Intubation and In-Hospital Mortality After Trauma With Glasgow Coma Scale Score Eight or Less-A Cohort Study.

INTRODUCTION: Most trauma societies recommend intubating trauma patients with Glasgow Coma Scale (GCS) scores ≤8 without robust supporting evidence. We examined the association between intubation and 30-d in-hospital mortality in trauma patients arriving with a GCS score ≤8 in an Indian trauma registry. METHODS: Outcomes of patients with a GCS score ≤8 who were intubated within 1 h of arrival (intubation group) were compared with those who were intubated later or not at all (nonintubation group) using various analytical approaches. The association was assessed in various subgroup and sensitivity analyses to identify any variability of the effect. RESULTS: Of 3476 patients who arrived with a GCS score ≤8, 1671 (48.1%) were intubated within 1 h. Overall, 1957 (56.3%) patients died, 947 (56.7%) in the intubation group and 1010 (56.0%) in the nonintubation group, with no significant difference in mortality (odds ratio = 1.2 [confidence interval, 0.8-1.8], P value = 0.467) in multivariable regression and propensity score-matched analysis. This result persisted across subgroup and sensitivity analyses. Patients intubated within an hour of arrival had longer durations of ventilation, intensive care unit stay, and hospital stay (P < 0.001). CONCLUSIONS: Intubation within an hour of arrival with a GCS score ≤8 after major trauma was not associated with differences in-hospital mortality. The indications and benefits of early intubation in these severely injured patients should be revisited to promote optimal resource utilization in LMICs.

Mortality and Risk Factors in Isolated Traumatic Brain Injury Patients: A Prospective Cohort Study.

INTRODUCTION: Outcomes in patients with isolated traumatic brain injury (iTBI) have not been evaluated comprehensively in low-income and middle-income countries. We aimed to study the in-hospital iTBI mortality and its associated risk factors in a prospective multicenter Indian trauma registry. METHODS: Patients with iTBI (head and neck Abbreviated Injury Score ≥2 and other region Abbreviated Injury Score ≤2) were included. Study variables comprised age, gender, mechanism of injury, systolic blood pressure (SBP) at arrival, Glasgow Coma Scale (GCS) score - classified as mild (13-15), moderate (9-12), and severe (3-8), transfer status, and time to presentation at any participating hospital. A multivariable logistic regression was performed to assess the impact of these factors on 24-h and 30-d mortality following iTBI. RESULTS: Among 5042 included patients, 24-h and 30-d in-hospital mortalities were 5.9% and 22.4%. On a regression analysis, 30-d mortality was associated with age ≥45 y (odds ratio [OR] = 2.1 [1.6-2.7]), railway injury mechanisms (OR = 2.1 [1.3-3.5]), SBP <90 mmHg (OR = 2.6 [1.6-4.1]), and moderate (OR = 3.8 [3.0-5.0]) to severe (OR = 21.1 [16.8-26.7]) iTBI based on GCS scores. 24-h mortality showed similar trends. Patients transferred to the participating hospitals from other centers had higher odds of 30-d mortality (OR = 1.4 [1.2-1.8]) compared to those arriving directly. Those who received neurosurgical intervention had lower odds of 24-h mortality (0.3 [0.2-0.4]). CONCLUSIONS: Age ≥45 y, GCS score ≤12, and SBP <90 mmHg at arrival increased the risk of in-hospital mortality from iTBI.

Outcomes of Renal Trauma in Indian Urban Tertiary Healthcare Centres: A Multicentre Cohort Study.

BACKGROUND: Renal trauma is present in 0.5-5% of patients admitted for trauma. Advancements in radiologic imaging and minimal-invasive techniques have led to decreased need for surgical intervention. We used a large trauma cohort to characterise renal trauma patients, their management and outcomes. METHODS: We analysed "Towards Improved Trauma Care Outcomes in India" cohort from four urban tertiary public hospitals in India between 1st September 2013 and 31st December 2015. The data of patients with renal trauma were extracted using International Classification of Diseases 10 codes and analysed for demographic and clinical details. RESULTS: A total of 16,047 trauma patients were included in this cohort. Abdominal trauma comprised 1119 (7%) cases, of which 144 (13%) had renal trauma. Renal trauma was present in 1% of all the patients admitted for trauma. The mean age was 28 years (SD-14.7). A total of 119 (83%) patients were male. Majority (93%) were due to blunt injuries. Road traffic injuries were the most common mechanism (53%) followed by falls (29%). Most renal injuries (89%) were associated with other organ injuries. Seven of the 144 (5%) patients required nephrectomy. Three patients had grade V trauma; all underwent nephrectomy. The 30-day in-hospital mortality, in patients with renal trauma, was 17% (24/144). CONCLUSION: Most renal trauma patients were managed nonoperatively. 89% of patients with renal trauma had concomitant injuries. The renal trauma profile from this large cohort may be generalisable to urban contexts in India and other low- and middle-income countries.

Association of age and severe injury in young motorcycle riders: A cross-sectional study from Karachi, Pakistan.

INTRODUCTION: The burden imposed by motorcyclist deaths and injuries is high in low- and middle-income countries. Many injured motorcycle riders in these settings are underage. The aim of this study was to assess the association between age and severe injury in young motorcycle riders. METHODS: We analysed road traffic injury surveillance data from the emergency rooms of five hospitals in Karachi from 2007 to 2015. We used logistic regression to assess the association of motorcycle riders' age, categorised as underage (13-17 years), early licensing age (18-19 years) and late licensing age (20-24 years), with severe injury, defined as an Injury Severity Score (ISS) ≥ 16. RESULTS: The study sample included 45,366 motorcycle riders. There were 10115 (22.3%) motorcycle riders aged 13-17 years, 9899 (21.8%) aged 18-19 years and 25352 (55.9%) aged 20-24 years. Almost all were male (99%). Being aged 13-17 years (adjusted odds ratio 1.25; 95% CI 1.11, 1.42) and 18-19 years (adjusted odds ratio 1.26; 95% CI 1.10, 1.43) were associated with higher odds of severe injury compared with being aged 20-24 years. CONCLUSION: Motorcycle riders who presented to the hospital with injuries after road traffic crashes and were aged 13-17 years and 18-19 years had significantly higher odds of severe injury than those aged 20-24 years.

'Coming home does not mean that the injury has gone'-exploring the lived experience of socioeconomic and quality of life outcomes in post-discharge trauma patients in urban India.

Trauma results in long-term socioeconomic outcomes that affect quality of life (QOL) after discharge. However, there is limited research on the lived experience of these outcomes and QOL from low - and middle-income countries. The aim of this study was to explore the different socioeconomic and QOL outcomes that trauma patients have experienced during their recovery. We conducted semi-structured qualitative interviews of 21 adult trauma patients between three to eight months after discharge from two tertiary-care public hospitals in Mumbai, India. We performed thematic analysis to identify emerging themes within the range of different experiences of the participants across gender, age, and mechanism of injury. Three themes emerged in the analysis. Recovery is incomplete-even up to eight months post discharge, participants had needs unmet by the healthcare system. Recovery is expensive-participants struggled with a range of direct and indirect costs and had to adopt coping strategies. Recovery is intersocial-post-discharge socioeconomic and QOL outcomes of the participants were shaped by the nature of social support available and their sociodemographic characteristics. Provisioning affordable and accessible rehabilitation services, and linkages with support groups may improve these outcomes. Future research should look at the effect of age and gender on these outcomes.

The State of Global Trauma and Acute Care Surgery/Surgical Critical Care.

Trauma is a leading cause of morbidity and mortality globally, with a significant burden attributable to the low- and middle-income countries (LMICs), where more than 90% of injury-related deaths occur. Road injuries contribute largely to the economic burden from trauma and are prevalent among adolescents and young adults. Trauma systems vary widely across the world in their capacity of providing basic and critical care to injured patients, with delays in treatment being present at multiple levels at LMICs. Strengthening existing systems by providing cost-effective and efficient solutions can help mitigate the injury burden in LMICs.

Management of pancreatic trauma in urban India: A multicenter study.

Background: Pancreatic trauma occurs in 0.2-2% of patients with blunt trauma and 1-12% of patients with penetrating trauma. The mortality and morbidity rates range from 9 to 34% and 30-60% respectively. We aimed to review the management of pancreatic trauma in a multicenter database from India. Methods: We analyzed all patients who suffered a pancreatic injury and who were included in the multicenter prospective observational study 'Towards Improved Trauma Care Outcomes (TITCO)'. Results: Of the 16047 trauma cases, 1134 (7.1%) patients suffered abdominal trauma. Of all those with abdominal trauma, 55 patients (4.9%) had injury to the pancreas. 28 patients (50.9%) with pancreatic trauma were managed conservatively. 27 patients (49.1%) underwent surgical exploration in the form of laparotomies. 11 procedures were undertaken for pancreas. A total of 45 (82%) patients had associated injuries along with pancreatic injury. Thorax (19) (including injuries to lung, pleura and ribs), liver (17), bowel (14) and spleen (13) were the most common associated injuries. Conclusion: Conservative management was as common as operative management in patients with pancreatic injuries. Most (80%) grade III/IV underwent operative treatment. Many patients (82%) had associated injuries. Level of evidence: III.

Mortality from fall: A descriptive analysis of a multicenter Indian trauma registry.

INTRODUCTION: Fall is the second most common mechanism of trauma worldwide after road traffic injuries. Data on fall predominantly comes from the high-income countries (HICs) and mostly includes injuries in children and elderly. There are very few studies from low- and middle-income countries(LMICs) that describe fall related injuries other than fragility fractures in elderly. This study describes the profile of poly-trauma patients admitted with a history of 'fall' and assesses the variables associated with mortality. METHOD: We analyzed data from the 'Towards Improved Trauma Care Outcome' (TITCO) database which prospectively collected data of poly-trauma patients admitted to four major tertiary care hospitals of India between 2013 to 2015. Patients across all age groups admitted to hospital with the history of 'fall'; were included in our study. Single bone fractures were excluded.  The Kaplan Meier survival analysis was used to estimate the survival probability in different age groups. RESULTS: A total of 3686 patients were included in our study. The median age of the patients was 28 years (IQR: 9, 47) with the majority being males (73.6%). Almost one-third of the patients were within the age group of 0-14 (30.4%). Most of the patients (79.9%) had a diagnosis of traumatic brain injury (TBI). The overall in-hospital mortality was 18% (664), but higher at 39.0% among patients over 65 years of age. Probability of survival decreased with increase of age. CONCLUSION: Falling from height is a common injury mechanism in India, occurring more in young males and usually associated with TBI. Isolated TBI and TBI associated with other injuries are the main contributors of mortality in fall injuries. Mortality from these injuries increased with age and ISS.

A cohort study of differences in trauma outcomes between females and males at four Indian Urban Trauma Centers.

Background Studies from high income countries suggest improved survival for females as compared to males following trauma. However, data regarding differences in trauma outcomes between females and males is severely lacking from low- and middle-income countries. The objective of this study was to determine the association between sex and clinical outcomes amongst Indian trauma patients using the Australia-India Trauma Systems Collaboration database. Methods A prospective multicentre cohort study was performed across four urban public hospitals in India April 2016 through February 2018. Bivariate analyses compared admission physiological parameters and mechanism of injury. Logistic regression assessed association of sex with the primary outcomes of 30-day and 24-hour in-hospital mortality. Secondary outcomes included ICU admission, ICU length of stay, ventilator requirement, and time on a ventilator. Results Of 8,605 patients, 1,574 (18.3%) were females. The most common mechanism of injury was falls for females (52.0%) and road traffic injury for males (49.5%). On unadjusted analysis, there was no difference in 30-day in-hospital mortality between females (11.6%) and males (12.6%, p = 0.323). However, females demonstrated a lower mortality at 24-hours (1.1% vs males 2.1%, p = 0.011) on unadjusted analysis. Females were also less likely to require a ventilator (17.3% vs 21.0% males, p = 0.001) or ICU admission (34.4% vs 37.5%, p = 0.028). Stratification by age or by ISS demonstrated no difference in 30-day in-hospital mortality for males vs females across age and ISS categories. On multivariable regression analysis, sex was not associated significantly with 30-day or 24-hour in-hospital mortality. Conclusion This study did not demonstrate a significant difference in the 30-day trauma mortality or 24-hour trauma mortality between female and male trauma patients in India on adjusted analyses. A more granular data is needed to understand the interplay of injury severity, immediate post-traumatic hormonal and immunological alterations, and the impact of gender-based disparities in acute care settings.

Global trends in adolescents' road traffic injury mortality, 1990-2019.

OBJECTIVE: The aim of this study was to determine the trends of road traffic injury (RTI) mortality among adolescents aged 10-14 years and 15-19 years across different country income levels with respect to the type of road users from 1990 to 2019. METHODS: We conducted an ecological study. Adolescents' mortality rates from RTIs at the level of high-income countries (HICs), upper-income to middle-income countries (UMICs), lower-income to middle-income countries and low-income countries were extracted from the Global Burden of Disease study. Time series were plotted to visualise the trends in mortality rates over the years. We also conducted Poisson regression using road traffic mortality rates as the dependent variable and year as the independent variable to model the trend of the change in the annual mean mortality rate, with incidence rate ratios (IRRs) and 95% CIs. RESULTS: There were downward mortality trends in all types of road users and income levels among adolescents from 1990 to 2019. HICs had more pronounced reductions in mortality rates than countries of any other income level. For example, the reduction in pedestrians in HICs was IRR 0.94 (95% CI 0.90 to 0.98), while that in UMICs was IRR 0.97 (95% CI 0.95 to 0.99) in adolescents aged 10-14 years. CONCLUSIONS: There are downward trends in RTI mortality in adolescents from 1990 to 2019 globally at all income levels for all types of road users. The decrease in mortality rates is small but a promising finding. However, prevention efforts should be continued as the burden is still high.

Measuring post-discharge socioeconomic and quality of life outcomes in trauma patients: a scoping review.

PURPOSE: Trauma is a global public health challenge. Measuring post-discharge socioeconomic and quality-of-life outcomes can help better understand and reduce the consequences of trauma. METHODS: We performed a scoping review to map the existing research on post-discharge outcomes for trauma patients, irrespective of the country or setting in which the study was performed. The scoping review was conducted by searching six databases - MEDLINE, EMBASE, the Cochrane Library, Global Index Medicus, BASE, and Web of Science - to identify all articles that report post-discharge socioeconomic or quality of life outcomes in trauma patients from 2009 to 2018. RESULTS: Seven hundred fifty-eight articles were included in this study, extracting 958 outcomes. Most studies (82%) were from high-income countries (HICs). More studies from low- and middle-income countries (LMICs) were cross-sectional (71%) compared with HIC settings (46%). There was a wide variety of different definitions, interpretations, and measurements used by various articles for similar outcomes. Quality of life, return to work, social support, cost, and participation were the main outcomes studied in post-discharge trauma patients. CONCLUSIONS: The wide range of outcomes and outcome measures reported across different types of injuries and settings. This variability can be a barrier when comparing across different types of injuries and settings. Post-discharge trauma studies should move towards building evidence based on standardized measurement of outcomes.

Associations of On-arrival Vital Signs with 24-hour In-hospital Mortality in Adult Trauma Patients Admitted to Four Public University Hospitals in Urban India: A Prospective Multi-Centre Cohort Study.

INTRODUCTION: In India, more than a million people die annually due to injuries. Identifying the patients at risk of early mortality (within 24 hour of hospital arrival) is essential for triage. A bilateral Government Australia-India Trauma System Collaboration generated a trauma registry in the context of India, which yielded a cohort of trauma patients for systematic observation and interventions. The aim of this study was to determine the independent association of on-arrival vital signs and Glasgow Coma Score (GCS) with 24-hour mortality among adult trauma patients admitted at four university public hospitals in urban India. METHODS: We performed an analysis of a prospective multicentre observational study of trauma patients across four urban public university hospitals in India, between April 2016 and February 2018. The primary outcome was 24-hour in-hospital mortality. We used logistic regression to determine mutually independent associations of the vital signs and GCS with 24-hour mortality. RESULTS: A total of 7497 adult patients (18 years and above) were included. The 24-hour mortality was 1.9%. In univariable logistic regression, Glasgow Coma Score (GCS) and the vital signs systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR) and peripheral capillary oxygen saturation (SpO2) had statistically significant associations with 24-hour mortality. These relationships held in multivariable analysis with hypotension (SBP<90mm Hg), tachycardia (HR>100bpm) and bradycardia (HR<60bpm), hypoxia (SpO2<90%), Tachypnoea (RR>20brpm) and severe (3-8) and moderate (9-12) GCS having strong association with 24-hour mortality. Notably, the patients with missing values for SBP, HR and RR also demonstrated higher odds of 24-hour mortality. The Injury Severity Scores (ISS) did not corelate with 24-hour mortality. CONCLUSION: The routinely measured GCS and vital signs including SBP, HR, SpO2 and RR are independently associated with 24-hour in-hospital mortality in the context of university hospitals of urban India. These easily measured parameters in the emergency setting may help improve decision-making and guide further management in the trauma victims. A poor short-term prognosis was also observed in patients in whom these physiological variables were not recorded.

A multicenter observational cohort study of 24 h and 30 day in-hospital mortality of pediatric and adult trauma patients - An Indian urban tertiary care perspective.

BACKGROUND/PURPOSE: India with its evolving trauma system needs multicenter studies on trauma outcomes to help determine the need for planning and structuring care better and to bridge the gap between the burden of disease and research. Therefore here we studied 24 h and 30 day mortality in adult and pediatric trauma population presenting to urban tertiary care hospitals. METHODOLOGY: Data from multicenter observational cohort study conducted from July 2013 to December 2015, Towards improved trauma care outcomes in India (TITCO) were used. MAIN FINDINGS: 3381 pediatric and 12,666 adult trauma patients. Unadjusted analyses of mortality were significantly less in pediatric compared to adult group within 24 h (OR 0.513, 99% CI 0.4-0.658, p < 0.001) and 30 days (OR 0.442, 99% CI 0.383-0.511, p < 0.001). In adjusted analyses pediatric group did not have significantly lower odds of 24-h mortality (OR 0.778, 99% CI 0.106-5.717, P = 0.746). At 30 days, pediatric group had 89% lower odds of death compared to adults (OR 0.11, 99% CI 0.017-0.0714, p = 0.002). CONCLUSION: Children had mechanisms of injury different from adults leading to less severe injuries than adults. Children are more likely than adults to survive until 30 days after admission for trauma in urban India. LEVEL OF EVIDENCE: Level II.