Risk Factors for Cervical Spine Injury in Patients With Mandibular Fractures.

PURPOSE: Patients with mandibular fractures are known to be at risk of concomitant cervical spine injuries (CSIs). The purpose of this study was to determine the incidence of and risk factors for CSIs in these patients. PATIENTS AND METHODS: We conducted a retrospective cohort study of adult trauma patients with mandibular fractures from June 1, 2007, through June 30, 2017. Patients were identified through the Massachusetts General Hospital trauma registry and were included as study patients if they had a mandibular fracture and computed tomography or magnetic resonance imaging of the cervical spine. The primary predictor variable was the site of the mandibular fracture; the primary outcome variables were the presence of CSIs and death. The other variables were demographic characteristics (age, gender, alcohol use, and drug use), Injury Severity Score, Glasgow Coma Scale, presence of midface and extra-craniofacial injuries, and etiology. Data analysis consisted of univariate correlations and construction of a multivariate model to determine independent risk factors for CSIs. RESULTS: Of 23,394 patients in the trauma registry, 3,950 (17%) had craniomaxillofacial fractures and 1,822 (7.7%) had CSIs. The frequency of CSIs in the overall cohort of mandibular fracture patients (n = 1,147) was 4.4%, and for admitted patients (n = 495), it was 10%. The mean age of patients with mandibular fractures plus CSIs was 40 years (range, 19 to 93 years); 84% were men. Patients with a ramus-condyle unit fracture, mandibular fracture plus any midface fracture, non-craniomaxillofacial injury, and motor vehicle crash etiology had the highest frequency of CSIs. Ramus-condyle unit fractures and chest injuries were independent risk factors for CSIs in the multivariate model (P = .0334 and P = .0013, respectively). The mortality rate was 4-fold higher in patients with CSIs versus those without CSIs. CONCLUSIONS: The presence of ramus-condyle unit fractures and the presence of chest injuries were independent risk factors for CSIs. Oral and maxillofacial surgeons should be diligent in ruling out CSIs in mandibular fracture patients.

Cost savings associated with transfer of trauma patients within an accountable care organization.

BACKGROUND: The Patient Protection and Affordable Care Act supports the establishment of accountable care organizations (ACOs) as care delivery models designed to save costs. The potential for these cost savings has been demonstrated in the primary care and inpatient populations, but not for patients with emergency conditions or traumatic injuries. METHODS: Our study evaluated adult trauma patients transferred to the tertiary care hospitals of a pioneer ACO, comparing those who were transferred from within the ACO to those from outside the ACO in terms of overall cost of hospitalization. Hospital length of stay and number of imaging studies were predetermined secondary outcomes. RESULTS: The study population included 7696 hospitalizations for traumatic injuries over a 5-year period, 85.1% of which were for patients transferred from outside the ACO. Patients transferred from within the ACO had a 7.2% lower overall cost of hospitalization (P = .032). Mean injury severity scores were not significantly different between groups. Differences in mortality, intensive care unit length of stay, and overall hospital length of stay were not significant. However, analysis of radiology studies performed during the hospitalization revealed that patients transferred from within the ACO had, on average, 0.47 fewer advanced imaging studies per hospitalization than did those transferred from outside the ACO (3.55 vs 4.02 studies per hospitalization, P = .003). CONCLUSIONS: Adult trauma patients transferred from within an ACO have significantly lower total costs of hospitalization than do those transferred from outside the system, without significant differences in disease burden, hospital length of stay, or mortality.

Prolonged emergency department length of stay is not associated with worse outcomes in traumatic brain injury.

BACKGROUND: Data suggest that prolonged Emergency Department length of stay (EDLOS) has a detrimental effect on outcomes in some critically ill patients. However, the relationship between EDLOS and outcomes in traumatic brain injury (TBI) has not been examined. OBJECTIVE: Our objective was to determine the effect of EDLOS on neurologic outcomes in TBI patients. METHODS: We performed a retrospective analysis of a prospectively identified cohort of patients with moderate (Glasgow Coma Scale [GCS] score 9-13) and severe (GCS ≤ 8) TBI who presented to a Level 1 trauma center (2006-2010). Inclusion criteria were transfer to the intensive care unit (ICU) or operating room (OR) from the ED. Primary outcome was Glasgow Outcome Scale (GOS) score, a measure of neurologic function, at discharge. We used a proportional odds model to control for significant predictors of GOS in univariate analysis. RESULTS: Two hundred and twenty-four patients were included in the analysis, 77 (34%) of which were transferred to the OR. Median EDLOS was 3.3 h and 81.2% of patients had a GOS score ≤3 (e.g., severe disability, vegetative, or deceased). In multivariable analyses, EDLOS was not associated with GOS score in either ICU bound (p = 0.57) or OR bound (p = 0.11) patients. Younger age, pupil reactivity, and absence of intubation were independent predictors of good outcomes in the ICU group. In OR patients, predictors of higher GOS score included presence of an epidural hemorrhage, absence of midline shift, and pupil reactivity. CONCLUSIONS: Our study demonstrates that EDLOS was not associated with poor outcomes in patients with moderate to severe TBI who required intensive care or early operative intervention in an academic Level 1 trauma center.

Interhospital transfers of acute care surgery patients: should care for nontraumatic surgical emergencies be regionalized?

BACKGROUND: Patients with major nontraumatic surgical emergencies (NTSEs) are commonly transferred from small hospitals to tertiary care centers. We hypothesized that transferred patients (TRANS) have worse outcomes than patients with similar diagnoses admitted directly to a tertiary center (DIRECT). METHODS: We reviewed all patients admitted to the acute care surgery service of our tertiary center (September 1, 2006-October 31, 2009) with one of eight diagnoses indicating a major NTSE. Patients transferred for reasons other than the severity of illness were excluded. Univariate and multivariable analyses compared TRANS and DIRECT patients. RESULTS: Of 319 patients eligible for analysis, 103 (34%) were TRANS and averaged 3.8 days in the referring hospital before transfer. Compared to DIRECT patients, TRANS patients were more likely to be obese (18.5 vs. 8.0%, P = 0.006) and have cardiac (24 vs. 14%, P = 0.022) or pulmonary (25 vs. 12%, P = 0.003) co-morbidities. TRANS patients were also more likely to present to the tertiary center with hypotension (9 vs. 2%, P = 0.021), tachycardia (20 vs. 13%, P = 0.036), anemia (83 vs. 58%, P < 0.001), and hypoalbuminemia (50 vs. 14%, P < 0.001). TRANS patients had higher mortality (4.9 vs. 0.9%, P = 0.038) and longer hospital stay (8 with 5-13 days vs. 5 with 3-8 days, P < 0.001). CONCLUSIONS: TRANS patients comprised a significant portion of the population with major NTSEs admitted to the acute care surgery service of our tertiary center. They presented with greater physiologic derangement and had worse outcomes than DIRECT patients. As is currently established for trauma care, regionalization of care for NTSEs should be considered.

Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma.

BACKGROUND: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS: The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS: Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS: CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

Is upper extremity deep venous thrombosis underdiagnosed in trauma patients?

It has been suggested that upper extremity deep venous thrombosis (UEDVT) is as common and dangerous as lower extremity deep venous thrombosis. Pulmonary embolism (PE) is often found with no evidence of associated lower extremity deep venous thrombosis and could have originated from UEDVT. Routine screening is well accepted for lower extremity deep venous thrombosis but not for UEDVT. We hypothesized that UEDVT in trauma is frequent but undetected; therefore, routine screening of trauma patients at risk will increase the UEDVT rate and decrease the PE rate due to early diagnosis and treatment. We evaluated the incidence of UEDVT and PE over 6 months before (Group BEFORE) and 6 months after (Group AFTER) implementing a policy of screening patients at high risk for deep venous thrombosis with Duplex ultrasonography. Group BEFORE was evaluated retrospectively and group AFTER prospectively. There were 1110 BEFORE and 911 AFTER patients. The two groups were similar. Of the AFTER patients, 86 met predetermined screening criteria and were evaluated routinely by a total of 130 Duplex exams. One patient in each group developed UEDVT (0.09% vs. 0.11%, P = 1.00). The brachial vein was involved in both patients. Six BEFORE (0.54%) and 1 AFTER (0.11%) patients developed PE (P = 0.137). The single AFTER patient with PE was not screened for UEDVT because he had no high-risk criteria. UEDVT is an uncommon event with unclear significance in trauma. Aggressive screening did not result in a higher rate of UEDVT diagnosis, nor an opportunity to prevent PE.

Falls from height: spine, spine, spine!

BACKGROUND: Falls from a height are a major cause of morbidity and hospital cost. Spinal injury is frequently associated with falls from height, but reliable predictive factors have not been identified. Diagnostic evaluation of the spine is complex and debated. Our objective was to characterize spinal injury after falls from height and identify predictive factors of spinal injuries. STUDY DESIGN: Medical records of patients with falls from height>10 feet admitted in a Level I trauma center during a period of 66 months were reviewed. Univariate and multivariate analyses were performed to identify independent risk factors of spinal injuries. RESULTS: Of 414 patients, 127 (31%) suffered 277 spinal injuries. Multiple spinal injuries at different levels were found in 62 (49%) patients; in 19 (15%) spinal injuries were at noncontinuous levels. The only independent predictor of spinal injury was alcohol intoxication (odds ratio=3.305; 95% CI, 1.75-6.242; p<0.001) but the number of intoxicated patients was low and the predictive ability weak. Level of falls from height did not correlate with likelihood of spinal injury. Twenty-four of 107 (22%) patients with spinal injuries and a reliable clinical examination had no symptoms related to the spine; all but 2 had distracting injuries. CONCLUSIONS: Spinal injury is frequent among survivors of falls from height>10 feet. Because of the absence of reliable predictors of spinal injury, the possibility of multiple noncontinuous fractures, and the presence of distracting injuries clouding the clinical presentation, aggressive evaluation of the entire spine is warranted.

Do trauma systems work? A comparison of major trauma outcomes between Aberdeen Royal Infirmary and Massachusetts General Hospital.

Trauma is an important matter of public health and a major cause of mortality. Since the late 1980s trauma care provision in the United Kingdom is lacking when compared to the USA. This has been attributed to a lack of organisation of trauma care leading to the formation of trauma networks and Major Trauma Centres in England and Wales. The need for similar centres in Scotland is argued currently. We assessed the activity of two quite different trauma systems by obtaining access to comparative data from two hospitals, one in the USA and the other in Scotland. Aggregate data on 5604 patients at Aberdeen Royal Infirmary (ARI) from 1993 to 2002 was obtained from the Scottish Trauma Audit Group. A comparable data set of 16,178 patients from Massachusetts General Hospital (MGH). Direct comparison of patient demographics; injury type, mechanism and Injury Severity Score (ISS); mode of arrival; length of stay and mortality were made. Statistical analysis was carried out using Chi-squared and Cochran-Mantel-Haenszel. There were significant differences in the data sets. There was a higher proportion of penetrating injuries at MGH, (8.6% vs 2.6%) and more severely injured patients at MGH, patients with an ISS>16 accounted for nearly 22.1% of MGH patients compared to 14.0% at ARI. ISS 8-15 made up 54.6% of ARI trauma with 29.6% at MGH. Falls accounted for 50.1% at ARI and 37.9% at MGH. Despite the higher proportion of severe injuries at MGH and crude mortality rates showing no difference (4.9% ARI vs 5.2% MGH), pooled odds ratio of mortality was 1.4 (95% confidence interval 1.2-1.6) showing worse mortality outcomes at ARI compared to MGH. In conclusion, there were some differences in case mix between both data sets making direct comparison of the outcomes difficult, but the effect of consolidating major trauma on the proportion and number of severely injured patients treated in the American Level 1 centre was clear with a significant improvement in mortality in all injury severity groups.

The impact and sustainability of the graduated driver licensing program in preventing motor vehicle crashes in Massachusetts.

BACKGROUND: Graduated driving licensing (GDL) programs phase in driving privileges for teenagers. We aimed to evaluate the effect of the 2007 GDL law on the incidence of total motor vehicle crashes (tMVCs) and fatal motor vehicle crashes (fMVCs) among teenagers in Massachusetts. METHODS: The Fatality Analysis and Reporting System, the Missouri Census Data Center, and the Massachusetts Department of Transportation databases were all used to create and compare the incidence of tMVCs and fMVCs before (2002-2006) and after (2007-2011) the law enactment. The following three driver age groups were studied: 16 years to 17 years (evaluating the law effect), 18 years to 20 years (evaluating the sustainability of the effect), and 25 years to 29 years (control group). As a sensitivity analysis, we compared the incidence rates per population and per licenses issued. RESULTS: tMVCs decreased following the law for all three age groups (16-17 years, from 7.6 to 4.8 per 1,000 people, p < 0.0001; 18-20 years, from 8.5 to 6.4 per 1,000 people, p < 0.0001; 25-29 years, from 6.2 to 5.2 per 1,000 people, p < 0.0001), but the percentage decrease in tMVC rates was less in the control group (37%, 25%, and 15%, respectively; both p's < 0.0001). The rates of fMVC also decreased in the age groups of 16 years to 17 years (from 14.0 to 8.6 per 100,000 people, p = 0.0006), 18 years to 20 years (from 21.2 to 13.7 per 100,000 people, p < 0.0001), and 25 years to 29 years (from 14.4 to 11.0 per 100,000 people, p < 0.0001). All of these results were confirmed in the sensitivity analyses. CONCLUSION: The 2007 Massachusetts GDL was associated with a decreased incidence of teenager tMVCs and fMVCs, and the effect was sustainable. This study provides further support to develop, implement, enforce, and maintain GDL programs aimed at preventing MVCs and their related mortality in the young novice driver population. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Routine repeat head CT for minimal head injury is unnecessary.

BACKGROUND: Patients with MHI and a positive head computed tomography (CT) scan frequently have a routine repeat head CT (RRHCT) to identify possible evolution of the head injury requiring intervention. RRHCT is ordered based on the premise that significant injury progression may take place in the absence of clinical deterioration. METHODS: In a Level I urban trauma center with a policy of RRHCT, we reviewed the records of 692 consecutive trauma patients with Glasgow Coma Scale scores of 13-15 and a head CT (October 2004 through October 2005). The need for medical or surgical neurologic intervention after RRHCT was recorded. Patients with a worse and unchanged RRHCT were compared, and independent predictors of a worse RRHCT were identified by stepwise logistic regression. RESULTS: There were 179 patients with MHI and RRHCT ordered. Of them, 37 (21%) showed signs of injury evolution on RRHCT and 7 (4%) required intervention. All 7 had clinical deterioration preceding RRHCT. In no patient without clinical deterioration did RRHCT prompt a change in management. A Glasgow Coma Scale score less than 15 (13 or 14), age higher than 65 years, multiple traumatic lesions found on first head CT, and interval shorter than 90 minutes from arrival to first head CT predicted independently a worse RRHCT. CONCLUSIONS: RRHCT is unnecessary in patients with MHI. Clinical examination identifies accurately the few who will show significant evolution and require intervention.

Cerebral fractional anisotropy score in trauma patients: a new indicator of white matter injury after trauma.

OBJECTIVE: Previous studies evaluating quantitative cerebral white matter diffusion anisotropy indexes have shown alteration in patients after trauma. To date, no clinically applicable scale exists by which to gauge and test the relevance of these findings. We propose the cerebral fractional anisotropy score in trauma (C-FAST) as an index of white matter injury, and we correlate C-FAST with several predictor and outcome variables. MATERIALS AND METHODS: Fifteen patients were randomly selected from the trauma surgery service. Thirty control patients were randomly selected from the emergency department. All patients were subjected to MRI evaluation, including a diffusion-weighted sequence. Data extracted from the record of each subject included Glasgow Coma Scale, revised trauma score, Abbreviated Injury Scale, initial head CT results, patient disposition, length of hospital stay, and length of stay in intensive care unit. Region of interest measurements were made in fractional anisotropy maps in each of 12 white matter regions. Univariate statistics and a two-tailed t test were performed on the raw fractional anisotropy data. Data were then dichotomized using thresholds from univariate statistics. A C-FAST score was devised from the dichotomized data. Logistic regression analyses were performed among the C-FAST, outcome, and predictor data. RESULTS: Good correlation was noted between the C-FAST and death, hospital stay greater than 10 days, and intensive care unit stay greater than 5 days. Correlation with discharge to rehabilitation facility was good when adjusted for age and sex. Glasgow Coma Scale, revised trauma score, and Abbreviated Injury Scale show good correlation as predictors of a critical C-FAST. CONCLUSION: The C-FAST is a promising index derived from MRI diffusion fractional anisotropy measurements that shows successful correlation with outcome and predictor variables. A larger investigation is needed to verify the validity and stability of the correlations.