US Trauma Centers Research Articles

Injuries sustained during contact with law enforcement: An analysis from US trauma centers.

Injuries sustained by civilians from interaction with police are a polarizing contemporary sociopolitical issue. Few comprehensive studies have been published using national hospital-based data. The aim of this study was to examine the epidemiology of these injuries to better understand this mechanism of injury. Patients entered into the National Trauma Data Bank (NTDB) (January 2007 to December 2012) with E-codes E970.0 to E976.0 (International Classification of Diseases, Ninth Revision, Clinical Modification), identifying injuries associated with law enforcement in the course of legal action, were enrolled. Patients' demographics, injury characteristics, procedures, and outcomes were collected and analyzed. Patients injured by other civilians (E960.0-E968.0) were used for comparison. Of 4,146,428 patients in the NTDB, 7,203 (0.17%) were injured during interaction with police. The numbers of patients in consecutive study years were 858, 1,103, 1,148, 1,274, 1,316, and 1,504. The incidence of these injuries was stable over time (0.17-0.18%) (p = 0.129). Patients had a median age of 31 years (range, 0-108), and 94.3% were male. Median injury severity score was 9 (interquartile range [IQR], 4-17). The most common mechanism of injury was gunshot wound (44%).Patients were white, 43%; black, 30%; Hispanic, 17%; Asian, 1%; and Other, 9%. As a proportion of the total race-specific NTDB trauma population, there was an average of 1.13 white patients, 2.71 Hispanic patients, and 3.83 black patients per 1,000. Mechanism, injury severity score, and outcomes did not vary by race. Compared to patients injured by civilians, patients injured by police are more likely to be white (43% vs 25%, p < 0.001) and injured by gunshot wounds (44% vs 32%, p < 0.001). Based on data from trauma centers across the United States, the rate of injuries sustained during interactions with police has been stable over time. Gunshot wounds are the most common mechanism of injury. Proportionally, black patients are the most frequently injured race. When compared to patients injured by civilians, however, patients injured by police are more likely to be white. This study provides a step toward a better understanding of police-associated injuries. Prognostic/epidemiologic study, level III.

Is "Early Total Care" a Safe and Effective Alternative to "Staged Protocol" for the Treatment of Schatzker IV-VI Tibial Plateau Fractures in Patients Older Than 50 Years?

To compare "Early Total Care" (ETC) with "Staged Protocol" (SP) for the treatment of Schatzker IV-VI tibial plateau fractures in patients older than 50 years regarding safety and effectiveness. Retrospective cohort study. An academic level 1 US trauma center. Eighty-one patients older than 50 years with Schatzker grade IV-VI tibial plateau fractures were included. Fifty-three patients were treated under SP with immediate external fixation followed by definitive internal fixation. Twenty-eight patients were treated under ETC with immediate internal fixation. Comparison of perioperative findings, time to bony and clinical union, soft-tissue and bony complications, radiological outcome, and secondary procedures. The 2 groups were comparable without significant difference regarding age, sex, side of involvement, body mass index, smoking status, American Society of Anesthesiologist classification, associated injuries, comorbidities, follow-up duration, and fracture classification. No statistically significant difference was found regarding the perioperative complications, quality of reduction, time to union, Rasmussen score at union or at the final follow-up, soft-tissue/bony complications, and the rate of the secondary procedures. ETC seems to be a safe, efficacious, and effective alternative to the SP for the treatment of some Schatzker IV-VI fractures in patients older than 50 years. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Antifibrinolytics in a rural trauma state: assessing the opportunities

BackgroundTranexamic acid (TXA) has demonstrated improved mortality among trauma patients. However, recent evidence from urban US trauma centers has failed to show a benefit among the civilian population. TXA in...

Hemotherapy algorithm for the management of trauma-induced coagulopathy: the German and European perspective.

This review presents a synopsis of best current knowledge with reference to the updated German and European guidelines and recommendations on the management of severe trauma hemorrhage and trauma-induced coagulopathy as well as a viscoelastic-based treatment algorithm based upon international expert consensus to trigger the administration of hemostatic agents and blood products. Uncontrolled hemorrhage and trauma-induced coagulopathy are the major causes for preventable death after trauma and early detection and aggressive management have been associated with improved outcomes. However, best practice to treat this newly defined entity is still under debate. In the acute phase, the clinical management usually follows the 'Damage Control Resuscitation' concept, which advocates the empiric administration of blood products in predefined and fixed ratios. As an alternative, several European but also a few US trauma centers have instituted the concept of 'Goal-directed Coagulation Therapy' based upon results obtained from early point-of-care viscoelastic testing. Current guidelines urge for the implementation of evidence-based local protocols and algorithms including clinical quality and safety management systems together with parameters to assess key measures of bleeding control and outcome.

Implications of Thoracic Epidural Analgesia on Hospital Charges in Rib Fracture Patients.

Rib fractures are present in more than 150,000 patients admitted to US trauma centers each year. Those who fracture two or more ribs are typically treated with oral analgesic drugs and are discharged with few complications. The cost of this care generally reflects its brevity. When a patient fractures three or more ribs, there is an elevated risk of complication. In response, treatments are often broadened and their durations prolonged; this affects cost. While health, function, and survival have been widely explored, patient billing has not. Thus, we evaluated the financial implications of one mode of treatment for patients with rib fractures: thoracic epidural analgesia (TEA). We retrospectively analyzed the registry of a level II trauma center. All patients who fractured one or more ribs (n = 1,344) were considered; 382 of those patients were not candidates for epidural placement and were eliminated from analyses. Epidural placement was determined by individual clinicians. We used multiple linear regressions to determine predictors of cost. After eliminating patients who were not eligible to receive TEA, the average patient bill was $59,123 ($10,631 per day of treatment). The administration of TEA predicted a 25% reduction in total billing (99% CI = -$21,429.55- -$7,794.66) and a 24% reduction in per-day billing (99% CI = -$3,745.99- -$1,276.14). Patients who received TEA were more severely injured and required longer treatments; controlling for these variables, the use of TEA associated with reductions in the cost of receiving care. From an administrative and insurance perspective, more frequent reliance on TEA may be indicated.

Sympathoadrenal activation and endotheliopathy are drivers of hypocoagulability and hyperfibrinolysis in trauma: A prospective observational study of 404 severely injured patients.

One third of severely injured patients present with a laboratory-based diagnosis of coagulopathy. This study investigated clinical and biomarker profile of patients with rapid thrombelastography (rTEG) coagulopathy, hypothesizing that sympathoadrenal activation and endothelial damage were drivers of this condition. Prospective observational study of 404 trauma patients admitted to a Level 1 US Trauma Center. Patients with admission rTEG and plasma measurements of catecholamines (adrenaline, noradrenaline) and biomarkers reflecting endothelial activation/damage (syndecan-1, thrombomodulin, sE-selectin, sVE-cadherin, nucleosomes) were included. Demography, injury type/severity, physiology, treatment, and inhospital mortality were recorded. Patients had a median Injury Severity Score (ISS) of 17, 73% from blunt injury. One third (35%) of the patients had rTEG coagulopathy, which was associated with higher plasma adrenaline, syndecan-1, and nucleosomes (all <0.05), higher transfusion requirements and higher early (<24 hours, 9.3% vs. 2.5%) and late (28 days, 23.8% vs. 13.4%) mortality. By adjusted linear regression analyses, high plasma adrenaline, sVE-cadherin, and syndecan-1 (reflecting sympathoadrenal activation and endothelial cell junction and glycocalyx damage) along with male sex, high ISS, low platelet count and prehospital red blood cell transfusion were independently associated with hypocoagulable rTEG, whereas prehospital plasma and sE-selectin (reflecting endothelial activation) were independently associated with more hypercoagulable rTEG. In this cohort of severely injured trauma patients, rTEG coagulopathy was associated with sympathoadrenal activation, endotheliopathy, and excess mortality. High adrenaline and biomarkers reflecting endothelial cell junction and glycocalyx damage were independently associated with hypocoagulability and hyperfibrinolysis. These findings support that sympathoadrenal activation and endotheliopathy contribute to trauma-induced coagulopathy and warrants further studies of endothelial repair management. Prognostic, Level III.

Then we all fall down: fall mortality by trauma center level

BackgroundGround-level falls (GLFs) are the predominant mechanism of injury in US trauma centers and accompany a spectrum of comorbidities, injury severity, and physiologic derangement. Trauma center levels define tiers of capability to treat injured patients. We hypothesized that risk-adjusted observed-to-expected mortality (O:E) by trauma center level would evaluate the degree to which need for care was met by provision of care. Materials and methodsThis retrospective cohort study used National Trauma Data Bank files for 2007-2014. Trauma center level was defined as American College of Surgeons (ACS) level I/II, ACS III/IV, State I/II, and State III/IV for within-group homogeneity. Risk-adjusted expected mortality was estimated using hierarchical, multivariable regression techniques. ResultsAnalysis of 812,053 patients' data revealed the proportion of GLF in the National Trauma Data Bank increased 8.7% (14.1%-22.8%) over the 8 y studied. Mortality was 4.21% overall with a three-fold increase for those aged 60 y and older versus younger than 60 y (4.93% versus 1.46%, P < 0.001). O:E was lowest for ACS III/IV, (0.973, 95% CI: 0.971-0.975) and highest for State III/IV (1.043, 95% CI: 1.041-1.044). ConclusionsRisk-adjusted outcomes can be measured and meaningfully compared among groups of trauma centers. Differential O:E for ACS III/IV and State III/IV centers suggests that factors beyond case mix alone influence outcomes for GLF patients. More work is needed to optimize trauma care for GLF patients across the spectrum of trauma center capability.

Patterns of Facial Fractures and Protective Device Use in Motor Vehicle Collisions From 2007 to 2012.

Facial fractures after motor vehicle collisions are a significant source of facial trauma in patients seen at trauma centers. With recent changes in use of seat belts and advances in airbag technology, new patterns in the incidence of facial fractures after motor vehicle collisions have yet to be quantified. To evaluate the incidence of facial fractures and assess the influence of protective device use in motor vehicle collisions in patients treated at trauma centers in the United States. Using a data set from the National Trauma Data Bank, we retrospectively assessed facial fractures in motor vehicle collisions occurring from 2007 through 2012, reported by level I, II, III, and IV trauma centers. Data analysis was performed from March 13 to September 22, 2015. We characterized the data set by subsite of facial injury using International Classification of Diseases, Ninth Revision codes including mandible, midface, and nasal fractures. We assessed the influence of variables such as age, sex, race/ethnicity, crash occupant (driver or passenger), use of protective device, and presence or suspicion of alcohol use. A total of 518 106 patients required assessment at a trauma center after a motor vehicle collision, with 56 422 (10.9%) experiencing at least 1 facial fracture. Nasal fracture was the most common facial fracture (5.6%), followed by midface (3.8%), other (3.2%), orbital (2.6%), mandible (2.2%), and panfacial fractures (0.8%). Of the subset sustaining at least 1 facial fracture, 5.8% had airbag protection only, 26.9% used a seat belt only, and 9.3% used both protective devices, while 57.6% used no protective device. Compared with no protective device, the use of an airbag alone significantly reduced the likelihood of facial fracture after a motor vehicle collision (odds ratio, 0.82; 95% CI, 0.79-0.86); use of a seat belt alone had a greater effect (odds ratio, 0.57; 95% CI, 0.56-0.58) and use of both devices provided the greatest odds reduction (odds ratio, 0.47; 95% CI, 0.45-0.48). Younger age, male sex, and alcohol use significantly increased the likelihood of facial fracture. For patients who presented to US trauma centers after motor vehicle collisions between 2007 and 2012, airbags, seat belts, and the combination of the 2 devices incrementally reduced the likelihood of facial fractures. 3.

Improved Outcomes Associated with the Liberal Use of Thoracic Epidural Analgesia in Patients with Rib Fractures.

Each year, more than 150,000 patients with rib fractures are admitted to US trauma centers; as many as 10% die. Effective pain control is critical to survival. One way to manage pain is thoracic epidural analgesia. If this treatment reduces mortality, more frequent use may be indicated. We analyzed the patient registry of a level II trauma center. All patients admitted with one or more rib fractures (N = 1,347) were considered. Patients who were not candidates for epidural analgesia (N = 382) were eliminated. Mortality was assessed with binary logistic regressions. Across the total population, mortality was 6.7%; incidence of pneumonia was 11.1%; mechanical ventilation was required in 23.8% of patients, for an average duration of 10.0 days; average stay in the hospital was 7.7 nights; and 49.7% of patients were admitted to the ICU for an average of 7.2 nights. Epidural analgesia was administered to 18.4% of patients. After matching samples for candidacy, patients who received epidurals were 3.7 years older, fractured 2.6 more ribs, had higher injury severity scores, and were more likely to present with bilateral fractures, flail segments, pulmonary contusions, hemothoraces, and pneumothoraces. Despite greater injury severity, mortality among these patients was lower (0.5%) than those who received alternative care (1.9%). Controlling for age, injury severity, and use of mechanical ventilation, epidural analgesia predicted a 97% reduction in mortality. Thoracic epidural analgesia associates with reduced mortality in rib fracture patients. Better care of this population is likely to be facilitated by more frequent reliance on this treatment.

Trends in open vascular surgery for trauma: implications for the future of acute care surgery

BackgroundTrauma patients with vascular injuries have historically been within a general surgeon's operative ability. Changes in training and decline in operative trauma have decreased trainees' exposure to these injuries. We sought to determine how frequently vascular procedures are performed at US trauma centers to quantify the need for general surgeons trained to manage vascular injuries. MethodsWe conducted a retrospective analysis of the National Trauma Data Base (NTDB) from 2012 compared with 2002. Patients with general surgical and vascular procedures were identified using International Classification of Diseases, Ninth Revision, procedure codes 38.0-39.99, excluding 38.9-38.99. ResultsGeneral surgery or vascular operations were performed on 12,099 (24%) of 50,248 severely injured adult patients in 2002 and 21,854 (16%) of 138,009 injured patients in 2012. Nineteen percent to 26% of all patients underwent vascular procedures. Patients with combined general surgery and vascular procedures were less likely to be discharged home and more likely to die. In 2002, 6% of severely injured adult trauma patients underwent open vascular procedures at level III/IV trauma centers; by 2012, only 1% of vascular surgery procedures were performed at level III/IV centers (P < 0.001). ConclusionsNeed for emergent vascular surgery remains common for severely injured patients. Future trauma systems and surgical training programs will need to account for the need for open vascular skills. The findings suggest that there is already a trend away from open vascular procedures at level III/IV trauma centers, which may be a sign of system compensation for changes in the workforce.

Concordance of performance metrics among US trauma centers caring for injured children

Several indicators of quality pediatric trauma care have been proposed including low in-hospital mortality, nonoperative management of blunt splenic injury, use of intracranial pressure monitors after severe traumatic brain injury, and craniotomy for children with severe subdural or epidural hematomas. It is not known if center-level performance is consistent in each of these metrics. We evaluated whether center performance in one area of quality predicted similar performance in other areas of quality. We reviewed patients 18 years or younger who were hospitalized with an injury Abbreviated Injury Scale (AIS) score of 2 or greater from 2010 to 2011 at trauma centers (n = 150) participating in the Trauma Quality Improvement Program. Random-intercept multilevel modeling was used to generate center-specific adjusted odds ratios for each quality indicator. We evaluated correlations between center-specific adjusted odds ratios of each quality indicator and mortality using Pearson correlation coefficients. Weighted κ statistics were used to test multiple pairwise agreements between indicators and the overall agreement across all four indicators. Among 84,880 children identified for analysis, 3,603 had blunt splenic injury, 3,503 had severe traumatic brain injury, and 1,286 had an epidural or subdural hematoma. A negative correlation between center-specific odds of mortality and craniotomy was present (Pearson correlation coefficient, -0.18; p = 0.03). There were no significant correlations between other indicators. Although κ statistics showed slight agreement for the pairwise comparison of odds of mortality and craniotomy (0.17, 0.02-0.32), there was no agreement for all other pairwise comparisons or the overall comparison of all four indicators (-0.01, -0.07 to 0.06). Our findings demonstrate a lack of concordance in center-level performance across the four pediatric trauma quality indicators we evaluated. These findings should be considered by pediatric trauma quality improvement initiatives to allow for comprehensive measurement of hospital quality as opposed to benchmarking using a single indicator.

Prospective derivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma

Unlike the cervical spine (C-spine), where National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rules can be used, evidence-based thoracolumbar spine (TL-spine) clearance guidelines do not exist. The aim of this study was to develop a clinical decision rule for evaluating the TL-spine after injury. Adult (≥15 years) blunt trauma patients were prospectively enrolled at 13 US trauma centers (January 2012 to January 2014). Exclusion criteria included the following: C-spine injury with neurologic deficit, preexisting paraplegia/tetraplegia, and unevaluable examination. Remaining evaluable patients underwent TL-spine imaging and were followed up to discharge. The primary end point was a clinically significant TL-spine injury requiring TL-spine orthoses or surgical stabilization. Regression techniques were used to develop a clinical decision rule. Decision rule performance in identifying clinically significant fractures was tested. Of 12,479 patients screened, 3,065 (24.6%) met inclusion criteria (mean [SD] age, 43.5 [19.8] years [range, 15-103 years]; male sex, 66.3%; mean [SD] Injury Severity Score [ISS], 8.8 [7.5]). The majority underwent computed tomography (93.3%), 6.3% only plain films, and 0.2% magnetic resonance imaging exclusively. TL-spine injury was identified in 499 patients (16.3%), of which 264 (8.6%) were clinically significant (29.2% surgery, 70.8% TL-spine orthosis). The majority was AO Type A1 282 (56.5%), followed by 67 (13.4%) A3, 43 (8.6%) B2, and 32 (6.4%) A4 injuries. The predictive ability of clinical examination (pain, midline tenderness, deformity, neurologic deficit), age, and mechanism was examined; positive clinical examination finding resulted in a sensitivity of 78.4% and a specificity of 72.9%. Addition of age of 60 years or older and high-risk mechanism (fall, crush, motor vehicle crash with ejection/rollover, unenclosed vehicle crash, auto vs. pedestrian) increased sensitivity to 98.9% with specificity of 29.0% for clinically significant injuries and 100.0% sensitivity and 27.3% specificity for injuries requiring surgery. Clinical examination alone is insufficient for determining the need for imaging in evaluable patients at risk of TL-spine injury. Addition of age and high-risk mechanism results in a clinical decision-making rule with a sensitivity of 98.9% for clinically significant injuries. Diagnostic test, level III.

Emergency Resuscitation of Patients Enrolled in the US Diaspirin Cross-linked Hemoglobin (DCLHb) Clinical Efficacy Trial.

Optimal emergent management of traumatic hemorrhagic shock patients requires a better understanding of treatment provided in the prehospital/Emergency Medical Services (EMS) and emergency department (ED) settings. Hypothesis/Problem Described in this research are the initial clinical status, airway management, fluid and blood infusions, and time course of severely-injured hemorrhagic shock patients in the EMS and ED settings from the diaspirin cross-linked hemoglobin (DCLHb) clinical trial. Data were analyzed from 17 US trauma centers gathered during a randomized, controlled, single-blinded efficacy trial of a hemoglobin solution (DCLHb) as add-on therapy versus standard therapy. Among the 98 randomized patients, the mean EMS Glasgow Coma Scale (GCS) was 10.6 (SD = 5.0), the mean EMS revised trauma score (RTS) was 6.3 (SD = 1.9), and the mean injury severity score (ISS) was 31 (SD = 17). Upon arrival to the ED, the GCS was 20% lower (7.8 (SD = 5.3) vs 9.7 (SD = 6.3)) and the RTS was 12% lower (5.3 (SD = 2.0) vs 6.0 (SD = 2.1)) than EMS values in blunt trauma patients (P < .001). By ED disposition, 80% of patients (78/98) were intubated. Rapid sequence intubation (RSI) was utilized in 77% (60/78), most often utilizing succinylcholine (65%) and midazolam (50%). The mean crystalloid volume infused was 4.2 L (SD = 3.4 L), 80% of which was infused within the ED. Emergency department blood transfusion occurred in 62% of patients, with an average transfused volume of 1.2 L (SD = 2.0 L). Blunt trauma patients received 2.1 times more total fluids (7.4 L vs 3.5 L, < .001) and 2.4 times more blood (2.4 L vs 1.0 L, P < .001). The mean time of patients taken from injury site to operating room (OR) was 113 minutes (SD = 87 minutes). Twenty-one (30%) of the 70 patients taken to the OR from the ED were sent within 60 minutes of the estimated injury time. Penetrating trauma patients were taken to the OR 52% sooner than blunt trauma patients (72 minutes vs 149 minutes, P < .001). Both GCS and RTS decreased prior to ED arrival in blunt trauma patients. Intubation was performed using RSI, and crystalloid infusion of three times the estimated blood loss volume (L) and blood transfusion of the estimated blood loss volume (L) were provided in the EMS and ED settings. Surgical intervention for these trauma patients most often occurred more than one hour from the time of injury. Penetrating trauma patients received surgical intervention more rapidly than those with a blunt trauma mechanism.

The 14th Bethune Round Table Conference on International Surgery1. Sustainable partnerships and local capacity building: Ukraine–Canada experience.2. COSECSA, achievements and challenges in improving global surgery.3. The VCU international trauma system development program in Central and South America.4. Establishing a contextually appropriate laparoscopic program in resource restricted environments: experience in Botswana.5. Collaborative care to reduce maternal deaths from postpartum hemorrhage.6. Building

The 14th Bethune Round Table Conference on International Surgery1. Sustainable partnerships and local capacity building: Ukraine–Canada experience.2. COSECSA, achievements and challenges in improving global surgery.3. The VCU international trauma system development program in Central and South America.4. Establishing a contextually appropriate laparoscopic program in resource restricted environments: experience in Botswana.5. Collaborative care to reduce maternal deaths from postpartum hemorrhage.6. Building

The Epidemiology and Injury Patterns of Acetabular Fractures: Are the USA and China Comparable?

Acetabular fractures are rare injuries in heterogeneous patient groups, making it difficult to develop adequately powered prospective single-center clinical trials in the USA or Europe. Chinese trauma centers treat a high volume of these injuries, and if the patient population and injury patterns are comparable to those in the USA, this might support development of multicenter studies in Level I trauma centers in the two countries. We determined whether the following parameters were similar between operative acetabular fractures treated at Chinese and US trauma centers: (1) epidemiology of injured patients, (2) mechanism of injuries and fracture types, and (3) hospital stay parameters, including symptomatic postoperative deep vein thrombosis (DVT) rate. We extracted data from trauma databases for patients admitted with acetabular fractures managed surgically from 2005 to 2012 for one Chinese center and from 2008 to 2012 for one US center. Sex, age, mechanism of injury, fracture classification, Injury Severity Score (ISS), time from injury to surgery, length of hospital stay, and symptomatic DVT rate were analyzed. We included 661 Chinese patients (539 men, 122 women) and 212 US patients (163 men, 49 women). Mean age at time of injury was different between China and the USA, at 40 years with a unimodal distribution and 44 years with a bimodal distribution (p<0.001), respectively. Incidence of surgically treated acetabular fractures has been increasing in China but decreasing in the USA. Mean ISSs were comparable. Although the distribution of mechanisms of injury was different (p=0.004), high-energy injuries (motor vehicle accidents, falls>10 feet) still accounted for most fractures in both centers. Fracture classifications (per Letournel) were comparable, with posterior wall fractures most common. Mean time from injury to surgery and mean hospital stay were longer in China than in the USA (9 versus 3 days [p<0.001] and 26 versus 11 days [p<0.001], respectively). Symptomatic DVT rates were comparable. Although we identified differences between the two centers, we also noted important similarities. Multicenter clinical studies involving these locations should be performed with caution and focus on similar end points, taking into account the populations' baseline differences. Because of the potential for such differences, this kind of validation study should be performed before embarking on resource-intensive multicenter trials. Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Venous Thromboembolism After Trauma

No national standardized guidelines exist to date for venous thromboembolism (VTE) prophylaxis after pediatric trauma. While the risk of VTE after trauma is generally lower for children than for adults, the precise age at which the risk of VTE increases is not clear. To identify the age at which the risk of VTE after trauma increases from the low rate seen in children toward the higher rate seen in adults. Multivariable logistic regression models were used to estimate the association between age and the odds of VTE when adjusting for other VTE risk factors. Participants included 402 329 patients 21 years or younger who were admitted following traumatic injury between January 1, 2008, and December 31, 2010, at US trauma centers participating in the National Trauma Data Bank. Diagnosis of VTE as a complication during hospital admission. Venous thromboembolism was diagnosed in 1655 patients (0.4%). Those having VTE were more severely injured compared with those not having VTE and more frequently required critical care, blood transfusion, central line placement, mechanical ventilation, and surgery. The risk of VTE was low among younger patients, occurring in 0.1% of patients 12 years or younger, but increased to 0.3% in patients aged 13 to 15 years and to 0.8% in patients 16 years or older. These findings remained when adjusting for other factors, with patients aged 13 to 15 years (adjusted odds ratio, 1.96, 95% CI 1.53-2.52; P < .001) and patients aged 16 to 21 years (adjusted odds ratio, 3.77; 95% CI, 3.00-4.75; P < .001) having a significantly higher odds of being diagnosed as having VTE compared with patients aged 0 to 12 years. These findings were consistent across the level of injury severity and the type of trauma center. The risk of VTE varies considerably across patient age and increases most dramatically at age 16 years, after a smaller increase at age 13 years. These findings can be used to guide future research into the development of standardized guidelines for VTE prophylaxis after pediatric trauma.

A prospective study of prevalence and characterization of headache following mild traumatic brain injury

Headache is one of the most common and persistent symptoms following traumatic brain injury (TBI). The current study examines the prevalence and characteristics of headache following mild TBI (mTBI). We prospectively enrolled 212 subjects within one week of mTBI who were hospitalized for observation or other system injuries in a single level 1 US trauma center and followed by telephone at three, six, and 12 months after injury for evaluation of headache. Headaches were classified according to ICHD-2 criteria as migraine, probable migraine, tension-type, cervicogenic, or unclassifiable headache. Subjects were 76% male and 75% white, and 58% were injured in vehicle-related crashes. A follow-up rate of 90% (190/212) occurred at 12 months post-injury. Eighteen percent (38/212) of subjects reported having a problem with headaches pre-injury while 54% (114/210) of subjects reported new or worse headaches compared to pre-injury immediately after injury, 62% (126/203) at three months, 69% (139/201) at six months, and 58% (109/189) at one year. Cumulative incidence was 91% (172/189) over one year. Up to 49% of headaches met criteria for migraine and probable migraine, followed by tension-type headaches (up to 40%). Age (≤ 60) was found to be a risk factor, but no significant difference was found in persistence of new or worse headache compared to pre-injury between males and females. More than one-third of the subjects reported persistent headache across all three follow-up time periods. Headache after mTBI is very common and persistent across the first year after injury. Assertive, early treatment may be warranted to avoid chronicity and disability. Further research is needed to determine whether post-traumatic headache (PTH) responds to headache treatment used in the primary headache disorders and whether chronic PTH is preventable.

Comparative Effectiveness of Inhospital Trauma Resuscitation at a French Trauma Center and Matched Patients Treated in the United States

The objective of this paper is to compare mortality outcomes between patients treated at a trauma center in France and matched patients in the United States. Although trauma systems in France and the United States differ significantly in prehospital and inhospital management, previous comparisons have been challenged by the lack of comparable data. Coarsened exact matching identified matching patients between a single center trauma database from Lyon, France, and the National Trauma Data Bank (NTDB) of the United States. Moderate to severely injured [injury severity score (ISS) > 8] adult patients (age ≥ 16) presenting alive to level 1 trauma centers from 2002 to 2005 with blunt or penetrating injuries were included. After matching patients, multivariate regression analyses were performed to determine difference in mortality between patients in Lyon and the NTDB. A total of 1043 significantly injured patients were presented to the Lyon center. Matching eligible patients with complete records were sought from 219,985 patients in the NTDB. The unadjusted odds of mortality at the Lyon center was 2.5 times higher than that of the NTDB [95% confidence interval (CI) = 2.18-2.98]. However, the Lyon center received patients with higher ISS, lower Glasgow Coma Score (GCS), and lower systolic blood pressure (SBP) (all P < 0.001). After 1:1 matching, 858 patient pairs were produced, and the odds of mortality became equivalent [odds ratio (OR) = 1.3, 95% CI = 0.91-1.73]. Similar results were found in multiple subset analyses. Trauma patients admitted to a single French trauma center had an equal chance of survival compared with similarly injured patients treated at US trauma centers.

A targeted performance improvement programme reduces mortality in exsanguinating pelvic trauma

Background Shocked patients with pelvic fractures are amongst the most severely injured patients requiring trauma care. They present a complex management challenge with mortality rates of up to 60%, the majority being the result of early exsanguination.[1] Errors and delays in the process of care contribute to this substantial mortality. Multidiscipline performance improvement programmes (PIP) aim to monitor the quality of care and identify opportunities for improvements that may affect outcome. They are a critical component of verified US trauma centres.[2] Our aim was to examine the impact of a targeted PIP on outcome in shocked patients with pelvic fractures.

A Randomized Stepped Care Intervention Trial Targeting Posttraumatic Stress Disorder for Surgically Hospitalized Injury Survivors

To test the effectiveness of a stepped care intervention model targeting posttraumatic stress disorder (PTSD) symptoms after injury. Few investigations have evaluated interventions for injured patients with PTSD and related impairments that can be feasibly implemented in trauma surgical settings. The investigation was a pragmatic effectiveness trial in which 207 acutely injured hospitalized trauma survivors were screened for high PTSD symptom levels and then randomized to a stepped combined care management, psychopharmacology, and cognitive behavioral psychotherapy intervention (n = 104) or usual care control (n = 103) conditions. The symptoms of PTSD and functional limitations were reassessed at 1, 3, 6, 9, and 12 months after the index injury admission. Regression analyses demonstrated that over the course of the year after injury, intervention patients had significantly reduced PTSD symptoms when compared with controls [group by time effect, CAPS (Clinician-Administered PTSD Scale): F(2, 185) = 5.50, P < 0.01; PCL-C (PTSD Checklist Civilian Version): F(4, 185) = 5.45, P < 0.001]. Clinically and statistically significant PTSD treatment effects were observed at the 6-, 9-, and 12-month postinjury assessments. Over the course of the year after injury, intervention patients also demonstrated significant improvements in physical function [MOS SF-36 PCS (Medical Outcomes Study Short Form 36 Physical Component Summary) main effect: F(1, 172) = 9.87, P < 0.01]. Stepped care interventions can reduce PTSD symptoms and improve functioning over the course of the year after surgical injury hospitalization. Orchestrated investigative and policy efforts could systematically introduce and evaluate screening and intervention procedures for PTSD at US trauma centers. ( clinicaltrials.gov identifier: NCT00270959).