Back to the Future: Impact of a Paper-Based Admission H&P on Clinical Documentation Improvement at a Level 1 Trauma Center.

The Medicare Severity Diagnosis Related Group (MS-DRG) weight, as derived from the MS-DRG assigned at discharge, is in part determined by the physician-documented diagnoses. However, the terminology associated with MS-DRG determination is often not aligned with typical physician language, leading to inaccurate coding and decreased hospital reimbursements. The goal of this study was to evaluate the impact of a diagnosis picklist within a paper-based history and physical examination (H&P) on the average MS-DRG weight and the Case-mix index (CMI). Our trauma center implemented a paper H&P form for trauma patients featuring picklist diagnoses aligned with the MS-DRG terminology and arranged by the physiologic system. To evaluate its impact, we conducted a cohort study using data from our trauma registry between July 2015 and November 2017. Our cohort included 442 (26.0%) paper and 1,261 (74.0%) dictated H&Ps. Average CMI (2.56 vs 2.15) and expected patients ($25,057 vs $19,825) were higher for the paper group (P < 0.001, P = 0.002). Adjusted regression models demonstrated paper coding to be associated with 0.265 CMI points, translating to an average increase in expected payment of 6.5 per cent per patient. Utilization of a standardized, paper-based H&P template with picklist diagnoses was associated with a higher trauma service CMI and higher expected payments. Preprinted diagnoses that align with the MS-DRG terminology lead to clinical documentation improvement.

Community Need Index (CNI): a simple tool to predict emergency department utilization after hospital discharge from the trauma service.

BACKGROUND: Emergency department (ED) visits after hospital discharge may reflect failure of transition of care to the outpatient setting. Reduction of postdischarge ED utilization represents an opportunity for quality improvement and cost reduction. The Community Need Index (CNI) is a Zip code-based score that accounts for a community's unmet needs with respect to healthcare and is publicly accessible via the internet. The purpose of this study was to determine if patient CNI score is associated with postdischarge ED utilization among hospitalized trauma patients. METHODS: Level 1 trauma patient admitted between January 2014 and June 2016 were stratified by 30-day postdischarge ED utilization (yes/no). CNI is a nationwide Zip code-based score (1.0-5.0) and was determined per patient from the CNI website. Higher scores indicate greater barriers to healthcare per aggregate socioeconomic factors. Patients with 30-day postdischarge ED visits were compared with those without, evaluating for differences in CNI score and clinical and demographic characteristics. RESULTS: 309 of 3245 patients (9.5%) used the ED. The ED utilization group was older (38.3±15.7 vs. 36.3±16.4 years, p=0.034), more injured (Injury Severity Score 10.4±8.7 vs. 7.7±8.0, p<0.001), and more likely to have had in-hospital complications (17.5% vs. 5.4%, p<0.001). Adjusted for patient age, injury severity, gender, race/ethnicity, penetrating versus blunt injury, alcohol above the legal limit, illicit drug use, the presence of one or more complications and comorbidities, hospital length of stay, and insurance category, CNI score ≥4 was associated with increased utilization (OR 2.0 [95% CI 1.4 to 2.9, p<0.001]). DISCUSSION: CNI is an easily accessible score that independently predicts postdischarge ED utilization in trauma patients. Patients with CNI score ≥4 are at significantly increased risk. Targeted intervention concerning discharge planning for these patients represents an opportunity to decrease postdischarge ED utilization. LEVEL OF EVIDENCE: III, Prognostic and Epidemiological.

Pneumomediastinum in blunt trauma: If aerodigestive injury is not seen on CT, invasive workup is not indicated.

BACKGROUND: Pneumomediastinum following blunt trauma is often observed on CT imaging, and concern for associated aerodigestive injury often prompts endoscopy and/or fluoroscopy. In recent years, adoption of multi-detector CT technology has resulted in high resolution images that may clearly identify aerodigestive injuries. The purpose of this study was to evaluate the utility of multi-detector CT in the identification of blunt aerodigestive injuries. METHODS: Over five years, patients with pneumomediastinum following blunt trauma were identified from the registry of a level 1 trauma center. All CT imaging of trauma patients during this time period was accomplished with 64-slice scanners. RESULTS: 127 patients with blunt traumatic pneumomediastinum were identified. Five airway injuries were identified, and all injuries were evident on CT imaging. No patient was found to have airway injury by endoscopy that was not evident on CT. No patient had an esophageal injury. CONCLUSION: Multi-detector CT imaging identifies aerodigestive injuries associated with pneumomediastinum following blunt trauma. The absence of a recognizable aerodigestive injury by CT effectively rules out the presence of such injury.

Crisis under the radar: Illicit amphetamine use is reaching epidemic proportions and contributing to resource overutilization at a Level I trauma center.

INTRODUCTION: Trauma centers reported illicit amphetamine use in approximately 10% of trauma admissions in the previous decade. From experience at a trauma center located in a southwestern metropolis, our perception is that illicit amphetamine use is on the rise and that these patients utilize in-hospital resources beyond what would be expected for their injuries. The purposes of this study were to document the incidence of illicit amphetamine use among our trauma patients and to evaluate its impact on resource utilization. METHODS: We conducted a retrospective cohort study using 7 consecutive years of data (starting July 2010) from our institution's trauma registry. Toxicology screenings were used to categorize patients into one of three groups: illicit amphetamine, other drugs, or drug-free. Adjusted linear and logistic regression models were used to predict hospital cost, length of stay, intensive care unit admission, and ventilation between drug groups. Models were conducted with combined injury severity (Injury Severity Score [ISS]) and then repeated for ISS of less than 9, ISS 9 to 15, and ISS 16 or greater. RESULTS: Eight thousand five hundred eighty-nine patients were categorized into the following three toxicology groups: 1,255 (14.6%) illicit amphetamine, 2,214 (25.8%) other drugs, and 5,120 (59.6%) drug-free. Illicit amphetamine use increased threefold over the course of the study (from 7.85% to 25.0% of annual trauma admissions). Adjusted linear models demonstrated that illicit amphetamine among patients with ISS of less than 9 was associated with 4.6% increase in hospital cost (p = 0.019) and 7.4% increase in length of stay (p = 0.043). Logistic models revealed significantly increased odds of ventilation across all ISS groups and increased odds of intensive care unit admission when all ISS groups were combined (p = 0.001) and within the group with ISS of less than 9 (p = 0.002). CONCLUSIONS: Hospital resource utilization of amphetamine patients with minor injuries is significant. Trauma centers with similar epidemic growth in proportion of amphetamine patients face a potentially significant resource strain relative to other centers. LEVEL OF EVIDENCE: Prognostic/Epidemiological, level II; Therapeutic, level III.

Grey's Anatomy effect: television portrayal of patients with trauma may cultivate unrealistic patient and family expectations after injury.

BACKGROUND: Expectations of the healthcare experience may be influenced by television dramas set in the hospital workplace. It is our perception that the fictional television portrayal of hospitalization after injury in such dramas is misrepresentative. The purpose of this study was to compare trauma outcomes on television dramas versus reality. METHODS: We screened 269 episodes of Grey's Anatomy, a popular medical drama. A television (TV) registry was constructed by collecting data for each fictional trauma portrayed in the television series. Comparison data for a genuine patient cohort were obtained from the 2012 National Trauma Databank (NTDB) National Program Sample. RESULTS: 290 patients composed of the TV registry versus 4812 patients from NTDB. Mortality was higher on TV (22% vs 7%, P<0.0001). Most TV patients went straight from emergency department (ED) to operating room (OR) (71% vs 25%, P<0.0001). Among TV survivors, a relative minority were transferred to long-term care (6% vs 22%, P<0.0001). For severely injured (Injury Severity Score ≥25) survivors, hospital length of stay was less than 1 week for 50% of TV patients versus 20% in NTDB (P<0.0001). CONCLUSIONS: Trauma patients as depicted on television dramas typically go from ED to OR, and survivors usually return home. Television portrayal of rapid functional recovery after major injury may cultivate false expectations among patients and their families. LEVEL OF EVIDENCE: Level III.

Health literacy and quality of physician-trauma patient communication: Opportunity for improvement.

BACKGROUND: Although physician-patient communication and health literacy (HL) have been studied in diverse patient groups, there has been little focus on trauma patients. A quality improvement project was undertaken at our Level I trauma center to improve patient perception of physician-patient communication, with consideration of the effect of HL. We report the first phase of this project, namely the reference level of satisfaction with physician-patient communication as measured by levels of interpersonal care among patients at an urban Level I trauma center. METHODS: Level I trauma center patients were interviewed during hospitalization (August 2016 to January 2017). Short Assessment of Health Literacy tool was used to stratify subjects by deficient versus adequate HL. Interpersonal Processes of Care survey was administered to assess perception of physician-patient communication. This survey allowed patients to rate physician-patient interaction across six domains: "clarity," "elicited concerns," "explained results," "worked together (on decision making)," "compassion and respect," and "lack of discrimination by race/ethnicity." Each is scored on a five-point scale. Frequencies of "top-box" (5/5) scores were compared for significance (p < 0.05) between HL-deficient and HL-adequate patients. RESULTS: One hundred ninety-nine patients participated. Average age was 42 years, 33% female. Forty-nine (25%) patients had deficient HL. The majority of patients in both groups rated communication below 5/5 across all domains except "compassion and respect" and "lack of discrimination by race/ethnicity." Health literacy-deficient patients were consistently less likely to give physicians top-box scores, most notably in the "elicited concerns" domain (35% vs. 54%, p = 0.012). CONCLUSION: Health literacy-deficient patients appear relatively less satisfied with physician communication, particularly with respect to perceiving that their concerns are being heard. Overall, however, the majority of patients in both groups were unlikely to score physician communication in the "top box." Efforts to improve physician-trauma patient communication are warranted, with attention directed toward meeting the needs of HL-deficient patients. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, level I.

Risk factors for extubation failure at a level I trauma center: does the specialty of the intensivist matter?

INTRODUCTION: Extubation failure in critically ill patients is associated with higher morbidity and mortality. Although predictors of failed extubation have been previously determined in intensive care unit (ICU) cohorts, relatively less attention has been directed toward this issue in patients with trauma. The aim of this study was to identify predictors of extubation failure among patients with trauma in a multidisciplinary ICU setting. METHODS: A prospective observational study of extubation failures (EF) was conducted at an American College of Surgeons level I trauma center over 3 years (2011-2013). Case-control patients (CC) were then compared with the study group (EF) with respect to demographic/clinical characteristics and outcomes. Failure of extubation was defined as reintubation within 72 hours following planned extubation. RESULTS: 7830 patients were admitted to the trauma service and 1098 (14%) underwent mechanical ventilation. 63 patients met inclusion criteria for the EF group and 63 comprised the CC group. The overall rate of extubation failure was 5.7% and mean time to reintubation was 13.0 hours. Groups (EF vs CC) were similar for Injury Severity Score (21 vs 21), Glasgow Coma Scale at extubation (11 vs 10), number of comorbidities (1.5 vs 1.7), injury mechanism (blunt 79% vs 74%), and body mass index (27.9 vs 27.2). In addition, groups were similar with respect to weaning protocol compliance (84% vs 89%, p=0.57). EF group had significantly increased ICU length of stay (LOS) (15.7 vs 7.4 days, p<0.001), ventilator days (13.3 vs 4.8, p<0.001), and mortality (9.5% vs 0%, p=0.03). Multiple regression analysis identified that EF was associated with increased odds of: (1) temperature >38°C at time of extubation (OR 5.9, 95% CI 1.7 to 20.8), and (2) non-surgeon intensivist consultation (OR 24.2, 95% CI 5.5 to 105.9). CONCLUSIONS: Extubation failure is associated with increased LOS, ventilator days, and mortality in patients with trauma. Fever at time of extubation is associated with extubation failure, and the presence of such should give pause in the decision to extubate. Non-surgeon intensivist involvement increases risk of extubation failure, and a surgical critical care service may be most appropriate for the management of ventilated patients with trauma. LEVEL OF EVIDENCE: III, Prognostic and epidemiological.

The use of extracorporeal membrane oxygenation in blunt thoracic trauma: A study of the Extracorporeal Life Support Organization database.

BACKGROUND: Reports documenting the use of extracorporeal membrane oxygenation (ECMO) after blunt thoracic trauma are scarce. We used a large, multicenter database to examine outcomes when ECMO was used in treating patients with blunt thoracic trauma. METHODS: We performed a retrospective analysis of ECMO patients in the Extracorporeal Life Support Organization database between 1998 and 2014. The diagnostic code for blunt pulmonary contusion (861.21, DRG International Classification of Diseases-9th Rev.) was used to identify patients treated with ECMO after blunt thoracic trauma. Variations of pre-ECMO respiratory support were also evaluated. The primary outcome was survival to discharge; the secondary outcome was hemorrhagic complication associated with ECMO. RESULTS: Eighty-five patients met inclusion criteria. The mean ± SEM age of the cohort was 28.9 ± 1.1 years; 71 (83.5%) were male. The mean ± SEM pre-ECMO PaO2/FIO2 ratio was 59.7 ± 3.5, and the mean ± SEM pre-ECMO length of ventilation was 94.7 ± 13.2 hours. Pre-ECMO support included inhaled nitric oxide (15 patients, 17.6%), high-frequency oscillation (10, 11.8%), and vasopressor agents (57, 67.1%). The mean ± SEM duration of ECMO was 207.4 ± 23.8 hours, and 63 patients (74.1%) were treated with venovenous ECMO. Thirty-two patients (37.6%) underwent invasive procedures before ECMO, and 12 patients (14.1%) underwent invasive procedures while on ECMO. Hemorrhagic complications occurred in 25 cases (29.4%), including 12 patients (14.1%) with surgical site bleeding and 16 (18.8%) with cannula site bleeding (6 patients had both). The rate of survival to discharge was 74.1%. Multivariate analysis showed that shorter duration of ECMO and the use of venovenous ECMO predicted survival. CONCLUSION: Outcomes after the use of ECMO in blunt thoracic trauma can be favorable. Some trauma patients are appropriate candidates for this therapy. Further study may discern which subpopulations of trauma patients will benefit most from ECMO. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.

"Corkscrew stenosis": defining and preventing a complication of percutaneous dilatational tracheostomy.

OBJECTIVE: The short-term safety of percutaneous dilatational tracheostomy has been widely demonstrated. However, less is known about their long-term complications. Through an illustrative case series, we present and define "corkscrew stenosis," a type of tracheal stenosis uniquely associated with percutaneous dilatational tracheostomy. METHODS: Patients treated at our institution for tracheal stenosis after percutaneous dilatational tracheostomy were reviewed. Demographic data including gender, age, history of presentation, lesion morphology, imaging, and management was collected and evaluated. The pathology of the stenosis and the strategies for prevention are presented. RESULTS: From January, 2008 through December 2011, 11 patients had tracheal stenosis after percutaneous dilatational tracheostomy. The mean age was 54 ± 17 years and 55% were male. The stenotic lesions were characterized by a corkscrew morphology at the stoma site with a mean distance of 2.3 ± 0.8 cm from the vocal cords. Images of these lesions demonstrated disruption and fracture of the proximal tracheal cartilages and displacement of the anterior tracheal wall into the tracheal lumen. The majority of our patients required tracheal resection for definitive repair. CONCLUSIONS: We suggest that a unique form of tracheal stenosis can result from percutaneous dilatational tracheostomy. We observed corkscrew stenosis to be located proximally, associated with fractured tracheal rings, and morphologically appearing as interdigitation of these fractured rings. Recognizing corkscrew stenosis, its unique mechanism of formation, and technical means of prevention may be important in advancing the long-term safety of this procedure for critically ill patients who require prolonged ventilatory support.

Naturally occurring hypothermia is more advantageous than fever in severe forms of lipopolysaccharide- and Escherichia coli-induced systemic inflammation.

The natural switch from fever to hypothermia observed in the most severe cases of systemic inflammation is a phenomenon that continues to puzzle clinicians and scientists. The present study was the first to evaluate in direct experiments how the development of hypothermia vs. fever during severe forms of systemic inflammation impacts the pathophysiology of this malady and mortality rates in rats. Following administration of bacterial lipopolysaccharide (LPS; 5 or 18 mg/kg) or of a clinical Escherichia coli isolate (5 × 10(9) or 1 × 10(10) CFU/kg), hypothermia developed in rats exposed to a mildly cool environment, but not in rats exposed to a warm environment; only fever was revealed in the warm environment. Development of hypothermia instead of fever suppressed endotoxemia in E. coli-infected rats, but not in LPS-injected rats. The infiltration of the lungs by neutrophils was similarly suppressed in E. coli-infected rats of the hypothermic group. These potentially beneficial effects came with costs, as hypothermia increased bacterial burden in the liver. Furthermore, the hypotensive responses to LPS or E. coli were exaggerated in rats of the hypothermic group. This exaggeration, however, occurred independently of changes in inflammatory cytokines and prostaglandins. Despite possible costs, development of hypothermia lessened abdominal organ dysfunction and reduced overall mortality rates in both the E. coli and LPS models. By demonstrating that naturally occurring hypothermia is more advantageous than fever in severe forms of aseptic (LPS-induced) or septic (E. coli-induced) systemic inflammation, this study provides new grounds for the management of this deadly condition.

Management of pediatric occult pneumothorax in blunt trauma: a subgroup analysis of the American Association for the Surgery of Trauma multicenter prospective observational study.

BACKGROUND: Occult pneumothorax (OPTX) represents air within the pleural space not visible on conventional chest radiographs. Increased use of computed tomography has led to a rise in the detection of OPTX. Optimal management remains undefined. METHODS: A pediatric subgroup analysis (age <18 years) from a multicenter, observational study evaluating OPTX management. Data analyzed were pneumothorax size, management outcome, and associated risk factors to characterize those that may be safely observed. RESULTS: Fifty-two OPTX (7.3 ± 6.2 mm) in 51 patients were identified. None were greater than 27 mm; all those under 16.5 mm (n = 48) were successfully managed without intervention. Two patients underwent initial tube thoracostomy (one [21 mm] and the other with bilateral OPTX [24 mm, 27 mm]). Among patients under observation (n = 49), OPTX size progressed in 2; one (6.4mm) required no treatment, while one (16.5 mm) received elective intervention. Respiratory distress occurred in one patient (10.7 mm) who did not require tube thoracostomy. Nine received positive pressure ventilation; 8 did not have a tube thoracostomy. Twenty-four patients (51%) had one or more rib fractures; 3 required tube thoracostomy. CONCLUSION: No pediatric OPTX initially observed developed a tension pneumothorax or adverse event related to observation. Pediatric patients with OPTX less than 16 mm may be safely observed. Neither the presence of rib fractures nor need for PPV alone necessitates intervention.

Trauma-associated pneumonia in adult ventilated patients.

BACKGROUND: The clinical pulmonary infection score (CPIS) and bronchoalveolar lavage (BAL) are 2 tools that have been validated to diagnose pneumonia in critically ill patients. However, the role of the CPIS in diagnosing trauma-associated pneumonia (TAP) remains in question. METHODS: This prospective observational study included all trauma patients who were ventilated for longer than 48 hours from September 2008 to September 2009. The CPIS and quantitative culture results from the BAL were collected and used to define pneumonia. RESULTS: A total of 162 patients were identified. In all, 58 (35.8%) and 104 (64.2%) had a CPIS greater than 5 and a CPIS of 5 or less, respectively. There were 95 (58.6%) patients who had a BAL completed regardless of CPIS. There were 65 patients who met the bacteriologic definition of pneumonia (≥10(4) colonies/mL), for an overall TAP incidence of 40.1%. CONCLUSIONS: The CPIS is unreliable as a clinical tool to predict a positive BAL at 10(4) or 10(5) or higher threshold. Therefore, BAL should be used for the diagnosis of TAP based on clinical rationale and not the CPIS.

Harm reduction and 12 steps: complementary, oppositional, or something in-between?

BACKGROUND: Initially born of the desire to prevent the transmission of HIV among injection drug users, harm reduction presents a relatively new option for assisting individuals who struggle with drug and alcohol use. Twelve-step programs such as Alcoholics Anonymous (AA) are widely recognized as being a representative example of abstinence-based treatment and are often seen as oppositional to harm reduction. METHODS: The purpose of this study is to examine the ways in which harm reduction workers interpret the relationship between harm reduction and 12-step approaches to treatment. The study draws upon qualitative interviews with 18 staff members from two harm reduction-based substance use treatment programs. (1) RESULTS: Two central themes emerge from the qualitative data: (1) harm reduction and 12-step approaches can be complementary; and (2) 12-step approaches in high-threshold treatment settings may differ significantly from their original philosophy and intent. A third, much less prominent theme reflects some respondents' skepticism about the capacity of the two approaches to work together given the resistance to harm reduction by some in the 12-step community. CONCLUSION: Complementary conceptualizations of harm reduction and 12-step approaches have the potential to broaden the range of options available to people experiencing substance use problems.

Smoking in trauma patients: the effects on the incidence of sepsis, respiratory failure, organ failure, and mortality.

BACKGROUND: There is a high percentage of smokers among trauma patients. Cigarette smoking has been associated with the development of acute lung injury and the adult respiratory distress syndrome in critically ill patients. It is also known that nicotine exerts immunosuppressive and anti-inflammatory effects with chronic use. Trauma patients who are smokers usually go through acute nicotine withdrawal after the traumatic event and during their stay in ICU. How the smoking status and acute nicotine withdrawal affect outcomes after trauma is unknown. This question was addressed in this study by analyzing the incidence of sepsis, septic shock and multiple organ dysfunction syndrome, and other outcomes in smoking and nonsmoking trauma patients. METHODS: A retrospective cohort of trauma patients who met the criteria was randomly selected from the trauma registry. Individual charts were reviewed to confirm documented smoking status. Criteria for selection included the following: Injury Severity Score >or=20, age 18 to 65 years, hospital length of stay >72 hours. Patients with COPD/emphysema, diabetes mellitus, cardiac disease, malignancy, pregnancy, or steroid use were excluded. RESULTS: Overall, 327 patient charts were reviewed: 156 smokers and 171 nonsmokers. Men outnumbered women in the smoking group fourfold (p = 0.003 versus nonsmokers). Age, Injury Severity Score, the presence of shock on admission, the type of trauma (blunt or penetrating), ICU and hospital length of stay, and the duration of ventilator support were similar between smokers and nonsmokers. There were no differences in the incidence of sepsis, pneumonia, adult respiratory distress syndrome, or multiple organ dysfunction syndrome. Mortality was low (1.2% in smokers; 0.6% in nonsmokers) and did not differ significantly between the groups. CONCLUSIONS: The smoking status plays a minimal role in the outcome of healthy trauma patients. This suggests that the acute nicotine withdrawal that usually occurs in critically ill patients has no clinically significant implications after injury.

Nicotine administration and withdrawal affect survival in systemic inflammation models.

How different regimens of nicotine administration and withdrawal affect systemic inflammation is largely unknown. We studied the effects of chronic and acute nicotine administration and of nicotine withdrawal on the outcome of aseptic and septic systemic inflammation. Male C57BL/6 mice were implanted with subcutaneous osmotic pumps (to deliver nicotine) and intrabrain telemetry probes (to measure temperature). Aseptic inflammation was induced by lipopolysaccharide (40 mg/kg ip); sepsis was induced by cecal ligation and puncture. The chronic nicotine administration group received nicotine (28 mg.kg(-1).day(-1)) for 2 wk before the induction of inflammation and continued receiving nicotine until the end of the experiment; the acute nicotine administration group received saline for 2 wk and nicotine thereafter; the nicotine withdrawal group received nicotine for 2 wk and saline thereafter; and the no-nicotine group was infused with saline throughout the experiment. Compared with no nicotine, the chronic nicotine administration did not affect survival in either model of inflammation, possibly due to the development of nicotine tolerance. The acute nicotine administration increased the survival rate in aseptic inflammation from 11 to 33% (possibly by suppressing inflammation) but worsened the outcome of sepsis (possibly because the suppression of inflammation promoted microbial proliferation). Oppositely to acute nicotine, nicotine withdrawal increased the survival rate in sepsis from 18 to 40%. The effects on survival were not due to changes in body temperature. We conclude that acute nicotine administration and nicotine withdrawal affect survival in systemic inflammation and that these effects strongly depend on whether inflammation is aseptic or septic.

Helmet use and associated spinal fractures in motorcycle crash victims.

BACKGROUND: The effect of helmet use on the incidence of cervical and thoracic fractures sustained in motorcycle crashes remains controversial. METHODS: We retrospectively reviewed the incidence of these fractures in helmeted and nonhelmeted crash victims at a single Level I trauma hospital with a well-defined system for evaluating spinal fractures. RESULTS: Of 422 motorcycle crash victims treated during 3 years, 190 had a traumatic brain injury (TBI) and 75 sustained some form of spinal fracture. CONCLUSIONS: Based on the statistical analysis, there was no relationship between helmet use and cervical or thoracic fractures, after controlling for speed of crash. The protective effect of helmet use in TBI was verified. These findings re-emphasize the need for a well-defined radiologic protocol for spinal injury at centers that evaluate crash victims.