Tag Archives: outcomes

Trauma In Pregnancy 2: Predicting Outcome

The data on maternal outcome after trauma is mixed and somewhat confusing. Mortality after major trauma actually appears to be less. However, injury severity score (ISS) still correlates fairly well with overall mortality. But interestingly, other outcomes (complications) appear to be worse, even for relatively minor injuries. The reason behind this is not clear. Could it be a result of all of the physiologic changes noted above, hormonal factors, or something we don’t fully understand?

Fetal outcome is a function of the mechanism of injury (blunt vs penetrating), and extreme injury severity in the mother. Penetrating injury is uniformly devastating to the fetus, with 70% mortality for gunshots and 40% for stabs. Fetal death from blunt injury is primarily a function of placental abruption. About two thirds of blunt fetal deaths are due to abruption, with 50% of them due to car crashes. Maternal ISS does not correlate with fetal death, except in cases of very high scores. These women most likely experience anatomic and physiologic injuries that lead to fetal demise.

Tomorrow: Tips & Tricks

Reference: Trauma during pregnancy. OB Clinics of North America 40:47-57, 2013.

EAST 2017 #14: Long Term Consequences of Trauma: Why Aren’t We Looking?

I’m adding one more post to my EAST 2017 collection. This one struck me because it dovetails with another one I analyzed last week. After hearing both, something just clicked. The first was “When is mild TBI not so mild”, and opened my eyes to the fact that more TBI patients had ongoing problems than I imagined.

Now I just heard a presentation that looked at long term functional outcomes in patients with ISS > 9 at Brigham and Women’s Hospital. They identified patients in their trauma registry from 6 and 12 months prior to the study, and called these patients to administer several standard evaluation tools. Of 394 eligible patients, 27% could not be contacted, and 30% declined to participate, leaving 171 subjects. Half were 6 months out from their discharge, and half were a year  out.

The findings were very interesting. Here are the factoids:

  • 23% had a positive PTSD screen at 6 months, but this decreased to 16% at one year
  • A quarter of patients were still living with assistance that they did not need preinjury in both time periods
  • 20% of patients experienced a change in insurance
  • Half of the patients stopped working due to their injury, and this did not improve at one year
  • One in six were readmitted at some point for their injuries
  • The majority used some type of rehabilitation service (inpatient or outpatient) during their recovery

Bottom line: In my mind, this is a very big deal. All trauma centers collect a huge amount of data to monitor how things work while the patient is in the hospital. However, once discharged, they are on their own. We have no idea how they are doing, we have no mechanisms for finding out, and we have no systems in place to help if there are problems.

It is certainly simple enough to schedule a few phone calls at time intervals after discharge. We have tools and screening questions that we can ask. We can even include this information in the trauma registry and trend it. But then what?

This problem reaches beyond the trauma centers. Sure, we can make referrals for PTSD and rehab services. But what about the patient’s job, or their insurance? What if they don’t have insurance coverage or funds for needed services?

I believe that trauma centers should develop these processes and start collecting this information now. But we will also have to work with community and social service resources in order to marshal the services that our patients require. 

Reference: Routine inclusion of long-term functional and patient reported outcomes into trauma registries: can this be done? Paper #34, EAST 2017.

Subdural Hematoma: How Well Do They Really Do?

The common teaching is that patients with traumatic subdural hematoma don’t do well. This is generally due to the presence of more direct injury to the brain compared with patients who have epidural hematoma. Outcomes data tends to bear this out. However, this data is at least 20 years old and it would be nice to know if we’ve made any progress in the management of this injury.

Harborview Medical Center retrospectively reviewed four years worth of its trauma registry data on patients with subdural hematoma. They scrutinized the usual outcomes data, looking at patients with and without surgical decompression. During the study period, clinical management routines remained basically the same.

A total of 1427 patients were included in the study. The average age was 58. Interesting facts from the study include:

  • Falls were by far the most common mechanism (57%)
  • Most patients (58%) had a GCS of 13 or higher
  • The TRISS probability of survival was slightly lower in the evacuated group (85%) versus the non-evacuated group (91%), yet
  • Mortality rate was 14%, with traumatic brain injury the most common cause of death
  • 29% had positive urine toxicology testing. Marijuana was most prevalent.
  • Slightly more than half were discharged home. Independence was higher in the group who had undergone evacuation of their hematoma.

Bottom line: Patients with subdural hematoma do better these days than they used to. This is probably due to better imaging (CT), which leads to earlier and more accurate management. Additionally, these injuries are now treated at regional trauma centers like Harborview, which may also improve survival.

Related posts:

Reference: Acute traumatic subdural hematoma: Current mortality and functional outcomes in adult patients at a Level I trauma center. J Trauma 73(5):1348-1354, 2012.