Patients with cervical spine injuries are a high-risk group, with the highest reported early mortality rate in spinal trauma.
This cohort study investigated predictors for cervical spine injury in ...adult (≥ 16 years) major trauma patients using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Univariate and multivariate logistic regression analyses were used to determine predictors for cervical fractures/dislocations or cord injury.
A total of 250,584 patients were analyzed. Median age was 47.2 years (interquartile range, 29.8-66.0) and Injury Severity Score 9 (interquartile range, 4-11); 60.2% were male. Six thousand eight hundred two patients (2.3%) sustained cervical fractures/dislocations alone. Two thousand sixty-nine (0.8%) sustained cervical cord injury with/without fractures/dislocations; 39.9% of fracture/dislocation and 25.8% of cord injury patients suffered injuries to other body regions. Age ≥ 65 years (odds ratio OR, 1.45-1.92), males (females OR, 0.91; 95% CI, 0.86-0.96), Glasgow Coma Scale (GCS) score <15 (OR, 1.26-1.30), LeFort facial fractures (OR, 1.29; 95% confidence interval CI, 1.05-1.59), sports injuries (OR, 3.51; 95% CI, 2.87-4.31), road traffic collisions (OR, 3.24; 95% CI, 3.01-3.49), and falls >2 m (OR, 2.74; 95% CI, 2.53-2.97) were predictive for fractures/dislocations. Age <35 years (OR, 1.25-1.72), males (females OR, 0.59; 95% CI, 0.53-0.65), GCS score <15 (OR, 1.35-1.85), systolic blood pressure <110 mm Hg (OR, 1.16; 95% CI, 1.02-1.31), sports injuries (OR, 4.42; 95% CI, 3.28-5.95), road traffic collisions (OR, 2.58; 95% CI, 2.26-2.94), and falls >2 m (OR, 2.24; 95% CI, 1.94-2.58) were predictors for cord injury.
3.5% of patients suffered cervical spine injury. Patients with a lowered GCS or systolic blood pressure, severe facial fractures, dangerous injury mechanism, male gender, and/or age ≥ 35 years are at increased risk. Contrary to common belief, head injury was not predictive for cervical spine involvement.
Age has been identified as an independent risk factor for poor outcome following head injury in the elderly, and postulated reasons for this include nature, nurture, and variations in management. Do ...elderly head injuries do worse because of a self-fulfilling prophecy of poorer management? The aim of this study was to review the management of patients with cerebral contusions according to age to identify any trends. We retrospectively reviewed prospectively collected national data on cerebral contusion admissions between March 14, 1988, and May 4, 2012, to UK hospitals held in the Trauma Audit and Research Network database. Patients were included in the study if they had cerebral contusion(s) with an abbreviated injury score (AIS) of 3 or more; no other head injury with a AIS score of 4 or more, or no injury in any other body region with AIS score of 3 or more, and known outcome data. In total, 4387 patients met the inclusion criteria. Mortality was found to increase with increasing age (p<0.001). However, time from admission to CT head imaging (p=0.003) and the likelihood of not being transferred to a center with acute neurosurgical care facilities (p<0.001) increased with increasing age, too. Further, there was a significant trend for the most senior grade of doctor to review more younger patients and for only the most junior grade of doctor to review more older patients (both, p<0.001). To conclude, our data suggest differences in management practice may contribute to the observed differences in mortality between younger and older patients suffering brain contusions.
We sought to determine 30-day survival trends and prognostic factors following surgery for acute subdural hematomas (ASDHs) in England and Wales over a 20-year period.
ASDHs are still considered the ...most lethal type of traumatic brain injury. It remains unclear whether the adjusted odds of survival have improved significantly over time.
Using the Trauma Audit and Research Network (TARN) database, we analyzed ASDH cases in the adult population (>16 yrs) treated surgically between 1994 and 2013. Two thousand four hundred ninety-eight eligible cases were identified. Univariable and multiple logistic regression analyses were performed, using multiple imputation for missing data.
The cohort was 74% male with a median age of 48.9 years. Over half of patients were comatose at presentation (53%). Mechanism of injury was due to a fall (<2 m 34%, >2 m 24%), road traffic collision (25%), and other (17%). Thirty-six per cent of patients presented with polytrauma. Gross survival increased from 59% in 1994 to 1998 to 73% in 2009 to 2013. Under multivariable analysis, variables independently associated with survival were year of injury, Glasgow Coma Scale, Injury Severity Score, age, and pupil reactivity. The time interval from injury to craniotomy and direct admission to a neurosurgical unit were not found to be significant prognostic factors.
A significant improvement in survival over the last 20 years was observed after controlling for multiple prognostic factors. Prospective trials and cohort studies are expected to elucidate the distribution of functional outcome in survivors.
Blunt chest wall trauma accounts for over 15% of all trauma admissions to Emergency Departments worldwide. Reported mortality rates vary between 4 and 60%. Management of this patient group is ...challenging as a result of the delayed on-set of complications. The aim of this study was to develop and validate a prognostic model that can be used to assist in the management of blunt chest wall trauma.
There were two distinct phases to the overall study; the development and the validation phases. In the first study phase, the prognostic model was developed through the retrospective analysis of all blunt chest wall trauma patients (n = 274) presenting to the Emergency Department of a regional trauma centre in Wales (2009 to 2011). Multivariable logistic regression was used to develop the model and identify the significant predictors for the development of complications. The model's accuracy and predictive capabilities were assessed. In the second study phase, external validation of the model was completed in a multi-centre prospective study (n = 237) in 2012. The model's accuracy and predictive capabilities were re-assessed for the validation sample. A risk score was developed for use in the clinical setting.
Significant predictors of the development of complications were age, number of rib fractures, chronic lung disease, use of pre-injury anticoagulants and oxygen saturation levels. The final model demonstrated an excellent c-index of 0.96 (95% confidence intervals: 0.93 to 0.98).
In our two phase study, we have developed and validated a prognostic model that can be used to assist in the management of blunt chest wall trauma patients. The final risk score provides the clinician with the probability of the development of complications for each individual patient.
Prediction models for trauma outcome routinely control for age but there is uncertainty about the need to control for comorbidity and whether the two interact. This paper describes recent revisions ...to the Trauma Audit and Research Network (TARN) risk adjustment model designed to take account of age and comorbidities. In addition linkage between TARN and the Office of National Statistics (ONS) database allows patient's outcome to be accurately identified up to 30 days after injury. Outcome at discharge within 30 days was previously used.
Prospectively collected data between 2010 and 2013 from the TARN database were analysed. The data for modelling consisted of 129 786 hospital trauma admissions. Three models were compared using the area under the receiver operating curve (AuROC) for assessing the ability of the models to predict outcome, the Akaike information criteria to measure the quality between models and test for goodness-of-fit and calibration. Model 1 is the current TARN model, Model 2 is Model 1 augmented by a modified Charlson comorbidity index and Model 3 is Model 2 with ONS data on 30 day outcome.
The values of the AuROC curve for Model 1 were 0.896 (95% CI 0.893 to 0.899), for Model 2 were 0.904 (0.900 to 0.907) and for Model 3 0.897 (0.896 to 0.902). No significant interaction was found between age and comorbidity in Model 2 or in Model 3.
The new model includes comorbidity and this has improved outcome prediction. There was no interaction between age and comorbidity, suggesting that both independently increase vulnerability to mortality after injury.
Non-invasive systolic blood pressure (SBP) measurement is often used in triaging trauma patients. Traditionally, SBP<90mmHg has represented the threshold for hypotension, but recent studies have ...suggested redefining hypotension as SBP<110mmHg. This study aims to examine the association of SBP with mortality in blunt trauma patients.
This is an analysis of prospectively recorded data from adult (≥16 years) blunt trauma patients. Included patients presented to hospitals belonging to the Trauma Audit and Research Network (TARN) between 2000 and 2009. The primary outcome was the association of SBP and mortality rates at 30 days. Multivariate logistic regression models were used to adjust for the influence of age, gender, Injury Severity Score (ISS) and Glasgow Coma Score (GCS) on mortality.
47,927 eligible patients presented to TARN hospitals during the study period. Sample demographics were: median age: 51.1 years (IQR=32.8–67.4); male 60% (n=28,694); median ISS 9 (IQR=8–10); median GCS 15 (IQR=15–15); and median SBP 135mmHg (IQR=120–152). We identified SBP<110mmHg as a cut off for hypotension, where a significant increase in mortality was observed. Mortality rates doubled at <100mmHg, tripled at <90mmHg and were 5- to 6-fold at <70mmHg, irrespective of age.
We recommend triaging adult blunt trauma patients with a SBP<110mmHg to resuscitation areas within dedicated trauma units for close monitoring and appropriate management.
Right heart failure occurs in 9% to 44% of left ventricular assist device (LVAD) implants, of which less than 10% require right ventricular assist device (RVAD) support either concurrently with the ...LVAD or staged, as a delayed procedure. We have reported our outcomes based on whether the RVAD was placed concurrently or staged.
Clinical data were obtained from the Duke University Medical Center database. The study focused on all consecutive adult patients who received continuous flow LVAD with either concurrent or staged (within 7 days) extracorporeal, temporary RVAD, between October 2007 and October 2017. Adverse event profiles and ability to wean from RVAD were compared between these two groups.
Overall, 43 patients required an extracorporeal RVAD; 67% (n = 29) were implanted concurrently and 33% (n = 14) were implanted as staged after the LVAD. In all, 67% of patients (n = 29) could be weaned to an isolated LVAD. The 30-day, inhospital, and total mortality rates for our cohort were 14%, 28%, and 51% respectively. The mortality rate in the study period for the staged implants was 71% versus 45% for the concurrent implants (p = 0.101). In addition, staged RVAD implantation carried a significantly higher rate of postoperative renal failure (64% versus 28%, p = 0.044).
There was a low incidence of need for RVAD in our cohort. The majority could be weaned to an isolated LVAD. Morbidity and mortality rates of this mode of biventricular support remain high. Early institution of RVAD support was associated with reduced rates of post-LVAD renal failure rates.
Comparisons across trauma systems are key to identifying opportunities to improve trauma care. We aimed to compare trauma service structures, processes and outcomes between the English National ...Health Service (NHS) and the province of Quebec, Canada.
We conducted a multicentre cohort study including admissions of patients aged older than 15 years with major trauma to major trauma centres (MTCs) from 2014/15 to 2016/17. We compared structures descriptively, and time to MTC and time in the emergency department (ED) using Wilcoxon tests. We compared mortality, and hospital and intensive care unit (ICU) length of stay (LOS) using multilevel logistic regression with propensity score adjustment, stratified by body region of the worst injury.
The sample comprised 36 337 patients from the NHS and 6484 patients from Quebec. Structural differences in the NHS included advanced prehospital medical teams (v. "scoop and run" in Quebec), helicopter transport (v. fixed-wing aircraft) and trauma team leaders. The median time to an MTC was shorter in Quebec than in the NHS for direct transports (1 h v. 1.5 h,
< 0.001) but longer for transfers (2.5 h v. 6 h,
< 0.001). Time in the ED was longer in Quebec than in the NHS (6.5 h v. 4.0 h,
< 0.001). The adjusted odds of death were higher in Quebec for head injury (odds ratio OR 1.28, 95% confidence interval CI 1.09-1.51) but lower for thoracoabdominal injuries (OR 0.69, 95% CI 0.52-0.90). The adjusted median hospital LOS was longer for spine, torso and extremity injuries in the NHS than in Quebec, and the median ICU LOS was longer for spine injuries.
We observed significant differences in the structure of trauma care, delays in access and risk-adjusted outcomes between Quebec and the NHS. Future research should assess associations between structures, processes and outcomes to identify opportunities for quality improvement.
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