Large Cohort Of Trauma Patients Research Articles

Absence of July effect on trauma outcomes at the start of the academic medical calendar

Purpose The “July effect” refers to the phenomenon of a higher complication incidence and lower survival rate for patients treated at academic institutions during the beginning of the academic medical calendar. To date, no multi-center study has examined the presence of a “July effect” in a large cohort of trauma patients. We sought to determine if there is a by-month effect on survival and length of stay (LOS) for trauma patients in large academic centers. Methods We performed a multicenter, retrospective cohort study between 2010 and 2020 from five high-volume academic trauma centers in the United States. We included all adult motor vehicle collision (MVC) traumas evaluated at all centers in the study population (age >16 years, mechanism of injury classified as “motor vehicle collision”). Data included date and time of injury, injury severity score (ISS), LOS, and mortality. Each injury was classified as minor (ISS 1–8), moderate (9–15), severe (16–24), and very severe (>25). The mortality and LOS for each range over the entire epoch was calculated by month for each ISS classification. Results We analyzed 39,668 MVC traumas (mean age 41.83, range 39.9–43.3 among sites, 58.9% male and range 56.1–60.4%, 67.4% white range 42.3–84.7%). Survival for the “very severe” traumas ranged from 86.7–90.3%. Across the five sites, there was no significant change in survival (either increased or decreased mortality) or LOS for MVC patients in July or August for any injury classification level. Both age and ISS had a significant effect on survival (OR 0.02 for ISS >25, 0.22 for patients >65 years-old, both p < 0.05). Conclusions In five high-volume centers, there was no significant effect of the July transition on survival or LOS of MVC trauma patients.

Sex differences in time course and diagnostic accuracy of GFAP and UCH-L1 in trauma patients with mild traumatic brain injury

Glial Fibrillary Acidic Protein (GFAP) and Ubiquitin C-terminal hydrolase (UCH-L1) have been FDA-approved for clinical use in mild and moderate traumatic brain injury (TBI). Understanding sex differences in their diagnostic accuracy over time will help inform clinical practice. We sought to evaluate the sex differences in the temporal profile of GFAP and UCH-L1 in a large cohort of trauma patients presenting to the emergency department. To compare the biomarkers’ diagnostic accuracy in male versus female patients for detecting mild TBI (MTBI), and traumatic intracranial lesions on head CT. This prospective cohort study enrolled female and male adult trauma patients presenting to a Level 1 Trauma Center. All patients underwent rigorous screening to determine whether or not they had experienced a MTBI. Of 3025 trauma patients assessed, 1030 met eligibility criteria and 446 declined. Initial blood samples were obtained in 584 patients enrolled within 4 h of injury. Repeated blood sampling was conducted at 4, 8, 12, 16, 24, 36, 48, 60, 72, 84, 96, 108, 120, 132, 144, 156, 168, and 180-h post-injury. The main outcomes included the diagnostic accuracy in detection of MTBI and traumatic intracranial lesions on head CT scan. A total of 1831 samples were drawn in 584 patients over 7 days, 362 (62%) were male and 222 (38%) were female. The pattern of elevation was similar in both sexes. Although the pattern of elevation was similar between male and female for both biomarkers, male patients had significantly higher concentrations of UCH-L1 compared to female patients at several timepoints post-injury, particularly within 24 h of injury. There were no significant differences in diagnostic accuracy for detecting MTBI or for detecting CT lesions between male and female patients at any timepoint for both GFAP and UCH-L1. Although patterns of GFAP and UCH-L1 release in trauma patients over a week post-injury was similar between the sexes, there were significantly higher concentrations of UCH-L1 in males at several timepoints post-injury. Despite this, the overall diagnostic accuracies of both GFAP and UCH-L1 over time for detecting MTBI and CT lesions were not significantly different between male and female trauma patients.

Big data insights into predictors of acute compartment syndrome

BackgroundThere remain gaps in knowledge regarding the pathophysiology, initial diagnosis, treatment, and outcome of acute compartment syndrome (ACS). Most reported clinical outcomes are from smaller studies of heterogeneous patients. For a disease associated with a financial burden to society that represents billions of dollars worldwide the literature does not currently establish baseline diagnostic parameters and risk factors that may serve to predict treatment and outcomes. MethodsThis study looks at a very large cohort of trauma patients obtained from four recent years of the Trauma Quality Programs data from the American College of Surgeons. From 3,924,127 trauma cases - 203,500 patients with tibial fractures were identified and their records examined for demographic information, potential risk factors for compartment syndrome, an associated coded diagnosis of muscle necrosis, and presence of other outcomes associated with compartment syndrome. A recurrent multiple logistic regression model was used to identify factors predictive of fasciotomy. The results were compared to the reported results from the literature to validate the findings. ResultsThe rate of fasciotomy treatment for ACS was 4.3% in the cohort of identified patients. The analysis identified several clinical predictors of fasciotomy. Proximal and midshaft tibial fractures (P <0.0001) showed highest increases in the likelihood of ACS. Open fractures were twice (O.R [2.20–2.42]) as likely to have ACS. Having a complex fracture (P<0.0001), substance abuse disorder (P<0.0002), cirrhosis (P = 0.002) or smoking (P<0.0051) all increased the likelihood of ACS. Age decreased the likelihood by 1% per year (OR= [0.99–0.993]). Crush and penetrating injuries showed an important increase in the likelihood of ACS (O.R of 1.83 and 1.37 respectively). Additionally, sex, BMI, cirrhosis, tobacco smoking and fracture pattern as defined by OTA group and OTA subgroup had predictive value on actual myonecrosis. Fasciotomies for open tibial fractures were more likely to uncover significant muscle necrosis compared to closed fractures. Amputation resulted after 5.4% of fasciotomies. ConclusionThis big data approach shows us that ACS is primarily linked to the extent of soft tissue damage. However, newfound effect of some comorbidities like cirrhosis and hypertension on the risk of ACS imply other mechanisms.

A Retrospective Look at Term Outcomes After Definitive Surgical Repair for Traumatic Pelvic Fracture Urethral Injuries – Does Initial Management Make a Difference?

ObjectiveTo compare the long-term outcomes of initial management of pelvic fracture urethral injury (PFUI) in a large cohort of trauma patients undergoing urethral reconstruction. Materials and Methods119 patients underwent urethral reconstruction by a single surgeon for PFUI at our center between 1998-2018. We compared initial PFUI management - primary realignment vs suprapubic tube (SPT) insertion alone. Multivariable Cox proportional hazard analysis was used to assess the association between primary intervention and the risk of having a complication. ResultsPFUI was initially managed with primary realignment (57%) or SPT alone (43%). Ultimately, all patients underwent a primary perineal urethral anastomosis after a median of 7 months (IQR: 5-14). Overall, 27 patients (23%) had 1 or more long-term complications after a median 25 months (IQR:7-66), including urethral stricture, de novo erectile dysfunction, and urinary incontinence. On multivariable analysis, initial PFUI management did not predict for complications. ConclusionNo difference was found in long-term outcomes after urethral reconstruction when comparing initial PFUI management of primary realignment vs SPT insertion.

Traumatic tracheobronchial injuries: incidence and outcome of 136.389 patients derived from the DGU traumaregister

To describe the incidence, therapy and outcome of traumatic tracheobronchial injuries (TTBI) in trauma patients with multiple injuries derived from the DGU TraumaRegister. We analyzed the data on all patients listed on the TraumaRegister DGU (TR-DGU) in Germany between 2002 and 2015 aged 16 years or older and with an Injury Severity Score (ISS) of ≥ 9. We analyzed the data on 136,389 trauma patients, 561 of whom had suffered tracheobronchial injuries (0.4%). The majority were male (73.4%) and had a mean age of 43.7 years. In total, 84.0% of all TTBI injuries occurred secondary to blunt trauma, caused mainly by accidents (71.2%). TTBI was accompanied by several concomitant thoracic injuries such as pneumo- (41.2%) and hemothorax (23.2%), lacerations (7.8%) and contusions (32.3%) of the lung, as well as multiple rib fractures (29.6%). The severity of injury was classified via the abbreviated injury scale (AIS): 39.3% with AIS = 3, 51.3% with AIS = 4 and 60% with AIS = 5 patients underwent surgical interventions. The mortality of patients with tracheobronchial injuries was higher: 24.6%, versus 13.7% in all patients (control group). This high percentage reflects their generally severe injury burden through concomitant injuries. The incidence of TTBI in this large cohort of trauma patients is very low. However, its high mortality rate emphasizes its importance. Mortality was associated with higher ISS and AIS scores. Higher rates of concomitant injuries were therefore associated with a higher mortality rate. TTBI injuries revealed a higher rate of progression to surgical management, with 35% undergoing surgery within the first 24 h. This excessive mortality rate demonstrates a high overall injury burden in patients with TTBI and high mortality of associated injuries. A surgical intervention’s impact on mortality cannot be assessed in this study, as it would need to be investigated in a case-matched study.

Asymptomatic Trauma Patients Screened for Venous Thromboembolism Have a Higher Risk Profile with Lower Rate of Pulmonary Embolism: A Five-Year Single-Institution Experience

Deep vein thrombosis (DVT) is linked to reimbursements and publicly reported metrics. Some hospitals discourage venous duplex ultrasound (VDUS) screening in asymptomatic trauma patients because they often find higher rates of DVT. We aim to evaluate the association between lower extremity (LE) VDUS screening and pulmonary embolism (PE) in trauma patients. Trauma patients admitted to an urban Level-1 trauma center between 2010 and 2015 were retrospectively analyzed. We characterized the association of asymptomatic LE VDUSs with PE, upper extremity DVT, proximal LE DVT, and distal LE DVT by univariate and multivariable logistic regression controlling for confounders. Of the 3959 trauma patients included in our study-after adjusting for covariates related to patient demographics, injury, and procedures-there was a significantly lower likelihood of PE in screened patients (odds ratio (OR) = 0.02, P < 0.001) and a higher rate of distal LE DVT (OR 11.1, P = 0.004). Screening was not associated with higher rates of proximal LE DVT after adjustment for covariates (OR = 1.8, P = 0.193). PE was associated with patient transfer status, pelvis fracture, and spinal procedures in unscreened patients. After adjusting for covariates, we have shown that LE VDUS asymptomatic screening is associated with lower rates of PE in trauma patients and not associated with higher rates of proximal LE DVT. Our detailed institutional review of a large cohort of trauma patients over five years provides support for ongoing asymptomatic screening and better characterizes venous thromboembolism outcomes than similarly sized purely administrative data reviews. As a retrospective cohort study with a large sample size, no loss to follow-up, and a population with low heterogeneity, this study should be considered as level III evidence for care management.

Utility of CT angiography in screening for traumatic cerebrovascular injury

ObjectiveComputed tomographic angiography (CTA) is increasingly utilized to evaluate for traumatic cerebrovascular injury (TCVI). The purpose of this study was to determine the yield, management effect, and risk of stroke or poor outcome of a positive CTA in a large cohort of trauma patients. Patients and MethodsA retrospective analysis was performed on 1290 consecutive trauma patients that underwent head and/or neck CTA at our level I trauma center from 2006 to 2015. Clinical variables assessed include mechanism of injury, neurological status, CTA findings, subsequent imaging results, patient management, and clinical outcomes. ResultsAmong 1290 patients who underwent CTA, 200 (15.5%) were positive for TCVI, higher in blunt than penetrating trauma patients. In a generalized linear model, factors that increased likelihood of positive CTA included multiple cervical fractures, fractures with foraminal involvement, gunshot injury, Glasgow Coma Scale ≤ 13, and focal neurological deficit. Excluding cases with these factors lowered the positive rate to 4.3%. Of the 200 CTA-positives, 99 were treated for TCVI and 9 (4.5%) developed a subsequent stroke as compared to 5 (0.5%) in CTA-negative patients (odds ratio 10.2, Fisher exact test, p < 0.001). Risk of death or nursing facility discharge location was also higher in CTA-positive patients, correcting for age and presenting GCS (p < 0.01). ConclusionCTA had a modest yield in identifying TCVI in this cohort. When positive, CTA influenced management and predicted an increased risk of subsequent stroke and poor outcome.

Time Course and Diagnostic Accuracy of Glial and Neuronal Blood Biomarkers GFAP and UCH-L1 in a Large Cohort of Trauma Patients With and Without Mild Traumatic Brain Injury: Papa L, Brophy GM, Welch RD, et al. JAMA Neurol. 2016;73:551-560

Time Course and Diagnostic Accuracy of Glial and Neuronal Blood Biomarkers GFAP and UCH-L1 in a Large Cohort of Trauma Patients With and Without Mild Traumatic Brain Injury: Papa L, Brophy GM, Welch RD, et al. JAMA Neurol. 2016;73:551-560

Blood Test May Detect Concussions Days Later

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessBlood Test May Detect Concussions Days LaterNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:20 May 2016https://doi.org/10.1176/appi.pn.2016.5a18AbstractThe levels of two proteins activated after a head injury—GFAP and UCHL—may be predictive of whether an individual had a concussive event.Following a concussion, it can take days for symptoms to arise that would lead a patient to seek help; by then, the underlying lesions of the impact may have healed enough to make it difficult to confirm the concussion with a brain scan. A study published March 28 in JAMA Neurology suggests a blood test may be able to detect evidence of a concussion up to one week after the injury occurred.“Not only could this simple test greatly expand the window for diagnosing concussions, it could make CT scans unnecessary for many people, which reduces their exposure to radiation,” said Linda Papa, M.D., a physician at the Department of Emergency Medicine at the Orlando Regional Medical Center and lead author of the study. Pediatric patients could especially benefit, she told Psychiatric News, as they are particularly vulnerable to radiation damage. Papa added that minimizing computed tomography (CT) scans would save time and money and keep these machines available for people who really need them.Previous studies by Papa and her team found that changes in two proteins—glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase L1 (UCH-L1)—following head trauma injury can help to differentiate the patients in need of a neurosurgical intervention from others. (Both of these proteins are known to become elevated in the brain after a head injury, and both can also pass the blood-brain barrier.) In the current study, her group set out to better quantify the presence of these proteins over time, while also testing whether their diagnostic value could extend to predicting the presence of a concussion. They took periodic blood samples from 584 adult patients who had been admitted to the Orlando Health trauma center from 2010 to 2014 (325 of whom were diagnosed with a mild to moderate traumatic brain injury) over a week-long period (the first samples were taken within four hours of the injury). Almost all the patients with mild to moderate TBI had a CT scan to confirm the concussion.They found that both proteins became elevated in the blood within the first hour, though their time courses differed after that; UCH-L1 peaked at eight hours after injury and then declined rapidly over 48 hours, while GFAP levels peaked at 20 hours post-injury and then declined steadily over 72 hours.“And we generally saw that the more severe the injury, the higher the levels of these markers, which makes them very objective measures of trauma severity,” Papa said.In terms of predictive value, GFAP proved better at identifying mild to moderate TBI, with accuracy values ranging from 80 to 97 percent over the seven-day screening period (the test was most accurate 36 to 60 hours after injury). UCH-L1 was not as accurate, ranging from 31 percent to 77 percent over the seven-day period (the test was most accurate in the first eight hours). These protein signatures may also offer clues about long-term outcomes. “After we diagnose concussion patients and send them home, about 70 percent or so will be fine in the long term, but the rest will have recurring problems like headaches and irritability,” she said. “It would be great if we could anticipate potential problems and those patients could come back more regularly, but at this point, however, we can’t tell which patients are which.” Her team is continuing to monitor the outcomes of the study patients to see how they recover and if their previous GFAP and/or UCH-L1 readings correlate with how they feel six months after the injury.This study was funded by a grant from the National Institute of Neurological Disorders and Stroke. ■An abstract of “Time Course and Diagnostic Accuracy of Glial and Neuronal Blood Biomarkers GFAP and UCH-L1 in a Large Cohort of Trauma Patients With and Without Mild Traumatic Brain Injury” can be accessed here. ISSUES NewArchived

Time Course and Diagnostic Accuracy of Glial and Neuronal Blood Biomarkers GFAP and UCH-L1 in a Large Cohort of Trauma Patients With and Without Mild Traumatic Brain Injury.

Glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase L1 (UCH-L1) have been widely studied and show promise for clinical usefulness in suspected traumatic brain injury (TBI) and concussion. Understanding their diagnostic accuracy over time will help translate them into clinical practice. To evaluate the temporal profiles of GFAP and UCH-L1 in a large cohort of trauma patients seen at the emergency department and to assess their diagnostic accuracy over time, both individually and in combination, for detecting mild to moderate TBI (MMTBI), traumatic intracranial lesions on head computed tomography (CT), and neurosurgical intervention. This prospective cohort study enrolled adult trauma patients seen at a level I trauma center from March 1, 2010, to March 5, 2014. All patients underwent rigorous screening to determine whether they had experienced an MMTBI (blunt head trauma with loss of consciousness, amnesia, or disorientation and a Glasgow Coma Scale score of 9-15). Of 3025 trauma patients assessed, 1030 met eligibility criteria for enrollment, and 446 declined participation. Initial blood samples were obtained in 584 patients enrolled within 4 hours of injury. Repeated blood sampling was conducted at 4, 8, 12, 16, 20, 24, 36, 48, 60, 72, 84, 96, 108, 120, 132, 144, 156, 168, and 180 hours after injury. Diagnosis of MMTBI, presence of traumatic intracranial lesions on head CT scan, and neurosurgical intervention. A total of 1831 blood samples were drawn from 584 patients (mean [SD] age, 40 [16] years; 62.0% [362 of 584] male) over 7 days. Both GFAP and UCH-L1 were detectible within 1 hour of injury. GFAP peaked at 20 hours after injury and slowly declined over 72 hours. UCH-L1 rose rapidly and peaked at 8 hours after injury and declined rapidly over 48 hours. Over the course of 1 week, GFAP demonstrated a diagnostic range of areas under the curve for detecting MMTBI of 0.73 (95% CI, 0.69-0.77) to 0.94 (95% CI, 0.78-1.00), and UCH-L1 demonstrated a diagnostic range of 0.30 (95% CI, 0.02-0.50) to 0.67 (95% CI, 0.53-0.81). For detecting intracranial lesions on CT, the diagnostic ranges of areas under the curve were 0.80 (95% CI, 0.67-0.92) to 0.97 (95% CI, 0.93-1.00)for GFAP and 0.31 (95% CI, 0-0.63) to 0.77 (95% CI, 0.68-0.85) for UCH-L1. For distinguishing patients with and without a neurosurgical intervention, the range for GFAP was 0.91 (95% CI, 0.79-1.00) to 1.00 (95% CI, 1.00-1.00), and the range for UCH-L1 was 0.50 (95% CI, 0-1.00) to 0.92 (95% CI, 0.83-1.00). GFAP performed consistently in detecting MMTBI, CT lesions, and neurosurgical intervention across 7 days. UCH-L1 performed best in the early postinjury period.

Impact of Hormonal Protection in Blunt and Penetrating Trauma: A Retrospective Analysis of the National Trauma Data Bank

Over the last decade, gender and age-related hormonal status of trauma patients have been increasingly recognized as outcome factors. In the present study, we examine a large cohort of trauma patients to better appraise the effects of gender and age on patient outcome after blunt and penetrating trauma. We hypothesize that adult females are at lower risk for complications and mortality relative to adult males after both blunt and penetrating trauma. A retrospective analysis was conducted of the National Trauma Data Bank examining hormonally active females for advantages in survival and outcome after blunt and/or penetrating trauma. Over 1.4 million incident trauma cases were identified between 2002 and 2006. Multiple logistic regressions were calculated for associations between gender and outcome, stratified by injury type, age, comorbidity, Injury Severity Score (ISS), and complications. Risk factors associated with mortality in our multiple logistic regression analyses included: penetrating trauma (odds ratio [OR, 2.31; 95% confidence interval [CI], 2.27 to 2.36); adult male (OR, 1.45; 95% CI, 1.41 to 1.49); and ISS 15 or greater (OR, 14.68; 95% CI, 14.38 to 14.98). Adult females demonstrated a survival advantage over adult males (OR, 0.69; 95% CI, 0.67 to 0.71). Adult females with ISS less than 15 demonstrated a distinct survival advantage compared with adult males after both blunt and penetrating trauma. These results warrant further investigation into the role of sex hormones in trauma.

Innate Immune Dysfunction in Trauma Patients

Innate Immune Dysfunction in Trauma Patients

Missed injuries during the initial assessment in a cohort of 1124 level-1 trauma patients

IntroductionDespite the presence of diagnostic guidelines for the initial evaluation in trauma, the reported incidence of missed injuries is considerable. The aim of this study was to assess the missed injuries in a large cohort of trauma patients originating from two European Level-1 trauma centres. MethodsWe analysed the 1124 patients included in the randomised REACT trial. Missed injuries were defined as injuries not diagnosed or suspected during initial clinical and radiological evaluation in the trauma room. We assessed the frequency, type, consequences and the phase in which the missed injuries were diagnosed and used univariate analysis to identify potential contributing factors. ResultsEight hundred and three patients were male, median age was 38 years and 1079 patients sustained blunt trauma. Overall, 122 injuries were missed in 92 patients (8.2%). Most injuries concerned the extremities. Sixteen injuries had an AIS grade of ≥3. Patients with missed injuries had significantly higher injury severity scores (ISSs) (median of 15 versus 5, p<0.001). Factors associated with missed injuries were severe traumatic brain injury (GCS≤8) and multitrauma (ISS≥16). Seventy-two missed injuries remained undetected during tertiary survey (59%). In total, 31 operations were required for 26 initially missed injuries. ConclusionDespite guidelines to avoid missed injuries, this problem is hard to prevent, especially in the severely injured. The present study showed that the rate of missed injuries was comparable with the literature and their consequences not severe. A high index of suspicion remains warranted, especially in multitrauma patients.

Reply

We appreciate the reviewer's comments. We present our review of a large cohort of trauma patients in a single institutional study over 12 years, with all the limitations entailed in a retrospective trauma registry database review. We agree that it would be interesting to stratify the immediate versus the delayed from the overlooked injuries that subsequently declare themselves. However, we are not able to stratify these diverse injuries with the currently available dataset in a meaningful manner. We appreciate this limitation of trauma registry databases after our experience with this review. In many urban trauma centers throughout the United States and the world, there is poor clinical follow-up in trauma patients in general, and in gunshot victims in particular. As such, detailed treatment outcomes and follow-up data are often not available. This is a limitation of trauma series throughout the contemporary literature and is ,unfortunately, all too frequent with trauma registry databases. Many trauma centers have their own trauma team, and Urology may be involved and involved early. However, sometimes the fact is that Urology becomes involved late or not at all. Whether trauma center teams engage their Urology service directly and early contributes to variability in treatment protocols and clinical outcomes between trauma centers. This further makes prospective investigation of the evaluation, management, and outcomes of this heterogeneous and complex population with gunshot wound injuries trauma very challenging. A comprehensive multidisciplinary approach involving the Urology service in the evaluation and management of gunshot victims is highly recommended. Editorial CommentUrologyVol. 76Issue 4PreviewThis is a well written, comprehensive review of one institution's experience with civilian gunshot wounds to the genitourinary (GU) tract and genitalia. The authors demonstrate a correlation of associated injuries to other organs, both urological and nonurological, thus demonstrating how a ‘magic bullet’ can cause more damage than one initially might think. Full-Text PDF

Prevalence of Pain in Patients 1 Year After Major Trauma

To describe the prevalence of pain in a large cohort of trauma patients 1 year after injury and to examine personal, injury, and treatment factors that predict the presence of chronic pain in these patients. Sixty-nine hospitals in 14 states in the United States. There were 3047 patients (10 371 weighted) aged 18 to 84 years who were admitted to the hospital because of acute trauma and survived to 12 months after injury. Pain 12 months after injury measured with the Chronic Pain Grade Scale. At 12 months after injury, 62.7% of patients reported injury-related pain. Most patients had pain in more than 1 body region, and the mean (SD) severity of pain in the last month was 5.5 (4.8) on a 10-point scale. The reported presence of pain varied with age and was more common in women and those who had untreated depression before injury. Pain at 3 months was predictive of both the presence and higher severity of pain at 12 months. Lower pain severity was reported by patients with a college education and those with no previous functional limitations. Most trauma patients have moderately severe pain from their injuries 1 year later. Earlier and more intensive interventions to treat pain in trauma patients may be needed.