, Minnesota, during the period from 1935-2000. A survey was sent to eligible individuals that included elements of standardized instruments addressing health status and disability, and questions that assessed issues important to successful social reintegration after TBI. Of 1623 eligible participants sent surveys, 605 responded (37% response rate). Thirty-nine percent of respondents were female and 79% had mild injuries. Mean age at injury was 30.8 years, and mean years since injury was 28.8. Overall, respondents reported living in the community; the majority were married and had achieved education beyond high school. Problems with memory, thinking, and physical and emotional health were most often reported. Respondents reported low levels of depression and anxiety, and high levels of satisfaction with life. Seventy-three percent of respondents reported no problems that they attributed to their TBI. Increasing injury severity was associated with a significant risk of reporting injury-related problems at survey completion. Respondents with a longer time since injury were less likely to report any TBI-related problems. These results indicate that self-reported outcomes and adaptation to impairment-related limitations improve as the time since injury increases. These findings highlight the importance of providing coordinated medical rehabilitation and community-based support services to promote positive outcomes over the life span after TBI.

Attenuated hypocholesterolemia following severe trauma signals risk for late ventilator-associated pneumonia, ventilator dependency, and death: a retrospective study of consecutive patients

BackgroundPost-traumatic ventilator-associated pneumonia (VAP) is a substantial clinical problem that increases hospital costs and typically adds to the duration of mechanical ventilation. We evaluated the impact of VAP on ventilator days. We also assessed 48-hour total blood cholesterol (TC) and other potential risk factors for the development of VAP.MethodsWe performed a retrospective study of consecutive trauma patients requiring emergency tracheal intubation and evaluated TC, age, gender, ethanol status, smoker status, injury mechanism, chest injury, brain injury, Injury Severity Score (ISS), shock, day-one hypoxemia, and RBC transfusion as potential risks for VAP.ResultsThe 152 patients had ISS 28.1, brain injury 68.4%, VAP 50.0%, ventilator days 14.3, and death 9.9%. Ventilator days were increased with late VAP (p < 0.0001). TC was 110.7 mg/dL with expected TC 197.5 mg/dL. TC was lower with chest injury, shock, and RBC transfusion but, higher with brain injury (p ≤ 0.01). TC decreased as ISS increased (p = 0.01). However, one patient subset (ISS ≥ 20-&-TC ≥ 90 mg/dL) had a relative increase in TC despite an increase in ISS. ISS ≥ 20-&-TC ≥ 90 mg/dL, but not ISS alone, was the only independent predictor of late VAP (OR 3.0; p = 0.002). ISS ≥ 20-&-TC ≥ 90 mg/dL and day-one hypoxemia were the only independent predictors for increased ventilator days (p = 0.01). ISS ≥ 20-&-TC ≥ 90 mg/dL, but not ISS alone, was the only predictor of death (OR 3.8; p = 0.03).ConclusionsSevere traumatic injury produced substantial hypocholesterolemia that is greater with chest injury, shock, and RBC transfusion, but less with brain injury. Total blood cholesterol tended to decrease with increasing injury severity. However, attenuated hypocholesterolemia (ISS ≥ 20-&-TC ≥ 90 mg/dL) represents a unique response that can occur with critical injury. Attenuated hypocholesterolemia signals early risk for late VAP, ventilator dependency, and death.

Full time trauma service leads to improved Level III trauma center outcomes

Background Level III trauma centers are an effective component of a healthy trauma system. This study examined the effectiveness over time of a Level III trauma center in a predominately rural region. Methods For analysis, the data were divided into 2 equal time spans: an early period (1997–2002) and a late period (2003–2008). A dedicated trauma service was implemented in 2003. Results A total of 8,689 patient outcomes were analyzed. In those patients with an injury severity score of 15 or less, 49 of 3,307 (1.5%) patients died in the early period, and 74 of 4,244 (1.7%) died in the late period ( P = .40). In those with an injury severity score greater than 15, 66 of 402 patients (16.4%) died in the early period, whereas 81 of 736 (11.0%) patients died in the late period ( P = .01). Despite the increased injury severity, overall mortality rates remained unchanged. Conclusions Implementation of a full-time trauma service resulted in improved outcomes including a 33% mortality reduction in the severely injured.

Early fasciotomy in electrically injured patients as a marker for injury severity and deep venous thrombosis risk: an analysis of the National Burn Repository.

By using the National Burn Repository, the authors sought to identify markers for injury severity and deep venous thrombosis (DVT) risk after electrical injury. They identified adult patients in the National Burn Repository who were admitted with an electrical injury between 1995 and 2007 (n = 1469). Patients who died within 24 hours or were admitted for less than 1 day and hospitals reporting no complications were excluded. Independent variables included TBSA burned, duration of intensive care unit stay and hospital admission, duration of mechanical ventilation, the number of operative procedures, amputation, and early fasciotomy. Early fasciotomy was defined as fasciotomy performed on a patient's first trip to the operating room and was used as a proxy for severity of electrical injury. DVT and death were the dependent variables. Among electrically injured patients, 10.4% had early fasciotomy. Patients who had early fasciotomy had significantly prolonged intensive care unit stays (10.3 vs 4.8 days, P < .001), hospital days (36.7 vs 17.1 days, P < .001), amputations (49.0 vs 4.6%, P < .001), and a number of operative codes (17.6 vs 5.4, P < .001). DVT incidence was 0.9%. Electrically injured patients who had early fasciotomy were significantly more likely to have a DVT when compared with patients who did not have early fasciotomy (7.55 vs 0.95%, P = .002). Early fasciotomy after electrical injury is a marker for increased injury severity. Among patients who underwent early fasciotomy after electrical injury, 7.5% develop DVT, and 49% require amputation during their initial hospitalization.