Influence of combat blast-related mild traumatic brain injury acute symptoms on mental health and service discharge outcomes.

Assessment of acute mild traumatic brain injury (mTBI) symptoms after a combat blast could aid diagnosis and guide follow-up care. Our objective was to document acute mTBI symptoms following a combat blast and to examine associations between acute symptoms and mental health and service discharge outcomes. A retrospective cohort study was conducted with 1656 service personnel who experienced a combat blast-related mTBI in Iraq. Acute mTBI symptoms were ascertained from point-of-injury medical records. The associations between acute symptoms and posttraumatic stress disorder (PTSD), postconcussion syndrome (PCS), and type of service discharge were examined. Disability discharge occurred in 11% of patients, while 36% had a non-disability discharge and 52% had no recorded discharge. A PTSD and PCS diagnosis was made in 19% and 15% of the sample, respectively. The most common acute mTBI symptoms were headache (62.8%), loss of consciousness (LOC) (34.5%), and tinnitus (33.2%). LOC was predictive of PTSD (odds ratio [OR] 1.54; 95% confidence interval [CI] 1.18, 2.00) and PCS (OR 2.08; 95% CI 1.56, 2.77), while altered mental status (OR 1.53; 95% CI 1.07, 2.17) and previous blast history (OR 1.83; 95% CI 1.15, 2.90) also were predictive of PCS. While no acute mTBI symptoms were associated with discharge outcomes, injury severity was associated with disability discharge. LOC after blast-related mTBI was associated with PTSD and PCS, and injury severity was predictive of disability discharge. The assessment of cognitive status immediately after a blast could assist in diagnosing mTBI and indicate a need for follow-up care.

Combat blast injuries: injury severity and posttraumatic stress disorder interaction on career outcomes in male servicemembers.

The purpose of this study was to describe career performance outcomes after combat blast injury and to examine the relationship between the injury severity and type of military discharge. A retrospective cohort study of 4,255 male servicemembers injured in a combat blast as a part of Operation Iraqi Freedom was completed. In the total sample, 37.8% experienced a normal discharge and 8.3% had an early discharge. Of the 2,229 members who had a discharge code, 29.8% experienced a disability discharge. Both early attrition and disability discharge proportions were higher in those with posttraumatic stress disorder (PTSD) than in those without PTSD. There was a significant interaction between PTSD and injury severity in the discharge disability outcome. In those without PTSD, there was a dose-response relationship between injury severity and disability discharge. In those with PTSD, injury severity predicted disability discharge. The relationship between injury severity and disability discharge was less striking in servicemembers with PTSD than without PTSD. The effect of PTSD and injury severity on career performance outcomes after blast injuries should be factored into outcome planning.

Injuries from combat explosions in Iraq: injury type, location, and severity.

INTRODUCTION: Explosions have caused a greater percentage of injuries in Iraq and Afghanistan than in any other large-scale conflict. Improvements in body armour and field medical care have improved survival and changed the injury profile of service personnel. This study's objective was to determine the nature, body region, and severity of injuries caused by an explosion episode in male service personnel. MATERIALS AND METHODS: A descriptive analysis was conducted of 4623 combat explosion episodes in Iraq between March 2004 and December 2007. The Barell matrix was used to describe the nature and body regions of injuries due to a combat explosion. RESULTS: A total of 17,637 International Classification of Diseases, Ninth Revision (ICD-9) codes were assigned to the 4623 explosion episodes, with an average of 3.8 ICD-9 codes per episode. The most frequent single injury type was a mild traumatic brain injury (TBI; 10.8%). Other frequent injuries were open wounds in the lower extremity (8.8%) and open wounds of the face (8.2%), which includes tympanic membrane rupture. The extremities were the body regions most often injured (41.3%), followed by head and neck (37.4%) and torso (8.8%). CONCLUSION: The results of this study support previous observations of TBI as a pre-eminent injury of the wars in Iraq and Afghanistan, with mild TBI as the most common single injury in this large cohort of explosion episodes. The extremities had the highest frequency of injuries for any one body region. The majority of the explosion episodes resulted in more than one injury, and the variety of injuries across nearly every body region and injury type suggests a complex nature of explosion injuries. Understanding the constellation of injuries commonly caused by explosions will assist in the mitigation, treatment, and rehabilitation of the effects of these injuries.

Blast-related mild traumatic brain injury is associated with a decline in self-rated health amongst US military personnel.

INTRODUCTION: Mild traumatic brain injury (MTBI) has emerged as the preeminent injury of combat from the recent conflicts in Iraq and Afghanistan. Very little is known about short- and long-term outcomes after combat-related MTBI. As a measure of outcome after injury, self-rated health is a reliable, widely used measure that assesses perceived health. The primary aim of this study was to determine the effect of combat-related MTBI on self-reported health status after return from deployment. The secondary objective was to examine predictors of a decline in self-reported health status amongst US service members with MTBI, as compared to those service members with other minor non-TBI injuries. PATIENTS AND METHODS: MTBI cases and an injured comparison group were identified from the Expeditionary Medical Encounter Database records of 1129 male, US service members who experienced blast-related injuries in Iraq from March 2004 to March 2008. Self-rated health was assessed from the routinely administered pre- and post-deployment health assessment questionnaires by the following question, "Overall, how would you rate your health during the past month?" Possible responses were "poor", "fair", "good", "very good", or "excellent." A distinction was made between minor and major negative changes in health (i.e., very good to fair) based on these self-rated health outcomes captured post-injury. RESULTS: For all personnel, post-injury levels of self-rated health were statistically significantly worse than pre-injury health rating. At 6months post-injury, service members with MTBI were 5 times more likely to report a major negative change in health as compared to members with other mild injuries. This association was independent of age, rank, branch of service, Injury Severity Score, mental health diagnosis prior to injury, and having been referred to a health care professional. DISCUSSION: Blast-related injuries, specifically MTBI, during deployment have negative consequences on service members' perception of health. Future research is needed to improve our understanding of the overall effects of MTBI on health and quality of life.

The need for immediate computed tomography scan after emergency craniotomy for head injury.

BACKGROUND: Patients who undergo emergency craniotomy for head injury require vigilant postoperative (postop) care to obtain the best possible outcome. Although repeat head computed tomography (CT) scans are a key component of the management of these patients, there is no consensus on the optimal timing of the initial postop CT. METHODS: We conducted a retrospective registry-based review of the care of 199 consecutive trauma patients who underwent craniotomy for head injury at a Level I trauma center to evaluate the role of postop CT in their management. RESULTS: One hundred and ninety-nine patients underwent 218 craniotomies for head injury during the 78-month study period. Mean age was 48 years and 73.9% were men. Overall survival was 71.4%. The primary indication for operation included subdural hematoma (SDH) in 136 (62.4%), epidural hematoma (EDH) in 32 (14.7%), intraparenchymal hemorrhage or contusion in 21 (9.6%), depressed skull fracture in 17 (7.8%), and other indications in 12 (5.5%). Postop CTs were obtained after 197 (90.4%) of the operations at a mean of 19.2 hours and revealed a variety of unexpected findings with clinical implications. The only variable statistically associated with unexpected findings was SDH as an indication for operation (p < 0.01). Fourteen (7.0%) patients required a second craniotomy in the 2 days after their initial operation. In six (3.0%) patients, postop CTs were obtained between 4.2 hours and 21.1 hours after initial craniotomy and an earlier postop CT would most likely have prevented a significant delay in operation. Findings in these six patients included recurrent SDH or EDH in two, new SDH or EDH in two, and intraparenchymal hemorrhage in two. Neither neurologic examination nor postop intracranial pressure monitoring reliably predicted the presence of new or recurrent hemorrhage or other significant findings. CONCLUSION: Early, if not immediate, postop CT after emergency craniotomy for head trauma appears to be warranted. We found a significant incidence of unexpected findings on postop CT and encountered avoidable delays in treatment of new or recurrent findings.

Quality of Well-being profiles followed paths of health status change at micro- and meso-levels in trauma patients.

OBJECTIVE: The objective of this study is to analyze Quality of Well-being Scale scores and profiles tracing Trauma Recovery Project (TRP) patient scores over time. STUDY DESIGN AND SETTING: A total of 787 TRP patients had complete preinjury and injury day data. Of these 787, 574 patients were followed up 6 months after hospital release. Analyses include persons with head injury vs. long bone and pelvic injury. RESULTS: Paired t-tests found significant differences for scores between each measurement point. Means analyses found significant variation on first day of hospitalization vs. 6-month recovery scores by injury site--head worse off than long bone and pelvic injury at first, but becoming better off 6 months after release from hospital. These effects were traced to specific symptom/problem complexes and functional limitations. CONCLUSION: Examination of such profiles can add significant information about health implications not obvious from overall scores. The size and direction of such contributions to overall scores may be reliably traced over time.

Traumatic brain injury outcomes in pre- and post- menopausal females versus age-matched males.

Gender differences in outcomes from major trauma have been described previously, and exogenous female hormone administration appears to be neuroprotective following traumatic brain injury (TBI). This analysis explored outcomes in pre- and post-menopausal females versus age-matched males. A total of 13,437 patients (n = 3,178 females, n = 10,259 males) with moderate-to-severe TBI (head AIS > or = 3) were identified from our county trauma registry. Overall mortality was similar between males and females (22% for both). Logistic regression was used to compare gender outcome differences, with a separate analysis performed for premenopausal (< 50 years) versus postmenopausal (> or = 50 years) patients, and after stratification by decade of life. No statistically significant difference in outcomes was observed for pre-menopausal females versus males (odds ratio [OR] 1.06; 95% confidence interval [CI] 0.83, 1.35; p = 0.633), but outcomes were significantly better in postmenopausal females versus males (OR 0.63, 95% CI 0.48-0.81, p < 0.001) after adjusting for age, mechanism of injury, Glasgow Coma Scale (GCS), hypotension (SBP < or = 90 mm Hg), head Abbreviated Injury Score (AIS), and Injury Severity Score (ISS). Stratification by decade of life revealed the gender survival differential inflection point to occur between ages 40-49 (OR 1.06, 95% CI 0.66-1.71, p = 0.798) and ages 50-59 (OR 0.38, 95% CI 0.20-0.74, p = 0.005). In addition, Revised Trauma Score and Injury Severity Score (TRISS) was used to calculate probability of survival (PS); all patients were then stratified by decade of life, and males and females were compared with regard to mean survival differential (outcome - PS). The identical pattern of improved outcomes in post-menopausal but not pre-menopausal females versus age-matched males was observed. These data suggest that endogenous female sex hormone production is not neuroprotective.

High rates of acute stress disorder impact quality-of-life outcomes in injured adolescents: mechanism and gender predict acute stress disorder risk.

BACKGROUND: Injury is the leading cause of death and functional disability in adolescent children. Little is known about quality of life and psychological outcomes after trauma in adolescents. The Trauma Recovery Project in Adolescents is a prospective epidemiologic study designed to examine multiple outcomes after major trauma in adolescents aged 12 to 19 years, including quality of life (QoL) and psychological sequelae such as acute stress disorder (ASD) and posttraumatic stress disorder (PTSD). The specific objectives of the present report are to examine ASD rates and the association of ASD with QoL outcomes in injured adolescents. METHODS: Between April 26, 1999, and November 13, 2002, 401 eligible trauma patients aged 12 to 19 years triaged to five participating trauma center hospitals in a regionalized trauma system were enrolled in the study. The admission criteria for patients were as follows: (1) age 12 to 19 years and (2) injury diagnoses excluding severe traumatic brain injury (TBI) or spinal cord injury. QoL after trauma was measured using the Quality of Well-being (QWB) scale, a sensitive and well-validated functional index (range, 0 = death to 1.000 = optimum functioning). ASD (before discharge) was diagnosed with the Impact of Events Scale-Revised. Scores of 24+ were used to diagnose ASD. Patient outcomes were assessed at discharge and at 3, 6, 12, 18, and 24 months after discharge. RESULTS: ASD before discharge was diagnosed in 40% of adolescent trauma survivors. ASD status was associated with large QoL deficits during follow-up, as follows: 3-month, ASD-positive QWB score = 0.667 vs. ASD-negative QWB score = 0.710, p < 0.01; 6-month, ASD-positive QWB score = 0.704 vs. ASD-negative QWB score = 0.742, p < 0.001; 12-month: ASD-positive QWB score = 0.718 vs. ASD-negative QWB score = 0.757, p < 0.01; 24-month, ASD-positive QWB score = 0.725 vs. ASD-negative QWB score = 0.769, p < 0.01. Female sex and violent mechanism predicted ASD risk (47% female vs. 36% male; odds ratio, 1.6; p < 0.05; violence 54% vs. 38%; odds ratio, 1.9; p < 0.01). CONCLUSIONS: Adolescent trauma survivors have high rates of ASD. ASD severely impacts QoL outcomes and is associated with female sex and mechanism of injury in adolescents. Early recognition and treatment of ASD in seriously injured adolescents will improve QoL outcomes.

Long-term posttraumatic stress disorder persists after major trauma in adolescents: new data on risk factors and functional outcome.

BACKGROUND: Little is known about long-term psychological outcomes after major trauma in adolescents, a leading cause of death and preventable morbidity in this age group. A prospective epidemiologic study was conducted to examine quality of life (QoL) and posttraumatic stress disorder (PTSD) outcomes in injured adolescents. The specific objectives of the present report are to describe long-term PTSD and to identify risk factors for long-term PTSD and the impact of PTSD on QoL. METHODS: Between April 26, 1999, and November 13, 2002, 401 eligible trauma patients aged 12 to 19 years triaged to five participating trauma center hospitals in a regionalized trauma system were enrolled in the study. The admission criteria for patients were as follows: age 12 to 19 years and injury diagnoses excluding severe traumatic brain injury or spinal cord injury. PTSD was diagnosed with the Impact of Events Scale-Revised; scores of 24+ were used to diagnose PTSD. QoL after trauma was measured using the Quality of Well-Being scale, a sensitive and well-validated functional index (range: 0 = death to 1.000 = optimum functioning). Patient outcomes were assessed at discharge and at 3, 6, 12, 18, and 24 months after discharge. RESULTS: The rate of long-term PTSD was 27%, with high rates over the follow-up period. Risk factors for long-term PTSD were perceived threat to life (odds ratio [OR], 2.2; p < 0.001.); death of a family member at the scene (OR, 4.7; p < 0.001); no control over injury event (OR, 1.7; p < 0.05), and violence-related injury (OR, 2.2; p < 0.05). PTSD in adolescents was significantly and strongly associated with female gender, older age, low socioeconomic status, drug and alcohol abuse, and other adolescent behavioral problems. Long-term PTSD was also associated with marked and significant QoL deficits throughout the 24-month follow-up interval. CONCLUSION: High rates of long-term PTSD persist after major trauma in adolescents. Injury events such as perceived threat to life and control over the event are strongly associated with PTSD risk. Prolonged PTSD severely impacts QoL outcomes. Early identification and treatment of risk factors for long-term PTSD will be important to improve outcomes in injured adolescents.

The impact of major trauma: quality-of-life outcomes are worse in women than in men, independent of mechanism and injury severity.

BACKGROUND: The importance of gender differences in quality of life and psychologic morbidity after major trauma is a newly recognized focus of trauma outcomes research. The Trauma Recovery Project is a large, prospective, epidemiologic study designed to examine multiple outcomes after major trauma, including quality of life (QoL), and psychologic sequelae such as depression and early symptoms of acute stress reaction (SASR). The specific objectives of the present report are to examine gender differences in QoL outcomes and the early incidence of combined depression and SASR after injury, controlling for injury severity, specific body area injured, and mechanism. METHODS: Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the study. The enrollment criteria for the study included age 18 years and older, admission Glasgow Coma Scale score of 12 or greater, and length of stay greater than 24 hours. QoL outcome after trauma was measured after injury using the Quality of Well-being scale, a sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Depression was assessed using the Center for Epidemiologic Studies scale. SASR was assessed using the Impact of Events scale. Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. RESULTS: Women (n = 313) were significantly more likely to have poor QoL outcomes at follow-up than men (n = 735) (women vs. men: 12-month follow-up odds ratio [OR] = 2.2, p < 0.001; 18-month follow-up OR = 2.0, p < 0.001). Quality of Well-being scores at each of the 6-, 12-, and 18-month follow-up time points were markedly and significantly lower in women compared with men, independent of injury severity, serious and moderate injury status, lower extremity injury, intentional or unintentional injury type, and blunt or penetrating injury. Women were also significantly more likely to develop early combined depression and SASR at discharge (OR = 1.7, p < 0.01) and to have continuous depression throughout the 18-month follow-up period (OR = 2.3, p < 0.001). CONCLUSION: These analyses provide further important and more detailed evidence that women are at risk of worse QoL outcomes and early psychologic morbidity after major trauma than men, independent of mechanism and injury severity. A better understanding of the impact of major trauma in men and women will be an important component of efforts to improve trauma care and long-term outcome in mature trauma systems.

Gender differences in long-term posttraumatic stress disorder outcomes after major trauma: women are at higher risk of adverse outcomes than men.

BACKGROUND: The importance of psychological morbidity after major trauma, such as posttraumatic stress disorder (PTSD), is continuing to gain attention in trauma outcomes research. The Trauma Recovery Project is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma, including quality of life (QoL) and PTSD. Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. The specific objectives of the present report are to examine gender differences in prolonged PTSD (L-PTSD) and to assess the impact of PTSD by gender on QoL at the 6-, 12-, and 18-month follow-up time points in the Trauma Recovery Project population. METHODS: Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the study. The enrollment criteria for the study included the following: age 18 years and older; admission Glasgow Coma Scale score of 12 or greater; and length of stay greater than 24 hours. QoL was measured after injury using the Quality of Well-being (QWB) scale, a sensitive index to the well end of the functioning continuum (range: 0 = death to 1.000 = optimum functioning). Early symptoms of acute stress reaction (SASR) at discharge were assessed using the Impact of Events Scale (score > 30 = SASR). PTSD at 6-, 12-, and 18-month follow-up was diagnosed using standardized Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. PTSD (L-PTSD) was diagnosed if full or partial (F + P) or full (F) PTSD Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria were present at all follow-up time points. RESULTS: PTSD (L-PTSD) (F + P) was diagnosed in 35% (221 of 627) of patients at follow-up. PTSD (L-PTSD) (F) was present in 32% (153 of 627). Women were at significantly higher risk of PTSD (F + P) (odds ratio = 2.4, p = 0.001) and PTSD (F) (odds ratio = 2.8, p = 0.001) than men. The association of gender with PTSD was independent of mechanism and injury event-related factors such as perceived threat to life. In multivariate logistic regression, female gender, perceived threat to life, and SASR were strongly and independently associated with PTSD risk. Women were also at risk for worse QWB outcomes; beginning at discharge through the 18-month follow-up, women had significantly lower QWB scores at each follow-up time than men, regardless of prolonged PTSD status. CONCLUSION: These results provide important new evidence that high rates of PTSD persist in the long-term aftermath of major trauma. The association of gender with PTSD was independent of mechanism and injury event-related factors such as perceived threat to life. Within categories of specific mechanism of injury and injury event-related factors, women were at significantly higher risk of prolonged PTSD onset. Prolonged PTSD was associated with significantly reduced quality of life in both men and women, with markedly worse QWB outcomes in women regardless of prolonged PTSD status.