Comparison of Injury Severity Score, Glasgow Coma Scale, and Revised Trauma Score in Predicting the Mortality and Prolonged ICU Stay of Traumatic Young Children: A Cross-Sectional Retrospective Study

Beyond the Slopes and Highways: Endovascular Repair of Blunt Traumatic Aortic Injuries after Skiing versus Motor Vehicle Accidents

Background: Blunt traumatic aortic injury (BTAI) is a potentially fatal condition, typically resulting from high-velocity trauma. To date, little is known about this type of injury among skiers, who form the largest patient cohort with aortic injuries in the alpine region of Tyrol, Austria. Methods: This retrospective, single-center study at the University Hospital of Innsbruck analyzed patients who underwent endovascular treatment for blunt traumatic aortic injury from 2005 to 2023. Patient data were extracted from electronic and digitalized medical history records. Subsequent analyses compared the baseline characteristics and clinical results of the skiing accident (SA) group to the motor vehicle accident (MVA) group. Results: A total of 48 BTAI patients receiving TEVAR were included, 25 (52%) from SAs versus 23 (48%) from MVAs, who were predominantly male (92% vs. 78.3%). Despite similar preoperative risk profiles and ASA Scores (1.44 vs. 1.74) and no marked differences in BTAI injury grades or the affected aortic zones, significant disparities emerged: the SA group experienced shorter median ICU stays (3 vs. 11 days, p = 0.0007), fewer concomitant injuries (5 vs. 7, p = 0.005), and lower Injury Severity Scores (ISSs) (29 vs. 33, p = 0.003) than their MVA counterparts. The presence of rib fractures alongside other thoracic injuries, such as lung injury, pneumothorax, or hemothorax, was strongly correlated with BTAI in patients following skiing accidents (OR = 128.5). Conclusions: The injury severities and locations of BTAI in SA patients were comparable to those in MVA patients, indicating similar mechanisms of thoracic trauma. However, the SA patients experienced fewer concurrent pelvic and extremity fractures, had less post-procedural morbidity, and required shorter ICU stays. The presence of rib fractures combined with other thoracic injuries strongly suggests BTAI. These indicators should lead to prompt imaging and appropriate therapy.

Comparison of on-scene Glasgow Coma Scale with GCS-motor for prediction of 30-day mortality and functional outcomes of patients with trauma in Asia

BACKGROUND AND IMPORTANCE

This study compared the on-scene Glasgow Coma Scale (GCS) and the GCS-motor (GCS-M) for predictive accuracy of mortality and severe disability using a large, multicenter population of trauma patients in Asian countries.

OBJECTIVE

To compare the ability of the prehospital GCS and GCS-M to predict 30-day mortality and severe disability in trauma patients.

DESIGN

We used the Pan-Asia Trauma Outcomes Study registry to enroll all trauma patients >18 years of age who presented to hospitals via emergency medical services from 1 January 2016 to November 30, 2018.

SETTINGS AND PARTICIPANTS

A total of 16,218 patients were included in the analysis of 30-day mortality and 11 653 patients in the analysis of functional outcomes.

OUTCOME MEASURES AND ANALYSIS

The primary outcome was 30-day mortality after injury, and the secondary outcome was severe disability at discharge defined as a Modified Rankin Scale (MRS) score ≥4. Areas under the receiver operating characteristic curve (AUROCs) were compared between GCS and GCS-M for these outcomes. Patients with and without traumatic brain injury (TBI) were analyzed separately. The predictive discrimination ability of logistic regression models for outcomes (30-day mortality and MRS) between GCS and GCS-M is illustrated using AUROCs.

MAIN RESULTS

The primary outcome for 30-day mortality was 1.04% and the AUROCs and 95% confidence intervals for prediction were GCS: 0.917 (0.887-0.946) vs. GCS-M:0.907 (0.875-0.938), P  = 0.155. The secondary outcome for poor functional outcome (MRS ≥ 4) was 12.4% and the AUROCs and 95% confidence intervals for prediction were GCS: 0.617 (0.597-0.637) vs. GCS-M: 0.613 (0.593-0.633), P  = 0.616. The subgroup analyses of patients with and without TBI demonstrated consistent discrimination ability between the GCS and GCS-M. The AUROC values of the GCS vs. GCS-M models for 30-day mortality and poor functional outcome were 0.92 (0.821-1.0) vs. 0.92 (0.824-1.0) ( P  = 0.64) and 0.75 (0.72-0.78) vs. 0.74 (0.717-0.758) ( P  = 0.21), respectively.

CONCLUSION

In the prehospital setting, on-scene GCS-M was comparable to GCS in predicting 30-day mortality and poor functional outcomes among patients with trauma, whether or not there was a TBI.

Comparison of nine trauma scoring systems in prediction of inhospital outcomes of pediatric trauma patients: a multicenter study

Hereby, we aimed to comprehensively compare different scoring systems for pediatric trauma and their ability to predict in-hospital mortality and intensive care unit (ICU) admission. The current registry-based multicenter study encompassed a comprehensive dataset of 6709 pediatric trauma patients aged ≤ 18 years from July 2016 to September 2023. To ascertain the predictive efficacy of the scoring systems, the area under the receiver operating characteristic curve (AUC) was calculated. A total of 720 individuals (10.7%) required admission to the ICU. The mortality rate was 1.1% (n = 72). The most predictive scoring system for in-hospital mortality was the adjusted trauma and injury severity score (aTRISS) (AUC = 0.982), followed by trauma and injury severity score (TRISS) (AUC = 0.980), new trauma and injury severity score (NTRISS) (AUC = 0.972), Glasgow coma scale (GCS) (AUC = 0.9546), revised trauma score (RTS) (AUC = 0.944), pre-hospital index (PHI) (AUC = 0.936), injury severity score (ISS) (AUC = 0.901), new injury severity score (NISS) (AUC = 0.900), and abbreviated injury scale (AIS) (AUC = 0.734). Given the predictive performance of the scoring systems for ICU admission, NTRISS had the highest predictive performance (AUC = 0.837), followed by aTRISS (AUC = 0.836), TRISS (AUC = 0.823), ISS (AUC = 0.807), NISS (AUC = 0.805), GCS (AUC = 0.735), RTS (AUC = 0.698), PHI (AUC = 0.662), and AIS (AUC = 0.651). In the present study, we concluded the superiority of the TRISS and its two derived counterparts, aTRISS and NTRISS, compared to other scoring systems, to efficiently discerning individuals who possess a heightened susceptibility to unfavorable consequences. The significance of these findings underscores the necessity of incorporating these metrics into the realm of clinical practice.

Caregiver reported long-term outcomes in children with major trauma and traumatic brain injuries: A single-centre retrospective study

Introduction

We aim to investigate the functional outcomes and long-term health-related quality of life (HRQOL) in children with major trauma associated with traumatic brain injury (TBI).

Method

We performed a retrospective review of records among patients >2 and ≤16 years old in a tertiary paediatric hospital between January 2014 and October 2019 with major trauma (Injury Severity Score of ≥16) and TBI of all severities. We recorded each child's Glasgow Outcome Scale-Extended Pediatric Version (GOS-E Peds) at 12 months post-injury and Pediatric Quality of Life Inventory (PedsQL) scores at 6 and 12 months post-injury based on the parent proxy-report scales.

Results

We included 53 patients with a median age of 9.0 years old (interquartile range 2.3-15.5). Most injuries were due to falls (30, 56.6%) or road traffic collisions (15, 28.3%); 41 patients (77.3%) required intensive care while 30 patients (56.6%) underwent neurosurgical intervention. Most patients (43, 81.1%) had GOS-E Peds scores of ≤2 at 12 months post-injury. We reported a significant mean difference between the 6- and 12-month parent-reported scores for physical functioning (6.6, 95% confidence interval [CI] 0.3-12.8, P=0.041), psychosocial functioning (4.1, 95% CI 1.0-7.2, P=0.012) and overall scores (5.0, 95% CI 1.4-8.7, P=0.008). Compared with the validated PedsQL scores, our mean scores were higher across all domains at 12 months.

Conclusion

With current standard of care, parents of children with major trauma and TBI reported gains in quality of life, physical, psychosocial and overall function between 6 and 12 months post-injury.

Epidemiology of Anterior and Lateral Basilar Skull Fractures With CSF Leak: A National Trauma Data Bank Analysis

OBJECTIVE

Cerebrospinal fluid (CSF) leaks are a complication from dural violations that can occur in the setting of skull base fractures. No prior study provides a nationwide epidemiological analysis of traumatic CSF leaks. The objective of this report is to characterize patient demographics, injury-related variables, and operative management.

METHODS

The national trauma data bank was queried for both anterior and lateral skull base fracture cases between 2008 and 2016. Clinical data were extracted.

RESULTS

A total of 242 skull base fractures with CSF leak were identified. Most patients were male (84.3%), and the median patient age was 39.7±17.6 years old. Glasgow Coma Scale was 14.0 [interquartile range (IQR): 6.5-10.6] for lateral fractures, 13.0 (IQR: 3.0-10.0) for anterior fractures, and severe range for combined fractures at 7.0 (IQR: 5.0-9.0) (analysis of variance, P=0.122). Common mechanisms of injury were motor vehicle accidents (107, 44.2%), followed by falls and firearms (65, 26.9% and 20, 8.3%, respectively). The median length of stay was 2 weeks, with a median of 14 days (IQR: 10-25) for the anterior fractures and 10 days (IQR 5-19) among the lateral fractures (P=0.592). Patients were most commonly discharged home in both the anterior (43.8%) and lateral (49.2%) groups.

CONCLUSIONS

The prototypical patient tends to be a young adult male presenting with moderate-to-severe range neurological dysfunction after a vehicular accident. The overall prognosis of skull base fractures with CSF leak remains encouraging, with nearly half of these patients being discharged home within 2 weeks.

Those who speak survive: the value of the verbal component of GCS in trauma

Aim

To evaluate the value of the individual components of GCS in predicting the survival of trauma patients in the Emergency Department.

Methods

Trauma patients who were admitted for more than 24 h or died after arrival at Al-Ain Hospital from January 2014 to December 2017 were studied. Children < 16 years, elderly > 80 years, patients with facial injuries, those intubated in the ER, and those with missing primary outcomes were excluded. Demography, vital signs, Glasgow Coma Scale (GCS), GCS components, Injury Severity Score (ISS), head AIS, and death were compared between those who died and those who survived. Factors with a p value of < 0.1 were entered into a backward likelihood logistic regression model to define factors that predict death.

Results

A total of 2548 patients were studied, out of whom 11 (0.4%) died. The verbal component of GCS (p < 0.001) and the ISS (p = 0.047) were the only significant predictors for death in the logistic regression model. The AUC (95% CI) of the GCS-VR was 0.763 (0.58–0.95), p = 0.003. The best point of GCS-VR that predicted survival was 5, having a sensitivity of 97%, a specificity of 54.5%, positive predictive value of 99. 8%, negative predictive value of 7.3%, and likelihood ratio of 2.13.

Conclusion

In general trauma patients, acute trauma care professionals can use GCS-VR to predict survival when clinical condition permits instead of the total GCS score or ISS.

Validation of a five-level triage system in pediatric trauma and the effectiveness of triage nurse modification: A multi-center cohort analysis

INTRODUCTION

Triage is one of the most important tasks for nurses in a modern emergency department (ED) and it plays a critical role in pediatric trauma. An appropriate triage system can improve patient outcomes and decrease resource wasting. However, triage systems for pediatric trauma have not been validated worldwide. To ensure clinical reliability, nurses are allowed to override the acuity level at the end of the routine triage process. This study aimed to validate the Taiwan Triage and Acuity Scale (TTAS) for pediatric trauma and evaluate the effectiveness of triage nurse modification.

METHODS

This was a multicenter retrospective cohort study analyzing triage data of all pediatric trauma patients who visited six EDs across Taiwan from 2015 to 2019. Each patient was triaged by a well-trained nurse and assigned an acuity level. Triage nurses can modify their acuity based on their professional judgment. The primary outcome was the predictive performance of TTAS for pediatric trauma, including hospitalization, ED length of stay, emergency surgery, and costs. The secondary outcome was the accuracy of nurse modification and the contributing factors. Multivariate regression was used for data analysis. The Akaike information criterion and C-statistics were utilized to measure the prediction performance of TTAS.

RESULTS

In total, 45,364 pediatric patients were included in this study. Overall mortality, hospitalization, and emergency surgery rates were 0.17, 5.4, and 0.76%, respectively. In almost all cases (97.48%), the triage nurses agreed upon the original scale. All major outcomes showed a significant positive correlation with the upgrade of acuity levels in TTAS in pediatric trauma patients. After nurse modification, the Akaike information criterion decreased and C-statistics increased, indicating better prediction performance. The factors contributing to this modification were being under 6 years of age, heart rate, respiratory rate, and primary location of injuries.

CONCLUSION

The TTAS is a reliable triage tool for pediatric trauma patients. Modification by well-experienced triage nurses can enhance its prediction performance. Younger age, heart rate, respiratory rate, and primary location of injuries contributed to modifications of the triage nurse. Further external validation is required to determine its role in pediatric trauma worldwide.

Effectiveness of high flow nasal cannula oxygen therapy in patients of acute pulmonary thromboembolism with acute hypoxemic respiratory failure

Background

Acute Pulmonary thromboembolism (PTE) is associated with acute hypoxemic respiratory failure (AHRF), which is a leading cause of death in these patients. High-Flow Nasal Cannula (HFNC) oxygen therapy is a cornerstone of the treatment of respiratory failure. The aim of the present study is to explore the efficacy of HFNC in the treatment of patients of acute PTE with acute hypoxemic respiratory failure in India.

Methods

This is a retrospective study of patients admitted to a tertiary care center with acute PTE with AHRF during the period from January 2018 to January 2020. After reviewing medical files, patients of acute PTE with AHRF treated with HFNC were included in the study. We analyzed the improvement in oxygenation parameters and respiratory rate, as well as outcome in these patients.

Results

During the above specified period, 12 patients suffering from PTE with AHRF were treated with HFNC. After 1 h of the initiation of HFNC along with anticoagulation, the respiratory parameters of patients significantly improved. HFNC was applied for a period of 6-10 days. None of the patients required intubation for AHRF, and all patients were discharged from the hospital on oral anticoagulants.

Conclusion

HFNC oxygen therapy in patients with acute PTE with AHRF showed rapid improvement of oxygenation and respiratory rate. HFNC oxygen therapy is an efficacious treatment for patients with AHRF secondary to acute PTE without any significant hemodynamic effect. It acts as a superior modality of oxygen therapy avoiding noninvasive and invasive ventilatory support.

Rendimiento de escalas de trauma ISS, NISS y RTS en accidentes de tránsito para predecir mortalidad en un hospital de alta complejidad

Introducción. La población mundial crece y con ello los accidentes de tránsito, incrementando la morbimortalidad. La combinación de factores clínicos y paraclínicos mediante las escalas de trauma impacta en los desenlaces al permitir tomar acciones oportunas. Métodos. Estudio de corte transversal en el que se incluyeron pacientes con lesiones por colisión en accidentes de tránsito, atendidos entre 2017 y 2018, en urgencias del Hospital Universitario San José de Popayán, Colombia, un hospital de alta complejidad. Se recolectaron variables sociodemográficas y biológicas y se aplicaron tres escalas de trauma, Revised Trauma Score, Injury Severity Score y New Injury Severity Score. Posteriormente, se evaluó su rendimiento para predecir mortalidad. Resultados. Se atendieron en el servicio de urgencias 650 pacientes con lesiones en accidentes de tránsito y se presentaron 16 muertes. Al evaluar el rendimiento de las escalas de trauma se encontró que la sensibilidad para mortalidad varía entre el 75 % para Revised Trauma Score y el 93,8 % para Injury Severity Score y New Injury Severity Score, con una especificidad que varía entre 89,1 % y 96,8 %. Se identificó que la mejor razón de verosimilitud positiva fue para Revised Trauma Score, mientras que la mejor razón de verosimilitud negativa fue para Injury Severity Score y New Injury Severity Score. Conclusiones. Los resultados evidencian un adecuado rendimiento de las escalas de trauma evaluadas para predecir mortalidad. La escala que presentó mejor rendimiento fue Injury Severity Score por su sensibilidad, especificidad y razón de verosimilitud positiva.

Glasgow Coma Scale Versus Physiologic Scoring Systems in Predicting the Outcome of ICU admitted Trauma Patients; a Diagnostic Accuracy Study

Introduction

There is no consensus on the performance of decision rules in predicting the prognosis of trauma patients. Therefore, the present study aimed to compare the value of Glasgow coma scale (GCS) and physiologic scoring systems in predicting mortality and poor outcome of trauma patients.

Methods

This diagnostic accuracy study was conducted on multiple trauma patients admitted to the intensive care units of two hospitals in Tehran, Iran, from 21 November 2020 to 22 May 2021. The patients' demographic characteristics, length of stay in the intensive care unit (ICU), the vital signs, and the GCS on admission were recorded. Finally, the mortality, disability, and complete recovery of patients at the time of discharge were evaluated and receiver operating characteristics (ROC) curve analysis was used to compare the performance of physiologic scoring systems with GCS.

Results

200 trauma patients with the mean age of 43.53±19.84 years were evaluated (74% male). The area under the ROC curve for New Trauma Score (NTS), Revised Trauma Score (RTS), Worthing Physiological Scoring System (WPSS), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), Glasgow Coma Scale, Age, and Systolic Blood Pressure score (GAPS) ,Glasgow coma scale (GCS) in prediction of mortality were 0.95, 0.95, 0.83, 0.89, 0.91, 0.84, 0.77, 0.97, and 0.98 respectively. The performance of GCS was statistically superior to RTS (P=0.005), WPSS (P=0.0001), RAPS (P=0.0002), REMS (P=0.002), MEWS (P<0.0001), and NEWS (P<0.0001). However, the performance of GCS, NTS (P=0.146), and GAPS (P=0.513) were not significantly different. Also, in prediction of poor outcomes, the AUC of GCS (0.98) was significantly higher than RTS (0.95), RAPS (0.85), REMS (0.85), MEWS (0.84), NEWS (0.77), and WPSS (0.75).

Conclusion

The GCS score seems to be a better instrument to predict mortality and poor outcome in trauma patients compared to other tools due to its high accuracy, wide application, and easy calculation.

Comparison of pre-PICU and per-PICU interventions, clinical features and neurologic outcomes of motor vehicle collision trauma and other mechanisms of trauma in children

BACKGROUND

Motor vehicle collisions (MVCs) are the number one cause of death in the pediatric age group. The aim of this study was to determine the differences between MVCs and other trauma mechanisms (OTMs) in patients who were followed up at a pediatric intensive care unit (PICU).

METHODS

Data were retrospectively collected for pediatric trauma patients hospitalized at a third level PICU between 2014 and 2018. Patients have been divided into two groups as MVC and OTM. Demographic data, pre-PICU interventions (cardiopulmonary resuscitation, intubation, injury severity scores, time period before intensive care), intensive care interventions (invasive mechanical ventilation, non-invasive mechanical ventilation, need for surgery, type of surgery, need for transfusion, and inotrope therapy) were compared between two groups. Outcomes were evaluated by survival, discharge from hospital, Pediatric Cerebral Performance Cate-gory (PCPC) at discharge, tracheotomy presence, and amputation performed.

RESULTS

During the 5-year study period, 135 patients were hospitalized for trauma. The injured body regions were the head and neck (61.5%), abdomen and lumbar spine (39.4%), and extremities and pelvis (36.3%). Multiple trauma was mostly seen in the MVC trauma group (p=0.001). The need for invasive mechanical ventilation and inotrope therapy was greater in the MVC group (p=0.002, 0.001 respectively). One hundred and twenty-three patients (91.1%) survived. The mortality rate was higher in the MVC group (p=0.026). The PCPC results were better in the OTM group (p=0.017).

CONCLUSION

MVCs lead to more multiple trauma cases than OTMs. Invasive mechanical ventilation, inotropes, and other inten-sive care interventions were necessary much more often in MVC victims than in OTM patients.

A multicenter cohort study on the association between prehospital immobilization and functional outcome of patients following spinal injury in Asia

Prehospital spinal immobilization is a widely used procedure in the emergency medical service (EMS) system worldwide, while the incidence of patients with spinal injury (SI) is relatively low, and unnecessary prehospital spinal immobilization is associated with patient complications. This study aimed to determine the association between prehospital spine immobilization and favorable functional outcomes at hospital discharge among trauma patients with SI. We conducted a retrospective cohort study using the Pan-Asia Trauma Outcomes Study (PATOS) registry data from January 1, 2016, to November 30, 2018. A total of 759 patients with SI were enrolled from 43,752 trauma patients in the PATOS registry during the study period. The subjects had a median age of 58 years (Q1–Q3, 41–72), and 438 (57.7%) patients had prehospital spine immobilization. Overall, prehospital spinal immobilization was not associated with favorable functional outcomes at discharge in multivariable logistic regression (aOR 1.06; 95% CI 0.62–1.81, p = 0.826). However, in the subgroup of cervical SI, prehospital spinal immobilization was associated with favorable functional outcomes at discharge (aOR 3.14; 95% CI 1.04–9.50; p = 0.043). Therefore, we suggest that paramedics should be more careful when determining the presence of a cervical SI and should apply full spine immobilization if possible.

Multiregion Trauma Center Follow-Up Protocol for Transferred Trauma Patients

BACKGROUND

Trauma centers routinely utilize the Injury Severity Score for performance improvement. Yet, transferring facilities do not always have access to patients' final Injury Severity Score.

OBJECTIVE

The purpose of this project was to develop and implement a multiregion Injury Severity Score follow-up feedback protocol for transferring facilities to receive standardized information on patient treatment and the ability to calculate an accurate follow-up Injury Severity Score of transferred patients.

METHODS

This project included 25 Adult and Pediatric Level I, II, and III trauma centers within three regional trauma systems in a Midwestern state. This project included trauma centers that used one of the two different trauma registry software systems as a solution to develop and implement a protocol for follow-up feedback for transferred trauma patients. A template was created to capture data posttransfer to calculate a final Injury Severity Score.

RESULTS

The feedback protocol was well received by participating regions. Implementation revealed the impact of variable trauma registry software on the ability to create multi-institution feedback programs.

CONCLUSION

Trauma systems can implement similar strategies to ensure transferring trauma centers routinely receive standardized, timely patient feedback.

Acute Neurologic Dysfunction in Critically Ill Children: The PODIUM Consensus Conference

CONTEXT

Acute neurologic dysfunction is common in critically ill children and contributes to outcomes and end of life decision-making.

OBJECTIVE

To develop consensus criteria for neurologic dysfunction in critically ill children by evaluating the evidence supporting such criteria and their association with outcomes.

DATA SOURCES

Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020, by using a combination of medical subject heading terms and text words to define concepts of neurologic dysfunction, pediatric critical illness, and outcomes of interest.

STUDY SELECTION

Studies were included if the researchers evaluated critically ill children with neurologic injury, evaluated the performance characteristics of assessment and scoring tools to screen for neurologic dysfunction, and assessed outcomes related to mortality, functional status, organ-specific outcomes, or other patient-centered outcomes. Studies with an adult population or premature infants (≤36 weeks' gestational age), animal studies, reviews or commentaries, case series with sample size ≤10, and studies not published in English with an inability to determine eligibility criteria were excluded.

DATA EXTRACTION

Data were abstracted from each study meeting inclusion criteria into a standard data extraction form by task force members.

DATA SYNTHESIS

The systematic review supported the following criteria for neurologic dysfunction as any 1 of the following: (1) Glasgow Coma Scale score ≤8; (2) Glasgow Coma Scale motor score ≤4; (3) Cornell Assessment of Pediatric Delirium score ≥9; or (4) electroencephalography revealing attenuation, suppression, or electrographic seizures.

CONCLUSIONS

We present consensus criteria for neurologic dysfunction in critically ill children.

Integration of Metabolomic and Clinical Data Improves the Prediction of Intensive Care Unit Length of Stay Following Major Traumatic Injury

Recent advances in emergency medicine and the co-ordinated delivery of trauma care mean more critically-injured patients now reach the hospital alive and survive life-saving operations. Indeed, between 2008 and 2017, the odds of surviving a major traumatic injury in the UK increased by nineteen percent. However, the improved survival rates of severely-injured patients have placed an increased burden on the healthcare system, with major trauma a common cause of intensive care unit (ICU) admissions that last ≥10 days. Improved understanding of the factors influencing patient outcomes is now urgently needed. We investigated the serum metabolomic profile of fifty-five major trauma patients across three post-injury phases: acute (days 0–4), intermediate (days 5–14) and late (days 15–112). Using ICU length of stay (LOS) as a clinical outcome, we aimed to determine whether the serum metabolome measured at days 0–4 post-injury for patients with an extended (≥10 days) ICU LOS differed from that of patients with a short (<10 days) ICU LOS. In addition, we investigated whether combining metabolomic profiles with clinical scoring systems would generate a variable that would identify patients with an extended ICU LOS with a greater degree of accuracy than models built on either variable alone. The number of metabolites unique to and shared across each time segment varied across acute, intermediate and late segments. A one-way ANOVA revealed the most variation in metabolite levels across the different time-points was for the metabolites lactate, glucose, anserine and 3-hydroxybutyrate. A total of eleven features were selected to differentiate between <10 days ICU LOS vs. >10 days ICU LOS. New Injury Severity Score (NISS), testosterone, and the metabolites cadaverine, urea, isoleucine, acetoacetate, dimethyl sulfone, syringate, creatinine, xylitol, and acetone form the integrated biomarker set. Using metabolic enrichment analysis, we found valine, leucine and isoleucine biosynthesis, glutathione metabolism, and glycine, serine and threonine metabolism were the top three pathways differentiating ICU LOS with a p < 0.05. A combined model of NISS and testosterone and all nine selected metabolites achieved an AUROC of 0.824. Differences exist in the serum metabolome of major trauma patients who subsequently experience a short or prolonged ICU LOS in the acute post-injury setting. Combining metabolomic data with anatomical scoring systems allowed us to discriminate between these two groups with a greater degree of accuracy than that of either variable alone.

Machine Learning Algorithms to Predict In-Hospital Mortality in Patients with Traumatic Brain Injury

Traumatic brain injury (TBI) can lead to severe adverse clinical outcomes, including death and disability. Early detection of in-hospital mortality in high-risk populations may enable early treatment and potentially reduce mortality using machine learning. However, there is limited information on in-hospital mortality prediction models for TBI patients admitted to emergency departments. The aim of this study was to create a model that successfully predicts, from clinical measures and demographics, in-hospital mortality in a sample of TBI patients admitted to the emergency department. Of the 4881 TBI patients who were screened at the emergency department at a high-level first aid duty hospital in northern Taiwan, 3331 were assigned in triage to Level I or Level II using the Taiwan Triage and Acuity Scale from January 2008 to June 2018. The most significant predictors of in-hospital mortality in TBI patients were the scores on the Glasgow coma scale, the injury severity scale, and systolic blood pressure in the emergency department admission. This study demonstrated the effective cutoff values for clinical measures when using machine learning to predict in-hospital mortality of patients with TBI. The prediction model has the potential to further accelerate the development of innovative care-delivery protocols for high-risk patients.

Health-Related Quality of Life (HRQoL) Outcomes Following Injury in Childhood and Adolescence Using EuroQol (EQ-5D) Responses with Pooled Longitudinal Data

BACKGROUND

Injury is a leading contributor to the global disease burden in children, affecting their health-related quality of life (HRQoL)-yet valid estimates of burden are absent.

METHODS

This study pooled longitudinal data from five cohort studies of pediatric injury survivors (5-17 years) at baseline, 1-, 4-, 6-, 12-, and 24- months (n = 2334). HRQoL post-injury was measured using the 3-level EQ-5D utility score (EQ-5D) and five health states (mobility, self-care, activity, pain, anxiety and depression (anxiety)).

RESULTS

Mean EQ-5D post-injury did not return to baseline level (0.95) by 24 months (0.88) and was lower for females over time (-0.04, 95%CI -0.05, -0.02). A decreased adjusted risk ratio over time (ARR) was observed for intentional injuries (pain: 0.85, 95%CI 0.73,0.98; anxiety: 0.62, 95%CI 0.49,0.78); spinal cord injuries (mobility: 0.61, 95%CI 0.45,0.83), self-care: 0.76, 95%CI 0.63,0.91, activity: 0.64, 95%CI 0.47,0.88); moderate/severe traumatic brain injury (activity: 0.83, 95%CI 0.71,0.96). ARRs were also low for certain fractures, with various health states affected.

CONCLUSIONS

HRQoL outcomes over time for children and adolescents post-injury differed across key demographic and injury related attributes. HRQoL did not reach levels consistent with full health by 24 months with recovery plateauing from 6 to 24 months. Tailored interventions are required to respond to the varying post-injury recovery trajectories in this population.

The July Phenomenon and Pediatric Trauma

BACKGROUND

The July Phenomenon describes concerns that patients presenting early in the academic year experience worse outcomes. Given the standardized approach to pediatric trauma patients, we hypothesized that the July Phenomenon would not impact morbidity or mortality.

METHODS

A retrospective review of patients ≤16 Y presenting to a level I pediatric trauma center between March 2009 and March2019 was performed. Pediatric patients admitted during the study period were compared for differences in outcome by month of presentation. The primary outcome was mortality. Secondary outcomes were complications, and length of emergency department, hospital and Intensive Care Unit stay. Multivariable regression was used to evaluate the effect of month of admission on outcomes.

RESULTS

A total of 6,135 patients were evaluated, with 605 patients presenting in July. Univariate analysis failed to demonstrate consistently increased mortality, complications, or length of emergency department, hospital or Intensive Care Unit stay in July compared to months later in the academic year. On multivariate analysis, admission in July was not an independent predictor of worse outcomes.

CONCLUSIONS

In this level I pediatric trauma center, pediatric trauma patients presenting earlier in the academic year have similar outcomes to those presenting later, and there is no evidence of a July Phenomenon in this population.

Clinical, epidemiological, and management aspects of burn injuries in Saudi Arabia - A cross-sectional study

Background

Burns are a deleterious, but largely preventable health problem foisting physical, economic, social, emotional, and relational issues worldwide.

Methods

A cross-sectional study was conducted at the King Khalid Hospital and Prince Sultan Center for Health Services, and Prince Sattam Bin Abdulaziz University hospital in Al Kharj in the Kingdom of Saudi Arabia. The study included patients who presented themselves to the emergency department of the targeted hospitals with at least one documented burn injury between October 2018 and October 2019. The patients were followed from presentation to discharge. The etiology, location, severity, and options of treatment offered to them were recorded. The SPSS version 22.0 was used to analyze the data. Descriptive statistics were used to summarize the data as means, frequencies, and standard deviations. Categorical variables were compared using the Pearson's chi-square test.

Results

180 patients with burn injuries were included in the study. The majority were adolescents and adults under the age of 40 (n = 171). The prevalence of first-degree burns was 12.8%, that of second-degree burns was 71.1%, and that of third-degree burns was 16.1%. The most common cause, area, and type of treatment were hot water injuries (36.1%), upper limbs (62.2%), and skin debridement respectively.

Conclusion

Adolescents and young adults are the most frequently affected by burns while skin debridement was the most common treatment offered to the patients. In this context emergency hospital staff was required to be adequately equipped and trained.

Association between prehospital time and outcome of trauma patients in 4 Asian countries: A cross-national, multicenter cohort study

BACKGROUND

Whether rapid transportation can benefit patients with trauma remains controversial. We determined the association between prehospital time and outcome to explore the concept of the "golden hour" for injured patients.

METHODS AND FINDINGS

We conducted a retrospective cohort study of trauma patients transported from the scene to hospitals by emergency medical service (EMS) from January 1, 2016, to November 30, 2018, using data from the Pan-Asia Trauma Outcomes Study (PATOS) database. Prehospital time intervals were categorized into response time (RT), scene to hospital time (SH), and total prehospital time (TPT). The outcomes were 30-day mortality and functional status at hospital discharge. Multivariable logistic regression was used to investigate the association of prehospital time and outcomes to adjust for factors including age, sex, mechanism and type of injury, Injury Severity Score (ISS), Revised Trauma Score (RTS), and prehospital interventions. Overall, 24,365 patients from 4 countries (645 patients from Japan, 16,476 patients from Korea, 5,358 patients from Malaysia, and 1,886 patients from Taiwan) were included in the analysis. Among included patients, the median age was 45 years (lower quartile [Q1]-upper quartile [Q3]: 25-62), and 15,498 (63.6%) patients were male. Median (Q1-Q3) RT, SH, and TPT were 20 (Q1-Q3: 12-39), 21 (Q1-Q3: 16-29), and 47 (Q1-Q3: 32-60) minutes, respectively. In all, 280 patients (1.1%) died within 30 days after injury. Prehospital time intervals were not associated with 30-day mortality. The adjusted odds ratios (aORs) per 10 minutes of RT, SH, and TPT were 0.99 (95% CI 0.92-1.06, p = 0.740), 1.08 (95% CI 1.00-1.17, p = 0.065), and 1.03 (95% CI 0.98-1.09, p = 0.236), respectively. However, long prehospital time was detrimental to functional survival. The aORs of RT, SH, and TPT per 10-minute delay were 1.06 (95% CI 1.04-1.08, p < 0.001), 1.05 (95% CI 1.01-1.08, p = 0.007), and 1.06 (95% CI 1.04-1.08, p < 0.001), respectively. The key limitation of our study is the missing data inherent to the retrospective design. Another major limitation is the aggregate nature of the data from different countries and unaccounted confounders such as in-hospital management.

CONCLUSIONS

Longer prehospital time was not associated with an increased risk of 30-day mortality, but it may be associated with increased risk of poor functional outcomes in injured patients. This finding supports the concept of the "golden hour" for trauma patients during prehospital care in the countries studied.

The severity of fall injuries in Saudi Arabia: a cross-sectional study

Introduction

fall injuries constitute a major public health concern worldwide, contributing to over 646,000 deaths every year. The aim of this study was to determine the nature and severity of fall injuries at a tertiary hospital in the Kingdom of Saudi Arabia (KSA).

Methods

we conducted a cross-sectional study at the King Khalid Hospital and Prince Sultan Centre for Health Care in Al Kharj. We recruited the patients and followed them through the triage, admission and discharge processes. We analyzed the participant´s clinical notes on the electronic health record (EHR) to obtain information relevant to the study, including the nature, cause, mechanism of injury, demographic characteristics and prognostic factors captured through the injury severity score (ISS), the Glasgow coma scale (GCS) and the presence or absence of shock.

Results

of 264 patients, most of the patients were children under the age of ten (25.7%), followed by young adults between the ages of twenty-one and thirty (18.2%). The ISS was associated with severe head, chest, skull, brain, scalp, rib, abdominal, pelvic and lower limb injuries. The GCS was associated with severe the head, chest, skull, brain and rib injuries (p<0.005). The degree of shock was also significantly associated with pelvic, head, chest, skull, brain, scalp, abdominal and upper limb injuries (p<0.05). Conclusion: fall injuries in our setting are severe. Training of staff should prioritize head, chest, skull, brain, abdominal and rib injury management. As a reference hospital, minor injuries are more likely to be managed at lower levels of care.

High-flow nasal cannula oxygen therapy in acute respiratory failure at Emergency Departments: A systematic review

OBJECTIVES

The use of high-flow oxygen therapy (HFOT) through nasal cannula for the management of acute respiratory failure at the emergency department (ED) has been only sparsely studied. We conducted a systematic review of randomized-controlled and quasi-experimental studies comparing the early use of HFOT versus conventional oxygen therapy (COT) in patients with acute respiratory failure admitted to EDs.

METHODS

A systematic research of literature was carried out for all published control trials comparing HFOT with COT in adult patients admitted in EDs. Eligible data were extracted from Medline, Embase, Pascal, Web of Science and the Cochrane database. The primary outcome was the need for mechanical ventilation, i.e. intubation or non-invasive ventilation as rescue therapy. Secondary outcomes included respiratory rate, dyspnea level, ED length of stay, intubation and mortality.

RESULTS

Out of 1829 studies screened, five studies including 673 patients were retained in the analysis (350 patients treated with HFOT and 323 treated with COT). The need for mechanical ventilation was similar in both treatments (RR = 0.75; 95% CI 0.41 to 1.35; P = 0.31; I² = 16%). Respiratory rate was lower with HFOT (Mean difference (MD) = -3.14 breaths/min; 95% CI = -4.9 to -1.4; P < 0.001; I² = 39%), whereas sensation of dyspnea did not differ. (MD = -1.04; 95% CI = -2.29 to -0.22; P = 0.08; I² = 67%). ED length of stay and mortality were similar between groups.

CONCLUSION

The early use of HFOT in patients admitted to an ED for acute respiratory failure did not reduce the need for mechanical ventilation as compared to COT. However, HFOT decreased respiratory rate.

REGISTRATION

PROSPERO ID CRD42019125696.