Increased Injury Severity Research Articles

Immunology of Septic Shock and Traumatic Injury: A Review

Sepsis remains a major worldwide cause of morbidity and mortality and remains amongst the leading causes of death in medical Intensive Care Units (ICUs). Increasing injury severity associated with trauma is a significant independent risk factor for sepsis and many of these patients require intensive care unit resource utilization with increased rates of mortality. There are many postulated theories regarding the mechanism surrounding the correlation between trauma and shock. One such theory evaluated the deterioration of the immune system after trauma with the activation of Damage Associated Molecular Proteins (DAMPs) and the potential role of mitochondrial release into the bloodstream following physical injury leading to the onset of the Systemic Inflammatory Response Syndrome (SIRS). Despite these proposed theories, a breach of cellular integrity seems to unravel a multitude of immunologic responses that in essence account for the deleterious symptoms associated with sepsis. The association between traumatic injury and sepsis is very complex. This review explores the multifaceted immunoinflammatory response and gives an in depth immunologic explanation of the fundamental mediators in the initiation and continuation of the inflammatory response following the loss of cellular integrity.

Why do farmworkers delay treatment after debilitating injuries? Thematic analysis explains if, when, and why farmworkers were treated for injuries.

Farmworkers who delay treatment after workplace injuries may increase injury severity and experience longer recovery times. To understand why farmworkers delay treatment we employed a mixed-methods analysis of 393 farmworker injury narratives from the National Agricultural Workers Survey (NAWS). First, open-ended injury narratives were coded for attitudes related to injury timing and delay. Next, narratives were compared against demographic survey attributes to assess contextual information and patterns linked to treatment timing. Four treatment timings were identified: immediate medical treatment (57.9%), delayed medical treatment (18.2%) self- administered treatment (14.9%), and no treatment at all (8.9%). Delay was primarily attributed to attitudes prioritizing work over pain, and when workers were able to work despite injury. However, immediate treatment was sought when workers were completely debilitated and unable to work, when a supervisor was notified, or when exposed to pesticides during injury. Timing choices varied by education, gender and migrant status. Training on timely treatment, including notification of supervisors, may help reduce treatment delay for farmworkers.

Time interval to surgery and outcomes following the surgical treatment of acute traumatic subdural hematoma

Although the pre-surgical management of patients with acute traumatic subdural hematoma prioritizes rapid transport to the operating room, there is conflicting evidence regarding the importance of time interval from injury to surgery with regards to outcomes. We sought to determine the association of surgical timing with outcomes for subdural hematoma. A retrospective review was performed of 522 consecutive patients admitted to a single center from 2006–2012 who underwent emergent craniectomy for acute subdural hematoma. After excluding patients with unknown time of injury, penetrating trauma, concurrent cerebrovascular injury, epidural hematoma, or intraparenchymal hemorrhage greater than 30mL, there remained 45 patients identified for analysis. Using a multiple regression model, we examined the effect of surgical timing, in addition to other variables on in-hospital mortality (primary outcome), as well as the need for tracheostomy or gastrostomy (secondary outcome). We found that increasing injury severity score (odds ratio [OR] 1.146; 95% confidence interval [CI] 1.035–1.270; p=0.009) and age (OR1.066; 95%CI 1.006–1.129; p=0.031) were associated with in-hospital mortality in multivariate analysis. In this model, increasing time to surgery was not associated with mortality, and in fact had a significant effect in decreasing mortality (OR 0.984; 95%CI 0.971–0.997; p=0.018). Premorbid aspirin use was associated with a paradoxical decrease in mortality (OR 0.019; 95%CI 0.001–0.392; p=0.010). In this patient sample, shorter time interval from injury to surgery was not associated with better outcomes. While there are potential confounding factors, these findings support the evaluation of rigorous preoperative resuscitation as a priority in future study.

Elevated Tissue Plasminogen Activator and Reduced Plasminogen Activator Inhibitor Promote Hyperfibrinolysis in Trauma Patients

Severe hyperfibrinolysis after trauma is a poorly understood phenomenon associated with profound shock, serious anatomic injuries, increased transfusions, and high mortality rates. Molecular mechanisms driving hyperfibrinolysis in trauma have not been completely delineated. The authors aimed to determine the relationship between severe hyperfibrinolysis and outcomes in trauma patients and characterize the role of the plasminogen activator (PA) system in this condition. A prospective observational study was performed in 163 adult level I trauma patients admitted between April and August 2012. Blood was collected on admission, and fibrinolysis was determined by plasmin-α2 antiplasmin (PAP) levels. Tissue-derived and urokinase PA (tPA and uPA, respectively), PA inhibitor (PAI-1), fibrinogen, and antithrombin levels were also measured. Patient demographics, vital signs, laboratory values, mechanisms and severity of injuries, transfusions, and outcomes were collected at admission or from patient records. Moderate fibrinolysis was defined as PAP level 1,500 to 20,000 μg/L and severe hyperfibrinolysis as PAP level more than 20,000 μg/L. Severe hyperfibrinolysis was observed in 10% of patients and associated with increased injury severity, greater transfusions, fewer ventilator and hospital-free days, and higher mortality. Plasmin-α2 antiplasmin level was directly correlated with tPA level and inversely correlated with PAI-1 level. Patients with both elevated tPA and reduced PAI-1 were more severely injured, received more transfusions, and experienced fewer ventilator and hospital-free days. In conclusion, Severe hyperfibrinolysis is observed in a small percentage of trauma patients and is associated with severe injuries, greater transfusions, and worse outcomes. This condition is mediated, in part, by excessive upregulation of profibrinolytic tPA in the absence of concomitant increases in antifibrinolytic PAI-1.

VALIDATING THE 3-STEP RETURN TO PLAY DECISION MAKING MODEL

BackgroundA recent return to play decision-making (RTP-DM) model for sport medicine has organized the underlying concepts into 3 steps but has not yet been validated.ObjectiveTo examine the validity of the...

The amount of consolation compensation in road traffic accidents

This study aimed to investigate the amount of consolation compensation that road accident perpetrators were willing to pay victims. It used 2010 statistics for general road accidents from Taiwan's National Police Agency (NPA) for further sampling and to mail questionnaires. In investigating consolation compensation, the framework of the contingent valuation method was used, and the data were collected through the design of different scenarios. In this study, five injury levels were designed to further analyse the consolation compensation price the perpetrators were willing to pay: minor injury, moderate injury, serious injury, disability, and death. The results revealed the price that many perpetrators were willing to pay was zero; however, we overcame this issue by using the Spike model. The estimated results showed that road accident perpetrators were willing to pay more consolation compensation with increased injury severity.

Potential bud bank responses to apical meristem damage and environmental variables: matching or complementing axillary meristems?

Soil nutrients, dormant axillary meristem availability, and competition can influence plant tolerance to damage. However, the role of potential bud banks (adventitious meristems initiated only after injury) is not known. Examining Central European field populations of 22 species of short-lived monocarpic herbs exposed to various sources of damage, we hypothesized that: (1) with increasing injury severity, the number of axillary branches would decrease, due to axillary meristem limitation, whereas the number of adventitious shoots (typically induced by severe injury) would increase; (2) favorable environmental conditions would allow intact plants to branch more, resulting in stronger axillary meristem limitation than in unfavorable conditions; and (3) consequently, adventitious sprouting would be better enabled in favorable than unfavorable conditions. We found strong support for the first hypothesis, only limited support for the second, and none for the third. Our results imply that whereas soil nutrients and competition marginally influence plant tolerance to damage, potential bud banks enable plants to overcome meristem limitation from severe damage, and therefore better tolerate it. All the significant effects were found in intraspecific comparisons, whereas interspecific differences were not found. Monocarpic plants with potential bud banks therefore represent a distinct strategy occupying a narrow environmental niche. The disturbance regime typical for this niche remains to be examined, as do the costs associated with the banks of adventitious and axillary reserve meristems.

Cortical contusion injury disrupts olfactory bulb neurogenesis in adult mice

BackgroundExperimental brain trauma activates quiescent neural stem cells (NSCs) to increase neuronal progenitor cell proliferation in the adult rodent brain. Previous studies have shown focal brain contusion in the form of a unilateral controlled cortical impact (CCI) stimulates NSCs to bilaterally increase neurogenesis in the adult hippocampus.ResultsIn this study we clarified the bi-lateral effects of a unilateral CCI on proliferation in the subventricular zone (SVZ) NSC niche and on neurogenesis in the olfactory bulb of adult mice. By varying the depth of impact from 1 mm to 2 mm depth, we show CCI to the left somatosensory cortex resulted in graded changes in mouse behavior and cellular pathology in the forebrain. As expected, contusion to the sensorimotor cortex resulted in motor coordination deficits in adult mice. During the first 3 days after injury, CCI increased proliferation in the impacted cortex, deeper striatum and SVZ of the forebrain ipsilateral to the CCI. In each of these regions proliferation was increased with increasing injury severity. At 30 days post-procedure, CCI resulted in a significant reduction in neurogenesis in the olfactory bulb ipsilateral to the CCI. Olfactory avoidance testing indicated disruptions in olfactory bulb neurogenesis were associated with impaired olfactory discrimination in mice post-injury.ConclusionThe data demonstrate a focal cortical contusion injury to the left somatosensory cortex disrupts SVZ-olfactory bulb neurogenesis and impairs olfactory discrimination and motor coordination in adult mice.

Influence of neuropathology on convection-enhanced delivery in the rat hippocampus.

Local drug delivery techniques, such as convention-enhanced delivery (CED), are promising novel strategies for delivering therapeutic agents otherwise limited by systemic toxicity and blood-brain-barrier restrictions. CED uses positive pressure to deliver infusate homogeneously into interstitial space, but its distribution is dependent upon appropriate tissue targeting and underlying neuroarchitecture. To investigate effects of local tissue pathology and associated edema on infusate distribution, CED was applied to the hippocampi of rats that underwent electrically-induced, self-sustaining status epilepticus (SE), a prolonged seizure. Infusion occurred 24 hours post-SE, using a macromolecular tracer, the magnetic resonance (MR) contrast agent gadolinium chelated with diethylene triamine penta-acetic acid and covalently attached to albumin (Gd-albumin). High-resolution T1- and T2-relaxation-weighted MR images were acquired at 11.1 Tesla in vivo prior to infusion to generate baseline contrast enhancement images and visualize morphological changes, respectively. T1-weighted imaging was repeated post-infusion to visualize final contrast-agent distribution profiles. Histological analysis was performed following imaging to characterize injury. Infusions of Gd-albumin into injured hippocampi resulted in larger distribution volumes that correlated with increased injury severity, as measured by hyperintense regions seen in T2-weighted images and corresponding histological assessments of neuronal degeneration, myelin degradation, astrocytosis, and microglial activation. Edematous regions included the CA3 hippocampal subfield, ventral subiculum, piriform and entorhinal cortex, amygdalar nuclei, middle and laterodorsal/lateroposterior thalamic nuclei. This study demonstrates MR-visualized injury processes are reflective of cellular alterations that influence local distribution volume, and provides a quantitative basis for the planning of local therapeutic delivery strategies in pathological brain regions.

Anion Gap as a Predictor of Trauma Outcomes in the Older Trauma Population: Correlations with Injury Severity and Mortality

The relationship among traumatic injury, the associated metabolic/physiologic responses, and mortality is well established. Tissue hypoperfusion and metabolic derangement may not universally correlate with initial clinical presentation. We hypothesized that anion gap (AG) could be a useful gauge of trauma-related physiologic response and mortality in older patients with relatively lower injury acuity. We retrospectively analyzed data from 711 trauma patients older than 45 years. Parameters examined included demographics, injury characteristics, laboratories, morbidity, and mortality. Univariate and survival analyses were performed using PASW 18. A stepwise correlation exists between increasing Injury Severity Score and AG. Although AG less than 8 to 15 was not associated with a significant increase in mortality, greater mortality was seen for AG greater than 16 with further stepwise increases for AGs greater than 22. Anion gap correlated moderately with serum lactate and poorly with base excess. Increasing AG also correlated with morbidity and greater incidence of intensive care admissions. The presence of any complication increased from 28.6 per cent for patients with AG 12 or less to 45.5 per cent for patients with AG 22 or greater (P < 0.04). These findings support the contention that "low acuity" trauma patients with high AGs may not appear acutely ill but may harbor significant underlying metabolic and physiologic disturbances that could contribute to morbidity and mortality. Higher AG values (i.e., greater than 16) may be associated with worse clinical outcomes.

Let it snow

Current research examining the impact of mechanism of injury and daily snowfall amounts on injury severity among skiers and snowboarders is limited. The purpose of this study was to define correlations between injury mechanism and daily snowfall on injury patterns and severity among skiers and snowboarders. This observational study analyzed daily snowfall measurements coupled with trauma admissions during the 2011 and 2012 ski seasons from a Level III trauma center servicing a large North American ski resort. Post hoc adjusted analyses and multivariate modeling was used to determine independent predictors of increased injury severity. Six hundred forty-four trauma admissions were analyzed, with primary research considerations detailing the variances in injury severity resulting from collisions with other skiers or snowboarders and daily total snowfall. Findings demonstrated that collisions were independently associated with increased (1) injury severity (Injury Severity Score [ISS ≥ 16]) (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.0-7.6; p < 0.001), (2) thoracic injury severity (Abbreviated Injury Scale [AIS] score ≥ 3) (OR, 7.5; 95% CI, 3.7-15.0; p < 0.001), and (3) renal injuries (OR, 3.2; 95% CI, 1.2-8.1; p = 0.017) as well as and axial skeleton fractures (OR, 4.5; 95% CI, 2.6-7.7; p < 0.001). In addition, mean ISS was significantly higher in the setting of a collision when compared with a fall (8.6 vs. 5.8; p < 0.001). Findings regarding total snowfall demonstrate a negative correlation between snowfall and injury severity (r = -0.08, p = 0.05); the majority (65.5%) of injuries were sustained when there was 1 inch or less of recent snowfall, and a snowfall total of 2 inches or less was independently associated with increased injury severity (ISS ≥ 16) (OR, 3.1; 95% CI, 1.1-9.1; p = 0.036). Collisions between snowsport enthusiasts and total trace snowfall predict an increase in injury severity among alpine skiers and snowboarders. Findings from this project may lead to an increased understanding of predictive factors contributing to injury, alter the diagnostic evaluation of patients, provide educational opportunities for alpine enthusiasts, and enhance resort safety initiatives tailored to ambient conditions.

Bilateral lower-extremity amputation wounds are associated with distinct local and systemic cytokine response

Approximately 25% of U.S. military members sustaining extremity amputations in recent military conflicts have bilateral lower-extremity amputations (BLA). We investigated among combat-related extremity wounds whether BLA exhibit different bacterial burden, inflammatory response, and local complications. A total of 75 patients with combat-related extremity wounds (19 BLA) were evaluated for age, tobacco use, body mass index, Injury Severity Score, Acute Physiology and Chronic Health Evaluation II, and delayed primary closure time. Blood, wound exudates, and muscle biopsies were obtained and analyzed for cytokine and quantitative bacteriology, excluding patients using nonsteroidal anti-inflammatory medications and corticosteroids, due to potential effects on their inflammatory profile. BLA was not associated with differences in age, tobacco use, body mass index, and delayed primary closure time, but these patients had increased Injury Severity Score, Acute Physiology and Chronic Health Evaluation II, and rates of critical colonization. Proinflammatory cytokines including tumor necrosis factor-α (exudate), interleukin (IL)-1 (exudate) and IL-6 (serum) were increased in BLA patients. They also had serum and exudate increased IL-8 and decreased IL-13 and granulocyte-macrophage colony-stimulating factor. Both wound dehiscence (WD) and heterotopic ossification (HO) were more common in BLA patients. BLA patients were more likely to exhibit critical bacterial colonization, a distinct inflammatory response, and develop WD and HO. Modulating this response represents an attractive target in an effort to prevent complications such as WD and HO.

Injury Severity Score Underpredicts Injury Severity and Resource Utilization in Combat-Related Amputations

Assess effectiveness of Injury Severity Score (ISS) in predicting injury severity in combat-related amputations. Retrospective evaluation of prospectively collected data. Military medical center. One hundred and nine patients with major extremity amputations sustained in overseas combat. Standard combat casualty care. Difference in injury severity as measured by ISS, numbers of extremity(s) amputated, number of associated injuries, blood products used, intensive care unit length of stay, hospital length of stay in those with an upper extremity amputation (UEA) compared with those with an isolated lower extremity amputation. Thirteen patients (11.9%) sustained at least one UEA. Patients with an UEA had a greater number of amputations per casualty compared with patients with a lower extremity alone (2.5 vs. 1.5; P < 0.001). The mean hospital length of stay (P = 0.02) and intensive care unit length of stay (P = 0.02) were significantly greater in those with an UEA. Mean blood product utilization was also significantly greater in those with an upper extremity amputation (P < 0.05). There was no difference in ISS between the two groups (P > 0.05). The presence of an UEA is associated with increased injury severity as evident by increased intensive care unit requirements, blood product utilization, and hospital length of stay. ISS underestimates the severity of injury and therefore resource utilization in patients with multiple combat-related amputations. Recognition of this limitation in addition to the development of a military-specific ISS is required for more effective resource utilization to continue to improve combat casualty care. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Surgical strategies in polytraumatized patients with femoral shaft fractures – Comparing a German and an Australian level I trauma centre

BackgroundFemoral shaft fractures are one of the most common injuries in multiple trauma patients. Due to their prognostic relevance, there is an ongoing controversial discussion as to the optimal treatment strategy in terms of Damage Control Orthopaedics (DCO) and Early Total Care (ETC). We aimed to describe the differences in fracture management and clinical outcome of multiple trauma patients with concomitant femoral shaft fractures treated at a German and an Australian level I trauma centre using the same inclusion criteria. MethodsPolytraumatized patients (ISS≥16) with a femoral shaft fracture aged≥16 years treated at a German and an Australian trauma centre between 2003 and 2007 were included. According to ETC and DCO management principles, we evaluated demographic parameters as well as posttraumatic complications and clinical outcome. ResultsSeventy-three patients were treated at the German and 134 patients at the Australian trauma centre. DCO was performed in case of increased injury severity in both hospitals. Prolonged mechanical ventilation time, and length of ICU and hospital stay were demonstrated in DCO treatment regardless of the trauma centre. No differences concerning posttraumatic complications and survival were found between both centres. Survival of patients after DCO was similar to those managed using ETC despite a greater severity of injury and lower probability of survival. There was no difference in the incidence of ARDS. DCO was, however, associated with a greatly increased length of time on mechanical ventilation and length of stay in the ICU. ConclusionWe found no differences concerning patient demographics or clinical outcomes in terms of incidence of ARDS, MODS, or mortality. As such, we propose that comparability between German and Australian trauma populations is justified. Despite a higher ISS in the DCO group, there were no differences in posttraumatic complications and survival depending on ETC or DCO treatment. Further research is required to confirm whether this is the case with other countries, too.

Analysis of radiation exposure among pediatric trauma patients at national trauma centers

Injured children undergo radiologic studies as part of trauma evaluations. Children are more sensitive than adult patients to the effects of ionizing radiation. Few studies have described the radiation exposure to pediatric patients during trauma evaluations. We sought to describe the rate of use of radiology studies and to estimate the effective dose of radiation delivered to pediatric trauma patients presenting to trauma centers within the United States. We performed an analysis of pediatric patients younger than 19 years who presented to an American College of Surgery-verified trauma center in 2010 (National Trauma Data Bank). We excluded patients who were transferred from another facility, patients who died at the scene or those who presented to the emergency department dead on arrival. We examined the use of computed tomography (CT) and standard radiographs (x-ray). Radiologic studies were identified through common procedure codes (CPT). Using published criteria, we estimated the effective radiation dose per trauma patient. Among the 84,863 eligible pediatric trauma patients, 26,360 (31.1%) underwent imaging with x-ray or CT. Of these patients, 17,321 (65.7%) were male, median age was 13.0 years (interquartile range, 6.0-17.0), and 20,965 (79.5%) had an Injury Severity Score (ISS) of less than 16. A total of 23,148 (27.4%) underwent CT. X-ray studies accounted for a small amount of exposure to radiation as compared with CT. Mean (SD) effective radiation exposure of patients imaged with CT was 12.0 (8.2) mSv. Younger children and those with increasing injury severity were exposed to higher doses of radiation (β = -0.04, p < 0.001). The majority of radiation exposure to pediatric trauma patients is secondary to CT. Younger children and those with more severe injuries are exposed to higher doses of radiation. Pediatric trauma patients are exposed to levels of radiation, which could potentially lead to long-term harm. Epidemiologic study, level III.

Comparison of injury severity by age group

In 2009, there were 106 fatalities per 1,000 car accidents on Korean expressways, more than double those of other road types. In terms of accident casualties by age, the fatality rate for older drivers was nearly five times more than other age groups, while the injury rate for younger drivers was almost one and a half times more than other age groups. The casualty rates have shown varying degrees of injury by age. To determine the factors that influence injury severity by age, accident data on Korean expressways for the last five years were analyzed. The results show that, for younger drivers, intentional violations increased injury severity. For older drivers, less physical capability of reaction and drowsiness were identified as factors that increased injury severity. It would help to develop systematic grounds towards formulation of safety policies.

Admission Temperature and Survival in Patients Admitted to Burn Centers

It is commonly believed that hypothermia occurring during burn resuscitation is associated with poor outcome, but there is little direct supporting evidence. The authors conducted an analysis of a statewide trauma registry to determine whether hypothermia (T ≤36.5°C) was associated with mortality when controlling for clinical confounders. They included all patients treated at an accredited burn center from 2000 to 2011 where the trauma registrar recorded the primary injury type as a burn. They excluded records with missing data and nonphysiologic temperature (<26°C or >42°C). The primary exposure of interest was hypothermia. The authors constructed a hierarchical, multivariable logistic regression model to examine the effect of hypothermia on survival, controlling for potentially confounding variables. Predictors of mortality are presented as odds ratio (95% confidence interval). Primary burn injury was coded 17,098 times during the study period. Of these, 3809 were not treated at a burn center and 1192 were excluded for missing data. Admission hypothermia was independently associated with mortality (1.91 [1.58-2.29]) when adjusting for age, sex, total second- and third-degree burn surface area (TBSA), comorbid conditions, injury severity score, direct transport vs referral, method of temperature measurement, year, and the hospital providing care. Increasing age, female sex, TBSA >40%, presence of multiple comorbid conditions, and increasing injury severity score were associated with mortality. Other variables in the model were not independently associated with outcome. There was a weak correlation between TBSA and admission temperature (r = .18). Hypothermia at hospital admission is independently associated with mortality in burn patients when controlling for clinical confounders. Future studies should address potential causes underlying this observation.

The Shock Index revisited – a fast guide to transfusion requirement? A retrospective analysis on 21,853 patients derived from the TraumaRegister DGU®

IntroductionIsolated vital signs (for example, heart rate or systolic blood pressure) have been shown unreliable in the assessment of hypovolemic shock. In contrast, the Shock Index (SI), defined by the ratio of heart rate to systolic blood pressure, has been advocated to better risk-stratify patients for increased transfusion requirements and early mortality. Recently, our group has developed a novel and clinical reliable classification of hypovolemic shock based upon four classes of worsening base deficit (BD). The objective of this study was to correlate this classification to corresponding strata of SI for the rapid assessment of trauma patients in the absence of laboratory parameters.MethodsBetween 2002 and 2011, data for 21,853 adult trauma patients were retrieved from the TraumaRegister DGU® database and divided into four strata of worsening SI at emergency department arrival (group I, SI <0.6; group II, SI ≥0.6 to <1.0; group III, SI ≥1.0 to <1.4; and group IV, SI ≥1.4) and were assessed for demographics, injury characteristics, transfusion requirements, fluid resuscitation and outcomes. The four strata of worsening SI were compared with our recently suggested BD-based classification of hypovolemic shock.ResultsWorsening of SI was associated with increasing injury severity scores from 19.3 (± 12) in group I to 37.3 (± 16.8) in group IV, while mortality increased from 10.9% to 39.8%. Increments in SI paralleled increasing fluid resuscitation, vasopressor use and decreasing hemoglobin, platelet counts and Quick’s values. The number of blood units transfused increased from 1.0 (± 4.8) in group I to 21.4 (± 26.2) in group IV patients. Of patients, 31% in group III and 57% in group IV required ≥10 blood units until ICU admission. The four strata of SI discriminated transfusion requirements and massive transfusion rates equally with our recently introduced BD-based classification of hypovolemic shock.ConclusionSI upon emergency department arrival may be considered a clinical indicator of hypovolemic shock in respect to transfusion requirements, hemostatic resuscitation and mortality. The four SI groups have been shown to equal our recently suggested BD-based classification. In daily clinical practice, SI may be used to assess the presence of hypovolemic shock if point-of-care testing technology is not available.

Effect of implementation of a paediatric neurocritical care programme on outcomes after severe traumatic brain injury: a retrospective cohort study

Outcomes after traumatic brain injury are worsened by secondary insults; modern intensive-care units address such challenges through use of best-practice pathways. Organisation of intensive-care units has an important role in pathway effectiveness. We aimed to assess the effect of a paediatric neurocritical care programme (PNCP) on outcomes for children with severe traumatic brain injury. We undertook a retrospective cohort study of 123 paediatric patients with severe traumatic brain injury (Glasgow coma scale scores ≤8, without gunshot or abusive head trauma, cardiac arrest, or Glasgow coma scale scores of 3 with fixed and dilated pupils) admitted to the paediatric intensive-care unit of the St Louis Children's Hospital (St Louis, MO, USA) between July 15, 1999, and Jan 15, 2012. The primary outcome was rate of categorised hospital discharge disposition before and after implementation of a PNCP on Sept 17, 2005. We developed an ordered probit statistical model to assess adjusted outcome as a function of initial injury severity. We assessed care-team behaviour by comparing timing of invasive neuromonitoring and scored intensity of therapies targeting intracranial hypertension. Characteristics of treated patients (aged 3-219 months) were much the same between treatment periods. Before PNCP implementation, 33 (52%) of 63 patients had unfavourable disposition at hospital discharge (death or admission to an inpatient facility) and 30 (48%) had a favourable disposition (home with or without treatment); after PNCP implementation, 20 (33%) of 60 patients had unfavourable disposition and 40 (67%) had favourable disposition (p=0·01). Seven (11%) patients died before PNCP implementation compared with two (3%) deaths after implementation. The probit model indicated that outcome improved across the spectrum of Glasgow coma scale scores after resuscitation (p=0·02); this improvement progressed with increasing injury severity. Kaplan-Meier analysis suggested that neuromonitoring was started earlier and maintained longer after implementation of the PNCP (p=0·03). Therapeutic intensity scores were increased for the first 3 days of treatment after PNCP implementation (p=0·0298 for day 1, p=0·0292 for day 2, and p=0·0471 for day 3). The probit model suggested that increasing age (p=0·03), paediatric risk of mortality III scores (p=0·0003), and injury severity scores (p=0·02) were reliably associated with increased probability of unfavourable outcomes whereas white race (p=0·01), use of intracranial pressure monitoring (p=0·001), and increasing Glasgow coma scale scores after resuscitation (p=0·04) were associated with increased probability of favourable outcomes. Outcomes for children with traumatic brain injury can be improved by altering the care system in a way that stably implements a cooperative programme of accepted best practice. St Louis Children's Hospital and the Sean Glanvill Foundations.

The relationship between pre-season fitness testing and injury in elite junior Australian football players

Australian Football (AF) is a collision sport containing high injury rates in junior competition. Successful performance at the elite junior level not only requires superior specific football knowledge and skills, but also well developed fitness qualities. However, no studies have examined the link between physical fitness qualities and injury in AF. Prospective cohort. Injury data were collected through the use of a Player Movement Record (PMR) and a standardized Injury Report Form (IRF). Fitness test data was collected during the pre-season of the 2010 and 2011 seasons. 382 players consented to participate in the study. The cohort experienced an injury incidence rate of 24.29/standardized club (40 players/club). A faster 5-m sprint was associated with 'injury status' (p=0.016) and a 'knee' region (p≤0.001) injury. A faster planned agility score was associated with an increased risk of a 'hip/groin/thigh' region (p=0.010) injury, and specifically a 'quadriceps strain' (p=0.005). A lower 20-m shuttle run was associated with an increased risk of a 'shin/ankle/foot' (p=0.045) injury. Increased injury severity was associated with a higher left foot running vertical jump (VJ) (p=0.040), and faster 5-m sprint (p=0.043). Lower aerobic endurance, faster 5-m acceleration and greater planned agility were associated with an increased risk of various injury types in elite junior AF players. Furthermore, a higher left foot running VJ and faster 5-m acceleration were associated with injury severity. These results may largely relate to a greater work capacity placing a higher load upon the musculoskeletal system in contact and non-contact situations.