Poor Outcomes In Trauma Patients Research Articles

Glasgow Coma Scale Versus Physiologic Scoring Systems in Predicting the Outcome of ICU admitted Trauma Patients; a Diagnostic Accuracy Study

Introduction:There is no consensus on the performance of decision rules in predicting the prognosis of trauma patients. Therefore, the present study aimed to compare the value of Glasgow coma scale (GCS) and physiologic scoring systems in predicting mortality and poor outcome of trauma patients.Methods:This diagnostic accuracy study was conducted on multiple trauma patients admitted to the intensive care units of two hospitals in Tehran, Iran, from 21 November 2020 to 22 May 2021. The patients' demographic characteristics, length of stay in the intensive care unit (ICU), the vital signs, and the GCS on admission were recorded. Finally, the mortality, disability, and complete recovery of patients at the time of discharge were evaluated and receiver operating characteristics (ROC) curve analysis was used to compare the performance of physiologic scoring systems with GCS.Results:200 trauma patients with the mean age of 43.53±19.84 years were evaluated (74% male). The area under the ROC curve for New Trauma Score (NTS), Revised Trauma Score (RTS), Worthing Physiological Scoring System (WPSS), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), Glasgow Coma Scale, Age, and Systolic Blood Pressure score (GAPS) ,Glasgow coma scale (GCS) in prediction of mortality were 0.95, 0.95, 0.83, 0.89, 0.91, 0.84, 0.77, 0.97, and 0.98 respectively. The performance of GCS was statistically superior to RTS (P=0.005), WPSS (P=0.0001), RAPS (P=0.0002), REMS (P=0.002), MEWS (P<0.0001), and NEWS (P<0.0001). However, the performance of GCS, NTS (P=0.146), and GAPS (P=0.513) were not significantly different. Also, in prediction of poor outcomes, the AUC of GCS (0.98) was significantly higher than RTS (0.95), RAPS (0.85), REMS (0.85), MEWS (0.84), NEWS (0.77), and WPSS (0.75).Conclusion:The GCS score seems to be a better instrument to predict mortality and poor outcome in trauma patients compared to other tools due to its high accuracy, wide application, and easy calculation.

Time Spent at Outlying Hospitals Prior to Transfer Is Not Associated with Poor Outcomes in Trauma Patients

Time Spent at Outlying Hospitals Prior to Transfer Is Not Associated with Poor Outcomes in Trauma Patients

Impact of blood products on platelet function in patients with traumatic injuries: a translational study

BackgroundReductions in platelet (PLT) count and function are associated with poor outcomes in trauma patients. We proposed to determine if patients expected to receive blood products have a decrease in PLT function higher than expected based on the reduction in PLT count, and if the reduction in function could be associated with the donor plasma/supernatant received. MethodsPLT count and function were measured on admission to the emergency department and intensive care unit in severely injured patients expected to receive a transfusion. PLT function was measured by Multiplate aggregometry in response to five agonists. Function was corrected for alterations in count. In vitro studies were conducted in the blood of normal subjects to assess the effect of dilutions with AB donor plasma on PLT function. ResultsForty-six patients were enrolled, with 87% requiring a transfusion. Median Injury Severity Score was 23 (13, 29) and mortality 15%. PLT count and function were decreased from emergency department to intensive care unit admission by 25% and 58%, respectively. Decreases in function persisted after adjustment for count. Patients requiring large volumes of blood products had reductions in function that were disproportionately greater. Reductions in PLT function were greatest after transfusion of PLTs. In in vitro studies with a 30% dilution by autologous plasma caused a relational reduction in function, whereas allogenic plasma resulted in greater decreases that were highly variable between donors. ConclusionsWithin hours of injury a decrease in both PLT count and function occurs, that is aggravated with the administration of blood products, with transfusion of PLTs showing the greatest effect. The effect on PLT function of allogenic transfused plasma appears to be highly donor related.

Utilizing quantitative measures of visceral adiposity in evaluating trauma patient outcomes

IntroductionBody mass index (BMI) has commonly been used as a parameter to assess obesity in trauma patients. However, the variability of height and weight data in trauma patients limits the use of BMI as an accurate assessment tool in the trauma population. Quantitative radiologic measurements of visceral adiposity is an accurate method for assessing obesity in patients but requires further analysis before it can be accepted as a measurement tool for trauma patients. MethodsA retrospective review of trauma cases with pre-operative CT scan from 2008 to 2015 produced 57 patients for evaluation. Preoperative BMI was calculated using measured height (m2) and weight (kg). Radiologic measurements of adiposity were obtained from preoperative CT scans using OsiriX DICOM viewer software. Visceral fat areas (VFA) and subcutaneous fat areas (SFA) were measured from a single axial slice at the level of L4-L5 intervertebral space. ResultsNo statistically significant results were found relating visceral fat:subcutaneous fat ratios to length of stay or post-operative complications. Initial clinical observations noting an increased incidence of complications among patients with a V/S ≥ 0.4 demonstrates a possible link between obesity and poor outcomes in trauma patients. A statistically significant correlation was noted between length of stay, peri-nephric fat and injury severity score. Discussion and ConclusionOur pilot study should be viewed as the foundation for a larger prospective study, utilizing quantitative measurements of visceral adiposity to assess outcomes in trauma patients.

Admission biomarkers of trauma-induced secondary cardiac injury predict adverse cardiac events and are associated with plasma catecholamine levels.

Secondary cardiac injury and dysfunction may be important contributors to poor outcomes in trauma patients, but the pathophysiology and clinical impact remain unclear. Early elevations in cardiac injury markers have been associated with the development of adverse cardiac events (ACEs), prolonged intensive care unit stays, and increased mortality. Studies of preinjury β-blocker use suggest a potential protective effect in critically ill trauma patients. This study aimed to prospectively examine the association of early biomarker evidence of trauma-induced secondary cardiac injury (TISCI) and ACEs and to examine the potential contribution of circulating catecholamines to its pathophysiology. Injured patients who met the study criteria were recruited at a single major trauma center. A blood sample was collected immediately on arrival. Serum epinephrine (E), norepinephrine (NE), and cardiac biomarkers including heart-related fatty acid binding protein (H-FABP) were assayed. Data were prospectively collected on ACEs. Of 300 patients recruited, 38 (13%) developed an ACE and had increased mortality (19% vs. 9%, p = 0.01) and longer intensive care unit stays (13 days, p < 0.001). H-FABP was elevated on admission in 56% of the patients, predicted the development of ACE, and was associated with higher mortality (14% vs. 5%, p = 0.01). Admission E and NE levels were strongly associated with elevations in H-FABP and ACEs (E, 274.0 pg/mL vs. 622.5 pg/mL, p < 0.001; NE, 1,063.2 pg/mL vs. 2,032.6 pg/mL, p < 0.001). Catecholamine effect on the development of TISCI or ACEs was not statistically independent of injury severity or depth of shock. Admission levels of H-FABP predict the development of ACEs and may be useful for prognosis and stratification of trauma patients. The development of TISCI and ACEs was associated with high admission levels of catecholamines, but their role in pathogenesis remains unclear. Clinical trials of adrenergic blockade may have the potential to demonstrate outcomes in patients presenting with TISCI. Prognostic/epidemiologic study, level II.

Syndecan-1 a Marker of Endothelial Injury is Associated with Increased Blood Product Requirement and Poor Outcomes in Trauma Patients

Syndecan-1 a Marker of Endothelial Injury is Associated with Increased Blood Product Requirement and Poor Outcomes in Trauma Patients

Salvage techniques in traumatic cardiac arrest

Survival from traumatic cardiac arrest is associated with a very high mortality despite aggressive resuscitation including an Emergency Department thoracotomy (EDT). Novel salvage techniques are needed to improve these outcomes. More aggressive out-of-hospital interventions, such as chest decompression or thoracotomy by emergency physicians or anesthesiologists, seem feasible and show some promise for improving outcomes. For trauma patients who suffer severe respiratory failure or refractory cardiac arrest, there seems to be an increasing role for the use of extracorporeal life support (ECLS), utilizing heparin-bonded systems to avoid systemic anticoagulation. The development of exposure hypothermia is associated with poor outcomes in trauma patients, but preclinical studies have consistently demonstrated that mild, therapeutic hypothermia (34 °C) improves survival from severe hemorrhagic shock. Sufficient data exist to justify a clinical trial. For patients who suffer a cardiac arrest refractory to EDT, induction of emergency preservation and resuscitation by rapid cooling to a tympanic membrane temperature of 10 °C may preserve vital organs long enough to allow surgical hemostasis, followed by resuscitation with cardiopulmonary bypass. Salvage techniques, such as earlier thoracotomy, ECLS, and hypothermia, may allow survival from otherwise lethal injuries.

Innate Immune Dysfunction in Trauma Patients

Innate Immune Dysfunction in Trauma Patients

Elderly trauma patients have high circulating noradrenaline levels but attenuated release of adrenaline, platelets, and leukocytes in response to increasing injury severity

High patient age is a strong predictor of poor outcome in trauma patients. The present study investigated the effect of age on mortality and biomarkers of sympathoadrenal activation, tissue, endothelial, and glycocalyx damage, coagulation activation/inhibition, fibrinolysis, and inflammation in trauma patients at admission. Prospective observational study. Single level I trauma center. Eighty adult trauma patients (≥18 yrs) who met criteria for full trauma team activation and had an arterial cannula. Blood sampling a median of 68 min (interquartile range 48-88) post injury. Data on demography, biochemistry, Injury Severity Score, and 30-day mortality were recorded and plasma/serum was analyzed for biomarkers reflecting sympathoadrenal activation (adrenaline, noradrenaline), tissue/endothelial cell/glycocalyx damage (histone-complexed DNA fragments, annexin V, thrombomodulin, syndecan-1), platelet activation (soluble CD40 ligand), coagulation activation/inhibition (prothrombin fragment 1.2, thrombin/antithrombin complex, antithrombin, protein C, activated protein C, protein S, soluble endothelial protein C receptor, tissue factor pathway inhibitor, von Willebrand factor, fibrinogen, factor XIII), fibrinolysis (D-dimer, tissue-type plasminogen activator, plasminogen activator inhibitor-1), and inflammation (interleukin-6, terminal complement complex). Patients were stratified according to the median age (46 yrs) of the full cohort. Older trauma patients had markedly higher noradrenaline (p < .001) but an attenuated increase in adrenaline with increasing Injury Severity Score and lower platelets and leukocytes (both p < .05) compared to the younger patients. Older patients displayed a biomarker profile suggestive of enhanced release, activation, and consumption of the natural anticoagulants (low antithrombin, high activated protein C, protein S, and tissue factor pathway inhibitor) and hyperfibrinolysis (high tissue-type plasminogen activator) (all p < .05 vs. younger patients). Age was an independent predictor of mortality (hazard ratio 1.04 [95% confidence interval 1.01-1.07], p = .005) after adjusting for Injury Severity Score, prehospital Glasgow Coma Scale, and plasma catecholamines. In trauma patients, the association between age and mortality was confirmed. Older patients had high plasma noradrenaline but attenuated adrenaline release with higher Injury Severity Score, impaired platelet and leukocyte mobilization, enhanced consumption of anticoagulants, and hyperfibrinolysis, which may all contribute to the poor outcome in these patients.

Direct Peritoneal Resuscitation Improves Obesity-Induced Hepatic Dysfunction after Trauma

The metabolic syndrome and associated fatty liver disease are thought to contribute to poor outcomes in trauma patients. Experimentally, obesity compromises liver blood flow. We sought to correlate the effect of obesity, injury severity, and liver dysfunction with trauma outcomes. We hypothesized that obesity-related liver dysfunction could be mitigated with the novel technique of adjunctive direct peritoneal resuscitation (DPR). This study has clinical and experimental arms. The clinical study was a case-controlled retrospective analysis of ICU trauma patients (n = 72 obese, n = 187 nonobese). The experimental study was a hemorrhagic shock model in obese rats to assess the effect of DPR on liver blood flow, liver function, and inflammatory mediators. In trauma patients, univariate and multivariate analyses demonstrated increasing mortality (p < 0.05), septic complications (p < 0.05), liver dysfunction (p < 0.001), and renal impairment (p < 0.05) with increasing body mass index and injury severity score. Obesity in rats impairs liver blood flow, liver function, renal function, and inflammation (interleukin [IL]-1β, IL-6, high mobility group protein B1[HMGB-1]). The addition of DPR to shock resuscitation restores liver blood flow, improves organ function, and reverses the systemic proinflammatory response. Our clinical review substantiates that obesity worsens trauma outcomes regardless of injury severity. Obesity-related liver and renal dysfunction is aggravated by injury severity. In an obese rat model of resuscitated hemorrhagic shock, the addition of DPR abrogates trauma-induced liver, renal, and inflammatory responses. We conclude that the addition of DPR to the clinical resuscitation regimen will benefit the obese trauma patient.

Effects of environmental hypothermia on hemodynamics and oxygen dynamics in a conscious swine model of hemorrhagic shock.

Hypothermia is associated with poor outcome in trauma patients; however, hemorrhagic shock (HS) model with anesthetized swine was different from that of clinical reality. To identify the effects of environmental hypothermia on HS, we investigated hemodynamics and oxygen dynamics in an unanesthetized swine model of HS under simulating hypothermia environment. Totally 16 Bama pigs were randomly divided into ambient temperature group (group A) and low temperature group (group B), 8 pigs in each group. Venous blood (30 mL/kg) was continuously withdrawn for more than 15 minutes in conscious swine to establish a hemorrhagic shock model. Pulmonary arterial temperature (Tp), heart rate (HR), mean arterial pressure (MAP), pulmonary arterial pressure (PAP), pulmonary arterial wedge pressure (PAWP), central venous pressure (CVP), cardiac output (CO), hemoglobin (Hb), saturation of mixed venous blood (SvO2) and blood gas analysis were recorded at the baseline and different hemorrhagic shock time (HST). The whole body oxygen delivery indices, DO2I and VO2I, and the O2 extraction ratio (O2ER) were calculated. Core body temperature in group A decreased slightly after the hemorrhagic shock model was established, and environmental hypothermia decreased in core body temperature. The mortality rate was significantly higher in group B (50%) than in group A (0%). DO2I and VO2I decreased significantly after hemorrhage. No difference was found in hemodynamics, DO2I and VO2I between group A and group B, but the difference in pH, lactic acid and O2ER was significant between the two groups. Environmental hypothermia aggravated the disorder of oxygen metabolism after hemorrhagic shock, which was associated with poor prognosis.

Morbid Obesity is Not a Risk Factor for Mortality in Critically Ill Trauma Patients

Age, Injury severity score (ISS), hyperglycemia (HGL) at admission, and morbid obesity are known risk factors of poor outcome in trauma patients. Our aim was to which risk factors had the highest risk of death in the critically ill trauma patient. A Trauma Registry of the American College of Surgeons database retrospective study was performed at our Level I trauma center from January 2000 to October 2004. Inclusion criteria were age >15 years and >or=3 days hospital stay. Data collected included age, gender, and ISS. Groups were divided into nonobese and morbidly obese (MO) (body mass index, BMI >or=40 kg/m2) and into HGL (mean >or=150 mg/dL on initial hospital day) and non-HGL. Primary outcome was 30-day mortality. Differences in mortality and demographic variables between groups were compared using Fisher's exact and Wilcoxon's rank sum tests. Univariate and multivariate logistic regression was used to assess the relationship of HGL, morbid obesity, age, and injury severity to risk of death. Relationships were assessed using odds ratios (OR) and area under the receiver operator characteristic curve (AUC). A total of 1,334 patients met study criteria and 70.5% were male. Demographic means were age 40.3, ISS 25.7, length of stay 13.4, and BMI 27.5. The most common mechanism of injury was motor vehicle collision 55.1%. Overall mortality was 4.7%. Mortality was higher in HGL versus non-HGL (8.7% vs. 3.5%; p < 0.001). Mortality was higher in MO versus nonobese, but not significantly (7.8 vs. 4.6%; not significant [NS] p = 0.222). Univariate logistic regression relationships of death to age OR: 1.031, p < 0.001, AUC +/- SE: 0.639 +/- 0.042; ISS OR: 1.044, p < 0.001, AUC +/- SE: 0.649 +/- 0.039; HGL OR: 2.765, p < 0.001; MO: OR: NS, p = NS, AUC +/- SE: NS. Relationships were similar in a combined multivariate model. HGL >150 mg/dL on the day of admission is associated with twofold increase in mortality, and an outcome measure should be followed. Morbid obesity (BMI >or=40) is not an independent risk factor for mortality in the critically ill trauma patient.

WITHDRAWN: The Effects of Cirrhosis on Trauma Outcomes: An Analysis of the National Trauma Data Bank

Introduction A number of small retrospective studies have shown that cirrhosis is associated with increased mortality and poor outcomes in trauma. While these studies have provided useful insight into the management of this unique group of patients, their clinical utility has been limited by very small sample size. The purpose of this study was to examine the relationship between cirrhosis and clinical outcomes using a much larger cohort of trauma patients than has previously been reported. Methods Data were obtained from the National Trauma Data Bank from 1994 to 2005. Of the 884,700 patients who met inclusion criteria, 0.11% had a known diagnosis of cirrhosis ( n = 956). Information regarding demographics, injury severity, preexisting comorbidities, and presence or absence of laparotomy was collected. Primary outcome measures were mortality and pulmonary, hematologic, infectious, and cardiac complications. Age, injury severity, comorbidities, and laparotomy status were analyzed as independent variables using logistic regression. Results The overall mortality rate for patients with cirrhosis was more than four times higher than patients without cirrhosis (17.7% versus 4.4%, P P P Discussion Cirrhosis is a strong predictor of poor outcome in trauma patients, regardless of age, injury severity, or number of comorbidities, especially among those requiring trauma-related laparotomies. Furthermore, TRISS fails to accurately predict survival in this group of patients. This study is the largest of its kind and is powered to detect statistically significant differences for a wide variety of outcomes while controlling for potential confounders. We have confirmed many trends previously seen in smaller studies and provided new information regarding the frequency and proportions of complications seen in this unique population.

Impact of Cirrhosis on Outcomes in Trauma

Cirrhosis as an independent predictor of poor outcomes in trauma patients was identified in 1990. We hypothesized that the degree of preinjury hepatic dysfunction is, by itself, an independent predictor of mortality. The trauma registry at our Level I trauma center was queried for all ICD-9 codes for liver disease from 1999 to 2003, and patients were categorized as having Child-Turcotte-Pugh (CTP) class A, B, or C cirrhosis. Data analyzed included age, mechanism of injury, Abbreviated Injury Score (AIS), Injury Severity Score (ISS), Glasgow Coma Score (GCS), hospital length of stay, ventilator days, procedures performed, transfusion of blood products, admission lactate, base deficit, and mortality. Trauma Related Injury Severity Score (TRISS) methodology was used to calculate the probability of survival. Outcomes data were analyzed, and statistical comparison was performed using group t-test. Of the 50 patients meeting study criteria, 31 had alcohol-related cirrhosis, 18 had a history of hepatitis C, and 1 had cryptogenic cirrhosis. Twenty (40%) met CTP A classification, 16 (32%) met CTP B criteria, and 14 (28%) had CTP class C cirrhosis. One death occurred in the CTP A and B groups. Comparison between the five survivors and nine nonsurvivors from CTP class C showed no statistical significance in terms of age, ISS, TRISS, or GCS. The mortality rate for class C cirrhotic patients posttrauma continues to be higher than that predicted by TRISS, although patients with less severe hepatic dysfunction do not appear to have significantly lower than predicted survival. The degree of hepatic dysfunction remains an independent predictor of mortality and CTP C criteria must be considered when determining outcomes for patients posttrauma.

Trauma in the elderly patient.

Advanced age is a well-known risk factor for poor outcomes in trauma patients. Older patients can benefit from the intensive monitoring and aggressive management associated with trauma team involvement. Several common topics were chosen for discussion in which the treatment options may differ slightly because of the advanced age of the patient. We discuss the following selected topics: resuscitation of the elderly trauma patient, solid organ injuries, hip fractures, rib fractures, and head injuries. The United States is witnessing a rapid growth of its elderly population. During the last century, the number of persons younger than 65 years tripled while the number of persons older than 65 years increased by a factor of 11. Because the elderly population in this country continues to grow and because elderly persons maintain i ndependent a nd a ctive lifestyles, there will be an increasing number of elderly patients requiring treatment for trauma-related injuries. Increasing age puts a trauma patient into a higher-risk category. Elderly patients sustaining major trauma are known to have higher complication and mortality rates than their younger counterparts. A study of almost 200 000 trauma patients found that there was an increase in mortality starting at the age of 40 years. 1 Many believe that the increase in morbidity and mortality that is seen in elderly trauma patients is partially due to preexisting medical conditions and the diminished physiologic reserves of elderly patients and the inability to compensate for severe injuries. 2,3 Although advanced age is a risk factor for poor outcomes in trauma patients, several articles have demonstrated that older patients can benefit from the intensive monitoring and aggressive management associated with trauma team involvement. 4-6 Because of this, we wanted to outline a few common topics in which the treatment options may differ slightly because of the advanced age of the patient. This is by no means meant to be a comprehensive review of trauma care for elderly patients.We selected the following topics for discussion: resuscitation of the elderly trauma patient, solid organ injuries, hip fractures, rib fractures, and head injuries.