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Summary Background Protective effects of safety devices in obese motorists in motor vehicle collisions (MVC) remain unclear. Aim of our study is to assess the association between morbid obesity and mortality in MVC, and to determine the efficacy of protective devices. We hypothesised that patients with morbid obesity will be at greater risk of death after MVC. Methods A retrospective analysis of MVC patients (age ≥16 y.o.) was performed using the National Trauma Data Bank from 2007 to 2010. Patients with recorded comorbidity of morbid obesity (BMI ≥ 40) were identified. Patients dead on arrival, with isolated traumatic brain injury, or incomplete data were excluded. The primary outcome was in-hospital mortality. Multivariate logistic regression was performed. Results Our sample of 214,306 MVC occupants included 10,260 (4.8%) morbidly obese patients. Mortality risk was greatest among occupants with morbid obesity (OR crude 1.74 [1.54–1.98]). After adjusting for patient demographics, safety device and physiological severity, odds of death was 1.52 [1.33–1.74] times greater in motorists with morbid obesity. Motorists with morbid obesity were at greater risk of death if no restraint (OR 1.84 [1.47–2.31]), seatbelt only (OR 1.48 [1.17–1.86]), or both seatbelt and airbag were present (OR 1.49 [1.13–1.97]). No significant differences in the odds of death exist between drivers with morbid obesity and non-morbidly obese drivers with only airbag deployment (OR 0.99 [0.65–1.51]). Conclusions Motorists with morbid obesity are at greater risk of MVC. Regardless of safety device use, occupants with morbid obesity remained at greater risk of death. Further research examining the effectiveness of vehicle restraints in drivers with morbid obesity is warranted. [ABSTRACT FROM AUTHOR]

Background: Basidiobolomycosis is a rare fungal infection caused by the fungus Basidiobolus ranarum. Gastrointestinal basidiobolomycosis (GIB) is an unusual presentation of the fungal infection that is reported sparsely in the literature, but is an emerging infection in the southwestern United States. Lack of awareness of GIB has resulted in its delayed diagnosis and in extensive morbidity and mortality in patients with GIB. Methods: Case report and literature review. Case Report: We report the rare case of a young female with GIB that presented as perforated appendicitis with abscess formation. Conclusion: Although GIB is rare, immediate and aggressive therapy should be initiated when it is diagnosed. Both long-term medical and surgical treatment is required for its definitive management. [ABSTRACT FROM AUTHOR]

Background Admission hypothermia (core temperature ≤ 35°C) is an independent risk factor for mortality after trauma. The predictive value of perioperative core temperatures during acute trauma surgery, however, although widely employed as a criterion for initiating damage control, is unknown. We hypothesized that for trauma patients undergoing laparotomy or thoracotomy, early postoperative hypothermia is a predictor of mortality.Methods After institutional review board (IRB) approval, all critically ill trauma patients undergoing cavitary surgery (laparotomy or thoracotomy) at a level 1 trauma center from 01/1998 to 07/2006 were identified from the trauma registry. Immediate postoperative core temperature (Tc) was used to classify patients as hypothermic (Tc ≤ 35°C) or normothermic (Tc > 35°C). The profoundly hypothermic subgroup of patients with a Tc < 33°C was also analyzed.Results During the study period, 2,489 patients required cavitary surgery, 1,252 of whom (50%) were admitted to the intensive care unit (ICU). On arrival in the ICU 15% of the patients had a Tc ≤ 35°C and were more likely to be ≥ 55 years old (12% versus 7%; p = 0.04); in addition, they were hypotensive on admission (25% versus 13%; p < 0.001), had a lower admission Glasgow Coma Score (GCS; 11 ± 5 versus 14 ± 3; p < 0.001), a higher Injury Severity Score (ISS; 29 ± 15 versus 22 ± 12; p < 0.001), higher head and chest Abbreviated Injury Scale (AIS), and greater intraoperative blood loss (2.6 ± 2.4 l versus 1.7 ± 1.8 l; p < 0.001). When compared to patients who were normothermic at the end of their operation, hypothermic patients had a significantly higher mortality (35% versus 8%; p < 0.001). With decreasing Tc, there was a stepwise increase in mortality. Compared to patients with a Tc > 35°C, the relative risk of death for patients with a Tc between 35°C and 33°C was 4.0, and that for patients with a Tc ≤ 33°C it was 7.1. After adjusting for multiple differences between groups, postoperative hypothermia remained an independent predictor of mortality (adjusted odds ratio [OR] 3.2; 95% confidence interval [CI] 1.9–5.3; p < 0.001).Conclusions Postoperative hypothermia is common in critically injured patients requiring cavitary surgery and is an independent predictor of mortality. The impact of measures to maintain or restore normothermia in the operating room warrants further investigation. [ABSTRACT FROM AUTHOR]

Hypothesis To identify significant risk factors associated with mortality in patients with a Glasgow Coma Scale score of 3. Design Trauma registry study. Setting Level I urban trauma center. Patients A total of 760 patients with head injury with an admission Glasgow Coma Scale score of 3. Analysis was performed in all patients and in only patients who reached the hospital alive and had no major extracranial injuries (exclusion of patients with a chest or abdominal Abbreviated Injury Score [AIS] >3). Main Outcome Measures Stepwise logistic regression analysis was used to identify independent risk factors associated with mortality. Results Blunt trauma accounted for 477 (63%) and penetrating trauma for 283 (37%) of the 760 head injuries. Penetrating trauma was significantly more likely to be associated with a lack of vital signs on admission (15% vs 9%; P = .03). Overall mortality was 76% (94% for penetrating injuries and 65% for blunt injuries; P<.001). Overall, 79% of patients had a head AIS of 4 or greater. Mortality in the subgroup was 64% (320/497) and was significantly higher in penetrating vs blunt trauma (89% vs 52%; P<.001). Penetrating trauma, high head AIS, hypotension on admission, and age older than 55 years were independent significant risk factors associated with mortality. Only 10% of the 177 survivors had good functional outcome at hospital discharge. Eighty-six patients (17% of those with vital signs on admission) became organ donors. Conclusions Patients with head injury with an admission Glasgow Coma Scale score of 3 have a poor prognosis. Mechanism of injury, head AIS, hypotension on admission, and age play a critical role in outcome. These patients are an important source of organ donation and should be evaluated and resuscitated aggressively. [ABSTRACT FROM AUTHOR]

Background Studies have proposed a neuroprotective role for alcohol (ETOH) in traumatic brain injury (TBI). We hypothesized that ETOH intoxication is associated with mortality in patients with severe TBI. Methods Version 7.2 of the National Trauma Data Bank (2007-2010) was queried for all patients with isolated blunt severe TBI (Head Abbreviated Injury Score ≥4) and blood ETOH levels recorded on admission. Primary outcome measure was mortality. Multivariate logistic regression analysis was performed to assess factors predicting mortality and in-hospital complications. Results A total of 23,983 patients with severe TBI were evaluated of which 22.8% (n = 5461) patients tested positive for ETOH intoxication. ETOH-positive patients were more likely to have in-hospital complications (P = 0.001) and have a higher mortality rate (P = 0.01). ETOH intoxication was an independent predictor for mortality (odds ratio: 1.2, 95% confidence interval: 1.1-2.1, P = 0.01) and development of in-hospital complications (odds ratio: 1.3, 95% confidence interval: 1.1-2.8, P = 0.009) in patients with isolated severe TBI. Conclusions ETOH intoxication is an independent predictor for mortality in patients with severe TBI patients and is associated with higher complication rates. Our results from the National Trauma Data Standards differ from those previously reported. The proposed neuroprotective role of ETOH needs further clarification. [ABSTRACT FROM AUTHOR]

BACKGROUND: Use of 5% normal saline (NS) is gaining renewed interest. The primary aim of our study was to compare the physiological effects after the administration of different concentrations of hypertonic saline (3% vs 5%NS) in the initial resuscitation of trauma. METHODS: We performed a retrospective analysis of a prospectively collected database of all trauma patients who received hypertonic saline during initial resuscitation. Medical records were reviewed for serum electrolytes and serum osmolarity, coagulation parameters, complications, and mortality. RESULTS: A total of 212 patients were included in the study, of which 170 patients received 5%NS and 42 patients received 3%NS. Both groups were similar in age (41.16 ± 19 vs 44.17 1 23.6; P = .45) and ISS score (26 [17 to 29] vs 25 [16 to 27]; P = .6). Mean serum osmolarity (316 ± 20.3 vs 294 ± 22.5; P = .02) and serum sodium levels (143 ± 8.6 vs 137 ± 10.9; P < .001) remained higher in the 5%NS group within 72 hours of admission. The pH was lower in the 5%NS group compared with the 3%NS group at 24 hours (7.29 ± .12 vs 7.33 ± .12; P = .01); however, at 48 and 72 hours (7.40 ± .07 vs 7.41 ± .07; P = .7), no difference was found. There was no difference in blood products requirement (1,734 vs 2,253 mL; P = .11) between the 2 groups. CONCLUSIONS: The 5%NS has sustained higher serum osmolarity and serum sodium concentration within the first 72 hours without any increase in adverse effects in comparison with 3%NS. [ABSTRACT FROM AUTHOR]

Background Geriatric patients are at higher risk for adverse outcomes after injury because of their altered physiological reserve. Mortality after trauma laparotomy remains high; however, outcomes in geriatric patients after trauma laparotomy have not been well established. The aim of our study was to identify factors predicting mortality in geriatric trauma patients undergoing laparotomy. Methods A retrospective study was performed of all trauma patients undergoing a laparotomy at our level 1 trauma center over a 6-y period (2006-2012). Patients with age ≥55 y who underwent a trauma laparotomy were included. Patients with head abbreviated injury scale (AIS) score ≥ 3 or thorax AIS ≥ 3 were excluded. Our primary outcome measure was mortality. Significant factors in univariate regression model were used in multivariate regression analysis to evaluate the factors predicting mortality. Results A total of 1150 patients underwent a trauma laparotomy. Of which 90 patients met inclusion criteria. The mean age was 67 ± 10 y, 63% were male, and median abdominal AIS was 3 (2-4). Overall mortality rate was 23.3% (21/90) and progressively increased with age (P = 0.013). Age (P = 0.02) and lactate (P = 0.02) were the independent predictors of mortality in geriatric patients undergoing laparotomy. Conclusions Mortality rate after trauma laparotomy increases with increasing age. Age and admission lactate were the predictors of mortality in geriatric population undergoing trauma laparotomies. [ABSTRACT FROM AUTHOR]

Abstract: Background: Sleep deprivation, common in intensive care unit (ICU) patients, may be associated with increased morbidity and/or mortality. We previously demonstrated that significant numbers of nocturnal nursing interactions (NNIs) occur during the routine care of surgical ICU patients. For this study, we assessed the quantity and type of NNIs in different ICU types: medical, surgical, cardiothoracic, pediatric, and neonatal. We hypothesized that the number and type of NNIs vary among different ICU types. Material and methods: We performed a prospective observational cohort study at our academic medical center examining potential sleep disruption in ICU patients secondary to NNIs from the hours 2200–0600 nightly. From May through November 2011, bedside nursing staff in five different ICUs collected data on NNIs, including the frequency and nature of each event (patient care activity, nursing intervention, nursing assessment, or patient-initiated contact) as well as the length of time of each event and whether the bedside care provider thought that the event could have been safely omitted without negatively affecting patient care. Additional data collected included patient demographics, the need for mechanical ventilation, and sedative/narcotic use. Results: Two hundred ICU patients were enrolled over 51 separate nocturnal time periods (3.9 patients/nocturnal time period). Of those 200 patients, 53 (26.5%) were mechanically ventilated; 12.5% underwent sedative infusion; and 23.0% underwent narcotic infusion. There were a total of 1831 NNIs; most (67%) were due to nursing assessment or patient care activity. The surgical ICU had the most frequent NNIs (11.8 ± 9.0), although they were the shortest (6.66 ± 6.06 min), as well as the highest proportion of NNIs that could have been safely omitted (20.9%). Nursing staff estimated that, of all NNIs in all ICU types, 13.9% could have been safely omitted. Conclusions: NNIs occur frequently and vary across different ICU types. Many NNIs are due to nursing assessment and patient care activities, much of which could be safely omitted or clustered. A protocol for nocturnal sleep promotion is warranted in order to standardize ICU NNIs and minimize nighttime sleep disruptions. [Copyright &y& Elsevier]

Abstract: Background: The purpose of this study is to characterize traumatic suicide attempts (TSA) by age, gender, race, and mechanism of injury. Methods: This is a retrospective review of TSA patients (identified by E-codes) admitted to our urban, level I trauma center from 1992 through 2005. Mechanisms of TSA included jump from height, firearm (gunshot wound [GSW]), cutting or piercing instrument (stab wound [SW]), and motor vehicle (MV)-related. Patients were categorized in groups by age in years (< 18, 18–35, 36–54, 55–69, ≥ 70). Results: A total of 876 TSA patients were identified; 83% were male, with a mean age of 35 years and a mean Injury Severity Score of 10. The most common mechanism was SW (39%), followed by jump (26%), GSW (21%), and MV-related (13%). Primary mechanism of TSA varied by age (p < 0.0001), with GSW most common in those patients aged < 18 years (64%) and ≥ 70 years (44%), and SW most common in all other age groups. Overall, 16% of TSAs were successful. The adjusted odds ratio (AOR) for mortality for age 70+ vs. age 36–54 was 12.4 (95% confidence interval [CI] 2.3–78, p = 0.005), and the AOR for mortality from GSW vs. SW was 9.8 (95% CI 2.6–44, p = 0.001). Conclusions: The most common mechanism for TSA was SW, although GSW was the most effective. The mechanism of choice for TSA depends on age, with the extremes of age more commonly choosing a firearm. Age and method of TSA are significant contributing factors to success of suicide attempts. [ABSTRACT FROM AUTHOR]

The objective of this study was to analyze the transfusion practices in trauma patients in one institution. A retrospective analysis of the Trauma Registry linked with the Blood Bank Database of a Level 1 trauma center was conducted. Over 6 years, 17 per cent of the 25,599 trauma patients received blood transfusions. The overall mortality in transfused patients was 20 per cent and remained the same during the study period. There was no change in the proportion of patients receiving transfusions throughout the years, however there was a significant 23.5 per cent reduction in the mean number of packed red blood cells (PRBC) units transfused (P < 0.001 for trend). This reduction in PRBC used remained true and even more evident in the group of more severely injured patients (Injury Severity Score ≥ 16), with a 27.9 per cent decrease in mean units of PRBC (P < 0.001 for trend). The highest reduction in PRBC transfusion was seen in blunt trauma patients (34.6%, P < 0.001). During the study period there was a concurrent increase in mean units of fresh frozen plasma used (60.7%, P < 0.001) and no change in the use of platelets and cryoprecipitate. In conclusion, transfusions of PRBC were significantly reduced over time in trauma patients without any evident negative impact on mortality. [ABSTRACT FROM AUTHOR]

Summary: Purpose: To evaluate the prevalence of the acute respiratory distress syndrome (ARDS) among blunt trauma patients with severe traumatic brain injury (TBI) and to determine if ARDS is associated with higher mortality, morbidity and worse discharge outcome. Methods: Blunt trauma patients with TBI (head abbreviated injury score {AIS}≥4) who developed predefined ARDS criteria between January 2000 and December 2004 were prospectively collected as part of an ongoing ARDS database. Each patient in the TBI+ARDS group was matched with two control TBI patients based on age, injury severity score (ISS) and head AIS. Outcomes including complications, mortality and discharge disability were compared between the two groups. Results: Among 362 TBI patients, 28 (7.7%) developed ARDS. There were no differences between the two groups with respect to age, sex, ISS, Glasgow coma score (GCS), head, abdomen and extremity AIS. The TBI+ARDS group had significantly more patients with chest AIS≥3 (57.1% versus 32.1%, p =0.03). There was no difference with respect to overall mortality between the TBI+ARDS group (50.0%) and the TBI group (51.8%) (OR 0.79: 95% CI 0.31–2.03, p =0.63). There was no significant difference with respect to discharge functional capacity between the two groups. There were significantly more overall complications in the TBI+ARDS group (42.9%) compared to the TBI group (16.1%) (OR 3.66: 95% CI 1.19–11.24, p =0.02). The TBI+ARDS group had an overall mean intensive care unit (ICU) length of stay of 15.6 days, versus 8.4 days in the TBI group (p <0.01). The TBI+ARDS group had significantly higher hospital charges than the TBI group ($210,097 versus $115,342, p <0.01). Conclusion: The presence of ARDS was not associated with higher mortality or worse discharge disability. It was, however, associated with higher hospital morbidity, longer ICU and hospital length of stay. [Copyright &y& Elsevier]

Background: We studied the association of the American College of Surgeons (ACS) trauma center designation and mortality in adult patients with severe trauma (Injury Severity Score > 15). ACS designation of trauma centers into different levels requires substantial financial and human resources commitments. There is very little work published on the association of ACS trauma center designation and outcomes in severe trauma. Study design: National Trauma Data Bank study including all adult trauma admissions (older than 14 years of age) with Injury Severity Score (ISS) > 15. The relationship between ACS level of trauma designation and survival outcomes was evaluated after adjusting for age, mechanism of injury, ISS, hypotension on admission, severe liver trauma, aortic, vena cava, iliac vascular, and penetrating cardiac injuries. Results: A total of 130,154 patients from 256 trauma centers met the inclusion criteria. Adjusted mortality in ACS-designated Level II centers and undesignated centers was notably higher than in Level I centers (adjusted odds ratio, 1.14; 95% CI, 1.09−120; p < 0.0001 and adjusted odds ratio, 1.09; CI, 1.05−1.13; p < 0.0001, respectively). Conclusions: Severely injured patients with ISS > 15 treated in ACS Level I trauma centers have considerably better survival outcomes than those treated in ACS Level II centers. [Copyright &y& Elsevier]

There is little published work on the effect of cirrhosis on outcomes in trauma patients undergoing laparotomy. The aim of this study was to evaluate the risk of death or serious complications in cirrhotic trauma patients undergoing laparotomy as compared with that in a similar group of patients without cirrhosis.During a 12-year period, there were 46 patients with the diagnosis of liver cirrhosis made during laparotomy for trauma. Each patient was matched with two noncirrhotic controls on the basis of 7 criteria: age (>55, ≤55 years), gender, mechanism of injury (blunt, penetrating), Injury Severity Score (≤15, 16–25, >25), head Abbreviated Injury Score (<3, ≥3), chest Abbreviated Injury Score (<3, ≥3), and abdominal Abbreviated Injury Score (<3, ≥3). Six cirrhotic patients were excluded because matching was not possible. The remaining 40 patients were matched with 80 noncirrhotic control patients selected from a pool of 4,771 patients who had trauma laparotomies. Outcomes included mortality, ARDS, pneumonia, renal failure, abdominal sepsis, disseminated intravascular coagulopathy, ICU and hospital stay, and hospital charges. Outcomes between the two study groups were compared with conditional logistic analysis. Hazard ratio (95% CI) and adjusted p value with the stepdown Bonferroni method were derived.The overall mortality in the cirrhotic group was significantly higher than that in the matched noncirrhotic group (45% versus 24%, hazard ratio: 7.60 [2.00, 28.94], p = 0.021). Mortality in patients with Injury Severity Score ≤15 was 29% in the cirrhotic group and 5% in the noncirrhotic group (p = 0.013) and in patients with Injury Severity Score 16–25, mortality was 56% and 11%, respectively (p = 0.024). The incidence of any of the predetermined complications was 45% in the cirrhotic group and 23% in the noncirrhotic group (p = 0.110). The mean surgical ICU stay was 11.5 days and 6.6 days, respectively (p = 0.037), and the mean hospital charges were $141,210 and $72,884, respectively (p = 0.031).Cirrhotic trauma patients undergoing laparotomy are at high risk of serious complications and death, even after fairly minor injuries. This group of patients should be admitted to the ICU for close monitoring and aggressive management irrespective of the severity of injuries. [Copyright &y& Elsevier]

Background: We assessed the prognostic value and limitations of Glasgow Coma Scale (GCS) and head Abbreviated Injury Score (AIS) and correlated head AIS with GCS.Study design: We studied 7,764 patients with head injuries. Bivariate analysis was performed to examine the relationship of GCS, head AIS, age, gender, and mechanism of injury with mortality. Stepwise logistic regression analysis was used to identify the independent risk factors associated with mortality.Results: The overall mortality in the group of head injury patients with no other major extracranial injuries and no hypotension on admission was 9.3%. Logistic regression analysis identified head AIS, GCS, age, and mechanism of injury as significant independent risk factors of death. The prognostic value of GCS and head AIS was significantly affected by the mechanism of injury and the age of the patient. Patients with similar GCS or head AIS but different mechanisms of injury or ages had significantly different outcomes. The adjusted odds ratio of death in penetrating trauma was 5.2 (3.9, 7.0), p < 0.0001, and in the age group ≥ 55 years the adjusted odds ratio was 3.4 (2.6, 4.6), p < 0.0001. There was no correlation between head AIS and GCS (correlation coefficient -0.31).Conclusions: Mechanism of injury and age have a major effect in the predictive value of GCS and head AIS. There is no good correlation between GCS and head AIS. [Copyright &y& Elsevier]