Adherence to New Zealand's Major Trauma Destination Policy: an audit of current practice

AIM

To evaluate adherence to the New Zealand Major Trauma Destination Policy (MTDP). This audit assessed if, based on their injuries, Emergency Medical Services (EMS) attended major trauma cases were taken to the MTDP determined appropriate hospital. Findings will guide and further improve pre-hospital trauma care and associated patient outcomes.

METHODS

A retrospective evaluation of adherence to the New Zealand MTDP for a random sample of 100 cases (ISS >12) injured between 31 November 2017-30 November 2018 who survived to hospital. The EMS electronic patient record (ePRF) was reviewed for each case. Adherence was indicated by the transport of injured patients from the scene to the appropriate initial destination based on meeting the respective regional MTDPs.

RESULTS

Overall, there was a 94% adherence rate to the MTDP. For patients that were not classified as requiring transport to an advanced-level trauma centre, there was a 98.9% (n=86/87) adherence compared to 61.5% (n=8/13) adherence in those that did require transport to an advanced-level trauma centre.

CONCLUSION

There was high adherence to the MTDP, with 94% of cases being taken to the appropriate destination directly from the incident scene. There is scope for improvement in cases whereby the nearest hospital should be bypassed in favour of a more distant advanced-level trauma centre.

Intentional physical self-injury in Auckland: patterns, associations and clinical implications in a single-centre cross-sectional study

INTRODUCTION

Intentional physical self-injury (IPSI) is a pressing health challenge and there is little awareness of injury patterns, management and outcomes. This study examines IPSI's epidemiological and clinical aspects in one major Auckland hospital, highlighting demography, injury patterns and implications for clinical practice and prevention.

METHODS

Using Auckland City Hospital Trauma Registry data, a retrospective, descriptive study was conducted covering adult patients admitted from January 2015 to December 2019. It assessed demographic characteristics, injury patterns and outcomes, using Mann-Whitney U tests, Fisher's exact tests and Chi-squared tests.

RESULTS

Among 137 IPSI admissions, 92 (67%) required surgery, and 24% experienced post-operative complications. Major trauma was identified in 39 (28.5%) admissions. Discharge destinations varied, with only 64 (47%) patients returning home unassisted. Injury severity did not significantly vary across sex, age or injury event location. Major injuries often resulted from falls (19 of 39) and minor injuries from lacerations/stabs (73 of 98).

CONCLUSIONS

IPSI represents a significant challenge to Auckland health services, with a notable burden of care. The study highlights the need for targeted interventions to reduce the incidence of IPSI and improve outcomes. It underscores the importance of multidisciplinary approaches to care, integrating surgical, mental health and rehabilitative services.

Rural and Ethnic Disparities in Out-of-hospital Care and Transport Pathways After Road Traffic Trauma in New Zealand

Introduction

The out-of-hospital emergency medical service (EMS) care responses and the transport pathways to hospital play a vital role in patient survival following injury and are the first component of a well-functioning, optimised system of trauma care. Despite longstanding challenges in delivering equitable healthcare services in the health system of Aotearoa-New Zealand (NZ), little is known about inequities in EMS-delivered care and transport pathways to hospital-level care.

Methods

This population-level cohort study on out-of-hospital care, based on national EMS data, included trauma patients <85 years in age who were injured in a road traffic crash (RTC). In this study we examined the combined relationship between ethnicity and geographical location of injury in EMS out-of-hospital care and transport pathways following RTCs in Aotearoa-NZ. Analyses were stratified by geographical location of injury (rural and urban) and combined ethnicity-geographical location (rural Māori, rural non-Māori, urban Māori, and urban non-Māori).

Results

In a two-year period, there were 746 eligible patients; of these, 692 were transported to hospital. Indigenous Māori comprised 28% (196) of vehicle occupants attended by EMS, while 47% (324) of patients' injuries occurred in a rural location. The EMS transport pathways to hospital for rural patients were slower to reach first hospital (total in slowest tertile of time 44% vs 7%, P ≥ 0.001) and longer to reach definitive care (direct transport, 77% vs 87%, P = 0.001) compared to urban patients. Māori patients injured in a rural location were comparatively less likely than rural non-Māori to be triaged to priority transport pathways (fastest dispatch triage, 92% vs 97%, respectively, P = 0.05); slower to reach first hospital (total in slowest tertile of time, 55% vs 41%, P = 0.02); and had less access to specialist trauma care (reached tertiary trauma hospital, 51% vs 73%, P = 0.02).

Conclusion

Among RTC patients attended and transported by EMS in NZ, there was variability in out-of-hospital EMS transport pathways through to specialist trauma care, strongly patterned by location of incident and ethnicity. These findings, mirroring other health disparities for Māori, provide an equity-focused evidence base to guide clinical and policy decision makers to optimize the delivery of EMS care and reduce disparities associated with out-of-hospital EMS care.

Major trauma in working-age adults in New Zealand

AIM

To describe the demographic and injury profile of major trauma among 20-65-year-old New Zealanders.

METHODS

A retrospective analysis of routinely collected data from the New Zealand Major Trauma Registry for the period 1 July 2017 to 30 June 2020 was conducted. Sex, age and ethnicity-based rates were then calculated using census-based population estimates to compare the rates of injury across different demographic groups.

RESULTS

Of the 4,186 major trauma incidents among 20-65-year-olds in New Zealand during the 3-year period reviewed, 235 died (5.6%). Males accounted for 77% of those injured. Māori (New Zealand's Indigenous population) had significantly higher rates of major trauma (79.2 per 100,000; 95% confidence interval [CI] 74.4-84.3) compared to non-Māori (44.4 per 100,000; 95% CI 42.9-46.0). The most common cause of injury was transport-related incidents (63%; n=2,632/4,186), followed by falls (19%; n=788/4,186).

CONCLUSIONS

Demographic characteristics have a significant relationship with major trauma injuries among 20-65-year-old New Zealanders. Continued injury prevention efforts focussing on males, Māori and transport incidents are required. Interventions that improve the safety of roads, such as lane separators, speed limits and raised intersections, should be implemented in high-crash-risk areas to reduce risk.

Narrative review of traumatic pneumorrhachis

Pneumorrhachis (PR) is defined as presence of free air in the spinal canal. Traumatic PR is very rare, and its exact incidence and pathogenesis is unknown. A comprehensive literature search was performed using the PubMed, Cochrane Library, Google Scholar and Scopus databases to identify articles relevant to traumatic PR published till January 2023. A total of 34 resources were selected for inclusion in this narrative review. Traumatic PR can be classified anatomically into epidural and intradural types. In the epidural type, air is present peripherally in the spinal canal and the patients are usually asymptomatic. In contrast, in intradural PR, air is seen centrally in the spinal canal and patients present with neurological symptoms, and it is a marker of severe trauma. It is frequently associated with traumatic pneumocephalus, skull fractures or thoracic spine fracture. Computed tomography (CT) is considered to be the diagnostic modality of choice. Epidural PR is self-limited and patients are generally managed conservatively. Patients with neurological symptoms or persistent air in spinal canal require further evaluation for a potential source of air leak, with a need for surgical intervention. Differentiation between epidural and intradural PR is important, because the latter is an indication of severe underlying injury. CT imaging of the entire spine must be performed to look for extension of air, as well as to identify concomitant skull, torso or spinal injuries Most patients are asymptomatic and are managed conservatively, but a few may develop neurological symptoms that need further evaluation and management.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Cohort profile: The Trauma Outcomes Project, a prospective study of New Zealanders experiencing major trauma

PURPOSE

Patient-reported outcome measures (PROMs) are useful for trauma registries interested in monitoring patient outcomes and trauma care quality. PROMs had not previously been collected by the New Zealand Trauma Registry (NZTR). More than 2500 New Zealanders are admitted to hospital for major trauma annually. The Trauma Outcomes Project (TOP) collected PROMs postinjury from three of New Zealand's (NZ's) major trauma regions. This cohort profile paper aims to provide a thorough description of preinjury and 6 month postinjury characteristics of the TOP cohort, including specifically for Māori (Indigenous population in Aotearoa me Te Waipounamu/NZ).

PARTICIPANTS

Between July 2019 and June 2020, 2533 NZ trauma patients were admitted to one of 22 hospitals nationwide for major trauma and included on the NZTR. TOP invited trauma patients (aged ≥16 years) to be interviewed from three regions; one region (Midlands) declined to participate. Interviews included questions about health-related quality of life, disability, injury recovery, healthcare access and household income adequacy.

FINDINGS TO DATE

TOP recruited 870 participants, including 119 Māori. At 6 months postinjury, most (85%) reported that the injury still affected them, 88% reported problems with≥1 of five EQ-5D-5L dimensions (eg, 75% reported problems with pain or discomfort, 71% reported problems with usual activities and 52% reported problems with mobility). Considerable disability (World Health Organization Disability Assessment Schedule, WHODAS II, score ≥10) was reported by 45% of participants. The prevalence of disability among Māori participants was 53%; for non-Māori it was 44%. Over a quarter of participants (28%) reported trouble accessing healthcare services for their injury. Participation in paid work decreased from 63% preinjury to 45% 6 months postinjury.

FUTURE PLANS

The 12 and 24 month postinjury data collection has recently been completed; analyses of 12 month outcomes are underway. There is potential for longer-term follow-up interviews with the existing cohort in future. TOP findings are intended to inform the National Trauma Network's quality improvement processes. TOP will identify key aspects that aid in improving postinjury outcomes for people experiencing serious injury, including importantly for Māori.

Enhanced perioperative care in emergency general surgery: the WSES position paper

Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients' outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.

The New Zealand National Trauma Registry: an essential tool for trauma quality improvement

PURPOSE

Trauma registries are essential tools for trauma systems and underpin any quality improvement activities. This paper describes the history, function, challenges, and future goals of the New Zealand National Trauma Registry (NZTR).

METHODS

Using the available publications and knowledge of the authors, the development, governance, oversight, and usage of the registry is outlined.

RESULTS

The New Zealand Trauma Network has run a national trauma registry since 2015 and this now contains over fifteen thousand major trauma patient records. Annual reports and a range of research outputs have been published. Key quality improvement initiatives have been undertaken and are described. Vulnerabilities include lack of longterm funding and a small workforce.

CONCLUSIONS

The NZTR has proven to be a critical component of trauma quality improvement in New Zealand. A user-friendly portal and a simple minimum dataset have been keys to successes but maintenance of an effective structure in a constrained healthcare system is a challenge.

ECLAPTE: Effective Closure of LAParoTomy in Emergency-2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings

Laparotomy incisions provide easy and rapid access to the peritoneal cavity in case of emergency surgery. Incisional hernia (IH) is a late manifestation of the failure of abdominal wall closure and represents frequent complication of any abdominal incision: IHs can cause pain and discomfort to the patients but also clinical serious sequelae like bowel obstruction, incarceration, strangulation, and necessity of reoperation. Previous guidelines and indications in the literature consider elective settings and evidence about laparotomy closure in emergency settings is lacking. This paper aims to present the World Society of Emergency Surgery (WSES) project called ECLAPTE (Effective Closure of LAParoTomy in Emergency): the final manuscript includes guidelines on the closure of emergency laparotomy.

Prevalence of psychoactive drugs in injured patients presenting to an emergency department

OBJECTIVE

The aim of the present study was to obtain an unbiased understanding of the prevalence of psychoactive drugs in trauma patients presenting to a large ED.

METHODS

Consecutive adult patients presenting to the ED with an injury resulting in a trauma call had an anonymised, additional blood test taken for detection of over 2000 drugs. Laboratory testing was to judicial standards. Drugs given by ambulance pre-hospital were detected but excluded from the analysis.

RESULTS

Over 6 months 276 (74.7%) of 371 patients were tested. Of the 276 patients tested, 158 (57.2%) had one or more psychoactive drug present. Recreational drugs were detected in 101 (36.6%) patients and medicinal drugs in 88 (31.8%) patients, with a combination of both detected in 31 (11.2%) patients. The most common drugs detected were cannabis (22.1%), antidepressants (18.4%), alcohol (15.5%), opioids (10.1%), benzodiazepine/z-drugs (9.4%) and methamphetamine (7.2%). The prevalence of psychoactive drugs differed by age group, sex and cause of injury.

CONCLUSIONS

The prevalence of psychoactive drugs in injury presentations to an ED is high, and provides an opportunity to reduce harm. The present study demonstrates the feasibility of an approach which limits bias and obtains results that accurately reflect the drug prevalence in injured cohorts. Systematic testing of injured patients is an important contribution to the epidemiology of injury.

A rare case of penetrating intra-abdominal trauma by a fishing speargun

Spearfishing is a popular sport in New Zealand. While there have been a few reported self-inflicted speargun injuries causing fatal intracranial damage, accidental speargun injuries while fishing are less common. Intra-abdominal speargun injuries are even less common. Its occurrence in a 30-year-old male patient reported here highlights the potential risk of life-threatening injuries. A 30-year-old male sustained an accidental speargun injury, with the spear passing through central small bowel loops and its pointed tip penetrating the left iliac wing. The patient underwent laparotomy, and the spear was removed in an antegrade fashion with primary closure of small bowel enterotomies and repair of the mesenteric defects. He had a re-look laparotomy 48 hours later with resection and anastomosis of two primary small bowel repairs and was eventually discharged after 12 days. Information obtained by radiological evaluation using computed tomography (CT) scan and angiography regarding the spear trajectory, injured organs, vasculature and spear tip mechanism is important to decide the best surgical approach. The spear should be removed in an antegrade fashion, because pulling the spear in the retrograde direction can cause further tissue and/or vascular injury. Currently, there is no legislation regarding the use of spearguns and users do not require a license, despite the potential for severe penetrating trauma similar to that caused by firearms. Spearguns can produce life-threatening injuries and the removal of the spear depends on the location of the tip in relation to adjacent structures and whether the flapper is open. It often requires a multidisciplinary team approach. Safety guidelines need to be published and widely available, and the potential risks of speargun injuries should be included in fishing rules. Introducing license requirement for possession and handling of this firearm-like weapon also needs to be considered.

Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery

Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

Background

In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved.

Methods

Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.

Results

Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications.

Conclusion

This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.

Disability-Adjusted Life Years and cost of health loss of hospitalised major trauma patients in New Zealand

AIMS

The aims of this study were to quantify the burden, and the cost of health loss, following hospitalisation for major trauma in New Zealand.

METHOD

Hospitalised major trauma patients injured between July 2017 and June 2020 were extracted from the New Zealand Trauma Registry. Case-mix of major trauma in each year was summarised using descriptive statistics. Disability-adjusted life years (DALYs) were calculated for the cohort. A cost per DALY was applied to estimate the cost of health loss.

RESULTS

A total of 6,629 major trauma cases were recorded, rising from 2,072 in 2017-2018 to 2,191 in 2019-2020. The patient case-mix remained relatively consistent over the timeframe while the in-hospital mortality rate declined from 9.2% to 7.3%. Hospitalised major trauma patients accrued 22,718 DALYs (average 7,573 DALYs per year) at an estimated health loss cost of $1.02 billion ($341 million per year). The cost of health loss per case declined from $162,747 in 2017-2018 to $143,577 in 2019-2020.

CONCLUSION

The burden of major trauma is high. As injury is a preventable condition, the findings highlight the need for dedicated investment in both primary prevention and trauma care in New Zealand to reduce these avoidable costs.

Activating Code Crimson in the emergency department: Expediting definitive care for trauma patients with severe haemorrhage in Singapore

"Trauma activation" is a process adopted across all emergency departments of public healthcare institutions in Singapore, with the aim of rapidly mobilising personnel and resources to care for patients with major trauma. A subset of trauma patients with exsanguinating haemorrhage has a particularly high mortality rate, and they require an additional response beyond the usual trauma activation for definitive haemorrhage control. To address this need, Code Crimson has been developed at Auckland City Hospital in New Zealand and other jurisdictions as a step-up response. This is aimed at early activation of the massive transfusion protocol for haemostatic resuscitation, involvement of additional multidisciplinary teams for rapid decision-making, and expediting definitive haemorrhage control. At present, there is no protocol for activation of Code Crimson in Singapore. Code Crimson may be effective in Singapore, as it has been in other jurisdictions, to reduce morbidity and mortality in major trauma patients with severe haemorrhage.

Lockdown Level 4 V2.0: different trauma patterns in Auckland in 2021?

AIMS

Coronavirus disease 2019 (COVID-19) resulted in the implementation of public health restrictions to reduce transmission. These restrictions have reduced trauma-related admissions to hospitals. Auckland, New Zealand, had two periods of Level 4 lockdowns, in 2020 and 2021. In the 2021 lockdown, Aucklanders were generally less compliant with the restrictions. Therefore, we hypothesised that trauma-related activity would be greater in the 2021 lockdown compared to 2020.

METHODS

A retrospective descriptive study of trauma admissions to Auckland City Hospital (ACH) during 2020 (26 March to 27 April 2020-33 days) and 2021 (18 August to 21 September 2021-35 days) lockdown periods was performed.

RESULTS

Trauma admissions and trauma call activations increased from 97 to 105 (8.2%) and from 35 to 46, respectively, in the 2021 lockdown compared to 2020. The numbers of males and road related injuries requiring admission were increased from 49 to 66 (p = 0.077) and from 21 to 28 (p = 0.439), respectively, in 2021 compared to 2020. Major trauma admissions increased from 13 to 23 in the 2021 lockdown compared to 2020.

CONCLUSIONS

Trauma-related presentations to hospital were higher in the 2021 Auckland lockdown compared to 2020. Lockdown fatigue and reduced compliance in 2021 may have contributed to this finding, suggesting that future lockdowns may be less effective.

Incidence, Mechanisms of Injury and Mortality of Severe Traumatic Brain Injury: An Observational Population-Based Cohort Study from New Zealand and Norway

BACKGROUND

Comparing trauma registry data from different countries can help to identify possible differences in epidemiology, which may help to improve the care of trauma patients.

METHODS

This study directly compares the incidence, mechanisms of injuries and mortality of severe TBI based on population-based data from the two national trauma registries from New Zealand and Norway. All patients prospectively registered with severe TBI in either of the national registries for the 4-year study period were included. Patient and injury variables were described and age-adjusted incidence and mortality rates were calculated.

RESULTS

A total of 1378 trauma patients were identified of whom 751 (54.5%) from New Zealand and 627 (45.5%) from Norway. The patient cohort from New Zealand was significantly younger (median 32 versus 53 years; p < 0.001) and more patients from New Zealand were injured in road traffic crashes (37% versus 13%; p < 0.001). The age-adjusted incidence rate of severe TBI was 3.8 per 100,000 in New Zealand and 2.9 per 100,000 in Norway. The age-adjusted mortality rates were 1.5 per 100,000 in New Zealand and 1.2 per 100,000 in Norway. The fatality rates were 38.5% in New Zealand and 34.2% in Norway (p = 0.112).

CONCLUSIONS

Road traffic crashes in younger patients were more common in New Zealand whereas falls in elderly patients were the main cause for severe TBI in Norway. The age-adjusted incidence and mortality rates of severe TBI among trauma patients are similar in New Zealand and Norway. The fatality rates of severe TBI are still considerable with more than one third of patients dying.