Tanya Charyk Stewart

Epidemiology of maxillofacial injuries at trauma hospitals in Ontario, Canada, between 1992 and 1997.

BACKGROUND The purpose of this study was to review the epidemiology of maxillofacial skeletal injuries in severely injured patients admitted to trauma hospitals in Ontario, Canada, with an Injury Severity Score > 12. METHODS The Ontario Trauma Registry was accessed to examine the epidemiology of maxillofacial skeletal injuries in severely injured patients treated at 12 trauma hospitals in the province of Ontario, Canada, between 1992 and 1997. Data were collected prospectively, and a descriptive analysis was performed to determine the pattern of maxillofacial injuries, including patient age, sex distribution, etiology of injury, time of injury, and injury profile. RESULTS There were 2,969 patients that met the inclusion criteria. The median age was 25 years, and men were injured at a 3:1 ratio over women. Most severely injured patients with maxillofacial fractures were injured as a result of motor vehicle collision (70%), with only 33% of the patients restrained with a seat-belt. The temporal distribution of injuries showed that most injuries occurred during evening hours, on weekends, and in the summer. The largest number of fractures was found in the maxilla and orbital bones. The Injury Severity Score of the patients in this study ranged from 13 to 75, with a median of 25. The injury most commonly associated with maxillofacial fractures was injury to the head and neck area. Of patients with injury to the head and neck, most had an altered level of consciousness or injuries to the skull, brain, or cranial vessels. CONCLUSION Many severely injured patients have maxillofacial injuries. Long-term collection of epidemiologic data regarding maxillofacial fractures is important for the evaluation of existing preventative measures and useful in the development of new methods of injury prevention. Furthermore, insight into the epidemiology of facial fractures and concomitant injuries is an integral component in evaluating the quality of patient care, developing optimal treatment regimens, and making decisions regarding appropriate resource and manpower allocations.

An evaluation of patient outcomes comparing trauma team activated versus trauma team not activated using TRISS analysis. Trauma and Injury Severity Score

OBJECTIVE The purpose of this study was to compare the outcomes of trauma patients with an Injury Severity Score (ISS) > 12 who had the trauma team involved (TTA) in their resuscitative care to those that did not (TTNA). SETTING Level I regional trauma center teaching hospital with university affiliation. METHODS All trauma patients admitted between July 1, 1991 and August 31, 1994 with an ISS > 12 were identified through the trauma registry. Burn patients, those who suffered their injury > 24 hours before admission, and deaths in the emergency room were excluded from analysis. The TRISS methodology, which offers a standard approval for evaluating outcomes for different populations of trauma patients, was used to determine whether there was a difference in outcomes between the two groups. To include patients who arrived at the trauma center intubated, a Trauma and Injury Severity Score (TRISS)-like analysis was also conducted on this patient population. MAIN RESULTS A total of 640 patients were identified; 174 (65.2%) in the TTA group and 223 (34.8%) in the TTNA group. A total of 448 (70%) were eligible for TRISS analysis and 574 (89.7%) were eligible for TRISS-like analysis. Using the TRISS analysis, the TTA group had a Z statistic of 3.36 yielding a W score of 4.27. This compared to the TTNA group whose Z statistic was 0.30. Using the TRISS-like logistic regression equation, the TTA group had a Z statistic of 6.50, yielding a W score of 8.60 compared with the TTNA group whose Z statistic was 0.88. After controlling for differences in the demographics of the two groups, the TTA still had consistently higher Z scores. CONCLUSION In a Level I trauma center, the outcomes of trauma patients with an ISS > 12 are statistically significantly better if the trauma team is activated than if the patients are managed on an individual service-by-service basis.

An evaluation of patient outcomes before and after trauma center designation using Trauma and Injury Severity Score analysis

In June 1990, the Ministry of Health designated 11 hospitals throughout Ontario to be lead hospitals in trauma care. An integral part of a trauma system is the evaluation of care, in particular, outcome of the trauma patients. The Trauma and Injury Severity Score (TRISS) methodology, which offers a standard approach for evaluating outcomes for different populations of trauma patients, was used to determine if there was an improvement in outcomes after the designation of trauma centers of patients involved in motor vehicle crashes (ICD-9-CM, E810.0-825.9), with an Injury Severity Score > 12 for two 12-month periods: one predesignation (1989/1990) and one postdesignation (1992/1993). The Revised Trauma Score, Injury Severity Score, age, and outcome were calculated or abstracted from the hospital chart of each patient at the trauma center. The probability of survival of each patient, the z- and W-statistics of both years were calculated. A measurable improvement was shown in z-statistics between the 2 years from z = -0.40 predesignation to z = +0.72 postdesignation. When the bias introduced by patients intubated before arrival at the trauma center being excluded from TRISS analysis was removed, using a TRISS-like (as per Offner et al: J. Trauma 32:32, 1992) logistic regression equation that allows analysis of intubated patients, the improvement was even greater, with z = +1.34 predesignation and z = +2.97 postdesignation. Only the statistically significant z-score of the postdesignated year required the W-score to be calculated, W = +5.60.(ABSTRACT TRUNCATED AT 250 WORDS)

An epidemiologic profile of pediatric concussions: identifying urban and rural differences.

BACKGROUND The objective of this study was to describe the epidemiology of concussions presenting to the emergency department (ED). METHODS A retrospective cohort of concussions for pediatric (age < 18 years) patients treated in the ED of a regional pediatric Level 1 trauma center from 2006 to 2011 was examined. Descriptive and geographic analyses were completed, with comparisons by age groups and residence (urban/rural). RESULTS There were a total of 2,112 treated pediatric concussions. Two thirds of the concussions occurred in males (67%), with a median age of 13 years (interquartile range [IQR], 6). Nearly half of the pediatric concussions were sports related (48%); 36% of these concussions were from hockey. Significant differences were found in the distribution of the mechanism of injury across age groups (p < 0.001). Falls were most prevalent among young children, and sports concussions, for children 10 years and older. Two fifths of concussions occurred during winter months. Discharge disposition significantly differed by age (p < 0.001), with home discharge increasing with age up to 14 years. There were a total of 387 rural (19%) and 1,687 urban (81%) concussed patients, for a mean ED concussion visit rate of 2.2 per 1,000 and 3.5 per 1,000, respectively. Rural patients were older (14 [IQR, 6] vs. 13 [IQR, 6], p = 0.019] and sustained 2.5 times more concussions from a motor vehicle crash compared with urban youth patients (p < 0.001). CONCLUSION Males in early adolescence are at highest risk for concussion, particularly from sport-related activities. Urban and rural children have differences in their etiology and severity of concussions. Concussions are predictable, and their prevention should be targeted based on epidemiologic and environmental data. LEVEL OF EVIDENCE Epidemiologic, study, level III.

Open or closed diagnostic peritoneal lavage for abdominal trauma? A meta-analysis.

OBJECTIVES To perform a meta-analysis of prospective, randomized controlled trials comparing the closed and open technique of diagnostic peritoneal lavage (DPL) in trauma patients to determine whether there are any difference in outcomes. METHODS A search of MEDLINE database of English language articles published from 1977 to 1999 was conducted by using the terms diagnostic peritoneal lavage, trauma, and randomized controlled trials. A manual search and Cochrane Library database search was also conducted. Seven randomized controlled trials, including a total of 1,126 patients were identified that compared closed versus open technique. Two reviewers assessed the trials independently. Trial quality was critically appraised by using the Jadad Instrument, a validated published quality scale. Data extraction of major complications, technical difficulties, procedure times, and false-negative and false-positive rates was carried out. The fixed effects model was used for statistical analysis. The Peto odds ratio (OR), weighted mean differences and 95% confidence intervals (95% CI) were calculated. RESULTS The overall quality of studies was poor (mean, 2.4/7). Major complications did not differ significantly between closed versus open technique (OR, 0.65; 95% CI, 0.15 to 2.92. Technical failures and difficulties were significantly higher in the closed group, i.e., OR 4.33 (95% CI, 1.96 to 9.56) and OR 4.19 (95% CI, 2.842 to 6.19), respectively. Accuracy of closed and open DPL was comparable with no difference in false-negative or false-positive rates between the two techniques. Procedure time was consistently lower in the closed technique. CONCLUSIONS The closed DPL technique is comparable to the standard open DPL technique in terms of accuracy and major complications. The advantage of reduced time to perform the closed DPL is offset by the increased technical difficulties and failures of this group. Therefore, any significant benefit of routine closed DPL in improving outcomes can be excluded with more confidence based on pooled data than by the individual trials alone.

Brain injury biomarkers as outcome predictors in pediatric severe traumatic brain injury

BackgroundTo systematically review the literature on brain injury biomarkers, defined as any injury biomarker detected in cerebrospinal fluid (CSF) or blood injury biomarkers primarily expressed in the brain parenchyma, to determine outcome prediction in pediatric severe traumatic brain injury (sTBI).MethodsA search of MEDLINE®, EMBASE®, PsycINFO®, Pubmed®, and the Cochrane Database, as well as grey literature sources, personal contacts, hand searches, and reference lists. The search terms used were traumatic brain injury, biomarkers, prognosis, and children. No language, publication type, or publication date restrictions were imposed. All articles were critically reviewed by two clinicians independently.ResultsA total of 7,150 articles were identified initially with 16 studies identified for review. Eighteen different biomarkers were examined; 11 in CSF and 7 in blood. Outcomes assessed included either in-hospital mortality or functional state (hospital discharge, 3-months or 6-months; Glasgow Outcome Scale or Pediatric Cerebral Performance Category). Significant correlations were established between sTBI outcomes and various biomarkers in CSF (IL-6, IL-8, IL-1β, S100β, NGF, NSE, DCX, ET-1, HMGB-1, cytochrome C) and blood (GFAP, NF-H, UCH-L1, SBDP-145, leptin). Mixed results were obtained for blood S100β. Outcome did not correlate with several biomarkers in either CSF (BDNF, GDNF, α-Syn) or blood (NSE, MBP). The Class of Evidence was considered II in 1 study and III in the remaining 15 studies.ConclusionsBased on the status of current sTBI biomarker research, we recommend that future research should be directed at both novel biomarker discovery and validation of biomarker panels in large, well-designed longitudinal studies.

The role of serious concomitant injuries in the treatment and outcome of pediatric severe traumatic brain injury.

BACKGROUND The study objective was to describe the epidemiology of serious concomitant injuries and their effects on outcome in pediatric severe traumatic brain injury (sTBI). METHODS A retrospective cohort of all severely injured (Injury Severity Score [ISS] ≥ 12) pediatric patients (<18 years) admitted to our pediatric intensive care unit, between 2000 and 2011, after experiencing an sTBI (Glasgow Coma Scale [GCS] score ⩽ 8 and head Abbreviated Injury Scale [AIS] ≥ 4) were included. Two groups were compared based on the presence of serious concomitant injuries (maximum AIS score ≥ 3). Multivariate logistic regression was undertaken to determine variable associations with mortality. RESULTS Of the 180 patients with sTBI, 113 (63%) sustained serious concomitant injuries. Chest was the most commonly injured extracranial body region (84%), with lung being the most often injured. Patients with serious concomitant injuries had increased age, weight, and injury severity (p < 0.001) and were more likely injured in a motor vehicle collision (91% vs. 48%, p < 0.001). Those with serious concomitant injuries had worse sTBI, based on lower presedation GCS (p = 0.031), higher frequency of fixed pupils (p = 0.006), and increased imaging abnormalities (SAH and DAI, p ⩽ 0.01). Non-neurosurgical operations and blood transfusions were more frequent in the serious concomitant injury group (p < 0.01). The differences in mortality for the two groups failed to reach statistical significant (p = 0.053), but patients with serious concomitant injuries had higher rates of infection and acute central diabetes insipidus, fewer ventilator-free days, and greater length of stays (p < 0.05). Multivariate analyses revealed fixed pupillary response (odd ratio [OR], 63.58; p < 0.001), presedation motor GCS (OR, 0.23; p = 0.001), blood transfusion (OR, 5.80; p = 0.008), and hypotension (OR, 4.82; p = 0.025) were associated with mortality, but serious concomitant injuries was not (p = 0.283). CONCLUSION Head injury is the most important prognostic factor in mortality for sTBI pediatric patients, but the presence of serious concomitant injuries does contribute to greater morbidity, including longer stays, more infections, fewer ventilator-free days, and a higher level of care required on discharge from hospital. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Central diabetes insipidus in pediatric severe traumatic brain injury.

Objectives: To determine the occurrence rate of central diabetes insipidus in pediatric patients with severe traumatic brain injury and to describe the clinical, injury, biochemical, imaging, and intervention variables associated with mortality. Design: Retrospective chart and imaging review. Setting: Children’s Hospital, level 1 trauma center. Patients: Severely injured (Injury Severity Score ≥ 12) pediatric trauma patients (>1 month and <18 yr) with severe traumatic brain injury (presedation Glasgow Coma Scale ⩽ 8 and head Maximum Abbreviated Injury Scale ≥ 4) that developed acute central diabetes insipidus between January 2000 and December 2011. Measurements and Main Results: Of 818 severely injured trauma patients, 180 had severe traumatic brain injury with an overall mortality rate of 27.2%. Thirty-two of the severe traumatic brain injury patients developed acute central diabetes insipidus that responded to desamino-8-D-arginine vasopressin and/or vasopressin infusion, providing an occurrence rate of 18%. At the time of central diabetes insipidus diagnosis, median urine output and serum sodium were 6.8 ml/kg/hr (interquartile range = 5–11) and 154 mmol/L (interquartile range = 149–159), respectively. The mortality rate of central diabetes insipidus patients was 87.5%, with 71.4% declared brain dead after central diabetes insipidus diagnosis. Early central diabetes insipidus onset, within the first 2 days of severe traumatic brain injury, was strongly associated with mortality (p < 0.001), as were a lower presedation Glasgow Coma Scale (p = 0.03), a lower motor Glasgow Coma Scale (p = 0.01), an occurrence of fixed pupils (p = 0.04), and a prolonged partial thromboplastin time (p = 0.04). Cerebral edema on the initial computed tomography, obtained in the first 24 hrs after injury, was the only imaging finding associated with death (p = 0.002). Survivors of central diabetes insipidus were more likely to have intracranial pressure monitoring (p = 0.03), have thiopental administered to induce coma (p = 0.04) and have received a decompressive craniectomy for elevated intracranial pressure (p = 0.04). Conclusions: The incidence of central diabetes insipidus in pediatric patients with severe traumatic brain injury is 18%. Mortality was associated with early central diabetes insipidus onset and cerebral edema on head computed tomography. Central diabetes insipidus nonsurvivors were less likely to have received intracranial pressure monitoring, thiopental coma and decompressive craniectomy.

Hypernatremia is associated with increased risk of mortality in pediatric severe traumatic brain injury.

Acquired hypernatremia in hospitalized patients is often associated with poorer outcomes. Our aim was to evaluate the relationship between acquired hypernatremia and outcome in children with severe traumatic brain injury (sTBI). We performed a retrospective cohort study of all severely injured trauma patients (Injury Severity Score ≥12) with sTBI (Glasgow Coma Scale [GCS] ≤8 and Maximum Abbreviated Injury Scale [MAIS] ≥4) admitted to a Pediatric Critical Care Unit ([PCCU]; 2000-2009). In a cohort of 165 patients, 76% had normonatremia (135-150 mmol/L), 18% had hypernatremia (151-160 mmol/L), and 6% had severe hypernatremia (>160 mmol/L). The groups were similar except for lower GCS (p=0.002) and increased incidence of fixed pupil(s) on admission in both hypernatremia groups (p<0.001). Mortality rate was four-fold and six-fold greater with hypernatremia and severe hypernatremia, respectively (p<0.001), and mortality rates were unchanged when patients with fixed pupils or those with central diabetes insipidus were excluded (p<0.001). Hypernatremic patients had fewer ventilator-free days (p<0.001). Survivors with hypernatremia had greater PCCU (p=0.001) and hospital (p=0.031) lengths of stays and were less frequently discharged home (p=0.008). Logistic regression analyses of patient characteristics and sTBI interventions demonstrated that hypernatremia was independently associated with the presence of fixed pupil(s) on admission (odds ratio [OR] 5.38; p=0.003); administration of thiopental (OR 8.64; p=0.014), and development of central diabetes insipidus (OR 5.66; p=0.005). Additional logistic regression analyses demonstrated a significant association between hypernatremia and mortality (OR 6.660; p=0.034). In summary, acquired hypernatremia appears to signal higher risk of mortality in pediatric sTBI and is associated with a higher discharge level of care in sTBI survivors.

Pediatric trauma in southwestern Ontario: linking data with injury prevention initiatives

BACKGROUND Our objective was to provide an epidemiologic description of pediatric trauma in SW Ontario using multiple data sets. Injury prevention (IP) initiatives were linked with predominant injury mechanisms to determine whether IP programs were supported by data. METHODS Descriptive analysis was undertaken for five pediatric age groups (<1 year, 1-4 years, 5-9 years, 10-14 years, 15-19 years) using the Ontario Trauma Registrys Death Data Set, Comprehensive Data Set (Lead Trauma Hospitals [LTH] patients), and Minimal Data Set (hospital admissions), 1999-2000, for all pediatric patients residing in SW Ontario. National Ambulatory Care Reporting System (NACRS) data from the Childrens Hospital of Western Ontario/London Health Sciences Centre were used to capture the Emergency Room (ER) injury data. Information on IP initiatives for children and youth was gathered through an Internet search, supplemented by a survey. RESULTS Injury in SW Ontario resulted in 13,197 ER visits, 1,616 hospital admissions, 70 severe trauma (ISS > 12) cases treated at a LTH and 47 deaths to children and youth. More males than females were injured, with the sex differential more pronounced as age increased. Falls were the leading mechanism for ER visits (37%) and hospital admissions (26%). Recreational injuries represented approximately 30% of injuries to the 10-14 yr age group. As ISS increased, MVCs emerged as an important mechanism, representing 71% of LTH cases and 53% of pediatric injury deaths in SW Ontario. There were 61 pediatric IP programs identified in SW Ontario. Eighty-four percent of programs (51/61) were supported by data, and were related to one of the predominant injury mechanisms. CONCLUSIONS Injury is a serious problem for children in SW Ontario. Data can be used to identify modifiable risk factors to develop and implement new IP initiatives with the goal of reducing childhood injury and death. There is a need to integrate and link IP programs in SW Ontario for full coverage of all injury mechanisms.