The Literature of Emergency Medicine

Trauma: an Annotated bibliography of the recent literature — 2004

1. Prehospital

Stockinger ZT, McSwain NE. Additional evidence in support of withholding or terminating cardiopulmonary resuscitation for trauma patients in the field. J Am Coll Surg 2004;198:227-231.

The authors of this report retrospectively reviewed the prehospital and hospital records of 588 trauma patients seen over a 6-year period who arrived at the Charity Hospital, New Orleans, ED with cardiopulmonary resuscitation ongoing. Overall survival was 3.7%. Sixty percent did not survive long enough to be admitted, and another 32.6% died on the day of admission. Only 1% of patients with penetrating injury survived: 1 of 307 with gunshot wound and 2 of 30 with Stab wounds. Patients with nonPenetrating injuries fared a little better: 6% (12/294) of those with blunt injury and 13.2% with drowning or hanging survived. No one who underwent defibrillation survived. No victim of penetrating trauma survived if the heart rate was zero; 1 of 47 patients with blunt trauma with asystole survived. Overall survival was not different for children versus adults. Based on their accumulated data, the authors have changed their prehospital protocol for adults 18 years or older: the order is bdo no resuscitateQ if the patient is apneic and pulseless on emergency medical service arrival, or asystolic or with pulseless electrical activity with a heart rate less than 40. This interesting article confirms the information that was previously presented in the 2003 article entitled, bGuidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest,Q in the Journal of the American College of Surgeons (2003;196:475-81).

Stockinger ZT, McSwain NE. prehospital endotracheal intubation for trauma does not improve survival over bag-valve-mask ventilation. J Trauma 2004;56:531-536.

The authors of the article above extended their work with this report, a retrospective review of 316 patients seen over a 34-month period who required prehospital ventilatory support, either with Endotracheal intubation or Bag-valve-mask . Their findings are interesting: patients who underwent ETI were significantly more likely to die than those with BVM only: 89% versus 31%. This finding could of course be due to the likelihood that the intubated patients were sicker/closer to death to begin with, that more of those who were bagged only had some respiratory effort, and others. However, even when corrected for injury severity score, Revised Trauma Score, and mechanism of injury, ETI was associated with similar or greater mortality than BVM. Prehospital time was only slightly prolonged (22 vs 20 minutes) for patients receiving ETI. The authors concluded that, at least in their Trauma system where transport times are fairly low, ETI in the field offers no Survival benefit to the trauma patient.

Weitzel N, Kendall J, Pons P. Blind Nasotracheal intubation for patients with penetrating Neck trauma. J Trauma 2004;56:1097-1101.

Nasotracheal intubation is an alternative in the provision of an invasive airway and is particularly beneficial when conscious patients need airway

protection. Blind nasotracheal intubation in the setting of Penetrating neck trauma has been frowned upon in the past because of concerns with causing further damage if there is a laryngotracheal injury or further bleeding by disturbing a hematoma. The authors of this report from Denver Health Medical Center retrospectively reviewed the records of 240 patients admitted to the ED with penetrating neck trauma seen over 8.5 years. Of these, 89 required airway management, and 40 underwent prehospital blind nasotracheal intubation. The success rate in these 40 with this technique was 90%, requiring a mean of

1.14 attempts (range 1- 4), and with no adverse airway outcomes.

Davis DP, Dunford JV, Ochs M, et al. The use of quantitative end-tidal capnometry to avoid inadvertent severe hyperventilation in patients with head injury after paramedic rapid sequence intubation. J Trauma 2004;56:808-814.

Davis DP, Dunford JV, Poste JC, et al. The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients. J Trauma 2004;57:1-10.

Most if not all patients with severe head injury require endotracheal intubation. We all know that current optimum ventilatory management of brain-injured patients includes maintenance of normal or slightly low Pco₂, not hyperventilation as was practiced several decades ago: excessive respiratory alkalosis can produce excessive cerebral vasoconstriction leading to regional hypoperfusion and further brain hypoxic damage. We all also know that after intubating patients in any emergency situation, the tendency for providers is to bag too much and too often. The authors of these 2 articles report that digital end-tidal CO₂ (ETCO₂) monitors, which are available in a combination fingertip O₂ saturation/ETCO₂ device, are not only practical and effectively prevent iatrogenic hyperventilation, but also decrease the mortality associated with hyperventilation. The first article is a retrospective case-control logistic regression analysis of 59 patients intubated in the field. The authors found a statistically significant association between Ventilatory rate and ETCO₂, as well as between low and ETCO₂ and mortality. The second article used a similar design and looked at episodes of hypoxia before, during, and after intubation, in addition to episodes of hyperventilation, and again found a significant increase in mortality if either hypoxia or hyperventilation was allowed to occur.

Frankema SPG, Ringburg AN, Steyerberg EW, et al. Beneficial effect of helicopter emergency medical services on survival of severely injured patients. Br J Surg 2004;91:1520-1526.

In contrast to the United States where physicians in general no longer ride with medical helicopter crews, many European countries still have emergency medicine or surgical physicians as part of the helicopter crews for scene calls. This article from the Netherlands compared the injury severity measures and overall outcomes of 239 patients transported to a large trauma center via ground emergency medical technician crew, versus 107 patients transported by helicopter crews which had a bspecially trained physicianQ and

0735-6757/$ – see front matter D 2005 doi:10.1016/j.ajem.2005.03.001

a paramedic (helicopter medical transport team [HMT]). All patients were severely injured as manifest by an Injury Severity Score (ISS) of 16 or more. Although the HMT patients had higher ISS and lower Glasgow Coma Score, the survival– corrected for ISS, respiratory rate, and blood pressure, Glasgow Coma Score, and age–was higher for the HMT group. The HMT group had a much higher rate of prehospital intubation and prehospital chest tube drainage. The study found ba positive association between the involvement of HMT and survival chances, but did not identify exactly how the benefit is derived.Q The authors postulate that the additional expertise provided more therapeutic options, especially in airway manage- ment. Of note, no data as to the time required for ground versus air transport are given. This article is suggestive at best and cannot by itself justify any

change to our present protocols.

1. Shock and resuscitation

Karmy-Jones R, Nathens A, Jurkovich TJ, et al. Urgent and emergency thoracotomy for penetrating chest trauma. J Trauma 2004;56:664-669.

This article is a well-written review of resuscitative ED thoracotomy (EDT) and review of the authors’ most recent experience. The purposes of an emergency thoracotomy are (1) relief of Pericardial tamponade,

(2) Hemorrhage control from a potentially reparable intrathoracic source,

1. cross-clamping of the pulmonary hilum after suspected air embolus, and
2. cross-clamping of the thoracic aorta as a last-ditch adjunct to cardiopulmonary resuscitation. It is important to refine indications for EDT such that patients have a reasonable chance of survival, and ED care providers are not placed at unnecessary risk. The best outcomes are possible

resuscitation (CPR) to try to define which patients are potentially salvageable and should undergo EDT. They reviewed the records of 959 patients who underwent EDT during the previous 26 years at their own level I center. Twenty-six of these patients required prehospital CPR and formed the focus of the study. Of these 26 patients, 18 had been stabbed, 4 had been shot, and 4 had had blunt trauma. Of these 26 patients, 21 were neurologically functional at follow-up, whereas 5 had severe Anoxic brain injury. The authors make the following conclusions: (1) patients with Stab wounds that result in cardiac arrest necessitating prehospital CPR for less than 15 minutes and who have some signs of life on admission to the ED should undergo EDT; (2) blunt Trauma victims requiring CPR for more than 5 minutes with no signs of life on ED arrival should not undergo EDT, but should be declared dead. These are eminently reasonable recommendations that will most likely be widely adopted.

Graham CA, Beard D, Henry JM, et al. Rapid sequence intubation of trauma patients in Scotland. J Trauma 2004;56:1123-1126.

This study reports the experience with endotracheal intubation of trauma patients in the ED at a Scottish teaching hospital. Intubations were performed by both ED physicians and anesthesiologists. The authors found that Endotracheal tubes were placed more rapidly by the ED physicians, and that ED physicians in general intubated a sicker group of individuals. On the other hand, anesthesiologists were requested to perform intubation in patients with more Difficult airways, and they generally obtained better views of the larynx. There was no difference in complications between the 2 groups.

for patients with isolated, single versus multiple, chest injuries, penetrating

rather than blunt mechanism, stab rather than gunshot wound, and the presence of some vital signs. The authors reviewed their own records of

218 patients who underwent urgent–within 60 minutes of hospital arrival–thoracotomy after penetrating trauma over a 4-year period. One hundred forty had gunshot wounds, and 78 had stab wounds. Thoracotomy was performed in the ED, in the resuscitation room just outside the operating room , or in the OR. Overall mortality was 69% for gunshot wounds and 37% for stab wounds. Patients who underwent thoracotomy in the ED were of course closer to being dead than those who made it to the resuscitation room or to the OR, and their mortality was of course higher: survival was 13 times more likely for patients who had EDT in the resuscitation room and 22 times as likely if they made it to the OR. Anoxic brain injury in survivors was likewise less likely if the patient made it to the resuscitation room or OR. For patients with no blood pressure on ED arrival, survival was dismal. Survival for patients with gunshot wounds was 1 of 58 for EDT, 0 of 4 for thoracotomy in the resuscitation room, and 2 of 10 for those who made it to the OR (these 2 made it to the OR because they regained some vital signs after rapid fluid bolus in the ED).

Powell DW, Moore EE, Cothren CC, et al. Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation? J Am Coll Surg 2004;199:211-215.

It is important that ED physicians recognize patients for whom resuscitation will be futile, but the role of resuscitative ED thoracotomy (EDT) still remains controversial. There is general agreement that asystole is a contraindication to EDT, but there is no consensus about pulseless electrical activity. The joint position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma reviewed last year (available at J Am Coll Surg 2003;196:106-112) concluded that EDT bdoes not appear to have a role in prehospital traumatic cardiopulmonary arrest as a result of blunt trauma.. .Traumatic cardiopul- monary arrest secondary to penetrating trauma, while still having a dismal prognosis, may be more amenable.. .in the case of isolated penetrating trauma to the thorax.Q In this year’s second article on EDT, the authors studied a select group of patients requiring prehospital cardiopulmonary

Bard MR, Goettler CA, Schenarts PJ, et al. language barrier leads to the unnecessary intubation of trauma patients. Am Surg 2004;70:783-786.

Imagine yourself in a foreign country, in severe pain and perhaps a bit dazed after a motor vehicle crash, lying on a stretcher, and hearing a lot of commotion around you but not having the faintest idea of what anyone is saying because you do not speak the language. Masked foreigners are ripping off your clothes, sticking you with needles, and causing you pain. You have no idea if someone is talking to you or not, and all you can do is brace yourself against the pain of your femur fracture. The next thing you know is you cannot move, and someone is putting a big instrument in your mouth: you did not respond to their questions, so they are now securing your airway with a rapid sequence intubation. Non-English-speaking patients are not just seen in inner cities anymore. Immigrants from Central and South America now supply most of the labor on farms in the United States. This report from rural North Carolina reviewed a 9-year experience of trauma patients who were intubated less than 48 hours and found that, comparing Spanish- and English-speaking patients, the former were more frequently intubated despite having significantly higher Glasgow Coma Score. The authors used this fact to support their claim that many of the intubations in the Spanish speakers were unnecessary and performed primarily because of the language barrier. This conclusion is certainly not proved, but it is quite plausible. The only remedies the authors suggest are to teach health providers Spanish and to have fluent Spanish speakers on the ED staff.

Ben-Nun A, Altman E, Best L-AE. Emergency percutaneous tracheostomy in trauma patients: an early experience. Ann Thorac Surg 2004;77: 1045-1047.

Percutaneous tracheostomy (PCT) has become an accepted, if not the standard, method of tracheostomy in intensive care unit patients. This article from a busy trauma center in Israel describes 10 patients with multiple severe injuries who could not be intubated orotracheally and who underwent successful emergency PCT in the ED. Mean time from skin incision to intubation was 5.5 minutes, and there were no complications either acutely or at 1-year follow-up. However: all these PCTs were performed by bexperienced thoracic surgeons.Q Moreover, the authors’ decision to use

PCT rather than cricothyrotomy, which is a procedure less likely to cause bleeding, is questionable; the only mention of cricothyrotomy in the article is that it bis not regarded as a definitive airway.Q Many articles from centers in the United States have demonstrated the safety and effectiveness of emergency cricothyrotomy, and although many thoracic surgeons still advocate conversion of cricothyrotomy to formal tracheostomy when the patient is stable, not all agree that this is in fact necessary.

Tisherman SA, Barie P, Bokhari F, et al. Clinical practice guidelines: endpoints of resuscitation. J Trauma 2004;57:898-912.

Treatment priorities for severely injured patients are the ABCs of airway, breathing, and circulation. Circulation management focuses on resuscitation from shock, which includes both fluid resuscitation and rapid control of hemorrhage. Resuscitation is complete when normal aerobic metabolism is restored, the oxygen debt has been repaid, and tissue acidosis is eliminated. Traditional criteria used to demonstrate adequate resuscitation include blood pressure, heart rate, and urine output. There is, however, much doubt as to the adequacy of these parameters to rule out occult hypoperfusion. This article is an effort to establish clinical practice guidelines using bEvidence based medicineQ for resuscitation. The Practice Management Committee of the Eastern Association for the Surgery of Trauma evaluated the literature which addressed the various parameters that have been studied to assess successful complete resuscitation, including hemodynamic parameters, Base deficit, serum lactate, end-tidal carbon dioxide, mixed venous oxygen saturation and content, systemic oxygen delivery, gastric tonometry, tissue oxygen measurements, and clinical physical examination. After an extensive review of a large number of articles and data, the authors concluded that during resuscitation from traumatic hemorrhage shock, normalization of standard clinical parameters, such as blood pressure, heart rate, and urine output, are not adequate to guarantee survival without organ system dysfunction. The authors were not, unfortunately, able yet to establish which of the newer parameters is most informative and reliable–none have been verified by class 1 data. However, the discussion of the various measures in the article is invaluable to all with an interest in the subject; the complete document is available on the Web at http://www.east.org/tpg/endpoints.pdf. Moreover, there is an interim take-home message: traditional clinical criteria alone are inade- quate, and we, clinicians, should decide on which of the newer measures we are going to use, fitted to our individual circumstances. In a large teaching and research institution, the cutting edge/high-technology tools might be most appropriate, whereas in a smaller rural ED, we can follow something simpler, such as base deficit or serum lactate.

Barron ME, Wilkes MM, Navickis RJ. A systematic review of the comparative safety of colloid. Arch Surg 2004;139:552-563.

The crystalloid versus colloid debate has been raging for over half a century. These authors searched the literature to compare the safety of various available colloid solutions, including albumin, dextran, hydroxy- ethyl starch (HES), and gelatin. Albumin is a 69-kDa protein purified from human plasma (formerly from bovine serum); dextran is composed of naturally occurring glucose polymers synthesized by bacteria; HES is synthesized by partial hydrolysis of amylopectin plant starch followed by hydroxyethylation; and gelatin is derived from hydrolysis of bovine collagen. The authors searched the MEDLINE and EMBASE bibliographic databases, the Cochrane Controlled Trials Register, and the Cochrane Medical Editors Trial Amnesty. One hundred thirteen studies were reviewed, with safety data encompassing 1.54 million patients and 109 million colloid infusions! Albumin appeared to be the safest colloid of the group. Compared with albumin, anaphylactoid reactions occurred 14 times more often with gelatin, 4 times as often with HES, and twice as often with dextran. Coagulopathy and clinical bleeding were more frequent with HES and dextran. One of the take-home messages from this review is that, when entering the colloid versus crystalloid debate, one needs to remember

that the colloids are not a uniform class, and results must be interpreted with the different safety profiles in mind.

Garrison RN, Conn AA, Harris PD, et al. Direct peritoneal resuscitation as adjunct to conventional resuscitation from hemorrhagic shock: a better outcome. Surgery 2004;136:900-908.

This article describes a very exciting new concept. bDirect peritoneal resuscitationQ refers to the use of Peritoneal dialysis with a hyperosmolar (398 mOsm/L) dextrose-containing balanced salt solution to rapidly restore perfusion to the abdominal contents, especially the gut. These workers from the University of Louisville first reported their idea in 2003 in the American Journal of Surgery, and this article reports their experimental results with peritoneal resuscitation in rats in a hemorrhagic shock model. They showed that direct peritoneal resuscitation reverses the selective splanchnic vaso- constriction and hypoperfusion seen after hemorrhagic shock, reverses the capillary No-reflow phenomenon, and decreases the systemic proinflamma- tory Cytokine response, the lactic acidosis, and the Fluid shifts associated with conventional intravenous fluid resuscitation. This article deserves to be read in its entirety by anyone who wants to keep up with the cutting edge of research, and this new treatment concept of direct peritoneal resuscitation deserves to be watched by all–it certainly appears to be a major advance.

Hildebrand F, Giannoudis PV, van Griensven M, et al. Pathophysiologic changes and effects of hypothermia on outcome in elective surgery and trauma patients. Am J Surg 2004;187:363-371.

Hopefully, we are all trying as hard as we can to prevent hypothermia in our trauma patients: using warm intravenous fluids, keeping the trauma bay warm, using warm blankets and forced-air heaters, and others. This is an excellent review of the Pathophysiology of hypothermia (core temperature b348C), including both the beneficial effects as well as the adverse ones. Clinical series and experimental studies, as well as biochemical and molecular biologic considerations, are all discussed.

Mahoney EJ, Walter LB, Harrington DT, et al. Isolated brain injury as a cause of hypotension in the blunt trauma patient. J Trauma 2003;55: 1065-1069.

A long-held teaching is that isolated intracranial injuries do not cause shock. However, there have been case reports of shock occurring in patients with Severe head injuries and no extracranial injuries. The purpose of this study was to determine the cause of hypotension in a cohort of adult blunt trauma patients. The authors performed a retrospective study of all trauma patients presenting to their level I trauma facility who had had blunt trauma. Of all patients who arrived hypotensive, 13% had isolated brain injury, including subarachnoid hemorrhage, subdural hematoma, Diffuse axonal injury, cerebral contusion, and/or intracerebral hemorrhage. They also found that shock and hypotension resulting from isolated head injury alone were associated with 100% mortality. The mechanism of brain injury-induced hypotension is thought to be multifactorial, ranging from central sympathetic-Adrenal suppression contributing to the loss of peripheral sympathetic tone, to herniation of the brain stem resulting from expanding hematoma or cerebral edema. The authors concluded that head injury may indeed be the cause of hypotension in trauma patients, but cautioned that, of course, hemorrhagic shock and spinal cord injuries must be ruled out.

Mostafa G, Gunter OL, Norton HJ, et al. Age, blood transfusion, and survival after trauma. Am Surg 2004;70:357-363.

Several studies have shown that blood transfusion is an independent predictor of posttraumatic morbidity and mortality, particularly infections and Multiple organ dysfunction. These studies claim that this represents a

cause-and-effect relationship, but many, including myself, feel that it is more a matter of the requirement for blood transfusion being a marker for more severe injury and/or shock. The present study retrospectively analyzed the charts of 1312 adult trauma patients seen over a 6-year period who required blood in the first 24 hours after injury and found that increasing age works synergistically with number of blood transfusions in increasing morbidity. The packed cell transfusion volume for patients older than 55 years was significantly less than that of younger survivors, and the transfusion volume versus mortality curves was progressively steeper with Advancing age. What is the implication of this finding. What is the take- home practical message? It is certainly not that we should avoid transfusing trauma patients who need blood; withholding transfusion and allowing the hematocrit to reach lower levels than in the past are for stable patients with anemia, not those with acute blood loss and hemorrhagic shock. Rather, we are reminded that we need to stop acute bleeding as quickly as possible: earlier operation, for example, in patients being managed nonoperatively for liver or spleen injury who have an ongoing volume requirement, or earlier abandonment of futile attempts at suture control of bleeding in favor of packing to return another day.

Brown CVR, Rhee P, Evans K, et al. Rhabdomyolysis after penetrating trauma. Am Surg 2004;70:890-892.

We are all attuned to looking for signs of rhabdomyolysis (RHAB) in blunt trauma, and especially Crush injury, patients. However, the group from this busy urban trauma center demonstrates that we should look for RHAB in victims of penetrating trauma as well. They retrospectively studied the records of over 100 patients–13% of all penetrating injury patients seen over a 5-year period–who had RHAB, defined as creatine kinase more than 5000 U/L. These patients, most of whom had severe extremity and/or Vascular injury, had a 6-fold higher rate of renal failure, longer intensive care unit and hospital stays, and higher mortality.

Blondell RD, Powell GE, Dodds HN, et al. Admission characteristics of trauma patients in whom delirium develops. Am J Surg 2004;187:332-337.

The development of delirium in any hospitalized patient not only is almost guaranteed to at least prolong the hospital stay and increase costs, but also often leads to other, even potentially lethal, complications. Early identification of those at risk for developing delirium could help in reducing its incidence. This article is a case-control study comparing 120 trauma patients in whom delirium developed to 145 trauma patients in whom it did not. Independently predictive admission characteristics for delirium were found to be age older than 45 years, positive serum alcohol, and elevated mean corpuscular volume (a sign of Chronic liver disease); if none of these were present, delirium developed in 20%; when 1 was present, 57%; when 2 were present, 88%, and when all 3 were present, 83%. A case-control study of this sort cannot prove anything. Moreover, these results are not even news: we all know that delirium is more likely in elderly and alcoholic patients. What I found more surprising was that the authors did not find head injury, history of loss of conciousness, or results of cranial computed tomography scans to be associated with delirium; perhaps that was only because patients who were delirious on ED arrival were excluded from the study.

Hoff WS, Sicoutris CP, Lee SY, et al. Formalized radiology rounds: the final

numbers of missed Radiographic injuries. Discrepancies between the initial readings of x-rays, made by either the trauma team or by on-call resident radiologists, and subsequent readings by staff radiologists are not uncommon. The authors established a formal radiology rounds, held in the radiology department at 9:30 am on the day after the patient’s admission, to review all radiographs obtained on trauma patients. Initial evaluation of the radiographs by the trauma surgeons was compared with the diagnoses that were made at formal radiology rounds. The authors found that there were a small but significant number (9.7%) of new diagnoses that resulted from formal trauma radiology rounds. Fortunately, the new diagnoses were not of major clinical significance, but they often required some alteration in care plan.

1. Chest

Molnar TF, Hasse J, Jeyasingham K, et al. Changing dogmas: history of development in treatment modalities of traumatic pneumothorax, hemo- thorax, and posttraumatic empyema thoracis. Ann Thorac Surg 2004;77:373-378.

This article is mentioned in the Annotated Bibliography just as an interesting review of the history of the treatment of chest wounds, with special emphasis on the developments of the 20th century.

MacFarlane C. Emergency thoracotomy and the military surgeon. Aust N Z J Surg 2004;74:280-284.

This article is an overview of the indications for and general approach to emergency thoracotomy. It was written to address modem military surgeons in forward battle areas, but the teaching points and discussion are valuable for any and all emergency physicians working in institutions where there is any significant amount of serious trauma, as well as any general surgeons in hospitals where there is no thoracic surgical specialist help available.

Kulshrestha P, Munshi I, Wait R. Profile of chest trauma in a level I trauma center. J Trauma 2004;57:576-580.

Chest injuries are major contributors to morbidity and mortality after trauma. The majority of chest injuries can be managed without thoracot- omy. In this report, the authors reviewed their level I trauma center experience to delineate the spectrum of chest injuries they deal with and to determine predictors of mortality. They examined the records of 1359 patients with Thoracic trauma seen over a 5-year period. Seventy percent were men, and 48% were between the ages of 20 and 50 years. Most injuries occurred from noontime to 6:00 pm, with a second peak around midnight. Ninety percent of the injuries were a result of a blunt mechanism. Associated injuries were common, with long bone fractures, head, and spinal injuries accounting for approximately 20% each. Forty-eight percent of the patients had rib fractures, and 20% had pneumothorax and/or hemothorax. Ten percent had lung contusion. There were diaphragmatic injuries in 2% of the patients, and crushed chest occurred in a small minority. The thoracic aorta was injured in 2.4% of the patients. The main predictors of mortality were low Glasgow Coma Score and advanced age of the patient.

component of the tertiary survey. J Trauma 2004;56:291-295.

Knudtson JL, Dort JM, Helmer SD, et al. Surgeon-performed ultrasound

The American College of Surgeons Advanced Trauma Life Support course pioneered and standardized the use of primary and secondary surveys in the initial evaluation and management of injured patients. As the care of trauma patients has evolved, it has now been recognized by many that a btertiary surveyQ is also necessary, usually performed the next day, when the dust has settled and the patient has stabilized, with a final head- to-toe examination searching for injuries that might have been over- shadowed by more major ones. The authors of this article focused on the

for pneumothorax in the trauma suite. J Trauma 2004;56:527-530. Kirkpatrick AW, Sirois M, Land KB, et al. Hand-held thoracic sonography for detecting post Traumatic pneumothoraces: the extended focused assessment with sonography for trauma (EFAST). J Trauma 2004;57: 2004;288-294.

Ultrasound examination of the abdomen–focused assessment sonogra- phy for trauma or FAST–is now a standard in all trauma centers. FAST, as it

is now performed, includes an examination of the pleural spaces to look for fluid. These studies evaluate sonography in looking for air in the pleural space: pneumothorax. At first glance, this seems to be a bad idea: air is the one medium through which the ultrasound waves do not propagate well. On the other hand, perhaps that property can be exploited: the presence of air where it should not be, in the pleural space, might be a reliable finding.

The authors of the first study used visualization of the 2 pleural surfaces to rule out air between the parietal and visceral pleura: the bsliding lung sign.Q If they could not see the 2 surfaces moving nicely over each other, but only 1 surface and then air, they diagnosed pneumothorax. They performed sonography on 328 patients before a chest x-ray is obtained, and then compared the findings. There were 312 true negatives, 12 true positives, 1 false negative, and 1 false positive.

The second article gives a bit more detailed description of the technique. The examination is performed by placing the ultrasound probe longitudinally on, and perpendicular to, the chest wall to identify the pleural surface with reference to the overlying ribs. The transducer is then rotated transversely between the ribs to bring the echogenic pleural stripe into profile, looking for respiratory motion of the surfaces bslidingQ or bglidingQ on each other. The absence of this motion is interpreted as sonographic evidence for a pneumothorax. The authors found that the participants in this study were able to reliably identify pneumothoraces with limited training. The bEFAST,Q as they dub it, had comparable specificity to chest x-ray and was more sensitive for the detection of a pneumothorax because a supine chest x-ray often fails to demonstrate a pneumothorax which rises to the anterior Pleural cavity.

The conclusion: add examination of the anterior pleura, looking for the

bsliding lung sign,Q to your standard FAST examination.

Gao J-M, Gao Y-H, Wei G-B, et al. Penetrating cardiac wounds: principles for surgical management. World J Surg 2004;28:1025-1029.

This article adds nothing new to the trauma canon. However, all relatively uncommon conditions we may encounter, especially those for which we must act quickly and decisively, deserve to be reviewed on a regular basis. The authors describe the 82 patients with penetrating wounds of the heart, most due to stabs, which they treated over a period of 14 years at an urban center. Important points to emphasize: the surface entry wound can be anywhere within knife range of the heart–left or right side, abdomen, and posterior chest; the right ventricle is the most frequent chamber injured; patients can present with tamponade, shock, a combination of both, or normal hemodynamics; pericardiocentesis was done in 3 of the patients, and in 1 of these, it was a false negative; the overall survival was over 95%, including 5 of 6 who required ED thoracotomy. Of note, echocardiography, which is currently the Diagnostic modality of choice in the United States, was done in only 3 of the cases and was true positive in all 3.

Turk EE, Tsokos M. Blunt cardiac trauma caused by fatal falls from height: an autopsy-based assessment of the injury pattern. J Trauma 2004; 57:301-304.

These authors retrospectively analyzed all autopsy cases performed at their institution over a 5-year period on victims of falls from height, to assess the pattern of cardiac injury such a mechanism causes. Sixty-one patients were analyzed after falls from heights ranging from 3 to 57 m. Heart injuries were found in 33 (54%) of 61 cases. The most frequent finding was pericardial tear. Transmural tears of the right atrium, left atrium, and right ventricle were next most common. sternal fractures occurred frequently. The authors conclude that cardiac trauma is a common condition among victims of falls from height. Many of these patients have potentially survivable injury if the diagnosis is made quickly and appropriate therapy is initiated. Tears of the pericardium can allow the heart to herniate through the pericardium, resulting in strangulation; tears of the low-pressure cardiac chambers cause pericardial tamponade. ED thoracotomy in these cases can be lifesaving; in fact, these are the exact

injuries which really are the only reason ever to perform ED thoracotomy on victims of blunt trauma.

Fitzharris M, Franklyn M, Frampton R, et al. Thoracic aortic injury in motor vehicle crashes: the effect of impact direction, side of body struck and seatbelt use. J Trauma 2004;57:582-590.

The objective of this study was to examine the relationship of motor vehicle impact parameters–impact direction, seat-belt use, and the side of the body directly exposed to the striking object–with the risk of thoracic aortic injury for front seat occupants. Data were generated from both the National Automotive Sampling System in the United States and the Cooperative Crash Injury Study in the United Kingdom. The benefits of wearing a seat belt were clear: unbelted occupants in frontal-impact crashes were at 3 times higher risk of aortic injury than those belted; front Air bags were also definitely protective. The authors also found that occupants involved in side-impact crashes are at higher risk for aortic injury than those in frontal collisions. A higher risk is also incurred by traveling in small passenger vehicles struck by the more tanklike sport utility or 4-wheel drive vehicles.

Melton SM, Kerby JD, McGriffin D, et al. The evolution of chest computed tomography for the definitive diagnosis of blunt aortic injury: a single- center experience. J Trauma 2004;56:243-250.

The authors of this study reviewed the blunt thoracic aortic injury experience at the University of Alabama at Birmingham over a 6-year period, with particular interest in the evolution of diagnostic techniques. At the beginning of this experience, injury to the aorta was suggested to the treating physicians by an abnormal chest x-ray and the mechanism of injury, and aortography was performed as the diagnostic tool of choice. In 1998, screening computed tomography (CT) scans were obtained in all patients presenting with blunt torso trauma, and aortography was used to both confirm the diagnosis and provide a surgical broad mapQ of the injury. In the final 2 years of this study, CT was used as both the screening and the definitive diagnostic tool. The authors reviewed the radiographic findings on all studies and compared them with the operative findings. In the authors’ experience, the chest x-ray has not proven to be a reliable screening modality for blunt aortic injury: 7% of patients later proven to have a blunt aortic injury had a normal admission chest x-ray, and 14% of the patients with a negative aortogram had an initial chest x-ray which was interpreted as definitely positive for blunt aortic injury. In contrast, current- generation high-speed helical CT has proven to be very reliable: lack of evidence of aortic injury on helical thoracic CT scan no longer requires confirmation by aortography. The thin-slice multiview helical CT scan, interpreted by experienced CT radiologists, is adequate for excluding and accurately delineating aortic injury and has become the definitive diagnostic tool for both screening and definitive diagnosis of thoracic aortic injury. Of note, transesophageal echocardiography, the diagnostic tool of choice for (nontraumatic) aortic dissection, has been abandoned at the University of Alabama as well as at most US trauma centers.

Ott MC, Stewart TC, Lawlor DK, et al. Management of blunt thoracic aortic injuries: endovascular stents vs. Open repair. J Trauma 2004;56: 565-570.

Thoracic aortic injuries are highly lethal events, causing death at the scene in 80% to 85% of the patients who incur them. For those who make it to the hospital, up to 50% die before operative repair. The operation itself carries significant morbidity and mortality. In an attempt to decrease the morbidity and mortality of repair, the authors studied endovascular grafting of the injured aorta. Considerable experience with endovascular grafting of nontraumatic aortic aneurysms has now been accumulated for over a decade, and there have been several isolated case reports of endovascular

approaches to acute traumatic aortic injuries. The present study is the first direct comparison of Endovascular repair versus the standard open operative technique. The authors report their results with 18 patients, 12 of whom underwent endovascular repair, and 6 of whom had the standard open repair. In the stented endovascular group, there were no deaths, no paraplegia, and a remarkably smooth postrepair course. In the standard repair group of 6 patients, there were 2 deaths and 2 incidences of paraplegia. Moreover, there was a clear excess of complications such as acute respiratory distress syndrome, sepsis, myocardial infarction, and prolonged ventilation with the open repair technique. This study clearly demonstrated improved outcome after endovascular repair, and it is likely that this technique will quickly become the new standard.

Hemmila MR, Arbabi S, Rowe SA, et al. delayed repair for blunt thoracic aortic injury: is it really equivalent to early repair? J Trauma 2004;56: 13-23.

Many patients with traumatic rupture of the thoracic aorta have associated severe injuries which make immediate Surgical repair of the aorta too risky. Delayed operative repair, with interval protection of the damaged aortic wall by aggressive antihypertensive medical treatment, was first reported from our institution (Massachusetts General Hospital) in 1981 and has become a bmostlyQ accepted approach. The objective of this study was to evaluate the outcome of delayed repair compared with immediate repair of blunt thoracic aortic injury. The authors used their own data as well as those obtained from the National Trauma Data Bank. They were primarily interested in the differences in morbidity and mortality of acute repair versus delayed repair, as well as in the effectiveness of their antihypertensive protocol. This is a retrospective study which reviewed all patients admitted to the University of Michigan with the diagnosis of traumatic thoracic aortic tear. Patients who underwent repair more than 16 hours after injury constituted the delayed repair group. The reasons for delay included poor pulmonary function, uncertain central nervous system status, ongoing current infection, contra- indication to anticoagulation, or need for other operation. Blood pressure was managed with b-blockade using intravenous esmolol. At the University of Michigan Health Systems, pulmonary dysfunction, with the inability to tolerate the single-lung ventilation required for operative repair, was the most common reason for delay. The authors found no significant difference in mortality for emergency repair versus delayed repair at the University of Michigan. There was a higher length of hospital stay and complication rate associated with delayed repair, but that was most likely due to the severe associated injuries which prompted the delay in the first place.

Wong P-S, Koirala RR, Lee C-N. Combined blunt aortic and bronchial injury. Ann Thorac Surg 2004;78:2157-2159.

This case report is interesting on several accounts. First, the patient’s blunt tear of the descending thoracic aorta was successfully repaired with an endovascular stent, which is still a new cutting-edge procedure that has a bright future. Second, the course of the what later was revealed to be a complete transection of the left main bronchus is described. There was an initial pneumothorax with air leak, but these resolved with tube thoracostomy. Over the next few days, the patient developed higher face- mask oxygen requirement to keep his saturation above 2%, and serial chest X-rays showed progressive left lung collapse. Finally, the report’s review and discussion of similar cases in the literature quite reasonably argue that we need to be more aggressive in using bronchoscopy to exonerate the tracheobronchial tree in patient with known serious injury to other mediastinal structures.

Stassen NA, Hoth JJ, Scott MJ, et al. Laryngotracheal injuries: does injury mechanism matter? Am Surg 2004;70:522-525.

The value of this article is more of an interesting review to remind us about the diagnosis and management of laryngotracheal injuries, rather

than as a real analysis of the significance on mechanism of injury. The records of 15 patients seen over a 7-year period at a large level I trauma center were reviewed. Nine had blunt injury, most commonly of course due to motor vehicle collision, and 6 — evenly divided among gunshot, shotgun, and knife–had penetrating injury. The presentations were that 4 had obvious injury, with the trachea visible in or gushing air from the penetrating wound, or inability to phonate after blunt injury; the remainder had subcutaneous emphysema, hoarseness, stridor, and/or and Neck tenderness. Chest x-rays showed no abnormalities in half; neck computed tomography scan was the method of diagnosis in most. All patients required operation. The larynx was injured more often than the cervical trachea, for intuitively obvious reasons (the larynx is larger and more superficial than the cervical trachea), and only those with laryngeal injuries required tracheostomy. Only 1 patient died and had an accompanying severe head injury; the long-term outcome is not given at all.

Navsaria PH, Vogel RJ, Nicol AJ. Thoracoscopic evacuation of retained posttraumatic hemothorax. Ann Thorac Surg 2004;78:282-286.

One of the long-term complications of hemothorax is fibrothorax, which occurs as the blood in the pleural space is turned into a fibrous peel which restricts expansion of the lung, thus decreasing lung capacity. Placement of a thoracostomy tube(s) is of course the primary treatment, but sometimes the blood, which in cases of traumatic hemothorax often does not defibrinate but rather clots, is loculated and cannot be easily or completely removed by chest tube. Instillation of fibrinolytics into the pleural space has not been proven to be very efficacious. This article reports a series of 46 patients who had their residual hemothorax removed by video-assisted thoracoscopic surgery over a 2-year period, and it was found to be safe and quite effective. Nine of the 42 patients had too dense adhesions which prevented video-assisted thoracoscopic surgery and necessitated open thoracotomy.

Smakman N, Nicol AJ, Walther G, et al. Factors affecting outcome in penetrating oesophageal trauma. Br J Surg 2004;91:1513-1519.

Noniatrogenic penetrating injury to the esophagus is not common: it is estimated that, worldwide, less than 10 present to level I trauma centers per year. The very busy trauma centers in South Africa see a large proportion of these, and this article describes 1 center’s experience with 52 patients (56% stab and 44% gunshot) seen over 8 years. The most common presenting symptoms and signs were prevertebral air on x-ray and/or subcutaneous emphysema on physical examination, seen in about half of patients; dysphagia or odynophagia were seen in a quarter. Contrast esophagography had a sensitivity of 93%; esophagoscopy, a sensitivity of 91%. All patients underwent operative intervention. The main thrust of the article is the finding that, besides the magnitude of the original injury, over which we have no control, the main factor affecting the outcome was the time required to make the diagnosis. It is not a matter of crucial minutes with the esophagus as it is with the airway or major vessels, but rather a matter of making the diagnosis during the initial course of evaluation, instead of discovering the previously missed esophageal injury in the course of dealing with an unexpected complication. The underlying message is that, as with so much in medicine, we must maintain the perennial bhigh index of suspicionQ to detect esophageal injuries. We only find what we look for, and we only look for what we think of.

Gill SS, Dierking JM, Nguyen KT, et al. Seatbelt injury causing perforation of the cervical esophagus: a case report and review of the literature. Am Surg 2004;70:32-34.

This a just a quick note describing a blunt tear of the esophagus from the shoulder harness in a high-speed motor vehicle collision. The patient presented with a contusion–a shoulder-strap sign– on the neck and subcutaneous emphysema. The tear was demonstrated on Gastrografin

swallow and was successfully treated nonoperatively with antibiotics and NPO; a second Gastrografin swallow 3 days later showed no leak; he was given PO liquids and did well. There was no associated vascular, airway, or spine injury. We have learned over the past decade that blunt cervical vascular injuries are much more common than previously thought; perhaps with increased use of motor vehicle shoulder harnesses, there is an actual increase in numbers. We must remember to think of the esophagus when we examine patients with potential neck injuries. Missed esophageal tears can be fatal because of mediastinal infection. The accepted approach to investigate the esophagus for both penetrating and blunt trauma is a combination of both esophagogram and esophagoscopy: either one alone has a sensitivity of 80%; together, they have a sensitivity approaching 99%.

Zellweger R, Navsaria PH, Hess F, et al. Transdiaphragmatic pleural lavage in penetrating thoracoabdominal trauma. Br J Surg 2004;91:1619-1623.

The pleural space is, compared with the peritoneal space, relatively more susceptible to serious infections after contamination, and the resulting infections–empyema–are relatively more difficult to eradicate. Current textbooks advocate that, in the face of pleural contamination by bilioenteric content from an Abdominal injury, one should perform a thoracotomy for thorough lavage and drainage. The authors of this study from 1 of the extremely busy trauma centers in South Africa reviewed the results of their prospective use of large-volume (average 3-5 L) washout of the thoracic cavity from the abdominal cavity through the diaphragmatic wound in patients with thoracoabdominal penetrating injury. A total of 217 patients seen over 3 years had either gunshot (72%) or stab (28%) thoracoabdominal wounds; 110 of these had gross contamination with biliary and/or gastrointestinal contents. This study did not compare one method of management with another; it just reports that their method was associated with a low rate of pleural space complications–only 2 of the 110 developed empyema; 4 more had pneumonia, but they may or may not have been a result of mechanical contamination. The authors conclude that this low rate of pleural infection supports their surgical management approach.

1. Abdomen

Bokhari F, Nagy K, Roberts R, et al. The ultrasound screen for penetrating truncal trauma. Am Surg 2004;70:316-320.

One of the first steps in managing patients with penetrating injuries to the torso is to try to determine if there has been penetration through the wall of the torso into the abdominal and/or thoracic cavities. In the absence of frank peritonitis, evisceration, shock, or the ability to pass a gentle probe through the wall, physical examination alone is unable to do this. Nor have wound exploration under local anesthesia, Diagnostic peritoneal lavage, or computed tomography been helpful: most centers use laparoscopy to determine peritoneal penetration. This prospective, but preliminary non- randomized, study used ultrasonography with a fine-resolution/low- penetration (10 MHz) transducer to examine the deep muscle and fascia of 49 patients with thoracoabdominal anterior, flank, and back penetrating injuries, both stab and gunshot. They were able to see the depth of the wound fairly well: 20 patients had true-positive examinations, 20 have false-positive examinations, but most importantly, there were no false- negative examinations. This approach is rather promising. Of course, all ultrasound examinations will always be operator-dependent. Of note, the ultrasounds were performed by trauma attending physicians or surgical or emergency medicine residents, not by radiographers or radiologists.

Soffer D, McKenney MG, Cohn S, et al. A prospective evaluation of ultrasonography for the diagnosis of penetrating torso injury. J Trauma 2004;56:953-958.

In stark contrast to the article above, the authors from this institution did not find ultrasonography to be helpful in the assessment of patients

with penetrating torso injuries. One hundred seventy-seven patients were prospectively evaluated, 92 of whom were stabbed, and 84 of whom had gunshot wounds. One patient had a nail-gun injury. The authors found that ultrasound examination had a low sensitivity and an overall accuracy of only 85% in evaluating penetrating torso injuries; clinical judgement alone was equal to or superior to the ultrasound examination. They concluded that, for the present at least, ultrasonography probably has no role in evaluations of patients with penetrating abdominal trauma.

Tsikitis V, Biffl WL, Majercik S, et al. Selective clinical management of anterior abdominal stab wounds. Am J Surg 2004;188:807-812.

How to decide on which patients with anterior abdominal stab wounds should be operated on has been debated back and forth for over half a century. All agree that shock, evisceration, and peritonitis are indications for immediate exploration, but in absence those conditions, only half of patients stabbed end up having injuries that require operative repair. As outlined above, Diagnostic approaches include observation alone, local wound exploration, diagnostic peritoneal lavage, Computed tomography scanning, Diagnostic laparoscopy, and perhaps now, ultrasonography. This report is 1 of many which concludes that 23-hour observation is safe. It is based on a single institution’s experience with a prospective protocol involving observation of 30 patients seen over 5 years. From other similar studies, the incidence of missed injuries/delayed diagnosis with observation alone is approximately 5%. However, this report is too small: 30 patients is not enough to detect potential problems.

Gonzales RP, Han M, Turk B, et al. Screening for abdominal injury prior to emergent extra-abdominal trauma surgery: a prospective study. J Trauma 2004;57:739-741.

Assessment of the abdomen in trauma patients is often difficult because of distracting extra-abdominal injuries and/or altered mental status, and we often order additional abdominal Screening tests beyond physical exami- nation. Performing these additional studies takes time and not infrequently delays the patients’ getting to the operating room for management of other, most often orthopedic, injuries. The purpose of this study was to call into question this practice and prospectively evaluate the reliability of physical examination as the sole screening modality in blunt trauma patients. The authors prospectively entered into the study all hemodynamically patients if they were awake and alert with a Glasgow Coma Score z14 and compared physical examination with computed tomography. Out of 162 patients, physical examination missed 2 injuries: one, a grade 1 splenic injury; and the other, a small bowel mesenteric hematoma, neither of which alterED management. The authors concluded that a normal physical examination without the addition of further diagnostic evaluation is adequate for the assessment of the trauma patient’s abdomen before surgery for extra-abdominal injuries. The authors provide a very interesting discussion of the significance of alcohol ingestion in their patient group: they do not feel that either alcohol ingestion or distracting injuries materially interfere with physical examination. Most of here in the United States will disagree with this opinion (perhaps partly because of the different medicolegal climate), and we are unlikely to change our practice on the basis of this study alone.

Allen TL, Mueller MT, Bonk RT, et al. computed tomographic scanning without oral contrast solution for blunt bowel and Mesenteric injuries in abdominal trauma. J Trauma 2004;56:314-322.

A prominent debate in the emergency radiology community is whether oral contrast should be used for Abdominal computed tomography (CT) scans performed for acute trauma. Intravenous contrast is always used. The advocates for use of gastrointestinal contrast argue that delineation of detail in the bowel wall, as well as of course demonstration of leak from bowel perforation, is much better with contrast. In the present study, 500 blunt

abdominal trauma patients were assessed for intra-abdominal injury, using

CT with intravenous contrast but without oral contrast, and compared the readings with operative findings and patient outcomes. CT without oral contrast was highly accurate and sensitive in assessing hollow viscous and mesenteric injuries.

Shinkawa H, Yasuhara H, Naka S, et al. Characteristic features of abdominal Organ injuries associated with gastric rupture in blunt abdominal trauma. Am J Surg 2004;187:394-397.

This is a quite limited descriptive study of 14 patients with gastric injury discovered at laparotomy after blunt trauma. Twelve patients were occupants in car crashes; 2 were injured in falls. Five patients, all of whom had had a full stomach at the time of injury, had a full-thickness rupture of the gastric wall, and 9, none of whom had a full stomach, had partial-thickness laceration. The location of the injury was most often on the anterior wall, closely followed by greater curvature and lesser curvature. Those patients whose stomachs were full and who had full- thickness rupture had a much lower incidence of concomitant injury to the liver or pancreas than those with laceration, leading the authors to suggest that the full stomach might have acted like an air bag, protecting other organs.

Blocksom AM, Tyburski JG, Sohn RL, et al. Prognostic determinants in duodenal injuries. Am Surg 2004;70:248-254.

This retrospective review of a large experience in managing patients with duodenal injuries attempts to identify factors which most affect morbidity and mortality in patients with injuries of the duodenum. The duodenum is of course located deep in the retroperitoneum, protected from the outside on all sides, so that injuries are not only uncommon but also imply that (1) a major destructive force has been applied, and (2) surrounding structures are likely to be injured as well. The authors retrospectively reviewed the records of 222 patients with duodenal injuries seen over a 22-year period at a single urban trauma center. Duodenal injuries were found in approximately 5% of all trauma laparotomies. Eighty-eight percent of those with duodenal wounds had penetrating injuries, nearly three quarters were gunshot wounds. Associated injuries were common, with a mean of 4.6 organs injured, the liver being the most common, followed by the colon and major abdominal veins. The overall mortality among patients with duodenal injury was 22.5%. The authors found that more than 5 U of blood transfusion, a final operating room core temperature of less than 358C, and the presence of abdominal arterial or pancreatic injury are risk factors for mortality and infectious complications. They concluded that bearly efforts to prevent shock and rapidly control bleeding are the most likely efforts to reduce mortality.Q

Fealk M, Osipov R, Foster K, et al. The conundrum of traumatic colon injury. Am J Surg 2004;188:663-670.

Another of the many controversies in trauma care that have been raging for more than half a century is how to deal with colon injuries: can they be repaired primarily, or must they be either resected or at least have the repair protected by a proximal diverting colostomy? From World War II until the late 1980s, the dogma was the latter. In the last 15 years, however, there have been over 30 retrospective articles and almost a dozen prospective studies and meta-analyses on the subject, with the

Navsaria PH, Shaw JM, Zellweger R, et al. Diagnostic laparoscopy and diverting sigmoid colostomy in the management of civilian extraperitoneal rectal gunshot injuries. Br J Surg 2004;91:460-464.

This article deals with exclusively rectal injuries. Twenty patients who had low-velocity gunshot wounds of the rectum were included in the protocol, which called for laparoscopy to confirm no intraperitoneal injury, followed by creation of a loop sigmoid colostomy as the sole treatment. No distal rectal washout or presacral drainage was performed. All patients recovered without development of infectious complications. Two developed rectocutaneous fistulas, but both healed spontaneously. The authors concluded that low-velocity gunshot wounds of the extraperitoneal rectum can be safely and effectively managed as above. This is a preliminary report, but an interesting and promising report.

Duane TM, Como JJ, Bochicchio GV, et al. Reevaluating the management and outcomes of severe blunt liver injuries. J Trauma 2004;57:494-500.

Nonoperative management of blunt liver injuries has been accepted as a standard for over a decade now. The authors of this article from the Maryland Shock-Trauma Center wanted to review their experience with high-grade liver injuries, as well as to delineate any risk factors that might predict the need for operative therapy. The authors’ protocol for management of blunt Liver trauma mandated that all patients with grade III and higher injuries on computed tomography who did not go directly to the operating room undergo angiography and embolization of bleeding vessels. They retrospectively reviewed their experience with 80 patients with grades 4 and 5 liver injuries seen over a 3-year period. Of the 80 patients, 44 underwent laparotomy with either packing, hepatorrhaphy, or resection. Of particular note was that operation and angiography were not mutually exclusive: 12 patients had both, 9 of these having operation followed by angiography, and 3 had operation for continued bleeding after angiography. Half of all patients who underwent angiography had extravasation and had the bleeding vessels embolized. There was no significant difference in age between the 44 operated and the 36 patients managed nonoperatively, although the initial Glasgow Coma Score was lower and the Injury Severity Score was significantly higher in the operated group. The patients who underwent laparotomy were less stable, required more fluid and blood products, and had higher mortality as the result of Uncontrolled bleeding. Initial platelet count, and crystalloid fluid use after 4 hours were predictive of the need for operative management. The authors concluded that nonoper- ative management (which includes the use of angiographic embolization) of high-grade blunt liver injuries can be successful but must be undertaken with the knowledge that urgent interventions, including surgical exploration, may be required for several days. Those patients with high fluid requirement and low platelet count are most likely to require operative intervention.

Finch R, Banting SW. Modern management of splenic injury: commentary. Aust N Z J Surg 2004;74:513.

[Commentary on Reddy CG, Chalasani V, Ptham-Nathan N. Splenic preservation: an additional haemostatic measure during mesh splenor- rhaphy. Aust N Z J Surg 2004;74:596-597]

This 1-page editorial is a commentary on an article about intraoperative surgical maneuvers used to preserve injured spleens; it is an excellent terse summary of the thinking behind the 20th century evolution of management of injured spleens.

majority favoring the former: Primary repair can and should be used in all

colon injuries. This article adds to the list. It is a retrospective single- center review of 74 patients with acute traumatic colon injuries, 80% of whom were successfully treated without performing colostomy; the other 20% had a colostomy performed at the discretion of the surgeon. The authors found no difference in complications between those with and without colostomy.

Haan JN, Biffl W, Knudson M, et al. splenic embolization revisited: a multi-

center review. J Trauma 2004;56:542-547.

The spleen is another organ that is particularly well suited to embolization for control of bleeding. At least 4 studies published in 2004 addressed angiography in the management of splenic trauma.

The first study, organized and supported by the Multi-institutional Trials Committee of the Western Trauma Association, examined the complica- tions of Transcatheter embolization of the spleen. All patients with blunt splenic injury who had contrast extravasation on computed tomography underwent angiography and embolization of areas of extravasation. One hundred forty patients from 4 different level I trauma centers were eligible for study and analysis. The splenic salvage rate was 87%. The authors found that the success rate of nonoperative management, which included angiographic embolization, was not influenced by the amount of hemoperitoneum or grade of injury but was reduced in the presence of an arteriovenous fistula. major complications identified included postembolization bleeding, splenic abscess, and splenic infarction. The authors concluded that in the era of splenic preservation, splenic embolization is a very useful and effective method of management.

Liu PP, Lee C, Cheng F, et al. Use of Splenic artery embolization as an adjunct to nonsurgical management of blunt splenic injury. J Trauma 2004;56:768-762.

The second article reports on the authors’ experience with 35 patients with blunt splenic rupture managed nonoperatively over a 1.5-year period. Patients who were hemodynamically stable were observed for 24 to 48 hours in the intensive care unit and then, if stability persisted, transferred to the floor where normal activity was resumed. If the initial computed tomography demonstrated grade 4 or 5 splenic injury, significant hemoperitoneum or extravasation of contrast media, or if there was recurrent hypotension despite fluid resuscitation, falling hematocrit, or need for blood transfusion, angiography was performed and areas of extravasation treated with embolization. The authors found an improved ability to preserve splenic tissue: splenic artery embolization increased the success rate for nonoperative management from 74% to 89%.

Dent D, Alsabook G, Erickson BA, et al. blunt splenic injuries: high nonoperative management rate can be achieved with selective emboliza- tion. J Trauma 2004;56:1063-1067.

In the third article, the authors added to their previously reported experience with nonoperative management and angiographic embolization of splenic injuries. Angiography was performed on all patients who had a vascular blush on computed tomography and/or persistent tachycardia and falling hematocrit; angiographic embolization was needed for only 7% of the nonoperative cases. The authors reported in the year 2000 that nonoperative management was successful in 65% of their patients; the 2004 results showed an 83% success rate.

Wahl WL, Ahrns KS, Chen S, et al. Blunt splenic injury: operation versus angiographic embolization. Surgery 2004;136:891-899.

Finally, this retrospective review of a prospectively collected data set from 164 patients seen over 4 years at a level I trauma center corroborates that angiographic embolization (AE) of injured spleens is a valuable addition to the trauma service’s armamentarium. Patients who underwent AE had similar injuries as those who went to the operating room (OR), and their mortality was also the same, whereas costs and complications were less with AE. The key question is: who should be taken to angiography, who can be managed nonoperatively without need for angiography, and who needs to be taken to the OR? The last word is not yet in, but the current norms approximate the following. Stable hemodynamically normal patients with low-grade (I and II) splenic injuries and without much free blood on computed tomography can be observed. Patients with peritonitis or ongoing hemodynamic instability in the face of aggressive fluid resusci- tation need to go to the OR. Patients who are relatively stable but who have a contrast blush on computed tomography should go to AE. As to the patients not in these 3 groups, the decision to embolize or operate is up to the surgeon’s judgement and the institution’s capabilities. The present

authors found that ongoing hypotension below 90 mm Hg systolic, acidosis, the need for more than 2 U of blood, and higher Injury Severity Score tended to indicate the need for operation, whereas Glasgow Coma Score, age, and heart rate were not helpful predictive factors.

Cochran A, Mann NC, Dean JM, et al. Resource utilization and its management in splenic trauma. Am J Surg 2004;187:713-719.

The present study compared the Management strategy and Costs of care of patients with blunt splenic injuries cared for in level I trauma centers versus nontrauma center hospitals in the state of Utah during the years 1996 and 1997. The findings were that (1) pediatric patients were more likely to be managed nonoperatively at pediatric regional referral centers than at either nonpediatric trauma centers or other hospitals, (2) adults were more likely to be managed nonoperatively at trauma centers, and (3) interestingly, the hospital lengths of stay and costs were higher at the trauma centers. Unfortunately, the article gives no information as to whether the outcomes were different at the different facilities. Until that information is known, one cannot comment on whether the increased cost incurred at the trauma centers was worth it.

Meguid AA, Ivascu FA, Bair HA, et al. Management of blunt splenic injury in patients with concurrent Infectious mononucleosis. Am Surg 2004;70:801-804.

Time and experience have shown us that the normal spleen can heal itself after injury most of the time, thus enabling us to manage most patients with blunt spleen injuries nonoperatively, with or without angiographic emboli- zation. But how about abnormal spleens? We know that patients with mononucleosis are at risk for Spontaneous rupture of the spleen; can we expect an injured spleen in a patient with mononucleosis to behave the same way? The authors of this report found 9 patients with blunt splenic injury who had concomitant mononucleosis seen over a 23-year period at their level I trauma center. Two of these were hemodynamically unstable and were operated on. Five of the other 7 were successfully managed nonoperatively. Only 2 of these had computed tomography (CT) scans, both of which showed American Association for the Surgery of Trauma grade III injuries without contrast blush. Of the 2 patients who failed nonoperative management, 1 had a grade III injury on CT without contrast blush, but he had a delayed bleed 10 days after injury. The other patient had been admitted to the hospital with mononucleosis, fevers, urinary tract stones, and urinary tract infection and fell while walking in the hall. CTshowed a grade III laceration and developed an abscess in the splenic hematoma necessitating splenectomy. The authors conclude that concurrent infectious mononucleosis does not preclude successful nonoperative management of blunt splenic injury, but I would add that these patients are definitely more likely to fail such management and need to be carefully observed for longer than otherwise healthy patients.

Bozeman C, Carver B, Zabari G, et al. Selective operative management of major Blunt renal trauma. J Trauma 2004;57:305-309.

It is generally accepted that minor Renal injuries, American Associ- ation for the Surgery of Trauma grades 1 to 3, which include small contusions, subcapsular nonexpanding hematoma, or penetrating injuries with less than 1 cm parenchymal laceration, should be managed conservatively. Nonoperative management of major renal trauma with parenchymal lacerations extending into the depth of the renal cortex, shattered kidney, and patients with avulsion of their renal hilum is more controversial. As with almost all injuries, if the patient is hemodynam- ically unstable, operative exploration is indicated. The authors of this article reviewed their experience with management of 178 stable patients with blunt renal trauma, 26 of whom had grade III or higher injury on computed tomography. Fourteen patients underwent nonoperative man- agement, and 12 patients underwent surgical exploration. All 14 who were managed nonoperatively survived with their kidneys intact, whereas 9 of

the 12 patients who were operated on ended up with nephrectomy. The

authors conclude that nonoperative management of Hemodynamically stable patients with blunt renal trauma is superior, regardless of the computed tomography injury grade, the presence of Urinary extravasation, or the mechanism of injury. The number of patients reported on here is small, and the conclusions need confirmation by a larger study, but it is clear that operative exploration of the kidney often results in nephrec- tomy. As always, hemodynamic stability is the key element in the decision process.

Loveland JA, Boffard KD. Damage control in the abdomen and beyond. Br J Surg 2004;91:1095-1101.

This concise well-written article describes both the rationale behind and the principles of performing damage control surgery in trauma patients. Briefly, in damage control surgery (also called babbreviated laparotomyQ), one quickly arrests hemorrhage and stops ongoing peritoneal soiling from leaking hollow viscera using temporary measures and terminates the operation before the severely injured patient develops the lethal triad of hypothermia, acidosis, and coagulopathy. The patient’s abdomen is closed with a loose (to prevent Abdominal compartment syndrome) temporary closure, further resuscitated in the intensive care unit, and then returned to the operating room later for definitive repairs of injuries under more controlled circumstances. This strategy is now standard both in the civilian world and in the military.

Asensio JA, Petrone P, Roldan G, et al. Has evolution in awareness of guidelines for institution of damage control improved outcome in the management of the posttraumatic open abdomen. Arch Surg 2004;139: 209-215.

The concepts of damage control laparotomy and staged laparotomy are very nicely reviewed in this study. As noted above, the technique includes packing areas of bleeding and quickly closing of injuries to the intestines, and often leaving the abdominal wall open. In this study, 2 eras of damage control laparotomies were evaluated. In the first group, the need for damage control operation was recognized only after the lethal triad of hypothermia, acidosis, and coagulopathy had developed. In the second group, patients were carefully monitored for temperature, pH, and Transfusion requirements; the operation was quickly terminated when any of the lethal triad appeared. The authors found that patients had a better outcome and shorter operative and hospital course, if early recognition of the need for damage control laparotomy occurred.

1. Head

Demetriades D, Kuncir E, Velmahos GC, et al. Outcome and prognostic factors in head injuries with an admission Glasgow Coma Score of 3. Arch Surg 2004;139:1066-1068.

A Glasgow Coma Score of 3 is given just for showing up–even a dead person scores a 3 (why they made the scale that way is 1 of those things that will always remain a mystery). What is the eventual outcome of patients who arrive in the ED with a Glasgow Coma Score of 3? The authors of this article reviewed the records of 760 patients seen at their level I trauma center over 10 years who had an initial Glasgow Coma Score of 3. They found that only one quarter of these patients survived. Mortality was significantly higher in patients with penetrating trauma (94%) compared with those with blunt trauma (65%). The study identified 4 significant risk factors for death: penetrating trauma, high Abbreviated Injury Score for head, age older than 55 years, and hypotension on admission. There were 177 survivors, but only 18 (10%) of these had good functional outcome at hospital discharge; interestingly, this 10% proportion of patients who were Neurologically intact was the same for both blunt and penetrating injuries.

Lavoie A, Ratte S, Clas D, et al. preinjury warfarin use among elderly patients with Closed head injuries in a trauma center. J Trauma 2004;56:802-806.

This study aimed to determine the impact of chronic warfarin use on the severity of injury among elderly patients presenting with closed head injury. The authors retrospectively reviewed the records of 35 patients older than 55 years seen over the course of 8 years at their level I center. Compared with the other 349 patients of the same age group seen over the same period who were not taking warfarin, the patients on warfarin had a higher risk of isolated head injury, severe head injury, and a much higher risk of death. The important take-home message is that a history of chronic warfarin anticoagulation needs to be taken very seriously, especially if there is even the slightest head injury.

Cochran A, Scaife ER, Hansen KW, et al. Hyperglycemia and outcomes from pediatric traumatic brain injury. J Trauma 2003;55:1035-1038.

The purpose of this study was to relate admission Blood sugar and outcome status in children who had head injuries. Two hundred ninety-three pediatric patients with head injuries were evaluated over a 1-year period; the mean age was 4 years, and the mean initial Glasgow Coma Score was

11. Patients who died had significantly higher Serum glucose on admission than those who survived (267 vs 135 mg/dL), and an admission glucose z300 (7 patients) was uniformly associated with death. The patients with the worst neurological outcomes had mean serum glucose in excess of

200 mg/dL on admission. This study confirmed prior research that demonstrated an association between poor neurological outcome and elevated admission blood sugar levels. Whether the elevated glucose is a result of the brain trauma (from release of catecholamines, cortisol, etc) or is a factor in making brain injury worse remains unclear. However, the authors do argue that there is reason to believe that early aggressive treatment of elevated blood glucose after head injury is warranted.

Boughey JC, Yost MJ, Bynoe RP. Diabetes insipidus in the head-injured patient. Am Surg 2004;70:500-503.

This is a descriptive article detailing the significance of diabetes insipidus (DI) in head-injured patients, not the proper treatment thereof. Of 888 patients with head injuries admitted to the intensive care unit over 4 years, 26 (2.9%) developed DI. Three had gun shot wounds of the head, and the rest had blunt injury, by far most due to motor vehicle impacts. Twenty-three of the 26 presented with Glasgow Coma Score V 6, all had Intracranial bleeding of some kind, most had cerebral edema, and many with Midline shift. The mean time of onset of DI was 1.5 F 0.7 days in nonsurvivors versus 8.9 F 10.2 days in survivors. If DI onset was on the first day, mortality was 100%; within the first 3 days after injury, 86%. All patients who developed DI on day 4 or later after injury survived. This is a small but interesting series, giving us some useful information concerning prognosis we can use in dealing with severe head injury patients.

1. Spine

Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003;340:2510-2518.

This is an important article for all ED physicians to read. Ruling out cervical spine injury in victims of blunt trauma is a task performed many times every day in every ED in the country. Anyone in a motor vehicle collision, anyone assaulted, and anyone bfound downQ are brought in C-spine immobilized, and we in the ED must ensure that they have no spine trauma. Must we get x-rays on everyone? The first widely published algorithm to use for deciding who does and does not need C-spine

radiographs was the NEXUS (National Emergency X-Radiography Utilization Study) criteria in 1992. Because of some limitations of the Nexus criteria (mostly the interpretation of criterion 5 below), another group published the Canadian C-spine rule in 2001. The goal of the present study was to compare prospectively the accuracy, reliability, and clinical acceptability of these 2 protocols. Of importance is that both are used only with alert and neurologically intact patients; patients whose mental status is not intact enough to get a reliable history and physical must have x-rays to rule out spine injury.

NEXUS low-risk criteria are the following: (1) no posterior midline cervical spine tenderness, (2) no evidence of intoxication, (3) a normal level of alertness, (4) no focal neurological deficit, and (5) no painful distracting injuries; stable patients who meet these criteria do not need cervical spine x-rays. The Canadian C-spine rule consists of a determination of risk factors that guide the use of Cervical spine radiography. The evaluation has 3 components. First, are there High-risk factors, the presence of which mandated x-rays: Age 65 years or older, dangerous mechanism, or paresthesias in the extremities? Second, are there any of 5 low-risk criteria, the presence of any of which suggests x-rays are not necessary: simple rear- end motor vehicle collision, sitting position in the ED, ambulatory at any time after the event, delayed onset of neck pain, or absence of midline or

Association for the Surgery of Trauma in the United States, which are available on the Web at www.east.org. They were assembled using comprehensive searches of the medical literature by acknowledged experts in the field, following standard 21st century evidence-based medical scientific methodology. The guidelines are concise and worth reading in their entirety, but to summarize briefly: diagnostic peritoneal lavage or focused assessment sonography for trauma should be used to search for intraperitoneal blood; if these are positive and there is ongoing hemorrhage, laparotomy and concomitant pelvic stabilization are indicated; angiography is indicated if there is pelvic arterial bleeding found at laparotomy or if there is ongoing hemorrhage in the face of a negative diagnostic peritoneal lavage or focused assessment with sonography for trauma; optimal angiographic embolization is with steel coils or gel foam; and the optimal pelvic stabilization technique is noninvasive, that is, a bed sheet wrapped around the pelvis in the ED, followed by external fixation in the operating room (before laparotomy, if possible).

The second article examines the authors’ experience over a 1.5-year period before the compilation of the guidelines and documents that the care given during that period in their own hospital fell short of optimum as defined by the guidelines.

cervical spine tenderness? Third, is the patient able to actively rotate his/her

neck 458 to either side? The authors used both systems to assess over 8000 patients with blunt trauma and found that the Canadian C-spine rule was superior, with higher sensitivity (99.4% vs 90.7%), specificity, reliability, and clinical acceptability, than the NEXUS system. Moreover, its use would have resulted in lower radiography rates than with the use of NEXUS criteria. This is an important article–read it and then decide for yourselves which system you want to use.

Brandt MM, Wahl WL, Yeom K, et al. Computed tomographic scanning reduces cost and time of complete spine evaluation. J Trauma 2004;56: 1022-1028.

It takes a lot of time and effort to get plain films of the spine on trauma patients. Can’t those fancy nth-generation computed tomography (CT)

Rowe SA, Sochor MS, Staples KS, et al. Pelvic ring fractures: implications of vehicle design, crash type, and occupant characteristics. Surgery 2004; 136:842-847.

The objective of this study was to determine if there are any vehicle- related factors associated with pelvic fractures. The data came from a National Highway Transportation Safety Administration database developed in 1996 called CIREN, which organizes information about motor vehicle crashes detailing vehicle, impact, and occupant medical characteristics. The data examined in this article covered 38 adults with Pelvic fractures seen over a 6-year period. The authors found that lateral-impact crashes, high- speed crashes, and crashes in which a car was struck by a van, truck, or sport- utility vehicle were most likely to produce pelvic fractures in the occupants and that women were 3 times as likely to have a pelvic fracture as men.

scanners get the information? This study was undertaken to see if the digital

data obtained from chest, abdominal, and pelvic CTs could indeed be used to obviate the need for plain films of the thoracic, lumbar, and sacral spine. The authors reviewed the plain radiographs of 55 blunt trauma patients and compared them with reformatted CT scans done on a GE Highspeed series or GE Lightspeed series helical scanner on the same patients. Of the 55, 47 had thoracolumbar fractures. Thirteen patients were found to have

33 thoracolumbar spine fractures that were identified by computed tomography, but not by Plain radiography. No injuries seen on plain film were missed by CT. The radiation required for the plain films was 350 mGy. Thus, CT scans are more sensitive than plain films for spine fractures. In addition, they give all the information on the Soft tissues as well. I would add that all the Orthopedic specialists I know want fine-cut CTs of any pelvic fractures seen on plain films. It certainly appears that the days of plain films of the spine are numbered.

1. Orthopedic

Heetveld MJ, Harris I, Schlaphoff G, et al. Guidelines for the management of hemodynamically unstable pelvic fracture patients. Aust N Z J Surg 2004;74:520-529.

Heetveld MJ, Harris I, Schlaphoff G, et al. Hemodynamically unstable pelvic fractures: recent care and new guidelines. World J Surg 2004;28: 904-909.

The first of these 2 articles presents a set of clinical practice guidelines developed by a multidisciplinary consensus committee in southwest Australia (Sydney, New South Wales). The guidelines are quite comparable with the practice management guidelines published by the Eastern

Kimbrell BJ, Velmahos GC, Chan LS, et al. Angiographic embolization for pelvic fractures in older patients. Arch Surg 2004;139:728-733.

Control of bleeding is the most challenging immediate aspect of dealing with acute pelvic fractures. Among the various methods of hemorrhage control are compression of the pelvic wings/Iliac crests with tools ranging from bedsheets, military antishock trousers, and mechanical clamps, to formal external fixators; angiographic embolization; and operative control with direct vascular ligation and/or packing. Angiogra- phy is labor-intensive and requires a major commitment by the hospital. The aim of this study was to define clinical characteristics by which we might be able to identify those patients who require and will benefit most from angiography. The authors reviewed all blunt trauma patients with pelvic fractures who required angiography over a 4-year period. Pelvic angiography was performed in patients who either were hemodynamically labile in the absence of other sources of bleeding or who had specific patterns of pelvic fractures such as a vertical-sheer, open-book, or butterfly fracture, along with a pelvic computed tomography demonstrat- ing a large pelvic hematoma. The patients were managed aggressively and proactively: angiography was most often performed before multiple units of blood and crystalloid had been infused. Of 92 patients who underwent pelvic angiography, 60% had bleeding demonstrated angiographically and successfully embolized. Besides the Fracture patterns noted above which are known to be often associated with arterial bleeding, the authors found that patients 60 years and older had a higher likelihood than younger patients of having angiographically identifiable and treatable bleeding. One main difficulty which remains is that many of patients with pelvic fracture have venous hemorrhage, which is not yet amenable to angiographic control.

Breederveld RS, Tuinebreijer WE. Investigation of computed tomographic scan concurrent criterion validity in doubtful scaphoid fracture of the wrist. J Trauma 2004;57:851-854.

Most emergency physicians are well aware of snuffbox pain and tenderness as being the cardinal indications scaphoid fracture. Fractures of the scaphoid bone of the wrist are the most common hand fractures and are often not visible on initial x-rays. Missed scaphoid fractures often lead to chronic osteoarthritis and pain. In the past, evaluation of the painful wrist has commonly used bone scanning to look for signs of an old missed scaphoid fracture. The authors of the present study investigated the performance of computed tomography (CT) scan in the Acute diagnosis of fracture of the scaphoid. Patients who entered the ED with wrist pain underwent a physical examination and plain film radiographic evaluation, and a CT was obtained within 4 days; bone scan was performed within a week. CT scan performed flawlessly in each of 29 patients thus managed, with a sensitivity, specificity, and positive and negative predictive values of 100%. The authors conclude that CT scan is a rapid, simple, and relatively inexpensive method to make the diagnosis of a scaphoid fracture and henceforth should be obtained in all patients with the appropriate symptoms and signs but negative plain films.

1. Vascular

Mayberry JC, Brown CV, Mullins RJ. Blunt Carotid artery injury, the futility of aggressive screening and diagnosis. Arch Surg 2004;139:609-613.

You may remember that in the mid-1990s, there appeared several reports from major trauma groups that blunt injury to the carotid and vertebral arteries was much more common than had previously been thought, that the consequences–dissection and/or thrombosis–led to devastating stroke, and that we all needed to be much more aggressive in ruling out such injuries. The issue is still very much alive and contentious. This article, the first of 3 discussed in this year’s bibliography concerning blunt injury to the extracranial cerebral vessels, addresses 1 of the thorny issues: how do we decide who needs to be studied to rule out cerebrovascular injury? Previously published series have used the following screening criteria to perform evaluations of the carotid artery: cervical hyperextension or hyperflexion, a direct blow to the head and/or neck, cervical seat-belt sign, a Glasgow Coma Score of 6 or lower, diffuse axonal brain injury on computed tomography, cervical spine fracture, Skull fracture, basilar skull fracture, midface fracture, and other significant maxillofacial trauma. The authors of this retrospective report reviewed the records of all patients admitted to 2 level I trauma centers over a 10-year period, seeking to evaluate several of these risk factors and find out if an aggressive screening protocol can lead to early diagnosis of blunt carotid injury and thereby prevent associated adverse outcomes. They reviewed a database containing 35212 blunt trauma admissions. Only 11 patients sustained blunt carotid injury-related stroke, and 9 of these developed stroke within 2 hours of injury. The authors concluded that screening for blunt carotid injury requires an enormous expense, yet very little can be gained because the irreversible damage is usually done before patients can even be screened, much less treated. The discussion at the end of the article, as well as the 2 articles discussed below, provides alternative opinions.

Berne JD, Norwood SH, McCauley CE, et al. Helical computed tomographic angiography: an excellent screening test for blunt cerebral vascular injury. J Trauma 2004;57:11-19.

If we do decide to screen for blunt injury to the extracranial cerebral vessels, which study should we use? The objective of this article was to report the performance of computed tomography (CT) angiography. The authors used helical CT angiography as a screening tool for patients presenting to their level I trauma center according to the following criteria:

patients with basilar skull fracture, cervical spine injury, multiple severe

Facial fractures, or cervical seat belt abrasion; patients with a Glasgow Coma Score 8 or less in the field or in the ED; and patients with lateralizing neurological signs. They identified 19 patients with 25 blunt cerebral vascular injuries and concluded that this technique is an excellent method to screen for this type of injury. It is noninvasive, can be performed relatively rapidly (more rapidly than conventional angiography, which requires mobilization of the angiography team and facilities), and is very accurate. On the other hand, CT angiography is still not available in many, if not most, hospitals and is in fact rather cumbersome and expensive to be used widely as a true screening test, examining large numbers of patients.

Cothren CC, Moore EE, Biffl WL, et al. Anticoagulation is the gold Standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg 2004;139:540-546.

Finally, we address the question of the optimum therapy for those extracranial cerebral vessel injuries we do find. This report comes from

1 of the trauma centers in which aggressive screening is being used. The authors note that blunt carotid artery injuries are now diagnosed in almost 1% of patients who have blunt trauma, and as discussed above, early and aggressive screening is necessary to establish the diagnosis before the onset of irreversible damage. Screening protocols are based on injury mechanism and associated injuries. Signs and symptoms of blunt carotid injury include Arterial hemorrhage, cervical bruit, expand- ing Cervical hematoma, focal neurological deficit, and frank stroke. Risk factors include high-energy transfer, basilar Skull fractures, Le Fort II or

III fractures, cervical spine fractures, and near hanging. The authors performed arteriography on all patients with the above symptoms, signs, or risk factors. Six hundred forty-three patients of 13280 patients sustaining blunt trauma underwent diagnostic angiography, and carotid artery injuries were found in 114 (overall incidence 0.86%). The injuries were graded 1 to 5. Grade 1 was a vessel wall irregularity with some dissection, but less than 25% luminal narrowing. Grade

2 included intraluminal hematomas or narrowing of the lumen greater than 25%. Grade 3 was a pseudoaneurysm; grade 4 was vessel occlusion, and grade 5 was vessel transection. Seventy-three of the 114 patients with carotid artery injuries underwent anticoagulation after diagnosis. Treatment included heparin in 54, low-molecular-weight heparin in 2, and Antiplatelet agents in 17. None of these patients had long-term neurological events. Forty-one patients did not receive anticoagulation therapy, and 19 of these developed neurological ischemia. Ischemic neurological events also occurred in 100% of patients who presented with symptoms before the angiographic diagnosis was made. The authors emphasized that a high index of suspicion is indeed required in patients with the appropriate mechanism of injury, that aggressive screening is warranted, that arteriography is the study of choice to make the diagnosis, and that anticoagulation is the appropriate therapy.

Klineberg EO, Crites BM, Flinn WR, et al. The role of arteriography in assessing popliteal artery injury in Knee dislocations. J Trauma 2004;56: 786-790.

It is important to recognize patients who have had vascular injury associated with fractures and dislocations. Injuries to the popliteal artery associated with anterior or posterior dislocations in the past have been associated with a very high amputation rate. Because of this, many have advocated that all patients with knee dislocation must undergo angiography. The authors of this article asked if physical examination findings could be used to rule out popliteal injury and obviate the need for angiography. They retrospectively reviewed the records of 55 patients with blunt knee dislocation and found that if the physical examination was completely normal, with full distal pulses and a normal ankle/brachial index, no patient had an arterial injury. Of 25 patients with an abnormal physical

examination, 11 had a major vascular injury, and all required revascular- ization with reverse saphenous vein bypass graft.

1. Burns

emergency medicine consultants (attending physicians) were on the teams, whereas consultant surgeons never were. Of note, this was a higher percentage than in adult hospitals in Australia, the United Kingdom, and the United States. The teams were activated from the field based on anatomical, physiological, and mechanistic criteria.

Sheridan RL, Tompkins RG. What’s new in burns and metabolism. J Am

Coll Surg 2004;198:243-263.

This review article by experts in the field summarizes the present status, new developments, and future directions in the field of burn care. Acute deaths from burn shock and intermediate deaths from wound sepsis have declined significantly. Sophisticated respiratory care for patients with inhalation injuries has made lung injury a less frequent cause of mortality. Techniques of using skin substitutes (including Integra) are described. The importance of care provided by an organized system is emphasized, as is rehabilitation, both physical and psychological. This is an excellent article, one well worth reviewing by anyone who ever sees acute burns.

1. Pediatric

Keller MS, Coln CE, Trimble JA, et al. The utility of routine trauma labo- ratories in pediatric trauma resuscitations. Am J Surg 2004;188: 671-678.

A universal component of the initial management of multitrauma patients, along with taking off all the victims clothes and starting Intravenous medications, is sending bloods off to the laboratory. This

Suthers SE, Albrecht R, Foley D, et al. Surgeon-directed ultrasound for trauma is a predictor of intra-abdominal trauma in children. Am Surg 2004;70:164-168.

abdominal computed tomography scan is the gold standard for diagnosis of intra-abdominal injury in blunt trauma victims who are stable and without peritoneal signs. This prospective study compared the combination of surgeon-performed physical examination (PEx) and FAST (focused assessment [formerly babdominalQ] sonography for trauma) versus abdominal CT. One hundred twenty injured children underwent all 3 examinations over a 22-month period. Focused assessment sonography for trauma alone had a sensitivity of only 70% but a specificity and positive predictive value of 100%. A combination of PEx and FAST gave a sensitivity of 100%, and now a negative predictive value of 100%, although specificity decreased to 74%. So what does this mean? We are in no way going to give up CT scans. The implication of this study to me is that we could be justified in using the combination of PEx and FAST a screen to decide which patients need a CT. If the screening PEx and FAST are negative– and, I would add, stay negative over at least several hours–then we can safely forego a CT.

article asks, do we need to do this, do we learn anything from these

laboratory tests? Admittedly, adults may have underlying diseases or conditions and may have ingested various toxins that we need to screen for. However, Pediatric trauma patients rarely have either of the above. Moreover, it is almost universal that pediatric trauma patients undergo computed tomography (CT) scanning, so that checking liver function tests as a sign of liver injury, for example, is unnecessary– we are going to get a picture of the liver anyway. The authors of this article reviewed all the routine admission blood tests obtained on 240 btrauma statsQ at their level I pediatric trauma center over a 2-year period. Only 10% had no laboratory test abnormality. However, less than 10% of the patients required intervention or management changes as a result of the blood test. Some of the abnormalities, such as hyperglycemia or hyperchloremia, were of no particular importance. Some, such as low hematocrit, were common (27%), but transfusions were given in only 9 children, and 7 of these were hemodynamically unstable; the 2 other patients received transfusion because they were in shock on examination, and they had normal Hematocrit levels. Children with elevated liver function tests often had liver injury, but the reason for obtaining the CT had nothing to do with the laboratory tests. Hematuria was predictive of intra-abdominal injury, but only those with gross hematuria had renal injury on CT. Abnormal Coagulation studies were associated with head injury, but only

Nwomeh BC, Nadler EP, Meza MP, et al. Contrast extravasation predicts the need for operative intervention in children with blunt splenic injury. J Trauma 2004;56:537-541.

The aim of this study was to determine whether the finding of contrast blush on computerized tomography predicts failure of nonoperative therapy in children with blunt splenic injury. bContrast blushQ is a well-circum- scribed area of contrast extravasation in the parenchyma. The study cohort consisted of all patients admitted with blunt splenic injury to the authors’ level I pediatric trauma center over a 6-year period. All patients underwent computerized tomographic scanning with intravenous contrast. In this retrospective review, the authors found a statistically significant correlation between the finding of contrast blush and the requirement for operative intervention. They concluded that the finding of contrast blush on splenic computed tomography is a specific marker of active, usually arterial, bleeding, which often does not spontaneously stop. Contrast blush alone is not a definite indication for operation, but it should at least increase one’s vigilance in continuous monitoring and reassessment. Many centers use contrast blush on computed tomography as an indication for angiographic embolization [cf, bAbdomenQ].

when the Glasgow Coma Score was less than 15. The authors’ conclusion

is that shotgun screening tests are, in general, of little use. They recommend that all patients have hematocrit, urinalysis; that prothrombin time, partial thromboplastin time, and international normalized ratio be done on any patient with an abnormal Glasgow Coma Score; and that other blood tests be ordered in the initial evaluation only when indicated by findings on physical examination.

Wong K, Petchell J, Paediatric trauma teams in Australia. Aust N Z J Surg 2004;74:992-996.

This is another article for those interested in how things are done outside the United States. All 8 pediatric Tertiary care hospitals in Australia were interviewed. Three quarters of the centers had organized pediatric trauma response teams, made up by registrars (residents) from both emergency medicine, surgery, and pediatrics; sometimes (daytime only)

Barsness KA, Bensard DD, Ciesla D, et al. Blunt diaphragmatic rupture in children. J Trauma 2004;56:80-82.

This is a retrospective review of Children’s Hospital and Denver Health Medical Center’s experience with children treated for diaphrag- matic injury over a 10-year period. Of 1397 pediatric patients with blunt abdominal trauma, 6 (0.4%) had diaphragmatic rupture. The diagnosis was occult, and most diagnostic testing was inaccurate. Four of the

6 diaphragmatic injuries were identified during the initial trauma evaluation. In one, the diagnosis was made by chest x-ray, and 3 others had suggestive findings on chest x-ray and/or computed tomography. Two children had missed diagnoses on initial evaluation; both of these had right hemidiaphragm injuries. Delayed diagnosis is a common problem in diaphragmatic injuries. Morbidity and mortality are increased by Delay in diagnosis, with a risk of herniation and strangulation. Children, as opposed to adults, often have disruption of the right hemidiaphragm.

Associated injuries, most often of the spleen and liver, are common. A high index of suspicion is required, and any diaphragmatic abnormality demonstrated on chest x-ray should be investigated.

Nance ML, Lutz N, Carr MC, et al. Blunt renal injuries in children can be managed nonoperatively: outcome in a consecutive series of patients. J Trauma 2004;57:474-478.

The authors of this report reviewed the records of all 95 pediatric patients with blunt renal injury they had seen over the previous 8 years. The most common mechanisms of injury were falls and pedestrian versus auto impacts, followed by Motor vehicle collisions, bicycle crashes, and assaults. Only 1 child of the 95 required laparotomy for the renal injury; all the rest was successfully managed nonoperatively, no matter what the AAST grade of renal injury. The few complications of nonoperative management, including urinoma and ureteral obstruction, were managed with minimally invasive techniques as well.

1. Obstetric

Warner MW, Salfinger SG, Rao S, et al. Management of trauma during pregnancy. Aust N Z J Surg 2004;74:125-128.

This is a well-written concise summary of the basic principles–no details here– of caring for trauma victims who are pregnant. The authors reviewed their own experience with 34 pregnant trauma patients seen over 8 years and then reviewed the literature. General items of note: only 20% of pregnant trauma patients have Obstetric complications, and by far most of these are the seriously injured; however, all pregnant trauma patients are at risk and therefore should be monitored. Initial management is of course to treat the mother, with obstetric evaluation and consultation being part of the secondary survey. Cardiotocographic monitoring is indicated whenever the gestational age is greater than 22 weeks; this can be discontinued if all is well with both mother and fetus over a 4-hour period. The most common obstetric complications of trauma are premature labor, spontaneous abortion, and placental rupture, the latter being the most common cause of fetal compromise. Ninety percent of premature contractions settle spontaneously.

Muench MV, Baschat AA, Dorio PJ, et al. Successful pregnancy outcome after splenic artery embolization for blunt maternal trauma. J Trauma 2004;56:1146-1148.

This is a case report of traumatic splenic artery disruption in a pregnant patient, illustrating the basic principle of caring for pregnant

anterior-superior iliac spines and pubic symphysis, and between the breasts for the shoulder harness. The main factors sited for not wearing seat belts were discomfort and forgetfulness. Education of patients on proper seat belt use should be an essential part of all prenatal care.

1. General/Miscellaneous

Peleg K, Aharonson-Daniel L, Stein M, et al. Increased survival among Severe trauma patients. The impact of a national trauma system. Arch Surg 2004;139:1231-1236.

The United States started developing trauma systems in the 1970s. This article describes some of the results of the establishment of an official trauma system in Israel (which is geographically about the size of the state of New Jersey). There are 6 designated level I trauma centers to which all major trauma patients are triaged. The authors present data from all 6 level I trauma centers in the country, noting the change in mortality and morbidity over a 5-year period. The authors focused on multiply injured trauma patients with an Injury Severity Score greater than 16 (7423 patients). The majority of patients were men (74%), the median age 28 years, and 90% had blunt mechanism. Sixty-six percent had brain injuries. The authors demonstrated a significant decrease in mortality over the 5-year period, decreasing from 21.6% to 14.7%. Improvements in the trauma delivery system included Prehospital advanced life support, ED growth and development including staffing with emergency medicine and trauma specialists, and formal designation of level I trauma centers. The trauma centers revamped their ED and trauma facilities, and the providers made great efforts to improve their Knowledge base and skills by participating in postgraduate courses on trauma management. The authors conclude that the implementation of a National Trauma System had indeed a significant and worthwhile effect on trauma morbidity and mortality in their country.

Taheri PA, Butz DA, Lottenberg L, et al. The cost of trauma center readiness. Am J Surg 2004;187:7-13.

For those of you who must deal with the administrative aspects of providing trauma care, this article is a good reference to use when both planning and trying to secure funding. The authors culled the information gathered from extensive questionnaires from 10 of the 20 level I and II trauma centers in Florida. Trauma centers had a median annual fixed cost of over US$2 million that is not billed or reimbursed just to provide physician coverage. The myriad direct and indirect costs and benefits of providing trauma care are discussed, and a framework is presented for determining and sorting out the various implications for planning and policy.

trauma patients: to save the fetus, one must save the mother. The 29-

year-old woman was pregnant with a fetus of 17 weeks’ gestation when she was involved in a motor vehicle collision with blunt abdominal trauma. Computed tomography demonstrated a grade III splenic disruption with a contrast blush in the spleen. Successful angiographic embolization of the splenic artery was performed. The pregnancy was otherwise uncomplicated and resulted in live-born healthy infant with Apgar score of 9.

McGwin G, Russell SR, Rux RL, et al. Knowledge, beliefs and practices concerning seat-belt use during pregnancy. J Trauma 2004;56:670-675.

In this study, 450 pregnant women receiving prenatal care at a county health facility were asked to complete a survey during their prenatal care visit, focusing on the patients’ understanding of the proper use of seat belts. Nearly all patients surveyed responded that their seat-belt use was either the same as, or greater than, their use had been before becoming pregnant. The majority knew how to wear the seat belt properly, which is of course with placement of the lap belt under the pregnant abdomen and over both

Demetriades D, Murray J, Charalambides K, et al. Trauma fatalities: time

and location of hospital deaths. J Am Coll Surg 2004;198:20-26.

The purpose of this study was to analyze when and where Trauma deaths occurred in relation to the mechanism of injury, age, injury severity, and injured body parts. The authors felt that identification of the time and place of trauma death would be useful in identifying areas that might benefit from more focused research, education, and allocation of resources. The Los Angeles County and University of Southern California Medical Center (1 of the largest trauma centers in the United States) provided the information on 64724 trauma admissions. Overall mortality for blunt trauma was 5.7%, penetrating trauma 11.7%, gunshot wounds 14.8%, and stab wounds 3.4%. Of the patients who died, 52% had penetrating trauma and 48% blunt trauma. Gunshot wounds accounted for 46% of the deaths, followed by pedestrians struck by automobiles (16%), motor vehicle crashes (13%), stab wounds (6%), and falls (3%). Most (82%) of the deaths were men, and the mean age was 36 years, with the highest number of traumatic deaths in the age group 21 to 40 years. Most of those who died had a Glasgow Coma Score of 3 on admission. Patients arriving with no vital signs or dying within

60 minutes of admission accounted for 39.3% of the deaths; penetrating trauma caused 53% of the these. Thirty-four percent of the deaths occurred between 1 and 24 hours of admission. Deaths due to severe chest trauma were more likely to occur within the first 60 minutes of admission in the ED. Deaths of patients with severe abdominal trauma occurred mainly in the operating room, and deaths of victims with severe head injury occurred in the intensive care unit. The temporal distribution of deaths depended on the mechanism, the injured body part, injury severity score, and age. This article is excellent reading, and it should stimulate other trauma centers to analyze similarly their own data.

MacLeod JBA, Lynn M, McKenney MG, et al. Predictors of mortality in trauma patients. Am Surg 2004;70:805-810.

As we move into the 21st century and the era of evidence-based medicine, outcomes research is 1 of the best ways we have to scientifically study trauma care, as prospectively randomized controlled trials are not in general feasible. The authors of this article, from 2 large academic trauma centers, analyzed a large database from the National trauma registry to find independent risk factors which are identifiable early in trauma patients’ course. They found the potentially treatable independent prognosticators of all-cause mortality after trauma to be low hemoglobin, elevated prothrombin time and partial thromboplastin time, low scene and trauma bay systolic blood pressure, and elevatED base deficit. Untreatable independent indicators of mortality were head injury, increasing age, and Injury Severity Score. The authors were not able to demonstrate a causal relationship: did the low hemoglobin itself contribute to mortality, or was it just a marker of severe injury? However, the identification of these risk factors has at least 2 important implications. First, the presence of these risk factors should alert the clinician to maintain vigilance, especially when dealing with patients in whom obvious injuries are not at first recognized. Second, a foundation has been laid for future work to address whether treatment of these specific risk factors per se can directly impact outcome.

Sieling BA, Beem K, Hoffman MT, et al. Trauma in nonagenarians and centenarians: review of 137 consecutive patients. Am Surg 2004;70: 793-796.

The graying of America is a reality. However, the effect on the trauma community is 2-fold: bpeople are not only living longer lives, but more active ones, which increases their risk of being involved in a trauma.Q Many articles have documented the fact that the elderlies as a group have more severe injuries from a given magnitude of trauma, and also, they are more difficult and time consuming to manage because of more comorbidities and less physiological reserve. On the other hand, many articles have demonstrated that outcomes can be excellent if centers are willing and able to give the elderly trauma patients optimum care. This article is a retrospective review of 137 trauma patients, all 90 years or older seen over 2 years at a level I center. Five were 100 years or older, and 80% were women. The mechanism of injury was a fall in 93%, usually (64%) falls from ground level; surgery was required in one quarter. Despite the relatively low-energy mechanism, average Injury Severity Score, complication rate, length of hospital stay, and mortality were all higher in these extremely old patients compared even with the younger elderly. However, the outcomes were good in the great majority. Caring for elderly victims of trauma requires heightened attention to detail

trauma patients. All individuals admitted to the intensive care unit of the authors’ level I trauma facility over a 1-year period were separated into

2 groups by body mass index greater or less than 30 kg/m². Demographics, including injury scores, of the 2 groups were statistically the same. The authors found that obese patients had a significantly higher incidence of multiorgan failure and higher overall mortality. Postulated contributing factors were deep venous thrombosis, gastro- esophageal reflux, insulin resistance, and reduced lung functional residual capacity and compliance. The authors were able to demonstrate that obesity is an independent variable in predicting mortality as a result of blunt trauma.

Crandall ML, Nathens AB, Rivara FP. injury patterns among female trauma patients: recognizing intentional injury. J Trauma 2004;57:42-45.

domestic violence is a prominent source of injury to women. The lifetime risk of intimate partner violence ranges from 26% to 37%. Current or former partners murder approximately 30% to 50% of female homicide victims. Nearly 80% of the approximate 2.5 million women who are assaulted each year know their attacker. The ED is often the point of entry into the health care system for victims of domestic violence. Unfortunately, many, if not most, victims are reluctant to admit the mechanism. The authors felt that if specific patterns of injury in women with intimate partner violence could be recognized, it would help to alert the ED physicians to the underlying problem and the necessity for intervention. They compared patterns of injury caused by blunt intentional trauma with those caused by blunt unintentional trauma, using a database created from hospital inpatient discharge data from states maintaining a uniform hospital discharge reporting system. The authors found that facial, head, and neck injury were much more common in victims of domestic violence than in victims of unintentional trauma. This injury pattern should be recognized by ED caregivers and prompt deeper investigation.

Tominaga GT, Garcia G, Dzierba A, et al. Toll of methamphetamine on the trauma system. Arch Surg 2004;139:844-847.

Methamphetamine has become a commonly used drug in many areas of the United States. Crystal methamphetamine, popularly known as bice,Q is a free-base type of amphetamine and is the smokeable form. The drug is very much like cocaine and acts as a potent stimulator of the central nervous system that induces feelings of euphoria, increases alertness, reduces fatigue, intensifies emotions, increases aggression, and (perhaps) increases libido. Unlike cocaine, the effects last for 6 to 12 hours or more. When inhaled, the effects are almost instantaneous. The drug induces psychomotor impairment. The present study was undertaken to determine whether the use of methamphetamine impacts hospital length of stay and hospital resource use in minimally injured patients. The authors evaluated 212 consecutive trauma patients seen over a 12-month period. Fifty-seven were positive, and 155 were negative for methamphetamine. Most of the patients who tested positive were not significantly injured but spent a prolonged length of time in the hospital and in the intensive care unit. The authors postulated that much of the reason for the prolonged stays was due to the altered symptoms that patients on methamphetamine will manifest, including tachycardia, diapho- resis, and an altered sensorium. Trauma center resources are in a sense babusedQ by the abuse of this drug.

as well as abundant resources, but it is worth it. Rozycki GS. What’s new in trauma and critical care. J Am Coll Surg 2004;198:798-808.

Neville AL, Brown CVR, Weng J, et al. Obesity is an independent risk factor of mortality in severely injured blunt trauma patients. Arch Surg 2004;139:983-987.

We all know that obesity is now epidemic in the United States. The authors of this article examined the effects of obesity on the outcome of

This is a very nice review article of the trauma research literature published in the year 2003. The author emphasized articles that dealt with trauma organization, blood substitutes, nonoperative management of patients with Solid organ injuries, critical care medicine, and complications of trauma. There is an extensive bibliography.

1. Terrorism

Almogy G, Belzberg H, Mintz Y, et al. Suicide bombing attacks–update and modifications to the protocol. Ann Surg 2004;239:295-303.

Sharon E, Feigenberg Z, Weissman C, et al. Evacuation priorities in mass casualty terror-related events–implications for contingency planning. Ann Surg 2004;239:304-310.

Peleg K, Aharonson-Daniel L, Stein M, et al. Gunshot and explosion injuries–characteristics, outcomes and implications for cure in terror- related injuries in Israel. Ann Surg 2004;239:311-318

Frykberg E. Principles of mass. Casualty management following terrorist disasters (Editorials). Ann Surg 2004;239:319-321.

The authors found that the incidence of subdural hematomas and Subarachnoid hemorrhages increased progressively with age; epidural hematomas were uncommon in all groups. The occurrence of brain contusions was similar in all age groups, except age older than 65 years where the frequency doubled. The incidence of Spinal injury increased with age. The incidence of severe chest injury increased significantly with age; interestingly, there were no aortic tears in patients younger than 14 years. There was no significant difference in injuries to the liver, spleen, kidney, or gastrointestinal tract among the age groups. The younger age group had a higher incidence of femur fractures. Overall, older patients had both a higher number of and severity of injuries and had a higher morbidity and mortality.

Hirschberg A. Multiple casualty incidents: lessons from the front line

(Editorials) Ann Surg 2004;239:322-324.

Terrorist activity is a new brand of pathology to which most American surgeons and ED physicians are not accustomed. These 3 articles come from doctors caring for patients involved in multiple casualty incidents from terrorist acts in Israel. They summarize the management of the terrorist victims and emphasize the importance of control of the scene, assessing the victims for immediate life-threatening problems, and a bscoop and runQ policy to the nearest appropriate hospital. Immediate transport to a trauma center may not be possible if the distance is great. It is important that the patients be triaged, assessed, and repetitively reassessed, so that the appropriate therapeutic interventions can be made and injuries will not get missed.

As stated in the editorial by Doctor Frykberg, bIt is past time that we begin taking to heart the critical need to learn the basic principles of mass casualty management from terrorist disasters!Q This is an excellent group of articles, and I would recommend them highly.

Kales SN, Christian DC. Acute chemical emergencies. N Engl J Med 2004; 350;800-808.

This excellent review article discusses the medical aspects of exposure to several Toxic substances which can be encountered in industrial accidents or in chemical weapon attacks. It is important for ED clinicians to recognize the toxidromes associated with exposure to these substances. The article reviews asphyxiates (cyanide), cholinesterase inhibitors (organophosphorus nerve agents), and respiratory tract irritants (chlorine and vesicants [mustard]). Important specifics discussed include the importance of and methods used for immediate decontamination, protection of health care- givers, pathophysiology of toxicity of the agents, clinical symptoms and signs, and proper drug and supportive treatment.

Pikoulis EA, Petropoulos JCB, Tsigris C, et al. Trauma management in ancient Greece: value of surgical principles through the years. World J Surg 2004;28:425-430.

This is a fascinating, short (6-page), and entertaining description of ancient Greek traumatology for those who might be interested. Included among other tidbits are Hippocrates’ contributions, the mortality of arrow versus sword wounds in the Iliad, and the efficacy of wine as a wound irrigant.

1. Motor vehicle

Demetriades D, Murray J, Martin M, et al. Pedestrians injured by automobiles: relationship of age to injury type and severity. J Am Coll Surg

Cummings P, Rivara FP. Car occupant death according to the restraint use of other occupants. JAMA 2004;291:343-349.

The authors of this study used information from the National Highway Traffic Safety Administration database in a matched cohort design to see if there was any association between the death of a car occupant and the Use of restraints by other occupants in the vehicle. They found that there was indeed a relationship of deaths in a motor vehicle crash and the use of seat-belt restraints not only by the driver, but also of other occupants. The most important reason for this association was that unrestrained passengers in either the front or the backseat can become projectiles, striking other car occupants.

Estrada LS, Alonso JE, McGwin G, et al. Restraint use and lower extremity fractures in frontal motor vehicle collisions. J Trauma 2004;57:323-328.

The purpose of this study was to determine if there was any effect of the use of seat belts and/or air bags on the incidence of lower extremity injury from motor vehicle collisions. The authors used the National Highway Traffic Safety Administration’s National Automotive Safety Sampling System as a source of data for analysis, focusing on all front seat occupants, both drivers and passengers. They found that the incidence of lower extremity fractures was the highest when air-bag deployment alone was used as a safety device; occupants restrained with either seat belt only or seat belt and air bag had lower risks of fracture. The authors felt that these results suggest not only that seat belts are still imperative even in cars equipped with air bags, but also that alterations in air-bag design and deployment are needed.

Knudson MM, Schermer C, Speetzen L, et al. Motorcycle helmet laws: every surgeon’s responsibility. J Am Coll Surg 2004;199:261-264.

Although the benefits of motorcycle helmet use are clear to all of us involved in trauma care, the laws that mandate the use of helmets have unfortunately begun to be eroded. This article provides evidence from the American College of Surgeons Committee on Trauma Prevention Subcom- mittee to enable all providers of trauma care to support helmet laws and help prevent repeals or modifications in their states. The information includes financial and economic data as well as morbidity and mortality associated with nonhelmet injuries. Head injury continues to be the leading cause of death in motorcycle crashes, and helmet use decreases both mortality and morbidity. In patients injured but not killed, helmet use decreased the need for and duration of mechanical ventilation, the length of Intensive care unit stay, and the need for rehabilitation. In addition to the medical benefits, the cost savings of helmet use and the additional medical and rehabilitation expenses for nonuse were quoted to be US$35000000 and US$120000000, respectively.

199:382-387.

Adams BD, Medeiros R, Dereska P, et al. Geriatric all-terrain vehicle

The purpose of this study was to evaluate the association between age, on the one hand, and injury type and severity on the other, in pedestrians struck by cars. The records of more than 5000 trauma registry patients treated over the course of 10 years were reviewed. Patients were divided into 4 age groups: younger than 14, 15 to 55, 56 to 65, and older than 65 years.

trauma. Am Surg 2004;70:329-332.

All-terrain vehicles are not just for skateboarding risk-taking adolescents anymore. With the graying of America, the elderlies (herein N60 years old) are the fastest growing segment of ATV riders; most are in

rural areas. The authors of this report compared 8 elderly ATV drivers injured in crashes to younger ATV riders and found results that parallel those found after regular motor vehicle crashes: the predictive physiological scores, functional outcomes, and mortality were worse, and their hospital stays were longer. The authors call for organizations such as the AARP to extend driver safety programs to ATV training and for all ATV riders to be required to wear helmets.

Biffl WL, Schiffinan JD, Harrington DT, et al. Legal prosecution of alcohol- impaired drivers admitted to a level I trauma center in Rhode Island. J Trauma 2004;56:24-29.

This is an interesting and thought-provoking article. The authors report that in the year 2002, alcohol was involved in 41% of fatal motor vehicle crashes in the United States, making it the third straight year in which this percentage has increased. The purpose of this study was to document the frequency of prosecution and conviction for driving under the influence, and the rate of prior and subsequent driving violations among patients at the Rhode Island Hospital level I trauma facility. The Rhode Island Hospital Trauma Registry was queried for all patients older than 16 years with a blood alcohol concentration of greater than 100 mg/dL admitted to the trauma service during an 18-month period. Records were assessed to identify which patients had been charged with motor vehicle violations and what charges had been filed. Of 387 individuals where the blood alcohol concentration was measured, 137 had blood alcohol greater than 100 mg/dL. One hundred thirteen of these individuals were Rhode Island residents; of these, only 22 (19%) were charged with traffic offenses related to their motor vehicle crash: driving under the influence in 12 (11%), driving with a suspended license in 7 (6%), and reckless driving in 3 (3%). Two of the 12 driving under the influence charges were ultimately dismissed, resulting in a conviction rate of only 9% of the 113 intoxicated drivers. Of the 12 patients charged with driving under the influence, 2 (17%) had additional prior or subsequent driving under the influence charges. Ninety-one (81%) of the legally Intoxicated patients were not charged with any offenses related to their motor vehicle crash. Of these 91, 20 (22%) had had prior traffic offenses before their index motor vehicle crash, and 11 patients (12%) had subsequent traffic offenses. Ten (11%) had previous or subsequent driving under the influence charges. It is estimated that on Friday and Saturday nights between the hours of 10 pm and 3:00 am, 1 in every 10 drivers is intoxicated! From the results of this Rhode Island study, it can be seen that little has been done to prevent motor vehicle crashes occurring as a result of intoxicated drivers. Laws that are in existence are weak. This article should raise a red flag to all physicians who care for injured patients. There is no excuse for allowing this condition to persist!

Aaland MO, Hlaing T. Amish buggy injuries in the 21st century: a retrospective review from a rural level II trauma center. Am Surg 2004; 70:228-234.

There are approximately 150000 members of Amish religious commu- nities distributed over 26 states of the United States (mostly in Ohio, Pennsylvania, and Indiana, and all in the northeast), and that number is expected to double in the next 15 years. Because these people eschew motor vehicles and use horse-drawn buggies, this article was written to demarcate the pattern of injuries seen in crashes of buggies versus motor vehicles. The experience of a single trauma center over 7 years was reviewed, analyzing 36 patients in 24 crashes. There were 5 fatalities. Two thirds had closed head injury, almost all had extremity injuries, 7 had spine injuries (3 cervical, 4 thoracic or lumbar), and 16 required operation.

1. Firearms

Adibe OO, Caruso RP, Swan KG. Gunshot wounds: bullet caliber is increasing, 1998-2003. Am Surg 2004;70:322-325.

Ballistics and especially wound ballistics are fascinating subject. This report provides a review/primer of firearm ballistics and then

compares the bullets recovered from gunshot wound victims seen in the authors’ trauma center in the 1980s and early 1990s to those found in victims between 1998 and 2002. They found that the average bullet caliber in the earlier period was 31/7.83 mm, compared with an average bullet caliber in the later period of 35/9.16 mm. These values correspond to an increase in the kinetic energy of the projectile of 50%. Despite the increase in wounding capacity, the authors found no significant increase in overall mortality, although the data were not perfectly complete. There was no information given about Injury Severity Score or other measure of the severity of the gunshot wounds. They assert that the reason mortality has not increased is that both field and trauma center care for victims have become increasingly efficient and comprehensive, such that many patients who would have died of their wounds are now survivors.

Keller JE, Hindman JW, Kidd JN, et al. Air-gun injuries: initial evaluation and resultant morbidity. Am Surg 2004;70:484-490.

Air (or pneumatic or pellet or BB) guns are legally considered toys in most states, with little legislation restricting sales to minors or requiring adult supervision. Yet they are indeed, as demonstrated in this article, capable of producing significant, even lethal, injuries. An estimated 30000 emergency room visits per year are for air gun injuries, most by far of which occur in children, and an increasing number of which are intentional. Air gun projectiles have muzzle velocities of 300 to 900 ft/s; it takes a muzzle velocity of only 130 ft/s to penetrate the eye and some skin, 230 ft/s to penetrate thick skin, and 350 ft/s to penetrate the bone. Partly because air gun projectiles do not tumble, they cause little blast effect or cavitation and produce what superficially appear to be innocuous wounds. This retrospective review describes 35 air gun inju- ries (eye injuries were excluded because they are always serious) in children seen at a level I trauma center over 10 years. Twenty-one of the victims required admission, 19 required surgery for brain, spine and spinal cord, cardiac, vascular, and intestinal injuries, and 5 have permanent serious disability. The authors’ main point is that air gun injuries, although they appear on the surface to be unimpressive, must be treated with the same urgency and thoroughness as patients with conventional gunshot wounds.

Miller M, Hemenway D, Azrael D. Firearms and suicides in the northeast. J Trauma 2004;57:626-632.

This report investigates the relationship between firearm prevalence and suicide. The authors reviewed complete hospital discharge data for all suicide attempts in 7 New England states, where the authors were working in close cooperation with state health departments. They found that the suicide rate was positively related to the prevalence of firearms: wherever there are more firearms, there are more successful suicides. When it comes to suicide, the availability of household firearms matters.

1. Venous thromboembolism in trauma patients

Knudson MM, Ikossi DG, Khaw L, et al. Thromboembolism after trauma: an analysis of 1,602 episodes from the American College of Surgeons National Trauma Data Bank. Ann Surg 2004;240:490-498.

For those interested in venous thromboembolic (VTE) disease after trauma, this is a most interesting article. Trauma patients in general have all 3 components of Virchow triad for predisposition to Deep venous thrombosis : stasis, hypercoagulability, and endothelial damage. The incidence of VTE after trauma has been variously estimated to be anywhere between 7% and 58%, with the majority of reports over the past few decades agreeing on the higher figures. The authors of the present article, however, used the largest data bank available in the country, the

American College of Surgeons National Trauma Data Bank, to zero in on the best estimate. The data from over 730000 trauma patients from 268 trauma centers in 36 states were searched for all episodes of DVT, pulmonary embolism, or a combination of both, and all identifiable risk factors were sought. Risk factors associated with VTE were found to be age older than 40 years, pelvic fracture, lower extremity fracture, spinal cord injury, head injury, ventilator days greater than 3, lower extremity venous injury, shock on admission, and major surgical procedures. Patients who developed VTE were most often men with Blunt mechanisms of injury. The mean injury severity score of patients with VTE was not particularly high: 69% had an Injury Severity Score of less than or equal to 9, 24% were between 10 and 25, and only 7% were greater than

25. The overall incidence of DVT was quite surprisingly low, with 998 (0.36%) patients of 430375 developing DVT and 82 (0.13%) having pulmonary embolism. The authors could detect no benefit from prophylaxis using low-dose unfractionated heparin but did find that low- molecular-weight heparin (enoxaparin) was effective. The authors found that inferior vena caval filters had been used quite frequently, but most of the filters were prophylactic, and there was no evidence of DVT in the majority of the patients in whom it was used. In conclusion, the authors state that the incidence of VTE in trauma patients is much lower than has been thought. This may be because of the widespread use of prophylaxis. They felt that, because of this low incidence of VTE, prophylactic vena caval filters are rarely required, and they called for a review of the indications for its use. This very interesting article provides new data which are at odds with much of the literature of the past 2 decades, and it deserves careful attention.

Velmahos GC, Toutouzas KG, Vassiliu P, et al. Can we rely on computed tomographic scanning to diagnose pulmonary embolus in critically ill surgical patients. J Trauma 2004;56:518-526.

Pulmonary emboli (PE) are a significant surgical problem and a potentially preventable one: less than 10% of all PE deaths occur in patients in whom treatment is initiated. Early and accurate noninvasive diagnosis would be ideal. Recent studies have claimed that helical/Spiral computed tomography (CT) scan is highly sensitive and specific for detecting PE. The authors of this article compared CT pulmonary arteriography with conventional pulmonary arteriography in a group of critically ill surgical patients having severe trauma. A total of 37 patients suspected of having PE underwent both CT pulmonary arteriogram and conventional pulmonary arteriography. Conventional angiography was positive in 15; 9 of these had developed PE within the first 4 days of hospitalization, and 2 developed PE within the first 24 hours. Seven patients had peripheral emboli, and 8 had central emboli. Compared with standard pulmonary angiogram, 9 CT pulmonary arteriography scans were false negatives and 2 were false positives. Clots that form after trauma are usually soft clot and easily

without symptoms suggestive of a PE or Deep venous thrombosis . Patients were studied on postinjury days 3 and 7. PEs were graded using a modification of the Miller scoring system. In this system, anatomical scores range from 0.25 to 20 and are based on Blood clots in the pulmonary artery and its segments: each main pulmonary artery with clot receives a score of 10, each segmental artery a score of 1, and each involved subsegmental artery a score of 0.25. Patients were classified according to Clot burden:

0.25 to 2 is considered minimal burden, 2.25 to 4 is considered moderate burden, and greater than 4.25 is considered major clot burden. Treatment recommendations were no treatment of minimal clot burden without coexistent DVT and anticoagulant treatment of all patients with moderate or major clot burden or minor clot burden with coexistent DVT. The authors found that patients with PE were older (40 vs 31 years) and were more severely injured. They were more likely to have blunt injury and more likely to have received transfusions. Twenty-two of 90 asymptomatic patients had a PE; 4 of these had major clot burden, and 18 had minor clot burden. No patient in either group died. This article raises many questions. What is the significance of subsegmental PE? Should asymptomatic PE be treated? Is computed tomography scanning the appropriate screening test for PE? Many of the patients in this study received prophylaxis–how effective is the current prophylaxis?

Velmahos GC, Toutouzas K, Brown C, et al. Thromboprophylaxis does not protect severely injured patients against pulmonary embolism. Am Surg 2004;70:893-896.

Ever since the identification decades ago of trauma as 1 of the most common causes of venous thromboembolic (VTE) disease, the trauma community has been struggling with how to prevent DVT and PE in seriously injured patients. Methods used range from (pneumatic) sequential compression devices on the legs, to subcutaneous unfractionated heparin in various doses, low-molecular-weight heparin, coumadin, and even prophy- lactic inferior Vena cava filters; early detection in patients at high risk has also been tried using serial Doppler ultrasonography and even venography. We are all still frustrated by this sticky wicket. This prospective study was performed in response to a meta-analysis which concluded that presently used prophylaxis did not reduce VTE in trauma patients. The present article was not a prospective, randomized, control study, but rather analyzed all patients evaluated for clinical suspicion of PE with either computed tomography or conventional pulmonary angiography, and found that there was no difference between those with PE and those without in terms of whether prophylaxis was used or the type of prophylaxis used. VTE prophylaxis in trauma patients remains an important and unsolved problem. An interesting sidelight: of 21 patients with PE documented by angiography, only 7 had DVT on duplex ultrasonography of the legs–thus, if you suspect a trauma patient may have a PE, studying the legs will not give you any help.

broken up, so that they often lodge in the smaller peripheral pulmonary

arteries. Two findings from this study are surprising and quite important. First, PE occurs early in posttrauma patients. Second, CT angiography evaluates bperipheralQ emboli poorly. The popularity of using tomography for the diagnosis of PE should be questioned, and pulmonary arteriography still remains the bgold standardQ for diagnosis of PE.

Schultz DJ, Brasel KJ, Washington L, et al. Incidence of asymptomatic pulmonary embolus in moderately to severity injured trauma patients. J Trauma 2004;56:727-732.

The purpose of this study was to determine the incidence of pulmonary emboli (PE), as diagnosed by helical computed tomographic angiography, in asymptomatic trauma patients, as well as to determine the consequences of withholding anticoagulation in patients with minor clot burden. This is an excellent article which should be read after the article written by Velmahos et al above. This was a prospective study of consecutive trauma patients with an injury severity score greater than or equal to 9 who were

Kurtoglu M, Yanar H, Bilsel Y, et al. Venous thromboembolism prophylaxis after head and spinal trauma: intermittent pneumatic compression devices versus Low Molecular Weight Heparin. World J Surg 2004;28:807-811.

Patients with head and spine injuries are among the most at risk for developing VTE. This is a well-set-up and carried-out study comparing in a prospective, randomized, controlled trial the efficacy of intermittent pneumatic compression (IPC) devices with low-molecular-weight heparin (LMWH, enoxaparin 40 mg/d) in prevention of DVT and PE in patients with severe head and/or spine injuries. (Of note, patients with spinal cord injuries were excluded for some reason; I would guess–but I may be wrong–that this was because spinal cord injury patients are at such high risk for VTE that withholding heparin would be unsafe.) Patients were screened for DVT with weekly duplex color-flow Doppler ultrasound, and suspicion of PE was investigated with spiral computed tomography. DVT developed in 4 of 60 patients in the IPC group, and 3 of 60 in the LMWH group, whereas 2 of 60 in the IPC group died of PE versus 4 of 60 in the LMWH group. The incidence of exacerbation of hemorrhagic brain injury

was the same low 1 of 60 in each group, although the transfusion requirement was a bit higher in the LMWH group. Neither the DVT, PE, nor mortality was different between the groups. The power of this single- center study was not high enough for definitive proof (with a = .05 and b = .2, power = 0.2). The authors conclude that IPC can be used safely in head-injured patients. I would conclude rather that IPC and the dose of LMWH used here are equally safe and equally suboptimal–perhaps the combination would be even better.

Charles J. McCabe, MD

Department of Emergency Medicine Massachusetts General Hospital, Boston, MA, USA

Ralph L. Warren, MD

Department of Surgery Gallup Indian Medical Center, Gallup, NM, USA