Faculty Bibliography

BACKGROUND: This analysis explored the association between gender and systolic blood pressure (SBP) in trauma patients and then established how gender influenced outcomes in those with elevated SBP. METHODS: Demographics and outcomes were compared using the Los Angeles County Trauma System Database and multivariable modeling determined predictors for SBP, pneumonia, and mortality. RESULTS: Age and male sex were significant predictors for increased SBP, whereas the Injury Severity Score (ISS) >/=16 was a significant predictor for decreased SBP. In both male and female TBI patients, SBP >/=160 mmHg was associated with increased pneumonia (Adjusted odds ratio [AOR] = 1.74, P = .002 and AOR = 2.37, P = .046, respectively), whereas SBP >/=160 mmHg was a predictor for mortality only among male TBI patients (AOR = 1.48, P = .03). In non-TBI patients, SBP >/=160 mmHg was not a predictor for pneumonia or mortality in either sex. CONCLUSIONS: In this retrospective review of trauma registry data, men presented with higher SBP. In patients with TBI, regardless of gender, increased SBP was associated with increased pneumonia, and in men with TBI increased SBP was associated with increased mortality. The cause and relevance of these epidemiological findings require further investigation.

Although recent evidence suggests a beneficial effect of alcohol for patients with traumatic brain injury (TBI), the level of alcohol that confers the protective effect is unknown. Our objective was to investigate the relationship between admission blood alcohol concentration (BAC) and outcomes in patients with isolated moderate to severe TBI. From 2005 to 2009, the Los Angeles County Trauma Database was queried for all patients >/=14 years of age with isolated moderate to severe TBI and admission serum alcohol levels. Patients were then stratified into four levels based on admission BAC: None (0 mg/dL), low (0-100 mg/dL), moderate (100-230 mg/dL), and high (>/=230 mg/dL). Demographics, patient characteristics, and outcomes were compared across levels. In evaluating 3794 patients, the mortality rate decreased with increasing BAC levels (linear trend P < 0.0001). In determining the relationship between BAC and mortality, multivariable logistic regression analysis demonstrated a high BAC level was significantly protective (adjusted odds ratio 0.55; 95% confidence interval: 0.38-0.8; P = 0.002). In the largest study to date, a high (>/=230 mg/dL) admission BAC was independently associated with improved survival in patients with isolated moderate to severe TBI. Additional research is warranted to investigate the potential therapeutic implications.

The aim of this study was to assess how increasing age affects mortality in trauma patients with Glasgow Coma Scale (GCS) 3. The Los Angeles County Trauma System Database was queried for all patients aged 20 to 99 years admitted with GCS 3. Mortality was 41.8 per cent for the 3306 GCS 3 patients. Mortality in the youngest patients reviewed, those in the third decade, was 43.5 per cent. After logistic regression analysis, patients in the third decade had similar mortality rates to patients in the sixth (adjusted OR, 0.88; CI, 0.68 to 1.14; P = 0.33) and seventh decades (adjusted OR, 0.96; CI, 0.70 to 1.31; P = 0.79). A significantly lower mortality rate, however, was noted in the fifth decade (adjusted OR, 0.76; CI, 0.61 to 0.95; P = 0.02). Conversely, significantly higher mortality rates were noted in the eighth (adjusted OR, 1.93; CI, 1.38 to 2.71; P = 0.0001) and combined ninth/tenth decades (adjusted OR, 2.47; CI, 1.71 to 3.57; P < 0.0001). Given the high survival in trauma patients with GCS 3 as well as continued improvement in survival compared with historical controls, aggressive care is indicated for patients who present to the emergency department with GCS 3.

BACKGROUND: This study reviews our 10-year institutional experience with damage control management and investigates risk factors for early mortality. MATERIALS AND METHODS: The trauma registry of our level I trauma centre was utilized to identify all patients from 01/96 through 12/05 who underwent initial damage control procedures. Demographics, clinical and physiological parameters, and outcomes were abstracted. Patients were categorized as either early survivors (surviving the first 72 hours after admission) or early deaths. RESULTS: During the study period, 319 patients underwent damage control management. Overall, 52 patients (16.3%) died (early deaths) and 267 patients (83.7%) survived the first 72 hours (early survivors). Early deaths showed significantly deranged serum lactate (5.81+/-0.55 vs. 3.46+/-0.13 mmol/L; P<0.001), base deficit (10.10+/-0.95 vs. 4.90+/-0.28 mmol/L; P<0.001) and pH (7.16+/-0.03 vs. 7.29+/-0.01; P<0.001) levels compared to early survivors on hospital admission. An International Normalized Ratio >1.2, base deficit >3 mmol/L, head Abbreviated Injury Scale >/=3, body temperature <35 degrees C, serum lactate >6 mmol/L, and hemoglobin <7 g/dL proved to be independent risk factors for early mortality on hospital admission. CONCLUSIONS: Several risk factors for early mortality such as severe head injury and the lethal triad (coagulopathy, acidosis and hypothermia) in patients undergoing damage control procedures were identified and should trigger the trauma surgeon to maintain aggressive resuscitation in the intensive care unit.

HYPOTHESIS: A significant rate of postdischarge complications is associated with penetrating cardiac injuries. DESIGN: Retrospective trauma registry review. SETTING: Level I trauma center. PATIENTS: All patients sustaining penetrating cardiac injuries between January 2000 and June 2010. Patient demographics, clinical data, operative findings, outpatient follow-up, echocardiogram results, and outcomes were extracted. MAIN OUTCOME MEASURES: Cardiac-related complications and mortality. RESULTS: During the 10.5-year study period, 406 of 40,706 trauma admissions (1.0%) sustained penetrating cardiac injury. One hundred nine (26.9%) survived to hospital discharge. The survivors were predominantly male (94.4%), with a mean (SD) age of 30.8 (11.7) years, and 74.3% sustained a stab wound. Signs of life were present on admission in 92.6%. Cardiac chambers involved were the right ventricle (45.9%), left ventricle (40.3%), right atrium (10.1%), left atrium (0.9%), and combined (2.8%). In-hospital follow-up was available for a mean (SD) of 11.0 (9.8) days (median, 8 days; range, 3-65 days) and outpatient follow-up was available in 46 patients (42.2%) for a mean (SD) of 1.9 (4.1) months (median, 0.9 months; range, 0.2-12 months). Abnormal echocardiograms demonstrated pericardial effusions (9), abnormal wall motion (8), decreased ejection fraction (<45%) (8), intramural thrombus (4), valve injury (4), cardiac enlargement (2), conduction abnormality (2), pseudoaneurysm (1), aneurysm (1), and septal defect (1). No operative intervention was required for the complications. The 1-year and 9-year survival rates were 97% and 88%, respectively. CONCLUSIONS: Penetrating cardiac injuries remain highly lethal. A significant rate of cardiac complications can be expected and follow-up echocardiographic evaluation is warranted prior to discharge. The majority of these, however, can be managed without the need for surgical intervention.

BACKGROUND: Early endotracheal intubation in patients sustaining moderate to severe traumatic brain injury (TBI) is considered the standard of care. Yet the benefit of pre-hospital intubation (PHI) in patients with TBI is questionable. The purpose of this study was to investigate the relationship between pre-hospital endotracheal intubation and mortality in patients with isolated moderate to severe TBI. METHODS: The Los Angeles County Trauma System Database was queried for all patients > 14 y of age with isolated moderate to severe TBI admitted between 2005 and 2009. The study population was then stratified into two groups: those patients requiring intubation in the field (PHI group) and those patients with delayed airway management (No-PHI group). Demographic characteristics and outcomes were compared between groups. Multivariate analysis was used to determine the relationship between pre-hospital endotracheal intubation and mortality. RESULTS: A total of 2549 patients were analyzed and then stratified into the two groups: PHI and No-PHI. There was a significant difference noted in overall mortality (90.2% versus 12.4%), with the PHI group being more likely to succumb to their injuries. After adjusting for possible confounding factors, multivariable logistic regression analysis demonstrated that PHI was independently associated with increased mortality (AOR 5, 95% CI: 1.7-13.7, P = 0.004). CONCLUSIONS: Pre-hospital endotracheal intubation in isolated, moderate to severe TBI patients is associated with a nearly 5-fold increase in mortality. Further prospective studies are required to establish guidelines for optimal pre-hospital management of this critically injured patient population.

BACKGROUND: A distracting injury mandates cervical spine (c-spine) imaging in the evaluable blunt trauma patient who demonstrates no pain or tenderness over the c-spine. The purpose of this study was to examine which distracting injuries can negatively affect the sensitivity of the standard clinical examination of the c-spine. METHODS: This is a prospective observational study conducted at a Level I Trauma Center from January 1, 2008, to December 31, 2009. After institutional review board approval, all evaluable (Glasgow Coma Scale score >/=13) blunt trauma patients older than 16 years sustaining a c-spine injury were enrolled. A distracting injury was defined as any immediately evident bony or soft tissue injury or a complaint of non-c-spine pain whether or not an actual injury was subsequently diagnosed. Information regarding the initial clinical examination and the presence of a distracting injury was collected from the senior resident or attending trauma surgeon involved in the initial management. RESULTS: During the study period, 101 evaluable patients sustained a c-spine injury. Distracting injuries were present in 88 patients (87.1%). The most common was rib fracture (21.6%), followed by lower extremity fracture (20.5%) and upper extremity fracture (12.5%). Only four (4.0%) patients had no pain or tenderness on the initial examination of the c-spine. All four patients had bruising and tenderness to the upper anterior chest. None of these four patients developed neurologic sequelae or required a surgical stabilization or immobilization. CONCLUSION: C-spine imaging may not be required in the evaluable blunt trauma patient despite distracting injuries in any body regions that do not involve the upper chest. Further definition of distracting injuries is mandated to avoid unnecessary utilization of resources and to reduce the imaging burden associated with the evaluation of the c-spine.

The purpose of this study was to examine independent risk factors, and in particular the impact of alcohol on the development of delirium, in a cohort of trauma patients screened for ethanol ingestion on admission to hospital. The National Trauma Databank (v. 7.0) was used to identify all patients 18 years or older screened for ethanol on admission. Patients who developed delirium were compared with those who did not. Stepwise logistic regression analysis was used to identify independent risk factors for the development of delirium. A total of 504,839 patients with admission ethanol levels were identified. Of those, 2,909 (0.6%) developed delirium. Patients developing delirium were significantly older, more frequently male, and more likely to sustain thermal injuries and falls. Patients developing delirium had more comorbidities including chronic ethanol use (19.1% vs. 4.5%, P < 0.001) and cardiovascular disease (21.5% vs. 12.2%, P < 0.001). On admission, patients developing delirium were more likely to be intoxicated with ethanol (55.4% vs. 26.5%, P < 0.001) and were more likely to be uninsured (17.8% vs. 0.9%, P < 0.001). A stepwise logistic regression model identified lack of insurance, positive ethanol on admission, chronic ethanol use, Intensive Care Unit admission, age >/= 55 years, burns, Medicare insurance, falls, and history of cardiovascular disease as independent risk factors for the development of delirium. The incidence of delirium in this trauma patient cohort was 0.6 per cent. The above risk factors were independently associated with the development of delirium. This data may be helpful in designing interventions to prevent delirium.

BACKGROUND: The purpose of this investigation was to determine the yield of repeat follow-up imaging in patients sustaining renal trauma. METHODS: The Los Angeles County+University of Southern California Medical Center trauma registry was reviewed to identify all patients with a diagnosis of kidney injury from 2005 to 2008. All final attending radiologist interpretations and the dates of the initial and follow-up computerized tomography (CT) scans were also reviewed. Grades I, II, and III were grouped as low-grade injuries and grades IV and V as high-grade injuries. RESULTS: During the 4-year study period, 120 (1.2% of all trauma admissions) patients had a total of 121 kidney injuries: 85.8% were male, and the mean age+/-SD was 31.1 years+/-14.5 years. Overall, 22.6% of blunt and 35.6% of penetrating kidney injuries were high grade (IV-V; p=0.148). These high-grade injuries were managed operatively in 35.7% and 76.2% of blunt and penetrating injuries, respectively, (p=0.022). Overall, 31.7% underwent at least one follow-up CT; 24.2% of patients with blunt and 39.7% of patients with penetrating kidney injury, respectively. None of the patients with a low-grade injury managed nonoperatively developed a complication, independent of the injury mechanism. High-grade blunt and penetrating kidney injuries managed nonoperatively were associated with 11.1% and 20.0% complication rate identified on follow-up CT, respectively. For patients who underwent surgical interventions for penetrating kidney injuries, the diagnosis of the complication was made at 9.8 days+/-7.0 days (range, 1-24 days), with 83.3% of them diagnosed within 8 days postoperatively. The most frequent complication identified was an abscess in the renal fossa (50.0% of all complications). Other complications included urinoma, ureteral stricture, and pseudoaneurysm. All patients who developed complications were symptomatic, prompting the imaging that led to the diagnosis. All patients who developed a complication after a penetrating injury required intervention for the management of the complication. CONCLUSION: Selective reimaging of renal injuries based on clinical and laboratory criteria seems to be safe regardless of injury mechanism or management. High-grade penetrating injuries undergoing operative intervention should carry the highest degree of vigilance and lowest threshold for repeat imaging.

INTRODUCTION: Although gunshot and stab wounds are a common cause of self-inflicted injury, very little is understood about this mechanism of injury. The aim of this study was to characterise the epidemiology and outcomes of patients who injured themselves with a gun or sharp object. METHODS: After IRB approval, the LAC+USC Trauma Registry was utilised to identify all patients who sustained a self-inflicted injury caused by firearm (GSW) or stabbing (SW) from 1997 to 2007. Demographic data, injury characteristics, surgical interventions, and outcomes were abstracted and analysed. RESULTS: During the 11-year study period, a total of 753 patients (1.6%) were admitted for a self-inflicted injury. Of these, 369 (49.0%) had a self-inflicted penetrating injury, with 72 (19.5%) having sustained a GSW and 297 (80.5%) having a SW. Overall, the mean age was 36.4+/-15.8 years, 83.5% were male, with a mean ISS of 7.4+/-11.0. The most commonly injured body region in GSW patients was the head (76.4%), followed by the chest (15.3%) and in SW patients the upper extremity (37.0%), followed by the abdomen (36.4%). When compared to SW, GSW were significantly more frequent in males (21.4% vs. 9.8%, p=0.04), and were most commonly to the head (21.4% vs. 8.2%, p=0.02). Patients sustaining a GSW were more likely to be older than 55 years (22.2% vs. 8.4%, p<0.001). Intoxication was noted at presentation in 38.3% of screened GSW patients and 39.9% of SW patients. SW patients required operative intervention more frequently (40.9% vs. 22.2%, p<0.01), with 12.8% of them requiring exploratory laparotomy. However, patients who shot themselves were much more likely to die (66.7%) than those presenting with SW (1.7%). For those presenting with a GSW to the head, the mortality rate was even higher, at 80%. Mortality did not differ between males and females in either group. CONCLUSION: Although a self-inflicted SW is far more common than a self-inflicted GSW, patients sustaining a GSW are more severely injured, and have a nearly 110-fold increased risk of death. Though less lethal, stab wounds still consume significant amounts of healthcare resources and incur large in-hospital costs. The average hospital charge incurred for treating these self-inflicted injuries was five times the amount spent per annum on American citizens. Self-inflicted penetrating injuries represent a golden opportunity for secondary prevention through psychiatric intervention. These interventions may not only preserve life but also improve resource utilisation.