Trauma models to identify major trauma and mortality in the prehospital setting.

BACKGROUND: Patients with major trauma might benefit from treatment in a trauma centre, but early identification of major trauma (Injury Severity Score (ISS) over 15) remains difficult. The aim of this study was to undertake an external validation of existing prognostic models for injured patients to assess their ability to predict mortality and major trauma in the prehospital setting. METHODS: Prognostic models were identified through a systematic literature search up to October 2017. Injured patients transported by Emergency Medical Services to an English hospital from the Trauma Audit and Research Network between 2013 and 2016 were included. Outcome measures were major trauma (ISS over 15) and in-hospital mortality. The performance of the models was assessed in terms of discrimination (concordance index, C-statistic) and net benefit to assess the clinical usefulness. RESULTS: A total of 154 476 patients were included to validate six previously proposed prediction models. Discriminative ability ranged from a C-statistic value of 0·602 (95 per cent c.i. 0·596 to 0·608) for the Mechanism, Glasgow Coma Scale, Age and Arterial Pressure model to 0·793 (0·789 to 0·797) for the modified Rapid Emergency Medicine Score (mREMS) in predicting in-hospital mortality (11 882 patients). Major trauma was identified in 52 818 patients, with discrimination from a C-statistic value of 0·589 (0·586 to 0·592) for mREMS to 0·735 (0·733 to 0·737) for the Kampala Trauma Score in predicting major trauma. None of the prediction models met acceptable undertriage and overtriage rates. CONCLUSION: Currently available prehospital trauma models perform reasonably in predicting in-hospital mortality, but are inadequate in identifying patients with major trauma. Future research should focus on which patients would benefit from treatment in a major trauma centre.

ANTECEDENTES: Los pacientes con traumatismo mayor pueden beneficiarse del tratamiento en un centro de trauma, pero la identificación precoz del traumatismo mayor (Injury Severity Score, ISS > 15) sigue siendo difícil. El objetivo de este estudio fue validar externamente los modelos pronósticos existentes para los pacientes con traumatismos con el fin de evaluar su capacidad para predecir el traumatismo mayor y la mortalidad en el entorno pre-hospitalario. MÉTODOS: Los modelos pronóstico se identificaron mediante una búsqueda sistemática de la literatura hasta octubre de 2017. Los pacientes incluidos fueron pacientes con traumatismos que fueron trasladados mediante los servicios de emergencia médica (emergency medical services, EMS) a un hospital inglés perteneciente a Trauma Audit and Research Network (TARN) entre 2013 y 2016. Las variables evaluadas fueron los traumatismos graves (ISS > 15) y la mortalidad hospitalaria. El rendimiento de los modelos se analizó en términos de discriminación (índice de concordancia, c) y de beneficio neto para evaluar la utilidad clínica. RESULTADOS: Se incluyeron un total de 154.476 pacientes para validar los seis modelos de predicción propuestos previamente. La capacidad discriminatoria osciló entre c = 0,602 (i.c. del 95%: 0,596-0,608) para el modelo que incluye mecanismo, escala de coma de Glasgow, edad y presión arterial (MGAP) hasta c = 0,793 (0,789-0,797) para la puntuación de medicina de emergencia rápida modificada (mREMS) en la predicción de la mortalidad hospitalaria (n = 11.882). Se identificó un traumatismo mayor en 52.818 pacientes, con una discriminación de c = 0,589 (0,586-0,592) para mREMS a c = 0,735 (0,733-0,737) para la puntuación de trauma de Kampala en la predicción de traumatismo mayor. Ninguno de los modelos de predicción cumplió con las tasas aceptables de subtriaje (undertriage) y sobretriaje (overtriage). CONCLUSIÓN: Los modelos de trauma pre-hospitalarios actualmente disponibles tienen un rendimiento razonable para predecir la mortalidad hospitalaria, pero son inadecuados para identificar a los pacientes con traumatismo mayor. En el futuro, las investigaciones deberían centrarse en identificar a los pacientes que se podrían beneficiar del tratamiento en un centro de trauma especializado.

Fractures of the femoral shaft in children: national epidemiology and treatment trends in England following activation of major trauma networks.

AIMS: The aim of this study was to describe the epidemiology of closed isolated fractures of the femoral shaft in children, and to compare the treatment and length of stay (LOS) between major trauma centres (MTCs) and trauma units (TUs) in England. PATIENTS AND METHODS: National data were obtained from the Trauma and Audit Research Network for all isolated, closed fractures of the femoral shaft in children from birth to 15 years of age, between 2012 and 2015. Age, gender, the season in which the fracture occurred, non-accidental injury, the mechanism of injury, hospital trauma status, LOS and type of treatment were recorded. RESULTS: A total of 1852 fractures were identified. The mean annual incidence was 5.82 per 100 000 children (95% confidence interval (CI) 5.20 to 6.44). The age of peak incidence was two years for both boys and girls; this decreased with increasing age. Children aged four to six years treated in MTCs were more likely to be managed with open reduction and internal fixation compared with those treated in TUs (odds ratio 3.20; 95% CI 1.12 to 9.14; p = 0.03). The median LOS was significantly less in MTCs than in TUs for children aged between 18 months and three years treated in both a spica (p = 0.005) and traction (p = 0.0004). CONCLUSION: This study highlights the current national trends in the management of closed isolated fractures of the femoral shaft in children following activation of major trauma networks in 2012. Future studies focusing on the reasons for the differences which have been identified may help to achieve more consistency in the management of these injuries across the trauma networks. Cite this article: Bone Joint J 2018;100-B:109-18.

Regionalisation of trauma care in England.

AIMS: We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England. PATIENTS AND METHODS: An observational study was undertaken using the Trauma Audit and Research Network (TARN), Hospital Episode Statistics (HES) and national death registrations. The outcome measures were indicators of the quality of trauma care, such as treatment by a senior doctor and clinical outcomes, such as mortality in hospital. RESULTS AND CONCLUSION: A total of 20 181 major trauma cases were reported to TARN during the study period, which was 270 days before and after each hospital became a Major Trauma Centre. Following regionalisation of trauma services, all indicators of the quality of care improved, fewer patients required secondary transfer between hospitals and a greater proportion were discharged with a Glasgow Outcome Score of "good recovery". In this early post-implementation analysis, there were a number of apparent process improvements (e.g. time to CT) but no differences in either crude or adjusted mortality. The overall number of deaths following trauma in England did not change following the national reconfiguration of trauma services. Evidence from other countries that have regionalised trauma services suggests that further benefits may become apparent after a period of maturing of the trauma system. Cite this article: Bone Joint J 2016;98-B:1253-61.

An evaluation of the clinical and cost-effectiveness of alternative care locations for critically ill adult patients with acute traumatic brain injury.

BACKGROUND: For critically ill adult patients with acute traumatic brain injury (TBI), we assessed the clinical and cost-effectiveness of: (a) Management in dedicated neurocritical care units versus combined neuro/general critical care units within neuroscience centres. (b) 'Early' transfer to a neuroscience centre versus 'no or late' transfer for those who present at a non-neuroscience centre. METHODS: The Risk Adjustment In Neurocritical care (RAIN) Study included prospective admissions following acute TBI to 67 UK adult critical care units during 2009-11. Data were collected on baseline case-mix, mortality, resource use, and at six months, Glasgow Outcome Scale Extended (GOSE), and quality of life (QOL) (EuroQol 5D-3L). We report incremental effectiveness, costs and cost per Quality-Adjusted Life Year (QALY) of the alternative care locations, adjusting for baseline differences with validated risk prediction models. We tested the robustness of results in sensitivity analyses. FINDINGS: Dedicated neurocritical care unit patients (N = 1324) had similar six-month mortality, higher QOL (mean gain 0.048, 95% CI -0.002 to 0.099) and increased average costs compared with those managed in combined neuro/general units (N = 1341), with a lifetime cost per QALY gained of £14,000. 'Early' transfer to a neuroscience centre (N = 584) was associated with lower mortality (odds ratio 0.52, 0.34-0.80), higher QOL for survivors (mean gain 0.13, 0.032-0.225), but positive incremental costs (£15,001, £11,123 to £18,880) compared with 'late or no transfer' (N = 263). The lifetime cost per QALY gained for 'early' transfer was £11,000. CONCLUSIONS: For critically ill adult patients with acute TBI, within neuroscience centres management in dedicated neurocritical care units versus combined neuro/general units led to improved QoL and higher costs, on average, but these differences were not statistically significant. This study finds that 'early' transfer to a neuroscience centre is associated with reduced mortality, improvement in QOL and is cost-effective.

Mortality from trauma haemorrhage and opportunities for improvement in transfusion practice.

BACKGROUND: The aim of this study was to describe the prevalence, patterns of blood use and outcomes of major haemorrhage in trauma. METHODS: This was a prospective observational study from 22 hospitals in the UK, including both major trauma centres and smaller trauma units. Eligible patients received at least 4 units of packed red blood cells (PRBCs) in the first 24 h of admission with activation of the massive haemorrhage protocol. Case notes, transfusion charts, blood bank records and copies of prescription/theatre charts were accessed and reviewed centrally. Study outcomes were: use of blood components, critical care during hospital stay, and mortality at 24 h, 30 days and 1 year. Data were used to estimate the national trauma haemorrhage incidence. RESULTS: A total of 442 patients were identified during a median enrolment interval of 20 (range 7-24) months. Based on this, the national incidence of trauma haemorrhage was estimated to be 83 per million. The median age of patients in the study cohort was 38 years and 73·8 per cent were men. The incidence of major haemorrhage increased markedly in patients aged over 65 years. Thirty-six deaths within 24 h of admission occurred within the first 3 h. At 24 h, 79 patients (17·9 per cent) had died, but mortality continued to rise even after discharge. Patients who received a cumulative ratio of fresh frozen plasma to PRBCs of at least 1 : 2 had lower rates of death than those who received a lower ratio. There were delays in administration of blood. Platelets and cryoprecipitate were either not given, or transfused well after initial resuscitation. CONCLUSION: There is a high burden of trauma haemorrhage that affects all age groups. Research is required to understand the reasons for death after the first 24 h and barriers to timely transfusion support.

Effect of regional trauma centralization on volume, injury severity and outcomes of injured patients admitted to trauma centres.

BACKGROUND: Centralization of complex healthcare services into specialist high-volume centres is believed to improve outcomes. For injured patients, few studies have evaluated the centralization of major trauma services. The aim of this study was to evaluate how a regional trauma network affected trends in admissions, case mix, and outcomes of injured patients. METHODS: A retrospective before-after study was undertaken of severely injured patients attending four hospitals that became major trauma centres (MTCs) in March 2012. Consecutive patients with major trauma were identified from a national registry and divided into two groups according to injury before or after the launch of a new trauma network. The two cohorts were compared for differences in case mix, demand on hospital resources, and outcomes. RESULTS: Patient volume increased from 442 to 1326 (200 per cent), operations from 349 to 1231 (253 per cent), critical care bed-days from 1100 to 3704 (237 per cent), and total hospital bed-days from 7910 to 22,772 (188 per cent). Patient age increased on MTC designation from 45.0 years before March 2012 to 48.2 years afterwards (P = 0.021), as did the proportion of penetrating injuries (1.8 versus 4.1 per cent; P = 0.025). Injury severity fell as measured by median Injury Severity Score (16 versus 14) and Revised Trauma Score (4.1 versus 7.8). Fewer patients required secondary transfer to a MTC from peripheral hospitals (19.9 versus 16.1 per cent; P = 0.100). There were no significant differences in total duration of hospital stay, critical care requirements or mortality. However, there was a significant increase, from 55.5 to 62.3 per cent (P < 0.001), in the proportion of patients coded as having a 'good recovery' at discharge after institution of the trauma network. CONCLUSION: MTC designation leads to an increased case volume with considerable implications for operating theatre capacity and bed occupancy. Although no mortality benefit was demonstrated within 6 months of establishing this trauma network, early detectable advantages included improved functional outcome at discharge.

Risk Adjustment In Neurocritical care (RAIN)--prospective validation of risk prediction models for adult patients with acute traumatic brain injury to use to evaluate the optimum location and comparative costs of neurocritical care: a cohort study.

OBJECTIVES: To validate risk prediction models for acute traumatic brain injury (TBI) and to use the best model to evaluate the optimum location and comparative costs of neurocritical care in the NHS. DESIGN: Cohort study. SETTING: Sixty-seven adult critical care units. PARTICIPANTS: Adult patients admitted to critical care following actual/suspected TBI with a Glasgow Coma Scale (GCS) score of < 15. INTERVENTIONS: Critical care delivered in a dedicated neurocritical care unit, a combined neuro/general critical care unit within a neuroscience centre or a general critical care unit outside a neuroscience centre. MAIN OUTCOME MEASURES: Mortality, Glasgow Outcome Scale - Extended (GOSE) questionnaire and European Quality of Life-5 Dimensions, 3-level version (EQ-5D-3L) questionnaire at 6 months following TBI. RESULTS: The final Risk Adjustment In Neurocritical care (RAIN) study data set contained 3626 admissions. After exclusions, 3210 patients with acute TBI were included. Overall follow-up rate at 6 months was 81%. Of 3210 patients, 101 (3.1%) had no GCS score recorded and 134 (4.2%) had a last pre-sedation GCS score of 15, resulting in 2975 patients for analysis. The most common causes of TBI were road traffic accidents (RTAs) (33%), falls (47%) and assault (12%). Patients were predominantly young (mean age 45 years overall) and male (76% overall). Six-month mortality was 22% for RTAs, 32% for falls and 17% for assault. Of survivors at 6 months with a known GOSE category, 44% had severe disability, 30% moderate disability and 26% made a good recovery. Overall, 61% of patients with known outcome had an unfavourable outcome (death or severe disability) at 6 months. Between 35% and 70% of survivors reported problems across the five domains of the EQ-5D-3L. Of the 10 risk models selected for validation, the best discrimination overall was from the International Mission for Prognosis and Analysis of Clinical Trials in TBI Lab model (IMPACT) (c-index 0.779 for mortality, 0.713 for unfavourable outcome). The model was well calibrated for 6-month mortality but substantially underpredicted the risk of unfavourable outcome at 6 months. Baseline patient characteristics were similar between dedicated neurocritical care units and combined neuro/general critical care units. In lifetime cost-effectiveness analysis, dedicated neurocritical care units had higher mean lifetime quality-adjusted life-years (QALYs) at small additional mean costs with an incremental cost-effectiveness ratio (ICER) of £14,000 per QALY and incremental net monetary benefit (INB) of £17,000. The cost-effectiveness acceptability curve suggested that the probability that dedicated compared with combined neurocritical care units are cost-effective is around 60%. There were substantial differences in case mix between the 'early' (within 18 hours of presentation) and 'no or late' (after 24 hours) transfer groups. After adjustment, the 'early' transfer group reported higher lifetime QALYs at an additional cost with an ICER of £11,000 and INB of £17,000. CONCLUSIONS: The risk models demonstrated sufficient statistical performance to support their use in research but fell below the level required to guide individual patient decision-making. The results suggest that management in a dedicated neurocritical care unit may be cost-effective compared with a combined neuro/general critical care unit (although there is considerable statistical uncertainty) and support current recommendations that all patients with severe TBI would benefit from transfer to a neurosciences centre, regardless of the need for surgery. We recommend further research to improve risk prediction models; consider alternative approaches for handling unobserved confounding; better understand long-term outcomes and alternative pathways of care; and explore equity of access to postcritical care support for patients following acute TBI. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Civilian firearm injury and death in England and Wales.

INTRODUCTION: There is currently concern in the UK that injuries and deaths caused by firearms are increasing. This is supported by small local studies but not by wider research to inform targeted prevention programmes. METHODS: A retrospective analysis was performed of firearm injuries from the Trauma Audit and Research Network (TARN) database (1998-2007), the largest national registry of serious injuries. Data were analysed to determine temporal trends in the prevalence of firearm injuries and demographic characteristics of firearm victims. The UK Office of National Statistics provided data on all deaths by firearms as TARN does not record prehospital deaths. RESULTS: Of 91 232 cases in the TARN database, 487 (0.53%) were due to firearm injury. There were 435 men and 52 women of median age 30 years. The median New Injury Severity Score in men was 18 with a mortality of 7.4%, compared with 15.5 and 3.8% for women. The highest rate of firearm injuries as a proportion of all injuries was submitted from London (1.4%), with the South East (0.23%) submitting the lowest rate. 90.5% resided in urban areas, 78% presented outside 'normal' hours and 90% were alleged assaults. As a proportion of all injuries submitted, a small upward trend in the prevalence of deaths due to firearms was demonstrated over the study period. An increase in homicides since 2000 was also noted with an increasingly younger population being involved. In contrast, data from the Office of National Statistics showed that the greatest number of deaths were self-inflicted rather than homicides (984 vs 527), with Wales having the highest number of such deaths and predominantly involving older men. CONCLUSIONS: Deaths and serious injuries caused by firearms remain rare in the civilian population of England and Wales, although an upward trend can be described. Victims of assault and homicide are predominantly young men living in urban areas and the population involved is getting younger. However, of all deaths, self-inflicted wounds are nearly twice as common as assaults, affecting predominantly older men living in more rural areas.

Vital signs and estimated blood loss in patients with major trauma: testing the validity of the ATLS classification of hypovolaemic shock.

AIM: The Advanced Trauma Life Support (ATLS) system classifies the severity of shock. The aim of this study is to test the validity of this classification. METHODS: Admission physiology, injury and outcome variables from adult injured patients presenting to hospitals in England and Wales between 1989 and 2007 and stored on the Trauma Audit and Research Network (TARN) database, were studied. For each patient, the blood loss was estimated and patients were divided into four groups based on the estimated blood loss corresponding to the ATLS classes of shock. The median and interquartile ranges (IQR) of the heart rate (HR) systolic blood pressure (SBP), respiratory rate (RR) and Glasgow Coma Score (GCS) were calculated for each group. RESULTS: The median HR rose from 82 beats per minute (BPM) in estimated class 1 shock to 95 BPM in estimated class 4 shock. The median SBP fell from 135 mm Hg to 120 mm Hg. There was no significant change in RR or GCS. CONCLUSION: With increasing estimated blood loss there is a trend to increasing heart rate and a reduction in SBP but not to the degree suggested by the ATLS classification of shock.

Testing the validity of the ATLS classification of hypovolaemic shock.

AIM: The Advanced Trauma Life Support system classifies the severity of shock. The aim of this study is to test the validity of this classification. METHODS: Admission physiology, injury and outcome variables from adult injured patients presenting to hospitals in England and Wales between 1989 and 2007 and stored on the Trauma Audit and Research Network (TARN) database, were studied. Patients were divided into groups representing the four ATLS classes of shock, based on heart rate (HR) systolic blood pressure (SBP), respiratory rate (RR) and Glasgow Coma Score (GCS). The relationships between variables were examined by classifying the cohort by each recorded variable in turn and deriving the median and interquartile range (IQR) of the remaining three variables. Patients with penetrating trauma and major injuries were examined in sub-group analyses. RESULTS: In blunt trauma patients grouped by HR, the median SBP decreased from 128 mmHg in patients with HR<100 BPM to 114 mmHg in those with HR>140 BPM. The median RR increased from 18 to 22 bpm and the GCS reduced from 15 to 14. The median HR in hypotensive patients was 88 BPM compared to 83 BPM in normotensive patients and the RR was the same. When grouped by RR, the HR increased with increasing RR but there were no changes in SBP. CONCLUSION: In trauma patients there is an inter-relationship between derangements of HR, SBP, RR and GCS but not to the same degree as that suggested by the ATLS classification of shock.

Determinants of hospital costs associated with traumatic brain injury in England and Wales.

Using data from the Trauma Audit Research Network, we investigated the costs of acute care in patients > or = 18 years of age hospitalised for traumatic brain injury between January 2000 and December 2005 in England and Wales. Traumatic brain injury patients were defined and stratified using the Abbreviated Injury Scale. A total of 6484 traumatic brain injury patients were identified; 22.3% had an Abbreviated Injury Scale score of three, 38.0% of four and 39.7% of five. Median age (IQR) was 42 years (28-59) and 76.7% were men. Primary cause of injury was motor vehicle collisions (42.4%) followed by falls (38.0%). In total 23.7% of the patients died before discharge. Hospitalisation costs averaged 15,462 pounds sterling (SD 16,844 pounds sterling). Costs varied significantly by age, Glasgow Coma Score, Injury Severity Score, coexisting injuries of the thorax, spine and lower limb, hospital mortality, availability of neurosurgical services, and specialty of attendants seen in the Accident and Emergency department.

The incidence of neurogenic shock in patients with isolated spinal cord injury in the emergency department.

BACKGROUND: Spinal cord injury (SCI) is recognised to cause hypotension and bradycardia (neurogenic shock). Previous studies have shown that the incidence of this in the emergency department (ED) may be low. However these studies are relatively small and have included a mix of blunt and penetrating injuries with measurements taken over different time frames. The aim was to use a large database to determine the incidence of neurogenic shock in patients with isolated spinal cord injuries. METHODS: The Trauma Audit and Research Network (TARN) collects data on patients attending participating hospitals in England and Wales. The database between 1989 and 2003 was searched for patients aged over 16 who had sustained an isolated spinal cord injury. The heart rate (HR) and systolic blood pressure (SBP) on arrival at the ED were determined as was the number and percentage of patients who had both a SBP<100mm Hg and a HR<80 beats per minute (BPM) (the classic appearance of neurogenic shock). RESULTS: Four hundred and ninety patients had sustained an isolated spinal cord injury (SCI) with no other injury with an abbreviated injury scale (AIS) of greater than 2. The incidence of neurogenic shock in cervical cord injuries was 19.3% (95% CI 14.8-23.7%). The incidence in thoracic and lumbar cord injuries was 7% (3-11.1%) and 3% (0-8.85%). CONCLUSIONS: Fewer than 20% of patients with a cervical cord injury have the classical appearance of neurogenic shock when they arrive in the emergency department. It is uncommon in patients with lower cord injuries. The heart rate and blood pressure changes in patients with a SCI may develop over time and we hypothesise that patients arrive in the ED before neurogenic shock has become manifest.

Ocular injuries in patients with major trauma.

AIM: To study the epidemiology of ocular injuries in patients with major trauma in the UK, determining the incidence and causes of ocular injuries, and their association with facial fractures. METHODS: A retrospective analysis of the Trauma Audit Research Network database from 1989 to 2004, looking at data from 39,073 patients with major trauma. RESULTS: Of the 39,073 patients with major trauma, 905 (2.3%) patients had associated ocular injuries and 4082 (10.4%) patients had a facial fracture (zygoma, orbit or maxilla). The risk of an eye injury for a patient with a facial fracture is 6.7 times as that for a patient with no facial fracture (95%, confidence interval 5.9 to 7.6). Of the patients with major trauma and an eye injury, 75.1% were men, and the median age was 31 years. 57.3% of ocular injuries were due to road traffic accidents (RTAs). CONCLUSION: The incidence of ocular injuries in patients with major trauma is low, but considerable association was found between eye injuries and facial fractures. Young adults have the highest incidence of ocular injury. RTAs are the leading cause of ocular injuries in patients with major trauma. It is vital that all patients with major trauma are examined specifically for an ocular injury.

Predictors of persistent neck pain after whiplash injury.

OBJECTIVE: To establish the aetiological influences of persistent neck pain following a motor vehicle collision and to construct a model for use in the emergency department for identifying patients at high risk of persistent symptoms. DESIGN: Prospective cohort study. Patients recruited from hospital emergency departments were sent a questionnaire to gather information on various exposures. They were followed up at 1, 3, and 12 months to identify those with persistent symptoms. MAIN OUTCOME MEASURE: Persistent neck pain (pain at 1, 3, and 12 months after collision). RESULTS: The baseline survey included 765 patients. Subsequently, 480 completed a questionnaire at each follow up time point, of whom 128 (27%) reported neck pain on each occasion. Few collision specific factors predicted persistent neck pain. In contrast, a high level of general psychological distress, pre-collision history of widespread body pain, type of vehicle, whiplash associated symptoms, and initial neck disability best predicted the persistence of symptoms. Furthermore, these factors, in combination, accounted for more than a fivefold increase in the risk of persistent neck pain. CONCLUSION: The greatest predictors of persistent neck pain following a motor vehicle collision relate to psychological distress and aspects of pre-collision health rather than to various attributes of the collision itself. With these factors, and those relating to initial injury severity, it is possible to identify a subgroup of patients presenting with neck pain with the highest risk of persistent symptoms. Thus, it is possible to identify whiplash patients with a poor prognosis and to provide closer follow up and specific attention to management in these individuals.

Trends in head injury outcome from 1989 to 2003 and the effect of neurosurgical care: an observational study.

BACKGROUND: Case fatality rates after all types of blunt injury have not improved since 1994 in England and Wales, possibly because not all patients with severe head injury are treated in a neurosurgical centre. Our aims were to investigate the case fatality trends in major trauma patients with and without head injury, and to establish the effect of neurosurgical care on mortality after severe head injury. METHODS: We analysed prospectively collected data from the Trauma Audit and Research Network database for patients presenting between 1989 and 2003. Mortality and odds of death adjusted for case mix were compared for patients with and without head injury, and for those treated in a neurosurgical versus a non-neurosurgical centre. FINDINGS: Patients with head injury (n=22,216) had a ten-fold higher mortality and showed less improvement in the adjusted odds of death since 1989 than did patients without head injury (n=154,231). 2305 (33%) of patients with severe head injury (presenting between 1996 and 2003) were treated only in non-neurosurgical centres; such treatment was associated with a 26% increase in mortality and a 2.15-fold increase (95% CI 1.77-2.60) in the odds of death adjusted for case mix compared with patients treated at a neurosurgical centre. INTERPRETATION: Since 1989 trauma system changes in England and Wales have delivered greater benefit to patients without head injury. Our data lend support to current guidelines, suggesting that treatment in a neurosurgical centre represents an important strategy in the management of severe head injury.

Patterns and risks in spinal trauma.

BACKGROUND: Spinal injury in children is rare, and poses many difficulties in management. AIMS: To ascertain the prevalence of spinal injury within the paediatric trauma population, and to assess relative risks of spinal injury according to age, conscious level, injury severity score (ISS), and associated injuries. METHODS: Spine injured children were identified from the UK Trauma Audit & Research Network Database from 1989 to 2000. Relative risks of injury were calculated against the denominator paediatric trauma population. RESULTS: Of 19 538 on the database, 527 (2.7%) suffered spinal column fracture/dislocation without cord injury and 109 had cord injury (0.56% of all children; 16.5% of spine injured children). Thirty children (0.15% of all children; 4.5% of spine injured children) sustained spinal cord injury without radiological abnormality (SCIWORA). Cord injury and SCIWORA occurred more commonly in children aged < or =8. The risk of spine fracture/dislocation without cord injury was increased with an ISS >25 and with chest injuries. The risk of cord injury was increased with reduced GCS, head injury, and chest injury. CONCLUSIONS: Spinal cord injury and SCIWORA occur more frequently in young children. Multiple injuries and chest injuries increase the risk of fracture/dislocation and of cord injury. Reduced GCS and head injuries increase the risk of cord injury.

Lack of change in trauma care in England and Wales since 1994.

UNLABELLED: To demonstrate trends in trauma care in England and Wales from 1989 to 2000. STUDY POPULATION: Database of the Trauma Audit and Research Network that includes hospital patients admitted for three days or more, those who died, were transferred or admitted to an intensive care or high dependency area. METHOD: To demonstrate trends in outcome, severity adjusted odds of death per year of admission to hospital were calculated for all hospitals (n=99) and 20 hospitals who had participated since 1989 (adjustments are for Injury Severity Score, age, and Revised Trauma Score). The grade of doctor initially seeing the injured patient in accident and emergency and median prehospital times per year of admission were calculated to demonstrate trends in the process of care. Trend analyses were carried out using simple linear regression (odds ratio versus year). RESULTS: The analysis shows a significant reduction in the severity adjusted odds of death of 3% per year over the 1989-2000 time period (p=0.001). During the period 1989-1994 the odds of death declined most steeply (on average 6% per year p=0.004). Between 1994 to 2000 no significant change occurred (p=0.35). This pattern was mirrored by the 20 permanent members where the odds of death also declined more steeply over the 1989-1994 period. The percentage of severely injured patients (ISS >15) seen by a consultant increased from 29 to 40 from 1989-1994 but has remained static subsequently. Median prehospital times for severely injured patients have not changed significantly since 1994 (51 to 45 minutes). CONCLUSION: Most of the case fatality reduction for trauma patients reaching hospital over the 1989-2000 time period occurred before 1995 when there was most marked change in the initial care of severely injured patients.