Trauma: an annotated bibliography of the most recent literature—2006
Literature of Emergency Medicine
Trauma: an annotated bibliography of the most recent literature-2006
Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
Received 11 January 2007; accepted 11 January 2007
Resuscitation
FitzSullivan E, Salim A, Demetriades D, et al. serum bicarbonate May Replace the Arterial Base deficit in the Trauma Intensive Care Unit. The American Journal of Surgery 2005;190:941-946.
The primary goal in the treatment of patients who had significant volume loss and are hypotensive is to restore tissue perfusion. It is important to avoid the bvicious cycleQ of hypothermia, acidosis, and coagulopathy. A marker of adequate restoration of intravascular volume is illusive. The measurement of blood pressure, pulse, and urine output may be inadequate. In the past, arterial base deficit has been commonly used. The base deficit represents the number of milliequivalents of additional base that must be added to a liter of blood to normalize the pH. To obtain base deficit, an Arterial puncture is necessary, and for continued monitoring, an arterial catheter may be necessary. The authors were interested in determining whether the serum bicarbonate could provide the same information as the base deficit. They were able to demonstrate after evaluating over 3000 patients that the serum bicarbonate was equivalent to the base deficit in providing information that was superior to the serum lactate, pH, and anion gap. They suggest that serum bicarbonate, which is more easily obtained, would be a highly accurate and reliable test for identifying the presence of a significant metabolic acidosis and is clearly superior and outperforms the conventional methods of pH, lactate, and anion gap. A serum bicarbonate of 25 is equivalent to a base deficit of 0, and a bicarbonate of 19 correlates to a deficit of 5.
Shock
Rizoli SV, Rhind SG, Shek PN, et al. The Immunomodulatory Effects of Hypertonic Saline Resuscitation in Patients Sustaining Traumatic Hemor- rhagic Shock: A Randomized Controlled DoubleBlinded Trial. Annals of Surgery 2006;243:4757.
Resuscitation of traumatic hemorrhagic shock has been standardized and has normally included Ringer lactate, fresh frozen plasma, and blood. The objective of the present study was to investigate the
immunomodulatory effect of the hypertonic saline/dextran in patients sustaining hemorrhagic shock after trauma. Patients were randomized to receive either a single 250-mL bolus of hypertonic saline dextran or placebo. Blood was drawn subsequently to evaluate the cellular and molecular inflammatory markers known to be altered by shock resuscitation. These data were intended to provide bproof of principleQ for larger trials that intended to study clinical outcomes with this resuscitation regimen.
The authors’ results demonstrated anti-inflammatory and immunologic properties of hypertonic saline plus dextran in trauma patients having hemorrhagic shock. The authors found that hypertonic saline plus dextran exerts profound immunomodulatory effect promoting a more balanced inflammatory response.
This was an interesting and well-performed study, one that should be studied carefully by those who are interested in shock and in the use of dextran in shock.
Abdomen
Dente CJ, Feliciano DV, Rozycki GS, et al. The outcome of open pelvic fractures in the modern era. The American Journal of Surgery 2005;190:830-835.
The purpose of this article was to investigate the outcome for patients with open Pelvic fractures that have been noted in several studies during the past decade to have improved and to document the outcome of patients with combined Intra-abdominal injuries and open pelvic fractures. The authors reviewed the records of 44 patients diagnosed as having open pelvic fractures during a 10-year period. It was common for patients to have associated intra-abdominal injuries, resulting in 12 patients requiring laparotomy within the first 60 minutes of their admission. Rectal injuries occurred in 7 patients, in which 4 survived Initial resuscitation and were diverted within 24 hours. The overall mortality rate was 45%, and 11 patients died within 24 hours of arrival in the hospital from exsanguina- tion. Causes of death included pelvic sepsis, traumatic brain injury, respiratory arrest, and pulmonary embolism. The requirement for blood transfusion was common. They found that pelvic sepsis became a predictor
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of late mortality, whereas age, mechanism of injury, and the presence of a rectal injury did not.
Emergency management priorities in patients with open pelvic fractures include control of hemorrhage, stabilizing the pelvic ring, aggressive assessment and management of the open wounds, early diagnosis of rectal and abdominal/vaginal injuries, and the selective use of fecal diversion. Mortality remained high at 45%, and this was associated with increasing injury severity score, decreasing Revised Trauma Score, and Glasgow coma scores as well as Transfusion requirements.
The authors conclude that the outcome of patients with open pelvic fractures has not changed greatly in the past 2 decades. The need for therapeutic angiography in a patient with an open pelvic fracture is associated with a particularly poor outcome. Clearly, more work in the therapeutic intervention of this pathology is needed.
Kuan JK, Wright JL, Nathens AB, et al. American Association for the Surgery of Trauma Organ Injury Scale for Kidney Injuries predicts nephectomy, dialysis, and death in patients with blunt injury and nephrec- tomy for Penetrating injuries. Journal of Trauma 2006;60:351-356.
The authors used a retrospective cohort design to determine the association between increasing American Association for the Surgery of Trauma Organ Injury Scale Scores and nephrectomy, dialysis, and mortality. The cohort included all patients with a renal injury identified in the National Trauma Data Bank and admitted from 1994 to 2003. The purpose was to determine the use of this scoring system to predict outcome.
The American Association for the Surgery of Trauma Organ Injury Scale is relatively easy to remember. A grade 1 injury is a contusion with minor superficial nonexpanding hematomas. Grade 2 injury is less than 1 cm laceration without Urinary extravasation. A grade 3 is a greater than 1 cm laceration again with no urinary extravasation. Grade 4 injury is a parenchymal laceration extending through the renal cortex, medulla and collecting system, main renal vessel involvement. Grade 5 is a shattered kidney. The authors evaluated 742,724 patient records from the National Trauma Data Base, of which 8465 had renal injuries. Blunt mechanisms for renal trauma were predominant representing 81% of the cases. Nephrectomy was performed in 7.3%. Dialysis was required in 0.46% of renal injured patients. Death occurred in 11.3% with renal injury.
The authors demonstrated an association between the American Association for the Surgery of Trauma Renal Injury Grading System and patient morbidity (nephrectomy and dialysis) and mortality for blunt trauma and for nephrectomy in patients with penetrating injury. The scoring system was able to predict mortality and morbidity and is an excellent scoring system that should be used to assess patients in the emergency department and also help with retrospective evaluation of care.
Kozar RA, Moore FA, Cothren CC, et al. Risk factors for hepatic morbidity following Nonoperative management. Archives of Surgery 2006;141:451-459.
The current method of management of hepatic trauma is nonoperative observation in the hemodynamically stable patient. In this multicenter study, the authors evaluated a large number of patients over a 40-month period. Sixty thousand eight hundred forty-two blunt trauma admissions were screened to provide 2851 patients who sustained blunt hepatic injuries. nonoperative treatment was initially pursued in 453 patients with complex hepatic injuries that make up the study cohort.
The patients were vigorously followed to evaluate for complications associated with nonoperative management. The complications of nonoper- ative management required bmultimodality intervention.Q Endoscopic retrograde cholangeopancreatography with stenting and interventional radiology drainage procedures were used frequently. Angioembolization was commonly used for patients who had Bleeding complications. biliary complications were frequent, and bile peritonitis occurred requiring either
laparoscopic irrigation with drainage or laparotomy. Hepatic-related infections including abscess formation, lobar necrosis, and biloma were seen frequently. These were usually managed with interventional radiology. Nonoperative management of high-grade hepatic injuries has improved mortality, but there is a significant incidence of morbidity, and patients require careful monitoring and are primarily treated with nonoperative interventions. The nonoperative management of the complications of nonoperative management has continued to improve mortality associated with significant hepatic injuries.
Ollerton JE, Sugrue M, Balogh Z, et al. Prospective study to evaluate the influence of FAST on trauma patient management. Journal of Trauma 2006;60:785-790.
This study prospectively evaluated how focused assessment with sonography for trauma influences patient management in a major trauma service under standard working conditions. This is a study of all patients admitted to a major Australian hospital that receives trauma. The patients admitted required trauma team notification and were divided into 2 groups: one group receiving FAST and the second group receiving no FAST. At the time of the study, the authors were still performing Diagnostic peritoneal lavage at times. They found that performing the FAST examination avoided the necessity for performing diagnostic peritoneal lavage. Computed tomography was performed less frequently. Unstable patients who underwent sonography had emergency laparotomy performed expeditiously without the use of computed tomography. The sonography facilitated a more direct route to the operating room, a computed tomography, or observation.
The benefit of sonography includes the rapidity with which it can be performed while the patient is undergoing resuscitation. It is reproducible, portable, and noninvasive. It should be a part of all trauma patients’ assessment during resuscitation.
Salim A, Sangthong B, Martin M, et al. Use of computed tomography in anterior abdominal Stab wounds. Archives of Surgery 2006;141:745-752.
Selective conservatism is the ideal method of management of anterior abdominal stab wounds. The goal is to prevent unnecessary laparotomies. Laparotomy is reserved for patients with peritonitis, hypotension with peritonitis, and evisceration. All of the adjuncts to physical examination including local wound exploration, diagnostic peritoneal lavage, laparos- copy, and ultrasonography have been used in an effort to minimize unnecessary laparotomy. The purpose of the present study was to evaluate the role of single-contrast computed tomography using intravenous contrast as an adjunct to physical examination in patients with intra-abdominal Stab wounds selected for nonoperative management.
Under the protocol, all persons admitted with intra-abdominal stab wounds were observed with repetitive examinations with or without helical Computed tomographic scans. There were 67 patients who underwent computed scanning, 8 patients who had solid organ injury, 6 patients who had pneumoperitoneum, and 11 who had isolated free fluid in the peritoneal space. The authors found that computed tomography had a high sensitivity and a 100% negative Predictive power. The authors found that computed tomography is a very useful adjunct to both decreased hospitalization and the need for laparotomy. Diagnostic tests can help to identify injuries early and to potentially select patients who can be discharged from the emergency department with minimal observation.
Gaarder C, Dormagen JB, Eken T, et al. Nonoperative of splenic injuries: improved results with angioembolization. Journal of Trauma 2006; 61:192-198.
The purpose of this article was to investigate the impact of introducing an arterial embolization protocol in severe splenic injuries on outcome as
measured by laparotomy and splenectomy rates. The authors studied 149 adult patients admitted with splenic injuries and divided the patients into groups 1 and 2. Group 1 patients were those who provided the historical control when no protocol was established. Group 2 includes those who had arterial embolization in severe splenic injuries as part of their treatment protocol. In the protocol, large hemoperitoneum, high splenic injury grade with or without contrast extravasation, old age, and head injury were not considered contraindications to nonoperative management. According to the protocol, embolization was performed in all patients with diagnosed splenic injury with an organ injury score of 3 and higher and with any patient with ongoing hemorrhage.
A total of 69 patients were included in group 1, and 64 patients were included in group 2. The number undergoing emergency laparotomy decreased from 43% to 27% with the established protocol. Splenectomy was performed less frequently in group 2, with the overall splenic salvage rate increasing from 57% to 75%. The authors felt that their study documents that by introducing the new protocol requiring arterial embolization in grades 3 and 4, organ injury score improved nonoperative management and decreased the rate of nonoperative management failure.
Avidan V, Hersch M, Armon Y, et al. Blast lung injury: clinical manifestations, treatment and outcome. The American Journal of Surgery 2005;190:927-931.
The present study reviews the experience of a level II trauma center in Jerusalem with patients who have had blast injuries as a result of terrorist bombing. Forty-one patients required intensive care unit admission after being exposed terrorist bomb activity. Patients who had lung injury presented with hypoxemia and respiratory distress. Hypoxia was common with Pulmonary infiltrates demonstrated by chest x-ray. Butterfly patterns of pulmonary infiltrates were common, and they were often associated with pneumomediastinum and pneumothoraces. Seventy-six percent of the patients required endotracheal intubation and mechanical ventilation. Two patients had suspected air embolus. One patient developed ventricular tachycardia/fibrillation after their acute injury. Another patient had a left hemiparesis with no evidence of Brain infarction. Intracranial air or spinal cord injury was not evidenced on computerized tomography. The neurologic deficit gradually resolved.
There are 3 common primary blast injuries: (1) ruptured tympanic membrane, (2) blast lung injury, and (3) intestinal blast injury. The most common injuries seen by the authors were primary blast lung injury caused directly by the pressure wave. Chest wall displacement occurs toward the spinal column leading to high intrathoracic pressure. The alveolar septae are torn with stripping of the airway epithelium and rupture of the alveolar spaces with subsequent alveolar hemorrhage, edema, and alveolo venous fistulae. The triad of respiratory distress, hypoxia, and the characteristic bbutterfly or bat wingQ pulmonary infiltrates on chest x-ray is a common pattern. Decreased breath sounds may be evidenced on physical examination. Hypoxia is commonly associated in all patients with blast injury. Mechanical ventilation is the appropriate therapeutic intervention with care to use appropriate pressure when ventilating. Ruptured tympanic membrane is a common injury associated with blast injury. Observation is the appropriate management. Air emboli associated with blast lung injury is probably the most serious consequence and can result in emboli to the cerebral and coronary arteries. Treatment consists of oxygen to hasten absorption of the air bubbles. Hyperbaric oxygenation is an excellent therapy when available. The prognosis with the current available therapy is usually excellent.
Chest
Lebl D, Dicker RA, Spain DA, et al. Dramatic shift in the primary management of traumatic thoracic aortic rupture. Archives of Surgery 2006;141:177-180.
The objective of this study was to retrospectively analyze the treatment options and their respective outcomes for traumatic aortic injury at the authors’ level I trauma center. They were specifically investigating the use of endovascular stent grafts in the treatment of traumatic thoracic aortic rupture. The difficulties with treating the traumatic rupture of the aorta revolve around the operability of the patient for transthoracic repair of this injury. Often, patients are excluded because of significant head, lung, and risks of paraplesia, stroke, and renal failure.
The authors prospectively analyzed blunt traumatic patients admitted during a 6-year period at their institution. Hospital records were reviewed, and the anatomic location of the aortic injury was recorded. Three groups of patients were defined based on primary treatment of the traumatic aortic injury: (1) thoracotomy and open Surgical repair, (2) medical management only, and (3) endovascular stent placement. Medical management consisted of the use of substances like esmolol, metoprolol, or labetalol with monitoring of the systolic blood pressure both during hospitalization and after discharge.
The overall survival rate for this injury was 80% with no differences in morbidity or mortality among the 3 groups. The stented group had a shorter hospital length of stay. The authors conclude that endovascular stent grafting has become the treatment of choice in patients who have had a traumatic aortic rupture.
Andrassy J, Weidenhagen R, Meimarakis G, et al. Stent vs open surgery for acute and chronic traumatic injury of the thoracic aorta: a single center experience. Journal of Trauma 2006;60:765-772.
The objective of this study was to present the authors’ experience with the management of these lesions and compare the outcome of the endovascular treatment with the conventional Open repair. In this Retrospective investigation, 46 patients with traumatic injuries of the thoracic aorta were included. Since 1997, most patients at the authors’ center were treated with Endovascular therapy.
Patients were divided into 4 groups. Groups 1 and 2 had acute injuries to the thoracic aorta requiring repair as an emergency either by endovascular (n = 15) or the open route (n = 16). Groups 3 and 4 had chronic aortic aneurysms of their thoracic aorta. Endovascular treatment with a stent graph was performed in 15 acute patients and conventional open surgery in 16. The overall 30-day mortality was 16% in patients treated for acute or contained aortic rupture and not significantly different after endovascular versus open repair (13% vs 18%). There was no mortality in patients receiving elective stent grafting or open surgery for chronic posttraumatic aortic aneurysms. The authors found that the perioperative incidence of paraplegia was remarkably lower in patients who had a stent graft placed as was the duration of time in the intensive care unit.
Vignon P, Martaille JF, Francois B. et al. Transesophageal echocardiog- raphy and therapeutic management of blunt aortic injuries. Journal of Trauma 2005;58:1150-1158.
The authors sought to describe retrospectively transesophageal echocar- diographic findings observed in patients with major blunt aortic injury who underwent immediate versus postponed surgery. Blunt aortic injury can be considered minor (intramural hematoma or limited intimal flap) and major (subadventitial rupture or modification of the geometric shape of the aorta or acute transsection with active bleeding or aortic obstruction with ischemia). Thirty-one patients who sustained blunt aortic injury diagnosed by trans- esophageal echocardiography were included in this study. Thirteen patients had major aortic injury requiring rapid surgery. Eleven patients had major aortic injury that required delayed surgery because of closed head trauma, severe hypoxemia, or severe sepsis. These patients were treated with antihypertensive medicines and operated upon once their clinical condition improved. Seven patients had minor blunt aortic injuries including an intimal flap or small subadventitial hematoma and were managed conservatively. Of
note, no patient’s death could be attributable to free aortic rupture in patients managed conservatively or undergoing delayed repair. Patients who were managed conservatively were followed with transesophageal echocardiography.
The authors conclude that conservative management of blunt aortic injury with serial follow-up using echocardiography may be appropriate. Postponed (delayed) surgery in patients with injuries, which preclude immediate operation, is successful.
Pratesi C, Dorigo W, Troisi N, et al. Acute traumatic rupture of the descending thoracic aorta: endovascular treatment. American Journal of Surgery 2006;192:291-295.
The authors review their experience with the use of endovascular grafting in patients that have traumatic aortic injury. The major complica- tions associated with the surgical repair of this lesion have been mortality and paraplegia. The authors have a small study, but this technique was used in 11 cases. No patient developed temporary or permanent neurologic deficits or deaths, and the authors were able to conclude that this treatment of acute traumatic rupture of the descending thoracic aorta is safe and provides very low Morbidity and mortality rates.
Martin MJ, McDonald JM, Mullenix PS, et al. Operative management and outcomes of traumatic lung resection. Journal of the American College of Surgeons 2006;203:336-344.
The authors reviewed the National Trauma Data Bank to analyze the presenting injury patterns and outcomes among a large cohort of patients undergoing lung resection for trauma. Most lung resections were lobectomies and wedge resections performed for penetrating chest trauma. One hundred patients underwent complete pneumonectomy. The data demonstrated that patients undergoing more extensive lung resections had a higher percentage of blunt injury and considerably worse injury severity scores and outcomes. There was a 53% mortality for pneumonectomy. The procedure performed will depend upon the extent of lung damage, but this present study would opt for minimal resectional surgery.
Disaster
Fry DE, Schechter WP, Hartshorne MF. The surgeon and acts of civilian terrorism: radiation exposure.and injury. Journal of the American College of Surgeons 2006;202:146-154.
Radiation terrorism can be defined as the use of radioactive materials to create real or perceived injury to civilian populations. Radioactive material is readily available from nuclear waste processors, nuclear power plant materials, medical research radiotherapy units, and industrial sources. This terrorism can be accomplished where small amounts of radioactive materials, liquids, or gases could be disseminated in a public setting. Radioactive materials could be included in a conventional explosive device or bdirty bomb.Q Potential explosives could target a nuclear power plant or a nuclear waste storage facility. Public and professional knowledge concerning radiation injury and its overall management is inadequate. This article provides a discussion of the physics, injuries, and medical management of radiation injury. This is an excellent article and one that provides the basics to be prepared for the management of this type of incident.
Acute radiation sickness has 4 phases. The prodromal phase is principally identified by nausea, vomiting, and fever. The time of onset is a sensitive indicator of the severity of the exposure. The latent phase is the symptom-free interval that follows the acute nausea and vomiting. The manifest phase is when clinical symptoms of hematopoietic, gastrointestinal, and neurologic injury are seen. The final phase is recovery and is related to
the severity of exposure. There is a very good chart that depicts the pathoPhysiologic effects identified with their times to occurrence and exposure to radiation. Mortality is variable and dose-dependent.
Management of radioactivity exposure requires preparedness on the part of the prehospital emergency medical system and the medical community. The emergency response and evacuation of casualties is the key first event. Effective field triage, decontamination, and evacuation of casualties are essential. Decontamination in the field or in transport is necessary. The prehospital community must be prepared to keep themselves from also becoming injured when providing care to the radiation casualties.
There are 5 injuries that can potentially occur after radiation exposure. These include (1) Physical injury, (2) acute irradiation, (3) external radioactive contamination, (4) internal radioactive contamination, and (5) psychological injury. The article goes on to discuss each of these 5 potential injuries.
Radioactive materials can be included in a conventional explosive device or dirty bomb. With either a dirty bomb or nuclear detonation, there will be physically injured patients with unknown degrees of acute irradiation. Blast injuries, penetrating debris and glass, collapse of physical structures, and thermal wounds will potentially generate large numbers of mass casualties. Acute radiation exposure will result in physiologic events that will depend upon the amount and duration of radiation exposure. A very good chart summarizes the physiologic effect of duration and degree of radiation exposure. External radioactive exposure requires clothing removal and washing or shaving of the hair and rinsing the skin with tepid water. Internal radioactive contamination will occur as a result of either
ingestion or inhalation of radioactive materials. Inhaled particles greater than 5 lm will be cleared by normal mucociliary activity. Smaller insoluble particles will lodge in the alveolar level and may cause fibrosis over time. Ingestion of radioactive material can cause structural damage of the
gastrointestinal tract. gastric lavage can reduce ingested radioactivity immediately. Laxatives and purgatives can accelerate clearance of agents from the gut. Perhaps the most significant potential injury may occur as a result of psychological effect of radioactivity exposure. Dirty bombs, in general, will not cause any long-lasting problems and mortality, but the impact on a population particularly in an urban setting will be extensive. It is essential and necessary to understand the types of exposure that potentially can occur and the appropriate management. Caregivers must be prepared to protect themselves to provide appropriate care.
Almogy G, Rivkind AI. Surgical lessons learned from suicide bombing attacks. Journal of the American College of Surgeons 2006;202:313-319.
The medical world is much more aware of terrorist bombing activity. The September 11, 2001 coordinated attacks in the United States, the bombing of the Madrid trains, and the suicide bombing attacks on the public transportation system in London have accelerated our knowledge and necessitated the need to be prepared for this type of injury. A mass casualty incident is defined as a large number of casualties produced in a relatively short period, such as an earthquake, tsunami, or hurricane, during which the local abilities to handle the victims of such incidence are overwhelmed. Modern suicide terrorism is aimed at causing devastating physical damage, through which it inflicts profound fear and anxiety and disrupts routine daily life. Its goal is to produce a psychological effect on the community. The most extensive available database on terrorist activity comes from the Israeli National trauma registry. This database and the experience acquired at the Hadassah University Hospital in Jerusalem form the basis of the present review.
The targets for suicide bombing are chosen to amplify and dramatize the effect of the explosion. They usually include trendy cafes, crowded popular restaurants, busy nightclubs, commuter trains, Inner city buses, and crowded open public spaces. The choice of explosive device varies according to the target. When activating an explosive device next to a building or to a passing vehicle, the attackers have used large amounts of low-grade explosive material. Injuries in these circumstances are caused by
either the collapse of the building or the blast wave. Most deaths on buses and in semiconfined spaces are caused by blast effect. There has been a recent change in the type of Explosive devices being used. The explosive material, which in the past was a homemade, low-grade material, has been replaced by high-grade military material. Often, a large amount of heavy shrapnel is added to the bomb resulting in penetrating injuries. Detonation can occur through delayed timers. The explosive device is often carried now by the suicide bomber and detonated in the center of a crowd.
Four principle mechanisms result in injuries: (1) primary blast injury is caused by the rapid outward spread of the shock wave, (2) secondary blast injury is caused by penetrating missiles that are propelled by the blast wave,
(3) tertiary blast injury results from a patient’s body being displaced by expanding gases and landing on a solid object, (4) burns secondary to blast injury are often noted after explosions in a confined space.
The emergency medical services system, hospitals, and administration must be prepared for a multicasualty incident. It is important that the EMS system works on a bscoop-and-runQ technique. Patients are triaged at the scene with care being spent to decompress a Tension pneumothorax and to control hemorrhage. Patients with the most severe injuries and with no sign of life at the scene are usually not transported. Teams of trauma physicians with the appropriate paramedical personnel must be involved in the rapid assessment of the patient in the admitting area and transport of the patients to the operating room, intensive care unit, or to another facility. Preparation is absolutely essential and necessary. The most experienced and senior indi- vidual should be involved with the triage of arriving victims in the hospital’s admitting area. Aggressive evaluation and reevaluation are essential.
Nelson TJ, Wall DB, Stedje-Larsen ET, et al. Predictors of mortality in close proximity blast injuries during operation Iraqi freedom. Journal of the American College of Surgeons 2006;202:418-422.
The authors report their experience with blast injury in a forward deployed military, surgical unit with minimal medical resources. They sought to determine whether the presence of easily determined injuries by physical examination would help to triage patients in a multicasualty incident. The authors were members of a forward resuscitation surgical system in Iraq. Their care capabilities were limited. The authors found that sustained hypotension and the presence of 2 or more factors including 3 or more long bone fractures, penetrating head injury, and an associated fatality were associated with mortality. Having 2 or more of these factors was associated with a mortality of 86% versus 20% in patients having only less than 2 of these factors.
Those proximity blast injuries cause severe anatomic and physiologic damage. It is important to be able to assess these patients rapidly and to appropriately triage them to advanced care. Blast injuries are a thing of the present, and the emergency community must be ready to assess and triage these individuals rapidly and accurately.
Einav S, Aharonson-Daniel L, Weissman C, et al. In-hospital resource utilization during multiple-casualty incidents. Annals of Surgery 2006;243:533-540.
Unfortunately, terrorism is a present-day reality and something that a Knowledge base in necessity and preparation is essential. Explosions are, by far, the most common type of terror-induced, multicasualty incidents. The present study was undertaken to suggest guidelines for entire hospital organization during a multicasualty incident. In the study, a multicasualty incident was defined as an event that causes greater than 10 casualties or greater than 4 severely injured casualties to arrive within a brief time frame at a level 1 trauma center.
In this study, 34% of the patients arrived within 10 minutes of the incidents, and 65% arrived within 30 minutes. Severe injuries involved the chest, abdomen, and vascular system. Operative procedures were performed in 60% of the patients admitted (196), 116 of which were transferred by the
triage surgeon directly to the operating room. In Israel, a minimum amount of time is spent on the scene, so that the patients are quickly transferred to the hospital emergency department (ED). Providing an adequate number of Hospital beds at a moment’s notice and coordination of the operating room, the ED, and the intensive care unit is essential. Intensive care unit bed availability is crucial. Patients must be immediately evacuated from the ED to floor beds or to the recovery room. A simplified triage algorithm is used in the ED. In the ED, there is difficult balance between over and undertriage. Most of the significantly injured patients have abdominal, thoracic, or vascular injuries.
It is clear from studying this article that coordination of many aspects of the hospital is required to handle a multicasualty incident. There must be commitment on the part of the hospital, and it is essential that implementation of the necessary functions must be practiced with compliance of all the various departments.
Almogy G, Minetz Y, Zamir G, et al. Suicide bombing attacks: can external signs predict internal injuries? Annals of Surgery 2006;243:541-546.
Suicide bombing often results in numerous casualties. Victims need to be directed to the appropriate level of care, and life-threatening injuries need to be swiftly recognized and dealt with. Early diagnosis depends upon a focused physical examination and on limited imaging studies. Blast lung injury is frequently diagnosed and is caused by the rapid expansion of the blast wave, a phenomenon that is exacerbated in contained spaces. Intra- abdominal injuries are seen often as a result of penetrating trauma from shrapnel and bullets contained within the bomb. The present study attempted to develop the frequency and pattern of injuries associated with blast lung injury and intra-Abdominal injury.
The authors retrospectively reviewed the records of all patients injured as a result of suicide bombing attacks during the years 2001 to 2004. Three settings were normally targeted: (1) buses, (2) semiconfined spaces, and (3) open spaces. Patients injured in open spaces were more likely to have penetrating injury and less likely to have the effects of the blast wave (burns and tympanic membrane rupture). Blast lung injury can often be predicted if the terrorist attack occurred in a closed space. Penetrating injury to the head and injury to 4 or more areas were predictive of blast lung injury. Intra- abdominal injury could be predicted by the presence of penetrating torso injury or injuries to 4 or more areas of the body. Victims of terrorist bombing have a combination of blast injury, penetrating injury, and burns. Arrival of these patients in the emergency department obviously quickly leads to chaos. Triage cannot be performed according to conventional scoring systems. There is a need for a simple, quick, and intuitive method for determining the presence of internal injuries. The data demonstrate that external signs of injury to 4 or more body areas are predictive of blast, lung injury, and intra-abdominal injury. Injuries caused by the blast wave and the heat wave that ensues are increasingly more common as the setting changes from open spaces to semiconfined or confined spaces. Penetrating injury to the torso is highly predictive of intra-abdominal injury. Conservation of Imaging techniques is necessary with multiple casualties. In stable patients, computerized tomography and focused abdominal sonogram should be performed.
Einav S, Spira RM, Hersch M, et al. Surgeon and hospital leadership during terrorist-related multiple-casualty events. Archives of Surgery 2006;141:815-822.
This article summarizes the organization of a multiple-casualty response in an Israeli hospital. The study was designed to identify key staff members for hospital organization during multiple-casualty episodes and to obtain information regarding the strategies that have been developed and implemented by Israeli hospitals for the efficient overall hospital organization during multiple-casualty episodes. Clearly, this needs to be done before any event. The key individuals who were identified to ensure
that the response of the hospital would be organized included (1) surgeons,
(2) anesthesiologists, and (3) subspecialists in orthopedic surgery, emergency medicine, and critical care. The operating room and the emergency department must have a coordinated effort to ensure proper flow of patients. The postanesthesia care unit can operate to handle overflow as can the intensive care unit. A key element in all of this organization is to ensure security of the individuals that are providing care. The article should be read, studied, and used as a template for the development of organization during a multiple-casualty incident.
Sever MS, Vanholder R, Lanmeire N. Management of crush-related injuries after disasters. New England Journal of Medicine 2006;10:1052-1063.
Disasters can be natural, for example, earthquakes, hurricanes, tornados, and landslides, or manmade catastrophes that occur as a result of wars, mining accidents and terrorism attacks. One of the common problems is the Crush injury/syndrome that can occur. As a result of this type of crush injury, brenal disasterQ can ensue. This is a combination of hypovolemia and injury to the kidney that results from myoglobin and Uric acid in the renal tubulars. Early and vigorous volume resuscitation ideally to be established at the scene is essential. isotonic saline given at a rate of 1 L/h! After the patient has been removed from the rubble, a hypotonic saline solution may be started. Urinary output should be vigorous. The use of sodium bicarbonate may be essential to alkalinize the urine. Over the course of the early postinjury phase, vigorous volume support to the tune of 12 L/d may be necessary.
It is essential to monitor electrolytes, particularly potassium and calcium. Calcium supplementation should not be initiated unless the patient becomes symptomatic. Very careful monitoring of the serum potassium is essential. The major fear is the development of renal failure, which may require dialysis. Fasciotomy of the lower extremity may be necessary with the potential for infection sepsis and even death. Ultimately, the patient should be transferred to a stable facility that has not been damaged by the disaster. Unfortunately, the mortality associated with the Crush syndrome is significant and can be improved with early and vigorous resuscitation and transport. Unfortunately, in most disaster situations, transport is a major stumbling block.
Extremities
Tashjian RZ, Majercik S, Biffl WL, et al. Halo-vest immobilization increases early morbidity and mortality in elderly odontoid fractures. Journal of Trauma 2006;60:199-203.
The authors have previously evaluated their experience with cervical spine fractures and found that elderly patients treated with halo-vest immobilization had a 21% mortality. In the present study, they specifically evaluated elderly patients with odontoid fractures who were treated with halo-vest immobilization and postulated that they would have a worse outcome than those treated with cervical orthodics or internal fixation. In their study, they found that elderly patients with odontoid fractures treated with halo-vest immobilization have a higher rate of pneumonia, cardiac arrest, and death than those who were not treated with halo-vest. The authors recognize that the halo-vest is not a benign immobilization technique, and the patients require vigilant care and monitoring.
Inaba K, Potzman J, Munera F, et al. Multislice CT angiography for arterial evaluation of the injured lower extremity. Journal of Trauma 2006;60:502-507.
The purpose of this study was to evaluate the ability of computed tomography angiography to detect arterial injury in the traumatized lower extremity. This was a retrospective study that identified all patients
sustaining lower extremity trauma who underwent initial evaluation by computed tomographic angiography. The mechanism of injury was gunshot wounds in 42% of the patients. motorcycle crashes, stab wounds, and motor vehicle crashes made up the rest of the injuries evaluated.
Of the 63 computerized tomographic angiograms, 62 were diagnostic. There were 22 positive findings, which included 3 superficial femoral artery occlusions, 1 superficial femoral artery arterial venous fistula, and 1 pseudoaneurysm. There were 11 popliteal injuries. There were 40 negative injuries with follow-up of approximately 48 days. The authors state that their study demonstrated 100% sensitivity and specificity. I think this is a good diagnostic tool and one that can be performed in most emergency departments or radiology suites.
Durkin A, Sagi HC, Durham R, et al. Contemporary management of pelvic fractures. The American Journal of Surgery 2006;192:211-223.
This is an excellent article. It reviews the anatomy of the pelvis, the initial evaluation and management of the patient with pelvic fracture, as well as the categorization of pelvic fractures. These fractures do not occur in isolation and are commonly associated with other intra-abdominal as well as neurologic, vascular, rectal, and urologic injuries.
The authors offer a categorization of pelvic fractures based upon the mechanism of injury. They include (1) a lateral compression force followed by (2) an anterior/posterior compression and (3) a vertical shear type injury. The unstable hemodynamic status of the patient results from bleeding. The bleeding is primarily of venous origin. If bleeding recurs after initial stability, there is a good chance that the source is arterial in origin. Injuries to the pelvic structures need to be assessed, and these include vagina, uterus, rectum, bladder, urethra, as well as the pelvic vasculature. Intra-abdominal injuries should be evaluated in the unstable patient, and this often requires ultrasound and computed tomography. The authors describe management of the pelvic fractures with various orthopedic tools. Stabilization of the fracture in a simple fashion can occur with wrapping of the pelvis in a sheet. This is beneficial to control hemorrhage. An algorithm for the management of pelvic fractures is offered.
This is an excellent article and one that should be studied by emergency department physicians.
Stein DM, O’Connor JV, Kufera JA, et al. Risk factors associated with pelvic fractures sustained in Motor vehicle collisions involving newer vehicles. Journal of Trauma 2006;61:21-31.
This study was designed to evaluate both the epidemiologic and biomechanic risk factors associated with pelvic fractures. Pelvic fractures carry with them significant morbidity and mortality as well as functional disability. Associated injuries are common and often lead to mortality. Few studies in the trauma literature have detailed crash biomechanics and occupant kinematics to determine exactly how these injuries can be altered. The authors used a database that was created by the Department of Transportation’s National Highway Transportation Safety Administration. The Crash Injury Research Engineering Network provided data on the parameters surrounding car crashes and the pelvic fractures associated with
these injuries.
One thousand eight hundred fifty-one patients were evaluated. Each of these individuals was an occupant of a vehicle sustaining frontal or nearside lateral deformation. The incidence of PElvic fractures was high. Pelvic fractures were sustained in almost half of nearside lateral collisions as opposed to 20% of crashes involving a frontal deformation. A pelvic fracture was twice as likely to occur in a nearside lateral crash when the patient was riding in a small vehicle as opposed to a large vehicle. The authors found that in a nearside lateral crash, higher body mass index was protective. Seatbelts were found to be protective against pelvic fractures, in that unbelted patients had a 50% increased risk of pelvic fractures in a frontal crash. The authors found that the deployment
of airbags is associated with a decrease risk of pelvic fracture. Lateral crashes are significantly more likely to result in a pelvic fracture, and prevention of pelvic fractures should focus on improving occupant safety in nearside lateral impacts.
Blackmore CC, Cummings P, Jurkovich GJ, et al. Predicting major hemorrhage in patients with pelvic fracture. Journal of Trauma 2006;61:346-352.
The objective of the present study was to develop a clinical Predictive role to identify subjects at high risk of pelvic Arterial hemorrhage from factors that are immediately apparent upon initial presentations of trauma patients. Patients were admitted, and a pelvic anterior posterior radiograph was performed. Radiologists recorded the location and displacement of each fracture and joint diastasis in the pelvis. The radiologist also estimated the primary direction of force resulting in pelvic fracture. The authors found 4 factors that remained as Clinical predictors of major pelvic hemorrhage: (1) pulse of 130 of greater, (2) hematocrit of 30% or less, (3) opturator ring fracture displacement greater than 1 cm, or (4) diastasis of the pubic symphysis of 1 cm or more. For example, a patient with a displaced opturator ring fracture, a hematocrit of 25, and a pulse of 142 was predicted to have a high probability of major pelvic hemorrhage. The combination of these simple findings will allow for a prediction of significant hemorrhage and perhaps the need for early angiography.
General Information
MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. New England Journal of Medicine 2006:354:366-378.
The authors hypothesize that the risk of death secondary to trauma would be lower at a trauma center as compared with a nontrauma center and that the effect would be largest for younger patients with more severe injuries. In this report, the authors examine the effect of care in a trauma center on the risk of death. level I trauma centers and nontrauma centers in 14 states provided these data. Patients were eligible for this study if they were 18 to 84 years of age, arrived alive in a participating hospital, and were treated for a moderate to severe injury. The authors made appropriate adjustments for the case mix and found that the overall risk of death was 25% lower when care was provided at a trauma center than when it was provided at a nontrauma center. Differences in the risk of death according to the type of hospital also appeared to be greater among younger patients than older patients. Elderly patients are at higher risk for mortality as a result of multiple complications and preexisting disease. They were able to conclude that the risk of death is significantly lower when care is provided at a trauma center than a nontrauma center. This article argues for continued efforts to regionalize trauma care.
Demetriades D, Matthew M, Salim A, et al. Relationship between American College of Surgeons trauma center designation and mortality in patients with severe trauma (injury severity score N15). Journal of the American College of Surgeons 2006; 202:212-215.
The present study evaluated the effect of American College of Surgeons Trauma Center Designation on outcomes. The study population consisted of all trauma patients older than 14 years with an injury severity score of greater than 15 and who were alive on admission, reported in the National Trauma Data Bank during the 10-year period from 1994 through 2003. In a total of 130, 154 Severe trauma patients older than 14 years from 256 adult trauma centers were analyzed for this investigation. Patients were transferred to level I trauma centers (45), to level II trauma centers (39),
and to level III trauma centers (5 patients). One hundred sixty-seven hospitals that were not designated by the American College of Surgeons.
Overall crude mortality rate was 16.5%. The study demonstrated that these patients have a much better chance of survival in level I trauma centers than in level II trauma centers after adjusting for other patient risk factors. Trauma centers and trauma programs have an appreciable affect on survival in adversely injured patients.
Papa L, Langland-Orban B, Kallenborn C, et al. Assessing effectiveness of a mature Trauma system: association of trauma center presence with lower injury mortality rate. Journal of Trauma 2006;61:261-267.
The authors hypothesize that in a mature trauma system, injuries that occur in counties with trauma centers are associated with lower injury mortality than those occurring non-trauma center counties. Florida has a very mature statewide system that is approximately 20 years old. Statewide emergency medical system transport protocols exist with full integration of advanced life support services. Most patients can be transported to a level I facility within bthe gold hour.Q Primary outcome in the authors’ study was case fatality. In the present study, patients cared for by designated trauma centers had a lower motor vehicle case fatality and crash fatality rate than non-trauma center counties.
Schermer CR, Moyers TB, Miller WR, et al. Trauma center brief interventions for alcohol disorders decrease subsequent driving under the influence arrests. Journal of Trauma 2006;60:29-34.
The focus of this study was to determine whether a single brief intervention during hospitalization or injury could reduce subsequent driving-under-the-influence arrests. The hypothesis was that injured patients receiving a brief intervention would have a lower risk of driving-under-the-influence arrest within 3 years of discharge than those receiving Standard care. The patients were randomly assigned to receive brief intervention or standard care after being involved in motor vehicle crashes with injury, were residents of New Mexico, and either had admission blood alcohol concentration, which made them legally intoxicated, or had an Alcohol use disorder.
Participants randomized to the brief intervention arm had a 30-minute discussion in the style of motivational interviewing. The intervention mandated a specific style of interacting with the participant and offered several options regarding session content. The patient’s good and bad perceptions of drinking and the motivation and competence to change drinking behaviors were usually used to open the discussion. The conversation consisted of a nonconfrontational patient-centered discussion that allowed participants to talk about how alcohol use affected their life. Standard care consisted of providing the participant with a list of telephone numbers with alcohol treatment organizations near their homes.
Within 3 years of hospital discharge, 21 patients were arrested for at least 1 episode of driving under the influence; 14 of 64 patients in the standard care allocation had an arrest with only 7 of 62 patients who were allocated to the brief interview intervention. This study demonstrates that by simply talking to patients in a nonconfrontational way about their alcohol use while they are admitted for an injury has an impact on the likelihood of subsequent driving under the influence arrests.
Antevil JL, Sise MJ, Sach DJ. Retrievable Vena cava filters for preventing pulmonary embolus in trauma patients; a cautionary tail. Journal of Trauma 2006;60:35-40.
The current indications for the placement of an intra cava filter include deep venous thrombosis or pulmonary embolus with either failure of anticoagulation or a contraindication to anticoagulation. Additional criteria
include the very-high-risk group: severe head injury, spinal cord injury, Complex pelvic fracture with associated Long bone fractures, and multiple long bone fractures. The development of a bretrievableQ vena cava filter has perhaps loosened these criteria. The authors analyzed their use of the permanent and retrievable filter and the impact on their trauma patients by examining the clinical course of similar groups of trauma patients before and after the introduction of the retrievable filter. This study compares the indications for filter placement, the incidence of Thromboembolic events, and filter-related complications.
Patients were divided into group 1 and group 2 based on the availability of the retrievable vena cava filter. Indications for use of filters were not different in the 2 groups. There was no significant difference between the 2 groups in pulmonary embolus or major complications. The filter-related complications included 2 filter infections with sepsis, 1 vena cava thrombotic occlusion, 1 filter lodged in the jugular vein during retrieval, and 1 pulmonary embolus after filter placement. It is interesting that successful removal of the retrievable filters was verified in only 21% of the cases!
The authors conclude that their study has led them to question the rationale for a more liberal use of the vena cava filters.
Sing RF, Camp SH, Heniford BT, et al. Timing of pulmonary emboli after trauma: implication for retrievable vena cava filters. Journal of Trauma 2006;60:732-735.
The purpose of this study was to review the authors’ experience with the timing of pulmonary emboli after injury. This was particularly focused on the optimal timing for removal of the optional vena cava filters. They performed a retrospective medical record review. One hundred forty-six patients were reviewed. The diagnosis of pulmonary emboli was performed with helical chest computed tomography, pulmonary angiogram, ventilation perfusion scan, and autopsy. Prophylaxis was provided by sequential compression devices and pharmacologic agents. The mean time from injury to pulmonary embolus was 7.9 days. A total of 24 patients had pulmonary emboli at 15 days or later after their injury. Fifteen patients had pulmonary emboli that occurred after 21 days. Mortality of these trauma patients was identified at 17.8%. Pulmonary embolus was felt to contribute to or was considered the cause of death in 85% of the 26 deaths.
The mean time from injury to the occurrence of pulmonary emboli was after 21 days in 11% of the patients studied. The decision to remove the optional vena cava filter includes the manufacturer’s recommendations, continued risk for Thromboembolic disease, and the ability to anticoagulate the patient.
The authors feel that the manufacturer’s recommendation should not be the primary factor in the decision to remove the filter. It is the authors’ opinion that the duration of implantation for these filters should be individualized. It is also the authors’ opinion that they should be left in place until patients have substantially recovered from their injuries and the risk of pulmonary emboli is low. Removing these filters before 21 days leaves an unacceptably high percentage of patients at risk for pulmonary emboli postremoval.
Bergeron E, Clement J, Lavoie A, et al. A simple fall in the elderly: not so simple. Journal of Trauma 2006;60:268-273.
This article is from Canada and points out that a significant percentage of the population is considered elderly. These individuals have a high incidence of simple low velocity falls, which according to the authors will be evaluated in the emergency department. The authors studied approx- imately 2333 patients brought to the hospital as a result of low velocity falls. They found that despite the apparent minor mechanisms, these patients had injuries that were serious and often required a prolonged admission to the hospital. The overall mortality was approximately 13%. Elderly patients who had low velocity falls may have Significant injuries and require careful evaluation.
Kim PTW, Jangra D, Ritchie AH, et al. Mountain biking injuries requiring trauma center admission: a 10-year regional trauma system experience. Journal of Trauma 2006;60:312-318.
Mountain biking has become a much more popular recreational activity associated with an increase in the number of injuries that have been seen. Most of the studies that have been done thus far reveal that approximately 80% of mountain bike operators have injuries. Most of the injuries are minor. The purpose of the present study was to develop a population-based review of serious injury resulting from mountain biking at the authors’ trauma center.
Patients were included in this study if they were seriously injured while biking and required trauma center admission. The ages of the most commonly injured patients were between 21 and 30. orthopedic injuries were the most commonly seen and involved both the upper and lower extremities. There were a high number of individuals who had head injuries followed by spine, chest, facial, abdominal, and neck injuries. Cervical spine was the most commonly involved Spinal injury followed by the thoracic and lumbar spine. The study demonstrated that 38% of the injuries and 66% of the patients required operative intervention. Commonly, patients with spine and spinal cord injuries required a prolonged hospital stay and were often discharged to a rehabilitation facility with significant deficits.
The authors found that the number of mountain biking injuries requiring trauma center admission has increased alarmingly in the past 10 years. Control of the number of injuries and their prevention require attention. This topic very much duplicates the types of problems that are associated with the use of all terrain vehicles.
Celso B, Tepass J, Langland-Orban B, et al. Systemic review and meta- analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. Journal of Trauma 2006;60:371-378.
The statistics on trauma has not changed remarkably. Trauma is still the leading cause of death in persons less than 40 years of age, and morbidity associated with traumatic injuries causes excessive loss of productivity and expense. The improvement in trauma care has many components including injury prevention, prehospital care, services delivered at trauma centers, and other acute facilities and post hospital care. The authors systematically reviewed the published literature for population-based studies to assess if outcome from Severe traumatic injury was improved for patients after the establishment of a trauma system.
A literature review of all population-based study that evaluated trauma system performance was conducted. In reviewing the literature, the authors found 14 published articles that provided the information for review. The results of the authors’ analysis revealed a 15% reduction in mortality in favor of the presence of a trauma system. They point out that commitment on the part of the hospital is essential and necessary to provide the care necessary to produce the results.
Frykberg ER. Injury prevention forum editorial. Journal of Trauma 2006;60:443-454.
Doctor Frykberg points out that the burden of trauma both emotionally and financially is unaffected if the emphasis is only on treatment after the injury. The key to the decrease in the number of traumatic deaths is bprevention,Q and the author emphasizes the importance of injury prevention! This editorial is a commentary on articles that were submitted by the Injury Prevention Committee of the American Association for the Surgery of Trauma. The introductory article and the articles that follow on grading the effectiveness of injury prevention programs, the methods of controlling alcohol abuse, and the motor vehicle collisions that result and on pediatric trauma
demonstrate the benefits of injury prevention methodology. These are well worth reading.
Konkin DE, Garraway N, Hameed SM, et al. Population-based analysis of severe injuries from nonmotorized wheeled vehicles. Journal of the American College of Surgeons 2006;191:615-618.
In the authors’ geography, there has been an increased use of nonmotorized wheeled vehicles. These include bicycles, inline skates, and skateboards. Most injuries suffered were minor. However, there is a subset incidence that results in significant injury and potential mortality. The objective of the present study was to measure the rates of severe injury and to determine specific injury mechanisms, injury patterns, and to identify risk factors for morbidity and mortality. The authors reviewed the trauma registry and used this as their source of information for incidences that involve cycling, skateboarding, and inline skating.
There were 1475 cyclists, 141 skateboarders, and 112 inline skaters. There were 44 deaths, the majority occurring to cyclists. Head injuries and thoracic injuries were more common in the nonsurvivors. Sixty-three percent of the deaths involved collision with a motor vehicle.
Cyclists form most of those injured with skateboarding and inline skating, demonstrating an increased risk of severe injury. Patterns of injury were similar in all 3 groups, except for injuries of the chest and spine, which were more common in cyclists. Most injuries were orthopedic. The overall mortality for severe nonmotorized wheeled accidents was 2.7% for cyclists, 2.6% for inline skaters, and 0.7% for skateboarders. The use of helmets would be of benefit in decreasing mortality from head injuries. Other protective equipment including chest protection would be of benefit.
Kerwin AJ, Griffen MM, Tepas JJ. The burden of noncompliance with seatbelt use on a trauma center. Journal of Trauma 2006;60:489-493.
The National Highway Traffic Safety Administration has estimated that seatbelts have saved approximately 135,000 lives and prevented 3.8 million serious, nonfatal injuries since 1978. Unfortunately, seatbelt use is not mandatory. The authors sought to determine the Economic burden of noncompliance with seatbelt use in their trauma center. They reviewed a 1- year experience at their level one trauma center analyzing 3417 patients. There were 1744 patients who complied with 3-point seatbelt use and 1673 patients who did not.
The authors found that the no-seatbelt group had a significantly higher length of hospital and Intensive care unit stay as well as significantly longer ventilator days. Mortality was more than doubled in the no-seatbelt group. A significant number of people in the no-seatbelt required intensive care unit stays for a prolonged period. The hospital charges for the seatbelt group were calculated to be approximately 27,000,000 versus 51,000,000 for the no-seatbelt group. A fair percentage of the no-seatbelt group were uninsured or self-insured. This generates significant bad debt for the hospital. Seatbelt laws that require the use of seatbelts are long overdue in many states in this country. As of the year 2004, 21 states, the District of Columbia, and Puerto Rico have primary seatbelt laws. New Hampshire has no seatbelt law for adults.
Plurad D, Demetriades D, Gruzinski G, et al. Pedestrian injuries: the association of alcohol consumption with the type and severities and outcomes. Journal of the American College of Surgeons 2006;202:919-927.
The study was conducted to investigate the prevalence of alcohol use and blood alcohol level in a large trauma population and to determine the affect on injury severity, complication rate, and mortality.
All patients admitted to the authors’ level I trauma center were screened for blood alcohol level. Those individuals were divided into
groups depending upon the level of alcohol: no alcohol, low alcohol, and high alcohol. They found that there was no statistically significant association between the blood alcohol level and mortality or Intensive care unit length of stay. The authors did find an independent association between a high alcohol level and the occurrence of any in-hospital complication and between a high alcohol level and longer overall hospital stay.
Approximately half a million people are injured in alcohol-related traffic accidents yearly. Up to 40% of all crimes, both violent and nonviolent, are associated with alcohol. The present study confirmed that the general trend of alcohol consumption and intoxication was in young men. Up to 86% of trauma admissions can be associated with a positive drug and/or alcohol screen. Alcohol has a notable association with motor vehicle collision admissions, penetrating injuries, pedestrian versus automobile collisions, Motorcycle collisions, high-risk driving, Violent behavior, and suicidal ideation.
This is a good study that should be a valuable resource.
Biffl WL, Egglin T, Benedetto B. Sixteen-slice computed tomographic angiography is a reliable noninvasive screening test for clinically significant blunt cerebrovascular injuries. Journal of Trauma 2006;60:745-752.
The authors hypothesized that 16-slice computed tomographic angiog- raphy would reliably identify clinically significant blunt cerebrovascular injuries. The authors, using a specific protocol for screening blunt cerebrovascular injuries, evaluated patients with any of the following: (1) hemorrhage from the mouth, nose, ears, or wounds of potential arterial origin; (2) expanding Cervical hematomas; (3) cervical bruits; (4) evidence of cerebral infarction on computed tomography scan; (5) unexplained or computed tomographic incongruous central or lateralizing neurologic deficits, transient ischemic attack, or Horner syndrome. The 16-slice computed tomography scan was performed, and any positive study was confirmed with an arteriogram.
The authors found that computed tomographic angiography was
successful in detecting all clinical significant injuries. They conclude that the liberal use of this screening tool is appropriate, and a larger multicenter trial would be of benefit to further document its reliability.
Berne JD, Reuland KS, Villarreal DH, et al. Sixteen-slice Multidetector computed tomographic angiography improves the accuracy of screening for blunt cerebroVascular injury. Journal of Trauma 2006;60:1204-1210.
Blunt trauma results in injury to the cerebrovascular vessels. The estimated incidence is around 1%. Methods to screen for this injury are variable, but the gold standard for making the diagnosis has always been considered arteriography. The present study was performed to determine the accuracy and feasibility of 16-slice multidetector computed tomo- graphic angiography to screen for cerebrovascular injuries. The criteria used for screening included (1) identification or suspicion of any of the following injuries: basilar Skull fracture, cervical spine injury, multiple or severe Facial fractures, cervical hematoma, or cervical abrasion in a patient with an appropriate mechanism; (2) Glasgow Coma Score less than or equal to 8; (3) increasing neurologic signs. All patients must have an appropriate mechanism consistent with a high-peed deceleration injury or as a result of a direct blow to the cervical area. Hanging victims were also included.
Four hundred thirty-five patients met the criteria for screening. Twenty- five injuries were identified in 24 patients. No patient with a negative computed tomographic angiography was identified as having or having developed neurologic symptoms attributable to a missed cerebrovascular injury. The authors feel that their study demonstrated a clear improvement in the ability to screen for cerebrovascular injuries.
Thompson BT, Munera F, Cohn SM, et al. Novel computed tomography scan scoring system predicts the need for intervention after splenic injury. Journal of Trauma 2006;60:1083-1086.
The authors interpreted a computed tomographic scan in patients with splenic injury such that it was interpretable to surgeons, emergency physicians, and radiologists. Their interpretation criteria would predict the need for intervention via surgery or angiographic embolization. The criteria for a positive computed tomography included (1) devascularization or laceration involving 50% or more of the splenic parenchyma; (2) a blush of contrast greater than 1 cm in diameter; and (3) a large hemoperitoneum defined as fluid seen in 3 or more of the following areas: Morrison pouch, right subphrenic space, left subphrenic space, perisplenic space, right gutter, left gutter, or pelvis. Using these criteria, the specificity was 100%, and the overall accuracy was 93%. These scan findings were felt by the authors to reliably predict the need for intervention.
Inaba K, Munera F, McKenney M. Prospective evaluation of screening multislice helical computed tomographic angiography in the initial evaluation of penetrating neck injuries. Journal of Trauma 2006;61: 1301-1306.
The objective of this study was to prospectively assess multislice computed tomography as a stand-alone screening modality for the initial evaluation of Hemodynamically stable patients with penetrating neck injuries. In this study, patients with penetrating injuries of the neck over a 16-month period were prospectively studied. Patients who obviously needed Neck exploration were excluded from the protocol. The patients who were hemodynamically stable without obvious indications for surgery underwent multislice computed tomographic angiography (total of 91 patients; 34 gunshot wounds and 37 stab wounds). The authors found that the diagnostic tool was 100% sensitive and 93.5% specific in detecting all vascular and aerodigestive injuries sustained. They conclude that this diagnostic tool will be their initial screening methodology to exclude aerodigestive and vascular injuries in patients with penetrating neck injuries.
Eastridge BJ, Shafi S, Minei JP. economic impact of motorcycle helmets: from impact to discharge. Journal of Trauma 2006;60:978-984.
Motorcycle crashes are responsible for a disproportionate share of injury and death associated with motor vehicle crashes. Eighty percent of motorcycle crashes result in injury or death to the riders. Evidences accumulating that the injury-related Medical costs of unhelmeted riders are much more substantial than those of helmeted riders. The authors’ goal was to evaluate the direct Medical costs of motorcycle-associated injury from impact to hospital discharge. They hypothesized that inpatient charges underestimate the cost disparity between the medical care of the helmeted versus the unhelmeted motorcyclist. The authors also hypothe- sized the primary economic advantage of motorcycle helmets was a decreased use of the acute health care system after collision. The National Trauma Data Bank was queried from 1994 to 2002 to collect data including helmet use and hospital charges for injured motorcyclists. The authors found that the main economic advantage of the helmeted rider was the result of the following: (1) fewer injuries requiring transport to an emergency department (ED); (2) fewer inpatient admissions from the ED;
(3) decreased inpatient hospital costs; (4) lower rate of traumatic brain injury; (5) lower rate of maxillofacial injuries. Unhelmeted motorcyclists have nearly twice the rate of severe traumatic brain injury compared with helmeted motorcyclists. Unhelmeted motorcyclists were at significant increased risk of death when compared with helmeted riders (8.3% vs 3.6%). The authors estimate that the economic burden between unhelmeted and helmeted motorcyclists is approximately $250,000.000 and underscores the need for improved legislation to improve motorcycle helmet use.
Brooke BS, Efron DT, Chang DC, et al. Patterns and outcomes among penetrating trauma recidivists: it only gets worse. Journal of Trauma 2006;61:16-20.
The purpose of this study was to define patterns of injury among individual trauma recidivists and to determine whether injury mechanism is a predictor of mortality. Recidivism is defined as trauma in individuals who have previous admissions to the hospital for other injuries. It has been estimated that recidivists may constitute up to 40% of all hospital trauma admissions.
In this study, the authors reviewed retrospectively all patients who were identified with 2 or more unrelated trauma visits during a period from July of 1997 to June of 2004. The primary outcome measurement was all-cause mortality. The authors identified 15,973 trauma visits to their trauma facility, of which 2511 were patients previously treated in the hospital for trauma. The initial mechanism of injury among recidivists was penetrating trauma in 40% and blunt trauma in 60%. The highest percentage of Blunt injuries was caused by assaults. There was 5.7% mortality among trauma recidivists, with 15% occurring as a result of blunt trauma and 84% as a result of penetrating injury.
The authors found that there was a pattern among recidivists mechanism of injury, which in turn serves as a key prognostic indicator. Recidivists who presented primarily with penetrating trauma were more likely to return with the same injury pattern, and their risk of mortality was significantly increased with each consecutive trauma admission. Penetrating trauma is not likely a random event, and it is an indicator of an increased risk of excessive Violence exposure.
Moore FA, McKinley BA, Moore EE, et al. Guidelines for shock resuscitation. Journal of Trauma 2006;61:82-89.
The authors present a guideline to ensure early, consistent, and appropriate Resuscitative efforts. The challenges of this guideline included
(1) early identification of high-risk patients, (2) implementation in environments that are suboptimal for monitoring resuscitation, (3) early identification of resuscitation bnonrespondersQ who require more aggressive interventions, and (4) avoiding potentially harmful, overzealous interven- tions. The authors present their current understanding of how shock presents and various methods of assessing resuscitation. The use of saline versus Ringer lactate is discussed, as is the optimal hemoglobin level. Pulmonary artery catheter use and central venous pressure monitoring as well as the use of various anatropic agents discussed. A protocol for the resuscitation of a trauma patient is presented. This is a very good paper, and one that should be read and studied.
Gruen RF, Jurkovich GJ, McIntyre LK. Patterns of errors contributing to trauma mortality: lessons learned from 2594 deaths. Annals of Surgery 2006;244:371-380.
In this study, the authors aimed to identify errors that had contributed to the deaths of trauma patients at a specific high-volume, regional trauma center over a 9-year period. The authors aimed to examine the effect of introduction of local institutional policies on reducing error incidents. All Trauma deaths that occurred after arrival to the authors’ hospital from January of 1996 to December of 2004 were eligible for study. Those deaths identified at morbidity and mortality meetings as being possibly or definitely associated with errors in care were critically appraised. The definition of error was the failure of a planned action to achieve its defined goal.
In 9 years, 44,401 trauma patients were admitted with 2594 deaths (5.8%). Of the deaths, 69% were men with a median age of 46 years, and 74% were due to blunt trauma. The authors evaluated morbidity and mortality reports and found that 2.5% of the deaths had recognized errors in care. Major clinical groupings of errors included (1) Hemorrhage control, (2) air- way management, (3) inappropriate management of unstable patients,
(4) complications of procedures, (5) inadequate prophylaxis for deep venous thrombosis or Upper gastrointestinal bleeding, (6) missed or delayed diagnosis, (7) overresuscitation with fluids, and (8) other poor management decisions. This is a remarkably low incidence of potentially Preventable deaths. In reviewing their experience, errors occur during the initial assessment, resuscitation, and initial evaluation phases. Significant number of errors also occur in the critical care phase of treatment.
This is a remarkable evaluation of the trauma center, and the policies are to be emulated.
Holcomb JB, Hess JR. Early massive trauma transfusion: current state of the art. Journal of Trauma 2006;60:S1-S2.
This is an entire supplement that was issued by the Journal of Trauma. In it, the symposium that was held at the United States Army Institute of Surgical Research in 2005 is summarized. The articles include very up-to- date and appropriate information on the epidemiology of trauma, the coagulation problems associated with the resuscitation of the patients, and the use of red blood cells, fresh frozen plasma, and many of the controversies associated with resuscitation. This entire supplement is to be studied and read with vigor.
Hurtuk M, Reed RL, Esposito TJ, et al. trauma surgeons practice what they preach: the NTDB (National Trauma Data Base) story on solid organ injury management. Journal of Trauma 2006;61:243-255.
The development of nonoperative management has fostered since its initiation for the management of the pediatric ruptured spleen. The management principle has increased over time, and the authors attempted to use the National Data Base to document this as being true. This study sought to determine the degree to which the present changes in the management of solid organ injury management have changed clinical practice. The database has 1,130,093 trauma episodes from 1988 to 2004, which are available for analysis. A total of 25,509 spleen injury patients underwent successful nonoperative management. Blunt splenic trauma was managed nonoperatively in 85.6% of the cases. Thirty-five thousand five hundred ten blunt hepatic injuries were evaluated with 78% secondary to blunt trauma. There were 83.82% of the patients who underwent successful nonoperative management. The authors found that there was no significant difference that has occurred in the management of blunt injuries to the kidney because most of these were usually handled nonoperatively. The management of hepatic and splenic injuries has dramatically changed. There has been no decline in mortality associated with nonoperative management.
Sheffy N, Mintz Y, Rivkind AI, et al. Terror-related injuries: a comparison of gunshot wounds vs secondary fragments-induced injuries from explosives. Journal of the American College of Surgeons 2006;203:297-303.
Terror-related injuries are associated with a unique pattern that must be recognized to decrease morbidity and mortality. Most terror victims are injured either by explosive devices or from gunshots. The mechanism of injuries associated with explosions is traditionally divided into primary, secondary, and tertiary blast injuries. Primary blast injuries occur as a result of the blast wave-mediated atmospheric pressure changes. Secondary damage is caused by missiles and fragments that are imbedded inside the explosive device. The secondary missiles are propelled by the blast energy hitting the patient. Tertiary damage is caused by displacement of the patient’s body by the blast and the subsequent impact of the body with the ground or surrounding structures. Additional damage referred to as quaternary blast injury is caused by flash burns from hot gases and extreme heat caused by the explosion itself. Burns typically affect exposed body parts. Included in this quaternary injury can be the result of building collapse.
The authors used their experience in Israel to define the unique patterns and characteristics of injury caused by secondary missiles from explosive devices as opposed to gunshots. The authors used victims who had injuries inflected by explosive devices or gunshot wounds during a 4-year period. There was a marked difference in injury distribution between the two.
The severity of the injuries was greater for secondary fragment trauma than for gunshot wounds. Victims were more likely to be injured in multiple body regions with secondary fragments than with gunshot wounds. Over 40% of secondary fragment victims were injured in 3 or more distinct body regions. Although most gunshot victims were injured in the trunk, abdomen, and extremities, secondary fragment victims were much more likely to sustain injuries to upper body regions as well. Face and head injuries were significantly increased with secondary fragment mechanisms. The upper extremities were approximately the same. Burns were remarkably increased with secondary fragments as opposed to gunshot wounds.
Bochicchio GB, Joshi M, Bochicchio K, et al. Impact of obesity in the critically ill trauma patient: a prospective study. Journal of the American College of Surgeons 2006;203:533-538.
The purpose of this study was to determine the overall impact of obesity in critically ill trauma patients on morbidity and mortality. Obesity is defined in this study as a body mass index greater than 30 (body mass index is determined by the kilogram body weight divided by the height in meters squared). The present population of the United States is approximately 30% obese. Obesity carries with it individual risk factors that include diabetes, hypertension, and cerebrovascular disease.
The authors evaluated 1167 patients who were admitted to the shock trauma unit. Sixty-two of these patients were considered obese. With very careful evaluation and follow-up, the patients were found to be at an increased risk of infection for a substantially greater number of ventilator days and central venous catheter days. The obese patient was found to have substantially longer intensive care unit and hospital length of stay. Obesity was found to be an independent predictor for increased hospital and intensive care unit length of stay and mortality.
Ciesla DJ, Moore EE, Johnson JL, et al. Obesity increases risk of organ failure after severe trauma. Journal of the American College of Surgeons 2006;203:539-545.
In this work, the authors sought to define the relationship between obesity and postinjury organ dysfunction. The authors hypothesized that obesity is associated with an increase in multiorgan failure. The authors studied patients admitted to their intensive care unit at their level one trauma facility. Patients with a body mass index greater than or equal to 30 were included in this study. Two hundred seventy-eight patients met the criteria for inclusion in this study. The authors found that obesity was a strong, independent risk factor for postinjury organ dysfunction. There was also evidence for an altered inflammatory response in obese patients. This article in conjunct with the previously mentioned study give more evidence that the goal of the National Health Service to reduce the prevalence of obesity to 15% of the US population will be wise.
Head
Velmahos GC, Gervasini A, Petrovick L. Routine repeat head CT for minimal head injury is unnecessary. Journal of Trauma 2006;60:494-501.
The authors reviewed the trauma registry and medical records of patients admitted to their trauma center over a 1-year period. Patients with a Glasgow Coma Score of 13, 14, or 15 were considered with minimal head injury. In addition, patients with loss of consciousness, short-term amnesia,
headaches, emesis, and dizziness were included. An admission head computed tomography shortly after arrival was performed. If the initial scan indicated traumatic pathology, a routine repeat head CT was scheduled anywhere from 2 to 24 hours after the initial scan.
One hundred and seventy-nine cases were reviewed. Of these, 37 demonstrated evolution of the injury on their repeat scan, and 7 required intervention. All 7 had clinical deterioration. The authors concluded that a repeat head CT is unnecessary unless the patient demonstrates signs of deterioration in their neurologic examination.
Cohen DV, Rinker C, Wilberger JE. Traumatic brain injury in anti- coagulated patients. Journal of Trauma 2006;60:553-557.
The present study was undertaken to determine severity of head injury in Anticoagulated patients and to determine the affect of anticoagulation on outcome. This is a very important article and one that the emergency department (ED) physician should pay attention to. As our population is aging, the number of individuals who are anticoagulated for various reasons has increased. Patients who present to the ED with head trauma should be assessed for neurologic injury and their anticoagulation status determined. The authors evaluated 2 groups of individuals who had either severe traumatic brain injury or minor traumatic brain injury. Both groups were anticoagulated. The patients with severe injury presented with Glasgow Coma Scale scores less than 8. Patients with minimal head injury had Glasgow Coma Scores (GCSs) of 13 to 15. The patients with a GCS less than 8 had an average age of 65 years. Contusions and acute subdural hematomas were the most frequent computed tomography abnormality. Average Inter- national Normalization Ratio was 6.5. The mortality in this group of patients was 87.8%. Patients with a GCS of 13 to 15 presented with an International Normalization Ratio of 4.4 and had a mortality of 89%. A very disturbing finding was that 18 patients were evaluated and discharged from the ED only to be subsequently readmitted and diagnosed with a significant intracranial abnormality. Patients on Coumadin require an admission computed tomography if they have had head injury. The triad of anticoagulation, age more than 65 years, and traumatic brain injury is potentially lethal, and these patients should be assessed quickly, scanned, and very carefully monitored. Reversal of their anticoagulation is to be considered.
Franko J, Kish KJ, O’Connell BG, et al. Advanced age and preinjury warfarin anticoagulation increase the risk of mortality after head trauma. Journal of Trauma 2006;61:107-110.
The present study was designed to clarify the effects of warfarin anticoagulation and age on the mortality rate and risk of development of intracranial hemorrhage after head trauma. The authors evaluated 1493 adult trauma patients, 159 of which were warfarin-anticoagulated. They found that patients on anticoagulation were significantly more likely to have intracranial hemorrhage after trauma. The mortality in patients over 70 was significantly higher than in younger patients. Warfarin is associated with a high risk of traumatic intracranial hemorrhage and mortality. It is important to recognize trauma patients who are anticoagulated and to have a protocol for the reversal of their anticoagulation.
Pediatrics
Nance ML, Elliott MR, Abogast KB, et al. Delta V as a predictor of significant injury for children involved in frontal motor vehicle crashes. Annals of Surgery 2006:243;121-125.
To any physician who cares for patients who have had trauma as a result of motor vehicle crashes, it is clear that the faster the car was moving before it was involved in the crash, the more likely the passengers would have had an injury. The authors attempt to determine whether and
to what degree Delta V is predictive of injury risk in child occupants involved in motor vehicle crashes. The authors correlated the Delta V determined during detailed crash investigations from a large child-specific surveillance system with specific anatomic injury data. Detail crash investigation and clinical data were available on 207 children involved in 235 frontal crashes. The authors found that the unadjusted odds of at least one Abbreviated Injury Score greater than or equal to 2 increased an average by 53% for each 10-km/h increase in the Delta V. The unadjusted odds of at least one abbreviated injury score greater than or equal to 3 increased an average of 59% for each 10-km/h increase in Delta V.
In the authors’ opinion, this study was the first to demonstrate that the vehicles Delta V is a strong predictor of injury severity for children involved in frontal motor vehicle crashes. Information available on the Delta V will hopefully become more available as event data recorders become more commonly installed in motor vehicles. The information gleaned from the event data recorders includes Delta V, principal direction of force, Airbag deployment, and time of crash. This information will be most useful in the initial evaluation of the traumatized child.
Roaten JB, Partrick DA, Bensard DD, et al. Visceral injuries in nonaccidental trauma: spectrum of injury and outcomes. The American Journal of Surgery 2005;190:827-829.
This study evaluates the incidence of visceral injuries in nonaccidental trauma (NAT) patients. Its purpose was to characterize the spectrum and outcome of these injuries. Nonaccidental trauma is basically child abuse, and the authors found that the leading injury was head injury including Skull fractures and Traumatic brain injuries, which were followed by extremity fractures and Thoracic trauma. In the authors’ experience, they noted a higher incidence of concomitant thoracic trauma including rib fractures, clavicular fractures, and pulmonary contusions. It is highly unusual for a child to have rib fractures unless there has been some type of NAT. The authors also found a very high incidence of hollow Organ injuries in NAT. Fifty percent of the abdominally injured patients in their series had hollow viscous injuries. These included, gastric, duodenal, and jejunal ilium disruption. These were a common cause of emergency surgery. It is important to recognize injuries to the viscera in patients who have suffer had NAT.
Stylianos S, Egorova N, Guice KS. Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma center: a call for dissemination of American Pediatric Surgical Association Benchmarks and Guidelines. Journal of the American College of Surgeons 2006;202:247-251.
The authors sought to compare the rate of nonoperative treatment between hospitals with and without recognized trauma expertise using a large database of children with blunt, spleen injury. They identified 3232 patients with blunt spleen injury including 1933 patients with isolated spleen injury. The information was obtained from uniform hospital discharge data from California, Florida, New Jersey, and New York. Nearly two thirds of the patients were treated at trauma centers. Trauma centers had a significantly lower rate of operation for both multiple-injured patients and those with isolated splenic injury. Treatment of patients with blunt splenic injury differs significantly when comparing trauma centers versus non- trauma centers. The authors call for a dissemination of the American Pediatric Surgical Association’s Guidelines and Benchmarks for the treatment of the pediatric patients and, specifically, for splenic injury.
Pediatrics
Mooney DP, Rothstein DH, Forbes PW. Variation in the management of pediatric splenic injuries in the United States. Journal of Trauma 2006;61:330-333.
An analysis was undertaken on a national level to determine whether there is a variation in splenectomy rate between different types of institutions within the United States. The database was obtained from the health care costs and utilization project, and the records of all children with an international classification of disease diagnoses from 800.0 to
959.9 were extracted. Patients aged 15 years or less were considered children. This allowed for the development of a large database that included 734 of the potential 2784 hospitals from 28 states that contained approximately 68% of the United States population. Three types of pediatric hospitals were recognized: (1) freestanding pediatric, (2) pediatric unit within an adult hospital, and (3) adult hospital.
Overall, 12% of all patients underwent splenectomy, 4% underwent splenorrhaphy, and 84% were treated without operation. The authors found that children cared for at freestanding pediatric hospitals have a significantly lower risk of splenectomy than children treated at either adult hospitals or pediatric hospitals within an adult hospital.
Ivascu FA, Janczyk RJ, Junn FS. Treatment of trauma patients with intracranial hemorrhage on preinjury warfarin. Journal of Trauma 2006;61:318-221.
The purpose of the present study was to determine whether early identification of patients on preinjury warfarin could significantly reduce mortality in patients with traumatic intracranial hemorrhage. The authors established a protocol in their facility for early identification and potentially early therapy of patients on Coumadin. Patients were expedited from triage to a treatment area where they underwent rapid diagnostic testing and computerized tomography of the head. Falls were the main mechanism of injury for the study group. The authors identified 35 patients on Coumadin. There were 13 deaths in these35 patients for a 37% mortality. Intracranial hemorrhage included subdural, subarachnoid, epidural, or Intraparenchymal hemorrhage. It was anticipated in this study that the early identification of patients at risk of intracranial hemorrhage would lead to a decreased mortality. They found that this was not true. Mortality was not decreased with the protocol used. The protocol failed to reduce the time required for definitive diagnosis and for subsequent treatment. The interesting discovery was that progression of intracranial hemorrhage defined as an increase of at least one grade on follow-up computed tomography was predictive of mortality. Sixty percent of the patients with progression of intracranial hemorrhage died.
Any patient who presents after head trauma on Coumadin should be rapidly expedited, and assessment and evaluation should be performed. A determination of their anticoagulation status should be performed, and reversal, if necessary, with fresh frozen plasma should occur. It is not clear, however, if this will lead to improved outcome.
Giss SR, Dobrilovic N, Brown RL, et al. Complications of Nonoperative management of pediatric Blunt hepatic trauma: diagnosis, management and outcome. Journal of Trauma 2006;61:334-339.
As with splenic injuries, the management of pediatric patients with hepatic trauma is largely nonoperative. The authors performed this retrospective study of blunt, Hepatic injury to determine the incidence, diagnosis, and management as well as outcomes of complications associated with this treatment. In the authors’ experience, 185 patients of a potential 202 patients were initially managed nonoperatively. Of these patients, 168 (90.8%) were successfully managed nonoperatively without any adverse sequelae. Ten patients died. Seven patients (3.8%) developed clinically significant complications. None of the deaths were directly attributable to the hepatic injury. Complications occurred in 3.8% with grade 3 or 4 right lobe Liver lacerations and included biloma (5), hepatic injury pseudoaneurysm with hemobilia (1), and necrotic gallbladder (1). Nonoperative management can be successful, but it is vitally important to follow these patients in the periadmission period to ensure that development of one of these complications is recognized and appropriately managed.
Prehospital
Davis DP, Serrano JA, Vilke GM. The predictive value of field vs arrival Glasgow Coma Scale Score and TRISS calculations in moderate to severe traumatic brain injury. Journal of Trauma 2006;60:985-990.
The objective of the present study was to evaluate the predictive value of field Glasgow Coma Score with regard to arrival Glasgow Coma Scale Score as well as eventual outcome in patients with moderate to sever traumatic brain injury. The authors reviewed a very large number of patients who were involved in traumatic injuries in their EMS system. A field and arrival Glasgow Coma Score was obtained. They found that the values for the field score were highly predictive of the arrival score and were really identical. The data support the predictive value of the field Glasgow Coma Score and the its use for predictive purposes.
Fakhry SM, Scanlon JM, Robinson L, et al. Prehospital rapid sequence intubation for head trauma: conditions for a successful program. Journal of Trauma 2006;60:997-1001.
The primary purpose of this study was to formally review the procedural experience and outcomes of the authors’ prehospital units using rapid sequence intubation in severely injured patients. Using a helicopter paramedic crew, the authors evaluated 175 patients who underwent rapid sequence intubation. A total of 169 patients (96.6%) were successful. There were 70% intubated on the first attempt, 89% on the second attempt, and 96.6% on the third attempt. There were 6 failed intubations, 4 of which received scene cricothyroidotomy, and 2 were managed with bag valve mask. There were no Esophageal intubations.
The authors reported a very successful program on the rapid sequence induction. They also demonstrated a carefully monitored and policed training system. A small number of individuals who were carefully trained and who maintained their abilities resulted in a very successful use of this technique.
Matioc AA, Wells JA. Positive pressure ventilation with the laryngeal mask airway in the operating room and prehospital: a practical review. Journal of Trauma 2006;60:1371-1376.
This is a very good article. In it, the authors discuss the emergence of the laryngeal mask airway as a prehospital airway device. They focus on the contrast between hospital and Prehospital use and the optimal training for the use of the laryngeal mask airway. The laryngeal mask airway has been used in the operating room in situations that did not allow for ventilation or intubation. The device has been successfully used in the United Kingdom and in Australia.
There are awkward situations in the prehospital arena, such as patients presenting with a full stomach, patients that have not had their cervical spine cleared, and patients who have had failed Bag valve mask ventilation. The authors describe the ventilation device, its proper insertion, and use in the prehospital and clinical environment. There is no question in the authors’ experience that there is a role for the laryngeal mask airway both in the clinical and prehospital setting and in particular in situations where intubation has been unsuccessful.
Spine
Stassen NA, Williams VA, Gestring ML, et al. Magnetic resonance imaging in combination with helical computed tomography provides a safe and efficient method of cervical spine clearance in the obtunded trauma patient. Journal of Trauma 2006;60:171-177.
Evaluation of the cervical spine in the awake, alert, and nonintoxicated individual is relatively easy. The difficulty arises in patients that have an
altered mental status and are obtunded. The authors review their institution’s experience with the implementation of a cervical spine clearance guideline. In this protocol, all obtunded, blunt trauma patients are evaluated with a cervical spine computerized tomography. A magnetic resonance image of the cervical spine is performed if the person remains obtunded by day 3. If both the computerized tomography and the magnetic resonance imaging are interpreted as demonstrating no injury, then the cervical spine is considered negative. On the other hand, if either is positive, then the patient is appropriately treated. Thirteen patients had a negative computerized tomography, but a positive magnetic resonance image for c-spine ligamentous injury. All of these patients were treated with rigid cervical spine immobilization. Thirty-one patients had both a negative computerized tomography and a negative magnetic resonance image, and their Cervical immobilization was removed. Eight patients had a positive computerized tomography and a positive magnetic resonance image, and all 8 patients were treated with rigid cervical collar immobilization. This study demonstrates the benefit of a clearing computerized tomographic scan combined with magnetic resonance imaging to evaluate the cervical spine in an obtunded patient.
Ackland HM, Cooper DJ, Malham GM, et al. Magnetic resonance imaging for clearing the cervical spine in unconscious intensive care trauma patients. Journal of Trauma 2006;60:668-672.
Clearance of the cervical spine in the patient who is awake, alert, and not intoxicated has been well analyzed. A major difficulty occurs in patients who potentially have had a cervical spine injury who are unconscious either as a result of drugs or trauma. Clearance of the cervical spine in these individuals is no minor problem. The importance of maintaining cervical immobilization in these patients until the cervical spine can be cleared is obvious. The technique to clear the spine is the focus of this article. After an extensive review of the literature, the authors arrived at the following conclusions: it seems appropriate that routine magnetic resonance imaging should have a limited role in cervical clearance protocols for Unconscious trauma patients who by the nature of their mechanism of injury and injury severity score are at extremely high risk of cervical spine injury. There is hope that the multisliced computed tomography will add more to this topic and eliminate the potential need for magnetic resonance imaging.
Antevil JL, Sise MJ, Fack DL, et al. Spiral computed tomography for the initial evaluation of spine trauma: a new standard of care. Journal of Trauma 2006;61:382-387.
The purpose of this study was to compare the authors’ institutional experience before and after adoption of a practice guideline for spine imaging. They compared the time spent in the radiology department, the diagnostic sensitivity for spinal evaluation, levels of radiation exposure, costs and charges between those patients evaluated with plain film radiology and those evaluated with spiral computed tomographic scanning. I do not think this will come much as a surprise to the readers: the authors conclude that imaging with spiral computed tomography as the initial imaging of the trauma patient is superior in many ways, saves time, and is equivalent in cost to plain film radiography.
This is an excellent study and should be read by all emergency department physicians.
Vascular
Schneidereit NP, Simons R, Nicolaou S, et al. Utility of screening for blunt vascular neck injuries with computed tomographic angiography. Journal of Trauma 2006;60:209-216.
Blunt trauma to the neck particularly with Associated fractures has an opportunity to cause carotid artery and Vertebral artery injuries. The incidence has had variable estimates from 0.1% to 1.5%. The screening for this particular type of injury has normally required arteriography. In this study, the authors used computerized tomographic angiography to screen and detect for blunt, vascular injuries. They found that this method of screening was successful and increased the ability to diagnose blunt injuries to the blood vessels of the neck. Confirmatory angiography was not always performed.
This is a good article and one worth reading. The editorial does not agree with the conclusions.
Eastman AL, Chason DP, Perez CL, et al. Computed tomographic angiography for the diagnosis of Blunt cervical vascular injury: is it ready for primetime? Journal of Trauma 2006;60:925-929.
The purpose of this study was to conduct a prospective comparison of catheter arteriography and computed tomographic angiography for the detection of blunt cerebral vascular injury. There have been recent improvements in the computed tomographic technology, such that there is a 16-channel detector and coupling of the scanner with 3-dimensional imagery workstations that provide markedly improved images. It would clearly be much more efficient and effective if this technical advancement could replace cerebral arteriography to evaluate the carotid and vertebral artery.
All patients deemed to be at risk for blunt cerebral vascular injury underwent a screening computed tomographic angiography. In patients with injuries identified using this technique, catheter arteriograms were performed immediately to confirm these results. The authors evaluated 162 patients who were felt to be at risk for blunt cerebral vascular injury. The overall instance of Carotid artery injury was 0.54%. Twenty-six vertebral artery injuries were diagnosed. There were 96.2% of vertebral artery injuries associated with at least one cervical spine fracture. Overall, 46 blunt cerebral vascular injuries were identified among 43 patients. There was a single false-negative computed tomographic angiography in a patient with grade 1 vertebral artery injury. There were 103 patients with normal computed tomograms confirmed by a normal catheter angiogram. The overall sensitivity, specificity, predictive value, positive predictive value, negative predictive value, and accuracy for the diagnosis of blunt cerebral vascular injury was 92.7%, 100%, 100%, 99.3%, and 99.3%, respectively. The authors feel conclusively that a computed tomographic angiography with a 16-channel detector is ready to be used as a screening tool for blunt cerebral vascular injury.