Paediatric and adolescent trauma care within an integrated trauma system

Injury, Int. J. Care Injured 43 (2012) 2006–2011

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Paediatric and adolescent trauma care within an integrated trauma system Conor Deasy a,c,*, Belinda Gabbe a, Cameron Palmer b, Franz E. Babl b, Catherine Bevan b, Joe Crameri b, Warwick Butt b,c, Mark Fitzgerald c, Rodney Judson d, Peter Cameron a,c a

Monash University, Department of Epidemiology and Preventive Medicine, Australia Royal Children’s Hospital and Murdoch Children’s Research Institute, Melbourne, Australia c The Alfred Hospital, Melbourne, Australia d Royal Melbourne Hospital, Australia b

A R T I C L E I N F O

A B S T R A C T

Article history: Accepted 22 August 2011

Background: The aim of this study was to establish the profile and outcomes of paediatric major trauma care (PTMC) within an integrated inclusive regionalised trauma system. Methods: Prospectively collected data from July 2001 to June 2009 from the Victorian State Trauma Registry of patients aged <18 years were reviewed. Results: There were 1634 major trauma cases with a median (IQR) age of 13 (6–16) years and 69% were male. The median ISS (IQR) was 18 (16–26). There were 1361 patients treated at a major trauma centre of which 69% (n = 943) were treated at the PMTC. Head injury (AIS > 2) was the most frequent injury (n = 950, 58%). Surgery was required in 39% (n = 637) of all cases; 437 patients in the 10–17 year old group and 200 patients in the 0–9 year old group; the mortality was 6.6%. There were 530 patients (32.4%) ventilated in ICU; these had a median ISS (IQR) of 25 (17–34) and mortality of 7.4%. Improvements in riskadjusted mortality have occurred as the years have progressed [adjusted OR 95% CI: 0.87 (0.76, 0.99)] and being treated at a Level 1 trauma centre was associated with lower adjusted odds of mortality [adjusted OR 95% CI: 0.27 (0.11, 0.68)]. Conclusion: The establishment of this integrated inclusive regionalised trauma system has been associated with progressively improving risk-adjusted mortality. The relatively low volume of major trauma requiring surgery in the 0–9 year old age group is notable, creating a challenging environment for maintaining skills and institutional preparedness. ß 2011 Elsevier Ltd. All rights reserved.

Keywords: Prehospital Trauma Paediatric Prevention Mechanisms of injury Injury patterns

Introduction International evidence indicates that the outcome from major trauma in adults is improved with management at trauma centres and within trauma systems.1–5 Research from the 1990s in the state of Victoria, Australia to identify deficiencies in trauma management1,2,5 resulted in a governmental review of trauma care and the establishment of a state-wide trauma system which included triage of major trauma patients to designated major trauma services (MTS) comprising two adult and one paediatric level 1 equivalent centres. ‘‘Inclusive’’ systems are where there is

* Corresponding author at: Department of Epidemiology and Preventive Medicine, 5th Floor, Alfred Centre, 99 Commercial Road, Prahran, Melbourne, Victoria 3004, Australia. Tel.: +61 416486887. E-mail addresses: [email protected] (C. Deasy), [email protected] (B. Gabbe), [email protected] (C. Palmer), [email protected] (F.E. Babl), [email protected] (C. Bevan), [email protected] (J. Crameri), [email protected] (W. Butt), m.fi[email protected] (M. Fitzgerald), [email protected] (R. Judson), [email protected] (P. Cameron). 0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2011.08.032

coordination of prehospital and acute care services in an entire geographical area to ensure that the needs of the patient are matched to the facility providing definitive care in a timely manner.6,7 Despite the presence of paediatric trauma centres in other health jurisdictions, there is little in the literature describing the best practice for provision of paediatric major trauma care within trauma systems and their effectiveness.3,8 Paediatric trauma, particularly in the younger age groups, is considered to differ from adult trauma in the patterns of injury sustained, physiology,3,8 the number of trauma cases, the frequency of surgical procedures performed and recovery from injury. The injury profile changes through increasing age groups, with the older children adopting adult trauma characteristics.3,8 Understanding the epidemiology of paediatric major trauma is vital to informing how best to integrate paediatric trauma into the trauma system to maximise provision of services and quality of care delivered. It is difficult to improve trauma care without measurement.9 Using data from a population-based trauma registry, the aim of this study was to investigate the injury pattern, mechanisms, severity

C. Deasy et al. / Injury, Int. J. Care Injured 43 (2012) 2006–2011

and mortality of paediatric major trauma within an inclusive, regionalised trauma system. Materials and methods Setting The study setting was Victoria, Australia, which has a population of nearly 5 million of whom more than 1 million are under 18 years of age.10 Prehospital emergency care is administered by both road and air ambulance services supporting one paediatric and two adult major trauma (Level 1 equivalent) services (MTS), with another 135 metropolitan and rural health services. The Emergency Medical Service (EMS) is two tiered; paramedics are trained in advanced trauma life support skills (including basic paediatric airway skills) whilst mobile intensive care (MICA) paramedics are trained in advanced paediatric airway skills, intravenous/intraosseous cannulation and decompression of tension pneumothorax. The paediatric trauma triage guidelines state that the ambulance services should triage major trauma and suspected major trauma direct to the MTS hospitals when travel time is less than 30 min, but otherwise go to the next highest level of hospital available by Victorian State Trauma System (VSTS) designation for stabilisation with subsequent transfer to a MTS as appropriate.11

2007

proportion of paediatric major trauma in Victoria. The method used for variable selection and model building was that described by Hosmer and Lemeshow.14 Variables demonstrating an association with outcome on univariate testing were entered into the model. Age and ISS were categorised for ease of interpretation. Results of the Wald tests for determining coefficient significance were used to individually remove non-significant variables from the model. The reduced model was compared with the larger model using likelihood ratio tests and the coefficients were checked to ensure there was no potential confounding. This process was repeated to arrive at a parsimonious final model. Variables excluded from the initial model were then included to ensure that important variables were not missed. For the final model, interactions were explored and included if these were significant. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) of the AOR were calculated. All analyses were performed using Stata Version 10 (StataCorp, College Station, TX, USA). For all tests, a p-value < 0.05 was considered significant. Ethics Ethics approval for the VSTR was obtained from the Monash University Human Research Ethics Committee, and the Human Research Ethics committees of all participating institutions (n = 138).

Data collection Results The Victorian State Trauma Registry (VSTR) is a populationbased registry which collects data on all major trauma cases in Victoria, irrespective of where the cases receive definitive management. Major trauma is defined as the presence of at least one of the following: death after injury; admission to an Intensive Care Unit (ICU) for more than 24 h requiring mechanical ventilation; Injury Severity Score (ISS)12 > 15; or urgent surgery for intracranial, intrathoracic, intraabdominal injury or fixation of pelvic or spinal fractures.11 All major trauma cases captured by the Victorian State Trauma Registry (VSTR) with a date of injury between July 2001 and June 2009 (inclusive) aged less than 18 years of age were extracted for analysis. Patients were analysed by the four age groups 0–4, 5–9, 10–14 and 15–17 year olds in line with Australian Bureau of Statistics age categorisation.10 Demographic data, injury event details, clinical observations at presentation, ISS, management and in-hospital outcomes were analysed. The Glasgow Coma Scale (GCS) score recorded was the first figure documented, adjusted to child or infant.8 The patient was deemed to be hypotensive if the first measurement of systolic blood pressure (SBP) was below the lower limit of normal (5th percentile) for age. This was estimated by the formula: 70 mmHg + (2  age in years).8

There were 1634 major trauma patients aged less than 18 years old captured by the VSTR for the study period. The median (IQR) age was 13 (6–16) years with an overall median (IQR) ISS of 18 (16– 26). Table 1 shows the demographics, trauma type and injury event details by age group. Fig. 1 describes the distribution of injury (AIS  2, except head injury where AIS  3) per body site across age groups. Head injury was the most common injury throughout paediatric age groups, thoracic injury being more common in the 15–17 year old age group. Table 2 describes the injury pattern sustained, ISS, management and in-hospital outcomes. Just over half (51%) of children aged 0–4 years sustained an isolated head injury. The 15–17 year old age group had the highest proportion of head injury sustained in association with other injuries (30%) but had the lowest proportion of isolated head injury (21%). Thoracic injury in association with other injury increased through the age groups, reflective of the more mature rigid rib cages susceptibility to higher velocity trauma; thoracic injury was present in 32% of 15–17 year olds

Data analysis Medians with interquartile ranges are reported for continuous variables with a skewed distribution and compared using a Mann– Whitney’s test. In-hospital mortality rates were calculated for group data as well as individual injury mechanisms. The injury was considered isolated if the patient had not sustained any other injury with an Abbreviated Injury Scale (AIS) > 1, coded using the 1998 AIS13 version. A body region was considered significantly injured if AIS  2 except in the case of head injury where an AIS  3 was used. Chi-square tests were used to determine associations between categorical variables and age group or outcome. Univariate and multivariable binary logistic regression were performed to assess the impact of variables on mortality on cases of blunt trauma with an ISS > 15 which represent the largest

Fig. 1. Percent of patients with given injury by age group (AIS > 2 except head injury which includes AIS > 3). (For interpretation of the references to color in the artwork of Fig. 1, the reader is referred to the web version of the article.)

C. Deasy et al. / Injury, Int. J. Care Injured 43 (2012) 2006–2011

2008 Table 1 Patient and injury event profiles across age groups. Age group N (%) Gender Trauma type

Mechanisma

Place of injury n (%)

Intent

a

Male n (%) n (%) Blunt Penetrating Burn Other n (%) Motor vehicle occupant Motorcycle Pedal cyclist Pedestrian Low fall (<1 m) High fall (>1 m) Cutting or piercing object Struck by or collision with person Struck by or collision with object Burns Other mechanism n (%) Home School Road/street/highway Place for recreation Athletics/sports area Farm Other n (%) Unintentional Intentional self harm Abuse Assault Intent cannot be determined Other

0–4 years 311 (19)

5–9 years 280 (17)

10–14 years 390 (24)

15–17 years 653 (40)

184 (59)

181 (65)

274 (70)

496 (76)

262 8 34 7

(84) (3) (11) (2)

257 11 10 2

(92) (4) (4) (<1)

362 7 12 9

(93) (2) (3) (2)

587 41 19 6

(90) (6) (3) (1)

45 4 2 37 62 34 5 11 30 34 47

(15) (2) (1) (21) (43) (24) (10) (14) (21) (57) (34)

46 20 31 41 30 42 7 7 31 7 18

(13) (13) (19) (23) (21) (30) (14) (9) (22) (12) (13)

61 52 69 36 27 34 3 14 40 11 43

(17) (31) (43) (20) (19) (24) (6) (18) (28) (18) (31)

212 89 60 63 24 30 36 47 42 18 32

(58) (54) (37) (36) (17) (21) (70) (60) (29) (30) (23)

182 1 74 5 3 9 37

(59) (0.3) (24) (2) (1) (3) (11)

85 22 101 19 8 14 31

(30) (8) (36) (7) (3) (5) (11)

45 26 154 41 28 32 64

(12) (7) (39) (11) (7) (8) (16)

56 16 368 35 54 20 104

(9) (2) (56) (5) (8) (8) (17)

259 0 30 2 14 6

(83)

276 (98) 0 0 2 (1) 2 (1) 0

370 9 1 5 4 1

(95) (2)

558 10 2 73 6 4

(85) (2) (<1) (11) (1) (1)

(10) (4) (2)

(1) (1) (<1)

Data is presented as column percentages with the exception of mechanism which is presented as row percentages.

sustaining major trauma. There was an association between head and spinal injury (x2(1) = 31.9, p < 0.001); 44 (4.6%) patients with a head injury (n = 950) also had a spinal injury. The numbers of surgical procedures performed differed between those less than 10 years of age and older children (Table 2). There were 437 patients who received surgery in the 10–17 year old group compared to 200 patients in the 0–9 year old group. The paediatric trauma centre performed 52% of surgery and the two designated adult trauma centres performed 30%, the other surgery being performed at level 2 regional centres. In the age groups less than 15 years the paediatric trauma centre performed 85% of the surgery. In the patients aged under 15 years who had surgery at the designated paediatric centre compared to elsewhere ISS scores were similar—median (IQR) 18 (16–26) compared to 17 (16–25) respectively, p = 0.09 and no mortality difference was found (p = 0.8). Most patients were discharged home after acute hospital treatment. The 15–17 year old age group had the highest rate of discharge to an inpatient rehabilitation service (35%). The mortality for patients sustaining blunt trauma with an ISS > 15 was 6.7% (n = 85). Univariate analysis examining factors associated with mortality for patients with ISS > 15 after blunt trauma is included in Appendix A and shows the 0–4 year old age group had greater odds of mortality OR 1.88 (95% CI: 1.21, 2.94) compared to other age groups, that patients with a thoracic injury had greatest odds of mortality OR 4.4 (95% CI: 2.8, 6.9) followed by those with head injury OR 2.09 (95% CI: 1.18, 3.72). Patients transferred to a major trauma service were less likely to die OR 0.24 (95% CI: 0.14, 0.40). The 0–4 year old age group had the lowest median ISS associated with mortality whilst the 15–17 year old age group had the highest (p = 0.003). There were 22 patients with an ISS > 15 who sustained blunt injuries due to child abuse; 6 (27%) died. A

road, street or highway was the most frequent location associated with mortality (n = 61, 67%) followed by the home (n = 19, 20.9%) and farms (n = 3, 5.3%). The most lethal mechanism of injury was associated with pedestrian trauma—responsible for 35%, 16%, 19% and 29% of fatalities in the four age groups respectively. On multivariable analysis the 0–4 year old age group had nearly three times the adjusted odds of mortality compared to the 15–17 year old group. The risk-adjusted mortality has decreased over time [adjusted OR 95% CI: 0.87 (0.76, 0.99)] and being treated at a MTS was associated with lower adjusted odds of mortality [adjusted OR 95% CI: 0.27 (0.11, 0.68)]. A GCS of 9–12 was associated with a more than five-fold increased odds of mortality, and cases with a GCS of 3–8 demonstrated a more than 36-fold increased odds of mortality, compared to cases with a GCS of 13–15 (Table 3). Discussion Regionalised, inclusive trauma systems are a means to improve trauma care delivery to children15–23 with better outcomes dependent on where children receive medical care.24,25 It has been shown that improved hospital care results in lower mortality26 and that definitive care is best delivered at a paediatric centre.27 This study offers a comprehensive description of paediatric major trauma cases across a population, showing that mortality from major trauma in the paediatric age group is relatively low and that treatment at a level-1 equivalent MTS was associated with a reduction in the adjusted odds of mortality. Riskadjusted mortality has also decreased over time. This mirrors the experience of adult centres.28,29 This study reports injury patterns, mechanisms, severity and mortality; such data is important in informing service require-

C. Deasy et al. / Injury, Int. J. Care Injured 43 (2012) 2006–2011

2009

Table 2 Profile of injury pattern and management across age groups. Age group (n) ISS median (IQR) ISS > 15 Level of definitive management

Surgery performed Abdominal injury

Spinal injury

Upper extremity injury

Lower extremity injury

External injury

ICU stay Ventilated in ICU Length of stay

Discharge destination

In-hospital mortality

Median (IQR) n (%) n (%) Paediatric MTS Adult MTS Other n (%) n (%) Isolated Associated injuries Abdominal surgery performed n (%) Isolated Associated injuries Spinal surgery performed n (%) Isolated Associated injuries Upper limb surgery performed n (%) Isolated Associated injuries Lower limb surgery performed n (%) Isolated Associated injuries External surgery performed n (%) n (%) Median (IQR) Overall Ward ICU n (%) Home Inpatient rehabilitation Other n (%)

0–4 years (n = 311)

5–9 years (n = 280)

10–14 years (n = 390)

15–17 years (n = 653)

17 (16–26) 258 (83)

18 (16–26) 238 (85)

18 (16–26) 330 (85)

20 (16–29) 540 (83)

276 (89) 0 35 96 (31)

236 (84) 0 44 109 (37)

319 (82) 7 (2) 64 142 (36)

112 (17) 411 (63) 130 295 (45)

19 (6) 33 (11) 15

37 (13) 40 (14) 33

51 (13) 68 (17) 51

61 (9) 137 (21) 134

3 (1.0) 17 (5) 4

2 (1) 14 (5) 6

9 (2) 15 (4) 16

0 (0) 30 (9) 5

1 (<1) 10 (4) 8

1 (<1) 26 (7) 23

2 (1) 19 (6) 6

1 (<1) 33 (12) 20

4 (1) 57 (15) 34

28 5 41 153 109

(9) (2)

9 5 38 107 65

(49) (35)

5.9 (2.9–15.6) 3.7 (2–7) 3 (1–7.5) 248 13 50 36

(79) (4) (17) (12)

(3) (2) (38) (23)

5.9 (3–10) 4.5 (3–8) 3 (1–6) 229 23 28 15

(82) (8) (10) (5.4)

11 4 52 161 106

(3) (1) (41) (27)

7.3 (4–15) 5.3 (3–10) 3 (1–7) 299 52 39 21

(77) (13) (10) (5)

27 (4) 55 (8) 58 1 56 67 5 107 86

(<1) (9)

17 6 115 340 250

(3) (1)

(1) (16)

(52) (38)

7.4 (4–14) 4.8 (3–8) 3 (2–8) 366 228 59 41

(56) (35) (9) (6)

Percentage where the denominator is the number of patients with that injury type.

ments and the potential for preventive measures. The study found blunt trauma was the most common trauma type, with head injury the most commonly sustained injury. This is similar to findings from the UK.30 ‘Pedestrian struck by vehicle’ was the most lethal

Table 3 Important predictors of mortality in paediatric, blunt major trauma (ISS > 15) (results of the multivariable analysis). Covariate Age group 15–17 years 10–14 years 5–9 years 0–4 years Year Transferred No (reference) Yes Treatment at MTS Non-MTS MTS Thorax Injury Injury Severity Score ISS 16–17 ISS 18–25 ISS > 26 GCS category GCS 13–15 GCS 9–12 GCS < 9

Adjusted OR (95% CI) 1 0.81 0.94 2.87 0.87

(0.36, (0.36, (1.30, (0.76,

1.86) 2.40) 6.20) 0.99)

1 0.35 (0.17, 0.72) 1 0.27 (0.11, 0.68) 3.28 (1.67, 6.45) 1 0.90 (0.27, 3) 1.80 (0.61, 5.1) 1 5.16 (1.27, 20.90) 36.50 (11.80, 112.50)

mechanism of injury in all age groups responsible for 29% of all deaths, followed by motor vehicle crash which was responsible for 26% of deaths. The intentional nature of the traumatic brain injury (TBI) diagnosis may be frequently missed.31,32 There were 34 cases of intentional traumatic brain injury detected in this study of which 81% had a serious head injury; 56% were isolated head injuries. In terms of services required the 0–4 and the 15–17 year olds placed greatest demands on ICU having the greatest rates of ventilation. An important indication of the performance of a trauma system is the outcome of the most severely injured trauma patients surviving to hospital admission, i.e. those admitted to the paediatric intensive care unit (PICU).33–35 Previous work analysing the Victorian paediatric intensive care system advocated the centralisation of specialist paediatric intensive care units.36 In this study 47% of paediatric major trauma were admitted to ICU; the median (IQR) ISS of these patients was 25 (17–30), their median (IQR) length of stay was 3 (2–8) days, mean (SD) 5.8 (7.65) days and the mortality rate was 10%. Comparison of the current study with other studies is difficult as there are few paediatric-specific papers published; Franzen et al.37 examined 131 traumatised children (0– 16 years) in Sweden admitted to intensive care after trauma between 1990 and 2000; their median ISS was 14, mean length of stay was 4.2 days, and mortality 3.0%. However, their study did not include head injury patients as these were admitted to a separate neurosurgical ICU. It is possible to underestimate the effectiveness of a trauma system in improving care if an overwhelming number of patients with ‘minor’ injuries are included in a study population

2010

C. Deasy et al. / Injury, Int. J. Care Injured 43 (2012) 2006–2011

as these patients will do well at any centre;16 we avoid this by using the case definition set out in the methods section. Discharge to an inpatient rehabilitation centre increased through the age groups. This may relate to the preference for outpatient rehabilitation and family involvement in younger children, and/or a paucity of rehabilitation centres for children in this jurisdiction. It may also relate to the mechanism of injury and opportunity for compensation in motor vehicle trauma. This paper highlights that the number of major trauma patients and the subsequent volume of surgery performed is small and differs between those aged 10–17 years compared to younger patients. Despite an uneven age group distribution 437 patients received surgery in the 10–17 year old group, compared to 200 patients in the 0–9 year old group during the 8-year period of this study; there were 8797 adult (18 years) major trauma patients who received emergency surgery during this time. This translates to less than 15 major trauma patients less than 10 years of age who required surgery per year. The low volume of paediatric major trauma, relative to adult, creates a challenging environment for maintaining skills and institutional preparedness. Whether this low volume of emergency surgery is best performed by a paediatric surgical team or an adult trauma team with appropriate paediatric skills is debated and beyond the scope of this paper to resolve but warrants further research. Outcome measures beyond mortality are required to make such research meaningful. In the Victorian system, where no child less than 10 years, few children (n = 7) aged between 10–14 years and 78% of 15–17 year olds were treated at adult MTS hospitals, the mortality rates were low and the riskadjusted odds of mortality decreased over time suggesting that the trauma system is operating well. Concentrating resources and expertise at a single paediatric trauma centre is believed to have benefits beyond mortality outcomes. Potoka et al. demonstrated that children treated at a paediatric trauma centre in Pennsylvania had lower rates of mortality compared to those treated at the adult trauma centre, particularly for those with liver, spleen and traumatic brain injuries; patients at the paediatric trauma centre also had lower rates of splenectomy and higher rates of neurosurgical procedures.18 We were unable to analyse the appropriateness and timing of laparotomy and/or splenectomy however it is likely that specialised centres will less often undertake a laparotomy. Psychosocial management of patients and their parents is also important in the optimal management of paediatric patients–this is also likely to be more focused in a paediatric centre. This study has a number of limitations. Only patients who were admitted to hospital were considered, thus children dying at the scene were not represented in this dataset. Other authors have highlighted the limitations around the use of paediatric mortality30,38 and the lack of functional outcome and quality of life measures39,40 as quality of care indicators are acknowledged. There has been significant investment in preventive measures in this jurisdiction. Initiatives such as mandatory child restraints, reduction of speed limits in residential and school zones, enforcement of children crossings, compulsory helmets for cyclists are measures that potentially reduce mortality more than medical interventions.41,42 Capturing their effect on injury severity or mortality however is challenging. Missing registry data can influence the assessment of trauma system performance.43 These data reflect an Australian setting with a low rate of penetrating injuries. Conclusion These data provide a unique population based insight into the profile of patients, case load and resource needs for major paediatric trauma in a state-wide integrated trauma system with

concentration of paediatric services at one centre. The establishment of this integrated inclusive regionalised trauma system has been associated with progressively improving risk-adjusted mortality. The relatively low volume of paediatric major trauma is notable, creating a challenging environment for maintaining skills and institutional preparedness. Furthermore, measuring long term disability and the quality of survival of paediatric patients will be essential in demonstrating improved outcomes from the trauma system. Conflict of interest There are no conflicts of interest to declare by any authors.

Appendix A. Univariate analysis where mortality is the outcome measure, for patients with ISS > 15 and blunt trauma

Covariate

Survivors (n = 1183)

Age group 15–17 years (reference) 10–14 years 5–9 years 0–4 years

467 298 212 206

Sex Female (reference) Male

1 0.65 (0.34, 1.22) 0.65 (0.30, 1.34) 1.8 (1.06, 3.06)

355 (30) 828 (70)

38 (44.7) 47 (55.3)

1 1.88 (1.21, 2.94)

Year (n, %) 2002 (reference) 2003 2004 2005 2006 2007 2008 2009

115 123 123 118 167 185 144 208

17 11 11 8 12 7 12 7

1 0.60 0.60 0.46 0.49 0.25 0.56 0.23

Transferred No Yes

598 (50.6) 585 (49.4)

69 (81.2) 16 (18.8)

1 0.24 (0.14, 0.40)

178 (15.1) 1005 (84.9)

13 (15.3) 72 (84.7)

1 0.98 (0.53, 1.80)

Head injury No Yes

367 (31) 816 (69)

15 (17.7) 70 (82.3)

1 2.09 (1.18, 3.72)

Abdominal injury No Yes

881 (74.5) 302 (25.5)

54 (63.5) 31 (36.5)

1 1.70 (1.06, 2.65)

Thorax injury No Yes

882 (74.6) 301 (25.4)

34 (40.0) 51 (60.0)

1 4.4 (2.80, 6.90)

Spinal injury No Yes

1100 (93.0) 83 (7.0)

75 (88.2) 10 (11.8)

1 1.80 (0.88, 3.55)

Upper extremity injury No Yes

1105 (93.4) 78 (6.6)

80 (94.1) 5 (5.9)

1 1.16 (0.94, 1.44)

Lower extremity injury No Yes

1011 (85.5) 172 (14.5)

62 (72.9) 23 (27.1)

1 1.37 (1.17, 1.60)

24 7 4 28

1 0.56 (0.23, 1.33) 0.37 (0.13, 1.10) 2.48 (1.38, 4.44)

Injury mechanism Motor vehicle Motor cycle Pedal cyclist Pedestrian

276 143 123 130

(87.1) (91.8) (91.8) (93.3) (93.3) (96.4) (92.3) (96.7)

(23.4) (12) (10.4) (11)

34 14 10 27

Odds ratio (95% CI)

(40) (16.5) (11.8) (31.8)

Treatment at MTS No Yes

(39.5) (25.2) (17.9) (17.4)

Dead (n = 85)

(12.9) (8.2) (8.2) (6.7) (6.7) (3.6) (7.7) (3.3)

(28.4) (8.2) (4.7) (32.9)

(0.27, (0.27, (0.19, (0.19, (0.10, (0.26, (0.09,

1.35) 1.35) 1.10) 1.05) 0.63) 1.22) 0.56)

C. Deasy et al. / Injury, Int. J. Care Injured 43 (2012) 2006–2011 Appendix A (Continued ) Covariate High fall (>1 m) Struck by or collision with person Struck by or collsion with object Other

Survivors (n = 1183)

Dead (n = 85)

Odds ratio (95% CI)

126 (10.6) 60 (5)

3 (3.5) 6 (7.0)

0.27 (0.08, 0.93) 1.15 (0.45, 2.93)

109 (9.3)

7 (8.2)

0.74 (0.31, 1.76) 0.90 (0.35, 2.27)

216 (18.2)

6 (6.5)

Injury Severity Score ISS 16–17 ISS 18–25 ISS > 26

476 (40.2) 330 (27.9) 377 (31.9)

6 (7.1) 9 (10.6) 70 (82.3)

1 2.16 (0.76, 6.14) 14.70 (6.3, 34.3)

GCS category GCS 13–15 GCS 9–12 GCS < 9 Missing GCS data (n)

769 (68.6) 156 (13.9) 196 (17.5) 62

6 (6.2) 5 (7.8) 55 (85.9) 19

1 6.16 (1.64, 23.2) 54.00 (19.3, 150.6)

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