PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (568272)

Clipboard (0)
None

Related Articles

1.  Outcome analysis and outcome predictors of traumatic head injury in childhood: Analysis of 454 observations 
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.
doi:10.4103/0974-2700.82206
PMCID: PMC3132359  PMID: 21769206
Acute head injury; children; Glasgow coma scale score; intensive care unit; multivariate analysis; prognosis; trauma
2.  Road Trauma in Teenage Male Youth with Childhood Disruptive Behavior Disorders: A Population Based Analysis 
PLoS Medicine  2010;7(11):e1000369.
Donald Redelmeier and colleagues conducted a population-based case-control study of 16-19-year-old males hospitalized for road trauma or appendicitis and showed that disruptive behavior disorders explained a significant amount of road trauma in this group.
Background
Teenage male drivers contribute to a large number of serious road crashes despite low rates of driving and excellent physical health. We examined the amount of road trauma involving teenage male youth that might be explained by prior disruptive behavior disorders (attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder).
Methods and Findings
We conducted a population-based case-control study of consecutive male youth between age 16 and 19 years hospitalized for road trauma (cases) or appendicitis (controls) in Ontario, Canada over 7 years (April 1, 2002 through March 31, 2009). Using universal health care databases, we identified prior psychiatric diagnoses for each individual during the decade before admission. Overall, a total of 3,421 patients were admitted for road trauma (cases) and 3,812 for appendicitis (controls). A history of disruptive behavior disorders was significantly more frequent among trauma patients than controls (767 of 3,421 versus 664 of 3,812), equal to a one-third increase in the relative risk of road trauma (odds ratio  =  1.37, 95% confidence interval 1.22–1.54, p<0.001). The risk was evident over a range of settings and after adjustment for measured confounders (odds ratio 1.38, 95% confidence interval 1.21–1.56, p<0.001). The risk explained about one-in-20 crashes, was apparent years before the event, extended to those who died, and persisted among those involved as pedestrians.
Conclusions
Disruptive behavior disorders explain a significant amount of road trauma in teenage male youth. Programs addressing such disorders should be considered to prevent injuries.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In the latest World Health Organization (WHO) global burden of disease list, road traffic crashes are currently ranked eighth but are predicted to take fourth place by 2030 (by which time, road traffic deaths are likely to increase by more than 80% in developing countries and to decrease by nearly 30% in industrialized countries.) Every year, road traffic crashes kill an estimated 1.2 million people world-wide and injure or disable a further 20–60 million. Furthermore, the economic consequences of road traffic crashes account for about 2% of the gross national product of the entire global economy.
90% of road traffic deaths occur in developing countries where pedestrians, cyclists, and users of two-wheel vehicles (scooters, motorbikes) are the most vulnerable. In industrialized countries, teenage male drivers are the single most risky demographic group, with an incidence of road traffic crashes of twice that of the population average. Also, male teenagers are sometimes a hazard to other road users and contribute to more fatalities in older pedestrians than older drivers. Furthermore, teenage male drivers involved in serious crashes can have ongoing health care needs but are often resistant to standard road safety advice.
Why Was This Study Done?
Previous studies have suggested that disruptive behavior disorders might contribute to the risk of road traffic crashes in male teenagers but methodological problems with these studies make these results unclear. Given the importance of this topic, authorities have called for more research into the full range of behavioral disorders and relevant populations. This study attempted to avoid the methodological problems of previous studies and to rigorously assess whether disruptive behavior disorders predispose male teenagers to road traffic crashes.
What Did the Researchers Do and Find?
The researchers conducted a 7-year population-based case-control study in Ontario, Canada of consecutive male teenagers aged between 16 and 19 years who were admitted to a hospital due to a road traffic crash, including those who were pedestrians. For the controls, the researchers used consecutive males in the same age range who were admitted to the same hospitals during the same time interval for acute appendicitis (which is common and generally unrelated to traumatic injury). For each participant in the study, the authors used universal health care databases in Canada's single-payer health care system to identify relevant psychiatric diagnoses (attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder) during the decade before admission.
During the study period, 3,421 male teenagers were admitted to hospital as the result of a road traffic crash and 3,812 male teenagers were admitted to hospital for appendicitis. A history of disruptive behavior disorders was significantly more frequent among male teenagers admitted for road traffic crashes than controls (767 of 3,421 versus 664 of 3,812) giving an odds ratio 1.37. This higher risk was still present after the researchers adjusted for possible confounding factors (such as age, social status, and home location) and accounted for about one-in-20 road traffic crashes, including male teenagers who had died and those involved as pedestrians.
What Do These Findings Mean?
The results of this study suggest that disruptive behavior disorders explain a significant amount of road traffic crashes experienced in male teenagers. Overall, attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder are associated with about a one-third increase in the risk of a road traffic crash (which is similar to the relative risk among individuals treated for epilepsy.) As in previous studies in this area, some methodological problems may affect the interpretation of these findings. As this study did not document who was “at fault,” an alternative interpretation might be that behavioral disorders impair a teenager's ability to avoid a mishap initiated by someone else. Most importantly, the observed increase in risk as pedestrians indicates that male teenagers who abstain from driving do not escape the danger of road traffic crashes.
The researchers stress that any increased risk of road traffic crashes associated with disruptive behavior disorders in male teenagers does not justify withholding a driver's license, especially as many such disorders can be effectively treated or, indeed, because it does not address the issue of the increased risk for those teenagers who were pedestrians. Instead, they suggest that disruptive behavior disorders could be considered as contributors to road traffic crashes—analogous to seizure disorders and some other medical diseases. Therefore, greater attention by primary care physicians, psychiatrists, and community health workers might be helpful since interventions can perhaps reduce the risk including medical treatments and avoidance of distractions.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000369.
The World Health Organization has information on road traffic crashes
The US National Institutes of Health has information about behavior disorders in children as well as UK-based Kids Development
The Ontarion Ministry of Transportation has information on annual roadway collisions in Ontario
doi:10.1371/journal.pmed.1000369
PMCID: PMC2981585  PMID: 21125017
3.  Trauma admissions to the Intensive care unit at a reference hospital in Northwestern Tanzania 
Background
Major trauma has been reported to be a major cause of hospitalization and intensive care utilization worldwide and consumes a significant amount of the health care budget. The aim of this study was to describe the characteristics and treatment outcome of major trauma patients admitted into our ICU and to identify predictors of outcome.
Methods
Between January 2008 and December 2010, a descriptive prospective study of all trauma admissions to a multidisciplinary intensive care unit (ICU) of Bugando Medical Centre in Northwestern Tanzania was conducted.
Results
A total of 312 cases of major trauma were admitted in the ICU, representing 37.1% of the total ICU admissions. Males outnumbered females by a ratio of 5.5:1. Their median age was 27 years. Trauma admissions were almost exclusively emergencies (95.2%) and came mainly from the Accident and Emergency (60.6%) and Operating room (23.4%). Road traffic crash (RTC) was the most common cause of injuries affecting 70.8% of patients. Two hundred fourteen patients (68.6%) required surgical intervention. The overall ICU length of stay (LOS) for all trauma patients ranged from 1 to 59 days (median = 8 days). The median ICU length of hospital stay (LOS) for survivors and non-survivors were 8 and 5 days respectively. (P = 0.002). Mortality rate was 32.7%. Mortality rate of trauma patients was significantly higher than that of all ICU admissions (32.7% vs. 18.8%, P = 0.0012). According to multivariate logistic regression analysis, multiple injuries, severe head injuries and burns were responsible for a longer mean ICU stay (P < 0.001) whereas admission Glasgow Coma Score < 9, systolic blood pressure < 90 mmHg, injury severity core >16, prolonged duration of loss of consciousness, delayed ICU admission (0.028), the need for ventilatory support and finding of space occupying lesion on computed tomography scan significantly influenced mortality (P < 0.001).
Conclusion
Trauma resulting from road traffic crashes is a leading cause of intensive care utilization in our hospital. Urgent preventive measures targeting at reducing the occurrence of RTCs is necessary to reduce ICU trauma admissions in this region. Improved pre- and in-hospital care of trauma victims will improve the outcome of trauma patients admitted to our ICU.
doi:10.1186/1757-7241-19-61
PMCID: PMC3214823  PMID: 22024353
Intensive care unit; trauma admissions; prevalence; injury characteristics; outcome; Tanzania
4.  Mortality after road traffic crashes in a system with limited trauma data capability 
Background
Africa has 4% of the global vehicles but accounts for about one tenth of global vehicular deaths. Major trauma in Kenya is associated with excess mortality in comparison with series from trauma centers. The determinants of this mortality have not been completely explored.
Objectives
To determine the factors affecting mortality among road users in Nairobi, Kenya.
Methods
Cross-sectional study of prospectively collected data of trauma admissions at the Kenyatta National Hospital over a calendar year (2009–2010). Information collected included age, gender, road user type, principal anatomical region of injury, admission status, admission blood pressure and GCS, disposition destination, Injury Severity Score (ISS), injuries sustained, treatment and mortality at two weeks. Major or severe injury was defined as injuries of ISS > 15. Groups based on in-hospital survival were compared using determinants of mortality using X2 or students t-test as appropriate. Logistic regression was used to assess the independence of predictive variables.
Results
One thousand six hundred forty seven (1647) patients were admitted for trauma during the study period. Traffic admissions were 1013 (61.7%) and males predominated (79.8%). The average age of patients admitted was 31.7 years. Pedestrians, vehicle occupants and motorcyclists represented 43.3%, 27.2% and 15.2% of the road users injured. The proportion of patients with ISS > 15 was 10.9%.
The overall mortality was 7.7%. Mortality for ISS > 15 was 27.6%. The following factors significantly predicted mortality on univariate analysis: head injury, abdominal injury, transfer in status, blood transfusion, ICU admission, age > 60 years, Glasgow coma scale (GCS) and injury severity. GCS (p = 0.001) and ISS > 15 (p < 0.05) remained significant predictors on regression analysis.
Conclusion
Trauma mortality rates in this study exceed those from mature trauma systems. Head injury and injury severity based on the ISS are independent predictors of mortality after traffic trauma. Improvements in neurosurgical and critical care services ingrained within wider primary and secondary prevention initiatives are logical targets.
doi:10.1186/1752-2897-8-4
PMCID: PMC3937015  PMID: 24524582
5.  Dissecting Inflammatory Complications in Critically Injured Patients by Within-Patient Gene Expression Changes: A Longitudinal Clinical Genomics Study 
PLoS Medicine  2011;8(9):e1001093.
By studying gene expression changes over time in a cohort of trauma patients, Keyur Desai and colleagues identify genes and pathways strongly associated with longer-term complications, which could lead to improved outcome prediction in the first 80 hours after injury.
Background
Trauma is the number one killer of individuals 1–44 y of age in the United States. The prognosis and treatment of inflammatory complications in critically injured patients continue to be challenging, with a history of failed clinical trials and poorly understood biology. New approaches are therefore needed to improve our ability to diagnose and treat this clinical condition.
Methods and Findings
We conducted a large-scale study on 168 blunt-force trauma patients over 28 d, measuring ∼400 clinical variables and longitudinally profiling leukocyte gene expression with ∼800 microarrays. Marshall MOF (multiple organ failure) clinical score trajectories were first utilized to organize the patients into five categories of increasingly poor outcomes. We then developed an analysis framework modeling early within-patient expression changes to produce a robust characterization of the genomic response to trauma. A quarter of the genome shows early expression changes associated with longer-term post-injury complications, captured by at least five dynamic co-expression modules of functionally related genes. In particular, early down-regulation of MHC-class II genes and up-regulation of p38 MAPK signaling pathway were found to strongly associate with longer-term post-injury complications, providing discrimination among patient outcomes from expression changes during the 40–80 h window post-injury.
Conclusions
The genomic characterization provided here substantially expands the scope by which the molecular response to trauma may be characterized and understood. These results may be instrumental in furthering our understanding of the disease process and identifying potential targets for therapeutic intervention. Additionally, the quantitative approach we have introduced is potentially applicable to future genomics studies of rapidly progressing clinical conditions.
Trial Registration
ClinicalTrials.gov NCT00257231
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Trauma—a serious injury to the body caused by violence or by an accident—is a major global health problem. Every year, events that include traffic collisions, falls, blows, and fires cause injuries that kill more than 5 million people (9% of annual global deaths). Road traffic accidents alone are responsible for 1.3 million deaths a year and, if current trends continue, will be the fifth leading cause of death worldwide by 2030. Moreover, in many countries, including the US, trauma is the number one killer of individuals aged 1–44 y. Trauma can kill people rapidly through loss of blood or serious physical damage to internal organs, but it can also lead to localized infections and to sepsis, an infection of the bloodstream that is characterized by an amplified, body-wide (systemic) inflammatory response. Inflammation—redness, pain, and swelling—is an immune system response that normally provides protection against infections, but systemic inflammation can result in multiple organ failure (MOF) and death.
Why Was This Study Done?
Inflammatory complications of trauma are responsible for more than half of late trauma deaths, but at present it is impossible to predict which patients with major injuries will recover and which will spiral down into MOF and death, because the biological processes that underlie post-injury inflammatory complications are poorly understood. If the changes in gene expression (the process that converts the information encoded in genes into functional proteins) that accompany systemic inflammation could be elucidated, it might be possible to improve the diagnosis of MOF and to develop better treatments for post-trauma inflammatory complications. In this prospective, longitudinal clinical genomics study (part of the Inflammation and Host Response to Injury multi-disciplinary research program [IHRI]), the researchers developed an approach to associate early within-patient gene expression changes with later clinical outcomes. A prospective study is one in which patients with a specific condition are enrolled and then followed to see how various factors affect their outcomes; a longitudinal study analyzes multiple samples taken at different times from individual patients; a clinical genomics study investigates how genes and gene expression affect clinical outcomes.
What Did the Researchers Do and Find?
The researchers followed 168 patients for up to 28 d after they experienced blunt-force trauma (injuries caused when the human body hits or is hit by a large object such as a car). Using a molecular biology tool called a DNA microarray, they determined gene expression patterns in leukocytes (a type of immune system cell) isolated from multiple blood samples collected from each patient during the first few days after injury. Using clinical information collected by trained nurses, they organized the patients into five outcome categories based on a measure of MOF known as the Marshall score. Finally, they developed a statistical method (an analysis framework) to associate the early changes in gene expression with clinical outcomes.
A quarter of the patients' genes showed early expression changes that were associated with longer-term post-injury inflammatory complications. Among the associations revealed by this analysis, down-regulation (reduced expression) of MHC-class II genes (which encode proteins involved in antigen presentation, the process by which molecules from foreign invaders are presented to immune cells to initiate an immune response) and up-regulation of genes encoding components of the p38 MAPK signaling pathway (which helps to drive inflammatory responses) between 40 and 80 h post-injury were particularly strongly associated with longer-term post-injury complications and provided the strongest discrimination between patient outcomes.
What Do These Findings Mean?
The statistical approach used in this study to link the early changes in gene expression that occur after trauma to clinical outcomes provides a detailed picture of genome-wide gene expression responses to trauma. These findings could help scientists understand why some patients develop inflammatory complications of trauma while others do not, and they could help to identify those patients most at risk of developing complications. They could also help to identify targets for therapy, although further studies are needed to confirm and extend these findings. Importantly, the quantitative approach developed by the researchers for analyzing associations between within-patient gene changes over time and clinical outcomes should provide more robust predictions of outcomes than single measurements of gene expression and could be applicable to genomic studies of other rapidly progressing clinical conditions.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001093.
More details about the Inflammation and Host Response to Injury research program are available; the program's website includes a link to an article that explains how genomics can be used to understand the inflammatory complications of trauma
The World Health Organization provides information on injuries and on violence and injury prevention (in several languages)
The US National Institutes of Health has a factsheet on burns and traumatic injury in the USA
The US Centers for Disease Control and Prevention has information on injury and violence prevention and control
MedlinePlus provides links to further resources on injuries
doi:10.1371/journal.pmed.1001093
PMCID: PMC3172280  PMID: 21931541
6.  Injury characteristics and outcome of road traffic crash victims at Bugando Medical Centre in Northwestern Tanzania 
Background
Road traffic crash is of growing public health importance worldwide contributing significantly to the global disease burden. There is paucity of published data on road traffic crashes in our local environment. This study was carried out to describe the injury characteristics and outcome of road traffic crash victims in our local setting and provide baseline data for establishment of prevention strategies as well as treatment protocols.
Methods
This was a prospective hospital based study of road traffic crash victims carried out at Bugando Medical Centre in Northwestern Tanzania between March 2010 and February 2011. After informed consent to participate in the study, all patients were consecutively enrolled into the study. Data were collected using a pre-tested questionnaire and analyzed using SPSS computer software version 15.0.
Results
A total of 1678 road traffic crash victims were studied. Their male to female ratio was of 2.1:1. The patients ages ranged from 3 to 78 years with the mean and median of 29.45 (± 24.22) and 26.12 years respectively. The modal age group was 21-30 years, accounting for 52.1% patients. Students (58.8%) and businessmen (35.9%) were the majority of road traffic crash victims. Motorcycle (58.8%) was responsible for the majority of road traffic crashes. Musculoskeletal (60.5%) and the head (52.1%) were the most common body region injured. Open wounds (65.9%) and fractures (26.3%) were the most common type of injuries sustained. The majority of patients (80.3%) were treated surgically. Wound debridement was the most common procedure performed in 81.2% of the patients. The complication rate was 23.7%. The overall average length of hospital stay (LOS) was 23.5 ± 12.3 days. Mortality rate was 17.5%. According to multivariate logistic regression analysis, patients who had severe trauma (Kampala Trauma Score II ≤ 6) and those with long bone fractures stayed longer in the hospital and this was significant (P < 0.001) whereas the age of the patient, severe trauma (Kampala Trauma Score II ≤ 6), admission Systolic Blood Pressure < 90 mmHg and severe head injury (Glasgow Coma Score = 3-8) significantly influenced mortality (P < 0.001).
Conclusion
Road traffic crashes constitute a major public health problem in our setting and contribute significantly to unacceptably high morbidity and mortality. Urgent preventive measures targeting at reducing the occurrence of road traffic crashes is necessary to reduce the morbidity and mortality resulting from these injuries. Early recognition and prompt treatment of road traffic injuries is essential for optimal patient outcome.
doi:10.1186/1752-2897-6-1
PMCID: PMC3292995  PMID: 22321248
Road traffic crashes; Victims; Injury characteristics; Outcome; Tanzania
7.  Delayed Traumatic Intracranial Haemorrhage and Progressive Traumatic Brain Injury in a Major Referral Centre Based in a Developing Country 
A repeat Computer Tomographic (CT) brain after 24–48 hours from the 1st scanning is usually practiced in most hospitals in South East Asia where intracranial pressure monitoring (ICP) is routinely not done. This interval for repeat CT would be shortened if there was a deterioration in Glasgow Coma Scale (GCS). Most of the time the prognosis of any intervention may be too late especially in hospitals with high patient-to-doctor ratio causing high mortality and morbidity. The purpose of this study was to determine the important predictors for early detection of Delayed Traumatic Intracranial Haemorrhage (DTICH) and Progressive Traumatic Brain Injury (PTBI) before deterioration of GCS occurred, as well as the most ideal timing of repeated CT brain for patients admitted in Malaysian hospitals. A total of 81 patients were included in this study over a period of six months. The CT scan brain was studied by comparing the first and second CT brain to diagnose the presence of DTICH/PTBI. The predictors tested were categorised into patient factors, CT brain findings and laboratory investigations. The mean age was 33.1 ± 15.7 years with a male preponderance of 6.36:1. Among them, 81.5% were patients from road traffic accidents with Glasgow Coma Scale ranging from 4 – 15 (median of 12) upon admission. The mean time interval delay between trauma and first CT brain was 179.8 ± 121.3 minutes for the PTBI group. The DTICH group, 9.9% of the patients were found to have new intracranial clots. Significant predictors detected were different referral hospitals (p=0.02), total GCS status (p=0.026), motor component of GCS (p=0.043), haemoglobin level (p<0.001), platelet count (p=0.011) and time interval between trauma and first CT brain (p=0.022). In the PTBI group, 42.0% of the patients were found to have new changes (new clot occurrence, old clot expansion and oedema) in the repeat CT brain. Univariate statistical analysis revealed that age (p=0.03), race (p=0.035), types of admission (p=0.024), GCS status (p=0.02), pupillary changes (p=0.014), number of intracranial lesion (p=0.004), haemoglobin level (p=0.038), prothrombin time (p=0.016) as the best predictors of early detection of changes. Multiple logistics regression analysis indicated that age, severity, GCS status (motor component) and GCS during admission were significantly associated with second CT scan with changes. This study showed that 9.9% of the total patients seen in the period of study had DTICH and 42% had PTBI. In the early period after traumatic head injury, the initial CT brain did not reveal the full extent of haemorrhagic injury and associated cerebral oedema. Different referral hospitals of different trauma level, GCS status, motor component of the GCS, haemoglobin level, platelet count and time interval between trauma and the first CT brain were the significant predictors for DTICH. Whereas the key determinants of PTBI were age, race, types of admission, GCS status, pupillary changes, number of intracranial bleed, haemoglobin level, prothrombin time and of course time interval between trauma and first CT brain. Any patients who had traumatic head injury in hospitals with no protocol of repeat CT scan or intracranial pressure monitoring especially in developing countries are advised to have to repeat CT brain at the appropriate quickest time .
PMCID: PMC3341922  PMID: 22589639
delayed; intracranial; haemorrhage; progressive brain injury; computer tomographic scan
8.  Chest trauma experience over eleven-year period at al-mouassat university teaching hospital-Damascus: a retrospective review of 888 cases 
Background
Thoracic trauma is one of the leading causes of morbidity and mortality in developing countries. In this study, we present our 11-year experience in the management and clinical outcome of 888 chest trauma cases as a result of blunt and penetrating injuries in our university hospital in Damascus, Syria.
Methods
We reviewed files of 888 consequent cases of chest trauma between January 2000 and January 2011. The mean age of our patients was 31 ± 17 years mostly males with blunt injuries. Patients were evaluated and compared according to age, gender, etiology of trauma, thoracic and extra-thoracic injuries, complications, and mortality.
Results
The leading cause of the trauma was violence (41%) followed by traffic accidents (33%). Pneumothorax (51%), Hemothorax (38%), rib fractures (34%), and lung contusion (15%) were the most common types of injury. Associated injuries were documented in 36% of patients (extremities 19%, abdomen 13%, head 8%). A minority of the patients required thoracotomy (5.7%), and tube thoracostomy (56%) was sufficient to manage the majority of cases. Mean hospital LOS was 4.5 ± 4.6 days. The overall mortoality rate was 1.8%, and morbidity (n = 78, 8.7%).
Conclusions
New traffic laws (including seat belt enforcement) reduced incidence and severity of chest trauma in Syria. Violence was the most common cause of chest trauma rather than road traffic accidents in this series, this necessitates epidemiologic or multi-institutional studies to know to which degree violence contributes to chest trauma in Syria. The number of fractured ribs can be used as simple indicator of the severity of trauma. And we believe that significant neurotrauma, traffic accidents, hemodynamic status and GCS upon arrival, ICU admission, ventilator use, and complication of therapy are predictors of dismal prognosis.
doi:10.1186/1749-8090-7-35
PMCID: PMC3379930  PMID: 22515842
Chest trauma; Rib fractures; Traffic accident; Blunt injury; Penetrating injury
9.  Pattern and outcome of chest injuries at Bugando Medical Centre in Northwestern Tanzania 
Background
Chest injuries constitute a continuing challenge to the trauma or general surgeon practicing in developing countries. This study was conducted to outline the etiological spectrum, injury patterns and short term outcome of these injuries in our setting.
Patients and methods
This was a prospective study involving chest injury patients admitted to Bugando Medical Centre over a six-month period from November 2009 to April 2010 inclusive.
Results
A total of 150 chest injury patients were studied. Males outnumbered females by a ratio of 3.8:1. Their ages ranged from 1 to 80 years (mean = 32.17 years). The majority of patients (72.7%) sustained blunt injuries. Road traffic crush was the most common cause of injuries affecting 50.7% of patients. Chest wall wounds, hemothorax and rib fractures were the most common type of injuries accounting for 30.0%, 21.3% and 20.7% respectively. Associated injuries were noted in 56.0% of patients and head/neck (33.3%) and musculoskeletal regions (26.7%) were commonly affected. The majority of patients (55.3%) were treated successfully with non-operative approach. Underwater seal drainage was performed in 39 patients (19.3%). One patient (0.7%) underwent thoracotomy due to hemopericardium. Thirty nine patients (26.0%) had complications of which wound sepsis (14.7%) and complications of long bone fractures (12.0%) were the most common complications. The mean LOS was 13.17 days and mortality rate was 3.3%. Using multivariate logistic regression analysis, associated injuries, the type of injury, trauma scores (ISS, RTS and PTS) were found to be significant predictors of the LOS (P < 0.001), whereas mortality was significantly associated with pre-morbid illness, associated injuries, trauma scores (ISS, RTS and PTS), the need for ICU admission and the presence of complications (P < 0.001).
Conclusion
Chest injuries resulting from RTCs remain a major public health problem in this part of Tanzania. Urgent preventive measures targeting at reducing the occurrence of RTCs is necessary to reduce the incidence of chest injuries in this region.
doi:10.1186/1749-8090-6-7
PMCID: PMC3033810  PMID: 21244706
10.  Childhood motocross truncal injuries: high-velocity, focal force to the chest and abdomen 
BMJ Open  2012;2(6):e001848.
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.
doi:10.1136/bmjopen-2012-001848
PMCID: PMC3533044  PMID: 23166134
11.  Computed tomography for pancreatic injuries in pediatric blunt abdominal trauma 
AIM: To evaluate the efficacy of computed tomography scan in diagnosing and grading the pattern of pancreatic injuries in children.
METHODS: We conducted a retrospective study to review medical files of children admitted with blunt pancreatic injuries to the Maternity and Children Hospital Al-Madina Al-Munawwarah, Kingdom of Saudi Arabia. The demographic details and mechanisms of injury were recorded. From the database of the Picture Archiving and Communication System of the radiology department, multidetector computed tomography (MDCT) images of the pancreatic injuries, severity, type of injuries and grading of pancreatic injuries were established.
RESULTS: Seven patients were recruited in this study over a period of 5 years; 5 males and 2 females with a mean age of 7 years (age range 5-12 years). Fall from height was the most frequent mechanism of injury, reported in 5 (71%), followed by road traffic accident (1 patient, 14%) and cycle handlebar (1 patient, 14%) injuries. According to the American Association for the Surgery of Trauma grading system, 1 (14%) patient sustained Grade I, 1 (14%) Grade II, 3 (42%) Grade III and 2 (28%) patients were found to have Grade V pancreatic injuries. This indicated a higher incidence of severe pancreatic injuries; 5 (71.4%) patients were reported to have Grade III and higher on the injury scale. Three (42%) patients had associated abdominal organ injuries.
CONCLUSION: Pediatric pancreatic injuries due to blunt abdominal trauma are rare. The majority of the patients sustained extensive pancreatic injuries. MDCT findings are helpful and reliable in diagnosing and grading the pancreatic injuries.
doi:10.4240/wjgs.v4.i7.166
PMCID: PMC3420983  PMID: 22905284
Pediatric abdominal injuries; Pancreatic hematoma; Pancreatic laceration; Pancreatic transaction
12.  Demographic profile and outcome analysis of pediatric intensive care patients 
Hippokratia  2011;15(4):316-322.
Background: Demographic profile and outcome can vary in pediatric intensive care unit (PICU) patients. The aim of our study was to analyze demographic profile and outcome in a Greek PICU.
Methods: Prospective observational study. Data collected: demographic profile; co morbidities; source and diagnosis at admission; Pediatric Risk of Mortality (PRISM III-24); Glasgow Coma Scale (GCS, pediatric); Injury Severity Score (ISS); procedures; treatment; mechanical ventilation (MV); MV days; length of stay (LOS) and the outcome at PICU discharge. Statistical analysis: Student’s t-test; Mann-Whitney U test; Kruskall-Wallis test; χ2 criterion with relative risk (RR) estimation; Cox regression analysis; as appropriate. Values are mean ± SD, p < 0.05.
Results: 300 patients (196 boys/104 girls), aged 54.26 ± 49.93 months, were admitted due to respiratory failure (22.3%), head trauma (15.3%), seizures (13.7%), coma (9.7%), postoperative care (7.7%), polytrauma (7%), accidents (5.3%), sepsis-septic shock (5.3%), cardiovascular diseases (4.7%), metabolic diseases (3.3%), multiple organ failure syndrome (3%) and miscellaneous diseases (2.7%). PRISM III-24 score was 8.97 ± 7.79 and predicted mortality rate was 11.16% ± 18.65. MV rate was 67.3% (58.3% at admission) for 6.54 ± 14.45 days, LOS 8.85 ± 23.28 days and actual PICU mortality rate 9.7%. Patients who died had statistically worse severity scores. Significant mortality risk factors were inotropic use, PRISM III-24 > 8, MV, arterial and central venous catheterization, nosocomial infections, complications, and cancer. COX regression analysis showed that PRISM III-24 score and inotropic use were independent predictors of mortality.
Conclusions: Demographic profile followed similar patterns to relevant studies while there were major differences in case mix and the severity of the disease. Mortality rate (9.7%) was relatively high but better than predicted and in accordance with the characteristics of our population.
PMCID: PMC3876846  PMID: 24391412
pediatric intensive care unit; pediatric risk of mortality PRISM III-24; mortality; mortality risk factors
13.  Variability of ICU Use in Adult Patients With Minor Traumatic Intracranial Hemorrhage 
Annals of emergency medicine  2012;61(5):10.1016/j.annemergmed.2012.08.024.
Study objective
Patients with minor traumatic intracranial hemorrhage are frequently admitted to the ICU, although many never require critical care interventions. To describe ICU resource use in minor traumatic intracranial hemorrhage, we assess (1) the variability of ICU use in a cohort of patients with minor traumatic intracranial hemorrhage across multiple trauma centers, and (2) the proportion of adult patients with traumatic intracranial hemorrhage who are admitted to the ICU and never receive a critical care intervention during hospitalization. In addition, we evaluate the association between ICU admission and key independent variables.
Methods
A structured, historical cohort study of adult patients (aged 18 years and older) with minor traumatic intracranial hemorrhage was conducted within a consortium of 8 Level I trauma centers in the western United States from January 2005 to June 2010. The study population included patients with minor traumatic intracranial hemorrhage, defined as an emergency department (ED) Glasgow Coma Scale (GCS) score of 15 (normal mental status) and an Injury Severity Score less than 16 (no other major organ injury). The primary outcome measure was initial ICU admission. The secondary outcome measure was a critical care intervention during hospitalization. Critical care interventions included mechanical ventilation, neurosurgical intervention, transfusion of blood products, vasopressor or inotrope administration, and invasive hemodynamic monitoring. ED disposition and the proportion of ICU patients not receiving a critical care intervention were compared across sites with descriptive statistics. The association between ICU admission and predetermined independent variables was analyzed with multivariable regression.
Results
Among 11,240 adult patients with traumatic intracranial hemorrhage, 1,412 (13%) had minor traumatic intracranial hemorrhage and complete ED disposition data (mean age 48 years; SD 20 years). ICU use within this cohort across sites ranged from 50% to 97%. Overall, 847 of 888 patients (95%) with minor traumatic intracranial hemorrhage who were admitted to the ICU did not receive a critical care intervention during hospitalization (range between sites 80% to 100%). Three of 524 (0.6%) patients discharged home or admitted to the observation unit or ward received a critical care intervention. After controlling for severity of injury (age, blood pressure, and Injury Severity Score), study site was independently associated with ICU admission (odds ratios ranged from 1.5 to 30; overall effect P<.001).
Conclusion
Across a consortium of trauma centers in the western United States, there was wide variability in ICU use within a cohort of patients with minor traumatic intracranial hemorrhage. Moreover, a large proportion of patients admitted to the ICU never required a critical care intervention, indicating the potential to improve use of critical care resources in patients with minor traumatic intracranial hemorrhage.
doi:10.1016/j.annemergmed.2012.08.024
PMCID: PMC3880139  PMID: 23021347
14.  Chest Injuries Associated with Head Injury 
Background:
Although there have been significant advances in the management of traumatic brain injury (TBI), associated severe injuries, in particular chest injuries, remain a major challenge. This paper analyses the contribution of chest injuries to the outcome of head injuries in the University of Nigeria Teaching Hospital (UNTH) and the Memfys Hospital for Neurosurgery (MHN) in Enugu, Nigeria.
Materials and Methods:
This is a retrospective review of the medical records, operative notes, and radiological findings of all patients admitted for head injury who had associated significant chest injuries in the MHN from 2002 to 2009 and the UNTH between 2007 and 2010. Patients with only head injury and other extracranial injury not affecting the chest were excluded. Patients who were inadequately investigated were also excluded.
Results:
Nineteen patients from the MHN and 11 patients from the UNTH were analyzed. Ages ranged from 9 to 65 years and the male:female ratio was 3:1. Injuries were most common between 30 and 50 years and road traffic accident accounted for 60%. Barotrauma from ventilation was documented in 2 patients. The commonest types of intrathoracic injuries are pneumothorax and hemothorax. Chest wall injuries are more common but carry less morbidity and mortality. Only 20% of patients presented within 48 hours of injury. Management of the associated chest trauma commenced in the referring hospitals only in 26.4% of the patients. All patients with hemo-pneumothorax had tube thoracostomy as did 96% of patients with pneumothorax. 10% of patients with haemothorax needed thoracotomy. Mortality is 43%, which is higher than for patients with only TBI with comparable Glasgow coma scale. Outcome is influenced by the time to admission and the GCS on admission.
Conclusion:
Associated chest injuries result in higher mortality from head injuries. This association is more likely in the young and more productive. All patients presenting with head and spinal cord injury should be specifically and carefully evaluated for associated chest injuries. Computerized tomographic has not replaced the need for good quality chest radiograph in the emergency management of Head Injury associated chest trauma.
doi:10.4103/1117-6806.95473
PMCID: PMC3716241  PMID: 24027384
Chest injuries; head injuries; outcome
15.  Injuries associated with cycle rickshaws accidents 
Context:
Cycle rickshaw is an important means of transportation in Urban India. Pedestrians, rickshaw users, rickshaw pullers, two wheeled vehicle users and cyclists are among the most vulnerable road user groups in terms of injuries and fatalities resulting from road traffic accidents in India. Our objectives were to study characteristics of crashes and nature of injuries associated with cycle rickshaw.
Patients and Methods:
Between August 2008 to July 2009, a hospital based observational study was done of patients who presented to King George medical college trauma center with injury sustained due to cycle rickshaw in emergency department. Age, time of trauma, mode of trauma, contributing factors and type of injury were recorded.
Results:
The mean age of the patient was 32.1. Seventeen patients were rickshaw pullers and the rest were occupants of the rickshaw. Overloading with more than two passengers was found in 24 cases (28.5%). Most common cause of injury was collision with a moving vehicle (56 patients, %) followed by fall from rickshaw. The most common contributing factor was the overloading of rickshaw. On arrival to the hospital, the mean Injury severity score (ISS) was 3.5 ± 2.2 and the mean Glasgow coma scale (GCS) was 13.4 ± 4.3. Nine patients were admitted to ICU (Intensive care unit). The median ICU stay was 4 (1-24 days). Six of the ICU admitted patients had head injury.
Conclusion:
Rickshaw pullers and occupants are vulnerable to road traffic accidents. Urgent preventive measures targeted towards this group are needed to reduce the morbidity and mortality resulting from injuries involving rickshaws. The need for improved understanding of the risk characteristics of cycle rickshaw is emphasized.
doi:10.4103/0974-2700.130874
PMCID: PMC4013740  PMID: 24812450
Bicycle; crashes; injury; rickshaw; trauma
16.  Acute Care Clinical Indicators Associated with Discharge Outcomes in Children with Severe Traumatic Brain Injury 
Critical care medicine  2014;42(10):2258-2266.
Objective
The relationship between acute care clinical indicators in the first severe Pediatric traumatic brain injury (TBI) Guidelines and outcomes have not been examined. We aimed to develop a set of acute care guideline-influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes.
Design
Retrospective multicenter cohort study
Setting
Five regional pediatric trauma centers affiliated with academic medical centers.
Patients
Children under 17 years with severe TBI (admission Glasgow coma scale (GCS) score ≤ 8, ICD-9 diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head abbreviated injury severity score ≥ 3) who received tracheal intubation for at-least 48 hours in the intensive care unit (ICU) between 2007 -2011 were examined.
Interventions
None
Measurements and Main Results
Total percent adherence to the clinical indicators across all treatment locations (pre-hospital [PH], emergency department [ED], operating room [OR], and intensive care unit [ICU]) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow outcome scale (GOS) score.
Total adherence rate across all locations and all centers ranged from 68-78%. Clinical indicators of adherence were associated with survival (aHR 0.94; 95 % CI 0.91, 0.96). Three indicators were associated with survival: absence of PH hypoxia (aHR 0.20; 95% CI 0.08, 0.46), early ICU start of nutrition (aHR 0.06; 95% CI 0.01, 0.26), and ICU PaCO2 >30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (aHR 0.22; 95% CI 0.06, 0.8). Clinical indicators of adherence were associated with favorable GOS among survivors, (aHR 0.99; 95% CI 0.98, 0.99). Three indicators were associated with favorable discharge GOS: all OR CPP >40 mm Hg (aRR 0.64; 95% CI 0.55, 0.75), all ICU CPP > 40mm Hg (aRR 0.74; 95% CI 0.63, 0.87), and no surgery (any type; aRR 0.72; 95% CI 0.53, 0.97).
Conclusions
Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge GOS. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe TBI.
doi:10.1097/CCM.0000000000000507
PMCID: PMC4167478  PMID: 25083982
pediatrics; trauma; brain injury; indicators; outcomes; injury
17.  Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation 
Journal of neurosurgery  2009;111(4):683-687.
Object
A Glasgow Coma Scale (GCS) score of 3 on presentation in patients with severe traumatic brain injury due to blunt trauma has been recognized as a bad prognostic factor. The reported mortality rate in these patients is very high, even approaching 100% in the presence of fixed and dilated pupils in some series. Consequently, there is often a tendency to treat these patients less aggressively because of the low expectations for a good recovery. In this paper, the authors’ purpose is to report their experience in the management of this patient population, analyzing the mortality rate, prognostic factors, and functional outcome of survivors.
Methods
The authors performed a retrospective review of patients who presented between 1997 and 2007 with blunt head trauma and a GCS score of 3. Demographics, mechanism of injury, examination, blood alcohol level, associated injury, intracranial pressure (ICP), surgical procedures, and outcome were all recorded.
Results
A total of 189 patients met the inclusion criteria and were included in this study. The overall mortality rate was 49.2%. At the 6-month follow-up, 13.2% of the entire series achieved a good functional outcome (Glasgow Outcome Scale [GOS] score of 1 or 2).
The patient population was then divided into 2 groups: Group 1 (patients who survived [96]) and Group 2 (patients who died [93]). Patients in Group 1 were younger (mean 33.3 ± 12.8 vs 40.3 ± 16.97 years; p = 0.002) and had lower ICP on admission (mean 16.3 ± 11.1 vs 25.7 ± 12.7 mm Hg; p < 0.001) than those in Group 2. The difference between the 2 groups regarding sex, mechanism of injury, hypotension on admission, alcohol, surgery, and associated injuries was not statistically significant.
The presence of bilateral fixed, dilated pupils was found to be associated with the highest mortality rate (79.7%). Although not statistically significant because of the sample size, pupil status was also a good predictor of the functional outcome at the 6-month follow-up; a good functional outcome (GOS Score 1 or 2) was achieved in 25.5% of patients presenting with bilateral reactive pupils, and 27.6% of patients presenting with a unilateral fixed, dilated pupil, compared with 7.5% for those presenting with bilateral fixed, nondilated pupils, and 1.4% for patients with bilateral fixed, dilated pupils.
Conclusions
Overall, 50.8% of patients survived their injury and 13.2% achieved a good functional outcome afterat 6 months of follow-up (GOS Score 1 or 2). Age, ICP on admission, and pupil status were found to be significant predictive factors of outcome. In particular, pupil size and reactivity appeared to be the most important prognostic factor since the mortality rate was 23.5% in the presence of bilateral reactive pupils and 79.7% in the case of bilateral fixed, dilated pupils. The authors believe that patients having suffered traumatic brain injury and present with a GCS score of 3 should still be treated aggressively initially since a good functional outcome can be obtained in some cases.
doi:10.3171/2009.2.JNS08817
PMCID: PMC2798060  PMID: 19326973
blunt head injury; Glasgow Coma Scale; outcome
18.  Prospective study of post-traumatic stress disorder in children involved in road traffic accidents 
BMJ : British Medical Journal  1998;317(7173):1619-1623.
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
PMCID: PMC28739  PMID: 9848900
19.  Profiling genitourinary injuries in United Arab Emirates 
Background:
The epidemiology of genitourinary (GU) organ injury following general trauma is not well-studied especially in the Middle East.
Patients and Methods:
All patients with GU injuries from the Trauma Registry of Al-Ain Hospital were studied. The registry data was prospectively collected from March 2003 to March 2006.
Results:
Out of 2573 patients in the registry, 22 had GU injuries (incidence: 0.9%, 2.0 per 100,000 inhabitants per year). Road traffic collision was the most frequent mechanism of injury (50% of all cases). 41% of injuries were renal. In 73% of patients, GU injuries were associated with other organ injuries, the most frequent of which were injuries to the other abdominal and pelvic organs (94%). The mean Injury Severity Score, mean total hospital stay, the percentage of patients who required intensive care unit (ICU) admission were higher in patients with GU injuries compared to non-GU patients (17.1 vs. 5.5 (P 0.001), 15.4 vs. 9.2 days (P 0.040) and 43% vs. 8%, (P 0.0001), respectively.
Conclusions:
The incidence of trauma-related GU injuries in the current study appears to be comparable to those reported from the West. Patients with GU organ injuries tend to have more severe trauma compared to other patients. Road traffic collision was the most common mechanism of injury and the kidney was the most frequently injured organ.
doi:10.4103/0974-2700.83860
PMCID: PMC3162701  PMID: 21887022
Genitourinary injuries; Gulf region; trauma
20.  Red Blood Cell Transfusion and Mortality in Trauma Patients: Risk-Stratified Analysis of an Observational Study 
PLoS Medicine  2014;11(6):e1001664.
Using a large multicentre cohort, Pablo Perel and colleagues evaluate the association of red blood cell transfusion with mortality according to the predicted risk of death for trauma patients.
Please see later in the article for the Editors' Summary
Background
Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death.
Methods and Findings
A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: <6%, 6%–20%, 21%–50%, and >50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (p-value for interaction <0.0001). Transfusion was associated with an increase in all-cause mortality among patients with <6% and 6%–20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08–7.13, p<0.0001, and OR 2.31, 95% CI 1.96–2.73, p<0.0001, respectively), but with a decrease in all-cause mortality in patients with >50% predicted risk of death (OR 0.59, 95% CI 0.47–0.74, p<0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05–3.24, p<0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (<6%) predicted risk of death (p-value for interaction <0.0001). As this was an observational study, the results could have been affected by different types of confounding. In addition, we could not consider haemoglobin in our analysis. In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar.
Conclusions
The association of transfusion with all-cause mortality appears to vary according to the predicted risk of death. Transfusion may reduce mortality in patients at high risk of death but increase mortality in those at low risk. The effect of transfusion in low-risk patients should be further tested in a randomised trial.
Trial registration
www.ClinicalTrials.gov NCT01746953
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Trauma—a serious injury to the body caused by violence or an accident—is a major global health problem. Every year, injuries caused by traffic collisions, falls, blows, and other traumatic events kill more than 5 million people (9% of annual global deaths). Indeed, for people between the ages of 5 and 44 years, injuries are among the top three causes of death in many countries. Trauma sometimes kills people through physical damage to the brain and other internal organs, but hemorrhage (serious uncontrolled bleeding) is responsible for 30%–40% of trauma-related deaths. Consequently, early trauma care focuses on minimizing hemorrhage (for example, by using compression to stop bleeding) and on restoring blood circulation after blood loss (health-care professionals refer to this as resuscitation). Red blood cell (RBC) transfusion is often used for the management of patients with trauma who are bleeding; other resuscitation products include isotonic saline and solutions of human blood proteins.
Why Was This Study Done?
Although RBC transfusion can save the lives of patients with trauma who are bleeding, there is considerable uncertainty regarding the balance of risks and benefits associated with this procedure. RBC transfusion, which is an expensive intervention, is associated with several potential adverse effects, including allergic reactions and infections. Moreover, blood supplies are limited, and the risks from transfusion are high in low- and middle-income countries, where most trauma-related deaths occur. In this study, which is a secondary analysis of data from a trial (CRASH-2) that evaluated the effect of tranexamic acid (which stops excessive bleeding) in patients with trauma, the researchers test the hypothesis that RBC transfusion may have a beneficial effect among patients at high risk of death following trauma but a harmful effect among those at low risk of death.
What Did the Researchers Do and Find?
The CRASH-2 trail included 20,127 patients with trauma and major bleeding treated in 274 hospitals in 40 countries. In their risk-stratified analysis, the researchers investigated the effect of RBC transfusion on CRASH-2 participants with a predicted risk of death (estimated using a validated model that included clinical variables such as heart rate and blood pressure) on admission to hospital of less than 6%, 6%–20%, 21%–50%, or more than 50%. That is, the researchers compared death rates among patients in each stratum of predicted risk of death who received a RBC transfusion with death rates among patients who did not receive a transfusion. Half the patients received at least one transfusion. Transfusion was associated with an increase in all-cause mortality at 28 days after trauma among patients with a predicted risk of death of less than 6% or of 6%–20%, but with a decrease in all-cause mortality among patients with a predicted risk of death of more than 50%. In absolute figures, compared to no transfusion, RBC transfusion was associated with 5.1 more deaths per 100 patients in the patient group with the lowest predicted risk of death but with 11.9 fewer deaths per 100 patients in the group with the highest predicted risk of death.
What Do These Findings Mean?
These findings show that RBC transfusion is associated with an increase in all-cause deaths among patients with trauma and major bleeding with a low predicted risk of death, but with a reduction in all-cause deaths among patients with a high predicted risk of death. In other words, these findings suggest that the effect of RBC transfusion on all-cause mortality may vary according to whether a patient with trauma has a high or low predicted risk of death. However, because the participants in the CRASH-2 trial were not randomly assigned to receive a RBC transfusion, it is not possible to conclude that receiving a RBC transfusion actually increased the death rate among patients with a low predicted risk of death. It might be that the patients with this level of predicted risk of death who received a transfusion shared other unknown characteristics (confounders) that were actually responsible for their increased death rate. Thus, to provide better guidance for clinicians caring for patients with trauma and hemorrhage, the hypothesis that RBC transfusion could be harmful among patients with trauma with a low predicted risk of death should be prospectively evaluated in a randomised controlled trial.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001664.
This study is further discussed in a PLOS Medicine Perspective by Druin Burch
The World Health Organization provides information on injuries and on violence and injury prevention (in several languages)
The US Centers for Disease Control and Prevention has information on injury and violence prevention and control
The National Trauma Institute, a US-based non-profit organization, provides information about hemorrhage after trauma and personal stories about surviving trauma
The UK National Health Service Choices website provides information about blood transfusion, including a personal story about transfusion after a serious road accident
The US National Heart, Lung, and Blood Institute also provides detailed information about blood transfusions
MedlinePlus provides links to further resources on injuries, bleeding, and blood transfusion (in English and Spanish)
More information in available about CRASH-2 (in several languages)
doi:10.1371/journal.pmed.1001664
PMCID: PMC4060995  PMID: 24937305
21.  Multiple trauma in children: predicting outcome and long-term results 
Canadian Journal of Surgery  2002;45(2):126-131.
Objective
To analyze the management of pediatric trauma and the efficacy of the Pediatric Trauma Score (PTS) in classifying injury severity and predicting prognosis.
Design
A retrospective case series.
Setting
The Children’s Hospital of Eastern Ontario, a major pediatric trauma centre.
Patients
One hundred and forty-nine traumatized children with 2 or more injuries to 1 body system or a single injury to 2 or more body systems.
Interventions
Use of the PTS and Glasgow Coma Scale score in trauma management.
Main outcome measures
Types of injuries sustained, complications, missed injuries, psychosocial effects and residual deficiencies.
Results
The average PTS was 8.5 (range from −3 to 11). The total number of injuries sustained was 494, most commonly closed head injury (86). Forty-two percent of children with an average trauma score of 8.5 were treated surgically. There were 13 missed injuries, and complications were encountered in 57 children, the most common being secondary to fractures. Forty-eight (32%) children had residual long-term deficiency, most commonly neurologic deficiency secondary to head injury.
Conclusions
Fractures should be stabilized early to decrease long-term complications. A deficiency of the PTS is the weighting of open fractures of a minor bone. For example, metacarpal fracture is given the same weight as an open fracture of the femur. Neuropsychologic difficulties secondary to trauma are a major sequela of trauma in children.
PMCID: PMC3686935  PMID: 11939656
22.  Comorbidity-Polypharmacy Score: A Novel Adjunct In Post-Emergency Department Trauma Triage 
The Journal of surgical research  2012;181(1):16-19.
OBJECTIVE
Post-emergency department (ED) triage of older trauma patients continues to be challenging as morbidity and mortality for any given level of injury severity tend to increase with age. The Comorbidity-Polypharmacy Score (CPS) combines the number of pre-injury medications with the number of comorbidities to estimate the severity of co-morbid conditions. This retrospective study examines the relationship between CPS and triage accuracy for older (≥45 years) patients admitted for traumatic injury.
METHODS
Patients ≥ 45 years old presenting to level 1 trauma center from 2005 to 2008 were included. Basic data included patient demographics, injury severity score (ISS), morbidity/mortality, and functional outcome measures. CPS was calculated by adding total numbers of co-morbid conditions and pre-injury medications. Patients were divided into 3 triage groups: undertriage, appropriate triage, and over-triage. Under-triage criteria included initial admission to the floor or step-down unit followed by an unplanned transfer to ICU within 24 hours of admission. Over-triage was defined as initial ICU admission for <1 day without stated need for ICU level of care (i.e., lack of evidence for tracheal intubation/mechanical ventilation, injury-related hemorrhage, or other traditional ICU indications such as intracranial bleeding). All other patients were presumed to be correctly triaged. The three triage groups were then analyzed looking for contributors to mis-triage.
RESULTS
Charts for 711 patients were evaluated (mean age 63.5, 55.7% male, mean ISS 9.02). Of those, 11 (1.55%) met criteria for “under-triage” and 14 (1.97%) were “over-triaged”. The remaining 686 patients had no evidence of mis-triage. The three groups were similar in terms of injury severity and age. The groups were significantly different with respect to CPS, with undertriage CPS scores (14.9±6.80) being nearly three times higher than the overtriage CPS scores (5.14±3.48). There were more similarities between appropriate and overtriage groups, with the undertriage group being characterized by greater number of complications, and lower functional outcomes at discharge (all, p<0.05). The undertriage group had significantly higher mortality (27%) than the appropriate and over-triage groups (6% and 0%, respectively).
CONCLUSION
In the era of medication reconciliation, the CPS is easy to obtain and calculate in patients who are not critically injured. This study suggests that CPS may be a promising adjunct in identifying older trauma patients who are more likely to be under-triaged. The significance of our findings is especially important when considering that injury severity in the undertiage group was similar to injury severity in the other groups. Further evaluation of CPS as a triage tool in acute trauma is warranted.
doi:10.1016/j.jss.2012.05.042
PMCID: PMC3717608  PMID: 22683074
Trauma triage; Level of care; Undertriage; Overtriage; Older trauma patient; Comorbidity-polypharmacy score
23.  Paediatric injuries at Bugando Medical Centre in Northwestern Tanzania: a prospective review of 150 cases 
Background
Injuries continue to be the leading cause of death and disability for children. The is a paucity of published data on paediatric injuries in our local environment. This study describes the etiological spectrum, injury characteristics and treatment outcome of paediatric injuries in our local setting and provides baseline data for establishment of prevention strategies as well as treatment guidelines.
Methods
This was a descriptive cross-sectional study involving paediatric injury patients admitted to Bugando Medical Centre from August 2011 to April 2012. Statistical data analysis was done using SPSS version 17.0 and STATA version 12.0.
Results
A total of 150 patients were studied. The age of patients ranged from 1 month to 10 years with a median age of 5 years. The male to female ratio was 2.3:1. Road traffic accident was the most common cause of injury (39.3%) and motorcycle (71.2%) was responsible for the majority of road traffic accidents. Only 11 (7.3%) patients received pre-hospital care. The head /neck (32.7%) and musculoskeletal (28.0%) were the most frequent body region injured. Open wounds (51.4%), foreign bodies (31.3%) and fractures (17.3%) were the most common type of injuries sustained. The majority of patients 84 (56.0%) were treated surgically. Complication rate was 3.9%. The mean duration of hospitalization was 9.7 ± 13.1 days. Mortality rate was 12.7%. Age of the patient (< 5 years), late presentation and presence of complications were the main predictors of length of hospital stay (P < 0.001), whereas burn injuries, severe head injuries and severity of injury (Paediatric trauma score = 0–5) significantly predicted mortality (P < 0.0001).
Conclusion
Paediatric injuries resulting from road traffic accidents (RTAs) remain a major public health problem in this part of Tanzania. Urgent preventive measures targeting at reducing the occurrence of RTAs is necessary to reduce the incidence of paediatric injuries in this region.
doi:10.1186/1752-2897-7-10
PMCID: PMC3833645  PMID: 24499558
Paediatric injuries; Etiological spectrum; Injury characteristics; Treatment outcome; Tanzania
24.  Predicting Outcome after Traumatic Brain Injury: Development and International Validation of Prognostic Scores Based on Admission Characteristics 
PLoS Medicine  2008;5(8):e165.
Background
Traumatic brain injury (TBI) is a leading cause of death and disability. A reliable prediction of outcome on admission is of great clinical relevance. We aimed to develop prognostic models with readily available traditional and novel predictors.
Methods and Findings
Prospectively collected individual patient data were analyzed from 11 studies. We considered predictors available at admission in logistic regression models to predict mortality and unfavorable outcome according to the Glasgow Outcome Scale at 6 mo after injury. Prognostic models were developed in 8,509 patients with severe or moderate TBI, with cross-validation by omission of each of the 11 studies in turn. External validation was on 6,681 patients from the recent Medical Research Council Corticosteroid Randomisation after Significant Head Injury (MRC CRASH) trial. We found that the strongest predictors of outcome were age, motor score, pupillary reactivity, and CT characteristics, including the presence of traumatic subarachnoid hemorrhage. A prognostic model that combined age, motor score, and pupillary reactivity had an area under the receiver operating characteristic curve (AUC) between 0.66 and 0.84 at cross-validation. This performance could be improved (AUC increased by approximately 0.05) by considering CT characteristics, secondary insults (hypotension and hypoxia), and laboratory parameters (glucose and hemoglobin). External validation confirmed that the discriminative ability of the model was adequate (AUC 0.80). Outcomes were systematically worse than predicted, but less so in 1,588 patients who were from high-income countries in the CRASH trial.
Conclusions
Prognostic models using baseline characteristics provide adequate discrimination between patients with good and poor 6 mo outcomes after TBI, especially if CT and laboratory findings are considered in addition to traditional predictors. The model predictions may support clinical practice and research, including the design and analysis of randomized controlled trials.
Ewout Steyerberg and colleagues describe a prognostic model for the prediction of outcome of traumatic brain injury using data available on admission.
Editors' Summary
Background.
Traumatic brain injury (TBI) causes a large amount of morbidity and mortality worldwide. According to the Centers for Disease Control, for example, about 1.4 million Americans will sustain a TBI—a head injury—each year. Of these, 1.1 million will be treated and released from an emergency department, 235,000 will be hospitalized, and 50,000 will die. The burden of disease is much higher in the developing world, where the causes of TBI such as traffic accidents occur at higher rates and treatment may be less available.
Why Was This Study Done?
Given the resources required to treat TBI, a very useful research tool would be the ability to accurately predict on admission to hospital what the outcome of a given injury might be. Currently, scores such as the Glasgow Coma Scale are useful to predict outcome 24 h after the injury but not before.
Prognostic models are useful for several reasons. Clinically, they help doctors and patients make decisions about treatment. They are also useful in research studies that compare outcomes in different groups of patients and when planning randomized controlled trials. The study presented here is one of a number of analyses done by the IMPACT research group over the past several years using a large database that includes data from eight randomized controlled trials and three observational studies conducted between 1984 and 1997. There are other ongoing studies that also seek to develop new prognostic models; one such recent study was published in BMJ by a group involving the lead author of the PLoS Medicine paper described here.
What Did the Researchers Do and Find?
The authors analyzed data that had been collected prospectively on individual patients from the 11 studies included in the database and derived models to predict mortality and unfavorable outcome at 6 mo after injury for the 8,509 patients with severe or moderate TBI. They found that the strongest predictors of outcome were age, motor score, pupillary reactivity, and characteristics on the CT scan, including the presence of traumatic subarachnoid hemorrhage. A core prognostic model could be derived from the combination of age, motor score, and pupillary reactivity. A better score could be obtained by adding CT characteristics, secondary problems (hypotension and hypoxia), and laboratory measurements of glucose and hemoglobin. The scores were then tested to see how well they predicted outcome in a different group of patients—6,681 patients from the recent Medical Research Council Corticosteroid Randomisation after Significant Head Injury (MRC CRASH) trial.
What Do These Findings Mean?
In this paper the authors show that it is possible to produce prognostic models using characteristics collected on admission as part of routine care that can discriminate between patients with good and poor outcomes 6 mo after TBI, especially if the results from CT scans and laboratory findings are added to basic models. This paper has to be considered together with other studies, especially the paper mentioned above, which was recently published in the BMJ (MRC CRASH Trial Collaborators [2008] Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 336: 425–429.). The BMJ study presented a set of similar, but subtly different models, with specific focus on patients in developing countries; in that case, the patients in the CRASH trial were used to produce the models, and the patients in the IMPACT database were used to verify one variant of the models. Unfortunately this related paper was not disclosed to us during the initial review process; however, during PLoS Medicine's subsequent consideration of this manuscript we learned of it. After discussion with the reviewers, we took the decision that the models described in the PLoS Medicine paper are sufficiently different from those reported in the other paper and as such proceeded with publication of the paper. Ideally, however, these two sets of models would have been reviewed and published side by side, so that readers could easily evaluate the respective merits and value of the two different sets of models in the light of each other. The two sets of models are, however, discussed in a Perspective article also published in PLoS Medicine (see below).
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050165.
This paper and the BMJ paper mentioned above are discussed further in a PLoS Medicine Perspective article by Andrews and Young
The TBI Impact site provides a tool to calculate the scores described in this paper
The CRASH trial, which is used to validate the scores mentioned here, has a Web site explaining the trial and its results
The R software, which was used for the prognostic analyses, is freely available
The MedlinePlus encyclopedia has information on head injury
The WHO site on neurotrauma discusses head injury from a global perspective
The CDC's National Center for Injury Prevention and Control gives statistics on head injury in the US and advice on prevention
doi:10.1371/journal.pmed.0050165
PMCID: PMC2494563  PMID: 18684008
25.  Epidemiology and treatment outcome of head injury in children: A prospective study 
Summary:
Head injury in children is a major concern all over the world. The increasing level of poverty in the world is exposing more children to trauma situations. The future consequences of trauma in these children are enormous, hence prevention they say, is better than cure.
Aim of the Study:
The study was designed to determine the etiological pattern, age group affectation and treatment outcome in children managed for head injury in our center.
Methods:
It was a prospective, descriptive and cross-sectional study of children with head injuries managed in our center from July 2010 to December 2013. Data were collected using structured proforma that was part of our prospective Data Bank approved by our hospital Research and Ethics Committee. Data were collected in accident and emergency unit, Intensive Care Unit, wards and out-patient clinic. The data was analyzed using Epi Info 7 software.
Results:
Total of 76 children managed by the unit and followed-up to a minimum of 3 months qualified for the study. There were 42 males. The age ranged from 7 months to 18 years with a mean of 8.66 years. There were 30 adolescent/teenagers. Road traffic accident formed 63.15%. Pedestrian accident was more among preschool and school children. Thirty-seven patients had mild head injury. Sixty-six patients were managed conservatively. The commonest posttraumatic effect was seizure (15.79%). Good functional outcome (≥4) was seen in 92.1%. Mode of accident and severity of injury affected the outcome.
Conclusions:
The etiologies of traumatic brain injury, from our study, were age dependent with falls commonest in toddlers and pedestrian accident commonest in pre-school and school ages. The outcome of treatment was related to severity of injury.
doi:10.4103/1817-1745.147577
PMCID: PMC4302543  PMID: 25624926
Children; epidemiology; head injury; outcome

Results 1-25 (568272)