Ellen J. MacKenzie

A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores

Background: High-energy trauma to the lower extremity presents challenges with regard to reconstruction and rehabilitation. Failed efforts at limb salvage are associated with increased patient mortality and high hospital costs. Lower-extremity injury-severity scoring systems were developed to assist the surgical team with the initial decision to amputate or salvage a limb. The purpose of the present study was to prospectively evaluate the clinical utility of five lower-extremity injury-severity scoring systems. Methods: Five hundred and fifty-six high-energy lower-extremity injuries were prospectively evaluated with use of five injury-severity scoring systems for lower-extremity trauma designed to assist in the decision-making process for the care of patients with such injuries. Four hundred and seven limbs remained in the salvage pathway six months after the injury. The sensitivity, specificity, and area under the receiver operating characteristic curve were calculated for the Mangled Extremity Severity Score (MESS); the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA); and the Hannover Fracture Scale-97 (HFS-97) for ischemic and nonischemic limbs. The scores were analyzed in two ways: including and excluding limbs that required immediate amputation. Results: The analysis did not validate the clinical utility of any of the lower-extremity injury-severity scores. The high specificity of the scores in all of the patient subgroups did confirm that low scores could be used to predict limb-salvage potential. The converse, however, was not true. The low sensitivity of the indices failed to support the validity of the scores as predictors of amputation. Conclusions: Lower-extremity injury-severity scores at or above the amputation threshold should be cautiously used by a surgeon who must decide the fate of a lower extremity with a high-energy injury.

Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma

BACKGROUND Factors thought to influence the decision for limb salvage include injury severity, physiologic reserve of the patient, and characteristics of the patient and their support system. METHODS Eligible patients were between the ages of 16 and 69 with Gustilo type IIIB and IIIC tibial fractures, dysvascular limbs resulting from trauma, type IIIB ankle fractures, or severe open midfoot or hindfoot injuries. Data collected at enrollment relevant to the decision-making process included injury characteristics and its treatment, and the nature and severity of other injuries. Logistic regression and stepwise modeling were used to determine the effect of each covariate on the variable salvage/ amputation. RESULTS Of 527 patients included in the analysis, 408 left the hospital with a salvaged limb. Of the 119 amputations performed, 55 were immediate and 64 were delayed. The multivariate analysis confirmed the bivariate analysis: all injury characteristics remained significant predictors of limb status with the exception of bone loss; and soft tissue injury and absence of plantar sensation were the most important factors in accounting for model validity. CONCLUSION Soft tissue injury severity has the greatest impact on decision making regarding limb salvage versus amputation.

Using the SF-36 for characterizing outcome after multiple trauma involving head injury

BACKGROUND The purpose of this study was to evaluate the validity of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) for examining outcomes after multiple trauma and to investigate whether the addition of items selected to measure cognitive function could improve the sensitivity of the SF-36 for identifying differences in outcomes for patients with and without head injury. METHODS One thousand two hundred thirty patients discharged from 12 trauma centers were interviewed 1 year after injury. The interview included the SF-36 supplemented with four items chosen to assess cognitive function. RESULTS The resulting cognitive function scale is internally consistent and measures a component of health that is independent of the dimensions incorporated in the SF-36. It correlates well with established measures of brain injury severity and discriminates among patients with and without brain injury. CONCLUSION This study underscores the need to supplement the SF-36 with a measure of cognitive function when evaluating outcome from multiple trauma involving head injury. Further studies are needed to validate the specific items chosen for measuring cognitive function.

The relationship between time to surgical débridement and incidence of infection after open high-energy lower extremity trauma

BACKGROUND Urgent débridement of open fractures has been considered to be of paramount importance for the prevention of infection. The purpose of the present study was to evaluate the relationship between the timing of the initial treatment of open fractures and the development of subsequent infection as well as to assess contributing factors. METHODS Three hundred and fifteen patients with severe high-energy lower extremity injuries were evaluated at eight level-I trauma centers. Treatment included aggressive débridement, antibiotic administration, fracture stabilization, and timely soft-tissue coverage. The times from injury to admission and operative débridement as well as a wide range of other patient, injury, and treatment-related characteristics that have been postulated to affect the risk of infection within the first three months after injury were studied, and differences between groups were calculated. In addition, multivariate logistic regression models were used to control for the effects of potentially confounding patient, injury, and treatment-related variables. RESULTS Eighty-four patients (27%) had development of an infection within the first three months after the injury. No significant differences were found between patients who had development of an infection and those who did not when the groups were compared with regard to the time from the injury to the first débridement, the time from admission to the first débridement, or the time from the first débridement to soft-tissue coverage. The time between the injury and admission to the definitive trauma treatment center was an independent predictor of the likelihood of infection. CONCLUSIONS The time from the injury to operative débridement is not a significant independent predictor of the risk of infection. Timely admission to a definitive trauma treatment center has a significant beneficial influence on the incidence of infection after open high-energy lower extremity trauma.

Early packed red blood cell transfusion and acute respiratory distress syndrome after trauma

Background:Transfusion of packed red blood cells (PRBCs) is a risk factor for acute respiratory distress syndrome (ARDS) in trauma patients. Yet, there is a paucity of information regarding the risk of ARDS with incremental PRBCs exposure. Methods:For this retrospective analysis, eligible patients from National Study on Costs and Outcomes of Trauma were included. Our main exposure was defined as units of PRBCs transfused during the first 24 h after admission. The main outcome was ARDS. Results:A total of 521 (4.6%) of 14070 patients developed ARDS, and 331 patients (63.5%) who developed ARDS received PRBCs transfusion. Injury severity, thoracic injury, polytrauma, and pneumonia receiving more than 5 units of fresh frozen plasma and 6–10 units of PRBCs were independent predictors of ARDS. Patients receiving more than 5 units of PRBCs had higher risk of developing ARDS (patients who received 6–10 units: adjusted odds ratio 2.5, 95% CI 1.12–5.3; patients who received more than 10 units: odds ratio 2.6, 95% CI 1.1–6.4). Each additional unit of PRBCs transfused conferred a 6% higher risk of ARDS (adjusted odds ratio 1.06; 95% CI 1.03–1.10). Conclusions:Early transfusion of PRBCs is an independent predictor of ARDS in adult trauma patients. Conservative transfusion strategies that decrease PRBC exposure by even 1 unit may be warranted to reduce the risk of ARDS in injured patients.

Outcomes of trauma patients after transfer to a level I trauma center.

BACKGROUND : Trauma center physicians need to know the patients prognosis to make appropriate clinical decisions when they take over the care of a transferred patient. We sought to compare the survival of injured patients after transfer to a trauma center with survival from a comparable time after injury among patients who had been admitted to the trauma center directly from the scene of injury. METHODS : Study included 2,867 patients 18 years to 84 years of age with at least one Abbreviated Injury Scale score >/=3 injury transferred to a trauma center and 7,570 patients admitted directly to a trauma center. The outcome was death within one year after injury. Cox proportional hazards model for death was used accounting for time since injury, adjusted for age group, gender, injury severity, injury mechanism, and comorbidities. RESULTS : Overall, there was almost no increase in the adjusted risk of death for transfer patients in the year after injury [hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.78, 1.27]. The adjusted risk of death was higher in transfer patients than nontransfer patients between 50 days and 365 days after injury (HR 1.28, 95% CI 0.79, 2.07), but not within the first 50 days (HR 0.95, 95% CI 0.76, 1.18). However these modest differences in survival within each period were not statistically significant. CONCLUSIONS : After accounting for key demographic and clinical characteristics, transfer status does not appear to be a significant independent predictor of survival among patients with moderate to severe injuries treated at Level I trauma centers.

Alcohol and Risk of Mortality in Patients With Traumatic Brain Injury

BACKGROUND Laboratory and clinical studies demonstrate inconsistent findings on the effect of alcohol on traumatic brain injury (TBI) outcome. The purpose of this study is to use a comprehensive trauma database to determine whether blood alcohol concentration (BAC) is associated with mortality in patients with TBI. METHODS DESIGN Cohort study. SETTING Eighteen trauma centers and 51 nontrauma centers in the United States. PATIENTS A total of 1,529 patients aged 18 years to 84 years of age admitted to hospital with TBI between July 2001 and November 2002. EXPOSURE BAC assessed in the index hospital emergency department. OUTCOME Mortality in-hospital, 90 and 365 days after injury. RESULTS After adjusting for confounding variables, there was no significant difference for in-hospital, 90-day, and 365-day mortality by BAC. CONCLUSIONS When fully adjusted for injury severity, alcohol intoxication is not associated with significantly lower mortality after TBI. The trend toward lower mortality at higher BACs prompts questions about the complex interaction of alcohol and TBI, and warrants further investigation of the possible protective effect of alcohol.

Prevalence and predictors of sexual dysfunction 12 months after major trauma: A national study

BACKGROUND To determine the prevalence and predictors of sexual dysfunction (SDF) after moderate-to-severe trauma in a large multicenter study. METHODS The National Study on the Costs and Outcomes of Trauma was a prospective cohort study involving 69 hospitals from 15 regions in 14 states. Men and women aged 18 to 84 years with moderate-to-severe injures participated in 3 and 12 month postinjury interviews. At 12 months, sexual function was assessed using the Functional Capacity Index. Predictors of SDF were determined using adjusted multivariate Poisson regression. Sensitivity analyses were conducted on patients aged 18 to 30 years. RESULTS Of 10,122 weighted subjects, 3,087 (30.5%) reported some degree of SDF, with the majority reporting severe SDF. On multivariate analysis, independent predictors of SDF included increasing age (aRR 1.02 per year age), decreasing household income category (aRR 1.12-1.60), lower baseline global health status (aRR 1.27-3.54), preexisting diabetes (aRR 1.34) increasing Injury Severity Score (aRR 1.02 per point increase), pelvic fracture (aRR 1.45), lower extremity fracture (aRR 1.48), and spinal cord injury (aRR 3.73). CONCLUSIONS SDF is common and usually severe after major trauma. Injury severity is a significant independent predictor of SDF. This may be due to persistent physical, psychologic, or social limitations from injury. Given the effect on quality of life, these data support the need in the clinical setting to identify and address SDF after trauma. Further investigation is necessary to determine the mechanism by which injury severity mediates SDF and whether earlier interventions can decrease the later risk of SDF.