Trauma OverviewTrauma Overview

Avery B. Nathens MD PhD Avery B. Nathens MD PhD MPHMPH

Division of General Surgery Division of General Surgery & Trauma& Trauma

St. Michael’s HospitalSt. Michael’s Hospital

ObjectivesObjectives

Trauma epidemiologyTrauma epidemiology Prehospital carePrehospital care TriageTriage Long term outcomes after Long term outcomes after

injuryinjury

Trauma Trauma EpidemiologyEpidemiology

The Burden of InjuryThe Burden of Injury

Leading cause of death in first 4 decades of Leading cause of death in first 4 decades of lifelife

Third leading cause in all age groupsThird leading cause in all age groups 12% of hospital beds are consumed by injury12% of hospital beds are consumed by injury

0%

2%

4%

6%

8%

10%

12%

1984 1988 1992 1996 2000 2004

Trauma Mortality: 1985-Trauma Mortality: 1985-20032003

Injury mortality rateInjury mortality rate

40

45

50

55

60

65

70

80 82 84 86 88 90 92 94 96 98

Dea

ths

per

100

k p

op

'n

http://www.cdc.gov/ncipc/wisqars/

US, 1998: 53 per 100 000 pop’n

The Burden of InjuryThe Burden of Injury

Nearly ½ of all traumatic incidents Nearly ½ of all traumatic incidents involve the use of alcohol, drugs or involve the use of alcohol, drugs or other substance abuseother substance abuse

60% of all injuries are preventable60% of all injuries are preventable Is predominantly a disease of the Is predominantly a disease of the

young and carries potential for young and carries potential for permanent disabilitypermanent disability

Years of Potential Life Years of Potential Life Lost (YPLL) Before Age Lost (YPLL) Before Age

65 65

0 2 4 6 8 10 12

All Causes

Injury

Cancer

Heart Disease

Perinatal Period

Congenital

HIV

Cerebrovascular

Liver Disease

All Others

http://www.cdc.gov/ncipc/wisqars/

23%

2%

2%

3%

4%

8%

12%

17%

29%

100%

Number of Patients by Age

0

5,000

10,000

15,000

20,000

25,000

30,000

1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 101 106

Age (years)

Nu

mb

er o

f P

atie

nts

Distribution of injury by Distribution of injury by ageage

Figure 8A

Proportional distribution of patients, grouped by mechanism of injury.

Patients by Mechanism of Injury

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

500,000

Mechanism of Injury

Nu

mb

er o

f P

atie

nts

Motor vehicle traffic

Fall

Struck by, against

Firearm

Transport, other

Cut/pierce

Fire /burn

Pedal cyclis t, other

Other specified andclassifiableMachinery

Mechanism of injuryMechanism of injury

Mechanism of Injury by Age

02,0004,0006,0008,000

10,00012,00014,00016,000

1 8 15 22 29 36 43 50 57 64 71 78 85 92 99 106

Age (years)

Nu

mb

er o

f P

atie

nts Motor Vehicle Traffic

Fall

Struck by

Firearm

Transport, other

Mechanism of injury by Mechanism of injury by ageage

Deaths by Mechanism of Injury

0

5,000

10,000

15,000

20,000

25,000

Mechanism of Injury

Nu

mb

er o

f P

atie

nts

Motor vehicle traffic

Fall

Struck by, against

Firearm

Transport, other

Cut/pierce

Fire/burn

Pedal cyclist, other

Other specified andclassifiableMachinery

Deaths by mechanism of Deaths by mechanism of injuryinjury

Case Fatality by Age

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 101

Age (years)

Cas

e F

atal

itie

s (%

)

Mortality as a function of Mortality as a function of ageage

Abbreviated Injury Scale (AIS) Abbreviated Injury Scale (AIS) 6 body regions (head, neck, chest, abdomen, 6 body regions (head, neck, chest, abdomen,

pelvis, external)pelvis, external) Each injury coded from 1 to 6Each injury coded from 1 to 6 AIS>=3 is severeAIS>=3 is severe

Injury Severity Score (ISS)Injury Severity Score (ISS) Most common means of classifying injury Most common means of classifying injury

severityseverity Ranges from 1 to 75Ranges from 1 to 75 ISS>=16 – severe multisystem traumaISS>=16 – severe multisystem trauma

Grading Injury SeverityGrading Injury Severity

INJURY SEVERITY SCORE INJURY SEVERITY SCORE ExampleExample

Abbreviated Abbreviated Injury ScaleInjury Scale

Small subdural haematomaSmall subdural haematoma 44

Parietal lobe swellingParietal lobe swelling 33

Major liver lacerationMajor liver laceration 44

Upper tibial fracture (displaced)Upper tibial fracture (displaced) 33

ISS = 4ISS = 42 + 2 + 442 + 2 + 332 2 = 41= 41

Percentage of Patients and Injury Severity Score (ISS)

0

10

20

30

40

50

60

70

Per

cen

tag

e o

f P

atie

nts

ISS 1 - 9

ISS 10 - 15

ISS16 - 24

ISS > 24

Unknown

Injury severityInjury severity

Case Fatality by Injury Severity Score (ISS)

0

5

10

15

20

25

30

35

Injury Severity Score

Cas

e F

atal

ity

(%) ISS 1 - 9

ISS 10 - 15

ISS 16 - 24

> 24

Unknown

Mortality as a function of Mortality as a function of ISSISS

Unintentional Motor Vehicle Traffic Related Injuries

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

1 8 15 22 29 36 43 50 57 64 71 78 85 92 99

Age (years)

Nu

mb

er

of

Pa

tie

nts Occupant

Motorcyclist

Pedestrian

Pedal Cyclist

Unspecified

American College of Surgeons National Trauma Data Bank ® 2006. Version 6.0

© American College of Surgeons 2006. All Rights Reserved Worldwide

Figure 26A

Proportional distribution of patients, grouped by intent.

Patients by Intent

Unintentional

Assault

Se lf-inflicted

Undeterm ined

Other

American College of Surgeons National Trauma Data Bank ® 2006. Version 6.0

© American College of Surgeons 2006. All Rights Reserved Worldwide

Figure 27A

Proportional distribution of deaths, grouped by intent. Total N = 48,149.

Deaths by Intent

Self-inflicted

Undeterm ined

Other

Assault

Unintentional

Geographic variations in Geographic variations in MVC-mortality: MVC-mortality: Baker et al, Baker et al,

19871987MVC mortality (per 100 000 persons)

2.5

558

Population density (persons/sq mile)

64000

0.2

Esmerelda, NV versus Manhattan, NY

Trimodal Distribution of Trimodal Distribution of Trauma DeathsTrauma Deaths

Epidemiology of Trauma Epidemiology of Trauma DeathsDeaths

*Sauaia et al, J Trauma, 1995

AcuteAcute

( <48 ( <48 hrs)hrs)

EarlyEarly

(48 hr to (48 hr to 7d)7d)

LateLate

(> 7 d)(> 7 d)

CNS CNS injuryinjury

40%40% 64%64% 39%39%

Blood Blood lossloss

55%55% 9%9% 0%0%

MOFSMOFS 1%1% 18%18% 61%61%

Prehospital carePrehospital care

Clinical scenarioClinical scenario

64 yo female running for bus64 yo female running for bus Leg catches on bumperLeg catches on bumper Dragged 20 feetDragged 20 feet

Unconscious with occasional respiratory effortsUnconscious with occasional respiratory efforts Systolic blood pressure – 80Systolic blood pressure – 80 Heart rate 140Heart rate 140 45 minutes from trauma center45 minutes from trauma center

Clinical scenarioClinical scenario

American Civil War: 1861Mortality: 25%Transport time: 72 hrsFactors: +/- ambulance

WW I: 1914Mortality: 8.6%Transport time: 8 hrsFactors: ambulance (motorized)

World War II: 1939 Mortality: 4.5%Transport time: 4 hrsFactors: Ambulance, Medics, Plasma, Antibiotics

Korean War: 1951Mortality: 2.5%Transport time: 1.25 hrsFactors: Helicopter, MASH

Viet Nam War: 1965-1972Mortality 1.9%Transport time: 27 minutesFactors: Helicopter, Medics, Fixed wing

circa 1947

Prehospital transport Prehospital transport timestimes

UrbanUrban Houston - 32.6 minutesHouston - 32.6 minutes Portland ~ 25 minPortland ~ 25 min Chicago - 35 minutesChicago - 35 minutes Tucson - 21 minTucson - 21 min

RuralRural Georgia - 42 minGeorgia - 42 min Northern California - 55 minNorthern California - 55 min WA (Okanogan County) - 49 minWA (Okanogan County) - 49 min

Definitive Care

Any Hospital

Controversies in Controversies in Prehospital Trauma Prehospital Trauma

CareCareALS vs BLS ALS vs BLS Airway managementAirway managementFluid resuscitationFluid resuscitation

ALS vs BLS “packages”ALS vs BLS “packages”

Basic life supportBasic life support Splinting, spine immobilization, Splinting, spine immobilization,

hemorrhage controlhemorrhage control Advanced life supportAdvanced life support

Establish a definitive airwayEstablish a definitive airway Provide intravenous accessProvide intravenous access Administer pharmacologic agentsAdminister pharmacologic agents

““Load and go” or “stay and play”?Load and go” or “stay and play”?

Stay and Play:Stay and Play:Pre-hospital care - SAMUPre-hospital care - SAMU

French EMS - SAMU French EMS - SAMU (Service d'Aide Médicale (Service d'Aide Médicale Urgente)Urgente)

Physicians attend to Physicians attend to patient at scenepatient at scene Stabilize at scene, en Stabilize at scene, en

routeroute Identify receiving centerIdentify receiving center

Stay and PlayStay and Play

August 31, 1997August 31, 1997 Mercedes S-280 - 122 mphMercedes S-280 - 122 mph

4 occupants, 2 dead at scene 4 occupants, 2 dead at scene with torn aortaswith torn aortas

SAMU dispatch: 00:26SAMU dispatch: 00:26 SAMU scene arrival: 00:32SAMU scene arrival: 00:32 Extrication complete: 01:00Extrication complete: 01:00 ER arrival, Pitie Salpetriere ER arrival, Pitie Salpetriere

hospital 02:06hospital 02:06 Pronounced dead - 04:30Pronounced dead - 04:30

ALS vs BLS “packages”ALS vs BLS “packages”

No prospective RCT documenting No prospective RCT documenting the effectiveness of ALS in traumathe effectiveness of ALS in trauma

...yet ALS available in 98.5% of the ...yet ALS available in 98.5% of the 200 largest US cities200 largest US cities

ALS vs BLS in trauma: a meta-ALS vs BLS in trauma: a meta-analysisanalysis

Liberman et al, J Trauma, 2000Liberman et al, J Trauma, 2000 Included 15 studies (of 174 pertaining to Included 15 studies (of 174 pertaining to

trauma) that had sufficient data for trauma) that had sufficient data for analysisanalysis

Scene timesScene times ALS: 18.5 minALS: 18.5 min BLS: 13.5 minBLS: 13.5 min

ALS vs BLS in trauma: a meta-ALS vs BLS in trauma: a meta-analysisanalysis

0 1 2 3 4 5 6 7 8 9 10

Winchell, 97

Sampalis, 92

Potter, 88

Cayten, 86

Bickell, 94

Martin, 92

Cayten, 93

Murphy, 93

Cayten, 84

Aprahamian, 83

Ivaturi, 87

Clevenger, 88

Sampalis, 97

Demetriades, 96

Odds of death (ALS vs BLS)

Risk of death ~3 X greater

Multicenter Canadian Multicenter Canadian Study 2003Study 2003

Montreal: MD-ALS; Toronto:PM-ALS;Montreal: MD-ALS; Toronto:PM-ALS; Quebec: EMT-BLSQuebec: EMT-BLS 50% trauma patients in ALS communities 50% trauma patients in ALS communities

had ALS personnel present.had ALS personnel present. Prospective, observational study, Prospective, observational study,

n=9405n=9405 Increased mortality and scene time in Increased mortality and scene time in

MD-ALS group, No difference in MD-ALS group, No difference in mortality for PM-ALS and EMT-BLSmortality for PM-ALS and EMT-BLS

Liberman et al, Annals of Surgery, 2003

Multicenter Canadian Multicenter Canadian Study 2003Study 2003

Conclusion: In urban centers with highly specialized level 1 trauma centers, there is no benefit in having on-site ALS for the prehospital management of trauma patients

Airway Management Airway Management OptionsOptions

Mask ventilationMask ventilation Oral intubationOral intubation Nasal intubationNasal intubation Use of paralytic agentsUse of paralytic agents Surgical airway accessSurgical airway access

Needle Needle cricothyrotomycricothyrotomy

Open cricothyrotomyOpen cricothyrotomyRetrograde Retrograde intubationintubation

Intubation vs. Mask Intubation vs. Mask VentilationVentilation

Gausche et al, JAMA 2000Gausche et al, JAMA 2000 Questions the role of prehospital intubation for Questions the role of prehospital intubation for

pediatric patientspediatric patients 830 pts < age 12 randomized to ETI vs BVM830 pts < age 12 randomized to ETI vs BVM No difference in mortality or neurologic No difference in mortality or neurologic

outcome between the groupsoutcome between the groups Intubation success rate 57%, 14% tubes Intubation success rate 57%, 14% tubes

dislodged, 2% esophageal intubationdislodged, 2% esophageal intubation LimitationsLimitations

No paralytic agentsNo paralytic agents Inexperience paramedicsInexperience paramedics

Oral intubation success Oral intubation success ratesrates

Range 75 to 98% dependent on indications Range 75 to 98% dependent on indications and availability of paralytic agentsand availability of paralytic agents

BEST DATABEST DATA Hedges et al: Thurston County, WA 1983-84: Hedges et al: Thurston County, WA 1983-84:

96%96% Bulger et al: Seattle Fire Dept 1997-1999: 98.4%Bulger et al: Seattle Fire Dept 1997-1999: 98.4% Wayne et al: Bellingham/Whatcom County WA Wayne et al: Bellingham/Whatcom County WA

1999: 95.5%1999: 95.5% WORST DATAWORST DATA

Katz et al: Orlando, FL 1997: 25% of ET tubes Katz et al: Orlando, FL 1997: 25% of ET tubes were malpositioned, 37% for trauma patientswere malpositioned, 37% for trauma patients

Head InjuryHead Injury

Winchell, San Diego, 1997 Winchell, San Diego, 1997 Patients with severe head injury: mortality Patients with severe head injury: mortality

decreased from 57% to 36% with decreased from 57% to 36% with intubationintubation

Murray et al, Los Angeles CA, 2000:Murray et al, Los Angeles CA, 2000: Mortality 70% higher in patients with Mortality 70% higher in patients with

severe head injurysevere head injury Davis et al, San Diego, CA 2003:Davis et al, San Diego, CA 2003:

Trial of RSI for head injured patientsTrial of RSI for head injured patients Increased mortality for intubated patients: 33% Increased mortality for intubated patients: 33%

vs 24%vs 24%

Head InjuryHead Injury

Study design and applicability are Study design and applicability are problematicproblematic Retrospective designRetrospective design

Paralytics not allowed in many protocolsParalytics not allowed in many protocols Only the apneic and most unresponsive are intubated Only the apneic and most unresponsive are intubated

– worse prognosis– worse prognosis

In the study where RSI was usedIn the study where RSI was used Significant hyperventilation may have worsened Significant hyperventilation may have worsened

outcomeoutcome Increased pre-hospital timeIncreased pre-hospital time Poor matching (No GCS available in controls)Poor matching (No GCS available in controls)

Penetrating injuryPenetrating injury

Bickell et al, 1994Bickell et al, 1994 Randomized 598 patients with shock following Randomized 598 patients with shock following

penetrating truncal injury in urban Houston: penetrating truncal injury in urban Houston: Immediate fluid resuscitationImmediate fluid resuscitation Delayed fluid resuscitation – postponed until Delayed fluid resuscitation – postponed until

operative interventionoperative intervention Transport times<30 minutesTransport times<30 minutes Fluid administrationFluid administration

Immediate group – 2500 cc’s preoperatively (2/3rd of Immediate group – 2500 cc’s preoperatively (2/3rd of the fluid was given in the ER) the fluid was given in the ER)

Delayed group – 280 cc’s preoperativelyDelayed group – 280 cc’s preoperatively

ResultsResults

Delayed groupDelayed group Slightly improved survival – 62% vs Slightly improved survival – 62% vs

70%70% Shorter hospital LOSShorter hospital LOS Fewer complicationsFewer complications

CaveatsCaveats Young patientsYoung patients Short transport timesShort transport times Penetrating injuryPenetrating injury

High speed High speed rolloverrollover

35 yo 35 yo restrained restrained driverdriver

Epigastric Epigastric stab stab woundwound

StableStable

50 yo male50 yo male Had been drinkingHad been drinking Falls down flight of Falls down flight of

stairsstairs Transient LOCTransient LOC Now awake, alert, Now awake, alert,

GCS 15GCS 15

Triage of the Triage of the Major Trauma Major Trauma

PatientPatient

Triage: Triage: the sorting out and the sorting out and classification of casualties of war or classification of casualties of war or other disaster, to determine priority other disaster, to determine priority of need and proper place of treatmentof need and proper place of treatment

“Get the right patient to the right place at the right time”

A tale of two countiesA tale of two countiesWest & Trunkey, 1979West & Trunkey, 1979

Orange CountyOrange County Trauma patients transported to Trauma patients transported to

nearest of 39 facilitiesnearest of 39 facilities

San Francisco CountySan Francisco County Trauma patients transported to 1 Trauma patients transported to 1

centrally located trauma facilitycentrally located trauma facility

Preventable deaths: 43%

Preventable deaths: 1%

National Evaluation of the National Evaluation of the Effect of Trauma Center Care Effect of Trauma Center Care

on Mortalityon MortalityN Engl J Med, 2006N Engl J Med, 2006

25% lower risk of death at one year in trauma centers

0

2

4

6

8

10

12

14

In hospital 30 d 90 d 365 d

Time from injury

Mor

talit

y (%

)

NTCTC

N=15,000 patients

Ideal TriageIdeal Triage

Direct patients with serious injuries Direct patients with serious injuries to centers with available resources to centers with available resources and personneland personnel

Direct those with less serious Direct those with less serious injuries to all other centers within injuries to all other centers within same geographic areasame geographic area

Field triage goals – a Field triage goals – a balancebalance

Undertriage – major trauma patient Undertriage – major trauma patient triaged to center with inadequate triaged to center with inadequate resourcesresources Patient incurs riskPatient incurs risk

Overtriage – minimally injured trauma Overtriage – minimally injured trauma patient triaged to regional trauma patient triaged to regional trauma centercenter System incurs riskSystem incurs risk

Utilization of limited material, financial and Utilization of limited material, financial and human resourceshuman resources

Inconveniences family/patientInconveniences family/patient

Field Triage Tools - Field Triage Tools - OverviewOverview

Physiologic criteriaPhysiologic criteria

Anatomic criteriaAnatomic criteria

Mechanism of injuryMechanism of injury

ModifiersModifiers

Physiologic criteria - ACS Physiologic criteria - ACS field triagefield triage

GCS<14GCS<14 SBP<90SBP<90 RR<10 or >29RR<10 or >29

ProsPros Objective, Objective,

quantifiablequantifiable Easily assessedEasily assessed Predictive of deathPredictive of death

ConsCons Time dependentTime dependent

Anatomic criteria - ACS Anatomic criteria - ACS field triagefield triage

Penetrating injury Penetrating injury proximal to elbow or kneeproximal to elbow or knee

Flail ChestFlail Chest Trauma with burnsTrauma with burns >>2 proximal long-bone #2 proximal long-bone # Pelvic #Pelvic # Open & depressed skull Open & depressed skull

## ParalysisParalysis Amputation proximal to Amputation proximal to

wrist or anklewrist or ankle Major burnsMajor burns

ProsPros Accurate if injury obviousAccurate if injury obvious

ConsCons Physical exam not Physical exam not

predictive of injuriespredictive of injuries Time consuming examTime consuming exam

Mechanism of injury - Mechanism of injury - ACS field triageACS field triage

Falls >20 ftFalls >20 ft High risk crashHigh risk crash

EjectionEjection Death in same Death in same

compartmentcompartment Intrusion > 12 in Intrusion > 12 in

occupant compartmentoccupant compartment Intrusion > 18 in Intrusion > 18 in

anywhereanywhere Auto-pedestrian/cyclist Auto-pedestrian/cyclist

>20 mph>20 mph MCC > 20mphMCC > 20mph

ProsPros Estimate of type, Estimate of type,

amount, direction of amount, direction of force appliedforce applied

Readily assessed by Readily assessed by EMS personnelEMS personnel

ConsCons Estimate of potential, Estimate of potential,

not actual injurynot actual injury Limited value when Limited value when

used aloneused alone

Modifiers: permissive Modifiers: permissive criteria -criteria -

ACS field triageACS field triage Age <5 or >55Age <5 or >55 AnticoagulationAnticoagulation BurnsBurns PregnancyPregnancy

ProsPros Good predictor of Good predictor of

adverse outcomesadverse outcomes

ConsCons Cannot be ascertained Cannot be ascertained

in fieldin field UnderutilizedUnderutilized

Mechanism

Transport to highest level of trauma care available: alert trauma team

Field Triage Decision Scheme:Field Triage Decision Scheme:ACS COT, Resources for ACS COT, Resources for

Optimal Care, 2007Optimal Care, 2007Physiologic

criteria

Anatomic criteria

Consider transport to a trauma center

Modifiers(Permissive)

Predictors of undertriagePredictors of undertriage

Advanced age - single most important Advanced age - single most important predictor of undertriagepredictor of undertriage Zimmer-Gembeck, J Trauma, 1995Zimmer-Gembeck, J Trauma, 1995

Toronto Field Trauma Toronto Field Trauma Triage GuidelinesTriage Guidelines

Directs injured patients to trauma Directs injured patients to trauma centrescentres

CriteriaCriteria PhysiologicPhysiologic AnatomicAnatomic MechanismMechanism

Toronto Field Trauma Toronto Field Trauma Triage Guidelines: Triage Guidelines: Physiologic criteriaPhysiologic criteria

GCS<=10 GCS<=10 OROR Two or more ofTwo or more of

AnyAny alteration in level of consciousness. alteration in level of consciousness. A pulse rate less than 50 or more than A pulse rate less than 50 or more than

120.120. A blood pressure less than 80 or an A blood pressure less than 80 or an

absent radial pulseabsent radial pulse A respiratory rate less than 10 or greater A respiratory rate less than 10 or greater

than 24than 24

Toronto Field Trauma Toronto Field Trauma Triage GuidelinesTriage Guidelines

AnatomicAnatomic Spinal Cord injury with paraplegia or Spinal Cord injury with paraplegia or

quadriplegia.quadriplegia. Penetrating injury to head, neck, trunk or Penetrating injury to head, neck, trunk or

groin, ORgroin, OR Amputation above the wrist or ankleAmputation above the wrist or ankle

Toronto Field Triage Toronto Field Triage CriteriaCriteria

Diversion to closest Diversion to closest hospitalhospital Divert if anticipate won’t surviveDivert if anticipate won’t survive

Complete airway obstructionComplete airway obstruction Absence of spontaneous respirationsAbsence of spontaneous respirations Absence of a palpable carotid pulseAbsence of a palpable carotid pulse

Estimated transport time>30 minutesEstimated transport time>30 minutes

Organized Systems of Organized Systems of Trauma CareTrauma Care

Trauma Center•Most severely injured

Rehabilitation

Interfacility

Transfer

Non-Trauma Center•Other injured persons

Prehospital•Notification/EMS Access•EMS response•Triage•Transport

Ongoing•Prevention•Training•Evaluation

Effect of legislative Effect of legislative initiatives on MVC-initiatives on MVC-

mortalitymortalityNathens et al, JAMA, 2000Nathens et al, JAMA, 2000

LegislationLegislation Effect on crash mortalityEffect on crash mortality

Primary restraint lawsPrimary restraint laws 13% (11-16)13% (11-16)

State trauma systemState trauma system 9% (6-11)9% (6-11)

Secondary restraint lawsSecondary restraint laws 3% (0-5)3% (0-5)

65 mph (vs 55 mph) speed limit65 mph (vs 55 mph) speed limit

Administrative revocation lawsAdministrative revocation laws

7% (3-10)7% (3-10)

5% (3-7)5% (3-7)

Access time & trauma-Access time & trauma-mortality ratesmortality rates

3486 deaths

Field deaths54% (1882)

Reached hospital 46% (1604)

ED deaths 21% (732)

OR deaths4% (139)

Other in hospital22% (733)

ED 45%

OR 8%

Other 47%

Patient KLPatient KL 34 yo male truck 34 yo male truck

driver/moverdriver/mover High speed MVCHigh speed MVC

Mild traumatic brain injuryMild traumatic brain injury Liver laceration, splenectomyLiver laceration, splenectomy Bad pelvic fracture, femur Bad pelvic fracture, femur

fracturefracture Acetabular fractureAcetabular fracture

Angioembolization for Angioembolization for pelvic fracture bleedingpelvic fracture bleeding

ICU stay ~7 daysICU stay ~7 days

What will happen to KL What will happen to KL in 1 yearin 1 year

A) Working at full capacityA) Working at full capacityB) Desk jobB) Desk jobC) Not working, milling about the house on C) Not working, milling about the house on

disability compensation, driving his wife disability compensation, driving his wife crazycrazy

D) Not working, in chronic painD) Not working, in chronic painD) Nursing homeD) Nursing home

Why can’t he return to Why can’t he return to normal function normal function

A) Brain injuryA) Brain injury

B) Liver injury and lack of a spleenB) Liver injury and lack of a spleen

C) Acetabular/femur and pelvic C) Acetabular/femur and pelvic fracturefracture

D) Bad dreamsD) Bad dreams

What is his chance of re-What is his chance of re-injuryinjury

A) Less than the average person, he is A) Less than the average person, he is a more careful driver nowa more careful driver now

B) His injuries put him at slightly B) His injuries put him at slightly greater than average riskgreater than average risk

C) He is accident prone – he’ll likely C) He is accident prone – he’ll likely get himself into troubleget himself into trouble

Functional Outcomes Functional Outcomes After InjuryAfter Injury

Multisystem traumaMultisystem trauma

Specific injuriesSpecific injuries Traumatic brain injuryTraumatic brain injury Severe extremity injuriesSevere extremity injuries

Post traumatic stress Post traumatic stress disorder & functional disorder & functional outcomesoutcomes

Employment OutcomesEmployment Outcomes Brenneman, J Trauma, Brenneman, J Trauma,

19971997 N=195, ISS>10N=195, ISS>10

Sampling bias – too well and too sick excludedSampling bias – too well and too sick excluded 52% back at work at 1 year52% back at work at 1 year

Pre-injuryPre-injury % employed at 1 year% employed at 1 year

White collarWhite collar 8282

Blue collarBlue collar 4343

Employment & Financial Employment & Financial OutcomesOutcomes

Michaels, J Trauma, 2000 Michaels, J Trauma, 2000 Outcomes at 1 year (n=247)Outcomes at 1 year (n=247)

Excluded head injury, SCIExcluded head injury, SCI

EmploymentEmployment 64% had returned to work64% had returned to work 23% workers’ comp/disability23% workers’ comp/disability

FinancialFinancial 30% reported a decline income30% reported a decline income

Functional limitations & Functional limitations & DisabilityDisability

Enabling America: IOM, Enabling America: IOM, 19971997

Pathology

Osteoarthritis of the hip post acetabular

fracture

Impairment

Limited range of motion

Functional limitation

Unable to climb stairs

Disability

Cannot continue employ as mover

Functional limitations Functional limitations following multiple traumafollowing multiple trauma

Mackenzie, Qual Life Res, 2002Mackenzie, Qual Life Res, 2002 Prospective cohort study: n=1240, 1 yr Prospective cohort study: n=1240, 1 yr

follow upfollow up

Functional capacity index (FCI)Functional capacity index (FCI) Physical & cognitive function onlyPhysical & cognitive function only Focuses on tasks necessary for ADLFocuses on tasks necessary for ADL

Insensitive to socially defined roles “role Insensitive to socially defined roles “role performance”performance”

Less sensitive to personal/environmental influencesLess sensitive to personal/environmental influences Sensitive to specific medical interventionsSensitive to specific medical interventions

Limitation in functions by Limitation in functions by FCI dimensionFCI dimension

FCI FCI dimensiondimension

% with % with limitationlimitation

Bending/Bending/liftinglifting

6363

AmbulationAmbulation 6161

Cognitive Cognitive functionfunction

2727

Hand/arm Hand/arm functionfunction

2525

Sexual Sexual functionfunction

1818

FCI FCI dimensiondimension

% with % with limitationlimitation

VisionVision 1818

Excretory Excretory functionfunction

88

HearingHearing 55

EatingEating 44

SpeechSpeech 22

FCI & Return to WorkFCI & Return to Work

0%

5%

10%

15%

20%

25%

Pat

ien

ts (

%)

0-0.2 0.21-0.4 0.41-0.6 0.61-0.8 0.81-0.99

1

FCI

18% 65% 82%Return to work

Bad Good

Functional outcomes Functional outcomes following traumatic brain following traumatic brain

injuryinjury Dikmen, Arch Phys Med Rehabil, 2003Dikmen, Arch Phys Med Rehabil, 2003

N=261, 80% followup at 3-5 yearsN=261, 80% followup at 3-5 years Moderate to severe TBIModerate to severe TBI

Functional status examinationFunctional status examination Physical, social, psychologic assessmentPhysical, social, psychologic assessment

Functional Status in TBIFunctional Status in TBI Glasgow Outcome Scale Glasgow Outcome Scale

Moderate-severe disability in 24%Moderate-severe disability in 24%

Majority not institutionalized: 92%Majority not institutionalized: 92%

Return to work after injury: 84%Return to work after injury: 84% Only 58% still working by 3-5 yearsOnly 58% still working by 3-5 years

What percent are you “back to normal:” What percent are you “back to normal:” 80%80%

Functional Status in TBI: Functional Status in TBI: Partial/complete Partial/complete

dependencydependency

0 10 20 30 40 50 60

% of patients

Personal care

Ambulation

Standard of living

Home management

Travel

Financial independence

Cognitive competency

Social integration

Major activity

Leisure/recreation

Functional impact of Functional impact of Orthopedic InjuriesOrthopedic Injuries

Michaels, J Trauma, 2000Michaels, J Trauma, 2000

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Pain

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ealth

BaselineNon-orthopedicOrthopedic

Physical well being Mental well being

Functional impact of Orthopedic InjuriesFunctional impact of Orthopedic InjuriesMichaels, J Trauma, 2000Michaels, J Trauma, 2000

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BaselineNon-orthopedicOrthopedic

Physical well being Mental well beingPhysical well being Mental well being

Reconstruction or Reconstruction or amputation of limb amputation of limb

threatening injuries?threatening injuries?Bosse, NEJM, 2002Bosse, NEJM, 2002

Prospective cohort studyProspective cohort study 545 high energy trauma below the femur545 high energy trauma below the femur Baseline, 3, 6, 12, 24 mo assessmentBaseline, 3, 6, 12, 24 mo assessment 84% f/u at 24 mos84% f/u at 24 mos

Functional outcome measure: Sickness Functional outcome measure: Sickness Impact ProfileImpact Profile

Sickness Impact ProfileSickness Impact Profile

Measure of self reported health statusMeasure of self reported health status 12 categories of function12 categories of function 2 major dimensions: physical health, psychosocial 2 major dimensions: physical health, psychosocial

healthhealth

Score: 0-100Score: 0-100 Population norms: 2-3Population norms: 2-3 Differences of 2-3 are meaningfulDifferences of 2-3 are meaningful Severe disability: >10Severe disability: >10

Outcomes: Outcomes: Reconstruction vs Reconstruction vs

amputationamputation12 months12 months 24 months24 months

ReconstruReconstructct

AmputatAmputatee

ReconstruReconstructct

AmputaAmputatete

OverallOverall 1515 1414 1212 1313

PhysicalPhysical 1313 1212 1010 1010

PsychosociaPsychosociall

1212 1212 1010 1111

Work (%)Work (%) 4141 4242 3636 3939

• Amputation equivalent to reconstruction • Consider when determining care priorities in the critically ill injured patient

Factors associated with poor Factors associated with poor outcomeoutcome

Bosse, NEJM, 2002Bosse, NEJM, 2002

Low educational levelLow educational level NonwhiteNonwhite PovertyPoverty

Lack of private health Lack of private health insuranceinsurance

SmokingSmoking Disability Disability

compensation compensation litigationlitigation

Focus should be on non clinical interventions and psychosocial/vocational rehabilitation

Outcomes following Pelvic Outcomes following Pelvic FractureFracture

Wright, J Urol 2006Wright, J Urol 2006 Pelvic fractures associated with neurovascular and Pelvic fractures associated with neurovascular and

ligamentous injuryligamentous injury Impact on genitourinary, anorectal and sexual function Impact on genitourinary, anorectal and sexual function

never evaluatednever evaluated

Prospective cohort studyProspective cohort study 298 patients with pelvic fracture; 862 without298 patients with pelvic fracture; 862 without

Excluded patients with overt injuries known to Excluded patients with overt injuries known to impact on genitourinary, anorectal or sexual impact on genitourinary, anorectal or sexual dysfunctiondysfunction GU injuries Anorectal injuries Spinal cord injury with deficit

Outcomes following Pelvic Outcomes following Pelvic FractureFracture

Symphysis

Sacrum

Adjusted Risk of Male Adjusted Risk of Male Sexual & Excretory Sexual & Excretory

DysfunctionDysfunctionFracture configuration

Sexual dysfunctionRR (95% CI)

Excretory dysfunction

RR (95% CI)

Fracture involving the SI joints

3.6 (1.7-7.8) 2.4 (0.5-12.3)

Open pelvic fracture 2.0 (1.1-3.8) 4.6 (1.7-13)

Symphyseal fracture 1.2 (0.5-2.9) 4.3 (1.1-17)

Closed pelvic fracture 1.7 (0.4-6.9) 3.1 (0.4-23)

Adjusted Risk of Female Adjusted Risk of Female Sexual & Excretory Sexual & Excretory

DysfunctionDysfunctionSexual

dysfunctionRR (95% CI)

Excretory dysfunction

RR (95% CI)

Fracture involving the SI joints

0.6 (0.1-3.4)0.6 (0.1-3.4) 1.3 (0.2-6.6)1.3 (0.2-6.6)

Open pelvic fracture 0.8 (0.2-2.8)0.8 (0.2-2.8) N/AN/A

Symphyseal fracture 2.4 (0.6-8.7)2.4 (0.6-8.7) 6.2 (1.7-22)6.2 (1.7-22)

Closed pelvic fracture 1.3 (0.3-6.81.3 (0.3-6.8 N/AN/A

Post-Traumatic Stress Post-Traumatic Stress DisorderDisorder

PTSD symptomsPTSD symptoms Intrusive: flashbacks, memories, Intrusive: flashbacks, memories,

nightmaresnightmares Avoidant: emotional detachment, Avoidant: emotional detachment,

restricted emotion, avoidance of remindersrestricted emotion, avoidance of reminders Arousal: insomnia, irritability, vigilanceArousal: insomnia, irritability, vigilance

Common following traumatic injuryCommon following traumatic injury 10-40% of all patients admitted following 10-40% of all patients admitted following

injuryinjury

“The PTSD Demon”

Predictors of PTSDPredictors of PTSDZatzick, Am J Psych 2002Zatzick, Am J Psych 2002

Longitudinal study (1 year)Longitudinal study (1 year) PTSD in 30-40% at 1, 4, or 12 mo post injuryPTSD in 30-40% at 1, 4, or 12 mo post injury

PredictorsPredictors PTSD symptoms at baselinePTSD symptoms at baseline Greater prior traumaGreater prior trauma +ve toxicology screen for stimulants+ve toxicology screen for stimulants FemaleFemale

Notable negatives Notable negatives Injury severity or type, pre-event functioning, Injury severity or type, pre-event functioning,

income, educationincome, education

0102030405060708090

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Role e

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fn

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No PTSD PTSD

PTSD & Functional PTSD & Functional outcomesoutcomes

Zatzick, Arch Surg, 2002Zatzick, Arch Surg, 2002PTSD : strongest predictor of poor functional outcome

Physical well being Mental well being

Screening and Intervention Screening and Intervention for PTSDfor PTSD

Zatzick et al, Arch Gen Zatzick et al, Arch Gen Psychiatry, 2004Psychiatry, 2004

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30

35

0 1 3 6 12Time (months)

% P

TS

D

Control

Intervention

National Evaluation of the National Evaluation of the Effect of Trauma Center Care Effect of Trauma Center Care

on Mortalityon MortalityN Engl J Med, 2006N Engl J Med, 2006

25% lower risk of death at one year in trauma centers

0

2

4

6

8

10

12

14

In hospital 30 d 90 d 365 d

Time from injury

Mor

talit

y (%

)

N=15,000 patients

No real difference in functional outcome

Injury RecividismInjury RecividismWorrel & Nathens, J Trauma, Worrel & Nathens, J Trauma,

20062006

Increasing ageMaleAlcohol abuse

SummarySummary Mortality is the tip of the icebergMortality is the tip of the iceberg

Gross underestimate of the personal and Gross underestimate of the personal and societal burden of injurysocietal burden of injury Only 50% employed at 1 yearOnly 50% employed at 1 year

Functional limitations dominated by Functional limitations dominated by orthopedic and head injuriesorthopedic and head injuries

PTSDPTSD Likely a major contributor to adverse functional Likely a major contributor to adverse functional

outcomesoutcomes

Where should efforts be Where should efforts be directed?directed?

Vocational & psychosocial Vocational & psychosocial rehabilitationrehabilitation

Screening and intervention for PTSDScreening and intervention for PTSD

Prevention of recurrent injuryPrevention of recurrent injury Brief interventions for alcohol abuseBrief interventions for alcohol abuse