Non-survivable Injury Research Articles

Evaluation of the Glasgow Coma Scale-Pupils score for predicting inpatient mortality among patients with traumatic subdural hematoma at United States trauma centers.

The Glasgow Coma Scale-Pupils (GCS-P) score has been suggested to better predict patient outcomes compared with GCS alone, while avoiding the need for more complex clinical models. This study aimed to compare the prognostic ability of GCS-P versus GCS in a national cohort of traumatic subdural hematoma (SDH) patients. Patient data were obtained from the National Trauma Data Bank (2017-2019). Inclusion criteria were traumatic SDH diagnosis with available data on presenting GCS score, pupillary reactivity, and discharge disposition. Patients with severe polytrauma or nonsurvivable head injury at presentation were excluded. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of GCS-P versus GCS scores for inpatient mortality prediction were evaluated across the entire cohort, as well as in subgroups based on age and traumatic brain injury (TBI) type (blunt vs penetrating). Calibration curves were plotted based on predicted probabilities and actual outcomes. A total of 196,747 traumatic SDH patients met the study inclusion criteria. Sensitivity (0.707 vs 0.702), specificity (0.821 vs 0.823), and AUC (0.825 vs 0.814, p < 0.001) of GCS-P versus GCS scores for prediction of inpatient mortality were similar. Calibration curve analysis revealed that GCS scores slightly underestimated inpatient mortality risk, whereas GCS-P scores did not. In patients > 65 years of age with blunt TBI (51.9%, n = 102,148), both GCS-P and GCS scores underestimated inpatient mortality risk. In patients with penetrating TBI (2.4%, n = 4,710), the AUC of the GCS-P score was significantly higher (0.902 vs 0.851, p < 0.001). In this subgroup, both GCS-P and GCS scores underestimated inpatient mortality risk among patients with lower rates of observed mortality and overestimated risk among patients with higher rates of observed mortality. This effect was more pronounced in the GCS-P calibration curve. The GCS-P score provides better short-term prognostication compared with the GCS score alone among traumatic SDH patients with penetrating TBI. The GCS-P score overestimates inpatient mortality risk among penetrating TBI patients with higher rates of observed mortality. For penetrating TBI patients, which comprised 2.4% of our SDH cohort, a low GCS-P score should not justify clinical nihilism or forgoing aggressive treatment.

306 Review of CRRT in Burn Patients with Non-survivable Injuries

Abstract Introduction There is a subset of burn patients that have a non-survivable injury. Careful and thoughtful use of health care resources in this population is needed to provide end of life care. The purpose of this quality improvement project was to review patients with non-survivable injuries (NSI), started on continuous renal replacement (CRRT), to identify areas of improvement in end-of-life care. Methods A retrospective review of all patients admitted to one verified burn center from 1/1/2020 – 5/9/2022 who received CRRT as a life prolonging measure in patients with NSI. NSI was defined as modified BAUX predicted mortality of &amp;gt;90 0 and/or significant comorbidities, peri burn events ( i.e. Delayed presentation, cardiac arrest in the field) and physician judgement as documented in the chart. Data points collected include, age, TBSA and BAUX scores, indication for CRRT, any documented goals of care discussions, duration of CRRT, days from admit to initiation of CRRT and additional blood products and CRRT filters. Results A total of 21 patients who received CRRT were reviewed. Of those, 1 survived, 2 had incorrect MRNs in the hospital database, leaving 17 patients who died for analysis. The median age was 68 (IQR 18). The median TBSA was 43% (IQR 42). There were 2 patients with 0 % TBSA, 1 sustained a lightning strike and 1 with inhalation only. The median BAUX was 112 (IQR 37). The median hospital Length of stay (LOS) was 12 days (IQR 24). The median time in days to start of CRRT from time of injury was 2.5 days (IQR 11.5). Median time of CRRT initiation to time of death was 48 hours (IQR 239.5 range of 2.5 hours to 720 hours.). Blood product and filter use related to the initiation of CRRT for the 17 patients is in Table 1. Of the patients included in the review, there were several issues related to the initiation of CRRT. One had a DNR, but family did not provide documentation and/or follow patient’s wishes. Several families were offered CRRT as an option despite futility and then insisted on that progression of care. Others were started on CRRT to allow time for family to be located or to arrive before transitioning to comfort care. Conclusions In patients with NSI, CRRT was often initiated within 24 hours of death. In several cases, when comfort measure only was the known plan of care. This in turn led to increased use of blood products and filters. For patients with non-survivable injuries, establishing early goals of care and discussing end of life care is imperative. Applicability of Research to Practice Early goals of care conversations and thoughtful use of resources in patients with non-survivable injuries should be examined to determine the appropriateness of care offered and interventions provided.

A Reappraisal of the Pathophysiology of Cushing Ulcer: A Narrative Review.

In 1932, Harvey Cushing described peptic ulceration secondary to raised intracranial pressure and attributed this to vagal overactivity, causing excess gastric acid secretion. Cushing ulcer remains a cause of morbidity in patients, albeit one that is preventable. This narrative review evaluates the evidence pertaining to the pathophysiology of neurogenic peptic ulceration. Review of the literature suggests that the pathophysiology of Cushing ulcer may extend beyond vagal mechanisms for several reasons: (1) clinical and experimental studies have shown only a modest increase in gastric acid secretion in head-injured patients; (2) increased vagal tone is found in only a minority of cases of intracranial hypertension, most of which are related to catastrophic, nonsurvivable brain injury; (3) direct stimulation of the vagus nerve does not cause peptic ulceration, and; (4) Cushing ulcer can occur after acute ischemic stroke, but only a minority of strokes are associated with raised intracranial pressure and/or increased vagal tone. The 2005 Nobel Prize in Medicine honored the discovery that bacteria play key roles in the pathogenesis of peptic ulcer disease. Brain injury results in widespread changes in the gut microbiome in addition to gastrointestinal inflammation, including systemic upregulation of proinflammatory cytokines. Alternations in the gut microbiome in patients with severe traumatic brain injury include colonization with commensal flora associated with peptic ulceration. The brain-gut-microbiome axis integrates the central nervous system, the enteric nervous system, and the immune system. Following the review of the literature, we propose a novel hypothesis that neurogenic peptic ulcer may be associated with alterations in the gut microbiome, resulting in gastrointestinal inflammation leading to ulceration.

Exploring clinicians' decision-making processes about end-of-life care after burns: A qualitative interview study.

Little is known about treatment decision-making experiences and how/why particular attitudes exist amongst specialist burn clinicians when faced with patients with potentially non-survivable burn injuries. This exploratory qualitative study aimed to understand clinicians' decision-making processes regarding end-of-life (EoL) care after a severe and potentially non-survivable burn injury. Eleven clinicians experienced in EoL decision-making were interviewed via telephone or video conferencing in June-August 2021. A thematic analysis was undertaken using a framework approach. Decision-making about initiating EoL care was described as complex and multifactorial. On occasions when people presented with 'unsurvivable' injuries, decision-making was clear. Most clinicians used a multidisciplinary team approach to initiate EoL; variations existed on which professions were included in the decision-making process. Many clinicians reported using protocols or guidelines that could be personalised to each patient. The use of pathways/protocols might explain why clinicians did not report routine involvement of palliative care clinicians in EoL discussions. The process of EoL decision-making for a patient with a potentially non-survivable burn injury was layered, complex, and tailored. Processes and approaches varied, although most used protocols to guide EoL decisions. Despite the reported complexity of EoL decision-making, palliative care teams were rarely involved or consulted.

Treatment Decisions in Patients With Potentially Nonsurvivable Burn Injury in Australia and New Zealand: A Registry-Based Study.

Whilst burn-related mortality is rare in high-income countries, there are unique features related to prognostication that make examination of decision-making practices important to explore. Compared to other kinds of trauma, burn patients (even those with nonsurvivable injuries) may be relatively stable after injury initially. Complications or patient comorbidity may make it clear later in the clinical trajectory that ongoing treatment is futile. Burn care clinicians are therefore required to make decisions regarding the withholding or withdrawal of treatment in patients with potentially nonsurvivable burn injury. There is yet to be a comprehensive investigation of treatment decision practices following burn injury in Australia and New Zealand. Data for patients admitted to specialist burn services between July 2009 and June 2020 were obtained from the Burns Registry of Australia and New Zealand. Patients were grouped according to treatment decision: palliative management, active treatment withdrawn, and active treatment until death. Predictors of treatment initiation and withholding or withdrawing treatment within 24 hours were assessed using multilevel mixed-effects logistic regression. Descriptive comparisons between treatment groups were made. Of the 32,186 patients meeting study inclusion criteria, 327 (1.0%) died prior to discharge. Fifty-six patients were treated initially with palliative intent and 227 patients had active treatment initiated and later withdrawn. Increasing age and burn size reduced the odds of having active treatment initiated. We demonstrate differences in demographic and injury severity characteristics as well as end of life decision-making timing between different treatment pathways pursued for patients who die in-hospital. Our next step into the decision-making process is to gain a greater understanding of the clinician's perspective (eg, through surveys and/or interviews).

Machine Learning Prediction of Liver Allograft Utilization From Deceased Organ Donors Using the National Donor Management Goals Registry.

Several machine learning classifiers were trained to predict transplantation of a liver graft. We utilized 127 variables available in the DMG dataset. We included data from potential deceased organ donors between April 2012 and January 2019. The outcome was defined as liver recovery for transplantation in the operating room. The prediction was made based on data available 12-18 h after the time of authorization for transplantation. The data were randomly separated into training (60%), validation (20%), and test sets (20%). We compared the performance of our models to the Liver Discard Risk Index. Of 13 629 donors in the dataset, 9255 (68%) livers were recovered and transplanted, 1519 recovered but used for research or discarded, 2855 were not recovered. The optimized gradient boosting machine classifier achieved an area under the curve of the receiver operator characteristic of 0.84 on the test set, outperforming all other classifiers. This model predicts successful liver recovery for transplantation in the operating room, using data available early during donor management. It performs favorably when compared to existing models. It may provide real-time decision support during organ donor management and transplant logistics.

Modern Phineas Gage: A Man with a Knife in the Brain

An accident with a tamping iron made Phineas Gage a historically famous brain-injury survivor. (1) Each year, approximately 1.6 million people sustain traumatic brain injury, leading to 52,000 deaths annually. (2) However, there is limited literature regarding traumatic brain penetration injury that could be found. A 42-year-old male with psychosis forcefully inserted a butter knife through nostril, traversed via sella turcica into posterior corpus callosum in a mental health facility. He was intubated in his local hospital and transferred over to a tertiary hospital for neurosurgical intervention. Radiological imaging showed impingement of knife against the posterior cerebral artery (PCA), multiple brain infarcts, intraventricular, and subarachnoid haemorrhage. The knife was removed after securing the PCA with the collaboration between neurosurgery and interventional radiology team. Sinus repair was immediately performed by the otorhinolaryngologists. External ventricular drain was inserted due to hydrocephalus secondary to brain haemorrhage. He eventually developed ventriculitis leading to sepsis and was treated with multiple antibiotics. The traumatic brain injury led to anterior hypopituitarism and diabetes insipidus which was treated using hormone therapy. He not only survived the fatal brain injury but also regained his Glasgow Coma Scale (GCS) score. This case demonstrates the potential of a multi-disciplinary and specialty approach to achieve outcomes a single specialty team could not. The outcome of a case which was deemed to be a non-survivable brain injury was made different due to the bold decision making, experience and innovative surgical strategy. Future research is needed to better understand and manage brain penetration injury.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S27

Surviving Nonsurvivable Injuries: Patients Who Elude the ‘Lethal’ Abbreviated Injury Scale Score of Six

The Abbreviated Injury Scale (AIS) score is used widely to quantify injury severity by body region. The maximal AIS score is 6, which defines a nonsurvivable injury. This study was undertaken to define mortality after AIS-6 injuries in order to determine if they are uniformly lethal and, if not, if differences between survivors and nonsurvivors exist which may aid in prognostication or refinement of the current AIS system. All patients in the National Trauma Data Bank (2007-2017) with ≥1 AIS-6 injury were included. Exclusions were age <16 years, AIS-6 coding in the face/extremities (i.e., coding errors, as there are no AIS-6 injuries in these regions), and missing data. In-hospital mortality defined study groups, i.e., survivors vs. nonsurvivors. Univariable analysis compared clinical/injury data and outcomes. Multivariable analysis examined independent factors associated with mortality. 19,247 patients met inclusion/exclusion criteria. Of these, 25% (n=4,886) survived to hospital discharge and 75% (n=14,361) died. The most common discharge destination among survivors was home (n=2,187,45%) Nonsurvivors had significantly worse GCS in the field (3 vs. 14, p<0.001) and ED (3 vs. 15, p<0.001). Median AIS was higher among nonsurvivors in the Head (5 vs. 3, p<0.001), Abdomen (3 vs. 2, p<0.001), and External regions (1 vs. 1, p<0.001). Median time to death was 0.65h, with maximum time to death 8.76h. Multivariable analysis revealed External AIS-6 injuries were associated with greatest odds of mortality (OR 34.002, p<0.001) followed by Head AIS-6 (OR 10.501, p<0.001). AIS-6 injuries are not uniformly fatal, with 25% of such patients surviving to hospital discharge. Therefore, AIS-6 injuries may not be as catastrophic as previously considered. External and Head AIS-6, i.e. extensive burns and severe traumatic brain injuries, were associated with greatest odds of mortality. When death occurs after AIS-6 injury, it occurs rapidly, with all mortalities in this series occurring <9h after arrival. We suggest that the AIS-6 verbiage be revised to remove 'nonsurvivable'.

Impact of benzodiazepines on time to awakening in post cardiac arrest patients

AimAlthough guidelines recommend use of short acting sedation after cardiac arrest, there is significant practice variation. We examined whether benzodiazepine use is associated with delayed awakening in this population. MethodsWe performed a retrospective single center study including comatose patients treated after in- or out-of-hospital cardiac arrest from January 2010 to September 2019. We excluded patients who awakened within 6 h of arrest, those who arrested due to trauma or neurological event, those with nonsurvivable primary brain injury and those with refractory shock. Our primary exposure of interest was high-dose benzodiazepine (>10 mg of midazolam equivalents per day) administration in the first 72-h post arrest. Our primary outcome was time to awakening. We used Cox regression to test for an independent association between exposure and outcome after controlling for biologically plausible covariates. ResultsOverall, 2778 patients presented during the study period, 621 met inclusion criteria and 209 (34%) awakened after a median of 4 [IQR 3–7] days. Patients who received high-dose benzodiazepines awakened later than those who did not (5 [IQR 3–11] vs. 3 [IQR 3–6] days, P = 0.004). In adjusted regression, high-dose benzodiazepine exposure was independently associated with delayed awakening (adjusted hazard ratio 0.63 (95% CI 0.43–0.92)). Length of stay, awakening to discharge, and duration of mechanical ventilation were similar across groups. ConclusionHigh-dose benzodiazepine exposure is independently associated with delayed awakening in comatose survivors of cardiac arrest.

Compassionate Deactivation of Pediatric Ventricular Assist Devices: A Review of 14 Cases

ContextCompassionate deactivation (CD) of ventricular assist device (VAD) support is a recognized option for children when the burden of therapy outweighs the benefits. ObjectivesTo describe the prevalence, indications, and outcomes of CD of children supported by VADs at the end of life. MethodsReview of cases of CD at our institution between 2011 and 2020. To distinguish CD from other situations where VAD support is discontinued, patients were excluded from the study if they died during resuscitation (including extracorporeal membrane oxygenation), experienced brain or circulatory death prior to deactivation, or experienced a non-survivable brain injury likely to result in imminent death regardless of VAD status. ResultsOf 24 deaths on VAD, 14 (58%) were CD. Median age was 5.7 (interquartile range (IQR) 0.6, 11.6) years; 6 (43%) had congenital heart disease; 4 (29%) were on a device that can be used outside of the hospital. CD occurred after 40 (IQR: 26, 75) days of support; none while active transplant candidates. CD discussions were initiated by the caregiver in 6 (43%) cases, with the remainder initiated by a medical provider. Reasons for CD were multifactorial, including end-organ injury, infection, and stroke. CD occurred with endotracheal extubation and/or discontinuation of inotropes in 12 (86%) cases, and death occurred within 10 (IQR: 4, 23) minutes of CD. ConclusionCD is the mode of death in more than half of our VAD non-survivors and is pursued for reasons primarily related to noncardiac events. Caregivers and providers both initiate CD discussions. Ventilatory and inotropic support is often withdrawn at time of CD with ensuing death.

Paradoxical Contralateral Herniation Detected by Pupillometry in Acute Syndrome of the Trephined.

Severe traumatic brain injury has historically been a non-survivable injury. Recent advances in neurosurgical care, however, have demonstrated that these patients not only can survive, but they also can recover functionally when they undergo appropriate cerebral decompression within hours of injury. At the present, general surgeons are deployed further forward than neurosurgeons (Role 2 compared to Role 3) and have been provided with guidelines that stipulate conditions where they may have to perform decompressive craniectomies. Unfortunately, Role 2 medical facilities do not have access to computed tomography imaging or intracranial pressure monitoring capabilities rendering the decision to proceed with craniectomy based solely on exam findings. Utilizing a case transferred from downrange to our institution, we demonstrate the utility of a small, highly portable quantitative pupillometer to obtain reliable and reproducible data about a patient's intracranial pressures. Following the case presentation, the literature supporting quantitative pupillometry for surgical decision-making is reviewed.

At the heart of organ donation. Case reports of organ donation after cardiac death in two patients with successfully repaired AAST grade V cardiac injuries

BackgroundTrauma victims could be an important source of organs. This article presents two cases of successful organ donation and transplant, after Maastricht category III cardiac death in patients with successfully repaired AAST grade V traumatic cardiac injuries.Case presentationThe first donor was an adult patient with self-inflicted heart stab wound and non-survivable burn injury. The second one was an adult patient with blunt cardiac and abdominal trauma and an anoxic brain injury due to a car accident. The cardiac injury was promptly repaired in both patients. In the first case, adequate organ perfusion ante-mortem was achieved thanks to venoarterial extracorporeal membrane oxygenation and intensive care unit support. The above procedure allowed successful organ donation and transplantation even after Maastricht category III cardiac death. This is the first case reported where, for organ donation purposes, it was made necessary first thing to avoid the immediate death of the patient, due to a rare and frequently not survivable cardiac injury. The challenge of preserving organ perfusion, due to major burn injury effects, was faced afterwards.ConclusionsThe outcomes of these two cases suggest that a repaired heart injury should not be considered as an absolute contraindication to organ donation, even if it is associated with non-survivable major burns. Therefore, cardiac death could provide an opportunity for these kinds of patients to contribute to the pool of potential organ donors.

Ventilation Is an Important Confounding Variable When End-Tidal Carbon Dioxide Is Used to Help Guide Cardiopulmonary Resuscitation

Ventilation Is an Important Confounding Variable When End-Tidal Carbon Dioxide Is Used to Help Guide Cardiopulmonary Resuscitation

Catastrophic Non-Survivable Brain Injury Care-Role 2/3.

A catastrophic brain injury is defined as any brain injury that is expected to result in permanent loss of all brain function above the brain stem level. These clinical recommendations will help stabilize the patient so that they may be safely evacuated from theater. In addition to cardiovascular and hemodynamic goals, special attention must be paid to their endocrine dysfunction and its treatment-specifically steroid, insulin and thyroxin (t4) replacement while evaluating for and treating diabetes insipidus. Determining the futility of care coupled with resource management must also be made at each echelon. Logistical coordination and communication is paramount to expedite these patients to higher levels of care so that there is an increased probability of reuniting them with their family.

Time is the enemy: Mortality in trauma patients with hemorrhage from torso injury occurs long before the “golden hour”

IntroductionThe concept of the “Golden Hour” has been a time-honored tenet of prehospital trauma care, despite a paucity of data to substantiate its validity. Non-compressible torso hemorrhage has been demonstrated to be a significant cause of mortality in both military and civilian settings. We sought to characterize the impact of prehospital time and torso injury severity on survival. Furthermore, we hypothesized that time would be a significant determinant of mortality in patients with higher Abbreviated Injury Scale (AIS) grades of torso injury (AIS ≥ 4) and field hypotension (prehospital SBP ≤ 110 mmHg) as these injuries are commonly associated with hemorrhage. MethodsData for this analysis was generated from a registry of 2,523,394 injured patients entered into the National Trauma Data Bank Research Data Set from 2012 to 2014. Patients with torso injury were identified utilizing Abbreviated Injury Scale (AIS) for body regions 4 (Thorax) and 5 (Abdomen). Specific inclusion criteria for this study included pre-hospital time, prehospital SBP ≤110 mmHg, torso injury qualified by AIS and mortality. Patients with non-survivable torso injury (AIS = 6), severe head injuries (AIS ≥ 3), no signs of life in the field (SBP = 0), interfacility transfers, or those with any missing data elements were excluded. This classification methodology identified a composite cohort of 42,135 adult patients for analysis. ResultsThe overall mortality rate of the study population was 7.9% (3326/42,135); Torso AIS and prehospital time were noted to be strong independent predictors of patient mortality in all population strata of the analysis (P < 0.05). The data demonstrated a profound incremental increase in mortality in the early time course after injury associated with torso AIS ≥4. ConclusionIn patients with high-grade torso injury, AIS grades ≥4, the degree anatomic disruption is associated with significant hemorrhage. In our study, a precipitous rise in patient mortality was exhibited in this high-grade injury group at prehospital times <30 min. Our data highlight the critical nature of prehospital time in patients with non-compressible torso hemorrhage. However, realizing that evacuation times ≤30 min may not be realistic, particularly in rural or austere environments, future efforts should be directed toward the development of therapies to increase the window of survival in the prehospital environment.

Early venous thromboembolism chemoprophylaxis in combat-related penetrating brain injury.

OBJECTIVE Traumatic brain injury (TBI) is independently associated with deep vein thrombosis (DVT) and pulmonary embolism (PE). Given the numerous studies of civilian closed-head injury, the Brain Trauma Foundation recommends venous thromboembolism chemoprophylaxis (VTC) after severe TBI. No studies have specifically examined this practice in penetrating brain injury (PBI). Therefore, the authors examined the safety and effectiveness of early VTC after PBI with respect to worsening intracranial hemorrhage and DVT or PE. METHODS The Kandahar Airfield neurosurgery service managed 908 consults between January 2010 and March 2013. Eighty of these were US active duty members with PBI, 13 of whom were excluded from analysis because they presented with frankly nonsurvivable CNS injury or they died during initial resuscitation. This is a retrospective analysis of the remaining 67 patients. RESULTS Thirty-two patients received early VTC and 35 did not. Mean time to the first dose was 24 hours. Fifty-two patients had blast-related PBI and 15 had gunshot wounds (GSWs) to the head. The incidence of worsened intracranial hemorrhage was 16% after early VTC and 17% when it was not given, with the relative risk approaching 1 (RR = 0.91). The incidence of DVT or PE was 12% after early VTC and 17% when it was not given (RR = 0.73), though this difference was not statistically significant. CONCLUSIONS Early VTC was safe with regard to the progression of intracranial hemorrhage in this cohort of combat-related PBI patients. Data in this study suggest that this intervention may have been effective for the prevention of DVT or PE but not statistically significantly so. More research is needed to clarify the safety and efficacy of this practice.

Injuries caused by fragmenting rifle ammunition

IntroductionAlthough penetrating injuries are encountered on a regular basis in high volume trauma centres, most civilian trauma teams will be unfamiliar with the treatment of patients with injuries caused by fragmenting ammunition. The terrorist attacks in Norway on July 22, 2011 included a shooting spree causing 69 deaths and 60 injured. One of the weapons used was a semi-automatic rifle, calibre 5.56mm, with soft tip, short stop ammunition. The aim of the present study was to describe the characteristic injury patterns and lessons learned from the treatment of multiple patients admitted at the regional trauma centre with injuries from this type of ammunition. MethodsWe undertook an observational study of patients admitted at Oslo University Hospital, Ulleval after the shooting spree at Utoya on July 22, 2011. Data on demographics, injuries, injury severity, surgical procedures and outcome were collected prospectively. ResultsOf the 21 patients admitted after the shooting incident, 18 were identified with injuries caused by fragmenting ammunition and included in the study. Median age was 17 years (IQR 16, 19), median ISS 21 (IQR 12, 30) and 12 patients were female. They had been hit by a total of 38 projectiles, of which 32 were fragmenting bullets. Of the seven patients who sustained injuries to the head, neck and face, one patient required a craniotomy and one patient had a non-survivable head injury. Of the 11 patients with torso injuries, six of the eight patients with chest injuries had intra-thoracic injuries that could be treated with chest tubes only. One patient had cardiac tamponade, requiring thoracotomy. Six patients underwent laparotomy, four of them more than one. Of the 10 patients with extremity injuries, two had nerve injuries and six patients had fractures. Five amputations were performed within the first nine days.A total of 101 operations were required within the first four weeks. The majority of these were repeated soft tissue debridements due to progressive necrosis. ConclusionKnowledge about the specific challenges created by the progressive soft tissue necrosis caused by fragmenting ammunition should lead to planned, repeated debridements to reduce total tissue loss and complications.

An analysis of Brain Trauma Foundation traumatic brain injury guideline compliance and patient outcome

IntroductionEvidence-based guidelines for the care of severe traumatic brain injury have been available from the Brain Trauma Foundation (BTF) since 1995. A total of 15 recommendations compose the current guidelines. Although each individual guideline has been validated in isolation, to date, little research has examined the guidelines in composite. We examined the relationship between compliance with the BTF severe TBI guidelines and mortality. Materials and methodsIn a Pennsylvania-verified, mature Level II trauma centre, patients with an admission Glasgow Coma Scale (GCS) ≤8 and an abnormal head CT from 2007 to 2012 were queried from the trauma registry. Exclusion criteria included: patients who sustained a non-survivable injury (AIS head 6), died ≤24h, and/or were transferred to a paediatric trauma centre. Strict adherence to the BTF guidelines was determined in a binary fashion (yes/no). We then calculated each patient's percent compliance with total number of guidelines. Bivariate analysis was used to find significant predictors of mortality (p<0.05), including percent BTF guidelines compliance. Significant factors were added to a multivariable logistic regression model to look at mortality rates across the percent compliance spectrum. Results185 Patients met inclusion criteria. Percent compliance ranged from 28.6% to 94.4%, (median=71.4%). Following adjustment for age, AIS head, and GCS motor, patients with 55–75% compliance (AOR: 0.20; 95%CI: 0.06–0.70) and >75% compliance (AOR: 0.27; 95%CI: 0.08–0.94) had reduced odds of mortality, as compared to <55% compliance to the BTF guidelines. When the unadjusted rate of mortality was compared across the compliance spectrum, the odds of mortality decreased as compliance increased until 75%, and then reversed. ConclusionOur data indicate that full compliance with all 15 severe TBI guidelines is difficult to achieve and may not be necessary to optimally care for patients.

Effect of Marijuana Use on Outcomes in Traumatic Brain Injury

Traumatic brain injury (TBI) is associated with significant morbidity and mortality. Several studies have demonstrated neuroprotective effects of cannabinoids. The objective of this study was to establish a relationship between the presence of a positive toxicology screen for tetrahydrocannabinol (THC) and mortality after TBI. A 3-year retrospective review of registry data at a Level I center of patients sustaining TBI having a toxicology screen was performed. Pediatric patients (younger than 15 years) and patients with a suspected nonsurvivable injury were excluded. The THC(+) group was compared with the THC(-) group with respect to injury mechanism, severity, disposition, and mortality. Logistic regression was used to determine independent associations with mortality. There were 446 cases meeting all inclusion criteria. The incidence of a positive THC screen was 18.4 per cent (82). Overall mortality was 9.9 per cent (44); however, mortality in the THC(+) group (2.4% [two]) was significantly decreased compared with the THC(-) group (11.5% [42]; P = 0.012). After adjusting for differences between the study cohorts on logistic regression, a THC(+) screen was independently associated with survival after TBI (odds ratio, 0.224; 95% confidence interval, 0.051 to 0.991; P = 0.049). A positive THC screen is associated with decreased mortality in adult patients sustaining TBI.

The association between a quantitative computed tomography (CT) measurement of cerebral edema and outcomes in post-cardiac arrest—A validation study

AimPrevious studies have examined the association between quantitative head computed tomography (CT) measures of cerebral edema and patient outcomes reporting that a calculated gray matter to white matter attenuation ratio (GWR) of <1.2 indicates a near 100% non-survivable injury post-cardiac arrest. The objective of the current study was to validate whether a GWR <1.2 reliably indicates poor survival post-cardiac arrest. We also sought to determine the inter-rater variability among reviewers, and examine the utility of a novel GWR measurement to facilitate easier practical use. MethodsWe performed a retrospective analysis of post-cardiac arrest patients admitted to a single center from 2008 to 2012. Inclusion criteria were age ≥18 years, non-traumatic arrest, and available CT imaging within 24h after ROSC. Three independent physician reviewers from different specialties measured CT attenuation of pre-specified gray and white matter areas for GWR calculations. ResultsOut of 171 consecutive patients, 90 met the study inclusion criteria. Thirteen patients were excluded for technical reasons and/or significant additional pathology, leaving 77 head CT scans for evaluation. Median age was 66 years and 64% were male. In-hospital mortality was 65% and 70% of patients received therapeutic hypothermia. For the validation measurement, the intra-class correlation coefficient was 0.70. In our dataset, a GWR below 1.2 did not accurately predict mortality or poor neurological outcome (sensitivity 0.56–0.62 and specificity 0.63–0.81). A score below 1.1 predicted a near 100% mortality but was not a sensitive metric (sensitivity 0.14–0.20 and specificity 0.96–1.00). Similar results were found for the exploratory model. ConclusionA GWR <1.2 on CT imaging within 24h after cardiac arrest was moderately specific for poor neurologic outcome and mortality. Based on our data, a threshold GWR <1.1 may be a safer cut-off to identify patients with low chance of survival and good neurological outcome. Intra-class correlation among reviewers was moderately good.