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Aim:

To determine factors associated with poor outcome in children suffering traumatic head injury (HI).

Materials and Methods:

A retrospective study over an 8-year period including 454 children with traumatic HI admitted in the Intensive Care Unit of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during the ICU stay. Prognosis was defined according Glasgow outcome scale (GOS) performed after hospital discharge by ICU and pediatric physicians.

Results:

There were 313 male (68.9%) and 141 female patients. Mean age (±SD) was 7.2±3.8 years, the main cause of trauma was traffic accidents (69.4%). Mean Glasgow coma scale (GCS) score was 8±3, mean injury severity score (ISS) was 26.4±8.6, mean pediatric trauma score (PTS) was 4±2 and mean pediatric risk of mortality (PRISM) was 11.1±8. The GOS performed within a mean delay of 7 months after hospital discharge was as follow: 82 deaths (18.3%), 5 vegetative states (1.1%), 15 severe disabilities (3.3%), 71 moderate disabilities (15.6%) and 281 good recoveries (61.9%). Multivariate analysis showed that factors associated with poor outcome (death, vegetative state or severe disability) were: PRISM ≥24 (P=0.03; OR: 5.75); GCS ≤8 (P=0.04; OR:2.42); Cerebral edema (P=0.03; OR:2.23); lesion type VI according to Traumatic Coma Data Bank Classification (P=0.002; OR:55.95); Hypoxemia (P=0.02; OR:2.97) and sodium level >145 mmol/l (P=0.04; OR: 4.41).

Conclusions:

A significant proportion of children admitted with HI were found to have moderate disability at follow-up. We think that improving prehospital care, establishing trauma centers and making efforts to prevent motor vehicle crashes should improve the prognosis of HI in children.

The study aims were to examine the association between age, comorbidity, and cause of injury in older adults with traumatic brain injury (TBI); and to determine which comorbidities relate to mortality, length of stay, and functional outcome at hospital discharge, controlling for initial injury severity, age, and sex. A retrospective cohort study design was used; clinical and outcome trauma registry data were obtained for 196 adults 55 and older with TBI. The majority had at least one comorbid condition (e.g., hypertension, alcohol abuse). In-hospital mortality was 31%. Among the oldest-old, motor vehicle collisions and falls were significantly associated with specific chronic diseases. Prior myocardial infarction was significantly associated with an increased risk of in-hospital death. Injury Severity Score and Glasgow Coma Scale score were predictive of discharge function, but comorbidity did not add significantly to the model. Primary TBI prevention efforts in older adults must consider the impact of comorbidity and cause of injury, particularly in the oldest-old. Alcohol abuse is common in older adults with TBI; screening should be conducted and interventions developed to prevent future injury. Future study is warranted to understand the interplay between pathophysiology of comorbid disease and injury and how to best manage rehabilitation within the context of aging.

BACKGROUND

To meet community needs, injury prevention programs for children should be targeted to trends in objective data on mechanisms of injury. The aim of the present study was to identify the most important severe injury mechanisms.

METHODS

The present study retrospectively reviewed severe paediatric trauma patients in two regional trauma centres. Injury prevention priority scores were computed using different severity measures – injury severity score (ISS), revised trauma score, trauma-related injury severity score, Glasgow Coma Scale (GCS) and mortality – to identify prevention priorities.

RESULTS

A total of 3732 children with severe injury were identified; mean age (±SD) was 9.0±5.2 years and 2469 (66.2%) were boys. The GCS was 7 or lower in 209 patients (5.6%) and the median ISS was 9. Overall, there were 77 deaths (2.1%). ‘Fall from height’ was the most frequent mechanism of injury, and ‘motor vehicle traffic injury’ resulted in the most severe injury. The most significant mechanisms of injury, using ISS, were ‘fall from height’, ‘motor vehicle traffic injury’, ‘pedestrian struck by motor vehicle’, ‘bicycle injuries’ and ‘child abuse’. Different priorities were identified depending on the severity measures used – ‘fall from height’ would be the priority with ISS, revised trauma score and trauma-related injury severity score; ‘motor vehicle traffic injury’ with mortality and ‘drowning/submersion’ with GCS. ‘Fall from height’ was the highest ranked mechanism of injury in one centre compared with ‘motor vehicle traffic injury’ in the other. Younger children tended to have injuries as a result of falls, while adolescents had more motor vehicle occupant injuries. Failure to use safety devices, such as helmets and seat belts, was a common finding among severely injured children.

CONCLUSION

The present study shows that the severe injury prevention priorities identified vary depending on the severity measures used. The variations seen across age groups and between the two centres are also important factors that must be taken into account when developing prevention programs or considering research initiatives.

Objective

To determine the prevalence of severe psychological trauma—that is, post-traumatic stress disorder—in children involved in everyday road traffic accidents.

Design

12 month prospective study.

Setting

Accident and emergency department, Royal United Hospital, Bath.

Subjects

119 children aged 5-18 years involved in road traffic accidents and 66 children who sustained sports injuries.

Main outcome measure

Presence of appreciable psychological distress; fulfilment of diagnostic criteria for post-traumatic stress disorder.

Results

Post-traumatic stress disorder was found in 41 (34.5%) children involved in road traffic accidents but only two (3.0%) who sustained sports injuries. The presence of post-traumatic stress disorder was not related to the type of accident, age of the child, or the nature of injuries but was significantly associated with sex, previous experience of trauma, and subjective appraisal of threat to life. None of the children had received any psychological help at the time of assessment.

Conclusions

One in three children involved in road traffic accidents was found to suffer from post-traumatic stress disorder when they were assessed 6 weeks after their accident. The psychological needs of such children after such accidents remain largely unrecognised.

Key messagesOne in three children involved in everyday road traffic accidents was found to suffer from post-traumatic stress disorderPost-traumatic stress disorder was experienced by children of all ages, although girls were most likely to be affectedNeither the type of accident nor the nature and severity of the physical injuries were related to the presence of post-traumatic stress disorderThe child’s personal appraisal of the accident was important, with those children perceiving the event as life threatening being more likely to develop post-traumatic stress disorderThe psychological needs of children involved in road traffic accidents largely remain unrecognised

Purpose

The purpose of the present study was to determine (1) the prevalence and degree of hypothermia in patients on emergency department admission and (2) the effect of hypothermia and rate of rewarming on patient outcomes.

Methods

Secondary data analysis was conducted on patients admitted to a level I trauma center following severe traumatic brain injury (n = 147). Patients were grouped according to temperature on admission according to hypothermia status and rate of rewarming (rapid or slow). Regression analyses were performed.

Findings

Hypothermic patients were more likely to have lower postresuscitation Glasgow Coma Scale scores and a higher initial injury severity score. Hypothermia on admission was correlated with longer intensive care unit stays, a lower Glasgow Coma Scale score at discharge, higher mortality rate, and lower Glasgow outcome score–extended scores up to 6 months postinjury (P < .05). When controlling for other factors, rewarming rates more than 0.25°C/h were associated with lower Glasgow Coma Scale scores at discharge, longer intensive care unit length of stay, and higher mortality rate than patients rewarmed more slowly although these did not reach statistical significance.

Conclusion

Hypothermia on admission is correlated with worse outcomes in brain-injured patients. Patients with traumatic brain injury who are rapidly rewarmed may be more likely to have worse outcomes. Trauma protocols may need to be reexamined to include controlled rewarming at rates 0.25°C/h or less.

Background

Increase in lactate (LAC) within the central nervous system after head trauma is an established marker of traumatic brain injury (TBI).

Objective

To investigate the utility of arterial base deficit (BD) and LAC in identifying TBI in patients with isolated head injury (IHI).

Materials and methods

TBI was defined as Glasgow Coma Scale ⩽8, head Abbreviated Injury Severity Score >2 or brain haematoma on CT scan. Patients were divided into two groups: IHI with and without TBI. Data were reported as means (SDs). 131 patients with IHI were studied (mean (SD) age 39 (19) years, 78% male).

Results

17% of the patients sustained TBI. The mean differences for arterial BD (0.65 mmol/l, 95% CI −0.8 to 2.1) and LAC (0.34 mmol/l, 95% CI −0.7 to1.4) in patients with and without TBI were not significant. Analysis of receiver operating characteristic curves confirmed that arterial BD and LAC were unable to detect TBI in patients with IHI.

Conclusion

Arterial BD and LAC are poor predictors of TBI in isolated head trauma.

Introduction

Despite the integral role played by tracheostomy in the management of trauma patients admitted to intensive care units (ICUs), its timing remains subject to considerable practice variation. The purpose of this study is to examine the impact of early tracheostomy on the duration of mechanical ventilation, ICU length of stay, and outcomes in trauma ICU patients.

Methods

The following data were obtained from a prospective ICU database containing information on all trauma patients who received tracheostomy over a 5-year period: demographics, Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II, Glasgow Coma Scale score, Injury Severity Score, type of injuries, ICU and hospital outcomes, ICU and hospital length of stay (LOS), and the type of tracheostomy procedure (percutaneous versus surgical). Tracheostomy was considered early if it was performed by day 7 of mechanical ventilation. We compared the duration of mechanical ventilation, ICU LOS and outcome between early and late tracheostomy patients. Multivariate analysis was performed to assess the impact of tracheostomy timing on ICU stay.

Results

Of 653 trauma ICU patients, 136 (21%) required tracheostomies, 29 of whom were early and 107 were late. Age, sex, Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II and Injury Severity Score were not different between the two groups. Patients with early tracheostomy were more likely to have maxillofacial injuries and to have lower Glasgow Coma Scale score. Duration of mechanical ventilation was significantly shorter with early tracheostomy (mean ± standard error: 9.6 ± 1.2 days versus 18.7 ± 1.3 days; P < 0.0001). Similarly, ICU LOS was significantly shorter (10.9 ± 1.2 days versus 21.0 ± 1.3 days; P < 0.0001). Following tracheostomy, patients were discharged from the ICU after comparable periods in both groups (4.9 ± 1.2 days versus 4.9 ± 1.1 days; not significant). ICU and hospital mortality rates were similar. Using multivariate analysis, late tracheostomy was an independent predictor of prolonged ICU stay (>14 days).

Conclusion

Early tracheostomy in trauma ICU patients is associated with shorter duration of mechanical ventilation and ICU LOS, without affecting ICU or hospital outcome. Adopting a standardized strategy of early tracheostomy in appropriately selected patients may help in reducing unnecessary resource utilization.

Introduction

This report describes the case mix and outcome (mortality, intensive care unit (ICU) and hospital length of stay) for admissions to ICU for head injury and evaluates the predictive ability of five risk adjustment models.

Methods

A secondary analysis was conducted of data from the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme, a high quality clinical database, of 374,594 admissions to 171 adult critical care units across England, Wales and Northern Ireland from 1995 to 2005. The discrimination and calibration of five risk prediction models, SAPS II, MPM II, APACHE II and III and the ICNARC model plus raw Glasgow Coma Score (GCS) were compared.

Results

There were 11,021 admissions following traumatic brain injury identified (3% of all database admissions). Mortality in ICU was 23.5% and in-hospital was 33.5%. Median ICU and hospital lengths of stay were 3.2 and 24 days, respectively, for survivors and 1.6 and 3 days, respectively, for non-survivors. The ICNARC model, SAPS II and MPM II discriminated best between survivors and non-survivors and were better calibrated than raw GCS, APACHE II and III in 5,393 patients eligible for all models.

Conclusion

Traumatic brain injury requiring intensive care has a high mortality rate. Non-survivors have a short length of ICU and hospital stay. APACHE II and III have poorer calibration and discrimination than SAPS II, MPM II and the ICNARC model in traumatic brain injury; however, no model had perfect calibration.

Introduction

The study was aimed at verifying whether the occurrence of hypernatremia during the intensive care unit (ICU) stay increases the risk of death in patients with severe traumatic brain injury (TBI). We performed a retrospective study on a prospectively collected database including all patients consecutively admitted over a 3-year period with a diagnosis of TBI (post-resuscitation Glasgow Coma Score ≤ 8) to a general/neurotrauma ICU of a university hospital, providing critical care services in a catchment area of about 1,200,000 inhabitants.

Methods

Demographic, clinical, and ICU laboratory data were prospectively collected; serum sodium was assessed an average of three times per day. Hypernatremia was defined as two daily values of serum sodium above 145 mmol/l. The major outcome was death in the ICU after 14 days. Cox proportional-hazards regression models were used, with time-dependent variates designed to reflect exposure over time during the ICU stay: hypernatremia, desmopressin acetate (DDAVP) administration as a surrogate marker for the presence of central diabetes insipidus, and urinary output. The same models were adjusted for potential confounding factors.

Results

We included in the study 130 TBI patients (mean age 52 years (standard deviation 23); males 74%; median Glasgow Coma Score 3 (range 3 to 8); mean Simplified Acute Physiology Score II 50 (standard deviation 15)); all were mechanically ventilated; 35 (26.9%) died within 14 days after ICU admission. Hypernatremia was detected in 51.5% of the patients and in 15.9% of the 1,103 patient-day ICU follow-up. In most instances hypernatremia was mild (mean 150 mmol/l, interquartile range 148 to 152). The occurrence of hypernatremia was highest (P = 0.003) in patients with suspected central diabetes insipidus (25/130, 19.2%), a condition that was associated with increased severity of brain injury and ICU mortality. After adjustment for the baseline risk, the incidence of hypernatremia over the course of the ICU stay was significantly related with increased mortality (hazard ratio 3.00 (95% confidence interval: 1.34 to 6.51; P = 0.003)). However, DDAVP use modified this relation (P = 0.06), hypernatremia providing no additional prognostic information in the instances of suspected central diabetes insipidus.

Conclusions

Mild hypernatremia is associated with an increased risk of death in patients with severe TBI. In a proportion of the patients the association between hypernatremia and death is accounted for by the presence of central diabetes insipidus.

Background:

One of the hallmarks of modern medicine is the improving management of chronic health conditions. Long-term control of chronic disease entails increasing utilization of multiple medications and resultant polypharmacy. The goal of this study is to improve our understanding of the impact of polypharmacy on outcomes in trauma patients 45 years and older.

Materials and Methods:

Patients of age ≥45 years were identified from a Level I trauma center institutional registry. Detailed review of patient records included the following variables: Home medications, comorbid conditions, injury severity score (ISS), Glasgow coma scale (GCS), morbidity, mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, functional outcome measures (FOM), and discharge destination. Polypharmacy was defined by the number of medications: 0–4 (minor), 5–9 (major), or ≥10 (severe). Age- and ISS-adjusted analysis of variance and multivariate analyses were performed for these groups. Comorbidity–polypharmacy score (CPS) was defined as the number of pre-admission medications plus comorbidities. Statistical significance was set at alpha = 0.05.

Results:

A total of 323 patients were examined (mean age 62.3 years, 56.1% males, median ISS 9). Study patients were using an average of 4.74 pre-injury medications, with the number of medications per patient increasing from 3.39 for the 45–54 years age group to 5.68 for the 75+ year age group. Age- and ISS-adjusted mortality was similar in the three polypharmacy groups. In multivariate analysis only age and ISS were independently predictive of mortality. Increasing polypharmacy was associated with more comorbidities, lower arrival GCS, more complications, and lower FOM scores for self-feeding and expression-communication. In addition, hospital and ICU LOS were longer for patients with severe polypharmacy. Multivariate analysis shows age, female gender, total number of injuries, number of complications, and CPS are independently associated with discharge to a facility (all, P < 0.02).

Conclusion:

Over 40% of trauma patients 45 years and older were receiving 5 or more medications at the time of their injury. Although these patients do not appear to have higher mortality, they are at increased risk for complications, lower functional outcomes, and longer hospital and intensive care stays. CPS may be useful when quantifying the severity of associated comorbid conditions in the context of traumatic injury and warrants further investigation.

Objective

There is no information regarding the relationship between middle cerebral artery flow velocity (Vmca) and cerebral perfusion pressure in pediatric traumatic brain injury (TBI). We determined the incidence of low, normal and high mean Vmca when CPP is > 40 mm Hg in children with severe TBI.

Design

Prospective observational study

Setting

Level 1 pediatric trauma center

Patients

42 children < 17 years of age with an admission diagnosis of severe TBI (admission Glasgow Coma Scale [GCS] score < 9), TBI on computed tomography (CT) scan, tracheal intubation/mechanical ventilation and intracranial pressure (ICP) monitoring.

Interventions

None.

Measurements and Main Results

Bilateral middle cerebral arteries were insonated using transcranial Doppler ultrasonography (TCD) to calculate mean Vmca after TBI. Low mean Vmca was defined as Vmca < 2SD and high was defined as mean Vmca > 2SD. Patients were grouped by age (0.8–2.9, 3–5.9, 6–9.9, and 10–16.9 years) and gender to examine the relationship between CPP and low, high or normal mean Vmca. Potential confounders of the relationship between CPP and mean Vmca (ICP, PaCO2, hematocrit [Hct], sedation, fever and impaired autoregulation were examined). Most (33; 79%) children had normal mean Vmca but 4 (9%) patients had low mean Vmca and 5 children (12%) had high mean Vmca despite CPP > 40 mm Hg. There was no difference in potential confounders of the relationship between CPP and mean Vmca except for Hct, which was lower (25 ± 4 [range 21–30]) in children with high mean Vmca. An inverse relationship between mean Vmca and Hct was also found in boys 10–16.9 years.

Conclusions

Both low and/or high mean Vmca occur with CPP > 40 mm Hg in severe pediatric TBI. Of the potential confounders considered, only lower Hct was associated with high mean Vmca.

Background

Severe traumatic brain injury (TBI) has been increasing with greater incidence of injuries from traffic or sporting accidents. Although there are a number of animal models of TBI using progesterone for head injury, the effects of progesterone on neurologic outcome of acute TBI patients remain unclear. The aim of the present clinical study was to assess the longer-term efficacy of progesterone on the improvement in neurologic outcome of patients with acute severe TBI.

Methods

A total of 159 patients who arrived within 8 hours of injury with a Glasgow Coma Score ≤ 8 were enrolled in the study. A prospective, randomized, placebo-controlled trial of progesterone was conducted in the Neurotrauma Center of our teaching hospital. The patients were randomized to receive either progesterone or placebo. The primary endpoint was the Glasgow Outcome Scale score 3 months after brain injury. Secondary efficacy endpoints included the modified Functional Independence Measure score and mortality. In a follow-up protocol at 6 months, the Glasgow Outcome Scale and the modified Functional Independence Measure scores were again determined.

Results

Of the 159 patients randomized, 82 received progesterone and 77 received placebo. The demographic characteristics, the mechanism of injury, and the time of treatment were compared for the two groups. After 3 months and 6 months of treatment, the dichotomized Glasgow Outcome Scale score analysis exhibited more favorable outcomes among the patients who were given progesterone compared with the control individuals (P = 0.034 and P = 0.048, respectively). The modified Functional Independence Measure scores in the progesterone group were higher than those in the placebo group at both 3-month and 6-month follow-up (P < 0.05 and P < 0.01). The mortality rate of the progesterone group was significantly lower than that of the placebo group at 6-month follow-up (P < 0.05). The mean intracranial pressure values 72 hours and 7 days after injury were lower in the progesterone group than in the placebo group, but there was no statistical significance between the two groups (P > 0.05). Instances of complications and adverse events associated with the administration of progesterone were not found.

Conclusion

Our data suggest that acute severe TBI patients with administration of progesterone hold improved neurologic outcomes for up to 6 months. These results provide information important for further large and multicenter clinical trials on progesterone as a promising neuroprotective drug.

Trial Registration

ACTRN12607000545460.

In a five year period, 39 children (29 boys, 10 girls) aged 2 months to 13 years (mean 7.8 years) were studied who had suffered a major head injury (29 road traffic accidents, six falls, and four non-accidental injury). The injury had been assessed clinically and by cranial computed tomography or cranial ultrasound (in a single baby of 2 months). Initial Glasgow coma scores for all subjects ranged from 3-11 (mean 5.5), intact survivors 5-11 (7.4), minor handicap 4-11 (6.1), major handicap 3-6 (4.3), fatalities 3-6 (4.1). All were treated with sedation, paralysis, hyperventilation (arterial carbon dioxide tension 3.0-3.5 kPa), intracranial pressure monitoring and moderate body surface hypothermia to 32 degrees C. Nine children died and 30 survived (nine intact, 13 minor disability, and eight major disability). The worst cerebral perfusion pressure was over 40 mm Hg in all but one survivor, and less than 40 mm Hg in seven of nine fatalities. Severe hypocapnia both in the first 24 hours and overall was correlated with poor outcomes (dead or major disability), as were bilateral contusions or diffuse axonal injury.

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Objectives

To review the need for operative intervention and critical care services for motocross truncal injuries in children.

Design cohort

Retrospective review of patients identified via the hospital trauma registry.

Setting

Our Level 1 Pediatric Trauma Center serves five motocross tracks. These patients require frequent medical care for injuries.

Participants

All patients ≤17 years of age with truncal injuries sustained during motocross activities, between 2000 and 2011, were identified through the trauma registry.

Primary and secondary outcome measures

Operative intervention, intensive care unit (ICU) admission, length of stay, morbidity and demographics were reviewed.

Results

Motocross injured 162 children. Thirty (18.5%) were thoracic or abdominal injuries. Operative intervention was required in eight (27%) patients. Mean injury severity score (ISS) was 11.8. ICU admission was required in 50% and average hospital length of stay was 4.1 days. The most common injuries include pulmonary contusion, pneumothorax, spleen and liver lacerations. 13% of subjects suffered truncal injury from motocross on more than one occasion.

Conclusions

Paediatric motocross-related truncal injuries are significant. Surgical intervention is required in 27% of patients. The lower ISS incurred from motocross combined with high surgical and ICU admission rates suggests focal high-impact injuries to the chest and abdomen. Despite significant injury, 13% of motocross patients suffer recurrent injuries. Parents and children need injury prevention education.

Background

The relationship between severe traumatic brain injury (TBI) and blood levels of matrix metalloproteinase-9 (MMP-9) or cellular fibronectin (c-Fn) has never been reported. In this study, we aimed to assess whether plasma concentrations of MMP-9 and c-Fn could have predictive values for the composite endpoint of intensive care unit (ICU) length of stay (LOS) of survivors and mortality after severe TBI. Secondary outcomes were the state of consciousness measured with the Glasgow Coma Scale (GCS) of survivors at 14 days and Glasgow Outcome Scale Extended (GOSE) at 3 months.

Methods

Forty-nine patients with abbreviated injury scores of the head region ≥ 4 were included. Blood was sampled at 6, 12, 24 and 48 hours after injury. MMP-9 and c-Fn concentrations were measured by ELISA. The values of MMP-9 and c-Fn, and, for comparison, the value of the GCS on the field of the accident (fGCS), as predictors of the composite outcome of ICU LOS and death were assessed by logistic regression.

Results

There was a linear relationship between maximal MMP-9 concentration, measured during the 6-12-hour period, and maximal c-Fn concentration, measured during the 24-48-hour period. The risk of staying longer than 9 days in the ICU or of dying was increased in patients with a maximal early MMP-9 concentration ≥ 21.6 ng/ml (OR = 5.0; 95% CI: 1.3 to 18.6; p = 0.02) or with a maximal late c-Fn concentration ≥ 7.7 μg/ml (OR = 5.4; 95% CI: 1.4 to 20.8; p = 0.01). A similar risk association was observed with fGCS ≤8 (OR, 4.4; 95% CI, 1.2-15.8; p = 0.02). No relationship was observed between MMP-9, c-Fn concentrations or fGCS and the GCS at 14 days of survivors and GOSE at 3 months.

Conclusions

Plasma MMP-9 and c-Fn concentrations in the first 48 hours after injury are predictive for the composite endpoint of ICU LOS and death after severe TBI but not for consciousness at 14 days and outcome at 3 months.

Background

Cerebral oedema is associated with significant neurological damage in patients with traumatic brain injury. Bradykinin is an inflammatory mediator that may contribute to cerebral oedema by increasing the permeability of the blood-brain barrier. We evaluated the safety and effectiveness of the non-peptide bradykinin B2 receptor antagonist Anatibant in the treatment of patients with traumatic brain injury. During the course of the trial, funding was withdrawn by the sponsor.

Methods

Adults with traumatic brain injury and a Glasgow Coma Scale score of 12 or less, who had a CT scan showing an intracranial abnormality consistent with trauma, and were within eight hours of their injury were randomly allocated to low, medium or high dose Anatibant or to placebo. Outcomes were Serious Adverse Events (SAE), mortality 15 days following injury and in-hospital morbidity assessed by the Glasgow Coma Scale (GCS), the Disability Rating Scale (DRS) and a modified version of the Oxford Handicap Scale (HIREOS).

Results

228 patients out of a planned sample size of 400 patients were randomised. The risk of experiencing one or more SAEs was 26.4% (43/163) in the combined Anatibant treated group, compared to 19.3% (11/57) in the placebo group (relative risk = 1.37; 95% CI 0·76 to 2·46). All cause mortality in the Anatibant treated group was 19% and in the placebo group 15.8% (relative risk 1.20, 95% CI 0.61 to 2.36). The mean GCS at discharge was 12.48 in the Anatibant treated group and 13.0 in the placebo group. Mean DRS was 11.18 Anatibant versus 9.73 placebo, and mean HIREOS was 3.94 Anatibant versus 3.54 placebo. The differences between the mean levels for GCS, DRS and HIREOS in the Anatibant and placebo groups, when adjusted for baseline GCS, showed a non-significant trend for worse outcomes in all three measures.

Conclusion

This trial did not reach the planned sample size of 400 patients and consequently, the study power to detect an increase in the risk of serious adverse events was reduced. This trial provides no reliable evidence of benefit or harm and a larger trial would be needed to establish safety and effectiveness.

Trial Registration

This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN23625128.

Introduction

There is a lack of information on the cost of treating trauma in children in developing countries. Therefore, in the pediatric emergency unit of a university hospital in Turkey, we prospectively investigated the cost factors of pediatric trauma and attempted to identify cost predictors.

Methods

We prepared questionnaires and charts for 91 children (50 boys, 41 girls) admitted with multiple trauma to obtain data on age, gender, date and mechanism of injury, site of injury, type of the treatment and length of hospital stay. We studied the physical findings, Pediatric Trauma Score (PTS), Revised Trauma Score (RETS) and pediatric Glasgow Coma Scale (GCS) score, and we totalled all hospital-based costs according to Ministry of Health guidelines.

Results

The mean (and standard deviation [SD]) age of the children was 79.4 (52.3) months. Motor vehicle crashes accounted for 45% of the injuries, followed by falls (41%) and bicycle accidents (14%). The mean (and SD) total cost of care was US$376.60 ($428.20) (range from $20–$1995). The cost associated with motor vehicle crashes was higher than that for the other injury types (p < 0.05). Seventeen patients required major and 27 patients required minor surgical treatment, whereas 44 patients were treated conservatively; 3 died. Forty-eight percent of patients were referred from another hospital, and the cost of care of referred patients was significantly higher than for those admitted directly (p < 0.001). The mean (and SD) duration of hospital stay was 98 (150) hours. Total cost correlated directly with the duration of hospital stay and distance of the referred hospital or accident scene from our hospital (p < 0.001, r = 0.827 and 0.374 respectively), but the cost correlated inversely with the PTS, the RETS and the pediatric GCS score (p < 0.001, r = –0.339, –0.301 and –0.453 respectively).

Conclusion

Our findings indicate that the cost of pediatric trauma is high and may be predicted from admission data and trauma scores.

Background

This epidemiological study was carried out in Sfax (south of Tunisia) and focused on genital Chlamydia trachomatis (C. trachomatis) genovar distribution.

Methods

One hundred and thirty seven genital samples from 4067 patients (4.2%) attending the Habib Bourguiba University hospital of Sfax over 12 years (from 2000 to 2011) were found to be C. trachomatis PCR positive by the Cobas Amplicor system. These samples were genotyped by an in house reverse hybridization method.

Results

One hundred and eight (78.8%) samples contained only one genovar and 29 (21.2%) samples contained two or three genovars. Genovar E was the most prevalent (70.8%) single genovar and it was detected in 90.6% of all the cases. Genovars J, C and L1-L3 were not detected in our samples whereas ocular genovars A and B were in 5 cases. All the five cases were mixed infections. Men had more mixed infections than women (p=0.02) and were more frequently infected by genovars F and K (p<0.05). No associations between current infection, infertility and the genovar distribution were observed. Patients coinfected with Neisseria gonorrhoeae were also significantly more frequently infected with mixed genovars (p=0.04).

Conclusions

In conclusion, we have reported a high prevalence of genovar E and of mixed infections in our study population. Such data could have implications for the control and vaccine development of C. trachomatis in Tunisia.

Objective

To examine the influence of definition and location (field, emergency department [ED] or Pediatric Intensive Care Unit [PICU]) of hypotension on outcome following severe pediatric Traumatic Brain Injury (TBI).

Design

Retrospective Cohort study.

Setting

Harborview Medical Center (level I pediatric trauma center), Seattle, WA over a 5 year period between 1998–2003.

Participants

93 children < 14 years of age with TBI following injury, head abbreviated injury score (AIS) ≥ 3, and PICU admission Glasgow Coma Sale (GCS) score < 9 formed the analytic sample. Data sources included the Harborview Trauma Registry and Hospital Records.

Outcome Measures

The relationship between hypotension and outcome was examined comparing two definitions of hypotension: 1) systolic blood pressure (SBP) < 5th percentile for age and 2) SBP < 90 mmHg. Hospital discharge Glasgow Outcome score (GOS) < 4, or disposition of either death or discharge to a skilled nursing facility were considered poor outcomes. PICU and hospital length of stay (LOS) were also examined.

Results

SBP < 5th percentile for age was more highly associated with poor hospital discharge GOS (p = 0.001), poor disposition (p = 0.02), PICU LOS (RR 9.5; 95% CI 6.7–12.3) and hospital LOS (RR 18.8; 95% CI 14.0–23.5) than SBP < 90mmHg. Hypotension occurring in either the field or ED, but not in the PICU, was associated with poor GOS (p = 0.008), poor disposition (p= 0.03) and hospital LOS (RR 18.7; 95% CI 13.1–24.2).

Conclusions

Early hypotension, defined as SBP < 5th percentile for age in the field and/or ED, was a better predictor of poor outcome than delayed hypotension or the use of SBP < 90 mmHg.

Objective

To determine the incidence of vasospasm in children who have suffered moderate to severe traumatic brain injury.

Methods

A prospective observational pilot study in a 24-bed pediatric intensive care unit was performed. Twenty-two children aged 7 months to 14 years with moderate to severe traumatic brain injury as indicated by Glasgow Coma Score ≤12 and abnormal head imaging were enrolled. Transcranial Doppler ultrasound was performed to identify and follow vasospasm. Patients with a flow velocity in the middle cerebral artery (MCA) >120 cm/s were considered to have vasospasm by criterion A. If flow velocity in the MCA was >120 cm/s and the Lindegaard ratio was >3, vasospasm was considered to be present by criterion B. Patients with basilar artery (BA) flow velocity >90 cm/s met criteria for vasospasm in the posterior circulation (criterion C).

Results

In the MCA, 45.5% of patients developed vasospasm based on criterion A and 36.3% developed vasospasm based on criterion B. A total of 18.2% of patients developed vasospasm in the BA by criterion C. Typical day of onset of vasospasm was hospital day 2–3. Duration of vasospasm in the anterior circulation was 4 ± 2 days based on criteria A and 3 ± 1 days based on criteria B. Vasospasm in the posterior circulation persisted for 2 ± 1 days.

Conclusions

Using the adult criteria outlined above to diagnose vasospasm, a significant proportion of pediatric patients who have suffered moderate to severe traumatic brain injury develop vasospasm during the course of their treatment.

Background:

Cerebral vasospasm is a preventable cause of death and disability in patients who experience aneurysmal subarachnoid hemorrhage (SAH). The aim of this study is to investigate the incidence of cerebral vasospasm following traumatic SAH and its relationship with different brain injuries and severity of trauma.

Methods:

This cross-sectional study was conducted from October 2006 to March 2007 in department of Neurosurgery in Al-Zahra Hospital. Consecutive head-injured patients who had SAH on the basis of an admission CT scan were prospectively evaluated. The severity of the trauma was evaluated by determining Glasgow Coma Scale (GCS) score on admission. Transcranial Doppler ultrasonography evaluations were performed at least 48 hours after admission and one week thereafter. Vasospasm in the MCA and ACA was defined by mean flow velocity (FV) of more than 120 cm/sec with a Lindegaard index (MVA/ICA FV ratio) higher than 3. Basilar artery vasospasm was defined by FV higher than 85 cm/sec.

Results:

Seventy seven patients with tSAH were enrolled from whom 13 were excluded. The remaining were 52 (81.2%) men and 12 (18.7%) women, with a mean age of 37.89 years. Trauma was severe in 11 (17.2%), moderate in 13 (20.3%), and mild in 40 (62.5%) patients. From all, 27 patients (42.1%) experienced at least one vasospasm during the study period and MCA vasospasm was the most common in the first and second weeks (55.5%).

Conclusions:

Traumatic SAH is associated with a high incidence of cerebral vasospasm with a higher probability in patients with severe TBI.

Background:

Trauma is the most common cause of morbidity and mortality in people younger than 45 years and head injury is mostly highly weighted predictor of outcome in trauma population, anything than can improve the outcome from severe head injury has the potential of improving the lives of many accident victims.

Objective:

A study regarding factors influencing outcome of traumatic brain injury patients was conducted at a tertiary care hospital of Srinagar (India). The basic predictors in this study included age, sex, rural/urban, time taken from site of trauma to arrival at hospital, mode of transportation, referral from other hospitals, referral to other hospitals, and Glasgow Coma Scale.

Methods:

Traumatic Brain Injury (TBI) patients (n 547) were taken prospectively by simple random sampling method for a period of one year (2004) for this study.

Results:

Majority of patients belonged to age group 0 to 10 years (25.5%) and a maximum death (8) were seen in age group 51 to 60 years. Maximum number of patients were males (75.9%) and (71.1%) TBI patients were from rural areas. (26.7%) reached this hospital within a period of one hour. (66%) were shifted through ambulance service. 6.4% expired after treatment.

Conclusion:

Factors responsible for improved outcome in severe head injury patients are improvement in early recognition, resuscitation and triage, coupled with prompt computed tomography (CT) scanning and aggressive surgical management.

Context:

Though some studies have described traumatic brain injuries in tertiary care, urban hospitals in India, very limited information is available from rural settings.

Aims:

To evaluate and describe the epidemiological and clinical characteristics of patients with traumatic brain injury and their clinical outcomes following admission to a rural, tertiary care teaching hospital in India.

Settings and Design:

Retrospective, cross-sectional, hospital-based study from January 2007 to December 2009.

Materials and Methods:

Epidemiological and clinical data from all patients with traumatic brain injury (TBI) admitted to the neurosurgery service of a rural hospital in district Wardha, Maharashtra, India, from 2007 to 2009 were analyzed. The medical records of all eligible patients were reviewed and data collected on age, sex, place of residence, Glasgow Coma Scale (GCS) score, mechanism of injury, severity of injury, concurrent injuries, length of hospital stay, computed tomography (CT) scan results, type of management, indication and type of surgical intervention, and outcome.

Statistical Analysis:

Data analysis was performed using STATA version 11.0.

Results:

The medical records of 1,926 eligible patients with TBI were analyzed. The median age of the study population was 31 years (range <1 year to 98 years). The majority of TBI cases occurred in persons aged 21 - 30 years (535 or 27.7%), and in males (1,363 or 70.76%). Most patients resided in nearby rural areas and the most frequent external cause of injury was motor vehicle crash (56.3%). The overall TBI-related mortality during the study period was 6.4%. From 2007 to 2009, TBI-related mortality significantly decreased (P < 0.01) during each year (2007: 8.9%, 2008: 8.5%, and 2009: 4.9%). This decrease in mortality could be due to access and availability of better health care facilities.

Conclusions:

Road traffic crashes are the leading cause of TBI in rural Maharashtra ffecting mainly young adult males. At least 10% of survivors had moderate or more severe TBI-related disabilities. Future research should include prospective, population based studies to better elucidate the incidence, prevalence, and economic impact of TBI in rural India.

Objectives

To evaluate the effect of age on intensity of care provided to traumatically brain-injured adults and to determine the influence of intensity of care on mortality at discharge and 12 months postinjury, controlling for injury severity.

Design

Cohort study using the National Study on the Costs and Outcomes of Trauma (NSCOT) database. Risk ratio and Poisson regression analyses were performed using data weighted according to the population of eligible patients.

Setting and Patients

A total of 18 level 1 and 51 level 2 non-trauma centers located in 14 states in the United States and 1,776 adults aged 25−84 yrs with a diagnosis of traumatic brain injury.

Measurements

Injury severity was determined by the motor component of the Glasgow Coma Scale score, the Injury Severity Score, pupillary reactivity, and presence of midline shift. Factors evaluated as contributing to intensity of care included: admission to the intensive care unit, mechanical ventilation, placement of an intracranial pressure monitor, placement of a jugular bulb catheter, placement of a pulmonary artery catheter, critical care consultation, the number of specialty care consultations, mannitol use, treatment with barbiturate coma, decompressive craniectomy, number of nonneurosurgical procedures performed, the presence of a do-not-resuscitate order, and withdrawal of therapy.

Main Results

Controlling for injury-related factors, sex, and comorbidity, as age increased, the overall likelihood of receiving various interventions decreased. After controlling for injury severity, sex, and comorbidity, factors associated with higher risk of in-hospital death were: being aged 75−84 yrs (relative risk [RR] 1.32, 95% confidence interval [CI] 1.13, 1.55), pulmonary artery catheter use (RR 1.56, 95% CI 1.30, 1.86), intubation (RR 4.17, 95% CI 2.28, 7.61), the presence of a do-not-resuscitate order (RR 3.21, 95% CI 2.21, 4.65), and withdrawal of therapy (RR 2.33, 95% CI 1.69, 3.23). In contrast, a higher number of specialty care consultations (surgical consults: RR 0.63, 95% CI 0.54, 0.74; medical consults: RR 0.87, 95% CI 0.79, 0.95; and other consults: RR 0.43, 95% CI 0.26, 0.69) were associated with decreased risk of death. The results were similar for factors associated with death at 12 months, with the exception that the number of medical consultations was not significant, whereas the number of nonneurosurgical procedures performed was associated with lower risk of death (RR 0.96, 95% CI 0.92, 0.99), as was obtaining critical care consultation services (RR 0.84, 95% CI 0.71, 1.0).

Conclusions

There is a lower intensity of care provided to older adults with traumatic brain injury. Although the specific contributions of specialists to patient management are unknown, their consultation was associated with decreased risk of in-hospital death and death within 12 months. It is important that careproviders have an increased awareness of the potential contribution of multidisciplinary clinical decision making to patient outcomes in older traumatically brain-injured patients.

Objective:

The purpose of this study was to investigate the effect of prophylactic anticoagulation on the incidence of venous thromboembolic events (VTE) in patients suffering from isolated severe traumatic brain injury (TBI).

Materials and Methods:

Retrospective matched case-control study in adult patients sustaining isolated severe TBI (head AIS ≥3, with extracranial AIS ≤2) receiving VTE prophylaxis while in the surgical intensive care unit from 1/2007 through 12/2009. Patients subjected to VTE prophylaxis were matched 1:1 by age, gender, glasgow coma scale (GCS) score at admission, presence of hypotension on admission, injury severity score, and head abbreviated injury scale (AIS) score, with patients who did not receive chemical VTE prophylaxis. The primary outcome measure was VTE. Secondary outcomes were SICU and hospital length of stay (HLOS), adverse effects of anticoagulation, and mortality.

Results:

After propensity matching, 37 matched pairs were analysed. Cases and controls had similar demographics, injury characteristics, rate of craniotomies/craniectomies, SICU LOS, and HLOS. The median time of commencement of VTE prophylaxis was 10 days. The incidence of VTE was increased 3.5-fold in the controls compared to the cases (95% CI 1.0-12.1, P=0.002). The mortality was higher in patients who did not receive anticoagulation (19% vs. 5%, P=0.001). No adverse outcomes were detected in the anticoagulated patients.

Conclusion:

Prophylactic anticoagulation decreases the overall risk for clinically significant VTE in patients with severe isolated TBI. Prospective validation of the timing and safety of chemical VTE prophylaxis in these instances is warranted.