Joseph J. Tepas

Terrorist bombings. Lessons learned from Belfast to Beirut.

Experience in the management of mass casualties following a disaster is relatively sparse. The terrorist bombing serves as a timely and effective model for the analysis of patterns of injury and mortality and the determination of the factors influencing casualty survival in the wake of certain forms of disaster. For this purpose, a review of the published experience with terrorist bombings was carried out, providing a study population of 3357 casualties from 220 incidents worldwide. There were 2934 immediate survivors of these incidents (87%), of whom 881 (30%) were hospitalized. Forty deaths ultimately occurred among these survivors (1.4%), 39 of whom were among those hospitalized (4.4%). Injury severity was determined from available data for 1339 surviving casualties, 251 of whom were critically injured (18.7%). Of this population evaluable for injury severity, there were 31 late deaths, all of which occurred among those critically injured, accounting for an overall “critical mortality” rate of 12.4%. Overall triage efficiency was characterized by a mean overtriage rate (noncritically injured among those hospitalized or evacuated) of 59%, and a mean undertriage rate (critically injured among those not hospitalized or evacuated) of .05%. Multiple linear regression analysis of all major bombing incidents demonstrated a direct linear relationship between overtriage and critical mortality (r2 = .845), and an inversely proportional relationship between triage discrimination and critical mortality (r2 = 0.855). Although head injuries predominated in both immediate (71%) and late (52%) fatalities, injury to the abdomen carried the highest specific mortality rate (19%) of any single body system injury among immediate survivors. These data clearly document the importance of accurate triage as a survival determinant for critically injured casualties of these disasters. Furthermore, the data suggest that explosive force, time interval from injury to treatment, and anatomic site of injury are all factors that correlated with the ultimate outcome of terrorist bombing victims. Critical analysis of past disasters should allow for sufficient preparation so as to minimize casualty mortality in the future.

The pediatric trauma score as a predictor of injury severity in the injured child

The ability of the Pediatric Trauma Score (PTS) to accurately predict the degree of injury severity of the injured child was assessed by comparing two separate groups of pediatric trauma victims. The first group consisted of 110 patients evaluated at a regional pediatric trauma center whose data was collected and assessed by a single investigator. The second group consisted of a similar matched cohort of 120 patients from the National Pediatric Trauma Registry whose data was collated from multiple participating institutions. In both cases, a linear relationship between PTS and Injury Severity Score (ISS) was documented that was statistically significant to P less than .001. The linear regression coefficients of each group were similar as was the distribution of PTS and ISS. This study documents the validity of the PTS as an initial assessment tool and confirms its reliability as a predictor of injury severity.

Ubiquitin C-terminal hydrolase is a novel biomarker in humans for severe traumatic brain injury

Objective:Ubiquitin C-terminal hydrolase (UCH-L1), also called neuronal-specific protein gene product (PGP 9.3), is highly abundant in neurons. To assess the reliability of UCH-L1 as a potential biomarker for traumatic brain injury (TBI) this study compared cerebrospinal fluid (CSF) levels of UCH-L1 from adult patients with severe TBI to uninjured controls; and examined the relationship between levels with severity of injury, complications and functional outcome. Design:This study was designed as prospective case control study. Patients:This study enrolled 66 patients, 41 with severe TBI, defined by a Glasgow coma scale (GCS) score of ≤8, who underwent intraventricular intracranial pressure monitoring and 25 controls without TBI requiring CSF drainage for other medical reasons. Setting:Two hospital system level I trauma centers. Measurements and Main Results:Ventricular CSF was sampled from each patient at 6, 12, 24, 48, 72, 96, 120, 144, and 168 hrs following TBI and analyzed for UCH-L1. Injury severity was assessed by the GCS score, Marshall Classification on computed tomography and a complicated postinjury course. Mortality was assessed at 6 wks and long-term outcome was assessed using the Glasgow outcome score 6 months after injury. TBI patients had significantly elevated CSF levels of UCH-L1 at each time point after injury compared to uninjured controls. Overall mean levels of UCH-L1 in TBI patients was 44.2 ng/mL (±7.9) compared with 2.7 ng/mL (±0.7) in controls (p <.001). There were significantly higher levels of UCH-L1 in patients with a lower GCS score at 24 hrs, in those with postinjury complications, in those with 6-wk mortality, and in those with a poor 6-month dichotomized Glasgow outcome score. Conclusions:These data suggest that this novel biomarker has the potential to determine injury severity in TBI patients. Further studies are needed to validate these findings in a larger sample.

αII-Spectrin Breakdown Products (SBDPs): Diagnosis and Outcome in Severe Traumatic Brain Injury Patients

In this study we assessed the clinical utility of quantitative assessments of alphaII-spectrin breakdown products (SBDP145 produced by calpain, and SBDP120 produced by caspase-3) in cerebrospinal fluid (CSF) as markers of brain damage and outcome after severe traumatic brain injury (TBI). We analyzed 40 adult patients with severe TBI (Glasgow Coma Scale [GCS] score <or=8) who underwent ventriculostomy. Patients requiring CSF drainage for other medical reasons served as controls. CSF samples were taken at admission and every 6 h thereafter for a maximum of 7 days and assessed using novel quantitative fragment-specific ELISAs for SBDPs. Outcome was assessed using the 3-month Glasgow Outcome Scale. Mean CSF levels of SBDPs were significantly higher in TBI patients than in controls at all time points examined. Different temporal release patterns of CSF SBDP145 and SBDP120 were observed. SBDP145 provided accurate diagnoses at all time points examined, while SBDP120 release was more accurate 24 h after injury. Within 24 h after injury, SBDP145 CSF concentrations significantly correlated with GCS scores, while SBDP120 levels correlated with age. SBDP levels were significantly higher in patients who died than in those who survived. SBDP145 levels (>6 ng/mL) and SBDP120 levels (>17.55 ng/mL) strongly predicted death (odds ratio 5.9 for SBDP145, and 18.34 for SBDP120). The time course of SBDPs in nonsurvivors also differed from that of survivors. These results suggest that CSF SBDP levels can predict injury severity and mortality after severe TBI, and can be useful complements to clinical assessment.

The pediatric trauma score as a predictor of injury severity: an objective assessment

The ability of the Pediatric Trauma Score (P.T.S.) to predict injury severity and mortality was evaluated by analysis of its relationship with the Injury Severity Score (I.S.S.) of 615 children entered into the National Pediatric Trauma Registry (N.P.T.R.). Mean age was 8.2 years and mortality was 3.5%. Mean I.S.S. of survivors was 8.1 in comparison to 59.7 for nonsurvivors. Linear regression coefficient determined from analysis of these variables produced a slope of -3.7 with a statistically significant correlation of P.T.S. to I.S.S. (p less than 0.001; r2 = 0.89). Analysis of the mortality for each cohort of patients with the same P.T.S. identified three categories of mortality potential. Children whose P.T.S. was greater than 8 had a 0% mortality. Children whose P.T.S. was between 0 and 8 had an increasing mortality related to their decreasing P.T.S. (r2 = 0.86), and children whose P.T.S. was below 0 had 100% mortality. This study documents the direct linear relationship between P.T.S. and injury severity, and confirms the P.T.S. as an effective predictor of both severity of injury and potential for mortality.

Biokinetic Analysis of Ubiquitin C-Terminal Hydrolase-L1 (UCH-L1) in Severe Traumatic Brain Injury Patient Biofluids

Ubiquitin C-terminal hydrolase-L1 (UCH-L1) is a neuron-specific enzyme that has been identified as a potential biomarker of traumatic brain injury (TBI). The study objectives were to determine UCH-L1 exposure and kinetic metrics, determine correlations between biofluids, and assess outcome correlations in severe TBI patients. Data were analyzed from a prospective, multicenter study of severe TBI (Glasgow Coma Scale [GCS] score ≤ 8). Cerebrospinal fluid (CSF) and serum data from samples taken every 6 h after injury were analyzed by enzyme-linked immunosorbent assay (ELISA). UCH-L1 CSF and serum data from 59 patients were used to determine biofluid correlations. Serum samples from 86 patients and CSF from 59 patients were used to determine outcome correlations. Exposure and kinetic metrics were evaluated acutely and up to 7 days post-injury and compared to mortality at 3 months. There were significant correlations between UCH-L1 CSF and serum median concentrations (r(s)=0.59, p<0.001), AUC (r(s)=0.3, p=0.027), Tmax (r(s)=0.68, p<0.001), and MRT (r(s)=0.65, p<0.001). Outcome analysis showed significant increases in median serum AUC (2016 versus 265 ng/mL*min, p=0.006), and Cmax (2 versus 0.4 ng/mL, p=0.003), and a shorter Tmax (8 versus 19 h, p=0.04) in those who died versus those who survived, respectively. In the first 24 h after injury, there was a statistically significant acute increase in CSF and serum median Cmax((0-24h)) in those who died. This study shows a significant correlation between UCH-L1 CSF and serum median concentrations and biokinetics in severe TBI patients, and relationships with clinical outcome were detected.

Mortality and head injury: The pediatric perspective

The records of 10,098 children entered into the National Pediatric Trauma Registry (NPTR) were analyzed to define the characteristics of pediatric head injury and the impact of extracranial trauma on Central Nervous System (CNS) injury. The 4,400 NPTR head injuries were then compared with 16,524 head injuries recently reported from a predominantly adult trauma registry to illustrate potential population differences. Results indicate that children have a lower mortality, that the addition of extracranial injury significantly reduces recovery potential, that CNS injury is the predominant and most common cause of pediatric traumatic death, and that the automobile is the most lethal component of a childs environment.

National pediatric trauma registry

The National Pediatric Trauma Registry (NPTR) is a multi-institutional database designed to compile information concerning all aspects of pediatric trauma care. The registry is designed and operated in a manner that maximizes data accuracy and provides this information to all participating investigators. The growth of the database has allowed the NPTR to provide the first accurate epidemiologic description of pediatric trauma as a national disease, as well as to develop national norms for pediatric trauma care. The registry presently contains 10,177 patients, and is undergoing revisions (phase II) to allow a more focused evaluation of various aspects of the clinical care and rehabilitation of the pediatric trauma patient.

Do pediatric trauma centers have better survival rates than adult trauma centers? An examination of the National Pediatric Trauma Registry.

BACKGROUND Pediatric trauma centers (PTCs) were developed to improve the survival of injured children, but it is currently unknown if children admitted to PTCs are more likely to survive than those admitted to adult trauma centers (ATCs). METHODS Fifty-three thousand one hundred thirteen pediatric trauma cases from 22 PTCs and 31 ATCs included in the National Pediatric Trauma Registry were reviewed to evaluate survival rates at PTCs and ATCs. RESULTS Overall, 1,259 children died. The raw mortality rate was lower at PTCs (1.81% of 32,554 children) than at ATCs (3.88% of 18,368 children). However, patients admitted to ATCs were more severely injured. When Injury Severity Score, Pediatric Trauma Score, mechanism (blunt or penetrating), gender, age, clustering, and American College of Surgeons (ACS) verification status were controlled for using a single logistic regression model, there was no statistically significant difference in survival between PTCs and ATCs (odds ratio, 1.02; 95% confidence interval, 0.83-1.26; p = 0.587). A similar comparison of the 12 ACS-verified trauma centers with the 41 nonverified centers showed verification to be associated with improved survival (odds ratio, 0.75; 95% confidence interval, 0.58-0.97; p = 0.013). CONCLUSION Although PTCs have higher overall survival rates than ATCs, this difference disappears when the analysis controls for Injury Severity Score, Pediatric Trauma Score, age, mechanism, and ACS verification status. ACS-verified centers have significantly higher survival rates than do unverified centers.

Evaluation of a mature trauma system.

Introduction:An effective trauma system should offer patients triaged to a trauma center (TC) a survival advantage and cost-effective treatment. Three questions were asked: 1) Does treatment at a TC versus a nontrauma center (NTC) improve survival? 2) Is the system cost-effective? 3) Is access to the system equitable? Methods:The 2003 Florida discharge database identified patients with ICD9 codes 800 to 959. Survival risk ratios (SRR) were calculated using1999–2000 data and ICISS were produced for each code. Using 2003 data, mortality rates were calculated for matched patients at TCs and NTCs. Instrumental variables methodology was used to account for differences in mortality risks of patients triaged to TCs versus NTCs. Logistic regression analysis was used to determine differences in mortality. Charge/cost ratios were analyzed to compute the cost care and cost/life saved. Accessibility to a TC within 85 minutes of injury was assessed. Results:Treatment at a TC was associated with an 18% reduction in mortality. Mean costs of care in TCs and NTCs were