Post-Discharge Mortality of Older Adults with Traumatic Brain Injury or Other Trauma.

OBJECTIVES: Prior studies of mortality following traumatic brain injury (TBI) have not focused specifically on older adults compared with a non-TBI trauma cohort or included specific causes of death. The objectives of this study were, among adults aged 65 years and older, to (1) generate standardized mortality ratios (SMRs) by cause of death for TBI and a non-TBI trauma cohort compared with a general population, and (2) assess risk of mortality associated with TBI compared with a non-TBI trauma cohort. DESIGN: Retrospective cohort study of adults aged 65 years and older who were treated at an urban trauma center from 1997 to 2008. MEASUREMENTS: Data from the trauma registry were linked to the National Death Index through 2008 to obtain date and cause of death. We identified individuals with TBI and non-TBI trauma and calculated age- and sex-adjusted SMRs by comparing with the state general population. We next compared time to mortality between individuals with TBI (n = 852) and non-TBI trauma (n = 1050), adjusting for potential confounders. RESULTS: Compared with the age- and sex-adjusted state general population, older adults with TBI (SMR = 8.1; 95% confidence interval [CI] = 7.4-9.0) and non-TBI trauma (SMR = 6.7; 95% CI = 6.1-7.4) were at a greatly increased risk of mortality. Highest SMRs in both cohorts were observed for accidents. In adjusted Cox regression models, TBI was not associated with increased risk of all-cause mortality (hazard ratio = 1.03; 95% CI = .87-1.23) compared with non-TBI trauma. CONCLUSION: This study provides evidence that, over a 4-year follow-up of older adults, any moderate to severe injury is associated with increased mortality risk. Specifically, older injured adults are at high risk of death from accidental and therefore preventable causes, suggesting that intervention could reduce mortality. J Am Geriatr Soc 67:2382-2386, 2019.

Effect of Maryland's 2011 Alcohol Sales Tax Increase on Alcohol-Positive Driving.

INTRODUCTION: The 2011 Maryland alcohol sales tax increase from 6% to 9% provided an opportunity to evaluate the impact on rates of alcohol-positive drivers involved in injury crashes. METHODS: Maryland police crash reports from 2001 to 2013 were analyzed using an interrupted time series design and a multivariable analysis employing generalized estimating equations models with a negative binomial distribution. Data were analyzed in 2014-2015. RESULTS: There was a significant gradual annual reduction of 6% in the population-based rate of all alcohol-positive drivers (p<0.03), and a 12% reduction for drivers aged 15-20 years (p<0.007), and 21-34 years (p<0.001) following the alcohol sales tax increase. There were no significant changes in rates of alcohol-positive drivers aged 35-54 years (rate ratio, 0.98; 95% CI=0.89, 1.09). Drivers aged ≥55 years had a significant immediate 10% increase in the rate of alcohol-positive drivers (rate ratio, 1.10; 95% CI=1.04, 1.16) and a gradual increase of 4.8% per year after the intervention. Models using different denominators and controlling for multiple factors including a proxy for unmeasured factors found similar results overall. CONCLUSIONS: The 2011 Maryland alcohol sales tax increase led to a significant reduction in the rate of all alcohol-positive drivers involved in injury crashes especially among drivers aged 15-34 years. This is the first study to examine the impact of alcohol sales taxes on crashes; previous research focused on excise tax. Increasing alcohol taxes is an important but often neglected intervention to reduce alcohol-impaired driving.

On equal footing: Trends in ankle/foot injuries for men vs. women.

OBJECTIVES: The objective of the current study was to examine trends in ankle/foot (A/F) injuries during the period 2001-2014, in order to determine whether the incidence of these injuries has changed and whether a previously identified difference in risk by gender still existed. In addition, other driver and crash-related risk factors were examined separately for men and women. METHODS: Passenger vehicle drivers aged 16+ were identified from NASS-CDS; weighted data were analyzed for model years 2001-2014. Model years (MY) were grouped as 2001-2004 (older) vs. 2005-2014 (newer), and drivers in frontal crashes were included. Ankle injuries included fractures and dislocations to the malleolus and distal tibia/fibula. Foot injuries included fractures and dislocations of the talus, calcaneus, and tarsal/metatarsal bones. Logistic regression models were constructed to identify risk factors, including MY, age, belt use, toepan/instrument panel intrusion, and body mass index (BMI) separately for each gender using odds ratios. RESULTS: The incidence of A/F injuries declined significantly between older and newer MY, especially for women. Whereas before MY 2005, ankle and foot injury risk was significantly higher for women than men, risks for ankle injury are now virtually the same for both genders, and women are only 1.2 times more likely than men to sustain a foot injury in a frontal crash. From multivariable regression models, however, it is apparent that there are different risk factors for A/F injuries for men vs. women. Body weight was a significant factor for both groups, but for men it was a risk only for those extremely obese, whereas for women those who were categorized as overweight were also at increased risk. Age greater than 55 was also found to be a risk factor for foot injuries among women but not men. For men and women, toepan intrusion remained the most important factor for both foot and ankle injuries, with significantly higher odds ratios noted for men. Foot pedals were a more likely injury source for women, whereas the toepan was more likely for men. In addition, belt use was protective for ankle injuries in women but not men. CONCLUSIONS: Significant declines in A/F injuries have been noted in recent years, especially for women, whose risks are now similar to those for men. However, significant risk factors remain for each gender, primarily related to body habitus (BMI) and toepan intrusion. Age was a risk factor for foot injuries among women, for whom the foot pedals were more likely to be an injury source. Toepan intrusion remains a major factor for both men and women, but, with the exception of 30+ cm of intrusion, odds ratios were primarily much higher for men in each category of intrusion.

S-100ß does not predict outcome after mild traumatic brain injury.

OBJECTIVE: To determine the usefulness of S-100ß, a marker for central nervous system damage, in the prediction of long-term outcomes after mild traumatic brain injury (MTBI) Hypothesis: Mid- and long-term outcomes of MTBI (i.e. 3, 6 and 12 months post-injury and return-to-work or school (RTWS)) may be predicted based on pre-injury and injury factors as well as S-100ß. METHODS: MTBI subjects without abnormal brain computed tomography requiring intervention, focal neurological deficits, seizures, amnesia > 24 hours and severe or multiple injuries were recruited at a level I trauma centre. Admission S-100ß measurements and baseline Concussion Symptom Checklist were obtained. Symptoms and RTWS were re-assessed at follow-up visits (3-10 days and 3, 6 and 12 months). Outcomes included number of symptoms and RTWS at follow-up. Chi-square tests, linear and logistic regression models were used and p < 0.05 was considered statistically significant. RESULTS: One hundred and fifty of 180 study subjects had S-100ß results. Eleven per cent were unable to RTWS at 12 months. S-100ß levels were not associated with post-concussive symptomatology at follow-up. In addition, no association was found between S-100ß levels and RTWS. CONCLUSION: Amongst MTBI patients, S-100ß levels are not associated with prolonged post-concussive syndrome or the inability to RTWS.

A comparison of KABCO and AIS injury severity metrics using CODES linked data.

OBJECTIVE: The research objective is to compare the consistency of distributions between crash assigned (KABCO) and hospital assigned (Abbreviated Injury Scale, AIS) injury severity scoring systems for 2 states. The hypothesis is that AIS scores will be more consistent between the 2 studied states (Maryland and Utah) than KABCO. METHODS: The analysis involved Crash Outcome Data Evaluation System (CODES) data from 2 states, Maryland and Utah, for years 2006-2008. Crash report and hospital inpatient data were linked probabilistically and International Classification of Diseases (CMS 2013) codes from hospital records were translated into AIS codes. KABCO scores from police crash reports were compared to those AIS scores within and between the 2 study states. RESULTS: Maryland appears to have the more severe crash report KABCO scoring for injured crash participants, with close to 50 percent of all injured persons being coded as a level B or worse, and Utah observes approximately 40 percent in this group. When analyzing AIS scores, some fluctuation was seen within states over time, but the distribution of MAIS is much more comparable between states. Maryland had approximately 85 percent of hospitalized injured cases coded as MAIS = 1 or minor. In Utah this percentage was close to 80 percent for all 3 years. This is quite different from the KABCO distributions, where Maryland had a smaller percentage of cases in the lowest injury severity category as compared to Utah. CONCLUSIONS: This analysis examines the distribution of 2 injury severity metrics different in both design and collection and found that both classifications are consistent within each state from 2006 to 2008. However, the distribution of both KABCO and Maximum Abbreviated Injury Scale (MAIS) varies between the states. MAIS was found to be more consistent between states than KABCO.

Aortic injuries in newer vehicles.

The occurrence of AI was studied in relation to vehicle model year (MY) among front seat vehicular occupants, age≥16 in vehicles MY≥1994, entered in the National Automotive Sampling System Crashworthiness Data System between 1997 and 2010 to determine whether newer vehicles, due to their crashworthiness improvements, are linked to a lower risk of aortic injuries (AI). MY was categorized as 1994-1997, 1998-2004, or 2005-2010 reflecting the introduction of newer occupant protection technology. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals for the association between AI and MY independent of possible confounders. Analysis was repeated, stratified by frontal and near lateral impacts. AI occurred in 19,187 (0.06%) of the 31,221,007 (weighted) cases, and contributed to 11% of all deaths. AIs were associated with advanced age, male gender, high BMI, near-side impact, rollover, ejection, collision against a fixed object, high ΔV, vehicle mismatch, unrestrained status, and forward track position. Among frontal crashes, MY 98-04 and MY 05-10 showed increased adjusted odds of AI when compared to MY 94-97 [OR 1.84 (1.02-3.32) and 1.99 (0.93-4.26), respectively]. In contrast, among near-side impact crashes, MY 98-04 and MY 05-10 showed decreased adjusted odds of AI [OR 0.50 (0.25-0.99) and 0.27 (0.06-1.31), respectively]. While occupants of newer vehicles experience lower odds of AI in near side impact crashes, a higher AI risk is present in frontal crashes.

Causation and outcomes of diaphragmatic injuries in vehicular crashes.

BACKGROUND: This study aimed to identify vehicular and crash factors associated with diaphragmatic injuries (DIs). METHODS: DI presence was analyzed among Crash Injury Research and Engineering Network vehicular occupants (age ≥ 16 years) in relation to occupant and crash factors. Contact points (i.e., components in direct contact with occupants) involved in injury causation were analyzed. Cases with and without DI were compared in relation to mortality, Injury Severity Score (ISS) and the occurrence of injuries with a maximum Abbreviated Injury Scale (MAIS) score of 3+. Student's t test, Wilcoxon test, χ(2), and multiple logistic regression were used for statistical analysis. RESULTS: Of a total of 2,344 cases with complete data for analysis, 80 cases (3.4%) experienced DI. Multiple logistic regression analysis revealed a significant association with the occurrence of DI for near lateral impact (odds ratio, 7.71 [4.20-14.58]) and change in velocity (ΔV) of 40 km/h or greater (odds ratio 2.58 [1.29-5.24]). The seat belt and steering wheel were the most common contact points among frontal impact crashes, and the side interior surface and side hardware or armrest were the more common contact points among side impact crashes. DI cases experienced more MAIS3+ injuries in the head, chest and abdominal regions and exhibited higher median ISS (q1-q3) [42 (29-62.5) vs. 17 (10-27), p < 0.0001]. While mortality was higher among occupants with DI (48% vs. 14%), this effect disappeared when adjusted by ISS. CONCLUSION: DI are associated with lateral crashes and higher ΔV. Head, chest, and abdominal injuries occur more commonly among DI patients, and the presence of these injuries rather than the DI itself is responsible for the increased mortality in these patients. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Does helicopter transport improve outcomes independently of emergency medical system time?

BACKGROUND: Helicopter emergency medical systems (HEMS) have been reported to improve trauma survival. This study seeks to determine HEMS effect on survival across different subpopulations in relation to injury severity, degree of physiologic derangement, and transportation time (TT). METHODS: The 2007 National Trauma Data Bank adult patients transported directly to hospitals by ground ambulance or HEMS were compared in relation to their survival with discharge and other possible confounders. Multivariate models were constructed to determine the adjusted odds ratios (OR) of survival for the entire cohort and across subpopulations stratified by different Injury Severity Score (ISS), hospital Revised Trauma Score (RTS), and TT. RESULTS: A total of 192,422 patients with complete data were analyzed. HEMS patients (15.3%) experienced lower survival rates than those transported by ground (93.8% vs. 96.1%, p < 0.001). Multivariate analysis revealed a survival advantage for HEMS in the entire cohort (OR, 1.78 [1.65-1.92]). Adding TT to the model did not affect HEMS effect on survival. HEMS effect was present across all ISS levels but was limited to those with RTS of less than 6 (n = 15,427; OR, 2.28 [2.10-2.49]). In contrast, those with RTS of 6 or greater experienced lower adjusted survival when transported by HEMS (n = 176,995; OR, 0.83 [0.74-0.94]). Stratification by RTS and ISS did not affect the results. Substratification by TT revealed no effect of HEMS on survival among patients with RTS of less than 6, ISS of less than 16, and TT of 60 minutes or greater. Remaining associations were not affected by TT substratification. CONCLUSION: HEMS beneficial effect on survival seems to be limited to patients with physiologic instability. Physiologically stable patients seem to have a worse outcome when transported by air. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Changes in the Severity and Injury Sources of Thoracic Aorta Injuries due to Vehicular Crashes.

Research using the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) suggested a decreased adjusted risk of thoracic aorta injuries (TAI) for newer vehicles during near-side crashes and an increased adjusted TAI risk during frontal crashes. This study attempted to explore possible explanations of these findings. Adult front seat occupants in the Crash Injury Research and Engineering Network (CIREN) database through June 2012 were studied. TAI cases were compared with remaining cases in relation to crash and vehicular characteristics. TAI cases of later crash year (CY) (2004-2012) were compared to those in earlier CY (1996-2003) in relation to TAI severity (minor, moderate, severe and non-survivable). TAI cases in newer model year (MY) vehicles (1999-2012) were compared to those in older vehicles (1988-98) in relation to injury source (steering wheel, front, left, seat belt, air bag and other or unknown). Analysis was stratified by direction of impact (frontal and near-side) and the use of restraints. The similar TAI severity of earlier and later CY among frontal crashes suggests that the observed changes in the adjusted odds of injury seen in NASS-CDS are not due to an increase in injury detection. The decrease in TAI severity among newer vehicles in near-side crashes of later CY is consistent with a beneficial effect of crashworthiness improvements for this crash configuration. A shift of injury source in frontal crashes from the steering wheel in older vehicles to "front of vehicle structures", "seat belts" and "unknown and other" in newer vehicles should suggest potential sites for crashworthiness improvements.

Declining statewide trends in motor vehicle crashes and injury-related hospital admissions.

Numbers of crashes, rates of police-reported injury severity, and hospital admission rates were calculated for the ten year period between 2001 and 2010 in Maryland. Comparisons were made for two 5-year periods of 2001-2005 and 2006-2010. Crash characteristics remained similar for the two five-year periods, but there was a significant increase in occupant age. Declines in police-reported injury severity were noted for each of four age groups: 16-29, 30-54, 55-64, and 65+, with smaller declines among older occupants. In addition, there were significant declines in hospital admissions, comparing the two time periods. Although reductions in crashes may be attributable to various roadway, behavioral, and other safety improvement efforts, reductions in hospital admission rates most likely reflect major improvements in crashworthiness implemented during the past decade. For those admitted to hospitals, significant increases in injury severity were noted between the first and second time periods. There was an association between age and ISS, a measure of total bodily injury, with the highest ISS scores noted for the youngest and oldest groups (16-29 and 55+, respectively). In addition, there was a significant increase in the mean age over time, from 39 in 2001 to 43 in 2010, p<.001. In general, the incidence and severity of injuries increased for all body regions. There was also a significant increase in hospital mortality, although length of hospital stay remained the same. Given these trends, increased efforts need to focus on both injury prevention and treatment for the increasing population of older, sometimes frail, vehicle occupants.

Frailty and injury causation.

PURPOSE: : The current study will attempt to elucidate whether frailty has a role in motor vehicle crash injury causation. METHODS: : The association between frailty and injury was studied among Crash Injury Research Engineering Network (CIREN) cases. The baseline "physical functioning" (PF) score of the SF-36 was used as a marker of frailty (i.e., PF score <75). Frailty associations with ISS and occupant, vehicular and crash factors were explored. Frailty association with delta V was analyzed among injured (i.e., brain, rib, or femur) belted occupants in frontal crashes to establish whether frailty confers a different risk of each particular injury. RESULTS: : Frailty occurred in 13.7 % of the cohort (n=1,747). Median (q1-q3) ISS was 14.0 (10-22) among the frail and 17.0 (10-24) among the non frail (p=0.40). Frailty was significantly associated with advanced age, male gender, the presence of co-morbidities, extreme BMIs, frontal and near-side crashes and delta V < 45 km/h. Seat belt use and ISS<16 were not associated with frailty. Multiple linear regressions, adjusting for age, gender and BMI revealed a negative association between frailty and log delta V (coefficient -0.188, p=0.04) among those with rib fractures but not among those with brain injuries or femur fractures. CONCLUSION: : PF score, a marker of frailty, is associated with similar ISS and lower delta V and is independently linked to lower delta V thresholds for some injuries (i.e. rib fractures) but not for others (i.e. brain injuries and femur fractures). These associations suggest a potential role of frailty in injury causation.

Degree of urbanization and mortality from motor vehicular crashes.

PURPOSE: : The purpose of this study is to establish whether motor vehicular crash (MVC) case fatality varies across different urbanization levels in the USA using a representative sample of crashes. METHODS: : Odds ratios (ORs) and 95% confidence intervals (CIs) for the association between urbanization level [i.e., central city (CC), suburban (SU) and others (OT)] and mortality were estimated in the 1997 - 2010 National Automotive Sampling System Crashworthiness Data System. Multiple logistic regression was used to adjust for confounders. Analysis was repeated for the occurrence of pre-hospital and hospital deaths. RESULTS: : 49,040,520 weighted occupants were included in the study. The distribution of occupants by urbanization categories was: SU 45%, OT 42%, and CC 13%. Case fatality was higher among OT occupants (0.81%) than among SU (0.51%) and CC (0.37%) occupants. Similar findings were present for pre-hospital deaths (OT 0.52%, SU 0.30%, and CC 0.21%) and hospital deaths (OT 0.29%, SU 0.21%, and CC 0.16%). Multivariate analysis revealed that adjusted odds of death were higher for OT cases [OR=1.55 (1.05-2.30)] than the CC. Adjusted odds of death for SU (OR=1.05 (0.81-1.37) were not different than CCs. Similar but accentuated findings were found for pre-hospital deaths. In contrast, adjusted odds of hospital death were not different among the 3 groups. CONCLUSION: : Occupants of vehicles crashing in OT (i.e., rural areas and small cities) experience a higher likelihood of dying after MVCs than those in CC and SU. Pre-hospital deaths, not hospital deaths, are responsible for this disparity.

Epidemiology of abusive abdominal trauma hospitalizations in United States children.

OBJECTIVES: (1) To estimate the incidence of abusive abdominal trauma (AAT) hospitalizations among US children age 0-9 years. (2) To identify demographic characteristics of children at highest risk for AAT. DESIGN: Secondary data analysis of a cross-sectional, national hospitalization database. SETTING: Hospitalization data from the 2003 and 2006 Kids' Inpatient Database (KID). MAIN EXPOSURE: Frequency and rate of hospitalizations for abusive abdominal trauma as identified by ICD-9CM codes for abdominal trauma and child abuse and E-codes for inflicted injury. OUTCOME MEASURES: Hospitalization rates by age, insurance status, and frequency of specific organ injury. RESULTS: AAT rates were higher for infants than for any other age group, with 17.7 (95% CI 11.7-23.9) cases per million in 2006. More than 25% of all abdominal trauma in children <1 year of age was abusive. For all age groups, rates were higher for males than females, and for children insured by Medicaid compared to those with private insurance. Organs most commonly injured were the liver (64% of hospitalizations), kidney (19%), and stomach/intestines (12%). CONCLUSIONS: Although experts have considered toddlers to be at highest risk for AAT, infants have higher rates of AAT hospitalization. Similar to other abusive injuries, young age, male gender, and poverty are risk factors for AAT.

Crash-related mortality and model year: are newer vehicles safer?

OBJECTIVE: The objective of this study was to determine whether occupants of newer vehicles experience a lower risk of crash-related mortality. METHODS: The occurrence of death was studied in relation to vehicle model year (MY) among front seat vehicular occupants, age ≥ 16 captured in the National Automotive Sampling System Crashworthiness Data System (NASS-CDS) between 2000 and 2008. The associations between death and other occupant, vehicular and crash characteristics were also explored. Multiple logistic regression models for the prediction of death were built with model year as the independent variable and other characteristics linked to death as covariates. Imputation was used for missing data; weighted data was used. RESULTS: A total of 70,314 cases representing 30,514,372 weighted cases were available for analysis. Death occurred in 0.6% of the weighted population. Death was linked to age>60, male gender, higher BMI, near lateral direction of impact, high delta v, rollover, ejection and vehicle mismatch, and negatively associated with seatbelt use and rear and far lateral direction of impact. Mortality decreased with later model year groups (MY<94 0.78%, MY 94-97 0.53%, MY 98-04 0.51% and MY 05-08 0.38%, p=<0.0001). After adjustment for confounders, MY 94-97, MY 98-04 and MY 05-08 showed decreased odds of death [OR 0.80 (0.69-0.94), 0.82 (0.70-0.97), and 0.67 (0.47-0.96), respectively] when compared to MY <94. CONCLUSION: Newer vehicles are associated with lower crash-related mortality. Their introduction into the vehicle fleet may explain, at least in part, the decrease in mortality rates in the past two decades.

Prescription medication usage and crash culpability in a population of injured drivers.

UNLABELLED: There has been increasing concern regarding the role of prescription drug use in the causation of traffic crashes. The goal of this research is to describe the prevalence of prescription drug use among injured trauma patients and determine the association between classes of drugs and crash culpability, a surrogate measure of crash risk. METHODS: Patient records, including chronic medication usage, for all drivers admitted to a trauma center following a traffic collision in 2008 (N=1,558) were linked with police crash reports to determine crash culpability. Multivariable analyses explored the association between medication use and crash culpability among non-drinking drivers. Adjusted odds ratios and 95% confidence intervals were compared among drivers who were and were not using central nervous system (CNS)-acting medications (single and multiple). RESULTS: 61.5% of all drivers were using any medications and usage increased with age, as did numbers of prescriptions per driver. Logistic regression analyses revealed that drivers who used CNS medications had an increased risk of culpability; those on more than one such medication had a crude (unadjusted) odds ratio of 2.16 for having caused the crash. Among drivers less than 45 years old, CNS medications did not significantly increase the risk of crash culpability. However, among drivers aged 45 or greater, the odds ratios for one, two, or 2+ CNS medications vs. none increased dramatically from 1.89 to 4.23 to 7.99, respectively. CONCLUSIONS: These results suggest that special attention should be given to older drivers (45+) using two or more CNS-acting agents.

Improving trauma triage using basic crash scene data.

OBJECTIVE: to analyze the occurrence of severe injuries and deaths among crash victims transported to hospitals in relation to occupant and scene characteristics, including on-scene patient mobility, and their potential use in triaging patients to the appropriate level of care. METHODS: the occurrence of death and ISS>15 were studied in relation to occupant, crash and mobility data readily available to EMS at the scene, using weighted NASS-CDS data. Data set was randomly split in two for model development and evaluation. Characteristics were combined to develop new triage schemes. Overtriage and undertriage rates were calculated for the NASS-CDS case trauma center allocation and for the newly developed triage schemes. RESULTS: Compared to the NASS-CDS distribution, a scheme using patient mobility alone showed lower overtriage of those with ISS≤15 (38.8% vs. 55.5%) and lower undertriage of victims who died from their crash-related injuries (2.34% vs. 21.47%). Undertriage of injuries with ISS> 15 was similar (16.0 vs. 16.9). A scheme based on the presence of one of many scene risk factors (age>55, GCS<14, intrusion ≥18", near lateral impact, far lateral impact with intrusion ≥12", rollover or lack of restraint use) resulted in an undertriage of 0.86% (death) and 10.5% (ISS>15) and an overtriage of 63.4%. The combination of at least one of the scene risk factors and mobility status greatly decreased overtriage of those with ISS<15 (24.4%) with an increase in death undertriage (3.19%). Further combination of mobility and scene factors allowed for maintenance of a low undertriage (0.86%) as well as an acceptable overtriage (48%). CONCLUSION: Patient mobility data easily obtained at the scene of a crash allows triaging of injured patients to the appropriate facility with a high sensitivity and specificity. The addition of crash scene data to scene mobility allows further reductions on undertriaging or overtriaging.

Scene mobility status as a predictor of injury severity and mortality due to vehicular crashes.

BACKGROUND: To examine the association of scene mobility status (SMS) and injury severity and mortality among motor vehicular crash (MVC) victims. METHODS: Adult MVC victims transported to medical facilities between 1997 and 2008 and included in the National Automotive Sampling System were studied. SMS was classified as follows: "ejected," "self-exited," "exited with assistance," "removed from the vehicle with decreased mental status," "removed due to perceived serious injury," and "removed for other reasons." Associations of SMS with Injury Severity Score and death were studied with contingency tables and multiple logistic regression models. RESULTS: A total of 62,634 cases representing 13,699,294 (weighted) cases were analyzed. Two percent of the cases were ejected, 38% self-exited, 18% exited with assistance, 4% removed with decreased mental status, 14% removed due to perceived serious injury, 1% other reasons, and 25% unknown. Mortality was highest among those ejected (8.7%). Those who self-exited and exited with assistance experienced a mortality of 0.02%. Injury Severity Score >8 occurred in 51% of those ejected, 37% of those removed with decreased mental status, 21% of those removed due to perceived serious injury, 4% of those who self-exited, and 5% of those exited with assistance. Multiple logistic regression revealed that those ejected, removed due to a low mental status or suspected injury, experienced higher adjusted odds ratios of dying than those who self-exited (odds ratio of 266 [69->999], 235 [61-903], and 66 (19-227), respectively). CONCLUSION: MVC occupants who "self-exited" or "exited with assistance" experienced a very low injury severity and mortality. Further efforts are needed to decrease the overtriaging of these patients.

Disparities in trauma center access of older injured motor vehicular crash occupants.

BACKGROUND: To evaluate whether older injured motor vehicular crash (MVC) occupants' access to trauma centers (TC) reflects the lower threshold suggested in triaging recommendations. METHODS: Adult front seat occupants of MVCs transported to a hospital from 1999 through 2006 included in the National Automotive Sampling System (NASS) were studied. Cases were classified by their age in years (≤60 years or >60 years). Younger and older injured MVC occupants were compared in relation to their likelihood of being transported to a TC. Multiple logistic regression models were built to adjust for confounders. RESULTS: A total of 35,830 cases representing 7,894,940 cases after weighting were analyzed. Older occupants were less likely to be transported to a TC than younger ones (47% vs. 55%, p < 0.0001). Older individuals were more likely to be restrained, passengers, and seated on the impacted side of lateral crashes. Injury severity was higher among the older group (mean Injury Severity Score, 4.1 vs. 3.1; p < 0.0001) and so was the resulting mortality (1.7% vs. 0.6%, p < 0.0001). Multiple logistic regression models after adjusting for confounders (i.e., other triage criteria) revealed a lower likelihood of TC transport (odds ratio, 0.75 [0.57-0.98]) for the older group. CONCLUSION: In contrast to the American College of Surgeons triaging recommendations, injured MVC occupants older than 60 years are less likely to be transported to a TC than their younger counterparts. Further studies should establish whether the lower access to TC experienced by the older population is a function of geographical factors, emergency medical services unconscious bias, or other factors.

Are current law enforcement strategies associated with a lower risk of repeat speeding citations and crash involvement? A longitudinal study of speeding Maryland drivers.

PURPOSE: To determine whether traffic court appearances and different court verdicts were associated with risk of subsequent speeding citations and crashes. METHODS: A cohort of 29,754 Maryland drivers ticketed for speeding who either went to court or paid fines by mail in May/June 2003 was followed for 3 years. Drivers appearing in court were categorized by verdicts: 1) not guilty, 2) suspension of prosecution/no prosecution (STET/NP), 3) case dismissed, 4) probation before judgment (PBJ) and fines, or 5) fines and demerit points. Cox proportional hazard models were used to estimate adjusted hazard ratios (AHR). RESULTS: Court appearances were associated with lower risk of subsequent speeding citations (AHR = 0.92; 95% confidence interval [CI], 0.88-0.96), but higher risk of crashes (AHR = 1.25; 95% CI, 1.16-1.35). PBJ was associated with significantly lower repeat speeding tickets (AHR = 0.83; 95% CI, 0.75-0.91) and a non-significant decrease in crashes (AHR = 0.87; 95% CI, 0.75-1.02). Both repeat speeding tickets and subsequent crashes were significantly lower in the STET/NP group. CONCLUSIONS: PBJ and STET/NP may reduce speeding and crashes, but neither verdict eliminated excess crash risk among drivers who choose court appearances. Randomized, controlled evaluations of speeding countermeasures are needed to inform traffic safety policies.

Outcomes for children hospitalized with abusive versus noninflicted abdominal trauma.

BACKGROUND: Abusive abdominal trauma (AAT) is the second leading cause of child abuse mortality. Previous outcome studies have been limited to data from trauma centers. OBJECTIVES: The goals of this study were (1) to examine mortality, length of hospitalization, and hospital charges among a national sample of children hospitalized for AAT; and (2) to compare these outcomes with children with noninflicted abdominal trauma. METHODS: Hospitalization data for children aged 0 to 9 years were obtained from the 2003 and 2006 Kids' Inpatient Database. Cases were identified using International Classification of Diseases, Ninth Revision, Clinical Modification and external cause of injury codes. Multivariable regression analyses were used to compare outcomes of children with AAT versus those with noninflicted injury. RESULTS: Children with AAT were younger, and more often insured by Medicaid. Among children surviving to discharge, those with AAT had longer hospitalizations (adjusted mean [95% confidence interval (CI)] length of stay: 7.9 (6.6-9.3) vs 6.4 (6.1-6.7) days, P < .01) and higher charges (adjusted mean [95% CI] costs: $24 343 [$20 952-$28 567] vs $19 341 [$18 770-$20 131]; P < .01). Among children aged 1 to 9 years, those with AAT had higher mortality (adjusted rate [95% CI]: 9.2% [5.0%-16.1%] vs 2.7% [2.2%-3.2%], P < .01). There was no significant difference in mortality for children aged younger than 1 year. CONCLUSIONS: Children hospitalized for AAT generally had poorer short-term outcomes compared with children with noninflicted abdominal trauma. Studies to explain these differences are needed. In addition, efforts to prevent these injuries and to assist families at risk should be supported.