Utility of the Marshall & Rotterdam Classification Scores in Predicting Outcomes in Trauma Patients.

BACKGROUND: Traumatic Brain Injury (TBI) is a leading cause of mortality in the trauma population. Accurate prognosis remains a challenge. Two common Computed Tomography (CT)-based prognostic models include the Marshall Classification and the Rotterdam CT Score. This study aims to determine the utility of the Marshall and Rotterdam scores in predicting mortality for adult patients in coma with severe TBI. METHOD: Retrospective review of our Level 1 Trauma Center's registry for patients ≥ 18 years of age with blunt TBI and a Glasgow Coma Scale (GCS) of 3-5, with no other significant injuries. Admission Head CT was evaluated for the presence of extra-axial blood (SDH, EDH, SAH, IVH), intra-axial blood (contusions, diffuse axonal injury), midline shift and mass effect on basilar cisterns. Rotterdam and Marshall scores were calculated for all patients; subsequently patients were divided into two groups according to their score (< 4, ≥ 4). RESULTS: 106 patients met inclusion criteria; 75.5% were males (n = 80) and 24.5% females (n = 26). The mean age was 52. The odds ratio (OR) of dying from severe TBI for patients in coma with a Rotterdam score of ≥ 4 compared to < 4 was OR = 17 (P < 0.05). The odds of dying from severe TBI for patients in coma with a Marshall score of ≥ 4 versus < 4 was OR = 11 (P < 0.05). CONCLUSION: Higher scores in the Marshall classification and the Rotterdam system are associated with increased odds of mortality in adult patients in come from severe TBI after blunt injury. The results of our study support these scoring systems and revealed that a cutoff score of < 4 was associated with improved survival.

The Need for Nutritional Education Reform in US Medical Education System.

BACKGROUND: To compare the setting, quality, and utility of nutritional education received by general surgery residents and faculty surgeons and their perceptions and challenges in managing patient nutritional needs. METHODS: Cross-sectional analysis utilizing anonymous survey data distributed by the Association of Program Directors in Surgery (APDS) to its affiliated general surgery residency programs. RESULTS: 90.2% (n = 65) of residents and 85.7% (n = 24) of faculty surgeons reported having received nutritional education. The majority (78%) of respondents utilize patient nutrition on a regular basis (monthly or more often), with 54% reporting utilization daily or weekly. Overall, 65% of respondents reported experiencing challenges in managing patient nutritional needs, and 86% agreed that additional nutritional education during training would assist with patient care. Residents and faculty surgeons both significantly reported challenges in determining which specific nutritional formula to use (X2 = 22.414, P = .049). Residents were associated with reporting challenges in successfully managing oral, enteral, and parenteral routes of nutrition (X2 = 16.241, P = .023). CONCLUSIONS: Despite receiving nutritional education, the majority of surgery residents and faculty surgeons report difficulty in managing their patients nutritional needs. Surgery residents report difficulties with all delivery modes of nutrition, including oral, parenteral, and enteral. Revising medical school nutritional education competencies to focus on more practical aspects of nutrition, reform of formal course format, greater interprofessional collaboration with dieticians starting at the student level, and enforcement of nutritional education requirements by medical school and residency program accrediting bodies can serve to advance physicians' nutritional knowledge and improve patient outcomes.

Subarachnoid versus Nonsubarachnoid Traumatic Brain Injuries: The Impact of Decision-Making on Patient Safety.

INTRODUCTION: Traumatic intracranial hemorrhages (ICHs) are high priority injuries. Traumatic brain bleeds can be categorized as traumatic subarachnoid hemorrhage (SAH) versus non-SAH-ICH. Non-SAH-ICH includes subdural, epidural, and intraventricular hematomas and brain contusions. We hypothesize that awake patients with SAH will have lower mortality and needless interventions than awake patients with non-SAH-ICHs. STUDY DESIGN AND METHODS: A review of data collected from our Level I trauma center was conducted. Awake was defined as an initial Glasgow coma score (GCS) 13-15. Patients were divided into two cohorts: awake SAH and awake non-SAH-ICH. Chi-square and t-test analyses were used with statistical significance defined as P < 0.05. RESULTS: A total of 12,482 trauma patients were admitted during the study period, of which 225 had a SAH and GCS of 13-15 while 826 had a non-SAH-ICH with a GCS of 13-15. There was no significant difference in demographics between the two groups. Predicted survival between the two groups was similar (97.3 vs. 95.7%, P > 0.05). Mortality rates were, however, significantly lower in SAH patients compared to the non-SAH-ICH (4/225 [1.78%] vs. 22/826 [2.66%], P < 0.05). The need for neurosurgical intervention was significantly different comparing the SAH group versus non-SAH-ICH (2/225 [0.89%] vs. 100/826 [12.1%], P < 0.05). CONCLUSION: Despite similar predicted mortality rates, awake patients with a SAH are associated with a significantly lower risk of death and need for neurosurgical intervention when compared to other types of awake patients with a traumatic brain bleed.