The Journal of trauma

Published by Lippincott, Williams & Wilkins
Print ISSN: 0022-5282
We still lack comparing data of the plasma volume (PV)-expanding effect of the most commonly used colloids including dextran 70. This study compares the PV-expanding effects of 6% dextran 70, 5% albumin, and 6% hydroxyethylstarch (HES) 130/0.4 after a standardized hemorrhage. The prospective and randomized study on 33 anesthetized adult male guinea pigs involved three groups (n = 11 each); the dextran group, the albumin group, and the HES group. The left carotis artery was cannulated for blood pressure measurements and blood samples, and the right jugular vein was cannulated for infusions. After hemorrhage of 20 mL/kg for 8 minutes, the animals were transfused with 20 mL/kg of the colloid for 10 minutes. PV was determined with a I-albumin tracer dilution technique at baseline and 3 hours after the colloid infusion. The PV just after hemorrhage was calculated as the baseline value minus bled PV. Blood gases were measured at baseline, after hemorrhage, just after the colloid infusion and at the end of the experiment. The increase in PV 3 hours after the colloid infusion, including the 20 mL infused, was 36.3 mL/kg +/- 2.3 mL/kg in the dextran group, 26.4 mL/kg +/- 4.7 mL/kg in the albumin group, and 17.6 mL/kg +/- 3.5 mL/kg in the HES group. At the end of the experiment, hematocrit was lower in the dextran group than in the albumin and the HES groups. Urine production was higher in the HES group than in the dextran and the albumin groups. After hemorrhage, the PV-expanding capacity of 6% dextran 70 was better than that of 5% albumin, which was in turn better than that of HES 130/0.4 given in equal volumes.
Voluven (hydroxyethyl starch [HES] 130/0.4), a new generation of HES product with low molecular weight, has been widely used for the treatment of traumatic and hemorrhagic shock in clinics. However, no data are available whether it affects the balance of cerebral oxygen supply and consumption when applied to resuscitate hemorrhagic shock. The purpose of this study was to address this question in rabbits subjected to a severe hemorrhagic shock. In New Zealand rabbits, an acute hemorrhagic shock was induced by withdrawing 45% to 50% of total blood volume from the femoral vein in 10 minutes when the mean arterial pressure was reduced to 60% of the baseline level. Thirty minutes after the hemorrhage, animals were infused with either an equal amount of Voluven (group V) or a tripled amount of lactated Ringer's solution (group R). The saturation of oxygen was obtained in arterial (Sao2) and venous (SjvO2) blood samples from the femoral artery and jugular bulb, respectively. Arterial oxygen content (Cao2), jugular oxygen content (CjvO2), arteriovenous oxygen difference (AVDO2), and cerebral oxygen extraction rate (CERO2) were calculated accordingly to evaluate the oxygenation state in the brain. Levels of SjvO2 and CjvO2 were decreased after hemorrhagic shock, and there were increases in AVDO2 and CERO2 values. After resuscitation, the SjvO2, AVDO2, and CERO2 levels in group V were quickly recovered to the basal levels, whereas the values in group R remained in the abnormal levels (p < 0.05). There were significant differences between the groups in their SjvO2 and CERO2 levels at 30 minutes after resuscitation. In addition, the mean arterial pressure was restored to the basal levels in group V but not in group R after resuscitation (p < 0.05). We conclude that early infusion of Voluven is beneficial for maintenance of the hemodynamic stability and for the balance of cerebral oxygen supply and consumption during the resuscitation of acute hemorrhagic shock.
This prospective study was undertaken to evaluate the efficiency of intercostal nerve block (ICNB) with 0.5% bupivacaine (Marcaine) for pain relief in patients with rib fractures and to correlate the degree of pain relief with changes in the peak expiratory flow rate (PEFR) and oxygen saturation (Sao2). Twenty-one consecutive adult patients admitted with rib fractures associated with severe pain formed the basis of the study. Chest pain was scored on a four-point scale before ICNB, 1 hour after ICNB, and 24 hours after ICNB. Sao2 was measured before and immediately after ICNB. PEFR was measured before and immediately after ICNB. Pain score and PEFR before and after ICNB showed statistically significant differences (p = 0.0000, df = 20). There was a significant difference between Sao2 before and after ICNB. Significant increases in Sao2 and PEFR occur after ICNB with 0.5% bupivacaine, which also provides sustained analgesia, leading to improvement in respiratory mechanics.
Although soft armor vests serve to prevent penetrating wounds and dissipate impact energy, the potential of nonpenetrating injury to the thorax, termed behind armor blunt trauma, does exist. Currently, the ballistic resistance of personal body armor is determined by impacting a soft armor vest over a clay backing and measuring the resulting clay deformation as specified in National Institute of Justice (NIJ) Standard-0101.04. This research effort evaluated the efficacy of a physical Human Surrogate Torso Model (HSTM) as a device for determining thoracic response when exposed to impact conditions specified in the NIJ Standard. The HSTM was subjected to a series of ballistic impacts over the sternum and stomach. The pressure waves propagating through the torso were measured with sensors installed in the organs. A previously developed Human Torso Finite Element Model (HTFEM) was used to analyze the amount of tissue displacement during impact and compared with the amount of clay deformation predicted by a validated finite element model. All experiments and simulations were conducted at NIJ Standard test conditions. When normalized by the response at the lowest threat level (Level I), the clay deformations for the higher levels are relatively constant and range from 2.3 to 2.7 times that of the base threat level. However, the pressures in the HSTM increase with each test level and range from three to seven times greater than Level I depending on the organ. The results demonstrate the abilities of the HSTM to discriminate between threat levels, impact conditions, and impact locations. The HTFEM and HSTM are capable of realizing pressure and displacement differences because of the level of protection, surrounding tissue, and proximity to the impact point. The results of this research provide insight into the transfer of energy and pressure wave propagation during ballistic impacts using a physical surrogate and computational model of the human torso.
LF 16-0687 Ms previously was reported to improve Neurological Severity Score (NSS) and decrease cerebral edema and prostaglandin E(2) (PGE(2)) release after closed head trauma (CHT) in rats. Here, we examined whether these beneficial effects of LF 16-0687 Ms are altered when CHT is accompanied by acute ethanol administration. Six groups of rats (n = 8 per group) were examined during combination of the following experimental conditions: CHT versus sham operation, LF 16-0687 Ms 3 mg/kg subcutaneously versus saline, and ethanol 2 g/kg versus saline. After CHT, brain water content decreased and NSS improved with ethanol + LF 16-0687 Ms as compared with values after saline or ethanol. PGE(2) release decreased with ethanol (147 +/- 59 pg/mg tissue) but not with ethanol + LF 16-0687 Ms (286 +/- 194 pg/mg tissue). Ethanol does not affect the improvement of NSS and the decrease of cerebral edema seen with LF 16-0687 Ms after CHT, but does reverse the ability of LF 16-0687 Ms to minimize the increase of PGE(2) release. In intoxicated patients, bradykinin antagonist therapy may improve post-CHT outcome without altering PGE(2) release.
The Eastern Association for the Surgery of Trauma Practice Management Guidelines identify indications (EI) for early intubation. However, EI have not been clinically validated. Many intubations are performed for other discretionary indications (DI). We evaluated early intubation to assess the incidence and outcomes of those performed for both EI and DI. One thousand consecutive intubations performed in the first 2 hours after arrival at our Level I trauma center were reviewed. Indications, outcomes, and trauma surgeon (TS) intubation rates were evaluated. During a 56-month period, 1,000 (9.9%) of 10,137 trauma patients were intubated within 2 hours of arrival. DI were present in 444 (44.4%) and EI in 556 (55.6%). DI were combativeness or altered mental status in 375 (84.5%), airway or respiratory problems in 21 (4.7%), and preoperative management in 48 (10.8%). Injury Severity Score was 14.6 in DI patients and 22.7 in EI patients (p < 0.001). Predicted versus observed survival was 96.6% versus 95.9% in DI patients and 75.2% versus 75.0% in EI patients (p < 0.001). Head Abbreviated Injury Scale score of >or=3 occurred in 32.7% with DI and 52.0% with EI (p < 0.001). Seven (0.7%) surgical airways were performed; two for DI (0.2%). Eleven (1.1%) patients aspirated during intubation and five (0.5%) suffered oral trauma. There were no other significant complications of intubation for either DI or EI and complication rates were similar in the two groups. Delayed intubation (early intubation after leaving the trauma bay) was required in 67 (6.7%) patients and 59 (88.1%) were for combativeness, neurologic deterioration, or respiratory distress or airway problems. Intubation rates varied among TS from 7.6% to 15.3% (p < 0.001) and rates for DI ranged from 3.3% to 7.4% (p < 0.001). There was a statistically insignificant trend among TS with higher intubation rates to perform fewer delayed intubations. Early intubation for EI as well as DI was safe and effective. One third of the DI patients had significant head injury. Surgical airways were rarely needed and delayed intubations were uncommon. The intubation rates for EI and DI varied significantly among TSs. The Eastern Association for the Surgery of Trauma Guidelines may not identify all patients who would benefit from early intubation after injury.
A 1,000-bed hospital ship designed for trauma patients was deployed to the Middle East with the objectives of preparing for large numbers of casualties resulting from Operation Desert Storm from conventional, chemical, and biological weapons. Plans for receipt and decontamination of casualties, triage, and optimal utilization of the 1,000-bed facility were developed. Mass casualty drills were conducted, involving all aspects of patient care from the flight deck to the wards. Trauma and critical care registries were developed to collect casualty data that could then be analyzed for specific military purposes and compared with current civilian registries. Attempts were made to identify the advances in shock resuscitation, systems management, and operative treatment from the civilian community that could be applied to care of combat casualties. Difficulties with accomplishing these objectives included limited trauma experience and supplies and poorly defined medical regulating and evacuation policies. The development of these programs, as well as the unique difficulties encountered, are discussed.
The aim of this study was to establish a head trauma registry to (a) examine demographics, etiology, severity, clinical course, and outcome; (b) compare results with previous published series; (c) identify causes of bad outcomes; and (d) propose methods to improve therapy and prognosis. The following data were collected on 1,000 consecutive victims with head injury over 14 years of age admitted during a 4-year period: demographic characteristics, cause of injury, clinical variables, neuroimaging, therapy data, and outcome in 6 months. Seventy-four percent were men, and mean age was 43 years. Seventy-one percent suffered injuries due to road crashes, 14% due to alcohol, and 2% due to substances. The secondary transfer rate was 49%. For severe injuries, the time intervals from incident to hospital and subsequently to neurosurgical unit were 35 minutes and 4 hours, respectively. In 65% and 72% of cases, there was no record of preresuscitation hypoxia or hypotension, respectively, whereas suspected or definite episodes of hypoxia and hypotension were 27% and 13%, respectively. Most cases were mild trauma (63%), the remaining were severe (26%) and moderate (11%) injuries. Severe systemic trauma coexisted in 18%. Cranial surgery rate was 19% and it increased to 39% in severe trauma. The 6-month overall good outcome was 71%, with lower rates in moderate (58%) and severe (24%) injuries. The organization of Greece's first head injury registry offered an important preliminary core data concerning brain trauma etiology, management, and long-term outcome.
The continuous increase in the number of fractures of the proximal femur is directly attributable to the worldwide increase in life expectancy. The standard version of the Gamma Interlocking-Nail (standard Gamma nail [SGN], 200-mm length, 10-degree valgus curvature, two distal locking bolts) was designed because of the demands in orthopedic hip surgery to develop an implant stable enough to mobilize old patients as soon as possible to avoid further morbidity and mortality. Between the years 1992 and 1998, 1,000 consecutive patients with peritrochanteric fractures were stabilized by using the SGN and included in this study. Special emphasis was given to the evaluation of the learning curve of the department of traumatology (not of single surgeons) and the influence of prognostic factors on the outcome of such operations. The results of this study show that increasing "department experience" resulted in a reduction of the intraoperative complication rate by a factor of 0.5 (p = 0.0001) per year. This means that even an inhomogeneous mass of 78 surgeons can lower the rate of intraoperative complications by 50% per year because of increased experience. The number of early postoperative complications annually decreased by a factor of 0.8 (p = 0.0042). Late postoperative complications correlate negatively with the patient's age (odds ratio, 0.9; p = 0.0001).
Diagnostic peritoneal lavage (DPL) and computed tomography (CT) are the primary diagnostic modalities used in the evaluation of patients with suspected blunt abdominal trauma (BAT). DPL is fast and accurate but is associated with complications. CT is also accurate, yet requires stability and transportability of the patients. Ultrasound (US) has been suggested as an aid in evaluating BAT. We evaluated US in the initial assessment of BAT in 1000 patients. Patients were eligible for the study if they met specified trauma criteria and had suspected BAT. We then followed the outcome of the patients and their further work-up. US showed a sensitivity of 88%, a specificity of 99%, and an accuracy of 97% for detecting intraabdominal injuries. We conclude that emergency ultrasound may be used as the initial diagnostic modality for suspected blunt abdominal trauma.
The literature on facial fractures has emphasized obstruction of the airway as the most common associated life-threatening problem. Other life-threatening injuries associated with facial fractures are not as well documented. For this reason, we conducted a retrospective study involving 1,025 patients with facial fractures admitted to the trauma center at Chang Gung Memorial Hospital in Taiwan from January 1995 through December 1998. This study identifies the incidence of facial fractures and establishes a management plan. Life-threatening injuries associated with facial fractures were those that warranted immediate invasive rescue procedures. Sixty-four (6.2%) of the patients with facial fractures required life-saving intervention; 21 patients had cerebral trauma prompting craniotomy, 19 had hemorrhagic shock, 17 had airway compromise, and 7 had pulmonary injury grave enough to necessitate tube thoracostomy. There were five mortalities, three due to cerebral trauma and two credited to hemorrhagic shock not identified until long after admission. These findings illustrate the need for prompt identification and proper management of the associated life-threatening injuries in facial fracture patients. Clinical assessment should begin with evaluation of cerebral trauma, followed by hemorrhagic shock, airway compromise, and hemopneumothorax. Proper management may require a multidisciplinary and coordinated team approach.
The value of cervical spine immobilization after penetrating trauma to the neck is the subject of lively debate. The purpose of this study was to review the epidemiology of unstable cervical spine injuries (CSI) after penetrating neck trauma in a large cohort of patients. This is a retrospective analysis of patients admitted with penetrating neck injuries to a Level I trauma center from January 1996 through December 2008. A penetrating neck injury was defined as a gunshot wound (GSW) or stab wound (SW) between the clavicles and the base of the skull. Univariate and multivariate analyses were performed to investigate associations between injury mechanisms, the presence of CSI instability, and mortality. Risk factors independently associated with the presence of a CSI were identified. A total of 1,069 patients met inclusion criteria, of which 463 patients (43.3%) and 606 patients (56.7%) were sustaining GSW and SW, respectively. Overall, 65 patients (6.1%) were diagnosed with a CSI with a significantly higher incidence after GSWs compared with SWs (12.1% vs. 1.5%; p < 0.001). In four patients (0.4%), the CSI was considered unstable, all of them following GSW. All patients with unstable CSI had obvious neurologic deficits or altered mental status at the time of admission. Risk factors independently associated with the presence of a CSI were GSW to the neck and a Glasgow Coma Scale score ≤8 on admission (R = 0.16). The overall incidence of unstable CSI after penetrating trauma to the neck is exceedingly low at 0.4%. Following GSW to the neck, an unstable CSI was noted in <1% of patients. After cervical SW, however, no spinal instability was noted precluding the need for spinal precautions in these instances.
Over a 2-year period 1,116 children admitted to an urban teaching hospital were studied prospectively. The overall group was analysed as to the nature of the injury and a subgroup of seriously injured children was identified and further analysed. All deaths were examined as to their cause and possible preventable as well as salvageable factors. The predictive value of the Trauma Score (T.S.) and Method of Injury (M.O.I.) were evaluated for their prospective prediction of serious injury as determined by the Injury Severity Score and outcome. Most of the children were not seriously injured, with the most common injury being due to a fall (57%) and involving a single injury to the upper limb. With the subgroup of 143 children (13% of the total) who suffered serious injuries, the cranial cavity (90%) was the most common site of injury, occurring most often in pedestrians (31% of the total injured). There were 16 deaths in the series, representing 1.4% of all paediatric trauma admissions and 11% of the admissions who were seriously injured. All deaths were related to motor vehicle accidents and associated with serious head injury. A Trauma Score less than or equal to 12 accurately included all deaths but when correlated with the I.S.S., the Trauma Score had a specificity of 99% and a positive predictive value of 86%; its sensitivity was only 27%. The Method of Injury was associated with an overtriage rate of 300% in relation to the I.S.S.. Of children admitted following pedal cycle accidents only 9% were wearing helmets. Of car occupants injured, 39% were unrestrained.(ABSTRACT TRUNCATED AT 250 WORDS)
Several small series have had mixed conclusions regarding the impact of obesity on outcomes of trauma patients. The purpose of the present study was to evaluate a large cohort of critically injured patients to better understand the influence of obesity on the outcomes of patients after severe blunt trauma. Retrospective review using the trauma registry and intensive care unit (ICU) database of all blunt trauma patients admitted to the ICU at our urban, Level I trauma center over a 5-year period (1998-2003). Obese patients (body mass index [BMI] > or = 30 kg/m) were compared with non-obese patients (BMI < 30 kg/m). There were 1,153 blunt trauma patients admitted to the ICU during the study period, including 283 (25%) obese (mean BMI = 35 +/- 6 kg/m) and 870 (75%) non-obese (mean BMI = 25 +/- 3 kg/m) patients. There was no difference between groups regarding age, sex, Injury Severity Score, or admission vitals. Obese patients had fewer head injuries (42 versus 55%; p = 0.0001) but more chest (45 versus 38%; p = 0.05) and lower extremity (53 versus 38%; p < 0.0001) injuries. There was no difference in the need for laparotomy, thoracotomy, or craniotomy. Obese patients suffered more complications (42 versus 32%; p = 0.002). Although there was only a trend toward higher mortality in obese patients (22 versus 17%; p = 0.10), stepwise logistic regression revealed obesity as an independent risk factor for mortality (odds ratio, 1.6; 95% confidence interval, 1.0-2.3; p = 0.03). Among survivors, obese patients required longer stays in the hospital (24 +/- 21 versus 19 +/- 17 days; p = 0.01), the ICU (13 +/- 14 versus 10 +/- 10 days; p = 0.005), and 2 more days of mechanical ventilation (8 +/- 13 versus 6 +/- 9 days; p = 0.07). Obese patients incur different injuries after severe blunt trauma than their non-obese counterparts. Despite sustaining fewer head injuries, obese patients suffer more complications, require longer stays in the hospital, more days of mechanical ventilation, and obesity is independently associated with mortality.
The experience of six regional trauma centers with severe hepatic trauma was reviewed to identify trends in management, mortality, and postoperative complications. During the 5-year period ending June 1987, 210 complex liver injuries were identified at laparotomy. There were 92 Class III, 59 Class IV, and 59 Class V injuries. Mechanism of injury was blunt in 101 (48%) patients and penetrating in 109 (52%). Shock was observed in 38%, 46%, and 85% of Class III, IV, and V patients, respectively. Emergency department thoracotomy was performed in 31 patients. There was only one (3%) survivor. Resuscitative operating room thoracotomy was performed in 34 patients with three (9%) survivors. Class III injuries were most frequently treated with hepatotomy and individual vessel ligation (41%) and deep liver suturing (25%). Class IV injuries were most often managed by resectional debridement (36%). Class V injuries required caval shunt placement in 38 (64%) patients. There were only four (10%) survivors after caval shunt placement. There were 20 (59%) survivors of 34 patients treated with packing placed as an adjunct after hepatic injury repair. There was no significant increase in the incidence of abscess formation after perihepatic packing. Routine peritoneal drainage was used in 94% of patients. Overall mortality rates for Class III, IV, and V injuries were 25%, 46%, and 80%, respectively (p less than 0.01). Death rates due to the liver injury in Class III, IV, and V patients were 7%, 30%, and 66%, respectively (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
The hospital records of all patients presenting to a large urban trauma center emergency department with facial fractures from 1980 through 1984 were reviewed retrospectively. There were 788 patients in the study group, averaging 1.8 fractures per patient for a total of 1,423 facial fractures. The study population had 638 (80.9%) males and 150 (19.1%) females. Racial mix was 71.6% black, 27.8% white, and 0.6% oriental. The most frequent fracture involved the zygoma (23.6%), followed by the orbital floor (21.4%), maxilla, mandible, and nasal bones. The most frequent etiology was assault with a blunt object or fist (70.1%) followed by motor vehicle accidents (13.5%), falls (9.3%), and gunshot wounds (6.1%). Initial diagnostic procedures included a facial X-ray series in 99.9%, tomograms in 43.1%, and CT studies in 8.1%. Surgical intervention was required in 61.2% of cases. Prosthetic materials were used in 8.5% of the cases. At our institution, personal assault was found to be the primary cause of both midface fractures and mandibular fractures.
Measurements of a patient's physiologic reserve (age, injury severity, admission lactic acidosis, transfusion requirements, and coagulopathy) reflect robustness of response to surgical insult. We have previously shown that cardiac uncoupling (reduced heart rate variability, HRV) in the first 24 hours after injury correlates with mortality and autonomic nervous system failure. We hypothesized: Deteriorating physiologic reserve correlates with reduced HRV and cardiac uncoupling. There were 1,425 trauma ICU patients that satisfied the inclusion criteria. Differences in mortality across categorical measurements of the domains of physiologic reserve were assessed using the chi test. The relationship of cardiac uncoupling and physiologic reserve was examined using multivariate logistic regression models for various levels of cardiac uncoupling (>0 through 28% reduced HRV in the first 24 hours). Of these, 797 (55.9%) patients exhibited cardiac uncoupling. Deteriorating measures of physiologic reserve reflected increased risk of death. Measures of acidosis (admission lactate, time to lactate normalization, and lactate deterioration over the first 24 hours), coagulopathy, age, and injury severity contributed significantly to the risk of cardiac uncoupling (area under receiver operator curve, ROC=0.73). The association between deteriorating reserve and cardiac uncoupling increases with the threshold for uncoupling (ROC=0.78). Reduced heart rate variability is a new biomarker reflecting the loss of command and control of the heart (cardiac uncoupling). Risk of cardiac uncoupling increases significantly as a patient's physiologic reserve deteriorates and physiologic exhaustion approaches. Cardiac uncoupling provides a noninvasive, overall measure of a patient's clinical trajectory over the first 24 hours of ICU stay.
Thoracic aortic injury (TAI) is a devastating condition in which prompt recognition can obviate morbidity and mortality. It is a long-held belief that TAI is more likely when there is a "major mechanism of injury." The purposes of this prospective study were to determine mechanism characteristics that are predictive of TAI and to evaluate chest computed tomography (CT) as a screening tool for TAI. Over a 5 1/2 year period, blunt chest trauma patients at two Level I trauma centers were evaluated for potential TAI. Patients were assigned mechanism and radiograph scores from 1 (low suspicion for TAI) to 5 (very high suspicion for TAI). Immediate aortography was obtained when suspicion for TAI was very high. The remaining patients were evaluated with contrast-enhanced chest CT. Confirmatory aortography was obtained on all positive chest CT scans and on all patients with mechanism scores of 4 or 5 even if the CT was negative. Mechanism and radiographic data were correlated with the results of aortic imaging. Of the 1,561 patients evaluated for TAI, 30 aortic injuries were found. The assessment of mechanism was imperfect with a reliance on often incomplete and subjective data. The subjective mechanism score proved to be the most useful predictor of TAI. Radiographic scores were useful but insensitive for intimal injuries. Computed tomography was found to have 100% and 100% NPV for TAI. Considering the inherent difficulties in identifying patients at risk for TAI and the effectiveness of chest CT as a screening tool for aortic injury, we recommend liberal use of chest CT in blunt chest trauma. Guidelines for determining the need for aortic imaging are outlined.
The difficulties of applying the rules of the International Classification of Diseases to trauma cases are discussed on the basis of coding the injuries of 1,797 injured patients from civil disorders in Northern Ireland, 1969-1971. Certain inadequacies of the code are indicated and suggestions made about ways to modify it and make its applications more informative.
The detrimental effects of coagulopathy, hypothermia, and acidosis are well described as markers for mortality after traumatic hemorrhage. Recent military experience suggests that a high fresh frozen plasma (FFP):packed red blood cell (PRBC) transfusion ratio improves outcome; however, the appropriate ratio these transfusion products should be given remains to be established in a civilian trauma population. Data were obtained from a multicenter prospective cohort study evaluating clinical outcomes in blunt injured adults with hemorrhagic shock. Those patients who required >/=8 units PRBCs within the first 12 hours postinjury were analyzed (n = 415). Patients who received transfusion products in >/=1:1.50 FFP:PRBC ratio (high F:P ratio, n = 102) versus <1:1.50 FFP:PRBC ratio (low F:P, n = 313) required significantly less blood transfusion at 24 hours (16 +/- 9 units vs. 22 +/- 17 units, p = 0.001). Crude mortality differences between the groups did not reach statistical significance (high F:P 28% vs. low F:P 35%, p = 0.202); however, there was a significant difference in early (24 hour) mortality (high F:P 3.9% vs. low F:P 12.8%, p = 0.012). Cox proportional hazard regression revealed that receiving a high F:P ratio was independently associated with 52% lower risk of mortality after adjusting for important confounders (HR 0.48, p = 0.002, 95% CI 0.3-0.8). A high F:P ratio was not associated with a higher risk of organ failure or nosocomial infection, however, was associated with almost a twofold higher risk of acute respiratory distress syndrome, after controlling for important confounders. In patients requiring >/=8 units of blood after serious blunt injury, an FFP:PRBC transfusion ratio >/=1:1.5 was associated with a significant lower risk of mortality but a higher risk of acute respiratory distress syndrome. The mortality risk reduction was most relevant to mortality within the first 48 hours from the time of injury. These results suggest that the mortality risk associated with an FFP:PRBC ratio <1:1.5 may occur early, possibly secondary to ongoing coagulopathy and hemorrhage. This analysis provides further justification for the prospective trial investigation into the optimal FFP:PRBC ratio required in massive transfusion practice.
Recent evidence suggests a survival advantage in trauma patients who receive controlled or hypotensive resuscitation volumes. This study examines the threshold crystalloid volume that is an independent risk factor for mortality after trauma. This study analyzed prospectively collected data from a Level I Trauma Center between January 2000 and December 2008. Demographics and outcomes were compared in elderly (≥70 years) and nonelderly (<70 years) trauma patients who received crystalloid fluid in the emergency department (ED) to determine a threshold volume that was an independent predictor for mortality. A total of 3,137 patients who received crystalloid resuscitation in the ED were compared. Overall mortality was 5.2%. Mortality among the elderly population was 17.3% (41 deaths), whereas mortality in the nonelderly population was 4% (116 deaths). After multivariate logistic regression analysis, fluid volumes of 1.5 L or more were significantly associated with mortality in both elderly (odds ratio [OR]: 2.89, confidence interval [CI] [1.13-7.41], p=0.027) and nonelderly patients (OR: 2.09, CI [1.31-3.33], p=0.002). Fluid volumes up to 1 L were not associated with significantly increased mortality. At 3 L, mortality was especially pronounced in the elderly (OR: 8.61, CI [1.55-47.75] p=0.014), when compared with the nonelderly (OR=2.69, CI [1.53-4.73], p=0.0006). ED volume replacement of 1.5 L or more was an independent risk factor for mortality. High-volume resuscitations were associated with high-mortality particularly in the elderly trauma patient. Our finding supports the notion that excessive fluid resuscitation should be avoided in the ED and when required, operative intervention or intensive care admission should be considered.
In 1976 Charters and Charters (2) described experiments intended to study effects of projectiles with a striking velocity greater than 1 km/sec. They postulated that the projectiles at higher velocity would cause shallow wounds with wide tissue destruction on the surface, especially when striking velocity exceeded the speed of sound in tissue (about 1.5 km/sec). We found no other studies reported dealing with projectiles in this velocity range, the conclusions and assumptions of Charters and Charters have been quoted by others and accepted as fact. We designed and performed experiments to test the hypothesis of Charters and Charters by comparing temporary cavity morphology and penetration in gelatin. We fired two types of blunt projectiles over a velocity range from 650 m/sec (2,137 ft/sec) to 2,016 m/sec (6,614 ft/sec). In these studies we found no evidence to indicate that shape and characteristics of the disruption in ordnance gelatin change significantly when missile striking velocity exceeds sonic speed in the target.
Ever-increasing numbers of in-house acute care surgeons and competition for operating room time during normal daytime business hours have led to an increased frequency of nonemergent general and vascular surgery procedures occurring at night when there are fewer residents, consultants, nurses, and support staff available for assistance. This investigation tests the hypothesis that patients undergoing such procedures after hours are at increased risk for postoperative morbidity and mortality. Clinical data for 10,426 operative procedures performed over a 5-year period at a single academic tertiary care hospital were obtained from the American College of Surgeons National Surgical Quality Improvement Program Database. The prevalence of preoperative comorbid conditions, postoperative length of stay, morbidity, and mortality was compared between two cohorts of patients: one who underwent nonemergent operative procedures at night and other who underwent similar procedures during the day. Subsequent statistical comparisons utilized chi tests for comparisons of categorical variables and F-tests for continuous variables. Patients undergoing procedures at night had a greater prevalence of serious preoperative comorbid conditions. Procedure complexity as measured by relative value unit did not differ between groups, but length of stay was longer after night procedures (7.8 days vs. 4.3 days, p < 0.0001). Patients undergoing nonemergent general and vascular surgery procedures at night in an academic medical center do not seem to be at increased risk for postoperative morbidity or mortality. Performing nonemergent procedures at night seems to be a safe solution for daytime overcrowding of operating rooms.
This study describes mandibular fracture incidence, causes, and consequences in a large population. California hospital discharge data from 1991 to 1993 were examined to describe causes, lengths of stay, and hospital charges for patients hospitalized for mandibular fractures. Rates were calculated per 100,000 population. There were 10,766 discharges with mandibular fracture as principal diagnosis or as diagnoses two through five on the discharge record (rate=11.5). Of these, 2,694 had mandibular fracture as the only diagnosis (principal diagnosis). For all 10,766 cases, assaults were responsible for more than half (54.0%) of all admissions for mandibular fracture. The highest rates were found among males (18.7), blacks (43.0), and adults aged 16 to 20 (26.5). Charges for the initial hospitalization (excluding physician's fees) for the 2,694 cases with only a diagnosis of mandibular fracture were used to estimate mean charges ($8,740). The total extrapolated 1993 inflation-adjusted hospital charges for mandibular fractures were $34 million per year. Most patients' bills were submitted to government payers, such as Medicaid. Treatment of mandibular fractures represents a considerable cost to public-supported programs as well as to patients.
Controversy exists regarding the interpretation of diagnostic peritoneal lavage results. This is especially true in the evaluation of patients sustaining penetrating trauma, specifically stab wounds to the lower chest and abdomen. Ideally one wants to avoid missed injuries and minimize unnecessary operations. This is a retrospective review of 195 patients sustaining stab wounds to the anterior lower chest and abdomen at Parkland Memorial Hospital between 1993 and 2005, looking at missed injuries and false positive rates using red cell counts of 100,000, 10,000, and the standard criteria for blunt trauma including >500 white blood cells (WBCs), amylase, and/or bile. The first analysis used >100,000 red blood cells (RBCs)/mm3 as a positive value. The false positive rate was 12.2%. The second analysis used >10,000 RBCs/mm3 as a positive value with a false positive rate of 44%. When considering the entire study population (195 patients), the false positive rate increased when using the lower number (>10,000) from 2.5% to 15.8% (p < 0.001). There were no missed injuries when using >100,000 red cells and/or >500 white cells, the presence of bile or amylase. Decreasing the red blood cell count from >100,000 to >10,000 as the criteria for operating on patients with stab wounds to the anterior lower chest and/or abdomen will significantly increase the number of nontherapeutic procedures. Based on this study, >100,000 RBCs/mm3 appears to be a valid and safe number to use when evaluating these patients, particularly when used with other positive criteria such as increased white cells, bile, and amylase.
This study aimed to compare serum and cerebrospinal fluid (CSF) S-100b protein levels after a severe head injury. The changes in serum S-100b and CSF S-100b concentrations were investigated as indicators of brain damage for patients suffering from severe head injuries. The sample included 48 patients with Glasgow Coma Scale scores of 8 or below who had been admitted to the authors' emergency service soon after their severe head injury occurred. Both blood and CSF samples were taken within 1 to 11 hours after admission, then 24, 48, and 72 hours after the injury. Samples of CSF were taken using a ventricular catheter. The outcome was evaluated 6 to 9 months after hospital discharge using the Glasgow Outcome Scale. The overall mean serum S-100b concentration was 3.5 +/- 6.4 among the patients with unfavorable outcomes and 1.3 +/- 2.5 among those with favorable outcomes. These results were not statistically significant (p > 0.05). The overall mean CSF S-100b concentration was 62.2 +/- 21.8 among the patients with unfavorable outcomes and 21.8 +/- 17.7 among those with favorable outcomes. These results, however, were statistically significant (p < 0.05). The results show that CSF S-100b levels clearly are superior to serum S-100b levels for predicting outcome after severe head injury.
Serum glial fibrillary acidic protein (GFAP) is a specific predictor of brain damage and neurologic outcome in patients with traumatic brain injury (TBI). In this study, serum GFAP, S-100B, and neuron-specific enolase (NSE) were compared in the same samples from severe trauma patients to assess their ability to predict abnormalities detectable on head computed tomography (CT). This study was a retrospective analysis at a single university emergency center. Thirty-four trauma patients were included. Serum samples were collected from the patients for 3 days. Serum GFAP, S-100B, and NSE concentrations were measured with enzyme-linked immunosorbent assays and compared in patients with and without TBI, as evaluated by head CT. Serum GFAP, S-100B, and NSE were significantly higher in the TBI patients than in the non-TBI patients (p < 0.05 for each protein). The receiver operating characteristic curves for TBI were compared for the three biomarkers for 3 days. Serum GFAP on day 1 had the largest area under the receiver operating characteristic curve (0.983), with 88.9% sensitivity and 100% specificity. Serum GFAP has remarkable diagnostic value for TBI, defined by abnormal head CT findings, in prehospital-triaged patients with severe trauma.
Children with head trauma are frequently seen in many emergency units. The clinical evaluation of these patients is difficult for a number of reasons and improved diagnostic tools are needed. S-100B, a protein found in glial cells, has previously been shown to be a sensible marker for brain damage after head injury in adults, but few studies have focused on its use in children. In this study, 111 children with head trauma were included and venous blood and urine samples were taken at arrival (S1 and U1) and 6 hours later (S2 and U2). S-100B levels were analyzed. Clinical and radiologic evaluations were performed according to hospital routine. Two groups were identified- group 1: no computed tomography (CT) scan performed ora CT scan without any sign of trauma-related intracranial pathology (n = 105). Group 2: A CT scan with signs of trauma-related intracranial pathology (n = 6). In group 1, the median (inter quartile range) serum S-100B value in S1-samples was 0.111 microg/L (0.086-0.153), and in group 2, it was 0.282 microg/L (0.195-1.44) (p < 0.01). Also, S2 values significantly differed between the two groups. Urine values were, however, not significantly differing between the groups. Serum S-100B values within 6 hours after head trauma in children were significantly higher in patients with intracranial pathology compared with those without intracranial complications. Identification of these high-risk patients already in the emergency department is of major importance, and we suggest that S-100B could be a valuable diagnostic tool in addition to those used in clinical practice today.
We have previously demonstrated a significant improvement in trauma patient outcome after the Advanced Trauma Life Support (ATLS) program in Trinidad and Tobago. In January of 1992, a Prehospital Trauma Life Support (PHTLS) program was also instituted. This study assessed trauma patient outcome after the PHTLS program. Morbidity (length of stay and degree of disability), mortality, injury severity score, mechanism of injury, age, and sex among all adult trauma patients transported by ambulance to the major trauma hospital were assessed between July of 1990 to December of 1991 (pre-PHTLS, n = 332) and January of 1994 to June of 1995 (post-PHTLS, n = 350). Age, sex distribution, percentage blunt injury, and injury severity score were similar for both groups. Mortality pre-PHTLS (15.7%) was greater than post-PHTLS (10.6%). Length of stay and disability were statistically significantly decreased post-PHTLS. Age, injury severity score, and mechanism of injury were positively correlated with mortality in both periods. The previously reported post-ATLS mortality was similar to the pre-PHTLS mortality. Post-PHTLS mortality and morbidity were significantly decreased, suggesting a positive impact of the PHTLS program on trauma patient outcome.
Of the 109 patients treated by interlocking nailing for lower leg fractures between 1985 and 1990 at the A.ö.KH Schwaz and the LKH Bad Ischl, Austria, 92 underwent follow-up examination. Data were analyzed using a personal computer. Special attention was paid to fracture pattern, level, complications, and length of sick leave. Compared with a previous study, an increasing number of compound fracture patterns were evaluated. Except for 14 misalignments and two late infections after new injuries, no other serious complications were detected. Interlocking nailing can be highly recommended even for open fractures up to the second degree at any level from the second fifth to the fourth fifth of the tibia.
American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) grades IV and V complex hepatic injuries are highly lethal. Our objectives were to review experience and identify predictors of outcome and to evaluate the role of angioembolization in decreasing mortality. This was a retrospective 8-year study of all patients sustaining AAST-OIS grades IV and V hepatic injuries managed operatively. Statistical analysis was performed using univariate and multivariate logistic regression. The main outcome measure was survival. The study included 103 patients, with a mean Revised Trauma Score of 5.61 +/- 2.55 and a mean Injury Severity Score of 33 +/- 9.5. Mechanism of injury was penetrating in 80 (79%) and blunt in 23 (21%). Emergency department thoracotomy was performed in 21 (25%). AAST grade IV injuries occurred in 51 (47%) and grade V injuries occurred in 52 (53%). Mean estimated blood loss was 9,414 mL. Overall survival was 43%. Adjusted overall survival rate after emergency department thoracotomy patients were excluded was 58%. Results stratified to AAST-OIS injury grade were as follows: grade IV, 32 of 51 (63%); grade V, 12 of 52 (23%); grade IV versus grade V (p < 0.001) odds ratio, 2.06; 95% confidence interval, 2.72 (1.40-3.04). Logistic regression analysis identified as independent predictors of outcome Revised Trauma Score (adjusted p < 0.0002), angioembolization (adjusted p < 0.0177), direct approach to hepatic veins (adjusted p < 0.0096), and packing (adjusted p < 0.0013). Improvements in mortality can be achieved with an appropriate operative approach. Angioembolization as an adjunct procedure decreases mortality in AAST-OIS grades IV and V hepatic injuries.
Local hemostatics have recently been introduced for field use to control external hemorrhage. The objective of this report is to describe the initial clinical experience with QuikClot, a zeolite that works by absorbing water and concentrating coagulation factors to stop bleeding in a series of patients. Documented cases using a self-reporting survey sheet submitted by the users and first-hand detailed interviews with the users when possible. There were 103 documented cases of QuikClot use: 69 by the US military in Iraq, 20 by civilian trauma surgeons and 14 by civilian first responders. There were 83 cases involving application to external wounds and 20 cases of intracorporeal use by military and civilian surgeons. All field applications by first responders were successful in controlling hemorrhage. The overall efficacy rate was 92% with eight cases of ineffectiveness noted by physicians in morbid patients with massive injuries when the QuikClot was used as a last resort. These reported failures were thought to be a result of the coagulopathic state of the patient from massive resuscitation or the inability to get the product directly to the source of hemorrhage. When the QuikClot was applied on responsive patients, the heat generated by the exothermic reaction caused mild to severe pain and discomfort. There were three cases of burns caused by the heat generated by the QuikClot application with one case requiring skin grafting. There was one major complication from intracorporeal use caused by scar formation from a foreign body reaction. QuikClot has been effectively used by a wide range of providers in the field and hospital to control hemorrhage.
One hundred three pregnant women hospitalized following blunt trauma had injuries classified as: major (20%); minor (17%); or significant (63%). Maternal mortality related only to the severity of maternal injuries: 24% of women who sustained major injuries died. Pregnancy ended unsuccessfully in 18% of all women with known pregnancy outcome. The incidence of unsuccessful pregnancy was 61% following major injuries and 27% following minor injuries. Insignificant maternal injuries did not affect pregnancy outcome. Fetal survival did not relate to gestational age per se. Pregnancy uniformly ended unsuccessfulla in the presence of maternal death, placental injury, uterine injury, and direct fetal injury, and occurred in 80% of women admitted in hemorrhagic shock. An understanding of the ways that the anatomic and physiologic changes of pregnancy alter the nature and frequency of maternal injuries and that maternal response to injury is altered is essential. The best chance for fetal survival is to assure maternal survival.
Optimal hand function has a very positive impact on the quality of survival after burn injury. Over a 10-year period, 659 patients with 1047 acutely burned hands were managed at the Sumner Redstone Burn Center of the Massachusetts General Hospital. Our approach to acutely burned hands emphasizes ranging and splinting throughout hospitalization, prompt sheet autograft wound closure as soon as practical, and the selective use of axial pin fixation and flaps. This approach is associated with normal function in 97% of those with superficial injuries and 81% of those with deep dermal and full-thickness injuries requiring surgery. Although only 9% of those with injuries involving the extensor mechanism, joint capsule, or bone had normal functional outcomes, 90% were able to independently perform activities of daily living.
Traumatic loading of the knee joint in man occurs at strain rates ranging from 0.5-1,500 m/m/sec. Experiments on the medial collateral ligament of rats demonstrate that the mode of failure is a function of the strain rate. Avulsions occurred more often at low rates; ligament tearing occurred more often at high rates.
To delineate the regulation of IL-6 production in unburned skin adjacent to a burn in an animal model. In C57BL/6 mice, at 15, 30, and 60 minutes after a 20% full-thickness burn, skin was removed from various sites. Control samples were obtained from unburned mice. Normal skins were incubated with tumor necrosis factor-alpha (TNF-alpha), interleukin-1 alpha (IL-1alpha), IL-1 beta, and IL-6. Unburned skin specimens were incubated with anti-TNF-alpha and IL-1alpha antibodies. Cytokine levels were measured by enzyme-linked immunosorbent assay. The burn increased the IL-6 levels at 30 minutes (p < 0.05) and the IL-1alpha levels at 15 and 60 minutes in the unburned skin. TNF-alpha, IL-1alpha, and IL-1beta increased IL-6 production in normal skin (p < 0.05). Anti-IL-1alpha antibody decreased IL-6 production in the unburned skin (p < 0.05). IL-1alpha modulates IL-6 production in unburned skin after injury. IL-6 and IL-1alpha might contribute to the alterations after a burn.
Recent randomized prospective data suggest that early hyperglycemia is associated with excess mortality in critically ill patients, and tight glucose control leads to improved outcome. This concept has not been carefully examined in trauma patients, and the relationship of early hyperglycemia to mortality from sepsis in this population is unclear. The objective of this study was to determine the relationship different levels of early blood glucose elevation to outcome in a trauma ICU population. The records of all patients admitted to the ICU over a 2-year period at a Level I trauma center were reviewed for age, injury severity scores (ISS), admission Glasgow Coma Scale (GCS) score, base deficit (BD), blood glucose, and mortality. Three possible cutoffs in defining hyperglycemia were examined (glucose > or =110 mg/dL, > or =150 mg/dL, > or =200 mg/dL) in relation to infection and mortality. Early hyperglycemia was defined as elevated blood glucose on hospital days 1 or 2. Those with diabetes mellitus were excluded. From 1/00-12/01, 516 eligible patients were admitted to the ICU after injury. Early hyperglycemia occurred in 483 at the > or =110 mg/dL level, 311 at the > or =150 mg/dL level, and 90 patients at the > or =200 mg/dL level. Univariate logistic regression demonstrated a significant relationship between ISS and subsequent infection(p = 0.02) and a trend toward such a relationship in GCS score, glucose > or =150 mg/dL, and glucose > or =200 mg/dL (p = 0.06, 0.12, and 0.06). A similar analysis for the relationship of these variables to eventual mortality showed a significant correlation with all examined variables except glucose > or =110 mg/dL. Multiple logistic regression to control for the effect of age, ISS, GCS score, and BD found early glucose > or =200 mg/dL to be an independent predictor of both infection and mortality while no such relationship was found with > or = 110 mg/dL or > or =150 mg/dL. Early hyperglycemia as defined by glucose > or =200 mg/dL is associated with significantly higher infection and mortality rates in trauma patients independent of injury characteristics. This was not true at the cutoffs of > or =110 mg/dL or > or =150 mg/dL. These data support the need for a prospective analysis of tight glucose control, keeping serum glucose <200 mg/dL in critically ill trauma patients. However, aggressive maintenance of levels <110 mg/dL as reported by others may not be necessary.
We aimed to study the relationship between the number of fractured scapular regions, and the severity and distribution of associated injuries in blunt trauma patients. One hundred seven consecutive patients with fractured scapulae (100 men) with a mean age of 35 (8-65) years were prospectively studied between January 2003 and December 2005. Mechanism of injury, associated injuries, Injury Severity Score (ISS), and the number of anatomic scapular regions involved in each fracture were studied. Patients were divided into single-region fracture (SRF), two-region fracture, and more than two-region fracture groups. Computer tomography was used for fracture classification in 99 patients and plain radiographs were used for the remaining 8. Road traffic collisions were the most common cause of scapular fracture. Ninety-five patients (89%) sustained associated injuries. The most frequent was chest injury (68 [64%]). The median ISS was 9 (4-57) for the SRF group (n = 55), 20 (4-59) for the two-region fracture group (n = 30), and 22.5 (4-54) for the more than two-region fracture group (n = 22) (p = 0.02, Kruskal-Wallis test). The median values of the Abbreviated Injury Scale for chest injuries for the three groups were 1 (0-4), 3 (0-5), and 3 (0-5), respectively (p = 0.001, Kruskal-Wallis test). The SRF group had significantly less posterior structure injury (9 of 55) compared with the multiple-region fracture group (46 of 52) (p < 0.001, Fisher's exact test). Associated injuries are common in patients with scapular fractures. ISS and Abbreviated Injury Scale score for chest injuries are higher and posterior structure injuries are more frequent in patients with fractures involving multiple scapular regions.
To compare the predictive power of International Classification of Diseases 10th Edition (ICD-10)-based International Classification of Diseases 9th Edition-based Injury Severity Score (ICISS) with Trauma and Injury Severity Score (TRISS) and ICD-9CM-based ICISS in the injury severity measure. ICD-10 version of survival risk ratios was derived from 47,750 trauma patients from 35 emergency centers for 1 year. The predictive power of TRISS, the ICD-9CM-based ICISS and ICD-10-based ICISS were compared in a group of 367 severely injured patients admitted to two university hospitals. The predictive power was compared by using the measures of discrimination (disparity, sensitivity, specificity, misclassification rates, and receiver operating characteristic curve analysis) and calibration (Hosmer-Lemeshow goodness-of-fit statistics), all calculated by logistic regression procedure. ICD-10-based ICISS showed a lower performance than TRISS and ICD-9CM-based ICISS. When age and Revised Trauma Score were incorporated into the survival probability model, however, ICD-10-based ICISS full model showed a similar predictive power compared with TRISS and ICD-9CM-based ICISS full model. ICD-10-based ICISS had some disadvantages in predicting outcomes among patients with intracranial injuries. However, such weakness was largely compensated by incorporating age and Revised Trauma Score in the model. The ICISS methodology can be extended to ICD-10 horizon as a standard injury severity measure in the place of TRISS, especially when age and Revised Trauma Score were incorporated in the model. For patients with intracranial injuries, the predictive power of ICD-10-based ICISS was relatively low because of differences in the classifying system between ICD-10 and ICD-9CM.
An 11-year retrospective review of 51 patients with diaphragmatic injuries revealed 33 blunt and 18 penetrating injuries. In the blunt trauma group 24 were left-sided and nine were on the right side. Preoperative diagnosis was made in 24 patients. Delayed diagnosis (greater than 24 hours) during life occurred in four patients and two injuries were found at autopsy. Chest X-ray was diagnostic or highly suggestive in 23 patients. All patients in this group had associated extra-abdominal injuries; 23 patients had concomitant intraabdominal injuries. Transabdominal repair was performed in 24 patients. Four deaths occurred in the blunt injury group. The penetrating diaphragmatic wounds consisted of 14 left-sided, three right-sided, and one pericardial wound. Preoperative diagnosis occurred in only three patients. The penetrating wound, hypotension, or peritoneal signs dictated operation in the remaining 15 patients. One death occurred from peritonitis and septic shock. Blunt and penetrating diaphragmatic injuries remain a diagnostic challenge and associated injuries determine the outcome.
Top-cited authors
Ernest E Moore
  • University of Colorado
Susan Baker
  • Johns Hopkins Bloomberg School of Public Health
Gregory J. Jurkovich
  • University of California, Davis
Frederick Alan Moore
  • University of Florida
Charles william Schwab
  • Hospital of the University of Pennsylvania