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Background: The purpose of Abbreviated Injury Scale (AIS) is to code various types of Traumatic Brain Injuries (TBI) based on their anatomical location and severity. The Marshall CT Classification is used to identify those subgroups of brain injured patients at higher risk of deterioration or mortality. The purpose of this study is to determine whether and how AIS coding can be translated to the Marshall Classification Methods: Initially, a Marshall Class was allocated to each AIS code through cross-tabulation. This was agreed upon through several discussion meetings with experts from both fields (clinicians and AIS coders). Furthermore, in order to make this translation possible, some necessary assumptions with regards to coding and classification of mass lesions and brain swelling were essential which were all approved and made explicit. Results: The proposed method involves two stages: firstly to determine all possible Marshall Classes which a given patient can attract based on allocated AIS codes; via cross-tabulation and secondly to assign one Marshall Class to each patient through an algorithm. Conclusion: This method can be easily programmed in computer softwares and it would enable future important TBI research programs using trauma registry data. [ABSTRACT FROM AUTHOR]

Objectives: To describe age-related systolic blood pressures and pulse rates in children following blunt injury. To compare these variables with standard reference values for uninjured children at rest and with reference ranges from the Advanced Paediatric Life Support (APLS) guidelines. Design: Secondary analysis of a prospective cohort. Setting: Emergency departments throughout England and Wales. Participants: 12 906 children presenting with acute blunt traumatic injury from August 1989 to September 1998. Main outcome measures: Systolic blood pressure and pulse rate on arrival. Results: Injured children had higher systolic blood pressures than the standard quoted ‘norms’. Standard reference values of systolic blood pressure for children at rest always appeared below the 50th percentile for our cohort of injured children (range 7th–27th percentiles). Pulse rates for children at rest were always towards the mid-range for injured children (range 41st–54th percentiles). These results appeared unrelated to injury severity. Age related APLS reference ranges for systolic blood pressure and pulse rate resembled the standard reference values for uninjured children at rest. Conclusions: Injured children have a relative systolic hypertension compared with children at rest. Pulse rates in the two groups are comparable. Following injury, children with apparently ‘normal’ age-specific systolic blood pressures on arrival in the Emergency Department are relatively hypotensive and should be carefully assessed. [Copyright &y& Elsevier]

Abstract: Traumatic injury is the leading cause of death in the first four decades of life. However, current estimates for traumatic injury rates fail to take into account burns. The aim of this work was to estimate the contribution of burns to serious traumatic injury in England and Wales. We have determined population-based burns rates using the International Burn Injury Database (iBID, www.ibidb.org) which collects data from regional burn centres, and non-burns rate using data from the Trauma Audit and Research Network (TARN) which collects data from emergency departments (ED, www.TARN.ac.uk). Due to incomplete national coverage of TARN, non-burns rates were estimated using data from 94 EDs that contributed data to TARN. Both non-burn and burns rates were calculated nationally and for each regional burn service catchment area (n =17). Only serious injuries (≥72h admission or death) were included. Burns rate was 4.7 and non-burns rate 82.7 per 100,000 per year nationally. Burns therefore contributed 5.4% of all serious traumatic injuries. Contribution of burns in different regional burn service catchment areas was between 1.5% and 12%. This data suggests that burns contribute significantly to the overall trauma workload, and should be carefully considered in healthcare planning and policy. [Copyright &y& Elsevier]

Age is an important factor in determining prognosis following severe head injury (SHI), although mortality in patients ≥65 years is poorly reported. The aim of this study was to document mortality in patients with SHI ≥65 years. A retrospective analysis of prospectively collected data from the TARN (Trauma Audit and Research Network) database (1996–2004) was performed. Six hundred and sixty-nine patients aged ≥65 with a GCS <9 after a head injury were identified, and mortality at 3 months was recorded. Mortality was 71% in 65- to 70-year-old patients ( n = 137) (CI, 64–79), 75% for patients aged 70–75 years ( n = 147) (CI, 68–82), 85% in patients aged 75–80 years ( n = 160) (79–91), and 87% for patients >80 years ( n = 225) (CI, 83–91). Mortality for all patients ≥65 years with a GCS 3–5 was >80%. A better outcome was observed in patients with a GCS = 6–8 [65–70 years, 47% (CI, 30–64); 70–75 years, 56% (CI, 43–69); 75–80 years, 73% (CI, 62–85); >80 years, 79% (CI, 70–87)]. SHI-related mortality continues to increase with age. Overall, these data support a conservative approach to the severely head-injured elderly patient; however, patients presenting with a GCS = 6–8 and below the age of 75 may represent a group where more aggressive therapy may be indicated. [ABSTRACT FROM AUTHOR]

Background: There are 27 receiving trauma hospitals in the Republic of Ireland. There has not been an audit system in place to monitor and measure processes and outcomes of care. The National Office of Clinical Audit (NOCA) is now working to implement Major Trauma Audit (MTA) in Ireland using the well-established National Health Service (NHS) UK Trauma Audit and Research Network (TARN).Aims: The aim of this report is to highlight the implementation process of MTA in Ireland to raise awareness of MTA nationally and share lessons that may be of value to other health systems undertaking the development of MTA.Methods: The National Trauma Audit Committee of the Royal College of Surgeons in Ireland, consisting of champions and stakeholders in trauma care, in 2010 advised on the adaptation of TARN for Ireland. In 2012, the Emergency Medicine Program endorsed TARN and in setting up the National Emergency Medicine Audit chose MTA as the first audit project. A major trauma governance group was established representing stakeholders in trauma care, a national project co-ordinator was recruited and a clinical lead nominated. Using Survey Monkey, the chief executives of all trauma receiving hospitals were asked to identify their hospital's trauma governance committee, trauma clinical lead and their local trauma data co-ordinator. Hospital Inpatient Enquiry systems were used to identify to hospitals an estimate of their anticipated trauma audit workload.Results: There are 25 of 27 hospitals now collecting data using the TARN trauma audit platform. These hospitals have provided MTA Clinical Leads, allocated data co-ordinators and incorporated MTA reports formally into their clinical governance, quality and safety committee meetings. There has been broad acceptance of the NOCA escalation policy by hospitals in appreciation of the necessity for unexpected audit findings to stimulate action.Conclusion: Major trauma audit measures trauma patient care processes and outcomes of care to drive quality improvement at hospital and national level. MTA will facilitate the strategic development of trauma care in Ireland by monitoring processes and outcomes and the effects of changes in trauma service provision. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Low systolic blood pressure (SBP) is an important secondary insult following traumatic brain injury (TBI), but its exact relationship with outcome is not well characterised. Although a SBP of <90mmHg represents the threshold for hypotension in consensus TBI treatment guidelines, recent studies suggest redefining hypotension at higher levels. This study therefore aimed to fully characterise the association between admission SBP and mortality to further inform resuscitation endpoints. Methods: We conducted a multicentre cohort study using data from the largest European trauma registry. Consecutive adult patients with AIS head scores >2 admitted directly to specialist neuroscience centres between 2005 and July 2012 were studied. Multilevel logistic regression models were developed to examine the association between admission SBP and 30 day inpatient mortality. Models were adjusted for confounders including age, severity of injury, and to account for differential quality of hospital care. Results: 5057 patients were included in complete case analyses. Admission SBP demonstrated a smooth u-shaped association with outcome in a bivariate analysis, with increasing mortality at both lower and higher values, and no evidence of any threshold effect. Adjusting for confounding slightly attenuated the association between mortality and SBP at levels <120mmHg, and abolished the relationship for higher SBP values. Case-mix adjusted odds of death were 1.5 times greater at <120mmHg, doubled at <100mmHg, tripled at <90mmHg, and six times greater at SBP<70mmHg, p <0.01. Conclusions: These findings indicate that TBI studies should model SBP as a continuous variable and may suggest that current TBI treatment guidelines, using a cut-off for hypotension at SBP<90mmHg, should be reconsidered. [Copyright &y& Elsevier]

Background: Traumatic brain injury (TBI) remains a leading cause of death and disability. The National Institute for Health and Clinical Excellence (NICE) guidelines recommend transfer of severe TBI cases to neurosurgical centres, irrespective of the need for neurosurgery. This observational study investigated the risk-adjusted mortality of isolated TBI admissions in England/Wales, and Victoria, Australia, and the impact of neurosurgical centre management on outcomes. Methods: Isolated TBI admissions (>15 years, July 2005-June 2006) were extracted from the hospital discharge datasets for both jurisdictions. Severe isolated TBI (AIS severity >3) admissions were provided by the Trauma Audit and Research Network (TARN) and Victorian State Trauma Registry (VSTR) for England/Wales, and Victoria, respectively. Multivariable logistic regression was used to compare risk-adjusted mortality between jurisdictions. Findings: Mortality was 12% (749/6256) in England/Wales and 9% (91/1048) in Victoria for isolated TBI admissions. Adjusted odds of death in England/Wales were higher compared to Victoria overall (OR 2.0, 95% CI: 1.6, 2.5), and for cases <65 years (OR 2.36, 95% CI: 1.51, 3.69). For severe TBI, mortality was 23% (133/575) for TARN and 20% (68/346) for VSTR, with 72% of TARN and 86% of VSTR cases managed at a neurosurgical centre. The adjusted mortality odds for severe TBI cases in TARN were higher compared to the VSTR (OR 1.45, 95% CI: 0.96, 2.19), but particularly for cases <65 years (OR 2.04, 95% CI: 1.07, 3.90). Neurosurgical centre management modified the effect overall (OR 1.12, 95% CI: 0.73, 1.74) and for cases <65 years (OR 1.53, 95% CI: 0.77, 3.03). Conclusion: The risk-adjusted odds of mortality for all isolated TBI admissions, and severe TBI cases, were higher in England/ Wales when compared to Victoria. The lower percentage of cases managed at neurosurgical centres in England and Wales was an explanatory factor, supporting the changes made to the NICE guidelines. [ABSTRACT FROM AUTHOR]

Abstract: Accurate information on the incidence of serious road traffic casualties is needed to plan and evaluate prevention strategies. Traditionally police reported collisions are the only data used. This study investigate the extent to which understanding of trends in serious road traffic injuries is aided by the use of multiple datasets. Health and police datasets covering all or part of Great Britain from 1996–2003 were analysed. There was a significantly decreasing trend in police reported serious casualties but not in the other datasets. Multiple data sources provide a more complete picture of road traffic casualty trends than any single dataset. Increasing availability of electronic health data with developments in anonymised data linkage should provide a better platform for monitoring trends in serious road traffic casualties. [Copyright &y& Elsevier]

Summary: Background: In the Trauma Audit and Research Network (TARN), currently the largest trauma network in Europe, outcome prediction is performed using the TRISS methodology since 1989. Its database contains 200,000 hospital admissions from 110 hospitals over the country, but a large amount of data is lost for the modelling because of missing data. To improve some of the shortcomings of TRISS a new model was developed. Methods: The data for modelling consisted of 100,399 hospital trauma admissions over the period 1996 to 2001. Using the Glasgow Coma Score (GCS) instead of RTS has dramatically reduced the number of missing cases. Gender and its interaction with age have also been included in the model. The model was tested on different subsets of cases traditionally excluded, such as children, those with penetrating injuries, and ventilated and transferred patients. The new model included all those subsets using age, a transformation of ISS, GCS, gender and gender by age interaction as predictors. Results: The model has shown a good discriminant ability tested by the area under the receiver operating characteristic (AROC) curve. The values of the AROC for the new model were 0.947 (95% CI: 0.943–0.951) on the prediction set and 0.952 (95% CI: 0.946–0.957) on the validation set compared respectively with 0.937 (95% CI: 0.932–0.943) and 0.941 (95% CI: 0.936–0.952) for TRISS. Conclusion: The new model has enabled us to include most of the cases that were excluded under the TRISS''s inclusion criteria, less missing data are incurred and the predictive performance was significantly better than that of the TRISS model as shown by the AROC curves. [Copyright &y& Elsevier]

The authors attempt to establish an algorithm to allow clinicians who treat patients with acute head injuries to determine which patients may require further observation and which can be discharged. It is stated that their recommendations are based on guidelines provided by the British National Institute for Health and Clinical Excellence (NICE) in 2007.