Identification of a neurologic scale that optimizes EMS detection of older adult traumatic brain injury patients who require transport to a trauma center.

OBJECTIVE: We sought to identify a scale or components of a scale that optimize detection of older adult traumatic brain injury (TBI) patients who require transport to a trauma center, regardless of mechanism. METHODS: We assembled a consensus panel consisting of nine experts in geriatric emergency medicine, prehospital medicine, trauma surgery, geriatric medicine, and TBI, as well as prehospital providers, to evaluate the existing scales used to identify TBI. We reviewed the relevant literature and solicited group feedback to create a list of candidate scales and criteria for evaluation. Using the nominal group technique, scales were evaluated by the expert panel through an iterative process until consensus was achieved. RESULTS: We identified 15 scales for evaluation. The panel's criteria for rating the scales included ease of administration, prehospital familiarity with scale components, feasibility of use with older adults, time to administer, and strength of evidence for their performance in the prehospital setting. After review and discussion of aggregated ratings, the panel identified the Simplified Motor Scale, GCS-Motor Component, and AVPU (alert, voice, pain, unresponsive) as the strongest scales, but determined that none meet all EMS provider and patient needs due to poor usability and lack of supportive evidence. The panel proposed that a dichotomized decision scheme that includes domains of the top-rated scales -level of alertness (alert vs. not alert) and motor function (obeys commands vs. does not obey) -may be more effective in identifying older adult TBI patients who require transport to a trauma center in the prehospital setting. CONCLUSIONS: Existing scales to identify TBI are inadequate to detect older adult TBI patients who require transport to a trauma center. A new algorithm, derived from elements of previously established scales, has the potential to guide prehospital providers in improving the triage of older adult TBI patients, but needs further evaluation prior to use.

Helicopters improve survival in seriously injured patients requiring interfacility transfer for definitive care.

BACKGROUND: Helicopter transport (HT) is frequently used for interfacility transfer of injured patients to a trauma center. The benefits of HT over ground transport (GT) in this setting are unclear. By using a national sample, the objective of this study was to assess whether HT impacted outcomes following interfacility transfer of trauma patients. METHODS: Patients transferred by HT or GT in 2007 were identified using the National Trauma Databank (version 8). Injury severity, resource utilization, and survival to discharge were compared. Stepwise logistic regression was used to determine whether transport modality was a predictor of survival after adjusting for covariates. Regression analysis was repeated in subgroups with Injury Severity Score (ISS)≤15 and ISS>15. RESULTS: There were 74,779 patients transported by helicopter (20%) or ground (80%). Mean ISS was higher in patients transported by helicopter (17±11 vs. 12±9; p<0.01) as was the proportion with ISS>15 (49% vs. 28%; odds ratio [OR], 2.53; 95% confidence interval [CI], 2.43-2.63). Patients transported by helicopter had higher rates of intensive care unit admission (54% vs. 29%; OR, 2.86; 95% CI, 2.75-2.96), had shorter transport time (61±55 minutes vs. 98±71 minutes; p<0.01), and had shorter overall prehospital time (135±86 minutes vs. 202±132 minutes; p<0.01). HT was not a predictor of survival overall or in patients with ISS≤15. In patients with ISS>15, HT was a predictor of survival (OR, 1.09; 95% CI, 1.02-1.17; p=0.01). CONCLUSIONS: Patients transported by helicopter were more severely injured and required more hospital resources than patients transported by ground. HT offered shorter transport and overall prehospital times. For patients with ISS>15, HT was a predictor of survival. These findings should be considered when developing interfacility transfer policies for patients with severe injuries.

Mechanism of injury and special consideration criteria still matter: an evaluation of the National Trauma Triage Protocol.

BACKGROUND: The Centers for Disease Control recently updated the National Trauma Triage Protocol. This field triage algorithm guides emergency medical service providers through four decision steps (physiologic [PHY], anatomic [ANA], mechanism, and special considerations) to identify patients who would benefit from trauma center care. The study objective was to analyze whether trauma center need (TCN) was accurately predicted solely by the PHY and ANA criteria using national data. METHODS: Trauma patients aged 18 years and older were identified in the NTDB (2002-2006). PHY data and ANA injuries (International Classification of Diseases, ninth revision codes) were collected. TCN was defined as Injury Severity Score (ISS)>15, intensive care unit admission, or need for urgent surgery. Test characteristics were calculated according to steps in the triage algorithm. Logistic regression was performed to determine independent association of criteria with outcomes. Receiver operating characteristic curves were constructed for each model. RESULTS: A total of 1,086,764 subjects were identified. Sensitivity of PHY criteria was highest for ISS>15 (42%) and of ANA criteria for urgent surgery (37%). By using PHY and ANA steps, sensitivity was highest (56%) and undertriage lowest (45%) for ISS>15. Undertriage for TCN based on actual treating trauma center level was 11%. CONCLUSION: Current PHY and ANA criteria are highly specific for TCN but result in a high degree of undertriage when applied independently. This implies that additional factors such as mechanism of injury and the special considerations included in the Centers for Disease Control decision algorithm contribute significantly to the effectiveness of this field triage tool.

The aging road warrior: national trend toward older riders impacts outcome after motorcycle injury.

Industry statistics suggest that motorcycle owners in the United States are getting older. Our objective was to analyze the effect of this demographic shift on injuries and outcomes after a motorcycle crash. Injured motorcyclists aged 17 to 89 years in the National Trauma Databank were reviewed from 1996 to 2005. Age trends and injury patterns were assessed over time. Injury Severity Score (ISS), length of stay (LOS), intensive care unit (ICU) use, comorbidities, complications, mortality, injury patterns, helmet use, and alcohol use were compared for subjects 40 and older versus those younger than 40-years-old. There were 61,689 subjects included. Over the study period, the mean age increased from 33.9 to 39.1 years (P < 0.01), and the proportion of subjects 40 years of age or older increased from 27.9 to 48.3 per cent. ISS, LOS, ICU LOS, and mortality were higher in the 40 years of age or older group (P < or = 0.01). The rates of admission to the ICU (32.3 vs. 27.3%), pre-existing comorbidities (20 vs. 9.7%), and complications (7.6 vs. 5.5%) were all higher in the 40 years of age and older group (P < 0.01). The average age of the injured motorcyclist is increasing. Older riders' injuries appear more serious, and their hospital course is more likely to be challenged by comorbidities and complications contributing to poorer outcomes. Motorcycle safety education and training initiatives should be expanded to specifically target older motorcyclists.

Trauma center designation correlates with functional independence after severe but not moderate traumatic brain injury.

BACKGROUND: The mortality of traumatic brain injury (TBI) continues to decline, emphasizing functional outcomes. Trauma center designation has been linked to survival after TBI, but the impact on functional outcomes is unclear. The objective was to determine whether trauma center designation influenced functional outcomes after moderate and severe TBI. METHODS: Trauma subjects presenting to an American College of Surgeons (ACS) Level I or II trauma center with a Glasgow Coma Score (GCS)

Helicopters and the civilian trauma system: national utilization patterns demonstrate improved outcomes after traumatic injury.

BACKGROUND: The role of helicopter transport (HT) in civilian trauma care remains controversial. The objective of this study was to compare patient outcomes after transport from the scene of injury by HT and ground transport using a national patient sample. METHODS: Patients transported from the scene of injury by HT or ground transport in 2007 were identified using the National Trauma Databank version 8. Injury severity, utilization of hospital resources, and outcomes were compared. Stepwise logistic regression was used to determine whether transport modality was a predictor of survival or discharge to home after adjusting for covariates. RESULTS: There were 258,387 patients transported by helicopter (16%) or ground (84%). Mean Injury Severity Score was higher in HT patients (15.9 ± 12.3 vs. 10.2 ± 9.5, p < 0.01), as was the percentage of patients with Injury Severity Score >15 (42.6% vs. 20.8%; odds ratio [OR], 2.83; 95% confidence interval [CI], 2.76-2.89). HT patients had higher rates of intensive care unit admission (43.5% vs. 22.9%; OR, 2.58; 95% CI, 2.53-2.64) and mechanical ventilation (20.8% vs. 7.4%; OR, 3.30; 95% CI, 3.21-3.40). HT was a predictor of survival (OR, 1.22; 95% CI, 1.17-1.27) and discharge to home (OR, 1.05; 95% CI, 1.02-1.07) after adjustment for covariates. CONCLUSIONS: Trauma patients transported by helicopter were more severely injured, had longer transport times, and required more hospital resources than those transported by ground. Despite this, HT patients were more likely to survive and were more likely to be discharged home after treatment when compared with those transported by ground. Despite concerns regarding helicopter utilization in the civilian setting, this study shows that HT has merit and impacts outcome.

Ground level falls are associated with significant mortality in elderly patients.

BACKGROUND: Falls from height are considered to be high risk for multisystem injury. Ground-level falls (GLF) are often deemed a low-energy mechanism of injury (MOI) and not a recommended triage criterion for trauma team activation. We hypothesize that in elderly patients, a GLF may represent a high-risk group for injury and concurrent comorbidities that warrant trauma service evaluation and should be triaged appropriately. METHODS: This is a retrospective study based on the National Trauma Data Bank. All patients with MOI consistent with GLF were identified. Demographics, type and severity of injuries, and outcomes were analyzed. RESULTS: We identified 57,302 patients with GLF. The group had 34% men, with mean age of 68 years ± 17 years and injury severity score of 8 ± 5. Overall mortality was 3.2%. There were 32,320 elderly patients (older than 70 years). The mortality in the elderly was significantly higher than the nonelderly (4.4% vs. 1.6%, p < 0.0001). The elderly were more likely to sustain long-bone fracture (54.5% vs. 35.9%, p < 0.0001), pelvic fracture (7.6% vs. 2.4%, p < 0.0001), and intracranial injury (10.6% vs. 8.7%, p<0.0001). Multivariate analysis showed that Glasgow Coma Scale (GCS) score <15 (odds ratio, 4.98) and older than 70 years (odds ratio, 2.75) were significant predictors of mortality inpatients after GLF. CONCLUSIONS: Patients older than 70 years and with GCS score <15 represent a group with significant inhospital mortality.

The incidence and clinical significance of pneumomediastinum found on computed tomography scan in blunt trauma patients.

With the increased use of chest computed tomography (CT) scan in the initial evaluation of major trauma, findings that were not seen on a chest radiograph (CXR) are increasingly identified. Pneumomediastinum (PM) seen on CXR in blunt trauma patients is considered worrisome for airway and/or esophageal injury. The purpose of this study was to determine the incidence and clinical significance of PM found on CT in blunt trauma patients. Blunt trauma patients admitted to a single Regional Trauma Center over a 2-year period were identified. Records were reviewed for demographics, mechanism, diagnostic evaluations, injuries, and outcome. A total of 2052 patients met study criteria. Fifty-five (2.7%) had PM; 49 patients (89%) had PM identified on CT alone, whereas six patients (11%) had it identified on both CXR and CT. There was no significant difference in gender or age between the two groups. Associated injuries were similar between groups. No patients had tracheobronchial or esophageal injuries. In this study, PM seen on CT was found to have little clinical significance other than as a marker for severe blunt trauma. No patients with airway or esophageal injuries were seen in any of the PM patients.

Prehospital spinal immobilization does not appear to be beneficial and may complicate care following gunshot injury to the torso.

BACKGROUND: Prehospital spinal immobilization (PHSI) is routinely applied to patients sustaining torso gunshot wounds (GSW). Our objective was to evaluate the potential benefit of PHSI after torso GSW versus the potential to interfere with other critical aspects of care. METHODS: A retrospective analysis of all patients with torso GSW in the Strong Memorial Hospital (SMH) trauma registry during a 41-month period and all patients with GSW in the National Trauma Data Bank (NTDB) during a 60-month period was conducted. PHSI was considered potentially beneficial in patients with spine fractures requiring surgical stabilization in the absence of spinal cord injury (SCI). RESULTS: Three hundred fifty-seven subjects from SMH and 75,210 from NTDB were included. A total of 9.2% of SMH subjects and 4.3% of NTDB subjects had spine injury, with 51.5% of SMH subjects and 32.3% of NTDB subjects having SCI. No SMH subject had an unstable spine fracture requiring surgical stabilization without complete neurologic injury. No subjects with SCI improved or worsened, and none developed a new deficit. Twenty-six NTDB subjects (0.03%) had spine fractures requiring stabilization in the absence of SCI. Emergent intubation was required in 40.6% of SMH subjects and 33.8% of NTDB subjects. Emergent surgical intervention was required in 54.5% of SMH subjects and 43% of NTDB subjects. CONCLUSIONS: Our data suggest that the benefit of PHSI in patients with torso GSW remains unproven, despite a potential to interfere with emergent care in this patient population. Large prospective studies are needed to clarify the role of PHSI after torso GSW.

The trauma severity model: An ensemble machine learning approach to risk prediction.

Statistical theory indicates that a flexible model can attain a lower generalization error than an inflexible model, provided that the setting is appropriate. This is highly relevant for mortality risk prediction with trauma patients, as researchers have focused exclusively on the use of generalized linear models for trauma risk prediction, and generalized linear models may be too inflexible to capture the potentially complex relationships in trauma data. To improve trauma risk prediction, we propose a machine learning model, the Trauma Severity Model (TSM). In order to validate TSM's performance, this study compares TSM to three established risk prediction models: the Bayesian Logistic Injury Severity Score, the Harborview Assessment for Risk of Mortality, and the Trauma Mortality Prediction Model. Our results indicate that TSM has superior predictive performance on National Trauma Data Bank data and on Nationwide Readmission Database data.

Mechanical ventilation strategies in massive chest trauma.

Patients in extremis because of trauma-related massive chest injury require expedient evaluation and prompt intervention. The initial pathophysiology relates to the significant intrapulmonary shunting caused by disruption of pulmonary capillaries and extravasation into the alveolar spaces. Disproportionate or unilateral lung involvement needs measures more technical than general supportive care. Independent lung ventilation (mostly with unilateral lung involvement) and other strategies like inhaled nitric oxide, prone positioning, partial liquid ventilation, and extracorporeal membrane oxygenation (ECMO) have had good results. Intensivists confronted with this clinical subset may consider using these strategies as alternative/adjunctive options for optimizing respiratory and hemodynamic status in the supportive management of trauma-related acute lung injury (ALI) and adult respiratory distress syndrome (ARDS).

Risk factors associated with venous thromboembolism in isolated blunt chest trauma.

Isolated chest trauma is not historically considered to be a major risk factor for venous thromboembolism (VTE). After blunt chest trauma, VTE may be underappreciated because pain, immobility, and inadequate prophylaxis as a result of hemorrhage risk may all increase the risk of VTE. This investigation determines the predictors and rate of VTE after isolated blunt chest trauma. A review of patients admitted to a Level I trauma center with chest trauma between 2007 and 2009 was performed. Demographics, injuries, VTE occurrence, prophylaxis, comorbidities, Injury Severity Score, intensive care unit/hospital length of stay, chest tube, and mechanical ventilation use were recorded. VTE rate was compared between those with isolated chest injury and those with chest injury plus extrathoracic injury. Predictors of VTE were determined with regression analysis. Three hundred seventy patients had isolated chest trauma. The incidence of VTE was 5.4 per cent (n = 20). The VTE rate in those with chest injury plus extrathoracic injury was not significantly different, 4.8 per cent (n = 56 of 1140, P = 0.58). Independent risk factors for VTE after isolated chest trauma were aortic injury (P < 0.01, odds ratio [OR], 47.7), mechanical ventilation (P < 0.01; OR, 6.8), more than seven rib fractures (P < 0.01; OR, 6.1), hemothorax (P < 0.05; OR, 3.9), hypercoagulable state (P < 0.05; OR, 6.3), and age older than 65 years (P < 0.05; OR, 1.03). Patients with the risk factors mentioned are at risk for VTE despite only having thoracic injury and might benefit from more aggressive surveillance and prophylaxis.

Impact of a graduated driver's license law on crashes involving young drivers in New York State.

BACKGROUND: Motor vehicle crashes constitute the greatest risk of injury for young adults. Graduated driver licensing (GDL) laws have been used to reduce the number of injuries and deaths in the young driver population. The New York State GDL law increased supervision of young driver and limited both time-of-day driven and number of passengers. This review examines the impact of a GDL enacted in New York in September 2003. METHODS: A retrospective review of New York State administrative databases from 2001 to 2009 was performed. During this period, a state-wide GDL requirement was implemented. Database review included all reported crashes to the New York State Department of Motor Vehicles by cause and driver age as well as motor fuel tax receipts by the New York State Comptroller's Office. Motor fuel tax receipts and consumption information were used as a proxy for overall miles driven. RESULTS: Before 2003, drivers younger than 18 years were involved in 90 fatal crashes and 10,406 personal-injury (PI) crashes, constituting 4.49% and 3.38% of all fatal and PI crashes in New York State, respectively. By 2009, the number of fatal and PI crashes involving drivers who are younger than 18 years decreased to 44 (2.87%) and 5,246 (2.24%), respectively. Of note, the number of crashes experienced by the age group 18 years to 20 years during this period also declined, from 192 (9.59% of all fatal crashes) and 25,407 (8.24% of all PI crashes) to 135 (8.81%) and 18,114 (7.73%), respectively. Overall numbers of crashes reported remained relatively stable, between 549,000 in 2001 and 520,000 in 2009. Motor fuel use during this period also declined, but to a lesser degree ($552 million to $516 million or 6.6%). CONCLUSION: The use of a GDL law in New York State has shown a large decrease in the number of fatalities and PI crashes involving young drivers. The delay in full driver privileges from the GDL did not result in an increase in fatal or PI crashes in the next older age group.

Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: During the last century, the management of blunt force trauma to the liver has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma in the Practice Management Guidelines for Nonoperative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the previous Eastern Association for the Surgery of Trauma guideline. METHODS: The National Library of Medicine and the National Institutes of Health MEDLINE database were searched using PubMed (http://www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords liver injury and blunt abdominal trauma. RESULTS: One hundred seventy-six articles were reviewed, of which 94 were used to create the current practice management guideline for the selective nonoperative management of blunt hepatic injury. CONCLUSION: Most original hepatic guidelines remained valid and were incorporated into the greatly expanded current guidelines as appropriate. Nonoperative management of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury or patient age. Nonoperative management of blunt hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt hepatic injuries. Repeated imaging should be guided by a patient's clinical status. Adjunctive therapies like angiography, percutaneous drainage, endoscopy/endoscopic retrograde cholangiopancreatography and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt hepatic injuries remain without conclusive answers in the literature.

Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: During the last century, the management of blunt force trauma to the spleen has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the Practice Management Guidelines for Non-operative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the current EAST guideline. METHODS: The National Library of Medicine and the National Institute of Health MEDLINE database was searched using Pub Med (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords splenic injury and blunt abdominal trauma. RESULTS: One hundred seventy-six articles were reviewed, of which 125 were used to create the current practice management guideline for the selective nonoperative management of blunt splenic injury. CONCLUSION: There has been a plethora of literature regarding nonoperative management of blunt splenic injuries published since the original EAST practice management guideline was written. Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury, patient age, or the presence of associated injuries. Its use is associated with a low overall morbidity and mortality when applied to an appropriate patient population. Nonoperative management of blunt splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and has an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt splenic injuries. Repeat imaging should be guided by a patient's clinical status. Adjunctive therapies like angiography with embolization are increasingly important adjuncts to nonoperative management of splenic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt splenic injuries remain without conclusive answers in the literature.

Does the need for noncardiac surgery during ventricular assist device therapy impact clinical outcome?

BACKGROUND: The role of the ventricular assist device (VAD) in the management of heart failure is expanding. Despite its success, the clinical course for patients requiring noncardiac surgery (NCS) during VAD support is not well described. The objective of this study was to identify VAD patients requiring NCS (+NCS) and compare outcomes with those not requiring NCS (-NCS). METHODS: Patients undergoing VAD implant from 2000 to 2007 were reviewed. NCS procedures, survival, and complications were collected. Survival at 1 year from implant, overall survival at the study conclusion, survival time from implant, and outcome of VAD therapy were compared between groups. RESULTS: We enrolled 142 subjects. Demographics did not differ between groups. Twenty-five subjects (18%) underwent 27 NCS procedures. Perioperative survival was 100% and 28-day survival was 64%. Survival to discharge was 56%. Bleeding occurred in 48%. Infection occurred in 33%. Estimated blood loss was 355 mL, and the international normalized ratio at time of NCS was 1.9. Laparoscopy was performed in 3 cases. There was no difference in 1-year survival (59% vs 54%), survival at study conclusion (44% vs 46%) or survival time (517 vs 523 days) between +NCS subjects and -NCS subjects. There were similar causes of death in both groups. The +NCS group was on VAD support longer (245 vs 87 days; P < .01), and less likely to undergo heart transplantation (12% vs 35%; P < .01). CONCLUSION: NCS is not uncommon during VAD therapy. Bleeding and infection were common complications. Despite this, NCS seems to be feasible and safe and does not seem to increase mortality in the VAD population.

Magnetic resonance imaging in combination with helical computed tomography provides a safe and efficient method of cervical spine clearance in the obtunded trauma patient.

BACKGROUND: Assessment of the cervical spine (c-spine) in the obtunded blunt trauma patient remains a diagnostic dilemma. In 2002, our institution implemented a new c-spine clearance guideline utilizing c-spine computed tomography (CT) and magnetic resonance imaging (MRI). This study evaluates the safety and efficacy of this guideline. METHODS: Obtunded blunt trauma patients admitted over a 1-year period, who underwent both a c-spine CT and a c-spine MRI, were identified. Records were reviewed for demographics, mechanism, diagnostic evaluations, injuries, and outcome. RESULTS: Fifty-two patients met inclusion criteria. On average, patients underwent a c-spine CT on postinjury day 0.4 and MRI on postinjury day 4. Forty-four patients had a negative c-spine CT, of whom 13 (30%) had a positive MRI for ligamentous injury (p < 0.01). Thirty-one patients had both a negative CT and a negative MRI. All patients (n = 8) with positive CTs had positive MRIs. The average Injury Severity Score, Abbreviated Injury Score head and neck, length of stay, and outcome was not significantly different for patients with a c-spine injury. No missed c-spine injuries and no areas of cervical collar-related skin breakdown were seen in follow up. CONCLUSIONS: In the obtunded patient, expeditious c-spine evaluation is important. Both missed injuries and prolonged unnecessary immobilization can result in adverse outcomes. This study confirms that c-spine CT, when used in combination with MRI, provides a safe and efficient method for c-spine clearance in this patient population. CT alone misses a statistically significant number of c-spine injuries.