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Head strikes can be fatal for patients taking blood thinners (anticoagulants or antiplatelets). Our trauma center instituted the "head strike protocol" to provide uniform and expedited care for adult trauma patients taking preinjury anticoagulants and antiplatelet medications with suspected head injury. The purpose of this article is to describe the development and implementation of the head strike protocol and compare time metrics and outcomes before and after implementing the protocol. Per the head strike protocol, patients with suspected traumatic intracranial hemorrhage (tICH) were screened for anticoagulants or antiplatelet medications by emergency medical service personnel/at first contact, activated as a Level II trauma and received a computed tomographic scan of the head within 30 min of arrival, and started reversal of blood products within 30 min of tICH confirmation. Compared with patients admitted before establishing the head strike protocol, patients treated postimplementation were significantly more likely to have trauma team activation (77% preprotocol vs. 89% postprotocol) and expeditious initiation of reversal agents (68 min preprotocol vs. 21 min postprotocol) and to survive their head injury for patients taking anticoagulants (42% preprotocol vs. 21% postprotocol). There were no differences in mortality for patients taking antiplatelet agents. This comprehensive nurse-driven reversal protocol presents an algorithm for managing patients with suspected tICH taking any preinjury blood thinners, allowing "ownership" by the nursing staff to ensure there are no delays in initiating blood products. This protocol may be particularly salient with the aging of the trauma population and parallel increase in the use of blood thinners.

The low-molecular-weight fraction of 5% human serum albumin (LMWF-5A) is being developed to treat the signs and symptoms of severe osteoarthritis of the knee. This study was a post hoc pooled analysis of 3 randomized placebo-controlled trials of a single intra-articular injection of LMWF-5A, focusing on the subset of patients with severe osteoarthritis of the knee (Kellgren-Lawrence grade 4). Patients were randomized 1:1 to receive a single 4-mL intra-articular knee injection of either LMWF-5A or saline. Safety was assessed as the incidence and severity of adverse events. Efficacy was assessed as the change from baseline to week 12 on the Western Ontario and McMaster Universities Osteoarthritis Index pain (primary outcome), stiffness, and physical function subscores and on patient global assessment scores and was presented as the least squares mean difference and 95% confidence interval. The proportion of responders was defined with the Outcome Measures in Rheumatology-Osteoarthritis Research Society International criteria for scenario D and examined with Pearson's chi-square test. For 417 patients with severe osteoarthritis of the knee, treatment with LMWF-5A resulted in a significant decrease in pain at 12 weeks compared with saline (mean difference, -0.19; 95% confidence interval, -0.34 to -0.04; P=.016), with improvements in function (mean difference, -0.15; 95% confidence interval, -0.31 to 0.01) and patient global assessment (mean difference, -0.30; 95% confidence interval, -0.49 to -0.12) and higher responder rates (64.25% vs 50.90%, P=.006). No drug-related serious adverse events and no deaths occurred, and the incidence and severity of adverse events were similar across treatment groups. This pooled analysis supports the use of LMWF-5A as a safe therapeutic agent for relief of the signs and symptoms of severe osteoarthritis of the knee. [Orthopedics. 2018; 41(1):e77-e83.]., (Copyright 2017, SLACK Incorporated.)

Objectives: In congestive heart failure (CHF), men are younger, more likely to have reduced ejection fraction (HF-rEF), and to be diabetic compared to women. Despite this, sex differences in oxidative stress have yet to be explored in CHF., Methods: Data from 67 males and 63 females hospitalized for CHF were collected. Static oxidation-reduction potential (sORP), a relative indicator of oxidative stress, and capacity ORP (icORP), a relative indicator of antioxidant capacity, were measured from plasma samples. We examined whether sex modified the relationship between ORP and hospital discharge disposition (poor outcome: death, hospice), along with other demographics, medications, and diagnostic parameters., Results: Males with poor outcomes had higher sORP and icORP values than females (P < 0.05). For those with a good outcome, there were no differences between the sexes (P > 0.05). Males were younger and more likely to have HF-rEF and diabetes. Controlling for these variables did not account for the sex differences in ORP measures. Regardless of sex, higher creatinine was related to higher sORP and icORP, while lower magnesium and potassium were related to higher sORP and icORP, respectively., Discussion: Increases in sORP during CHF are partially affected by sex and acute outcomes, but are also related to variables without sexual biases.

Background: Tibial plateau fractures (TPFs) are frequently associated with motor vehicle accidents, auto-pedestrian crashes and falls. However, hospitals near ski resorts commonly treat TPF resulting from skiing. The soft tissue envelope and original mechanism of injury are important determinants in the decision to proceed with immediate or delayed fixation of the fracture. Our objective was to assess whether immediate (≤24 hours) versus delayed (>24 hours) open reduction internal fixation (ORIF) affected in-hospital outcomes among snow sport participants., Methods: This was a retrospective study of patients with isolated TPF who were injured while skiing or snowboarding and treated at a Level III Trauma Center that serves four major ski resorts between 2010 and 2013. Clinical characteristics and in-hospital outcomes were obtained from an existing trauma database. Imaging was reviewed to classify the fracture as high (Schatzker IV-VI) or low (Schatzker I-III) energy. Differences in clinical characteristics and outcomes between immediate and delayed ORIF patients were analyzed with χ 2 and Wilcoxon two-sample tests. These analyses were also performed in the high-energy and low-energy fracture populations., Results: ORIF was performed on 119 snow sport patients, 93 (78%) immediately. Patients had a median age of 49 years (range 19-70) and were predominantly male (66%). Forty percent sustained a high-energy TPF. No differences were observed between the demographic characteristics, injury severity, Schatzker scores or time from injury to hospital arrival for patients treated immediately versus delayed treatment. Compared with delayed fixation, patients treated immediately had less compartment syndrome (3% vs 27%), needed fewer fasciotomies (6% vs 31%) and had a shorter length of stay (3 vs 6.5 days), p<0.05 for all. These results persisted in the stratified analysis of high-energy fracture patients., Discussion: Treating patients immediately led to more favorable in-hospital outcomes compared with delayed treatment, even among the patients with a high-energy fracture., Level of Evidence: Level IV, Therapeutic/Care Management., Competing Interests: Competing interests: None declared.

Objective: The safety and efficacy of intra-arterial treatment (IAT) in patients with acute ischemic stroke (AIS) due to cervical artery dissection (CeAD) has not been formally studied. The purpose of this study was twofold: first, describe a large series with CeAD treated with IAT; second, analyze outcomes with CeAD receiving IAT versus (a) CeAD not treated with IAT, (b) CeAD receiving intravenous thrombolysis (IVT) alone, and (c) non-CeAD mechanism of AIS receiving IAT., Design: Demographics, clinical characteristics, treatment, and outcomes were summarized for all CeAD patients treated with IAT from January 2010 to May 2015. Outcomes included favorable 90 day modified Rankin Scale (mRS) score of 0-2, symptomatic intracerebral hemorrhage (sICH), recanalization (Thrombolysis in Cerebral Infarction 2b-3), procedural complications, and mortality. Outcomes were analyzed with χ 2 tests and multivariate logistic regression., Results: There were 161 patients with CeAD: 24 were treated with IAT and comprised our target population. Dissections were more common in the internal carotid (n=18) than in the vertebral arteries (n=6). All but one patient had intracranial embolus. IAT techniques included thrombectomy (n=19), IA thrombolysis (n=17), stent (n=14), and angioplasty (n=7). Outcomes included favorable 90 day mRS score of 0-2 in 63%, 4 deaths, 1 sICH, and 3 procedural complications. After adjustment, favorable mRS in our target population was similar to comparison populations: (a) in CeAD, IAT versus no IAT (OR 0.62, p=0.56); (b) In CeAD, IAT versus IVT alone (OR 1.32, p=0.79); and (c) IAT in CeAD versus non-CeAD mechanism of AIS (OR 0.58, p=0.34)., Conclusions: IAT is a valid alternative therapeutic option for AIS caused by CeAD due to the low complication rate and excellent outcomes observed in this study., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Cerebral venous thrombosis is a rare cause of stroke that poses diagnostic, therapeutic, and prognostic challenges. Mainstay treatment is systemic anticoagulation, but endovascular treatment is increasingly advocated. Our objectives were to describe the epidemiology, treatment, and prognosis of 152 patients with cerebral venous thrombosis., Methods and Results: This was a retrospective study of consecutive cerebral venous thrombosis cases from 2006 to 2013 at a comprehensive stroke center through hospital discharge. Predictors of full recovery (modified Rankin Scale scores 0-1) were analyzed with multiple logistic regression and presented as adjusted odds ratios (AORs) with 95% confidence intervals (CIs). The population was young (average age: 42 years), majority female (69%), and commonly presenting with cerebral edema (63%), and 72% were transferred in. All patients received systemic anticoagulation; 49% (n=73) required endovascular treatment. Reasons for requiring endovascular treatment included cerebral edema, herniation, or hemorrhagic infarct (n=38); neurologic decline (n=17); rethrombosis, persistent occlusion, or clot propagation (n=10); extensive clot burden (n=7); and persistent headache despite anticoagulation (n=1). There were 7 (10%) procedural complications. Recanalization was successful (61%), partial (30%), and unsuccessful (9%). Overall, 60% fully recovered. Positive predictors of full recovery included hormonal etiology, particularly for patients who were transferred in (AOR: 7.06 [95% CI, 2.27-21.96], interaction P =0.03) and who had migraine history (AOR: 4.87 [95% CI, 1.01-23.50], P =0.05), whereas negative predictors of full recovery were cerebral edema (AOR: 0.11 [95% CI, 0.04-0.34], P <0.001) and motor weakness (AOR: 0.28 [95% CI, 0.09-0.96], P =0.04)., Conclusions: As one of the largest cohort studies, our findings suggest that cerebral edema, history of migraine, and hormonal etiology were prognostic and that endovascular treatment might be a safe and effective treatment for cerebral venous thrombosis when conventional management is inadequate., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Objective: The modified early warning score (MEWS) is a 'track and trigger' score using routine physiological vital signs. The objective is to determine if the pretransfer MEWS can be used for predicting outcomes in trauma patients requiring interfacility transfer to higher levels of care., Design, Setting and Participants: Retrospective study of consecutively transferred trauma patients into a level-II trauma centre from 2013 to 2014., Interventions: None., Outcome Measures: Mortality, intensive care unit (ICU) admission, operative procedure, MEWS deterioration in-transit, air transport interfacility, secondary overtriage (low injury severity score (ISS) <10, LOS<1 day, discharged home) and severe injury (ISS ≥16). The association between the pretransfer MEWS and outcomes were analysed with Cochran-Armitage trend tests, receiver operator characteristic (ROC) curves and univariate logistic regression., Results: There were 587 transferred patients; outcomes were reported in 339 patients with complete data on all five vital signs used to calculate the MEWS. The MEWS ranged from 0 to 9 (median of 1). There was a significant linear relationship between MEWS and study outcomes, especially mortality, ICU admission, air medical transport and severe injury (p<0.001 for all). A threshold score ≥4 was identified by ROC analysis; 11.2% of patients had MEWS ≥4. Outcomes were significantly worse in patients with MEWS ≥4 versus <4: mortality (26.2% vs 3.0%, OR=11.59, p<0.001); ICU admission (73.7% vs 47.2%, OR=3.14, p=0.003); air transfer (42.1% vs 15.6%, OR=3.93, p<0.001) and severe injury (59.5% vs 27.2%, OR=3.9, p<0.001). The MEWS was not associated with surgery, in-transit MEWS deterioration or secondary overtriage., Conclusion: Pretransfer MEWS ≥4 may be used by the receiving facility for predicting injury severity, mortality, air transport and ICU resource use. In the interfacility transport setting, the MEWS may be useful for identifying patients with less obvious need for transfer or requiring more expeditious transfer., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: We sought to determine occurrence, predictors, and prognosis of alcohol withdrawal syndrome and delirium tremens in patients with traumatic injury., Design: Retrospective multicenter cohort study., Setting: Three U.S. trauma centers., Patients: Twenty-eight thousand one hundred one trauma patients admitted from 2010-2014., Interventions: None., Measurements and Main Results: Measures included occurrence of alcohol withdrawal syndrome and delirium tremens, injury characteristics, risk factors for alcohol withdrawal syndrome, clinical outcomes, pharmacologic treatment for alcohol withdrawal syndrome, and Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) scores. Alcohol withdrawal syndrome severity was defined by CIWA-Ar score as minimal (< 10), moderate (10-20), and severe (> 20). Alcohol withdrawal syndrome developed in 0.88% (n = 246), including 12% minimal, 36% moderate, and 53% severe. Alcohol withdrawal syndrome progressed to delirium tremens in 11%. Before adjustment, alcohol withdrawal syndrome severity was associated with injury severity, hypokalemia, baseline CIWA-Ar score, and established alcohol withdrawal syndrome risk factors. Logistic regression identified the following predictors of delirium tremens: baseline CIWA-Ar score greater than or equal to 10 (odds ratio, 6.05; p = 0.02) and age greater than or equal to 55 (odds ratio, 3.24; p = 0.03). In patients with severe alcohol withdrawal syndrome, severe head injury also predicted progression to delirium tremens (odds ratio, 6.08; p = 0.01), and hypokalemia was borderline significant (odds ratio, 3.23; p = 0.07). Clinical outcomes of hospital length of stay, ICU length of stay, and alcohol withdrawal syndrome complications differed significantly by alcohol withdrawal syndrome severity and were worse with more severe manifestations of alcohol withdrawal syndrome. Mortality also significantly differed by alcohol withdrawal syndrome severity but was only greater in patients who progressed to delirium tremens (11.1%; p = 0.02); otherwise, there were no differences in mortality by severity (4%, 4%, and 0% by minimal, moderate, and severe alcohol withdrawal syndrome)., Conclusions: Trauma patients with alcohol withdrawal syndrome experience a high occurrence of delirium tremens that is associated with significant mortality. These data demonstrate the predictive ability of baseline CIWA-Ar score, age, and severe head injury for developing delirium tremens.

Purpose: To characterize trends and prognosis of severe traumatic brain injury (TBI)., Methods: This 5-year multicenter retrospective study included patients with TBI and Glasgow Coma Scale of 3. We analyzed demographic and clinical characteristics and mortality using Pearson χ 2 tests, Cochran-Armitage trend tests, and stepwise logistic regression. Analyses were stratified by vehicular and fall etiologies; other etiologies were excluded (24%)., Results: Included were 481 patients. Fall-related injuries increased 58% (P=.001) but vehicular etiology did not change (P=.63). The characteristics of the populations changed over time; with falls, the population became older and increasingly presented with normal vital signs, whereas with vehicular etiology, the population became younger, with more alcohol-related injury (P<.05 for all). Mortality from falls increased substantially from 25% to 63% (P<.001), whereas death from vehicular injures remained statistically unchanged but with a downward trend (50%-38%, P=.28). Predictors of mortality included injury severity and age at least 65 years for both groups. Additional variables that were prognostic were abnormal vital signs and subdural hematoma for vehicular injuries, and sex for fall injuries., Conclusions: The epidemiology of severe TBI is changing. These epidemiologic data may be used for management and resource decisions, monitoring, and directing injury prevention measures., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Prognosis in patients with traumatic brain injury (TBI) and Glasgow Coma Scale (GCS) score of 3 is poor, raising concern regarding the utility of aggressive operative neurosurgical management. Our purpose was to describe outcomes in a propensity matched population with TBI and GCS3 treated with operative neurosurgical procedures of craniotomy or craniectomy (CRANI)., Methods: We conducted a five-year, multicenter retrospective cohort study of patients with an ED GCS 3 and a positive head CT identified by ICD-9CM diagnosis codes. Two populations were examined: (1) patients with extra-axial mass lesion (subdural or epidural haematoma), (2) patients without mass lesion (subarachnoid and intraparenchymal haemorrhage including contusion, other intracerebral haemorrhage or intracranial injury including diffuse axonal injury). In patients with extra-axial mass lesion, propensity score techniques were used to match patients 1:1 by CRANI, and the following outcomes were analysed with conditional logistic regression: survival, favourable hospital disposition to home or rehabilitation, and development of complications., Results: There were 541 patients with TBI and GCS3; 19% had a CRANI, 83% were initiated within 4h. In those with mass lesion, 27% (91/338) had a CRANI; after matching, a significant survival benefit was observed with CRANI vs. without CRANI (65% vs. 34% survival, OR: 3.9 (1.6-10.5) p<0.001). There was borderline increased odds of favourable disposition (43% vs. 26%, OR: 2.4 (0.99-6.3, p=0.052) with CRANI vs. without CRANI, and no difference in developing a complication (58% vs. 48%, OR: 1.5 (0.7-3.4), p=0.30)., Conclusions: Survival was achieved in 65% of patients that underwent surgical intervention for subdural and epidural haematoma, despite a presenting GCS of 3. These results demonstrate prompt operative neurosurgical management of mass lesion is warranted for selected patients with a GCS of 3, contributing to a significant 4-fold survival benefit. In the absence of mass lesion the effect of immediate neurosurgery on outcomes is inconclusive., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Electrolyte imbalances are common among patients with traumatic brain injury (TBI). Cerebral salt wasting (CSW) is an electrolyte imbalance characterized by hyponatremia and hypovolemia. Differentiating the syndrome of inappropriate antidiuretic hormone and CSW remains difficult and the pathophysiological mechanisms underlying CSW are unclear. Our intent was to review the literature on CSW within the TBI population, in order to report the incidence and timing of CSW after TBI, examine outcomes, and summarize the biochemical changes in patients who developed CSW. We searched MEDLINE through 2014, hand-reviewed citations, and searched abstracts from the American Association for the Surgery of Trauma (2003-2014). Publications were included if they were conducted within a TBI population, presented original data, and diagnosed CSW. Publications were excluded if they were review articles, discussed hyponatremia but did not differentiate the etiology causing hyponatremia, or presented cases with chronic disease. Fifteen of the 47 publications reviewed met the selection criteria; nine (60%) were case reports, five (33%) were prospective and 1 (7%) was a retrospective study. Incidence of CSW varied between 0.8 - 34.6%. The populations studied were heterogeneous and the criteria used to define hyponatremia and CSW varied. Though believed to play a role in the development of CSW, increased levels of natriuretic peptides in patients diagnosed with CSW were not consistently reported. These findings reinforce the elusiveness of the CSW diagnosis and the need for strict and consistent diagnostic criteria.

Background: Do-Not-Resuscitate (DNR) orders in patients with traumatic injury are insufficiently described. The objective is to describe the epidemiology and outcomes of DNR orders in trauma patients., Methods: We included all adults with trauma to a community Level I Trauma Center over 6 years (2008-2013). We used chi-square, Wilcoxon rank-sum, and multivariate stepwise logistic regression tests to characterize DNR (established in-house vs. pre-existing), describe predictors of establishing an in-house DNR, timing of an in-house DNR (early [within 1 day] vs late), and outcomes (death, ICU stay, major complications)., Results: Included were 10,053 patients with trauma, of which 1523 had a DNR order in place (15%); 715 (7%) had a pre-existing DNR and 808 (8%) had a DNR established in-house. Increases were observed over time in both the proportions of patients with DNRs established in-house (p = 0.008) and age ≥65 (p < 0.001). Over 90% of patients with an in-house DNR were ≥65 years. The following covariates were independently associated with establishing a DNR in-house: age ≥65, severe neurologic deficit (GCS 3-8), fall mechanism of injury, ED tachycardia, female gender, and comorbidities (p < 0.05 for all). Age ≥65, female gender, non-surgical service admission and transfers-in were associated with a DNR established early (p < 0.05 for all). As expected, mortality was greater in patients with DNR than those without (22% vs. 1%), as was the development of a major complication (8% vs. 5%), while ICU admission was similar (19% vs. 17%). Poor outcomes were greatest in patients with DNR orders executed later in the hospital stay., Conclusions: Our analysis of a broad cohort of patients with traumatic injury establishes the relationship between DNR and patient characteristics and outcomes. At 15%, DNR orders are prevalent in our general trauma population, particularly in patients ≥65 years, and are placed early after arrival. Established prognostic factors, including age and physiologic severity, were determinants for in-house DNR orders. These data may improve physician predictions of outcomes with DNR and help inform patient preferences, particularly in an environment with increasing use of DNR and increasing age of patients with trauma.

Background: Clinical trials confirmed the safety and efficacy of intra-arterial therapy (IAT) in the management of ischemic stroke. At a community hospital, we compared outcomes in patients aged ≥80 and patients in the age range 55-79 years receiving IAT following ischemic stroke., Methods: Data were retrospectively abstracted for ischemic stroke patients ≥55 years treated with IAT at an urban comprehensive stroke center between 2010 and 2013. Baseline demographics, incidence of symptomatic intracranial hemorrhage (sICH), in-hospital mortality, discharge modified Rankin scale (mRS) score (favorable ≤2) and improvement in National Institutes of Health Stroke Scale Score (NIHSS; decreased score at discharge) were compared between patients in the age range 55-79 and patients ≥80 years. Data were analyzed using univariate analyses and multivariate logistic regression., Results: IAT was performed in 239 patients with ischemic stroke; 63 (26.4%) were ≥80 years. When compared to patients aged 55-79, the elderly patients were more often female and non-smokers, with a history of atrial fibrillation. No differences were observed in those ≥80 years compared to patients in the age range 55-79 years for sICH (10 vs. 5%, p = 0.23), mortality (24 vs. 18%, p = 0.28), favorable discharge mRS score (13 vs. 19%, p = 0.27), or improvement in NIHSS (83 vs. 92%, p = 0.10). The nonsignificant association of age with the outcomes persisted after adjusting for covariates and when analyzing the subset of patients who received IAT only., Conclusions: These findings suggest that in a cohort not subject to the criteria of a clinical trial, age ≥80 years should not be a contraindication to IAT., (© 2015 S. Karger AG, Basel.)

Importance: The Glasgow Coma Scale (GCS) is used frequently to define the extent of neurologic injury in patients with a traumatic brain injury (TBI). Whether age affects the predictive ability of the GCS for severity of TBI (determined by the Abbreviated Injury Scale [AIS] score) remains unknown., Objective: To investigate the effect of age on the association between the GCS and anatomic TBI severity., Design, Setting, and Participants: We examined all patients with a TBI, defined by diagnostic codes 850 to 854 from the International Classification of Diseases, Ninth Revision, Clinical Modification, who were admitted to 2 level I trauma centers from January 1, 2008, through December 31, 2012., Exposures: We compared elderly (≥65 years) and younger (18-64 years) adults with TBI., Main Outcomes and Measures: We examined differences by age in GCS category (defined by emergency department GCS as severe [3-8], moderate [9-12], or mild [13-15]) at each level of TBI severity (head AIS score, 1 [minor] to 5 [critical]). Cochran-Armitage χ² trend tests and stepwise multivariate linear and logistic regression models were used., Results: During the study period, 6710 patients had a TBI (aged <65 years, 73.17%). Significant differences in GCS category by age occurred at each AIS score (P ≤ .01 for all). In particular, among patients with an AIS score of 5, most of the elderly patients (56.33%) had a mild neurologic deficit (GCS score, 13-15), whereas most of the younger patients (63.28%) had a severe neurologic deficit (GCS score, 3-8). After adjustment, the younger adults had increased odds of presenting with a severe neurologic deficit (GCS score, 3-8) at each of the following AIS scores: 1, 4.2 (95% CI, 1.0-17.6; P = .05); 2, 2.0 (1.0-3.7; P = .04); 3, 2.0 (1.2-3.5; P = .01); 4, 4.6 (2.8-7.5; P < .001); and 5, 3.1 (2.1-4.6; P < .001). The interaction between age and GCS for anatomic TBI severity remained significant after adjustment (estimate, -0.11; P = .005)., Conclusions and Relevance: Age affects the relationship between the GCS score and anatomic TBI severity. Elderly TBI patients have better GCS scores than younger TBI patients with similar TBI severity. These findings have implications for TBI outcomes research and for protocols and research selection criteria that use the GCS.

Objective: This study sought to investigate outcomes after a novel nontransfer protocol for mild traumatic brain injuries patients with small intracranial hemorrhage (ICH) in a rural trauma center without neurosurgical capabilities., Methods: This was a retrospective cohort study. In 2007, a nontransfer protocol was implemented at a Level III Trauma Center. It included adult patients from April 2007 through December 2012 with mild traumatic brain injury (mTBI) (Glasgow Coma Scale score 13 to 15) and computed tomography (CT) showing small ICH and no coagulopathy. The following ICHs were allowed: 1) minimal or small traumatic subarachnoid hemorrhage, 2) punctuate or minimal superficial cerebral contusion, 3) punctuate or minimal intraparenchymal hemorrhage, or 4) very small subdural hemorrhage (SDH) without mass effect (a very thin smear SDH along the tentorium or falx). CT scans were reviewed by the on-call neurosurgeon at an affiliated Level I Trauma Center, and consensus was obtained on the suitability for nontransfer., Results: A total of 76 patients were included. The median hospital length of stay was 1 day (interquartile range = 1 day). No patient required a neurosurgical intervention or postadmission transfer to a Level I facility. There were no in-hospital deaths, and all patients were discharged with stable head CTs and in good neurologic condition. Two patients were readmitted for nonprotocol-related reasons: 1 acute-on-chronic SDH 6 weeks postdischarge, and 1 visual eye change with normal CT 2 days postdischarge., Conclusions: Our 6-year study corroborates the low neurosurgical rate reported in the literature for mTBI with small ICH. Nontransfer protocols may lead to a more efficient use of hospital resources while providing safe, effective and economical health care., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The abrupt discontinuation of statin therapy has been suggested as being deleterious to patient outcomes. Although pre-injury statin (PIS) therapy has been shown to have a protective effect in elderly trauma patients, no study has examined how this population is affected by its abrupt discontinuation. This study examined the effects of in-hospital statin discontinuation on patient outcomes in elderly traumatic brain injury (TBI) patients., Methods: This was a multicenter, retrospective cohort study on consecutively admitted elderly (≥ 55) PIS patients who were diagnosed with a blunt TBI and who had a hospital length of stay (LOS) ≥ 3 days. Patients who received an in-hospital statin within 48 hours of admission were considered continued, and patients who never received an in-hospital statin were considered discontinued. Differences in in-hospital mortality, having at least one complication, and LOS > 1 week were examined between those who continued and discontinued PIS., Results: Of 93 PIS patients, 46 continued and 15 discontinued statin therapy. The two groups were equivalent vis-a-vis demographic and clinical characteristics. Those who discontinued statin therapy had a 4-fold higher mortality rate than those who continued (n = 4, 27% vs. n = 3, 7%, P = 0.055). Statin discontinuation did not have a higher complication rate, compared to statin continuation (n = 3, 20% vs. n = 7, 15%, P = 0.70), and no difference was seen in the proportion with a hospital LOS > 1 week (P > 0.99)., Conclusions: Though our study is not definitive, it does suggest that the abrupt, unintended discontinuation of statin therapy is associated with increased mortality in the elderly TBI population. Continuing in-hospital statin therapy in PIS users may be an important factor in the prevention of in-hospital mortality in this elderly TBI population.

Background: Level I trauma centers have requirements on the percentage of trauma patients admitted to either a trauma surgeon or surgical subspecialist; however, surgical resources are in steady decline. Therefore, a trauma system might better utilize its surgical resources if trained hospitalists admitted a larger percentage of mild to moderately injured trauma patients. The objective of this report is to provide a 5-year evaluation of a trauma medical service (TMED) at treating mild to moderately injured trauma patients., Methods: Adult trauma patients consecutively admitted to a Level I trauma center between January 2006 and December 2010 were analyzed. Patients admitted to trauma surgical services were matched 1:1 to those admitted to TMED, via propensity scores. Paired t tests examined differences in hospital duration of stay (DOS), and exact conditional logistic regression examined differences in the odds of having a delayed diagnosis, developing a complication, and dying., Results: Of 1,202 TMED patients, 494 were matched; matched TMED patients had similar patient outcomes to nonmatched TMED patients. There were no differences between study groups in the mean hospital DOS, the proportion having a delayed diagnosis, or in the odds of dying in the hospital (P > .05 for all). The TMED group had a nominally higher complication rate (P = .12) owing to a higher rate of urinary tract infections., Conclusion: Since its inception, the TMED service has successfully and safely treated mild to moderately injured trauma patients, and decreased the dependency on trauma surgical services. Trauma centers might utilize declining surgical services more efficiently with the addition of trauma medical hospitalists., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Inconsistent application of trauma service resources and underevaluation of risk and resuscitation status in elderly trauma patients are problematic. We describe a geriatric protocol that includes initial lactate determination and trauma surgery admission. Protocol compliance rates were initial lactate determination, 67.9%; trauma service admission for overt or compensated (elevated lactate) shock, 73.6%; and trauma service consultation for nonshock patients, 67.8%. Implementation of this protocol resulted in a trend toward reduced mortality and reduced potentially preventable deaths.

Background: In the setting of mild traumatic brain injury (TBI), the clinical significance of a traumatic subarachnoid hemorrhage (tSAH) has not been sufficiently studied. We examined the impact of an isolated tSAH on patient outcomes in the mild TBI population., Methods: We retrospectively identified all mild TBI patients (Glasgow Coma Scale score ≥13) who presented to a Level I trauma center over a 10-year period. We compared isolated tSAH patients with isolated concussion patients. χ(2) and logistic regression analyses were used to compare intensive care unit (ICU) admission, ICU length of stay (LOS), hospital LOS, progression of tSAH, in-hospital mortality, and disposition to rehabilitation., Results: There were 1,144 concussion and 117 tSAH patients included in our study. After adjustment, tSAH patients had increased odds of admission to the ICU (odds ratio, [OR] = 8.87; p < 0.0001), yet their ICU LOS was significantly shorter (OR = 0.29; p = 0.01). The overall hospital LOS and mortality rate were not significantly different between the TBI groups. When stratified by age, only the 40-year to 69-year-old tSAH patients had significantly increased adjusted odds of disposition to rehabilitation compared with concussion patients, independent of ICU admission (OR = 7.96; p = 0.004). None of the patients required any neurosurgical interventions., Conclusions: We encourage healthcare facilities to consider revising or creating ICU admission criteria for the mild TBI population to help optimize the utilization of their ICUs. We believe clinicians should place more emphasis on variables such as age, comorbidities, and neurologic condition rather than the presence of a small volume of blood in the subarachnoid space when admitting mild isolated TBI patients to the ICU.

Background and Purpose: Patients with acute ischemic stroke require immediate medical treatment, and a CT to rule out hemorrhage is required before tPA. We adapted our protocol to include multimodal CT: unenhanced CT, CTA, and PCT. The purpose of this study was to determine whether multimodal CT imaging delays initiation of IV tPA beyond 60 minutes from hospital arrival., Materials and Methods: All patients admitted during 3 years through the ED with a stroke alert and time from symptom onset to hospital arrival <2.5 hours were included. We examined 2 subgroups (multimodal CT versus unenhanced CT) to determine whether multimodal CT delayed tPA administration. Logistic regression was used to identify variables that predicted tPA within 60 minutes., Results: There were 123 patients in the analysis, including 108 patients who were examined with multimodal CT. The median time from arrival to tPA was 56 minutes and was shorter for patients examined with multimodal CT (55 versus 78 minutes, P = .02). After adjustment, variables that were associated with tPA administration within 60 minutes included prehospital stroke alert (OR = 3.47, P = .03), time to CT (OR = 0.94, P = .01), and onset-to-arrival time (OR = 1.02, P = .04). There was no statistically significant difference in the odds of receiving timely tPA for multimodal versus unenhanced CT (OR = 3.99, P = .07)., Conclusions: In our single-center experience, the use of multimodal imaging in patients with acute stroke did not delay IV tPA beyond 60 minutes. Further study is needed to assess the feasibility of the routine use of multimodal imaging in the acute stroke setting.

Background: Pharmacologic thromboprophylaxis (PTP) may exacerbate intracranial hemorrhage (ICH) in patients with traumatic brain injury (TBI). We examined risk factors for hemorrhage progression in patients with blunt TBI and hypothesized that PTP would increase ICH progression in a subset of these patients., Methods: We retrospectively studied patients with TBI admitted to our level I trauma center during 19 months. Progression of hemorrhage was examined in two populations: patients with a stable initial follow-up (F/U) computed tomography (CT) and patients with hemorrhage progression on initial F/U CT. Risk factors potentially associated with hemorrhage progression were analyzed using logistic regression. Timing of PTP was defined two ways: exposed to PTP versus not exposed; early (<72 hours), late (>or=72 hours), or no PTP., Results: Three hundred forty patients with TBI were reviewed and hemorrhage progression occurred in 32.4% (n = 110) of patients of which 59.1% were considered clinically significant. In patients with ICH progression on initial F/U CT, predictors of subsequent hemorrhage progression include exposure to PTP (odds ratio [OR]: 13.07, p = 0.01), extradural/subdural hemorrhage (OR: 5.15, p = 0.03), Glasgow Coma Score 3-8 (OR: 4.64, p = 0.03), and body mass index >or=25 (OR = 4.32, p = 0.03). PTP was not significantly associated with hemorrhage progression in patients with a stable initial F/U CT., Conclusions: These findings suggest that PTP use is associated with a 13-fold increased odds of further hemorrhage progression in patients whose F/U CT within 1 day of admission showed ICH progression; 16% of this risk can be attributed to receiving PTP. Conversely, PTP may be safe in a subgroup of patients with TBI with no ICH progression on initial F/U CT.

Background: The abbreviated injury scale (AIS) was updated in 2005 from the AIS 1998 version. The purpose of this study is to describe the effects of this change on injury severity scoring and outcome measures., Materials and Methods: Analyses were performed on all trauma patients consecutively admitted over a 6-month period at two geographically separate Level I trauma centers. Injuries were manually double-coded according to the AIS 05 and the AIS 98. Changes in AIS, ISS, and new ISS (NISS) were analysed using paired t-tests. Apparent differences in outcome by ISS strata (<16, 16-24, >24) were compared for AIS 05 versus AIS 98 using the Wald-type statistic. Lastly, the percent of patients with a change in ISS strata are reported., Results: There were 2250 patients included in the study. Nearly half (46.4%) of AIS codes changed, resulting in a different AIS score for 18.9% of all codes. The mean ISS was significantly lower using the AIS 05 (11.7) versus the AIS 98 (13.3, p<0.001). Similarly, the mean NISS was significantly lower (16.3 versus 18.7, p<0.001). In the ISS strata 16-24 an apparent increase in mortality, length of stay, and percent of patients not discharged home was observed for the AIS 05 versus AIS 98. Changes in outcome measures for this stratum were as follows (AIS 98 versus AIS 05): mortality, 4.3% versus 7.7% (p=0.002); hospital length of stay, 5.2 days versus 7.3 days (p<0.001); percent of patients not discharged home, 39.2% versus 49.3% (p<0.001). Finally, there was a 20.5% reduction in patients with an ISS>or=16 and a 26.2% reduction in patients with an ISS>or=25 using the AIS 05., Conclusions: The AIS revision had a significant impact on overall injury severity measures, clinical outcome measures, and percent of patients in each ISS strata. Therefore, the AIS revision affects the ability to directly compare data generated using AIS 05 and AIS 98 which has implications in trauma research, reimbursement and ACS accreditation.

Objective: To quantify the cumulative effective dose of radiation received during hospitalization after traumatic injury and to compare the computed tomography (CT) utilization practices for two time periods in patients with trauma., Design: A retrospective analysis of radiologic and medical data., Setting: A level I trauma center., Patients: Consecutively admitted adult patients with trauma with moderate to severe injuries (injury severity score >8), an intensive care unit (ICU) length of stay of one or more days, who were directly admitted and not transferred to another acute care center., Measurements and Main Results: CT examination means and utilization were compared for April through August, 2003 and April to August, 2007. Cumulative effective doses were calculated for the 2007 period, and patients with a high radiation dose (>100 mSv) were identified. One hundred sixty-five adult patients with trauma were included. An increase in mean CT examinations per patient was observed in the 2007 period compared with the 2003 period, overall (4.41 vs. 3.44, p = 0.002) and among subsets of patients. The overall increase remained significant after adjustment for patient demographics (p = 0.05). The mean cumulative effective dose per patient was 11.13 mSv in 2007; 9% of patients received a dose >or=100 mSv., Conclusions: Patients with trauma are at an increased risk of adverse effects from CT studies, because they receive high doses of radiation, and the number of CT examinations that patients receive is increasing with time. We recommend that risk of radiation be prospectively monitored and estimated by hospitals through the use of CT examination count per patient.

Background: The American College of Surgeons criteria for Level I trauma centers calls for >90% of trauma patients to be admitted directly by a trauma surgeon or surgical subspecialist; however, the efficiency of the trauma system may be increased if patients presenting with comorbid conditions and minor injuries are treated by a hospitalist team (nonsurgical Trauma MEDical [TMED] service). We hypothesized outcomes would be equivalent for patients treated under TMED versus a surgical service., Methods: This retrospective review compared mortality, hospital length of stay (LOS), Emergency Department (ED) LOS, placement to rehabilitation facilities, and complication rates for patients who could have been treated by TMED as identified by an algorithm. The study population for 2003 (pre-TMED) was compared with the study population for 2006 (post-TMED). Univariate analyses and multivariate logistic and linear regression were used to identify outcomes that were different for patients treated in 2003 versus 2006. Sensitivity, specificity, and percent kappa agreement were calculated for patients who were treated by the TMED team in 2006 versus patients in 2006 who were identified using the algorithm., Results: The algorithm had reasonable sensitivity (78%) and specificity (90%); the kappa agreement was excellent (0.88). No differences were found in mortality (P = .31), rate of complications (P = .08), ED LOS (P = .77), or placement to rehabilitation facilities (P = .29) for patients identified in 2003 versus 2006. Hospital LOS was increased in 2006 (3.7 vs 4.1 days; P = .02)., Conclusion: These data support admission of trauma patients with nonsevere, single-system injuries to a nonsurgical hospitalist service. We hypothesize that overall system efficiency may be improved by applying this alternative model in other trauma centers.