Lower Injury Severity Score Research Articles

282 Optimizing Enrollment Strategies for Traumatic Brain Injury Clinical Trials: A Secondary Analysis of the ProTECT III Trial

No targeted pharmacotherapy has proven effective for the treatment of acute traumatic brain injury (TBI). One potential explanation for these failures is the inclusion of patients who likely will not benefit, either because they die very early in their hospital stay or have excellent early outcomes. The goal of this study was to describe 1) factors associated with mortality over time and, 2) factors associated with early discharge home for patients with TBI. This secondary analysis of the randomized and placebo-controlled Progesterone for Traumatic Brain Injury Experimental Clinical Treatment (ProTECT) trial (conducted at 49 trauma centers across the United States) included adults age > 18 years who had moderate to severe TBI due to a blunt mechanism (initial Glasgow Coma Scale [iGCS] score 4 to 12), and were randomized to treatment with either progesterone or placebo (72-hour infusion followed by a 24-hour taper) within 4 hours of injury. Primary outcomes for this study were death up to 180 days (poor outcome) and early discharge home before hospital day 3 (good outcome). Factors associated with death and early discharge were independently examined via proportional hazards model and logistic regression respectively. Rotterdam scores were derived from the initial CT scan and scores were dichotomized into low (1-3) and high (4-6) for the poor outcome regression model and baseline head CT result (normal or abnormal) was considered for good outcome in the analyses. Of the 882 patients enrolled, 442 (50.1%) were randomized to intravenous progesterone; the majority were male (73.7%), and the median age (min-max) was 35.5 (17-94). 152 patients died during the 180-day study period; the median age (min-max) was 55 (18-94), 30.3 % were female, 30.3% were intubated prior to randomization, 50.0% had moderate to severe injury (iGCS 6-8) and 46.1% had high Rotterdam scores. Thirty-five (35) patients were discharged early; the median age (min-max) was 29 (18-71), 25.7% were female, 28.6% had abnormal baseline head CT scan, 40.0% had moderate injury (iGCS 9-12) and the mean injury severity score (ISS) was 7.3 + 4.9. The table presents the main results of 1) hazard ratios for death and, 2) the odds ratios for early discharge. After accounting for CT findings, the interactions of age and iGCS category were associated with death whereas increases in age and in the ISS were associated with a decreased odds of early discharge (good outcome). Increasing age, in combination with iGCS score, and CT findings may be a useful aid to identify patients with TBI who are more likely to experience mortality. Conversely, younger patients, those with a lower ISS, and those with normal CT results were more likely to be discharged early with a good outcome. Since most studies of moderate to severe TBI therapies exclude patients who are less likely to benefit from therapies that require longer-term dosing, such as patients who are likely to die early and those with less severe injury (discharged very early with good outcomes), these factors may be worth consideration when designing therapeutic clinical trials for TBI patients.TableMULTIVARIABLE ANALYSESHazard Ratios for Survival at 6 MonthsHazard Ratio95% CIMale0.940.66, 1.34Low Rotterdam Scorea0.260.19, 0.37Placebo Arm0.850.62, 1.17Age*Moderate Injuryb1.091.06, 1.11Age*Severe Injuryc1.051.03, 1.06Age*Most Severe Injuryd1.031.01, 1.05Odds Ratios for Early DischargeOdds Ratio95% CINormal CT Scan4.091.67, 10.06Age0.950.92, 0.99ISS0.780.72, 0.85(a) Low Rotterdam Score=1-3, High Rotterdam Score=4-6; (b) Moderate Injury: iGCS=9-12; (c) Severe Injury: iGCS=6-8/iMotor=4-5; (d) Most Severe Injury: iGCS=4-5/iMotor=2-3; Abbreviations: CI, confidence interval; ISS, Injury Severity Score. Open table in a new tab

Pregnant trauma victims experience nearly 2-fold higher mortality compared to their nonpregnant counterparts

Trauma is the leading nonobstetric cause of death in women of reproductive age, and pregnant women in particular may be at increased risk of violent trauma. Management of trauma in pregnancy is complicated by altered maternal physiology, provider expertise, potential disparate imaging, and distorted anatomy. Little is known about the impact of trauma on maternal mortality. We sought to: (1) characterize nonviolent and violent trauma among pregnant women; (2) determine whether pregnancy is associated with increased mortality following traumatic injury; and (3) identify risk factors for trauma-related death in pregnant women. We studied 1148 trauma events among pregnant girls and women and 43,608 trauma events among nonpregnant girls and women of reproductive age (14-49 years) who presented to any accredited trauma center in Pennsylvania for treatment of trauma-related injuries from 2005 through 2015, as captured in the Pennsylvania Trauma Outcome Study. Traumas were categorized as violent (eg, homicide or assault) or nonviolent (eg, motor vehicle accident or accidental fall). We used modified Poisson regression to estimate relative rate of trauma-related death, adjusting for demographic characteristics and severity of trauma. Compared to nonpregnant women, pregnant women and girls had a lower injury severity score (8.9 vs 10.9, P < .001) and were significantly more likely to experience violent trauma (15.9% vs 9.8%, P < .001). Pregnant trauma victims had a 1.6-fold higher rate of mortality compared to their nonpregnant counterparts (P < .001), and were both more likely to be dead on arrival and to die during their hospital course (adjusted relative risk, 2.33, P < .001, and adjusted relative risk, 1.79, P= .004, respectively). Pregnancy was associated with increased mortality in both victims of nonviolent and violent trauma (adjusted relative risk, 1.69, P=.002, and adjusted relative risk, 1.60, P= .007, respectively). Pregnant trauma victims were less likely to undergo surgery (adjusted relative risk, 0.70, P= .001) and more likely to be transferred to another facility (adjusted relative risk, 1.72, P < .001). Even after adjusting for demographics and injury severity score, violent trauma was associated with 3.14-fold higher mortality in pregnant women and girls compared to nonviolent trauma (adjusted relative risk, 3.14, P= .003). Pregnant women and girls are nearly twice as likely to die after trauma and twice as likely to experience violent trauma. Universal screening for violence and trauma during pregnancy may provide an opportunity to identify women at risk for death during pregnancy.

Indicators of Survival and Favorable Functional Outcomes after Decompressive Craniectomy: A Multi-Institutional Retrospective Study

The role of decompressive craniectomy (DC) for severe traumatic brain injury (STBI) remains controversial. The purpose of this study was to identify factors that are indicators of survival and improved functional outcome in patients who undergo DC for STBI. A retrospective review of STBI patients who underwent DC was performed at four trauma centers during a 45-month period. Data collected included age, gender, mechanism of injury, Injury Severity Score (ISS), admission Glasgow Coma Scale (GCS), time from admission to DC, mortality, and extended Glasgow Outcome Score before discharge. Sixty-nine STBI patients were treated with DC during the study period. A higher initial GCS, lower ISS, and longer time to DC were all statistically significant for improved survival after DC. A younger age, higher initial GCS, and lower ISS were all statistically significant for a favorable functional outcome after DC. Patients with a higher initial GCS and lower ISS are more likely to survive DC and have a favorable functional outcome, whereas a longer time to DC was indicative of improved survival after DC.

Self-Inflicted Abdominal Stab Wounds Have a Higher Rate of Non-therapeutic Laparotomy/Laparoscopy and a Lower Risk of Injury.

The profile and management of self-inflicted abdominal stab wounds (SI-ASW) patients is still obscure. The National Trauma Data Bank (2012) was queried for adults with abdominal stab wounds (n=9544). Patients with SI-ASW (n=1724) and non-SI-ASW (n=7820) were compared. Predictors for non-therapeutic laparotomy/laparoscopy (non-TL) in SI-ASW patients were identified. SI-ASW patients were older, had more females and behavioral disorders, similar physiology, but a lower Injury Severity Score. They had more laparotomies overall (54 versus 48%, p<0.0001) and more non-TL (42 versus 32%, p<0.0001), but less injuries (43 versus 53%, p<0.0001), although peritoneal violation rate was similar. Complications and mortality were similar. In the SI-ASW cohort, non-TL patients were more likely to be female and younger, and to have Glasgow Coma Scale (GCS) ≥13 and a higher systolic blood pressure. History of psychiatric, drug and alcohol disorders was associated with SI-ASW, but did not independently predict the need for treatment in adjusted models. Patients with SI-ASW underwent more non-TL than patients with non-SI-ASW. Female gender, younger age, and a higher GCS and systolic blood pressure predicted non-TL in this group.

A retrospective cohort study of the utility of the modified early warning score for interfacility transfer of patients with traumatic injury

ObjectiveThe modified early warning score (MEWS) is a ‘track and trigger’ score using routine physiological vital signs. The objective is to determine if the pretransfer MEWS can be used for...

Pregnant Women Experiencing Violent Trauma Have Higher Death Rates Despite Less Severe Injuries [36G

INTRODUCTION: Trauma is the leading non-obstetric cause of maternal death with 5-8% incidence in the United States. We compared violence-related outcomes between pregnant women and their non-pregnant counterparts. METHODS: We studied 197 pregnant and 4658 non-pregnant women of reproductive age (14-49) who experienced violent trauma between 2005-2015 as captured in the Pennsylvania Trauma Outcomes Study. We used modified Poisson regression to estimate relative rates of trauma-related outcomes. All models were adjusted for injury severity score and age. RESULTS: Compared to non-pregnant women, pregnant women were younger (mean age=24.3 versus 30.6 years, p &lt; 0.001), more likely to be African-American (54.3% versus 40.1%, p&lt; 0.001), and to have Medicaid insurance (63.1% versus 57.6%, p=0.04). They were less likely to have preexisting psychiatric, drug use, and alcohol use disorders (18.8%, 8.6%, and 2.0% for pregnant women versus 30.1%, 14.2%, and 8.8% for non-pregnant women, respectively, p &lt; 0.03 for all). Pregnant women had a mean injury severity score of 8.7 compared to 9.5 for non-pregnant women (p=0.3), and were significantly more likely to suffer trauma secondary to assault (adjusted relative rate-aRR)=1.06, 95%CI: 1.00-1.12, p=0.04). Pregnant women were more likely to require surgery (aRR=1.06, 95%CI1.01-1.12, p=0.03), and were 3.4 times more likely to undergo hospital transfer (aRR=3.41, 95%CI: 2.32-5.00, p &lt; 0.001). Pregnant women had mortality rates twice that of their non-pregnant counterparts despite lower injury severity scores (aRR=1.98, 95%CI: 1.24-3.07, p=0.004). CONCLUSION: After violent trauma, pregnant women have twice the death rate of their non-pregnant counterparts. Screening for violence during pregnancy is paramount for prevention of trauma-related death.

Differences between the sexes in motorcycle-related injuries and fatalities at a Taiwanese level I trauma center

BackgroundFemale patients present with unique physiological and behavioral characteristics compared to male patients. The aim of this study was to investigate and compare the injury patterns, injury characteristics, and mortality of male and female patients hospitalized for treatment of motorcycle accident-related trauma in a level I trauma center. MethodsRetrospective analysis of motorcycle-related injuries from the Trauma Registry System was performed to identify and compare 4028 male and 2919 female patients hospitalized for treatment between January 1, 2009 and December 31, 2013. ResultsThe female patients were younger, less often drunken, more often wore helmets, were transported by emergency medical services, and arrived at the emergency department between 7 a.m. and 5 p.m. compared to male patients. Analysis of Abbreviated Injury Scale scores revealed that female patients sustained significantly higher rates of injuries to the extremities, but lower rates of injuries to the head/neck, face, and thorax than male patients did. Female patients had a significant lower Injury Severity Score (ISS) and adjusted odds ratio of in-hospital mortality (AOR 0.83, 95% CI: 0.83–0.86) after adjustment by ISS. However, the logistic regression analysis of propensity score-matched patients with adjusted confounders including helmet-wearing status and alcohol intoxication revealed that the gender did not significantly influence mortality (OR 0.82, 95% CI 0.47–1.43; p = 0.475), implying the an associated risky behaviors may attribute to the difference of odds of mortality between the male and female patients. In addition, a significantly fewer female patients were admitted to the intensive care unit (ICU), and female patients had a significantly shorter hospital and ICU length of stay. ConclusionFemale motorcycle riders have different injury characteristics, lower ISS and in-hospital mortality, and present with a bodily injury pattern that differs from that of male motorcycle riders. Level of evidenceEpidemiologic study, level III.

Mortality following helicopter versus ground transport of injured children

IntroductionInjured children may be transported to trauma centers by helicopter air ambulance (HAA); however, a benefit in outcomes to this expensive resource has not been consistently shown in the literature and there is concern that HAA is over-utilized. A study that adequately controls for selection biases in transport mode is needed to determine which injured children benefit from HAA. The purpose of this study was to determine if HAA impacts mortality differently in minimally and severely injured children and if there are predictors of over-triage of HAA in children that can be identified. MethodsChildren ≤18 years of age transported by HAA or ground ambulance (GA) from scene to a trauma center were identified from the 2010–2011 National Trauma Data Bank. Analysis was stratified by Injury Severity Score (ISS) into low ISS (≤15) and high ISS (>15) groups. Following propensity score matching of HAA to GA patients, conditional multivariable logistic regression was performed to determine if transport mode independently impacted mortality in each stratum. Rates and predictors of over-triage of HAA were also determined. ResultsTransport by HAA occurred in 8218 children (5574 low ISS, 2644 high ISS) and by GA in 35305 (30506 low ISS, 4799 high ISS). Overall mortality was greater in HAA patients (4.0 vs 1.4%, p<0.001). After propensity score matching, mortality was equivalent between HAA and GA for low ISS patients (0.2 vs 0.2%, p=0.82) but, for high ISS patients, mortality was lower in HAA (9.0 vs 11.1% p=0.014). On multivariable analysis, HAA was associated with decreased mortality in high ISS patients (OR=0.66, p=0.017) but not in low ISS patients (OR=1.13, p=0.73). Discharge within 24h of HAA transport occurred in 36.5% of low ISS patients versus 7.4% high ISS patients (p<0.001). ConclusionsBased on a national cohort adjusted for nonrandom assignment of transport mode, a survival benefit to HAA transport exists only for severely injured children with ISS >15. Many children with minor injuries are transported by helicopter despite frequent dismissal within 24h and no mortality benefit.

Injuries from all-terrain vehicles: An opportunity for injury prevention

BackgroundPatient demographics, behavior, and injury patterns were assessed to inform preventative efforts for reduced incidence of all-terrain vehicle (ATV) trauma. MethodsATV-related injuries treated at a Level I trauma center from 2008 to 2012 were retrospectively reviewed. Patient outcomes and incidence of traumatic brain injury (TBI) were compared by helmet use and alcohol intoxication. ResultsHelmet data were available for 304 patients of 404 patients included; of these, 75 (24.7%) wore a helmet. Incidence of TBI was lower in the helmeted (8.0%) versus the unhelmeted subgroup (26.6%) (P < 0.001). Helmeted patients had lower injury severity scores, lower intensive-care unit (ICU) admission rates, and shorter ICU and hospital length of stay (LOS) (P < 0.05). Intoxicated patients had higher rates of TBI and ICU admission as well as prolonged ICU LOS (P < 0.05). ConclusionsThese data support the requirement for a greater emphasis on injury prevention among ATV users.

A Comprehensive Investigation of Comorbidities, Mechanisms, Injury Patterns, and Outcomes in Geriatric Blunt Trauma Patients

The geriatric population is growing and trauma providers are often tasked with caring for injuries in the elderly. There is limited information regarding injury patterns in geriatric trauma patients stratified by mechanism of injury. This study intends to investigate the comorbidities, mechanisms, injury patterns, and outcomes in geriatric blunt trauma patients. A retrospective study of the 2012 National Trauma Databank was performed. Adult blunt trauma patients were identified; geriatric (>/=65) patients were compared with younger (<65) patients regarding admission demographics and vital signs, mechanism and severity of injury, and comorbidities. The primary outcome was injuries sustained and secondary outcomes included mortality, length of stay in the intensive care unit and hospital, and ventilator days. There were 589,830 blunt trauma patients who met the inclusion criteria, including 183,209 (31%) geriatric and 406,621 (69%) nongeriatric patients. Falls were more common in geriatric patients (79 vs 29%, P < 0.0001). Geriatric patients less often had an Injury Severity Score >/=16 (18 vs 20%, P < 0.0001) but more often a head Abbreviated Injury Scale >/=3 (24 vs 18%, P < 0.0001) and lower extremity Abbreviated Injury Scale >/=3 (24% vs 8%, P < 0.0001). After logistic regression older age was an independent risk factor for mortality for the overall population and across all mechanisms. Falls are the most common mechanism for geriatric trauma patients. Geriatric patients overall present with a lower Injury Severity Score, but more often sustain severe injuries to the head and lower extremities. Injury patterns vary significantly between older and younger patients when stratified by mechanism. Mortality is significantly higher for geriatric trauma patients and older age is independently associated with mortality across all mechanisms.

Predicting survival after acute civilian penetrating brain injuries: The SPIN score.

To identify predictors associated with survival in civilian penetrating traumatic brain injury (pTBI) utilizing a contemporary, large, diverse 2-center cohort, and to develop a parsimonious survival prediction score for pTBI. Our cohort comprised 413 pTBI patients retrospectively identified from the local trauma registries at 2 US level 1 trauma centers, of which one was predominantly urban and the other predominantly rural. Predictors of in-hospital and 6-month survival identified in univariate and multivariable logistic regression were used to develop the simple Surviving Penetrating Injury to the Brain (SPIN) score. The mean age was 33 ± 16 years and patients were predominantly male (87%). Survival at hospital discharge as well as 6 months post pTBI was 42.4%. Higher motor Glasgow Coma Scale subscore, pupillary reactivity, lack of self-inflicted injury, transfer from other hospital, female sex, lower Injury Severity Score, and lower international normalized ratio were independently associated with survival (all p < 0.001; model area under the curve 0.962). Important radiologic factors associated with survival were also identified but their addition to the full multivariable would have resulted in model overfitting without much gain in the area under the curve. The SPIN score, a logistic regression-based clinical risk stratification scale estimating survival after pTBI, was developed in this large, diverse 2-center cohort. While this preliminary clinical survival prediction tool does not include radiologic factors, it may support clinical decision-making after civilian pTBI if external validation confirms the probability estimates.

Demographic, Clinical, and Health System Characteristics Associated With Pain Assessment Documentation and Pain Severity in U.S. Military Patients in Combat Zone Emergency Departments, 2010-2013.

Emergency department (ED) pain assessment documentation in trauma patients is critical to ED pain care. This retrospective, cross-sectional study used trauma registry data to evaluate U.S. military combat zone trauma patients injured between 2010 and 2013 requiring ≥ 24-hr inpatient care. Study aims were to identify the frequency of combat zone ED pain assessment documentation and describe pain severity. Secondary aims were to construct statistical models to explain variation in pain assessment documentation and pain severity.Pain scores were documented in 60.5% (n = 3,339) of the 5,518 records evaluated. The proportion of records with ED pain scores increased yearly. Pain assessment documentation was associated with documentation of ED vital signs, comprehensive facility, more recent year, prehospital (PH) heart rate of 60-100 beats/min, ED Glasgow Coma Scale score of 15 vs. 14, blunt trauma, and lower injury severity score (ISS).Pain severity scores ranged from 0 to 10; mean = 5.5 (SD = 3.1); median = 6. Higher ED pain scores were associated with Army service compared with Marine Corps, no documented PH vital signs, higher PH pain score, ED respiratory rate < 12 or >16, moderate or severe ISS compared with minor ISS, treatment in a less-equipped facility, and injury in 2011 or 2012 vs. 2010. The pain severity model explained 20.4% of variance in pain severity.Overall, frequency of pain assessment documentation in combat-zone EDs improved yearly, but remained suboptimal. Pain severity was poorly predicted by demographic, clinical, and health system variables available from the trauma registry, emphasizing the importance of individual assessment.

Extracorporeal Life Support in Multiple Trauma Patients with Refractory Cardiopulmonary Failure: Predictors of Procedural Suitability and Success Rate

Background: Major trauma is a leading cause of death, particularly amongst young patients. New strategies in management are needed to improve the poor outcome of severe trauma. We report our initial experience with extracorporeal life support (ECLS) as a rescue therapy in severe multiple trauma patients with refractory cardiopulmonary failure. Objectives: The purpose of this study was to identify the pre-ECLS patient characteristics predicting appropriateness ECLS treatment. Methods: From December 2008 to May 2013, 420 multiple trauma patients were treated at our tertiary level referral trauma center. Our ECLS team was alerted on 35 and applied ECLS in 20 adult trauma patients. In 16 patients with cardiopulmonary failure with refractory shock, we adopted a veno-arterial ECLS; in 4 patients with isolated refractory acute respiratory failure, we used venovenous ECLS. Results: ECLS was initiated at a mean of 324.15 ± 197.8 (110 - 950) min from initial trauma. In 4 patients, ECLS treatment failed due to an incapability to maintain adequate ECLS flow and patient perfusion. In the other 16 patients efficiently supported by ECLS, the Cardiac Index, mean arterial pressure, lactate concentration, PaO2, PaCO2, and pH showed significant improvement with normal values reached at 3.2 ± 1.5 hours. Seven (43.7%) patients in the ECLS-Success Group donated organs, 2 patients (22.2%) died due to septic multi organ failure (MOF), and 7 (77.7%) patients were discharged from the hospital. ECLS was suitable and successful in patients with a significantly lower injury severity score, lower blood lactate level, lower number of blood units given, and significantly higher pH and Hb. Conclusions: From our data, ECLS seems to be a valuable option to resuscitate severe trauma patients when conventional therapies are insufficient: it is safe, feasible and effective in providing hemodynamic support and blood gas exchange. Our data permitted us to identify strong predictors of ECLS non-suitability and success in multiple trauma patients; these might be helpful in deciding whether ECLS should be used or not. Future improvements in materials and techniques are expected to make ECLS even easier and safer to manage, leading to a further extension of its use in disastrously injured patients

Preinjury Aerobic Fitness Predicts Postoperative Outcome and Activity Level After Acetabular Fracture Fixation.

To investigate whether aerobic fitness as determined by preoperative metabolic equivalents (METS) better predicts postoperative functional outcomes after open reduction and internal fixation (ORIF) of acetabular fractures than chronologic age. Retrospective review. Level 1 Trauma Center. A total of 157 patients underwent open surgical treatment for acetabular fracture between January 2005 and December 2013 with age ≥18 years and minimum 1-year follow-up inclusive of imaging, functional outcome scores, and complications. ORIF of acetabular fracture. Final postoperative functional outcomes as assessed with the University of California Los Angeles activity score and the Western Ontario and McMaster Universities Osteoarthritis Index. Multivariate logistic regression analysis demonstrated elevated preinjury METS, female gender, and lower injury severity score (<18) to be significant independent factors predictive of improved functional outcome per the University of California Los Angeles score. Similarly, preinjury METS were identified as significant predictors for improved Western Ontario and McMaster Universities Osteoarthritis Index scores for both the stiffness and physical function components. Chronologic age was not a significant predictor for any functional outcome score. Furthermore, a Pearson correlation analysis demonstrated a weak relationship between preoperative METS and chronologic age (r = -0.346). Pre-operative aerobic fitness as determined by METS may prove to be a superior prognostic factor for predicting postoperative functional outcome after acetabular fracture fixation than chronologic age. Consideration of aerobic fitness, in addition to other established prognostic factors, may be useful to patients and surgeons for injury counseling purposes. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is it safe to admit patients with acute injuries to nonsurgical services? A retrospective review

BackgroundGiven potential safety risks when admitting injured patients to nonsurgical services (NSS), the American College of Surgeons mandates trauma centers justification. However, evidence supporting this requirement is lacking. MethodsAdult patients cleared for admission to a NSS at a level 1 trauma center between 2012 and 2014 were retrospectively reviewed. Patient demographic, injury, and outcome characteristics were compared between nonsurgical (NSA) and surgical admission patients and analyzed for predictive value. ResultsCompared with surgical admission patients, NSA patients were significantly older, had a higher number of comorbidities and/or patient and a lower Injury Severity Score, while hospital length of stay, complications, and missed injury and adjusted mortality rates were similar. NSA did not predict mortality whereas increased age, increased Injury Severity Score, and number of comorbidities and/or patient did. ConclusionsAs all complications and mortalities were unrelated to injuries per se, admission to a NSS, after protocoled clearance by a trauma or Emergency Department attending, appears to be safe.

Trauma Triage and Trauma System Performance

Trauma systems seek to provide complex medical care at the correct time and the correct place. During the past four decades numerous articles have been published that validate trauma systems from many points of view. Achievements of trauma systems include improvement in mortality and morbidity, efficiencies of care, and economic outcomes. Prehospital policy execution is intrinsic to trauma system performance. Trauma system criteria are relatively standardized. However, flexibility in emergency medical service (EMS) decision-making is commonly allowed. These decisions have major impacts on resource allocation, trauma center utilization, and patient outcome. In this edition, Holst, et al1 reviewed adult emergency department (ED) trauma deaths as reported in the 2010 National Emergency Department Sample. They recorded the association of these deaths to trauma or non-trauma center designation, as well as geographic and patient demographics including rural vs urban site, gender, and patient income data. They found that one half of all trauma ED deaths nationally and one third of ED urban trauma patients died in non-trauma centers. Both elderly trauma deaths and deaths due to falls more frequently occurred in non-trauma centers. Like most studies describing trauma system performance, this is a retrospective review taken from a large database. Therefore, causation of outcome cannot be directly attributed to undertriage. However, the magnitude of the non-trauma center death rate merits further investigation. Trauma system literature often describes the undertriage of trauma patients with regard to trauma center designation. The American College of Surgeons has a goal for trauma systems to achieve less than 5% undertriage. However, studies frequently estimate a much higher rate. Like the study published in this journal, undertriage rates are higher with elderly patients.2 Centers for Medicare/Medicaid Services claims also identify a high rate of undertriage, and these non-trauma center visits are associated with worse outcomes. Staudenmayer, et al3 found that in California undertriage varied substantially by region. Patient factors such as age greater than 55 years, female sex, greater number of co-morbidities and a fall mechanism led to a higher rate of undertriage. Overtriage to trauma centers commonly occurs as well and contributes to resource mismatch. Tang, et al4 found that a significant number of trauma transfers were discharged within 24 hours. Tarima5 found that non-trauma centers were transferring 98% of their trauma patients including those with low Injury Severity Scores (ISSs) and high Glasgow Coma Scale (GCS) scores. Multiple factors contribute to trauma system formation. Population distribution and medical resource allocation strongly affect system performance. Commonly, injuries happen close to the home of the trauma victim. However, motor vehicle accidents have a higher rate of occurring farther from home. Trauma system volume is associated with improved trauma patient mortality and length of stay. Minei, et al6 found that increasing trauma center volume was also associated with more ventilator-free days and less severe organ failure outcomes. This triage process predictably leads to a large number of EDs without significant trauma experience, and hence makes them more likely to transfer out the mild to moderately injured patients they do see. As the cycle repeats, the distribution of trauma care skews even more toward trauma centers. Mohan, et al7 confirmed that emergency physicians working in non-trauma centers rarely encounter trauma patients with moderate to severe injuries. Trauma system improvement processes may initially realize gains that are hard to sustain. Winchell, et al8 found that trauma system evaluation planning committee consultations commonly improved outcomes. However, the gains were not self-sustaining after consultation. Trauma system literature is rich with retrospective analyses of trauma system performance. Holst, et al1 published in this edition contributes to this literature in a meaningful fashion by looking at all ED trauma deaths rather than trauma center mortality/morbidity alone. The study supports the body of literature that shows undertriage has a significant impact on system performance. Particular attention needs to be paid to the consistent theme of undertriage of elderly trauma and fall-related trauma. Moving forward, each system needs to examine its performance to the community it serves beyond the bounds of the trauma centers themselves. Regional trauma systems need to turn toward prospective validation of outcomes so that system structure and protocols can best serve our populations.

Intramedullary Lesion Length has a Negative Effect on Neurological Recovery in Cervical Spinal Cord Injury Patients with AIS Grades A-C

Introduction Experimental spinal cord injury and clinical studies indicate a relationship between MRI lesion length and outcome. In patients with AIS grades A-B, IMLL expands at a rate of 900 µm/hour, culminating in an intramedullary lesion (IML) which measures ~50 mm at 3 days post-injury. We performed a retrospective analysis to measure the effect of IML length on long-term neurological recovery and to determine the significance of intramedullary lesion length (IMLL) in long-term AIS grade conversion in traumatic cervical spine injury (TCSI). Methods Ninety-five adult patients who underwent decompressive surgery for cervical TSCI were included. Post-decompression IML length was measured and long-term AIS grades were recorded. A regression analysis was performed. Results AIS grade was A in 51, B in 26, and C in 18 patients. Mean IML length on postoperative MRI imaging was 72.6 mm. AIS grade conversion was noted in 46 (48.4%) patients. Conversion was noted in 27.5% of AIS grade A, 65.4% of AIS grade B and 83.3% of AIS grade C patients. Timing of decompression (18.2 hours) had no effect on AIS grade conversion, but conversion was significant in older patients, those with higher ASIA motor score, lower injury severity score, shorter IML length and better evidence of decompression on postoperative MRI. Regression analysis indicated a significant relationship between AIS grade conversion and IML length on postoperative MRI (OR 0.953, 95% CI = 0.9313–0.9761, p = 0.001). Conclusions In AIS grades A-C cervical TSCI, post-decompression rostrocaudal IML length was significant predictor of AIS grade conversion and neurological recovery. The timing of decompression did not correlate with recovery of function.

Trauma transfers to a rural level 1 center: a retrospective cohort study.

BackgroundThe regionalization of trauma care, the Emergency Medical Treatment and Active Labor Act of 1986, the advent of Accountable Care Organizations and bundled payments have brought Level 1 trauma centers (TC) to a new crossroads. By protocol, injured patients are preferentially transferred to designated TCs when a higher level of care is indicated. Trauma transfers frequently come during off hours and may not always appear to be related to injury severity. Based on this observation, we hypothesized patients transferred from regional hospitals to Level 1 TCs would have lower injury severity scores (ISS) and unfavorable payor status.MethodsWe queried our TC registry to identify trauma transfers (TTP) and primary trauma patients (PTP) treated at our level 1 TC between 2004 and 2012. Demographics, payor status, length of stay (LOS), injury severity score (ISS), and discharging service were compared.Results5699 TTP and 11147 PTP were identified. Uninsured patients comprised 11 % (n = 602) of TTP compared with 15 % (n = 1,721) of PTP (P < 0.0001). Surprisingly 52 % of TTP were Medicare or HMO (n = 3008) beneficiaries, versus 42 % of PTP being Medicare or HMO (n = 4614) recipients (P < 0.0001). Patients were discharged predominantly by neurosurgery and orthopedic surgery (i.e.: General Adult and General Pediatric comprised <50 % of discharges) for all trauma admissions. Adult and Pediatric Trauma services accounted for 29 % (n = 1674) of TTP versus 45 % of PTP (n = 5045) discharges (P < 0.0001). Mean Injury Severity Score of TTP was found to be 11.5 ± 0.11, in comparison to 11.6 ± 0.11 in PTP (P = 0.42), while mean LOS was 5.6 ± 0.1 days for TTP and 5.9 ± 0.1 days for PTP (P = 0.06).ConclusionsThese data suggest designated trauma centers should continue to encourage and accept appropriate transfer of trauma patients for surgical subspecialty care. The perception trauma transfers increase institutional fiscal burden is unsubstantiated.

Intubated Trauma Patients Do Not Require Full Trauma Team Activation when Effectively Triaged

Full trauma team activation in evaluating injured patients is based on triage criteria and associated with significant costs and resources that should be focused on patients who truly need them. Overtriage leads to inefficient care, particularly when resources are finite, and it diverts care from other vital areas. Although shock and gunshot wounds to the abdomen are accepted indicators for full trauma activation, intubation as the sole criterion is controversial. We evaluated our experience to assess if intubation alone merited the highest level of trauma activation. All trauma patients from 2012 to 2013 were assessed for level of activation, injury characteristics, presence of intubation, and outcomes. Of 5,881 patients, 646 (11%) were level 1 (full) and 2,823 (48%) were level 2 (partial) activations. Level 1 patients were younger (40 ± 17 vs 45 ± 20 years), had more penetrating injuries (42% vs 9%), and had higher mortality (26% vs 8%)(p < 0.001). Intubated level 2 patients (n= 513), compared with intubated level 1 patients (n= 320), had higher systolic blood pressure (133 ± 44 vs 90 ± 58 mmHg), lower Injury Severity Score (21 ± 13 vs 25 ± 16), more falls (25% vs 3%), fewer penetrating injuries (11% vs 23%), and lower mortality (31% vs 48%)(p < 0.01). Fewer intubated level patients went directly to the operating room from the emergency department (ED)(16% vs 33%), and most who did had a craniotomy (63% vs 13%). Only 3% of intubated level 2 patients underwent laparotomy compared with 20% of intubated level 1 patients (p < 0.001). The ED lengths of stay before obtaining a head CT (47 ± 26 vs 48 ± 31 minutes) and craniotomy (109 ± 61 vs 102 ± 46 minutes) were similar. Deaths in intubated level 2 patients were primarily from fatal brain injuries. When appropriately triaged, selected intubated trauma patients do not require full trauma activation to receive timely, efficient care.

Acute acalculous cholecystitis after blunt abdominal trauma

Severe trauma is a recognised risk factor for developing acute acalculous cholecystitis (AAC), which is associated with a high mortality rate. The sonographic features of AAC have been well described in the literature and debate continues over its definitive management. We present the case of a 52-year old man who presented with right upper quadrant pain three days after sustaining blunt abdominal trauma. Leucocytosis with neutrophilia and an elevated CRP level were noted on haematological investigation. The liver function tests and amylase were within normal limits. Radiological investigations using ultrasound scan and computed tomography demonstrated gallbladder features suggestive of AAC. The patient was managed with intravenous antibiotics and simple analgesia and did not require any surgical or radiological intervention. Follow-up ultrasound scan, performed three months after the initial presentation, demonstrated a tortuous acalculous gallbladder. Despite a delayed presentation and a low Injury Severity Score, a high index of clinical suspicion for AAC should be maintained given the history of significant trauma .