Injury Severity Score In Group Research Articles

Early Tracheostomy in Older Trauma Patient Is Associated With Comparable Outcomes to Younger Cohort

IntroductionEarly tracheostomy (ET) is associated with a lower incidence of pneumonia (PNA) and mechanical ventilation duration (MVD) in hospitalized patients with trauma. The purpose of this study is to determine if ET also benefits older adults compared to the younger cohort. MethodsAdult hospitalized trauma patients who received a tracheostomy as registered in The American College of Surgeons Trauma Quality Improvement Program from 2013 to 2019 were analyzed. Patients with tracheostomy prior to admission were excluded. Patients were stratified into 2 cohorts consisting of those aged ≥65 and those aged <65. These cohorts were analyzed separately to compare the outcomes of ET (<5 d; ET) versus late tracheostomy (LT) (≥5 d; LT). The primary outcome was MVD. Secondary outcomes were in-hospital mortality, hospital length of stay (HLOS), and PNA. Univariate and multivariate analyses were performed with significance defined as P value < 0.05. ResultsIn patients aged <65, ET was performed within a median of 2.3 d (interquartile range, 0.47-3.8) after intubation and a median of 9.9 d (interquartile range, 7.5-13) in the LT group. The ET group's Injury Severity Score was significantly lower with fewer comorbidities. There were no differences in injury severity or comorbidities when comparing the groups. ET was associated with lower MVD (d), PNA, and HLOS on univariate and multivariate analyses in both age cohorts, although the degree of benefit was higher in the less than 65 y cohort [ET versus LT MVD: 5.08 (4.78-5.37), P < 0.001; PNA: 1.45 (1.36-1.54), P < 0.001; HLOS: 5.48 (4.93-6.04), P < 0.001]. Mortality did not differ based on time to tracheostomy. ConclusionsET is associated with lower MVD, PNA, and HLOS in hospitalized patients with trauma regardless of age. Age should not factor into timing for tracheostomy placement.

Evaluating the definition of severely injured patients: a Japanese nationwide 5-year retrospective study

ObjectivesThe definition of severely injured patients lacks universal consensus based on quantitative measures. The most widely used definition of severe injury is based on the Injury Severity Score (ISS), which...

The Impact of Seatbelt Use on Trauma Outcomes in Adult Motor Vehicle Collision Patients With Rib Fractures: A National ACS-TQP-PUF Database Analysis

Motor vehicle collisions (MVCs) are a leading cause of morbidity and mortality. However, there is limited evidence examining the effects seatbelt use has on MVC-related injuries and outcomes in patients with rib fractures. We aim to assess how seatbelt use affects associated injuries and outcomes in adult MVC patients with ≥2 rib fractures. This retrospective study utilized the American College of Surgeons (ACS) Trauma Quality Programs (TQP) Participant Use File (PUF) Database. Drivers/passengers who sustained ≥2 rib fractures following an MVC and had an AIS ≤2 for extra-thoracic body regions were analyzed. Patients were then subdivided by presence of flail chest into two cohorts, which were subdivided according to injury severity score (ISS) and seatbelt use. Logistic and linear regression was used to assess the impact of seatbelt use on outcomes. Among both low and intermediate ISS classifications, restrained patients in the non-flail chest cohort had decreased incidence of pneumothorax, pulmonary contusion, and liver injury (P < 0.001). After adjusting for confounders, restrained patients (versus unrestrained) had decreased odds of pneumothorax (aOR=0.91, P=<0.001) and acute respiratory distress syndrome (aOR=0.65, P=0.02), while having increased odds of splenic laceration (aOR=1.18, P=0.003) (intermediate ISS group). Compared to unrestrained patients, restrained non-flail chest patients had a significantly decreased hospital length of stay (LOS) and intensive care unit LOS (P < 0.05). Seatbelt use may be protective against serious injuries in patients with ≥2 rib fractures, resulting in improved outcomes. Education programs should be developed to bolster seatbelt compliance.

Failure to Rescue in Geriatric Trauma: The Impact of Any Complication Increases with Age and Injury Severity in Elderly Trauma Patients

The interaction of increasing age, Injury Severity Score (ISS), and complications is not well described in geriatric trauma patients. We hypothesized that failure to rescue rate from any complication worsens with age and injury severity. The National Trauma Data Bank (NTDB) was queried for injured patients aged 65 years or older from January 1, 2013 through December 31, 2016. Demographics and injury characteristics were used to compare groups. Mortality rates were calculated across subgroups of age and ISS, and captured with heatmaps. Multivariable logistic regression was performed to identify independent predictors of mortality. 614,496 geriatric trauma patients were included; 151,880 (24.7%) experienced a complication. Those with complications tended to be older, female, non-white, have non-blunt mechanism, higher ISS, and hypotension on arrival. Overall mortality was highest (19%) in the oldest (≥86years old) and most severely injured (ISS ≥ 25) patients, with constant age increasing across each ISS group was associated with a 157% increase in overall mortality (P < .001, 95% CI: 148-167%). Holding ISS stable, increasing age group was associated with a 48% increase in overall mortality (P < .001, 95% CI: 44-52%). After controlling for standard demographic variables at presentation, the existence of any complication was an independent predictor of overall mortality in geriatric patients (OR: 2.3; 95% CI: 2.2-2.4). Any complication was an independent risk factor for mortality, and scaled with increasing age and ISS in geriatric patients. Differences in failure to rescue between populations may reflect critical differences in physiologic vulnerability that could represent targets for interventions.

Increased Mortality in Underinsured Penetrating Trauma Patients.

It remains unclear whether an increased mortality risk in uninsured patients exists across Injury Severity Score (ISS) classifications. We hypothesized that penetrating trauma self-pay patients would have a similarly increased mortality risk across all ISS categories. The National Trauma Data Bank (2013-2015) was queried for patients presenting with penetrating firearm, explosive, or stab wound injuries. 115651 patients were identified and a stratified multivariable logistic regression model was used. In the >15 ISS group, self-pay patients had a lower median total hospital Length of Stay (LOS) (3 vs 8, P < .001), lower median Intensive Care Unit LOS (1 vs 3, P < .001), and lower median ventilator days (0 vs 1, P < .001). Self-pay patients had an increased risk for mortality compared to patients with private insurance in both the ≤15 ISS group (OR 2.68, P < .001) and >15 ISS group (OR 1.56, P < .001). Uninsured patients have an increased mortality risk in both low and high ISS groups. A higher mortality risk among uninsured patients in the high ISS group can be explained by decreased resource availability and lower ICU days and ventilator time. However, more studies are needed to determine why there is an even greater mortality risk among uninsured patients with mild ISS.

Comorbidities in Trauma Injury Severity Scoring System: Refining Current Trauma Scoring System

The revised trauma score combined with the Injury Severity Score (ISS) remains the mostly commonly used system for predicting trauma mortality, but these scoring systems do not account for the patient's comorbidities. This study aims to evaluate the effect of comorbidities on ISS-related mortality and length of stay. A review of our trauma center's data registry from 2014 to 2016 was carried out. Patients were divided according to ISS into two groups: ISS ≤ 15 and ISS > 15. Each ISS group was then subdivided by number of comorbidities into two groups: 1 to 2 or ≥3 comorbidities. Demographic characteristics and outcome measures were compared. ANOVA, chi-squared, and t tests were used with significance defined as P < 0.05. A total 9845 adult trauma patients were admitted to our trauma center during the three-year study period. In the ISS ≤ 15 group, patients with <3 comorbidities had significantly higher mortality rate compared with patients with 1 to 2 comorbidities (1.50% vs 0.12%, P ≪ 0.000007). Comparing the ISS ≤ 15 group with ≥3 comorbidities with the ISS > 15 group with 1 to 2 comorbidities, the mortality rate was significantly higher (23.40% vs 4.50%, P ≪ 0.000002). The ICU length of stay was significantly higher in the ISS ≤ 15 groups (17 vs 10 days, P < 0.05) but similar in the ISS > 15 groups (31 vs 29 days) (P > 0.05). It was concluded that when controlling for injury severity, increased comorbidities are associated with a significantly higher mortality, indicating that they may serve as a marker of lower physiologic reserve and be an independent variable. Adding comorbidity parameters to the current trauma scoring systems can assist in predicting more accurate/reliable outcomes.

Impact of the severity of trauma on early retirement

ObjectiveTo assess the association between Injury Severity Score (ISS) and subsequent risk of early retirement. DesignObservational cohort study with follow-up based on prospectively collected data. Hospital-based data were linked to national register data on pension reception and vital status. SettingLevel-one urban trauma centre. ParticipantsPatients aged 18–64 years entering the trauma centre in Copenhagen during 1999–2007 who were alive after three days were followed until early retirement, death or emigration. Main outcome measuresPrimary outcome was early retirement, defined as receiving disability pension (unintentional) or voluntary early retirement pension (intentional) before the regular age of retirement (65 years). Relative risk of early retirement according to ISS (low, ISS 1–15 vs. high, ISS 16–75) was assessed using Cox proportional hazards regression, adjusted for age and gender. ResultsOf all 6687 patients admitted to the trauma centre, a total of 1722 trauma patients were included and followed for a median of 6.2 years (interquartile range (IQR) 3.7–9.1). Of these, 1305 (75.8%) were males, median age was 35.0 years (IQR 25.4–46.5), and median ISS was 16 (IQR 9–25). Three hundred and twenty-two patients retired during follow-up. Patients with high ISS, compared to patients with low ISS, had an increased risk of early retirement, adjusted hazard ratio 2.60 (95% confidence interval (CI) 2.05–3.30; p<0.001). Relative increase in retirement risk was 1.04 (95% CI 1.03–1.05) per ISS point and 1.03 (95% CI 1.03–1.04) per year older. Gender was not found to be a significant risk factor (p=0.69). Five-year absolute risks of early retirement were 9.9% (95% CI 7.8–12.0%) for the low ISS group and 24.6% (95% CI 21.6–27.5%) for the high ISS group. ConclusionsThe risk of early retirement is 2.6 times higher in severely injured patients (ISS 16–75) than the risk in low to moderately injured patients (ISS 1–15) and they have a high absolute 5-year risk as well. Early, targeted interventions to assist with return to work might be able to reduce this risk.

Impact of the severity of trauma on early retirement

A B S T R A C T Objective: To assess the association between Injury Severity Score (ISS) and subsequent risk of early retirement. Design: Observational cohort study with follow-up based on prospectively collected data. Hospitalbased data were linked to national register data on pension reception and vital status. Setting: Level-one urban trauma centre. Participants: Patients aged 18–64 years entering the trauma centre in Copenhagen during 1999–2007 who were alive after three days were followed until early retirement, death or emigration. Main outcome measures: Primary outcome was early retirement, defined as receiving disability pension (unintentional) or voluntary early retirement pension (intentional) before the regular age of retirement (65 years). Relative risk of early retirement according to ISS (low, ISS 1–15 vs. high, ISS 16–75) was assessed using Cox proportional hazards regression, adjusted for age and gender. Results: Of all 6687 patients admitted to the trauma centre, a total of 1722 trauma patients were included and followed for a median of 6.2 years (interquartile range (IQR) 3.7–9.1). Of these, 1305 (75.8%) were males, median age was 35.0 years (IQR 25.4–46.5), and median ISS was 16 (IQR 9–25). Three hundred and twenty-two patients retired during follow-up. Patients with high ISS, compared to patients with low ISS, had an increased risk of early retirement, adjusted hazard ratio 2.60 (95% confidence interval (CI) 2.05–3.30; p < 0.001). Relative increase in retirement risk was 1.04 (95% CI 1.03–1.05) per ISS point and 1.03 (95% CI 1.03–1.04) per year older. Gender was not found to be a significant risk factor (p = 0.69). Five-year absolute risks of early retirement were 9.9% (95% CI 7.8–12.0%) for the low ISS group and 24.6% (95% CI 21.6–27.5%) for the high ISS group. Conclusions: The risk of early retirement is 2.6 times higher in severely injured patients (ISS 16–75) than the risk in low to moderately injured patients (ISS 1–15) and they have a high absolute 5-year risk as well. Early, targeted interventions to assist with return to work might be able to reduce this risk.

Thrombelastography and biomarker profiles in acute coagulopathy of trauma: a prospective study

BackgroundSevere injury induces an acute coagulopathy associated with increased mortality. This study compared the Thrombelastography (TEG) and biomarker profiles upon admission in trauma patients.MethodsProspective observational study of 80 trauma patients admitted to a Level I Trauma Centre. Data on demography, biochemistry including standard coagulation tests, hematology, transfusions, Injury Severity Score (ISS) and TEG were recorded. Retrospective analysis of thawed plasma/serum for biomarkers reflecting tissue injury (histone-complexed DNA fragments), sympathoadrenal activation (adrenaline, noradrenaline), coagulation activation/inhibition and fibrinolysis (sCD40L, protein C, activated Protein C, tissue-type plasminogen activator, plasminogen activator inhibitor-1, D-dimer, prothrombinfragment 1+2, plasmin/α2-antiplasmin complex, thrombin/antithrombin complex, tissue factor pathway inhibitor, antithrombin, von willebrand factor, factor XIII). Comparison of patients stratified according to ISS/TEG maximum clot strength. Linear regression analysis of variables associated with clot strength.ResultsTrauma patients had normal (86%), hypercoagulable (11%) or hypocoagulable (1%) TEG clot strength; one had primary hyperfibrinolysis. Hypercoagulable patients had higher age, fibrinogen and platelet count (all p < 0.05), none had increased activated partial thromboplastin time (APTT) or international normalized ratio (INR) and none required massive transfusion (> 10 red blood cells the initial 24 h). Patients with normal or hypercoagulable TEG clot strength had comparable biomarker profiles, but the few patients with hypocoagulable TEG clot strength and/or hyperfibrinolysis had very different biomarker profiles.Increasing ISS was associated with higher levels of catecholamines, histone-complexed DNA fragments, sCD40L, activated protein C and D-dimer and reduced levels of non-activated protein C, antithrombin, fibrinogen and factor XIII (all p < 0.05). Fibrinogen and platelet count were associated independently with clot strength in patients with ISS ≤ 26 whereas only fibrinogen was associated independently with clot strength in patients with ISS > 26. In patients with ISS > 26, adrenaline and sCD40L were independently negatively associated with clot strength.ConclusionsTrauma patients displayed different coagulopathies by TEG and variables independently associated with clot strength changed with ISS. In the highest ISS group, adrenaline and sCD40L were independently negatively associated with clot strength indicating that these may contribute to acute coagulopathy.

Evolution of trauma management at a tertiary care hospital: A cohort study

Objective To analyze the characteristics of polytrauma patients and to assess the outcome of trauma care as this specialty has evolved over the years at a university hospital. Methods The study included all polytrauma patients treated between January 1998 and September 2005 at a tertiary care hospital in a megacity. Data of 1009 patients was collected prospectively and analyzed retrospectively. Patients were divided into two groups A and B, based on their presentation before and after the introduction of a formal trauma training course in 2002. The analysis included demographic data, injury severity score, vital signs including hemodynamics and GCS on admission, intubation rates, mortality and complications. Results 435 patients were included in group A (1998–2001) whereas group B (2002–2005) comprised of 574 patients. The proportion of patients with accidental versus intentional injuries was similar in both groups. The mean injury severity score of group A was 11.9 whereas that of group B was 11.7. Almost 50% of patients were transferred from other hospitals. Transferred patients had significantly lower GCS ( p < 0.001), higher ISS ( p < 0.001) and longer ICU stays ( p < 0.001) in both (A and B) patient groups, while in group A mortality was also higher ( p = 0.018). A significantly higher number of patients in group B went into shock. The overall mortality rate was 9.7% for group A which significantly decreased to 5.7% for group B ( p < 0.05). Conclusions This study supports the view that as trauma care evolved at our hospital with the establishment of a formal training program, the mortality rates have significantly decreased.

A Central Venous Line Protocol Decreases Bloodstream Infections and Length of Stay in a Trauma Intensive Care Unit Population

We evaluated the benefit of a central venous line (CVL) protocol on bloodstream infections (BSIs) and outcome in a trauma intensive care unit (ICU) population. We prospectively compared three groups: Group 1 (January 2003 to June 2004) preprotocol; Group 2 (July 2004 to June 2005) after the start of the protocol that included minimizing CVL use and strict universal precautions; and Group 3 (July 2005 to December 2006) after the addition of a line supply cart and nursing checklist. There were 1622 trauma patients admitted to the trauma ICU during the study period of whom 542 had a CVL. Group 3 had a higher Injury Severity Score (ISS) compared with both Groups 2 and 1 (28.3 +/- 13.0 vs 23.5 +/- 11.7 vs 22.8 +/- 12.0, P = 0.0002) but had a lower BSI rate/1000 line days (Group 1: 16.5; Group 2: 15.0; Group 3: 7.7). Adjusting for ISS group, three had shorter ICU length of stay (LOS) compared with Group 1 (12.11 +/- 1.46 vs 18.16 +/- 1.51, P = 0.01). Logistic regression showed ISS (P = 0.04; OR, 1.025; CI, 1.001-1.050) and a lack of CVL protocol (P = 0.01; OR, 0.31; CI, 0.13-0.76) to be independent predictors of BSI. CVL protocols decrease both BSI and LOS in trauma patients. Strict enforcement by a nurse preserves the integrity of the protocol.

Role of lung contusions on posttraumatic inflammatory response and organ dysfunction in traumatized patients.

Multiple trauma is often accompanied by lung contusion leading to secondary pulmonary inflammation and organ dysfunction. The particular role of lung contusions on the systemic inflammatory response remains unclear. Therefore, the aim of the present study was to compare the degree of lung contusion with markers of inflammation and multiple organ failure (MOF) in trauma patients. According to the Injury Severity Score (ISS), 45 patients were assigned to a low (< 25 points) and a high ISS group (> 25 points), respectively. Both groups were subdivided into minor and major lung injury groups as defined by computed tomography (CT) scan. Plasma levels of interleukin 6 (IL-6), interleukin 8 (IL-8), tumor necrosis factor (TNF) receptors, C-reactive protein (CRP), and polymorphonuclear (PMN) elastase were assessed, as well as the Murray lung score (MLS) and the MOF score. Patients with low ISS present moderate activation of inflammation which is not influenced by the degree of lung contusion. In contrast, patients with a high ISS develop significant posttraumatic inflammation and MOF. Patients with high ISS and severe lung contusions present significantly higher MLS and MOF scores. Interestingly, patients of the high ISS group without severe lung contusions develop a similar degree of MLS and MOF only after 5 days following the traumatic insult. However, the initial plasma levels of IL-6 and IL-8 differ significantly in this group. Our data show that severe lung contusions contributes to an immediate onset of posttraumatic inflammation in severely traumatized patients, resulting in MOF, while in severely injured patients without lung contusion, this development requires up to 5 days.

The Effects of Methamphetamine Use on Trauma Patient Outcome

A retrospective review was conducted to analyze the effect of methamphetamine use in trauma patients. Charts of all trauma patients admitted to Kern Medical Center from January 1, 2003, to January 5, 2006 (36 months) were analyzed for length of stay, intensive care unit (ICU) admission rate and number of ICU days, ventilator days, and mortality. Results were compared in patients testing positive for methamphetamine (M+) with those who tested negative (M-). Data were then stratified according to six Injury Severity Score (ISS) groups: 1-5, 6-10, 11-15, 16-20, 21-25, and 26-30. A total of 4759 patients were admitted to the trauma unit, 971 of whom had available urine toxicology results. Six hundred seventy-four tested M- and 297 tested M+. There were no differences in total ICU days or ventilator days in the M+ versus M- patients. There was a higher incidence of assault in the M+ group (P = 0.0001). A trend toward decreased mortality was noted in M+ patients (P = 0.0778). ISS subset analysis demonstrated an increased ICU admission rate in M+ patients in ISS group 1-5 (P = 0.0002). There was also an increased length of stay in M+ patients within the ISS 6-10 group (8 versus 5 days, respectively, P = 0.015).

Successful results of minimally invasive surgery for comminuted supracondylar femoral fractures with LISS: comparative study of multiply injured and isolated femoral fractures

BackgroundThe aim of this prospective study was to compare the outcomes of distal femoral fractures treated by the Less Invasive Stabilization System (LISS) in multiply injured and isolated fracture cases. MethodsThis study comprised 26 patients (16 men, 10 women), who had 27 distal femoral fractures. Patients were divided into two groups; multiple injuries (group I) or isolated distal femoral fracture (group II). The average Injury Severity Score of group I was 26.7. Operations were performed according to biological fixation principles in a submuscular manner. No bone grafting was performed to enhance the healing. The cases were evaluated based on the criteria of Schatzker–Lambert and the modified Hospital for Special Surgery (HSS) scoring system. ResultsThe mean follow-up period was 25.8 months. Union was achieved in all cases. Two patients in group I required débridement procedures due to deep infection. One of them healed completely but the other did not. The average range of knee motion of groups I and II at the last control were 112.8° and 121.8°, respectively. The mean modified HSS scores were 73.9 and 79.9, respectively. There was no significant difference in the HSS scores or the range of knee motion. The time to full weight bearing was longer in group I owing to the concomitant injuries. ConclusionsWe concluded that LISS is a useful method for comminuted supracondylar fractures with multiple trauma patients as the results showed no significant differences when compared with those of patients with isolated femoral fractures.

Epidural versus intravenous pain control in elderly patients with rib fractures

Background Epidural catheters are used in older patients with rib fractures to improve outcome. We reviewed the efficacy of epidural analgesia (EA) compared with intravenous narcotics (IVN) in this population. Methods Rib fracture patients >55 years old admitted to our level I trauma center from 1999 through 2002 were reviewed for demographics, Injury Severity Score (ISS), Abbreviated Injury Score for chest, length of stay, cardiopulmonary comorbidities, complications, and type of analgesia. Results There were 187 patients: 72 men and 115 women. The mean age was 77 years. For ISS <9, length of stay for EA patients was 12 ± 5 days versus 5 ± 4 days for IVN patients ( P <0.001). Complications occurred in 9 of 10 EA patients versus 21 of 52 IVN patients ( P <0.001). No difference was noted in length of stay for patients with ISS ≥9. Complications in the high ISS group occurred in 29 of 43 EA patients versus 37 of 82 IVN patients ( P <0.05). Stratification of patients based on low versus high Abbreviated Injury Score for chest yielded similar results. Conclusions EA is associated with prolonged length of stay and increased complications in elderly patients, particularly those with less significant injuries, regardless of cardiopulmonary comorbidities. EA for elderly patients with rib fractures should be prospectively re-evaluated.

Save the Trees

From 1981 to 1989, 323 patients whose diagnoses resulted from ski injuries were emergently admitted to a Class 1 Trauma Hospital. Of this group, 107 (33%) were injured in skier-tree collisions. This tree collision group (TC group) was compared with a group that did not hit a tree (non-tree-collision group or NTC group). The average age of the TC group was 26 years, compared with 31 years in the NTC group. The Revised Trauma Score (RTS) was recorded for each patient. The TC group's average trauma score was 7.205, compared with 7.7395 for the NTC group. The Injury Severity Score (ISS) was also recorded. The TC group's ISS averaged 14.7, compared with 9.1 for the NTC group. Both of these scores demonstrated statistical significance. Certain injuries such as skull fractures, head injuries, pelvic fractures, and chest injuries (including rib fractures, pneumothoraces, and pulmonary contusions) were more common in the TC group. Tibia fractures were more common in the NTC group. Femur fractures and upper extremity fractures were evenly distributed between the two groups. Seven deaths were recorded in the TC group and five deaths occurred in the NTC group.

Improved Outcome with Femur Fractures

Prior studies documented that early fixation of femur fractures results in a decreased incidence of adult respiratory distress syndrome (ARDS), fat embolism syndrome, and pneumonia. This study evaluates the impact of magnitude of injury on pulmonary complications and length of ICU and hospital stays in 339 trauma patients with femur fracture undergoing early (n = 121) vs. late (n = 218) operative fixation. Groups were similar with respect to transfusions, hypotension, and associated injuries, but more patients over age 50 years underwent early fixation. Patients were categorized according to Injury Severity Score (ISS): 1) less than 15 (n = 202), 2) 16-35 (n = 104), and 3) greater than 36 (n = 33). Delayed fixation significantly increased the incidence of pulmonary shunt in ISS (3) patients and of pneumonia in patients older than 50. Late fixation resulted in significantly longer hospital stays in all groups and more ICU days in the ISS (3) group. We believe that early femur fixation should be performed on all patients. Pulmonary complications were decreased and health care costs reduced.