David Plurad

Pediatric vs adult vascular trauma: a National Trauma Databank review

INTRODUCTION The purpose of this study was to examine nationwide data on vascular injuries in children and to compare pediatric and adult patients with respect to the incidence, injury mechanisms, and outcomes. METHODS This is a National Trauma Databank analysis based on dataset version 7.0 (spanning a 5-year period ending December 2006). Pediatric patients under the age of 16 with at least one reported diagnosis of a vascular injury were compared to the adult cohort aged 16 and greater with a vascular injury. RESULTS During the study period, of 251,787 injured patients younger than 16 years, 1138 (0.6%) had a vascular injury. The incidence in patients 16 years or older was significantly higher, at 1.6% (P < .01). Compared to the adult vascular patients, pediatric patients had a significantly lower Injury Severity Score (16.8 +/- 14.9 vs 26.3 +/- 16.7, P < .001) and encountered less frequently penetrating injuries (41.8% vs 51.2%, P < .001). The most commonly injured vessels in the pediatric population were vessels of the upper extremity (424 patients or 37.9%). The overall incidence of thoracic aortic injuries in children was seven-fold lower compared to the incidence in adults (0.03% vs 0.21%). After adjusting for confounding factors, pediatric patients demonstrated improved survival following vascular injuries (adjusted odds ratio, 0.60; 95% CI, 0.45-0.79; P < .001). No significant difference was identified in the rate of amputation between pediatric and adult patients who had sustained upper or lower extremity vascular injuries. CONCLUSION Vascular trauma in the pediatric population is uncommon, occurring in only 0.6% of all pediatric trauma patients. Although less frequent than adults, a significant proportion was due to penetrating injury. Vessels of the upper extremity were the most commonly injured and were associated with low mortality. Injuries of the thoracic aorta are rare. Overall, pediatric patients had an improved adjusted mortality when compared to adults.

Time course of coagulopathy in isolated severe traumatic brain injury.

BACKGROUND Time aspects of coagulopathy following severe traumatic brain injury (sTBI) are ill defined throughout the literature. Thus, the aim of this study was to evaluate the time course of coagulopathy following isolated sTBI and its relationship to in-hospital outcomes. METHODS Retrospective analysis of patients sustaining isolated sTBI (head AIS 3, extracranial injuries AIS < 3). TBI coagulopathy was defined as thrombocytopenia and/or elevated international normalised ratio (INR) and/or prolonged activated partial thromboplastin time (aPTT). Incidence, onset and duration of sTBI-coagulopathy and its impact on morbidity and mortality were analysed. RESULTS Overall, 45.7% (n = 127) of the 278 patients included developed coagulopathy. Coagulopathy occurred 23.1 ± 2.2 h [range: 0.1–108.2 h (0–4.5 days)] post-admission with a mean duration of 68.0 ± 7.4 h[range: 2.6–531.4 h (0.1–22.1 days)]. The time interval to onset of coagulopathy decreased significantly with increasing head injury severity (p = 0.015). Early coagulation abnormalities occurring within 12 h of admission along with markers of devastating head injury including head AIS 5, penetrating injury mechanism, subdural hematoma, and a low GCS on admission proved to be independent risk factors for mortality. CONCLUSIONS The sTBI-associated coagulopathy may ensue as late as 5 days after injury with a prolonged duration (>72 h) in 30% of patients. Early coagulopathy occurring within 12 h after injury is a marker of increased morbidity and poor outcomes. Pertinent prolonged screening of this sequela is warranted.

Incidence and clinical predictors for tracheostomy after cervical spinal cord injury: a National Trauma Databank review.

BACKGROUND The purpose of this study was to determine the incidence and identify clinical predictors for the need for tracheostomy after cervical spinal cord injury (CSCI). METHODS The National Trauma Databank version 7.0 (2002-2006) was used to identify all patients who sustained a CSCI. Patients with severe traumatic brain injury (TBI) were excluded. Demographics, clinical data, and outcomes were abstracted. Patients requiring tracheostomy were compared with those who did not require tracheostomy. Logistic regression analysis was used to identify independent predictors for the need of tracheostomy. RESULTS There were 5,265 eligible patients. Of these, 1,082 (20.6%) required tracheostomy and 4,174 (79.4%) did not. The majority patients were men and blunt trauma predominated. Patients requiring tracheostomy had a higher Injury Severity Score (ISS) (33.5±17.7 vs. 24.4±16.2, p<0.001) and required intubation more frequently on scene and Emergency Department (ED) (4.2 vs. 1.4%, p<0.001 and 31.1 vs. 7.9%, p<0.001, respectively). Patients requiring tracheostomy had higher rates of complete CSCI at C1-C4 (18.2 vs. 8.4%, p<0.001) and C5-C7 levels (37.8 vs. 16.9%, p<0.001). Patients requiring tracheostomy had more ventilation days, longer intensive care unit and hospital lengths of stay, but lower mortality. Intubation on scene or ED, complete CSCI at C1-C4 or C5-C7 levels, ISS≥16, facial fracture, and thoracic trauma were identified as independent predictors for the need of tracheostomy. CONCLUSION After CSCI, a fifth of patients will require tracheostomy. Intubation on scene or ED, complete CSCI at C1-C4 or C5-C7 levels, ISS≥16, facial fracture, and thoracic trauma were independently associated with the need for tracheostomy.

Early vasopressor use in critical injury is associated with mortality independent from volume status.

BACKGROUND Complications of excessive crystalloid after critical injury have increased interest in vasopressor support. However, it is hypothesized that vasopressor use in patients who are under-resuscitated is associated with death. We performed this study to determine whether volume status is associated with increased mortality in the critically injured exposed to early vasopressors. METHODS The intensive care unit database at a Level I center was queried for all adult admissions surviving for >24 hours from January 1, 2001, to December 31, 2008. Patients with spinal cord injury and severe traumatic brain injury were excluded. The vasopressor group [Vaso (+)] was exposed to dopamine, epinephrine, phenylephrine, norepinephrine, or arginine vasopressin within 24 hours of admission. Demographic and injury data were studied including intensive care unit admission central venous pressure. Hypovolemia [Hypov (+)] was considered an admission central venous pressure ≤8 mm Hg. The Vaso (+) group was analyzed to determine whether Hypov (+) was independently associated with death. RESULTS Of 1,349 eligible patients, 26% (351) were Vaso (+). Mortality was 43.6% (153) in the Vaso (+) versus 4.2% (42) in the Vaso (-) group (17.60 [12.10-25.60], <0.01). Vasopressor exposure was associated with death independent of injury severity. In Vaso (+) patients, Hypov (+) was not associated with mortality, whereas Emergency Department admission Glasgow Coma Scale ≤8 and multiple vasopressor use were. CONCLUSIONS Vasopressor exposure early after critical injury is independently associated with death and mortality is increased regardless of fluid status. Although it is not advisable to withhold support with impending cardiovascular collapse, use of any vasopressor during ongoing resuscitation should be approached with extreme caution regardless of volume status.

Isolated severe traumatic brain injuries: association of blood alcohol levels with the severity of injuries and outcomes

BACKGROUND Traumatic brain injury is a common cause of death after traumatic insults. Alcohol intoxication is a recognized contributor to the occurrence of these injuries. The specific effects of alcohol exposure on injury severity and subsequent outcomes, however, remain controversial. The aim of this study was to investigate the relationship between blood alcohol levels (BAL) and outcomes in patients with isolated severe traumatic brain injuries (sTBI). METHODS During the calendar year 2003, as part of a pilot project, the Los Angeles County Department of Health Services obtained routine BAL on all patients transported to any of its 13 trauma centers. This study analyzes the effect of BAL on outcomes in patients with isolated sTBI (head Abbreviated Injury Scale (AIS) score >or=3; extracranial AIS score <3). The Low/No ethanol (ETOH) group included patients with negative or low (<0.08 mg/dL) BAL. Patients with BAL >or=0.08 mg/dL constituted the high ETOH group. Logistic regression was performed to determine whether alcohol levels had an independent association with outcomes. RESULTS There were 815 patients with isolated severe head injuries. Overall, 468 patients (57%) constituted the Low/No ETOH group, and 347 (43%) the high ETOH group. Alcohol levels were not significantly associated with severity of injury, hypotension at admission, Glasgow Coma Scale score, incidence of major complications, and intensive care unit or hospital length of stay. However, adjusted mortality was significantly lower in the high ETOH group when compared with the Low/No ETOH (8.9% vs. 17.1%; adjusted odds ratio: 0.60, 95% confidence interval: 0.37-0.96, p = 0.037). In the subgroup of patients with Injury Severity Score >15 the relative risk for mortality in the high ETOH group was significantly lower than in patients with Low/No ETOH. There was also an increased survival with high ETOH in patients with Injury Severity Score >25, but this was not statistically significant. CONCLUSIONS Among patients with isolated sTBI, BAL do not seem to be associated with overall injury severity, head injury severity, or the occurrence of major morbidities. Similarly, hospital and intensive care unit lengths are not affected by high admission BAL level. The adjusted overall in-hospital mortality, however, is significantly lower in patients presenting with the high BAL (>or=0.08 g/dL) after isolated sTBI.

Prospective Evaluation of Multidetector Computed Tomography for Extremity Vascular Trauma

BACKGROUND Multidetector computed tomographic angiography (MDCTA) is increasingly being used for the assessment of extremity vascular injury. However, to date, there are only retrospective series and a single small prospective study evaluating its efficacy. Therefore, the objective of this study was to prospectively evaluate the ability of MDCTA to detect arterial injury in the injured upper and lower extremities. METHODS After institutional review board approval, all trauma patients aged 16 years or older admitted to a Level I trauma center who sustained extremity trauma and underwent initial evaluation with a 64-channel MDCTA from March 2009 to June 2010 were prospectively enrolled. The sensitivity and specificity of MDCTA were tested against an aggregate gold standard of operative intervention, conventional angiography, and clinical follow-up. RESULTS During the 20-month study period, 635 patients with extremity trauma underwent a structured clinical examination. Hard signs of vascular injury was observed in 5.5% of patients with a 97.1% incidence of clinically significant injury requiring operative intervention. Eighty-three percent of patients had no signs of vascular injury with no missed injuries detected during follow-up. Eighty-nine MDCTAs were performed in the remaining 73 patients (11.5%) with soft signs. The mechanism of injury was penetrating in 69.9% (42 gunshot wound, 5 stab wound, and 4 shotgun). There were 24 positive studies, 23 of which were confirmed at operation (5 brachial artery injuries, 2 radial, 1 ulnar, 1 external iliac, 2 common femoral, 5 proximal superficial femoral, 2 distal superficial femoral, 4 popliteal, and 1 posterior tibial artery injury). A left posterior tibial artery occlusion was managed nonoperatively. There were 58 negative studies with clinical follow-up available in 100%, for a mean of 10.6 days ± 11.7 days (median, 6 days; range, 1-41 days). MDCTA was nondiagnostic in seven patients (9.6%), five secondary to artifact from retained missile fragments (3 shotgun and 2 gunshot wound), and two secondary to technical errors in reformatting. In the absence of artifact, MDCTA achieved 100% sensitivity and 100% specificity in detecting all clinically significant arterial injuries. CONCLUSIONS Physical examination is critical in the decision-making process for the injured extremity and can accurately reduce unnecessary imaging. If imaging is required, MDCTA is a sensitive and a specific noninvasive modality for arterial evaluation and may replace conventional angiography as the diagnostic modality of choice for the evaluation of the acutely injured extremity.

Coagulopathy after isolated severe traumatic brain injury in children.

INTRODUCTION Few previous studies have been conducted on the severe traumatic brain injury (sTBI)-associated coagulopathy in children. The purpose of this study was to evaluate the incidence and risk factors of sTBI coagulopathy in a pediatric cohort and to evaluate its impact on outcomes. METHODS Retrospective analysis of pediatric patients (younger than 18 years) sustaining isolated sTBI [head Abbreviated Injury Scale (AIS) score ≥3 and extracranial injuries AIS score <3]. Criteria for sTBI-associated coagulopathy included thrombocytopenia (platelet count <100,000 per mm(3)) and/or elevated international normalized ratio >1.2 and/or prolonged activated partial thromboplastin time >36 seconds. Incidence and risk factors of sTBI coagulopathy and its impact on in-hospital outcomes were analyzed. RESULTS Overall, 42.8% (n = 137) of the 320 patients studied developed coagulopathy, with increasing incidence in a stepwise fashion with escalating head AIS score (31.1, 46.2, and 88.6% for head AIS score 3, 4, and 5, respectively; p < 0.001). Depressed GCS, increasing age, an ISS ≥16, and brain contusions/lacerations were independently associated with the presence of coagulopathy. The case fatality rate was 7.8% (n = 25); 17.5% versus 0.5% in coagulopathic versus noncoagulopathic patients, respectively. After logistic regression to adjust for confounders, no statistical significant mortality difference in patients with and without coagulopathy was noted (adjusted p = 0.912). CONCLUSIONS Incidence of coagulopathy in children suffering isolated sTBI is exceedingly high at 40% and reflect the head injury severity. A low GCS, increasing age, ISS ≥16 and intraparenchymal lesions proved to be independently associated with TBI coagulopathy.

Bicyclists Injured by Automobiles: Relationship of Age to Injury Type and Severity--A National Trauma Databank Analysis

BACKGROUND Bicycle riding is a popular recreational activity and a common mode of transportation. Impact with a motor vehicle, however, has the potential to result in significant injury to the rider. The magnitude of this problem, the incidence and types of injuries, and the effect of age on these variables are poorly defined in the literature. METHODS This was a National Trauma Databank study during a 5-year period. Injury Severity Score (ISS), specific injuries sustained by riders, and outcomes were analyzed according to age groups (≤ 14 years, 15-35 years, 36-55 years, 56-65 years, and >65 years). RESULTS During the study period, there were 12,429 admissions as a result of bicycle-related injuries involving motor vehicles (0.7% of all trauma admissions). There were 4,095 patients (32.9%) ≤ 14 years, 3,806 (30.7%) 15 to 35 years, 3,413 (27.5%) 36 to 55 years, 688 (5.5%) 56 to 65 years, and 427 (3.4%) >65 years. The incidence of severe or critical trauma (ISS ≥ 16) in the five age strata was 20.3%, 19.2%, 26.4%, 33.4%, and 38.2%, respectively (p < 0.001). The most commonly encountered injuries consisted of extremity fractures (34.9%). Patients ≤ 14 years old were significantly more likely to suffer fractures to the lower extremity and less likely to sustain fractures to the upper extremity. The overall incidence of head injury was 28.3% and increased in a stepwise fashion with increasing age, ranging from 26.5% in the age stratum 15 to 35 years to 38.6% in the age stratum >65 years, p < 0.001. The overall mortality was 3.7% and ranged from 2.4% in the age stratum ≤ 14 years, to 12.2% in the stratum >65 years. After adjusting for differences in age groups, there was a stepwise increase in the risk of death for bicyclists >65 years old who were 10-fold more likely to die than those ≤ 14 years old (adj. p < 0.001). CONCLUSION Bicycle-related injuries involving motor vehicles are associated with a high incidence of head injuries and extremity fractures. Age plays a critical role in the severity and anatomic distribution of injuries sustained, with a stepwise increase in mortality with increasing age. Further evaluation of specific preventative measures, especially for elderly bicyclists is warranted.

Blunt cardiac trauma: lessons learned from the medical examiner.

OBJECTIVE The objective of this study was to analyze autopsy findings after blunt traumatic deaths to identify the incidence of cardiac injuries and describe the patterns of associated injuries. METHODS All autopsies performed by the Los Angeles County Forensic Medicine Division for blunt traumatic deaths in 2005 were retrospectively reviewed. Only cases that underwent a full autopsy including internal examination were included in the analysis. The study population was divided into two groups according to the presence or absence of a cardiac injury and compared for differences in baseline characteristics and types of associated injuries. RESULTS Of the 881 fatal victims of blunt trauma received by the Los Angeles County Forensic Medicine Division, 304 (35%) underwent a full autopsy with internal examination and were included in the analysis. The mean age was 43 years +/- 21 years, patients were more often men (71%) and were intoxicated in 39% of the cases. The most common mechanism was motor vehicle collision (50%), followed by pedestrian struck by auto (37%), and 32% had a cardiac injury. Death at the scene was significantly more common in patients with a cardiac injury (78% vs. 65%, p = 0.02). The right chambers were the most frequently injured (30%, right atrium; 27%, right ventricle). Among the 96 patients with cardiac injuries, 64% had transmural rupture. Multiple chambers were ruptured in 26%, the right atrium in 25%, and the right ventricle in 20% of these patients. Patients with cardiac injuries were significantly more likely to have other associated injuries: thoracic aorta (47% vs. 27%, p = 0.001), hemothorax (81% vs. 59%, p < 0.001), rib fractures (91% vs. 71%, p < 0.001), sternum fracture (32% vs. 13%, p < 0.001), and intra-abdominal injury (77% vs. 48%, p < 0.001) compared with patients without cardiac injury. Of the 96 patients with a cardiac injury, 78% died at the scene of the crash and 22% died en route or at the hospital. CONCLUSION Cardiac injury is a common autopsy finding after blunt traumatic fatalities, with the majority of deaths occurring at the scene. Patients with cardiac injuries are at significantly increased risk for associated thoracic and intra-abdominal injuries.

Organ donation: an important outcome after resuscitative thoracotomy.

BACKGROUND The persistent shortage of transplantable organs remains a critical issue around the world. The purpose of this study was to investigate outcomes, including organ procurement, in trauma patients undergoing resuscitative emergency department thoracotomy (EDT). Our hypothesis was that potential organ donor rescue is one of the important outcomes after traumatic arrest and EDT. STUDY DESIGN Retrospective study at Los Angeles County and University of Southern California Medical Center. Patients undergoing resuscitative EDT from January 1, 2006 through June 30, 2009 were analyzed. Primary outcomes measures included survival. Secondary outcomes included organ donation and the brain-dead potential organ donor. RESULTS During the 42-month study period, a total of 263 patients underwent EDT. Return of a pulse was achieved in 85 patients (32.3%). Of those patients, 37 (43.5%) subsequently died in the operating room and 48 (56.5%) survived to the surgical intensive care unit. Overall, 5 patients (1.9%) survived to discharge and 11 patients (4.2%) became potential organ donors. Five of the 11 potential organ donors had sustained a blunt mechanism injury. Of the 11 potential organ donors, 8 did not donate: 4 families declined consent, 3 because of poor organ function, and 1 expired due to cardiopulmonary collapse. Eventually 11 organs (6 kidneys, 2 livers, 2 pancreases, and 1 small bowel) were harvested from 3 donors. Two of the 3 donors had sustained blunt injury and 1 penetrating mechanism of injury. CONCLUSIONS Procurement of organs is one of the tangible outcomes after EDT. These organs have the potential to alter the survival and quality of life of more recipients than the number of survivors of the procedure itself.