Initial Injury Severity Score Research Articles

Nominal Differences in Acute Symptom Presentation and Recovery Duration of Sport-Related Concussion Between Male and Female Collegiate Athletes in the PAC-12

BackgroundSport-related concussion (SRC) is a heterogenous injury that often presents with varied symptoms and impairment. Recently, research has focused on identifying subtypes, or clinical profiles of concussion to be used in assessing and treating athletes with SRC. The purpose of this study was to investigate sex differences in clinical profiles, recovery duration, and initial symptom severity after SRC in a cohort of collegiate athletes in the Pacific-12 Conference (Pac-12).MethodsThis prospective cohort study examined post-SRC symptoms, recovery, and return-to-play times using data from the Pac-12 CARE Affiliated Program and Pac-12 Health Analytics Program. Clinical profiles reported by student-athletes were defined by the number (> 50%) of specific symptoms frequently reported for each profile. Generalized linear mixed models were used to examine associations among sex, clinical profiles, time-to-recovery, and return-to-play times.Results479 concussion incidents met inclusion criteria. The probabilities of initial presentation of each clinical profile, initial injury severity scores, and recovery times within a profile did not differ between sexes (p = 0.33–0.98). However, both males and females had > 0.75 probabilities of exhibiting cognitive and ocular profiles. Initial injury severity score was a strong nonlinear predictor of initial number of clinical profiles (p < 0.0001), which did not differ between sexes. The number of clinical profiles was also a nonlinear predictor of time-to-recovery (p = 0.03) and return-to-play times (p < 0.0001).ConclusionsInitial symptom severity was strongly predictive of the number of acute clinical profiles experienced post-SRC. As the number of clinical profiles increased, time-to-recovery and time to return-to-play also increased. Factors other than sex may be better associated with acute symptom presentation post-concussion as no sex differences were found in reported clinical profiles or recovery. Understanding the number and type of clinical profiles experienced post-SRC may help inform concussion diagnostics and management.

Effect of Alternatives to Opiates Program on Discharge Opioid Prescribing in Trauma Patients

Background: Opioid overdose deaths have increased over the last two decades, despite efforts to reduce prescribing. This study aimed to determine if a hospital-wide Alternatives to Opiates (ALTOSM) program reduced opioid prescribing in hospital and upon discharge after trauma. Objectives: The primary outcome was incidence of opioid prescribing at hospital discharge Pre- and Post-ALTO. Secondary outcomes were the percent of patients with in-hospital opioid, non-opioid and multimodal analgesia, and hospital and intensive care unit (ICU) length of stay (LOS). Methods: This is a single-center, retrospective analysis of patients >/ = 18 years old admitted for >24 hours with the primary diagnosis of traumatic injury between August 2018 - October 2019. Patients with alcohol or polysubstance abuse, chronic opioid use, or in-hospital mortality were excluded. Results: A total of 703 patients were included, 471 in Pre-ALTO and 232 in Post-ALTO groups. The mean age was 59 ± 22 years and most were male (58.7%). Mean initial Injury Severity Score (ISS) was 9.1 ± 7.7. Opioid prescribing at hospital discharge occurred more in the Post-ALTO group (132/332, 39.4% vs 90/203, 43.8%; P = .1237). Most patients were prescribed in-hospital opioid (332/471, 70.4% vs 203/232, 87.5%, P < .0001) and non-opioid (441/471, 93.6% vs 229/232, 98.7%; P = .0027) analgesics, or multimodal analgesia (397/471, 84.3% vs 203/232, 87.5%; P = .2591). Median hospital and ICU LOS were also similar between groups [5 (3-9) vs 4(3-7), P = .3427] and ICU [2(0-4) vs 3(2-5), P = .3461]. Conclusion: Opioids remain mainstay for trauma-related pain treatment. ALTOSM was not associated with less in-hospital or discharge opioid prescribing.

Shift in Prehospital Mode of Transportation for Trauma Patients During the COVID-19 Pandemic

IntroductionSince the start of the COVID-19 pandemic, we experienced alterations to modes of transportation among trauma patients suffering penetrating injuries. Historically, a small percentage of our penetrating trauma patients use private means of prehospital transportation. Our hypothesis was that the use of private transportation among trauma patients increased during the COVID-19 pandemic and was associated with better outcomes. MethodsWe retrospectively reviewed all adult trauma patients (January 1, 2017 to March 19, 2021), using the date of the shelter-in-place ordinance (March 19, 2020) to separate trauma patients into prepandemic and pandemic patient groups. Patient demographics, mechanism of injury, mode of prehospital transportation, and variables such as initial Injury Severity Score, Intensive Care Unit (ICU) admission, ICU length of stay, mechanical ventilator days, and mortality were recorded. ResultsWe identified 11,919 adult trauma patients, 9017 (75.7%) in the prepandemic group and 2902 (24.3%) in the pandemic group. The number of patients using private prehospital transportation also increased (from 2.4% to 6.7%, P < 0.001). Between the prepandemic and pandemic private transportation cohorts, there were reductions in mean Injury Severity Score (from 8.1 ± 10.4 to 5.3 ± 6.6: P = 0.02), ICU admission rates (from 15% to 2.4%: P < 0.001), and hospital length of stay (from 4.0 ± 5.3 to 2.3 ± 1.9: P = 0.02). However, there was no difference in mortality (4.1% and 2.0%, P = 0.221). ConclusionsWe found that there was a significant shift in prehospital transportation among trauma patients toward private transportation after the shelter-in-place order. However, this did not coincide with a change in mortality despite a downward trend. This phenomenon could help direct future policy and protocols in trauma systems when battling major public health emergencies.

Parental report of levels of care and needs 7-years after severe childhood traumatic brain injury: Results of the traumatisme grave de l’Enfant (TGE) cohort study

This study investigated parental reports of the level of care and needs 7-years following severe childhood traumatic brain injury (TBI), and the factors associated with this outcome. From the 65 children (0–15 years) consecutively admitted to the Parisian regional TBI reference intensive care unit following severe TBI, included in this prospective longitudinal study, 39 patients [M(SD) age at injury = 7.5 years (4.6) and assessment 15.3(4.4)] were followed 7-years post-injury and matched with a control group composed of typically developing participants (n = 34) matched by age, sex and parental education level. We used the Care and Need Scale (CANS) and its Pediatric version (PCANS) to assess the primary outcome 7-years post-injury. Concurrent measures included overall level of disability, and parent- and/or self-reported questionnaires assessing executive functioning, behavior, quality of life, fatigue, participation and caregivers’ burden. The level of care and needs was significantly higher in the TBI group than in the control group, the difference being significant with the CANS only. PCANS scores were extremely variable in the control group. High level of dependency was associated with initial TBI severity (higher coma duration and initial Injury Severity Score), higher levels of behavioral problems, executive function deficits, fatigue, and lower participation levels. Caregivers’ burden was strongly associated with the CANS. The CANS provides a simple and reliable measure of the support needed long-term after childhood TBI, in accordance with previous studies. The PCANS scores were not significantly different between the TBI and the control groups, which seems to illustrate the difficulty to assess accurately mild-to-moderate deficits of functional independence/adaptive behavior in children based exclusively on parental reports.

Characteristics and outcomes of homicidal and accidental stab wounds in emergency hospitals: A medicolegal comparative study

Differentiation between the various manner of stab cases is challenging in forensic medicine. Although the distinction between homicidal and suicidal stabbing is well defined, there is a lack of discrimination between accidental and homicidal cases. Therefore, this study aimed to assess the characteristics of and outcomes for stab patients admitted to multiple emergency hospitals to highlight the distinction between accidental and homicidal stab wounds. This prospective cohort study assessed all patients with stab wounds admitted to multiple emergency hospitals from February 2021 to October 2021. Data collected on admission were demographics, trauma circumstances, internal organ damage, and patients' outcomes. Afterward, patients were categorized into homicidal or accidental stabs. Most of the included 51 stab cases were homicidal (78.4%). Most homicidal stabs were in middle-aged male drivers; were caused by sharp weapons, such as a penknife; and occurred in fights outdoors during the summer daytime. In contrast, most accidental stabs were occupational among building carpenters. Although homicidal stab wounds were significantly associated with a regular elliptical shape, oblique orientation, and defense wounds, the existence of a regular elliptical wound shape increased the likelihood of a homicidal stab. Additionally, penetrating stab type and a higher Injury Severity Score (ISS) were the dominant predictors of complications and mortality in stab patients, respectively. For fatal vague stab cases scenarios, the presence of an elliptical wound suggests the probability of homicidal injury than accidental. The initial ISS and stab wound type should be assessed to stratify stab patients who need intensive management in emergency hospitals.

Trauma Scores and Their Prognostic Value for the Outcome Following Pediatric Polytrauma.

Purpose: The management and prognostic assessment of pediatric polytrauma patients can pose substantial challenges. Trauma scores developed for adults are not universally applicable in children. An accurate prediction of the severity of trauma and correct assessment of the necessity of surgical procedures are important for optimal treatment. Several trauma scores are currently available, but the advantages and drawbacks for use in pediatric patients are unclear. This study examines the value of the trauma scores Injury Severity Score (ISS), Pediatric Trauma Score (PTS), National Advisory Committee for Aeronautics (NACA), and Glasgow Coma Score (GCS) for the assessment of the polytraumatized child.Methods: In a retrospective study, 97 patients aged 0–17 years who presented with polytrauma and an ISS ≥16 in the trauma bay were included in the study. Patient records including radiological studies were analyzed. Pathological imaging findings and emergency surgery were assessed as outcome variables and the predictive value of the trauma scores were analyzed using receiver operator characteristic (ROC) curves. Statistical significance was set at an alpha level of P ≤ 0.05.Results: In this study, 35 of the 97 studied children had pathological cranial computed findings. These either underwent craniectomy or trepanation or a parenchymal catheter was placed for intracranial pressure monitoring. Abdominal trauma was present in 45 patients, 16 of which were treated surgically. Forty-three patients arrived with thoracic injuries, 10 of which received a thoracic drainage. One child underwent an emergency thoracotomy. Predictive accuracy for emergency surgery calculated using receiver-operator characteristic (ROC) curves was highest for ISS and NACA scores (0,732 and 0.683, respectively), and lower for GCS (0.246) and PTS (0.261).Conclusion: In our study cohort, initial ISS and NACA scores better predicted operative interventions and outcome than PTS or GCS for polytraumatized pediatric patients.

Opioid Prescribing at Discharge in Opioid-Naïve Trauma Patients.

Opioid analgesics remain mainstay of treatment for trauma-related pain despite growing concerns for opioid dependency or misuse. The purpose of this study was to evaluate opioid prescribing at hospital discharge after traumatic injury. This is a single-center, retrospective analysis of patients ≥18years of age admitted for ≥24hours with a primary diagnosis of traumatic injury. Those with alcohol use disorder, polysubstance abuse, chronic opioid use, or in-hospital mortality were excluded. The primary outcome was the incidence of patients prescribed opioids at discharge. Secondary outcomes included percent of patients who received nonopioids, intensive care unit (ICU) admission, and hospital length of stay (LOS). Of the 927 encounters, 471 were included. The mean age was 60 ± 23years, and 62.0% were male. The majority were blunt trauma, and 49.9% were falls. Mean initial injury severity score (ISS) was 9 ± 7.2. Of the 70.4% of patients prescribed opioids, 39.4% were discharged on opioids. Age ≥30years, ICU admission, ISS <9, or Charlson Comorbidity Index >1 was less likely to have opioids prescribed at discharge. Most received nonopioids (93.6%) and multimodal analgesia (84.3%). The median hospital and ICU LOS were 5 (3-9) and 2 (0-4) days, respectively. Only 39.4% had opioids prescribed at discharge. Opioid-reductive strategies may decrease in-hospital and discharge opioid prescribing. While opioid analgesics remain a mainstay of trauma-associated pain management, institution-wide opioid-sparing strategies can further reduce discharge opioid prescribing after trauma.

69-YEAR-OLD MALE WITH ENTRAPPED CHEST TUBE: COMPLICATION OF CPR

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Cardiopulmonary resuscitation (CPR) is a lifesaving intervention routinely performed in medical institutions. However, it is associated with multiple complications including rib fractures requiring thoracostomy tube (TT) insertion. Additionally, there is a paucity of evidence identifying complications of CPR with a TT present. Here we describe a case of a patient who had their TT break due to CPR. CASE PRESENTATION: A 69-year-old male presented as a level two trauma status post motor vehicle collision. His initial injury severity score was 29 with injuries including: left-sided rib fractures with flail segment of ribs 1-6, left hemopneumothorax, comminuted fracture of the left scapular body and spine, left clavicle fracture with emphysema and hematoma. The patient was admitted to the surgical intensive care unit with management including a thoracotomy for rib plating and evacuation of the hematoma. Preoperative imaging is shown in Figure 1. The patient underwent left posterolateral thoracotomy with open reduction and internal fixation of left ribs 3-7 with evacuation of subcutaneous hematoma and left hemothorax. A 28 French TT was placed in the left posterior apical position, and a curved 28 French TT was placed in the left posterior inferior position. A postoperative chest x-ray confirmed lung re-expansion (Figure 2). On post-operative day 1, the patient became hypoxic, hypotensive, and bradycardic leading to cardiac arrest. Advanced cardiac life support was initiated including CPR and epinephrine for eight minutes until return of spontaneous circulation was achieved. A chest x-ray post arrest was taken showing the rib plating was intact. On post-operative day 2, removal of the TT was attempted. The distal portion of the left TT broke and remained within the thoracic cavity. A computed tomography of the chest (Figure 3) showed the broken portion of the tube. On post-operative day 3, the patient underwent left mini thoracotomy, removal of the retained TT under ultrasound guidance, and replacement of the apical TT. The distal end of the curved chest tube was found to be entrapped within the anterior rib fractures that resulted from CPR and successfully removed. The rest of the patient’s admission was unremarkable and he was discharged to a rehabilitation facility. DISCUSSION: To our knowledge this is one of the first cases to describe entrapment of a TT as a result of CPR. Additionally, this is one of the few cases to describe the use of a thoracotomy for removal of an entrapped tube. Thoracotomy has been reported as a management strategy in a similar case in which a nasogastric tube became entrapped intratracheally following lobectomy. There remains a paucity of data on the true incidence of abnormal positioning of tubes and the role of thoracotomy in the management of these patients. CONCLUSIONS: We present the case of a broken entrapped TT and successful removal via thoracotomy. Reference #1: Hoke RS, Chamberlain D. (2004). Skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation, 63(3):327-38. Reference #2: Deliliga A, Chatzinikolaou F, Koutsoukis D, Chrysovergis I, Voultsos P. (2009). Cardiopulmonary resuscitation (CPR) complications encountered in forensic autopsy cases. BMC Emergency Medicine, 28;19(1):23. DISCLOSURES: No relevant relationships by Jordan Debbrecht, source=Web Response No relevant relationships by Katherine Foerster, source=Web Response no disclosure on file for Brian Gilbert; No relevant relationships by Michael Nguyen, source=Web Response no disclosure on file for George Philip; No relevant relationships by William Waswick, source=Web Response

Patients Presenting with Bull-related Injuries to a Southern Indian Emergency Department.

IntroductionBull-related injuries are commonly observed in rural areas of India as result of the animal’s use in sporting events as well as for agricultural purposes. These patients need early resuscitation due to complications from severe injuries. Previous work examining the epidemiology of bull-related injuries is limited, with most studies focusing on injuries in Spain and Latin America. There is scant literature examining the prevalence of such injuries in India. The objective of this study was to evaluate the demographic and clinical characteristics of bull-related injuries at a hospital in Tamil Nadu, India.MethodsThis was a prospective, observational study of patients who presented to an emergency department (ED) in Madurai, India, with a reported history of bull-related injuries between June 2017 and March 2019. We recorded information about patient demographics, location of injury, disposition, initial Injury Severity Score (ISS), and transport time.ResultsOur sample included a total of 42 patients. Almost a third of patients who presented were between the ages of 20–30 years (31%, n = 13), and most were male (86%, n = 36). Approximately 59% of patients (n = 25) had provoked injuries, occurring as a result of active participation during sporting activities. Injuries to the trunk were most common (55%, n = 23), followed by injuries to the perineum (19%, n = 19). The majority of patients (59.5%) had penetrating injuries (n = 25), The mean ISS was 10.1 (standard deviation 6.3). Five (12%) patients had a complication after injury including intra-abdominal abscess formation, peritonitis, and sepsis. Two patients died as a result of septicemia from peritonitis.ConclusionBull-related injuries may result in significant morbidity and mortality. Education of the population about the dangers of bull injuries from sporting events and the need for early transportation to the ED have the potential for significant reduction in morbidity and mortality.

Characterization of disability following traumatic through knee and transfemoral amputations

IntroductionThe purpose of this study is to characterize through knee and transfemoral amputations following severe traumatic injuries. MethodsA retrospective review of all transfemoral and through knee amputations sustained by United States military service members from 1 October 2001 to 30 July 2011 was conducted. Data from the Department of Defense Trauma Registry, the Armed Forces Health Longitudinal Technology Application, inpatient medical records and the Physical Evaluation Board Liaison Offices were queried in order to obtain characteristics related to injury sustained, demographics, treatment, and disability/mental health outcome data. ResultsA total of 1631 amputations in 1315 patients were identified. Of these there were 37 through knee and 296 were transfemoral amputations. Adequate records for detailed analysis were available on 140 and 25 transfemoral and through knee amputations respectively. There were no significant differences in demographic information, injury mechanism, initial injury severity score, or associated injuries, to include contralateral amputations. There was no significant difference in average disability rating (67.9% vs 78.3%, p = 0.46) or number of service members determined to be fully disabled (42.2% vs 28.6% p = 0.33) between the transfemoral and through knee amputation groups. Whereas there was no difference between groups preoperatively, the knee disarticulation group displayed a higher rate of mental health diagnoses post-amputation (96% vs 72%, p < 0.001) and a higher preponderance of anxiety related disorders than the transfemoral amputees (26.92% vs 12.96%, p = 0.0129). Discussion/conclusionAmong this military amputee through knee and transfemoral amputees displayed similar physical disability profiles. However, the through knee amputees displayed a higher level of anxiety related disorders and mental health diagnosis overall. While we don’t believe this relationship to be causal in nature, this finding reflects the importance of paying particular attention to mental health in the final disposition of traumatic lower extremity amputees.

Associations of Initial Injury Severity and Posttraumatic Stress Disorder Diagnoses With Long-Term Hypertension Risk After Combat Injury.

The associations between injury severity, posttraumatic stress disorder (PTSD), and development of chronic diseases, such as hypertension, among military service members are not understood. We sought to (1) estimate the prevalence and incidence of PTSD within a severely injured military cohort, (2) assess the association between the presence and chronicity of PTSD and hypertension, and (3) determine whether or not initial injury severity score and PTSD are independent risk factors for hypertension. Administrative and clinical databases were used to conduct a retrospective cohort study of 3846 US military casualties injured in the Iraq and Afghanistan conflicts between February 1, 2002, and February 1, 2011. Development of PTSD and hypertension after combat injury were determined using the International Classification of Diseases, Ninth Revision codes. Multivariable competing risk regression models were used to assess associations between injury severity score, PTSD, and hypertension, while controlling for covariates. Overall prevalence of PTSD was 42.4%, and prevalence of hypertension was 14.3%. Unadjusted risk of hypertension increased significantly with chronicity of PTSD (1-15 diagnoses: hazard ratio, 1.77; 95% confidence interval, 1.46-2.14; P<0.001; >15 diagnoses: hazard ratio, 2.29; 95% confidence interval, 1.85-2.84; P<0.001) compared with patients never diagnosed with PTSD. The association between injury severity score (hazard ratio, 1.06 per 5-U increment; 95% confidence interval, 1.03-1.10; P<0.001) and hypertension was significant, with little change in effect in the multivariable model (hazard ratio, 1.05 per 5-U increment; 95% confidence interval, 1.01-1.09; P=0.03). In a cohort of service members injured in combat, we found that chronicity of PTSD diagnoses and injury severity were independent risk factors for hypertension.

P142: The anticoagulated trauma patient: a Canadian experience in the era of direct oral anticoagulants

Introduction: The anticoagulated trauma patient is a particularly vulnerable population. Our current practice is guided by experience with patients taking vitamin K dependent antagonists (VKA, like warfarin). It is currently unknown how the increasing use of direct oral anticoagulants (DOACs) will change our trauma population. We collected data about this new subset of patients to compare their clinical characteristics to patients on pre-injury VKA therapy. Methods: Retrospective review of anticoagulated trauma patients presenting to Toronto’s two adult trauma centres, Saint Michael’s Hospital and Sunnybrook Health Sciences Centre, from June 2014-June 2015 was undertaken. Patients were recruited through the institutions’ trauma registries and were eligible if they suffered a traumatic injury and taking an oral anticoagulant pre-injury. Clinical and demographic data were extracted by a trained reviewer and analysed with descriptive statistics. Results: Our study recruited 85 patients, 33% were taking DOACs and 67% VKAs. Trauma patients on DOACs &amp; VKAs respectively had similar baseline characteristics such as age (75.9 vs 77.4), initial injury severity score (ISS (16.9 vs 20.6)) and concomitant antiplatelet use (7.1% vs 5.4%). Both groups’ most common mechanism for injury was falls and the most common indication for anticoagulation was atrial fibrillation. Patients on DOACs tended to have lower average INR (1.25 vs 2.3) and serum creatinine (94.9 vs 127.4). Conclusion: Patients on DOACs pre-injury now account for a significant proportion of orally anticoagulated trauma patients. Patients on DOACs tended to have less derangement of basic hematological parameters complicating diagnosis and management of coagulopathy.

Prehospital neurologic deterioration is independent predictor of outcome in traumatic brain injury: analysis from National Trauma Data Bank

BackgroundThe prevalence and impact of prehospital neurologic deterioration (PhND) in patients with traumatic brain injury (TBI) have not been investigated. We aimed to determine the prevalence of PhND during emergency medical service (EMS) transportation among patients with TBI and its impact on patient's outcome. MethodsWe used the National Trauma Data Bank, using data files from 2009 to 2010 to identify patients with TBI through International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The initial Glasgow Coma Scale (GCS) score ascertained at the scene by EMS was compared with the subsequent GCS score evaluation in the emergency department (ED) to identify neurologic deterioration (defined as a decrease in GCS of ≥2 points). Patients' demographics, initial injury severity score (ISS), admission GCS score, and hospital outcome were compared between patients with PhND and patients without neurologic deterioration. ResultsA total of 257 127 patients with TBI were identified. Among patients with TBI, 22 254 patients had PhND, which comprised 9% of all patients with TBI. The mean of GCS score decrease during EMS transport was 5 points (±3). Patients without PhND tended to have higher GCS recorded by EMS (median, 15 vs 12; P < .0001). Patients with TBI who had PhND had significantly higher hospital length of stay and intensive care unit days after adjusting for baseline characteristics and EMS GCS score, EMS transport time, type of injury, presence of intracranial hemorrhages, and ED ISS (P < .0001). These patients had higher rate of in-hospital mortality after adjusting for the same variables (odds ratio, 2.30; 95% confidence interval, 2.18-2.41). ConclusionPrehospital neurologic deterioration occurs in 9% of patients with TBI. It is more prevalent in men and associated with lower EMS GCS level and higher ED ISS. Prehospital neurologic deterioration is an independent predictor of worse hospital outcome and higher resource use in patients with TBI.

Abstract TMP65: Endovascular and Surgical Treatment of Subarachnoid Hemorrhage Patients in Trauma Setting: Analysis from National Trauma Data Base (NTDB)

Background: Traumatic subarachnoid hemorrhage (tSAH) occurs in up to 60% of patients with traumatic brain injury (TBI) and is associated with higher death and disability in TBI patients. Vascular injury in the form of aneurysms, dissections, and transections may require treatment to prevent further bleeding episodes. We aimed to compare endovascular treatment with surgical treatment in tSAH patients. Methods: tSAH and related endovascular and surgical procedures were identified by ICD-9-CM codes from the National Trauma Data Bank (NTDB), using data files from 2009 to 2010. NTDB represents one of the largest trauma databases and contains data from over 900 trauma centers across the United States. Surgical and endovascular treatment groups were compared by variables of patient demographics, initial injury severity score (ISS) and Glasgow Coma Scale (GCS) assessment in the emergency department (ED), hospital course, and treatment outcomes. Results: A total of 119 tSAH patients were identified who required treatment for intracranial vascular injury. Of these, 53% received endovascular treatment and 47% were treated surgically. No differences in demographic characteristics between these two groups were observed. The mean Injury Severity Score (ISS) [23(19-26) versus 15(12-18); P=0.03] and frequency of skull base fracture (30% versus 2%; P&lt;.0001) were significantly higher in the endovascular treated group than in surgical group. Admission GCS scores were also significantly lower in the endovascular treated group (P=0.007). ICU days in the endovascular treatment group were significantly lower than in the surgical group [14(10-17) versus 16(13-17); P=0.04]. ICU days remained significantly lower in the endovascular group after adjusting for admission GCS, ISSAIS, skull base fracture, and other characteristics [0.4 (0.2-0.8); P=0.009]. Although the mean length of hospital stay was 3 days less in the endovascular group, this difference was not statistically significant. Conclusion: Despite more severe injury and lower admission GCS scores, patients who received endovascular treatment had lower ICU day requirement and similar discharge outcomes. Such observations support the preferential use of endovascular treatment in trauma settings.

Hypothermia and rapid rewarming is associated with worse outcome following traumatic brain injury.

The purpose of the present study was to determine (1) the prevalence and degree of hypothermia in patients on emergency department admission and (2) the effect of hypothermia and rate of rewarming on patient outcomes. Secondary data analysis was conducted on patients admitted to a level I trauma center following severe traumatic brain injury (n = 147). Patients were grouped according to temperature on admission according to hypothermia status and rate of rewarming (rapid or slow). Regression analyses were performed. Hypothermic patients were more likely to have lower postresuscitation Glasgow Coma Scale scores and a higher initial injury severity score. Hypothermia on admission was correlated with longer intensive care unit stays, a lower Glasgow Coma Scale score at discharge, higher mortality rate, and lower Glasgow outcome score-extended scores up to 6 months postinjury (P < .05). When controlling for other factors, rewarming rates more than 0.25°C/h were associated with lower Glasgow Coma Scale scores at discharge, longer intensive care unit length of stay, and higher mortality rate than patients rewarmed more slowly although these did not reach statistical significance. Hypothermia on admission is correlated with worse outcomes in brain-injured patients. Patients with traumatic brain injury who are rapidly rewarmed may be more likely to have worse outcomes. Trauma protocols may need to be reexamined to include controlled rewarming at rates 0.25°C/h or less.

Validation Study of an Automated Electronic Acute Lung Injury Screening Tool

ObjectiveThe authors designed an automated electronic system that incorporates data from multiple hospital information systems to screen for acute lung injury (ALI) in mechanically ventilated patients. The authors evaluated the accuracy of this system in diagnosing ALI in a cohort of patients with major trauma, but excluding patients with congestive heart failure (CHF). DesignSingle-center validation study. Arterial blood gas (ABG) data and chest radiograph (CXR) reports for a cohort of intensive care unit (ICU) patients with major trauma but excluding patients with CHF were screened prospectively for ALI requiring intubation by an automated electronic system. The system was compared to a reference standard established through consensus of two blinded physician reviewers who independently screened the same population for ALI using all available ABG data and CXR images. The system's performance was evaluated (1) by measuring the sensitivity and overall accuracy, and (2) by measuring concordance with respect to the date of ALI identification (vs. reference standard). MeasurementsOne hundred ninety-nine trauma patients admitted to our level 1 trauma center with an initial injury severity score (ISS) ≥ 16 were evaluated for development of ALI in the first five days in an ICU after trauma. Main ResultsThe system demonstrated 87% sensitivity (95% confidence interval [CI] 82.3–91.7) and 89% specificity (95% CI 84.7–93.4). It identified ALI before or within the 24-hour period during which ALI was identified by the two reviewers in 87% of cases. ConclusionsAn automated electronic system that screens intubated ICU trauma patients, excluding patients with CHF, for ALI based on CXR reports and results of ABGs is sufficiently accurate to identify many early cases of ALI.

Diagnostic accuracy in head-injured patients: an emergency department audit

Records of 197 patients admitted to hospital with head injury were studied retrospectively to assess the influence of altered conscious state on injury misdiagnosis in the Emergency department (ED). Diagnostic errors were identified by discrepancies between an initial Injury Severity Score (ISS) calculated according to injuries diagnosed in the ED and a final ISS based on diagnoses confirmed on discharge from hospital, or death. The Glasgow Coma Scale (GCS) was used to assess neurological status. ISS discrepancies were present in 56 patients (29 per cent). These discrepancies arose because of: (i) failure of interpretation of radiographs; (ii) inadequate clinical examination; and (iii) inaccurate injury description in the ED notes. The risk of injury misdiagnosis was greatest for thoracic, abdominal and spinal injury, followed in descending order by extremity (limb), head, and external (skin and subcutaneous) injury. Although there was no linear correlation between GCS and ISS discrepancy rate, ISS discrepancies were significantly more frequent in comatose patients that in non-comatose patients (χ 2 = 3.69, 1 df; P < 0.05). Individual staff performance is at least as important as head injury severity in determining diagnostic accuracy on initial assessment in the ED.