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Objectives To describe the prevalence of pain in a large cohort of trauma patients 1 year after injury and to examine personal, injury, and treatment factors that predict the presence of chronic pain in these patients. Setting Sixty-nine hospitals in 14 states in the United States. Patients There were 3047 patients (10 371 weighted) aged 18 to 84 years who were admitted to the hospital because of acute trauma and survived to 12 months after injury. Main Outcome Measure Pain 12 months after injury measured with the Chronic Pain Grade Scale. Results At 12 months after injury, 62.7% of patients reported injury-related pain. Most patients had pain in more than 1 body region, and the mean (SD) severity of pain in the last month was 5.5 (4.8) on a 10-point scale. The reported presence of pain varied with age and was more common in women and those who had untreated depression before injury. Pain at 3 months was predictive of both the presence and higher severity of pain at 12 months. Lower pain severity was reported by patients with a college education and those with no previous functional limitations. Conclusions Most trauma patients have moderately severe pain from their injuries 1 year later. Earlier and more intensive interventions to treat pain in trauma patients may be needed.

Background The leading cause of late mortality after trauma is multiple organ failure syndrome, due to a dysfunctional inflammatory response early after injury. Preclinical studies demonstrate that hypertonicity alters the activation of inflammatory cells, leading to reduction in organ injury. The purpose of this study was to evaluate the effect of hypertonicity on organ injury after blunt trauma. Design Double-blind, randomized controlled trial from October 1, 2003, to August 31, 2005. Setting Prehospital enrollment at a single level I trauma center. Patients Patients older than 17 years with blunt trauma and prehospital hypotension (systolic blood pressure, ≤ 90 mm Hg). Interventions Treatment with 250 mL of 7.5% hypertonic saline and 6% dextran 70 (HSD) vs lactated Ringer solution (LRS). Main Outcome Measures The primary end point was survival without acute respiratory distress syndrome (ARDS) at 28 days. Cox proportional hazards regression was used to adjust for confounding factors. A preplanned subset analysis was performed for patients requiring 10 U or more of packed red blood cells in the first 24 hours. Results A total of 209 patients were enrolled (110 in the HSD group and 99 in the LRS group). The study was stopped for futility after the second interim analysis. Intent-to-treat analysis demonstrated no significant difference in ARDS-free survival (hazard ratio, 1.01; 95% confidence interval, 0.63-1.60). There was improved ARDS-free survival in the subset (19% of the population) requiring 10 U or more of packed red blood cells (hazard ratio, 2.18; 95% confidence interval, 1.09-4.36). Conclusions Although no significant difference in ARDS-free survival was demonstrated overall, there was benefit in the subgroup of patients requiring 10 U or more of packed red blood cells in the first 24 hours. Massive transfusion may be a better predictor of ARDS than prehospital hypotension. The use of HSD may offer maximum benefit in patients at highest risk of ARDS. Trial Registration clinicaltrials.gov Identifier:NCT00113685

Measurement of pelvic hemorrhage on computed tomographic (CT) scans can estimate the pelvic fracture component of total patient blood loss and predict the need for angiography.Retrospective cohort study.Large level 1 trauma center.We examined data from 759 consecutive, nonreferral blunt trauma patients who sustained pelvic fracture.Pelvic-fracture-specific outcomes included estimation of extraperitoneal pelvic hemorrhage volume from emergency department CT scans and determination of arterial injury from angiograms. General patient outcomes determined from medical record review included transfusion requirement, estimated blood loss, and mortality. Subanalysis was performed on subjects with only pelvic fracture as a source of major hemorrhage (derived from discharge International Classification of Diseases, Ninth Revision, Clinical Modification codes).Overall mortality was 96 (13%) of 759 patients. Blood transfusion was given to 418 (55%) patients, and 258 (34%) received 6 or more units in the first 72 hours. Pelvic-fracture-related hemorrhage averaged 149 mL (range, 0-1423 mL). Angiography was performed on 163 patients, of whom 113 had arterial injury. Higher pelvic hemorrhage volumes on CT scans were seen in subjects with pelvic arterial injury demonstrated on angiograms (P.001). In subjects without another source of major hemorrhage, pelvic CT hemorrhage volumes were strongly associated with transfusion requirement (P.001). Subjects with large pelvic hemorrhage volumes (500 mL) were more likely to have pelvic arterial injury (risk ratio, 4.8; 95% confidence interval, 3.0-7.8; P.001) and require large-volume (/=6 U) transfusions (risk ratio, 4.7; 95% confidence interval, 1.8-12.3; P.001) than patients with smaller pelvic hemorrhage volumes.Pelvic hemorrhage volumes derived from pelvic CT scans were predictors of the need for pelvic arteriography and transfusions.

Background There are very few data on characteristics or policies that improve patient outcomes in academic medical institutions. We were interested in 2 such policies or characteristics that are commonly implemented in academic centers: an in-house on-call attending physician policy and the existence of postgraduate medical education. Hypothesis An in-house attending surgeon on-call policy and the presence of trauma and critical care fellowship programs improve outcomes of critically injured patients. Design Multicenter cohort study. Two cohorts were analyzed: blunt trauma (n = 601; mortality, 16.0%) and penetrating abdominal trauma (n = 503; mortality, 7.5%). Setting Thirty-one academic level I trauma centers, 10 (32.3%) with in-house on-call policy and 11 (35.5%) with fellowship programs. Main Outcome Measures Mortality, hospital length of stay, and intensive care unit length of stay. Results In-house on-call surgeon policy had no impact on mortality or length of hospital or intensive care unit stay for either the blunt or penetrating trauma cohort. However, the presence of fellowship programs was associated with a significant decrease in blunt trauma mortality (odds ratio, 0.4; 95% confidence interval [CI], 0.1-0.8) and a decrease in length of intensive care unit stay (mean difference, 4.7 days; 95% CI, 0.6-8.8 days) and hospital stay (mean difference, 3.2 days; 95% CI, 0.6-5.9 days). There were no significant effects of fellowship programs on penetrating trauma outcomes. Conclusions An in-house on-call attending surgeon policy is not associated with improved outcomes. In contrast, presence of a trauma and surgical critical care fellowship program, a potential surrogate marker for an institution that is committed to this specialty interest, is associated with improved outcomes for critically injured patients. An investment in advanced postgraduate medical education has potential benefits in patient care and outcomes.

Hypothesis: Patients undergoing trauma surgery for injury who have subsequent posttraumatic stress disorder (PTSD) or problem drinking will demonstrate significant impairments in functional outcomes compared with patients without these disorders. Design: Prospective cohort study. Setting: Level I academic trauma center. Participants: One hundred one randomly selected survivors of intentional and unintentional injuries were interviewed while hospitalized and again 1 year later. The investigation achieved a 73% 1-year follow-up rate. Main Outcome Measures: Posttraumatic stress disorder was assessed with the Post-traumatic Stress Disorder Checklist and problem drinking was assessed with the Alcohol Use Disorder Identification Test. Functional status was assessed with the Medical Outcomes Study 36-Item Short-Form Health Survey. Results: One year after injury, 30% of patients (n=22) met symptomatic criteria for PTSD and 25% (n=18) had AlcoholUseDisorderIdentificationTestscoresindicativeofproblem drinking. Patients with PTSD demonstrated significant adverse outcomes in 7 of the 8 domains of the Medical Outcomes Study 36-Item Short-Form Health Survey compared with patients without PTSD. In multivariate models that adjusted for injury severity, chronic medical conditions, age, sex, preinjury physical function, and alcohol use, PTSD remained the strongest predictor of an adverse outcome. Patients with problem drinking did not demonstrate clinically or statistically significant functional impairment compared with patients without problem drinking. Conclusions: Posttraumatic stress disorder persisted in 30% of patients 1 year after traumatic injury and was independently associated with a broad profile of functional impairment. The development of treatment intervention protocols for trauma patients with PTSD is warranted.

Objectives: To estimate the expected costs for acute trauma care, to quantify the costs associated with the development of complications in injury victims, and to determine the deficit incurred by patients in whom complications develop. Design: A retrospective, cohort design. Setting: A referral trauma center. Patients: A total of 12 088 patients admitted to a single regional trauma center during a period of 5 years. Interventions: This is an observational study, and no interventions specific to this study are included in the design. Main Outcome Measures: (1) The expected costs for injury victims based on readily available clinical data. (2) The costs associated with the most important complications of trauma. (3) The effect of complications on inadequate reimbursement for trauma care. Results: The expected costs were estimated using a linear model incorporating demographic variables and measures of injury severity. The expected costs averaged $14 567, and the observed costs averaged $15 032. Six complications were important predictors of cost. These included adult respiratory distress syndrome, acute kidney failure, sepsis, pneumonia, decubitus ulceration, and wound infections. For 1201 individuals with these complications, the predicted costs averaged $23 266 and the observed costs averaged $47 457. The mean excess costs for a single complication ranged from $6669 to $18 052. Multiple complications led to greater increases in excess cost, averaging $110 007 for the 62 patients with 3 or more complications. Costs exceeded reimbursement to a much greater degree in those in whom any of the 6 complications developed. Conclusion: Expected hospital costs can be estimated using admission clinical data. Each of 6 complications was associated with enormous increases in costs, indicating their importance as a cause of avoidable expenditures in injury victims and identifying situations in which reimbursement may not be adequate. Arch Surg. 1997;132:920-924

To determine if computed tomographic (CT) scanning can be used to identify patients with blunt trauma, positive results of diagnostic peritoneal lavage (DPL), and a stable hemodynamic status who could be managed safely and cost-effectively without celiotomy.Patients with blunt trauma who required an abdominal evaluation underwent DPL. Patients with a red blood cell count greater than 10(11)/L (10(5)/mm3) on lavage then underwent CT. Patients with solid organ injury alone, as detected on CT scan, were observed; those with evidence of hollow viscus injury underwent celiotomy.Sixty-seven hemodynamically stable patients had a red blood cell count greater than 10(11)/L on DPL; 38 patients underwent subsequent CT scanning, and 29 underwent immediate celiotomy in violation of the protocol. Eleven patients in the protocol group ultimately underwent celiotomy. Overall, there were significantly fewer nontherapeutic celiotomies performed in the protocol group (2/38 vs 9/29, P.01). There were no deaths in either group. Because DPL is less expensive than CT, limiting CT to patients with DPL-positive results and hemodynamic stability reduced the charges associated with abdominal evaluation by $580,594 over a period of 2 years.Limiting CT to the evaluation of patients with DPL-positive results and hemodynamic stability is safe, reduces charges, and results in a lower rate of nontherapeutic celiotomies compared with DPL alone.

Objective: To evaluate anatomic, physiologic, and mechanism-of-injury prehospital triage criteria as well as the subjective criterion of provider "gut feeling." Design: Prospective analysis. Setting: A state without a trauma system or official trauma center designation. Patients: Patients treated by emergency medical services personnel statewide over a 1-year period who were injured and met at least one prehospital triage criterion for treatment at a trauma center. Main Outcome Measures: Outcome was analyzed for injury severity using the Injury Severity Score and mortality rates. A major trauma victim (MTV) was defined as a patient having an Injury Severity Score of 16 or greater. The yield of MTV and mortality associated with each criterion was determined. Results: Of 5028 patients entered into the study, 3006 exhibited a singular entry criterion. Triage criteria tended to stratify into high-, intermediate-, and low-yield groups for MTV identification. Physiologic criteria were high yield and anatomic criteria were intermediate yield. Provider gut feeling alone was a low-yield criterion but served to enhance the yield of mechanism of injury criteria when the two criteria were applied in the same patient. Conclusions: A limited set of high-yield prehospital criteria are acceptable indicators of MTV. Isolated low- and intermediate-yield criteria may not be useful for initiating trauma center triage or full activation of hospital trauma teams. (Arch Surg. 1995;130:171-176)

Objective: To assess the efficacy of interferon gamma in reducing infection and death in patients sustaining severe injury. Design: Multicenter, randomized, double-blind, placebo-controlled trial with observation for 60 days and until discharge for patients with major infection on day 60. Setting: Nine university-affiliated level 1 trauma centers. Patients: Four hundred sixteen patients with severe injuries, assessed by Injury Severity Score and degree of contamination. Intervention: Recombinant human interferon gamma, 100 μg, was administered subcutaneously once daily for 21 days (or until patient discharge if prior to 21 days) as an adjunct to standard antibiotic and supportive therapy. Main Outcome Measures: Incidence of major infection, death related to infection, and death. Results: Infection rates were similar in both treatment groups; however, patients treated with interferon gamma experienced fewer deaths related to infection (seven [3%] vs 18 [9%]; P =.008) and fewer overall deaths (21 [10%] vs 30 [14%]; P =.17). While 12 early deaths (days 1 through 7) occurred in each treatment group, late death occurred in 18 placebo-treated patients and nine in interferon gamma—treated patients. The results were dominated by findings at one center, which had the highest enrollment and higher infection and death rates. Statistical analysis did not eliminate the possibility of an unidentified imbalance between arms as an explanation for the results. Conclusion: Further evaluation is required to determine the validity of the observed reduction in infection-related deaths in patients treated with interferon gamma. (Arch Surg. 1994;129:1031-1041)